A multivariate model to determine prognostic factors in gastrointestinal fistulas

New application of intestinal obstruction catheter in enterocutaneous fistula: A case report

BACKGROUND

Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and the skin. ECF can lead to massive body fluid loss, hypercatabolism, and malnutrition. Therefore, nutritional support plays a crucial role in managing ECFs and promoting the healing of fistulas. For nutritional support, enteral nutrition (EN) is the preferred method when gastrointestinal function is recovering. Currently, various EN approaches have been applied for different anatomical positions of the ECF. However, the effectiveness of administering EN support for treating lower ECFs still needs further exploration and improvement.

CASE SUMMARY

We present the case of a 46-year-old male who underwent gastrointestinal stromal tumour resection. Six days after the surgery, the patient presented with fever, fatigue, severe upper abdominal pain, and septic shock. Subsequently, lower ECFs were diagnosed through laboratory and imaging examinations. In addition to symptomatic treatment for homeostasis, total parenteral nutrition support was administered in the first 72 h due to dysfunction of the intestine. After that, we gradually provided EN support through the intestinal obstruction catheter in consideration of the specific anatomic position of the fistula instead of using the nasal jejunal tube. Ultimately, the patient could receive optimal EN support via the catheter, and no complications were found during the treatment.

CONCLUSION

Nutritional support is a crucial element in ECF management, and intestinal obstruction catheters could be used for early EN administration.

Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.

In situ bioprinting of double network anti-digestive xanthan gum derived hydrogel scaffolds for the treatment of enterocutaneous fistulas

The clinical treatment of enterocutaneous fistula is challenging and causes significant patient discomfort. Fibrin gel can be used to seal tubular enterocutaneous fistulas, but it has low strength and poor digestion resistance. Based on in situ bioprinting and the anti-digestive properties of xanthan gum (XG), we used carboxymethyl chitosan (CMC) and xanthan gum modified by grafted glycidyl methacrylate (GMA) and aldehyde (GCX) as the ink to print a double network hydrogel that exhibited high strength and an excellent anti-digestive performance. In addition, in vitro studies confirmed the biocompatibility, degradability, and self-healing of hydrogels. In our rabbit tubular enterocutaneous fistula model, the in situ printed hydrogel resisted corrosion due to the intestinal fluid and acted as a scaffold for intestinal mucosal cells to proliferate on its surface. To summarize, in situ bioprinting GCX/CMC double network hydrogel can effectively block tubular enterocutaneous fistulas and provide a stable scaffold for intestinal mucosal regeneration.

A review of platelet-rich plasma for enteric fistula management

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.

Superior Mesenteric Artery (SMA) Syndrome With Enterocutaneous Fistula in a Young Woman: A Rare Association

Superior mesenteric artery (SMA) syndrome is also known as Wilkie's syndrome. Sometimes it is the cause of obstruction in the duodenum. In SMA syndrome, the acute angulation of the SMA against the abdominal aorta can prevent duodenal contents from draining into the jejunum (upper small intestine); hence inadequate intake of nutrition leads to weight loss and malnutrition. This is primarily attributed to the loss of intervening pad of mesenteric fat tissue due to various debilitating conditions. Abnormal connections between the intra-abdominal gastrointestinal tracts and skin over the abdomen are known as enterocutaneous fistulas (ECF).  In this case report, a 37-year-old woman with a history of chronic dull pain in the upper abdominal region over the last seven months, who also complained of bloating, infrequent vomiting, nausea, and upper abdominal fullness for the same amount of time, was seen in the emergency room. Her symptoms had deteriorated by the time she approached the hospital. Additionally, she reports having had a foul-smelling, purulent discharge for the past five years right below the umbilicus. Upon close investigation, it was determined to be feces, and it was later discovered to be a low-output enterocutaneous fistula. She describes having an exploratory laparotomy and adhesiolysis for an intra-abdominal abscess and an acute intestinal obstruction caused by adhesions. This case emphasizes the provocation given a diagnosis of SMA syndrome with enterocutaneous fistula and demands increased awareness of this entity. This will ameliorate early identification to reduce immaterial tests and irrelevant treatments.

