Download Enterocutaneous Fistulas - Catalyst

ENTERO-CUTANEOUS FISTULAS- AN EVIDENCE
BASED APPROACH TO MANAGEMENT
PEARL QUARTEY
UNIVERSITY OF WASHINGTON
PGY1
CASE: JJ
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14 yo male

HPI: re-admitted with wound infection, leukocytosis. Found to have enterocutaneous fistula on wound exploration.
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PMH
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
Crohn’s disease due to IL-10 receptor deficiency
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History of stem cell transplant with unmatched donor at age 11
PSH
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Nissen @ 8 months
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History of severe strictures with resultant ileostomy at age 3
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Multiple dilations for perianal strictures
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Few orthopedic surgeries
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Ileostomy take down with sigmoid loop colostomy 7/11/14
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Wound I&D 7/25
BACKGROUND: ECF/EAF
 Typically complex patients with significant morbidity and mortality
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Mortality rates have dropped significantly since 1960s (65% to less than 10%) 2
 Most commonly occur in small bowel – 50%
 70-80% of fistulas will respond to conservative management and close in about 6-8 weeks
 Entero-atmospheric fistulas (EAF): communication between loops of bowel or other hollow viscus and the atmosphere
i.e. open abdomen or chest. Exposed hole in bowel lumen without overlying skin or tissue
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Trauma surgery night mare
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Do not close without surgical intervention, mortality remains high (10-15%)1
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Deep or superficial
 Significant cost to healthcare systems: extended hospital admissions, multiple surgeries, multi-disciplinary teams
 Significant psychosocial costs to patients and families
1.
2.
Dubose JJ, Lundy JB. Enterocutaneous fistulas in the setting of trauma and critical illness. Clinics in Colon and Rectal Surgery 2010;23(3):182–9
Martinez JL, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo F. Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World Journal of Surgery 2008;32(3):436–43.
COMMON CAUSES OF FISTULA FORMATION
 Spontaneous formation (15-25%)
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Malignant disease
 Radiation therapy
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Inflammatory conditions
 Inflammatory bowel disease (20% Crohn’s disease)
 Bowel obstruction or ischemia
 Complicated diverticular disease or appendicitis
 Perforated ulcer disease
 Infectious diseases: tuberculosis & actinomycosis
Lundy JB, Fischer JE (2010) Historical perspectives in the care of patients with enterocutaneous fistula. Clin Colon Rectal Surg 23:133–141
COMMON CAUSES (cont’d)
 Postoperative/iatrogenic (75-85%)
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Oncologic procedures
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Bowel resection
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Colostomy or ileostomy takedown
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Emergent laparotomy/ trauma
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Appendectomy
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Adhesiolysis
Lundy JB, Fischer JE (2010) Historical perspectives in the care of patients with enterocutaneous fistula. Clin Colon Rectal Surg 23:133–141
ILEOSTOMY WITH ASSOCIATED FISTULA
Courtesy of the Enterostomal Nursing Department, Cleveland Clinic, Cleveland, OH
CLASSIFICATION- SEVERAL SYSTEMS
 Physiologic: based on daily output. Debate about potential for spontaneous closure based
on volume of output.
 Low < 200mL/d: colonic, may tolerate PO intake
 Medium 200-500mL/day
 High > 500mL/day
 Anatomic location
 Simple or complex: based on number of fistula tracts
 Internal vs external
 Etiology: e.g. malignant, diverticular etc.
