Fistula Management
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history. | Level of Evidence Not Assessed |
| Address Patient-centered Concerns | ||
|---|---|---|
| 2 | Provide information and advice on prevention and treatment options. | Level of Evidence Not Assessed |
| Provide Local Care | ||
|---|---|---|
| 3 | Focus initially on hemodynamic stabilization of patients with enterocutaneous fistulas and treatment of infection. | Level of Evidence Not Assessed |
| 4 | Use appropriate imaging to determine fistula anatomy, treatment requirements, and likelihood of spontaneous closure. | Level of Evidence Not Assessed |
| 5 | Perform a comprehensive patient and fistula assessment and develop a management plan addressing perifistular skin protection, odour control, and electrolyte and nutritional supplementation requirements. | Level of Evidence Not Assessed |
| 6 | Manage fistulas using an interdisciplinary team and holistic approach, incorporating patient and family education. | Level of Evidence Not Assessed |
| 7 | Reassess fistula closure regularly and modify the management plan as necessary. | Level of Evidence Not Assessed |
| 8 | Use appropriate imaging to determine fistula anatomy, treatment requirements, and likelihood of spontaneous closure. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 9 | Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information. | Level of Evidence Not Assessed |
Background
Enterocutaneous fistulas (ECFs) may develop spontaneously, due to a variety of intestinal diseases, or postoperatively, due to complications. The first sign of an ECF is usually excess fluid leaking from an abdominal wound. Examination of the fluid can help to determine the origin of the tract. Concentrated digestive enzymes rapidly damage the skin around the fistula. ECFs can be classified according to output as low volume (<200 mL/24 hours), moderate volume (200–500 mL/24 hours) and high volume (>500 mL/24 hours). High-volume fistulas are associated with high morbidity and mortality and decreased likelihood of spontaneous closure.The management of enterocutaneous fistulas (ECFs) is based on addressing fluid and electrolyte balance and nutrition, preventing and controlling sepsis, containing effluent, maintaining periwound skin integrity, facilitating fistula closure, either spontaneously or surgically, and managing pain. Initial management focuses on managing sepsis, preventing hypovolemia, and decreasing intestinal output. This includes fluid resuscitation, NPO status, an H2-receptor antagonist and somatostatin. Imaging can determine the fistula anatomy, continuity of the bowel, presence of an abscess or obstruction, the likelihood of spontaneous closure and specific treatment needs. Spontaneous closure of enteric fistulas usually takes 1–2 months.
Holistic and interdisciplinary care is optimal for patients with a fistula. Appropriate management requires comprehensive assessment by an enterostomal therapist, expertise in product selection and use, and appropriate patient and family teaching to develop an effective individualized care plan. Effective fistula containment involves protection of perifistular skin, odour control, and measurement of effluent to determine electrolyte and nutritional supplementation requirements. Adequate nutritional support facilitates spontaneous closure, and a consultation with a dietitian may be beneficial. Effective containment is important to patient comfort, physical condition and psychosocial health. As fistula closure may take several months, inadequate control of odour and effluent can result in isolation, withdrawal, and depression. A social worker or psychologist may be of assistance in this regard.
Approaches to fistula management:
• Low-volume fistulas without odour problems can usually be managed simply, with dressings, such as hydrocolloid, alginate, hydrofibre, or foam dressings, and skin protectants.
• Low-volume fistulas associated with odour may require charcoal dressings and frequent dressing changes (with use of appropriate skin barriers and protectants), along with liquid and environmental deodorants and application of crushed metronidazole tablets. If this approach is ineffective, the high-volume fistula approach may be effective.
• High-volume fistulas can be managed with one- or two-piece ostomy systems (depending on the need for a window), a fecal incontinence collector, customized pouching system, vacuum-assisted closure dressing or catheter system in conjunction with appropriate skin barriers.
Many complex fistulas require surgical closure. The patient should be free of sepsis for at least 6–8 weeks and be in positive nitrogen balance before surgery. Surgical closure may occur between 10 weeks and 13 months after fistula development.
References
| Essential Publications |
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| n/a |