Lesson 38: Fistulas

Question 1

Etiology

Answer 1

Surgery most common precipitating factor

Question 2

Contributing Factors

Answer 2

• Malnutrition
• Abscess formation
• Compromised perfusion to anastomotic line
• Tension on anastomosis

Question 3

Fistula Classifications

Answer 3

Named from point of origin to point of termination
- Enterocutaneous = small bowel to skin
- Colovesical = colon to bladder
- Vesicovaginal = bladder to vagina

Via output
- < 500 cc/24 hours = low output
- > 500 cc/24 hours = high output

Simple vs complex
- Simple = direct tract to skin, no abscess, no organ involvement
- Complex = fistula complicated by abscess, organ involvement, and wound is present

Question 4

Management - Conservative

Answer 4

Goal #1: minimize output through fistula tract
- Facilitate management of high output fistula
- Reduce oral/enteric intake
- Octreotide PRN (reduces amount of intestinal fluid produced)

Goal #2: assure nutritional support
- TPN with minimal PO intake

Goal #3: partially or completely collapse fistula tract
- Via NPWT +/- isolating/pouching fistula

Question 5

Fistula not likely to close when

Answer 5

• There is stomatization
• Large fistula tract
• Previous radiation to area
• Malignancy present

Question 6

Management - Operative

Answer 6

Only indicated if spontaneous closure fails or fistula stomatized

Cannot go to OR until
- Correction of all factors affecting healing
- Sufficient time has passed for softening of adhesions
— 3-6 months
- Low fistula output
- commonly resection with end-to-end anastomosis

Question 7

Options for Drainage - Pouching

Answer 7

• Ostomy +/- wound pouch to provide containment
• Wound pouch > ostomy pouch
  — Have access cap and spout
• Size opening with adequate clearance (¼ to ½ inch)
• Use flat paste to protect skin

Question 8

Options for Drainage - Closed Suction Procedure

Answer 8

• For open wound with large amounts of drainage AND patient is bed/chairbound
• Treat any damaged skin around wound with crusting
• Apply stoma paste to margins around wound
• Line wound bed with several layers of damp gauze
• Suction catheter to just below fistula

Question 9

Options for Drainage - Trough Procedure

Answer 9

• Only for fistulas located in open wounds
• Easy for large wounds and irregular surfaces
• Can add suction for improved management of drainage