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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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de Barros NR, Gangrade A, Elsebahy A, Chen R, Zehtabi F, Ermis M, Falcone N, Haghniaz R, Khosravi S, Gomez A, Huang S, Mecwan M, Khorsandi D, Lee J, Zhu Y, Li B, Kim H, Thankam FG, Khademhosseini A. Injectable Nanoengineered Adhesive Hydrogel for Treating Enterocutaneous Fistulas. Acta Biomater 2024; 173:231-246. [PMID: 38465268 PMCID: PMC10919932 DOI: 10.1016/j.actbio.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
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.
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Affiliation(s)
- Natan Roberto de Barros
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Ankit Gangrade
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Ahmad Elsebahy
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - RunRun Chen
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Fatemeh Zehtabi
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Menekse Ermis
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Natashya Falcone
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Reihaneh Haghniaz
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Safoora Khosravi
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Alejandro Gomez
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Shuyi Huang
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Marvin Mecwan
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Danial Khorsandi
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Junmin Lee
- Department of Materials Science and Engineering, Pohang University of Science and Technology (POSTECH), Pohang, Gyeongbuk, 37673, Republic of Korea
| | - Yangzhi Zhu
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - Bingbing Li
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
| | - HanJun Kim
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
- College of Pharmacy, Korea University, Sejong, Republic of Korea, 30019
| | - Finosh G Thankam
- Department of Translational Research, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Ali Khademhosseini
- Terasaki Institute for Biomedical Innovation (TIBI), 1018 Westwood Blvd, Los Angeles, California, USA
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Liang S, Zheng Z, Li Y, Yang Y, Qin L, Zhao Z, Wang L, Wang H. A review of platelet-rich plasma for enteric fistula management. Front Bioeng Biotechnol 2023; 11:1287890. [PMID: 38033816 PMCID: PMC10685294 DOI: 10.3389/fbioe.2023.1287890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023] Open
Abstract
Enteric fistula (EF), a serious complication after abdominal surgery, refers to unnatural communication between the gastrointestinal tract and the skin or other hollow organs. It is associated with infection, massive fluid/electrolyte loss, and malnutrition, resulting in an unhealed course. Despite advances in surgical techniques, wound care, infection control, and nutritional support, EF remains associated with considerable morbidity and mortality. Autologous platelet-rich plasma (PRP) containing elevated platelet concentrations has been proposed to promote healing in many tissues. However, the mechanism of action of PRP in EF treatment remains unclear owing to its complicated clinical manifestations. In this review, we summarized the clinical approaches, outlined the principal cytokines involved in the healing effects, and discussed the advantages of PRP for EF therapy. In addition, we defined the mechanism of autologous PRP in EF management, which is essential for further developing EF therapies.
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Affiliation(s)
- Shuang Liang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
- Department of Clinical Laboratory, Zhangdian District People’s Hospital of Zibo City, Zibo, China
| | - Zhiqiang Zheng
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yaxin Li
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuanming Yang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lifeng Qin
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhen Zhao
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Licun Wang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haiyan Wang
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
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Pagotto VPF, Camargo CP, Cáceres PV, Altran SC, Gemperli R. Adipose tissue-derived stem cells as a therapeutic strategy for enterocutaneous fistula: an experimental model study. Acta Cir Bras 2023; 38:e384523. [PMID: 37851787 PMCID: PMC10578092 DOI: 10.1590/acb384523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/14/2023] [Indexed: 10/20/2023] Open
Abstract
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.
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Affiliation(s)
- Vitor Penteado Figueiredo Pagotto
- Universidade de São Paulo – Faculdade de Medicina – Disciplina de Cirurgia Plástica – São Paulo (SP) – Brazil
- Universidade de São Paulo – Faculdade de Medicina – Hospital das Clínicas – Serviço de Cirurgia Plástica – São Paulo (SP) – Brazil
| | - Cristina Pires Camargo
- Universidade de São Paulo – Faculdade de Medicina – Disciplina de Cirurgia Plástica – São Paulo (SP) – Brazil
- Universidade de São Paulo – Faculdade de Medicina – Hospital das Clínicas – Serviço de Cirurgia Plástica – São Paulo (SP) – Brazil
- Universidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil
| | - Paula Vitória Cáceres
- Universidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil
| | - Silvana Cereijido Altran
- Universidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil
| | - Rolf Gemperli
- Universidade de São Paulo – Faculdade de Medicina – Disciplina de Cirurgia Plástica – São Paulo (SP) – Brazil
- Universidade de São Paulo – Faculdade de Medicina – Hospital das Clínicas – Serviço de Cirurgia Plástica – São Paulo (SP) – Brazil
- Universidade de São Paulo – Faculdade de Medicina – Laboratório de Investigação Médica – São Paulo (SP) – Brazil
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N S, Jhanwar A, Singh N. Superior Mesenteric Artery (SMA) Syndrome With Enterocutaneous Fistula in a Young Woman: A Rare Association. Cureus 2023; 15:e39696. [PMID: 37398828 PMCID: PMC10308805 DOI: 10.7759/cureus.39696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
Superior mesenteric artery (SMA) syndrome is also known as Wilkie's syndrome. Sometimes it is the cause of obstruction in the duodenum. In SMA syndrome, the acute angulation of the SMA against the abdominal aorta can prevent duodenal contents from draining into the jejunum (upper small intestine); hence inadequate intake of nutrition leads to weight loss and malnutrition. This is primarily attributed to the loss of intervening pad of mesenteric fat tissue due to various debilitating conditions. Abnormal connections between the intra-abdominal gastrointestinal tracts and skin over the abdomen are known as enterocutaneous fistulas (ECF). In this case report, a 37-year-old woman with a history of chronic dull pain in the upper abdominal region over the last seven months, who also complained of bloating, infrequent vomiting, nausea, and upper abdominal fullness for the same amount of time, was seen in the emergency room. Her symptoms had deteriorated by the time she approached the hospital. Additionally, she reports having had a foul-smelling, purulent discharge for the past five years right below the umbilicus. Upon close investigation, it was determined to be feces, and it was later discovered to be a low-output enterocutaneous fistula. She describes having an exploratory laparotomy and adhesiolysis for an intra-abdominal abscess and an acute intestinal obstruction caused by adhesions. This case emphasizes the provocation given a diagnosis of SMA syndrome with enterocutaneous fistula and demands increased awareness of this entity. This will ameliorate early identification to reduce immaterial tests and irrelevant treatments.
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Affiliation(s)
- Shreyas N
- Surgery, Ananta Institute Of Medical Sciences and Research Centre, Udaipur, IND
| | - Atul Jhanwar
- Surgery, Ananta Institute Of Medical Sciences and Research Centre, Udaipur, IND
| | - Narender Singh
- General Surgery, Dr. Sampurnanand Medical College, Jodhpur, IND
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Wu TY, Lo KH, Chen CY, Hu JM, Kang JC, Pu TW. Cecocutaneous fistula diagnosed by computed tomography fistulography: A case report. World J Gastrointest Surg 2022; 14:1161-1168. [PMID: 36386395 PMCID: PMC9640336 DOI: 10.4240/wjgs.v14.i10.1161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/08/2022] [Accepted: 10/05/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Enterocutaneous fistula (ECF) is an abnormal communication between the skin and the gastrointestinal tract and is associated with considerable morbidity and mortality. To diagnose ECF, X-ray fistulography and abdominal computed tomography (CT) with intravenous or oral contrast are generally used. If the anatomic details obtained from CT are insufficient, CT fistulography may help diagnose and determine the extent of the abnormal channel. However, CT fistulography is seldom performed in patients with insufficient evidence of a fistula.
