Postoperative enterocutaneous fistula: when to reoperate and how to succeed

Perforated Meckel's Diverticulum and Adhesive Intestinal Obstruction in a Preterm Neonate: A Case Report

Perforated bowel and adhesive intestinal obstruction are common indications for emergency surgical intervention in a preterm neonate. The initial approach to managing perforation involves either peritoneal drain insertion or formal laparotomy. Once a neonate presents with complete bowel obstruction, prompt abdominal exploration becomes crucial. One prevalent cause of bowel obstruction in this population is adhesions resulting from previous surgeries. This report details the case of a preterm, extremely low birth weight neonate experiencing pneumoperitoneum, initially managed with an intraperitoneal drain. Despite temporary improvement, the infant developed recurrent pneumoperitoneum, necessitating formal exploratory laparotomy. Approximately one month post-surgery, the baby encountered complete bowel obstruction due to adhesive intestinal obstruction, requiring a second exploratory laparotomy. The child survived both surgical interventions and is thriving at follow-up. Our findings suggest that in select cases, intraperitoneal drain placement may suffice. However, there is a need for further research to improve the suspicion and diagnosis of Meckel's diverticulum perforations in neonates. Additionally, vigilant assessment and timely intervention for adhesive intestinal obstruction can enhance bowel salvage outcomes.

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

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

The Crucial Role of Nurses in the Comprehensive Management of Postoperative Enteroatmospheric Fistula: A Narrative Review

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.

Delayed enterocutaneous fistula after 17 years of gunshot wound injury: a case report

Enterocutaneous fistula (ECF) is a common complication of abdominal surgery. Postoperatively, it may be the result of a small intestinal injury or an anastomosis leak, and it typically manifests days or weeks following surgery.

CASE PRESENTATION

A 56-year-old man with a history of a gunshot wound injury in the abdomen with colon injury managed for colocolic anastomosis 17 years earlier presented to our hospital's general surgery clinic with the complaint of drainage at the scar area. It was discovered that he had an ECF. The patient underwent a laparotomy. Fistula tract excision and segmental colon resection with colocolic anastomosis were done.

CLINICAL DISCUSSION

ECF formation after an extraordinarily long latency due to an anastomotic leak, which has not been previously documented in the literature, is a distinctive aspect of the case. As a result, surgeons should consider ECF in their differentials for patients with a history of abdominal operations.

CONCLUSION

Surgical management is the definitive treatment of ECF after proper resuscitation and stabilization of the patient's condition. Preoperative imaging is crucial for determining the anatomy of the fistula and any associated intra-abdominal pathology.

Anastomotic Leakage after Colorectal Surgery: Risk Factors, Diagnosis and Therapeutic Options

Anastomotic leakage (AL) is the most severe and devastating complication of colorectal surgery. The objectives of this study were to identify the risk factors involved in the development of AL, evaluate diagnostic methods and explore therapeutic options in case of colorectal cancer surgery.

MATERIAL AND METHODS

we conducted a retrospective study on 28 AL recorded after 315 elective colorectal cancer surgeries performed in 1st Surgery Clinic of Craiova over an 8-year period (2014-2022).

RESULTS

The overall incidence of AL was 8.88%. The identified risk factors were rectal cancer (22.38%), low anterior rectal resection (50%), open approach, advanced age (82.15% over 60 years old), male sex (3:1), and the presence of two or more co-morbidities. Medical conservative treatment was the primary line of treatment in all cases. Leakage closure was achieved in 22 cases (78.56%), with exclusive conservative treatment in 15 cases (46.42%) and combined conservative and surgical treatment in 7 cases (25.0%). Overall morbidity was recorded at 64.28%, with 8 cases of general evolving complications and 10 cases of local complications. General mortality was reported at 6 (21.42%), with 3 (16.66%) occurring after conservative treatment and 3 after re-interventions (30%).

CONCLUSIONS

our study identified advanced age, the presence of two or more co-morbidities, male sex, rectal surgery, and neoadjuvant chemoradiation as the most important risk factors for AL. Medical conservative treatment was the primary treatment modality, while reoperation was necessary in cases of uncontrollable sepsis and MODS. Mortality after re-intervention was nearly double compared to conservative treatment.