Modified Frailty Index-5 Score and Post-Operative Infectious Complications in Patients Undergoing Surgery for Intestinal-Cutaneous Fistula: A Nationwide Retrospective Cohort Analysis

Background: Post-operative infectious complications after repair of intestinal-cutaneous fistulas (ICF) represent a substantial burden and these outcomes vary widely in the literature. We aimed to evaluate the use of the modified frailty index-5 (mFI-5) to account for physiologic reserve to predict infectious complications in patients with ICF undergoing operative repair. Methods: We used the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) 2006-2017 dataset to include patients who underwent ICF repair. The main outcome measure was 30-day infectious complications (surgical site infection [SSI], sepsis, pneumonia, and urinary tract infection [UTI]). The risk of 30-day post-operative infectious complications was assessed based on mFI-5 score. We performed multivariable logistic regression analyses to evaluate the association between infectious complications and mFI-5. Results: We identified 4,197 patients who underwent an ICF repair. The median age (interquartile range [IQR]) was 57 (46, 67) years, and the majority of patients were female (2,260; 53.9%); white (3,348; 79.8%); and 1,586 (38.3%) were obese. After adjustment for relevant confounders such as baseline patient characteristics, and operative details, mFI-5 was independently associated with infectious complications (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.25-3.21), particularly SSI (OR, 2.16; 95% CI, 1.28-3.63) and pneumonia (OR, 5.31; 95% CI, 2.29-12.35), but not UTI or sepsis. Conclusions: We showed that the mFI-5 is a strong predictor of infectious complications after ICF repair. It can be utilized to account for physiologic reserve, therefore reducing the variability of outcomes reported for ICF repair.

Clinical guidelines for the management of gastrointestinal fistula – developed by experts of the Polish Surgical Society

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).

[Conservative treatment of patients with small bowel fistula]

OBJECTIVE

To describe conservative treatment of patients with small bowel fistula.

MATERIAL AND METHODS

We report 3 patients with small bowel fistula.

CONCLUSION

A personalized approach in patients with small bowel fistula and a modified treatment technique were effective for conservative treatment. Moreover, this approach was valuable to avoid surgical intervention.

MR Enterography of Complicated Crohn Disease: Stricturing and Penetrating Disease

ABSTRACT

Stricturing and penetrating disease are complications of Crohn disease (CD) that significantly affect patient outcomes. Careful evaluation for such complications is critical to the interpretation of magnetic resonance enterography. This manuscript outlines the key findings related to stricturing and penetrating CD and discusses current understanding of the pathophysiology and prognosis of complicated CD based on the literature.

Using a bio-scanner and 3D printing to create an innovative custom made approach for the management of complex entero-atmospheric fistulas

Enteroatmospheric fistulae are challenging clinical conditions that require surgical expertise and that can result in chronic debilitating conditions placing the patient in a vicious cycle characterized by non healing wounds and malnutrition. They are a complex entity that presents great variability depending on the number, shape, and size of the fistulous orifices, their debit, and the dimensions of the wound. This means that, at present, there is no device that adapts to the anatomical characteristics of each patient and manages to control the spillage of intestinal effluvium from the wound. The aim of this study is to describe the manufacturing technique and to assess the preliminary results of a custom device designed through bioscanner imaging and manufactured using 3D printing for use with negative pressure wound therapy (NPWT) in the management of enteroatmospheric fistula. A proof of concept is given, and the design of the device is presented for the first time. After obtaining images of each fistula with a bioscanner, a personalised device was designed for each patient by 3D printing shape of a prism and a hollow base, taking into account the dimensions of the fistulous area in order to perform a floating ostomy to isolate the wound from the debit enteric. The polycaprolactone (PCL) device was placed including inside the fistulous surface and surrounding it with the NPWT system in order to accelerate wound healing.

Enterocutaneous fistula after emergency general surgery: Mortality, readmission, and financial burden

BACKGROUND

The burden of enterocutaneous fistula (ECF) after emergency general surgery (EGS) has not been rigorously characterized. We hypothesized that ECF would be associated with higher rates of postdischarge mortality and readmissions.

