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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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López J, Rodriguez K, Targarona EM, Guzman H, Corral I, Gameros R, Reyes A. Systematic review of cyanoacrylate embolization for refractory gastrointestinal fistulae: a promising therapy. Surg Innov 2014; 22:88-96. [PMID: 24902686 DOI: 10.1177/1553350614535860] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical management of gastrointestinal fistulae has been reported to carry a 30-day morbidity rate up to 82% and a mortality rate ranging from 2% to 4.8%; thus nonoperative alternatives are required. The aim of the present study was to assess the current experience on the use of cyanoacrylates in the management of these fistulae. METHODS A systematic review was carried out on Medline, Embase, The Cochrane database, Academic Search Complete, MedicLatina, and SciELO for English, Spanish, and Portuguese articles dealing with refractory fistulae by means of cyanoacrylate embolization therapy. Publication dates were restricted from 1969 to present. Outcome parameters were study design, number of participants, etiology of the fistula, approach, material used, success rate, complications, and mortality. RESULTS Electronic search yielded a total of 377 articles. After a meticulous screening, only 14 studies dealing with foregut/midgut fistulae and 6 addressing hindgut fistulae were included. All the included articles were prospective and retrospective case series. Cumulative success rate was 81% (range 0% to 100%) and 3 out of 203 patients (1%) developed minor complications. CONCLUSION Cyanoacrylate embolization of nearly all types of refractory gastrointestinal fistulae is a feasible and harmless technique. Prospective controlled studies are required to support the available evidence.
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Affiliation(s)
- Julio López
- Mexican Institute for Social Security, HGZ 11, Delicias, Mexico
| | | | | | - Heber Guzman
- Mexican Institute for Social Security, UMAE 25, Monterrey, Mexico
| | - Iván Corral
- Mexican Institute for Social Security, HGZ 6, Juarez, Mexico
| | - Rene Gameros
- Mexican Institute for Social Security, Chihuahua, Mexico
| | - Arturo Reyes
- Mexican Institute for Social Security, Chihuahua, Mexico
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Dionigi G, Dionigi R, Rovera F, Boni L, Padalino P, Minoja G, Cuffari S, Carrafiello G. Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience. Int J Surg 2007; 6:51-6. [PMID: 17869198 DOI: 10.1016/j.ijsu.2007.07.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 07/19/2007] [Accepted: 07/26/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects. MATERIALS AND METHODS Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present. RESULTS All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800ml/day (range 400-1600ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20-2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis. CONCLUSIONS After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.
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Affiliation(s)
- G Dionigi
- Department of Surgical Sciences, University of Insubria, Viale Borri 57, 21100 Varese, Italy.
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