Implementing a Pro-forma for Multidisciplinary Management of an Enterocutaneous Fistula: A Case Study

Optimal management of patients with an entercocutaneous fistula (ECF) requires utilization of the sepsis, nutrition, anatomy, and surgical procedure (SNAP) protocol. The protocol includes early detection and treatment of sepsis, optimizing patient nutrition through oral and parenteral routes, identifying the fistula anatomy, optimal fistula management, and proceeding to corrective surgery when appropriate. The protocol requires multidisciplinary team (MDT) coordination among surgeons, nurses, dietitians, stoma nurses, and physiotherapists. 

This case study describes a 70-year-old man who developed an ECF subsequent to a laparotomy for a small bowel obstruction. Following a period of ileus, 16 days post laparotomy the patient developed a high-output (2,000 mL per day) fistula. The patient also became pyrexial with raised inflammatory markers, requiring antibiotic treatment. Following development of his ECF, he was managed using the SNAP protocol for the duration of his admission; however, in implementing this protocol with this patient, clinicians noted fluid charts were inadequate to allow effective management of the variables. Thus, a new pro-forma was created that encompassed fluid balance, nutritional status, and pertinent blood test results, as well as perifistular skin condition, medication, and documentation of management plans from the MDT team. The pro-forma was recorded daily in the patient notes. Following implementation of the pro-forma and the SNAP protocol, the patient recovered well clinically over a period of 4 weeks with a decrease in his fistula output to 300–500 mL per day, and he was discharged with plans for further corrective surgery to resect the fistula and for bowel re-anastomoses. Although fluid charts are readily available, they do not include all pertinent variables for optimal management of patients with an ECF. Further research is needed to validate the pro-forma and evaluate its effect on patient outcomes. 

Enterocutaneous fistulas (ECFs) secondary to abdominal surgery can result in mortality and morbidity.¹ Patients with an ECF and a high-output stoma are at risk for developing sepsis, dehydration, renal failure, and malnutrition. Advances in the management of ECF have been made by ensuring diligent attention to preventing sepsis; monitoring patient nutritional, electrolyte, and fluid balance through a multidisciplinary approach; and performing additional definitive surgery to repair the fistula if appropriate — an evidence-based, validated approach referred to as the SNAP protocol.^1-3 The SNAP protocol aims to identify sepsis and implement early and aggressive management, ensure adequate nutritional control of the patient through the use of parenteral or oral nutritional supplements, identify the anatomy of the fistula, and proceed to definitive surgical management of the fistula once the patient has been clinically and physiologically stabilized. Although surgery often is delayed for several months to allow the patient to recover from the physical and psychological effects of the fistula, this protocol has been shown in retrospective studies, cohort studies, and literature reviews^1,3,4 to decrease mortality and morbidity and improve patient outcomes. 

    However, monitoring and addressing these risk factors often can be challenging because they fall under the jurisdiction of different members of the multidisciplinary team (MDT), which can include surgeons who monitor and manage sepsis and overall clinical care, nursing staff for daily patient care, stoma nurses for stoma and perifistular skin management, dietitians to ensure adequate nutritional support and management, and physiotherapists for patient mobilization and exercise. Effective communication among team members facilitates effective fistula management and overall patient care; this often can be difficult when different team members document care in several places in a patient’s clinical notes or do not document at all. 

    The management and monitoring of an ECF and utilization of the SNAP protocol remain a particular challenge for general surgeons due to complex nutritional, electrolyte, and fluid requirements.^2-4 The fistula often has a high output, requiring careful fluid balance to prevent dehydration and renal failure. Lack of absorption from the gastrointestinal tract and loss of fluids also can cause electrolyte imbalances that must be monitored and corrected. Furthermore, lack of absorption of nutrients can cause weight loss, anemia, and a lack of energy, which can slow physical rehabilitation.

    Presently, fluid charts are mostly limited to monitoring daily fluid input and output; they are inadequate to allow complex ECF fluid management, record nutrition and electrolyte requirements, and recognize early development of sepsis. An extensive literature search of Medline, Pubmed, and Google Scholar using the search terms enterocutaneous fistula, pro-forma, SNAP protocol, fluid balance, nutrition, sepsis, and multidisciplinary team did not yield any charts that encompassed this comprehensive monitoring or facilitated communication among MDT team members in 1 easy-to-read pro-forma.

    In response to the need for a care guidance instrument, the authors developed a pro-forma that allowed stringent documentation of current medication and stoma care; detailed the management plan with input from each member of the MDT team; and allowed for daily monitoring of sepsis, fluid, electrolyte, and nutritional balance (see Figure 1).

