Management of Enterocutaneous Fistula: Outcomes in 276 Patients

Continuity of Outpatient Care for Patients with an Intestinal Fistula in China

OBJECTIVE

To report on the current state of outpatient nursing care for patients with an intestinal fistula in a stoma clinic in China.

METHODS

This retrospective study included 41 patients with an intestinal fistula who visited the stoma clinic in a tertiary hospital in Shanghai, China, between January 2019 and December 2023. Electronic medical records were selected for analysis of patients' clinical data, fistula diagnosis and treatment process, and outcome regression.

RESULTS

Few patients with an intestinal fistula are referred to the stoma clinic for nursing care (1.29%). At patients' first visit to the stoma clinic, the majority of those with an intestinal fistula (87.80%) had perifistular moisture-associated skin damage (MASD). The mean discolor, erosion, and tissue score was 6.73 ± 4.35, the mean healing time for MASD was 8.77 ± 8.51 days, and the mean number of follow-ups was 3.41 ± 1.92. The majority of patients (87.80%) complained of accompanying pain of different degrees. The mean self-healing time for nonoperative treatment was 301.96 ± 193.95 days. Enterostomal therapists applied the dressings to care for the skin around the fistula and formulated and guided a personalized management method to effectively contain output.

CONCLUSIONS

The quality of outpatient nursing care for patients with an intestinal fistula needs to be optimized. Standardized assessment and individualized precise intervention can reduce the incidence of complications such as MASD and improve the quality of care and prognosis of patients.

A population-based study of incidence, aetiology, treatment and outcome of enterocutaneous fistula

AIM

The aim of this work was to investigate the incidence of enterocutaneous fistula (ECF), including both small bowel and colonic fistulas, in a defined population of 1.04 million during a 10-year period and to describe aetiology, treatments, care consumption and outcome.

METHOD

A comprehensive search algorithm including diagnostic and procedural codes, enterostomal therapy nurse notes and in-hospital care for >60 days yielded 1970 search hits. After reviewing medical records, 187 patients with ECF were identified.

RESULTS

The annual incidence of ECF was 2.3 per 100 000, the incidence of ECF with intestinal failure type II was 0.9 per 100 000. Spontaneous closure of the fistula occurred in 16.0% of patients, while closure was seen in 97.3% of patients who underwent reconstructive surgery with recurrences in 6.7% and 8.3%, respectively. Cumulative ECF-related in-hospital care until closure or end of follow-up was 4 (range 0-61) weeks. Eighty-eight patients (47%) received home-based healthcare including parenteral feeding and/or fistula wound care. The estimated overall mortality at 1, 3 and 5 years was 33.7%, 42.1% and 47.6% respectively. Mortality was mainly in patients without spontaneous closure or reconstructive surgery, and the risk of ECF-related death was 30.2%.

CONCLUSION

This study defines the population-based incidence of ECF and reports a high overall mortality rate. Initial survivors were characterized by either spontaneous closure or eligibility for later reconstructive surgery, but with an eventual mortality rate of approximately 20%. ECF patients are high consumers of care: 55.1% needed ≥4 weeks in hospital and many received home-based healthcare.

Engineered Regenerative and Adhesive Hydrogel for Concurrent Sealing and Healing of Enterocutaneous Fistulas

In addressing the intricate challenges of enterocutaneous fistula (ECF) treatment, such as internal bleeding, effluent leakage, inflammation, and infection, our research is dedicated to introducing a regenerative adhesive hydrogel that can seal and expedite the healing process. A double syringe setup was utilized, with dopagelatin and platelet-rich plasma (PRP) in one syringe and Laponite and sodium periodate in another. The hydrogel begins to cross-link immediately after passing through a mixing tip and exhibits tissue adhesive properties. Results demonstrated that PRP deposits within the pores of the cross-linked hydrogel and releases sustainably, enhancing its regenerative capabilities. The addition of PRP further improved the mechanical properties and slowed down the degradation of the hydrogel. Furthermore, the hydrogel demonstrated cytocompatibility, hemostatic properties, and time-dependent macrophage M1 to M2 phase transition, suggesting the anti-inflammatory response of the material. In an in vitro bench test simulating high-pressure fistula conditions, the hydrogel effectively occluded pressures up to 300 mmHg. In conclusion, this innovative hydrogel holds promise for ECF treatment and diverse fistula cases, marking a significant advancement in its therapeutic approaches.

