One discussion this week involved enterocutaneous fistulas.
Reference: Haak CI, Galloway JR, Srinivasan J. Enterocutaneous fistulas: a look at causes and management. Current Surgery Reports. 2014 Oct;2:71.
Summary: Despite advances in medical technology and surgical care, the management of enterocutaneous fistulas (ECF) remains one of the most challenging problems faced by physicians. Success depends on an expert multidisciplinary team, access to long-term enteral and parenteral nutrition support, advanced wound care, optimal medical management and meticulous, methodical, surgical decision-making and technique.
Team members involved in the care of these complex patients include: general and reconstructive surgeons, nutritional support staff, bedside and enterostomal nursing, social workers, radiologists, internists, psychiatrists and physical therapists, among others. While mortality rates have improved over the past four decades, leading institutions with dedicated surgeons and full multidisciplinary teams well versed in the management of these patients continue to publish very high morbidity rates, in excess of 85%.
Strict adherence to the following principles of management is paramount: (1) identification of the fistula; (2) resuscitation and sepsis control with correction of electrolyte imbalances; (3) protection of the skin and control of fistula output; (4) nutritional support; (5) radiographic investigation; and (6) definitive management, potentially with operative repair.
Overall mortality for ECF ranges from 10 to 30%. Medical management leads to spontaneous closure in approximately 30% of patients in most series. Most patients ultimately require definitive surgical closure which carries a 30 day operative mortality rate of 3–5% and a 1 year mortality rate of 7–19% from fistula-related complications.
Operative success in closing the fistula and keeping it closed is 75–89%. After definitive surgery, simple fistulas recur 5% of the time, while complex fistulas recur up to 30% of the time in most series.
Unfortunately, the incidence of ECF appears to be rising as surgeons attempt increasingly complex operations in older patients with higher acuity and multiple comorbidities. A dedicated, multidisciplinary approach is paramount in restoring gastrointestinal tract continuity while limiting morbidity, mortality, and fistula recurrence.