Background

A fistula is an abnormal communication between two epithelialized

surfaces; an enterocutaneous fistula (ECF), as the name indicates, is an
abnormal communication between the small or large bowel and the skin.
An ECF can arise from the duodenum, jejunum, ileum, colon, or rectum.

Almost healed wound around an enterocutaneous fistula.

Although fistulas arising from other regions of the gastrointestinal (GI) tract
(eg, stomach and esophagus) may sometimes be included in the definition
of ECF, the discussion in this article is limited to the conventional definition
of ECF. A fistula-in-ano, though anatomically an ECF, conventionally is not
referred to as such, because its presentation and management are
different.

An ECF, which is classified as an external fistula (as opposed to an internal

fistula, which is an abnormal communication between two hollow viscera),
is a complication that is usually seen after surgery on the small or large
bowel. In one study, about 95% of ECFs were postoperative, and the ileum
was the most common site of ECF [1] ; 49% of fistulas were high-output, and
51% were low-output.

ECFs are a common presentation in general surgical wards, and despite

advances in the management of these lesions, they are still responsible for
a significant mortality (5-20%), due to associated sepsis, nutritional
abnormalities, and electrolyte imbalances.
Understanding the pathophysiology of, as well as the risk factors for, ECFs
should help to reduce their occurrence. Moreover, the well-established
treatment guidelines for these lesions, along with some newer treatment
options, should help clinicians to achieve a better outcome in patients with
an ECF.

Treatment of ECFs continues to be a difficult task. The problems

associated with an intestinal wound breakdown were mentioned as early as
53 BCE, by Celsus, who stated that the large intestine can be sutured, not
with any certain assurance, but because this doubtful hope is preferable to
certain despair; for occasionally it heals up."

In the mid-19th century, John Hunter also described the difficulties in

treating ECFs, insisting that "in such cases nothing is to be done but
dressing the wound superficially, and when the contents of the wounded
viscus become less, we may hope for a cure."

In a landmark article, Edmunds et al provided a comprehensive discussion

of ECF. Of 157 patients in the study, 67 developed ECF following surgery.
Important complications of ECF included fluid and electrolyte imbalance,
malnutrition, and generalized peritonitis. Mortality was 62% in patients with
gastric and duodenal fistulas, 54% in patients with small-bowel fistulas, and
16% with colonic fistulas. [2]

Etiology
An ECF can occur as a complication following any type of surgery on the
GI tract. Indeed, more than 75% of all ECFs arise as a postoperative
complication, whereas about 15-25% result from abdominal trauma or
occur spontaneously in relation to cancer, irradiation, inflammatory bowel
disease (IBD), or ischemic or infective conditions. The etiology of ECFs can
thus be characterized as postoperative, traumatic, or spontaneous.
Postoperative

Postoperative causes of ECFs include the following:

Disruption of anastomosis
Inadvertent enterotomy - Occurs especially in patients with
adhesions, when dissection can cause multiple serosal tears and an
occasional full-thickness tear
Inadvertent small-bowel injury - Occurs during abdominal closure,
especially after ventral hernia repair
Disruption of anastomosis can result from inadequate blood flow due to an
improper vascular supply, especially when extensive mesenteric vessels
have to be ligated. Tension on anastomotic lines following colonic
resection, restoration of continuity without adequate mobilization, or a
minimal leak or infection can lead to perianastomotic abscess formation,
resulting in disruption, as seen in patients with anterior resection for rectal
carcinoma. In addition, if anastomosis is performed in an unhealthy bowel
(eg, diseased, ischemic), it can lead to disruption and cause an ECF.
Inadvertent picking up of the bowel during abdominal closure can result in a
small-bowel fistula; this especially can occur with the use of open inlay
mesh or intraperitoneal onlay mesh repair by the laparoscopic method,
when the viscera comes in contact with the mesh, leading to adhesions and
sometimes to disruption.

