Fistulas of the Gastrointestinal Tract

• An enterocutaneous fistula (ECF):
  • Is an abnormal communication between the small or large bowel and the skin that allows the contents of the stomach or intestines to leak through an opening in the skin

Classification:

• Congenital types:
  • Tracheoesophageal
  • Vitellointestinal duct
  • Patent urachus
  • Rectovaginal
• Acquired:
  • Trauma (postoperative)
  • Radiation
  • Malignancy,
  • Infection

Two categories:

• Low-output fistula:
  • Less than 500 mL/day
• High-output fistula:
  • Equal or greater than 500 mL/day

Three categories:

• Low-output fistula:
  • Less than 200 mL/day
• Moderate-output fistula:
  • 200ml to 500 mL/day
• High-output fistula:
  • Greater than 500 mL/day

• Etiology:

The mnemonic FRIENDS can be used to memorize characteristics which impede the closure of ECF:

• F Foreign body
• R Radiation
• I Infection or Inflammatory bowel disease
• E Epithelialization
• N Neoplasm
• D Distal obstruction
• S Short tract (less than 2 cm)

• Patients with enteric content exiting a wound on their abdomen are motivated to undergo operation:
  • The majority will close spontaneously within approximately 6 weeks
  • If it has not closed by 12 weeks:
    • It is unlikely to do so and definitive surgery should be planned:
      • The median time to definitive repair from fistula onset was 6 months (range 1 day to 28 months):
        • The 6-month time course is commonly utilized by groups with significant experience treating fistulas, owing to the trend in encountering a less hostile abdomen than in the early phases
        • Some evidence also suggests that somatostatin can be an effective treatment with respect to reducing closure time and improving the spontaneous closure rate of enterocutaneous fistulas

• References:

1. Lee SH (2012). “Surgical management of enterocutaneous fistula”. Korean Journal of Radiology. 13 Suppl 1: S17–S20. doi:10.3348/kjr.2012.13.S1.S17. PMC 3341456. PMID 22563283.
2. Galie KL, Whitlow CB (2006). “Postoperative enterocutaneous fistula: when to reoperate and how to succeed”. Clinics in Colon and Rectal Surgery. 19: 237–246. doi:10.1055/s-2006-956446. PMC 2780112. PMID 20011327.
3. Ross H (2010). “Operative surgery for enterocutaneous fistula”. Clinics in Colon and Rectal Surgery. 23: 190–194. doi:10.1055/s-0030-1262987. PMC 2967319. PMID 21886469.
4. Stevens, P; Foulkes, RE; Hartford-Beynon, JS; Delicata, RJ (October 2011). “Systematic review and meta-analysis of the role of somatostatin and its analogues in the treatment of enterocutaneous fistula”. European Journal of Gastroenterology & Hepatology. 23 (10): 912–922. doi:10.1097/MEG.0b013e32834a345d. PMID 21814141.
5. Metcalf C (1999). “Enterocutaneous fistulae”. Journal of Wound Care. 8 (3): 141–142. doi:10.12968/jowc.1999.8.3.25854.

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