How Fast Should A Gastric Fistula Be Repaired

Clin Colon Rectal Surg. 2022 Jun; 29(two): 130–137.

Enterocutaneous Fistula: Proven Strategies and Updates

Irena Gribovskaja-Rupp

¹Department of Surgery, University of Iowa, Iowa Urban center, Iowa

Genevieve B. Melton

^twoDivision of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota

Abstruse

Direction of enterocutaneous fistula represents one of the virtually protracted and difficult problems in colorectal surgery with substantial morbidity and bloodshed rates. This article summarizes the current nomenclature systems and successful direction protocols, provides an in-depth review of fluid resuscitation, sepsis control, diet management, medication direction of output quantity, wound intendance, nonoperative intervention measures, operative timeline, and considerations, and discusses special considerations such as inflammatory bowel disease and enteroatmospheric fistula.

Keywords: enterocutaneous fistula, enteroatmospheric fistula, spontaneous closure, mortality, timeline

An enterocutaneous fistula (ECF) is an aberrant connection between the intra-intestinal gastrointestinal (GI) tract and peel/wound. Because of differences in management and significant preponderance of small-scale intestinal and colonic fistulae, fistulae originating in the rectum, upper GI tract, or pancreas will not exist discussed in this article.

There are several ways in which ECF has been classified, including by output, etiology, and source.¹ ⁱⁱ ³ Well-nigh oft, a high-output ECF is characterized as 1 with >500 mL/24 hours, low output <200 mL/24 hours, and a moderate output fistula between 200 and 500 mL/24 hours. While the great majority of ECFs are iatrogenic (75–85%), betwixt fifteen and 25% occur spontaneously.³ Common causes of iatrogenic ECF are trauma; operations for malignancy, associated with extensive adhesiolysis, or in the setting of inflammatory bowel illness (IBD); and trauma.ⁱ With respect to postoperative minor bowel fistulae, about half are from an anastomotic leak, with the other half occurring from inadvertent injury to the small bowel during dissection.³ Spontaneous fistulae occur from IBD (most common), malignancy, appendicitis, diverticulitis, radiation, tuberculosis/actinomycosis, and ischemia.³ Organ of origin is some other classification used for ECF and is useful too in the consideration of management options: blazon I (abdominal, esophageal, gastroduodenal), type 2 (small-scale bowel), type III (big bowel), and type IV (enteroatmospheric, regardless of origin).²

Closure rates without operative intervention in the era of avant-garde wound care and parenteral nutrition (PN) vary considerably in reports 19 to 92%,^four ⁵ with nearly studies demonstrating closure rates in the 20 to xxx% range.⁵ ⁶ ⁷ ⁸ ⁹ ¹⁰ ^eleven With historical wound care measures, ninety% of spontaneous closure occurred in the kickoff calendar month after sepsis resolution, with an additional 10% closing in the 2d month, and none closing spontaneously after ii months.¹⁰ With vacuum assisted closure (VAC) and other negative pressure wound therapies (NPWT) therapy, there are instance reports of fistulae closure well into the second and third month.¹² Tabular array 1 cites favorable and unfavorable prognostic factors for spontaneous fistula closure.³ ⁴ ⁶ ⁸ ^xiii ¹⁴

Table 1

Favorable and unfavorable factors predictive of nonoperative fistula closure

Favorable	Unfavorable
Surgical etiology	Ileal, jejunal, nonsurgical etiology
Appendicitis, diverticulitis	IBD, cancer, radiations
Transferrin > 200 mg/dL	Transferrin < 200 mg/dL
No obstacle, bowel in continuity, no infection, no inflamed intestine	Distal obstruction, bowel discontinuity, adjacent infection, adjacent agile inflammation
Length > 2 cm, end fistula	Length < 2 cm, lateral fistula, multiple fistulas
Output < 200 mL/24 h	Output > 500 mL/24 h
No sepsis, balanced electrolytes	Sepsis, electrolyte disturbances
Initial referral to 3rd care center and subspecialty intendance	Delay getting to tertiary care center and subspecialty care