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.

Injectable Nanoengineered Adhesive Hydrogel for Treating Enterocutaneous Fistulas

Enterocutaneous fistula (ECF) is a severe medical condition where an abnormal connection forms between the gastrointestinal tract and skin. ECFs are, in most cases, a result of surgical complications such as missed enterotomies or anastomotic leaks. The constant leakage of enteric and fecal contents from the fistula site leads to skin breakdown and increases the risk of infection. Despite advances in surgical techniques and postoperative management, ECF accounts for significant mortality rates, estimated between 15-20%, and causes debilitating morbidity. Therefore, there is a critical need for a simple and effective method to seal and heal ECF. Injectable hydrogels with combined properties of robust mechanical properties and cell infiltration/proliferation have the potential to block and heal ECF. Herein, we report the development of an injectable nanoengineered adhesive hydrogel (INAH) composed of a synthetic nanosilicate (Laponite®) and a gelatin-dopamine conjugate for treating ECF. The hydrogel undergoes fast cross-linking using a co-injection method, resulting in a matrix with improved mechanical and adhesive properties. INAH demonstrates appreciable blood clotting abilities and is cytocompatible with fibroblasts. The adhesive properties of the hydrogel are demonstrated in ex vivo adhesion models with skin and arteries, where the volume stability in the hydrated internal environment facilitates maintaining strong adhesion. In vivo assessments reveal that the INAH is biocompatible, supporting cell infiltration and extracellular matrix deposition while not forming fibrotic tissue. These findings suggest that this INAH holds promising translational potential for sealing and healing ECF.

An alternative negative pressure treatment for enteroatmospheric fistula resulting from small intestinal leakage caused by incision dehiscence

BACKGROUND

To investigate the efficacy of an alternative negative pressure treatment for the treatment of enteroatmospheric fistula transformed from small intestinal leakage due to incision dehiscence after abdominal surgery.

METHODS

Patients with an enteroatmospheric fistula from small intestinal leakage owing to incision dehiscence following abdominal surgery between January 2010 and December 2019 were retrospectively reviewed.

RESULTS

A total of 83 patients (mean age: 38.3 ± 11.6 years; Body mass index: 19.9 ± 2.2 kg/m2) were enrolled. Of the 83 patients, 59 (71.1 %) achieved fistula closure. High-output fistula (Hazard ratio = 0.48; 95 % Confidence interval: 0.29-0.81; P = 0.006) and abdominal wall thickness >2 cm (Hazard ratio = 2.76; 95 % Confidence interval: 1.35-5.67; P = 0.006) were identified as factors affecting fistula closure. Lastly, 11/83 (13.3 %) patients exhibited re-dehiscence.

CONCLUSION

Appropriately applying the alternative negative pressure treatment may enable fistula closure in patients with enteroatmospheric fistula resulting from small intestinal leakage caused by incision dehiscence.

Adipose tissue-derived stem cells as a therapeutic strategy for enterocutaneous fistula: an experimental model study

PURPOSE

Enterocutaneous fistula (ECF) is a condition in which there is an abnormal connection between the intestinal tract and the skin. It can lead to high morbidity and mortality rates despite the availability of therapeutic options. Stem cells have emerged as a potential strategy to treat ECF. This study aimed to evaluate the effect of adipose tissue-derived stem cells (ASC) on ECF in an experimental model.

METHODS

ECF was induced in 21 Wistar rats, and after one month, they were divided into three groups: control group (C), culture medium without ASC group (CM), and allogeneic ASC group (ASC). After 30 days, the animals underwent macroscopic analysis of ECF diameter and histopathological analysis of inflammatory cells, tissue fibrosis, and vascular density.

RESULTS

The study found a 55% decrease in the ECF diameter in the ASC group (4.5 ± 1.4 mm) compared to the control group (10.0 ± 2.1 mm, p = 0.001) and a 59.1% decrease in the CM group (11.0 ± 4.3 mm, p = 0.003). The fibrosis score in the ASC group was 20.9% lower than the control group (p = 0.03). There were no significant differences in inflammation scores among the three groups.

CONCLUSIONS

This study suggests that ASC treatment can reduce ECF diameter, and reduction in tissue fibrosis may be a related mechanism. Further studies are needed to understand the underlying mechanisms fully.