METHODS

Using the 2016 National Readmission Database, we conducted a retrospective study of adults presenting for gastrointestinal (GI) surgery. Cases were defined as emergent if they were nonelective admissions with an operation occurring on hospital day 0 or 1. We used International Classification of Diseases, 10th Revision, code K63.2 (fistula of intestine) to identify postoperative fistula. We measured mortality rates and 30- and 90-day readmission rates censuring discharges occurring in December or from October to December, respectively.

RESULTS

A total of 135,595 patients underwent emergency surgery; 1,470 (1.1%) developed ECF. Mortality was higher in EGS patients with ECF than in those without (10.1% vs. 5.4%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.67-2.36) among patients who survived the index admission. Readmission rates were higher for EGS patients with ECF than without at 30 days (31.0% vs. 12.6%; OR, 3.12; 95% CI, 2.76-3.54) and at 90 days (51.1% vs. 20.1%; OR, 4.15; 95% CI, 3.67-4.70). Similar increases were shown in elective GI surgery.

CONCLUSIONS

Enterocutaneous fistula after GI EGS is associated with significantly increased odds of mortality and readmission, with rates continuing to climb out to at least 90 days. Processes of care designed to mitigate risk in this high-risk cohort should be developed.

LEVEL OF EVIDENCE

Prognostic and Epidemiological Study, Level III.

Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial

BACKGROUND

The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment.

PATIENTS AND METHODS

Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications.

RESULTS

Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur.

CONCLUSION

Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.

Gastrointestinal Stomas and Fistulas: What is Lost and What to Do?

Abnormal connections between gastrointestinal tract (GIT) and skin are called enterocutaneous fistulas (ECFs). Presence of ECF is associated with significant morbidity and mortality. A stoma refers to a surgically created opening in the abdomen to divert feces or urine to the outside of the body, to compensate for partial or complete loss of bowel function. Gastrointestinal (GI) stomas and postoperative ECFs present a unique challenge to the intensivist due to development of malnutrition, dehydration, and sepsis leading to high morbidity and mortality. This review focuses on the basic concepts about the type of fistula and stomas, their indications and complications, and management. Principles of clinical management include replacement of fluid and electrolyte losses, control of sepsis along with reducing fistula output, prevention of malnutrition and psychological support, and skin care.

How to cite this article: Pande RK, Gupta A. Gastrointestinal Stomas and Fistulas: What is Lost and What to Do? Indian J Crit Care Med 2020;24(Suppl 4):S175–S178.

Successful radiological embolization of a low output jejunal enterocutaneous fistula using a cyanoacrylate and lipiodol mixture

Enterocutaneous fistulas (ECFs) are a significant complication of abdominal surgery which present a significant therapeutic challenge for clinicians. Definitive surgical treatment of these fistulas is not without significant risk, which both patients and clinicians would seek to avoid. We present a case of successful treatment of a low output jejunal ECF by percutaneous embolization using an ethiodized oil and n-butyl-2-cyanoacrylate glue mixture in a 40-year-old man who developed an ECF after inadvertent jejunostomy tube removal. This case demonstrates the technique and suitability of a widely available embolic agent for treatment of proximal small bowel ECFs. In addition, the case illustrates the potential of minimally invasive interventional radiological procedures in the management of ECFs, particularly in high-risk patients, as an alternative to surgery.

Surgical Repair of Small Bowel Fistulas: Risk Factors of Complications or Fistula Recurrence

Background

Definitive surgical repair of persistent fistulas of the small intestine remains a surgical challenge with a high rate of re-fistulation and mortality. The aim of this study was to evaluate the type and incidence of complications after definitive surgical repair, and to identify factors predictive of severe postoperative complications or fistula recurrence.

Material/Methods

This was a retrospective study of 42 patients who underwent elective surgical repair of a persistent fistula of the small intestine. The analysis included preoperative and intraoperative parameters.

