Dr.

Shyam Sunder Mahansaria

Department of surgery
P.B.M. & AG Hospitals,
BIKANER
• A Fistula is defined as an
abnormal communication
between two epithelized
surfaces.
HISTORY
• The earliest record of an
enterocutaneous Fistula appears in the
old Testament Book of judges Written
BY Samuel Between 1043 BC and 1004
BC.

• Celsus described the first reported

attempt of surgical repair of a
colocutaneous fistula.

• In the 18th century John Hunter

advocated a conservative approach to
fistulas after he noted that fistulas
•In early 1900’s enterostomy was made
in healthy bowel proximally in obstructed
bowel

•This often would close spontaneously on

resolution of obstruction

•This lead to an unrealistic optimistic

approach towards all enterocutaneous
fistulas
CLASSIFICATION
Anatomical classification:

• (1) a. Internal: Two organ of same or different

system
• Enteroenteral, enterovesical,enterocolic, colovesical
b. External: Gut to body surface.
• Gastrocutaneous,duodenocutaneous, enterocutaneous.

• (2) a. Simple or direct.

b. Complicated-
• 1.Having multiple tracts
• 2. Connection with more than one viscus
Physiological
classification
• High output- output more than
500 ml/ day

• Moderate output- output 200-500

ml/day

• Low output- output less than

200ml/day
Etiologic Classification

1. Spontaneous(15-25%)-

• Radiation
• Duodenal ulcer
perforation
• Inflammatory
bowel disease
• Malignancies
• Diverticular
disease • Intestinal
tuberculosis
• Appendicitis
• Actinomycosis.
2. Post-operative (75-85%)

• Operations for • Adhesiolysis

perforations
• Blunt and
• Acute intestinal penetrating
obstruction abdominal
trauma.
• Intestinal
malignancies
3. Congenital
– Tracheo- esophageal
– Rectovaginal
– Umbilical fistula.

4. Traumatic
– Blunt and penetrating trauma of
abdomen, chest and perineum
ETIOLOGY
• Extension of bowel abnormalities to
surrounding structures.

• Extension of adjacent disease to

normal bowel

• Inadvertent or unrecognized trauma

to the bowel.

• Anastomotic disruption.
• Small intestinal fistula are most
common type of gastrointestinal
fistulas encountered.

• Most series report 70%-90-% of

small intestinal fistulas occurs
after an operative procedure.
• The operations commonly
causing small intestinal fistulas
– Operation for malignancy,
– Inflammatory bowel disease
– Adhesiolysis.

• The different complications

leading to fistula formation
include
– Disruption of an anastomosis,
– Unrecognized injury to the bowel at
the time of lysis of adhesions
– Inadvertent suture of the bowel at
the time of abdominal closures.
• Fistula may result from
anastomosis done in unprepared
bowel or in a bowel with less
than adequate blood supply.

• Anastomosis may also be

jeopardized by hypotension
owing to inadequate
resuscitation or by excess
tension placed on the suture
lines

• Poor nutritional status

Pathophysiology

• Fluid and electrolyte imbalance.

• Malnutrition

• Sepsis

• Skin irritation and excoriation

 Natural history
Likely to Unlikely to close
close
Anatomic Esophageal, Gastric,ileal
location Duodenal
stump, jejunal

Nutritional Well nourished malnourished

status
Sepsis absent Present

Etiology Appendicitis, Crohn’s, cancer,

diverticulitis foreign body, radiation
post operative
 Likely to close Unlikely to
close
Condition of Healthy Total
bowel adjacent disruption,absc
tissue, small ess,total
leak,quiescenc obstruction,
e disease, no active disease.
abscess.
miscellaneous Tract >2 cm epithelization
Defect < 1cm2

transferrin >200mg/dl <200mg/dl

Avg. Time to closure
• Varies with anatomical location;

1. Esophageal- 15-25 days

2. Duodenal- 30-40 days

3. Colonic - 30- 40 days

4. Small Bowel- 40-60 days

 Clinical presentation

• Recognized 5th-10th • Abdominal

days post tenderness
operatively.
• Drainage of enteric
• Fever material through
the abdominal
wound or through
• Leucocytosis or existing drains.

• Prolonged ileus
• Localized • May be
swelling of the – Hypotension
abdominal wall. – dehydration

• Point • Decreased
peripheral vascular
tenderness. resistance
Investigations
Objectives of investigation plan: To
define-

• Precise anatomical location

• Is the bowel in continuity or is disrupted

• Abscess cavity

• Condition of adjacent bowel

• Is there a distal obstruction

Radiological contrast
studies
• Fistulography : A water soluble
contrast material is injected into the fistula
tract through a 5 or 8 size pediatric tube
and it is observed fluoroscopically or
through static radiological films.