Medical management of small uterocutaneous fistulae with gonadotrophin releasing hormone analogs: Case report and literature review

Conventional management of uterocutaneous fistula involves open or laparoscopic excision as well as hysterectomy but there is now increasing recognition of successful medical treatment with gonadotrophin releasing hormone agonists. We describe the fourth case in the literature of successful nonsurgical treatment of uterocutaneous fistula and discuss two important factors affect the success of medical management, namely the size of the fistula and the duration of treatment. We would recommend that a trial of gonadotrophin releasing hormone analogues for at least 6 months particularly in cases of uterocutaneous fistula of 5 mm or less in diameter as this conservative treatment is likely to obviate the need for more hazardous surgical intervention.

Healthcare professionals' experiences of providing care for patients with enterocutaneous fistula in hospital and in homecare: A qualitative study

BACKGROUND

Enterocutaneous fistula is a rare but complex and serious condition that is both physically and psychologically demanding for the person affected. Infection, fistula dressing problems, electrolyte and fluid imbalance and malnutrition render the individual in need of long periods of in-hospital care and homecare. This place great demands on patients, families, and healthcare professionals. More research is needed to bridge the gap between hospital and home-based healthcare services.

AIM

To explore healthcare professionals' experiences of providing care for patients with enterocutaneous fistula in hospital and in homecare.

MATERIAL AND METHODS

A qualitative descriptive study design based on five focus group interviews involving 20 healthcare professionals. Data was analysed using content analysis.

RESULTS

Three categories with seven corresponding subcategories were developed; 1) Providing care for patients with enterocutaneous fistula in the hospital and at home was complex and time and resource consuming. Participants were struggling with practical issues and lacked disease-specific knowledge and skills; 2) Caring requires an integrated approach but it was challenging to work interprofessionally and cope with barriers in collaboration between providers; 3) Building long lasting relationships with patients and their families was fundamental to the caring process. Participants needed to hide their own feelings related to smell and appearance of the fistula as well as frustration when the fistula dressing did not hold without leaking. The healthcare professionals expressed that the involvement of the patient and their close family was important when proving care, likewise, to have a great understanding of the patients' suffering.

DISCUSSION

The care of patients with enterocutaneous fistula is complex and means engagement for long periods, both in hospital and in home-based healthcare. Regular team meetings of the multidisciplinary team, careful planning before discharge and providing person-centred care can facilitate the care process.

Rare sigmoid abdominal wall fistula after appendectomy: a case report

An extraintestinal fistula is a rare complication after appendectomy. To our knowledge, this study is the first to report a case of sigmoid abdominal wall fistula after appendectomy in a 45-year-old male patient who underwent appendectomy due to acute appendicitis. Purulent discharge was noted at the abdominal wall incision wound for more than 1 year postoperatively. The patient's clinical manifestation, medical history, physical examination, and auxiliary examination all suggested the formation of an abdominal sinus. After exploratory laparotomy at the Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, a diagnosis of sigmoid abdominal wall fistula was confirmed, and the fistula was cured after complete fistula resection. The reporting of this rare and atypical case may provide useful reference information for diagnosing and treating future cases of enterocutaneous fistula.

Duration of postoperative hyperlactatemia has predictive value in recurrent fistula after major definitive surgery for intestinal fistula

PURPOSE

The present study aimed to identify the predictive value of duration of postoperative hyperlactatemia in screening patients at high risk of recurrent fistula after major definitive surgery (DS) for intestinal fistula.

METHODS

If the initial postoperative lactate (IPL) > 2 mmol/L, DS was defined as major definitive surgery. The 315 enrolled patients with major DS were divided into group A (2 mmol/L < IPL ≤ 4 mmol/L), group B (mmol/L < IPL ≤ 6 mmol/L), and group C (IPL > 6 mmol/L). The characteristics of patients were collected, and the duration of postoperative hyperlactatemia was analyzed. According to the occurrence of recurrent fistula (RF), patients were further divided into RF group A, and Non-RF group A; RF group B, and Non-RF group B; and RF group C, and Non-RF group C.