Results

The healing rate after definitive surgery was 71.4%. Postoperative complications developed in 88.1% of patients. The mortality rate was 7.2%. Fistula recurrence was recognized in 21.4% of cases. Overall, 93 complications occurred in 37 patients. The most common complications were septic (48.0%). Hemorrhagic and digestive tract-related complications accounted for 19.0% and 15.0% of all complications, respectively. Severe complications (Clavien-Dindo grade III–V) made up 28.0% of all complications. In univariate analysis, multiple fistulas (p=0.03), higher C-reactive protein level (p=0.01), and longer time interval from admission to definitive surgery (p=0.01) were associated with an increased risk of severe complications or fistula recurrence. In multivariate analysis, only multiple fistulas were an independent risk factor for severe complications or fistula recurrence (OR=8.2, p=0.04).

Conclusions

Fistula complexity determines the risk of severe postoperative complications or fistula recurrence after definitive surgical repair of the persistent small intestine fistulas. Inflammatory parameters should be normalized before definitive surgery.

Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up

BACKGROUND

The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence.

METHODS

Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas.

RESULTS

Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not.

CONCLUSIONS

With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.

Successful nonoperative management of high output enterocutaneous fistulae in high surgical risk HIV-positive patients: Two case reports and literature review

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.

Bioinspired Anti-digestive Hydrogels Selected by a Simulated Gut Microfluidic Chip for Closing Gastrointestinal Fistula

The anti-digestive features given to hydrogels can prolong their action time in gut environment; however, these types of hydrogels have rarely been reported. Inspired by indigestibility of dietary fibers, we introduced an injectable covalent hydrogel through photopolymerization of glycidyl methacrylate-modified xanthan. This newly synthesized hydrogel exhibited a specific concentration-dependent porosity, swelling ratio, and stiffness. The intestinal epithelial cells-6 could grow on the surface of the stiffer hydrogel, and achieved their gut barrier functions. A simulated gut microfluidic chip was manufactured to demonstrate the hydrogel's good performance of anti-digestion compared with the current product, fibrin sealant. Furthermore, calcium ions could induce the swelling-shrinking behavior of the hydrogel, which assisted in removing the hydrogels at the proper time so as to avoid the mismatch of hydrogel degradation and tissue regeneration. Therefore, this hydrogel is expected to be an outstanding gut repair material, especially for closing gastrointestinal fistula.

Endoscopic Closure of Gastrointestinal Fistulae and Leaks

The development of new endoscopic techniques, such as gastrointestinal (GI) stenting, full-thickness suturing, clip application, and use of tissue adhesives, has had a significant impact on management of GI fistulae. These techniques have shown promising results, but further study is needed to optimize the efficacy of long-term closure. The advancement of endoscopic techniques, including the use of the lumen apposing metal stent (LAMS), has allowed for the deliberate creation of fistula tracts to apply endoscopic therapy that previously could not be achieved. This article examines the rapidly evolving area of endoscopic fistula closure and its relationship to LAMS.

The Management of Intestinal Penetrating Crohn's Disease

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.

Systematic review: pharmacotherapy for high-output enterostomies or enteral fistulas

BACKGROUND

High-output enterocutaneous fistula or enterostomies can cause intestinal failure. There is a wide variety of options in medical management of patients with high output.

AIM

To systematically review the literature on available pharmacotherapy to reduce output and to propose an algorithm for standard of care.

METHODS

Relevant databases were systematically reviewed to identify studies on pharmacotherapy for reduction in (high-) output enterostomies or fistula. Randomised controlled trials and within subjects controlled prospective trials were included. An algorithm for standard of care was generated based on the outcomes of the systematic review.

RESULTS

Two studies on proton pump inhibitors, six on anti-motility agents, three on histamine receptor antagonists, one on an α2- receptor agonist and eight on somatostatin (analogues) were included. One study examined a proton pump inhibitor and a histamine receptor antagonist within the same patients. Overall, we found evidence for the following medical therapies to be effective: omeprazole, loperamide and codeine, ranitidine and cimetidine. On the basis of these outcomes and clinical experience, we proposed an algorithm for standard of care which consists of high-dose proton pump inhibitors combined with high-dose loperamide as the first step followed by addition of codeine in case of insufficient output reduction. So far, there is insufficient evidence for the standard use of somatostatin (analogues).