• Barium transit studies : Barium

meal follow through & barium enemas.
FISTULOGRAM
Entero-colic fistula
 CT- Scan

Gastro cutaneous
fistula

Entero colic fistula Sigmoid

Endoscopic studies
• Gastro duodenoscopy : Demonstrates
both underlying disease and presence of
fistula.

• Colonoscopy : Fistula is usually not

visible but presence of disease and its
nature by biopsy can be demonstrated.

• CT scan : To evaluate the abdomen for

presence of abscess in an aseptic patient.
Colonoscopy
Management phases for
gastro intestinal fistulas
1. Stabilization Within 24-48 hrs.
2. Investigation After 7-10 days
3. Decision 7-10 days to 4-6
wks.
4. Definitive therapyWhen spontaneous
closure is unlikely
or after 4-6 wks.
5. Healing 5-10 days after
closure
Stabilization
• Rehydration • Osmotic pressure
restoration

• Correction of • Nutrition support

anaemia
• Control of fistula
• Drainage of drainage
sepsis
• Institution of local
skin care
• Electrolyte
repletion
Stabilization
• Resuscitation :

– Restoration of normal circulating blood

volume.

– Correction of electrolyte & acid base

imbalance.

– Plasma oncotic pressure should be

restored by exogenous albumin
administration.
• Nasogastric tubes : should be
removed if

– There is a no obstruction.

– Fistula is a low in intestinal tract.

Skin care management:
• Problems in skin around the fistula:
T – Wetness
– Burning pain
– Discomfort from skin edema

• Goals of skin care:

– Containing the effluent
– Patient independence and mobility
Techniques of skin care:

• Wound pouch dressings

– One/two piece design

– Clip closure or Urostomy type

– May be attached to a bed side bag or

suction catheter
Wound pouch dressing
• Skin Barriers:

– Solid wafers (pectin based)

– Powders (Pectin / Karaya based)

– Paste

– Spray and wipes

– Ointments and creams (zinc/petroleum

based)
• Sump Drainage:

– For fistulae draining with open abdominal

wound.

– Large bore drains or sumps

– High pressure suction (better results).

• Nutritional management:
– Plays Central role in management

– Adequate circulation and tissue

oxygenation must for optimal utilization.

– May be:
• Enteral
• Parenteral
Central line
 Recommended Nutritional
Support
Low Output High Output
Low Output High Output
Form Enteral Usually
Parenteral
Protein 1- 1.5-2.5g/kg/day
1.5g/kg/day
Calories BEE BEE x 1.5
Lipids Enteral (20- Parenteral (20-
30%) 30%)
Vitamins RDA 2RDA
Vit C – 2RDA Vit C – 5 –10RDA
Minerals Usually not Close watch
needed
Vitamin K 10mg/wk 10mg/wk
•Chapman and colleagues demonstrated
that patients receiving optimal
nutritional support (3000 calories per
day) had a mortality rate of 12% as
compared to 55% mortality among
patients receiving a sub optimal
nutritional regimen.

•Robauk and Nichdoff reported closure

of 73% enteric fistulae in patients with
adequate caloric supplementation but
only 19% healed when nutritional
support was inadequate.
• Patients should receive 3000 to
5000 non proteins calories per
day

• Amino acid 100 to 200 gm.

• TPN should initiate early in the

course of treatment while
adynamic ileus persist and
before the fistula tract is well
established.
• Patients daily protein
requirement is 1.2 to 2.0 gm
kg/day.

• Fluid requirement is
30ml/kg/day.

• Electrolyte requirement/day
• Na-70-100 meq/day
• K- 70-100 meq/day
• Mg- 15-20 meq/day
Total Parenteral
Nutrition
• Conc. dextrose: 500ml of 20% Dex.
(=400 kcal)

• Fat: 500 ml 10% fat emulsion (=450

kcal)

• Crystalline Amino Acids: 500 ml 10%

Amino acids (=8.4 g Nitrogen)

• Daily Vitamin Supplementation ( Vit.

