Enterocutaneous Fistulas in Uganda

You could see nearly every bone in his body; I’m not sure I have ever seen someone so emaciated. Over the previous few weeks, this once healthy and strong young man had transformed into the severely malnourished and frail figure I saw before me. A brief look at his abdomen would reveal the cause of such deterioration: a complex, high-output enterocutaneous fistula (ECF), which had formed after an emergent laparotomy for sigmoid volvulus and subsequent laparotomy for obstruction. These surgeries had been performed fairly recently at an outside, lower-level hospital, and he had been on our service for about a week before I arrived.

Prior to my time at Mulago National Referral Hospital in Kampala, Uganda (Figure 1), I was not familiar with the burden of ECFs in low- and middle-income countries (LMICs). I certainly had heard of obstetric fistulas and their associated morbidity, and was aware of obstetric fistula repair as an essential surgery for hospitals in LMICs. But again, ECFs were not really on my radar. I was surprised, then, when a second young, severely malnourished man with a complex, high-output ECF was admitted to our service a week later. His surgical history was similar; he had undergone an emergent laparotomy for gastric perforation, with a subsequent laparotomy for a leak at the initial repair site.

A quick literature search revealed there are a multitude of publications discussing ECFs and their management in high-income countries.^{1, 2} Surprisingly, only a few publications discuss ECFs in LMICs, with the majority published in regional journals.^3-7 ECFs are commonly associated with recent abdominal operations, particularly emergency cases.^{1, 3-5} Postoperative fistulas form from unrecognized bowel injuries, anastomotic leaks, or post-operative wound infections. Of the seven publications reviewed here, the mortality rate for patients with ECFs ranges from 7.0% to 23.5%, with mortality most frequently caused by septicemia, electrolyte abnormalities, or malnutrition.^1-7

Effective ECF management focuses on preventing the leading causes of mortality while waiting for fistula closure (either spontaneous or surgical). The principles of non-operative management include aggressive resuscitation, skin protection, nutritional support, and sepsis surveillance.^{2, 4} Non-operative management should be attempted for at least six weeks before considering surgical closure; though it is common in high-income countries to delay at least six months.^{1, 2, 4-6} If spontaneous closure is not achieved, surgical closure is considered, provided the patient is nutritionally optimized.^{1, 4, 6} The closure following non-operative management ranges from 14.0% to 69.8%, and increases to 45.0% to 87.0% when surgical management is undertaken.^1-7

Both of the young men were severely malnourished, having at least one proximal fistula that appeared to drain a significant amount of their oral intake. The team discussed a few nutritional options: oral feeds with high-protein porridge, distal cannulation of the fistula to create a feeding jejunostomy tube, and even the possibility of total parenteral nutrition (TPN). We strongly advocated for one of the two to receive TPN, which is a key component of nutritional support for ECF patients in high-income countries.^{1, 2} Unfortunately, peripherally inserted central catheters are not available in Uganda; and because of infection risk, Mulago requires all patients with central lines to be in the intensive care unit, which was not an option. In the end, these patients’ nutritional support consisted of an oral diet of high-protein porridge (porridge, milk, two raw eggs, powdered silver fish, margarine, and peanuts), supplemented with intravenous fluids.

Sadly, both of these patients passed away within the past week. Truthfully, I can’t say I am surprised; their conditions at hospital admission were abysmal, and they never responded to the oral nutrition regimen. A few days ago I switched to another surgical ward, where we are currently treating two more patients with fistulas. One is a high-output ECF that developed after an exploratory laparotomy with loop ileostomy for intestinal obstruction secondary to colon cancer (Figure 2). The second patient, admitted yesterday, has a high-output enteroatmospheric fistula, which developed after laparotomy for appendicitis and subsequent laparotomy for presumed leak, at which point her abdomen was left open (Figure 3).

The experience of working with these patients has left me wondering how this condition fits into the context of expanding access to surgical care in LMICs. The prevalence of ECFs in LMICs is largely unknown due to lack of data. However, given the young age of the patients encountered in my limited experience, it seems improved prevention and treatment protocols could have a large impact. Three of the four patients I saw were transfers from lower-level hospitals, making me question what systemic factors may have contributed to the development of these ECFs, such as limitations in early access to care, funding, infrastructure, or trained staff.⁸ There has been a strong focus on increasing access to surgical care at the district hospital level, but is this happening at the expense of quality surgical care? Am I seeing one of the consequences of having general medical doctors perform laparotomies? And with regards to the treatment of ECFs, what is the best approach to nutritional support in places like Uganda, where access to TPN is largely limited to private hospitals?

It seems the burden of ECFs in LMICs like Uganda is much greater than I previously realized, and literature is lacking on the topic.  Although treatment protocols have been developed that have reduced mortality in high-income countries, these advances are not readily available in countries such as Uganda. For a condition with such high morbidity and mortality, there is a need not only for increased data on the prevalence and etiology of ECFs in LMICs, but also on the most effective approach to manage them in these low-resource settings.

References:

1. Hollington P, Mawdsley J, Lim W, Gabe SM, Forbes A, Windsor AJ. An 11-year experience of enterocutaneous fistula. Br J Surg. 2004;91(12):1646-51.
2. Draus JM, Jr., Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula: are treatments improving? Surgery. 2006;140(4):570-6; discussion 6-8.
3. Ohanaka CE, Momoh IM, Osime U. Management of enterocutaneous fistulae in Benin City, Nigeria. Tropical Doctor. 2001;31:104-6.
4. Haffejee AA. Surgical management of high output enterocutaneous fistulae: a 24-year experience. Current Opinion in Clinical Nutrition and Metabolic Care. 2004;7:309-16.
5. Martinez JL, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo F. Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World J Surg. 2008;32(3):436-43; discussion 44.
6. Njeze G, Achebe U. Enterocutaneous fistula: A review of 82 cases. Nigerian Journal of Clinical Practice. 2013;16.2(174).
7. Badrasawi MMH, Shahar S, Sagap I. Nutritional management of enterocutaneous fistula: a retrospective study at a Malaysian university medical center. Journal of Multidisciplinary Healthcare. 2014;7:365-70.
8. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015;386(9993):569-624.