CASE SUMMARY A 35-year-old man with a prior appendectomy presented with purulence over the abdominal wall without gastrointestinal tract symptoms or a visible opening on the abdominal surface. His history and physical examination were negative for nausea, diarrhea, muscle guarding, and bloating. Local abdominal tenderness and redness over a purulent area were noted, which led to the initial diagnosis of cellulitis. He was admitted to our hospital with a diagnosis of cellulitis. We performed a minimal incision on the carbuncle to collect the pus. The bacterial culture of the exudate resulted positive for Enterococcus sp. ECF was thus suspected, and we arranged a CT scan for further investigation. CT images before intravenous contrast administration showed that the colon was in close contact with the abdominal wall. Therefore, we conducted CT fistulography by injecting contrast dye into the carbuncle during the CT scan. The images showed an accumulation of the contrast agent within the subcutaneous tissues, suggesting the formation of an abscess. The contrast dye tracked down through the muscles and peritoneum into the colon, delineating a channel connecting the subcutaneous abscess with the colon. This evidence confirmed cecocutaneous fistula and avoided misdiagnosing ECF without gastrointestinal tract symptoms as cellulitis. The patient underwent laparoscopic right hemicolectomy with re-anastomosis of the ileum and transverse colon.
CONCLUSION CT fistulography can rule out ECF in cases presenting as cellulitis if examinations are suggestive.
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Affiliation(s)
- Tung-Yen Wu
- Department of Surgery, Tri-Service General Hospital Songsang Branch, Taipei 105, Taiwan
| | - Kuang-Hua Lo
- Department of Surgery, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Chao-Yang Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, Taipei 114, Taiwan
| | - Je-Ming Hu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, Taipei 114, Taiwan
| | - Jung-Cheng Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Taiwan Adventist Hospital, Taipei 105, Taiwan
| | - Ta-Wei Pu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital Songsang Branch, National Defense Medical Center, Taipei 105, Taiwan
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Pepin EW, Nordeck SM, Fetzer DT. Nontraditional Uses of US Contrast Agents in Abdominal Imaging and Intervention. Radiographics 2022; 42:1724-1741. [DOI: 10.1148/rg.220016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Eric W. Pepin
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9096
| | - Shaun M. Nordeck
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9096
| | - David T. Fetzer
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9096
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Treatment of enterocutaneous fistula: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:863-874. [PMID: 35915291 DOI: 10.1007/s10151-022-02656-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/20/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Enterocutaneous fistula (ECF) is an abnormal communication between the gastrointestinal tract and skin, with a myriad of etiologies and therapeutic options. Management is influenced by etiology and specifics of the ECF, and patient-related factors. The aim of this study was to assess overall success, recurrence, and mortality rates of treatment for ECF. MATERIALS A systematic search of PubMed and Google Scholar was performed through October 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports, reviews, animal studies, studies not reporting outcomes, had no available English text, included patients < 16 years old or those assessing other abdominocutaneous/internal fistulas were excluded. RESULTS Fifty-three studies, between 1975 and 2020, incorporating 3078 patients were included. Patient age ranged between 16 and 87 years with a male:female ratio of 1.14:1. ECF developed postoperatively in 89.4%. Other common etiologies were inflammatory bowel disease, trauma, malignancy, and radiation. At least 28% of patients had complex fistulae (reported in 18 studies). Most common fistula site was small bowel. In 34 publications, 62.4% (n = 1371) patients received parenteral nutrition. In 45 publications, 72.5% underwent surgery to treat the fistula. Meta-analysis revealed an 89% healing rate; recurrence rate after initial successful treatment was 11.1%, and mortality rate was 8.5%. In a subgroup of patients who underwent combined ECF takedown and abdominal wall reconstructions (n = 315), 78% achieved fascial closure, mesh was used in 72%, hernia, and fistula recurrence rates were 19.7% and 7.6%, respectively. CONCLUSIONS Treatment of ECF must be individualized according to specific etiology and location of the fistula and the patient's associated conditions.
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Basukala S, Khand Y, Pahari S, Mainali P, Gurung N, Gurung S. Colorectal carcinoma presenting as spontaneous colocutaneous fistula - A rare case report and review of literature. Int J Surg Case Rep 2022; 96:107346. [PMID: 35763969 PMCID: PMC9237932 DOI: 10.1016/j.ijscr.2022.107346] [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: 04/27/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Colon cancer presenting as spontaneous enterocutaneous fistula are rare with only few cases reported in the literature. Such presentation signifies locally advanced disease with poorer outcomes. Enterocutaneous fistula increases morbidity and mortality in cancer and may potentially delay the definitive care. It poses a difficulty in management in terms of patient optimization, determining the type of resection (palliative or curative) and the operative timeline. CASE PRESENTATION A 47 years old female presented with complaints of foul smelling discharge from a fistulous opening in right iliac fossa with occasional per rectal bleeding for the past six months. Imaging showed ascending colon mass breaching the peritoneum with fistulous tract opening into subcutaneous plane. Exploratory laparotomy with right hemicolectomy and en bloc resection was performed. CLINICAL DISCUSSION Cutaneous fistula can be caused by traumatic, postoperative etiologies and about 20 % are of spontaneous etiologies. Colon cancer has the ability to mimic any abdominal disease with a wide spectrum of presentations. The locoregional extension from the bowel creates a passage of colonic contents to evacuate from the external opening. The fistulous tract of colon cancer is less likely to close spontaneously and may require surgical intervention following appropriate resuscitation. Due to features suggestive of bowel obstruction an early single stage surgery was performed in our case. CONCLUSION There are no existing guidelines for colon cancer with colocutaneous fistula because they are the same for benign fistulas (resuscitation, control of output, eradication of the infection, nutritional optimization, surgery) along with a multidisciplinary oncology team approach.
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Affiliation(s)
- Sunil Basukala
- Department of Surgery, Shree Birendra Hospital, Chhauni, Kathmandu 44600, Nepal
| | - Yugant Khand
- Nepalese Army Institute of Health Sciences – College of Medicine, Sanobharyang 44600, Kathmandu, Nepal,Corresponding author at: Nepalese Army Institute of Health Sciences-College of Medicine, Sanobharyang 44600, Kathmandu, Nepal.
| | - Soumya Pahari
- Nepalese Army Institute of Health Sciences – College of Medicine, Sanobharyang 44600, Kathmandu, Nepal
| | - Priya Mainali
- Nepalese Army Institute of Health Sciences – College of Medicine, Sanobharyang 44600, Kathmandu, Nepal
| | - Nirvik Gurung
- Nepalese Army Institute of Health Sciences – College of Medicine, Sanobharyang 44600, Kathmandu, Nepal
| | - Suman Gurung
- Department of Pathology, Shree Birendra Hospital, Chhauni, Kathmandu 44600, Nepal
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10
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McKee RF, Knight K, Leitch EF, Stevens P. The role of surgery in weaning patients from home parenteral support - A cohort study. Colorectal Dis 2022; 24:621-630. [PMID: 35066961 DOI: 10.1111/codi.16066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/18/2021] [Accepted: 01/11/2022] [Indexed: 02/08/2023]
Abstract
AIM Some patients with intestinal failure requiring home parenteral support (HPS) may be weaned. This study considered all abdominal surgery in a cohort of HPS patients over a 25-year period. Our aim was to identify how many patients can be weaned from HPS and by what means, and to identify what makes weaning more likely. METHOD A prospectively collected database of HPS patients to December 2018 was analysed for outcomes of care. RESULTS At 5 years 56% of 205 patients remained on HPS. Fifty eight patients (28%), who had 68 operations, stopped HPS after surgery. Patients stopping HPS had a longer median final small bowel length (155 cm, range 45-350 cm) and were more likely to have colon in circuit (84%) than patients who had reconstructive surgery but did not stop HPS (median small bowel length 50 cm, range 15-135 cm; 50% colon in circuit). The median period between HPS discharge and reconstructive surgery was 238 days. There were no deaths, but 18 Clavien-Dindo grade 3-4 complications occurred within 30 days. Ninety per cent of patients who stopped HPS survived for 5 years from the start of HPS in comparison with 53% of those who remained on HPS. CONCLUSIONS No previous study has examined surgery in an entire cohort of HPS patients. More than a quarter of HPS patients can be weaned after reconstructive surgery. The length of bowel available for recruitment at surgery is the main determinant of the ability to stop HPS. The possibility of reconstruction should be considered, since patients who stop HPS appear to have a survival advantage.
