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Pepe G, Chiarello MM, Bianchi V, Fico V, Altieri G, Tedesco S, Tropeano G, Molica P, Di Grezia M, Brisinda G. Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy. J Clin Med 2024; 13:1279. [PMID: 38592102 PMCID: PMC10932196 DOI: 10.3390/jcm13051279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Gilda Pepe
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Provincial Health Authority, 87100 Cosenza, Italy;
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Silvia Tedesco
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Perla Molica
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
- Department of Medicine and Surgery, Catholic School of Medicine “Agostino Gemelli”, Largo Francesco Vito 1, 00168 Rome, Italy
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Denicu MM, Preda SD, Râmboiu S, Bratiloveanu T, Nemes R, Chiutu L. The Crucial Role of Nurses in the Comprehensive Management of Postoperative Enteroatmospheric Fistula: A Narrative Review. CURRENT HEALTH SCIENCES JOURNAL 2024; 50:12-19. [PMID: 38854421 PMCID: PMC11157346 DOI: 10.12865/chsj.50.01.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/21/2024] [Indexed: 06/11/2024]
Abstract
Postoperative enteroatmospheric fistula (EAF) presents a complex challenge in surgical care, with multifactorial causes and significant implications for patient outcomes and quality of life. This narrative review explores the essential role of nurses in the comprehensive management of EAF, encompassing preoperative, intraoperative, and postoperative care. It emphasizes the importance of wound care management, nutritional support, psychosocial assistance, patient education, collaboration, continuous professional development, and research engagement in optimizing patient outcomes. By addressing these facets, healthcare providers can enhance their understanding and management of EAF, ultimately improving patient care in this intricate surgical complication.
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Affiliation(s)
- Maria Mădălina Denicu
- University of Medicine and Pharmacy of Craiova
- ICU Clinic, Craiova Emergency Clinical Hospital
| | - Silviu Daniel Preda
- University of Medicine and Pharmacy of Craiova
- First Clinic of Surgery, Craiova Emergency Clinical Hospital
| | - Sandu Râmboiu
- University of Medicine and Pharmacy of Craiova
- First Clinic of Surgery, Craiova Emergency Clinical Hospital
| | - Tudor Bratiloveanu
- University of Medicine and Pharmacy of Craiova
- First Clinic of Surgery, Craiova Emergency Clinical Hospital
| | | | - Luminita Chiutu
- University of Medicine and Pharmacy of Craiova
- ICU Clinic, Craiova Emergency Clinical Hospital
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3
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Risinger WB, Smith JW. Damage control surgery in emergency general surgery: What you need to know. J Trauma Acute Care Surg 2023; 95:770-779. [PMID: 37439768 DOI: 10.1097/ta.0000000000004112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
ABSTRACT Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.
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Affiliation(s)
- William B Risinger
- From the Department of Surgery, University of Louisville School of Medicine, Louisville, KY
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Iglay K, Bennett D, Kappelman MD, Reynolds K, Aldridge M, Karki C, Cook SF. A systematic review of epidemiology and outcomes of Crohn's disease-related enterocutaneous fistulas. Medicine (Baltimore) 2022; 101:e30963. [PMID: 36397360 PMCID: PMC10662878 DOI: 10.1097/md.0000000000030963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Enterocutaneous fistulas (ECF) are rare sequelae of Crohn's disease (CD) that occur either postoperatively or spontaneously. ECFs are associated with high morbidity and mortality. This systematic literature review assesses the disease burden of CD-related ECF and identifies knowledge gaps around incidence/prevalence, treatment patterns, clinical outcomes, healthcare resource utilization (HCRU), and patient-reported outcomes (PROs). METHODS English language articles published in PubMed and Embase in the past 10 years that provided data and insight into the disease burden of CD-related ECF (PROSPERO Registration number: CRD42020177732) were identified. Prespecified search and eligibility criteria guided the identification of studies by two reviewers who also assessed risk of bias. RESULTS In total, 582 records were identified; 316 full-text articles were assessed. Of those, eight studies met a priori eligibility criteria and underwent synthesis for this review. Limited epidemiologic data estimated a prevalence of 3265 persons with ECF in the USA in 2017. Clinical response to interventions varied, with closure of ECF achieved in 10% to 62.5% of patients and recurrence reported in 0% to 50% of patients. Very little information on HCRU is available, and no studies of PROs in this specific population were identified. CONCLUSION The frequency, natural history, and outcomes of ECF are poorly described in the literature. The limited number of studies included in this review suggest a high treatment burden and risk of substantial complications. More robust, population-based research is needed to better understand the epidemiology, natural history, and overall disease burden of this rare and debilitating complication of CD.
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Affiliation(s)
| | - Dimitri Bennett
- Takeda Pharmaceuticals, Cambridge, MA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kamika Reynolds
- CERobs Consulting, LLC, Chapel Hill, NC
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Alric H, Caudron E, Berger A, Daupin J, Perrod G, Wilhelm C, Gazeau F, Silva AKA, Rahmi G. Anastomotic leak after colorectal surgery: Management by combined use of an over-the-scope-clip and a thermoresponsive gel. Clin Res Hepatol Gastroenterol 2022; 46:101990. [PMID: 35792240 DOI: 10.1016/j.clinre.2022.101990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 06/26/2022] [Accepted: 07/01/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Hadrien Alric
- Assistance Publique-Hôpitaux de Paris, Service d'hépato-gastro-entérologie et endoscopies digestives, Hôpital Européen Georges Pompidou, France.
| | - Eric Caudron
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Pharmacie, France
| | - Arthur Berger
- Centre Hospitalier Universitaire de Bordeaux, Service de gastroentérologie, France
| | - Johanne Daupin
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Pharmacie, France
| | - Guillaume Perrod
- Assistance Publique-Hôpitaux de Paris, Service d'hépato-gastro-entérologie et endoscopies digestives, Hôpital Européen Georges Pompidou, France
| | - Claire Wilhelm
- Laboratoire Matière et Système Complexe, CNRS, UMR 7057, Université de Paris, France
| | - Florence Gazeau
- Laboratoire Matière et Système Complexe, CNRS, UMR 7057, Université de Paris, France
| | - Amanda K A Silva
- Laboratoire Matière et Système Complexe, CNRS, UMR 7057, Université de Paris, France
| | - Gabriel Rahmi
- Assistance Publique-Hôpitaux de Paris, Service d'hépato-gastro-entérologie et endoscopies digestives, Hôpital Européen Georges Pompidou, France.
