Palliative Care for a Malignant Enterocutaneous Fistula

© 2023 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Today's Wound Clinic or HMP Global, their employees, and affiliates.

An enterocutaneous fistula is an abnormal communication between an organ such as the small bowel and the skin. This causes gastrointestinal (GI) contents to leak out from the fistula opening onto the surrounding skin resulting in significant skin damage and associated pain. Surgery often precedes fistula formation. There are multiple causes of an enterocutaneous fistula, some of which are inflammatory bowel disease, cancer, intraperitoneal abscess and infection, intestinal ischemia, multiple surgeries, malnutrition, steroids, and immunosuppressant medications. 

The initial treatment is to control the fistula drainage, protect the periwound, identify the etiology, maintain patient hydration and nutrition, correct any electrolyte abnormalities, locate the bowel segment involved, and rule out distal bowel obstruction. The amount and type of drainage should be recorded along with the patient's weight and overall nutritional status.

Protection of the periwound is important to prevent further skin breakdown and control local pain. This is achieved by applying a proper fitting fistula appliance and pouch. Often, the fistulous opening is small and obtaining an exact appliance seal and fit may be difficult. One method to facilitate this is to place a sheet of clear plastic wrap over the fistula and surrounding skin and then mark the opening. The plastic wrap is then reversed and transferred to the appliance using it as a guide to locate and punch out the opening. A crusting technique alternating Skin-Prep (Smith & Nephew) and ostomy powder applied alternately and repeatedly several times to the damaged periwound skin will build up a protective layer.  

Depending upon the etiology, duration, and location of the involved bowel the fistula may spontaneously close; however, this is often not the case. A fistula that has been present for several months will epithelialize at the skin edge and will not close. Abdominal re-exploration with takedown of the fistula and limited bowel resection is the definitive treatment but has the downside of a major operation and recuperation. In a deconditioned and elderly patient, the risks may outweigh the benefits.

Patient Presentation and Treatment

The case presented concerns a 74-year-old female who was diagnosed with a malignant appendiceal tumor, a primary mucous cyst adenocarcinoma that had ruptured, seeding the peritoneal cavity with nests of jellylike mucus secreting cancer cells (Figure 1). As the disease progresses, a continuous accumulation of mucinous ascites fills the peritoneal cavity along with tumor implantation. This gives rise to the clinical entity known as pseudomyxoma peritonei. Small bowel ileus and partial obstruction often occur along with a general overall clinical decline.

The treatment of this tumor is difficult. Major surgical debulking of all visible peritoneal tumors (cytoreduction surgery) coupled with hyperthermic intraperitoneal therapy has been utilized. The treatment is not always successful and tumor recurrence is common often necessitating reoperation for debulking. The 3- to 5-year survival rate is approximately 70%.¹ 

Over a period of 6 years, the patient has had multiple abdominal exploratory procedures for the debulking of widespread cancerous implants. During the last procedure lysis of adhesions was required for a partial small bowel obstruction. Postoperatively the patient developed an enterocutaneous fistula involving the mid-jejunum with the fistula opening located in the central portion of the midline abdominal incision. She was not a candidate for any further operations. Caring for the fistula became a significant problem for the patient. The midline abdominal incision was significantly retracted making a functional ostomy appliance seal impractical (Figure 2). This produced periwound skin damage and localized pain and discomfort. Normal daily activity became extremely difficult as there was a sporadic, uncontrollable output from the fistula which could not be contained. The patient had been started on total parenteral nutrition—her oral intake was minimal and there was only minimal improvement of the partial small bowel obstruction caused by tumor implants which compromise peristalsis and bowel motility.

A Closer Look at the Treatment Solution

Our approach was to utilize a pediatric Foley catheter 8 French and insert it into the fistulous tract. The 3-cc balloon was inflated with 2 cc of saline, pulled back to abut the peritoneal cavity. The catheter was secured to the abdominal wall skin with tape. This produced a tamponade effect and the fistula drainage ceased. A crusting technique was used on the denuded periwound skin, which eventually returned to normal. The catheter was able to vent any bowel gas and GI liquid, although this was minimal.

This outpatient treatment allowed the patient to resume semi-normal daily activities avoiding concerns regarding fistula care. She has been followed for 6 months and in general is functioning and pleased with her outcome. She is able to self-catheterize the fistula with the Foley and has backup catheters in case the balloon breaks. This simple procedure has improved the patient's quality of life and has helped her avoid complicated interventions and hospitalization (Figure 3). 

James V. Stillerman, MD, CWSP, FACCWS, is the Medical Director of Samaritan Medical Center for Advanced Wound Care in Watertown, NY. He is a board-certified general surgeon and is board certified in advanced wound care by the American Board of Wound Management and has 35 years of experience including vascular surgery. Dr. Stillerman is a board member for Hospice in Jefferson County, New York. Most recently, he received the SAWC Grand Rounds award for his poster presentation the treatment of enterocutaneuos fistulas. Dr. Stillerman has initiated a wound care lecture series for teaching the medial students and medical residents. He also provides lectures to many of the regional wound care centers. He is currently is developing a wound care treatment template to assist the emergency department, local nursing homes and hospital with wound care and prevention. He also consults via telemedicine as an adjunctive evaluation tool.

Click here for a PDF of this article.

Reference
 
1. Smeenk RM, Verwaal VJ, Antonini N, Zoetmulder FAN. Survival analysis of pseudomyxoma peritonei patients treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg. 2007; 245(1):104-9.