Endovascular Management of Aortic Stump Blowout by Parallel Grafting and Coil Embolization of Visceral Aorta.

Aortic graft and endograft infections remain a significant source of morbidity and mortality after abdominal aortic aneurysm repair. With graft excision and extra-anatomic bypass, an infrarenal aortic stump remains which can have suture line dehiscence and catastrophic stump blowout. Treatment of this is extremely challenging, especially for severely co-morbid patients who cannot undergo major surgery, or in patients with a hostile abdomen. We present a case study of a 74-year-old male found to have an aortoenteric fistula (AEF). This case broadens operative options for this type of patient population by demonstrating an endovascular technique for addressing aortic stump blowout by parallel grafting and coil embolization of the visceral aorta.

Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease.

Crohn's disease (CD), a form of inflammatory bowel disease, involves chronic inflammation within the gastrointestinal tract. Intestinal strictures and fistulas are common complications of CD with varying severity in their presentations. Modifications in oral diet or use of exclusive enteral nutrition (EEN) are common approaches to manage both stricturing and fistulizing disease, although supporting research evidence is generally limited. In the preoperative period, there is strong evidence that EEN can reduce surgical complications. Parenteral nutrition (PN) is often utilized in the management of enterocutaneous fistulas, given that oral diet and EEN may potentially increase output in proximal fistulas. This narrative review highlights the current practices and evidence for the roles of oral diet, EEN, and PN in treatment and management of stricturing and fistulizing CD.

Hyperdry Human Amniotic Membrane as a Protective Dressing for Open Wounds With Exposed Bowel in Mice.

INTRODUCTION: An enteroatmospheric fistula forms when the exposed bowel is perforated with chronic enteric fistula formation. Currently, there is no established preventative method for this condition. Hyperdry (HD) amniotic membrane (AM) can promote early granulation tissue formation on the exposed viscera and is suitable for dressing intractable wounds as it possesses anti-inflammatory, antibacterial, and immunomodulatory properties. This study investigated whether HD-AM promotes early formation of blood vessel-containing granulation tissue for enteroatmospheric fistula treatment. METHODS: An experimental animal model of an open wound with exposed bowel was developed. A 15 × 20 mm wound was prepared on the abdomen of Institute of Cancer Research mice, and the HD-AM was placed. The mice were assigned to one of the following groups: HD-AM group, in which the stromal layer of the HD-AM was placed in contact with the exposed bowel; HD-AM UD group, in which the epithelial layer of the HD-AM was placed in contact with the exposed bowel; and the HD-AM (-) or control group, in which the HD-AM was not used. RESULTS: On postoperative days 7 and 14, granulation tissue thickness significantly increased in the HD-AM and HD-AM UD groups compared with that in the HD-AM (-) group. Macrophages accumulated in the HD-AM epithelium only in the HD-AM group. During HD-AM contact, a subset of invading macrophages switched from M1 to M2 phenotype. CONCLUSIONS: HD-AM is a practical wound dressing with its scaffolding function, regulation of TGF ß-1 and C-X-C motif chemokine 5 (CXCL-5), and ability to induce M1-to-M2 macrophage conversion.

[Chinese consensus on open abdomen therapy (2023 edition)].

Open abdomen therapy is an effective treatment to deal with severe abdominal infections, abdominal hypertension and other critical abdominal diseases. However, this therapy is difficult to implement and has many uncertainties in the timing, manners, and follow-up treatment, which leads to the fact that open abdomen therapy is not very accessible and standardized in medical systems of China. This consensus aims to provide guiding principles for indications and implementation of open abdomen, classification methods of open abdomen wounds, technologies for abdominal closure, and management of enteroatmospheric fistula, so as to improve the accessibility and success rate of open abdomen in China.

A systematic review of epidemiology and outcomes of Crohn's disease-related enterocutaneous fistulas.