RESULTS

The duration of postoperative hyperlactatemia was comparable between the RF group A and the Non-RF group A [12 (IQR: 12-24) vs 24 (IQR: 12-24), p = 0.387]. However, the duration of hyperlactatemia was associated with RF in group B (adjusted OR = 1.061; 95% CI: 1.029-1.094; p < 0.001) and group C (adjusted OR = 1.059; 95% CI: 1.012-1.129; p = 0.017). In group B, the cutoff point of duration of 42 h had the optimal predictive value (area under ROC = 0.791, sensitivity = 0.717, specificity = 0.794, p < 0.001). In group C, the cutoff point of duration of 54 h had the optimal predictive value (area under ROC = 0.781, sensitivity = 0.730, specificity = 0.804, p < 0.001).

CONCLUSION

The duration of postoperative hyperlactatemia has a value in predicting RF in patients with an IPL of more than 4 mmol/L after major definitive surgery for intestinal fistula.

Regenerative medicine for digestive fistulae therapy: Benefits, challenges and promises of stem/stromal cells and emergent perspectives via their extracellular vesicles

Despite current management strategies, digestive fistulae remain extremely debilitating complications associated with significant morbidity and mortality, generating a need to develop innovative therapies in these indications. A number of clinical trials and experimental studies have thus investigated the potential of stem/stromal cells (SCs) or SC-derived extracellular vesicles (EVs) administration for post-surgical and Crohn's-associated fistulae. This review summarizes the physiopathology and current standards-of-care for digestive fistulae, along with relevant evidence from animal and clinical studies regarding SC or EV treatment for post-surgical digestive fistulae. Additionally, existing preclinical models of fistulizing Crohn's disease and results of SC therapy trials in this indication will be presented. The optimal formulation and administration protocol of SC therapy products for gastrointestinal fistula treatment and the challenges for a widespread use of darvadstrocel (Alofisel) in clinical practice will be discussed. Finally, the potential advantages of EV therapy and the obstacles towards their clinical translation will be introduced.

Assessment of button-type jejunostomy for nutritional management after esophagectomy in 201 cases

BACKGROUND

Many surgeons preferably place a trans-nasal feeding tube or a feeding enterostomy for post-operative nutritional management after esophagectomy. Various types of tubes (such as nasogastric, transgastric, transduodenal, or transjejunal tubes) have been used for enteral feeding; however, the appropriate enteral feeding routes have not yet been proposed. Therefore, this study aimed to evaluate the feasibility and safety of button-type jejunostomy.

METHODS

We reviewed 201 patients who underwent esophagectomy with placement of a button-type jejunostomy at the Jikei University Hospital (Tokyo, Japan) between 2008 and 2019. The analyzed variables included clinicopathological characteristics, operative data, jejunostomy-related characteristics, and postoperative complications. Postoperative bodyweight loss was examined 6 months and 1 year after the operation.

RESULTS

Refractory enterocutaneous fistula and bowel obstruction occurred in 13 (6.5%) and 14 (7.0%) patients, respectively. The body mass index at button-type jejunostomy removal was significantly lower and the duration of button-type jejunostomy placement was significantly longer in patients with a refractory enterocutaneous fistula (p = 0.023 and p < 0.001, respectively). Bowel obstruction was significantly more likely to develop in patients with a non-squamous cell carcinoma (p = 0.021) and in patients who underwent open abdominal procedures (p < 0.001). After 1 year, the median bodyweight losses were 12.1% and 15.6% in patients with short and long jejunostomy placement durations (p = 0.642), respectively.

CONCLUSION

A button-type jejunostomy is durable and allows easy self-management for maintaining the bodyweight without any adverse events. However, it is strongly recommended that the button be removed within a year to prevent refractory enterocutaneous fistula formation.

Enhancing digestive fistula healing by the off-label use of a thermoresponsive vessel occluder polymer associated with esophageal stent placement: A case report

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.

Risk factors, outcomes, and complications associated with combined ventral hernia and enterocutaneous fistula single-staged abdominal wall reconstruction

PURPOSE

To compare two cohorts of patients; those with isolated ventral hernias (VH) and those with VH and enterocutaneous fistulas (ECF). Risk factors for surgical complications (including recurrent ECF) and outcomes during single-stage VH with ECF surgical reconstruction were analyzed.