Gastroduodenal fistulas are seen most often after surgery for perforated
peptic ulcer, especially in developing countries, where perforated peptic
ulcer is more common. In patients with a perforated duodenal ulcer, when
the perforation is large, extensive contamination is present. When the
duration between the perforation and the surgery is long, there is a high
possibility of a leak following surgery, leading to a lateral duodenal fistula.
This problem is difficult to treat, and the mortality is high. Other causes of
gastroduodenal leak include surgery for cancers of the stomach and the
biliary tract.

A colocutaneous fistula can develop after colonic surgery, especially when

the blood supply to a low colorectal/anal anastomosis is compromised or
when there is tension at the anastomotic suture line. This type of fistula can
also result from diseases of the colon, such as IBD or malignancy leading
to perforation, pericolic abscess formation, and ECF. Surgery for
appendicitis, appendicular perforation at the base, or drainage of an
appendicular abscess can also lead to a colocutaneous fistula. Radiation
therapy is also another major cause of colonic fistula. [3] In rare cases,
migration of a polypropylene or composite mesh from a hernia repair can
lead to ECF formation [4, 5]

Traumatic
Traumatic ECF results from iatrogenic surgical trauma to the bowel that
may or may not be recognized. Road traffic accidents with injury to the gut
can also lead to an ECF. [6]

Spontaneous
Spontaneous causes of ECF, seen in about 15-25% of cases, include the
following:
Malignancy
Radiation enteritis with perforation
Intra-abdominal sepsis
 IBD (eg, Crohn disease [3] )
Ulcerative colitis (UC) can also lead to spontaneous ECF, but most cases
of ECF associated with this IBD occur as a postoperative complication of
restorative proctocolectomy. [7] Rarely, inadvertent incision of a malignant
tumor can lead to an ECF (see the image below). In this patient, a urachal
tumor was inadvertently incised when the patient underwent an
appendectomy by midline incision. The patient presented with ECF
(colocutaneous fistula) as the urachal tumor that ulcerated on the
abdominal wall postoperatively had also infiltrated the sigmoid colon.

Postoperative malignant enterocutaneous fistula.

A duodenal fistula can occur in association with a perforated duodenal

ulcer, but again, it most often arises postoperatively, resulting from a leak.

Prognosis
ECF is a common condition in most general surgical wards. Mortality has
falen significantly since the late 1980s, from as high as 40-65% to as low
as 5-20%, largely as a result of advances in intensive care, nutritional
support, antimicrobial therapy, wound care, and operative
[8, 9]
techniques. Even so, the mortality is still high, in the range of 30-35%, in
patients with high-output ECFs.

Once a patient develops an ECF, the morbidity associated with the surgical
procedure or the primary disease increases, affecting the patient's quality
of life, lengthening the hospital stay, and raising the overall treatment cost.
Malnutrition, sepsis, and fluid electrolyte imbalance are the primary causes
of mortality in patients with an ECF.

If sepsis is not controlled, progressive deterioration occurs and patients

succumb to septicemia. Other sepsis-related complications include intra-
abdominal abscess, soft-tissue infection, and generalized peritonitis. [10]
However, patients with an ECF with favorable factors for spontaneous
closure have a good prognosis and a lower mortality.

Favorable factors for spontaneous closure

Spontaneous closure of an ECF is determined by certain anatomic factors.
Fistulas that have a good chance of healing include the following:
End fistulas (eg, those arising from leakage through a duodenal
stump after Plya gastrectomy)
Jejunal fistulas
Colonic fistulas
Continuity-maintained fistulas - These allow the patient to pass stool
Small-defect fistulas
Long-tract fistulas

In addition, a fistulous tract of more than 2 cm has a higher possibility of

spontaneous closure. Spontaneous closure is also possible if the bowel-
wall disruption is partial and other factors are favorable. If the disruption is
complete, surgical intervention is necessary to restore intestinal continuity.