Bloodshed rates in different series for patients with ECF are also markedly variable in distribution (5.five–33%),^four ⁷ ¹⁵ with most deaths attributable to sepsis, malnutrition, and fluid/electrolyte disturbances.⁴ ⁶ ⁷ ¹⁵ ^xvi Factors that are predictive of loftier mortality are infectious and noninfectious complications, high-output fistula,^ane ^eight ¹⁵ ¹⁷ and age.¹⁸ Toll of fistula care is significant and typically more than $500,000.^nineteen

Approach to Enterocutaneous Fistula

A common acronym used to describe ECF care protocol is "SNAP," which stands for management of southkin and sepsis, nutrition, definition of fistula anatomy, and proposing a procedure to address the fistula.²⁰ ²¹ Many authors take suggested various stepwise systems and protocols for treating ECF.¹³ ¹⁴ ²² ²³ ²⁴ ²⁵ In addition, information technology is of import that the patient is treated in a center with significant experience in treating ECFs and that multidisciplinary arroyo is used.^nine ¹¹ This later measure results in l% decrease in mortality.²⁶ The different components of ECF cares are listed every bit follows in the order of immediacy to the patient.

Initial Resuscitation and Electrolyte Repletion

Fluid and electrolyte losses should exist replaced with crystalloids. Patients with high-output ECFs will often require a urinary catheter until well characterized.^twenty Those patients with severe aridity and electrolyte disturbances will crave serum testing of renal part and electrolytes regularly to ensure the supplementation is progressing appropriately. Daily assessment of fluid status is mandatory, equally well as monitoring of all intake and output sources.

Electrolytes that often require significant supplementation are sodium, potassium, and magnesium. Hypomagnesemia may result in nausea, apathy, and neuromuscular hyperexcitability.^xx High-output fistula losses from the pocket-size intestine should be replaced with normal saline with x mEq/L potassium chloride.²³ One method that tin be used to deduce the composition of the best replacement fluid limerick is to measure out electrolyte concentration in fistula effluent and to match the electrolyte composition closely to the replacement fluid. Adequate intravenous access is mandatory to care for patients with dehydration and high-output fistulae. In addition to standard crystalloid fluid, the frequent and multiple electrolyte supplementation, as well as antibiotics, if infection is present, volition ofttimes be needed. Central venous access may be necessary and may require conscientious monitoring and care because of frequent infectious complications.

Treatment of Sepsis

Sepsis is responsible for 77% of mortality associated with ECF.⁸ Computed tomography of the abdomen and pelvis forth with percutaneous drainage with radiographic guidance is essential to evaluate and care for sources of infection. Computed tomography has an accuracy of more than 97% when enhancing contrast media are used appropriately.^xx Other radiologic studies, such as ultrasonography and MRI, can likewise be used as adjuncts. Radiologically guided drainage provides the fastest and safest route to evacuate and command significant infection. In addition, much information can be gained about fistula anatomy and the enteric source from a fistulogram, and percutaneous drainage may decompress a complex fistula and convert it to a simple ane. In cases of peritonitis and without the ability to obtain source command with more bourgeois means, prompt fluid resuscitation, antibiotic assistants, and operative command of infection are essential.

Antibiotic management should follow the Surviving Sepsis guidelines,²⁷ and empiric coverage should not exceed 4 to 7 days.¹⁹ ²⁷ Furthermore, there is no part for antibody coverage in a patient with ECF whose sepsis is fully controlled with percutaneous drainage.^xix Operative sepsis command should focus on infection drainage and exteriorization of the source in the small or large intestine, and no anastomoses should be created in a critically ill patient or in the setting of significant purulence or fecal contamination. Resection of healthy bowel that may exist involved in an inflammatory process should be avoided. Support of organ arrangement functions and utilization of the intensive unit care are oft necessary.

