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Liang S, Zheng Z, Li Y, Yang Y, Qin L, Zhao Z, Wang L, Wang H. A review of platelet-rich plasma for enteric fistula management. Front Bioeng Biotechnol 2023; 11:1287890. [PMID: 38033816 PMCID: PMC10685294 DOI: 10.3389/fbioe.2023.1287890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023] Open
Abstract
Enteric fistula (EF), a serious complication after abdominal surgery, refers to unnatural communication between the gastrointestinal tract and the skin or other hollow organs. It is associated with infection, massive fluid/electrolyte loss, and malnutrition, resulting in an unhealed course. Despite advances in surgical techniques, wound care, infection control, and nutritional support, EF remains associated with considerable morbidity and mortality. Autologous platelet-rich plasma (PRP) containing elevated platelet concentrations has been proposed to promote healing in many tissues. However, the mechanism of action of PRP in EF treatment remains unclear owing to its complicated clinical manifestations. In this review, we summarized the clinical approaches, outlined the principal cytokines involved in the healing effects, and discussed the advantages of PRP for EF therapy. In addition, we defined the mechanism of autologous PRP in EF management, which is essential for further developing EF therapies.
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Affiliation(s)
- Shuang Liang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
- Department of Clinical Laboratory, Zhangdian District People’s Hospital of Zibo City, Zibo, China
| | - Zhiqiang Zheng
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yaxin Li
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuanming Yang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lifeng Qin
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhen Zhao
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Licun Wang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haiyan Wang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
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Suter KJL, Fairweather L, Al-Habbal Y, Houli N, Jacobs R, Bui HT. How to isolate a high output enteroatmospheric fistula in the open abdomen with negative pressure therapy: an institution's step by step guide to the VAC donut. ANZ J Surg 2023; 93:682-686. [PMID: 36629275 DOI: 10.1111/ans.18270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/31/2022] [Indexed: 01/12/2023]
Abstract
There is multiple evidence to suggest that isolation techniques of high output enteroatmospheric fistulas (EAF) in open abdomens can be advantageous in controlling fistula effluent while allowing time for abdominal wall to granulate. The large loss of proteins, electrolytes and fluid, and the distressing nature of the open abdomen for both patients and doctors, make managing these EAFs a clinical challenge. We present our experience with a high output mucosal protruding EAF and the creation of a 'VAC donut' allowing a successful diversion of the enteric content whilst promoting granulation of the tissue bed.
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Affiliation(s)
- Katherine J L Suter
- Department of Upper Gastrointestinal and General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Luke Fairweather
- Department of Upper Gastrointestinal and General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Yayha Al-Habbal
- Department of Upper Gastrointestinal and General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Nezor Houli
- Department of Upper Gastrointestinal and General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Rodney Jacobs
- Department of Upper Gastrointestinal and General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Hai T Bui
- Department of Upper Gastrointestinal and General Surgery, Western Health, Melbourne, Victoria, Australia
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3
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Betzler A, Betzler J, Reissfelder C. Aktuelles Wund- und Fistelmanagement in der Viszeralchirurgie. Zentralbl Chir 2022; 147:6-9. [DOI: 10.1055/a-1209-5874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Alexander Betzler
- Chirurgische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Johanna Betzler
- Chirurgische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Christoph Reissfelder
- Chirurgische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
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Sobocki J, Jackowski M, Dziki A, Tarnowski W, Banasiewicz T, Kunecki M, Słodkowski M, Stanisławski M, Zaczek Z, Richer P, Matyja A, Frączek M, Wallner G. Clinical guidelines for the management of gastrointestinal fistula
– developed by experts of the Polish Surgical Society. POLISH JOURNAL OF SURGERY 2021. [DOI: 10.5604/01.3001.0015.0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction: Gastrointestinal fistula is one of the most difficult problems in gastrointestinal surgery. It is associated with high morbidity and mortality, numerous complications, prolonged hospitalization, and high cost of treatment. </br>Aim: This project aimed to develop recommendations for the treatment of gastrointestinal fistulas, based on evidence-based medicine and best clinical practice to reduce treatment-related mortality and morbidity. </br>Material and methods: The preparation of these recommendations is based on a review of the literature from the PubMed, Medline, and Cochrane Library databases from 1.01.2010 to 31.12.2020, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations in the form of a directive were formulated and assessed using the Delphi method. </br>Results and conclusions: Nine recommendations were presented along with a discussion and comments of experts. Treatment should be managed by a multidisciplinary team (surgeon, anesthetist, clinical nutritionist/dietician, nurse, pharmacist, endoscopist).
