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.

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.

Navigating reimbursement for home parenteral nutrition.

Reimbursement for home parenteral nutrition (HPN) is important for nutrition support clinicians to understand. This intent of this review is to provide nutrition support clinicians knowledge on navigating through the structured requirements of diagnosis driven billing to receive reimbursement for services related to HPN, provide information on coding, provide practical tips for surviving a Medicare billing audit, and discuss challenges of Medicare guidelines seen in clinical practice.

Effects of fistula on healthcare costs and utilization for patients with Crohn's disease treated in a managed care environment.

BACKGROUND: Fistulas are a common complication of Crohn's disease (CD) and are difficult to treat effectively. This study aimed to assess the effects of fistula on annual costs of healthcare and resource utilization for patients with CD. METHODS: A retrospective analysis, using the PharMetrics database, of patients with a diagnosis of CD from January 1, 2000 through June 30, 2005 was conducted. Using paid claim amounts, healthcare costs and resource utilization were compared for patients with and without fistula in the year following diagnosis. Further analysis compared costs for adult, pediatric, and older adult patients with and without fistula. RESULTS: This analysis included 13,454 patients with CD, of whom 12,683 (94.3%) had no diagnosis of fistula. The total median (range) cost per patient was higher for the fistula cohort ($10,863 [$0-$1,307,019]) than the nonfistula cohort ($6268 [$0-$1,181,485]), driven mainly by higher hospital and surgery costs. Median healthcare costs and resource utilization rates were generally higher for patients with fistula compared with those without fistula in all 3 age groups, with some of the largest differences observed in the pediatric cohort. CONCLUSIONS: Fistulas are often a difficult and costly complication of CD. This study determined that patients with fistulizing CD have higher healthcare costs and resource consumption than patients without fistula. Use of therapies that heal fistulas may help deter some of the high costs and intensive resource utilization found in this study. Economic analyses need to account for these issues when assessing the cost-effectiveness of therapies targeting fistulizing disease.

[Strategic risk reduction in the operative therapy for abdominal aortic aneurysms]. / Operative Risikoreduktion in der Therapie des abdominellen Aortenaneurysmas.

Advances in early diagnosis of abdominal aortic abnormalities, enhanced pre-and post-surgical care and improved pharmacological treatment, as well as new interventional strategies and surgical techniques have led to a considerable increase of those patients, who undergo surgical therapy, either using classical trans-abdominal open or endovascular techniques. These patients, as a result of their often underlying multi-morbidity, are prone to secondary complications that often require individual solutions. We present and discuss two cases of post-surgical complications that required individual strategies for risk reduction. The first case demonstrates the endovascular approach to a complication following open aortic surgery, the second describes a surgical intervention to solve a problem following endovascular therapy.

Experience with the use of vacuum dressings in the management of acute enterocutaneous fistulas.

High-output enterocutaneous fistulas involving an open abdominal wound are a difficult management problem. We report our experience on the use of vacuum dressings. The potential benefits, problems and new recommendations for the use of vacuum dressings in the management of enterocutaneous fistulas are discussed.

[Endoscopic treatment of intestinal anastomotic leakage in low anterior resection of the rectum by using fibrin adhesive. Our experience]. / Trattamento endoscopico delle deiscenze anastomotiche nelle resezioni anteriori del retto mediante applicazione di colla di fibrina. Nostra esperienza.

BACKGROUND: Personal experience about treatment of anastomotic leakage in low anterior resection of the rectum by using human fibrin adhesive "Tissucol" is reported. METHODS: Eight cases of anastomotic leakage treated with using human fibrin adhesive "Tissucol", are analyzed in a retrospective study. Patients had three/six months-one year follow up. Treatment with human fibrin adhesive "Tissucol" was performed in our Endoscopic ambulatory. Six cases had either an immediate resolution or an ambulatorial follow-up; in 2 cases only, general complications forced to a prolonged hospital stay. The study concerns 58 patients subjected to low anterior resection of the rectum and endoscopic treatment of 8/58 patients with anastomotic leakage. Fistulas were sealed with human fibrin adhesive "Tissucol" by using flexible endoscope. Anastomotic leakage identification leakage was made and low anterior resection of the rectum and sealing with human fibrin adhesive "Tissucol" were performed. RESULTS: Complete sealing of fistula and rectum patent. CONCLUSIONS: The excellent results obtained with this non invasive and fast treatment, easily practicable even in ambulatorial regimen, lead the authors to consider it effective and as first-choice treatment of this dangerous complication. The cost/benefit ratio is favorable if compared with the long hospital stay required for other treatments, which also present loaded high morbidity and mortality.

Clinical analysis of choledochoduodenal fistula with cholelithiasis in Taiwan: assessment by endoscopic retrograde cholangiopancreatography.