    The protocol was created during the management process of the case presented. It differed significantly from the existing protocol, which only monitored fluid input and output; no other variables had been recorded. MDT opinion was sought in the initial creation of the pro-forma through discussion with the MDT members involved in the care of this patient, so the variables MDT members believed to be important to record and monitor could be added and incorporated into the pro-forma.

    Although no standard protocol presently exists to state exactly which elements should be monitored daily in a patient with an ECF, the factors included in the pro-forma were selected based on the elements that are required to be monitored daily to ensure implementation of the SNAP protocol as described in current literature reviews.^2-4 

Monitored factors. Every 2 days, blood tests comprising a complete blood count and the inflammatory marker C-reactive protein are obtained and recorded to detect early signs of sepsis. Urea, creatinine, and urinary output are recorded to monitor for any deterioration in renal function. Electrolytes, liver function test, albumin, calcium, and glucose are measured twice weekly. The patient’s daily weight is recorded to aid the dietitian in monitoring nutritional status and adjusting parenteral and oral nutrition appropriately. Fluid balance is monitored and recorded by nursing staff and includes 24 hours’ input from oral, nasogastric, intravenous, and parenteral sources and total 24-hour fistula, urine, nasogastric tube, and rectal output. A total fluid balance is calculated based on these figures, including any gross fluid deficit, and appropriate adjustments such as additional intravenous fluids are made daily (if required) by the surgical team. Current medications are documented to ensure drugs are prescribed, omitted, and amended as appropriate. The pro-forma was reviewed by the surgical team on a daily basis and any appropriate amendments to the management plan were made accordingly.

    The chart is completed and recorded in the patient notes each day before the morning surgical review to allow clinicians and nursing staff to implement and document the daily clinical plan in the pro-forma. Thus, the pro-forma, which contains the fluid balance, blood tests, and the surgical plan, can be reviewed by the dietitian and the stoma nurse so appropriate adjustments can be made to the nutritional and stoma skin care plans and documented in the pro-forma for review by the surgical team in the afternoon patient review and acted on if required.

    Each element of the management plan on the pro-forma had to be signed off daily by the member of the MDT team who implemented the plan. 

    In the following case study, the plan was implemented 1 week after the diagnosis of the fistula was recorded. The actual form was an A5-size sticker placed daily in the patient clinical notes before the morning surgical patient review. 

Mr. P, a 70-year-old man with a medical history of an umbilical hernia repair through a midline incision, a high body mass index (BMI) of 35, and no cardiovascular comorbidities, presented with 3 days of abdominal pain and vomiting. On examination, his abdomen was distended, but soft bowel sounds were present and rectal examination was unremarkable. A computerized tomography (CT) scan revealed a small bowel obstruction secondary to adhesions. Subsequent to the scan, an emergency laparotomy with adhesiolysis was expediently performed. In the postoperative period, a prolonged ileus with persistent bowel obstruction occurred for which Mr. P was managed conservatively with a nasogastric tube and intravenous fluids and kept nil by mouth. Because 10 days post op his bowels had not opened, a repeat CT scan was performed, showing a further small bowel obstruction. He subsequently underwent a second laparotomy with adhesiolysis and repair of serosal tears, but his bowel still did not open. Day 3 post laparotomy, small bowel fecal content was discharged from the lower end of the midline laparotomy incision. An ECF was clinically diagnosed and confirmed with an abdominal CT scan. 

    The SNAP treatment protocol for an ECF with management of sepsis, nutrition, and anatomy assessment was initiated. On day 4 post laparotomy, total parenteral nutrition (TPN) was started following dietitian review. When a temperature of 38˚ C, a raised white cell count, and increased C-reactive protein levels raised suspicion of sepsis, intravenous vancomycin was started. To address Mr. P’s high daily fistula output (initially 2,000 mL), he also was provided oral crushed loperamide, omeprazole, and subcutaneous octreoride. His fistula output slowly reduced to 300–500 mL daily with this medication and fistula management that comprised stoma care and hydration. Because he was receiving TPN, he was not initially started on any oral nutritional supplements. To ensure optimal management, including strict monitoring of sepsis, fluids, nutrition, medications, and electrolyte levels required per the SNAP protocol, the pro-forma was implemented.

    Following implementation of the pro-forma document, Mr. P recovered well clinically, with a reduction in his fistula output to 300–500 mL daily, no further episodes of sepsis, and provision of an oral diet. At week 4 post-laparotomy, he was started on oral nutritional supplements and subsequently slowly weaned from his TPN over a 10-day period. At week 6 post-laparotomy, his clinicians initiated a combination of nutritional oral supplements and an elemental diet consisting of easily digestible carbohydrates, amino acids, and glucose, along with a low-fiber oral diet. He was discharged home with a stoma pouch at week 8 post-laparotomy. He continued his low-fiber diet and oral crushed loperamide and will be reviewed with a view for further definitive surgery once his clinical status and physical condition have improved and he has been assessed by the surgical team. 

