Percutaneous management of enterocutaneous fistulae and abscess-fistula complexes

Exploration of critical care nurses' challenges in caring for enterocutaneous fistula as a complication for an open abdomen: A qualitative study

Background and Aims

Enterocutaneous fistula is a severe complication of an open abdomen, which poses devastating challenges for critical care nurses. The study aimed to explore and describe the challenges faced by critical care nurses caring for patients with enterocutaneous fistulas in a tertiary public hospital in Gauteng, South Africa.

Methods

A qualitative, exploratory, descriptive, and contextual design was conducted to understand the challenges experienced by the critical care nurses caring for patients with enterocutaneous fistulas. The standards for reporting qualitative research checklists are utilized. The study conducted four semistructured focus group interviews with six members in each group.

Results

Critical care nurses revealed two overarching themes: the challenges regarding difficult nursing care and the lack of resources to provide quality patient care. Care of patients with ECF highlighted that nurses were not coping with the care of such patients.

Conclusion

Collaboration of a multidisciplinary team involving dieticians, surgeons, and enterostomal therapy nurses could improve the management of ECF without surgical intervention, increase the knowledge and skills of nurses, alleviate their challenges, and yield safe patient outcomes. Standardized and updated protocols will ensure the best practices toward quality patient care that facilitate healing, closure, and reducing mortality and morbidity rates. The key principles for caring for patients with open abdomen, presenting with enterocutaneous fistulas, are based on correcting fluids and electrolytes, nutritional optimization and support, control of abdominal sepsis, wound care management, pain control, and emotional support to critical care nurses and ward nurses.

Management of Enterocutaneous Fistula in Crohn's Disease by Embolization With Glue Injection and Coiling: A Case Report

There is one reported case of a pancreatoduodenal fistula that was managed using combined coil embolization and fibrin glue after the failure of other methods. Herein, we document this case to highlight the value of coil embolization and fibrin glue as surgical alternatives for fistula treatment. We present a case of a 39-year-old female patient who has a known case of Crohn's disease (CD) and presented with an enterocutaneous fistula (ECF) after her most recent surgery. With the failure of conservative approaches and as she refused any surgical interventions, fibrin glue injection and coiling were used. As a conclusion, embolization may work well as a surgical management alternative due to its simplicity.

Safety and clinical efficacy of EUS-guided pelvic abscess drainage

Background and Objectives

EUS is a potential alternative for the drainage of abscesses. The aim of this study was to determine if EUS-guided pelvic abscess drainage is technically feasible, safe, and a valid option for abscess resolution.

Methods

We conducted a retrospective review from 2002 to 2020 at a single quaternary institution. EUS-guided pelvic abscess drainage via the transrectal route was performed in all patients with or without drain/stent placement. Technical and clinical success of EUS-guided pelvic abscess drainage was analyzed. Descriptive analyses and Fisher exact test were performed.

Results

Sixty consecutive patients were included in the study (53.5% male; mean age, 53.8 ± 17.9 years). Pelvic abscesses occurred mainly postoperatively (33 cases; 60.0%) and from complicated diverticulitis (14 cases; 23.3%). Mean diameter was 6.5 ± 2.4 cm (80% unilocular). Drainage was performed with EUS-guided stent placement (double-pigtail plastic or lumen-apposing metal) in 74.5% of cases and with aspiration alone for the remainder. Technical success occurred in 58 cases (97%). Of those with long-term follow-up after EUS-guided pelvic abscess drainage (n = 55; 91.7%), complete abscess resolution occurred in 72.7% of all cases. Recurrence occurred in 8 cases (14.5%) and persisted in 7 patients (12.5%), 7 of which were successfully retreated with EUS-guided pelvic abscess drainage. Accounting for these successful reinterventions, the overall rate of abscess resolution was 85.5%. Abscess resolution rate improved with drain placement (83%). Accounting for 7 repeat EUS-guided pelvic abscess drainages, overall abscess resolution improved. Two deaths occurred (3.4%) because of sepsis from failed source control in patients who had previously failed medical, radiological, and surgical treatment.

