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SMALL INTESTINE 401
• Size <2 cm
• G1/2
• Size >2 cm
• G3
Curative situationPalliative situation
Colonic NETs
• Present or imminent
obstruction
• Tumor or hormoneassociated symptoms
FIGURE 77-3 Treatment algorithm for colonic neuroendocrine tumors (NETs).
Complete endoscopic
Oncological resection
of the colon and
lymph node drainage
Segmental resection,
discontinuity resection or
diverting colostomy
Evaluate debulking
resection
operation
T1, G1/2
• Size <1 cm
T2, G2/3
• Size 1– 2cm
Curative situationPalliative situation
• Size >2 cm
Rectal NETs
• Present or imminent
obstruction
• Tumor or hormoneassociated symptoms
FIGURE 77-4 Treatment algorithm for rectal neuroendocrine tumors (NETs).
T1/2, G1/2, N0
T3/4, G3, N1
Segmental resection,
discontinuity resection or
diverting colostomy
Evaluate debulking
operation
Complete endoscopic
resection
Wide local excision
Low anterior or
abdominoperineal
resection
NeuroeNdocriNe Tumors of The small aNd large iNTesTiNe402
Transcatheter arterial chemoembolization
Hedinger Syndrome
Cardiac surgery with replacement of the brotic valve may be indicated in persons with Hedinger syndrome.
ADJUVANT THERAPY
Little to no evidence related to adjuvant therapy in curatively resected
NETs is available. Beyond clinical trials, adjuvant therapy is reserved
for residual disease aer surgery, advanced unresectable tumors, and
metastatic disease in order to extend median time to progression
(antiproliferative eect) and relieve hormone-associated (antisecretory eect) and tumor-associated symptoms.
n Somatostatin analogues (SSAs) are considered the rst-line
adjuvant therapy and are eective against hypersecretory
symptoms, which are very frequent with liver metastases. SSAs
(octreotide and lanreotide), similar to somatostatin, dock at
the somatostatin receptor 2 and form a peptide-receptor complex that is consecutively internalized, resulting in an antisecretory eect. Furthermore, an antiproliferative eect with
increased median time to progression has been reported. SSAs
should be initiated preoperatively in advanced disease to reduce the risk of a carcinoid crisis. Prior to somatostatin receptor imaging, the SSAs therapy needs to be interrupted 72
hours and 6 weeks for normal and long-acting release drugs,
respectively, because of receptor saturation.
n Interferon alpha has both antisecretory and antiproliferative
eects and is used if SSAs are not well tolerated.
n Symptomatic therapy including analgesics, proton pump in-
hibitors, diazoxide, loperamide, adrenergic antagonists, and
antihistamines can be applied, depending on symptoms.
n Peptide-receptor radionuclide therapy with 90-yttrium la-
beled DOTA-d-Phe(1)-Tyr(3)-octreotide (DOTATOC) or
177-lutetium labeled DOTA-Tyr(3)-octreotate (DOTATATE)
showed encouraging results in patients with metastatic disease. e agents dock at the somatostatin receptor at the basal
membrane, leading to a localized eect of the radioisotope.
eir use in patients with advanced disease produced partial
remission in up to 33% of the patients. It is used as secondline therapy for advanced disease in patients who have strong
expression of somatostatin receptor 2 visualized by somatostatin receptor imaging.
n Chemotherapy has an ecacy of less than 30%. It is only used
in advanced stages with progression despite rst-line therapy.
e medical options are alkylating agents (oxaliplatin, cisplatin, streptozotocin, and temozolomide), antimetabolites
(uoropyrimidines 5-uorouracil, and capecitabine), and
topoisomerase inhibitors (irinotecan, etoposide, and doxorubicin).
n e use of percutaneous or stereotactic radiotherapy is re-
served for special indications only.
n Targeted therapies of the epidermal and vascular epithelial
growth factor receptors (with bevacizumab and sunitinib) and
mTOR (with everolimus) are in clinical trials.
Liver metastases
Anatomical or non-
anatomical liver resection
Resection in
combination with RFA,
Solitary or multiple
unilobar metastases
Bilobar
metastases
Diffuse metastases
* RFA = Radiofrequency ablation
LITT = Laser-induced thermotherapy
TAE = Transcatheter arterial embolization
TACE =
LITT and TAE/TACE*
Two-step surgery possibly
including right protal vein
embolization/ligation
Liver transplantation
(selected cases)
Medical treatment
FIGURE 77-5 Treatment algorithm for liver metastases.