Enterocutaneous fistulas are challenging for general surgeons, the extended MDT team, and members of the patient’s family.^2-4 Despite developments in understanding of and advances in ECF management, retrospective studies⁴ have determined the development of an ECF continues to confer a high (20%) mortality rate. However, if the ECF is managed appropriately through a multidisciplinary approach, retrospective studies^4-6 have shown patients with an ECF can have a favorable outcome. 

    Treating an ECF requires aggressive management of sepsis, fluid, and renal function; nutritional, electrolyte, and metabolic support; management of fistula output; assessment of fistula anatomy; and when appropriate, corrective surgery.^1,5,7,8 In the case presented, the aim was to optimize these areas of management, requiring the development of a new pro-forma that encompassed all relevant parameters. 

    A literature review by Williams et al⁷ reported sepsis is a common complication of an ECF. The pro-forma developed by the authors requires monitoring for early signs of sepsis through recording pertinent patient parameters, such as white cell count, C-reactive protein, and urinary output. This aids in aggressive and early management of sepsis through early administration of antibiotics and fluid management. 

    Compromised renal function can be an area of fistula management that may be overlooked. Decreasing urine output can be one of the first signs of developing renal failure.^3,4 By monitoring urea, creatinine, and urine output, deteriorating renal function can be detected and corrected expediently.^4,6,9 A retrospective study by Martinez and Luque-de-Leonl⁶ and literature reviews by Chung et al² and others^4,9 have reported strict fluid management to monitor for dehydration, acute kidney injury, and fluid overload are further key aspects of ECF management. The pro-forma includes strict fluid input and output measurements to ensure signs of dehydration and fluid overload are monitored and managed effectively and that any worsening renal function is noted and addressed. Fluid management was particularly key in caring for Mr. P, a patient with a high-output fistula. 

    Nutrition is a further consideration and often the most challenging aspect of fistula management in terms of MDT involvement. A literature review by Makhdoom et al⁵ reported poor nutrition management is associated with an unfavorable outcome in patients with ECF. To aid nutritional support, the pro-forma ensures documentation of minerals and electrolyte levels, patient weight, current nutritional requirements, and current oral/enteral feeding plans and provides a section for dietitians and nurses to document additional nutritional concerns. Haffejee’s⁹ literature review noted adequate doses of the appropriate medication should be prescribed and the perifistular skin should be monitored for deterioration. These factors were considered and assimilated into the pro-forma.

    The utilization of this pro-forma was valuable in managing this patient and ensuring effective MDT communication. MDT team advice was sought and considered when initially developing the pro-forma, and the MDT team believed using the pro-forma aided in communication among team members and allowed for a clear and succinct plan to be followed throughout the patient’s hospital stay. Additionally, the surgical clinicians believed the pro-forma aided in fluid management and early detection of sepsis and monitoring for any deterioration of renal function. 

    Since its implementation, use of the pro-forma has been expanded to include patients with high-output stomas as well as fistulas. Formal studies are needed to validate the form and evaluate its effect on patient recovery, time to discharge, and reduction in complications.  

In this case study, use of the pro-forma was beneficial; however, some limitations were noted. This was a single case study, limiting the ability to make inferences about the effect of the pro-forma on patient outcomes, patient recovery, time to discharge, and reduction in complications. Also, the pro-forma must be completed daily, and this can be time-consuming. Additionally, the pro-forma is completed by members of the MDT team; thus, it is prone to human recording error. 

A pro-forma was created to aid in the management of patients with a high-output ECF. Use of the form in 1 patient was found to be beneficial and believed to aid in communication and help ensure a clear structured plan was followed throughout the inpatient stay. This pro-forma has potential to reduce ECF-associated complications and effectively manage the nutritional and fluid status of patients with high-output fistulas and high-output stomas. However, further research is required to validate the pro-forma and determine its effect on patient outcomes.

Dr. Samad is a Senior House Officer, Guys and St Thomas’ Hospital NHS Foundation Trust, London, UK. Mr. Anele is a General Surgical Registrar; Mr. Akhtar is a General Surgical Consultant; and Dr. Doughan is a General and Colorectal Surgical Consultant, East Kent Hospitals University Foundation Trust, Queen Elizabeth the Queen Mother Hospital, London, UK. Please address correspondence to: Sohel Samad, MBChB, MPhil, General Surgical Department, Queen Elizabeth the Queen Mother Hospital, Margate, CT9 4AN UK; email:sohelsamad@doctors.org.uk.