CONCLUSIONS

The available evidence on the efficacy of medication to reduce enterostomy or enterocutaneous fistula output is hampered by low quality studies. We propose an algorithm for standard of care output reduction in these patients.

Practical Approaches to Definitive Reconstruction of Complex Abdominal Wall Defects

With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify "complex" are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.

Predictive value of preoperative serum C-reactive protein for recurrence after definitive surgical repair of enterocutaneous fistula

BACKGROUND

Recurrence rates after surgical repair of enterocutaneous fistula (ECF) have not changed substantially. Serum C-reactive protein (s-CRP) has been used as an indicator of postoperative complications in abdominal surgery. ​ The aim of this study was to determine the predictive value of preoperative s-CRP for recurrence after definitive surgical repair of ECF.

METHODS

Fifty consecutive patients with ECF persistence submitted electively to definitive surgical repair (ECF resection with primary anastomosis) were included. Among several variables, preoperative s-CRP (primary independent variable) was assessed as a factor related to recurrence (dependent variable). Univariate and multivariate analyses were performed.

RESULTS

ECF recurred in 19 patients (38%). Univariate and multivariate analyses disclosed operative blood loss greater than 325 mL (P < .05) and preoperative s-CRP greater than .5 mg/dL (P < .01) as the only risk factors for recurrence. ECF recurrence rates were significantly higher for patients with preoperative s-CRP above this level (53% vs 11%, P < .01). After conservative and surgical management, overall ECF closure was attained in 40 patients (80%).

CONCLUSIONS

Our results suggest that s-CRP may serve as a useful parameter to predict potential failure (recurrence) in patients submitted to definitive closure of ECF.

Enterocutaneous Fistula: Proven Strategies and Updates

Management of enterocutaneous fistula represents one of the most protracted and difficult problems in colorectal surgery with substantial morbidity and mortality rates. This article summarizes the current classification systems and successful management protocols, provides an in-depth review of fluid resuscitation, sepsis control, nutrition management, medication management of output quantity, wound care, nonoperative intervention measures, operative timeline, and considerations, and discusses special considerations such as inflammatory bowel disease and enteroatmospheric fistula.

Enterocutaneous fistula in patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Incidence, management and outcomes

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.

Colonization of Klebsiella pneumoniae inside fistula tracts: a possible risk factor for failure of fibrin glue-assisted closure

GOALS

This study was designed to investigate the risk factors affecting glue-assisted closure (GAC) in the enterocutaneous fistula (ECF) patients receiving glue application.

BACKGROUND

ECF is a challenging problem in surgical practice, and it is difficult to resolve by spontaneous closure. Currently, GAC is popular when treating fistulas, but data related to risk factors are limited.

METHODS

We retrospectively analyzed 82 patients with 93 ECFs, who had autologous glue sealing from 2010 to 2012 in a referral center. Their demographic data, clinical records, and fistula characteristics were collected. Both univariate analysis and multivariate Cox proportional hazards model were used to determine the prognostic factors affecting closure.

RESULTS

During the 14-day treatment period, 78.5% (73/93) of the fistulas achieved GAC. We excluded 3 reopened fistulas and investigated 90 ECFs from 79 patients. Univariate analysis demonstrated that patients with high levels of CRP, high CRP:prealbumin ratio, elevated blood glucose, and specific pathogen colonization, together with lower GI location, greater output volume, and shorter tract length, had a poor outcome (P<0.05). Using multivariate analysis, monomicrobial and polymicrobial colonization with Klebsiella pneumoniae inside the fistula tracts (hazard ratio, 0.191; 95% confidence interval, 0.045-0.810; P=0.025) was a statistically significant risk factor for failure of fistula closure.

CONCLUSIONS

The presence of monomicrobial and polymicrobial colonization with K. pneumoniae in fistulous tracts was an independent risk factor for failure of GAC in patients receiving glue application. Better debridement of the tracts should be performed before the glue sealing.