TRADITIONAL APPROACH TO MANAGEMENT

Sepsis control: most significant determinant of outcome
 Identification and treatment of source
 Empiric antibiotics, antifungals,
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Stabilization
 Fluid resuscitation
 Electrolyte abnormalities
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Nutritional support
 Enteral vs. parental feeding
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Effluent management
 PPIs, anti-motility agents, somatostatin analogues
 Wound care
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Definitive repair
 Surgical
 Reconstruction
REQUIRES MULTI-DISCIPLINARY TEAM- CREATION OF CENTERS OF
EXCELLENCE1
 Enterostomal therapists
 Surgeons- general, plastics
 Nurses
 Radiologists
 Nutritionists
 Infectious disease specialists
 Psychiatrists/psychologists
1. Jamie Murphy, Alexander Hotouras, Lena Koers, Chetan Bhan, Michael Glynn, Christopher L. Chan, Establishing a regional enterocutaneous fistula service: The Royal London
hospital experience, International Journal of Surgery, Volume 11, Issue 9, 2013, Pages 952-956,
SEPSIS CONTROL
 Abscess vs peritonitis
 Antibiotics
 CT guided drainage of intra-abdominal abscesses
 IR placement of drains: avoid early surgery
 Exlap for peritonitis
NUTRITION- PREVENTING THE CATABOLIC STATE
 Positive nitrogen balance
 High daily caloric requirements especially protein
 Aggressive fluid & eletrolyte replacement
 Early TPN:
 Early enteral feeding
 Fistuloclysis: enteral feeds through the fistula
 Indicators of worse survival:
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Albumin < 2.5g/dL carries 42% mortality vs albumin > 3.5 0% mortality1
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Pre-albumin
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Transferrin level
1.V.W. Fazio, T. Coutsoftides, E. Steiger. Factors
influencing the outcome of treatment of small bowel cutaneous fistula World J Surg, 7 (1983), pp. 481–488
ENTERAL FEEDING
 Early enteral feeding has become standard of care for critically ill patients
1,2
 No level 1 evidence for its use in ECF patients
 Various studies have reported improved fistula closure outcomes with enteral feeding either PO or via
fistuloclysis. Usually requires 60-70cm of bowel
 Common barriers:
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Intestinal discontinuity
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Inadequate bowel length
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Inability to maintain adequate enteral feeding access
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Dramatic increases in fistula output leading to further skin breakdown
1. Yuan Y, Ren J, Gu G, Chen J, Li J. Early enteral nutrition improves outcomes of open abdomen in gastrointestinal fistula patients complicated with severe sepsis. Nutrition in Clinical Practice
011;26(6):688–94
2. McClave SA, Martindale RG, Vanek VW (2009) Guidelines for the provision of nutrition support therapy in the adult critically ill patient: Society for Critical Care Medicine (SCCM) and American
Society for Parenteral and Enteral Nutrition (A.S.P.E.N). JPEN J Parenter Enteral Nutr 33:277–316
FISTULOCLYSIS- ENTERAL FEEDING THROUGH FISTULA
 No randomized trials
 Anecdoctal and isolated case reports
 Careful patient selection
An 18 French MIC transgastric jejunal feeding tube (Kimberly-Clark Health Care) inserted in the lumen of the distal fistula.
Wright S J et al. JPEN J Parenter Enteral Nutr 2012;37:550-553
Copyright © by The American Society for Parenteral and Enteral Nutrition
Stoma appliance linked to the universal access port.
Wright S J et al. JPEN J Parenter Enteral Nutr 2012;37:550-553
Copyright © by The American Society for Parenteral and Enteral Nutrition
EFFLUENT MANAGEMENT
 Proton pump inhibitors
 Anti-motility agents- loperamide
 Somatostatin and analogues: (octreotide & lanreotide) . Very Few RCTs- 8. Meta-analysis and systematic
reviews1,2,3
1.
2.
3.
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Decreased time to closure
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No difference in mortality
Rahbour G, Siddiqui MR, Ullah MR, Gabe SM, Warusavitarne J, Vaizey CJ. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Annals of
Surgery 2012;256(6):946–54.
