Principles of Fistula and Stoma Management
Dorothy B. Doughty
A significant number of patients with solid tumors involving the abdominal organs have surgically created stomas or spontaneously occurring fistulas. Palliative care for these patients must provide effective containment of the effluent and odor, protection of the adjacent skin, and maintenance of fecal and urinary elimination. This chapter addresses the specific needs of patients with stomas or fistulas involving the intestinal or urinary tract.
Fistula Management
Fistulas are abnormal openings between two internal organs or between an internal organ and the skin. Most fistulas arise from the gastrointestinal (GI) tract and are caused by delayed healing and anastomotic breakdown after a surgical procedure; fistulas may also occur as a result of direct tumor invasion or as a complication of radiation therapy (1, 2, 3, 4). Fistula is always a devastating development, and despite significant progress in the management of complications such as sepsis and malnutrition, fistulas continue to be associated with significant morbidity and mortality. For patients with cancer, fistula development may be even more devastating; the addition of a fistula may overwhelm the patient’s defenses, both physically and psychologically. Statistics indicate higher mortality rates among this patient population—for example, a retrospective review of patients treated at the National Institutes of Health Clinical Center from 1980 through 1994 revealed a 42% fistula-related mortality rate among patients with cancer who had enterocutaneous fistulas (2). In addition to the issues related to the fistula itself, the development of a fistula may delay or prevent treatment for the underlying malignancy, and malignant involvement of the fistulous tract may prevent closure, even with surgical intervention (2, 4). Effective fistula management is therefore a critical component of effective palliative care.
Classification Systems
Fistulas are commonly classified according to the organs involved, point of drainage, or volume of output (1, 4). Fistulas are named according to the organs involved and the pathway followed by the effluent (Table 24.1). Fistulas may also be classified as internal or external. Internal fistulas involve an abnormal communication between two internal organs (e.g., enteroenteric or enterocolic fistulas). These fistulas may be silent in that they produce no obvious pathology, but they can greatly affect the patient’s nutritional status by bypassing absorptive segments of the small bowel (4). External fistulas are those communicating with the skin or with organs that drain onto the skin, such as the vagina. These fistulas produce obvious symptoms and present major challenges in management (4). The third mechanism for classifying fistulas is by volume of output. Fistulas producing more than 500 mL of output per day have been labeled high-output fistulas, and those producing 200–500 mL per day are generally classified as low– or moderate-output fistulas (1, 4, 5). As might be expected, high-output fistulas are associated with greater risk of sepsis, malnutrition, and death than fistulas with low or moderate output (2).
Phases of Fistula Management
Effective fistula management can be divided into several distinct phases: stabilization, investigation, conservative therapy, and definitive management (1, 4).
Stabilization
Initial goals in fistula management include normalization of fluid and electrolyte balance, establishment of nutritional support, and elimination of sepsis (1, 4, 5, 6). Specific fluid and electrolyte needs depend on the type and volume of fistula output; for example, small bowel fistulas usually produce high volumes of effluent containing potassium, sodium, magnesium, phosphate, and zinc (1, 4). The patient with a high-output fistula requires close monitoring of fluid—electrolyte balance, with replacement titrated in response to type and volume of
output and on the basis of laboratory indices. Fluid and electrolyte anomalies remain a significant problem in the management of these patients, and effective management can significantly reduce morbidity (1, 4, 5, 7).
output and on the basis of laboratory indices. Fluid and electrolyte anomalies remain a significant problem in the management of these patients, and effective management can significantly reduce morbidity (1, 4, 5, 7).
