Question 15

Last updated 15/10/2021 - 05:24
 Topic: Gastroenterology and Hepatology
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Discuss the management of Enterocutaneous fistulae (ECF) in the critically ill patient.

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College answer

Not available.

Discussion

An approach directly relevant to enterocutaneous fistulae is described by Cohen et al (2016),  Lundy & Fischer (2010) and Evenson (2016).

  • Stabilisation where you resuscitate the septic shock
    • Fluid resuscitation should be conservative to prevent intestinal oedema
    • Vasopressor support should be careful to prevent intestinal ischaemia
  • Diagnosis where you confirm the location and extent of the fistula, by:
    • Methylene blue dyed feeds
    • Contrast "fistulogram" using water-soluble contrast and plain films or fluoroscopy (contrast both rectal and oral)
    • Contrast CT, which has largely surpassed the fistulogram
  • Evaluation for spontaneous resolution where you decide whether this needs to go to theatre urgently, or whether you can sit on it for a month. Apart from imaging and historical features, this includes
    • Nutritional assessment, incl. prealbumin, transferrin and clinical assessment
    • Attempted early surgery if you think you can't wait for it to get better on its own (and if the patient is likely to survive)
  • Trial of non-operative management if the impression is that surgery can be delayed
  • Management of infectious complications during conservative management:
    • Intra-abdominal faecal contamination initially - managed with broad-spectrum antibiotics (eg. piperacillin/tazobactam) as well as an antifungal if there are risk factors (malignancy, re-laparotomy, long term antibiotics)
    • Abdominal collections after a prolonged course of systemic antibiotics
  • Management of non-infectious complications during conservative management: 
    • Fluid losses particularly of high-output fistulas: strategies to decrease output include
      • avoidance of vac dressings
      • TPN
      • Octreotide, l​​​​​operamide, opiates
      • Diverting proximal stoma
      • Relief of distal bowel obstruction
    • Malnutrition: TPN and vitamin supplementation
    • Gut atrophy: low volume enteral feeds, or enteral nutrition given via the fistula
    • Electrolyte disturbance resulting from high stoma output (management of this depends mainly on vigilant replacement)
    • Skin excoriation due to spills (management of this requires a dedicated stoma service, or plastic surgical input to deal with tissue loss)
  • Definitive surgical management; or, when it becomes clear that this is not an option,
  • Palliative care

References

Cohen, Wess A., et al. "The complex surgical abdomen: What the nonsurgeon intensivist needs to know." Journal of intensive care medicine 31.4 (2016): 237-242.

Edmunds Jr, L. Henry, G. M. Williams, and Claude E. Welch. "External fistulas arising from the gastro-intestinal tract." Annals of surgery 152.3 (1960): 445.

Lundy, Jonathan B., and Josef E. Fischer. "Historical perspectives in the care of patients with enterocutaneous fistula." Clinics in colon and rectal surgery 23.3 (2010): 133.

Chapman, Richard, Robert Foran, and J. Englebert Dunphy. "Management of intestinal fistulas." The American Journal of Surgery 108.2 (1964): 157-164.

Evenson, Amy R., and Josef E. Fischer. "Current management of enterocutaneous fistula." Journal of gastrointestinal surgery 10.3 (2006): 455-464.

Gribovskaja-Rupp, Irena, and Genevieve B. Melton. "Enterocutaneous fistula: proven strategies and updates." Clinics in colon and rectal surgery 29.2 (2016): 130.

Hutchins, Robert R., et al. "Relaparotomy for suspected intraperitoneal sepsis after abdominal surgery." World journal of surgery 28.2 (2004): 137-141.

Green, Gemma, et al. "Emergency laparotomy in octogenarians: A 5-year study of morbidity and mortality." World journal of gastrointestinal surgery 5.7 (2013): 216.

Solomkin, Joseph S., et al. "Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections." Clinical Infectious Diseases 37.8 (2003): 997-1005.

Montravers, P., et al. "Emergence of antibiotic-resistant bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy." Clinical Infectious Diseases 23.3 (1996): 486-494.

Latifi, R., et al. "Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches." World journal of surgery 36.3 (2012): 516-523.

Galie, Kathryn L., and Charles B. Whitlow. "Postoperative enterocutaneous fistula: when to reoperate and how to succeed." Clinics in colon and rectal surgery 19.4 (2006): 237.

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