Enterocutaneous fistulas

ENTEROCUTANEOUS

FISTULAS

INTRODUCTION

Fistulas are abnormal communications between two epithelialized surfaces. These defects can develop quickly, such as those occurring after instrumentation or operation, or they can be more indolent, such as those occurring with tumor, inflammation, or irradiation, with most having as their underlying disease process inflammation or neoplasia. Gastrointestinal fistulas resulting from such a diverse array of intestinal abnormalities can be seen at diagnosis with a variety of signs and symptoms. Gastrointestinal fistulas have been classified by many different criteria (Table 1). It is most useful to classify them initially as either internal or external fistulas. Internal fistulas are those that communicate with other portions of the gastrointestinal tract or adjacent organs. They may be asymptomatic or produce relatively minor symptoms such as recurrent infections, as can be the case with sigmoidvesical fistulas. In addition, if the fistula in/elves adjacent loops of bowel and bypasses only a short intestinal segment, such as with an ileocolic fistula, it can occur without significant volume, electrolyte, or nutritional disturbance. Because of this situation, the patient may delay seeking medical attention when internal fistulas occur. For the same reasons, a physician may repeatedly render symptomatic treatment without diagnostic evaluation. Only when the recurrent nature of the problem is recognized will a more in-depth evaluation be undertaken. If long segments of bowel are bypassed, however, such as with gastrocolic fistulas, volume, electrolyte, and nutritional deficits can be profound and the symptoms prominent because of malabsorption from functional short-gut syndrome. External fistulas result in drainage of enteric contents directly onto the skin or out the vagina; their presence is obvious. Fistulas may be more specifically defined in descriptive terms, such as those describing anatomic course (e.g., gastrocutaneous). These anatomic descriptors have prognostic significance with regard to spontaneous ~losure~-~ and are useful for planning medical management and, if necessary, operative approach. In addition, fistulas are well classified in physiologic terms by output over a 24-hour period. Cur-r Pmbl

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TABLE 1.

Fistula

classifications

Twe

Classification

Use

Anatomic

Internal/external

Broad classification May suggest cause Predicting closure Planning operative therapy Predicting chances of death Anticipating metabolic deficits Correcting ongoing losses

Anatomic Physiologic

Etiologic

coume

Output (ml/day) Low (500) By disease process

Pmgnostic of closure Independently predictive chances of death

of

Enterocutaneous fistulas always result in external loss of fluid, electrolytes, trace minerals, and protein. These losses can be minimal in distal, generally colonic low-output fistulas or profuse in proximal, high-output fistulas. Three categories of fistulas based on output exist: (1) high-output fistulas (greater than 500 ml/24 hours); (2) moderate-output fistulas (200 to 500 ml/24 hours, and (3) low-output fistulas (less than 200 ml/24 hours.“5’8~s As stated, high-output fistulas tend to arise from the small bowel, whereas low-output fistulas tend to originate from the colon. Anticipating behavior of the fistula output assists the physician in preventing and treating metabolic deficits and correcting ongoing losses that can occur with enterocutaneous fistulas. Although a static measurement of fistula output is not predictive of spontaneous closure, it is predictive of whether a patient might die. Ideally, then, a fistula should be defined not only by precise anatomic terms that will allow prediction of spontaneous closure and define operative timing and approach but also by physiologic terms that define likely metabolic deficits, dictate ongoing needs, define sepsis, and predict the chances of death. Gastrointestinal fistulas have a high mortality rate despite the advances in parasurgical care, nutritional support, antibiotics, and intensive care. Few other surgical situations require such critical judgment and knowledge.’ It is only by an integrated anatomic and physiologic understanding that the physician is prepared to define a rational, goal-oriented, therapeutic plan that can serve as a stable foundation for both the physician and the patient during this unwieldy disease process. HISTORY

The earliest record of an enterocutaneous fistula appears in the Old Testament’s Book of Judges. It is the account of Eglon, who sustained 434

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an acute posttraumatic enterocutaneous fistula: “And Ehud put forth his hand, and took the dagger and thrust it into his belly. . . . And the dirt came out.” The first reported attempt at surgical repair of an enterocutaneous fistula was described by Celsus, who noted that when the colon has been penetrated, “It can be sutured, not with any certain assurance, but because this doubtful hope is preferable to certain despair; for occasionally it heals up.” In the eighteenth century, a conservative approach was espoused by John Hunter after he noted that fistulas occasionally close spontaneously: “In such cases nothing is to be done but dressing the wound superIicially, and when the contents of the wounded viscus become less, we may hope for cure.” In the late 1800s and early 19OOs, decompressive enterostomy was used to decompress the intestine proximal to an obstruction. When the obstruction resolved, the enterocutaneous fistula that had been created would often close spontaneously. The high spontaneous closure rate of fistulas that had been created in otherwise healthy bowel, coupled with most surgeons’ sporadic, almost anecdotal experience, fostered an unrealistically optimistic attitude toward this complication. The development of specialized referral centers allowed institutions to amass, analyze, and report large experiences with complex problems such as fistulas. The early reviews of the 1960s revealed the true severity of this disastrous complication. Reported mortality rates at that time were 40% to 60%, much higher than previously realized.l’ When the magnitude of the problem was realized, modern approaches to this surgical catastrophe began to evolve.

CAUSE AND PREVENTION

Gastrointestinal-cutaneous fistulas either are spontaneous or occur in the postoperative period. At one time most fistulas were spontaneous; however, with improved access to health care, advancements in surgical and anesthetic techniques, and with larger and more complex procedures being performed on sicker patients, the cause of fistulas has radually evolved, and now most occur in the Spontaneous causes collectively compostoperative period. f&,11-20 prise 15% to 25% of enterocutaneous fistulas and include radiation, inflammatory bowel disease, diverticular disease, appendicitis, ischemit bowel, erosion of indwelling tubes, perforation of duodenal ulcer, pancreatic and gynecologic malignancies, tuberculosis, and, rarely, intestinal actinomycosis.21-24 Unfortunately, other than early diagnosis and treatment, a physician can do little to prevent occurrence of fistulas from these disease processes. The cause of the fistula, like the site of origin, may prognosticate spontaneous closure. Therefore knowledge of fistula cause is crucial Curr

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for formulation of a successful management plan. Soeters and associates5 reported that patients with fistulas resulting from radiation or recurrent carcinoma were unlikely to undergo spontaneous closure, a finding recently reconfirmed by Kuvshinoff and coworkers.25 Those arising as a result of inflammatory bowel disease often close, only to reopen when enteral feedings are resumed. Therefore fistulas from these causes may require surgical c10sure.~~~~~~’ The remaining 75% to 85% of enterocutaneous fistulas are of iatrogenie origin. The operations that antecede the appearance of the fistula are generally of the following three types: (1) operations for cancer, (2) operations for inflammatory bowel disease, and (3) lysis of adhesions, generally from previous surgery. In addition, operations performed for peptic ulcer disease and pancreatitis may lead to enterocutaneous fistulas. These complications usually occur in settings of poor patient preparation, such as emergency procedures, or in situations in which the patient has been previously treated with radiation therapy. Furthermore, poor nutritional status may play a major role in anastomotic breakdown and in the inadequate response to infection in some patients. The following principles of operative technique that prevent fistula formation are those of any anastomosis: (1) healthy bowel with adequate blood supply; (2) when possible, mechanical bowel preparation (most advocate intraluminal antibiotic preparation as well); (3) intraluminal and/or systemic antibiotics; (4) tension-free anastomoses; (5) full visualization of bowel with meticulous technique; (6) meticulous hemostasis; (7) secure closure of the abdominal wall after anastomosis; (8) filling with live tissue or draining (closed suction) of dead space likely to collect blood or serum, especially in previously irradiated areas; (91 drains kept away from the anastomosis; (10) avoidance of hypotension with adequate hydration and blood transfusion, especially in emergency situations; (11) closed anastomoses (advocated by some), especially in emergency situations with unprepared bowel; and 02) preoperative nutritional support in patients who have lost weight, have a serum albumin less than 3.0 gmdl, or both. Specific intraoperative maneuvers may decrease the chances of postoperative fistula formation. Creation of false tissue planes during head and neck resections, particularly if the patient was previously irradiated, can devascularize tissue, leading to breakdown and fistula formation, and should be avoided. In addition, when flaps are used for reconstruction, vessels should lay as straight and tension free as possible. Flap ischemia may predispose to suture line breakdown with subsequent fistula formation. Interposing well-vascularized tissue, such as muscle, between hollow viscera (esophagus and trachea) will also lessen the chances of fistula formation. Reconstruction after thoracic esophageal resections can be reinforced with a pleural patch to help improve vascular@ and decrease 486

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the chances of anastomotic leakage. In addition, some authorities maintain that stapled anastomoses are less prone to breakdown. Dividing only the vessels necessary for gastric mobilization while maintaining the gastroepiploic arcade will lessen the chances of gastric necrosis and fistula formation. Adequate duodenal mobilization after antrectomy or, when mobilization is not possible, use of Billroth II reconstruction may decrease the incidence of gastric fistula. Moreover, particular attention should be paid to secure closure of the angle du mart when a Hofmeister reconstruction is used. Some authors use a carefully placed tripartite suture to secure this confluence of suture lines. Finally, postoperative gastric decompression should be maintained to allow suture lines to seal without increased intraluminal pressure. The duodenum should be- adequately mobilized to ensure secure closure. Liberal use of tube duodenostomy in addition to afferent loop tube placement will decrease the incidence of postoperative duodenal fistula formation. Because of the duodenum’s retroperitoneal location and proximity to the ascending colon, kidney, inferior vena cava, aorta, and pancreas, isolated duodenal trauma is uncommon. Associated injuries adversely atfect duodenal closure outcome; therefore diverticulization should be considered during the repair of all Primary closure with or without patch may be duodenal trauma.” adequate for only the least complex of injuries. Anomalies of the cystic duct anatomy may be variable. The duct may join directly, run parallel with, or spiral around the common hepatic duct before entering that structure to form the common bile duct. Conversely, the cystic duct may also enter the right or left hepatic duct directly. This variability predisposes to common bile duct or hepatic duct injury with possible fistula formation during open, and now more frequently, laparoscopic cholecystectomy. In addition, when reconstructing the common bile duct, the physician needs to pay strict attention to the anatomy and vascular supply. The common bile duct traverses the hepatoduodenal ligament anterior to the portal vein and to the right of the hepatic artery most often, but it will be in front of the replaced right hepatic artery 15% to 20% of the division of this replaced right part of the hetime.2”‘30 Inadvertent patic artery will devascularize most of the common bile duct and predispose to stricture or fistula formation. The distal common bile duct enters the parenchyma of the pancreatic head on course to the duodenal ampulla of Vater. The blood supply to the common bile duct is from the coalescence of vascular plexuses that arise from the axial vessels at the 3-o’clock and 9-o’clock positions. The blood supply to the axial vessels, and ultimately the vascular network, is from the right hepatic artery above and the posterior-superior pancreatoduodenal artery below. However, the arterial blood supply to the superior portion of the extrahepatic biliary Cur-r Probl

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487

tree is variable, because the blood supply to the right lobe of the liver and the common bile duct will be supplied from above by a replaced right hepatic artery when present. As stated, division or ligation of this vessel after extensive distal common bile duct dissection or common bile duct division can lead to complete devascularization of the extrahepatic biliary tree, breakdown of the biliary-enter-k anastomosis, and resultant fistula formation.31 When performing hepatic resections, the physician gives special attention to the raw edges of the liver. Adequate closed suction drains should be placed to eliminate fluid collections and dead space. The caudate lobe (segment 1) may be drained by the left, right, or both hepatic duct systems. Failure to ligate or incorporate these segment 1 ducts into the enteric segment during biliary-enteric reconstruction can lead to bile leak, fistula formation, and cholangitis. Small-bowel defects greater than half of the bowel circumference should be treated by resection with end-to-end anastomosis, especially when the mesenteric border is involved in the defect. Additionally, use of omental or serosal patch where closure is questionable may decrease the likelihood of suture line breakdown. When closure of multiple defects is necessary and viability is questionable, bypass or proximal diversion should be considered. These measures may prevent further soiling, and, in addition, they do not preclude future operative attempts at restoration of bowel continuity. The deleterious effects of pelvic irradiation are concentrated on the retroperitoneal portions of colon, which, because of their immobility, are essentially fixed in the radiation field. When possible, previously irradiated colon should be resected and anastomosis performed with healthy, well-vascularized tissue. When radiation damage to the rectum is severe, an endorectal pull-through procedure, or a Soave procedure, may be necessary to reestablish a continent fecal stream. When a colon anastomosis is questionable, proximal diverting colostomy may allow sufficient time for healing to occur before the suture line is tested by the fecal stream. In addition, some authorities have suggested that rectal tube decompression after a Hartmann procedure prevents increased pressure in the rectal stump postoperatively and may decrease rectal stump leak and subsequent pelvic sepsis and fistula formation. The raw denuded pelvic cavity after pelvic exenteration has been cited as a source of small-bowel obstruction and fistula formation.32-34 Jakowatz and associates3’ reported no gastrointestinal fistula formation in patients who had pelvic exenteration followed by omental, colonic, or myocutaneous flap reconstruction in the pelvis. Gastrointestinal fistulas developed in 11% of patients who received no tissue advancement for pelvic reconstruction. If the patients had received previous irradiation, the fistula formation rate 488

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rose to 12% with reconstruction and 21% without reconstruction. Therefore providing adequate pelvic coverage should be considered an integral part of exenteration procedures or procedures to repair fistulas in patients after pelvic exenteration, especially in patients with a previously irradiated pelvis (Fig. 11.~’ If patients are operated on in an emergency situation, then less can be done to decrease the chances of postoperative fistula formation, As stated, the patient should be fully hydrated, provided adequate circulatory support, and given antibiotics with activity against enteric bacteria. On-table luminal preparation is advocated by some authorities, but the chances of contamination are great. In cleancontaminated bowel cases, antibiotics may decrease the frequency of anastomotic breakdown and prevent abscesses and infections adjacent to the suture line. In addition, remote infections may delay anastomotic healing because sepsis-induced hypercatabolism can prevent adequate protein synthesis. If the operation is elective, nutritional preparation may be the most important step in preventing anastomotic breakdown.35-37 Patients with the following characteristics have been shown to be at increased risk for anastomotic breakdown: (1) weight loss of 10% to 15% of total body weight over a short period of time (3 to 4 months); (2) serum albumin concentration less than 3 gm/dl; (31 serum transferrin concentration less than 220 mg dl; and (4) significant functional impairment and inability to perform usual tasks because of weakness or easy fatigability. Reduction of enteric bacterial load may also decrease the risk of anastomotic breakdown. Mechanical bowel preparation to remove particulate fecal matter can decrease colonic bacterial counts from 10 12-15 to 104-5 . The addition of enteral nonabsorbable antibiotics may decrease these bacterial counts even further to 10ze3. Parenteral antibiotics, with proven activity against enteric bacteria, should be given at the time of the skin incision. This action will ensure adequate tissue levels as surgery commences. Additionally, because of the rapid increase in circulating volume necessary to maintain blood pressure during general anesthetic induction and because of large volume shifts during prolonged abdominal operations, systemic antibiotics should be administered every 4 hours during the procedure.38‘40 Systemic antibiotics, however, do not obviate the need for mechanical preparation or enteral antibiotics. It is not clear that enteral antibiotics decrease wound or abdominal infection rates in patients receiving parenteral antibiotics. In the absence of luminal preparation, the incidence of anastomotic breakdown, abscess, and wound infection seems unaffected by systemic antibiotics.41-44 Finally, fresh anastomoses should not be allowed to come into direct contact with the abdominal closure suture line and should be covered by fat or omentum when possible. The inflammatory response and intermittent minor leakage that occur during the healing Cum

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489

FIG. 1. Pelvic shows

490

defect

coverage after exenteration. A, Resection of anus leading into pelvis. 6, Bilateral medial thigh flaps.

and

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FIG. 1. C, Flaps rotated into position over defect.

of an anastomosis are usually sealed off by surrounding healthy tissues, such as peritoneum, adjacent loops of bowel, or omentum.45 The inflammatory process of two adjacent healing suture lines may predispose to fistula formation. Unless it has been removed, the greater omentum should be placed back in its anatomic position covering the intestines at the end of an abdominal procedure. This step will help protect and seal the enteric anastomosis. COMPLICATIONS

AND CAUSES OF DEATH

Early in the 1960% Claude Welch at the Massachusetts General Hospital recognized that nutrition, volume, and electrolyte deficits, as well as ongoing losses, must be corrected if the mortality rate assoCum

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FIG. 1. D, Final reconstruction. 492

E, Late result. Curr

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ciated with enterocutaneous fistulas was to be decreased from a high at that time of 40% to 60%. In a classic paper published in 1960, Welch and his coworkers” identified sepsis, electrolyte disturbance, and malnutrition as the three major causes of death in patients with fistulas. Their findings are still germane. The frequency with which these complications occur is directly related to the fistula output: the greater the output the greater the morbidity and mortality. Even with improvement in parasurgical care, enterocutaneous fistulas continue to carry a 6% to 20% mortality rate (Table 2). It might be expected that with current monitoring, electrolyte disturbance would no longer be a problem. However, as defined by abnormal serum electrolyte concentrations for 48 hours or longer, electrolyte disturbance is still common. Malnutrition and sepsis are the principal causes of death. Once established, malnutrition is difficult to correct, especially in the presence of sepsisz5 In addition to these factors, malignancy now accounts for 5% to 30% of the fistula mortality rate.46-48 Although the frequency of spontaneous closure is clearly not related to fistula output, morbidity and mortality rates are.

TABLE Series

2.