Table 24.1 Terminology for Common Fistulas | ||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Malnutrition is another major problem associated with GI fistulas, especially high-output fistulas; therefore, prompt initiation of nutritional support is an essential element of care. (5) Patients with small bowel fistulas usually require total parenteral nutrition (TPN), though low-volume enteral intake is frequently advocated to prevent atrophy of the villi; in contrast, patients with colonic fistulas can frequently be managed with oral or enteral nutrition (4, 6). Any nutritional support program must include ongoing monitoring of the patient’s weight and prealbumin; in addition, the patient receiving enteral or oral nutrition must be monitored for any significant increase in fistula output. While aggressive nutritional support is generally contraindicated in the setting of palliative care, failure to provide such support can produce a catabolic state that causes rapid deterioration in the patient’s overall condition. Therefore, decisions regarding nutritional support for the patient with cancer who has a high-output fistula must be made within the context of the overall treatment plan and management goals (1, 4).
Fistula development is often associated with intra-abdominal abscess formation, and sepsis is the most common complication of enterocutaneous fistulas. Therefore, initial management includes prompt management of any intra-abdominal infectious process (i.e., drainage of all abscesses and initiation of appropriate antibiotic therapy) (1, 4).
Investigation
The second goal in fistula management is to identify the origin of the fistulous tract and any anatomic conditions that would prevent spontaneous closure of the fistula, such as distal obstruction, development of an epithelial-lined tract between the skin and the fistula opening (i.e., pseudostoma formation), complete disruption of bowel continuity, persistent abscess, or tumor involvement of the fistulous tract (1, 4, 6). Studies commonly involved in the investigative phase of fistula management include fistulograms and radiographic studies of the small bowel (to identify the origin of the fistula) and computed tomography scans (to determine the presence of tumor involvement or persistent abscess) (4, 6).
Conservative Management
If there are no anatomic factors that would prevent spontaneous closure of the fistula tract, initial management usually involves medical measures to promote closure as opposed to surgical intervention. This approach is based on studies indicating that a significant proportion of fistulas close spontaneously (if there is no inhibiting pathology) and on the fact that surgical closure is frequently ineffective until the underlying factors contributing to fistula development have been corrected (1, 4). Even among patients with cancer, spontaneous closure of fistula tracts is possible: Chamberlain reported a spontaneous closure rate of 33% for enterocutaneous fistulas (2).
Conservative management includes continued attention to fluid and electrolyte balance, nutritional repletion, and control of infection. In addition, measures are instituted to reduce the volume of effluent and collapse the fistula tract. The goal is to ensure sufficient intake of nutrients to support the healing process while minimizing the volume of drainage. Specific measures to reduce fistula output and collapse the fistula tract include limitation (or elimination) of oral intake, administration of octreotide acetate, and implementation of negative pressure wound therapy (NPWT) (1, 4, 6, 8).
NPO status
Elimination or significant restriction of oral intake can markedly reduce fistula output; however, such restrictions can have a significant and negative impact on quality of life and should therefore be implemented only if fistula closure represents a primary treatment objective (7). If oral intake is significantly restricted, it may be beneficial to administer H2 receptor antagonists to prevent stress ulceration and reduce gastric secretions (4).
Octreotide acetate
Octreotide acetate is a synthetic somatostatin analog that reduces the volume of intestinal secretions and prolongs GI transit time. The data on octreotide acetate’s impact on fistula volume and fistula closure are inconclusive; however, in general, octreotide acetate has been shown to reduce the volume of fistula output and in some studies has appeared to significantly reduce the time frame for spontaneous closure. To date, there is no evidence that octreotide acetate actually increases the number or percentage of fistulas closing spontaneously, so the clinician must weigh the potential benefit against the expense of the therapy (3, 4, 9, 10).
Negative pressure wound therapy (NPWT)
NPWT was initially developed to manage exudate and promote granulation within chronic wounds; it has recently been approved for use with enteric fistulas and represents a major advance in conservative fistula management. The system with the strongest data related to closure of enteric fistulas is the VAC (vacuum-assisted closure) system of KCI (Kinetic Concepts, Inc., San Antonio, Texas). This therapy involves placement of a contact layer dressing and a porous foam dressing into the wound bed (but not the fistula tract), followed by application of a transparent adhesive drape to seal the entire wound; a small opening is then created in the drape and a suction device (TRAC Pad) is placed over the opening and connected to a portable negative pressure unit. (See Table 24.2 for the recommended procedure.) Therapy is begun at 150 mm Hg continuous negative pressure, and is titrated to the point required to collapse the fistula tract (as evidenced by cessation of fistula drainage), but not beyond -200 mm Hg. Therapy should be continued for at least 3 weeks following the collapse of the fistula tract to assure adequate healing. The therapy is expensive (>100.00 per day); therefore, failure to collapse the fistula
tract despite maximum negative pressure for a period of 4 days is generally considered a contraindication to continuation.
