Fistulas - Fistulas Enterocutaneas - Dr.

Daniel Wainstein

SYSTEMATIZED MANAGEMENT OF POSTOPERATIVE ENTEROCUTANEOUS

FISTULAS. A 14 YEARS EXPERIENCE

SYSTEMATIZED MANAGEMENT OF POSTOPERATIVE ENTEROCUTANEOUS

FISTULAS. A 14 YEARS EXPERIENCE

DE Wainstein, D. Delgado, M. Irigoyen, A. Sanchez and P. SiscoProceedings of the World. Medical Conference. Prague,
Czech Republic. Published by WSEAS Press. 2011. 126-129. ISBN978-1-61804-036-7

Abstract- AIM: to present a systematized management results, to asses the use of a vacuum system in local treatment
and to determine factors influencing the outcome of enterocutaneous (ECF) fistulas. DESIGN: Retrospective, descriptive,
observational. METHODS: All patients with postoperative ECF from March 1998 to March 2011 were registered. A
management protocol by stages was applied. Demographic aspects, fistula's characteristics and conservative treatment
modality were evaluated. Variables were faced with the mortality event using program SPSS version 18. Categorical
variables were analyzed using the chi-square or Fisher's exact test when suitable. RESULTS: This study included 125
patients. Fourteen (11.2%) were initially operated, 56 (51.4%) had spontaneous fistula closure only with conservative
treatment, whereas 49 patients (44.1%) required reconstructive surgery. Six patients (4.8%) underwent fistula's
recurrence and 12 (9.6%) died. Sepsis (p=0,002), multiple fistulas (p=0,024) and abdominal wall defect (p=0,022) were
predicting statistically significant mortality factors. CONCLUSIONS: A systematized management of ECF allows to
optimizing treatment results. Vacuum therapy was highly effective in output control and provided spontaneous healing in
many cases. Sepsis, multiple lesions and abdominal wall defect were negatives prognoses factors.

INTRODUCTION

Enterocutaneous fistulas (ECF) have always posed a great therapeutic challenge because of its high morbidity and
mortality. In recent years, advances in postoperative care and major surgical procedures rise have further increased the
degree of complexity and the number of cases, which justifies further study of this pathology. The aim of this research is
to present the results of a systematized management of this complication, to asses the use of a vacuum system in local
treatment of the lesion and to determine factors influencing the evolution of fistulized patients.
Methods

All cases of postoperative ECF were reviewed from October 1998 until March 2011. Terminally -ill patients and lesions
coexisting with biliopancreatic fistula were excluded. Demographics, patient characteristics and injury aspects were
recorded. Nutritional support was performed by parenteral (PN) and/or enteral nutrition (EN) according to the patient's
requirements and tolerance, indicating the latter one when the fistula output did not compromise wound management.

SIVACO (Spanish Acronym: vacuum compaction system) as first choice was used as local treatment of the lesion,
respecting the classical contraindications [1]. Aspiration methods and octreotide were implemented as alternative or
complementary options. The antiexocrine drug was indicated in case of superior gastrointestinal tract fistulas with
SIVACO contraindication and when output > 500 ml after a 3-day treatment. Management were performed using an own
protocol, in accordance with Chapman's Stages [2], which have been already presented in previous publications [1].

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 Fistulas - Fistulas Enterocutaneas - Dr. Daniel Wainstein

Variables were faced with the mortality event using program SPSS version 18. Categorical variables were analyzed
using the chi-square or Fisher's exact test when suitable. Binary logistic regression was carried out by multivariate
analysis of categorical risk factors.

Results

The series was integrated by 125 patients with 185 postoperative enterocutaneous fistulas (x = 1.4 per patient), of which
103 (82.4%) were referred from other care facilities. Eighty seven (69.6%) were men with a mean age of 51 years (range:
14- 86 years). Median of abdominal surgeries prior fistula appearance was 2 (range 1 to 10). Seventy six cases initially
presented sepsis (60.8%) whereas 91 (72.8%) hypoalbuminemia. Most frequent primary pathologies were colorectal
neoplasia, diverticulitis, abdominal trauma, appendicitis and hernia, of which 62 (49.6%) of these were surgical
emergencies. The direct causes were suture line or intestinal anastomosis disruption in 56 patients (44.8%); surgical
injury in 32 (25.6%); in 27 patients (21.6%) the small intestine lied in contact with a prosthetic mesh; and in remaining 10
the etiology were not identified. Location was jejunoileal in 87 cases (69.6%), gastroduodenal in 23 (18.4%) and
colorectal in 15 (12%). Forty-five patients (36%) presented more than one orifice, superficial fistulas 89 (71.2%), high
output 95 (76%) and 65 (52%) had major abdominal wall defect.