Mortality

and year

Edmunds, Lomnzo, Nassos, Sheldon,

rate

in studies

No. studied

1960

157

1969 1971 1971

18 21 51

Roback, 1972 McPhayden, 1973

55 61

Aguirre,

38

1974

Reber, 1978 Soeters, 1979 Tarazi, 1983 Sansoni, 1985 Gilmartin, 1985 Rossi, 1986 Rose, 1986 Schein, 1991

Prickett, Buechter, Kuvshinoff,

Cur-r Probl

186 404 47 71 13 18 114 117

1991 1991

58 15

1993

Surg,

116

June

1994

of patients Fistula

with

enterocutaneous

types

Gastric, duodenal, small and large bowel Small bowel Duodenal, small bowel Gastric, duodenal, small and large bowel Small bowel Gastric, duodenal, small and large bowel Gastric, duodenal, small and large bowel All gastrointestinal All gastrointestinal Gastric, duodenal Small bowel Lateral duodenal Duodenal All gastrointestinal Esophageal, gastric, duodenal, small and large intestine All gastrointestinal Duodenum, small and large intestine Gastric, duodenal, small and large intestine

fistulas Mortality

rate

l% 1

44 30 22 12 30 6.5

21 22 43.4 29.8 23.5 15 33 10.5 37

19 13 20.3

493

FLUID AND ELECTROLYTE IMBALANCES

Fluid and electrolyte imbalances are defined as abnormalities in serum electrolytes of more than 48 hours in duration, and they are primarily associated with high-output fistulas. Although they are usually no longer life threatening, such abnormalities occur in a high percentage of patients. Given the availability and ease of monitoring acidbase and electrolyte balance, it is surprising that this complication occurs so frequently. The most common electrolyte disturbances involve potassium, sodium, magnesium, phosphate, and zinc. The amount of fistula drainage will depend in part on the proximity of the fistula to the ligament of Treitz. Total diversion of gastrointestinal secretions at the level of the ligament of Treitz may result in drainage of up to 4 L/day. Approximately 2 of the 4 L originates from swallowed saliva and gastric secretions, and the other 2 L originates from pancreaticobiliary secretions. The fluid that is lost from the internal milieu to the environment is rich in protein and electrolytes. Pancreatic and biliary juices have high electrolyte concentrations, particularly with regard to sodium, potassium, and bicarbonate. It requires a lot of energy to secrete this electrolyte-rich fluid; therefore rapid protein and energy stores are depleted as a result of the electrolyte losses. ilh4LNlJTRITION

Even with aggressive nutritional support, malnutrition remains a major problem in patients with enterocutaneous fistulas (Table 3) .3,5,15,16,22,46-54 Malnutrition is related to the fistula output, being most profound with high-output fistulas. The three main contributing factors are as follows: (1) lack of adequate nutrient intake; (21 hypercatabolism associated with sepsis; and (3) the loss of protein-rich, energy-requiring secretions from the fistula. Clearly, the most important is malnutrition caused by uncontrolled sepsis. The hypermetabolism of sepsis results in rapid breakdown of body cell mass. If the sepsis is left unchecked, structural and functional protein depletion occurs, resulting in organ dysfunction and ultimately organ failure. To be sure, malnutrition occurs without sepsis and can usually be remedied in this circumstance with appropriate nutritional support. However, in the presence of uncontrolled sepsis, it is difficult, if not impossible, to prevent nutritional depletion. Sepsis and malnutrition are interrelated and directly contribute to an increased chance of patient death. As stated previously, uncontrolled sepsis and malignancy are the causes of death in most patients with gastrointestinal fistulas. Enteral nutrition has been increasingly used to support patients with enterocutaneous fistulas. However, use of this modality may be 494

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TABLE Series

3.

Recent

series

and year

Malnutrition

of malnutrition, PO 1

55

Aguirre, 1974 Reber, 1978 Soeters, 1979 Hollender, 1983 Tarazi, 1983 Sansoni, 1985 Gilmartin, 1985 Rossi, 1986 Rose, 1986 Galland, 1986” Garden, 1988 Schein, 1991 Prickett, 1991 Buechter, 199lt Kuvshinoff, 1993 ‘Includes tIncludes

and incidence

87 71 83 57

sepsis, Sepsis 61 76 5.5 63 63 17 15 61 28 70 58 26 47 25

only patients only patients

and (W )

malignancy cancer

ml) 16 23 36

21 4 8 6 27 100 21 14 0 23

with radiation-induced fistulas. with posttraumatic fistulas.

limited by the structural and functional status of the gastrointestinal tract. It is often necessary to provide at least a portion of the patient’s nutrition parenterally.55 Delivery of nutrients, electrolytes, vitamins, and trace elements can be performed parenterally irrespective of the state of the gastrointestinal tract. Although specifics of enteral nutrition will be given below, it is worthwhile emphasizing here that only a portion of the required calories given enterally will increase hepatic protein synthesis and provide some of the beneficial effects associated with enteral nutrition. Under normal circumstances, almost all protein in succus entericus is reabsorbed as peptides and free amino acids, which then enter the free amino acid pool and are reused for protein synthesis. This protein load is substantial; the 75 gm of desquamated cells together with 75 gm of secreted digestive enzymes represent half the free amino acid pool. In high-output fistulas, much, if not all, of this protein-rich material is lost to total body economy (Fig. 2). If uncontrolled sepsis occurs while marked fistula losses continue, metabolic repletion may be impossible. Currently available methods are unable to provide adequate nutritional support or reverse preexisting malnutrition in the face of the hypercatabolism of uncontrolled sepsis.25 If nutritional stabilization is to proceed, control of sepsis should be an early and singular goal. SEPSIS Sepsis is the most common complication (Table 3) of enterocutafistulas,3,5,15,16.22'46-54 in addition to being the most common

neOuS

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lt2OOOgTOTAL PROTEIN Intake

Muscle

Hemoglobin,

8gClgN) . Skin 2gC3OOmgN)

F&-l as Protein &%

Urin&N as Protein ?l

%$FIG. 2. Total protein pool. A total of 70 gm of protein composed of digestive enzymes and sloughed cells and 70 to 90 gm of protein from dietary sources pass through the gastrointestinal tract daily. Fistula losses can deplete this protein pool rapidly.

cause of death. If uncontrolled sepsis occurs, especially closed space sepsis, it is necessary to diagnose it early by computed tomography (CT), magnetic resonance imaging, ultrasonography, or indium scans. Aggressive treatment is mandatory. Patients will likely not survive unless all abscesses are drained. An undrained collection of purulence is unlikely to be within the abdomen if not identified by a CT scan. However, if central catheter sepsis, immune deficiency, and other conditions that may masquerade as intraabdominal sepsis are eliminated and the patient is dying of sepsis, little alternative exists but to explore the abdomen. The entire intestinal tract, from the ligament of Trek to the rectum, should be freed. All existing interloop abscesses should be drained and intestinal continuity restored. Edfor this operation. monds et allo used the term “refunctionalization” It was originally intended to restore intestinal continuity for nutrition. However, because nutrition can be adequately supplied parenterally, the purpose of the procedure is to drain occult sepsis and reestablish bowel continuity. MALIGNANCY Malignancy is the etiologic agent in 3% to 7% of fistulas, is present in 5% to 35% of patients with fistulas, and accounts for 30% of 40% of the deaths resulting from fistulas in most recent reported series However, those patients who die of malignancy (Table 31.3,5~15~16822J46-54 496

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usually do so with significant tumor burden. Enterocutaneous fistulas that result from malignancy usually signify advanced transmural disease and consequently carry a correspondingly poor prognosis. However, with current advances in oncologic care, these patients may have a reasonable life expectancy. Therefore malignancy should not be considered a contraindication to aggressive nonoperative and operative fistula management. Each case should be evaluated with respect to the type and nature of the malignancy. A fistula that is appropriately and aggressively cared for should not alter the natural history of the underlying malignancy to a significant degree, although local recurrence may be a problem. Therefore a rational treatment plan, based on known biologic aspects of the tumor, should be made. In patients with well-differentiated, slow-growing tumors, an argument can be made for early and aggressive operative management to minimize hospitalization. Operative correction may palliate these patients for many months. In addition, consideration should be given to early operative intervention for the following reasons: (1) fistulas complicating malignancy are unlikely to close spontaneously, ultimately requiring operation; and (2) if malignancy is transmural, as is likely, adjunctive therapy will be necessary to optimize a recurrencefree interval and survival. As long as the fistula is open, chemotherapy and radiation will not be administered. In addition, current forms of nutritional support likely increase tumor growth. The physician should therefore minimize the time of parenteral nutrition support in the absence of surgery or adjunctive treatment. SPECIFIC FISTULAS

ASPECTS

OF THE CAUSE OF ENTEROCUTANEOUS

OROPHARMVGEAL AND ESOPHAGEAL FISTULAS With improved access to health care, the cause of oropharyngeocutaneous fistulas has shifted from spontaneous fistulas complicating advanced head and neck tumors to fistulas resulting from the surgical treatment of the same. Because many patients with head and neck cancer smoke, consume alcohol, or both, their nutritional status may be poor on diagnosis. Adding to anorexia and the difficulty of rr&ntaining oral intake in the presence of sometimes painful lesions, many patients referred for surgical resection have undergone preoperative radiation therapy. This situation, coupled, with the already difficult task of reconstructing the large defects often created by radical resections, leads to a 5% to 20% postoperative oropharynsite for a fistula is geocutaneous fistula rate.56 The most common where the pharyngeal defect is closed at the base of the tongue. Most esophagocutaneous fistulas are due to either postoperative leaks at the cervical anastomosis after esophageal resection for canCurr

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497

cer or leaks resulting from undetected or inadequately repaired cervical esophageal trauma. Other rare causes of oropharyngeocutaneous or esophagocutaneous fistulas include infected congenital neck cysts, anterior cervical fusion, and foreign body perforations.57-62 Nonoperative treatment is similar to that of postoperative fistulas. After removal of foreign bodies, drainage of loculated sepsis, and debridement of devitalized tissues, these usually small fistulas can be repaired primarily with layered closures. Esophageal fistulas that occur in the chest are much different and are therefore considered separate from cervical esophagocutaneous fistulas. Causes of distal esophageal fistulas include congenital defects, malignancy, pulmonary infections, instrumentation, and foreign body and postemetic perforations.63 When esophageal defects occur in the chest, the usual result is an esophagopleural fistula with empyema and sepsis, an esophagobronchial fistula, or an esophagotracheal fistula but not usually an esophagocutaneous fistula. Their presentation is that of severe pneumonia, lung abscess, mediastinitis, or pleural effusion that can proceed rapidly to overwhelming sepsis and multiple organ failure. Spontaneous thoracic esophagocutaneous fistulas are exceedingly rare probably because overwhelming sepsis, mandating operative intervention, intercedes before spontaneous external drainage can occur. However, they may occur as a secondary phenomena after tube thoracostomy. If the patient survives and the esophageal defect remains open, then expectant management is warranted because these fistulas usually close spontaneously unless distal obstruction or an abnormality prevents closure.

GASTRIC

FISTULAS

Gastric fistulas are iatrogenic in 85% to 90% of cases in most modern series .54s64-6gOther causes include inflammation, ischemia, cancer, and radiation. Anastomotic leakage or fistula formation after gastric resection for cancer is a serious complication. Fistulas occur in 6% to 8% of cases and account for 50% of deaths after a gastric resection procedure.68 Many of these fistulas are due to residual malignancy at a suture line. High fevers, tachycardia, abdominal pain, and distention develop in most patients in the early postoperative period. Despite cervical esophagostomy, antibiotics, and surgical drainage of the abdomen and thorax, this complication carries a 50% to 75% mortality rate.6g-7z Gastric leak after resections for ulcer disease has become more rare compared with 20 years ago. The percentage of cases of leakage after gastric resection for benign disease has decreased from 3% to 1% in experienced hands. In addition, fewer resections are performed for ulcer disease. Gastric leak with 498

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subsequent fistula formation can also occur after antireflux procedures, usually those performed through the chest, and also carries a considerable mortality rate.73-77 In addition, 2.4% of patients who undergo gastric bariatric operations will have a gastric leak. Most of those patients (85%) will have an intraabdominal abscess at diagnosis that requires immediate drainage. The remaining 15% will have a gastrocutaneous fistula at diagnosis. Buckwalter and Herbst,78 in a series of 791 gastric bariatric operations, were able to manage all three of their gastrocutaneous fistulas successfully with nasogastric decompression and parenteral nutrition. The average time from diagnosis to closure was 40 days. The mortality rate for gastric fistulas is between 15% and 25%. However, if the fistula output is greater than 200 ml/day, then the mortality rate increases to 38%. In addition, if malnutrition is present, then the mortality rate approaches 60% .65 DUODENAL

FISTULAS

Between 50% and 85% of duodenocutaneous fistulas are complications of gastric resections or operations on the biliary tract, duodenum, pancreas, ascending colon, aorta, and kidney. The remaining 15% to 50% are due to trauma, perforated ulcers, and cancer.65’7g-81 The overall mortality rate from this complication ranges from 7% to 67%, with an average incidence in collected series of 28~.10,49,52,53,82,83 Factors associated with deaths in these studies include uncontrolled sepsis, age greater than 65 years, output greater than 500 ml/24 hours, malnutrition, and multiple operations. Of these factors, uncontrolled sepsis is by far the most important. When it occurs, the mortality rate is between 70% and 100%.82’84 Duodenal fistulas occur in approximately 3% of patients who undergo gastric resections. However, liberal use of catheter duodenostomy when closure of the duodenal stump is less than optimal, as advocated by Rodkey and Welch,” may decrease this complication to less than 1%. Reports of rates of spontaneous closure from collected series in the literature seem to fall into two distinct groups: those studies that report spontaneous closure rates between 29% and closure rates between 38% 4*66S83and those that report spontaneous 83% and 100% .2’37’4sP86 The disparity may represent differences in the types of fistulas encountered. Buzby and co11eagues3’ and Malangoni and colleagues83 found that lateral fistulas were less, likely to close than end duodenal stump fistulas. In addition, both groups seem to agree that when spontaneous closure does occur, the mean time to closure is 30 to 40 days. Our own experience has been somewhat different, with closure occurring slightly earlier (a mean time of 21 days) .’ Curr

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499

BIHARY

AND

PANCBEATIC

FISTULAS

With the advent of modern biliary tract surgery, spontaneous external biliary fistulas have become exceedingly rare, with only 65 reported cases since 1900.87 Most biliary fistulas now occur in the postoperative period and after percutaneous drainage of postcholecystectomy bile leak.” An emerging major source of bile duct injury is that which occurs after laparoscopic cholecystectomy. The incidence of injury varies with the experience and training of the operator, but rates of incidence from 0.7% to 7.0% have been reported.8s-sz Although choledochocutaneous fistulas from this cause are rare, they do occur. Hepatic trauma, resection, transplantation, devascularization, echinococcal cysts, and amebic abscess account for the remainder of biliary fistulas?3-s6 Spontaneous fistulas are usually cholecystoduodenal, cholecystocolic, and occasionally cholecystocutaneous. Usual causes include acute cholecystitis, chronic cholelithiasis, peptic ulcer disease, gallbladder cancer, and tuberculosis.s7 The most common complication (27%) after surgery for combined trauma to the duodenum and pancreas is pancreatic fistula.” However, 70% close within 2 weeks, and only 6% require reoperation. Similarly, pancreatic fistulas will develop in 17% to 27% of patients after operations for pancreatitis or pancreatic malignancy.ss-103 Internal pancreatic fistulas occur as a result of acute pancreatitis with disruption of the main pancreatic duct. They are seen as pancreatic ascites (68% 1, pancreatic pleural ei-fusion (18% 1, or a combination of the two 04% 1.lo4 SW

INTESTINE

FZSTULAS

Complications of surgery play an overwhelming role in the cause of jejunal and ileal fistulas (Table 4). Most series report that 70% to 90% of small intestine fistulas occur after operative proceTABLE Series

4. Etiologic and year

agents

in small

bowel

I%)

Ca (96)

PUD (WI

IBD

Aguirre, 1974 Reber, 1978

20 6

-

Soeters, 1979 Fazio, 1983 Sansoni, 1985 Rose, 1986 Rinesma, 1990 Kuvshinoff, 1993

9 40 56 10 11 9

10

fistulas Pancreatitis

-

16

2 6 5 4

3 -

Surgical

Other

(96)

77 94

-

-

72 26 25 51 83 80

6 18 3 27 1 1

6 3 -

(W)

-

IBD, Inflammatory bowel disease (Cmhn’s and ulcerative colitis); ease Igastric and duodenal ulcers); Surgical, postoperative.

600

(%I

8 3 6 Ca, malignancy;

3

PCJD, peptic

Cur-r Pro61

Surg,

ulcer

June

dis-

1994

dUms.&5,17,25.82

These causes include disruption of anastomosis, inadvertent injury to the bowel at the time of lysis of adhesions, or inadvertent suture of the bowel at the time of abdominal closure. Roughly half of postoperative fistulas are from disrupted anastomoses and half are from inadvertent bowel injuries. Small bowel fistulas may occur after any intraabdominal operation both with and without intestinal resection. The operations that antecede the appearance of small intestine fistulas are generally operations for cancer, operations for inflammatory bowel disease, and lysis of adhesions caused by previous surgery. In addition, operations performed for peptic ulcer disease and pancreatitis may lead to enterocutaneous fistulas. 1,3-7,11-20,26,27.35 Fistulas can result from anastomoses carried out in less than adequately prepared bowel or from bowel with less than adequate blood supply. Anastomoses can also be jeopardized by hypotension caused by inadequate resuscitation or undue tension placed on the suture line when approximating the ends of bowel. In addition, abscesses may form adjacent to intestinal anastomoses and necessitate into the bowel lumen, resulting in a fistula when the abscess is percutaneously drained. Poor nutritional status may play a major role in anastomotic breakdown and in the inadequate response to infection in some patients. When a patient is nutritionally depleted, protein synthesis is inadequate to allow anastomotic healing. Therefore well-vascularized, tension-free anastomoses in nutritionally replete patients will decrease the incidence of fistula formation.51 However, in emergency settings these goals are often impossible to achieve, and exteriorization may be necessary. Simple closure of small bowel defects greater than half the bowel circumference may lead to fistula formation, especially when the mesenteric border is involved in the defect. Resection with end-toend anastomosis should be performed when such compromise of the luminal diameter is evident. When closure of multiple defects is necessary and viability is questionable, bypass or proximal diversion should be considered. Spontaneous causes of small bowel fistulas include inflammatory bowel disease, cancer, peptic ulcer disease, and pancreatitis. Of the inflammatory bowel diseases, Crohn’s disease is by far the most common cause of spontaneous fistulas (see below). Malignancy causes 2% to 16% of spontaneous fistulas, peptic ulcer disease causes 3% to 6%, and pancreatitis causes 3% to 8% (Table 4). In Western countries, the most common primary small bowel disease that results in fistula formation is Crohn’s disease.105 The transmural ulcerating fissures of Crohn’s disease cause serosal inflammation leading to adherence to surrounding structures. When microperforation leads to abscess formation, the abscess discharges into the Curr

Probl

Surg

June

1994

601

adherent structure, and a fistula results. Fistulas will develop in 20% to 40% of patients with Crohn’s disease. Approximately one half of these fistulas will be external, and one half will be internal.106-“6 Apparently two types of external fistulas occur with Crohn’s disease. The first type includes fistulas that occur early in the postoperative period, after resection of a diseased segment, and are in otherwise uninvolved bowel. These fistulas behave like those not related to Crohn’s disease, have favorable spontaneous closure rates, and should be treated like any other enterocutaneous fistula.“’ The second type includes fistulas that arise from bowel involved in Crohn’s disease. They have a low spontaneous closure rate, often reopen on resumption of enteral intake, and should be considered for early surgical repair. Less common causes of external small intestine fistulas include actinomycosis, tuberculosis, and lymphoma.