Throughout the process of ECF and sepsis management, multidisciplinary care is important in the care of the fistula patient. Resolution of sepsis is mandatory in society for ECF to shut spontaneously. In the state on increased catabolism, malnutrition is a anticipated outcome,²⁰ as is immunosuppression. Sepsis can also present in a more subtle, subclinical fashion. For example, even in the absenteeism of overt sepsis, 50% of patients with ECFs harbor intra-abdominal abscesses, most of which are amenable to percutaneous drainage.

Diet

Nutrition is 1 of three necessities upon which the life and successful treatment of a patient with ECF hinges. The other ii tenets are fluid resuscitation and sepsis command. Fazio et al showed that mortality is 0% when serum albumin is > 3.5 mg/dL.^xvi For most patients, a combination of EN and PN will be employed, at least initially. Fistula closure rates are twice as high in those receiving acceptable supplemental diet every bit opposed to those who are not.²⁸ The goal of successful nutrition management is achieving an anabolic state with weight gain, improvement in albumin, prealbumin, and transferrin, and successful management of micronutrient needs for optimal healing.

Wound Intendance and Fistula Effluent Control

Establishing and maintaining effective control of fistula drainage that enables wound healing and skin protection requires a responsible and experienced multidisciplinary team of nurses and physicians. Every individual patient and fistula requires a unique arroyo that requires ongoing reassessment as the wound changes with time. The goals of fistula drainage and wound care are prevention of skin loss, minimization of hurting and social isolation, effective control of drainage, and facilitation of wound closure.

Definition of Fistula Beefcake

Defining fistula anatomy is essential to farther planning of operative repair, an optimal nutrition strategy, and patient counseling. Often, a combination of studies is necessary to fully appreciate the fistula beefcake. Computed tomography, fistulography, a small bowel follow-through written report, and dissimilarity enemas are all useful modalities for defining anatomy depending on the location of the fistula.^xi Magnetic resonance enterography is another adjunct, especially useful in patients with IBD.²⁴ These studies should only be undertaken at least 7 to 10 days after fluid and electrolyte resuscitation, infection command, and advisable wound treatment cares.^thirteen

Back up of Patient and Family unit

Treatments and chronic care of the fistula are psychologically draining for patients and families. Positive attitude, brusk-term goal-oriented discussions, and regularly planned social activities/diversions are essential. Patients find themselves isolated, living in fearfulness of appliance leak, physically hungry, angry, and depressed.²⁹ Positive coping mechanisms involve teaching both the patient and his/her family members dressing changes to accomplish greater independence, setting goals for daily physical activity, and involving family unit members at every step of the way.²⁹

Definitive Operative Intervention

Definitive operative intervention should accept the goal of creating no new enterotomy, giving the best chance of cure from ECF, and re-establishing bowel continuity whenever possible. Secondary goals should be minimization of wound cares and further operative procedures, likewise as maximal bowel length preservation. The time interval in which operative intervention is associated with a significantly college bloodshed has been outlined past Fazio et al, counting from the twenty-four hours of previous surgery: return to the operating room within 10 days resulted in 13% bloodshed, operating between xi and 42 days was associated with 21% mortality, and afterwards 42 days mortality returns to 11% in average patients.¹⁶

The accented minimal waiting interval afterward original surgery to return to the operating room is 6 weeks. However, the right calculation for an individual patient is not as unproblematic as a rigid time interval. Likewise waiting out the period of postoperative obliterative peritonitis, taking into business relationship the density of adhesions with the most contempo surgery, operative history, and the caste of sepsis treated as well as ensuring optimization of nutritional status are all important factors in considering the optimal timing for operative treatment.

