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The Surgical Anatomy and Etiology of Gastrointestinal Fistulas

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The Surgical Anatomy and Etiology of Gastrointestinal Fistulas Eur J Trauma Emerg Surg (2011) 37:209–213 DOI 10.1007/s00068-011-0104-7 REVIEW ARTICLE The surgical anatomy and etiology of gastrointestinal fistulas J. Pfeifer • G. Tomasch • S. Uranues Received: 17 February 2011 / Accepted: 1 March 2011 / Published online: 22 April 2011 Ó Springer-Verlag 2011 Abstract Introduction Background Fistulas are abnormal communications between two epithelial surfaces, either between two por- Fistulas are abnormal communications between two epi- tions of the intestine, between the intestine and some other thelial surfaces, either between two portions of the intes- hollow viscus, or between the intestine and the skin of the tine, between the intestine and some other hollow viscus, or abdominal wall. The etiology of intestinal fistulas is in between the intestine and the skin of the abdominal wall. most cases a result of multiple contributing factors. Despite Despite significant advances in their management over the significant advances in their management over the past past few decades, intestinal fistulas still present a major decades, intestinal fistulas remain a major clinical problem, clinical problem, with a disproportionally high overall with a high overall mortality rate of up to 30% due to the mortality rate of up to 30%, due to the high rate of com- high rate of complications. This paper aims to describe plications including sepsis, malnutrition, and electrolyte classification systems based on the anatomy, physiology imbalance [1]. Spontaneous fistula closures are reported to and etiology that may be helpful in the clinical manage- lie between 19.9 and 81.4% [2, 3]. Operative intervention ment of intestinal fistulas. is necessary in 13–80% of patients to achieve closure, Methods On the basis of anatomical differences, fistulas depending on the anatomical and physiological parameters can be classified based by the site of origin, by site of their of the fistula [4]. The aim of this paper is to describe openings, or as simple or complex. Physiologic classification classification systems used in terms of anatomy, physiol- as low, moderate or high output fistulas is most useful for the ogy, and etiology, that may be helpful in the clinical non-surgical approach. Concerning the etiology, we classi- management of intestinal fistulas. fied the possible causes as (postoperative) trauma, inflam- mation, infection, malignancy, radiation injury or congenital. Conclusion Fistula formation can cause a number of General remarks serious or debilitating complications ranging from distur- bance of fluid and electrolyte balance to sepsis and even The treatment of gastrointestinal fistulas is a complex death. They still remain an important complication fol- challenge for every gastrointestinal surgeon. Such patients lowing gastrointestinal surgery. are usually best managed by a multidisciplinary team, consisting of a surgeon, gastroenterologist, dietitian, Keywords Gastrointestinal fistula Á Fistula Á Anatomy Á enterostomal therapy nurse, and general nursing staff. The Etiology team members must treat aggressively in order to prevent mortality (which has decreased significantly worldwide in recent decades), and to improve patients’ quality of life, J. Pfeifer Á G. Tomasch Á S. Uranues (&) which can be significantly diminished for a long period of Department of Surgery, Section for Surgical Research, time. Basically, surgical treatment is reserved for patients Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria whose fistulas do not resolve with medical and non-surgical e-mail: [email protected] therapy. 210 J. Pfeifer et al. Gastrointestinal fistulas are rare, and therefore random- and colon. An enteroenteric fistula may refer to any ized studies are lacking and management is usually based intestinal fistula in the generic sense, although some may on expert opinions. There are, however, a few generally restrict this term to small bowel fistulas only. Extraintes- accepted empirical principles: (1) treatment of sepsis and tinal internal fistulas imply communication of the gastro- nutritional status are highly relevant for a good outcome, intestinal tract with another organ system, such as the (2) obstruction distal to the fistula usually prevents spon- genitourinary system, biliary tree, or respiratory tract. taneous healing of the fistula, (3) spontaneous closure is uncommon in fistulas with Crohn’s disease or a malig- Severity classification nancy, (4) low-output fistulas have a greater chance of healing than high-output fistulas, and (5) reconstructive Fistulas can be classified in anatomical terms as simple or surgery should usually be postponed for 3–6 months [1, 4, complex. Simple fistulas have a short, direct tract; there are 