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Affiliation(s)
- Ruth F McKee
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Katrina Knight
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - E Fiona Leitch
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Phil Stevens
- Department of Colorectal Surgery, Glasgow Royal Infirmary, Glasgow, UK
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Abstract
BACKGROUND Management of enterocutaneous fistulas in Crohn's disease is challenging. Most patients still need intestinal resection in the biologic era. OBJECTIVE The aim of this study was to evaluate the efficacy of endoscopic treatment for enterocutaneous fistulas. DESIGN This is a retrospective study of medical records. SETTINGS This study was conducted in a single institution. PATIENTS All consecutive patients with Crohn's disease with an enterocutaneous fistula who underwent endoscopic fistula closure with the use of an over-the-scope clip or a hemostatic clip were included. MAIN OUTCOME MEASURES The main outcome measured was the clinical success 3 months after the procedure, which was defined as the complete closure of all fistulas at physical examination and complete cessation of the drainage from the external opening, without surgery. RESULTS Eight patients (men, 25%; median age 45 years [interquartile range, 33-51]) were followed. Fistulas were localized at the ileocolonic or colocolonic anastomosis in 7 patients and at the stomach in 1 patient. Seven patients were treated with an over-the-scope clip, and one was treated with a hemostatic clip. Technical success was achieved in all cases. Clinical success at 3 months was achieved in 75% of cases (6/8 patients). After a median 16-month (interquartile range, 13-23) follow-up, 3 of 8 (37.5%) patients had enterocutaneous fistula closure and 2 of 8 (25%) needed intestinal resection. No complications were observed. LIMITATIONS The retrospective nature, the small sample size of the study, and the heterogeneity of the population limit the interpretation of the results. CONCLUSIONS Endoscopic treatment of enterocutaneous fistulas is feasible with a short-term effectiveness. Additional studies are needed to confirm these results. See Video Abstract at http://links.lww.com/DCR/B614. TRATAMIENTO ENDOSCPICO DE FSTULAS ENTEROCUTNEAS EN ENFERMEDAD DE CROHN ANTECEDENTES:Es desafiante el manejo de las fístulas enterocutáneas en enfermedad de Crohn. En la era biológica, la mayoría de los pacientes todavía requieren de resección intestinal.OBJETIVO:Evaluar la eficacia por tratamiento endoscópico de fístulas enterocutáneas.ENTORNO CLINICO:Estudio retrospectivo de registros médicos.AJUSTE:Realizado en una sola institución.PACIENTES:Se incluyeron todos los pacientes consecutivos con fístula enterocutánea en enfermedad de Crohn, sometidos a cierre endoscópico de la fístula con clip sobre el endoscopio o clip hemostático.PRINCIPALES MEDIDAS DE VALORACION:El éxito clínico a los 3 meses después del procedimiento. Definido al examen físico, como el cierre completo de todas las fístulas y cese completo del drenaje por la abertura externa, sin cirugía.RESULTADOS:Se estudiaron a ocho pacientes (hombres, 25%, mediana de edad de 45 años (rango intercuartílico, 33-51)). En 7 pacientes, las fístulas se localizaron en la anastomosis ileocolónica o colocolónica y un paciente, en el estómago. Siete pacientes fueron tratados con clip sobre el endoscopio y uno con clip hemostático. Se logró éxito técnico en todos los casos. Se logró éxito clínico a los 3 meses en 75% de los casos (6/8 pacientes). Después de una mediana de 16 meses (rango intercuartílico, 13-23), de seguimiento 3/8 (37,5%) pacientes presentaron cierre de fístulas enterocutáneas y 2/8 (25%) requirieron resección intestinal. No se observaron complicaciones.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de la muestra y heterogeneidad de la población, limitaron la interpretación de los resultados.CONCLUSIONES:Es posible el tratamiento endoscópico de fístulas enterocutáneas con efectividad a corto plazo. Se requieren nuevos estudios para confirmar estos resultados. Consulte Video Resumen en http://links.lww.com/DCR/B614. (Traducción-Dr. Fidel Ruiz Healy).
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Nikoupour H, Theodorou A, Arasteh P, Lurje G, Kalff JC, von Websky MW. Update on surgical management of enteroatmospheric fistulae in intestinal failure patients. Curr Opin Organ Transplant 2022; 27:137-143. [PMID: 35232927 DOI: 10.1097/mot.0000000000000960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The surgical management of enteroatmospheric fistula (EAF) in patients with intestinal failure represents a major challenge for a surgical team and requires proficiency in sepsis management, nutritional support and prehabilitation, beside expertise in visceral and abdominal wall surgery. This review provides an update on the current recommendations and evidence. RECENT FINDINGS Reconstructive surgery should be performed at a minimum of 6-12 months after last laparotomy. Isolation techniques and new occlusion devices may accelerate spontaneous EAF closure in selected cases. Chyme reinfusion supports enteral and parenteral nutrition. Stapler anastomosis and failure to close the fascia increase the risk of EAF recurrence. Posterior component separation, intraoperative fascial tension and biological meshes may be used to accommodate fascial closure. SUMMARY Timing of reconstructive surgery and previous optimal conservative treatment is vital for favorable outcomes. Wound conditions, nutritional support and general patient status should be optimal before attempting a definitive fistula takedown. Single stage procedures with autologous gut reconstruction and abdominal wall reconstruction can be complex but well tolerated.
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Affiliation(s)
- Hamed Nikoupour
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Peyman Arasteh
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Georg Lurje
- Department of Surgery, Charité Berlin, Berlin, Germany
| | - Joerg C Kalff
- Department of Surgery, University Hospital of Bonn, Bonn
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13
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Patel T, Patel S. Enterocutaneous Fistula and Pneumoretroperitoneum due to Ruptured Psoas Abscess. Surg J (N Y) 2021; 7:e286-e288. [PMID: 34703886 PMCID: PMC8536649 DOI: 10.1055/s-0041-1735901] [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: 09/03/2020] [Accepted: 07/28/2021] [Indexed: 12/02/2022] Open
Abstract
Psoas abscess is a rare condition that can present with vague clinical features. Its insidious onset can lead to a delay in diagnosis, resulting in high rates of complications and mortality. Here we describe a unique case of a patient presenting with enterocutaneous fistula and pneumoretroperitoneum due to ruptured psoas abscess.
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Affiliation(s)
- Tapan Patel
- Department of General Surgery, Medical College Baroda, Vadodara, Gujarat, India
| | - Shivani Patel
- Department of General Surgery, Medical College Baroda, Vadodara, Gujarat, India
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14
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Klek S, Salowka J, Choruz R, Cegielny T, Welanyk J, Wilczek M, Szczepanek K, Pisarska-Adamczyk M, Pedziwiatr M. Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study. Nutrients 2021; 13:1953. [PMID: 34200140 PMCID: PMC8229866 DOI: 10.3390/nu13061953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS An enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS®) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF. METHODS ERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick's Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. NCT04771832. RESULTS ERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, p = 0.025), overall complication rate (11 vs. 10, p = 0.021), median length of hospital stay (overall and after surgery, p = 0.022 and 0.002, respectively). CONCLUSIONS ERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care.
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Affiliation(s)
- Stanislaw Klek
- Surgical Oncology Clinic, National Cancer Institute, 31-115 Krakow, Poland; (J.W.); (M.W.)