Nutrition

Sources of malnutrition in a patient with ECF are three and can overlap for an private patient: inadequate calorie intake, catabolism related to ongoing sepsis, and ongoing losses from the GI tract.²⁵ Upward to 75 g of protein can exist lost from enteric secretions daily.²⁵ Basal energy needs may be estimated using the Harris-Benedict equation. However, a patient with ECF will require i to 2.5 times the basal energy of a healthy adult.²⁵ A celebrated lookout man publication in 1964 reported a significant difference for survival with ECF in the setting of adequate nutritional support. Patients who consumed at least ane,500 kcal/day had 3.half-dozen-fold lower mortality than those whose caloric intake did not accomplish i,500 kcal/day.³⁰ Table 2 details energy needs for caloric intake, vitamins, and elements.^xiii ¹⁹ ²² ²⁵ ³¹

Table 2

Nutrition needs of patient with ECF

	Calorie requirement^a (kcal/kg/d)	Poly peptide requirement (m/kg/d)	Vitamin C	Other vitamins	Elements (zinc, copper, selenium)
Low-output fistula	xx–30	1–1.five	5–10 times normal	At least normal	At least normal
Loftier-output fistula	25–35^b	ane.5–2.v^c	10 times normal	2 times normal	2 times trace elements

Monitoring for acceptable nutrition intake can also exist complicated. 1 measure of tracking success weekly is checking albumin, prealbumin, weights, and transferrin levels in a stable patient with ECF at least weekly while an inpatient. Albumin, prealbumin, and transferrin are all acute reactants, and their levels will be inaccurate in the setting of acute physiologic distress and sepsis. Prealbumin and albumin levels provide indirect assessment of visceral poly peptide stores, while transferrin is a principle plasma iron transport protein. In addition, anthropometric assessment based on triceps skin fold thickness (approximates body fatty reserves) and midarm muscle circumference (approximates muscle mass) can exist utilized in the office every bit low-cost, noninvasive measures of progress.³² Both albumin and transferrin levels have been shown to predict spontaneous closure rates¹⁵ ¹⁶ and bloodshed.³³ ³⁴

To accommodate the initial caloric intake goal and follow patient's progress, serum albumin, prealbumin, transferrin, CRP, patient weight, and anthropometrics can be followed over fourth dimension. In add-on, a nitrogen residuum calculation with correction for enteric losses can be used to ensure that positive nitrogen balance is accomplished and maintained. To do the calculation and follow the patient sequentially, regular 24-hour urine tests should be sent for urea nitrogen levels. It is important to note that calculation of nitrogen balance is only meaningful in one case the patient has had resolution of sepsis. Nitrogen balance can be calculated co-ordinate to the following equation²²:

NB = [Protein intake (g)/6.25] − [24-hour urine urea nitrogen + 4 g + (2 g × liters output from enteric sources and wound)]

Positive nitrogen residue signifies anabolic state. Negative balance implies inadequate calorie intake, excessive GI losses, or unresolved sepsis.²⁵

Caloric intake can be in the form of EN or PN. As long as at least 20% of caloric intake is enteric, mucosal integrity, hormonal signaling, and immune functions of the gut tend to be preserved.¹³ In order for EN to exist at least moderately successful (whether or non PN is likewise supplemented), the patient needs at least iv anxiety of salubrious intestine from the ligament of Treitz to the external fistula opening. While enteralfeeding in the situation of high-output small bowel fistula is challenging, information technology is often possible with careful treatment. A sentinel report that enrolled 335 patients with high-output ECF demonstrated 85% of enrollees ultimately tolerating exclusively enteric regimen, with a xl% spontaneous fistula closure rate and 19% bloodshed rate.¹⁷ Similarly, Rahbour et al reported initial 33% PN use during resuscitation and only 11.9% utilize of PN at belch.^xi

After initial fluid and electrolyte resuscitation and percutaneous or operative drainage of infection, PN is started expeditiously in high-output fistula patients and an enteric diet is started in low-output fistula patients. The goal enteric output in 24 hours is < ane.v Fifty.²⁴ High-calorie supplemental drinks are strongly recommended for those who can tolerate EN. In patients requiring supplementation of their orally ingested diet, nasogastric or nasojejunal tubes may exist used to help deliver EN versus a percutaneous endoscopic gastric tube or percutaneous endoscopic gastrojejunostomy tube potentially in patients incapable of taking adequate oral intake on a medium to longer term basis.