tract despite maximum negative pressure for a period of 4 days is generally considered a contraindication to continuation.
Table 24.2 Application of Negative Pressure Wound Therapy (Vacuum-Assisted Closure) to Promote Fistula Closure | |
|---|---|
|
Definitive Therapy
When it is recognized that spontaneous closure is unlikely or impossible, a decision must be made regarding further management. The two options are palliative management (with no expectation of closure) and surgical intervention. The increasing availability of laparoscopic procedures makes surgical intervention a feasible option even for patients receiving palliative care (11, 12). The optimal surgical approach involves resection of the fistulous tract with end-to-end anastomosis (4, 5, 6). If the involved segment of bowel cannot be isolated because of dense adhesions, it may be necessary to perform a bypass procedure, or, occasionally, to divert the fecal stream proximal to the fistula (1, 4). If the fistulous tract is embedded in tumor and a radical resection is not feasible, the fistula tract may be defunctionalized by dividing the involved bowel segment proximal and distal to the fistula with a stapling device and performing an end-to-end anastomosis between the proximal and distal limbs of the normal bowel (6). Fistula drainage is therefore reduced to the small volume of mucous and intestinal secretions produced by the isolated segment of bowel containing the fistula (13). There are also reports of a successful “extra-abdominal” approach to fistula closure in a small series of patients with dense adhesions or irradiated tissue (14). Finally, the infusion of fibrin glue into low-output fistula tracts to significantly reduce the time to closure has been reported; however, this approach is not appropriate in high-output fistulas (15).
Palliative Fistula Management
In the patient with advanced malignancy, neither spontaneous closure nor surgical correction of the fistula may be achievable or practical. In this case, therapy is directed toward maintenance of patient comfort through containment of drainage and odor, protection of the perifistular skin, continued attention to fluid—electrolyte balance, nutritional support, and control of sepsis (1, 5, 6, 7).
A major component of effective fistula management is containment of the effluent and odor and protection of the surrounding skin; these aspects of care have a profound impact on the patient’s quality of life (7). Today, fistulas are treated as spontaneously occurring stomas, and ostomy pouches and products are used to protect the skin while containing the drainage and odor (5, 6). In addition to promoting the patient’s psychological and physical comfort, an effective pouching system permits quantification of output, which is critical for accurate replacement of fluid losses (1, 4).
Guidelines for Pouching
Many products and techniques for containing drainage and odor and protecting the perifistular skin are now available. Selection is determined by the type and volume of drainage, the contours of the surrounding tissue, and the integrity of the perifistular skin (1). Additional factors to be considered include the cost and availability of products, the technical difficulty of the procedures compared to the caregiver’s cognitive abilities and technical skills, and the availability of professional assistance, such as wound, ostomy, continence also known as enterostomal therapy, or ET nurses and home care nurses (6).
Products for skin protection
The volume and characteristics of the effluent dictate the level of skin protection required. Drainage that contains proteolytic enzymes or is highly alkaline or acidic can produce rapid and severe skin breakdown (especially if the fistula is also high output). Therefore, gastric, pancreatic, and small bowel fistulas require aggressive protection of all perifistular skin and effective containment of the drainage, if at all possible (1). In contrast, drainage from the colon is usually low volume and nonenzymatic; severe skin breakdown is unlikely, and containment is needed more for odor control than for skin protection. Products available for skin protection include plasticizing skin sealants, pectin-based pastes and wafers, and moisture barrier ointments. The indications and guidelines for use of each of these products are outlined in Table 24.3.
