Current Problems in Surgery
Volume 46, Issue 5 , Pages 384-430 , May 2009

Management of Complex Gastrointestinal Fistula

  • Myles R. Joyce, MD

      Affiliations

    • Clinical Associate, Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
    • ,
  • David W. Dietz, MD

      Affiliations

    • Staff Surgeon, Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio

References 

  1. Draus JM, Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula: are treatments improving?. Surgery. 2006;140:570–576discussion 576-8
  2. Bosscha K, Hulstaert PF, Visser MR, van Vroonhoven TJ, van der Werken C. Open management of the abdomen and planned reoperations in severe bacterial peritonitis. Eur J Surg. 2000;166:44–49
  3. Schein M. Intestinal fistulas and the open management of the septic abdomen. Arch Surg. 1990;125:1516–1517
  4. Fischer JE. The management of high-output intestinal fistulas. Adv Surg. 1975;9:139–176
  5. Fischer JE. The pathophysiology of enterocutaneous fistulas. World J Surg. 1983;7:446–450
  6. Chintapatla S, Scott NA. Intestinal failure in complex gastrointestinal fistulae. Nutrition. 2002;18:991–996
  7. Berry SM, Fischer JE. Enterocutaneous fistulas. Curr Prob Surg. 1994;31:469–566
  8. Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am. 1996;76:1009–1018
  9. Evenson AR, Fischer JE. Current management of enterocutaneous fistula. J Gastrointest Surg. 2006;10:455–464
  10. Soeters PB, Ebeid AM, Fischer JE. Review of 404 patients with gastrointestinal fistulas (Impact of parenteral nutrition). Ann Surg. 1979;190:189–202
  11. Datta V, Windsor AC. Surgical management of enterocutaneous fistula. Br J Hosp Med (Lond). 2007;68:28–31
  12. Edmunds LH, Williams GM, Welch CE. External fistulas arising from the gastro-intestinal tract. Ann Surg. 1960;152:445–471
  13. Levy E, Frileux P, Cugnenc PH, Honiger J, Ollivier JM, Parc R. High-output external fistulae of the small bowel: management with continuous enteral nutrition. Br J Surg. 1989;76:676–679
  14. Soeters PB, Fischer JE, Franklin C. One hundred and nineteen patients with gastrointestinal fistulas. Arch Chir Neerl. 1977;29:19–31
  15. Segar RJ, Bacon HE, Gennaro AR. Surgical management of enterocutaneous fistulas of the small intestine and colon. Dis Colon Rectum. 1968;11:69–73
  16. Felley C, Mottet C, Juillerat P, Pittet V, Froehlich F, Vader JP, et al. Fistulizing Crohn's disease. Digestion. 2007;76:109–112
  17. Disa JJ, Goldberg NH, Carlton JM, Robertson BC, Slezak S. Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts. Plast Reconstr Surg. 1998;101:979–986
  18. Kaushal M, Carlson GL. Management of enterocutaneous fistulas. Clin Colon Rectal Surg. 2004;17:79–88
  19. Lynch AC, Delaney CP, Senagore AJ, Connor JT, Remzi FH, Fazio VW. Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg. 2004;240:825–831
  20. Broe PJ, Bayless TM, Cameron JL. Crohn's disease: are enteroenteral fistulas an indication for surgery?. Surgery. 1982;91:249–253
  21. Carter R. Percutaneous management of necrotizing pancreatitis. HPB (Oxford). 2007;9:235–239
  22. Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008;71:143–152
  23. Larvin M. Management of infected pancreatic necrosis. Curr Gastroenterol Rep. 2008;10:107–114
  24. Bax TW, McNevin MS. The value of diverting loop ileostomy on the high-risk colon and rectal anastomosis. Am J Surg. 2007;193:585–587discussion 587-8
  25. Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, Preen M, et al. The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum. 2006;49:470–477
  26. Tsuei BJ, Skinner JC, Bernard AC, Kearney PA, Boulanger BR. The open peritoneal cavity: etiology correlates with the likelihood of fascial closure. Am Surg. 2004;70:652–656