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Affiliation(s)
- Jacek Sobocki
- Department of General Surgery and Clinical Nutrition, Postgraduate Medical Education Center, Warsaw, Poland; Head: Jacek Sobocki MD PhD, CMPK Professor
| | - Marek Jackowski
- Department of General Surgery, Gastrointestinal Surgery and Surgical Oncology, Collegium Mediucm at the Nicolaus Copernicus University in Torun, Poland; Head: prof. Marek Jackowski MD PhD
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Poland; Head: prof. Adam Dziki MD PhD
| | - Wiesław Tarnowski
- Department of General Surgery, Gastrointestinal Surgery and Surgical Oncology, Postgraduate Medical Education Center, Warsaw, Poland; Head: prof. Wiesław Tarnowski MD PhD
| | - Tomasz Banasiewicz
- Department of General Surgery, Endocrine Surgery and Gastrointestinal Oncology, Institute of Surgery, Poznan University of Medical Sciences, Poland; Head: prof. Tomasz Banasiewicz MD PhD
| | - Marek Kunecki
- General and Vascular Surgery Unit, Center for Nutritional Therapy, M. Pirogow Regional Specialist Hospital, Lodz, Poland; Head: Marek Kunecki MD PhD
| | - Maciej Słodkowski
- Department of General Surgery, Gastrointestinal Surgery and Surgical Oncology, Medical University of Warsaw, Poland; Head: Maciej Słodkowski MD PhD
| | - Michał Stanisławski
- Department of General Surgery and Clinical Nutrition, Postgraduate Medical Education Center, Warsaw, Poland; Head: Jacek Sobocki MD PhD, CMPK Professor
| | - Zuzanna Zaczek
- Department of General Surgery and Clinical Nutrition, Postgraduate Medical Education Center, Warsaw, Poland; Head: Jacek Sobocki MD PhD, CMPK Professor
| | - Piotr Richer
- Department and Clinical Unit of General Surgery, Gastrointestinal Surgery and Transplantology, Jagiellonian University Medical College, Cracow, Poland; Head: prof. Piotr Richter MD PhD
| | - Andrzej Matyja
- II Department of Surgery, Clinical Unit of General Surgery, Surgical Oncology, Metabolic Surgery and Emergency Surgery, Jagiellonian University Medical College, Cracow, Poland; Head: prof. Andrzej Matyja, MD PhD
| | - Mariusz Frączek
- II Department and Clinic of General Surgery, Vascular Surgery and Surgical Oncology at the Medical University of Warsaw, Poland; Head: prof. Mariusz Frączek MD PhD
| | - Grzegorz Wallner
- II Department and Clinic of General Surgery, Gastrointestinal Surgery and Gastrointestinal Neoplasia, Medical University of Lublin, Poland; Head: prof. Grzegorz Wallner MD PhD
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Kong X, Cao Y, Yang D, Zhang X. Continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration for the management of postoperative high-output enterocutaneous fistulas: Three case reports and literature review. Medicine (Baltimore) 2019; 98:e18010. [PMID: 31725672 PMCID: PMC6867794 DOI: 10.1097/md.0000000000018010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Enterocutaneous fistula is considered one of the most serious complications in general surgery and is associated with high morbidity and mortality. Although various treatments are reported to have varying success, high-output enterocutaneous fistulas (output over 500 ml/day) continue to be associated with high mortality, and few papers on this topic exist in the literature. The aim of this study is to describe an effective multidisciplinary treatment method for postoperative high-output enterocutaneous fistula and discuss the clinical development of the therapeutic strategy. PATIENT CONCERNS Three patients suffered high-output enterocutaneous fistulas, in which case 1 presented with duodenal fistula, case 2 with ileal fistula, and case 3 with small bowel fistula. DIAGNOSIS All 3 cases were diagnosed with high-output enterocutaneous fistulas by drainage of intestinal contents. INTERVENTIONS With the exception of routine treatment including fluid resuscitation, correction of the electrolyte balance, control of infection, and optimal nutrition, all the cases accepted continuous irrigation and suction with triple-cavity drainage tubes in combination with sequential somatostatin-somatotropin administration were given. With regard to establishing effective drainage, the triple-cavity tube placement was performed by insertion through the initial drainage channel in case 1, percutaneous puncture with dilation by graduated dilators in case 2, and tract reconstruction in case 3. The technical details of the approach are described and clinical characteristics including fistula location, defect size, output volume, approach of triple-cavity tube placement, length of fistula tract, somatostatin and somatotropin administration time, and fistula healing time were recorded and compared. In addition, other various techniques reported in the literature are reviewed and discussed. OUTCOMES All the patients were cured by the multidisciplinary treatments and were followed up without fistula recurrence and other relevant complications at 1 week, 1 month, and 3 months after the treatments. CONCLUSION The strategy involving continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration may be a safe and effective alternative treatment for postoperative high-output enterocutaneous fistula and a more practical method that is easy to execute to manage this problem. Long-term studies, involving more patients, are still necessary to confirm this suggestion.
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Affiliation(s)
| | - Yuning Cao
- Department of Digestion, Liaocheng People's Hospital, Liaocheng, Shandong Provence
| | | | - Xiangyang Zhang
- Department of General Surgery, Wanshan Branch of Xiangyang Central Hospital, Xiangyang, Hubei Provence, China
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Muchuweti D, Muguti EG, Mungazi SG. Successful nonoperative management of high output enterocutaneous fistulae in high surgical risk HIV-positive patients: Two case reports and literature review. Clin Case Rep 2018; 6:2438-2444. [PMID: 30564345 PMCID: PMC6293185 DOI: 10.1002/ccr3.1840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/13/2018] [Accepted: 08/26/2018] [Indexed: 11/25/2022] Open
Abstract
Management of enterocutaneous fistulae is challenging, often requiring a multidisciplinary approach. In high output fistulae, surgery is advocated after control of sepsis, adequate fluid and electrolyte repletion, and nutritional support. Surgery may, however, be contraindicated in the presence of sepsis and malnutrition. The presence of HIV infection brings extra challenges.
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Affiliation(s)
- David Muchuweti
- Department of Surgery, College of Health SciencesUniversity of ZimbabweHarareZimbabwe
| | | | - Simbarashe Gift Mungazi
- Department of Surgery and Anaesthetics, Faculty of MedicineNational University of Science and TechnologyBulawayoZimbabwe
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Shah M, Wani MA. Spontaneous Tubercular Enterocutaneous Fistula. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2017; 5:275-277. [PMID: 30787802 PMCID: PMC6298300 DOI: 10.4103/1658-631x.213301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Spontaneous enterocutaneous fistula can occur in patients with Crohn's disease, malignancy, typhoid or radiation exposure. Tuberculosis is a rare cause of enterocutaneous fistula. A 60-year-old female with no significant previous history presented with a feculent discharge from a fistulous opening on the right gluteal region for 3 months. There was also a history of extrusion of multiple Ascaris worms through the opening. Abdominal ultrasonography showed no intraperitoneal fluid collections. A contrast-enhanced computed tomography of the abdomen, magnetic resonance (MR) imaging and MR fistulogram revealed cortical destruction of the right iliac bone with fluid coursing along a tract, from the small gut loops attached to bone internally through the iliac bone to the soft tissues in the right gluteal region before opening on the skin. A biopsy from the tissue of the fistula site revealed tuberculosis. The patient responded well to conservative management and was discharged after 4 weeks.