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Barq RM, Gassie HE, Sulkowski JP. Necrotizing soft tissue infection following use of Punch Excision of Epithelialized Tract (PEET) procedure for gastrocutaneous fistula closure. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Single Institution Outcome of Minimally Invasive Enterocutaneous Fistula Management Utilizing the Biodesign® Fistula Plug. Cardiovasc Intervent Radiol 2022; 45:846-851. [DOI: 10.1007/s00270-022-03099-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 02/10/2022] [Indexed: 11/02/2022]
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Alser O, Gallastegi AD, Christensen MA, Mashbari H, Saillant N, Parks J, Mendoza A, Fagenholz P, King D, Hwabejire J, Kaafarani HM, Velmahos GC, Fawley JA. Modified Frailty Index-5 Score and Post-Operative Infectious Complications in Patients Undergoing Surgery for Intestinal-Cutaneous Fistula: A Nationwide Retrospective Cohort Analysis. Surg Infect (Larchmt) 2021; 22:903-909. [PMID: 33926272 PMCID: PMC11079609 DOI: 10.1089/sur.2020.441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Osaid Alser
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mathias A. Christensen
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hassan Mashbari
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M.A. Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George C. Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A. Fawley
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Berger A, Caudron E, Perrod G, Boucenna I, Gazeau F, Wilhelm C, Berger A, Clément O, Cellier C, Silva AKA, Rahmi G. Enhancing digestive fistula healing by the off-label use of a thermoresponsive vessel occluder polymer associated with esophageal stent placement: A case report. Clin Res Hepatol Gastroenterol 2021; 45:101474. [PMID: 32917564 DOI: 10.1016/j.clinre.2020.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
This case report relates to the first-in-man use of a vessel occluder gel medical device as a fistula occluder in a repurposing strategy. A patient with chronic colocutaneous fistula received an off-label treatment with a thermoresponsive Poloxamer 407 gel (20%) via percutaneous administration and injected under endoscopic control. Treatment consisted in the association of esophageal stent placement and gel injection. The product was administered just after the stent placement at<20°C in its liquid form, gelling at body temperature to form a fistula plug. However, the stent was removed at day 26 because of major pain and the fistula was still present. Treatment was continued a total of 14 administrations of thermoresponsive Poloxamer 407 gel during 7 weeks via the external fistula orifice. The treatment reduced fistula orifice diameter from 4.0±0.5 to 1mm and fistula daily output decreased from 425±65 to 23±4mL, when comparing the months before and after treatment. Gel administration was not associated with any toxic effects. The therapeutic outcome remained stable 1 year after treatment. The external fistula diameter and the fistula output were similar to what was observed after the last Poloxamer 407 gel administration.
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Affiliation(s)
- Arthur Berger
- Department of Gastroenterology and Endoscopy, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Inserm UMR970, Paris Cardiovascular Research Centre, Paris, France
| | - Eric Caudron
- Department of Pharmacy, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Perrod
- Department of Gastroenterology and Endoscopy, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Inserm UMR970, Paris Cardiovascular Research Centre, Paris, France
| | - Imane Boucenna
- Laboratoire Matière et Systèmes Complexes (MSC), Université de Paris/CNRS (UMR 7057), Paris, France
| | - Florence Gazeau
- Laboratoire Matière et Systèmes Complexes (MSC), Université de Paris/CNRS (UMR 7057), Paris, France
| | - Claire Wilhelm
- Laboratoire Matière et Systèmes Complexes (MSC), Université de Paris/CNRS (UMR 7057), Paris, France
| | - Anne Berger
- Department of Gastroenterology and Endoscopy, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Clément
- Department of Radiology, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Cellier
- Department of Gastroenterology and Endoscopy, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Amanda K A Silva
- Laboratoire Matière et Systèmes Complexes (MSC), Université de Paris/CNRS (UMR 7057), Paris, France
| | - Gabriel Rahmi
- Department of Gastroenterology and Endoscopy, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; Inserm UMR970, Paris Cardiovascular Research Centre, Paris, France.
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Noori IF. Postoperative enterocutaneous fistulas: Management outcomes in 23 consecutive patients. Ann Med Surg (Lond) 2021; 66:102413. [PMID: 34040778 PMCID: PMC8144527 DOI: 10.1016/j.amsu.2021.102413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/15/2021] [Accepted: 05/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND About 75%-85% of enterocutaneous fistulas are postoperative. Such fistulas are still disastrous and frustrating complication for surgeon and the patient and their management remains one of major challenge and dilemma in general surgical practice. Strict adherence to treatment guideline according to SOWATS protocol could results in better outcomes. THE OBJECTIVE of this study was to assess the management outcomes of 23 patients with postoperative enterocutaneous fistulas. METHODS A total of 23 consecutive patients with postoperative enterocutaneous fistulas during the period of study were included. These fistulas were classified anatomically and physiologically. The predictive factors for spontaneous closure, management outcomes and mortality rate factors for were studied. RESULTS Overall Closure of the fistulas was accomplished in 16 patients (69.6%). Spontaneous closure after successful conservative management was seen in 4 patients (17.4%). The average time between fistula development and spontaneous closure was 32 days (range12-66 days). Of 19 patients underwent corrective surgery, closure was achieved in 12 patients (52.2%), thus the surgical success rate was 63.2%. Surgical intervention was performed after an average period of 28 days (range 18-42 days) from diagnosis of the fistula. Five patients with high output (21.7%) died because of sepsis, severe malnutrition and organ failure. CONCLUSION adherence to standardized protocol and multidisciplinary approach of patients with enterocutaneous fistulas could results in good outcomes. A reasonable period of conservative treatment is always required to optimize patient's general conditions and for spontaneous closure of fistula. Operative correction is usually required for proximal high output and complex fistulas. The complexity of the fistulas, sepsis, high output effluent and comorbidities are the main factors affecting healing rates and fistula related mortality.
