Fistulas

A fistula is an abnormal opening between two epithelial surfaces,^1-3 usually involving a communication tract from one body cavity or hollow organ to another body cavity or hollow organ. For example, a gastrointestinal fistula joints the lumen of the gastrointestinal tract to another organ, while an enterocutaneous fistula involves a communication between the lumen of the gastrointestinal tract and the skin.² Fistulas may be therapeutic (as in a colostomy or tracheostomy, for example) or pathologic, as in the enterocutaneous example given above.

The incidence of fistulas has increased over recent years, partly because of the increase in open abdominal procedures performed in the treatment of sepsis and trauma, and partly because of the growing popularity of mesh in the repair of abdominal wounds.

The ultimate goal of the medical management of a fistula is to achieve spontaneous closure. This is successful in up to approximately 70% of all fistulas following control of sepsis and provision of adequate nutritional support.² Nutritional management, in particular, is one of the cornerstones of fistula management.³  Most fistula patients are malnourished to some degree, and the problem only tends to increase with the passage of time as the fistula increases. Of those fistulas that ultimately close, around 90% do so within a period of 5 weeks.¹

Although originally contraindicated in fistula, negative pressure wound therapy (NPWT) has more recently been shown to offer some benefit in achieving closure in patients with a low-output fistula. Moreover, NPWT may be effective when used to occlude the fistula. Management of high-output fistulas may be achieved with administration of subcutaneous octreotide or lanreotide, although evidence in support of this approach is mixed.³

The presence of a fistula can be a frustrating and disappointing experience for patients, as it represents a major complication.²  However, in many cases, a fistula can successfully be managed through a combination of effective assessment, good pathological understanding, excellent technical skills, careful follow-up, and, above all, single-minded persistence.²

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References

1. Baranoski S and Ayello EA. Wound Care Essentials 2^nd Edition. Lippincott Williams & Wilkins, Philadelphia, US. 2008.
2. Bryant RA  and Nix DP. Acute and Chronic Wounds. Current Management Concepts. 3^rd Edition. Mosby Elsevier. St Louis, Missouri, US. 2007.
3. Sussman C and Bates-Jensen B. Wound Care. A collaborative practice manual for health professionals. 3^rd Edition. Lippincott Williams & Wilkins, Philadelphia, US. 2007.