  27. Carbonell AM, Matthews BD, Dreau D, Foster M, Austin CE, Kercher KW, et al. The susceptibility of prosthetic biomaterials to infection. Surg Endosc. 2004;19:430–435
  28. Friedmann R, Feldman H, Sonnenblick M. Misplacement of percutaneously inserted gastrostomy tube into the colon: report of 6 cases and review of the literature. J Parenter Enteral Nutr. 2007;31:469–476
  29. Roozrokh HC, Ripepi A, Stahlfeld K. Gastrocolocutaneous fistula as a complication of peg tube placement. Surg Endosc. 2002;16:538–539
  30. Baraza W, Lee F, Brown S, Hurlstone DP. Combination endo-radiological colorectal stenting: a prospective 5-year clinical evaluation. Colorectal Dis. 2008;Apr 9 (Epub ahead of print)
  31. Cerisoli C, Diez J, Gimenez M, Oria M, Pardo R, Pujato M. Implantation of migrated biliary stents in the digestive tract. HPB. 2003;5:180–182
  32. Rogart J, Greenwald A, Rossi F, Barrett P, Aslanian H. Aortoesophageal fistula following polyflex stent placement for refractory benign esophageal stricture. Endoscopy. 2007;39:E321–E322(suppl 1)
  33. Verbo A, Manno A, Mattana C, Pedretti G, Rizzo G, Coco C. Colonic perforation due to ventricular-peritoneal shunt migration: a laparoscopic approach. Tech Coloproctol. 2006;10:65–66
  34. Killelea BK, Arkovitz MS. Perforated appendicitis presenting as appendicoumbilical fistula. Pediatr Surg Int. 2006;22:286–288
  35. Agrawal V, Prasad S. Appendico-cutaneous fistula: a diagnostic dilemma. Trop Gastroenterol. 2003;24:87–89
  36. Tekkis PP, Fazio VW, Remzi F, Heriot AG, Manilich E, Strong SA. Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy. Br J Surg. 2005;92:1270–1276
  37. Tsujinaka S, Ruiz D, Wexner SD, Baig MK, Sands DR, Weiss EG, et al. Surgical management of pouch-vaginal fistula after restorative proctocolectomy. J Am Coll Surg. 2006;202:912–918
  38. Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, Preen M, et al. The outcome after restorative proctocolectomy with or without defunctioning ileostomy. Dis Colon Rectum. 2006;49:470–477
  39. Ziv Y, Fazio VW, Church JM, Lavery IC, King TM, Ambrosetti P. Stapled ileal pouch anal anastomoses are safer than handsewn anastomoses in patients with ulcerative colitis. Am J Surg. 1996;171:320–323
  40. Sandborn WJ. Pouchitis and functional complications of the pelvic pouch. In:  Fazio VW,  Church JM,  Delaney CP editor. Current Therapy in Colon and Rectal Surgery. 2nd ed.. Philadelphia: Elsevier, Mosby; 2005;p. 229–233
  41. Sagar PM, Dozois RR, Wolff BG, Kelly KA. Disconnection, pouch revision and reconnection of the ileal pouch-anal anastomosis. Br J Surg. 1996;83:1401–1405
  42. Shah NS, Remzi F, Massmann A, Baixauli J, Fazio VW. Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy. Dis Colon Rectum. 2003;46:911–917
  43. Fazio VW, Tjandra JJ. Pouch advancement and neoileoanal anastomosis for anastomotic stricture and anovaginal fistula complicating restorative proctocolectomy. Br J Surg. 1992;79:694–696
  44. Shen B, Remzi FH, Lavery IC, Lashner BA, Fazio VW. A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol. 2008;6:145–158quiz 124
  45. Colombel JF, Ricart E, Loftus EV, Tremaine WJ, Young-Fadok T, Dozois EJ, et al. Management of Crohn's disease of the ileoanal pouch with infliximab. Am J Gastroenterol. 2003;98:2239–2244
  46. Ricart E, Panaccione R, Loftus EV, Tremaine WJ, Sandborn WJ. Successful management of Crohn's disease of the ileoanal pouch with infliximab. Gastroenterology. 1999;117:429–432
  47. Raval MJ, Schnitzler M, O'Connor BI, Cohen Z, McLeod RS. Improved outcome due to increased experience and individualized management of leaks after ileal pouch-anal anastomosis. Ann Surg. 2007;246:763–770
  48. Kockerling F, Schneider C, Reymond MA, Scheidbach H, Scheuerlein H, Konradt J, et al. Laparoscopic colorectal surgery study group Laparoscopic resection of sigmoid diverticulitis (Results of a multicenter study). Surg Endosc. 1999;13:567–571