- General Surgery Unit with Intestinal Failure Center, Stanley Dudrick’s Memorial Hospital, 32-082 Skawina, Poland; (J.S.); (R.C.); (T.C.); (K.S.)
| | - Jerzy Salowka
- General Surgery Unit with Intestinal Failure Center, Stanley Dudrick’s Memorial Hospital, 32-082 Skawina, Poland; (J.S.); (R.C.); (T.C.); (K.S.)
| | - Ryszard Choruz
- General Surgery Unit with Intestinal Failure Center, Stanley Dudrick’s Memorial Hospital, 32-082 Skawina, Poland; (J.S.); (R.C.); (T.C.); (K.S.)
| | - Tomasz Cegielny
- General Surgery Unit with Intestinal Failure Center, Stanley Dudrick’s Memorial Hospital, 32-082 Skawina, Poland; (J.S.); (R.C.); (T.C.); (K.S.)
| | - Joanna Welanyk
- Surgical Oncology Clinic, National Cancer Institute, 31-115 Krakow, Poland; (J.W.); (M.W.)
| | - Mariusz Wilczek
- Surgical Oncology Clinic, National Cancer Institute, 31-115 Krakow, Poland; (J.W.); (M.W.)
| | - Kinga Szczepanek
- General Surgery Unit with Intestinal Failure Center, Stanley Dudrick’s Memorial Hospital, 32-082 Skawina, Poland; (J.S.); (R.C.); (T.C.); (K.S.)
| | | | - Michal Pedziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Kraków, Poland;
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15
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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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16
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Christensen MA, Gaitanidis A, Parks J, Mendoza A, Saillant N, Kaafarani HMA, Fagenholz P, Velmahos G, Fawley J. Thirty-day outcomes in the operative management of intestinal-cutaneous fistulas: A NSQIP analysis. Am J Surg 2021; 221:1050-1055. [PMID: 32912660 DOI: 10.1016/j.amjsurg.2020.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/14/2020] [Accepted: 08/28/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Intestinal-cutaneous fistulas (ICFs) constitute a major surgical challenge. Definitive surgical treatment of ICFs continues to be associated with significant morbidity. The purpose of this study was to utilize a nationwide database to define the morbidity associated with current treatment strategies in the surgical management of ICFs. METHODS The 2006-2017 American College of Surgeon National Surgical Quality Improvement datasets (ACS-NSQIP) were used to assess 30-day morbidity and mortality after surgical repair of ICFs. Outcomes for emergent repair were compared to elective repair of ICFs. RESULTS Overall, 4197 patients undergoing ICF-repair were identified. Mean age was 55.9 (SD 15.3). Patients were generally comorbid (62.9% were in ASA class III). The observed in-hospital mortality was 2.3%. However, the observed morbidity rate was 47.3%. Of the observed morbidity, 35.6% was due to post-operative infectious complications (superficial surgical site infections (SSI), deep SSI, organ/space SSI, wound disruption, pneumonia, urinary tract infection (UTI) sepsis or septic shock). The most common infectious complication was sepsis (13.1%). 30-day readmission rate was 15.3% and the 30-day reoperation rate was 11.0%. Emergent repair was associated with a sevenfold increase in mortality (11.9% vs 1.8%, P < 0.001) CONCLUSION: The management of patients with ICFs is complex and is associated with significant morbidity. Half of patients undergoing surgical management of ICFs developed in-hospital complications.
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Affiliation(s)
- Mathias A Christensen
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Department of Anesthesia, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Apostolos Gaitanidis
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Harvard Medical School, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Harvard Medical School, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Harvard Medical School, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Harvard Medical School, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Harvard Medical School, USA
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Harvard Medical School, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, USA; Harvard Medical School, USA.
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17
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Dogu D, Akkapulu N, Yazici SE, Kavuncuoglu A. Recurrent Type 1 Enterocutaneous Fistula and Granulomatous Gastritis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e928532. [PMID: 33547268 PMCID: PMC7877792 DOI: 10.12659/ajcr.928532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient: Female, 34-year-old Final Diagnosis: Enterocutaneous fistula Symptoms: Abdominal pain • fistula Medication: — Clinical Procedure: Distal subtotal gastrectomy Specialty: Surgery
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Affiliation(s)
- Dogukan Dogu
- Department of General Surgery, Hacettepe University Hospital, Ankara, Turkey
| | - Nezih Akkapulu
- Department of General Surgery, Hacettepe University Hospital, Ankara, Turkey
| | - Sinan Efe Yazici
- Department of General Surgery, Hacettepe University Hospital, Ankara, Turkey
| | - Altan Kavuncuoglu
- Department of Pathology, Hacettepe University Hospital, Ankara, Turkey
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18
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Klifto KM, Othman S, Messa CA, Piwnica-Worms W, Fischer JP, Kovach SJ. Risk factors, outcomes, and complications associated with combined ventral hernia and enterocutaneous fistula single-staged abdominal wall reconstruction. Hernia 2021; 25:1537-1548. [PMID: 33538927 DOI: 10.1007/s10029-021-02371-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/22/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- K M Klifto
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - S Othman
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - C A Messa
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - W Piwnica-Worms
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - S J Kovach
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA.
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de Vries FEE, Claessen JJM, van Hasselt-Gooijer EMS, van Ruler O, Jonkers C, Kuin W, van Arum I, van der Werf GM, Serlie MJ, Boermeester MA. Bridging-to-Surgery in Patients with Type 2 Intestinal Failure. J Gastrointest Surg 2021; 25:1545-1555. [PMID: 32700102 PMCID: PMC8203517 DOI: 10.1007/s11605-020-04741-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/07/2020] [Indexed: 01/31/2023]
Abstract
AIM Type 2 intestinal failure (IF) is characterized by the need for longer-term parenteral nutrition (PN). During this so-called bridging-to-surgery period, morbidity and mortality rates are high. This study aimed to evaluate to what extent a multidisciplinary IF team is capable to safely guide patients towards reconstructive surgery. METHODS A consecutive series of patients with type 2 IF followed up by a specialized IF team between January 1st, 2011, and March 1st, 2016, was analyzed. Data on their first outpatient clinic visit (T1) and their last visit before reconstructive surgery (T2) was collected. The primary outcome was a combined endpoint of a patient being able to recover at home, have (partial) oral intake, and a normal albumin level (> 35 g/L) before surgery. RESULTS Ninety-three patients were included. The median number of previous abdominal procedures was 4. At T2 (last visit prior to reconstructive surgery), significantly more patients met the combined primary endpoint compared with T1 (first IF team consultation) (66.7% vs. 28.0% (p < 0.0001), respectively); 86% had home PN. During "bridging-to-surgery," acute hospitalization rate was 40.9% and acute surgery was 4.3%. Postoperatively, 44.1% experienced a major complication, 5.4% had a fistula, and in-hospital mortality was 6.5%. Of the cohort, 86% regained enteral autonomy, and when excluding in-hospital mortality and incomplete follow-up, this was 94.1%. An albumin level < 35 g/L at T2 and weight loss of > 10% at T2 compared with preadmission weight were significant risk factors for major complications. CONCLUSION Bridging-to-surgery of type 2 IF patients under the guidance of an IF team resulted in the majority of patients being managed at home, having oral intake, and restored albumin levels prior to reconstructive surgery compared with their first IF consultation.
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Affiliation(s)
- Fleur E. E. de Vries
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Jeroen J. M. Claessen
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Elina M. S. van Hasselt-Gooijer
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Oddeke van Ruler
- grid.414559.80000 0004 0501 4532Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | - Cora Jonkers
- grid.509540.d0000 0004 6880 3010Nutrition Support Team, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Wanda Kuin
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Irene van Arum
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - G. Miriam van der Werf
- grid.509540.d0000 0004 6880 3010Nutrition Support Team, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Mireille J. Serlie
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Marja A. Boermeester
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
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Layec S, Seynhaeve E, Trivin F, Carsin-Mahé M, Dussaulx L, Picot D. Management of entero-atmospheric fistulas by chyme reinfusion: A retrospective study. Clin Nutr 2020; 39:3695-3702. [DOI: 10.1016/j.clnu.2020.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/01/2020] [Accepted: 03/27/2020] [Indexed: 02/06/2023]
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Jung SM, Lee S, Park HJ, Kim HJ, Min JK, Seo JM. Multidisciplinary intestinal rehabilitation in acute type II intestinal failure: Results from an intestinal rehabilitation team. Asian J Surg 2020; 44:549-552. [PMID: 33262044 DOI: 10.1016/j.asjsur.2020.11.010] [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: 09/14/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Type II (acute) intestinal failure (IF) is usually caused by complications of abdominal surgery resulting in enteric fistulas or proximal stomas and requires parenteral nutrition (PN) for several months. This study aimed to evaluate clinical management and outcome of type II IF patients in a single center. METHODS Medical records of patients referred to the Intestinal Rehabilitation Team (IRT) at Samsung Medical Center (Seoul, Korea) were retrospectively analyzed. RESULTS From 2014 to 2019, 34 patients with IF were referred. 28 patients were type II IF and were included in the analysis. There were 17 males and 11 females. Mean age of patients was 56.7 years. Pathophysiology of IF were high-output stoma in 16 cases, extensive bowel resection (with bowel in continuity) in 7 cases, and enterocutaneous fistula in 5 cases. The catastrophic events necessitating abdominal surgery in the patients were adhesive ileus in 9 cases, superior mesenteric artery thrombosis in 8 cases, internal herniation of bowel in 5 cases, traumatic bowel injury in 3 cases, and ischemic enteritis in 3 cases. Following medical and surgical rehabilitation, 10 patients (35.7%) were weaned off PN and overall mortality was 28.5%. Deaths were related to progression of underlying malignancies in 4 cases, liver failure in 3 cases, and sepsis in 1 case. Thirteen patients underwent surgery to restore bowel continuity. Six postoperative complications occurred in 4 patients (30.7%) and there were no postoperative mortalities. CONCLUSION Standardized care including restorative surgery resulted in successful outcomes in type II IF patients in this cohort.
