Fistulas Enterocutaneas Maingot

10
ABDOMINAL ABSCESS
AND ENTERIC FISTULAE
Patrick S. Tawadros t Jory Simpson t Josef E. Fischer
t Ori D. Rotstein
ABDOMINAL ABSCESS Thethree major defense mechanisms in the peritoneal cavity

are (1) mechanical clearance of bacteria via the diaphragmatic
Definition and Etiology lymphatics, (2) phagocytosis and destruction of suspended or
adherent bacteria by phagocytic cells, and (3) sequestration
Abscesses are well-defined collections of infected purulent and walling off of bacteria coupled with delayed clearance by
material that are walled off from the rest of the peritoneal phagocytic cells.5 The first two mechanisms act rapidly, usually
cavity by inflammatory adhesions, loops of intestine and their within hours. Egress of bacteria from the peritoneal cavity via
mesentery, the greater omentum, or other abdominal viscera. the lymphatics is responsible for the early septic response due
Abscesses may occur in the peritoneal cavity, either within or to bacteremia and initiation of the innate immune response
outside of abdominal viscera (extravisceral), as well as in the to infection.
retroperitoneum.1 Most relevant to the surgeon are extravisceral The initial peritoneal response to bacterial contamina-
abscesses that usually arise in one of two situations: (1)after res- tion is characterized by hyperemia, exudation of protein-
olution of diffuse peritonitis in which a loculated area of infec- rich fluid into the peritoneal cavity, and a marked influx
tion persists and evolves into an abscess and (2) after perforation of phagocytic cells. Resident peritoneal macrophages pre-
of a viscus or an anastomotic breakdown that is successfully dominate early in the infection, but the rapid influx of
walled off by peritoneal defense mechanisms. More than 80% neutrophils after a 2- to 4-hour delay makes them the pre-
of intra-abdominal abscesses occur in the postoperative period, dominant phagocytic cell in the peritoneal cavity for the
the majority of which occur after pancreaticobiliary or colorec- first 4872 hours.6 The combination of resident peritoneal
tal surgery and are usually related to anastomotic dehiscence.2,3 cells plus the influxing into the peritoneum serves to propa-
Occasionally, postsurgical abscesses result from infection of gate the initiation of the innate immune response, including
an intraperitoneal hematoma that develops following surgery. the elaboration of inflammatory cytokines and the proco-
Less frequently, intra-abdominal abscesses are unassociated agulant response. In humans with severe intra-abdominal
with previous surgery and are usually attributable to spontane- infection, peritoneal levels of tumor necrosis factor-alpha
ous inflammatory processes associated with a small, localized (TNF-), interleukin (IL)-1, and IL-6 are higher than lev-
perforation, such as in appendicitis, diverticulitis, and Crohns els measured simultaneously in plasma.7,8 Haecker and col-
disease.3,4 Visceral abscesses are most commonly caused by leagues reported that TNF- and IL-10 levels are increased
hematogenous or lymphatic spread of bacteria to the organ. and reach 100- to 1000-fold that is observed in the plasma
Retroperitoneal abscesses may be caused by several mecha- following appendiceal perforation. In adult patients, a cor-
nisms, including perforation of the gastrointestinal (GI) tract relation between the magnitude of the cytokine response
into the retroperitoneum and hematogenous or lymphatic and outcome in infected patients has been demonstrated in
spread of bacteria to retroperitoneal organs, particularly the several clinical studies.9 Higher levels of circulating TNF-
inflamed pancreas. and IL-6 have been recorded in patients who later die with
intra-abdominal infection.7 Interestingly, elevated perito-
neal persist even after systemic inflammatory response has
Pathophysiology of Abscess Formation abated. This suggests that during resolving peritonitis, there
is compartmentalization of the response with local cytokine
After bacterial contamination of the peritoneal cavity, a elaboration, thereby promoting local resolution of infec-
complex series of events is initiated that, under ideal circum- tion. Other cell types are likely important in the initiation
stances, effects complete eradication of invading bacteria. of the local peritoneal response. Peritoneal mast cells and
197
198 Part II Abdominal Wall
mesothelial lining cells have also been shown to be potent aswellas abscess factors such location and size of the abscess
producers of a range of cytokines and procoagulants. Fibrin and how well walled off the abscess is. For example, sub-
deposition appears to play an important role in this com- phrenic abscesses can present with vague upper quadrant
partmentalization of infection, not only by incorporating abdominal pain, referred shoulder pain, and occasionally
large numbers of bacteria within its interstices10 but also hiccoughs but with no localized abdominal tenderness or
by causing loops of intestine to adhere to each other and palpable mass. By contrast, paracolic abscesses present with
the omentum, thereby creating a physical barrier against localized tenderness and may manifest as a palpable mass on
dissemination. Fibrin deposition is initiated after the exu- abdominal examination. Pelvic abscesses may also cause local
dation of protein-rich fluid containing fibrinogen into the irritation of the urinary bladder causing frequency, or of the
peritoneal cavity. The conversion of fibrinogen to fibrin rectum resulting in diarrhea and tenesmus. Retroperitoneal
is promoted by the elaboration of tissue factor by both collections, particularly psoas abscesses, can manifest as leg
mesothelial cells and stimulated peritoneal macrophages.11 and back pain with muscular spasm and flexion deformity
In addition, generation of other inflammatory mediator of the hip. In reality, with the ready availability of computed
molecules and components of the complement cascade (eg, tomography (CT) scanning in most institutions, almost any
C3a and C5a) further promotes the development of local deviation from the normal recovery trajectory in the post-
inflammation. The net effect of these responses is the local- operative period will prompt a CT scan and possible early
ization of the bacterial infection in the peritoneal cavity, detection of the abscess.
wherein ultimate resolution can occur. However, a number
of local factors thwart complete resolution and presum-
ably establish the local environment for persistent infection DIAGNOSTIC TESTS
and hence abscess formation. These include regional fibrin Imaging provides the definitive evidence of the presence of an
deposition that impedes phagocytic cell migration, factors intra-abdominal abscess. Abdominal plain films can be help-
that inhibit phagocytic cell function such as hemoglobin, ful in identifying air-fluid levels in the upright or decubitus
particulate stool, low pH, and hypoxia. On the micro- positions, extraluminal gas, or a soft tissue mass displacing the
bial side, polymicrobial flora of these infections as well as bowel. In the postoperative patient, however, extraluminal gas
the near ubiquitous presence of Bacteroides fragilis and its may be present for up to 7 days. Overall, plain radiography
unique capsular polysaccharide have been implicated in may suggest the presence of an abscess, but other imaging
persistence of infection and abscess formation. Considered modalities have essentially replaced plain films in the evalua-
together, while the process of abscess formation represents tion of intra-abdominal abscesses.
a successful outcome of the peritoneal response to bacterial CT scanning has emerged as the radiological investigation
contamination of the peritoneal cavity, one is left with a of choice in the diagnosis of intra-abdominal abscess.12 With
residual infection that carries with it morbidity and poten- its ready availability, it has essentially supplanted abdominal
tial mortality and must be actively managed. ultrasound (US) as the main diagnostic tool in this setting,
mainly because of its accuracy, but also because its function-
ality is not impaired in the setting of ileus, wound dressings,
stomas, and the open abdomen. The accuracy of the scan is
Clinical Presentation and Diagnosis improved if contrast is used. IV contrast increases the accu-
racy of defining the presence of an abscess, while GI tract
CLINICAL PRESENTATION
contrast helps to distinguish fluid-filled bowel loops from an
Diagnosis of an intra-abdominal abscess is based on clinical abscess and in addition may detect the presence of an anas-
suspicion complemented by radiologic confirmation of tomotic leak. In a retrospective study that compared US and
the presence of the abscess. High spiking fevers, chills, CT in diagnosing intra-abdominal abscesses, the sensitivity of
tachycardia, tachypnea, and leukocytosis, associated with US in 123 patients was 82% compared to 97% in 74 patients
localized abdominal pain, anorexia, and delay in return of by CT, and the overall accuracy of US was found to be 90%
bowel function in the postoperative patient are the classic versus 96% for CT.13 Criteria for identification of an abscess
signs and symptoms associated with the presence of an intra- by CT have been well described and include identification
abdominal abscess. The presence of a well-localized tender of an area of low CT attenuation in an extraluminal location
mass on clinical examination is consistent with the presence or within the parenchyma of solid abdominal organs. The
of an abscess. However, there may be considerable variabil- density of abscesses usually falls between that of water and
ity in the clinical appearance of the patient with this infec- solid tissue.14 Other radiological signs of an abscess are mass
tion, ranging from a relatively mild picture where the patient effect that replaces or displaces normal anatomic structures,
appears generally well but is slow to recover from his surgi- a lucent center that is not enhanced after the intravenous
cal procedure to those who manifest evidence of profound administration of a contrast medium, enhancing rim around
systemic inflammation. There may be no mass palpable on the lucent center after IV contrast administration, and gas
clinical examination. A number of factors may contribute in the fluid collection. One of the major advantages of CT
to this variability, including patient factors such as age, over US is the ability to detect abscesses in the retroperito-
immunocompetence, and concurrent use of antimicrobials, neum and pancreatic area. There are also some disadvantages
Chapter 10 Abdominal Abscess and Enteric Fistulae 199
to CTscanning. In the absence of contrast rim enhancement, ANTIMICROBIAL THERAPY

