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A1-G Surg Note Small Bowel > Enterocutaneous Fistulas > Flashcards

Enterocutaneous Fistulas Flashcards

1
Q

What are enterocutaneous (EC) fistulas?

A

Abnormal connections between the lumen of the gastrointestinal tract and the skin.

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2
Q

What is an enteroatmospheric (EA) fistula?

A

A direct communication between the bowel and a nonepithelialized granulating wound, often occurring after temporary abdominal closures.

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3
Q

How common are enteroatmospheric fistulas after temporary abdominal closures?

A

They occur in nearly 10% of cases.

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4
Q

What percentage of EC fistulas are iatrogenic or postoperative in etiology?

A

75%–85%

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5
Q

What are the primary causes of iatrogenic EC fistulas?

A

Anastomotic leaks (50%)
missed enterotomies (45%)
missed traumatic injuries
bowel puncture by percutaneous catheters
and erosion of foreign material (e.g., mesh) into adjacent bowel

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6
Q

What conditions are commonly associated with the spontaneous development of EC fistulas?

A

Inflammatory bowel disease
malignancy
prior radiation

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7
Q

What are some significant impacts on quality of life for patients with EC fistulas?

A

Malnutrition and chronic wounds that can be difficult to manage.

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8
Q

What is the overall mortality rate for patients with EC fistulas?

A

15% to 25%.

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9
Q

What are the primary causes of mortality in patients with EC fistulas?

A

Sepsis, malnutrition, and electrolyte imbalances.

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10
Q

What is the classic presentation of an EC fistula?

A

A patient several days to weeks after surgery developing fever, leukocytosis, and erythema around their incision, followed by purulent drainage that becomes bilious green or brown.

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11
Q

What signs might indicate an EC fistula in postoperative patients with abdominal pain, fever, and leukocytosis?

A

Intraabdominal fluid collections on CT scans.

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12
Q

What might happen after an image-guided percutaneous drain is placed in a patient with an EC fistula?

A

The drain initially produces purulent output, which then turns bilious or feculent

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13
Q

How do the symptoms of patients with EC fistulas vary?

A

They range from severe sepsis with localized or diffuse peritonitis to mild abdominal discomfort and leukocytosis

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14
Q

What is an important initial sign of an EC fistula in the context of wound infection?

A

The drainage of purulent fluid from the incision site that later becomes bilious or feculent in color.

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15
Q

What are the classifications of EC fistulas based on daily output?

A

Low-output: < 200 mL per day
Moderate-output: 200 to 500 mL per day
High-output: > 500 mL per day

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16
Q

Why should patients with EC fistulas be made nil per os (NPO) after recognition?

A

To establish baseline fistula output without oral or enteral stimulation

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17
Q

How does the classification of EC fistulas influence their management?

A

Low-output fistulas are more likely to close spontaneously

while high-output fistulas are associated with complications such as dehydration, electrolyte disturbances, and malnutrition.

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18
Q

What types of EC fistulas are classified based on the origin of the gastrointestinal leak?

A

Gastric
duodenal
enteric (small intestine)
and colonic (colocutaneous) fistulas

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19
Q

What is the first step in the management of EC fistulas?

A

Stabilization and sepsis control

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20
Q

How should septic patients with EC fistulas be managed initially?

A

According to the Surviving Sepsis Guidelines

including fluid resuscitation, hemodynamic assessment, potential transfer to ICU, and broad-spectrum antibiotics

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21
Q

What percentage of mortality associated with EC fistulas is due to sepsis and uncontrolled infection?

A

More than 70%

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22
Q

What is the next step after stabilizing a patient with an EC fistula?

A

Obtain source control by draining any intraabdominal abscesses.

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23
Q

What type of imaging should be obtained to identify and characterize abscesses in EC fistula patients?

A

Abdominal axial imaging.

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24
Q

How can superficial abscesses be managed in EC fistula patients?

A

Through a small incision and debridement bedside procedure to ensure continued drainage.

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25
Q

How should deeper intraabdominal or pelvic abscesses be managed?

A

With image-guided percutaneous catheter placement by interventional radiology.

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26
Q

What is the goal of managing an uncontrolled enteric leak in EC fistulas?