Total proctocolectomy with permanent ileostomy for ulcerative colitis removes all diseased mucosa and therefore is curative. In 1947, Ravitch and Sabistonl” introduced the ileoanal pull-through procedure, which also is curative but offers the advantage of continence and defecation per anus. However, it was not until the addition of various pouches to the ileoanal anastomosis procedure in the late 1970s that the ileoanal pull-through procedure became the treatment of choice for ulcerative colitis and familial polyposis.118-132 Construction of the ileal pouch and pouch-anal anastomosis presents technical challenges. With the introduction of the pouch arose a new set of complications, such as pouchitis, ileoanal strictures, anastomotic separation, pelvic sepsis, pouch leakage, and pouch fistulas.133-137 Because stool continence, volume, and frequency have reportedly been similar between pouch and primary ileoproctoscopic anastomoses, some groups have resorted to primary ileoproctostomy without pouch construction?38 Whether primary ileoproctostomy decreases the complications associated with ileoanal pull-through procedures is unknown. In addition, the large number of stools during the first year after ileoproctostomy can be debilitating to the patient. The likely cause of most pouch fistulas is surgical error. Ileoanal separation may occur because of poor vascular supply or undue tension when positioning the pouch in the pelvis. Adequate mobilization of the pouch mesentery is requisite to tension-free ileoanal anastomoses. Alternatively, when the pouch is positioned in the pelvis, the mesenteric vessels may be compressed as they cross the sacral promontory. Adequate mesenteric mobilization will prevent this compression from occurring. In addition, particular attention should be paid to the orientation of the pouch. Rotation of the pouch when 602

Cur-r

Probf

Surg,

June

1994

positioning it in the pelvis may impair blood supply. Because the ileal segment that will form the ileoanal anastomosis is furthest from the small bowel mesenteric blood supply, it may be particularly prone to ischemia. Some series have reported ileoanal pouch procedures performed without protecting proximal ileostomy.‘3g-141 However, postoperative pelvic sepsis seems more common when the pouch is not protected by a diverting ileostomy. The pelvis may remain woody and indurated and pouch function unsatisfactory even after sepsis is supposedly resolved. Therefore we recommend diverting ileostomy with all ileoanal pouch procedures. Fistulas may also form from the pouch itself. Long, continuous suture lines may break down because of poor blood supply or increased intrapouch pressure in the postoperative period when anal sphincter spasm is extreme. In addition, if an early stricture develops at the anastomosis, then fistulas can result. Finally, intermediate cases of inflammatory bowel disease may actually be Crohn’s disease rather than ulcerative colitis. Pathologic specimens should be reinspected and diagnostic accuracy confirmed. It is important that the operation not be attempted in patients with Crohn’s colitis. The inflammatory process of Crohn’s disease involves the full thickness of bowel wall, and mucosal stripping will not eliminate the disease. In addition, recurrence of Crohn’s disease will prevent a good result, particularly recurrence in the pouch. Patients who have a history of fistula-in-ano or perirectal abscess may have Crohn’s disease. In addition, perirectal disease may be exacerbated by the ileoanal pullthrough procedure.142 Fistulas may form from the pouch to the anterior abdominal wall, urinary tract, vulva, vagina, perineum, or adjacent loops of bowel. These fistulas are usually diagnosed by a “pouchogram” performed before ileostomy closure. However, they may be unrecognized by the pouchogram performed before ileostomy reversal, necessitating exploration and the reestablishment of proximal ileostomy or the prolongation of the period when the patient cannot take anything by mouth.143-145 When a pouch fistula develops, operative intervention with repair or reconstruction of the pouch is usually necessary. COLONZC FZSTUIAS Colocutaneous fistulas result primarily from diverticulitis, cancer, inflammatory bowel disease, appendicitis, or secondarily from surgical treatment of these diseases. These fistulas are generally of a lowoutput nature except those that have a small bowel component. Inadequate resection of a diseased segment of colon may lead to fistula formation. When incomplete sigmoid resection is performed Curr

Probl

Surg,

June

1994

503

for diverticulitis, diverticula may be left behind, predisposing to fistula formation from recurrent diverticulitis. The same is true for cancer resection when margins are not clear of tumor. Anastomotic healing may be impaired by the presence of malignancy, or tumor progression may lead to fistula formation. Radiotherapy is another major cause of colonic fistulas. Although adjuvant radiotherapy has improved long-term survival of patients with many abdominal and pelvic malignancies, it has led to a 5% to 15% occurrence of radiation-induced gastrointestinal complications .146-14gBowel resection with primary anastomosis in irradiated tissues has been reported to have a 31% incidence of anastomotic breakdown with subsequent intraabdominal sepsis or fistula.15’ In addition, leaks from a colon or rectal anastomosis may cause not only local infectious complications and fistula formation but also spillage of neoplastic cells that may subsequently lead to locally recurrent cancer.151,152 Techniques such as the covering of anastomoses with omentum or the filling of irradiated dead space with muscle flaps,153 sigmoid exclusion,154 or anal pull-through procedures may decrease the incidence of postoperative leaks and fistula formation from irradiated pelvic anastomoses. The least common type of intestinal fistula is that involving the append$55,156; primary appendicocutaneous fistulas are expectedly rare. Secondary fistulas usually follow simple drainage of an appendiceal abscess but may also follow appendectomy.156‘163 Appendiceal fistulas after appendectomy in a cecum involved in Crohn’s disease are exceedingly rare. More commonly, fistulas in this situation arise from a site proximal to the appendiceal stump, usually terminal ileum. The transmural ileal inflammation of Crohn’s disease may cause adherence to the healing abdominal closure suture line with subsequent fistula formation. Interposed omentum may decrease this complication. These fistulas are true Crohn’s disease fistulas and should be treated accordingly. SPECIFIC

ASPECTS

OF THE CAUSE OF INTERNAL

FISTULAS

Internal enteroenteral fistulas may not be detected when short segments of bowel are bypassed. As such, treatment is directed at the underlying disorder. However, intestinal fistulas involving the urinary bladder or vagina are rarely asymptomatic. Crohn’s disease, diverticulitis, and malignancy together account for most internal fistulas. CROHN’S

DISEASE

The incidence of Crohn’s disease has increased steadily during the last 30 years,l13 and the cause of the malady remains unknown. Ana504

Cum

Probl

Surg,

June

19%

tomically, the distribution of Crohn’s disease is similar in most studies: 25% to 30% small intestine only, 40% to 50% small and large bowel involvement, and 25% large bowel involvement only. Gastrointestinal fistulas are common with Crohn’s disease, the incidence being higher in the ileocolic pattern of disease.l13 Bowel perforation is the underlying pathophysiologic condition to Crohn’s disease- associated fistulas. However, the transmural inflammation of Crohn’s disease leads initially to adherence of adjacent structures. When it does occur, perforation is rarely self-contained (less than 5% of the time) but instead usually enters into the adherent structure. Fistulas develop in approximately 20% to 40% of patients with Crohn’s disease; half of them are external and half are internal.106‘116 The internal fistulas associated with Crohn’s disease tend to be enteroenteric, enterovesical, enterocolonic, or co10vaginal.5’10g Duodenal fistulas occur in 0.5% of patients with Crohn’s disease; however, the duodenum is not usually the primary site of Crohn’s disease but is secondarily involved from small-intestine disease.13’ It is a common observation that people with Crohn’s disease have a reduced voluntary food intake. The adverse effects of this reduced intake may be compounded by poor intestinal absorption. Vitamin B,, and folate, in addition to zinc, iron, and magnesium, may be depleted in these patients. Dietary supplements and daily vitamins may help correct these deficits, but parenteral nutrition is often necessary. These measures, although useful for replenishing a nutritional deficit, do not treat the primary bowel lesions. Various medical regimens have been used to treat acute exacerbations of Crohn’s disease. Immune-modulating drugs, such as steroids, sulfasalazine, and azathioprine, are the mainstay of most regimens, although oral antibiotic therapy with ciprofloxacin and metronidazole may be as efficacious. Most researchers have agreed that Crohn’s disease is more common in whites than blacks. However, recent studies have questioned this contention. Goldman and associates1og reported a lo-year experience of treating Crohn’s disease and found that blacks comprised 11% of their population. The clinical pattern of disease was somewhat different than reported in the white population. Ileocolic disease, perineal disease, extraintestinal manifestations, recurrence, and need for operation were increased in their black patient population. However, the occurrence of internal fistulas was 20%, similar to studies in white patients. Whether this finding is a selection bias or truly represents a more severe form of the disease is unknown. Surgical treatment for Crohn’s disease is usually confined to severe complications that compromise the patient’s ability to function, such as persistent enterocutaneous or symptomatic internal fistulas. The reason is obvious: recurrence is common, and cures occur in probably less than 50% of those patients who undergo operations. The Cur-r Probl

Surg,

June

1994

SOS

progressive nature of the disease and its tendency gical treatment are troublesome features.

to recur after sur-

DZVEATZCULZTZS Fistulas associated with diverticulitis tend to be colovesical both in males and in females who have had hysterectomies. Colovaginal fistulas are probably more common in females when the uterus is in place. The sigmoid colon is the most common segment of bowel involved with diverticulitis. It is because of the sigmoid colon’s anatomic relationship to the vagina or urinary bladder that these fistulas occur. Depending on the rate of progression of the inflammation or the severity of prior episodes, the colon may or may not become adherent to adjacent structures, making free perforation more common with diverticulitis than with Crohn’s disease. MALZGNANCY Malignancy accounts for the rest of internal fistulas, although obstruction or perforation caused by malignancy are more common than fistulization. Malignancy is the etiologic factor in 3% to 7% of fistulas and is present in 5% to 35% of patients with fistulas (Table 3) .3,5,15,16,22,46-54 Any intraabdominal malignancy can cause fistula formation. The fistulas can occur because of the malignancy itself or as a direct result of radiation therapy for malignancy. The most common tumors associated with fistulas are lymphoma,47 pancreatic cancer, bladder cancer, cervical cancer,43’78 gastric cancer,45 colon cancer, and rectal cancer.4 Fistulas that result from malignancy usually signify transmural disease with direct extension into adjacent viscera, although intestinal perforation with abscess formation and subsequent perforation into adjacent viscera can occur. As with enterocutaneous malignant fistulas, malignancy should not be considered a contraindication to aggressive nonoperative and operative management. A rational treatment plan should be made on the basis of the biologic condition of the tumor and the disease state. THERAPEUTIC

APPROACH

Therapeutic goals for enterocutaneous fistulas are closure of the fistula and reestablishment of intestinal continuity by nonoperative or operative means. If sepsis is present, patients should be taken to the operating room for exploration. Antibiotics and parenteral nutrition are unlikely to be effective in situations where sepsis is persistent. Use of the term “conservative management” to denote nonop506

Curr

Probl

Surg,

June

1994

erative management of enterocutaneous fistulas is intentionally avoided in this monograph because it is a term that is relative to the patient’s condition and prognosis in addition to the cause, anatomy, and physiologic condition of the fistula. In situations where a patient is fully resuscitated and spontaneous closure of the fistula is unlikely, or where sepsis is unresponsive to percutaneous drainage, prolonged nonoperative management would be “radical” and would likely result in death. As with any difficult situation, it is helpful to divide the management of a patient with an enterocutaneous fistula into various stages. With the plan organized in this way, the physician can focus on the principal challenges and therapeutic decisions at each stage of management (Table 5). Fistulas can be tenaciously persistent and resistant to intervention. Having a framework allows the physician and the patient to establish scheduled expectations and assists in defining realistic goals. The anticipated course of a patient with a fistula TABLE

5. Management

phases

Phase

Goals

Time

Recognition/ stabilization

Rehydration Correction of anemia Drainage of sepsis Electrolyte repletion Oncotic pmssue restoration Nutrition support institution Control of fistula drainage Institution of local skin cam Fistulogram to define anatomic and pathophysiologic conditions CT to localize collections and to stage cancer, when present EGD or colonoscopy as indicated Assess likelihood of spontaneous closure Plan therapeutic course Decide surgical timing Plan operative approach Bowel resection with end-to-end anastomosis Ensure secure abdominal closure Gastrustomy Jejunostomy Continue nutritional support Transition feedings

Within

24-48

After

7-10 days

From

7-10 days

Investigation

Decision

Definitive

therapy

Healing

EGD, Esophagogastroduodenoscopy;

Cur-r Ptabl

Surg

June

1994

CT, computed

courSe hours

When closure 4-6 weeks

From

5-10 days

to 4-6 weeks

is unlikely

after

or after

closure

tomography. 507

can be divided into the following five sequential but overlapping phases: (1) recognition and stabilization, (2) investigation, (3) decision, (4) definitive therapy, and (5) healing. PHASE 1: RECOGNITION

AND STABILIZATION

Resuscitation

Most enterocutaneous fistulas occur in the postoperative period. In the usual setting in which these fistulas are identified, the patient has been well for 5 to 6 days after an operation. The patient is usually febrile and has a persistent ileus. A wound abscess appears and is drained, resulting in defervescence. Within the next 24 hours, enteric contents appear on the wound dressing. The additive effects of the primary disease process that necessitated the initial operation, the period of preoperative bowel preparation, the metabolic stress of the operation, and the prolonged postoperative course culminating in sepsis and fistula formation can lead to profound metabolic disturbances. The patient usually has significant deficits in body cell mass, circulating fluid volume, red cell mass, and serum proteins. Adequate circulating volume, oxygen-carrying capacity, and colloid oncotic pressure are requisite for organ function and tissue healing. Therefore crystalloid resuscitation, usually 3 to 4 L, to offset intravascular fluid losses sequestered in the bowel and bowel wall is necessary. Anemia should be corrected to a hematocrit of 32% by transfusion of packed red blood cells. Serum albumin plays an important role in the partitioning of extracellular fluid. Areas particularly sensitive to hypoalbuminemia include skin, lungs, and intestines. Several reports have described an association between hypoalbuminemia and impaired gastrointestinal absorption, leading to the conclusion that exogenous albumin administration may promote absorption of intestinal luminal contents.1s4-170 We believe that exogenous albumin should be administered until serum albumin reaches 3.0 mgdl unless sepsis-induced pulmonary capillary leak is prominent. Albumin administration will improve plasma oncotic pressure and promote bowel function. Drainage

of Obvious Abscesses

Although it is not common, implantation of enteral bacteria on central venous catheters used for parenteral nutrition does occur and may be more common with multiple-lumen catheters than singlelumen cathetersl’l This situation occurs especially when bacteria continue to shower from undrained abscesses. Therefore, when possible, abscesses that are evident should be drained before catheter insertion. If such an abscess is evident or is pointing to the abdominal wall, the physician should inject water-soluble contrast under fluoroscopy SOS

Cur-r Probl

Surg,

June

1994

before operative drainage. With the abscess studied in this way, information may be gained that would be otherwise unobtainable. Drainage may then be undertaken. Bacterial showering after manipulation and drainage of the abscess is predictable; therefore 24 hours should be allowed to pass before a central venous catheter is placed. of Fistula Drainage In the event that an operation is necessary, an intact abdominal wall is requisite if permanent fistula closure is to be achieved. Wound care assumes a high priority because, if an operation is necessary, it should not be performed through a septic, indurated, infected, and denuded abdominal wallT6 Fistula drainage is best controlled by the use of a sump (Fig. 3). With simple bagging of fistulas, especially lowoutput fistulas, skin closure over the fistula tract can occur while enteric leakage persists, leading to abscess formation. A soft latex catheter such as a Robinson nephrostomy tube, which is soft at body temperature and will not erode, is preferred. An air vent to break suction can be made by inserting a 14-gauge intravenous catheter directly through the drainage tube. In addition to improving local skin care, this step will provide accurate records of fistula output, which are requisite to daily volume and electrolyte management. In addition, accurate output records provide some indication of whether closure is taking place. In previous studies (unpublished data; 1976) we investigated whether suction cup drainage applied to the skin was superior to sump drainage inserted into the wound. Sump drainage was required to close the fistula and deep tissues; suction cup drainage closed the skin but resulted in undrained purulent collections. More recently, high-pressure suction has been advocated with seemingly miraculous, yet unverified, results.17z Control

