I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
Managing Complex, High-Output, Enterocutaneous Fistulas: A Case Study
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42 Abstract: Gastrointestinal (GI) fistulas are an uncommon but serious complication. Following diagnosis, management strategies may have to be adapted frequently to address changes in fistula output, surrounding skin or wound condition, overall patient clinical and nutritional status, mobility level, and body contours. Following a motor vehicle accident, a 49-year-old man with a body mass index of 36.8 and a history of multiple previous surgeries, including gastric bypass, experienced excessive output from a fistula within a large open abdominal wound measuring 45 cm x 40 cm x 5 cm. Abdominal creases and the need to protect a split-thickness skin graft of the wound surrounding his fistula complicated wound management. During his prolonged 4-month hospital stay, the patient underwent several surgical procedures, repeated wound debridement, and various nutritional support interventions; a wide variety of wound and fistula management systems were utilized. One year after the initial trauma, the fistula was surgically closed. One week later, the patient died from a cardiac event. This case study confirms that GI fistulas increase costs of care and hospital length of stay and require the experience and expertise of a wide array of patient support staff members and clinicians.
Key Words: enterocutaneous fistula, gastric bypass, postoperative complications, negative pressure wound therapy
Please address correspondence to: Barbara Hahler, MSN, RN, ACNS-BC, CWOCN, Mercy St. Vincent Medical Center, 2213 Cherry Street, Toledo, OH 43608; email: hahlb@yahoo.com.
A fistula is an abnormal passage between two hollow organs or a hollow organ and the skin.1 Fistulas in the gastrointestinal (GI) system are classified by the site of origin and termination, volume of drainage, and etiology. Care of a GI fistula can be very challenging for the healthcare team and initiates a prolonged course of recovery for the patient.2 Fistulas into an open abdominal wound create even more complex management challenges.
GI fistulas may occur after a surgery or spontaneously. An estimated 80% of GI fistulas occur as complications after abdominal surgery3 with an estimated overall incidence of 0.8% to 2%.4 Fistulas-associated morbidity includes malnutrition, electrolyte imbalances, skin excoriation, abscess formation, sepsis, and dehydration.5 The development of enterocutaneous fistulas in trauma patients has been shown to increase length of stay an average of 21 days in the intensive care unit and 66 days in the hospital.6 Direct treatment costs for patients with enterocutaneous fistulas have been found to average $412, 313 or higher.6 Mortality rates are at 5% to 21% for all enterocutaneous tracts and 35% for jejunal fistulas. The predominant causes of death are sepsis, electrolyte imbalance, and malnutrition.7
Factors contributing to the development of postoperative enterocutaneous fistulas are classified as patient-specific or technique-specific.8 Patient-specific risk factors include a history of radiation therapy, inflammatory bowel disease, adhesiolysis, malnutrition, infection, and operations in the emergency setting with possible hypotension, hypothermia, anemia, or poor oxygen delivery.8 
Technique-specific factors related to protocols. According to a literature review8 of enterocutaneous fistula management, the nutritional status of the patient should be assessed preoperatively.
References:
1. Burch J. Priorities in nursing management of fistulas in community setting. Br J Community Nurs. 2004;6 suppl:S6–S14.
2. Pontieri-Lewis V. Management of gastrointestinal fistulas: a case study. Med Surg Nurs. 2005;14(1):68–72.
3. Colwell JC, Goldberg M, Carmel J. The state of the standard diversion. J WOCN. 2001;28(1):6–17.
4. Wainstein DE, Fernandez E, Gonzalez D, Chara O, Berkowski D. Treatment of high-output enterocutaneous fistulas with a vacuum-compaction device. A ten-year experience. World J Surg. 2008;32:430–435.
5. Gray M, Jacobson T. Are somatostatin analogues (octreotide and lanreotide) effective in promoting healing of enterocutaneus fistulas? J WOCN. 2002;29:228–233.