gas or visible septations, CT cannot distinguish between ster-
Considerations regarding antimicrobial use are based on the
ile and infected fluid collections. Occasionally, there may be a
microbial flora recovered from the infections. Over the past
solid-appearing collection that is really an abscess with a high
decade, there has been increasing appreciation that there is an
leukocyte and protein content. Septations and other signs
evolution of the flora with increasing severity of abdominal
of loculated abscesses can often be better visualized with US
infection.20 For example, Table 10-1 shows the bacteriol-
than CT. Finally, CT scanning is sometimes unable to differ-
ogy of peritonitis in patients with community-acquired
entiate between subphrenic and pulmonic fluid, a relatively
peritonitis and those with postoperative peritonitis. The
common situation in abdominal surgery.15 In these limited
major pathogens in community-acquired intra-abdominal
circumstances, US may be considered as a complement to
infections are coliforms (esp. Escherichia coli) and anaerobes
CT imaging.
(esp. B. fragilis). As illustrated, while both are polymicro-
Other modalities include magnetic resonance imaging
bial, postoperative peritonitis has a higher incidence of more
(MRI). While MRI can sometimes better delineate the extent
resistant microbes. Aside from patients with postoperative
of an abscess, particularly in relation to adjacent soft tissue
peritonitis, other factors predict this shift in microbiology,
structures such as muscles and major blood vessels, it does not
including advanced age, severe physiologic derangement,
clearly have advantages over CT scanning and its practicality
immunosuppression, previous use of antibiotics, and resi-
may be limited in the sick surgical patient.16 One area where
dence in a health care institution in hospitals and nursing
US and MRI may be relevant is in the investigation of the
homes, etc. Guidelines have been developed recently by the
pregnant patient with abdominal pain.17 US is particularly
Surgical Infection Society and the Infectious Diseases Soci-
useful when appendicitis/appendiceal abscess is suspected, and
ety of America regarding the use of antimicrobial therapy
MRI may be useful when localization is less clear. The roles
in intra-abdominal infection.21 These authors have risk-
of radiolabelled compounds in the diagnosis of abdominal
stratified patients into three categories and provided recom-
abscesses are limited at present.18
mendations for empiric antimicrobial regimens according to
category. The three categories are (1) community-acquired
infections of mild to moderate severity; (2) high-risk or
Management severe community-acquired infections; and (3) health care
associated infections. Factors that dictate conversion from
The basic principles underlying the successful treatment of mild-to-moderate severity to high severity include severe
intra-abdominal abscesses are threefold: physiologic derangement (eg, high Acute Physiology and
1. Adequate resuscitation and support Chronic Health Evaluation II [APACHE II] score), advanced
2. Antimicrobial therapy
3. Source control/abscess drainage
TABLE 10-1: MICROBIOLOGY OF

RESUSCITATION AND SUPPORT COMMUNITY-ACQUIRED PERITONITIS
COMPARED TO HEALTH CAREASSOCIATED
In keeping with the variable presentation of patients with PERITONITIS
intra-abdominal abscesses, the initial approach to resus-
citation and support will vary considerably. Attention to Percent of Isolates of
the ABCs (airway, breathing, circulation) while individual-
Postoperative
izing the intervention for each patient according to his/ Community- (Health Care
her deviation from normal physiology is appropriate. Strain Acquired Associated)
Particularly in the postsurgical patient, nutritional sup-
port should be considered. When feasible, oral nutrition Enterococci 5 21
should be given in preference to total parenteral nutrition. Escherichia coli 36 19
Some patients are able to ingest food and/or supplements Enterobacter sp 3 12
by mouth, while others might require an enteral feeding Bacteroides sp 10 7
tube, due to anorexia, precluding adequate ingestion of Klebsiella sp 7 7
nutrients. Systematic review of the literature suggests that Staphylococcus aureus 1 6
infectious complications and cost are reduced in critically ill Coagulase-negative staph 1 5
patients receiving enteral nutrition compared to parenteral Candida 7 4
nutrition.19 One can presumably extrapolate to patients Pseudomonas sp 2 6
with intra-abdominal infection. When abscess formation Streptococci 14 4
occurs due to an anastomotic leak, there is a sense that this Hemolytic strep 3 0
might preclude use of enteral nutrition. This concern is Other 11 9
likely unfounded, unless there is profound ileus associated From Roehrborn A, Thomas L, Potreck O, et al. The microbiology of
with the infection. postoperative peritonitis. Clin Infect Dis. 2001;33:1513.
TABLE 10-2: RECOMMENDATIONS FOR ANTIMICROBIAL THERAPY

IN THE COMMUNITY-ACQUIRED SETTING
Community-Acquired Infection in Adults
Mild-to-Moderate Severity:
Perforated or Abscessed
Appendicitis and Other High Risk or Severity: Severe
Community-Acquired Infection in Infections of Mild-to- Physiologic Disturbance, Advanced
Regimen Pediatric Patients Moderate Severity Age, or Immunocompromised State
Single agentErtapenem, meropenem, imipenem- Cefoxitin, ertapenem, moxifloxacin, Imipenem-cilastatin, meropenem,

cilastatin, ticarcillin-clavulanate, and tigecycline, and ticarcillin-clavulanic doripenem, and piperacillin-tazobactam
piperacillin-tazobactam acid
Combination Ceftriaxone, cefotaxime, cefepime, or Cefazolin, cefuroxime, ceftriaxone, Cefepime, ceftazidime, ciprofloxacin, or
ceftazidime, each in combination with cefotaxime, ciprofloxacin, or levofloxacin, each in combination with
metronidazole; gentamicin or tobramycin, levoflox acin, each in combination metronidazolea
each in combination with metronidazole or with metronidazolea
clindamycin, and with or without ampicillin
a
Because of increasing resistance of Escherichia coli to fluoroquinolonoes, local population susceptibility profiles and, if available, isolate susceptibility should be reviewed.
From Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical
Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133, with permission.
age, or immunocompromised state. Table 10-2 shows discussion to abscess drainage, but adequate source control
the recommended agents according to this stratification. may also include debridement of necrotic tissue, surgical
These guidelines are therefore readily applicable to decision repair, resection, and/or exteriorization of the anatomic defect
making regarding patients coming into the hospital with causing peritoneal contamination.22
abscesses, including processes such as appendiceal abscess or Over the past two decades, percutaneous drainage of
peridiverticular abscess. It is noteworthy that while entero- abscesses has become an established technique and a safe
coccus is frequently recovered in isolates in these infections, alternative to surgery. This evolution of care has not been
the evidence demonstrates no additional benefit to treating based on a series of strong randomized trials showing equiv-
this microbe as part of empiric therapy. When possible, swi- alence or superiority of this approach. Rather, observational
tchover to oral agents is appropriate. The duration of anti- studies from a number of centers have shown it to be a safe
biotics should be 47 days, anticipating resolution of the effective alternative to surgical intervention, with equiva-
clinical signs and symptoms during this period. Should there lent success rates, comparable mortality (1020%) and
be no resolution by this time, reevaluation of the patient for morbidity (~25%).2325 Combined with other advantages
the presence of persistent infection in the abdomen and else- of percutaneous approaches including avoidance of general
where is appropriate. anesthesia, lower costs, and the potential for fewer compli-
Patients who present in the postsurgical period fall into cations, it has now become the default approach to abscess
the category of patients with health careassociated infection. management. Prerequisites for catheter drainage include an
In these patients, empiric therapy should include agents with anatomically safe route to the abscess, a well-defined uni-
expanded spectra against gram-negative aerobic and facultative locular abscess cavity, concurring surgical and radiologic
bacilli, including meropenem, imipenem-cilastatin, doripenem, evaluation, and surgical backup for technical failure. Mul-
piperacillin-tazobactam, or ceftazidime or cefepime in combi- tiple abscesses, abscesses with enteric connections as seen
nation with metronidazole. Table 10-3 shows the considerations with enterocutaneous fistulas, and the need to traverse solid
regarding selection depending on local institutional microbial viscera are not contraindications. Indeed, as the technique
isolates. Empiric anti-enterococcal treatment should be given. has evolved over several decades, the barriers to accessing
Treatment of Candida with fluconazole when recovered from unusually positioned collections have disappeared with the
cultures and treatment of methicillin-resistant Staphylococcus use of unconventional routes (transgluteal, transvaginal,
aureus with vancomycin should be followed if the patient is transrectal) and the advent of new technologies including
colonized with the microbe. endoscopic US.26,27 Even the presence of septations and
loculations has not precluded at least an attempt to use per-
cutaneous drainage.28
SOURCE CONTROL Percutaneous drainage can be performed with US or CTguid-
Source control is a term used to include all physical measures ance. CT provides for more precise identification of organsand
taken to control a focus of infection. Here we focus our bowel loops and is more accurate for planning of drainageroute.15
TABLE 10-3: RECOMMENDATIONS FOR ALTERATIONS IN ANTIMICROBIAL THERAPY IN

