How to Approach Enterocutaneous Fistulas

Educational Objectives

The goal of this program is to improve treatment of enterocutaneous fistula. After hearing and assimilating this program, the clinician will be better able to:

1. Explain maximal medical therapy in management of enterocutaneous fistulas.
2. Test hand-grip strength in patients who are being prepared for enterocutaneous fistula repair.

Summary

Enterocutaneous fistulas: fistulas can close spontaneously unless mucosa is visible; spontaneous closure rates are as high as 70%; patients must be primed, and closure usually occurs within 2 mo of maximal medical therapy, including nutritional recovery comprising micronutrients and macronutrients; regardless of how long the fistula has been present or how high the output is, spontaneous closure remains a possibility; speaker opines maximal medical therapy should start from the beginning, regardless of previous interventions; per speaker, patients should be strictly nothing by mouth and started on total parenteral nutrition (TPN); speaker uses high-dose loperamide off-label and states it is safe to use above the recommended dose limit; tincture of opium, diphenoxylate-atropine, and high-dose proton pump inhibitors (PPIs) can also be used; octreotide is controversial; if responsive to treatment, changes is typically seen in the first couple of days; if the output reduces during this time, it is ideal to continue treatment; fiber can be added to thicken the output; if no response is seen, oral or enteral nutrition can be restarted; strict bowel rest for prolonged periods is no longer recommended

Surgical repair: ideally, patients should wait at least 1 yr after their last operation (excluding skin grafts); the use of adjunctive procedures and TPN has resulted in >90% success rate, with a median time to repair of 12 mo; the wait allows patients to recover functionally, regain body weight, and replenish micronutrients; micronutrient depletion can occur 1 or 2 wk after fistula formation; deficient nutrient levels should be monitored monthly, with a full screening panel done every 6 mo; relative testosterone deficiency can be screened for, as it is detrimental to functional recovery and anabolic growth; an intramuscular injection of testosterone 100 mg can be given and the level rechecked after 2 wk; patients should approach their prefistula functional status before undergoing repair; hand-grip strength is validated as a measure of functional status and is checked weekly for inpatients and at every outpatient visit; the fistula should be scanned to understand its course; distance, transit time, and the number of fistulas should be established to decide the nutritional strategy, prognosis, and to set expectations; speaker uses an informal absorption study with acetaminophen by giving 1000 mg of liquid acetaminophen and checking the serum level after 1 hr; such patients should not be given medications that depend on good enteral absorption; fistuloclysis refers to feeding distal to the fistula; feeding tubes are inserted and tunneled to exit outside the wound care area; interventional radiology may be needed to identify the distal loop, and they can also insert the feeding tubes

Planning surgery: for new fistulas, it is possible to attempt repair, resect, or exteriorize the bowel as a loop ileostomy; the Davol Abramson drain is a triple sump that can help provide a sluice; it can be modified by cutting additional holes in the tubing with a rongeur if more drainage capacity is needed; if enteral access is likely to be needed, a jejunopexy can be done using only seromuscular bites while leaving the lumen unviolated; it can be marked with clips and secured before closure to facilitate easy identification if a percutaneous jejunostomy is needed later; for patients with older fistulas, accessing the abdomen is challenging, but the fistula can be diverted away from the midline to simplify wound care easier; the goal is to transform the short, squat fistula into a long, tunnel fistula; this surgery is time-consuming, as abdominal wall reconstruction can be complicated

Readings

Droege ME, Rhoades AG, Droege CA, et al. Clinical experience, characteristics, and performance of an acetaminophen absorption test in critically ill patients. Am J Ther. 2023;30(2):e95-e102. doi:10.1097/MJT.0000000000001436; Norman K, Stobäus N, Gonzalez MC, et al. Hand grip strength: outcome predictor and marker of nutritional status. Clin Nutr. 2011;30(2):135-142. doi:10.1016/j.clnu.2010.09.010; Taggarshe D, Bakston D, Jacobs M, et al. Management of enterocutaneous fistulae: a 10 years experience. World J Gastrointest Surg. 2010;2(7):242-246. doi:10.4240/wjgs.v2.i7.242.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Yeh is a consultant for Irrimax Corporation and Takeda Pharm; and receives royalties from UpToDate. Members of the planning committee reported nothing relevant to disclose. Dr. Yeh's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Yeh was recorded at Mattox Vegas Trauma, Critical Care and Acute Care Surgery 2024, held April 15-17, 2024, in Las Vegas, NV, and presented by the Trauma and Critical Care Foundation. For information about upcoming CME activities from this presenter, please visit https://www.trauma-criticalcare.com. Audio Digest thanks the speakers and the Trauma and Critical Care Foundation for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS720103

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.