Open abdomen treatment for complicated intra-abdominal infection patients with gastrointestinal fistula can reduce the mortality.

To evaluate the effect of the open abdomen (OA) and closed abdomen (CA) approaches for treating intestinal fistula with complicated intra-abdominal infection (IFWCIAI), and analyze the risk factors in OA treatment.IFWCIAI is associated with high mortality rates and healthcare costs, as well as longer postoperative hospital stay. However, OA treatment has also been linked with increased mortality and development of secondary intestinal fistula.A total of 195 IFWCIAI patients who were operated over a period of 7 years at our hospital were retrospectively analyzed. These patients were divided into the OA group (n = 112) and CA group (n = 83) accordingly, and the mortality rates, hospital costs, and hospital stay duration of both groups were compared. In addition, the risk factors in OA treatment were also analyzed.OA resulted in significantly lower mortality rates (9.8% vs 30.1%, P < .001) and hospital costs ($11721.40 ±â€Š$9368.86 vs $20365.36 ±â€Š$21789.06, P < .001) compared with the CA group. No incidences of secondary intestinal fistula was recorded and the duration of hospital stay was similar for both groups (P = .151). Delayed OA was an independent risk factor of death following OA treatment (hazard ratio [HR] = 1.316; 95% confidence interval [CI] = 1.068-1.623, P = .010), whereas early enteral nutrition (EN) exceeding 666.67 mL was a protective factor (HR = 0.996; 95% CI = 0.993-0.999, P = .018). In addition, Acinetobacter baumannii, Pseudomonas aeruginosa, and Candida albicans were the main pathogens responsible for the death of patients after OA treatment.OA decreased mortality rates and hospital costs of IFWCIAI patients, and did not lead to any secondary fistulas. Early OA and EN also reduced mortality rates.

Duodenal fistula: The most lethal surgical complication in a case series of radical gastrectomy.

BACKGROUND: Despite all advances regarding the surgical treatment of gastric cancer (GC), duodenal stump fistula (DF) continues to negatively affect postoperative outcomes. This study aimed to assess DF regarding its incidence, risk factors, management and impact on overall survival. METHODS: We retrospectively analyzed 562 consecutive patients who underwent gastrectomy for GC between 2009 and 2017. Clinicopathological characteristics analysis was performed comparing DF, other surgical fistulas and patients with uneventful postoperative course. RESULTS: DF occurred in 15 (2.7%) cases, and 51 (9%) patients had other surgical fistulas. Tumor located in the lower third of the stomach (p = 0.021) and subtotal gastrectomy (p = 0.002) were associated with occurrence of DF. The overall mortality rate was 40% for DF and 15.7% for others surgical fistulas (p = 0.043). The median time of DF onset was on postoperative day 9 (range 1-75). Conservative approach was performed in 8 patients and surgical intervention in 7 cases. Age (OR 7.41, p = 0.012) and DF (OR 9.06, p=0.020) were found to be independent risk factors for surgical mortality. Furthermore, patients without fistula had better long-term survival outcomes comparing to patients with any type of fistulas (p = 0.006). CONCLUSION: DF is related with distal tumors and patients submitted to subtotal gastrectomy. It affects not only the postoperative period with high morbidity and mortality rates, but may also have a negative impact on long-term survival.

Respiratory-digestive tract fistula: two-center retrospective observational study.

Background Aerodigestive fistulae can be defined as abnormal communications between the gastrointestinal tract and the respiratory tract. Choking after meals, coughing, feeding difficulties, tachycardia, and persistent pneumonia are the main presentations. The aim of our study was to review our experience in the management of 27 cases of acquired aerodigestive fistulae of different types, levels, and management. Methods We conducted a retrospective observational study on 27 cases of fistulae between the respiratory and digestive tracts, which were managed in 2 hospitals in Saudi Arabia in the last 5 years. The patients comprised 16 females and 11 males, with a mean age of 29 years (range 17-67 years). Results The most common aerodigestive tract fistula was tracheoesophageal in 8 patients, followed by esophagobronchial in 6, and esophagopleural in 5. Four postendoscopic fistulae were included. The least common were gastropleural and esophagopulmonary fistulae. The most common etiologies were iatrogenic and esophageal cancer, and the least common was blunt chest trauma. The main presentations were fever, chocking after or during meals, and tachycardia. We used various modalities of treatment: conservative, cervical repair, thoracoabdominal repair, hybrid insertion of a T-tube, endoscopic esophageal stenting, and endoscopic clipping of the fistulous tract. During follow-up, 6 patients died due to advanced esophageal cancer in 5 and upper airway obstruction after iatrogenic tracheobronchial fistula in one. Conclusion Acquired aerodigestive fistula is a devastating condition that should be managed early and aggressively by a multidisciplinary team.