The Complex Surgical Abdomen: What the Nonsurgeon Intensivist Needs to Know

Intensivists are often called upon to help care for patients who develop severe sepsis syndrome and septic shock where the primary source is an enterocutaneous fistula (ECF). The purpose of this article is to describe to the nonsurgeon intensivist how these complex surgical situations arise in the first place and provide the reader with a detailed understanding of the potentially devastating complications of ECF. In addition, we will describe a structured algorithm regarding the management of this often highly challenging surgical situation.

Fistulizing Crohn's disease: Diagnosis and management

Fistulizing Crohn's disease represents an evolving, yet unresolved, issue for multidisciplinary management. Perianal fistulas are the most frequent findings in fistulizing Crohn's disease. While enterocutaneous fistulas are rare, they are associated with considerable morbidity and mortality. Detailed evaluation of the fistula tract by advanced imaging techniques is required to determine the most suitable management options. The fundamentals of perianal fistula management are to evaluate the complexity of the fistula tract, and exclude proctitis and associated abscess. The main goals of the treatment are abscess drainage, which is mandatory, before initiating immunosuppressive medical therapy, resolution of fistula discharge, preservation of continence and, in the long term, avoidance of proctectomy with permanent stoma. The management of enterocutaneous fistulas comprises of sepsis control, skin care, nutritional optimization and, if needed, delayed surgery.

Open Abdomen Treatment for Septic Patients with Gastrointestinal Fistula: From Fistula Control to Definitive Closure

The use of open abdomen in the management of gastrointestinal fistula complicated with severe intra-abdominal infection is uncommon. This study was designed to evaluate outcomes of our staged approach for the infected open abdomen. Patients who had gastrointestinal fistula and underwent open abdomen treatment were retrospectively reviewed. Various materials such as polypropylene mesh and a modified sandwich package were used to achieve temporary abdominal closure followed by skin grafting when the granulation bed matured. A delayed definitive operation was performed for final abdominal closure without implant of prosthetic mesh. Between 1999 and 2009, 56 (68.3%) of 82 patients survived through this treatment. Among them, 42 patients achieved final abdominal closure. Spontaneous fistula closure occurred in 16 patients with secondary fistula recorded in six patients. Besides, wound complications occurred in 13 patients with two cases for pulmonary infection. Within a 12-month follow-up period after definitive closure, no additional fistula was recorded excluding planned ventral hernia repair. Open abdomen treatment was effective for gastrointestinal fistula complicated by severe intra-abdominal infection. A delayed and deliberate operative strategy aiming at fistula excision and fascial closure, with simultaneous abdominal wall reconstruction, was required for the infected open abdomen.

Definitive surgical closure of enterocutaneous fistula: outcome and factors predictive of increased postoperative morbidity

AIM

Enterocutaneous fistula (ECF) presents a complex management problem with significant mortality and morbidity. The aim of this study was to assess the outcome of patients undergoing surgical cure for ECF and to predict factors that might relate to increased postoperative morbidity.

METHOD

Medical records of all patients who underwent definitive surgery for cure of an ECF within our colorectal surgery unit between 2000 and 2010 were reviewed.

RESULTS

Forty-one patients (18 male) were identified, in whom 44 definitive procedures were performed. The median age was 54 (17-81) years. The median postoperative length of stay in hospital was 14 (2-213) days. Half (50%) of the ECFs occurred as a postoperative complication followed by spontaneous fistulation in Crohn's disease (36%). The interval to definitive surgery was influenced by the aetiology of the fistula. The median time to surgery after formation of postoperative fistula was 240 days (7.9 months). There was no 30-day postoperative mortality. There were two (4.5%) recurrences at 3 months. Thirty-eight (86%) patients suffered postoperative morbidity as defined by the Clavien-Dindo classification. High-grade morbidity occurred in 32% of patients. On univariate analysis, factors identified as being significantly associated with high-grade morbidity included a fistula output of > 500 ml/day (P = 0.004) in patients with postoperative ECF, malnutrition at presentation (P = 0.04) and a serum albumin value of < 30 g/l (P = 0.02) in patients with spontaneous ECF due to Crohn's disease.