Local Skin Care

Local skin care is crucial not only for short-term management but also for future surgical therapy. Many devices have been tried for the local management of fistula drainage?2”73-176 The ability to prevent excoriation or superinfection of the skin surrounding a fistulous tract may define whether future surgical therapy will be successful. Therefore good control involves integument protection and a mechanism of drainage collection.” A number of preparations are useful in preventing skin maceration and breakdown. Karaya powder or seal, ileostomy cement, glycerine, or ion exchange resins that keep the skin acidic and prevent activation of pancreatic enzymes by basic environment are useful. An enterostomal therapist can be invaluable in this difficult portion of management. In our experience, the most effective form of management is a protective skin dressing. Stomadhesive or similar product may be effective. If such a product can be affixed to the skin successfully, it can be left in place for 7 to 10 days, Curr

Probl

Surg,

June

1994

609

Fistula Umbilicus

FIG. 3. Local control structed from Robinson graph of apparatus. 610

of fistula drainage. nephrostomy tube

A, Fistula and

site. large-bore

B, Fistula sump apparatus conintravenous catheter. C, PhotoCurr

Probl

.%rg,

June

$994

provided the fistula drainage does not leak under the patch. When the product is used properly, the skin underneath is well protected, and skin healing can occur (Fig. 3). Nutritional Support The management of enterocutaneous fistulas has evolved significantly during the last three decades, and, appropriately, nutritional support has gained a central management role. The need for nutritional support in the patient with an enterocutaneous fistula should always be evaluated with respect to other, more urgent care problems. Priorities such as airway, breathing, circulation, tissue oxygenation, acid-base neutrality, normal electrolyte concentrations, and volume status supersede nutritional management.177 Circulation and tissue oxygenation must be adequate to optimize nutrient metabolism.6 However, after initial stabilization, timely initiation of nutritional support is crucial to maximize the benefits nutrition has on patient outcome. The breakdown of lean body mass is relentless and sufficiently rapid that after 5 or 6 days of starvation, particularly septic starvation, sign&cant deficits are compounded each day the patient is without adequate nutrition.26 Although patients with enterocutaneous fistulas have increased calorie and protein requirements, overfeeding can be as detrimental to patient outcome as underfeeding. Overfeeding can lead to carbon dioxide overproduction, retention, hepatic steatosis, carbohydrate intolerance, immunosuppression, and suboptimal macronutrient use. Carbon dioxide overproduction is less common than the sensationalists would have us believe, but hepatic steatosis and carbohydrate intolerance are commonly seen. Underfeeding can lead to breakdown of protein for fuel substrate, immunoincompetence, poor wound healing, cellular dysfunction, and ultimately organ dysfunction.178-181 These undesirable effects can be minimized by providing the patient with the calories and protein necessary to support the metabolic state without overfeeding. A common method used to determine a patient’s nutritional needs is to use calculations based on factors known to influence metabolic rate. Of the many formulas used, the most widely accepted is the Harris-Benedict equation, which takes into account energy expenditure variation for sex, weight, height, and age. For male patients, the equation is 66 + (13.7 X weight For female patients,

[kg]) + (5 X height [cm]) - (6.8 X age [yrl)

the equation

665 + (9.6 X weight

is as follows:

[kg]) + (1.7 X height [cm11 - (4.7 X age [yrl)

The number attained is the basal energy expenditure. The basal energy expenditure is then multiplied by a stress factor, which is determined by the patient’s underlying illness. This product is the restCurr

Probl

Sur5

June

1994

511

ing energy expenditure and defines the amount of calories that need to be provided in each 24-hour period. In addition, a small activity coefficient is added. Because of the hypercatabolic state and ongoing nutrient losses associated with many enterocutaneous fistulas, we recommend feeding at a rate that is 1.3 to 1.5 times the basal energy expenditure, although 1.5 is probably high. Caution should be used, however; in patients who do not have sepsis and whose losses are not excessive, an adjustment factor of 1.2 or lower may be more appropriate. A decreased calorie/nitrogen ratio of 1OO:l to 125: 1 is probably also beneficial. Indirect calorimetry is another method of determining metabolic needs. It measures oxygen consumption and carbon dioxide production noninvasively by analyzing inspired and expired gases. It is an accurate method but is not available in all institutions. If the patient is intubated the instrument can be interposed into the ventilator circuit where direct measurement of oxygen use can be performed. If the patient is not intubated, a hood is placed over the patient’s head, and oxygen use is determined from the captured gases. An activity coefficient should be added to the resting energy expenditure as well. In a recent study, we found that both methods were equally variable, and both required adjustment for activity.“’ All methods of determining metabolic needs are directed toward the goal of providing patients with nutrients to meet their exact metabolic requirements.

Metabolic

Requirements

in Patients with Enterocutaneous

Fistulas

The energy requirements of an healthy individual are primarily related to body size, age, sex, and energy expenditure of muscle activity. However, critical illness in general, and enterocutaneous fistulas in particular, lead to increased calorie and protein requirements. Correction of volume status, electrolytes, and acid-base balance is crucial if nutrients provided by nutritional support are to be used effectively. Weight gain, which is usually reflective of fluid retention more than building of body cell mass, should not be a priority. The goal of nutritional therapy in this setting should include nitrogen equilibrium with maintenance or restoration of structural and functional protein synthesis.6 If protein intake is inadequate, body tissues may not be replaced. Generally, healthy individuals require 0.8 to 1.0 gm of protein/kg/day. However, external losses and the additional metabolic stress present with enterocutaneous fistulas increase this protein requirement to 1.5 to 2.5 gm of protein/kg/day.3’“‘7 This amount of protein should be provided along with adequate calories (as much as 1.3 to 1.5 times the calculated basal energy expenditure, as stated above) to maintain protein synthesis in hypercatabolic patients with enterocutaneous fistulas (Table 6). Fluid requirements for maintenance can be estimated from either body weight (30 ml/kg) or body surface area (1500 ml/m’) and adjusted 612

Cur-r

Probl

Sur5

June

1994

TABLE 6.

Metabolic

Calories Protein Lipids

Vitamins

Minerals

REE, Resting

energy

needs

of patient

with

enterocutaneous

fistula

Low output (
High output G-500 ml/dav)

Calculated REE 1-1.5 gmkgfday 20% to 30% of total calories May consider enteral short-chain fatty acids RDA for water-soluble vitamins Two to five times RDA of vitamin C Vitamin K weekly Weekly renal, magnesium, phosphorus, and calcium profiles

Calculated REE X 1.5 1 S-2.5 gm/wday 20% to 30% of total calories

expenditure;

RDA,

recommended

Two times RDA for water-soluble vitamins Five to 10 times the RDA of vitamin C Vitamin K weekly Renal and magnesium profiles every other day Biweekly phosphorus and calcium profiles Zinc, copper and other trace elements given empirically daily allowance.

for existing deficits and ongoing fistula losses. The necessity of keeping accurate records regarding fistula output can not be overstated. With high-output fistulas the patient may become volume depleted literally overnight. Therefore the fistula losses must be added to daily fluid requirements. In addition, patients with fistulas often have a low-grade fever, which adds 500-800 ml/day to their volume requirement for each degree centigrade over 37’. In addition, patients with large bile or pancreatic juice losses seem to require more volume than their measured losses would suggest, which in part may be because of the nature of these secretions. We have found it useful to use 3% saline under these circumstances. After ongoing electrolyte needs are established, supplemental sodium, potassium, calcium, phosphorus, magnesium, and trace elements can be added to the parenteral nutrition solution. It is rarely necessary to supplement volume or electrolytes in addition to that received by the parenteral nutrition except in patients whose fistula outputs are excessive. Acid-base balance should be achieved before nutritional support is started. Treatment is always directed at the underlying cause of the acid-base disorder. Chloride-sensitive, volume contraction alkalosis can be treated by adding chloride-containing salts of sodium, potassium, or calcium directly to the parenteral nutrition solution. In addition, acidosis can be lessened or corrected by the addition of sodium or potassium acetate to the parenteral nutrition solution. Cum- Probl

Surg,

June

1994

513

Providing adequate calories for energy to spare protein breakdown while providing amino acids allows protein synthesis and ultimately improved organ function. Glucose generally makes up 40% to 80% of calories provided. In the presence of insulin it is used as a fuel source without further modification by most tissues. However, overfeeding of carbohydrate calories may lead to elevated blood sugars, osmotic diuresis, hyperosmotic nonketotic coma, increased carbon dioxide production, and hepatic steatosis. By supplying 20% to 30% of the patient’s caloric requirement as lipid, carbohydrate calories can be lessened, and therefore the complications associated with carbohydrate overfeeding are also lessened. In addition, most viscera normally use lipid, and perhaps some hepatic and renal protection is achieved. Because of its caloric density (9 kcal@n1, lipid provides calories in a relatively small volume. It may therefore be useful in patients with volume restrictions to increase the amount of calories provided as lipid. Additionally, patients with enterocutaneous fistulas who are considered candidates for enteral nutrition often cannot tolerate the osmotic load of glucose-based enteral formulas. Lipid-based enteral formulas present a lower osmotic load than isocaloric carbohydrate-based formulas and therefore may be absorbed from the gastrointestinal tract lumen better. Also, lipid does not exacerbate hyperglycemia and may be used in increased concentration as an alternate source of calories in patients in whom serum glucose management is difficult. When hypertriglyceridemia is present the amount of lipid that can be safely provided to a patient is decreased. Because of dietary requirements for the essential fatty acids, linoleic and linolenic, a minimum of 2% to 6% of total calories should be provided as lipid weekly. A theoretical limit of 2 gm/kg/day of parenteral lipid will avoid the fat overload syndrome, which consists of bone and joint pain, fever, and, at times, a rash. Vitamins and trace elements may be rapidly depleted when adequate nutrition is provided to malnourished patients. Patients with high-output enterocutaneous fistulas should receive approximately twice the recommended daily allowance for water-soluble vitamins. If the patient has a large granulating wound, extensive tissue repair will be occurring, and therefore vitamin C should be provided at 5 to 10 times the recommended daily allowance. Patients with fistulas can lose considerable amounts of copper, zinc, and magnesium in addition to disturbances in the commonly monitored electrolytes. We find it useful to monitor serum magnesium levels biweekly and supplement the patient as necessary by adding magnesium directly to the parenteral nutrition solution. We do not check serum copper or zinc levels routinely; however, the amount of copper contained in two ampules of commercially prepared preparations of vitamin and trace elements will usually suf514

Curr

Probl

Surg

June

1994

fice. Additionally, day of elemental

with high-output fistulas we routinely add 10 mg/ zinc to the parenteral nutrition solution (Table 61.

Enteral or Parenteral Nutritional Support The route of nutrient delivery appears to affect the response to critical illness. Enteral alimentation may be physiologically su erior to parenteral nutrition and is preferred whenever possible.8,1 Ps-18’ Enterally fed patients have improved systemic immunity, reduced incidence of infection, and better toleration of septic insult than identical patients fed parenterally.3’183-18” The gastrointestinal tract should be used if possible to provide at least a portion of the patient’s nutritional needs because this method may provide sufficient beneficial effects.l14 At least 4 feet of functional bowel must be available either proximal or distal to the fistula to use enteral nutrition support in patients with enterocutaneous fistulas. Nutrition can be administered through the fistula provided partial or complete bowel obstruction does not exist distally. Respectable rates of fistula closure have been achieved with enteral support, although the rates are slightly less than those achieved with parenteral nutrition.4g~114~172~187~1s1It should be recognized, however, that severe nutritional depletion is present in many patients with fistulas. Because of mucosal brush border atrophy and hypoalbuminemia, enteral nutrition may be poorly absorbed, leading to diarrhea and continued nutritional decay.ls2 Tube feeding intolerance may make it impossible to administer all of the patient’s nutritional needs enterally. Furthermore, generally 4 to 5 days are needed to attain target caloric provision with enteral therapy. Therefore a period of concurrent enteral and parenteral nutrition may be necessary to restore mucosal function.1s2”s3 The absence or presence of bowel sounds is not predictive of enteral feeding tolerance. Unless a specific contraindication to the use of the gastrointestinal tract exists, nutritional therapy should be attempted through an appropriate tube whose position has been confirmed radiographically. Enteral Nutrition Nasoenteral feeding is the method preferred for short-term nutrition when the patient’s oral intake is limited. However, intragastric feeding may be poorly tolerated because of impaired gastric emptying. In addition, increased gastroesophageal reflux may be present in individuals with reduced lower esophageal sphincter pressure and increased intragastric pressure. Many medications used in hospitalized patients, such as theophylline, anticholinergics, calcium channel blockers, B-agonists, and a-antagonists cause reduction in lower esophageal sphincter pressure. In general, intestinal feeding is tolerCurr

Probl

Surg,

June

1994

516

ated better and carries a lower aspiration risk than gastric feeding and should be used when possible.177,fs4-1s6 Duodenal or jejunal access can be established by spontaneous passage of a nasogastric tube, fluoroscopic or endoscopic placement of a nasointestinal tube, placement of a pH-sensing tube, or open surgical placement of a jejunostomy-tube. Elemental tube feedings may allow enteral nutrition without significant exacerbation of fistula output. However, their composition may be critical to establishing tolerance. Free amino acids increase the osmolarity of tube feedings, which leads to decreased tolerance. Because dipeptides and tripeptides in the bowel lumen are transported into the mucosal cell and then hydrolyzed to free amino acids, providing protein in the form of free amino acids does not confer any advantage and is probably unnecessary. Oligopeptides from protein hydrolysates are better tolerated and probably are absorbed better than free amino acids and therefore should be the major protein source of an elemental diet.188~1s7-201Glucose or oligosaccharides, which usually constitute most of the calories in enteral formulas, may be tolerated poorly in patients with diseased bowel. Distention, crampy pain, diarrhea, and increased fistula output may result from the osmotic load of glucose-based formulas. Therefore, in patients with enterocutaneous fistulas, we favor lipid-based formulations that use increased amounts of medium-chain triglycerides as well as oligosaccharides to minimize osmolarity. Medium-chain fatty acids are absorbed unchanged into the portal system and can be used as a fuel source. However, they provide no essential fatty acids, so a portion of the lipid provided must be long-chain fatty acids. Tube feedings are adjusted to 40 ml/hour of isosmolar, or just slightly less than isosmolar, feeding and advanced 20 ml/hour/day to the target rate. The stomach is the only defense the gastrointestinal tract has against an osmolar load. When hypertonic enteral formulas are given intragastrically, motility slows and secretions increase until isosmolarity is achieved, at which time 2 to 4 ml aliquots of thyme is allowed to pass through the pylorus every 30 seconds.202 The intestine has less defense against hyperosmotic loads. The obvious advantages to digestion that intragastric feedings confer are offset by the variability of gastric emptying in critical illness, which may lead to high aspirates and intolerance to enteral feeding. When intragastric feedings are used, the patient should be able to protect the airway and have intact gag and cough reflexes. Elevating the head of the bed to 30 degrees and running the tube feedings only during day and evening nursing shifts (7 am to 11 pm) may decrease the risk of aspiration. If gastric feeding is used, osmolarity is increased, and then rate is advanced. Aspirates through the feeding tube should be checked every 4 hours. If an aspirate is more than 50% of the volume fed to the 516

Cum

Probl

Surg,

June

1994

patient during the previous 4 hours, the aspirate should be returned, the tube feeding stopped, and the tube flushed with 30 ml of water. After 4 hours the aspirate should again be checked. If less than half the original aspirate is present, the tube feeding should be resumed at a rate that is 20 to 40 ml/hour less than the original rate. The rate can then be increased 20 ml/hour/day up to target. If duodenal or jejunal feeding is used, the rate is increased first, and then osmolarity is advanced. If evidence of tube feeding intolerance occurs or if an aspirate more than 100 ml is found, the tube feeding should be stopped, the feeding tube flushed with 30 ml of water, and the aspirate checked in 4 hours. If the aspirate is less and the clinical symptoms of intolerance have subsided, the tube feeding can be resumed at a slower rate and then advanced 20 ml/hour/day to target. For the patient with altered mental status, methylene blue can be added to the tube feeding. If pulmonary suctioning reveals bluetinged secretions, aspiration into the tracheobronchial tree is occurring. Tube position should be confirmed by a radiograph. If the tube is not displaced, advancing it further distally may improve tolerance. The patient who receives enteral nutritional support should have physiologic and metabolic parameters determined at appropriate intervals (Fig. 4). This step will ensure that adequate support is being provided and that metabolic derangements are detected in a timely fashion. In addition, the so-called short-turnover proteinstransferrin, prealbumin, and retinol-binding proteinshould be determined weekly. Nutritional management may need to be altered if protein synthesis is found to be inadequate. Additional fluids or electrolytes, when necessary, can be given through the tube separately, added to the tube feeding, or be supplemented parenterally. The fistula output may increase transiently after enteral feeding is begun. This increase usually resolves within a few days; however, if the output continues to increase or remains high, the tube feeding rate should be decreased, and the patient given supplemental parenteral nutrition.

Parented

Nutrition

The patient with an enterocutaneous fistula who cannot tolerate enteral feeding should receive parenteral nutrition by way of a central vein. Peripheral formula is available in most hospitals, but it is designed for short-term use (3 to 5 days) and is rarely indicated in the management of patients with enterocutaneous fistulas. It has a relatively low caloric density because there are limitations to the osmotic load of highly caloric solutions that are poorly tolerated in peripheral veins. Therefore large volumes are required to approximate a patient’s nutritional needs. Lipid, because of its high caloric density, can be added (up to but no more than 60% of total calories) to Curr

Probl

Surg,

June

1994

517

UMC-390 Revned Slsa

Unwersity Physicm’s

oi Cmcinnatl Hospital Checklml/Order Sheet

All appkubk ordm ham been checked. A line has been placed through orden that hawebeen voided ORDERS NOT CHECKED ARE NOT TO SE FOLLOWED. Orders have been moddied Bccordina lo the medical condilion of the Mlient. TheM Orders

4. 5.

7. -8. 9. -.-i!L -!112. -u2 -K

L7.

STAT blood

glucose

for

1/4X or gre.ter

Fvlyacw1 WhitbC~ll -lop&by

Yellow-Kardex _ert

FIG. 4. Standing odically

518

evaluated

Dale -__.