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Roeder HA, Fuller B, Scoular S. Septic Shock Caused by Rahnella aquatilis Bacteremia in an Immunocompetent Adult. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930888. [PMID: 33861730 PMCID: PMC8057651 DOI: 10.12659/ajcr.930888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patient: Male, 37-year-old Final Diagnosis: Septic shock Symptoms: Fever • rigors Medication: — Clinical Procedure: — Specialty: Infectious Diseases
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Affiliation(s)
- Heidi A Roeder
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Benjamin Fuller
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah Scoular
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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12
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Alser O, Christensen MA, Saillant N, Parks J, Mendoza A, Fagenholz P, King D, Kaafarani HMA, Velmahos GC, Fawley J. Peri-operative blood transfusion and risk of infectious complications following intestinal-cutaneous fistula surgical repair: A retrospective nationwide analysis. Am J Surg 2021; 223:417-422. [PMID: 33752875 DOI: 10.1016/j.amjsurg.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 03/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Peri-operative blood transfusion (BT) may lead to transfusion-induced immunomodulation. We aimed to investigate the association between peri-operative BT and infectious complications in patients undergoing intestinal-cutaneous fistulas (ICF) repair. METHODS We queried the ACS-NSQIP 2006-2017 database to include patients who underwent ICF repair. The main outcome was 30-day infectious complications. Univariate and multivariable logistic regression analyses were performed to assess the predictors of post-operative infections. RESULTS Of 4,197 patients included, 846 (20.2%) received peri-operative BT. Transfused patients were generally older, sicker and had higher ASA (III-V). After adjusting for relevant covariates, patients who received intra and/or post-operative (and not pre-operative) BT had higher odds of infectious complications compared (OR = 1.22, 95% CI 1.01-1.48). Specifically, they had higher odds of organ-space surgical site infection (OR = 1.61, 95% CI 1.21-2.13), but not other infectious complications. CONCLUSIONS Intra and/or post-operative (and not pre-operative) BT is an independent predictor of infectious complications in ICF repair.
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Affiliation(s)
- Osaid Alser
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mathias A Christensen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Berger A, Araújo-Filho I, Piffoux M, Nicolás-Boluda A, Grangier A, Boucenna I, Real CC, Marques FLN, de Paula Faria D, do Rego ACM, Broudin C, Gazeau F, Wilhelm C, Clément O, Cellier C, Buchpiguel CA, Rahmi G, Silva AKA. Local administration of stem cell-derived extracellular vesicles in a thermoresponsive hydrogel promotes a pro-healing effect in a rat model of colo-cutaneous post-surgical fistula. NANOSCALE 2021; 13:218-232. [PMID: 33326529 DOI: 10.1039/d0nr07349k] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Extracellular vesicles (EVs), especially from stem/stromal cells (SCs), represent a cell-free alternative in regenerative medicine holding promises to promote tissue healing while providing safety and logistic advantages in comparison to cellular counterparts. Herein, we hypothesize that SC EVs, administered locally in a thermoresponsive gel, is a therapeutic strategy for managing post-surgical colo-cutaneous fistulas. This disease is a neglected and challenging condition associated to low remission rates and high refractoriness. Herein, EVs from a murine SC line were produced by a high-yield scalable method in bioreactors. The post-surgical intestinal fistula model was induced via a surgical cecostomy communicating the cecum and the skin in Wistar rats. Animals were treated just after cecostomy with PBS, thermoresponsive Pluronic F-127 hydrogel alone or containing SC EVs. A PET-monitored biodistribution investigation of SC EVs labelled with 89Zr was performed. Fistula external orifice and output assessment, probe-based confocal laser endomicroscopy, MRI and histology were carried out for therapy follow-up. The relevance of percutaneous EV administration embedded in the hydrogel vehicle was indicated by the PET-biodistribution study. Local administration of SC EVs in the hydrogel reduced colo-cutaneous fistula diameter, output, fibrosis and inflammation while increasing the density of neo-vessels when compared to the PBS and gel groups. This multi-modal investigation pointed-out the therapeutic potential of SC EVs administered locally and in a thermoresponsive hydrogel for the management of challenging post-surgical colon fistulas in a minimally-invasive cell-free strategy.
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Affiliation(s)
- Arthur Berger
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, PARCC, INSERM U970, Université de Paris, 75015, Paris, France.
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14
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Alser O, Naar L, Christensen MA, Saillant N, Parks J, Mendoza A, Fagenholz P, King D, Kaafarani HMA, Velmahos GC, Fawley J. Preoperative frailty predicts postoperative outcomes in intestinal-cutaneous fistula repair. Surgery 2021; 169:1199-1205. [PMID: 33408040 DOI: 10.1016/j.surg.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/19/2020] [Accepted: 11/12/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The outcomes of operative repair of intestinal-cutaneous fistulas vary widely throughout the literature. We aimed to investigate whether the modified frailty index-5 is a reliable tool to account for physiologic reserve and whether it serves as a predictor of Clavien-Dindo grade IV complications in those with intestinal-cutaneous fistulas undergoing operative repair. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program 2006 to 2017 database to include patients who underwent intestinal-cutaneous fistulas repair. The outcome of interest was 30-day Clavien-Dindo grade IV complications. The incidence of 30-day post-operative Clavien-Dindo grade IV complications were evaluated based on calculated modified frailty index-5 score. Multivariable logistic regression analyses were performed to assess the association of Clavien-Dindo grade IV complications and modified frailty index-5. RESULTS A total of 3,995 patients were identified who underwent an intestinal-cutaneous fistulas repair. The median age (interquartile range) was 57 years (46, 67), and most patients were female (2,143 [53.7%]), White (3,206 [80.3%]), and 1,512 (38.2%) were obese. After adjusting for relevant covariates such as demographics, comorbidities, and operative details, modified frailty index-5 was independently associated with Clavien-Dindo grade IV complications (odds ratio = 2.81, 95% confidence interval 1.64-4.82; P < .001). CONCLUSION Modified frailty index-5 is an independent predictor of Clavien-Dindo grade IV complications following intestinal-cutaneous fistulas repair. It can be used to account for physiologic reserve, thus reducing the variability of outcomes reported for intestinal-cutaneous fistulas repair.