A

To convert it into a controlled EC fistula.

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27
Q

When is operative intervention indicated in the initial management of EC fistulas

A

Rarely, except in cases of peritonitis or free perforation.

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28
Q

What should be avoided during the initial operation for EC fistulas due to the high risk of injury?

A

Extensive lysis of adhesions, as it can lead to injury of healthy bowel loops

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29
Q

What surgical actions are recommended if the source of the leak is identified during emergency surgery?

A

Bowel resection without creating an anastomosis, as primary repairs are often not durable.

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30
Q

What operations should be considered for damage control in EC fistula patients?

A

Fecal diversions and leaving drains to create a controlled fistula

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31
Q

When can antibiotics typically be stopped in EC fistula patients after initial source control?

A

After 4 to 7 days, pending clinical improvement

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32
Q

What should clinicians do if a patient with an EC fistula develops recurrent fevers, leukocytosis, or abdominal pain?

A

Have a low threshold to reimage, as new abscesses could develop even after initial source control

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33
Q

When does long-term management of EC fistulas begin?

A

As soon as the patient is stabilized and sepsis is controlled, usually within 2 days of diagnosis

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34
Q

How long can the long-term management of EC fistulas last?

A

Months to years.

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35
Q

What are the key components of long-term management for EC fistulas?

A

Fluid and electrolyte repletion
nutritional optimization
pharmacologic control of effluent volume
and wound care

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36
Q

What percentage of EC fistulas heal spontaneously with appropriate long-term management?

A

Approximately 30% to 35%.

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37
Q

How long does it typically take for EC fistulas to heal spontaneously with long-term management?

A

Within 5 to 6 weeks of diagnosis

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38
Q

What is the goal of long-term management in EC fistula patients?

A

To increase the likelihood of spontaneous closure and optimize the patient for potential operative intervention

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39
Q

Algorithm for the management of enterocutaneous fistulas.

A

see

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40
Q

What complications can develop in patients with high-output EC fistulas?

A

Severe dehydration and electrolyte derangements.

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41
Q

What type of central access is often used for TPN in patients with high-output EC fistulas?

A

Long-term central access, such as peripherally inserted central catheters (PICCs)

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42
Q

What common electrolyte abnormalities occur in patients with high-output EC fistulas?

A

Hyponatremia, hypokalemia, and hypomagnesemia

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43
Q

What metabolic complication can develop in patients with duodenal fistulas?

A

Metabolic acidosis requiring sodium bicarbonate replacement.

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44
Q

What syndrome must be monitored for when starting or resuming nutrition in EC fistula patients?

A

Refeeding syndrome

45
Q

Which laboratory value should be frequently checked to monitor for refeeding syndrome?

A

Serum phosphorus levels

46
Q

How much protein can patients with EC fistulas lose daily, contributing to malnutrition?

A

Up to 500 g of protein

47
Q

What markers should be closely monitored to assess nutritional status in patients with EC fistulas?

A

Prealbumin, albumin, and transferrin.

48
Q

What is the nutritional requirement for patients with low-output EC fistulas?

A

20 kcal/kg per day of carbohydrates and fat, and 1 g/kg per day of protein

49
Q

What are the nutritional requirements for patients with high-output EC fistulas?

A

30 kcal/kg per day of carbohydrates and fat, and 1.5 to 2.5 g/kg per day of protein.

50
Q

Why is enteral feeding preferred over parenteral nutrition in EC fistula management?

A

Because it promotes mucosal integrity, maintains intestinal function, and supports immune function.

51
Q

What is a potential drawback of oral intake for patients with EC fistulas?

A

It can substantially increase fistula output, complicating wound care

52
Q

When is TPN typically used for patients with EC fistulas?

A

As a bridge to enteral feeding or for long-term nutrition if oral intake is not tolerated

53
Q

What initial approach is often taken for patients with newly diagnosed EC fistulas?

A

A few days of bowel rest, with or without TPN, to observe if the fistula closes spontaneously or output decreases.

54
Q

What should be done if fistula output persists after an initial period of bowel rest?

A

Gradually reintroduce an oral diet and monitor for increased output and malabsorption; consider TPN if needed

55
Q

Can patients with high-output fistulas continue an oral diet?