H. llovcr,

orders during

H.1).

m

I

I

slycoauria.

-

---

signam Tin*

4180

for enteral nutrition. Laboratory enteral nutrition therapy.

and

metabolic

Curr

Probl

parameters

Sur5

June

peri-

19%

peripheral formula to decrease the volume requirement; however, a limit of fat of 2 gm/kg/day exists. Peripheral formula is not nutritionally balanced and does not provide patients with sufficient protein and calories for the period of time necessary for closure of the enterocutaneous fistulas. In addition, loss of peripheral venous access resulting from the hyperosmotic nature of parenteral nutrition will further complicate patient management. For most patients a 15% dextrose formula with 5% amino acids administered by way of a central vein is appropriate. A total of 250 ml of a 20% lipid emulsion should be provided daily. It can be infused separately over a lo- to U-hour period by central or peripheral vein or combined with the dextrose and amino acid components in a single solution and infused as a total nutrient admixture or “3 in 1" mixture. This solution provides a calorie/nitrogen ratio of 100 : 1 while supplying 25% to 40% of calories as lipid. If serum protein concentrations are not improved after 1 week of adequate calorie provision, the amino acid content of the parenteral nutrition can be increased to 6% to 8% to provide more synthetic precursors, provided the blood urea nitrogen is not greatly elevated. For patients with minor volume restrictions who have no history of glucose intolerance, the dextrose concentration can be increased to 25% and the lipid given twice weekly. This formula will still provide adequate nutrition, yet decrease infused volume by approximately 15%. Parenteral nutrition should be provided through a central vein in the upper body. Temporary percutaneous groin catheters limit patient mobility, make catheter dressings difficult, and are associated with higher catheter infection rates when compared with subclavian or internal jugular vein catheters. Single-lumen catheters are preferred, and, once placed, they should be dedicated solely to parenteral nutrition. If we use a double- or triple-lumen multiuse catheter or a pulmonary artery catheter or its introducer for parenteral nutrition, we change it every 72 hours to lessen the chance of central line sepsis. Increased rates of sepsis with central line multiple-lumen catheters have been well documented and are likely the result of manipulation of the non-parenteral nutrition ports171 When standard 15% to 25% dextrose-based formulas are used, the initial rate of infusion is 40 ml/hour with a standard electrolyte complement. The metabolic status of the patient with an enterocutaneous fistula changes rapidly, especially during initiation of parenteral nutrition. Supplemental electrolytes or insulin in the parenteral nutrition solution may also require peripheral supplementation until the patient’s condition stabilizes.177 If the patient’s metabolic picture has changed so that the additives become unnecessary, the bag will usually have to be discarded. If it can be tolerated, the rate should be advanced 20 ml/hour/day until target caloric provision is reached. In the face of glucose intolerance, finger-stick blood sugars with slidCur-r

Probl

Surg,

June

1994

519

ing scale insulin coverage beginning at 200 mgdl should be instituted. If insulin coverage continues to be necessary, then 15 IU/L of regular insulin can be added to the parenteral nutrition bag with continued finger-stick blood sugar monitoring and insulin sliding scale coverage. When parenteral nutrition orders are written each day, two thirds of the previous day’s insulin requirements can be added, up to 80 IU/L, to the parenteral nutrition bag. This step will assist in the careful control of blood glucose. As the patient’s underlying sepsis resolves, the insulin requirement may decrease. If blood sugar levels are routinely less than 140 mgdl, insulin should be withdrawn from the parenteral nutrition in 10 to 15 IU increments. The patient who receives parenteral nutrition also should have certain physiologic and metabolic parameters determined routinely to prevent or detect early in the process the more prevalent metabolic derangements that can occur with parenteral nutrition (Fig. 5). As enteral nutrition is established, either orally or by feeding tube, parenteral nutrition can be weaned. Parenteral nutrition is usually decreased 20 to 40 ml/hour/day to a rate of 40 ml/hour. At this point parenteral nutrition can be discontinued. With rapid weaning, rebound hypoglycemia rarely occurs; therefore, after weaning is complete, serial blood sugars should be continued after parenteral nutrition is stopped. Alternatively, 5% dextrose solution can be infused for 24 to 48 hours. Volume and Electrolytes

It is rarely necessary to supplement volume and electrolyte requirements by peripheral vein. It should be possible to adjust serum electrolytes with the parenteral nutrition solution. With frequent monitoring of electrolytes and a knowledge of the fistula output volume and composition during the previous 24 hours, appropriate parenteral nutrition orders can be written. Fluids of appropriate composition and volume can be added directly to the parenteral nutrition and the infusion rate adjusted accordingly (e.g., 1.8 L of parenteral nutrition with 1.2 L one-half normal saline infused at 125 ml/hour). The exception to this procedure may be patients with extremely high (more than 3 L/day) fistula outputs. The physician should be aware of the high sodium content of biliary and pancreatic secretions. The loss of 1 to 2 L of this fluid through a proximal fistula could result in marked hyponatremia when insufficient exogenous sodium is administered. The chloride, acetate, or phosphorus (but not the bicarbonate) salts of sodium can be added directly to the parenteral nutrition solution. If acidemia is present and refractory to acetate therapy, then bicarbonate can be administered as a separate infusion. 520

Cur-r

Probl

Surg,

June

1994

WC-R?4 mm

University of Cincinnati Hospital Physician’s ChecklisUOrdsr Sheed

z!slllJI

14.

,/

PHYSICIAN'S

p5waEtNotify

Nutritional

culture

mn.-Fri.

STANDING ORDERS PARENTERAL NUTRITION

Support 9:oo

it

for

a.m.-O:00

catheter

removal

and

p.m.

FIG. 5. Standing orders for parenteral nutrition. Laboratory and metabolic parameters are periodically evaluated during parenteral nutrition therapy.

Curr

Probl

Surg,

June

19%

521

Antibiotics

Reviews of large clinical series reporting intercutaneous fistulas reveal that the average patient receives seven to nine different antibiotics during the hospital course.5*7~27~36~37 It is important to use antibiotics only when they are needed to prevent superinfection by resistant organisms. Antibiotics should be withheld unless a patient has sepsis, as evidenced by mental status change, hemodynamic instability, high fevers, or signs of impaired organ function. The most common organisms causing sepsis in patients with enterocutaneous fistulas are of bowel origin (i.e., coliforms, bactemides, and enterococcus). Staphylococcus also often plays a role in intraabdominal sepsis. CT scans should be used liberally if sepsis is suspected. Percutaneous drainage under CT guidance can be efficacious in draining suitable abscesses. If sepsis is not readily controlled by percutaneous drainage and antibiotics, then operative therapy is indicated. Nasogastric

Tubes

Unless the intestine is obstructed, little evidence exists to indicate that a nasogastric tube is helpful. Several reports have failed to demonstrate improved outcome from the use of decompressive tubes.3S5 Unless the fistula is high in the intestinal tract, the nasogastric tube can be removed without a great deal of influence on the amount of fistula drainage? Aside from patient discomfort, the presence of longterm indwelling nasogastric tubes may result in impaired cough, serous otitis media, pharyngitis, alar necrosis, mucosal erosion, and esophageal reflux with late esophageal stricture. If intestinal obstruction is present, a long tube can be passed to the area of the fistula to decompress the obstruction. If a gastrostomy or tube enterostomy is already present, it should be opened to gravity. If the obstruction cannot be relieved by nonoperative means, then operation may be necessary to relieve the obstruction and close the fistula. Measures

to Decrease

Volume of Secretion

After volume and electrolyte repletion and control of the external component of the fistula have been achieved, measures to decrease enteric volume should be used. Although fistula output does not correlate with overall spontaneous closure rates, decreased enteric output may shorten the time to closure. Orogastric secretions account for 1.5 to 2 Yday of enteric volume, and pancreaticobiliary secretions constitute 2 to 2.5 L/day of enteric volume. When these amounts are added to the 7 to 9 L the small intestine produces each day, it becomes evident that inhibition of these secretions is prudent. 62.2

Cum

Probl

Surg,

June

1994

Histamine,

Antagonists

Unless a specific contraindication exists, the patient should be placed on therapeutic doses of either an H, antagonist or an H+-K+ ATPase inhibitor because stress and prolonged periods of strict adherence to a regimen where nothing is taken by mouth may predispose patients to peptic ulceration. Additionally, the direct effect these drugs have on the gastric mucosa will decrease gastric acid secretions and thereby decrease intraluminal voltrne. In addition, diminished gastric acid secretion may indirectly lessen pancreaticobiliary secretion.

Somatostatin Although the use of somatostatin to decrease pancreatic fistula volume is well established, no prospective studies have demonstrated an increased rate of closure. The role of somatostatin in the treatment of other fistulas is less clear. Somatostatin accelerates gastric emptying but inhibits motility in the remainder of the gastrointestinal tract. A single 50 Fg subcutaneous injection of somatostatin increases mouth-to-cecum transit time 350~6, from 57 to 204 minutes.203-205 The same dose has been shown to decrease endogenous fluid secretion and increase absorption of water and electrolytes from the small bowel in patients with diarrhea resulting from neuroendocrine tumors such as carcinoid, glucagonoma, and vasoactive intestinal polypeptide secreting tumor.11~206~208 Because of these abilities, somatostatin’s efficacy in enterocutaneous fistulas has been inferred but never proved. Generalizations about somatostatin’s ability to decrease intraluminal intestinal volume in patients with relatively normal intestinal secretory and absorptive function are tenuous at best. Kingsnorth and coworkers’l treated six patients with uncomplicated fistulas of suture line origin with parenteral nutrition and continuous intravenous somatostatin infusion (250 pghour for 48 hours, then 125 kg/hour for 48 hours). Fistula output was decreased in all patients. However, acceleration of enterocutaneous fistula closure by this short course of somatostatin could not be demonstrated. In contrast, Hild and associates”’ administered somatostatin for the duration of medical management. They reported 80% closure after 11 days with a continuous intravenous infusion of somatostatin at 3 to 3.5 pg/kg/hour. Mean treatment duration with somatostatin and parenteral nutrition was 13 days. In early studies, somatostatin’s short duration of action necessitated continuous intravenous infusion.210-213 This problem has been resolved by the introduction of the long-lasting somatostatin analogue SMS 201-995 (Sandostatin, Sandoz Pharmaceuticals, East Hanover, NJ.). Therapeutic equivalence to continuous intravenous infusion can be attained with subcutaneous SMS 201-995. One hundred Curr

Probl

Sur5

June

1%~

623

to 600 kg/day are given in two to four divided doses. Nubiola and coworkers214 treated 27 patients with postoperative enterocutaneous fistulas with parenteral nutrition and SMS 201-995 (100 kg subcutaneously every 8 hours). The mean reduction in fistula output was 55% within 24 hours of instituting therapy. Spontaneous closure was achieved in 21 patients (77%) after a mean of 5.8 + 2.7 days. Of the six remaining patients, one died of sepsis, two had distal obstruction, and three had total anastomotic disruption. Combined parenteral nutrition and SMS 201-995 therapy would not, and should not, be expected to influence closure in such anatomically hostile situations. Conservative treatment with parenteral nutrition alone succeeds in closing between 60% to 75% of fistulas. In collected series of fistulas treated with parenteral nutrition and somatostatin or SMS 201-995, the closure rate is 60% to 92%, similar to parenteral nutrition alone. However, time to closure is decreased from an average of 50 days for parenteral nutrition alone to 5 to 10 days when SMS 201-995 is administered.11’210-216 However, it is not clear that fistulas selected for somatostatin treatment are more favorable than others. At best, somatostatin may accelerate rates of closure, but it is unlikely to render anatomically unfavorable fistulas more likely to close. Emotional Support The external drainage of enteric contents can be a particularly humiliating and demoralizing experience for both the patient and physician. The persistent nature and severe metabolic consequences of many fistulas may necessitate complex and prolonged medical management, leading to loss of personal confidence, loss of confidence in the health care team, and ultimately major depression for the patient. Continued physician involvement and reassurance, with particular attention to ambulation and physical therapy, will help to reduce the emotional duress of such an intense medical condition. At times psychotropic drugs or consultation with a psychiatric service may be necessary. PHASE 2: INVESTIGATION Radiologic investigations are usually the most important step in defining the anatomy of a fistula. Approximately 7 to 10 days after surgery, when the patient’s stamina has improved and the tract has matured sufficiently to be injected with a radiographic contrast medium, a collaborative effort between the surgeon and the radiologist is undertaken To provide maximal information a senior radiologist who has expertise with equipment and positioning and the senior surgeon responsible for the patient’s care should be present during fluoroscopic evaluation. We prefer using a water-soluble contrast mate-

rial injected into the fistula tracts through a 5F or SF pediatric feeding tube. Standard barium gastrointestinal tract examinations, such as an upper gastrointestinal series, small-bowel follow-through, and barium enema, are usually unnecessary because they rarely yield information not already obtained from the fistulogram. With these studies, the surgeon is trying to define those characteristics of a fistula that determine whether spontaneous closure is likely. We refer here principally to fistulas of the small bowel, colon, or both, but the information provided may apply to others as well. Questions to be answered regarding intestinal fistulas include the following: (1) Is the bowel in continuity, or has it been completely disrupted? (2) Does the fistula arise from the lateral bowel wall, or is it an end fistula with complete disruption and absence of communicating bowel distally? (3) Is there an associated abscess cavity, how large is it, and does the fistula drain into the cavity? (4) What is the condition of the adjacent bowel? Is it damaged, strictured, or inflamed? (5) Is there a distal obstruction? (6) In what part of the gastrointestinal tract does the fistula tract arise? (7) What is the etiologic disease process? (8) Is the length of the tract less than 2 cm? (9) Is the bowel wall defect greater than 1 cm’? (Fig. 6) Characteristics associated with nonhealing fistulas include the fol-

FIG. 6. Anatomlc

appearance of fistulas unlikely to close spontaneously. Upper left, Total anastomotic disruption. Upper right, Partial disruption with adjacent abscess. Middle left, Lateral fistula with distal obstructlon. Middle right, Fistula in strictured intestine. Lower, End flstula with distal obstruction. Curt- Probl

k.

Surg

June

1994

525

lowing: large adjacent abscess, intestinal discontinuity, distal obstruction, poor adjacent bowel, fistulas of the stomach ileum or jejunum at the ligament of Treitz, fistula tracts less than 2 cm in length, and enteral defects greater than 1 cm2 (Table 71. In addition, fistulas arising from radiation-damaged intestine or from malignant intestinal lesions are not likely to heal. Those that arise from inflammatory bowel disease may close but will likely reopen as soon as oral intake is resumed. In general, CT or magnetic resonance imaging are not useful in the initial evaluation of a patient without sepsis who has an enterocutaneous fistula. If the patient has sepsis, CT should be used to evaluate the abdomen for undrained abscesses. Undrained collections should be treated by percutaneous drainage if possible.217Sz1e Although CT scans may not provide useful information regarding the fistula itself, they may be helpful in evaluation for recurrent tumor that, if present, changes the entire nature of the therapeutic direction. PHASE 3: DECISION Likelihood of Spontaneous Closure The main goal of therapy in patients with enterocutaneous fistulas is the reestablishment of intestinal continuity. This goal is most favorably achieved by spontaneous closure; however, in complicated fistulas this type of closure occurs in only one third of the patients. Spontaneous closure is invariably preceded by a decrease in fistula output. Even if no unfavorable factors are present (Fig. 61, the ability TABLE 7.

Predictive

Factor Anatomic

location

Nutritional Sepsis Cause

status

Condition

of bowel

Miscellaneous Transferrin

526

factors

for spontaneous

closure

Favorable

Unfavorable

Omphatyngeal, esophageal, duodenal stump, pancreatobiliary, and jejunal Well nourished Absent, Appendicitis, diverticulitis, postoperative Healthy adjacent tissue, small leak, quiescent disease, no abscess

Gastric, lateral duodenal ligament of Treitz, and ileal

Tract >2 cm in length Defect 200 mgdl

Malnourished Present Cmhn’s, cancer, body, radiation Total disruption, distal obstruction, active disease tumor) Epithelialization, body
Curr

Pmbl

Surg,

foreign abscess, (Cmhn’s, foreign

June

1994

to predict spontaneous closure in anatomically suitable gastrointestinal fistulas is inexact. Many attempts have been made to catalogue the characteristics of fistulas that predict whether a fistula will close spontaneously or will require operation. Underlying disease, presence or absence of sepsis, anatomic location, condition of the bowel at the fistula site and distally, and nutritional status may carry prognostic significance with regard to the likelihood of spontaneous closure. In addition, when a fistula is persistent, epithelia may migrate from either end to line the tract and thus in essence form an “ostomy” (Fig. 7). When this situation occurs, spontaneous closure is highly unlikely, and operative therapy is usually required.

Location The highest rate of spontaneous closure has been consistently reported for fistulas involving the oropharynx, esophagus, duodenal stump, pancreatobiliary region, and the jejunum.26 Fistulas arising from the stomach, small bowel at the ligament of Treitz, or ileum are resistant to spontaneous closure and, therefore, are more likely to require operative closure (Table 7).’