  49. Szojda MM, Cuesta MA, Mulder CM, Felt-Bersma RJ. Management of diverticulitis [review]. Aliment Pharmacol Ther. 2007;26:67–76(suppl 2)
  50. Singh B, May K, Coltart I, Moore NR, Cunningham C. The long-term results of percutaneous drainage of diverticular abscess. Ann R Coll Surg Engl. 2008;90:297–301
  51. Garcea G, Majid I, Sutton CD, Pattenden CJ, Thomas WM. Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases. Colorectal Dis. 2006;8:347–352
  52. Roche-Nagle G, O'Donnell DH, Brophy DP, Barry MC. Primary aortoenteric fistula. Am J Surg. 2008;195:506–507
  53. Tsai TJ, Yu HC, Lai KH, Lo GH, Hsu PI, Fu TY. Primary aortoduodenal fistula caused by tuberculous aortitis presenting as recurrent massive gastrointestinal bleeding. J Formos Med Assoc. 2008;107:77–83
  54. Caes F, Vierendeels T, Welch W, Willems G. Aortocolic fistula caused by an ingested chicken bone. Surgery. 1988;103:481–483
  55. Bergqvist D, Bjorck M, Nyman R. Secondary aortoenteric fistula after endovascular aortic interventions: a systematic literature review. J Vasc Interv Radiol. 2008;19(2 Pt 1):163–165
  56. Danneels MI, Verhagen HJ, Teijink JA, Cuypers P, Nevelsteen A, Vermassen FE. Endovascular repair for aorto-enteric fistula: a bridge too far or a bridge to surgery?. Eur J Vasc Endovasc Surg. 2006;32:27–33
  57. Onodera H, Nagayama S, Mori A, Fujimoto A, Tachibana T, Yonenaga Y. Reappraisal of surgical treatment for radiation enteritis. World J Surg. 2005;29:459–463
  58. Sher ME, Bauer J. Radiation-induced enteropathy. Am J Gastroenterol. 1990;85:121–128
  59. Joyce M, Thirion P, Kiernan F, Byrnes C, Kelly P, Keane F, et al. Laparoscopic pelvic sling placement facilitates optimum therapeutic radiotherapy delivery in the management of pelvic malignancy. Eur J Surg Oncol. 2008;Mar 19 (Epub ahead of print)
  60. Collins D, Ridgway PF, Winter DC, Fennelly D, Evoy D. Gastrointestinal perforation in metastatic carcinoma: a complication of bevacizumab therapy. Eur J Surg Oncol. 2008;Apr 15 (Epub ahead of print)
  61. August DA, Serrano D, Poplin E. “Spontaneous,” delayed colon and rectal anastomotic complications associated with bevacizumab therapy. J Surg Oncol. 2008;97:180–185
  62. Veillette G, Dominguez I, Ferrone C, Thayer SP, McGrath D, Warshaw AL, et al. Implications and management of pancreatic fistulas following pancreaticoduodenectomy: the Massachusetts General Hospital experience. Arch Surg. 2008;143:476–481
  63. Subramanian A, Dente CJ, Feliciano DV. The management of pancreatic trauma in the modern era. Surg Clin North Am. 2007;87:1515–1532
  64. Kong J, Gananadha S, Hugh TJ, Samra JS. Pancreatoduodenectomy: role of drain fluid analysis in the management of pancreatic fistula. ANZ J Surg. 2008;78:240–244
  65. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13
  66. Fujiwara T, Kamisawa T, Fujiwara J, Tu Y, Nakajima H, Egawa N. Pancreaticopleural fistula visualized by computed tomography scan combined with pancreatography. JOP. 2006;7:230–233
  67. Oh YS, Edmundowicz SA, Jonnalagadda SS, Azar RR. Pancreaticopleural fistula: report of two cases and review of the literature. Dig Dis Sci. 2006;51:1–6
  68. Dhebri AR, Ferran N. Nonsurgical management of pancreaticopleural fistula. JOP. 2005;6:152–161
  69. Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin: non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg. 2008;Aug 2 (Epub ahead of print)
  70. Shin JH, Song HY, Ko GY, Lim JO, Yoon HK, Sung KB. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology. 2004;232:252–259
  71. Carlson GL. Surgical management of intestinal failure. Proc Nutr Soc. 2003;62:711–718
  72. Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg. 1983;7:481–488
  73. Thomas HA. Radiologic investigation and treatment of gastrointestinal fistulas. Surg Clin North Am. 1996;76:1081–1094