SMALL INTESTINE 403
FOLLOW-UP
Chromogranin A, 5-HIAA, and imaging are used for follow-up. A
CT scan is used for persons with small intestinal, appendiceal, and
colonic NETs (MRI may be used in young and fertile patients), and
MRI and/or endoanal/rectal ultrasound is used for persons with rectal NETs. Colonoscopy is performed for the surveillance of colorectal NETs and, given the increased risk of secondary gastrointestinal
neoplasms, it also should be considered for small intestinal NETs.
Follow-up should be performed at intervals of 2, 3, 6, or 12 months,
depending on the malignant potential of the tumor. Somatostatin
receptor imaging is indicated for the follow-up of metastatic disease or if recurrence is suspected. No follow-up is recommended for
appendiceal NETs less than 1 cm aer complete resection by appendicectomy and for colorectal NETs less than 1 cm aer complete
endoscopic resection.
PROGNOSIS
e prognosis for NETs is variable and depends on the tumor site,
dierentiation, size, stage, grade, and patient age. Metastases occur in
lymph nodes, liver, mesentery, peritoneum, and lung, rarely in bones,
and very rarely in the brain, heart, and ovaries. In the small intestine,
appendix, and rectum, prognosis for NETs is considerably better than
for adenocarcinomas, sarcomas, or lymphomas.
Five-year tumor-specic survival rates between 50% and 60% have
been reported for small intestinal NETs. Survival highly depends on
stage, grade, and Ki67 expression. e 5-year survival for appendiceal NET is considerably better, with numbers ranging from 70% to
85%, and approximates 100% in early stages. Metastasized appendiceal NETs are rare but have a poor prognosis, with a 5-year survival
of approximately 20%. NETs of the colon (right-sided in particular)
have the poorest prognosis of all intestinal NETs, with a 5-year survival as low as 40% to 50%. Approximately 30% to 45% are metastatic at diagnosis (right colonic NETs are in the upper portion of this
range). NETs of the rectum have a favorable prognosis, with a 5-year
survival of 75% to 88%. e majority present in early stages, with size
less than 2 cm and a grade of 1.
Patients with metastatic disease have median survival rates of 5
months (G3 tumors) and 33 months (G1 and G2 tumors). However,
current national databases supply evidence for improved 5-year overall survival for metastatic disease with numbers between 60% and
80%, which is possibly an eect of enhanced treatment options and
multidisciplinary approaches including use of somatostatin analogues, peptide-receptor radionuclide therapy, and surgery for liver
metastases.
S u g g e S t e d R e a d i n g
Niederle B, et al. ENETS consensus guidelines update for neuroendo-
crine neoplasms of the jejunum and ileum. Neuroendocrinology.
2016;103(2):125–138.
O’Toole D, etal. ENETS 2016 consensus guidelines for the management of pa-
tients with digestive neuroendocrine tumors: an update. Neuroendocrinol-
ogy. 2016;103(2):117–118.
Pape U-F, etal. ENETS consensus guidelines for neuroendocrine neoplasms
of the appendix (excluding goblet cell carcinomas). Neuroendocrinology.
2016;103(2):144–152.
Pavel M, et al. ENETS consensus guidelines update for the management of
distant metastatic disease of intestinal, pancreatic, bronchial neuroendo-
crine neoplasms (NEN) and NEN of unknown primary site. Neuroendo-
crinology. 2016;103(2):172–185.
Ramage JK, etal. ENETS consensus guidelines update for colorectal neuroen-
docrine neoplasms. Neuroendocrinology. 2016;103(2):139–143.
Sobin LH, Gospodarowicz MK, Wittekind C, eds. TNM Classication of Ma-
lignant Tumours. 7th ed. Hoboken, NJ: Wiley-Blackwell; 2009.
E
F
Josef E. Fischer
INTRODUCTION
Enterocutaneous stulas, dened as an abnormal communication
between the small bowel and skin, are among the most daunting
problems for an intestinal surgeon. e impact of an enterocutaneous
stula on a patient varies from a minor inconvenience to fatal malnutrition and dehydration. Depending on the cause and output of the
stula and the comorbidity of the patient, enterocutaneous stulas
can be very challenging to manage. ey must be handled correctly.
Colocutaneous stulas are a dierent proposition with dierent, usually less major challenges. ey are sometimes included if the term
“enterocutaneous” is used more generically. However, this chapter
deals primarily with stulas relating to the small bowel.
PATHOGENESIS
Most enterocutaneous stulas are iatrogenic as a result of events such as
failed anastomoses, leaks, and unrecognized inadvertent enterostomies.