THE HEALTH CAREASSOCIATED SETTING
Regimen
Organisms Seen in Ceftazidime

Health Careassociated or Cefepime,
Infection at the Local Piperacillin- Each With
Institution Carbapenema Tazobactam Metronidazole Aminoglycoside Vancomycin
<20% Resistant Pseudomonas Recommended Recommended Recommemded Not recommended Not recommended
aeruginosa, ESBL-producing
Enterobacteriaceae,
Acneobacter, or other MDR
GNB
ESBL-producing Recommended Recommended Not recommended Recommended Not recommended
Entorobacteriaceae
P. aeruginosa >20% resistant Recommended Recommended Not recommended Recommended Not recommended
to ceftazidime
MRSA Not recommended Not recommended Not recommended Not recommended Recommended
ESBL, extended-spectrum -1actamase; GNB, gram-negative bacilli: MDR, multidrug resistant; MRSA, methicillin-resistant Staophylococcus aureus.
NOTE. Recommended indicates that the listed agent or class is recommended for empiric use, before culture and susceptibility data are available, at institutions that
encounter these isolates from other health careassociated infections. These may be unit-or hospital-specific.
a
Imipenem-cilastatin, meropenem, or doripenem
Reproduced from Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the
Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133, with permission.
Once the abscess is identified, initial diagnostic aspiration should demonstrate comparable efficacy. In one study, patients were
be sent for Grams stain and microbiological culture. The cath- matched for age, abscess location, and etiology, and had similar
eter used for drainage should be as small as possible for safety, APACHE II scores. There were no differences between percu-
yet large enough so that the tubing does not become obstructed. taneous and surgical drainage in patient morbidity, mortality,
Most commonly used catheters range in size from 8 to 12F. or duration of hospital stay.24 Furthermore, initial percutane-
With appropriate catheter placement, the abscess cavity typically ous drainage of abscesses in the context of diverticular disease
decompresses and collapses. Irrigation of the catheter should be allowed for subsequent definitive operative resection and pri-
done once daily to ensure tube patency. As catheter drainage mary anastomosis in one rather than two operations. Another
decreases, repeat CT scanning can be performed to evaluate for group retrospectively examined postoperative intra-abdominal
residual contents. If drainage increases over time or continues at abscesses after laparotomy. This study similarly demonstrated
a steady rate, the development of an enteric fistula must be sus- that use of either form of drainage resulted in similar cure rates
pected. This may not have been unexpected when the catheter for postoperative intra-abdominal abscesses.25
was initially placed near a perianastomotic abscess or an abscess With clear demonstration of its efficacy when compared
adjacent to some underlying pathological process. Potential to surgical drainage, percutaneous drainage should be con-
complications of catheter placement include bacteremia, sepsis, sidered the preferred approach in source control of abscesses.
vascular injury, enteric puncture, cutaneous fistula, or transpleu- Table 10-4 shows outcome of percutaneous drainage accord-
ral catheter placement. ing to underlying pathological processes. In general, one
Catheters should be maintained on closed drainage sys- should predict a successful outcome in patients with a single,
tems. There does not appear to be benefit to the use of suction well-defined abscess with no enteric communication. The
or irrigation of these catheters, although flushing once per presence of enteric communication per se does not reduce
day with saline ensures patency. Patients should respond with the likelihood of success as it is defined by the resolution
defervesce of symptoms within 48 hours of catheter insertion. of the infection. In a postoperative abscess, following drain-
If they do so, a repeat CT scan is done at approximately 57 age of the infection, the underlying anastomotic defect will
days to ensure shrinkage of the abscess. Criteria for removal usually close. In other settings, there may be a requirement
of the drain include (1) clinical resolution of septic param- for subsequent surgery to manage the underlying disease
eters, including patient well-being, normal temperature, and process such as diverticular disease or Crohns disease. For
leukocyte count; (2) minimal drainage from the catheter; and example, in one study, approximately 75% of patients with
(3) CT evidence of the resolution of the absence. large peridiverticular abscesses were drained percutaneously
As noted previously, studies comparing outcomes of sur- and then they went on to a single-stage sigmoid colectomy.28
gical and percutaneous drainage of intra-abdominal abscesses Other circumstances such as fungal abscesses, infected
TABLE 10-4: DETERMINANTS OF OUTCOME FOLLOWING PERCUTANEOUS

DRAINAGE OF ABSCESSES
Successfully
Clinical Condition Treats Abscess Comment
Single, well-defined bacterial abscess with no Yes
enteric communication
Abscess with enteric communication (eg, May require subsequent surgery to
diverticular abscess or Crohns disease abscess) treat pathological process or residual
fistula
Interloop abscess or other difficult-to-access Usually Requires alternative approaches to
abscesses (eg, deep pelvic) access successfully, eg, transrectal,
transvaginal, transgluteal, etc
Early postoperative diffuse peritonitis (eg, Low Inappropriateneeds surgery
caused by anastomotic dehiscence or bile
peritonitis)
Infected tumor mass Low Inadequate drainage
Fungal abscess
Infected hematoma
Pancreatic necrosis
Small abscess (<4 cm in diameter) Low Difficult to drain; antibiotics alone
may be suitable
hematomas, peripancreatic necrosis, or necrotic-infected caveats being those indicated. Specifically, when the infection
tumor have a lower success rate for percutaneous drainage and is diffuse rather than localized, surgical intervention is clearly
early consideration for surgical intervention.29 CT features indicated. Second, when the content of the abscess is too thick
such as the presence of a rind, a sharp exterior margin, for percutaneous drainage, an initial percutaneous attempt
air-fluid levels, and septations do not predict outcome and may be reasonable, but conversion to surgery early in the
therefore should not be determinants as to whether or not course is reasonable. Finally, when access is impossible, surgery
initial percutaneous drainage should be used.30 Finally, one is indicated. This last circumstance is increasingly rare.
should use clinical judgment as to the need for percutaneous The transperitoneal approach allows for examination
drainage for small abscess (<5 cm diameter) such as those of the entire abdominal cavity and allows for the drainage
that might occur associated with acute diverticulitis, Crohns ofmultiple abscesses. Subphrenic abscesses and right subhe-
disease, and interloop collections. These may well respond to patic abscesses may also be approached by lateral abdominal
antibiotics alone, and the use of percutaneous drainage may incisions. Once abscess cavities are identified, they are entered
be meddlesome and potentially morbid.31 and drained quickly to minimize spillage and contamination
There are circumstances where percutaneous drainage of the rest of the peritoneal cavity. The abscess cavity should
should be considered contraindicated. Most important then be widely opened. Specimens should be sent for Grams
among these is the circumstance where peritoneal infection stain and culture. Copious warm irrigation must be used at
is not localized, such as in the early postsurgical period where the end of the operation to properly cleanse the abdominal
an anastomotic leak leads to diffuse peritonitis. Abdominal cavity. Closed-suction drains should be placed in dependent
CT scans performed in this scenario may demonstrate one or positions to reduce the risk of reaccumulation. In extremely
more discrete fluid collections. When there is diffuse perito- contaminated cases, the incision may be left open and packed
neal irritation on clinical examination, fluid collections distant to prevent wound infection.
from the anastomosis, or the presence of massive intraperito-
neal air, surgical intervention is clearly indicated. Attempts
to manage such situations with percutaneous interventions
invariably lead to delayed definitive surgical management and ENTERIC FISTULAS
adverse outcome.
Introduction
SURGICAL DRAINAGE
A fistula is defined as an abnormal communication
As stated previously, percutaneous drainage is the procedure of between two epithelial surfaces. Enteric fistulas may arise
choice for the majority of intra-abdominal abscesses, with the in a number of settings: (1) diseased bowel extending to
surrounding epithelialized structures; (2) extraintestinal Classification

disease eroding into otherwise normal bowel; (3) surgical
trauma to normal bowel including inadvertent or missed Fistulas involving the alimentary tract have traditionally been
enterotomies; or (4) anastomotic disruption following classified in three distinct ways: by the etiology responsible
surgery for a variety of conditions. The first two generally for their formation, that is, spontaneous versus postopera-
occur spontaneously, while the latter two occur following tive, by the anatomy of the structures involved, and finally by
surgical procedures. For the surgeon, the latter two are the amount and composition of drainage from the fistula. Such
generally more problematic, in part because they are iatro- distinctions may provide important prognostic information
genic complications of surgery, but also because their early about the physiologic impact of fistulas and the likelihood
management often requires treatment of the critically ill that they will close without surgical intervention.
patient with sepsis.
While this chapter overviews general considerations SPONTANEOUS VERSUS POSTOPERATIVE
regarding the pathophysiology and management of enteric
fistulas, it focuses on postsurgical enteric fistulas, particu- Enterocutaneous fistulas may be classified as either spon-
larly fistulas to the skin, that is, enterocutaneous fistulas. In taneous or postoperative. Approximately three-quarters of
this particular patient population, the mortality rate remains fistulas occur in the postoperative setting, most commonly
high, between 3 and 22% in series dating back six decades, subsequent to procedures performed for malignancy, inflam-
largely due to the frequent complications of sepsis and matory bowel disease (IBD), or adhesive bowel obstruction.32
malnutrition (Table 10-5). Successful outcome requires a These fistulas become evident to the surgeon in a number
multidisciplinary team of health care workers, including sur- of different ways: (1) They may occur in the early postop-
geons, infectious disease specialists, intensivists, radiologists, erative period as a septic complication of surgery, sometimes
nurses, enterostomal therapists, and nutrition specialists. with catastrophic physiological deterioration. This is usually
Management of these patients must also take into account a result of uncontrolled diffuse intra-abdominal infection
the psychosocial and emotional needs of the patient and his/ caused by anastomotic leakage, breakdown of enterotomy
her family through a prolonged and often complex treatment closure, or a missed enterotomy. (2) They may occur in a
course. more delayed manner, following treatment of a postsurgical
One of the challenges in attempting to discern optimal infection with percutaneous drainage of a deep abscess or
management of these patients relates to the quality of the opening of a superficial wound infection may reveal that an
medical literature. Most reports are retrospective reviews underlying connection to the GI tract as a cause. (3) They
of large case series emanating from referral institutions. may occur very late after the surgery due to unanticipated
Notwithstanding this shortcoming, these series pro- injury to the GI tract. The development of a wound infection
vide general approaches to therapy, which help to guide following use of mesh for hernia repair would fall into this
treatment. category either through erosion of mesh into bowel or due
TABLE 10-5: COLLECTED SERIES OF OUTCOMES IN PATIENTS WITH OPERATIVE REPAIR OF

ENTEROCUTANEOUS FISTULAS
No. (%)
Source Period Definitive Operation Recurrence Death

Edmunds et al, 1960
32
19461959 67 8 (12) 10 (15)
Soeters et al, 33 1979 19601970 76 13 (17) 11 (14)
Reber et al, 34 1978 19681977 108 22 (20) 22 (20)
Aquirre et al, 35 1974 19701973 38 8 (30) 6 (22)
Soeters et al, 33 1979 19701975 88 19 (22) 18 (20)
Conter et al, 36 1988 19781986 46 5 (11) 4 (9)
Hollington et al,37 2004 19922002 167 55 (33) 5 (3)a
Lynch et al, 38 2004 19942001 203 42 (21) 6 (3)
Draus et al,39 2006 19972005 77 8 (11) b
Visschers et al,40 2008 19902005 107 10 (9) 13 (12)