Conclusions

EUS-guided pelvic abscess drainage is technically feasible, safe, and an effective alternative to radiological or open surgical drainage. It also offers favorable clinical outcomes in different clinical situations.

Combined endoscopic-percutaneous treatment of upper gastrointestinal enterocutaneous fistula using vacuum therapy and resorbable plug insertion (Vac-Plug)

After gastrointestinal resections, leakages can occur, persist despite conventional therapy and result in enterocutaneous fistulae. We developed a combination method using flexible endoscopic techniques to seal the enteric orifice with an absorbable plug in addition to a percutaneously and fistuloscopically guided open-pore film drainage (Vac-Plug method). We retrospectively searched our endoscopy database to identify patients treated with the outlined technique. The clinical and pathological data were assessed, the method analyzed and characterized and the technical and clinical success determined. We identified 14 patients that were treated with the Vac-Plug method (4 females, 10 males with a mean age of 56 years, range 50-74). The patients were treated over a time period of 23 days (range 4-119) in between one to thirteen interventions (mean n = 5). One patient had to be excluded due to short follow-up after successful closure. Seventy-seven percent (10/13) were successfully treated with a median follow-up of 453 days (range 35-1246) thereafter. No treatment related complications occurred during the therapy. The data of the analysis showed that the Vac-Plug therapy is safe and successful in a relevant proportion of the patients. It is easy to learn and to apply and is well tolerated. In our opinion, it is a promising addition to the armamentarium of interventional methods of these difficult to treat patients. Of course, its usefulness must be further validated in larger prospective studies.

Cyanoacrylate glue for closure of proximal enterocutaneous fistula: a case report

Enterocutaneous fistula (ECF) is a distressing complication. Commonly, it follows abdominal operations that require extensive adhesiolysis. Its management is challenging, burdening health systems. Complete healing can take several weeks. Several modalities have been described, with varying success rates. A 48-year-old male underwent a trauma laparotomy, with resection of a segment of the proximal bowel and anastomosis. He experienced an anastomosis leak, wound infection and ECF and was managed conservatively for 5 weeks with parenteral nutrition and bowel rest. He was then referred to us and treated with approximation sutures and cyanoacrylate adhesive. His wound was closed with a subcutaneous drain. He experienced complete healing of the fistula and wound after undergoing a minimally invasive approach using sutures and a cyanoacrylate sealant. Cyanoacrylate glue is a safe initial non-invasive treatment of low-output ECF. It can be selected over approximation sutures to ensure sealing of the tract before surgery.

Paired Drainage Catheter Insertion: Feasibility of Placing Two Catheters within the Same Complex Abscess Cavity as a Primary and Salvage Percutaneous Drainage Technique

RATIONALE AND OBJECTIVES

To assess the feasibility of paired catheter drainage for management of complex abdominal abscesses.

MATERIALS AND METHODS

This was a single-center retrospective study of 54 patients (35 males; mean age 48.9 years) that underwent paired catheter insertion for complex abdominal fluid collections in an 18-month period. Complex collections were defined as abscesses ≥6 cm in diameter with septations, high viscosity fluid or necrotic debris, or abscesses with an associated fistula. Abscess etiologies included postoperative (n = 28), pancreatitis (n = 12), perforated bowel (n = 7), liver abscess (n = 4), and perihepatic from gallbladder perforation (n = 3). Paired catheter insertion was defined two catheters co-located within one collection through the same skin incision or two closely spaced insertion sites. Paired catheter insertion was used primarily as initial drainage for complex intraabdominal abscesses and for salvage drainage in collections that could not be evacuated by a single catheter. Primary paired catheter insertion was used in 45 patients and as salvage in nine patients.

RESULTS

Abscess resolution occurred in 51 (94.4%) patients. Patients had a median of three drainage procedures. Median duration of paired catheterization was 22 days. Seven abscesses recurred and all resolved with repeated drainage. Complications included one hemorrhage that was taken for surgical exploration. Overall, 48 patients had good clinical outcome, 3 patients died (multiorgan failure, n = 2; sepsis, n = 1), and 3 patients were lost to follow-up.