BACKGROUND: Enterocutaneous fistulas (ECF) are rare sequelae of Crohn's disease (CD) that occur either postoperatively or spontaneously. ECFs are associated with high morbidity and mortality. This systematic literature review assesses the disease burden of CD-related ECF and identifies knowledge gaps around incidence/prevalence, treatment patterns, clinical outcomes, healthcare resource utilization (HCRU), and patient-reported outcomes (PROs). METHODS: English language articles published in PubMed and Embase in the past 10 years that provided data and insight into the disease burden of CD-related ECF (PROSPERO Registration number: CRD42020177732) were identified. Prespecified search and eligibility criteria guided the identification of studies by two reviewers who also assessed risk of bias. RESULTS: In total, 582 records were identified; 316 full-text articles were assessed. Of those, eight studies met a priori eligibility criteria and underwent synthesis for this review. Limited epidemiologic data estimated a prevalence of 3265 persons with ECF in the USA in 2017. Clinical response to interventions varied, with closure of ECF achieved in 10% to 62.5% of patients and recurrence reported in 0% to 50% of patients. Very little information on HCRU is available, and no studies of PROs in this specific population were identified. CONCLUSION: The frequency, natural history, and outcomes of ECF are poorly described in the literature. The limited number of studies included in this review suggest a high treatment burden and risk of substantial complications. More robust, population-based research is needed to better understand the epidemiology, natural history, and overall disease burden of this rare and debilitating complication of CD.

Treatment of pouchitis, Crohn's disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium.

Pouchitis, Crohn's disease of the pouch, cuffitis, polyps, and extraintestinal manifestations of inflammatory bowel disease are common inflammatory disorders of the ileal pouch. Acute pouchitis is treated with oral antibiotics and chronic pouchitis often requires anti-inflammatory therapy, including the use of biologics. Aetiological factors for secondary pouchitis should be evaluated and managed accordingly. Crohn's disease of the pouch is usually treated with biologics and its stricturing and fistulising complications can be treated with endoscopy or surgery. The underlying cause of cuffitis determines treatment strategies. Endoscopic polypectomy is recommended for large, symptomatic inflammatory polyps and polyps in the cuff. The management principles of extraintestinal manifestations of inflammatory bowel disease in patients with pouches are similar to those in patients without pouches.

THE ROLE OF FISTULOCLYSIS IN THE TREATMENT OF PATIENTS WITH ENTEROATMOSPHERIC FISTULAS.

BACKGROUND: Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric fistulas, in which the origin is the gastrointestinal tract in connection with the external environment through an open wound in the abdomen. Due to the high output in enterocutaneous fistulas, the loss of fluids, electrolytes, minerals and proteins leads to complications such as sepsis, malnutrition and electrolyte derangements. The parenteral nutrition has its secondary risks, and the fistuloclysis, that consist in the infusion of enteral feeding and also the chyme through the distal fistula, represents an alternative to the management of these patients until the definitive surgical approach. AIM: To evaluate the current evidence on the fistuloclysis technique, its applicability, advantages and disadvantages for patients with high output fistulas. METHOD: A systematic literature search was conducted in May 2020 with the headings "fistuloclysis", "chyme reinfusion" and "succus entericus reinfusion", in the PubMed, Medline and SciELO databases. Results: There were 29 articles selected for the development of this narrative synthesis, from 2003 to 2020, including reviews and case reports. CONCLUSION: Fistuloclysis is a safe method which optimizes the clinical, nutritional, and immunological conditions of patients with enteroatmospheric fistulas, increasing the chances of success of the reconstructive procedure. In cases where the definitive repair is not possible, chances of reducing or even stopping the use of nutrition through the parental route are increased, thus representing a promising modality for the management of most challenging cases.

Review article: investigation and management of internal fistulae in Crohn's disease.