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Affiliation(s)
- Osaid Alser
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mathias A Christensen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - April Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Couper C, Doriot A, Siddiqui MTR, Steiger E. Nutrition Management of the High-Output Fistulae. Nutr Clin Pract 2020; 36:282-296. [PMID: 33368576 DOI: 10.1002/ncp.10608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 10/31/2020] [Indexed: 11/05/2022] Open
Abstract
Enterocutaneous fistulae (ECFs) are commonly encountered complications in medical and surgical practice. High-output fistulae are associated with significant morbidity and mortality, poor quality of life, and a substantial healthcare burden. An interdisciplinary team approach is crucial to prevent and mitigate the adverse clinical consequences of high-output ECFs including sepsis, metabolic derangements, and malnutrition. Patients with ECFs are at a significantly higher risk of developing malnutrition and close monitoring by nutrition support professionals and/or a nutrition support team is an essential component of their medical management. High-output ECFs often require the initiation of nutrition support through either enteral or parenteral routes. Historically, parenteral nutrition (PN) has been the primary method of nutrition support in these patients. However, oral and enteral nutrition (EN) should remain viable options if an evaluation of the location of the ECF, amount of remaining functional bowel, and volume of ECF output identifies favorable conditions. Additionally, in contrast to PN, oral nutrition and EN are the preferred method of feeding because of the maintenance of the structural and functional integrity of the gastrointestinal tract. The inclusion of pharmacological interventions can greatly assist with the reduction and stabilization of ECF output and thereby permit sustained enteral feeding. Initiation of supplemental or full PN will be required if oral nutrition and EN lead to metabolic derangements, fail to meet energy requirements, or do not maintain or improve the patient's nutrition status. The main focus of this review is to discuss the nutrition management of patients with high-output ECFs.
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16
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Guo K, Gong W, Zheng T, Hong Z, Wu X, Ren H, Wang G, Gu G, Nthumba P, Ren J, Li J. Clinical parameters and outcomes of necrotizing soft tissue infections secondary to gastrointestinal fistulas. BMC Infect Dis 2019; 19:597. [PMID: 31288746 PMCID: PMC6617561 DOI: 10.1186/s12879-019-4248-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 07/01/2019] [Indexed: 12/14/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTIs) is severe surgical infections which can occur following trauma or abdominal surgery. NSTIs secondary to gastrointestinal (GI) fistula is a rare but severe complication. Methods A retrospective cohort study was performed on all subjects presenting with GI fistulas associated NSTIs were included. Clinical characteristics, microbiological profile, operations performed, and outcomes of patients were analyzed. Results Between 2014 and 2017, 39 patients were finally enrolled. The mean age were 46.9 years and male were the dominant. For the etiology of fistula, 25 (64.1%) of the patients was due to trauma. Overall, in-hospital death occurred in 15 (38.5%) patients. Microbiologic findings were obtained from 31 patients and Klebsiella pneumoniae was the most common species (41.0%). Eight patients were treated with an open abdomen; negative pressure wound therapy was used in 33 patients and only 2 patients received hyperbaric oxygen therapy. Younger age and delayed abdominal wall reconstruction repair were more common in trauma than in non-trauma. Non-survivors had higher APACHE II score, less source control< 48 h and lower platelet count on admission than survivors. Multiple organ dysfunction syndrome, multidrug-resistant organisms and source control failure were the main cause of in-hospital mortality. Conclusions Trauma is the main cause of GI fistulas associated NSTIs. Sepsis continues to be the most important factor related to mortality. Our data may assist providing enlightenment for quality improvement in these special populations.
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Affiliation(s)
- Kun Guo
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Wenbin Gong
- Department of General Surgery, School of Medicine, Southeast University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Tao Zheng
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Zhiwu Hong
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Xiuwen Wu
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Huajian Ren
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Gefei Wang
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Guosheng Gu
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | | | - Jianan Ren
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China.
| | - Jieshou Li
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
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Zemrani B, McLeod E, Rogers E, Lawrence J, Feldman D, Evans V, Shalley H, Bines J. Vascular Ehlers-Danlos Syndrome: An Unusual Cause of Chronic Intestinal Failure in a Child. J Pediatr Gastroenterol Nutr 2019; 68:e14-e15. [PMID: 29927864 DOI: 10.1097/mpg.0000000000002074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Boutaina Zemrani
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition
| | | | - Elizabeth Rogers
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition
| | - Joanna Lawrence
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition
| | - Debi Feldman
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Victoria Evans
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition
| | - Helen Shalley
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition
| | - Julie Bines
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition
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18
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Silva AKA, Perretta S, Perrod G, Pidial L, Lindner V, Carn F, Lemieux S, Alloyeau D, Boucenna I, Menasché P, Dallemagne B, Gazeau F, Wilhelm C, Cellier C, Clément O, Rahmi G. Thermoresponsive Gel Embedded with Adipose Stem-Cell-Derived Extracellular Vesicles Promotes Esophageal Fistula Healing in a Thermo-Actuated Delivery Strategy. ACS NANO 2018; 12:9800-9814. [PMID: 30231208 DOI: 10.1021/acsnano.8b00117] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Extracellular vesicles (EVs) are increasingly envisioned as the next generation of biological pro-regenerative nanotherapeutic agents, as has already been demonstrated for heart, kidney, liver, and brain tissues; lung injury repair; and skin regeneration. Herein, we explore another potential EV therapeutic application, fistula healing, together with a local minimally invasive delivery strategy. Allogenic extracellular vesicles (EVs) from adipose tissue-derived stromal cells (ASCs) are administered in a porcine fistula model through a thermoresponsive Pluronic F-127 (PF-127) gel, injected locally at 4 °C and gelling at body temperature to retain EVs in the entire fistula tract. Complete fistula healing is reported to be 100% for the gel plus EVs group, 67% for the gel group, and 0% for the control, supporting the therapeutic use of Pluronic F-127 gel alone or combined with EVs. However, only the combination of gel and EVs results in a statistically significant (i) reduction of fibrosis, (ii) decline of inflammatory response, (iii) decrease in the density of myofibroblasts, and (iv) increase of angiogenesis. Overall, we demonstrate that ASC-EV delivery into a PF-127 gel represents a successful local minimally invasive strategy to induce a therapeutic effect in a swine fistula model. Our study presents prospects for EV administration strategies and for the management of post-operative fistulas.