Brenner et al,41 2009 19892005 135 23 (17) 11 (8)
a
These deaths were fistula related within 30 days of surgery.
b
The number of deaths in patients who were operated on could not be determined in this study.
Adapted from Brenner M, Clayter JL, Tillou A, et al. Risk factors for recurrence after repair of enterocutaneous fistula. Arch Surg. 2009;144:500505, with permission.
to iatrogenic injury to the bowel as one attempts to debride when the tube had been in situ for more than 9 months.49 The
infected mesh. Overly aggressive management of an open rate of gastrocutaneous fistula following operations for non-
abdominal wound can also lead to intestinal injury and fistula malignant processes such as ulcer disease, reflux disease, and
formation. This complication has been reported to occur in obesity is between 0.5 and 3.9%.50 The recent rapid increase in
up to 25% of patients during treatment with an open abdo- the number of bariatric surgical procedures was anticipated to
men for abdominal sepsis.42 lead to an increase in the incidence of gastrocutaneous fistula
The remaining 25% of fistulas occur spontaneously, that following surgery for benign disease, as the rate of anasto-
is, without an antecedent surgical intervention. These fistu- motic leakage after gastric bypass surgery is 25%. One study
las often develop in the setting of cancer or inflammatory has reported that approximately 10% of patients with staple
conditions. Fistulas occurring in the setting of malignancy or line leaks go on to form chronic fistulas, making the overall
irradiation are unlikely to close without operative interven- rate less than 0.5%.51 Fistula formation following resection
tion. Inflammatory conditions such as IBD, diverticular dis- for gastric cancer remains a dreaded complication with sig-
ease, perforated ulcer disease, or ischemic bowel can result in nificant mortality rates. Spontaneous gastrocutaneous fistulas
fistula development.43 Of these, fistulas in patients with IBD are uncommon but can result from inflammation, ischemia,
are most common; these fistulas may close following a pro- cancer, and radiation.
longed period of parenteral nutrition, only to reopen when
enteral nutrition resumes.33 Duodenal Fistulas. The majority of duodenocutaneous
fistulas develop after distal or total gastric resections or sur-
gery involving the duodenum or pancreas. Inadvertent injury
ANATOMIC CLASSIFICATION
to or intentional excision of a portion of the duodenum dur-
Fistulas may communicate with the skin (external fistulas: ing surgery of the colon, aorta, kidney, or biliary tract may
entero- or colocutaneous fistulas) or other intra-abdominal also result in fistula formation. Spontaneous cases resulting
or intrathoracic organs (internal fistulas). Internal fistulas that from trauma, malignancy, Crohns disease, and ulcer disease
bypass only short segments of bowel may not be symptom- account for the remaining duodenal fistulas.52,53 Prognosti-
atic; however, internal fistulas of bowel that bypass significant cally, duodenal fistulas segregate into two groups: lateral
length of bowel or that communicate with either the bladder duodenal fistulas and duodenal stump fistulas. Some authors
or vagina typically cause symptoms and become clinically evi- have reported a decreased spontaneous closure rate with lat-
dent. Identification of the anatomic site of origin of external eral duodenal fistulas when compared to that with duodenal
fistulas may provide further information on the etiology and stump fistulas.32,54
management of the fistula.
Small Bowel Fistulas. Fistulas arising in the small bowel
Oral, Pharyngeal, and Esophageal Fistulas. Radical account for the majority of gastrointestinal-cutaneous
resections and reconstructions for head and neck malignancy fistulas, the majority of which (7090%) occur in the post-
may be complicated by postoperative fistulas in 525% of operative period.33,34,55 Postoperative small bowel fistulas
cases.44 Alcohol and tobacco use, poor nutrition, and preop- result from either disruption of anastomoses (either small
erative chemoradiation therapy all contribute to poor wound bowel anastomoses or small bowel to colon anastomoses)
healing and increase the risk of fistula formation. Failure of or inadvertent and unrecognized injury to the bowel dur-
closure of the pharyngeal defect at the base of the tongue ing dissection or closure of the abdomen. Operations for
most commonly leads to fistula formation, and free micro- cancer, IBD, and adhesiolysis for bowel obstruction are
vascular flaps are the preferred method for closure. Brown the most common procedures antecedent to small bowel
and colleagues reported a significantly decreased postopera- fistula formation. As noted previously, spontaneous small
tive fistula rate in patients who underwent free flap closure bowel fistulas arise from IBD, cancer, peptic ulcer disease,
versus those with pedicled pectoralis flap closure, 4.5 versus or pancreatitis. Crohns disease is the most common cause
21%, respectively.45 Most esophagocutaneous fistulas result of spontaneous small bowel fistula. The transmural inflam-
from either breakdown of the cervical anastomosis following mation underlying Crohns disease may lead to adhesion of
resection of esophageal malignancy or following esophageal the small bowel to the abdominal wall or other abdominal
trauma. Less common causes of oropharyngeocutaneous or structures. Microperforation may then cause abscess for-
esophagocutaneous fistula include tuberculosis, laryngeal mation and erosion into adjacent structures or the skin.
or thoracic surgery, trauma, congenital neck cysts, anterior Approximately half of Crohns fistulas are internal and half
cervical spine fusion, and foreign body perforations.4648 are external.5658 Crohns fistulas typically follow one of two
courses. The first type represents fistulas that present in the
Gastric Fistulas. The most commonly reported proce- early postoperative period following resection of a segment
dure associated with gastrocutaneous fistula formation is of diseased bowel. These fistulas arise in otherwise healthy
the removal of a gastrostomy feeding tube, particularly in bowel and follow a course similar to non-Crohns fistulas
children. The duration of gastrostomy tube placement appears with a significant likelihood of spontaneous closure. The
to be related to the likelihood of development of a fistula after other group of Crohns fistulas arises in diseased bowel and
tube removal, with nearly 90% of children developing a fistula has a low rate of spontaneous closure.
Appendiceal Fistulas. Fistulas of appendiceal origin may

result from drainage of an appendiceal abscess or post- TABLE 10-6: PREDICTED OUTPUT AND
appendectomy in a patient either without or with Crohns ELECTROLYTE COMPOSITION OF FISTULAS
ACCORDING TO LOCATION
disease.59,60 In the latter case, the fistula often originates
from the terminal ileum, not the cecum. The inflamed ileum Volume
adheres to the abdominal wall closure and subsequently Source (mL/d) pH Na K HCO3 Cl
results in fistula formation.
Gastric 20002500 <4 60 10 90
Colonic Fistulas. While spontaneous fistulas of the colon >4 100 10 100
may result from inflammatory conditions such as diverticu- Pancreatic 1000 140 5 90110 3045
litis, appendicitis and IBD, or from advanced malignancy, Bile 1500 140 5 35 100
the majority of colocutaneous fistulas are postsurgical, usu- Small bowel 3500 100130 15 2535 100140
ally secondary to anastomotic breakdown following colonic All values for sodium, potassium, bicarbonate, and chloride given in
resection for one of these conditions. Preoperative radiation milliequivalents per liter.
Adapted from Evenson AR, Fischer JE. Current management of enterocutaneous
therapy reduces the risk of local recurrence and death from fistula. J Gastrointest Surg. 2006;10:455.
advanced rectal cancer and is an accepted practice.61 However,
radiation therapy contributes to both spontaneous and post-
operative colocutaneous fistulas. Russell and Welch authors
reported a 31% incidence of breakdown of primary anasto- close spontaneously. These fistulas, while initially high out-
moses performed in irradiated tissues with resulting sepsis or put, will often close because of favorable local conditions. In
fistula formation.62 essence, prediction of closure should be based on the local
conditions, and particularly the nature of the fistula rather
than the output. To the extent that the output often reflects
PHYSIOLOGIC CLASSIFICATION
the nature of the fistula, it will then be predictive.
Traditionally, fistulas have been classified into high-output
(>500 mL/d), moderate-output (200500 mL/d), and low-
output (<200 mL/d) groups. Enterocutaneous fistulas cause Predicting Closure of
the loss of fluid, minerals, trace elements, and protein, and, Enterocutaneous Fistulas
when improperly managed, they can result in profound irri-
tation of the skin and subcutaneous tissues. Depending on Spontaneous closure of enterocutaneous fistulas without the
the origin of the fistula and its anatomy, the amount ofout- need for major surgical intervention is clearly a desirable
put and nature of the effluent may be estimated (Table 10-6). outcome for these patients. The precise probability of spon-
However, direct measurement of these parameters for an indi- taneous closure is somewhat difficult to assess since the large
vidual fistula allows for accurate replacement and an under- series reporting management of fistulas are usually derived
standing of the physiologic and metabolic challenges to the from specialty centers for fistula management and thus not
patient. Classification of enterocutaneous fistulas by the vol- only represent a biased sample but also reflect differences in
ume of daily output provides information regarding mortality referral practice. Thus, spontaneous closure has been reported
and has been used to predict spontaneous closure and patient to occur in 1075% of patients.36,39,40,66,67 Nevertheless, a
outcome.32,6365 In the classic series of Edmunds and associ- number of factors have been suggested to be predictive of
ates, patients with high-output fistulas had a mortality rate failure of spontaneous closure of fistulas (Table 10-7). Some
of 54%, compared to a 16% mortality rate in the low-output of these factors are modifiable, for example nutritional status,
group.32 More recently, Levy and colleagues reported a 50% presence of local infection, and foreign bodies, while many
mortality rate in patients with high-output fistulas, while do not include location, presence of an open wound, and the
those with low-output fistulas had a 26% mortality.63 Soeters presence of distal obstruction. Knowledge of these factors
and coworkers reported no association between fistula output should prove to be helpful in discussion of outcome with the
and rate of spontaneous closure,33 while multivariate analysis patient and family members, as well as with the multidisci-
by Campos and associates suggested that patients with low- plinary team.
output fistulas were three times more likely to achieve clo-
sure without operative intervention.65 The reason for these
different closure rates most likely relates to the nature of the Risk Factors and Prevention of
particular fistula, rather than the volume of output per se. If Enterocutaneous Fistulas
the fistula totally diverts flow, for example a pouting small
bowel opening in the center of an open abdomen, it will be The majority of enterocutaneous fistulas arise in the post-
both high output and unlikely to close, without these two operative period, often related to leakage of small bowel/
factors being causally related. By contrast, a defect at a small colonic anastomoses or enterotomy closure. A number of
bowel anastomotic site with a long fistula tract and no local factors have been associated with postsurgical enteric leaks.
infection will likely be walled off by surrounding tissues and These can be divided into patient factors such as old age,
to buttress a colonic anastomosis did not reduce the rate of