In the 15% to 20% of stulas that are not iatrogenic, disease results from
a perforation of the bowel with surrounding inammation that quarantines the leak and prevents peritoneal contamination with fecal peritonitis. Instead, an abscess is usually present that, when drained, results in
a stula or erodes through tissues as it works its way to the surface and
drains spontaneously. Deep sepsis will always seek drainage via the path
of least resistance. is mechanism of development is typical of stulas
due to Crohn disease or perforating cancers. Fistulas that arise from diseased bowel will not heal until the diseased bowel is treated or resected,
and ischemic or malignant stulas are unlikely to heal spontaneously. Iatrogenic stulas that occur where the bowel is healthy may well heal with
time as long as no distal obstruction and no associated abscess cavity or
foreign body are present and the bowel has not matured itself to the skin,
as in a stoma. When stula output is low (<200 mL euent per day),
stulas oen heal spontaneously as long as other factors are favorable.
GENERAL ASPECTS OF CARE
e care and repair of enterocutaneous stulas require meticulous
attention to detail. Control of the associated sepsis, protecting the
skin against the corrosive eects of the euent, and optimization of
nutritional and metabolic status are all important aspects of patient
care. Treatment also requires patience. It is tempting to perform a
second operation immediately to x a postoperative stula and make
the patient normal, but this temptation should be resisted. Because
of the nature of enterocutaneous stulas (especially those occurring aer surgery), it is proper to allow 4 to 5 months (if possible)
between surgeries that are designed to x the stula. By this time,
intra-abdominal adhesions soen, and it is much easier and less dangerous to operate again.
404
COMPLICATIONS
Enterocutaneous stulas always result in loss of uid, protein, trace
minerals, and electrolytes. eir eects and complications are related
primarily to their output:
1. High-output stulas: An output of more than 500 mL per 24
hours normally indicates a stula in the proximal small bowel.
2. Moderate-output stulas: An output of 200 to 500 mL per 24
hours indicates that the stula is likely to be more distal in the
small bowel.
3. Low-output stulas: An output of less than 200 mL per 24 hours
suggests that most of the stool is passing through the small bowel normally and the stula is diverting a small fraction of it.
e three major complications seen in these patients are sepsis,
uid and electrolyte imbalance, and malnutrition. eir occurrence is
directly related to stula output; higher output corresponds to a higher
morbidity and mortality. Mortality rates have historically been in the
range of 20% to 40%, with higher rates if the patient has associated
cancer. With good treatment, mortality should now be much lower.
Most enterocutaneous stulas appear postoperatively, oen at
about the time that bowel function resumes aer the usual postoperative ileus. Five to six days aer the procedure the patient has pain
and a fever, with leukocytosis. e patient may have abdominal tenderness that is increasingly localized to the wound, a drain hole, or
an old incision. Drainage may be required, or drainage may occur
spontaneously. e euent oen begins as pus that changes to bile or
stool. Although the patient is in no acute danger, a lengthy and possibly complicated course of treatment begins that is summarized in the
Plan of Care (see the following sections) and in Table 78-1.
PLAN OF CARE
Six phases of care are required for the patient with gastrointestinal
(GI) cutaneous stulas:
1. Prevention
2. Stabilization
3. Investigation
4. Decision
5. Denitive therapy
6. Healing
Prevention
Because most enterocutaneous stulas are iatrogenic, the best treatment
is prevention. Technical issues may exist that should be correctable, such
as bowel damage during lysis of adhesions or wound closure, incarceration of bowel in a Richter hernia, inadequate anastomotic technique,
SMALL INTESTINE 405
TABLE 78-1: Management Phases for Enterocutaneous Fistulas
Phase Goal Time Prior to Disease
Prevention Elective
Volume adequate—preferably albumin
Nutrition normal—transferrin, albumin
Pulmonary status—chest physical therapy
Potential status re: sepsis—treated
Cardiac status normal or treated
Hematocrit and hemoglobin—normal
Renal function—normal
Physical therapy—stamina adequate
Perioperative antibiotics (30-60 min before incision)
Bowel preparations: cathartics, nonabsorbed antibiotics
Hibiclens, chlorhexidine washes (72 hr)
Coagulation factors—normal
Prevent pulmonary emboli
30-60 min before incision
72 hours
Emergency
Volume restoration
Albumin
Hematocrit, hemoglobin
Chlorhexidine wash
Pulmonary status
Prevent pulmonary emboli
Prophylactic antibiotics—30-60 min before incision
Presentations Recognition and stabilization
Volume resuscitation—colloid, crystalloid
Correct anemia: factors, red blood cells
Drain obvious sepsis
Correct electrolyte abnormalities
Initial nutritional support
Total parenteral nutrition
Begin enteral nutrition
Control stula drainage
Institute local skin care
Engage stoma nurses
Protect gastric, esophageal, duodenal mucosa with a proton pump inhibitor
+
or H
inhibitors
Use nasogastric tubes only if necessary
Estimate or measure nutritional needs
Investigation/elucidation Delay 10 days or more
Drainage and radiology: pointing abscess
Radiologic investigation
30-60 min before incision
Up to 72 hr
Aer 7-10 days
erapeutic decisions Will it close?