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Affiliation(s)
- Mudassar Shah
- Department of General Surgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Munir A Wani
- Department of General Surgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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9
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Mauri G, Pescatori LC, Mattiuz C, Poretti D, Pedicini V, Melchiorre F, Rossi U, Solbiati L, Sconfienza LM. Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue. Radiol Med 2016; 122:88-94. [PMID: 27752970 DOI: 10.1007/s11547-016-0693-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/03/2016] [Indexed: 02/06/2023]
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10
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Fukuchi S, Seeburger J, Parquet G, Rolandelli R. Nutrition Support of Patients With Enterocutaneous Fistulas. Nutr Clin Pract 2016. [DOI: 10.1177/088453369801300202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Valle SJ, Alzahrani N, Alzahrani S, Traiki TB, Liauw W, Morris DL. Enterocutaneous fistula in patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Incidence, management and outcomes. Surg Oncol 2016; 25:315-20. [PMID: 27566038 DOI: 10.1016/j.suronc.2016.05.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/20/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for peritoneal carcinomatosis (PC) from multiple origins, however is associated with increased complications compared to conventional gastrointestinal surgery. The aetiology of enterocutaneous fistulas (ECF) in most cases is a result of various contributing factors and therefore remains a major clinical problem, occurring in 4-34% of patients post-CRS. The aim of this study was to analyze the incidence and outcome of ECF following CRS/HIPEC. METHOD From April 1999 to September 2015, 53 patients of 918 CRS/HIPEC procedures developed an ECF. Patient, operative and postoperative data were retrospectively analyzed to determine aetiology, classification outcome and possible contributing factors were reviewed on univariate and multivariate analysis. RESULTS We report a 5.8% ECF rate, diagnosed at a median of 13 days. The mortality rate was 5.7% and other morbidity was significantly increased (p = 0.0001). Twenty-five (47.2%), 8 (15.1%) and 20 patients (37.7%) had low, moderate and high output ECF respectively. Patients that had a CC2 cytoreduction, abdominal VAC or smoked had a higher risk of fistula (p = 0.004, p < 0.0001, p = 0.008). Spontaneous closure was achieved in 49.2% with conservative treatment (median 29 days) and 33.9% underwent surgical intervention. Preoperative serum albumin <35 g/L (p = 0.04), PCI>17 (p = 0.025) and operation >8.6 h s (p = 0.001) were independent risk factors on multivariate analysis. Overall and 5-year survival was significantly reduced (p < 0.0001,p = 0.016). CONCLUSION CRS/HIPEC remains an effective treatment modality for PC in selected patients with a comparable ECF incidence to reported elective gastrointestinal surgery rates. This study identifies multiple risk factors that should be considered in patients undergoing CRS/HIPEC.
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Affiliation(s)
- Sarah J Valle
- UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia
| | - Nayef Alzahrani
- UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia; Al-Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia.
| | - Saleh Alzahrani
- UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia
| | - Thamer Bin Traiki
- UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia
| | - Winston Liauw
- UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia; Cancer Care Centre, St George Hospital, Kogarah, NSW, Australia
| | - David L Morris
- UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.
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López J, Rodriguez K, Targarona EM, Guzman H, Corral I, Gameros R, Reyes A. Systematic review of cyanoacrylate embolization for refractory gastrointestinal fistulae: a promising therapy. Surg Innov 2014; 22:88-96. [PMID: 24902686 DOI: 10.1177/1553350614535860] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical management of gastrointestinal fistulae has been reported to carry a 30-day morbidity rate up to 82% and a mortality rate ranging from 2% to 4.8%; thus nonoperative alternatives are required. The aim of the present study was to assess the current experience on the use of cyanoacrylates in the management of these fistulae. METHODS A systematic review was carried out on Medline, Embase, The Cochrane database, Academic Search Complete, MedicLatina, and SciELO for English, Spanish, and Portuguese articles dealing with refractory fistulae by means of cyanoacrylate embolization therapy. Publication dates were restricted from 1969 to present. Outcome parameters were study design, number of participants, etiology of the fistula, approach, material used, success rate, complications, and mortality. RESULTS Electronic search yielded a total of 377 articles. After a meticulous screening, only 14 studies dealing with foregut/midgut fistulae and 6 addressing hindgut fistulae were included. All the included articles were prospective and retrospective case series. Cumulative success rate was 81% (range 0% to 100%) and 3 out of 203 patients (1%) developed minor complications. CONCLUSION Cyanoacrylate embolization of nearly all types of refractory gastrointestinal fistulae is a feasible and harmless technique. Prospective controlled studies are required to support the available evidence.
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Affiliation(s)
- Julio López
- Mexican Institute for Social Security, HGZ 11, Delicias, Mexico
| | | | | | - Heber Guzman
- Mexican Institute for Social Security, UMAE 25, Monterrey, Mexico
| | - Iván Corral
- Mexican Institute for Social Security, HGZ 6, Juarez, Mexico
| | - Rene Gameros
- Mexican Institute for Social Security, Chihuahua, Mexico
| | - Arturo Reyes
- Mexican Institute for Social Security, Chihuahua, Mexico
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Novel Techniques Using Negative Pressure Wound Therapy for the Management of Wounds With Enterocutaneous Fistulas in a Long-term Acute Care Facility. J Wound Ostomy Continence Nurs 2013; 40:481-8. [DOI: 10.1097/won.0b013e3182a21c08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Runström B, Hallböök O, Nyström PO, Sjödahl R, Olaison G. Outcome of 132 Consecutive Reconstructive Operations for Intestinal Fistula—Staged Operation Without Primary Anastomosis Improved Outcome in Retrospective Analysis. Scand J Surg 2013; 102:152-7. [DOI: 10.1177/1457496913490452] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: To study factors that influenced healing and survival after attempted closure of enterocutaneous fistula. Material and Methods: Retrospective analysis of prospective data concerning 101 patients operated on 132 instances for 110 enterocutaneous fistulae at two hospitals. Results: In all, 96 (87%) of the 110 fistulae healed and 92 (91%) patients survived. A total of 9 patients with unhealed fistula died. Multivariate analysis revealed jaundice as an independent factor for both death and failed closure and operation without anastomosis as an independent positive factor for healing. Failure rate was lower after an operation with stoma without anastomosis (6 of 43, 14%) than after an operation with anastomosis (30 of 89, 34%) p = 0.0213. Of the 36 instances with unhealed fistula, 13 (36%) could be ascribed to inadvertent bowel lesions at the reconstructive operation. In addition, univariate analysis revealed that patients with previous multiple laparotomies or with multiple operations for enterocutaneous fistula healed less likely and had higher mortality. A low serum albumin, high white blood cell count, high C-reactive protein concentration, high fistula output, total parenteral nutrition, and operation for recurrent fistula were associated with death together with long operation time and operative bleeding, both indicators of surgical complexity. Over time, staged surgery avoiding anastomosis increased from 27% to 57%. Mortality decreased from 12% to 6%, and healing increased from 73% to 94%. Conclusions: Chronic inflammation, malnutrition, and liver failure causing an impaired healing capacity are important reasons for failure. Staged operation without primary anastomosis may allow the patient to reverse this condition and improve outcome. The high surgical complexity is a negative factor that requires careful planning of the operation.