A

Yes, as long as fistula output is controlled, wound care is manageable, and ostomy appliances are well-seated

56
Q

What is fistuloclysis?

A

A method of enteral feeding distal to the EC fistula by cannulating the distal limb for tube feed instillation

57
Q

How is the distal limb of the EC fistula identified for fistuloclysis?

A

Using a fistulogram performed by interventional radiology or in the operating room with fluoroscopy

58
Q

What step can help secure the catheter and facilitate wound care during fistuloclysis?

A

Tunneling the catheter under the skin.

59
Q

What is done with the high-volume liquid output from patients during fistuloclysis?

A

The effluent can be collected, strained, and refed into the distal feeding tube.

60
Q

In what type of patients is fistuloclysis indicated?

A

In patients with EC fistulas not expected to close spontaneously, as cannulating the distal limb prevents closure

61
Q

What are the benefits of fistuloclysis for patients who may require operative intervention?

A

maintains mucosal integrity and promotes intestinal adaptation and lengthening.

62
Q

How does fistuloclysis affect the need for parenteral nutrition?

A

It enables patients to potentially wean off parenteral nutrition

63
Q

What physiological effect does refeeding of succus have during fistuloclysis?

A

It activates the “ileal brake,” decreasing gastric acid secretion, pancreatic enzyme secretion, and peristalsis, which reduces EC fistula output.

64
Q

What is a key component of long-term management for EC fistulas?

A

Controlling effluent volume

65
Q

What are the first-line pharmacologic agents for controlling EC fistula output?

A

Opiate receptor agonists such as loperamide, diphenoxylate/atropine, codeine, and distilled tincture of opium.

66
Q

How do opiate receptor agonists help manage EC fistula output?

A

They act on intestinal muscles to decrease peristalsis.

67
Q

What role do proton pump inhibitors and H2 receptor antagonists play in EC fistula management?

A

They lower the acidity of fistula output and decrease volume through antisecretory effects.

68
Q

What is the effect of amitriptyline in EC fistula management?

A

It causes constipation via anticholinergic pathways and helps slow output.

69
Q

How does clonidine help manage EC fistula output?

A

As an alpha 2-adrenergic agonist, it increases mucosal absorption of fluids and electrolytes

70
Q

What are examples of bulking agents used in EC fistula management?

A

Psyllium and banana flakes

71
Q

When is cholestyramine particularly useful in managing EC fistulas?

A

In decreasing output from more proximal fistulas, such as those from the duodenum or proximal jejunum

72
Q

What is the action of octreotide in high-output EC fistulas?

A

It reduces gastric acid and pancreatic enzyme secretions and enhances fluid and electrolyte absorption by prolonging transit time.

73
Q

Does octreotide increase the likelihood of spontaneous fistula closure?

A

No, but it decreases output and the time to closure

74
Q

What is the target output volume for managing high-output EC fistulas effectively?

A

Less than 1 to 1.5 liters per day.

75
Q

What combination of products is often used to manage complex wounds surrounding EC fistulas?

A

Stoma paste, powders, barrier rings, hydrocolloid dressings, and specialty ostomy appliances.

76
Q

Why are catheters that tunnel under the skin preferred for fistuloclysis

A

Because they come out away from the wound, allowing better placement of pouches and wound protection

77
Q

What is the purpose of sump drains in the management of EA fistulas?

A

To collect effluent and divert it away from the surrounding skin.

78
Q

How can vacuum dressings benefit wound care in EC fistula patients?

A

They promote granulation of surrounding tissues and protect them from effluent

79
Q

What caution must be taken when using vacuum dressings on EC fistula patients?

A

They should not be placed directly on granulation tissue or skin grafts over the bowel to avoid creating new fistulas.

80
Q

Why is it critical to characterize the anatomy of an EC fistula?

A

To determine the location of the fistula, assess the amount of bowel proximal and distal to it, and check for multiple fistulas

81
Q

What imaging studies are used to characterize EC fistulas?

A

CT scans with oral contrast
upper GI swallow studies with small bowel follow-through,
contrast enemas
and fistulograms

82
Q

What is the purpose of a fistulogram in EC fistula assessment?