Unfavorable factors for spontaneous closure

When an ECF is associated with adverse factors, then spontaneous
closure does not commonly occur, and surgical intervention, despite its
associated risks, is frequently required. In these patients, the outcome is
less likely to be good. [11]
Factors preventing the spontaneous closure of an ECF can be
remembered by using the acronym FRIEND, which represents the
following [12] :
Foreign body
Radiation
Inflammation/infection/IBD
Epithelialization of the fistula tract
Neoplasm
 Distal obstruction - A distal obstruction prevents the spontaneous
closure of an ECF, even in the presence of other favorable factors; if
present, surgical intervention is needed to relieve the obstruction
In addition, lateral duodenal, ligament of Treitz, and ileal fistulas have less
tendency to spontaneously close. [10]

Excoriation
Skin excoriation (see the image below) is one of the complications that can
lead to significant morbidity in patients with ECF. When the enteric contents
are more fluid than solid, this becomes a difficult problem; the skin
excoriation makes it difficult to put a collecting bag or dressings over the
fistula, and more leakage leads to an increase in the excoriation.

Enterocutaneous fistula with severe skin excoriation.

History and Physical Examination

Features suggestive of an enterocutaneous fistula (ECF) include
postoperative abdominal pain, tenderness, distention, enteric contents from
the drain site, and the main abdominal wound. Tachycardia and pyrexia
may also be present, as may signs of localized or diffuse peritonitis,
including guarding, rigidity, and rebound tenderness.
The type of ECF, as based on the output of the enteric contents, also
determines the patient's health status and how the patient may respond to
therapy. ECFs are usually classified into three categories, as follows [3] :
Low-output fistula (<200 mL/day),
Moderate-output fistula (200-500 mL/day)
High-output fistula (>500 mL/day)

Complications
Patients with ECF present with associated complications, such as sepsis,
fluid and electrolyte abnormalities, and malnutrition.
The degree of sepsis depends on the state of the ECF. If the fistula forms a
direct tract through which the bowel contents are draining onto the skin,
then the sepsis may be minimal, whereas if the fistula forms an indirect
tract through which the bowel contents are draining into an abscess cavity
and then onto the skin, the degree of sepsis may be higher. In the presence
of extensive peritoneal contamination or generalized peritonitis with ECF,
the patient can be toxic due to severe sepsis.

Leakage of protein-rich enteric contents, intra-abdominal sepsis, or

electrolyte imbalancerelated paralytic ileus, as well as a general feeling of
ill health, leads to reduced nutritional intake by these patients, resulting in
malnutrition. Nearly 70% of patients with ECFs may have malnutrition, and
it is a significant prognostic factor for spontaneous fistula closure. [13]
Sepsis, malnutrition, and electrolyte imbalance are the predominant factors
that lead to death in patients with ECF. [14] Rarely, intestinal failure can occur
as one of the complications of ECF, which results in significant morbidity
and mortality. [15]

A high-output fistula increases the possibility of fluid and electrolyte

imbalance and malnutrition.

Laboratory Studies
The following laboratory studies are performed in the evaluation of an
enterocutaneous fistula (ECF):
Total leukocyte count - This is important because sepsis can lead to
leukocytosis
Serum sodium, potassium, and chloride levels - Electrolyte
abnormalities can result from fluid and electrolyte loss
Complete blood count (CBC), total proteins, serum albumin, and
globulin - These can demonstrate the presence of malnutrition-
associated anemia/hypoalbuminemia
Serum transferrin - Low levels (<200 mg/dL) are a predictor of poor
healing
Serum C-reactive protein - Levels may be elevated

Imaging Studies
Fistulography
During fistulography (see the images below), a water-soluble contrast is injected into
the fistulous tract.
Fistulogram showing enterocutaneous fistula.

Fistulogram showing a colocutaneous fistula following anastomotic leak

after colostomy closure.

Fistulography is conventionally performed 7-10 days after the presentation of an

ECF and provides the following information:
Length of the tract
 Extent of the bowel-wall disruption
Location of the fistula
Presence of a distal obstruction

Water-soluble contrast enema

The different types of tracts that can be seen by using a water-soluble contrast
enema (WCE) in patients with ECF with failure of low colorectal anastomosis may be
classified as follows [16] :
I Simple, short blind ending, <2 cm
II - Continuous linear, long single, >2 cm
III - Continuous complex, multiple linear
Tract positions are as follows:
Anterior - Ventral, 10-oclock to 2-oclock position
Posterior - Dorsal, 4-oclock to 8-oclock position
Lateral - Right (2-oclock to 4-oclock position) or left (8-oclock to 10-oclock position)
Additional tract features seen with a WCE include the cavity (pooling of contrast
within space) and/or a stricture (narrowing of anastomosis, with hold of contrast).
The presence of a stricture and a large cavity on WCE predicts failure of healing.