TABLE 10-7: FACTORS THAT PREDICT postoperative radiological leaks, alter mortality or change the
FAILURE OF SPONTANEOUS FISTULA need for reoperation.70 However, while omentoplasty per se
CLOSURE
does not reduce the probability of anastomotic leakage, inter-
Distal obstruction position of an omental flap to separate the anastomosis from
Local infection the abdominal incision may lessen the probability of injur-
Foreign body ing the bowel during closure or of an enterocutaneous fistula
Open abdomen should anastomotic leakage occur. A recent study pooling the
Epithelialized tract data from five European randomized clinical trials studying
Fistula characteristics: rectal cancer care demonstrated that diverting stomas reduced
Multiple fistula openings the rate of symptomatic anastomotic leaks and improved
Defect >1 cm overall survival but had no effect on cancer-specific survival.71
Short fistula tract The differential survival was primarily attributable to early
Abnormal bowel at origin of fistula (radiation, inflammatory bowel postoperative mortality. Proximal diverting colostomy or
disease) ileostomy may allow sufficient anastomotic healing prior to
Profound malnutrition suture-line challenge by luminal contents.
High-output fistula
Jejunal origin of fistula
Adapted from Evenson AR, Fischer JE. Current management of enterocutaneous
Approach to Management
fistula. J Gastrointest Surg. 2006;10:455.
An organized treatment approach is of paramount importance
to ensuring the optimal patient outcome. Table 10-4 lists
overall mortality of patients presenting with enterocutaneous
immunosuppression, malnutrition, emergency surgery, and fistulas from a number of reports dating back six decades.
peritoneal contamination, and surgical factors such as emer- Overall, the more recent studies appear to be associated with
gency surgery, level of anastomosis, preoperative radiation, a lesser mortality rate, presumably a result of improvements
duration of surgery, blood loss, tension on anastomosis, in imaging, fluid resuscitation, antibiotic management, and
inadequate blood supply to anastomosis, and technical error intensive care support. However, the ultimate goals in treat-
in suturing or stapling. Use of mechanical bowel prepara- ing patients with enterocutaneous fistulas are closure of the
tion, anastomotic technique (stapled vs hand-sewn; single fistula with abdominal wall closure and return to baseline
vs double layer), and omentoplasty has not been shown to functioning level. Evenson and Fischer72 outlined five distinct
influence anastomotic integrity. A recent meta-analysis in phases of management that can be used to guide care of this
2008 of 13 trials and 4601 patients showed no difference in patient population. These phases are discussed in detail and
the anastomotic leak rate when a mechanical bowel prepara- also summarized in Table 10-8.
tion was used compared to when it was not used in elective
colon resection.68
PHASE 1: RECOGNITION AND STABILIZATION
Clearly, optimization of modifiable factors will serve to
reduce anastomotic leak. In the elective setting, operations Identification and Resuscitation. As noted in the
may be delayed to allow for normalization of nutritional Introduction, the clinical presentation of patients with entero-
parameters, thus optimizing wound healing and immune cutaneous fistulas depends on the underlying pathophysi-
function. In emergency operations, the luxury of optimizing ological process. Invariably, the patient who develops a
nutritional status preoperatively is not possible. Instead, postoperative enterocutaneous fistula will do well clinically
emphasis should be on adequate resuscitation and restoration for the first few days after operation. Within the first week,
of circulating volume, normalization of hemodynamics, and however, the patient may suffer delayed return of bowel func-
use of appropriate antibiotic therapy. tion, as well as fever and leukocytosis, together suggestive of
Once a patient has been optimized preoperatively, atten- intra-abdominal infection. This setting will usually prompt a
tion is then turned to operative techniques to minimize the request for an abdominal CT scan that demonstrates a peri-
development of a fistula. Performance of anastomoses in anastomotic abscess. Percutaneous drainage for therapeutic
healthy, well-perfused bowel without tension provides the best management of the abscess will serve to confirm anastomotic
chance for healing. Testing of the rectal and sigmoid anasto- disruption, either immediately or a few days later when there
moses with intraoperative air insufflations has been shown to is evidence of enteric content. Occasionally, erythema of the
reduce radiologic leak rate through guiding placement of wound develops and opening the wound reveals purulent
additional sutures as needed.69 Careful hemostasis to avoid drainage that is soon followed by enteric contents. In both
postoperative hematoma formation will decrease the risk of these circumstances, the peritoneal host defenses have suc-
abscess, while inadvertent enterotomies and serosal injuries cessfully walled off and contained infection. By contrast, in
should be identified and repaired. A recent meta-analysis some patients, diffuse peritoneal contamination arising from
based on three randomized trials showed that omentoplasty a leaking anastomosis or enterotomy causes profound and
TABLE 10-8: APPROACH TO MANAGEMENT OF ENTEROCUTANEOUS FISTULAS
Phase Goals Time Course