6. Teixeira P, Inaba K, Dubose J, et al. Enterocutaneous fistula complicating trauma laparotomy: a major resource burden. Am Surg. 2009;75(1):30–32.
7. Makhdoom ZA, Komar MJ, Still CD. Nutrition and enterocutaneous fistula. J Gastroenterol. 2003;31:195–204.
8. Evenson A, Fischer F. Current management of enterocutaneous fistula. J Gastrointestinal Surg. 2006;10:455–464.
9. Reed T, Economon D, Wiersema-Bryant L. Colocutaneous fistula management in a dehisced wound: a case study. Ostomy Wound Manage. 2006;52(4):60–66.
10. Beck D. Intestinal fistulas. The Phoenix. 2005;Winter:58–61.
11. Draus J, Huss S, Harty N, Cheadle W, Larson G. Enterocutaneous fistula: are treatments improving? Surgery. 2006;140:570–578.
12. Levy E, Frileux P, Cugnenc PH, Honinger J, Ollivier JM, Parc R. High-output external fistulas of the small bowel: management with continuous enteral nutrition. Br J Surg. 1989;76:676–679.
13. Reber CE, Roberts C, Way LW, Dunphy JE. Management of external gastrointestinal fistulas. Ann Surg. 1978;188:460–467.
14. Beck F, Rosenthal T. Prealbumin: a marker for nutritional evaluation. Am Fam Phys. 2002;65(8):1575–1579.
15. Singh R. Evaluation of nutritional status by different parameters and to predict spontaneous closure, morbidity and mortality in patients with enterocutaneous fistulas: a study of 92 cases. Int J Nutrition Wellness. 2008;6(1). Available at: www.ispub.com/journal/the.internet.journal_of_nutrition_and_wellness.html. Accessed April 4, 2009.
16. Torres AJ, Landa JI, Moreno-Azcoita M, et al. Somatostatin in the management of gastrointestinal fistulas. Arch Surg. 1992;127:97–99.
17. Sancho JJ, diCostanzo J, Nubiola P, et al. Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistulas. Br J Surg. 1995;82:638–641.
18. Nubiola-Calonge P, Badia JM, Sancho J, Gil MJ, Segura M, Sitges-Serra A. Blind evaluation of the effect of octreotide , a somatostatin analogue, on small-bowel fistula output. Lancet. 1987;2:672–674.
19. Alvarez C, McFadden D, Reber H. Complicated enterocutaneous fistulas: failure of octreotide to improve healing. World J Surg. 2000;24:533-538.
20. Dudrick S, Mahara AR, McKelvey AA. Artificial nutritional support in patients with gastrointestinal fistulas. World J Surg. 1999;23:570–576.
21. Martinez J, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo R. Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World J Surg. 2008;32:436–443.
22. Rolstad B, Bryant R. Management of drain sites and fistulas. In: Bryant R (ed). Acute and Chronic Wounds, 2nd ed. St. Louis, MO; Mosby;2009:490–516.
23. Erdmann D, Drye C, Heller, L, Wong MS, Levin SL. Abdominal wall defect and enterocutaneous fistula treatment with vacuum assisted closure (VAC) system. Plast Reconstr Surg. 2001;108:2066–2068.
24. Alvarez AA, Maxwell GL, Rodriquez GC. Vacuum-assisted closure for cutaneous gastrointestinal fistula management. Gynecol Oncol. 2001;80:413–416.
25. Cro C, George KJ, Donnelly J, Irwin ST, Gardiner KR. Vacuum assisted closure system in management of enterocutaneous fistulas. Postgrad Med J. 2002;78:364–365.
26. Goverman J, Yelon J, Platz J, Singson R, Turcinovic M. The “fistula vac”: a technique for management of entercutaneous fistulas arising within an open abdomen: report of 5 cases. J Trauma. 2006;60:428–431.
27. Lloyd DA, Gabe SM, Windsor ACJ. Nutrition and management of enterocutaneous fistula. Br J Surg. 2006;93:1045–1055.
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