Interventional Management of Gastrointestinal Fistulas

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Abstract

Gastrointestinal (GI) fistulas are frequently very serious complications that are associated with high morbidity and mortality. GI fistulas can cause a wide array of pathophysiological effects by allowing abnormal diversion of the GI contents, including digestive fluid, water, electrolytes, and nutrients, from either one intestine to another or from the intestine to the skin. As an alternative to surgery, recent technical advances in interventional radiology and percutaneous techniques have been shown as advantageous to lower the morbidity and mortality rate, and allow for superior accessibility to the fistulous tracts via the use of fistulography. In addition, new interventional management techniques continue to emerge. We describe the clinical and imaging features of GI fistulas and outline the interventional management of GI fistulas.

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Most cited references 11

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Classification and pathophysiology of enterocutaneous fistulas.

Sonia Fischer, Meredith Berry (1996)

Enterocutaneous and aortoenteric fistulas arise from a diverse array of pathophysiologic states. Classification by anatomic, physiologic, and etiologic systems is critical to both nonoperative and operative treatment planning.

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The relevance of gastrointestinal fistulae in clinical practice: a review.

P Pederzoli, M. Falconi (2001)

Gastrointestinal fistulae most frequently occur as complications after abdominal surgery (75-85%) although they can also occur spontaneously--for example, in patients with inflammatory bowel disease (IBD) such as diverticulitis or following radiation therapy. Abdominal trauma can also lead to fistula formation although this is rare. Postoperative gastrointestinal fistulae can occur after any abdominal procedure in which the gastrointestinal tract is manipulated. Regardless of the cause, leakage of intestinal juices initiates a cascade of events: localised infection, abscess formation and, as a result of a septic focus, fistulae formation. The nature of the underlying disease may also be important, with some studies showing that fistula formation is more frequent following surgery for cancer than for benign disease. Fistula formation can result in a number of serious or debilitating complications, ranging from disturbance of fluid and electrolyte balance to sepsis and even death. The patient will almost always suffer from severe discomfort and pain. They may also have psychological problems, including anxiety over the course of their disease, and a poor body image due to the malodorous drainage fluid. Postoperative fistula formation often results in prolonged hospitalisation, patient disability, and enormous cost. Therapy has improved over time with the introduction of parental nutrition, intensive postoperative care, and advanced surgical techniques, which has reduced mortality rates. However, the number of patients suffering from gastrointestinal fistulae has not declined substantially. This can partially be explained by the fact that with improved care, more complex surgery is being performed on patients with more advanced or complicated disease who are generally at higher risk. Therefore, gastrointestinal fistulae remain an important complication following gastrointestinal surgery.

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Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue.

Karl R Rábago, J. Marco, N Ventosa … (2002)

Postoperative fistulae occur frequently in standard surgical practice, but there is no general agreement on how to treat them. We summarize here our experience with endoscopic treatment. Postoperative digestive fistulae resistant to conservative treatment, in 15 patients, are retrospectively reviewed. Our series included two internal fistulas: (one rectovesical, and one high-output pleuroesophagic), and 13 external fistulas (one low-output gastrocutaneous, two low-output esophagocutaneous, seven low-output enterocutaneous, and three high-output enterocutaneous). After failure of conservative treatment, the fistulas were endoscopically located and 2 - 4 ml of reconstituted fibrin glue, Tissucol 2.0 at 37 degrees C, was injected through a catheter. The mean age of the patients was 61.2 years (38 - 86), and 60 % were men. Of the fistulas, 26.6 % were of the high-output type. The mean healing time was 16 days (5 - 40), and a mean of 2.5 sessions per patient were required (1 - 5). Complete sealing of fistulas was achieved in 86.6 % of cases; (87.5 % of the low-output and internal fistulas, and 55 % of the high-output fistulas). After follow-up ranging between 2 months and more than 3 years, only one of the sealed fistulas reopened. No complications were encountered. Overall mortality was 13.3 % (two out of 15), but in only one patient was this related to clinical deterioration because of the persistence of the fistula. We think that conservative treatment should not be prolonged beyond 14 days and that endoscopic treatment should be performed at that stage. Endoscopic sealing treatment achieves a very high success rate, without complications and at a lower cost. It could probably reduce the hospital stay, and avoid some unnecessary surgical interventions. Appropriate multicenter randomized trials are needed to confirm these results.

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Author and article information

Journal

Journal ID (nlm-ta): Korean J Radiol

Journal ID (publisher-id): KJR

Title: Korean Journal of Radiology

Publisher: The Korean Society of Radiology

ISSN (Print): 1229-6929

ISSN (Electronic): 2005-8330

Publication date (Print): Nov-Dec 2008

Publication date (Electronic): 23 December 2008

Volume: 9

Issue: 6

Pages: 541-549

Affiliations

[1 ]Department of Diagnostic Radiology, Kyung Hee University Medical Center, Seoul 130-702, Korea.

[2 ]Department of Surgery, Kyung Hee University Medical Center, Seoul 130-702, Korea.

Author notes

Address reprint requests to: Joo Hyeong Oh, MD, Department of Diagnostic Radiology, Kyung Hee University Medical Center, Hoeki-dong 1, Dongdaemun-gu, Seoul 130-702, Korea. Tel. (822) 958-8622, Fax. (822) 968-0787, ohjh6108@ 123456hanmail.net

Article

DOI: 10.3348/kjr.2008.9.6.541

PMC ID: 2627247

PubMed ID: 19039271

SO-VID: f1c82dd1-cad8-4156-b0c2-6ee750480b3c

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Interventional Management of Gastrointestinal Fistulas

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Most cited references 11

Classification and pathophysiology of enterocutaneous fistulas.

The relevance of gastrointestinal fistulae in clinical practice: a review.

Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue.

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