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Affiliation(s)
- Amanda K A Silva
- Laboratoire Matières et Systèmes Complexes (MSC), UMR 7057 CNRS, Université Sorbonne Paris Cité (USPC) , Université Paris-Diderot , 10 rue Alice Domon et Léonie Duquet , 75205 Paris cedex 13 , France
| | - Silvana Perretta
- Department of Digestive and Endocrine Surgery , Hôpital Civil de Strasbourg, Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD) , 67091 , Strasbourg , France
- IHU, Minimally Invasive Hybrid Surgical Institute , 67091 , Strasbourg , France
| | - Guillaume Perrod
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, PARCC, INSERM U970, Université Sorbonne Paris Cité (USPC) , Université Paris Descartes , 56 rue Leblanc , 75015 , Paris , France
| | - Laetitia Pidial
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, PARCC, INSERM U970, Université Sorbonne Paris Cité (USPC) , Université Paris Descartes , 56 rue Leblanc , 75015 , Paris , France
| | - Véronique Lindner
- Department of Pathology , Hôpital Hautepierre , 1, Avenue Molière , 67098 Strasbourg , France
| | - Florent Carn
- Laboratoire Matières et Systèmes Complexes (MSC), UMR 7057 CNRS, Université Sorbonne Paris Cité (USPC) , Université Paris-Diderot , 10 rue Alice Domon et Léonie Duquet , 75205 Paris cedex 13 , France
| | - Shony Lemieux
- Laboratoire Matières et Systèmes Complexes (MSC), UMR 7057 CNRS, Université Sorbonne Paris Cité (USPC) , Université Paris-Diderot , 10 rue Alice Domon et Léonie Duquet , 75205 Paris cedex 13 , France
| | - Damien Alloyeau
- Laboratoire Matériaux et Phénomènes Quantiques (MPQ) , UMR 7162 CNRS/Université Paris - Diderot , 10 rue Alice Domon et Léonie Duquet , 75205 Paris cedex 13 , France
| | - Imane Boucenna
- Laboratoire Matières et Systèmes Complexes (MSC), UMR 7057 CNRS, Université Sorbonne Paris Cité (USPC) , Université Paris-Diderot , 10 rue Alice Domon et Léonie Duquet , 75205 Paris cedex 13 , France
| | - Philippe Menasché
- Department of Cardiovascular Surgery , Hôpital Européen Georges Pompidou; Paris Cardiovascular Research Center, INSERM U970, Université Paris Descartes , Paris , 75015 France
| | - Bernard Dallemagne
- Department of Digestive and Endocrine Surgery , Hôpital Civil de Strasbourg, Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD) , 67091 , Strasbourg , France
| | - Florence Gazeau
- Laboratoire Matières et Systèmes Complexes (MSC), UMR 7057 CNRS, Université Sorbonne Paris Cité (USPC) , Université Paris-Diderot , 10 rue Alice Domon et Léonie Duquet , 75205 Paris cedex 13 , France
| | - Claire Wilhelm
- Laboratoire Matières et Systèmes Complexes (MSC), UMR 7057 CNRS, Université Sorbonne Paris Cité (USPC) , Université Paris-Diderot , 10 rue Alice Domon et Léonie Duquet , 75205 Paris cedex 13 , France
| | | | - Olivier Clément
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, PARCC, INSERM U970, Université Sorbonne Paris Cité (USPC) , Université Paris Descartes , 56 rue Leblanc , 75015 , Paris , France
| | - Gabriel Rahmi
- Laboratoire Imagerie de l'Angiogénèse, Plateforme d'Imagerie du Petit Animal, PARCC, INSERM U970, Université Sorbonne Paris Cité (USPC) , Université Paris Descartes , 56 rue Leblanc , 75015 , Paris , France
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Bernardes A, Melo C, Ferraz S. Surgical treatment of postoperative laparostomy and pyloroduodenostomy-Case report. Int J Surg Case Rep 2018; 48:131-134. [PMID: 29894924 PMCID: PMC6038102 DOI: 10.1016/j.ijscr.2018.05.020] [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: 03/26/2018] [Accepted: 05/08/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Postoperative duodenal-cutaneous fistula represents a rare and very complex problem. In most cases operative management becomes necessary, but only after local and systemic stabilization and sepsis control. CASE PRESENTATION A 39-year-old man was admitted for surgical management of laparostomy and pyloro-duodenostomy of the first (DI) and second (DII) duodenal segments with one year of evolution, as a complication of several surgical interventions. The patient had been previously submitted to surgical interventions in another institution for: 1- lower gastrointestinal haemorrhage: treated with total colectomy; 2- upper gastrointestinal haemorrhage: performed a pyloroduodenotomy and pyloroplasty; 3- evisceration: abdominal wall closure; 4- biliary peritonitis due to pyloroplasty dehiscence: submitted to laparotomy with placement of a gastrostomy tube and pyloroduodenostomy tube; 5- intestinal haemorrhage through the pyloroduodenostomy tube: inconclusive exploratory laparotomy plus laparostomy; 6- gastrointestinal haemorrhage and shock: submitted to jejunal segmental resection (haemorrhagic mucous nodule); 7- several complications related to drainage, fistulae and celiostomy. DISCUSSION After initial medical treatment for local and systemic stabilization during four months, the following surgical procedures were performed: antrectomy; duodenectomy of DI and the suprapapillary part of DII; T-L gastrojejunostomy; duodenojejunostomy (DII and DIII) L-L at 40 cm of the gastrojejunal anastomosis; T-L jejunojejunostomy; abdominoplasty with a mesh and fibrin glue application; primary cutaneous closure. A multitubular drain was positioned near the duodeno-jejunal anastomosis and a suction drain was positioned in the subcutaneous space. CONCLUSION The patient was discharged at the 60th postoperative day, asymptomatic and with a weight gain of 10 kg.