Nutritional

PaFaITIeteFS

Kuvshinoff and coworkersz5 recently published findings of a lo-year review of 79 patients with 116 fistulas. As is now usual, 80% of the fistulas occurred postoperatively, with a reported mortality rate of 20.3%, mainly the result of sepsis and cancer. The presence of local sepsis, systemic sepsis, or remote sepsis (such as pneumonia or line sepsis), the number of fistulas, fistula output, and the number of blood transfusions were not predictive of spontaneous closure. However, at the time of diagnosis or after 3 weeks of therapy, a serum transferrin level greater than 200 mg/dl was an accurate predictor of spontaneous closure. Although the value of this protein synthesis marker may not be absolute, its determination in the face of adequate protein and calorie provision may be useful. If serum levels failed to rise after 3 weeks of aggressive nutritional therapy, spontaneous closure was unlikely. These investigators also found that serum transferrin, retinol-binding protein, and prealbumin were predictors of whether a patient might die. These factors were useful in identifying patients with sepsis or malignancy, which were clinically significant.z5

Duration

of Therapy for Spontaneous

Closure

Whether the physician chooses to wait for spontaneous closure or proceed to surgical closure, a period of definitive, often parenteral, nutritional therapy is usually worthwhile provided that uncontrolled Cur-r Probl

Surg,

June

1994

527

FIG. 7. fistula

Epithelialized tract. Operative

fistula tract intervention

and functional was necessary

“ostomy.” for fistula

Arrow points closure.

to epithelialized

sepsis does not mandate operative intervention. Seven to 10 days of parenteral nutrition may lead to the following: (1) it may permit the patient’s abdominal skin to heal, allowing reasonable closure after major surgery; (2) it may restore some sense of physical and emotional well-being because the patient with an enterocutaneous fistula is usually hypercatabolic and nutritionally depleted when diagnosed, 528

Cur-r

Probl

Sur5

June

1%~

and immediate operation is probably dangerous and may result in death; and (3) it may allow for spontaneous closure. The average time for fistula closure varies with its anatomic location in the gastrointestinal tract. This knowledge can aid the surgeon in planning a rational time course for nonoperative management. Esophageal fistulas can be expected to heal in 15 to 25 days. A similar period, or perhaps a slightly longer interval, may be expected with duodenal fistulas. Colonic fistulas take longer to heal, approximately 30 to 40 days. Small bowel fistulas, especially ileal fistulas, may take 40 to 60 days to heal, if they heal at all3 If fistula closure has not been achieved spontaneously, and no signs of imminent closure are apparent after 4 to 5 weeks of nutritional support in a patient without sepsis, it is unlikely that the fistula will close, and the patient should be prepared for operation. If uncontrolled sepsis is present at any time during the patient’s clinical course, urgent drainage of abscesses or resection of a phlegmon with restoration of intestinal continuity should be carried out expeditiously. If the patient’s condition is extreme, only drainage of an abscess should be carried out at the initial operation. Proximal total diversion of the gastrointestinal tract with end ileostomy and mucous fistula or loop colostomy (Fig. 8) may be necessary if death is likely from persistent soiling. Definitive fistula repair carried out at a future time, although disappointing to the patient and surgeon, is preferable to a fatal outcome. At times fistulas that anatomically seem favorable do not close. Silent abscesses may be present. Once detected by ultrasonography or CT and drained, spontaneous closure may occur. Patients with solid organ allografts represent the exception to many of the rules accepted when managing fistulas. Because of their ongoing need for immunosuppression, patients probably should not be subjected to prolonged nonoperative management. Septic complications from fistulas and from parenteral nutrition are increased in the immunosuppressed population. In addition, their healing is impaired. Therefore early operative correction is recommended as soon as evidence of short-turnover protein synthesis exists. PHASE 4: DEFlNITlVE

THERAPY

Oropharyngeocutaneous and Esophageal Fistulas Often the oropharyngeocutaneous fistula will pursue a long subcutaneous course and exit at the lower end of the neck incision, When this occurs, an incision should be made higher in the neck to shorten and control the fistula tract. Not only will this promote healing of the tract, but it also will prevent further tissue loss and possibly exposure of the carotid artery. The patient with an oropharyngeal fistula should not be allowed to take anything by mouth, and a Curr

Probl

Surg,

June

1994

629

FIG. 8. Colostomy performed with patient under local anesthesia. A, Ideal location for proximal diverting colostomy in the right subcostal position. 6, Skin injection of local anesthesia. Although subcutaneous tissues are relatively insensitive, fascia should be copiously injected also.

530

Cum

Probf

Surg,

June

1994

FIG. 8. mesenteric

Cur-r

Pmbl

C, Transverse defect.

Surg,

June

colon

19%

should

be tacked

to fascia

and

a rod

placed

through

small

631

FIG. 8. D, Colostomy can be matured primarily on the next day, or conversely tube colostomy can be performed.

feeding tube should be placed. Antisialagogues are usually not necessary and may result in sialoadenitis if used. Provided no distal obstruction, tumor recurrence, or foreign body exist to prevent spontaneous closure, expectant management, with particular attention to hydration and nutritional repletion, is indicated. Most of these oropharyngeocutaneous fistulas will heal with nonoperative management even in irradiated tissues. If spontaneous closure has not occurred within 4 to 6 weeks, thyroid function studies should be carried out. Radiation and partial resection of the thyroid during therapy for head and neck cancers may lead to impaired healing from hypothyroidism. In addition, with any nonhealing fistula tract, persistent tumor should be considered and ruled out by biopsy. Enteral nutrition support with a balanced formulation should be used in patients with oropharyngeocutaneous or esophagocutaneous fistulas when access distal to the fistula can be obtained. The excep632

Curt-

Probl

Surg,

June

19%

tion may be in the 1% to 2% of neck dissections where the thoracic duct has been injured, resulting in chylous fistulas.21g Although this condition is not a true enterocutaneous fistula, nonoperative management is similar to the management of patients with enterocutaneous fistulas. A conservative policy preferentially with parenteral nutrition but possibly with enteral nutrition, with either elemental or medium-chain triglycerides as the sole fat source, is usually recommended because both theoretically decrease chyle flow.220~222 Whether enteral or parenteral nutrition support is given, patients should receive a minimum of 250 ml of 10% lipids by central or peripheral vein every 10 to 14 days to prevent essential fatty acid deficiency. Fistulas that persist without signs of closing after 4 to 6 weeks of sepsis-free management should be considered for operative management. Numerous techniques for repairing oropharyngeocutaneous and cervical esophagocutaneous fistulas have been described in the literature. These techniques include primary closure, skin graft, local and regional cutaneous flaps, myomucosal flaps, muscle flaps, gastric and colonic interpositions, and free jejunal grafts.223-235 Appropriate application of these techniques depends on the size and location of the fistula tract. Small oropharyngeocutaneous or esophagocutaneous fistulas can often be closed primarily by separating mucosal and skin edges and closing each layer independently. The success with primary closure decreases significantly when attempted on previously irradiated tissues .223,224 Primary closure is most successful in small fistulas through otherwise healthy tissues. However, these fistulas are also the most likely to close spontaneously. The advantage of closing them surgically is a shorter period of convalescence. Skin grafts have limited use for pharyngeal reconstruction and are generally unsuccessful for fistula closure because they lack sufficient blood supply to be self-sustaining in tissues previously operated on or irradiated.223 In addition, neither primary closure nor skin grafts can be used to close large oropharyngeocutaneous or esophagocutaneous fistulas. Vascularized flaps and sometimes myocutaneous vascularized flaps or enteric interpositions are required. Numerous cutaneous, myomucosal, myocutaneous, and muscle flaps exist that can be used to transfer healthy tissues into the damaged area.225-22s The type and donor site of these various flaps are dictated by the location, size, and condition of the recipient bed. Gastric or colonic interposition grafts and free jejunal grafts can be technically demanding to perform but may give excellent results.230-235 Interposition grafts are reserved mainly for those patients who need complete circumferential reconstruction of the pharynx or esophagus. Curr

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633

Gastric Fistulas

Nonoperative care usually involves nasogastric suction, fluid replacement, and aggressive nutritional supplementation. Aggressive management of sepsis is paramount if nonoperative treatment is to be attempted because the mortality rate doubles when sepsis occurs. It is often possible to feed patients who have low-output fistulas; however, achieving adequate nutrition can be problematic with highoutput fistulas. If access distal to the fistula can be obtained, enteral nutrition is preferred; however, this access may not possible. Because as many as 50% of patients with gastrocutaneous fistulas will have malnutrition, parenteral nutrition should be instituted early and continued until access can be achieved or the patient can be sustained by an enteral route. Most series report 30% to 50% spontaneous closure of gastrocutaneous fistulas after 4 to 6 weeks of nonoperative management.54~“6~236 Duodenal

Fistulas

The same basic rules of nutritional provision pertain to duodenal fistulas as to gastric fistulas.83 Parenteral nutrition should be instituted early and changed over to enteral nutrition as soon as possible. Simple closure or repair of an established duodenal fistula is associated with a high likelihood of recurrence. Therefore, when primary closure is attempted, omental or serosal patch reinforcement or exclusion and bypass with tube duodenostomy should also be performed.237~238 A preferred operative approach to duodenal fistulas is not to attack the fistula directly but rather to bypass the fistula while providing a route of gastric drainage, such as gastrojejunostomy. Access for enteral nutrition can be instituted by jejunostomy. A gastrostomy should be placed as well, thus allowing the bypassed fistula to heal. The use of bypass in duodenal fistulas is in sharp contrast to data showing that treating other intestinal fistulas with bypass is not efficacious.5 Biliary and Pancreatic

Fistulas

In the absence of distal obstruction most biliary and pancreatic fistulas can be managed expectantly with percutaneous drainage and a low-fat diet. If distal obstruction exists, endoscopic sphincterotomy with or without placement of a stent either by a percutaneous transhepatic or endoscopic transsphincteric route will allow decompression while spontaneous closure proceeds.23s-24” Some investigators advocate sclerosis or embolization of the well-formed fistulous tract if the fistula persists after these interventions.247J248 In patients with cholecystic fistulas, the gallbladder should be removed at operation unless it is needed to serve as a decompressive conduit. The secondary fistula defect at the termination of the fistulous tract should be repaired primarily. Recently, opinion has changed regarding the re534

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pair of what is still a common cause of internal fistulization, gallstone ileus. In previous years repair of the internal fistula was deemed essential; at present many investigators think this procedure is unnecessary. External pancreatic fistulas, although common, frequently close spontaneously with parenteral nutrition and administration of somatostatin. Adequate drainage of the pancreatic bed after surgical manipulation of the pancreas will usually prevent septic collections. In addition, somatostatin given prophylactically after pancreatic surgery may lessen the occurrence of pancreatic fistula formation.24s Initial treatment for internal pancreatic fistulas should consist of the patient having nothing by mouth, parenteral nutrition, administration of somatostatin, and the use of paracentesis or thoracentesis as necessary. Tube thoracostomy should be considered for patients who need more than three thoracenteses. Lipsett and Cameron1o4 reported successful resolution in 47% of cases with this regimen. However, a 14% mortality rate was noted with all deaths occurring after 3 to 4 weeks of nonoperative therapy. By limiting medical management to 2 weeks, the mortality rate can be reduced significantly. If 2 weeks of nonoperative management fails, preoperative endoscopic retrograde cholangiopancreatography should be used to define the disruption. If the damaged duct is in the tail of the pancreas, then distal pancreatectomy should be performed. If it is in the body or head of the pancreas, then internal drainage is preferred. Sphincteroplasty with transampullary septectomy can be added if structural or functional obstruction is present at the level of the sphincter of Oddi.

Small Bowel Fistulas Small bowel fistulas or small bowel colon-cutaneous fistulas are the most common type of fistula encountered by the surgeon. Unless they are from‘the terminal ileum, small bowel fistulas tend to be highoutput fistulas, making nonoperative management more complicated. In addition, because patient survival is directly proportional to the amount of fistula output and the severity of uncontrolled sepsis, the mortality rate resulting from small bowel fistulas tends to be particularly high compared with fistulas at other sites in the intestine. Factors associated with enterocutaneous fistulas that may raise the current average mortality rate of between 10% and 30% (the mean is around ZOW), include the following: age greater than 70 years; a fistula arising in irradiated, ischemic, or inflamed bowel; malignancy at the site of the fistula; evisceration; sepsis; out ut reater than 200 13,‘E,47,& S250In addition, ml/24 hours; and the presence of malnutrition. the presence of strictured or inflamed bowel, large abscesses adjacent to the fistula, or obstruction distal to the fistula are indications for early operative repair. The presence in an unstable patient of an abscess or undrained sepsis refractory to antibiotics or signs of mulCurrProblSurg,

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535

tiple organ system failure should result in prompt operative intervention Patients with small bowel fistulas, as compared with patients with fistulas at other sites, tend to be the most metabolically unstable. Therefore prevention of fluid and electrolyte imbalances and malnutrition require careful management. The prognostic nature of ongoing malnutrition has recently been stressed by Kuvshinoff and colleagues,25 who found that the serum transferrin level is a good prognostic indicator of whether fistulas will close and that the shortturnover proteins - retinol-binding protein, thyroxin-binding prealbumin, and transferrin-provide a good index of patient mortality. As stated earlier, in the management of small bowel fistulas, resuscitation of fluid volume, red cell mass, and oncotic pressure should be accomplished within 24 to 48 hours (Table 51. Drainage of abscesses, local control of fistula drainage, and nutritional therapy should follow shortly thereafter (Table 61. Attempts at altering volume through H, antagonists and somatostatin to decrease fistula output are well documented.1*‘1gg‘205 Although overall closure rates may not be altered by somatostatin, the uniform decrease in fistula output seen in small bowel fistulas treated with somatostatin may simplify care considerably and may accelerate closure in anatomically favorable fistulas.11’12 In reports from three different institutions experienced in the care of gastrointestinal cutaneous fistulas, spontaneous closure occurred in only 32% of patients.3’5’25 The rest of the patients required operative closure. This requirement is particularly true for patients with ileal fistulas in which even the most favorable series reported spontaneous closure rates of only 40% .’ This tendency for ileal fistulas to stay open was recently reconfirmed by Kuvshinoff and coworkersz5 although the reason for this inclination is not clear. The smaller ileal diameter, the more vigorous ileal motility, the presence of relative obstruction at the ileocecal valve, the increased number of Peyer’s patches, and the infiltration by lymphocytes may be somewhat responsible for this finding. Thus most patients with ileal fistulas will require operation independent of how favorable the anatomic features appear. After the operation has been decided on, the timing of the procedure must be considered carefully because it is critical to the patient’s outcome. Even under the best of circumstances, an operation is often technically demanding and may lead to further fistula formation, abscess, sepsis, and peritonitis. Unfortunately, the worst time to undertake the operation is within 3 months of the initial operative procedure because adhesions are likely to be dense and blood loss appreciable. A 3month (or preferably 4-month) waiting period will allow adhesions to become more filmy and less adherent. Unfortu536

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nately, the decision to operate must usually be made within 6 weeks of the fistula’s development. Fazio and coworkerszso evaluated surgical success and mortality based on operative timing and found that when the operation was carried out within 10 days of fistula formation, the success rate was 67%. When the operation was delayed so that it was carried out between 11 and 42 days, the success rate was 70%, and when operation was delayed even more than 42 days, the operative success rate rose to 84%. More impressive, however, was the difference in the mortality rate, which was 11% to 13% when the operation was performed within 10 days, or after 42 days after fistula formation. However, in the intermediate period, between 11 and 42 days after fistula formation, the mortality rate climbed to 21%. An alternative to early operative intervention is home nutrition, with either enteral or parenteral therapy, provided other aspects of management can be accomplished in the home care setting. Thus, as long as the patient is gaining metabolically, it is reasonable to pursue a course of nonoperative management. Jejunal fistulas, provided they are not directly at the ligament of Treitz, have a higher likelihood of spontaneous closure than ileal fistulas, which, in the most favorable cases, will close in 30% to 50% of cases. If closure has not occurred after 5 or 6 weeks of medical management in a patient free of significant sepsis, but fistula output is diminishing, serum albumin is rising, and normal bowel function is returning, medical management should continue. Even with complex enterocutaneous fistulas, an additional 10% of fistulas will close after 8 If, however, the patient is not improving weeks of medical therapy.” or the anatomy of the fistula is such that spontaneous closure is unlikely, there is little point in delaying the operative procedure if, in the surgeon’s judgment, the operation can be safely performed technically. When long segments of bowel are involved by complex abscesses or an inflammatory process, it may be wise to delay operative intervention 3 to 6 months while inflammation subsides. Once the decision for operation is made, careful preparation should begin. Every effort should be made to assure a well-healed abdominal wall. This effort may require sump drainage and protective measurements to assure that inflammation within the abdominal wall is minimal. If it is clear that a secure abdominal wall closure cannot be obtained through standard incisions, then consultation with a plastic surgeon should be obtained. Rotational flaps or microvascular anastomoses can be performed by plastic surgeons after the intraabdominal portion of the operation is completed (Fig. 91. These surgeons’ contribution of a secure abdominal closure may mean the difference between failure and success. Before the operation, the fistula drainage should be cultured so that appropriate antibiotics can be given. Tube feedings should be decreased so that a respite of 2 to 3 days with antibiotic luminal prepaCurr

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537

FIG. 9. Abdominal reconstruction with flap closure. A, Fistula site with granulation tissue. B, Operative exposure of bowel from where fistula originated. C, After resection with endto-end anastomosis, flap closure is completed. 538

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ration and cathartics, if appropriate, can be given as well. Washing of the abdominal wall and surrounding areas with antibacterial solution such as chlorhexidine gluconate (Hibiclens, Stuart Pharmaceuticals, Wilmington, Del,) is useful to decrease bacterial flora. Finally, training of the patient in postoperative pulmonary physiotherapy should begin. In addition to studying routine preoperative laboratory data, particular attention should be paid to the patient’s coagulation factors because prolonged parenteral nutrition may result in vitamin K deficits. Ample red cell mass, circulating volume, and colloid oncotic preparation should be achieved. The availability of blood and coagulation factors should be ascertained. The operative approach should take place through a new incision so that the operative field is relatively clean and the abdominal wall is relatively healthy. In addition,. if sepsis exists in the abdominal wall, the incision should be made remote from this area. Abscess cavities, if present, should be drained through separate stab wounds distant from the primary incision. The operative incision should be planned so that if an end-to-end anastomosis is necessary, it can be carried out free from the area of maximal contamination. Fresh anastomoses surrounded by sepsis are likely to fail and result in the patient’s death. After incision, wound protectors or wound towels should be placed to protect the skin and subcutaneous tissues. Some authorities recommend beginning dissection at the distal ileum and working proximally. In the event that the operation must then be aborted, internal bypass may be feasible. However, our experience indicates that the pattern of dense adhesions determines where dissection is easiest. As the operation proceeds, laparotomy pads, soaked with antibiotic solutions, should be applied. It is usually easier to define the anatomical nature of the loops after a period of soaking, making them easier to free. Adhesions should never be lysed in the frontal attack; the easiest way is the lateral approach. In our experience, the operator’s left hand is the easiest way to control the loop of bowel containing the fistula. By placing one hand behind the fistulous bowel, the operator is always working in a controlled environment. Serosal rents should be repaired with nonabsorbable Lembert sutures. Where full-thickness bowel defects are created, closure should be attempted with two layers of nonabsorbable sutures in HeinekeMikulicz fashion unless the rent involves the mesentery. When the mesentery is involved, blood supply may be compromised. Resection and anastomosis should be considered in this circumstance. When the fistula tract or tracts are identified, the segment or segments of bowel involved should be resected. End-to-end anastomosis is recommended because this procedure provides the best chance for permanent resolution. The presence of cancer will, of course, alter the approach (discussed later). Irradiated bowel is particularly difficult Cum