CONCLUSION

The majority of persistent complex ECFs can be cured surgically with low mortality and recurrence in a multidisciplinary setting. Postoperative morbidity, however, remains a significant burden.

Autologous platelet rich fibrin glue for sealing of low-output enterocutaneous fistulas: an observational cohort study

BACKGROUND

Glue sealing has become an alternative option for occlusion of enterocutaneous fistula (ECF) because of it minimal invasiveness and simplicity. This study aimed to determine efficacy and safety of autologous, platelet-rich fibrin glue (PRFG) in promoting closure of ECFs.

METHODS

This was a nonrandomized cohort study, recruiting patients who had low-output ECFs (<200 mL/24 h). Beside standard of care, patients were assigned to either the PRFG or control group. Clinical efficacy and safety were determined prospectively. Moreover, a well-balanced subcohort was generated by propensity score (PS) matching. Unadjusted and adjusted Cox proportional hazard models were employed to determine hazard ratios (HRs) of ECF closure in both cohorts.

RESULTS

From January 2008 to January 2012, 145 patients were enrolled initially, with 70 in the control group and 75 in the PRFG-treated group. Compared with the control group, patients in the PRFG group had lesser median time of fistula closure (7 vs 23 days; P = .0010). In addition, PRFG healed more fistulas within the first 28 days (77% vs 57%; P = .0127). For all fistulas included, PRFG-treated fistulas were 3.13 (95% confidence interval [CI], 1.82-5.36) times more likely to achieve closure than those with the non-PRFG approach in the adjusted Cox model. In a PS-matched cohort with 28 paired fistulas, HRs were 3.41 (95% CI, 1.91-6.07) for all fistulas regardless of location. No adverse events related to glue applications were observed.

CONCLUSION

Autologous PRFG seems to be safe and effective in the treatment of low-output ECFs, and can lessen closure times and promote closure rates.

Outcome of 132 Consecutive Reconstructive Operations for Intestinal Fistula—Staged Operation Without Primary Anastomosis Improved Outcome in Retrospective Analysis

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.

Early feeding in pediatric patients following stoma closure in a resource limited environment

BACKGROUND

Establishment of enteral nutrition is necessary after intestinal surgery. In resource-strained environments, it can be critical. This study examined the effect of early feeding in pediatric patients undergoing stoma closure in a country with mid-level socioeconomic indices.

METHODS

With parenteral consent and ethics board approval, patients were prospectively enrolled in early feeding (Group 1), starting feeds 24h post-operation with a protocol driven increase. They were compared with similar patients managed without a specific protocol over the 12 months prior (Group 2).

RESULTS

There were 31 patients in each group with similar mean age and weight. The mean first sustained feed was achieved at 28.5 ± 4.4 h* in Group 1 vs. 153.8 ± 28.6 h in Group 2. Full feeds were achieved within 62.3 ± 19.2 h* vs. 196.0 ± 40.5 h in Group 1 and 2, respectively. Mean hospital stay was 7.2 days* in Group 1 vs. 9.4 days in Group 2. A reduction in postoperative fever and wound infections was observed in Group 1 (*p<0.05).

CONCLUSION

Early enteral feeding after elective bowel anastomosis is well tolerated in children and results in shorter hospital stay and fewer complications.

Guided treatment improves outcome of patients with enterocutaneous fistulas

BACKGROUND

The present study was designed to evaluate the effects of guided treatment of patients with an enterocutaneous fistula and to evaluate the effect of prolonged period of convalescence on outcome.

METHODS

All consecutive patients with an enterocutaneous fistula treated between 2006 and 2010 were included in this study. Patient information was gathered prospectively. Treatment of patients focused on sepsis control, optimization of nutritional status, wound care, establishing the anatomy of the fistula, timing of surgery, and surgical principles. Outcome included spontaneous and surgical closure, mortality, and postoperative recurrence. The relationship between period of convalescence and recurrence rate was determined by combining the present prospective cohort with a historical cohort from our group.