  74. Brolin RE, Nosher JL, Leiman S, Lee WS, Greco RS. Percutaneous catheter versus open surgical drainage in the treatment of abdominal abscesses. Am Surg. 1984;50:102–108
  75. Metcalf C. Enterocutaneous fistulae. J Wound Care. 1999;8:141–142
  76. Metcalf C. Stoma care: empowering patients through teaching practical skills. Br J Nurs. 1999;8:593–600
  77. Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg. 1983;7:481–488
  78. Kuvshinoff BW, Brodish RJ, McFadden DW, Fischer JE. Serum transferrin as a prognostic indicator of spontaneous closure and mortality in gastrointestinal cutaneous fistulas. Ann Surg. 1993;217:615–622discussion 622-3
  79. Rombeau JL, Rolandelli RH. Enteral and parenteral nutrition in patients with enteric fistulas and short bowel syndrome. Surg Clin North Am. 1987;67:551–571
  80. Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg. 2006;93:1045–1055
  81. Ham M, Horton K, Kaunitz J. Fistuloclysis: case report and literature review. Nutr Clin Pract. 2007;22:553–557
  82. Mettu SR. Fistuloclysis can replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula [correspondence]. Br J Surg. 2004;91:1203
  83. Dionigi G, Dionigi R, Rovera F, Boni L, Padalino P, Minoja G, et al. Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience. Int J Surg. 2008;6:51–56
  84. Gonzalez-Pinto I, Gonzalez EM. Optimising the treatment of upper gastrointestinal fistulae. Gut. 2001;49(suppl 4):iv22–iv31
  85. Hoffer EK, Cosgrove JM, Levin DQ, Herskowitz MM, Sclafani SJ. Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison. J Vasc Interv Radiol. 1999;10:413–420
  86. Colwell JC, Gray M. Does preoperative teaching and stoma site marking affect surgical outcomes in patients undergoing ostomy surgery?. J Wound Ostomy Continence Nurs. 2007;34:492–496
  87. Israelsson LA. Parastomal hernias. Surg Clin North Am. 2008;88:113–125
  88. Klempa I, Schwedes U, Usadel KH. Prevention of postoperative pancreatic complications following duodenopancreatectomy using somatostatin. Chirurg. 1979;50:427–431
  89. Beglinger C, Drewe J. Somatostatin and octreotide: physiological background and pharmacological application. Digestion. 1999;60:2–8(suppl 2)
  90. Torres AJ, Landa JI, Moreno-Azcoita M, Arguello JM, Silecchia G, Castro J, et al. Somatostatin in the management of gastrointestinal fistulas (A multicenter trial). Arch Surg. 1992;127:97–99discussion 100
  91. Scott NA, Finnegan S, Irving MH. Octreotide and postoperative enterocutaneous fistulae: a controlled prospective study. Acta Gastroenterol Belg. 1993;56:266–270
  92. Sancho JJ, di Costanzo J, Nubiola P, Larrad A, Beguiristain A, Roqueta F, et al. Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistula. Br J Surg. 1995;82:638–641
  93. van Goor H. Consequences and complications of peritoneal adhesions. Colorectal Dis. 2007;9(suppl 2):25–34
  94. Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW. A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. Int J Colorectal Dis. 2007;22:683–687
  95. de Vries Reilingh TS, Bodegom ME, van Goor H, Hartman EH, van der Wilt GJ, Bleichrodt RP. Autologous tissue repair of large abdominal wall defects. Br J Surg. 2007;94:791–803
  96. Connolly PT, Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL. Outcome of reconstructive surgery for intestinal fistula in the open abdomen. Ann Surg. 2008;247:440–444
  97. Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm): a new alternative for abdominal hernia repair. Ann Plast Surg. 2004;52:188–194
  98. Kolker AR, Brown DJ, Redstone JS, Scarpinato VM, Wallack MK. Multilayer reconstruction of abdominal wall defects with acellular dermal allograft (AlloDerm) and component separation. Ann Plast Surg. 2005;55:36–41discussion 41-2