BACKGROUND: Crohn's disease is an inflammatory, penetrating intestinal disease associated with fistula formation. Fistulae in Crohn's disease can be classified into external and internal fistulae. Internal fistulae form between the gastrointestinal tract and another internal organ and include enteroenteric, enterocolic, enterovesical and rectovaginal fistulae. They are associated with significant morbidity and a decreased quality of life. AIM: To review the classification, diagnosis, medical and surgical management of internal fistulae in Crohn's disease, and propose a treatment algorithm. METHODS: A literature review on internal fistulae in Crohn's disease in the adult population was undertaken, synthesised and summarised. RESULTS: Internal fistulae occur in up to 15% of patients with Crohn's disease. Multi-modal assessment including a combination of endoscopy and cross-sectional imaging, usually magnetic resonance, is required to diagnose fistulae and determine extent of disease. Determining optimal treatment strategies for these complex fistulae remains a challenge due to limited and generally low-quality data. Most studies to date have focussed on luminal disease, with (usually post hoc) outcomes more often reported for external fistulae, particularly perianal fistulae, than internal fistulae. Anti-tumour necrosis factor therapies have emerged as the mainstay of medical therapy, with particularly promising data for enterovesical fistulae, but many patients will still require surgical intervention. The indications and optimal timing of surgery vs medical therapy remains uncertain; thus multi-disciplinary input when making such decisions is important. CONCLUSIONS: Internal fistulae result in significantly increased morbidity in Crohn's disease, and further studies to determine optimal multi-modality management strategies incorporating medical and surgical therapy are required.

Management of an Aortoenteric Fistula in a Patient with End Stage Renal and Liver Disease, Prior Endovascular Aortic Repair With Type II Endoleak.

Primary aortoenteric fistula (AEF) is an uncommon but life-threatening condition. We present a case of primary AEF in an octogenarian with previous endovascular aortic repair, type II endoleak and end stage liver and renal disease. He was successfully treated with accessory renal artery ligation, duodenojejunostomy, aneurysm sac debridement and irrigation and closure of the aneurysm sac over a drain. The patient made an excellent recovery and was discharged on POD #7, with no complications noted after over a year of follow up. This approach may represent a valuable option to manage primary AEF versus open endograft explant, particularly in severely ill patients.

Chyme reinfusion nutritional management for enterocutaneous fistula: first international application of a novel pump technique.

AIM: High-output enterocutaneous fistulas (ECFs) are an established cause of intestinal failure. Parenteral nutrition (PN) remains the gold standard for nutritional management but is complex, expensive and associated with significant complications. Chyme reinfusion (CR) has been reported by multiple centres as a viable option for nutritional management that improves nutritional status, provides the capacity to cease PN and is cost-effective. The aim of this paper is to describe the first use of a novel pump device (The Insides System™) by an independent centre in Australia for the nutritional management of a patient with high-output ECF. METHOD: CR was performed on a 66-year-old woman with a high-output ECF. The device consists of two main components: a centrifugal pump that sits inside the stoma appliance and a battery-powered driver that is magnetically coupled externally onto the pump. The device allows for bolus CR at a rate of infusion that is manually controlled by the patient based on comfort, volume and effluent viscosity. RESULTS: CR provided adequate nutritional support, with successful cessation of PN. Effective use of the device was learnt easily by the patient with minimal demands on nursing assistance. Side effects of CR (diarrhoea, abdominal cramping) were overcome by the patient's ability to manually adjust the reinfusion rate. CONCLUSION: Our experience with the novel Insides System™ device showed promising results in maintaining nutritional status as well as providing a minimally invasive, easy to use and low-cost system for CR. CR should be considered as a viable alternative for the nutritional management of patients with a high-output ECF.

Traumatic Arterio-Enteric Fistula-A Report of 2 Cases With Review of Literature.

BACKGROUND: Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries. CASE DESCRIPTION: Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully. CONCLUSION: Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.

Combined treatment of enterocutaneous fistula with laser diode and embolization. / Tratamiento de fístula enterocutánea combinando láser diodo y embolización.