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Affiliation(s)
- B. Runström
- Department of Surgery, Falun County Hospital, Falun, Sweden
| | - O. Hallböök
- Department of Surgery, Linköping University Hospital, Linköping and Faculty of Health Sciences, University of Linköping, Sweden
| | - PO. Nyström
- Department of Gastrointestinal Surgery, Karolinska University Hospital, Huddinge and Department of Clinical Sciences, Intervention and Technology, CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - R. Sjödahl
- Department of Surgery, Linköping University Hospital, Linköping and Faculty of Health Sciences, University of Linköping, Sweden
| | - G. Olaison
- Department of Surgery, Holbaek Hospital, Holbaek and Faculty of Health Sciences, University of Copenhagen, Denmark
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15
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Stevens P, Burden S, Delicata R, Carlson G, Lal S. Somatostatin analogues for treatment of enterocutaneous fistula. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Philip Stevens
- Salford Royal NHS Foundation Trust; Surgery; Stott Lane Salford UK M6 8HD
| | - Sorrel Burden
- University of Manchester; School of Nursing, Midwifery and Social Work; Room 6.32, Jean McFarlane Building, Oxford Road Manchester UK M13 9PL
| | - Raymond Delicata
- Gwent Healthcare NHS Healthboard ? Nevill Hall Hospital; General Surgery; Brecon Road Abergavenny UK NP7 7EG
| | - Gordon Carlson
- Salford Royal NHS Foundation Trust; General Surgery; Stott Lane Salford UK M6 8HD
| | - Simon Lal
- Salford Royal Foundation Trust; Intestinal Failure Unit; Salford UK M6 8HD
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16
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Abstract
Enterocutaneous fistula and its variations are some of the most difficult problems encountered in the practice of general surgery. Reliable evidence that can be used to direct the care of patients afflicted with this malady is limited. There are controversies in several areas of care. This article addresses some of the gray areas of care for the patient with enterocutaneous fistula. There is particular attention directed toward the phenomenon of enteroatmospheric fistula, as well as prevention and abdominal wall reconstruction, which is often required in these individuals.
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Affiliation(s)
- Kurt G Davis
- Section of Colon and Rectal Surgery, Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX 79920, USA
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17
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Kumar A, Pahwa HS, Pandey A, Kumar S. Spontaneous enterocutaneous fistula due to femoral hernia. BMJ Case Rep 2012; 2012:bcr-2012-006939. [PMID: 23060376 DOI: 10.1136/bcr-2012-006939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Spontaneous enterocutaneous fistula is a rare entity. We encountered a case of spontaneous enterocutaneous fistula in the groin region due to femoral hernia. A 60-year-old man presented with spontaneous enterocutaneous fistula in the left groin region without signs of peritonitis. He was kept on conservative treatment, but on third postadmission day, he developed a swelling in his right groin, which became firm and irreducible with signs of intestinal obstruction. On exploratory laparotomy, bilateral femoral hernias were noted with formation of enterocutaneous fistula on the left side. Reduction and repair of hernia was performed. In view of the rarity of this complication, this case is being reported here.
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Affiliation(s)
- Awanish Kumar
- Department of Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India.
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Iezzi LE, Feitosa MR, Medeiros BA, Aquino JC, Almeida ALNRD, Parra RS, Rocha JJRD, Féres O. Crohn's disease and hyperbaric oxygen therapy. Acta Cir Bras 2012; 26 Suppl 2:129-32. [PMID: 22030829 DOI: 10.1590/s0102-86502011000800024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Evaluate the application of Hyperbaric Oxygen Therapy (HBO) in patients with Crohn's disease (CD) refractory to pharmacologic therapy, who developed abdominal, anorectal or skin complications. METHODS Fourteen selected patients with refractory CD and treated at the School of Medicine of Ribeirao Preto, University of Sao Paulo (FMRP-USP) and at the Center of Hyperbaric Medicine, São Paulo Hospital (CEMEHI) were submitted to HBO. RESULTS Of the 14 patients evaluated, 11 had a satisfactory response. CONCLUSION HBO has shown benefits in patients with CD refractory to pharmacologic therapy.
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Systematic review and meta-analysis of the role of somatostatin and its analogues in the treatment of enterocutaneous fistula. Eur J Gastroenterol Hepatol 2011; 23:912-22. [PMID: 21814141 DOI: 10.1097/meg.0b013e32834a345d] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Somatostatin analogues may help pancreatic fistula although it remains unclear whether they help nonpancreatic fistula. This study involved meta-analysis of somatostatin analogues for treatment of enterocutaneous fistula. METHODS Meta-analysis of studies was undertaken, to estimate the effect of somatostatin analogues on spontaneous closure, time to closure and mortality. RESULTS Results showed significant associations between somatostatin and both spontaneous closure rate [odds ratio (OR) 6.61, 95% (CI) confidence interval 1.35-32.43] and time to closure (standardized mean difference -0.80, 95% CI: -1.34 to -0.26). Octreotide reduced closure time (standardized mean difference -0.57, 95% CI: -0.95 to -0.20) but not spontaneous closure (OR: 1.74, 95% CI: 0.64-4.76). Lanreotide also improved time to closure (mean of 17 days vs. 26 days, standard deviation not stated) but not spontaneous closure (OR: 0.94, 95% CI: 0.42-2.12). Somatostatin, octreotide and lanreotide did not significantly affect mortality (OR: 0.30, 0.82, and 0.48; 95% CI: 0.03-3.47, 0.38-1.78, and 0.04-5.07 respectively). CONCLUSION Somatostatin and octreotide improved fistula closure time but only somatostatin improved spontaneous closure rate.
