Enterocutaneous fistula treatment: case report and review of the literature.

OBJECTIVE: The aim of this work is to evaluate the treatment strategies for a common major surgery complication like the enterocutaneous fistula (ECFs). Since there is not any standard treatment for this common disease and since new therapies, like NPWT and fibrin sealants, have come up a review of all their indications seemed useful. We also present two clinical cases treated in this way. PATIENTS AND METHODS: A research was made in the principle databases such as: "Cochrane", "Pubmed", "Google Scholar" and "Google" using the following Key words "enterocutaneous fistula", "fibrin glue", "VAC", "VAC treatment", "fistula", "conservative treatment", "surgery" and using the MESH Function to search similar key words and expand the research. When two or more article with the same design were encountered (e.g. systematic reviews or case reports etc.) the newest one was chosen as data source. RESULTS: As far as somatostatine and its analogues are concerned, they showed a significant reduction of both time (13.95 vs 20.5 days) and percentage (72% vs 44%) of fistula closure against placebo in 2 meta-analysis. NPWT showed a high success rate between 90% and 100% but longer closure time between 4 weeks and 6 months. Fibrin glues showed heterogeneous results due to the great differencies in fistulas anatomy and treatment technique in the various studies, with 64-100% success rate in closure and a median 11,25 vs 23,25 days against total parenteral nutrition (TPN) alone. CONCLUSIONS: Because of ECFs often come up in patient in bad conditions who are not fitted for surgery and because of their high Mortality and Morbidity, a multimodal approach is necessary. Although TPN is a cornerstone of their treatment, NPWT showed is superiority in reducing fistula output and in some cases leading to fistula closure, nevertheless it often needs long treating time. Fibrin glues often needs complex devices and are nota s good as NPWT in treating the around tissues, but they can be useful when fistulas are only accessible from a little external orifice or they show a complex branched tract; thus they are good when surgery is not possible and the fistula has a mid- or low- output. The lack of prospective randomized studies or meta analysis and systematic review to compare the different methodics makes it impossible to show any evidence of superiority, but the combined application seems reasonable for a tailored treatment.

Adhesions small bowel obstruction in emergency setting: conservative or operative treatment?

Adhesions small bowel obstructions (aSBO) are among the leading causes of emergency operative intervention. About the 80% of aSBO cases resolve without a surgical treatment. It's important to identify which patients could undergo a conservative treatment to prevent an useless surgery The aim of this study is to determine findings that can indicate whether patients with aSBO should undergo a conservative or a surgical treatment. 313 patients with diagnosis of submission of aSBO were restudied. Patients were divided into two groups based on the different type of treatment received, 225 patients who underwent surgical treatment within 24 hours after admission, 88 patients which underwent conservative treatment successfully. For each patient, clinical, hematochemical and radiological findings have been analysed. The treatment of aSBO should be, at the beginning, conservative except that cases that presents clinical and/or CT-scan findings predictive for a surgical treatment (free peritoneal fluid, mesenterial edema, transitional point) or a peritonitis (pneumatosis intestinalis, pneumoperitoneum).