Experiencia en el manejo de fístulas enterocutáneas postoperatorias en el Hospital Nacional del 2017 al 2022

Introducción: la mayoría de las fistulas enterocutáneas se producen como complicación de una o varias cirugías previas. La mortalidad sigue siendo muy elevada. Su tratamiento supone un reto para el cirujano y gran uso de recursos humanos, económicos y prolongada estancia hospitalaria. Objetivo: determinar la experiencia del manejo de las fístulas enterocutáneas postoperatorias en el servicio de cirugía general del Hospital Nacional de Itauguá durante el periodo 2017-2022. Metodología: estudio observacional descriptivo retrospectivo de corte transversal, con muestreo no probabilístico. Solo hubo 30 casos con fichas completas, las cuales sometimos a procesamiento y análisis de las variables de interés. Resultados: de la muestra final 70 % fueron hombres, el promedio de edad fue de 49,6 años y de días de internación 28,6. Solo 5 pacientes consultaron por secreción fecaloide, los demás refirieron secreción seropurulenta por herida o cicatriz operatoria. Del total, 9 fueron de alto débito. El 100 % recibió antibioticoterapia; obitaron 4 de los 14 pacientes intervenidos quirúrgicamente con fin terapéutico. La técnica quirúrgica mayormente utilizada fue: laparotomía + liberación de adherencias e identificación de la fístula + resección intestinal + anastomosis. De los antecedentes la mayoría fueron postoperados de oclusión intestinal mecánica alta o peritonitis aguda de origen apendicular. Conclusión: debido a su alto impacto en la capacidad laboral y social las fístulas enterocutáneas representan patologías quirúrgicas muy complejas y relevantes con bajas tasas de curación definitiva. La mayoría se presentan como complicación de cirugías de urgencia; requiere intervención multidisciplinaria adaptada para cada caso en particular.

Introduction: the occur enterocutaneous fistula as a complication of one or several previous surgeries. Mortality is still very high. Its treatment represents a challenge for the surgeon and great use of human and economic resources and a long hospital stay. Objective: to determine the experience in the management of postoperative enterocutaneous fistulae in the general surgery service of the Itauguá National Hospital during the period 2017-2022. Methodology: retrospective, cross-sectional, descriptive, observational study with non-probabilistic sampling. There were only 30 cases with complete records, which we subjected to processing and analysis of the variables of interest. Results: of the final sample, 70 % were men, the average age was 49,6 years and 28,6 days of hospitalization. Only 5 patients consulted due to fecaloid discharge, the rest reported seropurulent discharge from wound or surgical scar. Of the total, 9 were high debit. 100 % received antibiotic therapy, 4 of the 14 patients who underwent surgery as therapeutics, died. The most commonly used surgical technique was: laparotomy + release of adhesions and identification of the fistula + intestinal resection + anastomosis. Most of the antecedents were post-operated for high mechanical intestinal occlusion or acute peritonitis of appendiceal origin. Conclusion: due to their high impact on work and social capacity, enterocutaneous fistulas represent very complex and relevant surgical pathologies with low definitive cure rates. Most present as a complication in emergency surgeries; requires multidisciplinary intervention adapted to each particular case.

Successful Closure of a Persistent Enterocutaneous Fistula with a Myocutaneous Flap.

Enterocutaneous fistulas can present with significant morbidity and mortality for affected patients, as the abnormal connection can result in exorbitant loss of enteral fluids, electrolyte disturbances, and sepsis, among other complications. We present a patient with a chronic complex enterocutaneous fistula who underwent several surgeries, resulting in a considerable amount of bowel resection. Based on history and findings of high output fistula with diverting transverse colostomy, the fistula was closed with a left rectus myocutaneous pedicle flap to avoid entering the abdominal cavity and prevent the possibility of short bowel syndrome. This case contributes to the growing body of literature supporting the use of rectus myocutaneous flaps for the closure of intractable complex enterocutaneous fistulas in patients unable to undergo resection of the affected bowel.