INTRODUCTION: Enterocutaneous fistula treatment in patients undergoing multiple surgeries is complex and requires creative solutions. We present the case of an enterocutaneous fistula managed with laser diode and cyanoacrylates. CLINICAL CASE: 15-year-old patient, diagnosed with ulcerative colitis at 12 years of age, undergoing full colectomy with urgent ileostomy as a result of a flare-up refractory to medical treatment. Five months later, an ileoanal pull-through with pouch was carried out, leaving a protection ileostomy in place. However, postoperative evolution was poor, with pelvic infection, so two further urgent open surgeries were required for lavage and hemostasis purposes. Six months later, anastomotic stricture was noted. It was healed following various pneumatic dilations under ultrasound vision and at-home dilations using Hegar dilators. One year following this, ileostomy was closed, but one month later, abdominal distension occurred. It was associated with a fistula in the abdominal midline, which could be endoscopically guided, with its origin being located at the ileoanal anastomosis. Laser diode sessions were applied for treatment purposes, with partial improvement, but still with gas emission. One year later, embolization was performed by placing platinum coils and lipiodol-diluted cyanoacrylates, and clinical signs disappeared. 17 months following this surgery, the patient has no symptoms, with full day and night fecal continence and 3 daily stools, and the fistula is completely closed. CONCLUSION: Combined treatment with laser diode and platinum coil and cyanoacrylate embolization proves effective in the management of enterocutaneous fistula, with low morbidity.

INTRODUCCION: El tratamiento de las fístulas enterocutáneas establecidas en pacientes multioperados es complejo y requiere de soluciones creativas. Presentamos la resolución de un caso con láser diodo y con cianoacrilatos. CASO CLINICO: Paciente de 15 años, diagnosticado a los 12 de colitis ulcerosa y sometido a pancolectomía con ileostomía urgente por brote refractario al tratamiento médico. Cinco meses después se realizó un descenso ileoanal con reservorio dejando ileostomía de protección, pero presentó un posoperatorio tórpido con infección pélvica, precisando dos nuevas laparotomías urgentes, para lavado y hemostasia. Seis meses después, se evidenció una estenosis de la anastomosis que se resolvió tras varias dilataciones, neumáticas bajo visión endoscópica y domiciliarias con tallos de Hegar. Un año después se cerró la ileostomía, presentando al mes una distensión abdominal y aparición de fístula en línea media abdominal, que pudo tutorizarse endoscópicamente, observando su origen en la anastomosis ileoanal. Se trató mediante sesiones de láser diodo, con mejoría parcial, aunque persistía la salida de gases. Un año después se embolizó implantando espirales de platino y cianoacrilatos diluidos con lipiodol, resolviéndose totalmente el cuadro. Transcurridos 17 meses de esta última intervención, el paciente se encuentra asintomático, con continencia fecal total diurna y nocturna, tres deposiciones al día y la fístula está totalmente cerrada. CONCLUSION: El tratamiento con láser diodo, combinado con embolización con espirales de platino y cianoacrilatos, puede ser un tratamiento eficaz con baja morbilidad de las fístulas enterocutáneas establecidas.

Enterocutaneous fistula from migration of hepatic artery infusion catheter.

We present an 84-year-old man with erosion of the chemotherapy port on his chest wall. He had a history of colorectal cancer with liver metastases more than 20 years ago, when he underwent right hemicolectomy and liver resection. A hepatic artery infusion catheter was placed for targeted administration of chemotherapy for the liver metastases. Imaging showed the catheter had migrated into the small bowel lumen. We considered the best approach for removing the migrated catheter - either remove the catheter and accept the likelihood of a low-volume enterocutaneous fistula that may self-resolve, or explore the enterocutaneous tract with a view to small bowel resection. We discuss the advantages and disadvantages here.

Parenteral and Enteral Nutrition: A Bridge to Healing and Biological Therapy in a Patient With Enterocutaneous Fistula and Sepsis Complicated Crohn's Disease.

