This column summarizes patient cases posted to SIR Connect (SIR’s popular online member community), the responses from other SIR members and how that feedback helped the original poster. To see how SIR’s online community can help you, visit SIR Connect at connect.sirweb.org.
Original post, lightly edited for flow:
bit.ly/2Oox4B0
My patient is a 67-year-old female with an enterovaginalcolocutaneous fistula following complete resection of an ovarian carcinoma. She has not had any radiation and there is no evidence of recurrent cancer. A drain was placed 6 months ago and there has been no change in imaging findings. She is getting along fairly well. and changing pads about three times a day and emptying 50 ccs enteric contents from the bulb every time she voids. We change the tube every 3 months. When we put the tube to bag drainage, or she eats the wrong stuff, she pours small bowel contents out of her vagina and stool sometimes leaks around the outside of the drain. Surgical repair would involve high risk of additional complications. She and her GYN-ONC would like to avoid these risks. Does anybody have any relatively low-risk ideas for sealing this up?
What specifically prompted you to reach out regarding this case?
This particular case (Fig. 1) had the twist of high-output vaginal fistula and the combination of enteric and colonic fistulas. I don’t believe I’ve encountered an intractable vaginal fistula before, let alone one that involves both colon and small bowel.
What posts were most valuable to you and why?
The literature references were nice to have but can be found independently with a literature search. The advantage of SIRConnect is that we can get one-to-one advice from other IRs with real-world experience with these techniques. My plan included techniques recommended by all of the respondents, specifically improving external drainage, abrading the tract, and plugging with Gelfoam. I think simpler is better and I prefer not to use techniques or devices that I have not used before and am not likely to use again so I didn’t initially consider laser or plugs.
The patient was not offered any surgical options at our institution due to high risk of complications, and her other doctors recommended that IR continue to work on it. She underwent surgery at a referral hospital and ended up with a colostomy and numerous drains managed by their IR service and an open wound that is healing. She is on the road to recovery and is glad to have it over with—she has nothing but good things to say about IR at each institution. It makes me wish I had pushed her a little more to try these less invasive techniques first.
Do you find that the responses will shape your practice pattern and lead to an outcome that you did not think could have been achieved otherwise?
The advice was excellent and I’m sure I will use these techniques in the future. I will also offer them to patients sooner. It seems like I’m seeing fistulas quite a bit more lately and I suspect it is because we have had so much success dealing with them that surgeons are more and more reluctant to operate on them. Since definitive management of these fistulas has shifted toward IR at my institution, it has become necessary to thoroughly explore all options available. Many of the things I have learned in IR were learned after I was out in practice. In the past it could be very time-consuming to learn new techniques or approaches in IR. Now, the electronic resources available are amazing and one of the most useful resources to me really has been SIRConnect.
What approaches would you consider for the next patient with a similar problem?
I’ve recently acquired another surgery orphan who has an unusual fistula to the perineum following abdominoperineal colon resection. It involves fat necrosis and chylous-type fluid drainage. This has been going on for months and the drainage is keeping him from working as a computer programmer because all the chairs get ruined. I abraded the tract with a biopsy brush and plugged the tract with thick Gelfoam 3 weeks ago but the fistula persists, though drain output is low. I looked into the Cook Biodesign Fistula Plug as suggested in the thread but it did not turn out to be appropriate for this patient. So I will be moving on to the final suggestion—ablation with laser catheter. If this fails, I’ll be back on SIRConnect for more advice.
Additional commentary
Enterocutaneous fistulas (EF) form between the gastrointestinal tract and the skin. Classically, EF are reported to be of iatrogenic origin in 75–85% of cases with spontaneous EF ranging between 15–25%.1 Organ of origin is used to classify EF2 while 24-hour fistula output can stratify EF to be high (>500 mL), moderate (200–500mL) and low output (<200 mL)1. Notably, interventional radiologists encounter abscesses in the setting of bowel perforation or leak, which then drain through a controlled iatrogenic tract. The original post described a spontaneous fistula to the vagina and iatrogenic tract to the skin.
Initial assessment of EF anatomy can be performed via endoscopy or imaging such as computed tomography, magnetic resonance imaging, radiography or fluoroscopy.3,4 CT and MRI will also identify any associated abscess. If a drainage catheter is in place, a fluoroscopic or CT abscessogram utilizing contrast or air can delineate the fistula anatomy.
Conservative management involves wound care, medical treatment (to reduce output and mitigate gastric or pancreatic secretions) and nutrition maintenance, which are mostly outside the scope of this article.3,4 Briefly, protecting skin from enteral effluent promotes wound healing. Placing drainage catheters into the fistula has been performed but remains controversial due to potential tract widening.4 Negative pressure therapy is also controversial as it has mixed results and may promote bowel erosion.3,4 Moreover, somatostatin analogues such as octreotide promote fistula closure and decrease fistula output but do not improve mortality.5,6
Although surgical intervention is considered definitive, recurrence rates of 34% have been reported.3 Endoscopic clipping or gluing is also a consideration, often early on.3,4 Percutaneous approaches involve EF cannulation for control. Closure rates of 81% have been reported when control and healing are achieved by placing a catheter near the enteric site.7 Alternatively, fibrin glue (with or without ethiodized oil) or Gelfoam may be considered to seal the tract itself as in the case above.4,8 A recent series reported healing in 89% of cases utilizing a combination of glue and ethiodized oil.9 Laser ablation of EF tracts is also promising and has reported reported 63–64% primary and 88% secondary closure rates.10,11
References
- Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am. 1996;76(5):1009–1018.
- Schein M, Decker GA. Postoperative external alimentary tract fistulas. Am J Surg. 1991;161(4):435–438.
- Gribovskaja-Rupp I, Melton GB. Enterocutaneous fistula: Proven strategies and updates. Clin Colon Rectal Surg. 2016;29(2):130–137.
- Ashkenazi I, Turégano-Fuentes F, Olsha O, Alfici R. Treatment options in gastrointestinal cutaneous fistulas. Surg J (N Y). 2017;3(1):e25–e31.
- Coughlin S, Roth L, Lurati G, Faulhaber M. Somatostatin analogues for the treatment of enterocutaneous fistulas: A systematic review and meta-analysis. World J Surg. 2012;36(5):1016–1029.
- Rahbour G, Siddiqui MR, Ullah MR, Gabe SM, Warusavitarne J, Vaizey CJ. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Ann Surg. 2012;256(6):946–954.
- D’Harcour JB, Boverie JH, Dondelinger RF. Percutaneous management of enterocutaneous fistulas. AJR Am J Roentgenol. 1996;167(1):33–38.
- Lisle DA, Hunter JC, Pollard CW, Borrowdale RC. Percutaneous Gelfoam embolization of chronic enterocutaneous fistulas: Report of three cases. Dis Colon Rectum. 2007;50(2):251–256.
- Mauri G, Pescatori LC, Mattiuz C, et al. Non-healing post-surgical fistulae: Treatment with image-guided percutaneous injection of cyanoacrylic glue. Radiol Med. 2017;122(2):88–94.
- Srinivasa RN, Gemmete JJ, Hage AN, Sherk W, Chick JFB. Laser ablation facilitates closure of chronic enterocutaneous fistulae. J Vasc Interv Radiol. 2018;29(3):335–339.
- Wilhelm A, Fiebig A, Krawczak M. Five years of experience with the FiLaC™ laser for fistula-in-ano management: Long-term follow-up from a single institution. Tech Coloproctol. 2017;21(4):269–276.