Therapeutic Options in Postoperative Enterocutaneous Fistula—A Retrospective Case Series

Objectives: The aim of the study was to present the results obtained in our experiment regarding the management of postoperative enterocutaneous fistulas (PECF). Materials and Methods: We conducted a retrospective study on 64 PECF registered after 2030 abdominal surgeries (1525 digestive tract surgeries and 505 extra-digestive ones) over a period of 7 years (1st of January 2014–31th of December 2020) in the 1st and 2nd Surgery Clinics, Clinical County Emergency Hospital of Craiova, Romania. The group included 41 men (64.06%) and 23 women (35.34%), aged between 21–94 years. Of the cases, 71.85% occurred in elderly patients over 65 years old. Spontaneous fistulas in Crohn’s disease, intestinal diverticulosis, or specific inflammatory bowel disease were excluded. Results: The overall incidence of 3.15% varied according to the surgery type: 6.22% after gastroduodenal surgery, 1.78% after enterectomies, 4.30% after colorectal surgery, 4.28% after bilio-digestive anastomoses, and 0.39% after extra-digestive surgery. We recorded a 70.31% fistula closure rate, 78.94% after exclusive conservative treatment and 57.61% after surgery; morbidity was 79.68%, mortality was 29.68%. Conclusion: PECF management requires a multidisciplinary approach and is carried out according to an algorithm underlying well-established objectives and priorities. Conservative treatment including resuscitation, sepsis control, output control, skin protection, and nutritional support is the first line treatment; surgery is reserved for complications or permanent repair of fistulas that do not close under conservative treatment. The therapeutic strategy is adapted to topography, morphological characteristics and fistula output, age, general condition, and response to therapy.

Colocutaneous fistula following Clostridioides difficile infection managed as an 'autocolostomy': a novel approach to a recognised complication

Colocutaneous fistula is a rare entity in colorectal disease. We present a case of colocutaneous fistula in a patient whose postoperative course following a laparoscopic anterior resection for sigmoid cancer was complicated by Clostridioides difficile colitis. During the follow-up period, it was found that his bowel contents were preferentially discharging through this fistula which had taken up the role of an 'autocolostomy'. Given the physiological impact of an additional surgical procedure, a definitive repair of the fistula was deferred and instead the patient was taught to manage it in keeping with general principles of stoma care. Over the subsequent follow-up period, he has now developed a large parastomal hernia and is being considered for definitive repair.

Challenges Encountered in Placement of Ostomy Bag for Palliative Care in a Patient with Colorectal Cancer

Fecal fistula develop in patients with cancer associated with difficult management situation, which is often complicated by prior treatment including surgery, radiation therapy, and chemotherapy. Affecting factors such as timing of additional adjuvant therapy or palliative care, technical considerations for operating on irradiated bowel, poor wound healing, increased risk of additional fecal fistula, and decreased likelihood of spontaneous fecal fistula closure all need to be considered in this scenario. Here, the authors focus specifically on the management of fecal fistula associated with cancer and/or radiation- induced injury to the bowel.

Evaluation and Management of Enterocutaneous Fistula

A 36-year-old woman presents with an abscess at her midline wound 4 weeks following an ileocecectomy for Crohn's disease. After the abscess is incised, there is purulent drainage followed by the drainage of enteric contents; the output is 750 mL per 24 hours.

Surgical treatment of postoperative laparostomy and pyloroduodenostomy-Case report

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.

Use of a biological mesh for the treatment of perineal fistula following radical colorectal resection

Patients with postradiation therapy for malignancies and/or extensive colorectal surgery are prone to the development of enteroperineal fistulas. Application of biological meshes may prove beneficial in treating complicated enteroperineal fistulas as they provide a stable ground for closing pelvic defects even in contaminated fields.

Endoscopic Closure of Gastrointestinal Fistulae and Leaks

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

Postoperative enterocutaneous fistula - principles in non-operative approach

Introduction

Postoperative enterocutaneous fistulae could constitute a challenge when they occur following an abdominal surgery. Astute application of correct principles in its management is essential for good outcomes.

Methods

A retrospective review of records of patients with enterocutaneous fistulas managed non-operatively was done. Clinical assessment, anatomic and physiologic classification of fistula, fluid resuscitation, electrolyte correction, parenteral/enteral nutrition, antibiotic use and fistula effluent monitoring, formed the basis of management.

Results

(4/14)Four out of 14 patients with enterocutaneous fistulae were managed exclusively non-operatively. Their ages ranged between 34 and 63 years. Mean age 46years. All four fistulae occurred postoperatively. Laparatomy for ectopic pregnancy, bowel obstruction constituted the primary surgery. There were two high output cases and two low output cases. Initial parenteral nutrition was employed in two cases while enterals were used solely in two cases. Fistula closure was achieved in all 4 cases at durations ranging from 7 to 16 days, a mean time of 12.5 days.

Conclusion

Non-operative approach to management for postoperative enterocutaneous fistulas was successful in these cases.

Enterocutaneous fistula: analysis of clinical outcomes from a single Victorian tertiary referral centre

BACKGROUND

Enterocutaneous fistulas (ECFs) are complex and can result in significant morbidity and mortality. The study aimed to evaluate ECF outcomes in a single tertiary hospital.

METHODS

A retrospective study of all patients treated with ECF between the period of January 2009 and June 2014 was conducted. Baseline demographic data assessed included the primary aetiology of the fistula, site of the fistula and output of the fistula. Outcomes measures assessed included re-fistulation rate, return to theatre, wound complications, fistula closure rate and death over the study period.