Giant squamous cell carcinoma developed on a mesh-related enterocutaneous fistula: A case report.

INTRODUCTION: Squamous cell carcinoma degeneration on enterocutaneous fistulas (EF) is infrequent. There are some reports of malignant conversion in Crohn's disease-associated fistulas. Literature about the malignant development of mesh-related EF is even more limited. PRESENTATION OF THE CASE: A 66-year-old patient who developed necrotizing pancreatitis was managed through an open necrosectomy approach with a prolonged open abdomen that derived an incisional hernia which was repaired using a synthetic mesh. Years later, the patient was admitted to the service because of hypovolemic shock due to gastrointestinal bleeding. An abdominal wound with mesh exposition and cloudy discharge was observed. A high-output enterocutaneous fistula diagnosis was established. After an institutional surgical committee, a surgical approach was defined, a 60 cm en-block resection of the involved small bowel was done, and the surgical specimen was obtained for histopathological analysis. DISCUSSION: The use of prosthetic mesh in the case of incisional hernias is associated with a higher incidence of complications. However, there is no evidence of the development of squamous cell carcinoma developed on a mesh-related enterocutaneous fistula. This is a condition associated with Chron's disease and its diagnosis should be suspected by the exacerbation of local signs and symptoms. The scarce literature published suggests that this pathology can be managed by radical surgery and even chemoradiation, the last one required only for patients with associated Chron's disease. CONCLUSION: Squamous Cell Carcinoma developed on a mesh-related enterocutaneous fistula is a rare condition with no classic signs and symptoms that allow diagnostic identification.

Enterocutaneous fistula due to a Richter's hernia after a Tenckhoff catheter removal.

Richter's hernia is a rare type of hernia that occurs when the antimesenteric intestinal wall protrudes through a defect in the abdominal fascia leading to ischaemia, gangrene, bowel perforation and enterocutaneous fistulae. In this article, we describe a rare case of enterocutaneous fistula due to a Richter's hernia after a Tenckhoff catheter removal. This type of complication has not been previously reported in the literature. An 82-year-old man presented with a 1-day history of enteric content at the Tenckhoff catheter insertion site. Seven weeks earlier, the catheter was removed due to peritonitis. Removal was performed using open technique, and the fascia was not closed. Computed tomography revealed a small incarcerated hernia and subcutaneous fluid collection at the previous catheter insertion site. He underwent laparoscopy, which showed a Richter's hernia with perforation of the ileum causing an enterocutaneous fistula. A laparoscopic enterectomy was performed using a primary mechanical anastomosis. The hernia was repaired by primary suture without a mesh because of wound enteral contamination and the small size of the hernia. Richter's hernia has a misleading clinical presentation and contributes to high rates of morbidity and mortality. A secure myofascial closure during catheter removal may reduce the chances of this complication.

Management of High Output Enterocutaneous Fistula due to Richter's Hernia After Gastric Bypass: Video Demonstration.

INTRODUCTION: The increase in laparoscopic surgery in patients with obesity increases the incidence of trocar site hernia (TSH). Therefore, TSH represents a risk for the development of Richter's hernia (RH). METHODS: We present the unusual case of a postoperative gastric bypass patient complicated with a high output enterocutaneous fistula through a trocar site wound. RESULTS: The Laparoscopic surgery consists of an RH reduction, enterotomy, and repair of the preperitoneal space. CONCLUSION: RH complicated by high-output enterocutaneous fistula has not been previously reported. It is essential to close the preperitoneal space in bariatric surgery to avoid these complications.