Recognition/stabilization Resuscitation with crystalloid, colloid, or blood 2448 h
Control of sepsis with percutaneous or open drainage and antibiotics
Electrolyte repletion
Provision of nutrition
Control of fistula drainage
Commencement of local skin care and protection
Investigation Fistulogram to define anatomy and characteristics of fistula 710 d
Other GI studies
CT scan to define pathology
Operative notes from prior surgery
Decision Evaluate the likelihood of spontaneous closure 10 d6 wk
Decide duration of trial of nonoperative management When closure, unlikely or after 46 wk
Definitive management Plan operative approach
Refunctionalization of entire bowel Surgical intervention at 36 mo after
Resection of fistula with end-to-end anastomosis patient stabilized
Secure abdominal closure
Gastrostomy and jejunostomy
Postsurgical Usual postoperative protocol Ensure access to ICU for management of
Psychological and emotional support potential complication
Team approach to management facilitates
recovery
CT, computed tomography; GI, gastrointestinal; ICU, intensive care unit.
Adapted from Evenson AR, Fischer JE. Current management of enterocutaneous fistula. J Gastrointest Surg. 2006;10:455.
rapid deterioration of the patient with diffuse abdominal ten- Control of Sepsis. Uncontrolled infection with the
derness, evidence of organ dysfunction, and hemodynamic development of a septic response and the concomitant
instability. Usually, these patients exhibit signs of organ dys- fluid imbalance and malnutrition are the leading causes of
function in the days prior to their catastrophic deterioration, mortality in modern series of enterocutaneous fistulas. The
including reduced level of consciousness, tachycardia, and leakage of enteric contents outside of the bowel lumen may
mild renal impairment. The diagnosis then becomes clear lead to a localized abscess or to generalized peritonitis. Percu-
and management shifts from routine postoperative care to taneous management of localized abscesses accompanied by
the management of a potentially critically ill patient. As with appropriate antibiotic therapy and supportive measure is usu-
all critically ill patients, attention should turn to management ally sufficient to resolve infection in this subgroup. Diffuse
of the ABCs. The patient with a localized collection or one peritoneal infection represents a much greater management
that has necessitated into the wound can usually be managed challenge. In general, the generalized nature of the infection
on the ward, while the patient with a more significant septic precludes successful therapy with percutaneous drainage and
response may require transfer to an intensive care unit (ICU) therefore an operative approach is indicated. Particularly in
setting. In both scenarios, restoration of intravascular volume the early postoperative period, the surgeon should be wary
usually crystalloid is appropriate with or without inotropic of attempting to treat multiple intra-abdominal fluid collec-
support as determined by physiologic monitoring. A recent tions observed on CT scan with percutaneous drains, when
Cochrane Database Systematic Review showed no difference in surgical intervention is required for definitive management.
outcome in critically ill patients managed with crystalloid ver-
sus colloid and therefore recommended crystalloid as the pref- Surgical Approach. The goals of operative management
erable resuscitation fluid.73 The initiation of broad-spectrum of peritonitis are to eliminate the source of contamination,
antibiotic therapy should occur early and be directed toward reduce the bacterial inoculum, and prevent recurrent or
the most likely pathogens involved. Patients with postopera- persistent infection. The operative technique used to con-
tive peritonitis have increased probability of having multire- trol contamination depends on the location and the nature
sistant microorganisms and should receive broader-spectrum of the pathological condition in the GI tract.43 For patients
antibiotics. The consensus guidelines published by the Surgi- progressing to diffuse peritonitis in the early postoperative
cal Infection Society/Infectious Diseases Society of America period, the abdomen is usually reentered through the previ-
address antimicrobial options for these severe health care ous incision with the discovery of pus and enteric content.
associated infections21 (see Tables 10-2 and 10-3). After aspiration of the fluid, an exploration to find the source
of contamination is warranted. Anastomotic dehiscence/ promotion of closure. For example, Wainstein and coauthors
enterotomy should generally be managed by exterioriza- reported promising results after reviewing their 10-year expe-
tion of the affected bowel. Whether this is performed via a rience with it. In this study, fistula output was profoundly
single stoma site or with separate stomas (ie, end stoma plus suppressed soon after commencing use of the device and
mucous fistula) depends on the specific scenario. Obviously, spontaneous closure was achieved in 46% of patients. The
if one is able to exteriorize the intestinal defect, the likeli- use of a vacuum-assisted device was also found to reduce
hood of a postoperative enteric fistula is markedly reduced. It thefrequency of wound dressing changes and improve der-
is attractive to hope that a surgically repaired enterotomy or matitis in all cases.76 These findings are consistent with most
leaking enterotomy might heal primarily, given the obvious surgeons anecdotal experience with vacuum treatment. Some
simplicity of the procedure. However, this is rarely successful authors have reported a small number of patients developing
in the setting of diffuse peritoneal infection, and therefore new enteric fistulas with the vacuum device. Therefore, some
this approach is not recommended. Reoperation after this judgment is required in patient selection; presumably stabi-
misjudgment is fraught with potential difficulty, in that the lized patients with some granulation overlying the exposed
surgeon is faced with the need to reoperate on the patient in bowel may be appropriate.77,78
the early postoperative period. This laparotomy is invariably
more difficult, often associated with bleeding, further entero- Reduction in Fistula Output. While fistula output does not
tomies, and a bowel that is extremely difficult to exteriorize. correlate with the rate of spontaneous closure, reduction in fis-
Under these circumstances, there should be consideration of tula drainage may facilitate wound management and decrease
a proximal defunctioning stoma if technically feasible. These the time to closure. Further, reduced output enhances the
cases are frequently the ones associated with inability to close ease of fluid and electrolyte management and may make local
the abdominal wall. wound care easier. In the absence of obstruction, prolonged
A number of anatomical circumstances may also preclude nasogastric drainage is not indicated and may even contrib-
exteriorization of a leaking anastomosis. The principle of ute to morbidity in the form of patient discomfort, impaired
defunction and drain is appropriately applied in this set- pulmonary toilet, alar necrosis, sinusitis or otitis media, and
ting. Most important among these is the rectal or sigmoid late esophageal stricture. Measures to decrease the volume of
anastomosis where the distal end can be neither exteriorized enteric secretions include administration of histamine antag-
nor closed. Unless the anastomosis is greater than 50% dis- onists or proton pump inhibitors. Reduction in acid secre-
rupted, it is reasonable to defunction with an ileostomy or a tion will also aid in the prevention of gastric and duodenal
colostomy upstream and drain the site of the hookup. This ulceration as well as decrease the stimulation of pancreatic
approach is preferred as it increases the probability of future secretion. Antimotility agents such as loperamide and codeine
restoration of the GI tract. This is particularly true of leaks may also be effective.
below the peritoneal reflection.74 If the anastomosis is almost As inhibitors of the secretion of many GI hormones,
completely disrupted, the surgeon is obliged to perform an somatostatin, and octreotide were postulated to promote
end stoma and drain the pelvis, as the preserved anastomosis nonoperative closure of enterocutaneous fistulas. As recently
would stricture and preclude later stoma closure. reviewed, these agents did not accomplish this, although the
data suggest that fistula output is reduced and time to sponta-
Control of Fistula Drainage and Skin Care. Concurrent neous closure is lessened.79 This effect is more pronounced with
with drainage of sepsis, a plan to control fistula drainage and somatostatin infusion than with its longer-acting analogue,
provide local skin care will prevent continued irritation of the octreotide. Infliximab, a monoclonal antibody to TNF-, has
surrounding skin and abdominal wall structures. Obviously, been shown to be beneficial in inflammatory and fistulizing
fistulas created following percutaneous drainage of abscesses IBD.80 In a randomized trial of patients with chronic fistulas
are usually well managed by the drain itself. Indeed, the (duration >3 months), administration of infliximab resulted
drainage of a local infection is frequently sufficient to permit in a significantly increased rate of closure of all fistulas when
closure of the fistula. For small low-output fistulas, dry dress- compared to placebo.80 Some evidence suggests a role for inflix-
ing may suffice. In less controlled circumstances, particularly imab in treatment of fistulas complicating IBD and its use has
in the setting of the open abdomen, control of the effluent been reported to promote healing of persistent fistulae even in
is not straightforward and must be managed aggressively. A non-IBD patients.81 A number of other approaches to manag-
skilled enterostomal therapist can often provide useful insight ing fistula output and promoting closure have been reported.
into these issues and should work in concert with a dedicated These include endoscopic injection of fibrin glue into identi-
nursing team.75 The goals of therapy are to protect the skin, fied fistula openings,82 radiologically guided percutaneous Gel-
accurately monitor output, and minimize patient anxiety foam embolization of the enteric opening,83 and the insertion
over effluent control. Use of a drainable wound pouch that of an absorbable fistula plug using a combination of percutane-
is tailored to the size of the open wound is effective. This is ous and endoscopic approaches.84 All three involve the plug-
often combined with some of colloid paste to protect skin ging of the opening with a biological material, presumably
and have an improved base on which to secure the stoma. with the expectation of tipping the local conditions toward
Vacuum-assisted closure devices have been reported to aid healing. These low-morbidity techniques may therefore be
in the care of these complicated wounds, including the considered as adjuvant considerations for fistula management.
One would speculate that their greatest efficacy would be in the In patients with high-output proximal fistulas, it has been
setting of a long tract, without epithelialization and with low suggested to provide enteral nutrition by a technique called
output. Recently, endoscopic insertion of a silicone-covered fistuloclysis. In fistuloclysis, an enteral feeding tube is placed
stent across the fistula opening related to gastrojejunal leak directly into the matured high-output fistula.88 Teubner et al
following gastric bypass surgery has been described as a means reported on their experience using fistuloclysis in 12 patients
of allowing early feeding and promoting fistula closure.51 One before reconstructive surgery.89 Eleven of twelve patients were
well-documented and potentially morbid complication of the able to discontinue parenteral support and nutritional status
stent use is its downstream migration with obstruction and was maintained until surgery in nine patients (19422 days)
erosion of the intestine. Clearly, no consensus regarding use and for at least 9 months in the two patients who did not
of this approach has been achieved, given the small patient undergo operative intervention.89 Of note, surgeons in this
numbers described. study also reported improved bowel caliber, thickness, and
ability to hold sutures in patients who had received enteral
Nutritional Support. Provision of nutritional support and nutrition.89 Other measures such as the use of recombinant
time may be all that are necessary for spontaneous healing of human growth hormone (rGH) on fistula patients have been
enterocutaneous fistulas. Alternatively, should operative inter- examined. While able to promote intestinal mucosal epithe-
vention be required, normalization of nutritional parameters lial cell proliferation; increase levels of total proteins, albumin,
will optimize patients in preparation for their surgery. Malnu- fibronectin, and prealbumin; and transfer and reduce nitro-
trition, identified by Edmunds in 1960 as a major contributor gen excretion, its clinical role has not been clearly defined.90
to mortality in these patients, may be present in 5590% of
patients with enterocutaneous fistulas.33 Patients with post- Psychological Support. Patients who develop postoperative
operative enterocutaneous fistulas are often malnourished enterocutaneous fistulas require considerable psychological
due to a combination of poor enteral intake, the hypercata- support. They have sustained a major complication of surgery
bolic septic state, and the loss of protein-rich enteral contents and are frequently faced with prolonged postoperative stay,
through the fistula and via the open abdominal wall. The opti- excessive abdominal discomfort, and potentially one or more
mal route of nutrition in the management of enterocutaneous additional surgical interventions. In aggregate, all of these fac-
fistulas has not been critically studied. Parenteral nutrition tors lead to psychological distress for patient and their families
has long been the cornerstone of support for patients with and should be addressed once the acute disease is dealt with.
enterocutaneous fistulas.33,8587 This, in part, is related to the
fear that early enteral feeds will exacerbate the fistula through PHASE 2: INVESTIGATION
increasing output and also that enteral feeds may not be an
adequate form of nutritional support. Parenteral nutrition can Once the patient has been stabilized with control of sepsis
be commenced once sepsis has been controlled and appro- and commencement of nutritional support, early radiologi-
priate intravenous access has been established. Transition to cal investigation may be of value. Abdominal CT scanning
partial or total enteral nutrition has been advocated in recent with GI contrast with help to discern whether there is resid-
reports to prevent atrophy of GI mucosa as well as support the ual local infection that requires drainage, to localize the level
immunologic and hormonal functions of the gut and liver. of the fistula and the amount of contrast flowing beyond the
Additionally, parenteral nutrition is expensive and requires defect, and occasionally whether there is distal obstruction.
dedicated nursing care to prevent undue morbidity and mor- Fistulograms down drainage tracts will elucidate the length,
tality from line insertion, catheter sepsis, and metabolic com- course, and relationships of the fistula tract. If the fistula is
plications. Thus, attempting enteral feeding is appropriate in spontaneous, the nature of the local pathological process from
most fistula patients. As achieving goal rates of enteral feeding which the fistula arises may be determined. In the setting
may take several days, patients are often maintained on paren- where the mucosal bud of the fistula is readily observed in
teral nutrition as tube feedings are advanced. Enteral feeding the center of an open abdomen, aside from a CT scan to rule
may occur per os or via feeding tubes placed nasogastrically out distant infection, little further early imaging is required.
or nasoenterically. Enteral support typically requires 4 ft of Because patients with enterocutaneous fistulas are frequently
small intestine and is contraindicated in the presence of dis- referred to larger centers for management, it is essential that
tal obstruction. Drainage from the fistula may be expected to all notes, particularly operative notes, be obtained from the
increase with the commencement of enteral feeding, although referring hospital. Personal communication with the surgeon
this does not uniformly occur and is often dependent on fis- may further elucidate other factors in the patients disease
tula location and size of the fistula defect; however, spontane- that are not readily evident from the notes.
ous closure may still occur, often preceded by a decrease in
fistula output. When parenteral and enteral nutrition are both
options, the latter is preferred. It is far less expensive, safer, PHASE 3: DECISION
and is easier to administer (particularly if the intent is to man- Spontaneous closure of fistulas restores intestinal continuity
age the patient as an outpatient). A meta-analysis by Gramlich and allows resumption of oral nutrition. As noted previously,
etal19 indicated that ICU patients receiving enteral feeds have the rate of spontaneous closure varies considerably from
a lesser infection rate than those receiving parenteral feeds. series to series, with an average of approximately one-third
of patients. This wide range likely represents patient selec- will influence where, in this interval, surgery is performed.
tion in the various series, and in particular whether the series Patient factors such as nutritional status, ease of managing the
emanates from a referral center where the patient population fistula, and family support may influence decision making.
tends to be more complex. A number of factors predict spon- Some authors talk about the soft abdomen and prolapse
taneous closure. These are listed in Table 10-7. One might of the fistula as being a valuable clinical signs that peritoneal
consider two case scenarios to illustrate these points. A long, conditions are reasonable to proceed with surgery.37 On occa-
narrow fistula tract originating from a small leak in a colonic sion, there is intense pressure from the patient and family to
anastomosis with no evidence of distal obstruction and a reoperate and fix the fistula during this early period. This
well-drained perianastomotic abscess is almost certain to approach should be resisted.
close spontaneously. By contrast, a small bowel defect reveal-
ing itself as a mucosal bud in the middle of an open abdo-
PHASE 4: DEFINITIVE MANAGEMENT
men is unlikely to heal as the tract is short and epithelialized,
in essence mimicking a stoma. Fistulas associated with IBD Operations repairing enterocutaneous fistulas may be com-
often close with nonoperative management only to reopen plex and often lengthy. In addition to repairing the fistula,
upon resumption of enteral nutrition. These fistulas should many of these patients require complex abdominal wall
be formally resected once closed to prevent recurrence. closures. Before definitive management, the patient should
Fistulas in the setting of malignancy or irradiated bowel are have achieved optimal nutritional parameters and be free of
particularly resistant to closure and would suggest the need all signs of sepsis. Through careful management of fistula
for earlier operative intervention. drainage, a well-healed abdominal wall without inflamma-
Most authors agree that once resuscitation, wound care, tion should be present.
and nutritional support are established, 9095% of fistulas
that will spontaneously close typically do so within 48 weeks Consent. As for all operations, the patient should be fully
of the original operation.25,85 In the absence of closure, there apprised of the nature of the procedure and its potential for
should be consideration of surgical closure. Like any surgi- complications. Connolly and colleagues reported a very high
cal procedure, weighing of the risk and benefits of surgical incidence of complications following intestinal reconstructive
intervention is critical prior to proceeding to operation. This surgery (82.5% of procedures) when one considered
is particularly relevant in this patient population where the postoperative nosocomial infections including surgical site
surgical procedure is a major one and has a finite risk of recur- infections, respiratory infections, and central line sepsis
rence. Some patients are perfectly well, are tolerating a regular together with postsurgical myocardial dysfunction, GI bleed-
diet, and have fistula effluent that is trivial in volume and ing, and deep vein thrombosis.94 In discussions with patients
requires only coverage with dry gauze. The potential risks of and their families, the unique difficulty of these procedures
a major operation in this type of patient might outweigh the should be raised, pointing out the potential for adhesions
ultimate benefit. The timing of elective operative interven- and therefore inadvertent injury and excessive bleeding. The
tion for fistulas that are unlikely to or fail to close is extremely fistula recurrence rate is also significant with reported rates
