Management of Enterocutaneous Fistula in ESRD Patients After Exploratory Laparotomy
The management of enterocutaneous fistula in ESRD patients requires a systematic approach focusing first on controlling sepsis, optimizing nutrition, and managing fluid/electrolyte balance before considering definitive surgical intervention. 1
Initial Assessment and Stabilization
Rule out intra-abdominal sepsis immediately:
- Obtain imaging (CT with non-nephrotoxic contrast or ultrasound) to identify collections
- Drain any abscesses radiologically
- Start broad-spectrum antibiotics for infection control
- Delay anti-TNF therapy until abscesses are treated 1
Fluid and electrolyte management:
- Correct dehydration with IV fluids while keeping patient NPO for 24-48 hours
- For high-output fistulas (>500 ml/day), reduce oral hypotonic fluids to 500 ml/day
- Provide glucose/saline solution with sodium concentration ≥90 mmol/l 1
- Monitor electrolytes closely due to ESRD (particularly potassium, phosphate, calcium)
Nutritional Support
- For proximal or high-output fistulas: Implement partial or exclusive parenteral nutrition 1
- For low ileal/colonic fistulas with low output: Consider enteral nutrition if tolerated 1
- Nutritional requirements:
- Higher protein intake (1.2-1.5 g/kg/day) accounting for dialysis losses
- Monitor for refeeding syndrome in malnourished patients
- Optimize nutritional status before surgical correction 1
Fistula Output Control
Pharmacological management:
- Loperamide 2-8 mg before food to reduce motility
- Add codeine phosphate if additional output reduction needed
- For "secretory" output (>3 L/24 hours), use proton pump inhibitors
- Consider octreotide if unable to absorb oral drugs 1
Practical strategies:
- Separate solids and liquids (no drinks 30 minutes before/after food)
- Add sodium chloride to liquid feeds to achieve sodium concentration near 100 mmol/l 1
Wound and Fistula Management
For visible fistulae:
- Create a "floating stoma" by isolating with an ostomy bag
- Consider negative pressure wound therapy (NPWT) to manage and divert output 1
- Protect surrounding skin from fistula output with barrier products
For entero-atmospheric fistulas:
- NPWT is the best available option for managing these complex wounds
- Consider converting to an enterocutaneous fistula via separate incision 1
Vascular Access Considerations
- Prioritize arteriovenous access (AVF or AVG) over tunneled central venous catheters for dialysis access in these patients 2
- If using a catheter, employ "closed connector" devices to reduce infection risk 2
- For patients with existing buttonhole cannulation, use mupirocin antibacterial cream to reduce infection risk 2
Timing of Definitive Management
Indications for surgery:
- Fistulas with high-volume output
- Multiple fistula tracts
- Associated strictures
- Failed medical management 1
Timing of surgery:
- Delay definitive surgery for at least 3-6 months after initial fistula development 3
- Ensure complete resolution of intra-abdominal sepsis
- Optimize nutritional status and correct anemia
- Coordinate with nephrology team for optimal dialysis schedule around surgery
Surgical Approach
Surgical options:
Perioperative considerations for ESRD patients:
- Schedule dialysis 12-24 hours before surgery
- Monitor fluid status closely
- Adjust medication dosages for renal failure
- Consider extended antibiotic prophylaxis
Outcomes and Prognosis
Success rates:
ESRD-specific considerations:
- Higher risk of poor wound healing and infection
- Increased mortality risk compared to non-ESRD patients
- Longer hospital stays should be anticipated
Follow-up Care
- Regular monitoring of fistula output
- Ongoing nutritional assessment
- Coordination between nephrology and surgical teams
- Vigilance for recurrence (occurs in approximately 19% of surgically treated patients) 4