Computed tomography
Computed tomography (CT) is useful for demonstrating intra-abdominal abscess
cavities. Such cavities can occur if an ECF has an indirect tract when it first drains
into an abscess cavity and then drains to the exterior cavity. If an ECF is associated
with intra-abdominal sepsis, then interloop abscesses may be present.

Other Tests
Oral administration of a nonabsorbable marker (eg, charcoal, Congo red)
can help confirm the presence of an ECF.
Methylene blue diluted in saline can be administered through a nasogastric
tube as a simple bedside test to confirm the presence of an ECF, especially
in patients with a gastrocutaneous or lateral duodenal fistula. This test can
also help to determine whether the leak is from a segment that is in the
continuity of the gastrointestinal tract, especially in the case of proximal
fistulas. However, because methylene blue loses diagnostic efficacy as it
becomes diluted with intestinal secretions, its role in identifying distal ECFs
is limited.

Approach Considerations
The conventional therapy for an enterocutaneous fistula (ECF) in the initial
phase is always conservative. Immediate surgical therapy on presentation
is contraindicated, because the majority of ECFs spontaneously close as a
result of conservative therapy. Surgical intervention in the presence
of sepsis and poor general condition would be hazardous for the patient.
However, patients with an ECF with adverse factors, such as a lateral
duodenal fistula, an ileal fistula, a high-output fistula, or a fistula associated
with a diseased bowel, may require early surgical intervention.

Conservative Therapy
Conservative treatment should usually be administered for a period ranging
from a few weeks to a few months. The principles of nonsurgical therapy
for ECFs include the following:
Rehydration
Administration of antibiotics
Correction of anemia
Electrolyte repletion
Drainage of obvious abscess
Nutritional support
Control of fistula drainage
Skin protection
With the above-mentioned supportive therapy, spontaneous closure occurs
in almost 70% of patients. In a study of 186 patients, Reber et al found that
91% of small-bowel fistulas that closed spontaneously did so within 1
month after sepsis was cured. The remaining fistulas that closed
spontaneously did so by the end of 3 months after sepsis cure, with the rest
of the lesions requiring surgical closure. [17]

Uba et al reported that the majority of ECFs in children closed

spontaneously following high-protein and high-carbohydrate
nutrition. [18] They found that hypoalbuminemia and jejunal location were
important variables resulting in nonspontaneous closure, whereas
hypokalemia, sepsis, and hypoproteinemia/hypoalbuminemia were risk
factors for high mortality in children with ECF.

Rehydration, electrolyte repletion, and nutritional support

Common fluid and electrolyte problems that must be corrected in patients
with an ECF include the following:
Dehydration
Hyponatremia
Hypokalemia
Metabolic acidosis
The author uses parenteral nutrition more often in patients with a proximal
small-bowel ECF, especially if it is in the proximal jejunum, or with a high-
output fistula. In patients with a distal ECF, the author prefers to use enteral
nutrition whenever possible.

Studies have shown that the provision of only 20% of calories fed enterally
may protect the integrity of the mucosal barrier, as well as the immunologic
and hormonal function of the gut. [10] Hence, a combination of parenteral and
enteral nutrition can be used. In high-output fistulas, the author uses this
combination therapy.