Fourteen out of 125 fistulized patients were initially operated, 4 of them electively, while surgery for peritonitis was
indicated in the remaining 10. Ostomy was performed to 4 of them, leaving definitive reconstruction for further surgery.
Mortality in this group was 7.1% (1 case).One hundred and eleven patients (88.8%) received conservative treatment.
Forty-six presented sepsis during conservative treatment, mainly due to catheter contamination and respiratory disease.
Nine of them, with abdominal collections, were treated by percutaneous drainage, 2 of which were completed by directed
laparotomy.TPN was indicated throughout treatment to 6 patients for a median of 75 days (range 36 to 92 days), 49
patients received PN combined with EN; and 56 others were fed only enterally,4 of them by fistuloclysis . After reaching
stability, 32 patients continued treatment at home. Regarding local lesion management, 92 cases (82.9%) were treated
only with SIVACO, 5 with SIVACO + octreotide, and 4 with octreotide + local aspiration. Collection bag or simple dressing
were indicated in the remaining 10 cases with low output fistulas.Output control was obtained in 109 cases (98.2%) from
an initial median of 900 mL /d to 50 mL / d 72 hours later, representing a fall of 94.5%. Fifty-six patients (51.4%) healed
with conservative treatment only between 2 and 24 weeks (median 5 weeks). During this period 6 patients died (5.4%), 5
from sepsis and 1 from stroke. Lastly, 49 patients (44.1%) required surgery after a median of 4 months (range 1 to 36
months) with the following results: healed 43 (87.7%), recurrence 6 (12,2%), chronic fistula 2 (4.8% ) and 5 deaths
(12.1%), 3 from sepsis and 2 from coagulopathy. Global healing was possible in 111 patients of the series (88.8%),
whereas 12 (9.6%) died. Sepsis (p = 0.02), multiple lesions (p = 0.024), and abdominal wall defect (p = 0.022) proved
statistically significant predictors of mortality in univariate analysis. Logistic regression test did not show meaningful
results in any variable probably due to the low number of events (deaths) recorded in the sample.
DiscussionIn the early 60's, Chapman et al. proposed management of the ECF sequentially in 4 stages, acting primarily
on the mortality factors and delaying surgical repair until clinical and nutritional recovery [1]. This proposal was the basis
of modern approach of this pathology. Years later, several protocols were suggested; they underwent some modifications
to update ECF management. [3] - [4]. When we began our experience, we observed that, in said protocols, the aims to
be achieved were mixed in different stages, some terms were not clearly defined and mainly, they did not represent
faithfully our current conduct. As a result, without departing from Chapman’s principles, we also staged a protocol,
applying diagnostic and therapeutic resources alternately [5]. After 14 years of use, this protocol has proved it a practical
resource to guide patient management. While it is true that these patients require frequent decision-taking during
treatment, surgery as initial indication is a major issue. The results of these series, consistent with other studies [6] [7],
support this procedure in patients with acute abdomen and those who, maintaining a good general condition, developed
early fistulas.Controlling the main mortality factors is a priority for the remaining patients to be treated conservatively.
Sepsis treatment and hidroelectrolite balance restoration do not differ substantially from that applied in the routine
management of critically ill patients so that it will not be analyzed in this presentation. The importance of nutritional
support for successful treatment in a coordinated way, using parenteral and enteral route, either by naso-jejunal tube,
jejunostomy or fistuloclysis, is clear. The advantages of enteral over parenteral nutrition (PN) as regards physiological
aspects, less morbidity, and cost reduction are widely known [8] - [9] However in complex cases, PN is difficult to avoid.
Vischers et al. [7] strongly indicate TPN throughout treatment when spontaneous closure is expected. Nevertheless, it
has not been shown that gastrointestinal secretion and volume overload reduction on the fistula increases the possibility
of spontaneous closure [10]. Both EN and PN are resources that the specialist team should handle so as to indicate
them, either in combination or alternatively, according to the case nature. Our approach, especially in high output fistulas,
begins with fasting and TPN. Then, after controlling intestinal effluent, the parenteral route is gradually replaced by the
enteral one, if it is well tolerated and does not complicate wound management. Controlling fistula’s output is one
of the requirements to reverse catabolism and, eventually, toachieve spontaneous closure. New methods have been
proposed in order to block intestinal flow: biological adhesives, porcine intestinal submucosa cylinders, fast-hardening
aminoacid solutions, acrylates, and others [11] - [12] - [13]. Although some, at first, showed encouraging results, they
have failed to prove their full effectiveness as most of the published series make reference to a few patients, usually of
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 Fistulas - Fistulas Enterocutaneas - Dr. Daniel Wainstein