When fistula output is on the high side, attempting oral nutrition should be made with the post-obit modifications²⁴: (1) limit intake of low sodium fluid to 500 mL/day,(2) provide patient with oral solution high in sodium (at to the lowest degree 90–120 mmol/L sodium content),(3) small book of fluid intake with solid meals, and (four) proton pump inhibitor (PPI) therapy, antimotility drugs, and octreotide (see section "Medical ManagementFistula Output"). While no randomized study of ECF outcomes comparing EN and PN has been conducted, due to complications associated with PN, and physiological and system cost advantages of EN, PN is generally recommended as a supplement or a bridge to EN. Contraindications to PN are liver dysfunction/failure and difficulty with vascular access, or infection of the vascular access device. PN is necessary in the majority of high-output fistula patients, at to the lowest degree initially, as it decreases GI secretions by 30 to l%, thereby aiding with ECF closure.²² PN can exist started much before than EN and can be used to help with fluid and electrolyte resuscitation. In a rare patient with loftier-output fistula or intestinal failure due to diffuse illness, PN may be the only option. Additionally, the cost of PN is high: based on nutrition therapy solitary, PN is four times as expensive as EN.³⁵ In add-on, forty% of all peripherally placed vascular devices develop some caste of DVT and upwardly to 80% of patients present at some point with a blood-borne infection.¹⁹

In some cases, EN can exist contraindicated, including when insufficient bowel length is present (<75 cm), in cases of intestinal discontinuity, if fistula output increases significantly with start of EN and leads to electrolyte disturbances, if at that place is symptomatic intolerance of EN, and when feeding access is unable to be established/maintained.²² It is recommended to effort EN if fistula output is < 1.5 Fifty. Polymeric formula is tried get-go, and, if non tolerated or fistula output increases significantly, semielemental formula tin can be introduced. Semielemental nutrition has been demonstrated to significantly reduce volume of fistula output.²² If semielemental feeds are not tolerated, an elemental feeding regimen should exist attempted.³⁶ While expensive and non shown to improve mortality or closure rates in EC fistula patients, immunomodulated nutrition formulas are also available.

Finally, fistuloclysis can evangelize EN to a distal opening in cases where distal enteric tract is devoid of obstruction. Details of fistuloclysis technique are well described elsewhere.³⁵ While fistuloclysis is a cost-effective therapy and is typically successful, it can be fourth dimension-consuming. Almost patients will experience abdominal discomfort/diarrhea in the offset after its initiation.³⁵ In a small accomplice of patients, fistuloclysis was effective in feeding 11 out of 12 patients.³⁵ The setup for fistuloclysis requires an ostomy appliance, a gastrostomy or another enterostomy tube, and an adapter that allows the enterostomy tube to exist fixed to the ostomy appliance, as it passes through the wall of the stoma bag, and tube feed bag and tubing.³⁵

Medical Management of Fistula Output

Ane of the chief problems with skin integrity and initiation of EN occurs in fistulae with output exceeding 1 Fifty/day. Nasogastric drainage tubes are to be avoided because they practice not better outcomes and contribute significantly to sinusitis, sore throat, decreased mobility, and a decrease in quality of life.⁹ PPIs or H₂ channel blockers decrease acidity and amount of gastric secretions and are recommended as part of standard treating regimen in a high-output fistula.⁴ ⁹ ^thirteen In addition, sucralfate tin be used for its gastric acid neutralizing and its constipating effects.¹³ None of the acid reduction therapies have been shown to increase rate of fistula closure.