High preoperative ratio of blood urea nitrogen to creatinine increased mortality in gastrointestinal cancer patients who developed postoperative enteric fistulas.

Development of an enteric fistula after surgery is a major therapeutic complication. In this study, we retrospectively examined the potential relationship between preoperative laboratory data and patient mortality by collecting patient data from a tertiary medical center. We included patients who developed enteric fistulas after surgery for gastrointestinal (GI) cancer between January 2005 and December 2010. Patient demographics and data on preoperative and pre-parenteral nutritional statuses were compared between surviving and deceased patients. Logistic regression analysis and receiver operating characteristic (ROC) curves were used to determine the predictors and cut-off values, respectively. Patients with incomplete data and preoperative heart, lung, kidney, and liver diseases were excluded from the study; thus, out of 65 patients, 43 were enrolled. Logistic regression analysis showed that blood urea nitrogen-to-creatinine (BUN/Cr) ratio [p = 0.007; OR = 0.443, 95% confidence interval (CI), 0.245-0.802] was an independent predictor of mortality in patients who developed enteric fistulas after surgery for GI cancer. In conclusion, the results of our study showed that a high preoperative BUN/Cr ratio increases the risk of mortality in patients who develop enteric fistulas after surgery for GI cancer.

Surgical management of pharyngocutaneous fistula after total laryngectomy.

PURPOSE: The increased use of radiation in the primary management of laryngeal carcinoma has resulted in an increase in pharyngocutaneous fistula (PCF) formation after salvage laryngectomy. The impact of this practice on surgical management strategies has been analyzed. METHODS: A retrospective review of 177 patients treated by total laryngectomy for laryngeal or hypopharyngeal squamous cell carcinoma was performed. PCF formation was documented and management strategies were analyzed. RESULTS: Preoperative radiation therapy (XRT) was administered to 86 patients (48.6%). Postoperative PCF developed in 47 patients (26.5%), including 30 (34.9%) who had received preoperative XRT versus 17 (18.6%) who had not received XRT (P = 0.015). Spontaneous PCF closure occurred in 23 patients (48.9%). Two patients died with persistent, untreated PCF. Surgical closure of PCF was performed in 22 patients (46.8%), including 17 who had received preoperative radiation (77.3%). Reconstructive methods included 9 local flaps, 17 pectoralis major (PM) flaps, and 2 free jejunal flaps. Seven of the 9 (77.8%) patients treated with local flaps had received XRT. Three patients had successful fistula closure including 2 who had not received radiation. Six of 9 patients (66.7%) developed recurrent fistulization after local flap closure necessitating PM flap closure. Overall, 14 patients (82.4%) had received preoperative XRT prior to PM flap closure. Six patients (35.3%) who had received XRT developed recurrent fistulization and 5 of these fistulas eventually closed with local wound care. The remaining patient succumbed to a carotid artery rupture. Two patients required a completion pharyngectomy and free jejunal flap reconstruction. PM flaps were used in both cases to provide soft-tissue coverage. CONCLUSIONS: Preoperative XRT increases the risk of PCF after laryngectomy and the need for surgical closure. Local flap closure has a limited role in the surgical management of PCF. PM flap reconstruction has a high complication rate including recurrent fistulization in the setting of preoperative radiation.

Digestive system fistula: a problem still relevant today.

Digestive system fistula originates most frequently as a complication after surgical procedures, less often occurs in the course of inflammatory diseases, but it can also result from neoplasm and injuries. THE AIM OF THE STUDY was to analyze the causes and retrospectively assess the perioperative procedures as well as the results of digestive system fistula treatment. MATERIAL AND METHODS. Own experience in digestive system fistula treatment was presented. The subject group consisted of 32 patients treated at the General Surgery, Oncology and Endocrinology Clinical Department between 01.05.2005 and 30.04.2010 due to different digestive tract diseases. The causes of the occurrence of digestive system fistula, methods and results of treatment were analyzed. RESULTS. The analysis covered 32 patients with digestive system fistula, among them 15 men and 17 women. Average age for men was 57 years (20-78), and for women 61 years (24-88). In 11 patients idiopathic fistula causally connected with primary inflammatory disease (7 cases) and with neoplasm (4 cases) was diagnosed, in 19 patients fistula was the result of complications after surgery, in 2 - after abdominal cavity injury. Recovery from fistula was achieved in 23 patients (72%) with the use of individually planned conservative therapy (TPN, EN, antibiotics, drainage, and others) and surgery, depending on the needs of individual patient. 5 patients (16%) died, whereas in 4 left (12%) recovery wasn't achieved (fistula in palliative patients, with advanced stages of neoplasm - bronchoesophageal fistula, the recurrence of uterine carcinoma). CONCLUSIONS. Recently the results of digestive system fistula treatment showed an improvement which manifests itself in mortality decrease and shortening of fistula healing time. Yet, digestive system fistula as a serious complication still poses a very difficult surgical problem.