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Affiliation(s)
- Soo-Min Jung
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Sanghoon Lee
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea.
| | - Hyo Jung Park
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Departments of Pharmaceutical Services, Samsung Medical Center, Seoul, South Korea
| | - Hyun-Jung Kim
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Departments of Dietetics, Samsung Medical Center, Seoul, South Korea
| | - Ja-Kyung Min
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Departments of Nursing, Samsung Medical Center, Seoul, South Korea
| | - Jeong-Meen Seo
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
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23
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Tang QQ, Hong ZW, Ren HJ, Wu L, Wang GF, Gu GS, Chen J, Zheng T, Wu XW, Ren JA, Li JS. Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression. Front Nutr 2020; 7:564379. [PMID: 33123545 PMCID: PMC7573310 DOI: 10.3389/fnut.2020.564379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Qin-Qing Tang
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China.,Department of General Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhi-Wu Hong
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Hua-Jian Ren
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Lei Wu
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Ge-Fei Wang
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Guo-Sheng Gu
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Jun Chen
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Tao Zheng
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Xiu-Wen Wu
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Jian-An Ren
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Jie-Shou Li
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
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Laparoscopic Repair for Enterocutaneous Fistula Caused by Laparoscopic Right Hemicolectomy for Pan-Peritonitis due to Cecal Cancer Perforation. THE JOURNAL OF MINIMALLY INVASIVE SURGERY 2020; 23:144-148. [PMID: 35602388 PMCID: PMC8985614 DOI: 10.7602/jmis.2020.23.3.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 11/23/2022]
Abstract
Enterocutaneous fistula (ECF) can occur after any intra-abdominal procedure and is a concern for most surgeons. We report a case of laparoscopic treatment of an ECF in a 65-year-old male patient who had undergone a laparoscopic right hemicolectomy for peritonitis due to perforated colon cancer four months previously. Two weeks after discharge from the hospital, he visited the outpatient clinic complaining of a malodorous abscess draining from the right trocar site. Although we allowed two months for the fistula to close naturally, it did not close and formed an abscess. The patient subsequently underwent a laparoscopic colectomy of the fistula between the colonic stump and the skin. The operation time was 110 minutes, and he was discharged 10 days after surgery without any postoperative complication.
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25
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Papa A, Lopetuso LR, Minordi LM, Di Veronica A, Neri M, Rapaccini G, Gasbarrini A, Papa V. A modern multidisciplinary approach to the treatment of enterocutaneous fistulas in Crohn's disease patients. Expert Rev Gastroenterol Hepatol 2020; 14:857-865. [PMID: 32673498 DOI: 10.1080/17474124.2020.1797484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn's disease (CD) that is challenging to treat and has considerable morbidity and mortality rates. AREAS COVERED This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients. EXPERT OPINION Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-α therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting.
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Affiliation(s)
- Alfredo Papa
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Loris Riccardo Lopetuso
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy.,Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy
| | - Laura Maria Minordi
- Dipartimento di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
| | - Alessandra Di Veronica
- Dipartimento di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
| | - Matteo Neri
- Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy.,Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara , Chieti, Italy
| | - Gianludovico Rapaccini
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Antonio Gasbarrini
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Roma, Italy.,Università Cattolica del Sacro Cuore , Roma, Italia
| | - Valerio Papa
- Università Cattolica del Sacro Cuore , Roma, Italia.,Dipartimento di Chirurgia, Fondazione Policlinico Universitario A. Gemelli IRCCS , Roma, Italia
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Wang Y, Alnumay A, Paradis T, Beckett A, Fata P, Khwaja K, Razek T, Grushka J, Deckelbaum DL. Management of Open Abdomen After Trauma Laparotomy: A Comparative Analysis of Dynamic Fascial Traction and Negative Pressure Wound Therapy Systems. World J Surg 2020; 43:3044-3050. [PMID: 31506714 DOI: 10.1007/s00268-019-05166-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Management of the post-traumatic open abdomen (OA) using negative pressure wound therapy (NPWT) alone is associated with low rates of primary fascial closure. The abdominal reapproximation anchor (ABRA) system exerts dynamic medial fascial traction and may work synergistically with NPWT to facilitate primary fascial closure. METHODS Patients with an OA following trauma laparotomy between 2009 and 2018 were identified from a prospectively maintained institutional database. Patients treated with ABRA in conjunction with NPWT (ABRA) versus NPWT alone (NPWT) were compared in terms of primary fascial closure rate, number of surgeries to closure, tracheostomy duration, length of stay and incidence of entero-atmospheric fistula. Multivariable linear regression was performed to identify predictors of tracheostomy duration. RESULTS We identified 48 patients [ABRA, 12 and NPWT, 36]. The ABRA group was significantly younger (25 vs. 37 years, p = 0.027) and included a lower proportion of males (58% vs. 89%, p = 0.032). Groups were similar with respect to the incidence of hollow viscus injury, injury severity score and abdominal abbreviated injury score. Compared to the NPWT group, the ABRA group had a significantly higher rate of primary fascial closure (100% vs. 28%, p < 0.001), fewer surgeries to abdominal closure (2 vs. 2.5, p = 0.023) and shorter duration of tracheostomy (15.5 vs. 36 days, p = 0.008). There were no differences in length of stay or incidence of entero-atmospheric fistula. On multivariable linear regression, ABRA placement was an independent predictor of shorter tracheostomy duration, after adjusting for covariates (β = - 0.294, p = 0.036). CONCLUSION For the post-traumatic OA, ABRA coupled with NPWT achieves a higher rate of primary fascial closure compared to NPWT alone, while requiring fewer surgeries and a shorter duration of tracheostomy.
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Affiliation(s)
- Yifan Wang
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Abdulaziz Alnumay
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Tiffany Paradis
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Andrew Beckett
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Paola Fata
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Kosar Khwaja
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Tarek Razek
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada.,Centre for Global Surgery, McGill University, Montreal, QC, Canada
| | - Jeremy Grushka
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Dan L Deckelbaum
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada. .,Centre for Global Surgery, McGill University, Montreal, QC, Canada.
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27
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Soop M. Challenges in Crohn's disease: Intestinal failure and short bowel syndrome in Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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Jiang Z, Ren J, Ren H, Hong Z, Wang G, Gu G, Wu X. Early Active Irrigation-Suction Drainage among Enterocutaneous Fistulas Patients with Chronic Critical Illness: A Retrospective Cohort Study. Am Surg 2020. [DOI: 10.1177/000313482008600431] [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
Enterocutaneous fistulas (ECFs) requiring admission to ICU is a serious surgical complication. A growing number of patients survive ECFs but remain chronically critically ill. The aim of our study was to investigate the risk factors of hospital death in patients with chronic critical illness attributed to ECFs. A retrospective single-center study was conducted in 163 ECF patients between 2013 and 2017. Patient-specific baseline characteristics, outcomes, and process of care variables were collected. Risk factors for hospital mortality were determined using univariate and multi-variate analyses. Patients were divided into the following two groups according to the hospital discharge outcome: group survivors (n = 106) and group nonsurvivors (n = 57). Patients who received active irrigation-suction drainage (AISD) within 24 hours after the diagnosis of ECFs had a significantly lower hospital mortality rate than those who received AISD after more than 24 hours (17.9% vs 46.9%, P < 0.001). Multivariate logistic regression analysis demonstrated that delayed AISD (adjusted odds ratio [AOR], 10.24; 95% confidence interval [CI], 3.03234.59; P < 0.001) and no rehabilitation therapy (AOR, 4.77; 95% CI, 1.43215.98; P = 0.011) were independently associated with a greater risk of hospital mortality. The hospital mortality rate in patients with more than or equal to four risk factors was 92.6 per cent (n = 57), compared with a mortality rate of 9.4 per cent (n = 106) in patients who did not have these risk factors ( P < 0.001). The risk of hospital death is exceptionally high among patients with chronic critical illness attributed to ECFs. Efforts aimed at early AISD and rehabilitation therapy are likely to be associated with improved clinical outcomes.