Antidiarrheals (loperamide, diphenoxylate/atropine, codeine, and tincture of opium) take been used widely to decrease fistula output. In a British abdominal failure heart, high doses of loperamide (up to xl mg/day) and codeine (upward to 240 mg/day) are beingness used to control many otherwise refractory high-output fistulas with success.^ix ²⁴

Somatostatin is a natural antisecretory hormone with a half-life of 1 to 2 minutes produced in the pancreas and the GI tract. Octreotide is a somatostatin analogue with a one-half-life of 113 minutes.³⁷ Physiologic studies accept demonstrated that octreotide treatment (three times daily) reduces the volume of pancreatic secretions.³⁷ Despite that, pancreatic enzyme concentration in those secretions begin to rise four hours postinjection.³⁸ Small cohort report suggested that octreotide event diminishes with repeat administrations, probable due to receptor downregulation. Highest output fistulas seem to be affected the most past octreotide (twice the effect than on depression-output ECF).³⁹ Somatostatin is renally cleared, and while it presents no physiologic problem for normal patients and those with liver affliction, renal affliction may impair its metabolism.⁴⁰

Nine randomized or prospective studies of somatostatin analogues/somatostatin versus placebo accept been published between 1992 and 2009.⁴¹ ⁴² ⁴³ ⁴⁴ ⁴⁵ ⁴⁶ ⁴⁷ ⁴⁸ ⁴⁹ Two recent meta-analyses summarize their results: somatostatin analogues and somatostatin exercise non improve mortality, but they seem to subtract fistula output, allow faster spontaneous closure, and subtract hospital stay.⁵⁰ ⁵¹ The longest follow-upward interval in studies is 90 days.⁴¹ Somatostatin analogues versus control resulted in greater success of spontaneous fistula closure (relative take chances [RR] 1.36) and shorter time interval to closure.⁵¹ Somatostatin versus command resulted in even greater success of spontaneous fistula closure (RR 2.79) and demonstrated shorter time interval to closure.⁵¹ Out of the six trials that recorded fistula output, three noted no difference in amount of fistula secretions,⁴¹ ⁴⁴ ⁴⁸ while the other three reported 45 to 50% decrease in fistula output (two studies used somatostatin hormone, one study used lanreotide).⁴³ ⁴⁵ ⁴⁷ Data on length of hospital stay are also based on a unmarried study.⁴⁹ In the finish, abdominal failure units typically utilize a trial of somatostatin analogues for 3 days in an try to decrease output in a fistula that produces >1L/day.⁹ ²⁴ If successful inside 72 hours, the handling is then utilized over a longer period of time.

Wound Management

Wound intendance is a priority in a malnourished patient. Information technology is quintessential for patient's quality of life and ability to manage the physical and mental stresses of living with an ECF. Enteric output, especially succus from the proximal small-scale intestine, will erode skin in less than 3 hours.⁵² Low-output fistulas can be treated with a moisture to dry dressing or simply a dry out gauze. Moderate output fistulas can be managed with an ostomy appliance with appropriate skin protection effectually the fistula in the course of agglutinative ring, paste, pulverization, or hydrophilic dressing.⁵³ The real claiming is management of loftier-output fistulas. Several collection device types exist, such equally ostomy appliances, wound managers, pouching systems that can be connected to wall suction, and NPWT. The VAC is a type of NPWT that is non specifically canonical for ECF, with increasing application but currently controversial utility for ECF. The option and fit of the particular organisation is instrumental in wound healing and requires the expertise of a wound and ostomy nurse.

