Suresh Khanna Natarajan, MD, Darwin P, MD. Stanley Medical College & Hospital
Introductions: In spite of immense recent advancement in post-operative care, enterocutaneous fistulas (ECF) remain one of the fascinating challenges because of their anatomical abnormalities, metabolic derangement and associated extensive sepsis. They also remain to the surgeon the fallibility of surgical technique and of the stress that falls upon both the surgeon and patient when major complications occur.
Method: Prospective analysis of ECF cases over one year was done from diagnosis till their discharge. Details regarding type of surgery performed, category of fistula, their origin and their individualised management policy were noted. Retrospective analysis was made to draw the principles for ECF prevention. Fistulas arising from small bowel and colon were included. Those arising from pharynx, oesophagus, stomach, biliary tract, rectum and anal canal were excluded.
Results: Among 20 ECF patients, 85% were postoperative, 10% traumatic and 5% malignant. Among the postoperative ECF, appendicectomy (29.4%), perforation peritonitis (23.5%) and anastomotic leaks (17.6%) were predominant causes. All of them had Ultrasound while 85% fistulogram and only 45% CT. 45% were small bowel fistula, 40% colonic and 15% duodenal. Malnutrition (30%), sepsis (25%) and dyselectrolytemia (20%) were commonest adverse factors. Only the duodenal fistulas were high output (15%).
All patients were managed initially by conservative through a sequential planning phase for 4-6weeks (compared to Sheldon’s four-phase management). Then surgery (70%, n=14) was done if there is no likelihood of spontaneous closure. Parenteral nutrition (TPN) was used in 10% (n=2) during stabilisation phase and were later switched to enteral nutrition (EN). EN was achieved in others by oral, nasogastric or feeding jejunostomy due to non-availability or cost factors in TPN. We used three-category management for ECF skin problems (compared to Irving-Beadle’s four categories).
Among conservatively managed ECF (30%, n=6), two died (10%) and four (20%) were successful. Among surgical ECF, four (20%) had resection-anastomosis because of bowel defect >1cm and tract <2cm. Remaining ten (50%) had proximal diversion stoma, care of ECF to allow spontaneous closure and stoma closure after three months – of which one died.
Conclusion: Surgery accounts for majority of cause for ECF. Anatomical origin, length of tract, bowel wall defect, others like sepsis, malnutrition, malignancy, serum albumin are factors that influence spontaneous closure. The importance of nutrition cannot be overemphasized. Definitive surgery is required in: no spontaneous closure after 4-6weeks of conservative, complex fistula anatomy, including intra-abdominal abscess, distal bowel obstruction, bowel defect >1cm diameter, fistula tract length <2cm.