In patients with a proximal fistula, if a nasojejunal tube can be introduced

beyond the site of the fistula, then these patients can be supported with
enteral nutrition, provided that there is at least 4-5 ft (1.2-1.5 m) of small
bowel distal to it and no distal obstruction. Patients with chronic small-
bowel ECFs may need additional supplementation with copper, folic acid,
and vitamin B12. [10]

Total parenteral nutrition

Total parenteral nutrition (TPN) is usually indicated with suspected gastric,
duodenal, or small-bowel fistula. When the fistula output is very high,
discontinuance of oral intake is recommended because oral intake
stimulates further losses of fluids, electrolytes, and protein via the fistula. A
decrease in fistula output frequently occurs with the initiation of TPN.
Water requirements for TPN are 1 mL/kcal/day. Electrolyte requirements for
TPN are as follows:
Sodium (Na) - 80-100 mEq/day
Potassium (K) - 75-100 mEq/day
Magnesium (Mg) - 15-20 mEq/day
Calcium (Ca) - 15-20 mEq/day
Calorie and protein requirements are as follows:
Maintenance 25-30 kcal, 1.0-1.2 g/kg/day
Moderate stress 30-40 kcal, 1.3-1.4 g/kg/day
Severe stress 40-45 kcal, 1.5-2.0 g/kg/day
Protein (g)/6.25 should equal nitrogen (g), and the nonprotein calorie-to-
nitrogen ratio should be as follows:
Maintenance - 200-300:1
Moderate stress - 150:1
Severe stress - <100:1
A standard, general purpose formula for TPN consists of the following:
Glucose, 75 g
Amino acids, 20 g
Lipids, 30 g/L

The introduction of ethyl vinyl acetate bags has made the admixture of fat
emulsion with dextrose and amino acids possible (3-in-1 concept). [19] This
leads to a more uniform administration of a balanced solution containing
the three macronutrients plus micronutrients over a 24-hour period.

Enteral nutrition
Enteral nutrition is the mainstay of treatment for patients with ECFs. In
fistulas of the distal ileum, colon, or duodenum, enteral nutrition should be
considered and can be administered via various routes. Conventionally,
when a gastroduodenal anastomosis or closure is needed in adverse
conditions, a concomitant feeding jejunostomy is performed, so that access
is available for enteral nutritional support in case of an anastomotic leak.

The other routes of administration can be via nasogastric/jejunal tubes or a

gastrostomy. High rates of feeding should be avoided to prevent
hyperosmolar diarrhea. Elemental diets, that is, nonresidue balanced diets
with protein components reduced to their basic elements, are preferred.
When a tube enterostomy is performed, proper fixation is necessary to
prevent complications, such as dislodgement of the tube or antegrade
migration in the gastrointestinal (GI) tract. [20]

Fistuloclysis
Enteral nutrition can also be administered in patients with high-output
proximal jejunocutaneous or ileocutaneous fistulas with good
mucocutaneous continuity. Feeding can be administered through a feeding
tube inserted in the distal limb of the ECF. Teubner et al and Ham et al
have reported good results with this method in select patients to improve
the nutrition of the patient, which is helpful for subsequent fistula closure
and promotes healing of the fistula. [21, 22, 23] An interprofessional approach is
needed. [24]

Skin management
Irrgang et al developed a fistula assessment guide that has aided skin
management related to ECFs [25] This guide is based on the following
characteristics:
Origin of fistula
Nature of effluent
Condition of skin
Location of fistula opening
For a high-output fistula, a pouch system is preferable to a conventional
skin dressing. For a low-output fistula, a skin barrier with a dressing or
pouch is advocated.
The degree of skin irritation present (from erythema to maceration to skin
loss) guides the type of skin-protecting agents that should be applied and
the type of pouch system that should be used. In addition, an important
consideration is whether the opening is flush with the skin, retracted and
deep, close to bony prominences, or in an open wound.

Pouches used for skin care

When the fistula output is high, it is desirable to use a pouch for collecting
the enteric effluents. Ostomy pouches in one- or two-piece designs with
either a drainable clip or a urostomy-type closure can be cut and fit to
perifistular skin. If the area of the fistula is on an irregular body contour (eg,
close to bony prominences), then a one-piece pouch is more suitable
because it can adhere better.

A transparent pouch is preferred to an opaque pouch, for visualization of

the fistula. A pouch with a skin-barrier backing is more durable than one
with an adhesive backing. Wound manager bags (see the image below) are
preferable in that they are specifically designed to help make wound care
easier with good skin protection and access to the wound for its care.

Wound manager.