RESULTS

A total of 16 patients with ECF were recorded within the study period. Mean age of the patient cohort was 55.8 ± 11.8 years with a female predominance (11 females, 5 males). Primary aetiology were Crohn's disease (31%), post intra-abdominal surgery not related to bowel neoplasia (50%) and post intra-abdominal surgery related to bowel neoplasia (19%). Majority of the fistulas developed from the small bowel (75%) and had low output (63%). Operative intervention was required in 81% of patients with an overall closure rate of 100%. Median operations required for successful closure was 1.15 operations. Mean duration between index operation and curative operation was 8 ± 12.7 months.

CONCLUSION

Appropriate bundle of care (perioperative care, surgical timing and surgical technique) can produce excellent results in patients with ECF.

Enterocutaneous Fistula: Proven Strategies and Updates

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

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

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for peritoneal carcinomatosis (PC) from multiple origins, however is associated with increased complications compared to conventional gastrointestinal surgery. The aetiology of enterocutaneous fistulas (ECF) in most cases is a result of various contributing factors and therefore remains a major clinical problem, occurring in 4-34% of patients post-CRS. The aim of this study was to analyze the incidence and outcome of ECF following CRS/HIPEC.

METHOD

From April 1999 to September 2015, 53 patients of 918 CRS/HIPEC procedures developed an ECF. Patient, operative and postoperative data were retrospectively analyzed to determine aetiology, classification outcome and possible contributing factors were reviewed on univariate and multivariate analysis.

RESULTS

We report a 5.8% ECF rate, diagnosed at a median of 13 days. The mortality rate was 5.7% and other morbidity was significantly increased (p = 0.0001). Twenty-five (47.2%), 8 (15.1%) and 20 patients (37.7%) had low, moderate and high output ECF respectively. Patients that had a CC2 cytoreduction, abdominal VAC or smoked had a higher risk of fistula (p = 0.004, p < 0.0001, p = 0.008). Spontaneous closure was achieved in 49.2% with conservative treatment (median 29 days) and 33.9% underwent surgical intervention. Preoperative serum albumin <35 g/L (p = 0.04), PCI>17 (p = 0.025) and operation >8.6 h s (p = 0.001) were independent risk factors on multivariate analysis. Overall and 5-year survival was significantly reduced (p < 0.0001,p = 0.016).

CONCLUSION

CRS/HIPEC remains an effective treatment modality for PC in selected patients with a comparable ECF incidence to reported elective gastrointestinal surgery rates. This study identifies multiple risk factors that should be considered in patients undergoing CRS/HIPEC.

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

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

Interventional radiologic management and treatment of enterocutaneous fistulae

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.

Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches

Damage-control surgery and open-abdomen is an acceptable—and often lifesaving—approach to the treatment of patients with severe trauma, abdominal compartment syndrome, necrotizing soft tissue catastrophes, and other abdominal disasters, when closing the abdomen is not possible, ill advised, or will have serious sequelae. However, common consequences of open-abdomen management include large abdominal wall defects, enterocutaneous fistulas (ECFs), and enteroatmospheric fistulas (EAFs). Furthermore, in such patients, a frozen and hostile abdomen (alone or combined with ECFs) is not uncommon. Adding biologic mesh to our surgical armamentarium has revolutionized hernia surgery.

Surgical management of enterocutaneous fistula

Enterocutaneous (EC) fistula is an abnormal connection between the gastrointestinal (GI) tract and skin. The majority of EC fistulas result from surgery. About one third of fistulas close spontaneously with medical treatment and radiologic interventions. Surgical treatment should be reserved for use after sufficient time has passed from the previous laparotomy to allow lysis of the fibrous adhesion using full nutritional and medical treatment and until a complete understanding of the anatomy of the fistula has been achieved. The successful management of GI fistula requires a multi-disciplinary team approach including a gastroenterologist, interventional radiologist, enterostomal therapist, dietician, social worker and surgeons. With this coordinated approach, EC fistula can be controlled with acceptable morbidity and mortality.

Historical perspectives in the care of patients with enterocutaneous fistula

Evidence can be found throughout surgical history of how devastating an enterocutaneous fistula (ECF) can be for both patient and surgeon. From antiquity, this complication of abdominal surgery, malignancy, radiation, trauma, or inflammatory processes has been a significant challenge to surgeons due to high associated mortality and significant morbidity. An ECF causes dehydration, malnutrition, skin excoriation, and sepsis, and has profound psychological effects on the patient. Recent mortality rates of patients suffering an ECF approach 20%. The authors illustrate the history of management of patients with ECF and discuss advances in perioperative care including parasurgical care, nutrition, wound care, and the history of surgical techniques.