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Affiliation(s)
- António Bernardes
- General Surgery, Coimbra Hospital and University Centre, Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal.
| | - Catarina Melo
- General Surgery, Coimbra Hospital and University Centre, Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal.
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Bi H, Li J, Xue C, Marks M. Early Closure of Infected Laparotomy Wound with Negative-Pressure Wound Therapy: Safety and Efficacy in 42 Consecutive Cases. Am Surg 2018. [DOI: 10.1177/000313481808400645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postoperative surgical site infections (SSIs) are one of the most common complications. SSIs after laparotomy have a high incidence and are complicated and expensive to heal. The aim of this study was to evaluate the safety and efficacy of a novel therapy of early closure of open abdominal SSIs wound combining wound irrigation with negative pressure wound therapy (NPWT). Open abdominal SSIs wounds were closed with sutures in 42 consecutive patients. Topical NPWT was applied over a closed wound with a deep drain to allow dynamic drainage and wound irrigation. CT scan with contrast medium injected through the deep drain was performed in patients with suspicious tracts detected during debridement surgery three days after surgery to identify a potential fistula. Wound healing and safety of the therapy was evaluated during an average six months follow-up. Closed wounds healed successfully in all the patients without recurrence of wound infection. Fistulas were easily diagnosed in all four fistula patients by using CTscan with contrast medium injection through the wound. Fistula was confirmed in these four patients at re-exploration. All the drain tube wounds healed spontaneously after drain removal. No severe adverse event occurred during therapy in any patients. With the aid of topical NPWT and deep drainage and irrigation, early closure of open SSIs wound can be done safely. We were also able to diagnose gastrointestinal fistulas at an early stage with the use of CTscan imaging after contrast injection into the wound.
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Affiliation(s)
- Hongda Bi
- Department of Plastic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Junhui Li
- Department of Plastic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chunyu Xue
- Department of Plastic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Malcolm Marks
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
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Rahimi H, Venbrux AC, Obias V. Successful embolization of a enterocutaneous fistula tract with Onyx 34 following low anterior resection for rectal cancer. Radiol Case Rep 2018; 13:728-731. [PMID: 29765484 PMCID: PMC5948473 DOI: 10.1016/j.radcr.2017.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 09/08/2017] [Accepted: 09/08/2017] [Indexed: 12/25/2022] Open
Abstract
Enterocutaneous fistulas (ECFs) can be one of the complications found after surgical intervention for rectal cancer. Interventional modalities consisting of surgical, endoscopic, and radiological methods are often implemented to treat postoperative symptomatic complications. We present the case of 61-year-old Caucasian man who presented to us with a recent diagnosis of rectal cancer that had invaded the levators as well as anteriorly into the prostate, and who underwent low anterior resection with a diverting loop ileostomy. The patient was found to have a persistent presacral abscess due to an ECF tract. This case highlights the off-label use of ethylene-vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx 34) to seal an ECF.
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Affiliation(s)
- Hamza Rahimi
- Department of Radiology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Anthony C Venbrux
- Department of Radiology, The George Washington University School of Medicine, Washington, DC
| | - Vincent Obias
- Department of Colorectal Surgery, The George Washington University School of Medicine, Washington, DC
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22
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Lauro A, Cirocchi R, Cautero N, Dazzi A, Pironi D, Di Matteo FM, Santoro A, Faenza S, Pironi L, Pinna AD. Surgery for post-operative entero-cutaneous fistulas: is bowel resection plus primary anastomosis without stoma a safe option to avoid early recurrence? Report on 20 cases by a single center and systematic review of the literature. G Chir 2017; 38:185-198. [PMID: 29182901 DOI: 10.11138/gchir/2017.38.4.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND A review was performed on entero-cutaneous fistula (ECF) repair and early recurrence, adding our twenty adult patients (65% had multiple fistulas). METHODS The search yielded 4.098 articles but only 15 were relevant: 1.217 patients underwent surgery. The interval time between fistula's diagnosis and operative repair was between 3 months and 1 year. A bowel resection with primary anastomosis was performed in 1.048 patients, 192 (18.3%) underwent a covering stoma: 856 patients (81.7%) had a fistula takedown in one procedure. RESULTS The patients had 14.3% recurrence and 13.1% mortality rate. In our experience 75% were surgically treated after a period equal or above one year from fistula occurrence: surgery was very demolitive (in 40% remnant small bowel was less than 100 cm). We performed a bowel resection with a hand-sewn anastomosis (95%) without temporary stoma. In-hospital mortality was 0% and at discharge all were back to oral intake with 0% early re-fistulisation. CONCLUSIONS Literature supports our experience: ECF takedown could be safely performed after an adequate period of recovery from 3 months to one year from fistula occurrence. In our series primary repair (bowel resection plus reconnection surgery without temporary stoma) avoided an early recurrence without mortality.