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Klek S, Sierzega M, Turczynowski L, Szybinski P, Szczepanek K, Kulig J. Enteral and parenteral nutrition in the conservative treatment of pancreatic fistula: a randomized clinical trial. Gastroenterology 2011; 141:157-63, 163.e1. [PMID: 21439962 DOI: 10.1053/j.gastro.2011.03.040] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 02/15/2011] [Accepted: 03/08/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Postoperative pancreatic fistula is the most common and potentially life-threatening complication after pancreatic surgery. Although nutritional support is a key component of conservative therapy in such cases, there have been no well-designed clinical trials substantiating the superiority of either total parenteral nutrition or enteral nutrition. This study was conducted to compare the efficacy and safety of both routes of nutritional intervention. METHODS A randomized clinical trial was conducted in a tertiary surgical center of pancreatic and gastrointestinal surgery. Seventy-eight patients with postoperative pancreatic fistula were treated conservatively and randomly assigned to groups receiving for 30 days either enteral nutrition or total parenteral nutrition. The primary end point was the 30-day fistula closure rate. RESULTS After 30 days, closure rates in patients receiving enteral and parenteral nutrition were 60% (24 of 40) and 37% (14 of 38), respectively (P=.043). The odds ratio for the probability that fistula closes on enteral nutrition compared to total parenteral nutrition was 2.571 (95% confidence interval [CI]: 1.031-6.411). Median time to closure was 27 days (95% CI: 21-33) for enteral nutrition, and no median time was reached in total parenteral nutrition (P=.047). A logistic regression analysis identified only 2 factors significantly associated with fistula closure, ie, enteral nutrition (odds ratio=6.136; 95% CI: 1.204-41.623; P=.043) and initial fistula output of ≤200 mL/day (odds ratio=12.701; 95% CI: 9.102-47.241; P<.001). CONCLUSIONS Enteral nutrition is associated with significantly higher closure rates and shorter time to closure of postoperative pancreatic fistula.
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Affiliation(s)
- Stanislaw Klek
- 1st Department of Surgery, Jagiellonian University Medical College, Krakow, Poland.
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Ozdil B, Yamak YZ, Kece C, Cebi K. Successful endoscopic therapy of postoperative duodenal fistula by lipiodol injection: a new therapeutic approach. MINIM INVASIV THER 2010; 20:193-6. [PMID: 20929423 DOI: 10.3109/13645706.2010.518791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Postoperative upper gastrointestinal fistulas or anastomotic leaks with peritonitis are rare but serious clinical conditions. Due to severe fluid and electrolyte imbalance and risk of development of sepsis implementation of efficient and timely management is crucial. Various endoscopic interventions have been performed to date for postoperative upper gastrointestinal fistulas. We herein describe a new therapeutical approach involving lipiodol injection, which we performed to treat a patient who had unsuccessfully undergone surgery for a posttraumatic duodenal fistula. The fistula was then successfully managed by endoscopic lipiodol injection. We present this case due to its interesting nature of a postsurgical duodenal fistula without evident fistula tract, and a successful therapy by a new approach, lipiodol injection. We conclude that this new method offers an option for patients with high operation risk or for those with failed surgery, and this new method may decrease morbidity, mortality and the time required for the closure of duodenal fistulas.
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Affiliation(s)
- Burhan Ozdil
- Department of Gastroenterology, Research Hospital, Trabzon, Turkey.
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Abstract
Enterocutaneous fistula (ECF) is a challenging clinical problem with many etiologies; however, the most common cause is iatrogenic, complicating abdominal surgery. Advances in the overall care of the ECF patient have resulted in dramatic reductions in morbidity and mortality over the last five decades. A structured approach to the management of ECF has been shown to result in improved outcomes. Initial physiologic stabilization of the postoperative patient, focused on hemodynamic and fluid support as well as aggressive sepsis control are the critical initial maneuvers. Subsequent optimization of nutrition and wound care allows the patient to regain a positive nitrogen balance, and allow for healing. Judicious use of antimotility agents as well as advanced wound care techniques helps to maximize healing as well as quality of life, and prepare patients for subsequent definitive surgery.
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Affiliation(s)
- Joshua I. S. Bleier
- Department of Surgery, Division of Colorectal Surgery, Pennsylvania Hospital/Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Traci Hedrick
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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Avalos-González J, Portilla-deBuen E, Leal-Cortés CA, Orozco-Mosqueda A, Estrada-Aguilar MDC, Velázquez-Ramírez GA, Ambriz-González G, Fuentes-Orozco C, Guzmán-Gurrola AE, González-Ojeda A. Reduction of the closure time of postoperative enterocutaneous fistulas with fibrin sealant. World J Gastroenterol 2010; 16:2793-800. [PMID: 20533600 PMCID: PMC2883136 DOI: 10.3748/wjg.v16.i22.2793] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess whether the use of fibrin sealant shortens the closure time of postoperative enterocutaneous fistulas (ECFs).
METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application directly through the external hole. Outcome variables included closure time, time to resume oral feeding and morbidity related to nutritional support.
RESULTS: There were no differences in mean age, fistula output, and follow-up. Closure-time for all patients of the study group was 12.5 ± 14.2 d and 32.5 ± 17.9 d for the control group (P < 0.001), and morbidity related to nutritional support was 8.6% and 42.5%, respectively (P < 0.01). In patients with colonic fistulas, complete closure occurred 23.5 ± 19.5 d after the first application of fibrin glue, and spontaneous closure was observed after 36.2 ± 22.8 d in the control group (P = 0.36). Recurrences were observed in 2 patients because of residual disease. One patient of each group died during follow-up as a consequence of septic complications related to parenteral nutrition.
CONCLUSION: Closure time was significantly reduced with the use of fibrin sealant, and oral feeding was resumed faster. We suggest the use of fibrin sealant for the management of stable enterocutaneous fistulas.
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Randomized, Placebo-Controlled, Double-Blind Study of the Efficacy of Lanreotide 30 mg PR in the Treatment of Pancreatic and Enterocutaneous Fistulae. Ann Surg 2009; 250:872-7. [DOI: 10.1097/sla.0b013e3181b2489f] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Nikfarjam M, Champagne B, Reynolds HL, Poulose BK, Ponsky JL, Marks JM. Acute Management of Stoma-Related Colocutaneous Fistula by Temporary Placement of a Self-Expanding Plastic Stent. Surg Innov 2009; 16:270-3. [DOI: 10.1177/1553350609345851] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post—stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.
