ＦＩＳＴＥＬ ＥＮＴＥＲＯＫＵＡ

ＮＥＵＳ
 Fistel Enterokutaneus

 Fistel merupakan hubungan abnormal antara suatu saluran

dengan saluran lain atau suatu saluran dengan dunia luar
melalui kulit.
Saluran penghubung  permukaannya dilapisi epitel

 Fistel enterokutaneus  hubungan abnormal antara usus

dengan kulit

 Asal : duodenum, jejunum, ileum bahkan colon

Klasifikasi
Klasifikasi penting  untuk prediksi morbiditas dan mortalitas serta
kemungkinan terjadinya “spontaneous closure”

 ANATOMIC CLASSIFICATION
(Intestinal Stomas, Principle, Techniques and management, John M.MacKeigan and Peter A Cataldo,
1993)

Complex
Simple Type 1
Short, direct tract Associated with abscess
No associated abscess Multiple organ involvement
No other organ involvement Type 2
Open into base of disrupted wound
Simple
Short, direct tract
No associated abscess
No other organ involvement
 Complex
Type 1
Associated with abscess
Multiple organ involvement
Type 2
Open into base of disrupted wound

Type 2
Type 1
Klasifikasi
Seluruh fistel  simple / complex  dibagi atas 2
kelompok berdasarkan asalnya :

 Berasal dari usus halus

 Morbiditas dan mortalitas tinggi
“Spontaneous closure” rendah
 Berasal dari colon
 Morbiditas dan mortalitas lebih rendah
“Spontaneous closure “ lebih tinggi

Fistel complex  Morbiditas dan mortalitas tinggi

“Spontaneous closure” rendah
Klasifikasi
Berdasarkan volume out put tiap hari
 Low out put < 500 cc / 24 jam
Berasal dari colon
 High out put > 500 cc / 24 jam
Berasal dari usus halus
 ETIOLOGI
I. Post operative occurance
A. Anastomotic problems
1. Technical factors
a. Tension
b. Blood supply
c. Technique
2. Intestinal factors
a. Inflammation
b. Ischemia
c. Malignancy
d. Infection
3. Systemic factors
a. Malnutrition
b. Steroids
c. Malignancy (incl.chemoth/
and radioth/ )
d. Systemic disease
(DM, renal failure)
B. Incidental injury
1. Lysis of adhesions
II. Spotaneous occurance
A. Intrinsic disease
1. Inflamation
(Inflamation Bowel Disease,
Diverticulosis)
2. Malignancy
3. Infection (TBC, actinomycosis,
amoebiasis)
4. Ischemia (embolus,
thrombosis, low flow)
5. Foreign body
6. Collagen vascular disease
7. Radiation
B. Extrinsic disease
1. Trauma
2. Other organ
 Gejala klinis

 More commonly, however, the process is more or less walled-off in the

immediate area of the leak, with formation of an abscess. This usually
underlies the operative incision, so that when a few skin sutures are
removed to ascertain why the incision is becoming red and
tender, contents of the abscess are discharged and the fistula established.

 The discharge initially may be purulent or bloody, but this is followed—

sometimes immediately, sometimes within a day or two—by drainage of
obvious small-bowel contents. If the diagnosis is in doubt, confirmation
can be obtained by oral administration of a nonabsorbable marker such as
charcoal or Congo red.
 MORBIDITAS & MORTALITAS
 Sangat tergantung dari 
 Etiologi
 Karakteristik individual penderita
 Keseimbangan cairan dan elektrolit
 Ada tidaknya sepsis
 Malnutrisi
 Efek lokal korosi cairan usus pada kulit
 Beberapa faktor yang mempengaruhi mortalitas
 Usia lanjut
 Penderita dengan malignancy
 Anemia / hipoproteinemia
Levy et al (1989)  risk score for severity factors :

 Multiple fistulas  ARDS

 Intraabdominal abscess  Upper GIT hemorrhage
 Septicaemia  Renal / hepatic failure
 Ileus  Thromboembolic
complications

Bila terdapat 3 atau lebih gejala  mortalitas rate 50%

Factors that prevent spontaneous closure
(Intestinal Stomas, Principle, Techniques and management, John M.MacKeigan and Peter A Cataldo, 1993)

1. Undrained sepsis
2. Distal obstruction
3. Underlying disease
(e.q.,Crohn’s disease,
radiation-induced bowel
injury and malignancy