Successful bridging treatment and healing of enteric fistulae by vacuum-assisted closure (VAC) therapy and targeted drainage in patients with open abdomen.

PURPOSE: The object of this study was to investigate the bridging treatment of enteric fistulae by vacuum-assisted closure (VAC) therapy in patients with open abdomen. METHODS: We retrospectively analyzed patients who have been treated between 1 January 2007 and 31 December 2008 at the intensive care unit of the Department of General Surgery, Medical University Vienna. Control of the fistula was established by VAC therapy to bridge the patients to the time of the fistula resection. RESULTS: In the period of investigation, we treated nine (six men/three women) patients suffering from enteric fistulae with VAC therapy. The median age of the patients was 48 (range, 37-67) years. The median duration of VAC therapy was 76 (range, 53-128) days. The median length of stay in the intensive care unit was 44 (range, 25-127) days. The median APACHE II score was 23 (range, 18-25). The predicted mortality was 40%; the actual mortality was 11% (one patient). Primary fascial closure was achieved after median 91 (range, 89-92) days in three patients (33%) and secondary fascial closure after median 292 (range, 252-546) days in another three patients (33%). Fistulae were cured with VAC (five patients, 56%) and surgical resection (three patients, 33%). None of the patients developed a refistulation at the time of follow-up. CONCLUSIONS: Control of enteric fistulae by VAC therapy can lead to spontaneous fistula closure and is associated with a low mortality.

Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas.

We evaluated the short- and intermediate-term results of endovascular aneurysm repair (EVAR) for mycotic aneurysms. We reviewed all patients undergoing EVAR for mycotic aneurysms at our institution. To be consistent with the existing literature, patients with associated aortoaerodigestive fistulas were included. Aneurysm location, demographics, clinical findings, EVAR success, morbidity, and short- (<30 days) and long-term mortality were reviewed. From 2000 to 2007, 326 patients underwent EVAR. Nine of these (3%) had treatment of a mycotic aneurysm. The average age was 72 years (range 53-86), and seven patients were male. Four of the aneurysms were located in the thoracic aorta, two in the abdominal aorta, and three in the thoracoabdominal aorta. Four patients presented with gastrointestinal bleeding, two with hemoptysis, one with hemothorax, and two with fever. Etiologies included bacteremia from endocarditis and central catheter infection, erosion of anastomotic aneurysms from a previous aortic repair or endograft, erosion of a penetrating ulcer with pseudoaneurysm, infected aortic repair, left chest empyema, and unknown in one patient. Methicillin-resistant Staphylococcus aureus was the only bacteria isolated in 56% of the patients. EVAR successfully excluded the aneurysm or fistula in all nine patients; however, five patients experienced at least one postoperative complication. Two patients expired within 30 days. After 30 days, four additional patients expired; three of these deaths were procedure/aneurysm-related. Of the three survivors, over a mean follow-up of 257 days (range 60-417), one has required excision of an infected endograft with extra-anatomic bypass grafting but is now alive and well. All three surviving patients and two out of four patients expiring after 30 days had received long-term postoperative antibiotics. Despite an in-hospital mortality of 22.2%, EVAR can be used to treat acute complications from mycotic aneurysms and associated aortoaerodigestive fistulas, such as gastrointestinal bleeding, hemoptysis, or hemodynamic instability. As a definitive treatment, EVAR remains suspect and therefore should be considered a bridge to open surgical repair.

Outcome after endovascular stent graft repair of aortoenteric fistula: A systematic review.

BACKGROUND: Aortoenteric fistula (AEF) is a critical clinical condition, which may present with gastrointestinal hemorrhage, with or without signs of sepsis. Conventional open surgical repair is associated with high morbidity and mortality. Endovascular stent graft repair has been attempted, but recurrent infection remains of major concern. We conducted a systematic review to assess potential factors associated with poor outcome after endovascular treatment. METHODS: The English literature was searched using the MEDLINE electronic database up to April 2008. All studies reporting on the primary management of primary or secondary AEF with endovascular stent graft repair were considered. RESULTS: Data were extracted from 33 reports that included 41 patients and were entered in the final analysis. Persistent/recurrent/new infection or recurrent hemorrhage developed in 44% of the patients, after a mean follow-up period of 13 months (range, 0.13-36). Secondary, as compared to primary, AEF had an almost threefold increased risk of persistent/recurrent infection. Evidence of sepsis preoperatively was found to be a factor indicating unfavorable outcome (P < .05). Persistent/recurrent/new infection after treatment was associated with worse 30-day and overall survival compared with those who did not develop sepsis (P < .05). CONCLUSION: Endovascular stent graft repair of AEF was associated with a high incidence of infection or recurrent bleeding postoperatively. Evidence of sepsis preoperatively was indicating poor outcome.