deep and low output fistulas, which generally heal whichever conservative treatment. Octreotide, a synthetic
somatostatine analogue , is a powerful inhibitor of gastrointestinal biliary and pancreatic secretions. It has become
widespread used drug when treating ECF since the last two decades so far [14] - [15]. In recent years, enthusiasm has
waned because it could be seen that, while it is effective to reduce enteric output, and even to accelerate some fistulas
closure time, it has not been possible to demonstrate a rise in percentage of spontaneous closure or a fall in mortality
rate. In our experience, it has been a valuable resource in cases of high- output fistulas of gastric, duodenal and jejunal
origins, when vacuum proved inconvenient, or as reinforcement of the latter if output reduction was not satisfactory.
SIVACO, developed in the mid-'80s by Fernandez et al. [16] has been the main choice because it has proved the most
effective method to reduce intestinal effluent, with down output between 85 to 95% within a few hours after treatment
beginning[2] - [16]. Consequently, the following benefits have been previously described and were thus confirmed in our
experience:· Effective and rapid control of dermatitis and abdominal wall infection. · Early intake is possible in most
cases without significantly increasing the output which reduces the need for PN· Wound management is simplified by
requiring less frequent dressings compared to other methods.· SIVACO showed healing without surgery in a large
percentage of cases meanwhile in those who eventually will be operated, it allows patients to optimize the clinical and
nutritional condition to face surgical treatment in a timely manner.· Once the stabilization phase is reached, it is feasible
to continue treatment at home which, together with reduced use of PN, octreotide, dressing materials and reduced length
of stay, suggests a significant cost reduction. Teams who have been working with SIVACO are convinced about its
benefits; however, due to the difficulty to perform comparative studies, because of the diversity of variables that affect the
different series, increasing on spontaneous closure rate and decreased mortality has not been scientifically proven yet.
Moreover, some recent publications have suggested, after observing certain complications that may be related to the
method, taking caution in the application of negative pressure therapy [17] - [18].From the analysis of those studies and
our own experience, we believe that besides classical contraindications [19] SIVACO should be avoided when more than
one daily compaction is required during 3 consecutive days, in presence of intestinal divorce or when exposed
viscera.The right timing to complete conservative treatment and proceed with surgical repair remains controversial. For a
long time, it has been convention to wait 4 and 6 weeks for a spontaneous resolution and then, in case of persistence, to
proceed with reconstructive surgery [1]. First, it should be pointed out that fistula closure has been achieved in some
cases, after this time period, with the assistance of innovative treatments, such as sub-atmospheric pressure [2] - [6].
Second, the time span previously defined, usually, is not enough to obtain an adequate clinical and nutritional status in
order to perform complex reconstructive surgery. Infectious complications such as sepsis from central line catheter and
pulmonary infection may delay nutritional recovery, as well as surgical opportunity. Lynch et al. (2004), as many other
authors, conclude in favour of delaying surgery for at least 12 weeks to decrease chances of recurrence [20]. Other
authors share his opinion and caution against early reoperation. They reason that dissection in a dense peritoneal
reaction is prone to cause hemorrhages and bears high fistula recurrence rates [21]- [22]. In particular after multiple
laparotomies for severe intraabdominal infection, awaiting consolidation and the formation of neoperitoneum seems
comprehensible. The latest studies time spectrum ranges from 2 to 11 months.[ 23]-[24]. Despite employing meticulous
statistical analysis, exact interpretations of these results are limited due to selection of patients and lack comparative
studies.In this series, as in others [24], sepsis, multiple lesions and abdominal wall defects have been statistically
significant mortality factors. Other studies have also identified the following negative factors: hypoalbuminemia, previous
laparotomies, comorbidities, age, prolonged use of TPN, and anatomic location among others [25]. Brenner et al. [26]
have pointed out to the male sex, a delay greater than 36 weeks in surgical repair and use of mechanical suture as
unfavorable prognosis, although they have not been accurately interpreted. Obviously, both, the large number of
variables and, consequently, the unlikelihood to perform out comparative studies make it difficult to reach firm
conclusions. Until this happen, all of these variables must be considered when evaluating a fistulized patient.

CONCLUSIONS

The application of a systematized management was helpful in guiding fistulized patient management.Initial surgery is a
valid option in patients maintaining a good general condition and is a necessity in cases where the fistula coexists with
acute abdomen. SIVACO is highly effective in controlling fistula’s output and healing in a variable percentage of
cases. Conservative treatment should be extended several weeks, if necessary, to detect a halting in the wound healing
process and until achieve a complete patient clinical and nutritional recovery. Sepsis, multiple lesions and those located
in open abdomen have proven negative prognostic factors in this study. However, it is possible that many other factors
should significantly impact fistulized patient outcomes.Due to not only substantial differences between patients within one
study but also inter-study variations in the currently available data, it is difficult to draw definite conclusion on their
respective treatment effect. It seems, therefore, necessary that multidisciplinary teams gather detailed information to be
able to collectively pool the data in order to reach sound conclusions.

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