METHODS

A retrospective review was performed from 2008 to 2019. We compared two cohorts of patients with single-stage VH repairs: (1) ventral hernia repair alone (hernia alone), and (2) combined VH repair and ECF repair (hernia plus ECF). Inclusion criteria were patients ≥ 18 years of age with pre-operative VH either with or without an ECF, who underwent open hernia repair and ECF repair in a single-stage operation, with a minimum follow-up of 12 months. Patient risk factors, operative characteristics, outcomes and surgical-site complications were compared using univariate and multivariate analyses.

RESULTS

We included 442 patients (hernia alone = 401; hernia plus ECF = 41) with a median follow-up of 22 months (12-96). Hernia plus ECF patients were more likely to have inflammatory bowel disease (IBD)(OR 4.4, 95% CI 1.1-17.5, p = 0.037), a history of abdominal wound infections (OR 3.4, 95% CI 1.5-7.9, p = 0.004), reoperations (OR 4.9, 95% CI 1.6-15.4, p = 0.006), superficial soft tissue infections (OR 2.5, 95% CI 1.1-6.1, p = 0.044) and hematomas (OR 8.4, 95% CI 1.2-58.8, p = 0.031), compared to hernia alone patients. ECF recurrence was associated with diabetes mellitus (DM) (n = 8, 73% vs. n = 6, 20%; p = 0.003) and surgical-site complications (n = 10, 91% vs. n = 16, 53%; p = 0.048), compared to ECF resolution.

CONCLUSION

Risk factors for developing ECF were IBD and history of abdominal wound infections. Single-staged combined ECF reconstruction was associated with reoperations, soft tissue infections and hematomas. DM and surgical-site complications were associated with ECF recurrence.

Open Abdomen Negative Pressure Device Applied for Two-stage Closure of Enterocutaneous Fistula

Enterocutaneous fistula (ECF), which is an abnormal connection between the gastrointestinal tract and skin, is a serious complication of abdominal surgery, and a multidisciplinary approach is required for its treatment. Here, we report the case of a 46-year-old woman who had a large ECF measuring 6 × 12 cm that was successfully treated with a 2-stage surgery. After the first surgery of intestinal wall reconstruction, an abdominal negative pressure wound therapy (NPWT) device was administered to facilitate the reexploration of the abdominal cavity. On postoperative day 5, intestinal perforation and abdominal cavity infection were found during dressing change and were immediately repaired. Subsequently, after 10 days of abdominal NPWT, the second surgery comprising abdominal wall reconstruction was performed using a pedicled anterolateral thigh flap (8 × 19 cm) combined with the fascia lata (12 × 20 cm). The defective rectus sheath and skin were uneventfully closed with the fascia lata and flap skin paddle, respectively. In the follow-up after 7 months, ECF had not recurred. The abdominal NPWT device enabled easy reentry of the abdominal cavity and reduced the size of the flap needed to cover the defect. Moreover, open abdominal management can be performed consistently, independent of the surgeon’s expertise. Therefore, this report suggests that 2-stage surgery with abdominal NPWT management is a useful strategy for ECF treatment.

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

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.

[Features and choice of surgical strategy in patients with gastrointestinal fistulas]

OBJECTIVE

To evaluate the features and choice of surgical strategy in patients with gastrointestinal fistula based on classification of their types.

MATERIAL AND METHODS

There were 398 patients with gastrointestinal fistula. Fistula type 1 was found in 126 (31.7%) cases, type 2 - 38 (9.6%) cases, type 3 - 73 (18.3%) cases, type 4 - 26 (6.5%) patients, type 5 - 135 (33.9%) cases. One-stage and two-stage treatment was applied in patients with fistula type 1, two-stage treatment only - for fistula type 2. In patients with fistula type 3, treatment strategy depended on timing of fistula formation, its level and amount of intestinal chymus loss. In case of fistula type 4, radical treatment is difficult. However, surgery is safer when adhesions between intestinal loops are not yet dense enough. Indeed, dissection is associated with less risk of their damage. Reconstructive procedures were applied for fistula type 5 depending on its localization.