Skin barriers
Powder, paste, wafers, spray, and creams are used as skin barriers for the
protection of skin from the enteric effluents.
Pectin-based wafers that melt and seal with the skin provide a good barrier
and offer protection for a variable period before the skin breaks down and
ulcerates. In low-output fistulas, absorbent dressings can be put on top of
the skin-barrier wafer to absorb any effluent overflow. The skin wafer
protects the adjoining skin from erythema and maceration.
Pectin- or karaya-based powders and paste are used. Powders are
preferred over a paste in wet, weepy, perifistular skin when severe skin
maceration is present. A generous amount of powder should be used and
continuously added for good results. In patients with weepy skin and a
high-output fistula, management becomes difficult.
A spray provides a protective film and is helpful for pouching, but it might
not be beneficial if used alone.

Zinc creams (see the images below) are used to waterproof and protect the
skin. Again, a generous amount with continuous replacement is necessary
because the cream is washed away with discharging enteric effluents.

Zinc oxide cream for skin protection.

Zinc oxide cream barrier around enterocutaneous fistula, with the fistula
opening seen.

Control of fistula drainage

The fistula tract is intubated with a drain (see the image below). Volume
depletion from a proximal high-output fistula can be controlled with the use
of the long-acting somatostatin analogue octreotide, which acts by
inhibiting GI hormones. The administration of octreotide reportedly
diminishes fistula output, but whether it shortens the time required for
fistula closure remains to be determined. [26]
Intubation of fistulous tract with drain.

Draus et al recommended a 3-day trial of octreotide, maintaining that if the

fistula output is reduced during this time, then administration of the drug
should be continued. [27] (Octreotide use is associated with an increased
incidence of cholelithiasis. [10] ) Two meta-analyses showed that
somatostatin and its analogues decreased the time for fistula closure and
increased the closure rate. [28, 29]However, there was no significant change in
the mortality with the use of somatostatin or its analogues.

Hyon et al reported on a vacuum-sealing method to reduce output, in which

a semipermeable barrier was created over the fistula by vacuum packing a
synthetic, hydrophobic polymer covered with a self-adherent surgical sheet.
To set up the system, the investigators built a vacuum chamber equipped
with precision instruments; the chamber supplied subatmospheric
pressures of 350-450 mm Hg. The pressure reduced the daily fistula output
from 800 mL to about 10 mL, thus restoring bowel transit and physiology. [30]

Draus et al reported that the use of a vacuum-assisted closure (VAC)

system for wounds, which consisted of an evacuation tube embedded in a
polyurethane foam dressing, helped improve the condition of the wound,
prevented skin excoriation, and promoted wound contracture and
healing. [27, 31]

Electrical nerve stimulation

Electrical nerve stimulation (ENS) increases blood flow in ischemic tissues
and encourages healing. Berna et al reported the successful use of ENS in
two patients with a low-output ECF. In the study, the direction and depth of
the fistula tract were ultrasonographically determined. A sterile compress
impregnated with saline solution was then introduced through the fistula.
The positive electrode was positioned on the compress, and the negative
electrode was positioned over the fistula orifice. [32]

The treatment was given once daily for 1 hour, with one patient requiring 10
treatment sessions to heal and the second patient requiring 20 sessions.
ENS was well tolerated by both patients, and no complications were noted.
No recurrence of the fistula developed over a 3-year follow-up period.
Surgical Therapy
Indications for surgery
Patients who an ECF with adverse factors may require earlier surgical
intervention. These adverse factors include the following:
Lateral duodenal or ligament of Treitz fistula
Ileal fistula
High-output fistula
Fistula associated with diseased bowel, distal obstruction, or
eversion of mucosa (see the image below)

Eversion of mucosa in an enterocutaneous fistula, an unfavorable condition

for spontaneous closure.

Enteroatmospheric fistula (EAF), a special subset of ECF, is defined as a

communication between the GI tract and the atmosphere. [33] It can occur as
a complication of "damage control" laparotomy (DCL) and results in
significant morbidity and mortality. The etiology is complex and ranges from
persistent abdominal infection, anastomotic dehiscence, and adhesions of
the bowel to fascia with a laparostoma.