5]. no associated abscesses and no other organs are involved. There are two types of complex fistulas.AType 1 complex fistula is associated with an abscess or involves multiple Classification organs. A Type 2 complex fistula opens into the base of a disrupted wound (exposed fistula). By nature, complex Many classification schemes have been used to define fis- fistulas have higher morbidity and mortality rates, as well tulas of the gastrointestinal tract. Anatomical, physiologi- as a lower rate of spontaneous closure [7]. cal, and etiological classification schemes are the most commonly used. Each type of classification system carries Physiological classification specific implications, with regard to the likelihood of spontaneous closure, prognosis, operative timing, and non- Physiological classification is most useful if a non-surgical operative care planning. conservative treatment approach is selected. The most useful parameter is the output of the fistula. We distinguish Anatomical classification among low output (\200 ml/24 h), moderate output (200–500 ml/24 h), and high output fistulas ([500 ml/ Site of origin 24 h). The problem with high output secretion is the danger of intestinal failure due to reduced intestinal absorption, so Gastrointestinal fistulas are generally named according to that macronutrient and/or water and electrolyte supple- the anatomical components involved, and virtually every ments are needed to maintain health or growth. By defi- imaginable combination has been reported in the medical nition, in mild intestinal failure oral supplementation or literature. Anatomical information has prognostic signifi- dietary modification is sufficient. In severe intestinal failure cance with regard to spontaneous healing of the fistula parenteral nutrition and/or fluid replacement are needed. tract. Anatomical segments with favorable closure rates include oropharyngeal, esophageal, duodenal stump, pan- creatobiliary, and jejunal. Anatomical features associated Etiology with non-healing fistulas include large adjacent abscesses, intestinal discontinuity, distal obstruction, poor adjacent The etiology of intestinal fistula formation is important for bowel, short fistula tracts (\2 cm in length), enteral defects subsequent treatment. Table 1 provides an overview of the [1 cm, fistulas with complete epithelialization, and fistu- etiology of acquired enterocutaneous fistulas. Not surpris- las arising from special segments such as the stomach, ingly, many cases are the result of multiple contributing lateral duodenum, ligament of Treitz, and ileum [6]. factors; common examples include cancer patients who have undergone radiation therapy and patients with Crohn’s Site of the openings disease who have undergone prior bowel surgery. Acquired gastrointestinal fistulas can be categorized as Congenital external or cutaneous if they communicate with the skin surface, or internal if they connect to another internal organ First, it is useful to differentiate between congenital and system or space, including elsewhere along the gastroin- acquired fistulas, since their clinical settings and implica- testinal tract itself. Internal gastrointestinal fistulas can be tions obviously differ greatly. Congenital gastrointestinal further divided into two types: intestinal and extraintesti- fistulas are best understood in the light of their embryo- nal. Intestinal fistulas refer to a gut-to-gut connection and logical origin and include such entities as bronchial, tra- may consist of any combination of stomach, small bowel, cheoesophageal, and omphalomesenteric fistulas. The most The surgical anatomy and etiology of gastrointestinal fistulas 211 Table 1 Etiology of acquired enterocutaneous fistulas Patients undergoing extensive adhesiolysis are at highest (I) Post-operative occurrence risk of inadvertent enterotomies. An enterotomy in and of itself is not a complication, but failure to recognize and (A) Anastomotic problems adequately repair an enterotomy may lead to serious (a) Technical factors Tension problems. The result of leakage of bowel content into the Blood supply abdomen can be either peritonitis within 24–48 h or Technique abscess formation. The latter may erode the abdominal (b) Intestinal factors Inflammation wall, mainly at the incision or drainage site, leading to an Ischemia enterocutaneous fistula. Therefore, in cases with any form Infection of adhesiolysis, the entire bowel should be inspected at the Malignancy end of the procedure. In cases with multiple enterotomies (c) Systemic factors Malnutrition in a short bowel segment, resection of the involved seg- Steroids ment is recommended. The same is true for inadvertent Immunosuppression damage to the bowel mesentery, which otherwise can lead Malignancy to partial necrosis of the bowel wall and secondary fistula (d) Systemic disease Diabetes mellitus formation. Renal failure
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