OBJECTIVES: Choledochoduodenal fistula (CDF) is occasionally found during endoscopic retrograde cholangiopancreatography (ERCP). Cholelithiasis is suspected to be the leading cause in some endemic areas. We focus on this cause of CDF to determine which clinical characteristics are relevant to formation of fistulas and to learn whether CDF of various types would imply different clinical significance. METHODS: In 1882 ERCP studies from 1988 to 1993, we found 27 CDF with cholelithiasis in 1066 patients. Their clinical backgrounds and ERCP findings were compared with those of 492 patients who had cholelithiasis but no CDF. RESULTS: The prevalence of CDF was 2.53%. A longer past history of biliary stones, recurrent biliary tract infection (BTI), and the presence of common bile duct stones (CBS) were factors relevant to the formation of fistula. In the case of 24 distal fistulas, including seven of type I and 17 of type II, there was concurrent distal CBS. Three cardinal features of fistula of the distal type were: 1) the length of CDF was less than 1.5 cm, 2) its orifice was just around or on the papillary fold, and 3) all cases of distal type II had prominent pneumobilia, less jaundice, and larger CBS than type I. Aggressive endoscopic or surgical treatment of distal type CDF decreased the recurrence of BTI, as indicated by surveillance for 1 yr. Three fistulas of the proximal type were longer and drained into the duodenum far from the papilla. All of these cases deserved early surgical intervention. CONCLUSIONS: CDF really serves as a chronic sequel of cholelithiasis. Different clinical features of CDF of various types help one to establish diagnosis and treatment. To avoid recurrence of BTI, aggressive therapy to correct CDF is mandatory.

Incidence and management of pancreatic and enteric fistulas after surgical management of severe necrotizing pancreatitis.

OBJECTIVE: To determine the incidence, type, and outcome of complications of necrotizing pancreatitis. SETTING: Major tertiary referral center (Mayo Clinic, Rochester, Minn). PATIENTS: Sixty-one patients seen from 1985 to 1994 who underwent surgical management of severe necrotizing pancreatitis and who developed pancreatic or gastrointestinal fistulas. MAIN OUTCOME MEASURES: Incidence, management, and outcome of pancreatic and gastrointestinal fistulas. RESULTS: Twenty-five patients (41%) developed pancreatic (14 patients) and/or gastrointestinal tract cutaneous (19 patients) fistulas. While three duodenal fistulas and one colonic fistula were recognized at the initial operation for pancreatic necrosectomy, the remainder developed 4 to 60 days after the initial operation. Spontaneous closure occurred in nine of 14 pancreatic, two of two gastric, two of four enteric, two of eight colonic, and four of five duodenal fistulas. Mortality of the group with fistulas was 24% (6/25) and was not different from the mortality of the patients with necrotizing pancreatitis without fistulas (28% [10/36]). CONCLUSIONS: Pancreatic and gastrointestinal tract fistulas are common complications of surgical treatment of severe necrotizing pancreatitis. Well-controlled gastric, pancreatic, and enteric fistulas have the greatest likelihood of spontaneous closure. Duodenal and colonic fistulas may need surgical intervention for control or repair. Mortality in these patients parallels the mortality for severe necrotizing pancreatitis.

[Effects of over feeding on the energy expenditure and substrates oxidative rate in surgical patients].

In this study, computerized indirect calorimetric measurements were made using a medical graphics critical care monitor (CCM) desktop analysis system in the observation of metabolic state of 20 patients complicated with external gastrointestinal fistula. While these malnourished patients were provided with 1.5 x REE in total energy intake, the malnutrition state could be reversed. But with 1.75 or 2.0 x REE or up total energy intake, the general nutritional state could not be improved faster, the O2 consumption and CO2 production and energy expenditure increased, while the net glucose oxidation increased and net lipid oxidation decreased or net lipogenesis occurred simultaneously. We believed that superfluous energy intake is harmful to critically ill patients and may lead to cell injury and dysfunction.

Influence of rapid amino acid and lipid emulsion administration on gas exchange and resting energy expenditure.

The aim of this study was to observe the effect of rapid lipid and amino acid infusion on resting energy expenditure (REE) in patients on parenteral nutrition. Eight people were studied. After 8 h of saline administration, they received 20% lipid emulsion and 8% amino acid solution during the next 5 h (rate 3.8 mg.kg-1.min-1 fat and 1.9 mg.kg-1.min-1 amino acid). Before the onset of the infusion and 3 and 5 h after, gas exchange and REE were measured. The rapid lipid emulsion administration led to a significant rise in serum triglyceride level. A significant increase in VO2 (from 269.0 +/- 66.8 to 319 +/- 55.8 ml/min) and REE (from 1858 +/- 438 to 2155 +/- 385 kcal/24 h) was observed 5 h after the onset of substrate administration (P less than 0.01). Pulmonary ventilation and VCO2 production were not influenced by the infusion. The thermic effect of nutrients administered reached 3.5 and 6.5% 3 and 5 h after the start of infusion, respectively. We conclude that REE can be increased by the rapid administration of lipid-based parenteral nutrition.