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Affiliation(s)
- Zhizhao Jiang
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, P R China and
- Department of Intensive Care Unit, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, P R China
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, P R China and
| | - Huajian Ren
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, P R China and
| | - Zhiwu Hong
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, P R China and
| | - Gefei Wang
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, P R China and
| | - Guosheng Gu
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, P R China and
| | - Xiuwen Wu
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, P R China and
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Martinez JL, Bosco-Garate I, Souza-Gallardo LM, Méndez JD, Juárez-Oropeza MA, Román-Ramos R, Ferat-Osorio E. Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial. J Gastrointest Surg 2020; 24:426-434. [PMID: 30710211 DOI: 10.1007/s11605-018-04099-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 12/28/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment. PATIENTS AND METHODS Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications. RESULTS Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur. CONCLUSION Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.
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Affiliation(s)
- Jose L Martinez
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades - Centro Médico Nacional Siglo XXI (Instituto Mexicano del Seguro Social, IMSS), Mexico City, Mexico
- Programa de Doctorado en Ciencias Biológicas, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico
| | - Ilka Bosco-Garate
- Unidad de Investigación Médica en Inmunoquímica, UMAE Hospital de Especialidades - Centro Médico Nacional Siglo XXI (Instituto Mexicano del Seguro Social, IMSS), Av.Cuauhtémoc 330, 3er piso, Colonia Doctores, Delegación Cuauhtémoc, 06720, Mexico City, Mexico
| | - Luis Manuel Souza-Gallardo
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades - Centro Médico Nacional Siglo XXI (Instituto Mexicano del Seguro Social, IMSS), Mexico City, Mexico
| | - José D Méndez
- Unidad de Investigación Médica en Enfermedades Metabólicas, UMAE Hospital de Especialidades, Centro Médico Nacional Siglo XXI (Instituto Mexicano del Seguro Social, IMSS), Mexico City, Mexico
| | | | - Ruben Román-Ramos
- División Ciencias Biológicas y de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico
| | - Eduardo Ferat-Osorio
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades - Centro Médico Nacional Siglo XXI (Instituto Mexicano del Seguro Social, IMSS), Mexico City, Mexico.
- Unidad de Investigación Médica en Inmunoquímica, UMAE Hospital de Especialidades - Centro Médico Nacional Siglo XXI (Instituto Mexicano del Seguro Social, IMSS), Av.Cuauhtémoc 330, 3er piso, Colonia Doctores, Delegación Cuauhtémoc, 06720, Mexico City, Mexico.
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Method for Establishing Continuous Reinfusion of Succus Entericus in Complex High-output Fistula. Surg Laparosc Endosc Percutan Tech 2020; 30:227-232. [PMID: 31977971 DOI: 10.1097/sle.0000000000000757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To establish a continuous reinfusion of succus entericus and enteral nutrition (EN) in complex high-output fistula (HOF). Percutaneous puncture and catheterization technique was used to establish continuous reinfusion of succus entericus and EN in complex HOF. From May 2010 to June 2018, 21 patients with complex HOF used continuous reinfusion of succus entericus and EN. Six of them were completely cured, and 15 cases were cured after definitive surgery. Percutaneous puncture and catheterization technique was shown to be a useful and effective method for establishing continuous reinfusion of succus entericus and EN in patients with complex HOF. This method can prevent succus entericus loss and remove the barrier to implementing EN in HOF.
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Pande RK, Gupta A. Gastrointestinal Stomas and Fistulas: What is Lost and What to Do? Indian J Crit Care Med 2020; 24:S175-S178. [PMID: 33354037 PMCID: PMC7724941 DOI: 10.5005/jp-journals-10071-23620] [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] [Indexed: 11/23/2022] Open
Abstract
Abnormal connections between gastrointestinal tract (GIT) and skin are called enterocutaneous fistulas (ECFs). Presence of ECF is associated with significant morbidity and mortality. A stoma refers to a surgically created opening in the abdomen to divert feces or urine to the outside of the body, to compensate for partial or complete loss of bowel function. Gastrointestinal (GI) stomas and postoperative ECFs present a unique challenge to the intensivist due to development of malnutrition, dehydration, and sepsis leading to high morbidity and mortality. This review focuses on the basic concepts about the type of fistula and stomas, their indications and complications, and management. Principles of clinical management include replacement of fluid and electrolyte losses, control of sepsis along with reducing fistula output, prevention of malnutrition and psychological support, and skin care. How to cite this article: Pande RK, Gupta A. Gastrointestinal Stomas and Fistulas: What is Lost and What to Do? Indian J Crit Care Med 2020;24(Suppl 4):S175–S178.
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Affiliation(s)
- Rajesh K Pande
- Department of Critical Care, BLK Center for Critical Care, BLK Superspeciality Hospital, New Delhi, India
| | - Arpit Gupta
- Department of Critical Care, BLK Center for Critical Care, BLK Superspeciality Hospital, New Delhi, India
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Kong X, Cao Y, Yang D, Zhang X. Continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration for the management of postoperative high-output enterocutaneous fistulas: Three case reports and literature review. Medicine (Baltimore) 2019; 98:e18010. [PMID: 31725672 PMCID: PMC6867794 DOI: 10.1097/md.0000000000018010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Enterocutaneous fistula is considered one of the most serious complications in general surgery and is associated with high morbidity and mortality. Although various treatments are reported to have varying success, high-output enterocutaneous fistulas (output over 500 ml/day) continue to be associated with high mortality, and few papers on this topic exist in the literature. The aim of this study is to describe an effective multidisciplinary treatment method for postoperative high-output enterocutaneous fistula and discuss the clinical development of the therapeutic strategy. PATIENT CONCERNS Three patients suffered high-output enterocutaneous fistulas, in which case 1 presented with duodenal fistula, case 2 with ileal fistula, and case 3 with small bowel fistula. DIAGNOSIS All 3 cases were diagnosed with high-output enterocutaneous fistulas by drainage of intestinal contents. INTERVENTIONS With the exception of routine treatment including fluid resuscitation, correction of the electrolyte balance, control of infection, and optimal nutrition, all the cases accepted continuous irrigation and suction with triple-cavity drainage tubes in combination with sequential somatostatin-somatotropin administration were given. With regard to establishing effective drainage, the triple-cavity tube placement was performed by insertion through the initial drainage channel in case 1, percutaneous puncture with dilation by graduated dilators in case 2, and tract reconstruction in case 3. The technical details of the approach are described and clinical characteristics including fistula location, defect size, output volume, approach of triple-cavity tube placement, length of fistula tract, somatostatin and somatotropin administration time, and fistula healing time were recorded and compared. In addition, other various techniques reported in the literature are reviewed and discussed. OUTCOMES All the patients were cured by the multidisciplinary treatments and were followed up without fistula recurrence and other relevant complications at 1 week, 1 month, and 3 months after the treatments. CONCLUSION The strategy involving continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration may be a safe and effective alternative treatment for postoperative high-output enterocutaneous fistula and a more practical method that is easy to execute to manage this problem. Long-term studies, involving more patients, are still necessary to confirm this suggestion.
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Affiliation(s)
| | - Yuning Cao
- Department of Digestion, Liaocheng People's Hospital, Liaocheng, Shandong Provence
| | | | - Xiangyang Zhang
- Department of General Surgery, Wanshan Branch of Xiangyang Central Hospital, Xiangyang, Hubei Provence, China
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Abstract
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.