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Affiliation(s)
| | - Brad Champagne
- Department of Surgery, University Hospitals, Cleveland, Ohio
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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; 32:436-43; discussion 444. [PMID: 18057983 DOI: 10.1007/s00268-007-9304-z] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Most enterocutaneous fistulas are postoperative in origin. Sepsis, malnutrition, and hydroelectrolytic deficit are still the most important complications to which patients with postoperative enterocutaneous fistulas (PEF) are exposed. Knowledge of prognostic factors related to specific outcomes is essential for therapeutic decision-making processes. METHODS We reviewed files of all consecutive patients with PEF treated in our hospital during a 10-year period. Our aim was to identify factors related to spontaneous closure, need for operative treatment, and mortality. Univariate and multivariate analyses were performed. RESULTS A total of 174 patients were treated. The most frequent site of origin was the small bowel (90 patients: 48 jejunal, and 42 ileal), followed in frequency by the colon (50 patients). Postoperative enterocutaneous fistula closure was achieved in 151 patients (86%), being spontaneous in 65 (37%) and surgical in 86 (49%). Factors that significantly precluded spontaneous closure were jejunal site, multiple fistulas, sepsis, high output, and hydroelectrolytic deficit at diagnosis or referral. Origin of PEF at our hospital was the only factor significantly associated with spontaneous closure. The most frequent operative indication was PEF persistence without sepsis. Factors significantly associated with the need for operative treatment were high output, jejunal site, and multiple fistulas. Closure was achieved in 84% of patients who underwent operation. A total of 23 patients died (13%). Factors associated with mortality were serum albumin <3.0 g/dl (at diagnosis or referral), high output, hydroelectrolytic deficit, multiple fistulas, jejunal site, sepsis, and a complex fistulous tract. CONCLUSIONS In spite of advances in management of PEF, the associated morbidity and mortality remain high. Among several variables influencing outcome, our multivariate analysis disclosed high output, jejunal site, multiple fistulas, and sepsis as independent adverse factors related to non-spontaneous closure, need for operative treatment, and/or death.
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Affiliation(s)
- Jose L Martinez
- General and Gastrointestinal Surgery, Centro Médico Nacional, Siglo XXI, Instituto Mexicano del Seguro Social, Cuauhtémoc #330, Col. Doctores, Deleg. Cuauhtémoc, 06725 México, D.F, México.
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Sakuraba M, Asano T, Yano T, Yamamoto S, Moriya Y. Reconstruction of an enterocutaneous fistula using a superior gluteal artery perforator flap. J Plast Reconstr Aesthet Surg 2007; 62:108-11. [PMID: 17959426 DOI: 10.1016/j.bjps.2007.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 01/17/2007] [Accepted: 09/11/2007] [Indexed: 12/19/2022]
Abstract
Enterocutaneous fistula is an uncommon complication of surgery for colorectal cancer. However, once a fistula has developed, treatment is complicated by previous treatments. Here, we describe an enterocutaneous fistula that developed after multiple treatments for rectal cancer in a 62-year-old woman. The woman had previously undergone several colorectal surgeries, radiation therapy and five courses of chemotherapy. Four years after the final surgery, an enterocutaneous fistula developed between the small intestine and the sacral skin. The fistula was resected, and the resulting defect was successfully reconstructed with a superior gluteal artery perforator flap.
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Affiliation(s)
- M Sakuraba
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Chiba, Japan.
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Ramón Rábago L, Moral I, Delgado M, Guerra I, Quintanilla E, Castro JL, Llorente R, Martínez Veiga JL, Gea F. [Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:390-6. [PMID: 16938253 DOI: 10.1157/13091451] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We summarize our experience of endoscopic treatment of gastrointestinal fistulas with fibrin glue. PATIENTS AND METHOD We retrospectively reviewed the outcome of 30 patients with gastrointestinal fistulas (9 internal and 21 external) refractory to standard conservative treatment for at least 10 days. Once the fistula was endoscopically located, 4 to 8 ml of reconstituted fibrin glue (Tissucol 2.0) at 37 degrees C was injected through a Duplocath catheter on a weekly basis. RESULTS The mean age was 59 years (32-87) and 63% were men. A total of 21.9% of the patients had high output fistulas. We were able to find all fistular orifices what were located close to the surgical anastomosis. Healing time was 17 days (4-90); 2.8 sessions were required per patient (1-5) but only 2.3 sessions were required in responders. Complete sealing of fistulas was achieved in 75%; (80% in low-output, 25% in high-output and 55.5% in internal fistulas). The frequency of fistula recurrence was 3.3%. No complications related to the sealing procedure were found. Overall mortality was 10%, but only 6.6% was related to persistence of the fistula. CONCLUSIONS Endoscopic treatment of fistulas with biological glue has a high success rate in sealing without complications, helping to speed up the healing process and reduce costs, particularly in low-output enterocutaneous fistulas.
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Affiliation(s)
- Luis Ramón Rábago
- Sección de Digestivo. Hospital Severo Ochoa. Leganés. Madrid. España.
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Abstract
Formation of enteric fistulas frequently complicates the open abdomen in patients who have sustained traumatic injury. The post-traumatic subset of patients with enterocutaneous fistula enjoy better than average recovery. To optimize this recovery, a systematic management approach is required. Patients must first be stabilized with nutritional support, control of sepsis, and special wound management systems to prevent further deterioration of the abdominal wall. Investigation of the origin, course, and characteristics of the fistula provides information about its likelihood to close without operation. Definitive operative therapy may be necessary to resolve the fistula and close the abdominal wall. Finally, healing support includes nutritional support and physical and occupational therapies to restore patients to pre-injury states.
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Kang YJ, Oh JH, Yoon Y, Kim EJ, Ryu KN, Lim JW, Kim DY, Kang HS. Covered metallic stent placement in the treatment of postoperative fistula resistant to conservative management after Billroth I operation. Cardiovasc Intervent Radiol 2005; 28:90-2. [PMID: 15625590 DOI: 10.1007/s00270-004-0103-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A 55-year-old man presented with a case of postoperative enterocutaneous fistula with anastomotic stenosis after a Billroth I operation that was resistant to conservative treatment. This fistula was successfully treated with the placement of a covered metallic stent under fluoroscopic guidance. To our knowledge, this is the first report of postoperative enterocutaneous fistula that was successfully treated with a covered metallic stent.