Stevens P, Foulkes R, Hartford-Beynon J, Delicata RJ. Systematic review and meta-analysis of the role of somatostatin analogues in the treatment of non-pancreatic enterocutaneous fistulae. European Journal of
Gastroenterology and Hepatology 2011;23(10):912–22
Koti RS, Gurusamy KS, Fusai G, Davidson BR. Metaanalysis of randomized controlled trials on the effectiveness of somatostatin analogues for pancreatic surgery: a Cochrane Review. HPB (Oxford) 2010;12:155–65
WOUND CARE
 Large ostomy appliances used historically
 Skin graft: reduces fluid losses and bacterial colonization
 VAC system3: reduces wound edema, removes purulent material, encourages angiogenesis
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Significant cost however less than prolonged hospital stay. Managed well in the community
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2Concern
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1.
2.
3.
1Small
about contact with bowel and formation of more fistulas when used with wounds that contain fistulas
study showed shorter closure times in patients with no visible mucosa
L.A. Gunn, K.E. Follmar, M.S. Wong, S.C. Lettieri, L.S. Levin, D. Erdmann Management of enterocutaneous fistulas using negative-pressure dressings Ann Plast Surg, 57 (2006), pp. 621–625.2.
2. J.E. Fischer. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula
development Am J Surg, 196 (2008), pp. 1–2
J. Goverman, J.A. Yelon, J.J. Platz, R.C. Singson, M. Turcinovic. The “Fistula VAC,” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma,
60 (2006), pp. 428–431 discussion 431
DEFINITIVE REPAIR
 Consensus is to delay surgery for a minimum of 6 months after the initial surgery 1. Reasons are:
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Clear infection
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Improve nutritional status
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Well controlled wound
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Intra-abdominal adhesions can lead to difficult dissection and multiple enterotomies with ensuing fistulas
 Reasons for earlier surgical intervention:
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Source control
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Proximal stoma creation
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Intolerable wound management
1. Martinez
JL, Luque-de-León E, Ballinas-Oseguera G, Mendez JD, Juárez-Oropeza MA, Román-Ramos R. Factors predictive of recurrence and mortality after surgical repair of enterocutaneous fistula. Journal of
Gastrointestal Surgery 2012;16(1):156–63
RECONSTRUCTION
 Tissue flaps
 Muscle flaps
 Mesh and other synthetics
 Porcine materials
OTHER POINTS TO CONSIDER

1Laparoscopic
surgery: requires high level of expertise in laparoscopic colorectal surgery, high risk of missed
enterotomies
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2Percutanous
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3Metal
gelfoam embolization: CT scan, fistulogram, embolization under fluoroscopic guidance
clips: idea derived from using clips for closing perforations during colonoscopies. Limited use in very few
patients
 Transplant for intestinal failure
 Anti-TNF therapy in Crohn’s patients
1.
2.
3.
N. Pokala, C.P. Delaney, K.M. Brady, A.J. Senagore. Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases Surg Endosc, 19 (2005), pp. 222–225
D.A. Lisle, J.C. Hunter, C.W. Pollard, R.C. Borrowdale. Percutaneous gelfoam embolization of chronic enterocutaneous fistulas: report of three cases. Dis Colon Rectum, 50 (2007), pp. 251–256
R. Kumar, S. Naik, N. Tiwari, S. Sharma, S. Varsheney, H.S. Pruthi Endoscopic closure of fecal colo-cutaneous fistula by using metal clips Surg Laparosc Endosc Percutan Tech, 17 (2007), pp. 447–451
STOMA THROUGH MIDLINE INCISION DUE TO TENSION
Courtesy of the Enterostomal Nursing Department, Cleveland Clinic, Cleveland, OH
SUMMARY
 75% of fistulas are iatrogenic. Prevention is key to managing fistulas
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Patient selection, basic surgical practices key to preventing fistula formation
 Use of minimally invasive procedures in high risk patients can help with reducing the risk of fistulization
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Interventional radiology embolizing mesenteric arteries in GI bleed, placing drains in intra-abdominal abscesses
 Key is to wait for several months before re-operation if possible.
FUTURE DIRECTIONS
 Enteral vs parental feeding?
 RCT for somatostatin analogues