Because EAFs almost never close spontaneously, definitive repair usually

requires major surgical intervention. Complex abdominal-wall
reconstruction immediately after fistula resection is necessary for all EAFs
once the infection has subsided, which may be 6-12 months after the
original insult. [34] A fistula patch technique has also been reported for
protecting open abdominal wounds from being contaminated by intestinal
fistulae drainage, while and simultaneously applying enteral nutrition. [35]
Because the possibility of spontaneous closure is reduced in patients with
adverse factors, surgical intervention should be undertaken after a 4- to 6-
week trial of conservative therapy, if no signs of spontaneous closure exist.
Surgical procedures in patients with adverse factors can include draining
an abscess, creating stomas by exteriorizing the bowel, or creating
controlled fistulas. When feasible, resection of the fistula with restoration of
GI continuity is performed.

In patients with no associated adverse factors, the author usually waits for
about 3-4 months before planning surgical therapy for an ECF.
Surgical therapy [36, 37] should be undertaken in patients with conventional
fistulas without any adverse factors if the patient is stable, free from all
sources of sepsis, and can withstand the resectional procedure needed for
fistula closure. [10] It is also important that it be technically feasible to perform
the procedure without posing a very high risk of injury to the bowel or other
important structures. Patients with an almost completely healed wound with
a fistulous opening (shown below) have a good chance of responding to
surgical therapy.

Almost healed wound around an enterocutaneous fistula.

Fistula tract being excised.

Operative details
In addition to ensuring that patients are stable and free from sources of
sepsis before surgical correction of an ECF is undertaken, antibiotic
prophylaxis should be performed and parenteral nutritional
supplementation provided as necessary during the preoperative and the
perioperative periods to achieve good results. Enteral feeding should be
decreased to allow luminal antibiotic preparation. Antibiotic therapy should
be administered after the culture sensitivity of earlier-grown organisms has
been checked. [10]

Incision
When performing surgery for an ECF, the author makes a point of always
entering the abdomen through a fresh incision, given that there is a
possibility of the gut being adherent to the site of the incision of the index
operation. If the native incision follows a supraumbilical midline route, then
the author takes an infraumbilical midline route and then extends it to the
operative site.

If it is in the middle portion of the midline, then the author makes either an
incision in the midline superior or inferior to the native incision or a
transverse incision to approach the abdomen. The author always enters the
peritoneal cavity in a relatively virgin area to lessen the chance of an
inadvertent enterotomy.
Excision and restoration of bowel continuity
Once an assessment is made in the peritoneal cavity, then the entire bowel
from the ligament of Treitz to the rectum is made free of all adhesions.
Once this is achieved, the fistulous site is dissected free from the
surrounding structures, and a complete excision is done. The author
prefers to restore bowel continuity by using a two-layer anastomosis,
employing interrupted nonabsorbable suture of healthy and well-
vascularized bowel. The author uses it for small-bowel, as well as large-
bowel, anastomosis.

An inner layer consisting of continuous absorbable suture and an outer

layer consisting of interrupted nonabsorbable sutures can also be used to
restore bowel continuity. Other alternatives include the use of staplers,
especially in low colorectal anastomoses.

Treatment of abscess or diseased bowel

If an abscess or diseased bowel segments are seen, then drainage of the
abscess or resection of the diseased bowel is performed. [9] If the patient is
too sick to tolerate a resectional procedure, then exteriorization of the
bowel via ileostomy or colostomy is carried out.

Roux-en-Y drainages or a serosal patch can sometimes be used,

especially for a lateral duodenal fistula following a leak after simple closure
of a perforated duodenal ulcer. [10] However, the results of these procedures
are not very encouraging. Converting a lateral duodenal fistula into an end
fistula with a tube duodenostomy is a good option but may not be possible
in most patients.

If anastomosis is performed close to a duodenojejunal flexure, then

adequate decompression by gastrostomy and feeding jejunostomy are
carried out. The latter is also performed when proximal fistula repair is
undertaken (eg, lateral duodenal fistula).