  99. Parker DM, Armstrong PJ, Frizzi JD, North JH. Porcine dermal collagen (Permacol) for abdominal wall reconstruction. Curr Surg. 2006;63:255–258
  100. Pokala N, Delaney CP, Brady KM, Senagore AJ. Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases. Surg Endosc. 2005;19:222–225
  101. Young-Fadok TM, HallLong K, McConnell EJ, Gomez Rey G, Cabanela RL. Advantages of laparoscopic resection for ileocolic Crohn's disease (improved outcomes and reduced costs). Surg Endosc. 2001;15:450–454
  102. Zapletal C, Woeste G, Bechstein WO, Wullstein C. Laparoscopic sigmoid resections for diverticulitis complicated by abscesses or fistulas. Int J Colorectal Dis. 2007;22:1515–1521
  103. Engledow AH, Pakzad F, Ward NJ, Arulampalam T, Motson RW. Laparoscopic resection of diverticular fistulae: a 10-year experience. Colorectal Dis. 2007;9:632–634
  104. Binenbaum SJ, Goldfarb MA. Inadvertent enterotomy in minimally invasive abdominal surgery. JSLS. 2006;10:336–340
  105. Rotholtz NA, Laporte M, Zanoni G, Bun ME, Aued L, Lencinas S, et al. Predictive factors for conversion in laparoscopic colorectal surgery. Tech Coloproctol. 2008;12:27–31
  106. Watanabe M, Hasegawa H, Yamamoto S, Hibi T, Kitajima M. Successful application of laparoscopic surgery to the treatment of Crohn's disease with fistulas. Dis Colon Rectum. 2002;45:1057–1061
  107. Khairy GE, al-Saigh A, Trincano NS, al-Smayer S, al-Damegh S. Percutaneous obliteration of duodenal fistula. J R Coll Surg Edinb. 2000;45:342–344
  108. Lisle DA, Hunter JC, Pollard CW, Borrowdale RC. Percutaneous gelfoam embolization of chronic enterocutaneous fistulas: report of three cases. Dis Colon Rectum. 2007;50:251–256
  109. Kumar R, Naik S, Tiwari N, Sharma S, Varsheney S, Pruthi HS. Endoscopic closure of fecal colo-cutaneous fistula by using metal clips. Surg Laparosc Endosc Percutan Tech. 2007;17:447–451
  110. Hwang TL, Chen MF. Randomized trial of fibrin tissue glue for low output enterocutaneous fistula. Br J Surg. 1996;83:112
  111. Gage EA, Jones GE, Powelson JA, Johnson MS, Goggins WC, Fridell JA. Treatment of enterocutaneous fistula in pancreas transplant recipients using percutaneous drainage and fibrin sealant: three case reports. Transplantation. 2006;15:82;1238-40
  112. Dumanian GA, Llull R, Ramasastry SS, Greco RJ, Lotze MT, Edington H. Postoperative abdominal wall defects with enterocutaneous fistulae. Am J Surg. 1996;172:332–334
  113. Cheong EC, Ong WC, Lim TC, Lim J. Successful split-thickness skin grafting in a contaminated wound with an enterocutaneous fistula. Plast Reconstr Surg. 2005;115:1221–1222
  114. Goverman J, Yelon JA, Platz JJ, Singson RC, Turcinovic M. The “Fistula VAC,” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma. 2006;60:428–431discussion 431
  115. Thompson JT, Marks MW. Negative pressure wound therapy. Clin Plast Surg. 2007;34:673–684
  116. Delman KA, Johnstone PA. Vacuum-assisted closure for surgical wounds in sarcoma. J Surg Oncol. 2007;96:545–546
  117. Siegel HJ, Long JL, Watson KM, Fiveash JB. Vacuum-assisted closure for radiation-associated wound complications. J Surg Oncol. 2007;96:575–582
  118. Chen Y, Almeida AA, Mitnovetski S, Goldstein J, Lowe C, Smith JA. Managing deep sternal wound infections with vacuum assisted closure device. ANZ J Surg. 2008;78:333–336
  119. Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis. 2007;9:266–268
  120. Gunn LA, Follmar KE, Wong MS, Lettieri SC, Levin LS, Erdmann D. Management of enterocutaneous fistulas using negative-pressure dressings. Ann Plast Surg. 2006;57:621–625
  121. Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development. Am J Surg. 2008;196:1–2

PII: S0011-3840(08)00193-7

doi: 10.1067/j.cpsurg.2008.12.006

Current Problems in Surgery
Volume 46, Issue 5 , Pages 384-430 , May 2009

Article Tools

* Image Usage & Resolution