4. A short fistula tract (<2 cm)

5. A foreign body, a bowell defect
> 1 cm in diameter and
epithelialization of the tract
Underlying sepsis can be a reason for non closure
Distal obstruction may inhibit closure of fistula
Underlying bowel disease may be a reason for nonclosure
Disrupted anastomosis as a reason for non closure
Short tract may explain failure of a fistula to a close spontaneously
Epithelization of the tract may prohibit spontaneous closure
PENATALAKSANAAN

1. Stabilization
2. Investigation
3. Conservative treatment
4. Decision / definitive
surgery
1. Stabilization
 Pasien fistel enterokutaneus :
 Inflamasi
 Malnutrisi
KU jelek
 Dehidrasi
 Defisit volume intravaskuler

 Tujuan tindakan pada fase ini  menstabilkan penderita :

 Menurunkan intestinal out put
 Mengurangi kehilangan cairan & elektrolit  sekaligus “makes wound
and skin care easier”

 Tindakan pertama  segera mengembalikan volume intravaskuler

dengan :
 Kristaloid, koloid dan darah  untuk memperbaiki perfusi
jaringan
 Bila sepsis  kontrol sepsis
 Abses  drainase
 Antibiotik
 An abscess associated with an enterocutaneous
fistula (complex type 1) should be drained
percutaneous whenever feasible

Attempt percutaneous drainage

 When percutaneous drainage fails (or is not
technically feasible) for complex type 1 fistulas,
a laparotomy with drainage of abscess
2. Investigation
 Investigasi dilakukan bila pasien sudah :
 Teresusitasi
 Stabil
 Sepsis sudah terkontrol

 Investigasi untuk menentukan :

1. Course & origin of the fistula tract
2. Presence of a persistence abscess
3. Condition of adjecent bowel
4. The presence of distal obstruction or discontinuity
 Fistulogram  terbaik

 CT scan :
 Terbatas
 Berguna untuk re-evaluasi
penderita yang tidak
respons terhadap terapi
konservatif

 Pemeriksaan lain :
 Sistoskopi & IVP  bila
sudah melibatkan
organ-organ urogenital
Fistulogram performed in a patient with a small-
bowel fistula. A distal obstruction is
demonstrated (arrow).
3. Conservative treatment
a. Total Parenteral Nutrition
 Wolfe ,et al (1972)  TPN menurunkan output
 “spontaneous closure”
 TPN 
 Allowed better timing for operative intervention when
required
 Improved the nutritional status of patients undergoing
reoperation
 Increased the rate of post operative recovery

 TPN  dimulai sedini mungkin  setelah :

 Koreksi defisit volume dan elektrolit
 Sepsis sudah terkontrol
 TPN :
 30 – 40 kcal/kg/hari dengan ratio kalori–nitrogen 150 : 1

 ± 0,25 – 0,35 gr Nitrogen /kgBB/hari diberikan untuk

mempertahankan balans nitrogen positif

 Lipid emulsion 
 3 hari /minggu
 Untuk meningkatkan densitas kalori dan untuk
mencegah defisiensi asam lemak esensial

 Trace elements, multivitamin dan vitamin K  diberikan tiap

minggu
b. Somatostatin
 Diberikan untuk menurunkan fistula out put

 Kerja somatostatin 
 Menurunkan sekresi gastrointestinal dengan cara
menghambat sekresi gastrin, gastric acid, biliary flow,
pancreatic out put dan intestinal secretion
 Menghambat motilitas sistem GI tract
 Meningkatkan intestinal transit time
d. Fibrin glue
 Menyuntik bahan tertentu kedalam fistula tract  obliterasi

 Bahan yang disuntik 

 Cyanoacrylate glue
 Fibrin glue  yang terbaik
 MoA fibrin glue  fibrin glue menginduksi respons
seluler sehingga terbentuk neovaskularisasi dan
proliferasi fibroblast

 Dengan endoskopik  fibrin glue disuntikan

 Hasil terapi konservatif
 Secara keseluruhan dengan tindakan konservatif  spontaneous
closure 60% - 70%  tergantung dari :
 Anatomi
 Etiologi
 Ada tidaknya sepsis
 Fistel simple  highest sucsess rate and spontaneous closure ± 90%
 Fistel kompleks tipe 2  spontaneous closure < 10%

 Fistel karena penyakit intrinsik  spontaneous closure lebih rendah

dari fistel karena post operasi

 Reber, et al (1978)  melaporkan spontaneous closure rates :

 Chrons’ disease 8%
 Cancer 26%
 Radiasi 14%
4. Decision / definitive surgery

The operation of choice for a simple

fistula is resection and primary
end-to-end anastomosis
A radiation-induced fistula is often
best managed with a bypass
procedure
TERIMA KASIH