Myocutaneous or fasciocutaneous flap

De Weerd et al described the use of a sandwich-design myocutaneous flap
cover to close a high-output ECF. [38] In the initial phase of treatment, the
authors used a VAC system for wound care to promote the development of
granulation tissue around the fistulous opening. The fistula was then closed
with serratus muscle from a composite free latissimus dorsiserratus flap.

The large abdominal wall defect was closed with the musculocutaneous
latissimus dorsi flap taken from the composite flap. The placement of a
VAC system between the serratus and the latissimus dorsi helped to fix the
serratus to the fistula.

Successful direct repair of an ECF using a surrounding fasciocutaneous

flap has also been reported. [39]

Postoperative care
In the postoperative phase of surgical therapy for an ECF, good nutritional
status is essential, because healing of the tissue and anastomosis depends
on it.

Antibiotic coverage is needed if the operation is performed in the presence

of sepsis. Any flare-up of sepsis increases the possibility of breakdown of
the anastomosis and of the abdominal wall closure (leading to dehiscence).
However, unnecessary use of antibiotics can lead to resistance and should
therefore be avoided.

Fluid and electrolyte balance with appropriate correction is also important,

especially in patients with adverse factors (eg, high-output fistula).
Patients who develop spontaneous fistula due to disease need appropriate
therapy (eg, infliximab for Crohn disease or antituberculous therapy for
tuberculosis) during follow-up to prevent disease recurrence or recurrence
of the ECF. [40] In patients with a malignancy-related ECF, appropriate
chemotherapy and radiation, if required, are administered to control the
primary disease.

After healing of a conventional fistula by spontaneous closure, patients

should be informed that because healing occurs with secondary intention,
there is a possibility of development of an incisional hernia as a long-term
complication of ECF.

Other Interventions
Use of fibrin glue and plugs
In a study of 10 patients with low-output (n=7) or high-output (n=3) ECFs that had
failed to close after conservative therapy, Rabago et al observed that fibrin glue
completely sealed the majority of ECFs. [41] Once a fistula had been endoscopically
located, 2-4 mL of reconstituted fibrin glue (Tissucol 2.0 at 37C) was injected
through a catheter. The patients required a mean 2.5 treatment sessions (range, 1-5
sessions), and the mean healing time was 16 days (range, 5-40 days). After
treatment, 87.5% of the low-output fistulas and 55% of the high-output fistulas sealed
completely. No complications occurred.
Truong et al described the use of a Vicryl plug in combination with fibrin glue in the
treatment of ECFs. [42] After the site of an ECF or anastomotic leak was
endoscopically sealed with the plug and glue, seven of the study's nine patients
healed completely.

In another study, however, when fibrin glue was introduced directly into an ECF
through the fistula opening in the skin, the results were not encouraging, with the
fistula healing in only one out of eight patients. [27]

Autologous platelet-rich fibrin glue also has been reported to be safe and effective in
the treatment of low-output ECFs by reducing the closure time and promoting
closure. [43]

Good results with endoscopic therapy suggest that this technique, when possible,
can be used when other conservative methods fail.
Successful closure of a duodenocutaneous fistula has been reported with the use of
the Biodesign enterocutaneous fistula plug (Cook Medical, Bloomington, IN),which is
derived from a biologic plug used in fistula-in-ano tracts. The plug is introduced into
the fistulous tract percutaneously. [44]

Gelfoam embolization
Lisle et al described successful treatment of three cases of ECF with embolization of
Gelfoam at the enteric opening of the fistula. [45] In this technique, the ECF was
assessed by means of computed tomography (CT) and fistulography to rule out any
intra-abdominal abscess, distal bowel obstruction, active bowel inflammation, or
foreign body that would prevent the fistula from healing. Fistulography also provided
information about the fistulous tract and the site of communication with the bowel.
A 5-French introducer sheath was passed along a guide wire into the tract under
fluoroscopy and then removed, after which Gelfoam strips or pledgets soaked in
contrast material were introduced into the tract through the sheath and pushed down
to plug the enteric opening of the ECF. All of the patients healed completely, with no
recurrence of ECF over a 2- to 3-year follow-up period. [45]