K 10 mg weekly)
 Administration:

• Central Line:
– Subclavian Vein
– Internal Jugular Vein
• Peripheral line
Rate of Infusion:
•Starting: 50 – 100 ml/hr
•Gradually increased by 25 – 50 ml/hr every second d
Patient Monitoring:
• Clinically: (daily)
– Sense of well being
– Graded activity
– Vitals
– Weight / input-output

• Laboratory profile: (daily until patient

stable then twice weekly)
– Serum Electrolytes
– RFT
– LFT/ coagulation profile
– Lipid profile
Complications of TPN

• Mechanical
– Catheter tip malposition (6%)
– Arterial laceration (1.4%)
– Hydro-pneumo-haemo thorax (1.1%)
– Subclavian/Superior vena cava
thrombosis (0.3%)
– Thrombophlebitis (0.1%)
– Catheter embolism (0.1%)

• Septic
– Catheter related sepsis (7.4%)
• Metabolic
– Acute
• Hyperglycemia/hypoglycemia
• Electrolyte abnormalities
• Fluid overload
• Hyperlipidemia

– Chronic
• Metabolic bone disease
• Alterations in bile composition
Enteral Nutrition
• Benefits:
– Trophic effect on bowel
– Stimulates hepatic protein synthesis

• 4 ft of functional bowel required (proximal

or distal)

• Lipid based formula absorbed more

efficiently
Control of Sepsis
• Management of local wound infections

• Drainage if Intra-abdominal collections

(percutaneous)

• Laparotomy may be required for:

– Extensive cellulitis/necrotising fascitis
– Incomplete percutaneous drainage of
collections
– Disruption of anastomosis
 Antibiotics
• To be withheld unless the patient is
septic
Measures to decrease secretions
•Shortens time to closure ( no role in
spontaneous closure)

•H2 antagonists/ Proton pump inhibitors

•Somatostatin / octreotide

•Infliximab (monoclonal antibody) (in Crohn’s disese

•Oral tacrolimus (in Crohn’s disese)

Emotional support

• External drainage of enteric contents

can be demoralizing

• Psychiatric evaluation and use of

antidepressant drugs

• Reassurance
DECISION:
• No signs of imminent closure after 4- 5
weeks then patient should be prepared
for surgery.

• Unfavorable characteristics since

beginning

• Uncontrolled sepsis urgent drainage of

sepsis.

• If patient general condition very poor

then only abscess drainage should be
 Treatment
• Patient should be amply resuscitated

• Drainage cultured

• Intraluminal and intravenous antibiotic

• Discontinuation enteral nutrition 1-2 day

prior while continuing parenteral nutrition

• Operative approach preferably through a new

incision
• Protective diverting stoma proximal
to anastomosis

• Secure closure of abdominal wall over

the fistula

• Post-op nasogastric decompression

• Feeding jejunostomy ( for proximal

fistulae)

• Post op continuation of nutrition with

gradual shift from parenteral to
Operative procedure of fistula
Operated case of enterocutaneous fistula
Late Complications:
• Short bowel syndrome (after multiple
fistula repair)

• Stricture and partial obstruction at

fistula site

• Esophageal stricture after prolonged

nasogastric sump decompression
Prevention of Fistula:
• Prophylactic Antibiotics and Bowel
Preparation:

– Polythelene glycol administrtion

decreases bacterial load from 10 12-15
to 10
4-5

– Enteral non-absorbable antibiotics reduce

it to 10 2-3

– Prophylactic I/v antibiotic at time of

induction of anaesthesia with repetition
of dose in case of prolonged surgery
• Appropriate hydration to prevent Hypotension
and compromised circulation

• Anastomosis in healthy bowel with adequate

blood supply; without tension

• Meticulous and precise hemostasis

• Selection of proper needle size,suture

• Omental covering if possible

• Dead space obliterated with live tissue and

properly drained
Decision making
• Adequate duodenal mobilization in case of
gastroduodenal anastomosis

• Tube duodenostomy to prevent duodenal

stump blow out

• In multiple typhoid perforations resection of

diseased segment and end to end
anastomosis is better than primary repair

• Small bowel defects greater than half the

circumference should be treated by
resection and anastomosis

• Proximal diverting stoma should be

• Stomas with mucus fistula or exteriorization
to be considered in medically unfit or aged
patients

• Proper proximal decompression while doing

anastomosis.
 HEALING
• In the postoperative period, it is necessary to
ensure that the patient continues to receive
full nutritional support.

• Adequate protein and calories must be

provided to maximize healing and minimize
complications.

• Although enteral nutrition may be attempted

early in the post-operative course, it is nearly
impossible to meet the patient's entire
nutritional demand by this route.

• Postoperative care will most likely include

parenteral and enteral supplementation in an
• After fistula closure, whether by
spontaneous or surgical means, the
patient will need to resume oral
intake.

• This may be especially difficult in an

individual who has had little or no
oral intake for 4 to 6 weeks or more,
and enlisting the assistance of a
dietician and the patient's family is
often helpful.