Enterocutaneous fistula; Management challenges,Areterospective review of 11 patients treated in our institute

Enterocutaneous fistula is a local pathology and systemic disorder. Objectives: To analyze postoperative outcomes, morbidity, and mortality in patients treated for enterocutaneous fistula in our institute for past 18 months. Design, setings and patients: Reterospective review of records of patients presented to Liaquat national university hospital Karachi, Pakistan between Jan 2010 to June 2011 with diagnosis of EC fistula. Results: A total of eleven patients presented with diagnosis of enterocutaneous fistula in our institute in specified duration. Mean age at presentation was 33 years with amle to female ratio of 3:1.72.7 % had high output fistula and 27.2 % had low output fistula. Small bowel was involved in 72.7%, large bowel in 18.18% and 9.0% had both small and large bowel fistula.45.45% patients had single fistula while 54.55 had multiple fistula. Total length of stay varied between 22-150 days .6/11 (54.54%) had nosocomial infection, 3/11(27.27%) had bed sores.2/11(18.18%) had TPN related complications.Spontaneous closure occurred in 8/11(72.77) patients and definitive surgical closure was performed in one patient. Mortality rate was 18.8 %. Conclusion: Enterocutaneous fistula is a devastating outcome for both surgeons and patients, sytemetic timely multidisciplinary approach can save lives.

There are several ways in which ECF has been classified, including by output, etiology, and source [1,2,3]. Most often, a high-output ECF is characterized as one with >500 mL/24 hours, low output <200 mL/24 hours, and a moderate output fistula between 200 and 500 mL/24 hours [1].
Historical reported mortality rates as high as 10-30%. Sepsis is the leading cause of death. Other factor include high output and comorbidity.Recent reported series show a declining mortality  or less) with improving supportive care, especially nutrition [3].
There is consensus among authorities that the management of a patient with EC fistula should proceed in an ordered sequence [3].

I.
Stabilize the patient by fluid resuscitation and control of sepsis. II.
Induce physical rebuilding and immunity with nutritional supplementation and wound management.

III.
Restore intestinal continuity. Management can be divided in to three phases Acute phase: • Presentation usually happens 5 to 7 days after initial surgery -Fever, ileus, wound infection and drainage of feculent material • This may be coupled with repair or resection of the fistula and bowel anastomosis if peritoneal reaction secondary to contamination is minimal as long as it is within the window period.
Window period: • We define window period as the time within 7 to 12 days from the most recent laparatomy • Within this "window period" severity of adhesions are usually milder and repeat laparotomy with the intent of diverting and or repairing the fistula is justified since caring for a well matured stoma is much easier than ECF. • Operations to correct an ECF need to be performed under optimal conditions. • Spontaneous closure rate varies between 60% -80%. Objective: • we have noticed an increase in cases of enterocutaneous fistula in our unit ,refered to our unit from all over the country as well as from abroad for a duration between Jan 2010 to June 2011 with diagnosis of EC fistula • This reterospective study was conducted to look for presentation, management challenges and outcomes of patients treated in our hospital.

Materials and methods:
• It is a reperospective observational study of 11 patients presented to our unit in last 18 months with enterocutaneous fistula.

•
The study was conducted to look for management challenges and outcomes of patients with entero cutaneous fistula patients treated in our hospital. • Records of all patients were retrospectively reviewed from the case files of patients and updates were also taken form concerned surgeons directly involved in management, patients were also contacted whenever needed.

Inclusion criteria:
All patients who presented to hospital with enterocutaneous fistula for previous 2 years were included in study. They were all primarily treated in peripheral hospitals.