Fístula enterocutánea en una hernia incisional / Enterocutaneous fistula in an incisional hernia

Introducción: Los defectos técnicos en el cierre de la laparotomía, como la utilización de suturas inadecuadas, muy apretadas o distancia incorrecta entre los puntos, presencia de cuerpos extraños, hematomas o la inclusión de un asa intestinal (pellizcamiento de esta), pueden provocar la aparición de una hernia incisional, y peor aún acompañarse de una fístula intestinal. Objetivo: Corroborar la importancia del cierre correcto y cuidadoso de la pared abdominal después de una laparotomía. Presentación del caso: Se trata de una paciente de 34 años de edad con antecedentes de tres cesáreas en un período de seis años, la última hace seis meses, que fue atendida en el Hospital Mnazi Mmoja, en Tanzania, refiriendo salida de contenido líquido amarillento a nivel de la cicatriz quirúrgica. Al examen físico se constata hernia incisional y un asa intestinal adherida a la piel con un orificio de menos de un cm por donde sale contenido intestinal amarillento. Se interviene con diagnóstico preoperatorio de hernia incisional y fístula enterocutánea; se realiza resección de 3 tres cm del íleon, anastomosis termino-terminal donde se encuentra el orificio fistuloso y hernioplastia mediante la técnica de Rives con utilización de malla de polipropileno. La evolución posoperatoria fue satisfactoria. Conclusiones: Se refuerza la afirmación que es de suma importancia el cierre correcto y cuidadoso de la pared abdominal después de una laparotomía, sobre todo si se realiza con urgencia(AU)

Introduction: In the closure of the laparotomy, technical defects such as the use of inadequate sutures, too tight or incorrect distance between stitches, the presence of foreign bodies, hematomas or the inclusion of an intestinal loop (pinching) can cause the appearance of an incisional hernia which, even worse, can be accompanied by an intestinal fistula. Objective: To corroborate the importance of the correct and careful closure of the abdominal wall after performing laparotomy. Case presentation: A 34-year-old patient with a history of three previous cesarean sections in a six-year period, the last one performed six months, was treated at the Mnazi Mmoja Hospital in Tanzania when she reported the release of a yellowish liquid content at the surgical scar level. Physical examination revealed an incisional hernia and an intestinal loop attached to the skin with a hole of less than one cm through which yellowish intestinal content was coming out. She was operated on with the preoperative diagnosis of incisional hernia and enterocutaneous fistula; a three-cm resection of the ileum, end-to-end anastomosis where the fistulous orifice was located, and hernioplasty were performed using the Rives technique with polypropylene mesh. The postoperative evolution was satisfactory. Conclusions: The assertion that correct and careful closure of the abdominal wall after laparotomy is of utmost importance, especially if it is performed urgently, is reinforced(AU)

Complex giant incisional hernia repair with intraperitoneal mesh: A case report.

INTRODUCTION AND IMPORTANCE: An incisional hernia is one of the most frequent complications after abdominal surgery, with an estimated incidence of 2-20% after midline laparotomy. They are often caused by poor wound healing. We present the case of a complex giant incisional hernia that was repaired by implanting an intraperitoneal mesh. CASE PRESENTATION: A 63-year-old man with obesity, hypertension, and multiple previous laparotomies, who developed a complex giant incisional hernia (xipho-pubic > 10 cm wide). An open technique repair was decided with the introduction of a large mesh (Parietex ™ Composite) in an intraperitoneal position, covering a 25 × 16 cm hernial ring. After two years, the patient continues to be followed due to a low-output distal enterocutaneous fistula. CLINICAL DISCUSSION: Currently, there is no technique or approach that has become a gold standard for ventral incisional hernia repair. The introduction of an intraperitoneal mesh with two surfaces by laparotomy is recommended when there are contraindications for laparoscopic surgery, for example in obese patients, and patients with multiple previous laparotomies. However, it has been reported to be a complex technique with an enterocutaneous fistula rate of 0.3-4%. CONCLUSION: The introduction of a composite mesh represents an alternative surgical technique for the repair of giant incisional hernias.

No enterocutaneous fistula development in a cohort of 695 patients after incisional hernia repair using intraperitoneal uncoated polyproylene mesh.

