Gastrointestinal Fistula : Audit of management in a remote hospital

Background: The management of gastrointestinal fistula continues to present considerable challenge to the surgeon in general and gastrointestinal surgeon in particular. Objectives: To audit the management and report the outcome of the gastrointestinal fistula in a remote hospital. Setup: Eldamazeen Hospital is a regional hospital in the Blue Nile state, south east of Sudan. Methods: Retrospective analysis of demographic and clinical data of patients with gastrointestinal fistula admitted to the surgical department in the period from Feb 2003 through Feb 2008. Results: 10(83.3%) patients had high out-put fistula. Two fistulas were complex and 10 were simple. The small intestine was the commonest site of fistula followed by the large bowel. The commonest causes of the gastrointestinal fistula are emergency operations for stab wounds, laparotomy and caesarean section. The overall mortality rate is 2(16, 7%) patients mainly due to inter-abdominal abscesses. Conclusion: Conservative treatment with nutritional support is the corner stay for successful treatment. However, early surgical management of septic foci should be considered.

istula is an abnormal communication that permits the passage of fluid or secretions between two epithelial surfaces.Fistulae are associated with considerable morbidity and mortality.Death is related to high output gastrointestinal (GIT) fistula that remains high.Commonly GIT fistula is a complication of abdominal surgery, however it can be due to inflammatory bowel diseases e.g.Crohn's disease, tuberculosis, bowel ischaemia, trauma, malignancy or radiation.Sepsis is a leading cause of death in cases of GIT fistulas.
Favorable outcome is due to an early control of sepsis, adequate nutritional support, treatment of fluid and electrolyte imbalance and skin protection.Yet, the management of fistula continues to present considerable challenge to the surgeons in general and the gastrointestinal surgeon in particular.
The mortality rate in patients with GIT fistula have been decreased significantly during the past few decades i.e. from 40-65 % to 5.3-21.5% 1 as a result of advances in intensive care, nutritional support, antimicrobial therapy, wound care and improved operative technique.
Objectives: Objectives: To audit the management and report the outcome of the gastrointestinal fistula in a remote hospital.Setup: Eldamazeen Hospital is a regional hospital in the Blue Nile state, south east of Sudan.There are 45 beds in the surgical wards of this 280 bed-hospital.For the last six years surgery is being conducted by a single surgeon who is the first author of this paper.The hospital has ultrasound facility served by a junior hospital staff that is not trained in interventional radiology.The hospital serves about 700,000 inhabitants.The work load in the surgical department, apart of the admissions for observations and those who receives conservative treatment, is about 40 operations/ month.Out of this number there are a considerable number of cases of penetrating trauma due to stab wounds and bullet injuries.Our hospital policy is to relay on entral feeding whenever it could be instituted because Total parenteral Nutrition is not available.

Material and method
All-patients admitted to Eldmazeen Hospital with GIT fistula in the period from Feb 2003 through Feb 2008 were included in this study.Medical records were reviewed for sex, age, symptoms and signs, diagnosis, volume of out-put of fistula and magnitude of electrolytes disturbance were noted.DIT fistulae were classified according to the anatomical site into small and large bowel fistulae.Also the fistulae were classified according the volume of output into high output fistula with >500ml/24hours and low output fistula with < 500ml/24hours.Complexity of the fistula was noted whether it has a direct or branching tract with multiple external orifices and internal collections or abscesses.On arrival to the unit, patients was allowed sips of fluid, a record was kept for the volume of the fistula output, presence of urine, bile and/or feacal matter.The out-put during this time fluid was replaced with intravenous fluids containing sodium, potassium, and calcium.High calorie high protein diet was introduced as early as possible.The oralintake often requires supplementary enteral feeding through nasogastric tube.Total parenteral feeding is not available.All patients received high calorie-high protein sachets (Forceval-Alliance Pharmaceuticals Ltd. UK), blood transfusion and metronidazole and third generation cephalosporin Ceftriaxone (Samixon-Alhikma Pharmaceuticals Ltd. Jordan).Sources of sepsis were identified with the aid of ultrasonic scanning.The intra-abdominal abscesses and collections were drained surgically.Samples were taken from infected sites for culture and sensitivity.Patients were encouraged to ambulate as early and frequently as possible.All patients were followed up to six month.

Results
In the period from Feb 2004-2008 a total of 12 patients diagnosed to have GIT fistulae were admitted to the surgical department of Eldmazeen Hospital,.They were nine males and 3 females.The median age was 28 range (11-75)  After complete fistula closure we kept the patients in the hospital for one to two weeks because we were afraid of complications at home due to poor housing, poor hygiene and low socioeconomic status.In this study we encountered two deaths due to septicaemia following inter-abdominal collections which were treated by laparotomy making an overall mortality rate (16.7%).

Discussion
Gastrointestinal fistulae are one of the most difficult complications that a surgeon faces [2][3][4][5] .In spite of the advances in management the mortality remains high.Early recognition and control of sepsis, management of fluid and electrolyte imbalance, meticulous wound care, nutritional support and the delay of definitive surgery for at least four months has resulted in low mortality 6 .The site of origin of fistula also plays a crucial role in the outcome, because high output proximal fistulas are difficult to control 5, 10-12 .The risk of dehydration, electrolyte imbalance, malnutrition and sepsis increases in patients with high fistula 11- 15 .The probability and timing of spontaneous closure is therefore related to location of fistula.The proximal small bowel fistulas have longer time interval between identification of fistula and spontaneous closure than the large bowel fistulas 4, 10-14 .The policy in our unit is to start enteric feeding and encourage oral intake early in treatment of our patients.This policy is in keeping with the methods of management in the medical literature 11,17,19 .Early treatment of sepsis is very important and in this study sepsis led to deaths in two out of 12 patients.Similarly, adequate nutritional support is recognized as a key factor in reducing the mortality associated with both conservative and operative treatment of gastrointestinal fistula.On the other hand, the fistula out-put, mortality rate and spontaneous closure rate are improved with nutritional support 11, 19 .Protein-calorie malnutrition leads to an impairment of many components of immune system.Entral feeding prevents mucosal atrophy, and plays an important role in immune system in preservation of the mucosal barrier and preventing of bacterial translocation 17 .Entral feeding facilitates more rabid healing, and helps preventing sepsis, especially when prolonged non-operative management is contemlated 17 .

Conclusion
Treatment of GIT fistula should concentrate initially on correction of fluid and electrolyte imbalance, drainage of collections, treatment of sepsis and control of fistula output.Malnutrition is common, and nutritional assessment and provision are essential.Although restriction of enteral intake and bowel rest is often advocated, there is no evidence to suggest that such practice results in increased rate of fistula closure.On the contrary it may increase incidence of complications.Therefore, entral feeding is easy to formulate and should be instituted as early as possible.Operative repair should be performed when spontaneous closure does not occur and should be delayed for at least four months.

Table 2 :
years.The age distribution is shown in table 1. Predisposing factors encountered in patients with GIT fistula.