Enterocutaneous Fistula
Michael A. Valente
Perioperative Considerations
Basic principles of enterocutaneous fistula (ECF) (Fig. 27-1) management should be multidisciplinary in nature and include:
Controlling fistula output with nutritional and metabolic support
Wound care
Proper timing of definitive repair (delay for minimum of 6 months)
Achieving fistula closure
Restoring/maintaining intestinal continuity
 FIGURE 27-1 ▪ Multiple enterocutaneous fistulas (midline and lateral) in a morbidly obese patient with Crohn’s disease and previous placement of permanent mesh. |
Operative Preparation
Imaging such as water-soluble enema, fistulogram, small bowel series, computed tomography scans, or stoma injection should be obtained prior to any operative intervention to fully delineate the anatomy of the gastrointestinal tract and to plan the appropriate operation.
Patient Positioning
Patients are placed in Lloyd-Davies position with stirrups (Yellowfins or similar); alternatively, a split-leg table may be utilized.
Access to the perineum should be readily accessible in cases where a colorectal anastomosis may be constructed or if colonoscopy is indicated.
The patient’s arms should be tucked at their sides bilaterally and padded appropriately to avoid nerve injury.
This allows for optimal exposure to all quadrants of the abdomen and may enhance the surgeon’s ergonomics in these sometimes-lengthy operations.
Approach and Equipment
These operations are generally not suited for minimally invasive techniques, and as such, an open approach is warranted.
Ureteral catheters may be utilized, when appropriate. In cases of prior pelvic dissection and/or radiation therapy, catheters should be strongly considered.
Packed red blood cells should be readily available, as these procedures are generally lengthy and difficult with a potential steady blood loss throughout its duration.
Standardized laparotomy set with deep instruments available
Wound protector
Abdominal wall retractor
Appropriate lighting
Technique
Opening of the abdomen in the midline is performed above (occasionally below) any prior incision. These incisions are usually quite large and may require a xiphoid process to pubic symphysis approach.
The use of aggressive electrocautery is generally discouraged in these reoperative cases, and rather, sharp dissection with the scalpel is the preferred method of entry into the potentially hostile abdominal cavity.
Once the abdomen is entered, a general survey of the upper abdomen should be undertaken, and the amount of adhesions are to be assessed.
A decision at this time is to be made if further opening of the abdomen is warranted versus aborting the operation and backing out due to severe adhesions/frozen abdomen.
If deemed appropriate, the incision is continued in the midline to then include the fistula tract(s) (Fig. 27-2).
FIGURE 27-2 ▪ Large midline incision that skirts around the fistulae. The incision begins either high above or below the area of concern.
Some fistulae are located off the midline; these tracts will need to be separately removed by coring out the tract down to the affected bowel segment(s).
Once the abdomen is fully opened, it is imperative that the entirety of the small bowel from the ligament or Treitz to the ileocecal valve is evaluated and freed of adhesions.
Full adhesiolysis of the small bowel will ensure that the full anatomy is ascertained and as well as to exclude any distal obstruction or other fistulae.
Small bowel adhesions that are severely matted together should be released en masse, especially if adhered down in the pelvis.
Dissection of adhesions from the least difficult to the most difficult is the generally accepted method in these difficult cases. Dissection is carried out in known anatomic planes if possible.
The bowel that is involved with the fistula should be dissected last, as this is generally the most difficult and potentially dangerous portion to free up (Fig. 27-3).
FIGURE 27-3 ▪ Dissection of the bowel in which the enterocutaneous fistula is dissected last.
The method of adhesiolysis should be performed with sharp dissection with scissors (Harrington- or Metzenbaum-type scissors).
The utilization of a #15-blade scalpel may also be necessary in dense adhesions, and often, an extrafascial dissection is necessary in which an extra-anatomical plane is created to release the bowel from the fascia/abdominal wall/peritoneum.
In this scenario, it is advantageous to leave behind a piece of peritoneum/fascia/muscle on the bowel wall, rather than trying to clean the bowel off and causing further damage.Related posts:
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