PURPOSE: To determine the incidence of enterocutaneous fistulas (ECFs) developed after elective incisional hernia (IH) repair using intraperitoneal uncoated polypropylene (PPE) mesh. METHODS: This is a retrospective descriptive study of a prospective cohort of patients undergoing elective IH repair using intraperitoneal uncoated PPE mesh at the Department of General Surgery of a high complexity University Hospital. RESULTS: Between January 1992 and December 2013, 695 IH repairs were performed using intraperitoneal uncoated PPE mesh. The omentum was placed between the mesh and bowel in 507 patients (73 %). In 188 patients (27 %) it was not possible to place the omentum between the mesh and bowel; therefore, in 69 patients (9.92 %) the PPE mesh was placed over the bowel, whereas in 119 patients (17.12 %) a Vicryl® mesh was placed between the bowel and PPE mesh. Six hundred and seventy-eight (97.5 %) IH repairs were open whereas 17 (2.5 %) were laparoscopic. Postoperative complications consisted of seroma (5.9 %), hematoma (4.3 %), wound infection (4.8 %), and mesh infection (4.0 %). Recurrence of IH occurred in 52 patients (7.4 %) after a mean follow-up of 59 months. Four (0.5 %) patients required additional surgery due to intestinal occlusion. Neither acute nor chronic ECFs were encountered during follow-up in 695 patients. CONCLUSION: Based on these results, the placement of intraperitoneal uncoated PPE mesh for elective IH repair might be a safe procedure that is not associated with ECF formation.

Fístula enterocutánea en yegua reporte de um caso / Enterocutaneous fistula in a mare case roport / Fístula enterocutânea em égua relato de caso

Las hernias umbilicales ocurren a menudo en los caballos jóvenes y puede resultar en fístulas estercorales. Entre ellas, la fístula enterocutánea, son por lo general causada por una hernia umbilical. El objetivo fue describir una fístula enterocutánea en equino. Una yegua, castaña, Quarto de Milha, de cinco años de edad, de Paranhos, Mato Grosso do Sul fue servida, cuya referencia histórica fue un aumento de volumen en el ombligo, hace unos años, evolucionando con señales de dolor abdominal y posteriores fuga del contenido intestinal por la hinchazón en el área del orificio. Después de la exploración física, el animal se había convertido en parámetros de alerta y fisiológicas dentro de los límites normales. Al realizar paracentesis que no se encuentro contaminación de la cavidad peritoneal fue recomendado laparotomía exploratoria. Hubo adhesiones en segmento yeyuno a la pared abdominal y optó por la enteroanastomosis terminal final luego enterectomía. Después de 16 días sin complicaciones, el animal mostró señales de dolor abdominal no responsible a los analgésicos. El día 21 de hospitalización el animal murió. En la autopsia, se encontraron con las adherencias que involucran el íleon, ciego y los músculos abdominales, la necrosis intestinal y absceso. A pesar de la falta de literatura sobre el tema tratado, se concluyó que el caso reportado fue una fístula enterocutánea resultante de una hernia umbilical.

Umbilical hernia often occurs in young horses and may result in stercoral fistula. Among them, enterocutaneous fistula is usually related to umbilical hernia. The objective is to describe a case of enterocutaneous fistula in an equine. A mare, which historic was a swelling in the umbilical scar, a few years ago, evolving with colic and leakage of intestinal contents through the hole in the swollen area. After the physical examination, exploratory laparotomy was recommended. There were adhesions over jejunum segment to the abdominal wall and enterectomy followed by end-to-end enteroanastomosis were opted. After 16 days, without complications, the animal showed signs of colic. On the 21st day the animal died. By necropsy, adhesions involving the ileum, cecum and abdominal muscles, bowel necrosis and abscess were found.