Inflammatory bowel disease (IBD) patients with severe infections, abscess, or sepsis are ineligible for standard treatment using biological and immunosuppressive drug regimens. We report a case of complicated Crohn's disease with ruptured abdominal abscess, presence of enterocutaneous fistula, and sepsis. We also report and discuss patient management with parenteral nutrition (PN) and enteral nutrition (EN) and treatment outcomes. We report a case of a 31-year-old female with a 10-year history of IBD in clinical remission, who, after previous total proctocolectomy with J-pouch, presented to the clinic with severe abdominal pain of 2 days, unintentional weight loss, fatigue, fever, and abdominal abscess, which ruptured, and her clinical state became complicated by sepsis. PN was initiated using individually prepared admixture according to patient requirements, because of inability to tolerate any oral intake. Following the remittance of ileus symptoms, EN was added using a semielemental formula via a nasojejunal tube. Upon completion of the treatment, the fistula resolved, the wound had healed, and Crohn's Disease Activity Index score showed remission. This qualified the patient for initiation of biological therapy with infliximab. Patients with severe infections, abscesses, or sepsis are ineligible for standard IBD treatment using biological and immunosuppressive drug regimens. Furthermore, usually patients' nutrition condition prevents them from combating infection and initiating proper healing process. This case demonstrates the importance of considering nutrition therapy-PN and EN-in unstable patients who cannot be treated with standard pharmacological therapy. Nutrition therapy offers a bridge that allows patients to stabilize and heal before starting standard pharmacological treatment with immunosuppressive agents or biological therapy.

The impact of enteric fistulas on US hospital systems.

BACKGROUND: There is limited characterization of patients with enteric fistula. Our objective is to determine the incidence of the disease, and characterize demographics, healthcare costs, co-diagnoses, and procedures in this population. METHODS: The National Inpatient Sample database 2004-2014 was queried to identify patients with enteric fistula using ICD-9 code 569.81. RESULTS: There were 317,000 admissions with a diagnosis of enteric fistula from 2004 to 2014, accounting for 230,000 hospital days annually. Costs totaled $500 million with charges of $1.5 billion annually. Inpatient mortality is 4.1%. Patients had significant comorbidities and 3 procedures or surgical interventions per admission. CONCLUSIONS: This descriptive study elucidates the impact of enteric fistula on patients and hospitals by characterizing incidence, clinical associations, and admission characteristics. There is significant financial impact with 28,000 admissions and $500 million dollars in annual costs. This study lays the groundwork for future research by characterizing the impact of enteric fistula.

The role of fistuloclysis in the treatment of patients with enteroatmospheric fistulas / O papel da fistuloclise no tratamento de pacientes com fístulas enteroatmosféricas

ABSTRACT Background: Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric fistulas, in which the origin is the gastrointestinal tract in connection with the external environment through an open wound in the abdomen. Due to the high output in enterocutaneous fistulas, the loss of fluids, electrolytes, minerals and proteins leads to complications such as sepsis, malnutrition and electrolyte derangements. The parenteral nutrition has its secondary risks, and the fistuloclysis, that consist in the infusion of enteral feeding and also the chyme through the distal fistula, represents an alternative to the management of these patients until the definitive surgical approach. Aim: To evaluate the current evidence on the fistuloclysis technique, its applicability, advantages and disadvantages for patients with high output fistulas. Method: A systematic literature search was conducted in May 2020 with the headings "fistuloclysis", "chyme reinfusion" and "succus entericus reinfusion", in the PubMed, Medline and SciELO databases. Results: There were 29 articles selected for the development of this narrative synthesis, from 2003 to 2020, including reviews and case reports. Conclusion: Fistuloclysis is a safe method which optimizes the clinical, nutritional, and immunological conditions of patients with enteroatmospheric fistulas, increasing the chances of success of the reconstructive procedure. In cases where the definitive repair is not possible, chances of reducing or even stopping the use of nutrition through the parental route are increased, thus representing a promising modality for the management of most challenging cases.