Probl

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to deal with and, along with duodenal fistulas, may represent an exception to the rule of end-to-end anastomosis. Irradiated bowel is probably best dealt with by stricturoplasty rather than resection and end-to-end anastomosis. Because of the microvascular thrombosis and fibrosis associated with previous radiation therapy, the end artery blood supply to the bowel wall may be inadequate to support a healing anastomosis. If it is unsafe to resect the bowel segment containing the fistula or if anastomosis would be unwise because of sepsis, resection with anastomosis or exteriorization of the two bowel ends can be carried out with staged closure after sepsis reso1ves.50~251~252Bypassing the fistula containing bowel segment rarely results in closure of the fistula, and operative closure is usually necessary after the bypass. Because the presence of abscess or distal obstruction will cause surgical closure to fail, the bowel should be freed from the ligament of Treitz to the rectum. Once the fistula is resected, the temptation to conclude a fistula operation before this goal is attained may be great. However, if the operation is not completely and carefully carried out, intestinal reoperation may be required, and it definitely will be more difficult, and the chance of failure will be greater. One technically superior and complete operation is far better for both patient and surgeon than many inferior and incomplete operations. Therefore it is advisable to begin this type of operation early in the day and thus provide ample time for completing the task. During the operation, laparotomy pads soaked with an antibiotic (preferably kanamycinl should be used throughout. The concentration of kanamycin absorbed is sufficiently low so that renal toxicity is not a problem. Irrigation with copious amounts of antibioticcontaining solution is also helpful. Final inspection of the entire bowel length and fresh anastomoses should be performed to ensure that inadvertent enterotomies and serosal rents are adequately repaired and that no distal narrowing of the bowel lumen exists. Bowel strictures should be managed by stricturoplasties or bowel resection with anastomoses. Decompressive gastrostomy and a feeding jejunostomy should be used after every abdominal procedure of this magnitude. We do not use needle catheter jejunostomies because a No. 14 latex nephrostomy tube allows more freedom in the use of different tube feedings in the postoperative period. Finally, a secure abdominal closure is crucial to success. Prosthetic materials result in recurrence of the fistula. Thus, if a secure closure cannot be obtained by various tissue mobilization procedures, such as rectus abdominus flaps, musculocutaneous flaps should be used to secure the abdominal closure. Some deviation from the standard procedure will be required after the extensive resection required to remove fistulous bowel in an irradiated pelvis. The incidence of fistulous recurrence and abscess for540

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mation is extraordinarily high in this setting. It is absolutely essential to use musculocutaneous flaps, preferably gracilis flaps if they are available, to fill the pelvis (Fig. 1). This step will prevent bowel, especially newly anastomosed bowel, from prolapsing into an infected area with poor blood supply after irradiation. Likewise, the skin incision should be made transverse and high in the abdominal wall above the irradiated tissue. The presence of recurrent cancer resulting in fistula makes the operative procedure even more difficult. In many cases, a significant tumor burden is present. The chance of operative failure is increased under these circumstances. Resection of the tumor mass should be attempted; however, the primary purpose of the operation is to resect the fistula and establish bowel continuity with healthy tissue. Whenever possible, the bowel, especially the freshly anastomosed bowel, should be walled off from the tumor. Omentum should be used to compartmentalize the bowel; however, if it is not present, prosthetic absorbable mesh should be considered. The incidence of failure is likely to be high when operating in the presence of cancer. In extreme cases where a massive tumor exists that cannot be extirpated, intestinal bypass may be necessary, with the understanding that the fistula may not totally be obviated but that at least oral nutrition can be resumed and the patient can leave the hospital. Here, too, an incision through an abdominal wall that will enable closure free of recurrent disease is a vital consideration in the therapy of these difficult patients. Finally, sometimes an operation is undertaken in a patient in whom multiple extensive abscesses exist within the abdomen. Under these circumstances, it may be necessary to completely resect all of the fistulas, perform anastomoses, and exteriorize the bowel proximally with an end jejunostomy and a mucous fistula. After an appropriate period, the surgeon then confirms the patency of the distal end through the mucous fistula and carries out a limited procedure with closure of the jejunostomy. We probably do not perform this maneuver as often as we should. A major question is how to deal with intraoperative fluid loss. Often multiple raw and denuded surfaces exist that ooze and weep both blood and lymphatic fluid. In addition, areas with large abscesses may exist that will be drained during the course of the procedure. The dictum seems to have arisen in American surgery that the physician does not use drainage, even closed suction drainage, under any circumstances. This understanding probably came about because a number of studies indicated that the incidence of postoperative infections increases with the use of Penrose drains. We agree with these findings; however, such drainage is prophylactic rather than therapeutic and involves open, “two-way” drainage. It is our contention that the dictum of using no drains, if it applies at any time, CurrProblSurg.

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should certainly not apply to these patients. For one thing, in the area of abscesses that are drained, this drainage is not prophylactic but therapeutic. Closed suction drains should be left in just as a closed suction drain would be left for any abscess, more for 5 to 10 days rather than 2 to 3 days. The proximity of drains to infected and potentially infected areas is such that their use should be looked on not necessarily as totally prophylactic but therapeutic. We do not use Penrose drains or stuffed Penrose drains in our practice. Closed suction drains made of polymeric silicone or a similar compliant material are preferable. We generally remove drains when excretions are less than 25 ml over a 24-hour period. Occasionally the phenomenon of decreased drainage followed by increasing amounts of clear serous material is seen. We believe that the drains are provoking exudation of fluid; the drains are removed and the tips cultured. Overall, we have found that the incidence of infection is decreased by the use of closed suction drainage. The nature of nutritional supplementation in patients with gastrointestinal-cutaneous fistulas is evolving. When the importance of nutritional support was first realized, bowel rest and the provision of all calories by vein was thought to be the preferred mode of therapy. However, with the recognition that gut mucosa not only contributes significantly to absorption but has important immunologic functions and plays a role in hepatic protein synthesis, the importance of gut feeding has been understood better. Gut feeding, even in the presence of sepsis-free parenteral nutrition, often has dramatic effects on wound closure and on the patient’s overall sense of wellbeing. Whether these results occur because of increasing gut mucosal integrity, hepatic protein synthesis, or beneficial immunologic effects is not clear, but the outcome can be dramatic. Recently, the improvement we observed in a patient’s well-being and closure of the fistula was astounding. It is clear that all of the calories do not need to be provided by the enteral route to achieve this effect. Indeed, it has been estimated that the amount provided is only 20% to 30% of the caloric need.l14 Thus, regardless of whether the entire caloric need can be provided, the provision of some enteral nutrition will yield a better outcome even though initially fistula drainage may increase. The nature of the components provided is also of interest. Recent studies have suggested that alterations in fatty acids supplied to provide the omega-3 polyunsaturated fatty acids and the use of arginine, nucleotides, soluble pectins, and other experimental nutritional supplements give superior results in postoperative patients.253S254 Only multiple-component formulas are commercially available, and studies on single dietary components are incomplete. Nonetheless, we strongly believe that a decided attempt should be made to provide at least some nutrition by gut. 542

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One other biologic aspect of the gut and nutrition should be mentioned: the occasional necessity for refeeding bile to resupply the enterohepatic circulation, thus increasing the bile acid pool. The effect has been difficult to quantitate, but we believe that it does exist. Consequently, in the presence of large bile fistulas or biliary obstruction, every attempt should be made to refeed bile on a regular basis. Because of problems of bacterial contamination, bile feeding should be carried out rapidly so that the fluid does not stand for a prolonged period of time. Alternatively, it can be refrigerated and warmed immediately before infusion into the bowel. When fistulas are very complex, it may be possible to place a feeding tube or jejunostomy and maintain the patient on home enteral nutrition for a long period of time. This step allows inflammation to subside. Pouch Fistulas Pouch fistulas may be more difficult to manage than fistulas that occur in the otherwise healthy ileum. Most will require preservation or the reestablishment of a diverting ileostomy for resolution, and some will require permanent ileostomy with loss of the pouch.13gJ255 Some clinicians have attempted to determine when it is safe to perform primary ileal pouch and anastomosis without ileostomy.140,141 The most recent studies suggest that this procedure be performed only in restricted populations such as patients under 40 years of age without active inflammatory bowel disease.14’ Even under the best of circumstances, pouch loss occurs, and if the patient has compromising factors, the incidence of pouch loss is high.14’ Treatment with metronidazole and ciprofloxacin and possibly the administration of short-chain fatty acid enemas for pouchitis should probably be performed after diversion is established. In addition, the slides of the resected colon should be reinspected to ensure that ulcerative colitis and not Crohn’s disease is present. Crohn’s involvement of the pouch may mandate permanent ileostomy.lls-lzo Many pouch fistulas can be repaired by division and layered closure. In addition, interposed advancement flaps may prevent future fistula formation. Those that cannot be salvaged must be resected with either permanent ileostomy or ileostomy with later ileoproctostomy. On occasion a new pouch can be created with proximal ileostomy for protection. If this procedure is successful it can be followed by ileostomy closure.118-12o Colonic Fistulas Spontaneous closure in the face of active diverticulitis, cancer, or Crohn’s disease is unlikely, but spontaneous closure of postoperative colonic fistulas can be expected to occur in 80% to 90% of paCurr

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tients by 40 to 50 days.215,25” Postoperative fistulas tend to be lowoutput fistulas and can often be effectively treated with either a chemically defined diet or parenteral nutrition without proximal diverting colostomy.Z57 Primary repair of traumatic colon injuries and one-stage procedures for diverticulitis should, by classic teaching, increase the incidence of postoperative fistulas; however, such an incidence has not been found.258-260 Resection with primary anastomosis for diverticulitis in the face of fistula or abscess has been carried out without significant morbidity and mortality.2”1 In addition, Burch and coworkersz5’ reported a 1% to 2% fistula rate after primary repair of penetrating colon injuries. However, these cases were highly selective; in the same series, colostomy was used in 21% of simple descending colon injuries, 85% of complex transverse colon injuries, and 96% of complex descending colon injuries. Use of diversion for questionable simple descending colon and complex transverse and descending colon injuries may explain their outstanding results and therefore seems appropriate (Fig. 8). Most appendicocutaneous fistulas are low-output fistulas and close spontaneously within 3 weeksz6’ as inflammation resolves and the tract heals. If surgical intervention is necessary, excision of the tract with simple closure of the cecum is the treatment of choice, because more involved procedures tend to be meddlesome.263 When fistulas occur after an appendectomy is performed in a patient with Crohn’s disease of the cecum, the fistula is virtually always from the terminal ileum and not the appendiceal stump. These fistulas behave as Crohn’s disease-related fistulas do. Therefore their management is that of a Crohn’s fistula (see below).

Internal

Intestinal

Fistulas

Patients with symptoms and internal enteroenteral fistulas unresponsive to medical therapy require operation. Operative intervention for Crohn’s disease fistulas is reserved for specific complications such as malabsorption, intractable diarrhea, obstruction, short-bowel syndrome, or chronic urinary tract infection. Once diverticulitis has become complicated by abscess or fistula formation, resection of the involved colonic segment is indicated regardless of whether the fistula has closed. Operative indications for malignant internal fistulas are similar to Crohn’s disease fistulas. Short life expectancy or prohibitive operative risk will preclude operation for malignant fistulas. In these cases, unless resection will be curative, operation is reserved for specific complications such as malabsorption, intractable diarrhea, obstruction, or short-bowel syndrome. Symptomatic enteroenteric or enterocolonic fistulas and all colovaginal or colovesical fistulas should be repaired by operation unless specific contraindication exists, such as advanced ma1ignancy.l” 544

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Crohn’s Disease .-Traditionally, Crohn’s disease has been surgically treated in a manner similar to intestinal malignancy. Wide resection with clear margins was offered as the only chance for cure, even though severe nutritional and metabolic consequences commonly occurred. However, with the recognition of Crohn’s disease as a diffuse abnormality of the gastrointestinal tract, the operative approach has been somewhat modified. Because microscopic involvement of margins at the time of operation does not reduce recurrence rates, conservative resection is now accepted as adequate surgical therapy. Because it is usually not curative, resection is reserved for symptomatic lesions only. At operation for Crohn’s ileocolitis, a large matted mass of bowel may be found in the right lower quadrant. Specific attention should be paid to the length of bowel resected because postresection shortbowel syndrome after repeated resections is common. If resection will place the patient at risk for short-bowel syndrome, then measures such as stricturoplasty, serosal patching, and intestinal tapering should be considered to preserve intestinal length.111’1’3’121’264~266 The margins of resection for Crohn’s disease need only be grossly disease free. The presence of microscopic disease does not increase the likelihood of late recurrence of Crohn’s disease as compared with margins completely free of Crohn’s disease. In our practice, the margins are no more than 3 to 4 cm beyond obvious fatty overgrowth and mesenteric adenopathy immediately adjacent to the bowel. En bloc resection of the fistula and diseased intestine with end-toend anastomosis is the preferred treatment for patients where both segments of bowel are involved in a Crohn’s disease fistula. However, when the fistula is between diseased bowel and otherwise healthy bowel, the site of the secondary fistula becomes critical in making operative decisions. Repair of the secondary defect should be undertaken by freshening the edges and suturing the defect if stomach, small intestine, ascending colon, or bladder is involved.‘16 Intestine containing secondary defects should be resected only if adjacent to diseased bowel that itself requires resection. Sigmoid colon and duodenal defects have a greater tendency for fistulization postoperatively.ll’ Therefore, if the sigmoid colon is secondarily involved, primary closure can be performed safely only if the patient’s nutritional status is good. If the patient manifests poor nutritional status, primary repair with proximal diverting colostomy should be considered. When the bladder is involved by a Crohn’s disease iistula, primary bladder repair with interrupted, layered, absorbable sutures can usually be satisfactorily accomplished. A balloon-tipped retention catheter should be left in place for 7 to 10 days for bladder decompression. Likewise, colovaginal fistulas can be repaired with layered, absorbable sutures from an abdominal approach when high on the vaginal wall and by a perineal approach when on the mid wall or Curr

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lower?“7 A circumvaginal incision with dissection in the plane of the colovaginal septum usually provides adequate fistula exposure. The fistula tract is excised, and the vaginal wall is closed in layers. Although the vaginal mucosa can be closed from inside, we prefer to close it extravaginally. The muscular layers of the vagina can be closed externally to interpose layers between the vagina and rectum. In a similar fashion, the bowel wall is closed in two layers externally. Interposition of healthy tissue such as levator or other perineal musculature is useful to prevent refistulization. The duodenum is usually not involved with fistulous Crohn’s disease.266 Therefore it can be repaired primarily. However, because many deaths result from postoperative duodenal fistulas, the duodenum should be reinforced by omentum or a serosal patch, excluded and decompressed by tube duodenostomy, or the duodenal fistula should be diverted into a Roux-en-Y loop.‘15~2”4~266 Diverticulitis.-Fistulas associated with diverticulitis have a high rate of spontaneous closure. However, after closure has occurred and inflammation has subsided, resection with end-to-end anastomosis should be carried out unless the patient has prohibitive operative risks. In cases of acute diverticulitis, end colostomy with oversewing of the rectal stump is preferred. Although successful resection and primary anastomosis in patients with acute diverticulitis have been reported, complicated diverticulitis (established abscess or fistula) is probably best handled by Hartmann’s procedure. Complete resection of the colon with the diverticula is essential for successful treatment. Inadequate sigmoid resection can lead to recurrent diverticulitis with subsequent abscess or fistula formation, or a leak or refistulization can occur if diverticula are left at the anastomosis. When the bladder is involved by fistulization, primary repair of the bladder wall should be undertaken with or without an omental patch. A balloon-tipped retention catheter should be left in place 10 days for bladder decompression. Interposition of healthy tissue such as levator or other perineal musculature is useful to prevent refistulization. Malignancy.Fistulas complicating malignancy are unlikely to close spontaneously. The following preliminary questions need to be answered when evaluating a patient for definitive operative therapy: (1) What is the extent of disease? (2) What are the biologic aspects of the tumor? (3) What is the patient’s life expectancy? (4) How does the fistula atfect the patient’s quality of life? (5) Will the operation be palliative or curative? (6) Will chemotherapy or radiation therapy be necessary? (7) What are the patient’s operative risks? The operative goals for malignant fistulas will be altered by the answers to these questions. When possible, all bowel should be freed, and resection with end-to-end anastomosis should be performed. 646

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However, freeing the entire bowel length may not be realistic, and bypass is preferred in certain circumstances. In addition, disease-free resection margins may be impossible without massive small bowel resection. The price of profuse diarrhea from short-gut syndrome is rarely worth the small gains from such massive resections. In those cases where cure is unlikely, conservative resection is indicated. In addition, abdominal wall resection with extensive reconstruction may be necessary to ensure adequate disease-free margins. Because of the incidence of recurrent disease, gastrostomy should be performed in all cases of malignant fistula. Healthy, vascularized tissue such as gracilis or rectus femoris muscle flaps should be rotated to fill the irradiated dead space. This step has been shown to decrease the incidence of postoperative fistula formation markedly.” If the pelvis has been subjected to prior radiation therapy, segmental resection of the affected bowel may be necessary to ensure adequate healing of the anastomosis.