Site of stula
Time estimation
Trend of drainage
Decision to operate
Optimum time 5-6 mo
Other considerations—malignant stula
4-6 wk
2-4 wk?
Continued
EntErocutanEous Fistulas406
TABLE 78-1: Management Phases for Enterocutaneous Fistulas—cont’d
Phase Goal Time Prior to Disease
Denitive therapy Time of surgery
State of adhesions (estimated)
Presence or absence of sepsis
State of abdominal wall
Nutritional parameters
Septic challenges—emergency intervention
Plan incision
Plan closure
Plastic surgery help
Component release
Approach to adhesions
Freeing up bowel
Approach to stula
Sacrice 8-18 inches
Anastomosis or anastomoses
Type of suture
2-layer interrupted sutures
Gastrostomy and feeding jejunostomy
Tapering enteral and parenteral nutrition
Preferences—resection and 2-layer interrupted nonabsorbable anastomosis
Healing phase
Healing Mortality, prognosis, and complications
e central nervous system
5-6 mo
Up to 18 mo
or unrecognized enterotomies. Performing a repeat operation in
patients with severe adhesions increases the risk of bowel damage, and
sometimes a repeat laparotomy must be deferred until postoperative
adhesions soen. Operating on diseased bowel can increase the risk of
leaks and stulas, especially if an anastomosis is unwisely attempted.
Diverting an anastomosis does not necessarily prevent leaks and stulas, but not making an anastomosis at all can be wise and preventative.
e same comments apply to patients in poor condition—that is, those
with an obstruction, sepsis, or anemia, who are malnourished, or who
are taking steroids. e choice of strategy to minimize risk is a matter
of recognizing increased risk and taking appropriate steps. Sometimes
the best strategy is to delay any surgery and operate when conditions
are more favorable. In some cases, risk factors can be improved. For
example, abscesses can be drained, anemia can be corrected, and the
biochemical eects of malnutrition can be reversed. Patients who have
inadvertently lost 10% to 15% of their well body weight over a 3- to
4-month period are at risk of poor healing and other complications of
malnutrition. Preoperative nutritional support for 5 to 10 days will not
restore nutrition but will likely decrease the risk of a poor outcome.
Stabilization
Initial management of an enterocutaneous stula is geared toward
resuscitation. Fluid and electrolyte imbalances should be identied
and corrected. In persons with a chronic stula, trace metals and vitamins should be administered as well.
Concurrent with the resuscitation, control of stula drainage and
skin care should begin. e stula should be managed with a pouch
as if it were a stoma so the euent can be controlled and its volume
recorded. Sometimes the stula is easy to manage with a pouching
system, but oen the euent exits at the base of a complex wound,
thus creating challenges in pouching. In such cases, the services of
specialized enterostomal and wound nurses can be very helpful.
Closed suction dressings also can be helpful in managing deep complex wounds by controlling the euent and allowing it to be measured.
Rarely, a stula may reach the skin in the midst of an abscess.
When this situation occurs, the abscess should be drained and the
pus cultured. A urologic latex catheter in which an extra hole is cut
works well, and a No. 14 intracatheter is placed near the end to be a
suction catheter that will not erode. is approach will help protect
the skin. Drainage of abscesses should proceed, and 24 hours should
elapse before a central line is placed for the purpose of nutrition. If
the line is placed before the abscess is drained, bacteremia may infect
the catheter. Administration of antibiotics is not necessary unless the
patient has a clinically signicant infection.
Septic patients who display evidence of mental status change,
hemodynamic instability, high fever, or signs of impaired organ function should undergo a computed tomography (CT) scan and may
need intensive care. In most instances, systemic organ dysfunction
is due to an undrained septic focus that must be eectively drained.
Once the stula is established, the next priority is to measure the
output. Enterocutaneous stulas sometimes gush when they rst
appear. Patients are placed on nothing by mouth status to minimize
stimulation of the GI tract and dene baseline output. e stula output can then be characterized as high or low, and decisions can be
made about nutrition: parenteral for patients with high-output stulas and perhaps elemental oral diets for patients with low-output
stulas. Monitoring and recording stula output is important to show
the likelihood of spontaneous closure and to judge the adequacy of
supportive treatment.