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Tonolini M, Magistrelli P. Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and MRI. Insights Imaging 2017; 8:537-548. [PMID: 28963700 PMCID: PMC5707219 DOI: 10.1007/s13244-017-0572-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 12/16/2022] Open
Abstract
Abstract Enterocutaneous fistulas (ECFs) represent abnormal communications between the gastrointestinal tract and the skin. Nowadays, the majority (~80%) of ECFs develops secondary to abdominal surgeries; alternative, less common causes include chronic inflammatory bowel diseases (IBD) such as Crohn’s disease, tumours, and radiation enteritis in descending order of frequency. These rare disorders require thorough patient assessment and multidisciplinary management to limit the associated morbidity and mortality. This pictorial review includes an overview of causes, clinical manifestations, complications and management of ECFs. Afterwards, the imaging appearances, differential diagnoses, and therapeutic options of post-surgical, IBD-related, and malignant ECFs are presented with case examples. Most of the emphasis is placed on the current pivotal role of CT and MRI, which comprehensively depict ECFs providing cross-sectional information on the underlying postsurgical, neoplastic, infectious, or inflammatory conditions. Radiographic fistulography remains a valid technique, which rapidly depicts the ECF anatomy and confirms communication with the bowel. The aim of this paper is to increase radiologists’ familiarity with ECF imaging, thus allowing an appropriate choice between medical, interventional, or surgical treatment, ultimately resulting in higher likelihood of therapeutic success. Teaching Points • Enterocutaneous fistulas may complicate abdominal surgery, sometimes Crohn’s disease and tumours. • The high associated morbidity and mortality result from sepsis, malnutrition and metabolic imbalance. • The multidisciplinary management of ECFs requires thorough imaging for correct therapeutic choice. • Radiographic fistulography rapidly depicts fistulas and communicating bowel loops in real-time. • Multidetector CT and MRI provide cross-sectional information on fistulas and underlying diseases.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Paolo Magistrelli
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy
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Ortiz LA, Zhang B, McCarthy MW, Kaafarani HMA, Fagenholz P, King DR, De Moya M, Velmahos G, Yeh DD. Treatment of Enterocutaneous Fistulas, Then and Now. Nutr Clin Pract 2017; 32:508-515. [PMID: 28358595 DOI: 10.1177/0884533617701402] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND An enterocutaneous fistula (ECF) is an aberrant connection between the gastrointestinal tract and the skin or atmosphere (enteroatmospheric fistula [EAF]). Multimodal treatment includes surgical procedures, nutrition support, and wound care. We evaluated our practice and compared our outcomes with previous results published from our institution. MATERIALS AND METHODS We performed a retrospective analysis of hospitalized ECF/EAF patients admitted between January 2011 and November 2015. Patients with internal fistulas; active inflammatory bowel disease; malignancy; radiation treatment; end-stage renal, hepatic, or cardiac disease; and active alcoholism were excluded. Data collected included demographics, fistula characteristics, nutrition therapy, treatment, operative success, and hospital mortality. Parametric and nonparametric tests for independent and paired groups were performed. RESULTS Thirty-one patients were included in the analysis. The median (interquartile range) age was 60 (53-76) years, and 81% were female. Parenteral nutrition was initially prescribed in 80% of patients, but 61% received enteral nutrition (EN) at some point during their hospitalization. Two patients were fed by fistuloclysis. Eighty percent of the patients underwent surgical repair a median of 12 months after diagnosis with 92% operative success. Surgical repair had a modest correlation with home discharge (ρ = 0.517, P = .003). A large proportion of patients (77%) were discharged home. The in-hospital mortality at our institution decreased from 44% in 1960 to 21% in 1970 to 3% in the current study. CONCLUSIONS Modern treatment of ECF/EAF, including EN and advanced local wound care, is associated with improvements in clinical outcomes such as hospital mortality.
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Affiliation(s)
- Luis Alfonso Ortiz
- 1 Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, Massachusetts, USA
| | - Bin Zhang
- 2 Massachusetts General Hospital, Department of Pharmacy, Boston, Massachusetts, USA
| | - Maureen Walsh McCarthy
- 3 Massachusetts General Hospital, Department of General Surgery, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- 1 Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, Massachusetts, USA
| | - Peter Fagenholz
- 1 Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, Massachusetts, USA
| | - David R King
- 1 Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, Massachusetts, USA
| | - Marc De Moya
- 1 Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, Massachusetts, USA
| | - George Velmahos
- 1 Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, Massachusetts, USA
| | - Daniel Dante Yeh
- 1 Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, Massachusetts, USA
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Novel Approach for Enterocutaneous Fistula Treatment with the Use of Viable Cryopreserved Placental Membrane. Case Rep Surg 2016; 2016:8797691. [PMID: 27847669 PMCID: PMC5101382 DOI: 10.1155/2016/8797691] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/14/2016] [Accepted: 10/09/2016] [Indexed: 12/16/2022] Open
Abstract
Enterocutaneous fistulas (ECF) are a difficult and costly surgical complication to manage. The standard treatment of nil per os (NPO) and total paraenteral nutrition (TPN) is not well tolerated by patients. TPN is also known for complications associated with long term central venous catheterization and for high cost of prolonged hospital stay. We present two low output ECF cases successfully treated with viable cryopreserved placental membrane (vCPM) placed into the fistula tracts. One patient is a 59-year-old male with a low output ECF from a jejunostomy tube site four weeks after the surgery. The second patient is an 87-year-old male with a low output ECF following a small bowel resection secondary to a strangulated inguinal hernia. He was evaluated on day 41 after surgery. NPO and TPN for several weeks did not resolute the ECF. The fistulae were closed postoperatively in both patients with zero output on the same day after one vCPM application. On day 3 postoperatively both patients were started on clear liquid diets and subsequently advanced to regular diets. The ECF have remained resolved for over 2 months. The use of vCPM is a novel promising approach for treatment of ECF.
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Singh AP, Mathur V, Tanger R, Gupta AK. Low Voltage Electric Current Causing Ileal Perforation: A Rare Injury. APSP J Case Rep 2016; 7:17. [PMID: 27170922 PMCID: PMC4852060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/15/2016] [Indexed: 10/31/2022] Open
Abstract
Post-electric burn ileal perforation is a rare but severe complication leading to high morbidity and mortality if there is delay in diagnosis and management. We are describing a case of electric current injury of left forearm, chest, and abdominal wall with perforation of ileum in an 8-year old boy. Patient was successfully managed by primary closure of the ileal perforation.
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BADRASAWI M, SHAHAR S, SAGAP I. Nutritional Management in Enterocutaneous Fistula. What is the evidence? Malays J Med Sci 2015; 22:6-16. [PMID: 26715903 PMCID: PMC4683844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/12/2014] [Indexed: 06/05/2023] Open
Abstract
The management of Enterocutaneous fistula (ECF) is challenging. It remains associated with morbidity and mortality, despite advancements in medical and surgical therapies. Early nutritional support using parenteral, enteral or fystuloclysis routs is essential to reverse catabolism and replace nutrients, fluid and electrolyte losses. This study aims to review the current literature on the management of ECF. Fistulae classifications have an impact on the calories and protein requirements. Early nutritional support with parenteral, enteral nutrition or fistuloclysis played a significant role in the management outcome. Published literature on the nutritional management of ECF is mostly retrospective and lacks experimental design. Prospective studies do not investigate nutritional assessment or management experimentally. Individualising the nutritional management protocol was recommended due to the absence of management guidelines for ECF patients.