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Affiliation(s)
- Yun Jung Kang
- Department of Diagnostic Radiology, Kyung Hee University Hospital, Hoeki-dong 1, Dongdeamun-gu, Seoul 130-702, Korea
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Huang CS, Hess DT, Lichtenstein DR. Successful endoscopic management of postoperative GI fistula with fibrin glue injection: Report of two cases. Gastrointest Endosc 2004; 60:460-3. [PMID: 15332047 DOI: 10.1016/s0016-5107(04)01724-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Christopher S Huang
- Section of Gastroenterology, Department of Surgery, Boston University Medical Center, 88 East Newton Street, Boston, MA 02118, USA
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Torres OJM, Salazar RM, Costa JVG, Corrêa FCF, Malafaia O. Fístulas enterocutâneas pós-operatórias: análise de 39 pacientes. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000600010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJETIVO: As fístulas enterocutâneas podem ocorrer de forma espontânea ou no período pós-operatório. A fístula pós-operatória representa mais de 90% de todas as fístulas intestinais e estão quase sempre relacionadas com alguma das principais complicações da cirurgia do aparelho digestivo. De acordo com os fatores de risco e as características destas fístulas, têm sido propostas diferentes classificações prognósticas. Este estudo tem por objetivo analisar o resultado do tratamento de pacientes portadores de fístulas enterocutâneas pós-operatórias. MÉTODO: Foram analisados 39 pacientes submetidos a tratamento cirúrgico que desenvolveram fístula enterocutânea. Havia 27 pacientes do sexo masculino (69,2%) e 12 do sexo feminino (30,8%) com média de idade de 45,8 anos. Os fatores de risco considerados foram sepse, nível da albumina sérica, débito da fístula, idade do paciente e cirurgia de emergência. RESULTADOS: Sepse esteve presente em 13 pacientes com 61,5% de mortalidade, fístula de alto débito em 23 pacientes com 30,4% de mortalidade, idade acima de 60 anos em 14 pacientes com 28,5% de mortalidade e a albumina sérica baixa na admissão também esteve relacionada com mortalidade. CONCLUSÃO: Os autores concluem que a presença de sepse não controlada foi o fator mais importante de mortalidade.
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Closure of Proximal Colorectal Fistulas Using Fibrin Sealant. Am Surg 2002. [DOI: 10.1177/000313480206800712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Fibrin glue has been used in upper gastrointestinal and perianal fistula disease, but its success in proximal colorectal pathology has not been widely documented. This report describes the use of endoscopically injected fibrin glue as a successful adjunct to traditional methods in accelerating the closure of colorectal fistulas. A retrospective review was performed on cases of colon and rectal fistulas treated with fibrin glue using an endoscopic technique of injection. Fistulas were injected via a flexible fiberoptic endoscope with fluoroscopic guidance (three) or directly with a rigid proctoscope (one). Fibrin glue was mixed directly from cryoprecipitate, thrombin, and calcium (one) or using a Tisseel® kit (three) (Baxter, Deerfield, IL). Four patients were identified and included: two J-pouch fistulas, a colocutaneous fistula, and a complex rectocutaneous fistula. The median duration of fistula was 33 days (range 4–365 days). Total parenteral nutrition and bowel rest were used in two patients and three required drainage of an abscess. All fistulas were obliterated and patients required a mean of one application of fibrin glue (range one to two). The mean time to resuming a regular diet postinjection was 2 days (range 1–5). No complications were identified. Fistula resolution was documented in all cases with a contrast enema and no patient has had a fistula recurrence at a median follow-up of 12 months (range 6–65). This preliminary series demonstrates that fibrin glue can be used to obliterate proximal rectal, colonic, and pouch fistulas. Endoscopy and fluoroscopy may aid in administering the fibrin glue. This adjunctive technique may shorten the time to fistula closure and may allow some patients to avoid further surgery.
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Abstract
We report a prospective study of 17 cases of enterocutaneous fistulae managed at the University of Benin Teaching Hospital, Benin City, Nigeria between June 1992 and June 1999. All the cases were iatrogenic in origin and all age groups (6 weeks to 68 years, mean 27) were represented. There were 10 males and 7 females. Emergency surgery for acute appendicitis and intestinal obstruction were the commonest causes. Management should be conservative initially but surgery should be resorted to if there is no significant improvement, particularly in circumstances where facilities for total parenteral nutrition are not available. A literature review has been carried out and measures to prevent the development of enterocutaneous fistula are outlined.
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Affiliation(s)
- C E Ohanaka
- The Department of Surgery, Benin Teaching Hospital, Nigeria
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Abstract
Enterocutaneous fistulas (ECFs) are a complex topic in terms of classification. ECF-related morbidity and mortality can be high due to fluid loss and electrolyte imbalance, sepsis, and malnutrition. Most prognostic factors influencing the outcome of ECF are now well-known. ECF treatment is complex; and, based on various situations, it can be surgical or conservative/ medical. Depending on fistula site and nutritional status, clinicians have to decide whether total parenteral or enteral nutrition should be established. In cases where total parenteral nutrition alone for 7 days has failed to influence the high output fistulas, overall data support the use of adjuvant drug, somatostatin, or its synthetic analogue, octreotide. Somatostatin 250 microg/d and octreotide 300-600 microg/d have been tried along with total parenteral nutrition to decrease the healing time of ECFs and to reduce the number of complications.
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Affiliation(s)
- Z A Makhdoom
- Section of Gastroenterology/Nutrition, Penn State Geisinger Medical Center, Danville, Pennsylvania 17822, USA.
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Shackley DC, Brew CJ, Bryden AA, Anderson ID, Carlson GL, Scott NA, Clarke NW. The staged management of complex entero-urinary fistulae. BJU Int 2000; 86:624-9. [PMID: 11069366 DOI: 10.1046/j.1464-410x.2000.00871.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To present the results of the staged management of complex entero-urinary fistulae. PATIENTS AND METHODS Ten patients with complex entero-urinary fistulae were reviewed; all patients were referred to a national intestinal failure unit after failed treatment in other centres. Each patient was treated in three stages. The acute stage involved proximal defunctioning and distal drainage of both the gastrointestinal and urinary tracts to isolate the fistula, together with the eradication of sepsis. The recovery stage involved total parenteral nutrition, organ support, radiological planning of surgical reconstruction and intensive nursing. The reconstructive stage followed when the patient was stable, nutritionally replenished and intra-abdominal sepsis was controlled. Surgery was undertaken jointly by urological and gastrointestinal surgeons. RESULTS The fistulae were treated successfully in all patients, with functional restoration in four, and/or diversion of the gastrointestinal and urological tracts in six. The mean (range) time to reconstruction was 5 (1-20) months. There were no postoperative deaths. CONCLUSION A staged multidisciplinary approach with delayed reconstruction can achieve a successful outcome in the management of complex entero-urinary fistulae.