RESULTS

The causes of gastrointestinal fistula were complications after surgery for acute ileus in 73 patients (17 ones died), blunt abdominal trauma in 81 (8), open abdominal trauma with cold weapons in 39 (6) and firearms in 11 cases (2), mesenteric thrombosis in 33 patients (8), pancreatic necrosis in 25 cases (9), abdominal hernia in 15 cases (4), acute appendicitis in 40 patients (3), colonic diverticulosis in 24 patients (1), urological diseases in 5 cases, colon perforation by a foreign body in 3 cases, colonoscopy in 5 patients, Hirschsprung's disease in 2 patients, Crohn's disease in 11 cases (3), colon polyps in 4 patients, intestinal tuberculosis in 1 case (1), small bowel resection for obesity in 1 patient and gynecological diseases in 25 patients (2). Fistulas type 1 and 4 were followed by the highest postoperative mortality since these interventions are associated with the most severe changes in abdominal cavity. Low mortality was observed in patients with fistula type 5, no abdominal inflammation and normalized intestinal passage. The overall mortality in patients with gastrointestinal fistulas was 16.1%.

CONCLUSION

Treatment strategy in patients with gastrointestinal fistula primarily depends on the type of fistula that requires emergency, urgent, delayed or reconstructive surgery. Staged approach in patients with gastrointestinal fistulas can improve treatment outcomes.

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression

The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.

Combined stomach and duodenal perforating injury following blunt abdominal trauma: a case report and literature review

Background

Gastrointestinal injury following blunt abdominal trauma is uncommon; a combined stomach and duodenal perforating injury is even more rare. Because these two organs are located in different spaces in the abdomen, such injuries are difficult to identify.

Case presentation

A young woman involved in a motor vehicle crash presented to our emergency department with concerns of severe peritonitis. Contrast-enhanced computed tomography of the abdomen revealed pneumoperitoneum and retroperitoneal hematoma in zone 1. An emergency laparotomy was performed, revealing a stomach-perforating injury, which was resolved with primary repair. No obvious injury was observed on retroperitoneal exploration. However, peritonitis presented again on the second postoperative day, and a second laparotomy was performed, revealing a duodenum-perforating injury in its third portion. We performed primary repair with multi-tube-ostomy. The patient recovered well without permanent tube placement or internal bypass.

Conclusions

Assessing associated injuries in blunt abdominal trauma is crucial because they may be fatal if timely intervention is not undertaken. These types of complicated injuries require a feasible surgical strategy formulated by experienced surgeons, which gives the patient a better chance of survival.

The successful management for long-term intractable enteroatmospheric fistula: A case report

Introduction

Efficacy of open abdomen management with negative pressure wound therapy for enteroatmospheric fistula has been performed. But, few reports have shown its utility for enteroatmospheric fistula several years after onset.

Presentation of case

A 46 year-old woman underwent total colectomy due to total ulcerative colitis in her twenties. Three years before the onset of enteroatmospheric fistula, she underwent simple total hysterectomy for uterine smooth muscle tumor. Small bowel obstruction occurred early and a small bowel bypass was performed. However, she had sudden abdominal pain and was diagnosed with anastomotic leakage of small bowel bypass. Although antibiotic treatment was initiated, infection was difficult to control, and a midline abdominal incision was performed, followed by the formation of enteroatmospheric fistula. She declined early surgical intervention and started receiving home parenteral nutrition with antibiotic treatment. Although central vein management was continued, catheter infection became frequent. Hence, surgical intervention was planned 30 months after the formation of enteroatmospheric fistula. Two-stage abdominal wall reconstruction using open abdomen management with negative pressure wound therapy was planned. The definitive abdominal wall reconstruction was performed 14 days after the initial operation. Finally, she was discharged without reoperation.

Discussion

Enteroatmospheric fistula has no overlying soft tissue and no real fistula tract. Besides these complications, there were complications of the scarred abdominal wall from intestinal fluid exposure for 30 months.

Conclusion

The strategy using open abdomen management with negative pressure wound therapy for long-term enteroatmospheric fistula will have a good postoperative outcome with the same as early intervention.

•

Negative pressure wound therapy is effective in postonset enteroatmospheric fistula.

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It repairs abdominal wall skin damage from 30-month intestinal fluid exposure.

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Open abdominal management was able to control infection in the perioperative period.