Management:
We adopted the three phase approach as described above for management of all patients with ECF (entero cutaneous fistula) In the first phase (the acute phase) recognition and stabilization of ec fistula was done. The goal of this phase was to correct fluid and electrolyte imbalances, malnutrition, sepsis,abscess formation and wound infection. These problems were addressed within first 24-48 hrs of admission. DVT prophylaxis.
The next phase was phase of anatomical delieniation. • Gastrograffin used for mapping of fistula. • Fistulas were characterized as low output if output was less than 500 ml and hight output if it was more than 500 ml. • Entral and refeeding was also given in two patient after making control fistula.
• One had fistula at 1 st part of duodenum (post pef duo repair). Other had multiple fistulae in both small and large gut (post gun shot, multiple laparotomies. Different ways used for enteral feeding. For all low output and distal fistulas enteral feeding was started immediately after delineation and predigested dietary supplements were uses. In two patients with high output proximal fistula fistuloclysis was tried that is fistula contents taken from proximal limb through a feeding tube and reinserted distally using a Foley catheter and balloon inflated with 15 ml of water, It was very difficult and messy and was not totally successful requiring loss as well as multiple time cleaning because of leakage but was continued. One patient feeding jejunostomy was made during initial surgery while controlling the sepsis and was used for enteral feeding. Different types of dressings and drains were used to prevent skin complications related to fistula Low output distal small bowel fistula.
Controlled fistula made after surgical intervention.
Magnesium sulphate paste used to prevent and treat excoriation of skin.

Discussion:
The enterocutaneous fistula (ECF) is a devastating complication for both surgeons and patients alike. Prior to the advent of sophisticated critical care support and parenteral nutrition, the development of an ECF nearly equated to a death sentence. In the current era, the mortality rate has been reduced to 5 to 20% [5,6]. However, the development and management of an ECF remains a chronic, debilitating condition [5].
We used the standard approach described by Schecter et al [6] for the management of EC fistula that is divided in 3 phases,first phase includes recognition and stabilization ,so patients after being diagnosed with having EC fistula were admitted in high dependency unit and correction of electrolytes and fluid balances were done along with control of fistula and sepsis source control. Patients with severe sepsis underwent ct scan abdomen with contrast in initial phase and those having intrabdominal collection and sepsis were taken to operation theater and drainage of abcess with controleed fistula formation was done as well as feeding jejunostomy was made in 2 cases, specialized vacuum dressings with laparostomy and vicryl mesh placement in presence of controlled fistula was performed in 2 patients. Broad spectrum antibiotics were started as per pus culture and blood transfusion was started when indicated. Parenteral nutrition was started in almost all patients and few of them with low output fistula were started on enteral feeding as well. Daily electrolytes and weight measurements were taken and strict in put out put charting was done along with chest and body physio and DVT prophylaxis The provision of total parenteral nutrition has been associated with an increased rate of spontaneous closure of fistulas in several series [9,10,11]. Parenteral nutrition has long been recognized to be an integral part of the management of enterocutaneous fistulas [9,10].We started TPN in all patients after insertion of PICC line /central line in acute phase. We don't have enough number of patients to determine that correlation. The fistulogram provides information not obtainable through any other study, and early films can be particularly useful in defining anatomy and relationships. As previously discussed, water-soluble contrast may also be injected into abscesses at the time of drainage as a type of early fistulogram [9]. In our study. After the phase of stabilization and defining fistula output fistulogram was done to delineate the site of fistula and bowel anatomy and then same management with dressings ,TPN ,enteral feeding ,different dressings ,wound and skin care using zinc oxide was continued including fistuloclysis and patients were observed for a period of 3-6 months .
We did not have a large enough sample to determine which factors determine good outcomes for enterocutaneous fistulas. However, several studies from other centers have looked at this. Using multiple logistic regression analysis, Visschers et al [15]. Found that intact abdominal walls and administration of parenteral nutrition were independent predictors of spontaneous closure of enterocutaneous fistulas. In our study Spontaneous closure was achieved in 3 months in 72.7 % cases without need for surgery and surgical intervention was done in 1 patient after completing 6 months of conservative treatment with mature fistula and repeat imaging using ct scan and fistulogram was done prior to surgery and excision of fistula followed by reconstructiuon and diversion ileostomy and abdominal wall reconstruction was done. 2 of our patients died in sub-acute phase because of hight output fistula and sever sepsis .Our mortality rate is 18.8% which is comparable to most institutes specialized in management of ECF.

Conclusion:
Enterocutaneous fistula is a local pathology and systemic disorder with major impact on patient's psychology,finance emotions and wellbeing . Given that most are iatrogenic, the most effective means of treatment is prevention with sound surgical judgment and meticulous technique. However, when faced with the development of an ECF, early recognition with systemic orderly approach by a multidisciplinary team specialized in treatment of these challenging patients can save lives.