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Affiliation(s)
- D C Shackley
- Department of Urological Surgery, and Intestinal Failure Unit, Hope Hospital, Salford Royal Hospitals Trust, Salford, UK.
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Lomis NN, Miller FJ, Loftus TJ, Whiting JH, Giuliano AW, Yoon HC. Refractory abdominal-cutaneous fistulas or leaks: percutaneous management with a collagen plug. J Am Coll Surg 2000; 190:588-92. [PMID: 10801026 DOI: 10.1016/s1072-7515(00)00237-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND We report the results of abdominal-cutaneous fistula tract occlusion with a collagen plug in a series of patients with fistulas or leaks refractory to conservative therapy. STUDY DESIGN Seven patients were found to have persistent fistula or leak after percutaneous drainage of abdominal pelvic fluid collections. All patients but one were refractory to surgical or percutaneous drainage. Under fluoroscopic guidance, modified Vasoseal (Datascope Inc, Montvale, NJ) collagen plugs were deployed into the fistulas using catheter-directed techniques. The plugs were split longitudinally to fit into an 8F or 9F peel-away sheath, placed into the fistula, and deployed. Results were tabulated and patients were followed up. RESULTS Six of seven patients undergoing fluoroscopically guided, catheter-directed tract occlusion had resolution of the fistula, with no evidence of fistula or abscess recurrence from 30 to 180 days after closure. There were no procedural complications. The technique was unsuccessful in dosing a gastrocutaneous fistula after removal of a large-bore gastrostomy tube; this failure was believed to be secondary to the short length and large caliber of the tract in a patient with hypercortisolemia. CONCLUSIONS Closure of abdominal-cutaneous fistula tracts by occlusion with a modified Vasoseal collagen plug shows promise in the management of fistulas refractory to catheter drainage.
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Affiliation(s)
- N N Lomis
- Department of Radiology, The University of Utah School of Medicine, Salt Lake City 84132, USA
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Campos AC, Andrade DF, Campos GM, Matias JE, Coelho JC. A multivariate model to determine prognostic factors in gastrointestinal fistulas. J Am Coll Surg 1999; 188:483-90. [PMID: 10235575 DOI: 10.1016/s1072-7515(99)00038-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Some studies have identified and selected factors that were associated with prognosis in patients with gastrointestinal fistulas, but a multivariate analysis to determine their relative importance and independent predictive value has not been done. The aim of this study was to determine independent prognostic factors for fistula closure and death in patients with gastrointestinal fistulas using a multivariate model. STUDY DESIGN Several variables were assessed related to spontaneous closure, surgical closure, and mortality in 188 patients with digestive fistulas (duodenal 22.3%, jejunoileal 28.7%, colonic 23.9%, biliopancreatic 25%). Selection of the variables was done through a forward stepwise logistic regression procedure; the final models were used to estimate the probability of closure, either spontaneous or surgical, and the probability of death. RESULTS Variables significant for spontaneous closure were: cause of the fistula (p = 0.027), fistula output (p = 0.037), institutional origin of the patient (p = 0.026), and occurrence of complications (p<0.001). Organ of origin of the fistula was only marginally significant (p = 0.068). Successful surgical closure was significantly associated with the presence of complications (p = 0.001) and was marginally associated with age (p = 0.069). Variables significant for death were fistula output (p = 0.009) and the presence of complications (p<0.001). CONCLUSIONS We conclude that the likelihood of spontaneous fistula closure is higher for fistulas with surgical causes, low output, and with no complications. Mortality is higher in patients with complications and with high-output fistulas.
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Affiliation(s)
- A C Campos
- Division of Gastrointestinal Surgery, Federal University of Parana, Curitiba, Brazil
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Abstract
The treatment of small bowel fistulas remains a difficult problem. Spontaneous closure rates of 30% are currently being achieved after 4 to 6 weeks of conservative therapy with bowel rest, TPN, octreotide, and control of sepsis. Resection of the fistulous bowel is warranted if fistula closure has not occurred by 4 to 6 weeks.
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Affiliation(s)
- A K Tassiopoulos
- Department of Surgery, State University of New York Health Science Center, Syracuse, USA
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Foster CE, Lefor AT. General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances. Surg Clin North Am 1996; 76:1019-33. [PMID: 8841362 DOI: 10.1016/s0039-6109(05)70496-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.
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Affiliation(s)
- C E Foster
- Department of Surgery, University of Maryland Medical System, Baltimore, USA
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Campos AC, Meguid MM, Coelho JC. Factors influencing outcome in patients with gastrointestinal fistula. Surg Clin North Am 1996; 76:1191-8. [PMID: 8841373 DOI: 10.1016/s0039-6109(05)70507-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The analysis of the prognostic factors in patients with gastrointestinal fistula requires an assessment of the quantitative and qualitative characteristics of the study population. General patient characteristics such as age, presence and degree of malnutrition, levels of plasma proteins, diagnosis of cancer or inflammatory bowel disease, or systemic sepsis must be considered, as well as local fistula characteristics. Besides the local anatomic characteristics of the fistulous tract, other factors such as fistula output, organ of origin, cause, and duration of the fistula must be considered in the assessment of a fistula patient. It is recognized, however, that it is very difficult to conclude that the presence of a single prognostic factor increases the risk in patients as complex and heterogeneous as those with digestive fistulas. It remains to be shown whether the combination of several predictive factors may enhance the chances of accurately predicting fistula closure and mortality in digestive fistulas.
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Affiliation(s)
- A C Campos
- Department of Surgery, Federal University of Parana, Curitiba, Brazil
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Campos AC, Loureiro MP, Gomes A, Coelho JC. Nutritional and surgical management of perforation of the esophagogastric junction. Nutrition 1996; 12:107-11. [PMID: 8724381 DOI: 10.1016/s0899-9007(96)00019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- A C Campos
- Department of Surgery, Federal University of Parana, Curitiba (PR), Brazil
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