important. Early operation is only indicated to control sep- up to 33% (see Table 10-5), depending on the individual cir-
sis not amenable to percutaneous intervention. These early cumstance. The patient and relevant family members should
procedures are typically limited to drainage of infected fluid know that the procedure may be prolonged and may require
collections and drainage, defunctioning, or exteriorization of an ICU stay in the postoperative period. Some of the anxiety
the defect. of the patient may be related to mistrust of physicians in gen-
There is some controversy in the literature as to how long eral following a previously complicated operation. Clearly,
one should wait before attempting definitive elective closure the sensitive nature of reoperation for prior complications
of enterocutaneous fistulae. Very early closure appears to be requires a strong physician-patient relationship to minimize
contraindicated because the patient condition is generally not patient anxiety prior to the planned procedure.
optimized. Further, from a technical standpoint, adhesions
tend to be dense and vascular, therefore rendering the proce- Patient Preparation. It is critically important for the
dure difficult. In one retrospective study, Keck et al observed operating surgeon to fully understand the nature of the prior
that operative difficulty and denser adhesions leading to inad- surgeries. Reviewing the previous operative notes as well as
vertent enteromies were more common when patients were speaking with the original surgeon will consolidate ones
taken to surgery for reversal of a Hartmanns procedure before knowledge of the initial pathological process and the precise
15 weeks compared to after.91 Poor outcome when surgery anatomy to be corrected in the reoperative setting. One should
is performed in the 2-week to 3-month window has been also be very liberal about using preoperative contrast imaging
report by several groups.38,92 At least two reports suggest that or endoscopy to completely define the anatomy. In the hypo-
a very long delay before definitive surgery (>36 weeks) might thetical case of reoperation after a colonic anastomotic dehis-
adversely affect outcome.41,93 It is generally recommended that cence, the need for definition of the anatomy varies accord-
definitive surgery be considered in the window of 36 months ing to the initial source control procedure. A prior operation
after the patient is stabilized from the initial recovery from the consisting of exteriorization of an end colostomy with nearby
procedure that lead to the fistula formation. Various factors mucus fistula or exteriorization of the disrupted anastomosis
is a circumstance where investigation is probably unnecessary. The use of the midline incision, beginning with entry
In preparation for closure of a Hartmanns procedure, the rec- either cephalad or caudad to this initial incision through an
tal stump should be routinely investigated by endoscopy. This unoperated field is the most common approach to reenter-
may help with planning of the operation as well as locating ing the abdomen. This approach provides broad access to the
the stump at surgery. Closure of a defunctioning ileostomy peritoneal cavity with opportunity for extension and is also
or colostomy should also be preceded by investigation of the readily closed. Other approaches may include unilateral or
downstream anastomosis. This is intended to rule out the bilateral subcostal incisions, transverse incisions, flank inci-
presence of a stricture or persistent defect at that site, both of sions, or thoracoabdominal incisions. In general, these should
which would alter surgical approach. Finally, contrast studies be considered when a specific area of the abdomen is oper-
are essential when complex fistulas exist and are to be treated ated on, because they generally afford less access to the overall
by reoperative surgery. peritoneal cavity. When placing new incisions, care should
The general principles related to preparation for any be taken not to render intervening tissue bridges ischemic.
surgery should be applied to reoperation. These would This might occur when a midline incision is placed adjacent
include optimization of the general medical status of the to a previous paramedian incision. It is preferable to use the
patient, administration of subcutaneous heparin and/or previous paramedian incision with extension into the midline
other antithrombotic strategies, and initiation of measures above or below. When the fistula opening is in the center of
aimed at reducing postoperative infectious complications. a reepithelialized section of the abdomen with no underlying
Orthograde intestinal lavage by mouth as well as distally fascia/muscle, one should preferably enter the abdomen as
via the defunctioned limb has been recommended for described above, either cephalad and caudad to the previously
mechanical preparation of the bowel. However, the evi- operated area. When this is not possible, one should consider
dence underlying this recommendation is limited and, in placing the initial incision along the line of the fascial edge,
fact, recent studies show that mechanical bowel prepara- rather than though the reepithelialized portion. In the latter
tion for elective colon surgeon does not improve outcome operative field, the skin may be very adherent to the underly-
and may have some deleterious effects.69 Our practice is to ing bowel, therefore increasing the chance of bowel injury.
forego the use of mechanical prep unless reconstruction This is particularly true when there is retained mesh, which
involves passage of stapling device transanally. Clearance of may have contributed to fistula formation in the first place.
inspissated mucus in the rectal stump with an enema may Upon entering the peritoneal cavity, adhesions between the
facilitate advancement of the stapler proximally. Finally, anterior abdominal wall and the underlying omentum and
prophylactic intravenous antibiotics with broad-spectrum bowel must be released. By 36 months following the initial
coverage of both facultative gram-negative enterics as well as surgery, adhesions are generally relatively filmy and readily
anaerobic bacteria are indicated. Consideration of coverage divided using scissor or cautery dissection. Gentle traction on
of resistant microbes should be made.21 the bowel with countertraction on the abdominal wall will
facilitate exposure of the appropriate tissue plane for division.
Operative Intervention. Patients should be positioned to A similar approach is appropriate for dense adhesions, with
permit optimal exposure to the field of surgery, to take into some surgeons preferring knife dissection. During this dissec-
account potential requirements for extension of the operation, it may be necessary to leave patches of abdominal wall
tive field, and to facilitate optimal reconstruction of the GI (peritoneum with or without fascia) or even mesh adherent to
tract and/or drainage of the operative field. In the majority bowel to avoid enterotomy. It is also noteworthy that enteroto-
of situations, the supine position is adequate. Concomitant mies may be caused by traction on the bowel due to retraction
lithotomy positioning is often helpful, particularly when on the abdominal wall. Clearance of the fascial edges along
reconstruction involves the left colon or rectum, where tran- both sides of the entire incision is necessary to achieve adequate
sanal access for endoscopy or stapling may be useful. When and safe closure of the abdominal wall.
reoperation involves the upper GI tract, left lateral decubitus Having successfully entered the abdominal cavity, one faces
positioning will allow an initial thoracoabdominal incision or varying degrees of interloop adhesions. The degree to which
extension of an abdominal incision into the chest. these must be lysed depends on the particular operation to be
Careful planning of the location and type of incision are performed. When one is operating on the colon for the pur-
mandatory prior to making the initial incision. It is preferable pose of stoma closure or reestablishment of colonic continuity,
to enter the peritoneal cavity through a previously unoperated there is generally little need to exhaustively take down small
area of the abdominal wall, thereby avoiding the areas where bowel adhesions. The fact that the patient has been tolerating
the most intense adhesions would be expected, that is, beneath a normal diet preoperatively provides ample evidence that the
the previous abdominal wall incision and in the region of the small bowel adhesions are not of physiological significance.
abdomen where the inflammation might have been the most While not having to lyse all adhesions, it is necessary, however,
severe. Inadvertent enterotomy is relatively common during to free small bowel loops from their attachments to the colon
reoperation, occurring in approximately 20% of patients, and so that the latter might be adequately mobilized to permit easy
is associated with a higher rate of postoperative complication closure or anastomosis. When operating to close a small bowel
and a longer postoperative hospital stay.95 In addition, it is a stoma or to correct an enterocutaneous fistula, when possible,
frustrating beginning to an often long and tedious operation. one should consider more comprehensive lysis of adhesions,
along the entire length of the small bowel, but in particular a flap of omentum between the fresh anastomosis and the
the distal small bowel. The presence of a stoma or fistula may abdominal wall closure may minimize recurrence of fistuliza-
serve to defunction a distal small bowel adhesive obstruction tion. Some have advocated the placement of a decompressive
prior to surgery and may therefore preclude its recognition. gastrostomy and/or the placement of a feeding jejunostomy,
The presence of a distal obstruction following upstream anas- both of which may aid in the postoperative care of patients
tomosis could prove catastrophic in the postoperative period. undergoing procedures of this scale.
Adhesiolysis varies considerably in its degree of difficulty. As the cumulative experience with complex laparoscopic
Even when the reoperation is appropriately delayed from the procedures has increased, several groups have reported laparo-
initial operative procedure and vascularized adhesions are no scopic approaches to enteric and enterocutaneous fistulas.97
longer present, the number and density of residual fibrous 102
The largest of these series reported 73 procedures in 72
adhesions may still be significant and represent a significant patients, 20% of which were enterocutaneous fistulas.101 The
technical challenge. As described for opening the peritoneal authors reported a mean operative time of 199 minutes with
cavity, good lighting of the operative field, excellent surgical a 4.1% conversion rate.101 Because surgical procedures for the
assistance, and a dose of patience are absolute requirements for management of enteric fistulas are generally complex ones, a
this part of the operation. Two experienced surgeons working laparoscopic approach would seem appropriate only in the
together facilitates adhesiolysis. During lysis of adhesions, one hands of a skilled and experienced laparoscopic surgeon and
should also be wary of encountering previous anastomoses. only in selected circumstances.
Adhesions may be particularly tenacious in these areas, particu-
larly when the prior anastomosis was performed using a stapled Abdominal Wall Closure. After the fistula has been appro-
technique. For side-to-side functional end-to-end stapled anas- priately managed, one is left with closure of the abdominal wall.
tomoses, the crotch of the anastomosis may be mistaken for The complexity of this aspect of the operation varies depending
intense adhesions. Failure to recognize this may result in inad- on the preoperative state of the abdominal wall. Closure may
vertent enterotomy and the attendant increased morbidity. be straightforward when the enterocutaneous fistula is along
When surgery has been timed appropriately, one usually a previous drain tract or through necessitation of an abscess
finds that the dissection distant from the fistula to be rea- through an abdominal wound. By contrast, when the prior
sonably straightforward. As one approaches the fistula site, patient management involved an open abdomen approach
it becomes increasingly tedious with multiple adherent loops with the fistula draining from the center of the wound, patients
of bowel. We recommend that the fistula be addressed rela- may present with large ventral hernias that are not amenable
tively late in the dissection, after most of the small bowel has to simple fascial closure. In advance of surgery, it is essential
been mobilized. This minimizes inadvertent injury to loops that the surgeon consider management of abdominal wall a
of bowel uninvolved in the fistula. significant part of the procedure and reflect upon the various
Several of the large case reviews address surgical technique surgical options. Included in these preoperative deliberations
and risk of recurrence.37,38,40,41 In general, it appears to be pref- should be the proactive involvement of a plastic surgeon to aid
erable to locally resect the segment of small bowel bearing the in the assessment of options and to potentially prepare him/
fistula rather than simply closing the intestinal opening. This her for involvement in the operation. Table 10-9 outlines the
may represent a biased finding since the instances where sim- various approaches. Prior to beginning abdominal wall closure,
ple closure was used correlated with the finding of an abdo-
men with impossibly dense adhesions, therefore precluding
mobilization and resection. Under these latter circumstances,
one might consider the addition of a temporary proximal TABLE 10-9: MANAGEMENT OF
defunctioning stoma. ABDOMINAL WALL FOLLOWING ELECTIVE
In the elective surgical setting, stapled anastomoses have CLOSURE OF GASTROINTESTINAL FISTULA
been shown to be equivalent to hand-sewn anastomoses in
terms of anastomotic dehiscence.96 By contrast, for closure No Preoperative Fascial Defect
of enterocutaneous fistulas, hand-sewn appears to be the t 1SJNBSZDMPTVSFXJUIPSXJUIPVUTPNFGBTDJBMSFMBYBUJPO
preferred approach to performing the anastomosis following Preoperative Fascial Defect
resection. Whether single layer versus two layers of sutures or t 4NBMMEFGFDU <5 cm)
running versus interrupted stitching should be used has not t 1SJNBSZGBTDJBMDMPTVSFXJUIPSXJUIPVUTPNFGBTDJBMSFMBYBUJPO
been systematically addressed. Frequently, the chronically t -BSHFEFGFDU
defunctioned bowel is atrophic, line-walled, and stiff. Under t 1SJNBSZGBTDJBMDMPTVSFVTJOHDPNQPOFOUTFQBSBUJPOUFDIOJRVF
these circumstances, the stapling devices are unable to accom- t *GWFSZMBSHF NBZCFDPNCJOFEXJUIQSPTUIFUJDNBUFSJBM
modate the pathological nature of this bowel, where hand t $PWFSBHFXJUIWBTDVMBSJ[FEBQ
sewing can better accommodate differences in size, thickness, t 6TFPGQSPTUIFUJDNBUFSJBM
and compliance of the intestine. t /POBCTPSCBCMF
Wrapping of the anastomosis with omentum has been t "CTPSCBCMF
examined as a means of preventing anastomotic leakagebut t /POCJPMPHJDBM
has not proven to be effective.71 However, placement of t #JPMPHJDBM
it is desirable to debride/remove any residual infected foci, treatment of fascial defects following repair of enterocuta-
including chronically infected suture material and previously neous fistulas.94,108
placed infected mesh. One should also attempt to position the In summary, management of the abdominal wall follow-
intestinal anastomosis away from the closure and, if possible, to ing reoperative surgery in these patients may be a consider-
interpose omentum between the anastomosis and the abdomi- able challenge. The major objective is to prevent recurrent
nal wall. Finally, it is generally considered that, in the setting fistula formation and minimize postoperative infection.
of GI surgery where there is contamination of the surgical Prevention of late ventral hernia formation is a secondary
field, the use of nonabsorbable permanent mesh is contraindi- goal. Involvement of a surgical team with expertise in the
cated as it is associated with an increased risk of infection and options, including the use of the component separation
refistulization.103 technique, would appear to broaden the clinical options for
When no defect or a small defect in the fascia exists, pri- the patient.
mary closure is usually achievable although there may be
some mild tension on the closure. This is, in part, related to
PHASE 5: POSTSURGICAL PHASE
the stiffness of the abdominal wall attendant with repeated
abdominal surgery. In these circumstances, relaxing inci- The postoperative period can be divided into two parts: the
sions placed in the aponeurosis of the external oblique early postsurgical recovery period and the later rehabilita-
muscle approximately 2 cm lateral to the edge of the rec- tion and convalescence phase. The former of these periods
tus muscle may minimize any tension. Polydioxanone, a can be somewhat complex as postoperative complications
slowly absorbable monofilament suture material, appears are frequent, with up to 80% of patients having one or
preferable as it is equivalent to nonabsorbable mono- more complications.94 In particular, these patients have a
filament suture in terms of recurrent hernias but has less significant incidence of postoperative infection, both at the
wound pain and sinus formation.104 Various closure tech- surgical site and at distant sites including lung and central
niques have been proposed when primary fascial closure is venous lines. As shown in Table 10-5, the incidence of recur-
not possible.103,105107 There has been increasing enthusiasm rent fistulization following surgery is considerable and is
regarding the use of the component separation technique associated with prolonged hospital stays and repeat admis-
as a means of achieving abdominal wall closure without sions to the ICU as well as repeat interventions. Brenner et
prosthetic material.105107 In brief, this approach involves al reported that recurrence of the enterocutaneous fistula in
the separation of the external oblique and internal oblique the postoperative period was the strongest predictor of mor-
muscles bilaterally plus division of the posterior rectus fas- tality, invariably due to the development of overwhelming
cia. Together, these accomplish approximately 12-, 22-, and sepsis and organ failure.41 Mortality is related to the presence
10-cm advancement of the upper, middle, and lower thirds of preoperative comorbidities.109 Short of death, the recur-
of the abdomen, respectively.105 This approach has been rence of enterocutaneous fistula following surgery represents
reported for abdominal wall closure after trauma surgery, in a major complication. Among those who survive this recur-
patients with sepsis managed with the open abdomen and rence, only 5066% go on to further surgery and successful
in patients with enterocutaneous fistulas. closure, while the remainder live with a chronic fistula.38,41 A
Wind and colleagues examined the application of this number of factors predict recurrence (Table 10-10).
technique in the presence of a contaminated abdominal wall By the time their fistulas have been surgically closed,
defect, including during closure of an enterocutaneous fis- these patients have often been undergoing medical care,
tula and/or stoma.106 This study reported the feasibility of usually both as inpatients and outpatients for several
this approach in terms of achieving abdominal wall closure
but noted considerable morbidity, including wound sero-
mas, wound infections, and hematomas as well as recurrent
abdominal wall hernias in approximately 22% of patients. TABLE 10-10: FACTORS PREDICTING
Recurrence of the enterocutaneous fistula occurred in 25% RECURRENCE AFTER ELECTIVE REPAIR OF
of patients. In a small percentage of patients, the use of ENTEROCUTANEOUS FISTULA
absorbable mesh was combined with the component separa-
tion technique, because the advancement of the abdominal Patient Factors
wall alone was not sufficient to cover the defect. Open abdomen
Finally, absorbable prosthetics may be considered for Origin of fistula (small bowel > large bowel)
management of the defect. Synthetic meshes such as polyg- Underlying inflammatory bowel disease
lactin effect good initial coverage but have the anticipated Frozen abdomen or residual intra-abdominal infection
long-term consequence of incisional hernia formation.94 Surgical Factors
As an alternative, biological prostheses including porcine Timing of surgery (<4 weeks, >36 weeks)
collagen mesh and acellular dermal matrix have been sug- Multiple inadvertent enterotomies at reoperation
gested with the potential advantage of increased resistance Oversewing of enteric defect, rather than resection and anastomosis
to infection and reduced late incisional hernias. These out- Use of stapled anastomosis, compared to hand-sewn anastomosis
comes have not been uniformly achieved when used in the Need to perform mesh closure of abdominal wall
months following the initial development of their entero- 3. Levison MA, Zeigler D. Correlation of APACHE II score, drainage
technique and outcome in postoperative intra-abdominal abscess. Surg
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10