A

To cannulate and inject contrast into the proximal and distal limbs of the fistula under fluoroscopy for detailed imaging

83
Q

What can imaging studies reveal about the feasibility of fistuloclysis?

A

They can help determine if fistuloclysis is possible by assessing the anatomy of the fistula.

84
Q

How can imaging studies help with operative planning for EC fistulas?

A

By assessing for distal obstructions that would make spontaneous closure unlikely and guiding surgical approaches

85
Q

Why is it important to know if there are multiple fistulas present?

A

Multiple fistulas may complicate management and affect treatment strategies

86
Q

What percentage of EC fistulas close within 2 months without operative intervention?

A

Approximately 30% to 35%

87
Q

What characteristics of EC fistulas make them more likely to heal spontaneously?

A

Fistula tracts longer than 2 cm
defect sizes of < 1 cm²
and decreasing output

88
Q

What are predictors that an EC fistula will require operative intervention?

A

Distal obstructions, ongoing sepsis or abscess, and malnutrition.

89
Q

Which causes of EC fistulas are associated with a lower likelihood of spontaneous closure?

A

Fistulas caused by Crohn’s disease, malignancy, radiation, or a foreign body

90
Q

How does the output of an EC fistula affect the likelihood of spontaneous closure?

A

Decreasing output increases the likelihood of spontaneous closure

91
Q

Characteristics Predictive of Spontaneous Closure of Enterocutaneous Fistulas

A

1

92
Q

Characteristics Predictive of Spontaneous Closure of Enterocutaneous Fistulas

A

2

93
Q

When should surgeons consider operative management for EC fistulas that have not closed spontaneously?

A

At least 6 months after diagnosis to allow intraabdominal adhesions to soften

94
Q

What is the purpose of the “pinch test” for EA fistulas?

A

To determine readiness for surgery by checking if tissue or skin graft overlying bowel separates easily.

95
Q

What patient conditions should be met before surgery for EC fistulas?

A

Nutritional optimization, sepsis control, and the patient being close to their baseline functional status.

96
Q

How should surgeons and anesthesiologists prepare for an EC fistula operation?

A

Prepare for a lengthy, difficult procedure with high insensible fluid losses, use a urinary catheter for accurate urine output recording, and consider epidural catheters or transversus abdominis blocks for pain management

97
Q

Where should the surgical incision be made for an EC fistula operation?

A

Away from prior incisions, usually subxiphoid

98
Q

What surgical technique is essential for managing adhesions in EC fistula operations?

A

Extensive lysis of adhesions with sharp dissection and full mobilization of the bowel.

99
Q

What should surgeons document during an EC fistula surgery?

A

The amount of remaining bowel after resection

100
Q

Why should fistula defects not be repaired primarily?

A

Because primary repair is likely to lead to recurrent leaks.

101
Q

What approach should be taken if simple primary closure of the abdominal wall is not possible?

A

Use component separations or place biologic mesh in an underlay fashion

102
Q

Who should be involved for complex abdominal wall defects during EC fistula surgery?

A

General surgeons or plastic surgeons specializing in abdominal wall reconstruction

103
Q

What alternatives should be considered if the EC fistula cannot be safely resected?

A

Creating a diverting stoma or placing a venting gastrostomy tube and/or distal feeding jejunostomy tube

104
Q

What is the current operative success rate for EC fistula takedowns?

A

Some studies report success rates as high as 92%

105
Q

How has the mortality rate for EC fistula surgery changed since the 1970s?

A

It has decreased from approximately 40% to around 20%, with some studies citing rates as low as 2%

106
Q

What is the 30-day morbidity rate for EC fistula surgery based on the American College of Surgeons dataset?

A

Nearly 50%

107
Q

What is the typical duration of postoperative recovery for EC fistula surgery?

A

Several months, with gradual weaning off parenteral nutrition as enteral nutrition improves.

108
Q

What postoperative care might EC fistula patients benefit from?

A

Postoperative physical therapy and, in some cases, stays in rehabilitation facilities

109
Q

what Percentage with EC fistulas will recur after surgery

A

Approximately 16% to 36%

A1-G Surg Note Small Bowel (10 decks)

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