Alternative

Closure Methods

Until recently, surgical intervention to close the fistula was the only available option. However, successful endoscopic injection of congenital tracheoesophageal fistulas has been performed since the early 1980s.268 In 1989, Marone and coworkersz6’ reported the endoscopic injection of a fast-hardening amino acid solution into the fistulous tracts of four patients. Successful closure occurred in all four. The fistula tracts included two postoperative esophagopleural fistulas, one bronchobiliary fistula, and one bronchoesophageal fistula. Because of the viscera involved, these fistulas were probably not highoutput fistulas, and thus the therapy was successful. However, between 1988 and 1990, five papers were published that collectively reported successful results in 30 patients with high-output proximal enterocutaneous fistulas treated by endoscopic injection of fibrin in patients with unacceptable opglue.26g-273 Use of this technique erative risks may be warranted; however, the use is limited by the reach of the endoscope. Also, the use in colocutaneous fistulas has not been reported to date.

General Considerations Operation is undertaken in patients when the anatomic features preclude spontaneous closure. In patients with anatomic features favorable for closure, an operation is also indicated if 4 to 5 weeks of sepsis-tree nutritional support has not resulted in a fistula output or signs of closure. If meticulous skin care and control of fistula drainage has been achieved, the operation can be carried out through a healthy abdominal wall. This will enhance the chance of secure abdominal closure, which will help the underlying anastomosis to heal. Particular attention should be paid to electrolyte and volume status Curr

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preoperatively, and where doubt exists, a pulmonary artery catheter should be placed. Fistula drainage should be cultured, and intraluminal antibiotics as well as targeted intravenous antibiotics should be administered to the patient. Enteral nutrition therapy should be discontinued several days before the operation because such a step could decrease abdominal distention and aid in attaining a secure abdominal closure. If parenteral nutrition has been used, a full day’s order should be submitted the morning of the operation and the rate decreased to 40 ml/hour just before the operation. This step will ensure that the patient does not run out of parenteral nutrition during the procedure and provides enough volume so that the rate can be set to the target in the recovery room. Parenteral nutrition should be continued throughout the operative procedure. The abdomen and operative site should be washed with antibacterial solutions for several days before the operation. The preferred operative approach is through a new incision so that the major operative field is relatively clean. Dissection should proceed from the ligament of Treitz to the rectum with the freeing of all adhesions. All reviews of patients with enterocutaneous fistulas reveal that the best rates of closure and the lowest incidence of complications are obtained by definitive resection and end-to-end anastomosis with two layers of 4-O silk (Fig. 1O).5'7 Overall, other approaches produce inferior results and should not be attempted unless mitigating circumstances exist. The anastomosis should be carried out in a relatively clean field away from any previous abscess cavity. The omentum should be placed in its anatomic position with a portion covering the anastomosis, preferably maintained there by sutures. Sufficient time should be allowed for this operation. Extensive dissection is usually necessary and requires an absolutely meticulous technique and hemostasis for the prevention of further fistula development. In few other types of cases will deviation from sound surgical principles result in such catastrophic consequences. Dissection should proceed to free all small bowel, with the surgeon making certain that no obstruction exists. Meticulous hemostasis is extremely important. Copious irrigation with antibiotic solutions and with laparotomy pads soaked in antibiotic solution are useful adjuncts as well. The importance of a secure abdominal wall closure above a fistula can not be overstated. This closure may be difficult in patients in whom the abdominal wall has been partially destroyed by sepsis .274,275If closure is complicated, a team of plastic surgeons should assist in this portion of the operation. In general, reconstructions with prosthetic material is contraindicated because it easily can become infected or lead to recurrent fistulas when used. Musculocutaneous flaps should be used if inadequate fascia is available for a tensionfree closure. A Stamm gastrostomy (Fig. 11) should be placed at the time of sur54s

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OPWRATION RESECTION

BY-PASS

STAGED

FIG. 10. Options for operative fistula management. Top, Resection with end-to-end anastomosis is preferred method for surgical fistula management. Middle, Permanent bypass, although no longer recommended, may be necessary in certain palliative circumstances, such as in patients with unresectable tumor and short life expectancy. Lower, Staged bypass with delayed resection may be considered in patients whose medical condition will not permit extensive operative procedures.

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FIG. 11. dure ered

Stamm gastrostomy for decompression in patients with extensive operative procedures. for patients who will likely require aggressive

or feeding should be standard proceJejunostomy should also be considnutritional therapy after operation.

gery for postoperative gastric decompression. It interferes less with pulmonary toilet and causes less discomfort than nasogastric sump tubes. In addition, it can be used for enteral nutrition supplementation if necessary. Providing a means of access for postoperative nutritional support is crucial. Feeding jejunostomies should be considered in all patients undergoing surgery for enterocutaneous fistulas, although their use in the postoperative period can be delayed if desired. Duodenal fistulas are the exception to the rule of resection with end-to-end anastomosis, partly because of the gravity of the dissection necessary and partly because of satisfactory outcomes achieved with bypass procedures. Gastrojejunostomy, preferably with vagotomy, gastrostomy, and catheter jejunostomy for feeding, will result in closure of most fistulas. If the patient’s condition is critical, then this procedure can be carried out with the patient under local anesthesia. 660

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PHASE 5: HEALING

It is crucial to continue full nutritional support and antibiotics well into the postoperative period. The postoperative period is often accompanied by a profoundly hypermetabolic state that, coupled with any preexisting nutritional depletion, places patients at risk for nutritional complications, such as poor wound healing, depressed immunity, and increased susceptibility to nosocomial infections.6*8+gJ276 Providing appropriate protein and adequate calories is crucial. The physician can try early enteral nutrition; however, it is often impossible to administer all the patient’s nutritional needs by this route. The physician should not taper the parenteral nutrition too rapidly because such an attempt can leave the patient with inadequate protein and calorie intake for.wound healing. When starvation occurs in the postoperative period, protein losses may be as high as 70 to 80 gm/day. In the face of such profound protein catabolism, anastomosis, fascia, and skin closure are adversely affected. Parenteral nutrition should be continued to supplement enteral nutrition support until at least 1500 k&/day can be taken enterally. Once closure is achieved, either spontaneously or surgically, it may be difficult to persuade patients to eat. Engaging the assistance of a dietitian and the patient’s family may be necessary to reestablish oral intake. The traditional dietary advancement from clear liquids through regular diet may not be tolerated well by a patient who has not had anything by mouth for 4 to 6 weeks. Starting with a soft diet without passing through the preliminary steps may help. In addition, if jejunal tube feedings are being used, running them only at night may decrease satiety. If parenteral nutrition is being used, then it may be necessary to wean the rate so anorexia is lessened. At times parenteral nutrition may need to be terminated and normal saline infused through the catheter for 4 to 5 days until appetite returns. Families should bring in the patient’s favorite food. Finally, alcohol given before a meal may improve appetite. Even after the fistula is healed, the patient remains at risk for delayed complications. Short-bowel syndrome after repeated bowel resection or correction of numerous fistulas may leave the patient without sufficient absorptive surface. The fistula may recur, especially if the underlying disease process is inflammatory bowel disease or malignancy. The fistula site may stricture if an inadequate resection of diseased intestine is performed. Finally, adhesive .small bowel obstruction can occur. Although reoperation should be approached cautiously, treatment of these complications should be carried out in accordance with established surgical principles. With regard to results and late complications, historically the principal causes of death have been electrolyte imbalance, malnutrition, Cur-r Probl

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and sepsis. To a certain extent all these conditions remain problems, particularly as the origin of the fistula nears the ligament of Treitz. Currently, however, uncontrolled sepsis and malignancy are the leading causes of death in most series. Advances in patient monitoring have decreased deaths directly related to electrolyte disturbances, although this complication still occurs with unexpected frequency, particularly in high-output fistulas. The role that nutritional support has played in decreasing the number of deaths resulting from enterocutaneous fistulas is debated. It is clear that the decrease in the number of deaths has been temporally related to advances in nutritional support techniques; however, causality is difficult to establish. In 1964, Chapman and coworkers277 showed that patients with enterocutaneous fistulas who received less than 1000 calories/day had a mortality rate of 58%, whereas those receiving 1500 to 2000 calories/day had a mortality rate of 16%. Contrariwise, Soeters and associates,’ in an extensive 30-year review of enterocutaneous fistulas, found that the mortality rate associated with enterocutaneous fistulas at the Massachusetts General Hospital had decreased from 48% to 15%, which is consistent with contemporary mortality rates before the institution of parenteral nutrition. They concluded that parenteral nutrition had not decreased the mortality rate associated with enterocutaneous fistulas. In addition, Reber and colleaguess2 reported their experience with enterocutaneous fistulas by arbitrarily dividing them in to two groups: 19681971, where 35% of patients received parenteral nutrition, and 1972 1977, where 71% received parenteral nutrition. The fistula-related mortality rates were 10% and 13%, respectively. They concluded that parenteral nutrition had no impact on whether a patient died. Although decreased mortality rates were not shown, spontaneous closure rates after 4 to 5 weeks of parenteral nutrition were usually improved regardless of the fistula site. In a recent review from Italy, however, different results were found.275 Patients treated between 1981 and 1984 who received surgery only for enterocutaneous fistulas were compared with patients treated between 1985 and 1990 who were treated with nutritional support and surgery. The mortality rate in the surgery plus nutrition group was 18%, whereas the rate of the surgery only group was 42%. Although numbers were small, this study compared two groups who received equivalent modern perioperative and surgical care, and therefore the results could be more telling than comparisons between preparenteral and postparenteral nutrition periods. The findings support the hypothesis that aggressive nutritional support may decrease the number of deaths resulting from fistulas. Additionally, although they may not have experienced decreases in the numbers of deaths with parenteral nutrition, these centers may have practiced some form of nutritional support before the era of parenteral nutrition. Furthermore, it is likely that 652

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the number of deaths of patients cared for outside of large referral centers with vast experience has decreased because of parenteral nutrition. Even after the fistula has healed, the patient remains at risk for delayed complications. Repeated attempts at resection or correction of numerous fistulas may leave the patient without sufficient absorptive surface. Frequently, home parenteral support will be necessary while accommodation of the remaining bowel occurs. We continue full enteral support during this time, and as nutritional parameters improve we wean parenteral support. Additionally, the fistula site may be the source of complications. Stricture with partial obstruction may lead to postprandial crampy abdominal pain and weight loss caused by the aversion to enteral nutrition. These conditions occur especially when the original fistulous opening involved a large portion of the diameter of the bowel and repair by other than resection with end-to-end anastomosis was performed. If these symptoms persist, then established surgical principles apply, and reoperation should be considered. Finally, esophageal stricture may occur after prolonged nasogastric sump decompression. In general, this condition will become manifest 3 to 4 months after the patient has been discharged from the hospital. Dilation is usually all that is necessary for symptomatic relief, although occasionally resection may be necessary.

FUTURE

DIRECTIONS

Research on nutrition has focused on maintenance and improvement of gut barrier functions. More specifically, three dietary constituents are thought to be trophic to the intestinal tract mucosa. Glutamine, an important nitrogen-carrying amino acid, is known to support the intestinal mucosa. Short-chain fatty acids, which may be the preferred fuel source for the colonocyte and may have beneficial effects on the ileal mucosa, have been shown to enhance mucosal healing when given regularly.142~278~27sFiber enhances bowel motility and supports bacterial production of short-chain fatty acids.Z80 Because of the gastrointestinal tract’s metabolic activity as a regulator of nitrogen flux and protein synthesis, these trophic nutrients may be critical not only for local healing but also for total body nitrogen equilibrium. Therefore bowel rest may deprive the intestihe of critical metabolic precursors needed to maintain intestinal integrity. It would seem logical to provide these mucosal fuels to patients with diseased mucosa; however, whether provision of these nutrients will promote healing of fistulas is speculative. In the case of glutamine, it is well established that enteral glutamine is effective in its trophic effect; however, whether it is effective parenterally is unclear. Additionally, Curr

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growth factors that are known to enhance epithelialization when applied locally and known to improve nitrogen equilibrium when given parenterally may be useful in the treatment of enterocutaneous fistulas. It is unlikely that these modalities will improve the spontaneous fistula closure rate, which is most dependent on fistula anatomy and underlying disease process; however, like somatostatin, they may affect the time to closure in favorable fistulas.

ACKNOWLEDGMENTS

This monograph is dedicated to Dr. Claude E. Welch, whose seminal work in fistulas and gastrointestinal surgery inspired an interest ln gastrointestinalcutaneous fistulas. Dr. Welch’s industry, vigor, concern for the patient, and scholarship selve as a role model for all surgeons. We thank Steve Wiesner for his assistance in manuscript preparation, and Jean Loos and Roger West for artwork and photography, respectively. Claude Welch, MD, Howard Reber, MD, and Victor Fazio, MD, noted authorities on fistulas, reviewed the manuscript at the authors’ request and made valuable suggestions. REFERENCES 1. Fischer JE. The management of gastrointestinal cutaneous fistulae. Contemp Surg 198629:104-S. 2. MacFayden VB Jr, Dudrick SJ, Ruberg Ill.,. Management of gastrointestinal fistulas with parenteral hyperalimentation. Surgery 1973;74:100-5. 3. Aguirre A, Fischer JE. Intestinal fistulas. In: Fischer JE, ed. Total pamnteral nutrition. Boston: Little, Brown and Company, 1976203-18. 4. Aguirre A, Fischer JE, Welch CE. The role of surgery and hyperalimentation in therapy of gastrointestinal-cutaneous fistulae. Ann Surg 1974;180:393-401. 5. Soeters PB, Ebeid AM, Fischer JE. Review of 404 patients with gastmintestinal fistulas: impact of parenteral nutrition. Ann Surg 1979;190:189-202. 6. Fischer JE. Enterocutaneous fistula. In: Norton LW, Eiseman B, eds. Surglcal decision making. 2nd ed. Philadelphia: WB Saunders Company, 1985:146-7. 7. Fischer JE. Enterocutaneous fistulas. In: Najarian JS, Delaney JP, eds. Progress in gastrointestinal surgery. Chicago: Year Book Medical Publishers, 1989:377-87. 8. Benson DW, Fischer JE. Fistulas. In: Fischer JE, ed. Total parenteral nutrition. 2nd ed. Boston: Little, Brown and Company, 1991253-62. 9. Fischer JE. The pathophysiolog of enterocutaneous fistulas. World J Surg 1983;7:446-50. 10. Edmunds LH, Williams GH, Welch CE. External fistulas arising from the gastrointestinal tract. Ann Surg 1960;152:445-71. 11. Klngsnorth AN, Moss JG, Small WP. Failure of somatostatin to accelerate closum of enterocutaneous fistulas in patients receiving total parenteral nutrltion [Letter]. Lancet 1986;1:1271. 12. Lange MP, Thebo LM, Tiede SM, et al. Management of multiple entemcutaneous fistulas. Heart Lung 1989;18:386-91. 664

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85. Rodkey GV, Welch CE. Duodenal decompression in gastmctomy. N Engl J Med 1960;262:498-501. 86. Levy E, Cugnenc PH, Frileux P, et al. Postoperative peritonitis due to gastric and duodenal fistulas: operative management by continuous intraluminal infusion and aspiration. Report of 23 cases. Br J Surg 1384;71:543-6. 87. Birch BRP, Cox SJ. Spontaneous external biliary fistula uncomplicated by gallstones. Postgrad Med J 1991;67:391-2. 88. Woods MS, Fat-ha GJ, Street DE. Cystic duct remnant fistulization to the gastrointestinal tract. Surgery 1992;111:101-4. 89. Moosa AR, Easter DW, van Sonnenberg E, et al. Laparoscopic injuries to the bile duct: a cause for concern. Ann Surg 1992;215:203-8. SO. Hunter JG: Avoidance of bile duct injury during laparoscopic cholecystectomy. Am J Surg 1991;162:71-6. 91. Phillips EH, Berci G, Carroll B, et al. The importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 1990;56:792-5. 92. Ponsky JL. Complications of laparoscopic cholecystectomy. Am J Surg 1991;161:393-5. 93. Chevallier JM, Jost JL, Menegaux F, et al. Hepatic trauma: experience with 13.5 consecutive liver injuries 11982-19891 and arguments for conservative surgery. Langenbecks Arch Chir 1991;376:335-40, 94. Schirmer WJ, Rossi RL, Hughes KS, et al. Common operative problems in hepatobiliary surgery. Surg Clin North Am 1991;71:1363-89. 95. Bynoe RP, Bell RM, Miles WS, et al. Complications of nonoperative management of blunt hepatic injuries. J Trauma 1992;32:308-15. 96. Hollands MJ, Little JM. Post-traumatic bile fistulae. J Trauma 1991;31:11720.

97. Kuo Y-C, Wu C-S. Spontaneous cutaneous biliary fistula: a ram complication of cholangiocarcinoma. J Clin Gastroenterol 1990;12:451-3. 98. Feliciano DV, Martin TD, Cruse PA, et al. Management of combined pancreatoduodenal injuries. Ann Surg 1987;205:673-80. 39. Pemberton JH, Nagorney DM, Becker JM, et al. Controlled open lesser sac drainage for pancreatic abscess. Ann Surg 1986;203:600-4. 100. Martin FM, Rossi RL, Munson JL, et al. Management of pancreatic fistulas. Arch Surg 1989;124:571-3. 101. Bartoli FG, Arnone GB, Ravera G, et al. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy: review and statistical meta-analysis regarding 15 years of literature. Anticancer Res 1991;11:1831-48. 102. Bradley EL III. Complications of chronic pancreatitis. Surg Clin North Am 1989;69:481-97. 103. Maki HS, Kolts RL, Kuehner ME. Prevention of pancreatic fistula by modified pancreaticojejunal anastomosis. Am J Surg 1990;160:533-4. 104. Lipsett PA, Cameron JL. Internal pancreatic fistula. Am J Surg 1992;163:21620.

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