ABDOMINAL ABSCESS Thethree major defense mechanisms in the peritoneal cavity

to CTscanning. In the absence of contrast rim enhancement, ANTIMICROBIAL THERAPY

TABLE 10-1: MICROBIOLOGY OF

TABLE 10-2: RECOMMENDATIONS FOR ANTIMICROBIAL THERAPY

Single agentErtapenem, meropenem, imipenem- Cefoxitin, ertapenem, moxifloxacin, Imipenem-cilastatin, meropenem,

TABLE 10-3: RECOMMENDATIONS FOR ALTERATIONS IN ANTIMICROBIAL THERAPY IN

Organisms Seen in Ceftazidime

TABLE 10-4: DETERMINANTS OF OUTCOME FOLLOWING PERCUTANEOUS

surrounding epithelialized structures; (2) extraintestinal Classification

TABLE 10-5: COLLECTED SERIES OF OUTCOMES IN PATIENTS WITH OPERATIVE REPAIR OF

Source Period Definitive Operation Recurrence Death

Visschers et al,40 2008 19902005 107 10 (9) 13 (12)

Appendiceal Fistulas. Fistulas of appendiceal origin may

to buttress a colonic anastomosis did not reduce the rate of

TABLE 10-8: APPROACH TO MANAGEMENT OF ENTEROCUTANEOUS FISTULAS

Phase Goals Time Course

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