[Postoperative digestive fistulas. Etiopathogenic considerations]. / Consideratii asupra etiopatogeniei fistulelor digestive externe postoperatorii.

The digestive fistula is one of the most serious complications that might appear following different types of resectional digestive surgery. This condition still carries a considerable morbidity and mortality rate and therefore all surgical and ICU staff pay a great deal of attention and intensify their care to avoid the fatalities. The postoperative digestive fistulas, through their physiopathological and clinical complexity induce the disturbance of the biological equilibrium with vital consequences. The trend of the last decades is the increasing of digestive fistulas incidence with a variable mortality rate after different authors. A therapeutic algorithm is needed. The mortality rate due to digestive fistulas, two decades ago was, around 60%; at the present there is a decrease of the mortality rate, which is around 10%. The explanation is the introduction of the new methods of treatment such as lactic acid lavage aspiration for alkaline fistulas or total parenteral nutrition, continuous enteral nutrition and antiexocrine chemotherapy. A fistula is a communication between two epithelial or endothelial surfaces, lined by granulation tissue. It can be a life-threatening condition.

Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA)--a multivariate analysis.

BACKGROUND: Pelvic sepsis is known to cause a detrimental outcome after ileal pouch-anal anastomosis (IPAA). The aim of this study was to examine potential factors associated with failure in managing pelvic sepsis after IPAA. METHODS: We performed univariate and multivariate logistic regression analysis on 2518 IPAA patients between 1983 and 2005. Failure was defined as pouch failure, the need for a permanent ileostomy, or mortality as a result of sepsis. There were 157 patients (6.2%) with pelvic sepsis after IPAA. These involved anastomotic leak 34% (54/157) and fistula 25% (40/157). There were 5 mortalities related to sepsis. Mean age at surgery was 38.1 +/- 14.4 years and mean follow-up was 5.5 +/- 4.7 years. RESULTS: Pouches were saved in 75.8% patients. Univariate analysis identified early sepsis (P = .040), preoperative steroid use (P = .007), and need for percutaneous drainage (P = .004) as significant factors associated with treatment success. Factors associated with failure were hypertension (P = .026), hand-sewn anastomosis (P = .038), associated fistula (P = .0003), need for transanal drainage (P = .0002), need for laparotomy to control septic complications (P < .0001), delayed ileostomy closure (P = .0003), and need for a new diverting ileostomy (P < .0001). By using multivariate analysis with selected covariates, significant factors associated with failure were associated fistula (P = .0013), need for transanal drainage (P = .003), delayed ileostomy closure (P = .022), need for a new ileostomy diversion (P = .004), and hypertension (P = .039). We developed a predictive scoring system for failure to use in management plans and decision-making for the treatment of septic complications of IPAA. CONCLUSIONS: Pelvic sepsis after IPAA has a significant impact on pouch failure. This predictive model for failure may play an important role in providing risk estimates for successful outcomes.

[Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue]. / Tratamiento endoscópico de fístulas gastrointestinales con un pegamento biológico tisular.

OBJECTIVE: We summarize our experience of endoscopic treatment of gastrointestinal fistulas with fibrin glue. PATIENTS AND METHOD: We retrospectively reviewed the outcome of 30 patients with gastrointestinal fistulas (9 internal and 21 external) refractory to standard conservative treatment for at least 10 days. Once the fistula was endoscopically located, 4 to 8 ml of reconstituted fibrin glue (Tissucol 2.0) at 37 degrees C was injected through a Duplocath catheter on a weekly basis. RESULTS: The mean age was 59 years (32-87) and 63% were men. A total of 21.9% of the patients had high output fistulas. We were able to find all fistular orifices what were located close to the surgical anastomosis. Healing time was 17 days (4-90); 2.8 sessions were required per patient (1-5) but only 2.3 sessions were required in responders. Complete sealing of fistulas was achieved in 75%; (80% in low-output, 25% in high-output and 55.5% in internal fistulas). The frequency of fistula recurrence was 3.3%. No complications related to the sealing procedure were found. Overall mortality was 10%, but only 6.6% was related to persistence of the fistula. CONCLUSIONS: Endoscopic treatment of fistulas with biological glue has a high success rate in sealing without complications, helping to speed up the healing process and reduce costs, particularly in low-output enterocutaneous fistulas.