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Musa N, Aquilino F, Panzera P, Martines G. Successful conservative treatment of enterocutaneous fistula with cyanoacrylate surgical sealant: case report. G Chir 2019; 38:256-259. [PMID: 29280707 DOI: 10.11138/gchir/2017.38.5.256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIM Enterocutaneous (EC) fistula is an abnormal communication between the gastrointestinal tract and the skin. The majority of EC fistulas result from surgery. Only 15-25% of EC fistulas are spontaneous and they often result from underlying diseases such as Crohn's disease, radiation and chemotherapy. CASE REPORT A 62-year old woman who, in 2012, underwent Pylorus-preserving cephalic pancreaticoduodenectomy (PPPD sec. Traverso-Longmire), due to an advanced pancreatic ductal adenocarcinoma (pT3N1M1). After surgery, the patient underwent chemotherapy with folfirinox regimen. In December 2016, as a result of the appearance of metastatic liver lesions and perianastomotic recurrence, the patient underwent second line treatment with Gemcitabine and pab-paclitaxel. After five months from the beginning of this new second line therapy she presented an EC fistula. The fistula of the patient was successfully treated with total parenteral nutrition and with percutaneous injection of cyanoacrylic sealant. RESULTS The result suggests the advisability of percutaneous injection of sealant devices, such as cyanoacrylate glue; in order to successfully control stable Enterocutaneous fistulas with acceptable morbidity and mortality especially in particular situations, such as, with low output EC fistulas without signs of complications or on patients considered not suitable for surgery, a conservative approach could ensure the control of the fistula. CONCLUSION This approach is easy and safe, viable and useful for future trials on the efficacy in conservative treatment of EC fistula.
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35
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Kluciński A, Wroński M, Cebulski W, Guzel T, Witkowski B, Makiewicz M, Krajewski A, Słodkowski M. Surgical Repair of Small Bowel Fistulas: Risk Factors of Complications or Fistula Recurrence. Med Sci Monit 2019; 25:5445-5452. [PMID: 31329573 PMCID: PMC6668489 DOI: 10.12659/msm.914277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Definitive surgical repair of persistent fistulas of the small intestine remains a surgical challenge with a high rate of re-fistulation and mortality. The aim of this study was to evaluate the type and incidence of complications after definitive surgical repair, and to identify factors predictive of severe postoperative complications or fistula recurrence. Material/Methods This was a retrospective study of 42 patients who underwent elective surgical repair of a persistent fistula of the small intestine. The analysis included preoperative and intraoperative parameters. Results The healing rate after definitive surgery was 71.4%. Postoperative complications developed in 88.1% of patients. The mortality rate was 7.2%. Fistula recurrence was recognized in 21.4% of cases. Overall, 93 complications occurred in 37 patients. The most common complications were septic (48.0%). Hemorrhagic and digestive tract-related complications accounted for 19.0% and 15.0% of all complications, respectively. Severe complications (Clavien-Dindo grade III–V) made up 28.0% of all complications. In univariate analysis, multiple fistulas (p=0.03), higher C-reactive protein level (p=0.01), and longer time interval from admission to definitive surgery (p=0.01) were associated with an increased risk of severe complications or fistula recurrence. In multivariate analysis, only multiple fistulas were an independent risk factor for severe complications or fistula recurrence (OR=8.2, p=0.04). Conclusions Fistula complexity determines the risk of severe postoperative complications or fistula recurrence after definitive surgical repair of the persistent small intestine fistulas. Inflammatory parameters should be normalized before definitive surgery.
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Affiliation(s)
- Andrzej Kluciński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Wroński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Włodzimierz Cebulski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Guzel
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Witkowski
- College of Economic Analysis, Division of Probabilistic Methods, Warsaw School of Economics, Warsaw, Poland
| | - Marcin Makiewicz
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Krajewski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Słodkowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
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Abstract
RATIONALE Enterocutaneous fistula (ECF) has long been difficult to treat in clinical settings. The current approaches, including surgery, antibiotics, and nutritional support, cannot achieve satisfactory outcomes. PATIENT CONCERNS A 54-year-old man presented with intermittent discharge of purulent material from the fistula of an umbilical incision post colon surgery. His symptoms did not improve after receipt of antibiotic and surgical treatment. DIAGNOSIS The patient's symptoms, radiographic findings, and pathological examination led to a diagnosis of ECF. INTERVENTIONS Sterilized Bletilla striata was injected into the fistula once every 3 days for a total of 6 doses. OUTCOMES The ECF completely healed, and the patient was symptom-free after 1 month. LESSONS The patient's pronounced improvement and the merit of this easy-to-perform low-cost method suggest that Bletilla striata may be used by surgeons for the treatment of chronic abdominal wall fistulas.
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Affiliation(s)
- Hong Zhou
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Jiangsu, PR China
| | - Yan Jin
- Departments of Gastroenterology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Jiangsu, PR China
| | - Chen Gu
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Jiangsu, PR China
| | - Yigang Chen
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Jiangsu, PR China
| | - Jiazeng Xia
- Department of General Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Jiangsu, PR China
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Bannon MP, Heller SF, Rivera M, Leland AL, Schleck CD, Harmsen WS. Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up. Surgery 2019; 165:1182-1192. [PMID: 30929896 DOI: 10.1016/j.surg.2019.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence. METHODS Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas. RESULTS Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not. CONCLUSIONS With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.
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Affiliation(s)
- Michael P Bannon
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN.
| | - Stephanie F Heller
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN
| | - Mariela Rivera
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN
| | - Ann L Leland
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN
| | - Cathy D Schleck
- Division of Biostatistics and Informatics, Mayo Clinic, Rochester, MN
| | - William S Harmsen
- Division of Biostatistics and Informatics, Mayo Clinic, Rochester, MN
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A Systematic Review and Meta-analysis of Timing and Outcome of Intestinal Failure Surgery in Patients with Enteric Fistula. World J Surg 2018; 42:695-706. [PMID: 28924879 PMCID: PMC5801381 DOI: 10.1007/s00268-017-4224-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background The timing of intestinal failure (IF) surgery has changed. Most specialized centers now recommend postponing reconstructive surgery for enteric fistula and emphasize that abdominal sepsis has to be resolved and the patient’s condition improved. Our aim was to study the outcome of postponed surgery, to identify risk factors for recurrence and mortality, and to define more precisely the optimal timing of reconstructive surgery. Methods PubMed, Embase, and the Cochrane Library were systematically reviewed on the outcomes of reconstructive IF surgery (fistula recurrence, mortality, morbidity, hernia recurrence, total closure, enteral autonomy). If appropriate, meta-analyses were performed. Optimal timing was explored, and risk factors for recurrence and mortality were identified. Results Fifteen studies were included. The weighted pooled fistula recurrence rate was 19% (95% CI 15–24). Lower recurrence rates were found in studies with a longer median time and/or, at the minimum of the range, a longer time interval to surgery. Overall mortality was 3% (95% CI 2–5). Total fistula closure rates ranged from 80 to 97%. Enteral autonomy after reconstructive surgery, mentioned in four studies, varied between 79 and 100%. Conclusions Postponed IF surgery for enteric fistula is associated with lower recurrence. Due to the wide range of time to definitive surgery within each study, optimal timing of surgery could not be defined from published data.
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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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40
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Abstract
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.
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Affiliation(s)
- Jaehoon Cho
- Department of Internal Medicine, Los Angeles County and University of Southern California Medical Center, 2020 Zonal Avenue, IRD 620, Los Angeles, CA 90033, USA
| | - Ara B Sahakian
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, 1510 San Pablo Street, Los Angeles, CA 90033, USA.
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Abstract
There are very few clinical studies that highlight a definitive and comprehensive guideline for the management of enterocutaneous fistulas. Most accepted guidelines are found in textbooks and are taken from expert advice and case reports. The goal of this review is to highlight advancements relevant to the management of enterocutaneous fistulas from the recent two to three years. Although strong evidence-based guidelines are lacking, the consensus is that a multidisciplinary team working with a clear treatment plan targeting multiple aspects of management can maximize patient outcomes.