There are no level ane data on the utilise of VAC. Several instance series report both positive and negative outcomes. Wainstein et alhave reported a large series of 92 patients with postoperative high-output ECFs.⁵⁴ All fistulas were dressed with a vacuumcompaction organisation with high negative pressure capability. The settings used were negative pressure at –350 to –600 mmHg,⁵⁴ whereas KCI recommends upwards to –125 mmHg.⁵⁵ Spontaneous closure charge per unit was 46%, and control of output was obtained in 98% of patients (40% had output entirely suppressed afterwards ane to 7 days of treatment, 57% had output decreased to <500 mL/twenty-four hour period).⁵⁴ However, 41% experienced no improvement and required surgical correction.⁵⁴ Medeiros et al reported another 74 patients with postoperative fistula managed with a Foley catheter, connected to a NPWT.⁵⁶ Of those 74 patients, 92% had spontaneous fistula closure past 15 days.⁵⁶ Both of these studies used mod ECF management algorithms. It is not possible to determine from these two studies whether there was a cause–consequence relationship between NPWT and fistula closure/output reduction. Multiple small example reports exist to document benefit of VAC therapy (n = 1–5).¹² ⁵⁷ ⁵⁸ ⁵⁹ Two case series report VAC therapy causing ECF.^sixty ⁶¹ The cost of VAC organization and the associated nursing care is substantial. Overall, at that place is no clear evidence that negative pressure wound direction organization leads to an improved fistula closure rate, and, in some cases it, may crusade harm. On the other hand, it is undeniably a tremendous quality-of-life advocacy for patients with ECFhaving open up wounds, high-output fistulas, or difficult to pouch fistulas, where NPWT acts to protect surrounding pare and effectively assemble effluent.

Nonoperative Therapies

Fibrin Sealant

An platonic fistula for treatment wound be long, narrow, low output, devoid of distal obstruction and IBD. From isolated instance series, information technology appears that fibrin sealant therapy may expedite fistula closure, only often requires several treatments. Avalos-González et al reported on a series of 23 patients who underwent fibrin sealant fistula closure, demonstrating fistula closure at 12.5 days in the treatment group versus 32.5 days in the control group.⁶² Some other study reported a serial of 15 patients who underwent an average of two.five fibrin sealant procedures, which resulted in an 86.six% healing rate at 16 days.⁶³ In contrast, Lippert et al reported a series of patients with heterogeneous fistulae (21 were small intestine and colorectal) that were treated with endoscopic therapies and fibrin sealant. These authors observed a 55.seven% closure rate overall and 37% closure rate with fibrin sealant solitary.⁶⁴ Overall, fibrin sealant therapy should be used in selected cases favorable in configuration.

Endoscopic Clips

Endoscopic clip engineering is available for acute fistulas and perforations and is not well suited to chronic ECF. With appearance of through-the-telescopic clips, repair of fresh injury has go more favorable in the setting of controlled sepsis and a small-sized fistula.⁶⁵ This engineering science has little awarding in the cure of chronic ECF.

Fistula Plug

Overall, only case series are available for fistula plugs in the treatment of ECF. However, fistula plugs have been more normally used equally an adjunct in the treatment of enteroatmospheric fistula (EAF). In item, one instance series of 6 patients using the Biodesign ECF plug (Cook Medical, Indianapolis, IN) described fistula closure in all patients followed past recurrence in two patients at 9 and 12 months.⁶⁶

Timeline and Principles of Definitive Surgical Repair

Definitive repair of the ECF should be planned if no spontaneous closure occurs past 12 weeks afterward sepsis command, nutritional optimization, and establishing wound cares. Timeline to definitive repair is not firmly established but may be delayed in cases where nutrition is maintained and multiple surgeries take been previously performed. Fazio et al demonstrated that mortality doubles if an operation is attempted betwixt x and 42 days later initial process resulting in ECF formation.^xvi ²³ Historically, performance was recommended in 12 weeks subsequently inciting consequence.²⁸ ⁵² However, loftier volume ECF 3rd intendance centers are currently reoperating on patients at vi to 12 months.⁹ ¹¹ ²⁰ ²⁴ ⁶⁷ Waiting longer than 12 months in those patients who have large wounds and potential hernias may cause loss of domain and complicate hernia repair,²⁸ merely may anecdotally exist helpful in patients with previous sepsis or multiple surgeries.