RESULTS

Between 2006 and 2010, 79 patients underwent focused treatment for enterocutaneous fistula. Cox regression analysis showed that period of convalescence related significantly with recurrence of the fistula (hazard ratio 0.99; 95 % confidence interval 0.98-0.999; p = 0.04). Spontaneous closure occurred in 23 (29 %) patients after a median period of convalescence of 39 (range 7-163) days. Forty-nine patients underwent operative repair after median period of 101 (range 7-374) days and achieved closure in 47 (96 %). Overall, eight patients (10 %) died.

CONCLUSIONS

Prolonging period of convalescence for patients with enterocutaneous fistulas improves spontaneous closure and reduces recurrence rate.

Factors influencing the outcome of image-guided percutaneous drainage of intra-abdominal abscess after gastrointestinal surgery

PURPOSE

To improve the selection of patients for percutaneous abscess drainage (PAD) to treat postoperative intra-abdominal abscess after gastrointestinal surgery, we investigated the factors predictive of outcome.

METHODS

Of 143 consecutive patients with symptomatic postoperative intra-abdominal abscess after a gastrointestinal tract resection, 104 who underwent image-guided PAD as the initial treatment were reviewed. We assessed the possible associations between successful PAD and patient-, abscess-, surgical-, and drainage-related variables, and investigated the success rates of PAD for patients with vs. those without the factors related to successful outcome.

RESULTS

Based on monitoring for 1 year after PAD, the success rate of this procedure was 85.6% (89/104). Multivariate analysis revealed that the interval between surgery and the onset of abscess (p = 0.0234) and a single abscess (p = 0.0038) were independently associated with a successful outcome. Single late-onset abscess resolved completely within 10 weeks in 91.4% of these patients.

CONCLUSIONS

Despite new strategies aimed at preventing surgical site infection, PAD remains an important factor in the postoperative management of gastrointestinal surgery in Japan. Initial recognition of the day of onset and the number of abscesses are important prognostic factors.

A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas

OBJECTIVE

Several randomized control trials (RCTs) have compared somatostatin and its analogues versus a control group in patients with enterocutaneous fistulas (ECF). This study meta-analyzes the literature and establishes whether it shows a beneficial effect on ECF closure.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Cochrane, and PubMed databases according to PRISMA guidelines. Seventy-nine articles were screened. Nine RCTs met the inclusion criteria. Statistical analyses were performed using Review Manager 5.1.

RESULTS

Somatostatin analogues versus control. Number of fistula closed: A significant number of ECF closed in the somatostatin analogue group compared to control group, P = 0.002.Time to closure: ECF closed significantly faster with somatostatin analogues compared to controls, P < 0.0001.Mortality: No significant difference between somatostatin analogues and controls, P = 0.68.Somatostatin versus control. Number of fistula closed: A significant number of ECF closed with somatostatin as compared to control, P = 0.04.Time to closure: ECF closed significantly faster with somatostatin than controls, P < 0.00001.Mortality: No significant difference between somatostatin and controls, P = 0.63

CONCLUSIONS

Somatostatin and octreotide increase the likelihood of fistula closure. Both are beneficial in reducing the time to fistula closure. Neither has an effect on mortality. The risk ratio (RR) for somatostatin was higher than the RR for analogues. This may suggest that somatostatin could be better than analogues in relation to the number of fistulas closed and time to closure. Further studies are required to corroborate these apparent findings.

Multiple spontaneous enterocutaneous fistulae on back: a rare presentation of colonic malignancy

We came across a case presenting with complaint of multiple fistulae present on back and lateral part of abdominal wall discharging faecal matter. Investigations revealed a fistulous tract arising from posterior wall of ascending colon. The patient did not respond to conservative management and therefore was subjected to exploratory laparotomy after thorough investigations. Peroperatively, an ileocaecal mass was found along with a fistulous tract which was arising from the posterior wall of ascending colon and communicating with the skin. A right haemicolectomy was performed followed by ileo-transverse anastomosis. Postoperative recovery was uneventful. The histopathology report came out to be adenocarcinoma of colon.

Controversies in the care of the enterocutaneous fistula

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.