CONCLUSION

Percutaneous paired catheter drainage is a feasible technique for the treatment of both complex intraabdominal abscesses and abscesses unresponsive to single catheter drainage.

Transrectal and transvaginal catheter drainages and aspirations for management of pelvic fluid collections: technique, technical success rates, and outcomes in 150 patients

PURPOSE

To evaluate outcomes of image-guided transrectal/transvaginal (TR/TV) drainage for symptomatic pelvic fluid collections (SPFCs).

MATERIALS AND METHODS

Single-center retrospective study of 150 consecutive patients (36 males, 114 females, average age 41 years) who underwent attempted TR/TV drainages of SPFCs during an 11-year, 5-month period. All patients presented with pain and had SPFCs with rectal or vaginal contact on preceding diagnostic CT. Routine technique included Foley catheter insertion, image-guidance with ultrasound and fluoroscopy, 18 g/20 cm Chiba needles, and Seldinger technique for catheter insertion. No anoscope or speculum was used. SPFCs causes were classified by etiology including postoperative-70 (47%); gynecologic-49 (33%); and gastrointestinal-31 (21%). Resolutions of the SPFCs without the need for surgical intervention, collection recurrence, and complications were assessed. Surgical management after attempted TR/TV drainage was considered a failure.

RESULTS

Technical success was achieved in 172/180 procedures [TR 128/134 (95%); TV 44/46 (96%)]. TR/TV drainage successfully managed SPFCs in 141/150 patients (94% success rate) and 145/150 patients (97%) did not require surgical intervention; 4 patients with failed TR/TV drainage attempts were managed conservatively. In 5 patients requiring surgery, 4 were after technically successful TR/TV and 1 was after a failed TR attempt. Complications occurred in 4 (3%) patients: 2 bladder punctures (both resolved with medical management), 1 propagation of sepsis, and 1 hemorrhagic return from TR drainage that prompted surgical exploration.

CONCLUSION

Transrectal and transvaginal drainage had high technical success rates and were successful in managing the majority (141/150; 94%) of patients with pelvic fluid collections.

Percutaneous drainage and management of fluid collections associated with necrotic or cystic tumors in the abdomen and pelvis

PURPOSE

The purpose of the study was to evaluate the efficacy and safety of percutaneous drainage for palliation of symptoms and sepsis in patients with cystic or necrotic tumors in the abdomen and pelvis.

MATERIALS AND METHODS

This is a single center retrospective study of 36 patients (18 men, mean age = 51.1 years) who underwent percutaneous drainage for management of cystic or necrotic tumors in the non-postoperative setting over an 11-year period. Nineteen patients with intraabdominal fluid collections associated with primary malignancies included: cervical (n = 7), colorectal (n = 3), urothelial (n = 3), and others (n = 6). The 17 patients with fluid collections associated with intraabdominal metastases stemmed from the following primary malignancies: oropharyngeal squamous cell carcinoma (n = 3), colorectal (n = 3), ovarian (n = 2), lung (n = 2), melanoma (n = 2) along with others (n = 5). Indications for percutaneous drainage were as follows: pain (36/36; 100%); fever and/or leukocytosis (34/36; 94%), and mass effect (21/36; 58%). Seven patients underwent additional sclerosis with absolute alcohol. Criteria for drainage success were temporary or definitive relief of symptoms and sepsis control.

RESULTS

Successful sepsis control was achieved in all patients with sepsis (34/34; 100%) and 30/36 (83%) patients had improvement in pain. Duration of catheterization ranged from 2 to 90 days (mean = 22 days). There were four cases of fluid re-accumulation and one patient developed catheter tract seeding. Alcohol ablation was successful in two patients (2/7; 29%). Nearly all patients (34/36; 94%) died during the follow-up period.

CONCLUSIONS

Percutaneous drainage was effective for palliative treatment of symptomatic cystic and necrotic tumors in the majority of patients in this series.