Wound Care
Breakdown of the skin around the stula may make control of the
euent and ultimate repair much more dicult. Wound and enterostomal therapy nurses are very helpful in implementing techniques
to provide eective drainage while protecting the skin.
SMALL INTESTINE 407
Nutritional Support
Nutritional support can start aer the sepsis is controlled and the stula is stabilized and eectively pouched. If the gut cannot be used at
all because of the eect of oral intake on stula output, total parenteral nutrition is indicated. Low-output stulas may be treated with
enteral nutritional support. Approximately 4 feet of relatively normal
bowel is necessary to sustain nutrient absorption, and a tube gastrostomy or a feeding jejunostomy sometimes facilitates enteral nutrition.
e goal of nutritional support of a patient with an active enterocutaneous stula should be to provide 30% to 40% more protein and
calories than the requirements calculated by normal weight and gender. Nutritional support may not be wholly parenteral but rather a
mixture of enteral and parenteral nutrition. It is important for the
patient to get the most appropriate doses and mixtures of protein and
calories. Because new components and products are now available for
enteral nutrition, 60% to 70% of nutritional support should be given
enterally if possible.
Monitoring of enteral and parenteral nutrition is essential. e
principle is to begin enteral feeding with a dilute solution, with an
osmolality no greater than 150 mOsm. If the stomach is used, the concentration of the enteral feeding solution can be gradually increased
until the required calories are delivered in a reasonable volume. If
nutritional support is given directly into the small bowel, osmolality should be 150 mOsm, and initially the volume rather than the
osmolality should be increased. Once the volume is at an appropriate
level and can be tolerated, the osmolality can be increased. Giving a
maximum osmolality of 250 mOsm helps prevent diarrhea.
Glucose is the primary caloric source for parenteral nutrition.
Starting slowly, a dose of 1.8 to 2.5 g of protein per kilogram is provided. is amount will be adequate for protein replacement, but
higher amounts may be needed if there is protein loss. At least 10%
to 20% of intravenous calories should be given as lipid, provided it is
tolerated (see Chapter 83).
Nasogastric Tubes and Other Drainage Tubes
Little evidence exists to show that use of nasogastric tubes or suctioning of the GI tract promotes spontaneous closure of enterocutaneous
stulas. If some element of obstruction is present or the nasogastric
tube delivers 500 to 1500 mL of gastric or upper GI secretions, this
valuable material includes the protein that is synthesized in the stomach and upper gut. It is usually discarded but has the potential to
be placed distally into a feeding jejunostomy. However, because the
material being suctioned is oen contaminated, it is best to avoid this
practice.
Protection of the Gastric, Duodenal, and Upper Gastrointestinal Tract Mucosa from Ulceration
Patients with a stula should be protected from high acid reux
under stress, which may result in Barrett esophagus or an esophageal
stricture. A therapeutic dose of an H2 antagonist or an H
+K+
adenosine triphosphatase inhibitor is administered provided there are no
contraindications. Stress and prolonged periods of taking very little
by mouth predispose patients to ulceration, and treatment with liquid antacids such as Gelusil or Maalox may cause diarrhea. In addition, a decrease in gastric acid secretion may inadvertently result in
an indirect decline in pancreatic biliary secretion.
Other Supplements
e use of somatostatin analogues in patients with enterocutaneous
stulas has received a great deal of attention. Long-acting preparations are currently available in a dosing schedule of 10 to 30 mg given
intramuscularly every month. e main area where somatostatin
may be of help is in the case of pancreatic stulas. Some studies suggest that treatment with parenteral nutrition alone leads to a pancreatic stula closure rate between 60% and 75%, whereas adding
somatostatin leads to closure rates of 60% to 92%. Although somatostatin may be helpful in treating persons with pancreatic stulas, it
does not help close stulas that are unlikely to undergo spontaneous
closure and those caused by radiation or neoplasia. However, somatostatin is usually eective in decreasing the volume of euent and
making the stula more manageable. In addition, it may decrease the
time to closure of stulas that are likely to close. e average time of
closure seen in patients treated with parenteral nutrition alone is 50
days, but this may be decreased to 5 to 10 days in selected patients
when somatostatin is added to the regimen.
Investigation/Elucidation
ere is no rush to investigate an enterocutaneous stula and determine whether it is likely to close. Closure is certainly not going to
happen within 7 to 10 days except perhaps in pancreatic stulas
alone. e situation can be investigated aer the acute complications
of stula development have settled, aer supportive care is established, and when the patient’s general state is stable. In patients with
a postoperative stula, investigation should wait for all the sequelae
of the surgery to resolve, unless the stula demands urgent attention.