[Prognosis of post-operative digestive fistulas in Chu de Yopougon: Abidjan/Cote d'Ivoire]. / Pronostic des fistules digestives post-operatoires au Chu de Yopougon : Abidjan/Cote d'Ivoire.

OBJECTIVE: Because of the difficulties to manage the post-operative digestive fistulas (FDPO) and their disappointing results, the authors led this survey. It's objective is to identify the prognosis factors in order to optimize their management and improve their prognosis. PATIENTS AND METHOD: It is a retrospective survey during 12 years, from January 1992 to December 2004 in the general and digestive surgery adult service of CHU Yopougon. It included 86 files of patients aged of 15 years at least presenting a FDPO. RESULTS: The middle age was of 36.8 years. The death rate was 29.06%. It rose with age. The risk of death was multiplied by 5.54 over age of 55 years (OR = 5.54 and p = 0.012). The number of death rose meaningfully with the length of the diagnostic delay (p = 0.016 for OR1 = 1.64 and OR2 = 8.94. The death rate was raised more in the exposed fistulas that in the controlled fistulas (87% against 45%). In 50% of the cases the death occurred when the debit was superior or equal to 500 cc daily. Among the patients submitted to the medical treatment 69.70% had a spontaneous closing of their fistula in a middle delay of 27.18 days for extremes varying between 13 and 47 days. CONCLUSION: The affection is very serious considering it's death rate. A precocious diagnosis and a fast and adapted management should permit to reduce this higher mortality.

Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue.

BACKGROUND AND STUDY AIMS: Postoperative fistulae occur frequently in standard surgical practice, but there is no general agreement on how to treat them. We summarize here our experience with endoscopic treatment. PATIENTS AND METHODS: Postoperative digestive fistulae resistant to conservative treatment, in 15 patients, are retrospectively reviewed. Our series included two internal fistulas: (one rectovesical, and one high-output pleuroesophagic), and 13 external fistulas (one low-output gastrocutaneous, two low-output esophagocutaneous, seven low-output enterocutaneous, and three high-output enterocutaneous). After failure of conservative treatment, the fistulas were endoscopically located and 2 - 4 ml of reconstituted fibrin glue, Tissucol 2.0 at 37 degrees C, was injected through a catheter. RESULTS: The mean age of the patients was 61.2 years (38 - 86), and 60 % were men. Of the fistulas, 26.6 % were of the high-output type. The mean healing time was 16 days (5 - 40), and a mean of 2.5 sessions per patient were required (1 - 5). Complete sealing of fistulas was achieved in 86.6 % of cases; (87.5 % of the low-output and internal fistulas, and 55 % of the high-output fistulas). After follow-up ranging between 2 months and more than 3 years, only one of the sealed fistulas reopened. No complications were encountered. Overall mortality was 13.3 % (two out of 15), but in only one patient was this related to clinical deterioration because of the persistence of the fistula. CONCLUSIONS: We think that conservative treatment should not be prolonged beyond 14 days and that endoscopic treatment should be performed at that stage. Endoscopic sealing treatment achieves a very high success rate, without complications and at a lower cost. It could probably reduce the hospital stay, and avoid some unnecessary surgical interventions. Appropriate multicenter randomized trials are needed to confirm these results.

[Management of enteric fistula].

OBJECTIVES: To evaluate the essentials for successful management of entero-cutaneous fistulas and their. METHODS: We analyzed. The therapeutic results of 1 168 cases treated in a single center from January. 1971 to December. 2000. RESULTS: In these patients, the cure rate of fistulas was 93% and 37.1% after non-operative treatment. Most cases died of sepsis (60/65 cases, 93.2%) with a total mortality of 5.5%. In 659 cases who had undergone operation for enteric fistula, 647 (98.2%) recovered. The cure rate, mortality rate and successful rate of operation (94.2%, 4.4%, 99.7%) in the period of January. 1985 - December. 2000 were better than those (90.4%, 8.2%, 95, 5%) in the early period of January 1971 December 1984 (P < 0.05). CONCLUSIONS: The change of therapeutic strategy, improved technique in control of sepsis, rational nutritional support and careful monitoring of vital organs are essential to the management of enteric fistulas. How to increase the spontaneous closure of fistula, the therapeutic rate of specific enteric fistula (e.g. IBD, radiation enteritis) and the operative rate of enteric fistula in the early period requires further study.