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Affiliation(s)
- Jamie Heimroth
- Hiram C. Polk, Jr MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Eric Chen
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Erica Sutton
- Hiram C. Polk, Jr MD Department of Surgery, University of Louisville, Louisville, Kentucky
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Martinez JL, Luque-De-LeÓN E, Souza-Gallardo LM, JimÉNez-LÓPez M, Ferat-Osorio E. Results after Definitive Surgical Treatment in Patients with Enteroatmospheric Fistula. Am Surg 2018. [DOI: 10.1177/000313481808400115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
As enteroatmospheric fistulas (EAF) lack healthy overlying tissue, spontaneous healing is very unlikely. Our aim was to identify risk factors for recurrence and mortality after definitive surgical treatment for EAF. Sixty-two consecutive patients with a diagnosis of EAF were submitted to definitive surgical repair (fistula resection and primary anastomosis) during a 6-year period. Several patient, disease, and operative variables were assessed as risk factors associated to our endpoints: recurrence and mortality. All patients were followed-up until hospital discharge or death. Univariate and multivariate analysis were performed. There were 24 females and 38 males with a median age of 53 years (interquartile ranges 43–63). EAF recurred in 23 patients. Univariate analysis identified several risk factors for recurrence which included performing more than one anastomosis (20 vs 52%, P = 0.013), failure of achieving total abdominal closure (16 vs 47%, P = 0.025), intraoperative hemorrhage >400 cc (28 vs 65%, P = 0.007), presence of multiple fistulas (25 vs 61%, P = 0.008), and preoperative C-reactive protein >0.5 mg/dL (54 vs 82%, P = 0.029). The latter two remained significant after multivariate analysis. Final EAF closure was attained in 47 patients (76%) and 8 more (13%) had a low-output (<50 mL/day) enterocutaneous fistula. Timing of surgery was not related to fistula recurrence. Eight patients died (13%), and fistula recurrence was the only risk factor found related to mortality both through univariate (26 vs 5%, P = 0.043) and after multivariate analysis. EAF management represents a rather challenging problem. Timing for surgical treatment is controversial and is based mostly on patient status and surgeon's criteria. Recurrence is associated to EAF characteristics and an inflammatory state; it was also the only factor associated to mortality.
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Affiliation(s)
- Jose L. Martinez
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades – Centro Médico Nacional Siglo XXI (IMSS), México City, México
| | - Enrique Luque-De-LeÓN
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades – Centro Médico Nacional Siglo XXI (IMSS), México City, México
| | - Luis Manuel Souza-Gallardo
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades – Centro Médico Nacional Siglo XXI (IMSS), México City, México
| | - Maricela JimÉNez-LÓPez
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades – Centro Médico Nacional Siglo XXI (IMSS), México City, México
| | - Eduardo Ferat-Osorio
- Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades – Centro Médico Nacional Siglo XXI (IMSS), México City, México
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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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45
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Postoperative enterocutaneous fistula - principles in non-operative approach. Ann Med Surg (Lond) 2017; 24:77-81. [PMID: 29276586 PMCID: PMC5734825 DOI: 10.1016/j.amsu.2017.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/13/2017] [Accepted: 09/17/2017] [Indexed: 11/21/2022] Open
Abstract
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.
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de Vries FEE, Reeskamp LF, van Ruler O, van Arum I, Kuin W, Dijksta G, Haveman JW, Boermeester MA, Serlie MJ. Systematic review: pharmacotherapy for high-output enterostomies or enteral fistulas. Aliment Pharmacol Ther 2017; 46:266-273. [PMID: 28613003 DOI: 10.1111/apt.14136] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/02/2017] [Accepted: 04/15/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND High-output enterocutaneous fistula or enterostomies can cause intestinal failure. There is a wide variety of options in medical management of patients with high output. AIM To systematically review the literature on available pharmacotherapy to reduce output and to propose an algorithm for standard of care. METHODS Relevant databases were systematically reviewed to identify studies on pharmacotherapy for reduction in (high-) output enterostomies or fistula. Randomised controlled trials and within subjects controlled prospective trials were included. An algorithm for standard of care was generated based on the outcomes of the systematic review. RESULTS Two studies on proton pump inhibitors, six on anti-motility agents, three on histamine receptor antagonists, one on an α2- receptor agonist and eight on somatostatin (analogues) were included. One study examined a proton pump inhibitor and a histamine receptor antagonist within the same patients. Overall, we found evidence for the following medical therapies to be effective: omeprazole, loperamide and codeine, ranitidine and cimetidine. On the basis of these outcomes and clinical experience, we proposed an algorithm for standard of care which consists of high-dose proton pump inhibitors combined with high-dose loperamide as the first step followed by addition of codeine in case of insufficient output reduction. So far, there is insufficient evidence for the standard use of somatostatin (analogues). CONCLUSIONS The available evidence on the efficacy of medication to reduce enterostomy or enterocutaneous fistula output is hampered by low quality studies. We propose an algorithm for standard of care output reduction in these patients.
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Affiliation(s)
- F E E de Vries
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - L F Reeskamp
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O van Ruler
- Department of Surgery, IJsselland Ziekenhuis, Cappele a/d Ijssel, The Netherlands
| | - I van Arum
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - W Kuin
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - G Dijksta
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M J Serlie
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
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48
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El-Sabbagh AH. Negative pressure wound therapy: An update. Chin J Traumatol 2017; 20:103-107. [PMID: 28202371 PMCID: PMC5392708 DOI: 10.1016/j.cjtee.2016.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/25/2016] [Accepted: 08/30/2016] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To get the maximum benefit of vacuum-assisted closure (VAC) in the management of acute and chronic wounds without abuse or misuse. METHODS Fourty one patients were included in the study. Among them, 9 patients had chronic wounds and the rest 32 patients had acute wounds. In acute wounds, 19 patients had co-morbid conditions. Seven patients had gaped wounds, 4 patients had necrotizing fasciitis and 2 patients had enterocutaneous fistula. RESULTS The hospitalization period varied from 1 to 6 weeks. The follow-up period was up to 6 months. No mortality was recorded during this study. All skin grafts showed complete healing. Necrotizing fasciitis was managed with good outcome. Wounds with enterocutaneous fistula have improved. In chronic wounds, good healing and excellent outcome were obtained. CONCLUSION The VAC therapy is an essential element for the management of problematic acute and chronic wounds.
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The Use of Latex Catheters to Close Enterocutaneous Fistulas: An Institutional Protocol and Retrospective Review. AJR Am J Roentgenol 2017; 208:1373-1377. [PMID: 28301212 DOI: 10.2214/ajr.16.17294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to retrospectively review an institutional protocol that uses latex catheters for the treatment of enterocutaneous fistulas (ECFs) that are resistant to simple drainage. MATERIALS AND METHODS Forty-six consecutive patients with ECFs that did not close with simple abscess drainage were treated with latex catheters. These patients' charts were retrospectively reviewed to determine treatment success rates and the relationship of treatment success to clinical characteristics. RESULTS ECFs in 26 of the 46 (56.5%) patients were treated successfully with latex catheters. On univariate analysis, the fistulas that originated from the stomach were statistically less likely to close (p = 0.03), whereas those originating from the small bowel were more likely to close (p = 0.01). The duration of treatment was significantly longer in patients for whom the treatment failed than in those who were successfully treated (p = 0.003). After a total treatment time of more than 116 days (odds ratio [OR], 9.8 [95% CI, 2.5-38.4]; p = 0.001) or latex catheter treatment time of more than 74 days (OR, 8.9 [95% CI, 2.2-35.0]; p = 0.002), the chance of ECF closure decreased significantly. CONCLUSION Treatment of ECFs that are resistant to simple abscess cavity drainage with a latex catheter is possible and decreases the need for surgery.
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Ashkenazi I, Turégano-Fuentes F, Olsha O, Alfici R. Treatment Options in Gastrointestinal Cutaneous Fistulas. Surg J (N Y) 2017; 3:e25-e31. [PMID: 28825016 PMCID: PMC5553539 DOI: 10.1055/s-0037-1599273] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/25/2017] [Indexed: 12/15/2022] Open
Abstract
Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.
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Affiliation(s)
- Itamar Ashkenazi
- Department of Surgery, Hillel Yaffe Medical Center, Hadera, Israel
| | | | - Oded Olsha
- Department of Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ricardo Alfici
- Department of Surgery, Hillel Yaffe Medical Center, Hadera, Israel
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