A stulogram performed using a No. 5 or No. 8 French pediatric feeding tube and water-soluble contrast material is helpful, with
the early lms yielding accurate and detailed information regarding
bowel continuity, location of the stula, presence of an abscess, presence of intestinal obstruction, the quality of the bowel, the length of
the stula tract, the size of the bowel wall defect, and perhaps the
cause of the stula.
Other studies such as an upper GI series, small bowel followthrough, and a barium enema are oen redundant, although if an
accurate picture of the anatomy of the stula in relation to the bowel
is not achieved with a stulogram alone, other studies are indicated.
e precise series of studies depends on the context of the patient,
his or her underlying disease, and the likely causes of the stula. e
use of CT scans or magnetic resonance imaging (MRI) is usually limited in the evaluation of the patient stula without sepsis; however, a
CT or MRI scan may be a valuable tool in the search for abdominal
abscesses in a patient with a stula who has sepsis and sometimes can
be used to place catheters, perhaps to facilitate drainage.
Therapeutic Decisions
Will It Close?
Management of the patient with a GI cutaneous stula will ultimately
lead to a decision about whether the stula will close. Esophageal and
lateral duodenal stulas typically close in 15 to 25 days, and colonic
stulas typically close in 30 to 40 days; small bowel stulas (especially
ileum) may take 40 to 60 days to close, if they close at all. Only a third
of the stulas in complicated cases close spontaneously, and a mere
10% to 20% will close without surgery if they are still open aer 4 to
5 sepsis-free weeks with adequate nutritional support. At this point
the stula is likely to become lined with epithelium growing toward
the skin, in which case it is unlikely to close. us only a third of
complicated stulas will resolve spontaneously. Predicting which stulas will close spontaneously is dicult. Table 78-2 lists the factors
associated with stula closure—favorable and unfavorable—to assist
with this prediction.
The Decision to Operate
When it is obvious that the stula is not going to heal, the decision to
perform a surgical repair is made. In general it is preferable to wait
5 to 6 months aer the stula has occurred to allow the adhesions to
become lmy and easier to dissect. Fistulas resulting from malignancies are usually indicative of advanced disease and a poor prognosis
EntErocutanEous Fistulas408
TABLE 78-2: Predictive Factors for Spontaneous Closure of Enterocutaneous Fistulas
Factor Favorable Unfavorable
Anatomic location Oropharyngeal, esophageal duodenal stump, pancreaticobiliary,
and jejunal
Nutritional status Well nourished; ability to get signicant enteral nutrition Malnourished
Sepsis Absent Present
Cause Appendicitis, diverticulitis postoperative Crohn disease, cancer, foreign body, radiation
Condition of bowel Healthy adjacent tissue, small leak, quiescent disease, no abscess Total disruption, abscess, distal obstruction,
Gastric, lateral duodenal, ligament of Treitz,
and ileal
active disease (Crohn disease, tumor)
Miscellaneous Tract >2 cm long
Epithelialization, foreign body
Defect size <1 cm
Transferrin >200 mg/dL <200 mg/dL
From Berry SM, Fischer JE. Enterocutaneous stulas. Curr Probl Surg. 1994;31:469.
and are exceptions to this recommendation. Nutritional support may
even encourage the malignancy associated with the stula to grow
rapidly. Each case of a malignant stula should be tailored according
to the type of tumor involved and whether there is a prospect of a
reasonable life expectancy and a decent life.
are administered prior to the initiation of the operation aer relevant
cultures have been obtained. Enteral nutrition should be stopped
before surgery to decrease abdominal distention and the amount
of stool. Nonabsorbable antibiotics should be administered, along
with cathartic agents if necessary, to ensure that the load of stool is
minimal because nonabsorbable antibiotics are not eective unless
the stool burden has been decreased as well. Parenteral nutrition can
Definitive Therapy
proceed but is slowed to 60 mL/hour. is rate can be maintained
throughout the operative procedure.
Surgery is indicated in patients with anatomically unfavorable stulas
that are unlikely to spontaneously close.
Timing of Surgery
e timing of surgery is an important issue. Usually dense adhesions
that need to be lysed make the operation dangerous until the time when
the adhesions become more lmy, which usually occurs at the earliest
at 3 months but preferably between 5 and 6 months. Some surgeons
believe that one should wait at least 6 months before performing surgery.