Prerequisites to definitive fistula operative intervention include optimization of nutrition, eradication of infection, addressing psychological morbidity, and clinical evidence of softening scars and abdominal wall on exam. These cases should be scheduled for at to the lowest degree 6 to 8 hours to let for complete adhesiolysis from the ligament of Treitz to the rectum.¹⁴ ^xx ⁵² Avoidance and proper repair of any enterotomy is essential since 36% of recurrent fistulas event from inadvertent injury to the bowel.⁶⁸ Operative success for definitive ECF resolution ranges from 80 to 95%.^nine ¹¹ ¹⁵ ²⁵ ⁶⁷ ⁶⁸ Failure is increased with the presence of infectious and noninfectious complications.⁸

Additionally, following surgery, ECF recurrence is 14 to 34%.¹¹ ¹⁵ ⁶⁷ ⁶⁸ Recurrence rates are minimized (18%) when the involved bowel is fully mobilized and resected. Oversewing or wedge resection/bowel repair results in higher rates of recurrence at 33%.⁶⁷ Similarly, Runströmet al reported that ECF failure rate is lower when no anastomosis is constructed and, instead, a stoma is chosen (recurrence rate 14 vs. 34% with anastomosis).⁶⁸ More than broadly, ane has to residue the risk of ECF recurrence with the morbidity of another functioning if anastomosis is avoided.

Enteroatmospheric Fistula

EAF represents a fistula with an external opening in an open wound or directly exposed bowel (Fig. 1). There is a higher propensity for EAF if the abdomen has been left open for more than than 8 days and in the absence of EN.²⁸ Nearly patients with EAF are critically ill and crave significant resuscitation. In these cases, the first priority should exist source command, which is often difficult in the absence of fistula tract and the ability to dispense edematous bowel safely.

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Enteroatmospheric fistula.

Management options include the cosmos of "floating stoma" by sewing exposed bowel mucosa in circumferential fashion to a plastic sheet that is used every bit an interface to attach the stoma appliance and placed on the surface of exposed bowel.⁶⁹ Over fourth dimension, a floating stoma with a deep EAF volition gradually become more superficial.⁶⁹

Overall, there are no significant differences in nutrition optimization or handling algorithms for an EAF except for wound intendance. The use of NPWT such equally VAC, applied so that blackness sponge is never in contact with bowel serosa or mucosa, may also substantially facilitate wound care in this population group and shrink the wound. Definitive operative intervention is not advised until at least 3 months subsequently resolution of sepsis, malnutrition, and other injuries.²⁴ Fistuloclysis in combination with NPWT may also be quite useful in select patients.

Inflammatory Bowel Disease

While all of the previously discussed fistula care protocols concur true for IBD, several additional considerations stand out for IBD patients. First, IBD patients tend to accept less tolerance for EN. In a serial of fifteen IBD patients with ECF or high-output stoma managed at home with an boilerplate of 75 days of PN, Evans et al reported that 80% were managed successfully, with 53% undergoing definitive surgery and 27% achieving spontaneous closure thus not requiring surgery.⁷⁰

ECF treated with infliximab in patients with IBD may result in an increase in fistula closure (upwards to 55%), compared with 13% closure with placebo,⁷¹ though only a minority of fistulas in this study were ECF. Another study with infliximab for ileal and ileocolonic ECF demonstrated 38% spontaneous fistula closure and 51% partial response.⁷² Even so, in that location was also a 50% recurrence rate in this cohort.⁷² Amiot et al reported on 47 patients with ECFs, including 35% postoperative ECFs after ileocolonic anastomotic leak, 33% complex in nature, and 23% high output.⁷³ Handling options included infliximab in 78%, adalimumab in 10%, and both drugs in sequence in 13%. Consummate closure was achieved in 33% just 50% of these ECFs afterward closure recurred in the follow-up flow. Successful fistula closure was associated with uncomplicated fistula and absence of stricture.⁷³ Poritz et al showed in a pocket-sized study of 26 patients (23% with ECF) that despite 61% of patients having complete or partial response to medical therapy, 54% still need definitive surgery.⁷⁴

Determination

ECF remains a complex problem that is optimally management using a careful and interdisciplinary approach. In improver to principal management of sepsis, conservative treatment remains the treatment mainstay, including the combination of wound management, nutritional support with EN or PN sometimes in combination, and social back up. Surgical treatment with resection should exist carefully planned and is used in cases that fail bourgeois treatment.

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