Pouching principles
As noted, effective containment of drainage and odor is best accomplished through successful application of an adherent pouching system, similar to the systems used to contain ostomy output. Successful pouch application requires adherence to the following principles: the pouching system selected should be compatible with the type of drainage; the pouching system must be applied to a dry skin surface; and the surface of the pouching system must “match” the perifistular skin contours (1).
In selecting a system that is compatible with the type of drainage, the clinician should assess the effluent for fluidity and odor. Output that is very fluid and relatively nonodorous can be effectively managed with pouches designed for urinary stomas. These systems are odor-resistant (but not completely odor-proof) and equipped with narrow drainage spouts that cannot accommodate thick effluents. Output that is thick or malodorous should be managed with either fecal pouches or wound drainage systems. These systems are odor-proof and are equipped with tapered openings that permit thick or solid drainage.
The clinician must assure a dry pouching surface to obtain a good seal between the pouch and the skin. Denuded and weeping perifistular skin is common because of the damaging nature of the drainage, and is best treated with a procedure known as crusting. A pectin-based powder [Stomahesive Powder by ConvaTec (Princeton, NJ) or Premium Powder by Hollister (Libertyville, IL)] is sprinkled onto the wet skin to absorb the drainage and create a “gummy” surface; the powder is then “sealed” to the skin by blotting over the powder with a moist gloved finger or an alcohol-free skin sealant [e.g., No-Sting Skin-Prep by Smith and Nephew (Largo, FL), or Cavilon No Sting by 3-M (Minneapolis, MN)] (1).
The contours of the pouching system are matched to the patient’s skin surface by carefully evaluating the perifistular skin with the patient in both the supine and sitting positions, and then selecting a pouch that is compatible with those contours. If the perifistular contours are fairly smooth, almost any system can be used. However, the patient with deep creases in the perifistular skin usually requires an all-flexible pouching system that will “bend and mold.” If the fistula is in a “valley” and the perifistular contours are concave, a convex pouching system is advantageous. It is frequently necessary to use “filler” products (pectin paste, barrier strips, or moldable barrier rings) to fill small defects and create a smoother pouching surface (1).
Pouching procedures
Most fistulas can be managed with a standard pouching procedure using either an ostomy pouch or a wound drainage pouch. The standard pouching procedure is outlined in Table 24.4.
In patients with very irregular abdominal contours or a large associated wound, the standard pouching procedure is frequently ineffective. One pouching procedure that is frequently effective when standard pouching fails is the trough procedure; however, it is important to note that this technique is appropriate only for fistulas located in open wounds. The basic concept is as follows:
The perifistular skin is protected with skin barrier paste and overlapping strips of a solid skin barrier (such as Stomahesive).
A large opening is created in a strip of transparent adhesive dressing (such as OpSite by Smith and Nephew, Largo, Florida), a drainable pouch is placed over this opening, and the strip of adhesive dressing and attached pouch are then applied to the inferior aspect of the wound.
Additional overlapping strips of a transparent adhesive dressing are used to cover the entire wound and the skin around the wound (1).
The wound therefore becomes a trough, with drainage funneled to the bottom of the wound, where it is collected. Suction can be added to this system for very high-output fistulas. The trough procedure is outlined in Table 24.5 and illustrated in Figure 24.1.
Table 24.3 Ostomy Products and Manufacturers | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
An alternative to the trough procedure for bedbound patients is the closed suction method of management. With this approach, the perifistular skin is again protected with overlapping strips of a skin barrier and skin barrier paste; the wound bed is then lined with a layer of damp fluffed gauze, suction catheters are placed over the gauze inferior to the fistulous opening(s), and damp fluffed gauze dressings are used to cover the suction catheters. Transparent adhesive dressings are then used to completely cover the wound and adjacent skin, and the suction catheters are connected to wall suction.
Table 24.4 Standard Pouching Procedure | |||||||
|---|---|---|---|---|---|---|---|
|
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