Sometimes it is not possible to wait for adhesions to become less
dangerous to dissect. e development of sepsis that cannot otherwise be controlled is an indication for rapid intervention, even if only
5 or 6 weeks have passed since the stula developed. Experience has
shown that this is the most dangerous time to try to resect the stula
and perform an anastomosis. Surgery should be undertaken only if
the surgeon believes the patient can withstand a prolonged proce-
Choice of Incision
It is best to reuse the old incision, provided sucient time has elapsed
since the last incision was made. is practice is particularly important
in patients with inammatory bowel disease, for whom a clean lateral
area of the abdomen might be needed for future stomas. In general,
begin the new incision slightly above the old one to allow entry to the
peritoneal cavity in an unoperated eld. If this approach is not possible, one should enter the abdomen in the epigastrium, where the bowel
tends not to be so closely applied to the abdominal wall. is entry can
be performed as illustrated in Figure 78-1. One should start close to the
xiphoid process as assistants hold up the fascia with Kocher clamps so
the fascia can be divided under direct vision and the bowel underneath
is not adherent. It is possible to divide the fascia with a combination of
gentle nger dissection and by taking the bowel down if the bowel is
not terribly adherent to achieve an area free of adherent bowel.
dure. In patients who are not able to withstand a prolonged operation, surgical drainage of the abscess should be performed, along with
proximal diversion of the GI tract to prevent continued soiling. It is
usually possible to go into the le upper quadrant of the abdomen
and exteriorize a proximal loop of jejunum as an ostomy. Once the
ostomy diverts the euent from the stula and an ostomy bag can
be applied, a prolonged period can ensue before another operation
is attempted. Total parental nutrition may be needed if the ostomy
is very high, but at least the patient can eat something and the stula and sepsis can resolve. Aer several months the stula can be
repaired and the proximal stoma can be taken down.
The Operation Itself
Aer gaining access to the abdomen, dissection proceeds laterally with
the assistant holding up the anterior abdominal wall as bowel adhe-
sions are addressed by nger dissection or scissor or knife dissection.
Adhesions are lysed, working laterally until the free space lateral to the
adhesed bowel is entered. is clear area of the abdomen in which the
bowel is free facilitates mobilization. is technique is performed on
both sides. e entire small bowel is then freed of adhesions from the
ligament of Treitz to the ileocecal valve. e strategy of adhesiolysis is for
dissection to start in an easy place, with the easy dissection performed
Surgery
e operation to correct the stula needs to be conducted under optimal conditions. e patient should be nutritionally replete or recovering. Meticulous skin care and control of stula drainage promote
a healthy abdominal wall with intact skin so that a reasonable and
secure abdominal closure can be performed. Prophylactic antibiotics
rst, so that nally the only areas le to dissect are the tightest adhesions
and the stula. It is then time to address the stula itself.
Dealing with the stula usually entails some sacrice of bowel.
is area is so adherent and dissection is so dicult because of dense
adhesions that some sort of enterotomy is inevitable. Dissection must
be performed as close to the stula as possible, disconnecting the
bowel from its adherence to the abdominal wall. e bowel is then
AB C
SMALL INTESTINE 409
D
FIGURE 78-1 A, Make the skin incision and clear the subcutaneous tissues from the fascia, lift up the fascia
with Kocher clamps to enhance visualization, and then use the other index finger to separate the bowel from
the underside of the fascia, without making an enterotomy. B, Lengthen the skin incision and fascia carefully.
The fascia may be divided with Metzenbaum scissors or a 15-blade scalpel. C, Further dissect until the bowel
and fistula are clearly seen at the bottom of the wound. Incise the fascia to where the fistulas are located.
The adherent area is rarely longer than 12 inches. Enterotomies are unavoidable, but only 8 to 12 inches
of bowel need to be resected. D, Adhesions sometimes can be compressed from a broad base down to a
narrow one and then sharply divided. (Fischer JE, Evenson AR. Gastrointestinal-cutaneous fistulas. In: Fischer JE, et al,
eds. Mastery of Surgery. 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2012.)
straightened out and examined. All kinks are liberated, and defects are
either repaired or resected. e amount of bowel damage varies, and
sometimes the need to ligate bleeding mesentery creates ischemic segments that also must be resected. e aim is to nish with an unobstructed bowel of maximum length and with no full-thickness damage.
Anastomosis
e anastomosis is a critical part of the operation. Use of any safe
technique is acceptable, although the use of staplers in fragile bowel
is unwise. Our own practice is to use interrupted 4-0 silk in the inner
layer and either 4-0 silk, 4-0 or 5-0 Prolene, or 4-0 PDS for the outer
layer, again interrupted. e anastomosis should be quarantined
from any abscess because the granulations can necessitate into the
bowel through the anastomosis. In general, it is not necessary to protect the anastomosis with a diverting stoma.