Factitious Disorder Presenting with Refractory Enterocutaneous Fistula that Underwent 7 Surgeries

The formation of a post-appendicectomy fistula is rare but devastating. Major etiological factors include leakage from the appendiceal stump, neoplasm of the appendix and/or cecum, infection, inflammatory bowel disease, and distal obstruction. The management of enterocutaneous fistula involves enteral nutrition, drainage, antibiotic coverage, as well as surgical excision and segmental resection of the involved bowel. Here we present a case where a young female suffered from refractory enterocutaneous fistula after appendicectomy. Despite extensive treatments, her symptoms persisted and contradicted with objective test results. Therefore, a diagnosis of factitious disorder was suspected. After questioning, she finally admitted to having applied feces to her wound to fake fistula. It was estimated that the lifetime prevalence of factitious disorder in the general population was 0.1%, which warrants the awareness of clinicians.

Enterocutaneous Fistula: A Simplified Clinical Approach

A “fistula” is an abnormal connection between two epithelial surfaces. Fistulae are named based on the two surfaces or lumens they connect to. Fistulae form due to loss of wall integrity from an underlying insult, leading to the penetrance of an adjacent organ or epithelized surface. Common causes of small bowel fistulae include sequelae of surgical intervention, foreign body, bowel diverticula, Crohn's disease, malignancy, radiation, and infection. A histopathological analysis displays acute and/or chronic inflammation due to the underlying pathology.

A thorough history and physical examination are important components of patient evaluation. Generally, patients will present with non-specific constitutional symptoms in addition to local symptoms attributed to the fistula. In rare instances, symptoms may be severe and life-threatening. Initial laboratory workup includes complete blood count, comprehensive metabolic panel, and lactate level. Radiologic imaging is useful for definitive diagnosis and helps delineate anatomy. In practice, computed tomography (CT) is the initial imaging modality. The addition of intravenous or enteric contrast may be helpful in certain situations. Magnetic resonance imaging (MRI) may also be used in special circumstances. Invasive procedures, such as endoscopy, can assist in the evaluation of mucosal surfaces to diagnose pathology such as inflammatory processes.

Appropriate management should include optimizing nutritional status, delineating fistulous tract anatomy, skincare, and managing the underlying disease. A non-operative approach is generally accepted as the initial approach especially in the acute/subacute setting. However, operative intervention is indicated in the setting of failed non-operative management. Successful management of small bowel fistulae requires a multidisciplinary team approach.

To conclude, a small bowel fistula is a complex clinical disease, with surgical intervention being the most common cause in developed countries. The non-operative approach should be trialed before an operative approach is considered.

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

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

Prevalence and Risk Factors for Pressure Ulcers in Patients with Enterocutaneous Fistula: A Retrospective Single-Center Study in China

BACKGROUND Prevalence and associated risk factors for pressure ulcers (PU) vary in different body areas and diseases. Few studies have focused on PU in patients with enterocutaneous fistula (ECF). The aim of the present study was to investigate the prevalence and risk factors for PU in patients with ECF. MATERIAL AND METHODS From January 2016 to June 2016, medical records of 140 patients with ECF who were transferred to the Enterocutaneous Fistula Treatment Center, Jinling Hospital, were reviewed and analyzed. The prevalence of PU was investigated. To evaluate the risk factors for PU in patients with ECF, 5 patients with PU before admission were excluded, and the remaining 135 patients were divided into 2 groups: the PU group and the non-PU group. The risk factors for PU were confirmed by multivariate logistic regression analysis of characteristics on admission. RESULTS There were 42 cases with PU (5 cases with PU before admission, 37 cases with PU in the treatment after admission), and the prevalence of PU in patients with ECF was 30%. In addition, Braden risk score <19 (OR=9.33, CI: 2.80-31.08, p<0.001); underweight (BMI<18.5) (OR=5.21, CI: 1.65-16.39, p=0.005); onset of duodenal fistula (OR=4.86, CI: 1.33-17.78, p=0.017); diabetes (OR=4.95, CI: 1.03-23.85, p=0.046); and APACHE II score (OR=1.34, CI: 1.04-1.72, p=0.019) were associated with PU. CONCLUSIONS The PU prevalence was 30% in patients with ECF. Braden risk score <19, underweight, onset of duodenal fistula, diabetes, and APACHE II score were risk factors for PU in patients with ECF.

Thermoresponsive Gel Embedded with Adipose Stem-Cell-Derived Extracellular Vesicles Promotes Esophageal Fistula Healing in a Thermo-Actuated Delivery Strategy

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.