Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression

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

Chyme Reinfusion for Small Bowel Double Enterostomies and Enteroatmospheric Fistulas in Adult Patients: A Systematic Review

BACKGROUND

High-output double enterostomies (DESs) and enteroatmospheric fistulas (EAFs) of the small bowel account for substantial patient morbidity and mortality. Management may include parenteral nutrition (PN) and prolonged admissions, at high cost. Reinfusion of chyme into the distal bowel is a proposed therapeutic alternative when the distal DES limb is accessible; however, standardized information on this technique is required. This review aimed to critically assess the literature regarding chyme reinfusion (CR) to define its current status and future directions.

METHODS

A systematic search of medical databases was conducted for articles investigating CR in adults. Articles reporting indications, methods, benefits, technical issues, and complications resulting from CR were reviewed. A narrative synthesis of the retrieved data was undertaken.

RESULTS

In total, 24 articles reporting 481 cases of CR were identified, although articles were heterogeneous in their structure and reporting. CR was most frequently performed for remediation of high-output DES and intestinal failure and for proximally located DES. Effluent output collection was commonly manual, with distal reinfusion more commonly automated, and with few dedicated systems. Multiple benefits attributed to CR were reported, encompassing weight gain, cessation of PN, and improvements in liver function. Technical problems included distaste, labor-intensive methods, reflux of contents, and tube dislodgement. No serious AEs or mortality directly attributable to CR were reported.

CONCLUSIONS

CR appears to be a promising, safe and well-validated intervention for small bowel DES and EAF. However, more efficient and acceptable methods are required to promote greater adoption of the practice of CR.

Pneumatosis intestinalis after fistuloclysis

We present an unique case report of pneumatosis intestinalis after fistuloclysis.

A technique to establish fistuloclysis for high-output jejunocutaneous fistula through percutaneous enterostomy: A case report

RATIONALE

Currently, fistucolysis helps to establish intestinal nutrition and succus entericus reinfusion in the case of controllable mature high-output enterocutaneous fistula. However, if the tube cannot reach the distal limb of a fistula, fistuloclysis is not achieved. We proposed a strategy to establish succus entericus reinfusion for intractable intestinal fistula through percutaneous enterostomy.

PATIENT CONCERNS

A 43-year-old man was transferred to our facility for postoperative enterocutaneous fistulae, sepsis, malnutrition, and electrolyte and fluid imbalance. The contrast X-ray demonstrated the breakdown of the primary anastomosis, with fistula output ranging from 1500 to 2000 mL/d, despite the administration of medications to reduce gastrointestinal secretions.

DIAGNOSES

The patient was diagnosed with high-output anastomosis fistula by gastrointestinal radiography.

INTERVENTIONS

We used percutaneous enterostomy to establish fistuloclysis.

OUTCOMES

Fistuloclysis was established by percutaneous enterostomy successfully. No complications were found during the past 4-month follow-up after percutaneous enterostomy. He is waiting for reconstruction surgery after 6 months' enteral nutrition (EN).

LESSONS

Fistuloclysis-assisted EN, if used appropriately, avoids the complications of long-term parenteral nutrition (PN) and may promote faster fistula healing.

Fistuloclysis as a method of nutritional management in a patient with high output enteroatmospheric fistula - a case report

Enteric fistula is a pathological communication between the small intestine and surrounding tissue. In case of communication with body surface it is called an enterocutaneous or enteroatmospheric fistula. There are many causes of enterocutaneous/enteroatmospheric fistula occurrence. A common result is malnutrition and organ dysfunction which leads to increased morbidity and mortality of the patients. Adequate nutritional support is a very important element in the management of patients with enterocutaneous/enteroatmospheric fistulas. One of the options of nutritional support is fistuloclysis which means administration of enteral nutrition formula to the distal fistula. We present the case of 76-year-old patient with a high-localized and high output enteroatmospheric fistula in whom we were able to reach adequate nutritional status using fistuloclysis, followed by closure of the fistula.

Treatment of Enterocutaneous Fistulas, Then and Now

BACKGROUND

An enterocutaneous fistula (ECF) is an aberrant connection between the gastrointestinal tract and the skin or atmosphere (enteroatmospheric fistula [EAF]). Multimodal treatment includes surgical procedures, nutrition support, and wound care. We evaluated our practice and compared our outcomes with previous results published from our institution.

MATERIALS AND METHODS

We performed a retrospective analysis of hospitalized ECF/EAF patients admitted between January 2011 and November 2015. Patients with internal fistulas; active inflammatory bowel disease; malignancy; radiation treatment; end-stage renal, hepatic, or cardiac disease; and active alcoholism were excluded. Data collected included demographics, fistula characteristics, nutrition therapy, treatment, operative success, and hospital mortality. Parametric and nonparametric tests for independent and paired groups were performed.

RESULTS

Thirty-one patients were included in the analysis. The median (interquartile range) age was 60 (53-76) years, and 81% were female. Parenteral nutrition was initially prescribed in 80% of patients, but 61% received enteral nutrition (EN) at some point during their hospitalization. Two patients were fed by fistuloclysis. Eighty percent of the patients underwent surgical repair a median of 12 months after diagnosis with 92% operative success. Surgical repair had a modest correlation with home discharge (ρ = 0.517, P = .003). A large proportion of patients (77%) were discharged home. The in-hospital mortality at our institution decreased from 44% in 1960 to 21% in 1970 to 3% in the current study.

CONCLUSIONS

Modern treatment of ECF/EAF, including EN and advanced local wound care, is associated with improvements in clinical outcomes such as hospital mortality.

Management of enterocutaneous fistulas

Despite advances in antimicrobial chemotherapy, nutritional support, and perioperative critical care, the development of an enterocutaneous fistula continues to represent a major therapeutic challenge, with appreciable morbidity and mortality. Specific problems that must be addressed for the successful management of patients with enterocutaneous fistulas are the control of sepsis, maintenance of adequate fluid and electrolyte balance, provision of adequate and complication-free nutritional support, and skin-stoma care. In addition, many patients with postoperative intestinal fistulation suffer from significant psychological morbidity, which must be addressed during often prolonged periods of rehabilitation. The complex nature of the care required for successful management of patients with enterocutaneous fistulas mandates a multidisciplinary team approach, with specialist nurses, dieticians, pharmacists, radiologists, physicians, and surgeons all having important roles to play.