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Affiliation(s)
- Manal BADRASAWI
- Dietetics Programme, School of Health Care Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Suzana SHAHAR
- Department of Surgery, Faculty of Medicine, UKM Medical Center, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Ismail SAGAP
- Department of Surgery, Faculty of Medicine, UKM Medical Center, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
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Hughes M, Roos J. Multiple vascular and enteric fistulas into an anal pouch. J Surg Case Rep 2015; 2015:rju157. [PMID: 25656168 PMCID: PMC4318495 DOI: 10.1093/jscr/rju157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michael Hughes
- Harrogate District Hospital, Harrogate, North Yorkshire, UK
| | - Jesper Roos
- Harrogate District Hospital, Harrogate, North Yorkshire, UK
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29
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Cohen WA, Horovitz JH, Kupfer Y, Savel RH. The Complex Surgical Abdomen: What the Nonsurgeon Intensivist Needs to Know. J Intensive Care Med 2015; 31:237-42. [PMID: 25636642 DOI: 10.1177/0885066615569974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/05/2014] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Wess A Cohen
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Joel H Horovitz
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Yizhak Kupfer
- Division of Critical Care Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Richard H Savel
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA Division of Critical Care Medicine, Maimonides Medical Center, Brooklyn, NY, USA
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Rahman FN, Stavas JM. Interventional radiologic management and treatment of enterocutaneous fistulae. J Vasc Interv Radiol 2014; 26:7-19; quiz 20. [PMID: 25443456 DOI: 10.1016/j.jvir.2014.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 09/10/2014] [Accepted: 09/13/2014] [Indexed: 12/15/2022] Open
Abstract
Enterocutaneous fistulae (ECFs) are abnormal sinus tract communications between the alimentary system and skin surface that can cause significant management problems and cost to the health care system. Interventional radiology can play an important role in diagnosis and treatment when conventional measures fail and additional surgery is difficult or poses a high risk. The management of patients with fistulae requires operator ingenuity and dedication, a multidisciplinary team approach, and an understanding of the pathophysiology. This article reviews the major issues in ECF management and the role of interventional radiology.
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Affiliation(s)
- Feraz N Rahman
- Division of Vascular and Interventional Radiology, University of North Carolina, 101 Manning Dr., CB 7510, Chapel Hill, NC 27599-7510
| | - Joseph M Stavas
- Division of Vascular and Interventional Radiology, University of North Carolina, 101 Manning Dr., CB 7510, Chapel Hill, NC 27599-7510.
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Fistuloclysis improves liver function and nutritional status in patients with high-output upper enteric fistula. Gastroenterol Res Pract 2014; 2014:941514. [PMID: 24719613 PMCID: PMC3955637 DOI: 10.1155/2014/941514] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/14/2014] [Accepted: 01/18/2014] [Indexed: 12/24/2022] Open
Abstract
Background. We aimed to determine the efficacy of fistuloclysis in patients with high-output upper enteric fistula (EF). Methods. Patients were assigned into the fistuloclysis group (n = 35, receiving fistuloclysis plus total enteral nutrition (TEN)) and the control group (n = 60, receiving TEN). Laboratory variables were measured during the four-week treatment. Results. At baseline, variables were similar between the two groups. Delta value was defined as the changes from baseline to day 28. Compared with the control group, the fistuloclysis group showed greater improvements in liver function (Delta total bilirubin (TB): 20.3 ± 9.7 in the fistuloclysis group versus 15.6 ± 6.3 in the control group, P = 0.040; Delta direct bilirubin (DB): 12.5 ± 3.4 versus 10.0 ± 3.6, P = 0.011; Delta alkaline phosphatase (ALP): 98.4 ± 33.5 versus 57.6 ± 20.9, P < 0.001); nutritional status (Delta total protein: 21.8 ± 8.7 versus 10.7 ± 2.1, P < 0.001; Delta albumin: 11.3 ± 2.5 versus 4.2 ± 1.3, P < 0.001). In the fistuloclysis subgroups, biliary fistula patients had the maximum number of variables with the greatest improvements. Conclusions. Fistuloclysis improved hepatic and nutritional parameters in patients with high-output upper EF, particularly in biliary fistula patients.
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Polk TM, Schwab CW. Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach. World J Surg 2012; 36:524-33. [PMID: 22033622 DOI: 10.1007/s00268-011-1315-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The care and outcome of enterocutaneous fistula (ECF) have improved greatly over several decades due to revolutionary advances in nutrition, along with dramatic improvements in the treatment of sepsis and the critically ill. However, as the collective experience with damage control surgery has matured, the frequent development of enteroatmospheric fistula (EAF) in the "open abdomen" patient has emerged as an even more vexing problem. Despite our best efforts, ECF and especially EAF continue to be highly morbid conditions, and sepsis and malnutrition remain the leading causes of death. Aggressive nutritional and metabolic support is the most significant predictor of outcome with ECF and EAF. RESULTS Discussion of the historical advances in nutritional therapy and their impact on ECF, as well as review of the classification of ECF and EAF, provides a framework for the suggested phased strategy that specifically targets the nutritional and metabolic needs of the ECF/EAF patient. These three phases include (1) diagnosis, resuscitation, and early interval nutrition; (2) definition of fistula anatomy, drainage of collections, nutritional assessment and monitoring, and placement of feeding access; and (3) definitive nutritional management, including pharmacologic adjuncts. Early nutritional support with parenteral nutrition followed by transition to enteral nutrition is advocated, including the merits of delivery of enteral nutrition via the fistula itself, known as fistuloclysis. CONCLUSION Aggressive nutritional therapy is necessary to reverse the catabolic state associated with ECF/EAF patients. Once established, it allows proper time, preparation, and planning for definitive management of the fistula, and in many cases provides the support for spontaneous closure.
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Affiliation(s)
- Travis M Polk
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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