RESUMO Racional: As fístulas enterocutâneas representam uma conexão entre o trato gastrointestinal e os tecidos adjacentes. Dentre elas, há uma subdivisão - as fístulas enteroatmosféricas, em que a origem é o trato gastrointestinal em conexão com o meio externo por meio de uma ferida aberta no abdômen. Devido ao alto débito nas fístulas enterocutâneas, a perda de fluidos, eletrólitos, minerais e proteínas levam a complicações como sepse, desnutrição e desequilíbrios eletrolíticos. A nutrição parenteral tem seus riscos secundários, e a fistuloclise, que consiste na infusão de nutrição enteral e também do quimo pela fístula distal, representa uma alternativa no manejo desses pacientes até a abordagem cirúrgica definitiva. Objetivo: Avaliar as evidências atuais sobre a técnica de fistuloclise, sua aplicabilidade, vantagens e desvantagens para pacientes com fístulas de alto débito. Método: Foi realizada uma busca sistemática da literatura em maio de 2020 com os títulos "fistuloclysis", "chyme reinfusion" e "succus entericus reinfusion", nas bases de dados PubMed, Medline e SciELO. Resultados: Foram selecionados 29 artigos para o desenvolvimento desta síntese narrativa, no período de 2003 a 2020, incluindo revisões e relatos de caso. Conclusão: A fistuloclise é um método seguro que otimiza as condições clínicas, nutricionais e imunológicas dos pacientes com fístulas enteroatmosféricas, aumentando as chances de sucesso do procedimento de reconstrução. Nos casos em que o reparo definitivo não é possível, aumentam as chances de reduzir ou mesmo interromper o uso da nutrição pela via parental, representando uma modalidade promissora para o manejo dos casos mais desafiadores.

[Acquired internal intestinal fistulae in children]. / Priobretennye vnutrennie mezhkishechnye svishchi u detei.

OBJECTIVE: To analyze the diagnosis and treatment of children with acquired internal intestinal fistulae. MATERIAL AND METHODS: There were 3 infants and young children with acquired internal intestinal fistulae. Clinical, laboratory and radiological diagnostic methods were used. RESULTS: Two out of 3 children with acquired internal intestinal fistulae underwent surgical treatment for congenital intestinal obstruction. Acute intestinal ulcers appeared after surgery. In a premature child, intestinal fistula arose on the background of necrotizing colitis. Conservative approach was applied in this case. All children were operated on; intestinal fistula was eliminated. Two children are alive, 1 died after surgery (multiple organ failure). CONCLUSION: Acquired internal intestinal fistulae are rare in children. Their causes may be acute intestinal perforation after surgery or covered (not diagnosed) ulcer as a complication of necrotizing colitis in premature children.

[Staged approach in the treatment of patients with enterocutaneous fistulae]. / Etapnyi podkhod v lechenii bol'nykh s nesformirovannymi kishechnymi svishchami.

OBJECTIVE: To determine an optimal approach in the treatment of patients with intestinal fistulae. MATERIAL AND METHODS: We have used the above-mentioned algorithm in the treatment of 46 patients. The majority of patients (n=44, 96%) were transferred under supervision of our multidisciplinary team with severe water-electrolyte disturbances and signs of secondary protein-energy malnutrition (PEM) that required complex combined nutritional support. A two-stage approach was applied in all cases. The first one was conservative and included correction and prevention of infectious complications, nutritional and metabolic therapy, local wound treatment, and anatomical assessment of the fistula. The second stage was reconstructive and implied various reconstructive interventions not earlier than 3 months after formation of the fistula. RESULTS: Conservative approach was followed by fistula healing in 6 patients, surgery was required in 25 patients. Complications with subsequent redo surgery occurred in 4 cases. In all cases, favorable outcome was noted. All 25 patients were discharged. Three patients refused reconstructive surgery after development of fistula, they were also discharged. Mortality rate was 26% (n=12). CONCLUSION: A multidisciplinary two-stage approach can significantly improve treatment outcomes in patients with intestinal fistulae.