Managements Of Enterocutaneous Fistula (ECF)

Objectives:-The aim of present study to evaluate the standardized Guideline And prognostic factors for outcome of patients with ECF. Patients &Methods:- A prospective clinical trial conducted from January 2002-July 2013. done in the surgical ward of Al-Yarmouk Teaching Hospital. In this study a database was created consisting of 115 patients with ECF. All have Been treated according to the SOWATS guideline, which consists of the following Components, Sepsis, Optimization of nutritional state , Wound care, Anatomy of Fistula,Timing of surgery and Surgical strategy. Results :- Data from 115 patients. Mean age 42 year(range from 8-76 year). Postoperative fistula after initial surgery for any reason appeared after mean 20 day (range from 3-37 day). The mean length of hospital stay was 57 day(range from 8-106 day). Mean period of treatment was 80 day(range from 10-150day). Conclusion:- The main lesson to be learned is that adherence to SOWATS Guideline can result in good patient outcome. Surgical repair is performed when the Patient is stable. Treatment of sepsis plays a key role and ongoing sepsis is still the Most important cause of death.


Introduction:-
A fistula is an abnormal epithalialized tract between two or more structures Or spaces. It may involve a communication tract from one body cavity or hollow Organ to another hollow organ or to the skin. (1) It is estimated that 90% of ECF arise After surgical procedures , 37% mortality rate in post-operative high output ECF. (2) The majority of these deaths are attributed to electrolyte imbalance, Malnutrition and sepsis. (3) Gynecologic patients are extremely vulnerable to fistula Development 5%-30% because of malignancy and aggressive treatment regimes. (4,5) Radiation induced endarteritis affects the vascular supply, causing vasculitis, fibrosis And impaired collagen synthesis. (6) Fistulas may develop immediately or years later in conjunction with other processes Such as diabetes mellitus, pelvic inflammatory disease, pelvic surgery, hypertension And atherosclerosis. (6,7,8) Fistula are either iatrogenic or spontaneous in development. (9,10) Post-operative complications include enterotomy and anastomotic breakdown 85-90% as a result of a foreign body close to the suture line ,tension on the suture line, Complicated suture techniques, distal obstruction, haematoma, abscess formation at Anastomotic site , or tumour. (11,12,13) Spontaneous fistula development 10%-15% is attributed to intestinal diseases such As Crohns disease, malignancy and infectious processes, as in tuberculosis, Diverticulitis , vascular insufficiency,radiation exposure and mesenteric Ischaemia. (14,15,16) Fistulas may be classified according to complexity, anatomic location or Physiology . (16,17) Patients & methods:-In this study a database was created consisting Of 115 patients with ECF, 85 males and 30 females . Mean age 42 year (range from 8-76 year).
All these patients treated in the surgical ward of Al-Yarmouk Teaching Hospital , From January 2002-July 2013.
All these patients have been treated according to the SOWATS guideline, which Consists of the following components, Sepsis, Optimization of nutritional state, Wound care, Anatomy of the fistula, Timing of surgery and Surgical strategy. Control of sepsis has highest priority. The suspicion of a septic focus is based on one Or more of these clinical signs ; fever, failure to respond to nutrition and jaundice, Accompanied with increased infection parameters like decreased plasma albumin Levels, increased ESR and development of organ failure. These patients assessed according to the age, sex, type of presentation, treatment , Morbidity , type of fistula and causes of fistula. Initially be resuscitated these patients to replace intravascular volume, anaemia, hypoalbuminemia less than 3g/dl. If Intraabdominal abscesses developed drainage done. Wound care by protection of skin By any means. Nutritional support by calculated the requirement and the route used For each patient. If spontaneous closure of fistula are not occure by 4-5 weeks in Spite of sepsis free and good nutritional support,then patient prepared for surgery. The anatomy of fistula investigated radiographically according to the need ,e.g Fistulagram, barium enema,CT and ultrasound. Definitive surgery obtained by Resection of the involved section of bowel with end-to-end anastomosis, bypass Procedure, according to condition of patient and type of fistula . Post-operative fistula after initial surgery for any reason appeared after Mean Twenty days (range from 3-37 days). The mean length of hospital stay was 57day (Range from 8-106 day). Mean period of treatment was 80 day (range from 10-150 Day). Tourteen patients (12.17%) are died due to ,sepsis developed in 9 patients (64.28%) of the Fourteen patient, and 5 patients (35.71%) died due to electrolyte Imbalance and nutritional imbalance.   Nutritional support (caloric requirement) should be determined from the Harris-Benedict equation with multiplication by a stress factor, or through indirect Calorimetry. Route of nutrition should be carefully considered.

Results
Spontaneous closure of fistula is the ideal outcome but if the fistula has not closed in Expected time, the patient should be prepared for operative closure.
In our study Spontaneous closure was 21.87% while in other study ranging between 30-75 %, depending on the series and selection criteria eg (high output fistula , Presence of a foreign body , active inflammatory bowel disease, active malignancy , Presence of any factor that decrease immunity, etc .). Closure of fistula through surgery was achieved in 75 patients (78.12%) , near to Other studies percentage (77.30%). The surgical success rate was 85.22% similar to Other studies 83.70%.
Recent studies have begun to examine the role of somatostatin in the treatment of Fistulas, but we are not used somatostatin in our study.
In this study we are not studed well the proper time for conservative treatment but We depend on patient condition while in other studies said the expected time frame From 4-5 weeks of sepsis free ,adequate parenteral nutrition e.g Timothy A Pritts and David R Fischer and Josef E Fischer studies.