Abdominal Wound Closure
Aer the anastomosis is complete, the omentum should be placed
between the anastomotic site and the abdominal wall. e abdominal
wall must then be closed securely. A plastic surgery consultation may
be obtained to help in a complicated closure requiring component
release. Synthetic mesh is not suitable for abdominal closure because
its use may result in recurrent stulization. e release of the external
oblique aponeurosis will assist in a secure closure.
e abdominal wall must be closed above the new anastomosis
to achieve healing. In general, drains are not used unless the patient
has an abscess. If drains are used, they should be le in place for at
least 10 days because that is when suppuration occurs. However, if
the wound is contaminated, I use two BLAKE 19 FR drains and leave
them in the subcutaneous tissue for a full 10 days. Usually we instill
dilute kanamycin, clamp the drain for 2 hours, and then allow drainage to occur.
What Type of Operation Should One Undertake?
e temptation may exist to perform a procedure other than a resection and end-to-end anastomosis. However, in a previous retrospective review, there was no question that resection and end-to-end
anastomosis was far superior to either bypass or a staged procedure
as pictured in Figure 78-2.
EntErocutanEous Fistulas410
21
58
61
Operation
Resection
Bypass
Staged
FIGURE 78-2 Types of operation, closure, and complication ratio (1960 to 1970). (From Soeters PE,
Ebeid A, Fischer JE. Review of patients with gastrointestinal fistulas. Impact of parenteral nutrition. Ann Surg.
1979;190:189-202.)
Total patients
45
18
13
Failure
Complications
2
1
Gastrostomy and Feeding Jejunostomy
If the patient does not already have a gastrostomy and feeding jejunostomy, they should be considered. We prefer to use a Stamm gastrostomy with a No. 20 whistle tip catheter with an extra hole in the
gastrostomy tube to allow free drainage without suction. e stomach
is then fastened to the abdominal wall with four individual permanent sutures to minimize the chance of leakage. A feeding jejunostomy is appropriate with a No. 14 latex whistle tip catheter with an
extra hole in it. is device is placed in the small bowel, and a series
of Witzel nonabsorbable sutures should be used to ensure that it does
not leak. Nonabsorbable sutures should be used to tack the bowel to
the anterior abdominal wall. e nasogastric tube can be removed
in 24 hours. Feeding can begin slowly in 24 hours even if parenteral
nutrition is also used.
The Healing Phase
It will be some time before patients who have undergone repair of
a stula are capable of maintaining their own nutrition, and thus
provision must be made for nutritional support. Parenteral nutrition
should be continued until the patient can tolerate enteral feeding to
avoid another period of starvation. Parenteral nutrition should be
provided until the ileus resolves and then continued as a supplement
until at least 1500 kcal per day of enteral nutrition is tolerated. Fistulas can recur, especially when associated with inammatory bowel
disease, malignancy, or irradiated bowel.
In patients who have little appetite, tube feedings should be carried out only at night. Hospital food may not be appealing to the
patient, and the family should be asked to supply the patient’s favorite
food. Alcohol is helpful at times.
Fibrin Glue
A recent option for simple enterocutaneous and colocutaneous stulas is the use of brin glue to seal the track. is glue is used in
patients with low-output stulas with no distal obstruction and no
cavity adjacent to the entry of the stula track into the bowel. e
glue is instilled via a catheter that has been inserted under radiologic
control. Some success in obtaining closure and shortening the time to
spontaneous closure has been reported.
Short Bowel Syndrome
Patients who have undergone multiple resections, such as for
inflammatory bowel disease, are at risk for short bowel syndrome.
In patients with short bowel syndrome, parenteral nutrition may
be necessary indefinitely. However, some calories can be given
enterally, even if it is only a portion of the total calories required.
In general, if patients have 36 inches of small bowel remaining, they ultimately will be able to become free of parenteral
nutrition.
PROGNOSIS
In general, the mortality of patients with gastrointestinal cutaneous
stulas varies between 20% and 40%. In the major series from referral practices appearing in the literature, mortality rates are between
15% and 25%. e rehabilitation of a patient with a stula aer successful surgery is long, and it is unreasonable to expect the patient
to go back to work or resume his or her previous occupation within
3 months. In these patients, malnutrition and sepsis have an eect
on the central nervous system. Most patients are not aware of this
eect until they attempt to return to work and are asked to make
decisions they oen cannot make. Patients should be forewarned
that their central nervous system facilitative function may be
impaired for a period as long as 12 to 18 months. ey may want to
retire or say that they cannot do the job. ey should be forewarned
that this situation may occur, and they should allow time for mental
faculties to return before making any permanent decisions about
working or retirement.