Hérnias umbilicais ocorrem frequentemente em equinos jovens, podendo resultar em fístulas estercorais. Entre estas, a fístula enterocutânea, é geralmente decorrente de hérnia umbilical. Objetiva-se descrever um caso de fístula enterocutânea em equino. Foi atendida uma égua, castanha, quarto de milha, com cinco anos de idade, proveniente de Paranhos, Mato Grosso do Sul, cujo histórico remetia a um aumento de volume na cicatriz umbilical, há alguns anos, evoluindo com sinais de dor abdominal e posterior extravasamento de conteúdo intestinal por orifício na área do aumento de volume. Após o exame físico, o animal apresentava-se alerta e os parâmetros fisiológicos dentro da normalidade. Ao realizar paracentese, não se constatou contaminação da cavidade peritoneal e foi preconizado a laparotomia exploratória. Observaram-se aderências abrangendo segmento de jejuno à parede abdominal e se optou pela enterectomia seguida de enteroanastomose término-terminal. Após 16 dias sem intercorrências, o animal apresentou sinais de dor abdominal não responsível aos analgésicos. No 21o dia de internação, o animal veio a óbito. Ao exame necroscópico, constataram-se aderências envolvendo íleo, ceco e musculatura abdominal, necrose de alças intestinais e de abscesso. Apesar da escassez da literatura sobre o tema abordado, concluiu-se que o caso relatado se tratava de uma fístula enterocutânea resultante de uma hérnia umbilical.

Fístula enterocutánea en yegua reporte de um caso / Enterocutaneous fistula in a mare case roport / Fístula enterocutânea em égua relato de caso

Las hernias umbilicales ocurren a menudo en los caballos jóvenes y puede resultar en fístulas estercorales. Entre ellas, la fístula enterocutánea, son por lo general causada por una hernia umbilical. El objetivo fue describir una fístula enterocutánea en equino. Una yegua, castaña, Quarto de Milha, de cinco años de edad, de Paranhos, Mato Grosso do Sul fue servida, cuya referencia histórica fue un aumento de volumen en el ombligo, hace unos años, evolucionando con señales de dolor abdominal y posteriores fuga del contenido intestinal por la hinchazón en el área del orificio. Después de la exploración física, el animal se había convertido en parámetros de alerta y fisiológicas dentro de los límites normales. Al realizar paracentesis que no se encuentro contaminación de la cavidad peritoneal fue recomendado laparotomía exploratoria. Hubo adhesiones en segmento yeyuno a la pared abdominal y optó por la enteroanastomosis terminal final luego enterectomía. Después de 16 días sin complicaciones, el animal mostró señales de dolor abdominal no responsible a los analgésicos. El día 21 de hospitalización el animal murió. En la autopsia, se encontraron con las adherencias que involucran el íleon, ciego y los músculos abdominales, la necrosis intestinal y absceso. A pesar de la falta de literatura sobre el tema tratado, se concluyó que el caso reportado fue una fístula enterocutánea resultante de una hernia umbilical.(AU)

Umbilical hernia often occurs in young horses and may result in stercoral fistula. Among them, enterocutaneous fistula is usually related to umbilical hernia. The objective is to describe a case of enterocutaneous fistula in an equine. A mare, which historic was a swelling in the umbilical scar, a few years ago, evolving with colic and leakage of intestinal contents through the hole in the swollen area. After the physical examination, exploratory laparotomy was recommended. There were adhesions over jejunum segment to the abdominal wall and enterectomy followed by end-to-end enteroanastomosis were opted. After 16 days, without complications, the animal showed signs of colic. On the 21st day the animal died. By necropsy, adhesions involving the ileum, cecum and abdominal muscles, bowel necrosis and abscess were found.(AU)

Hérnias umbilicais ocorrem frequentemente em equinos jovens, podendo resultar em fístulas estercorais. Entre estas, a fístula enterocutânea, é geralmente decorrente de hérnia umbilical. Objetiva-se descrever um caso de fístula enterocutânea em equino. Foi atendida uma égua, castanha, quarto de milha, com cinco anos de idade, proveniente de Paranhos, Mato Grosso do Sul, cujo histórico remetia a um aumento de volume na cicatriz umbilical, há alguns anos, evoluindo com sinais de dor abdominal e posterior extravasamento de conteúdo intestinal por orifício na área do aumento de volume. Após o exame físico, o animal apresentava-se alerta e os parâmetros fisiológicos dentro da normalidade. Ao realizar paracentese, não se constatou contaminação da cavidade peritoneal e foi preconizado a laparotomia exploratória. Observaram-se aderências abrangendo segmento de jejuno à parede abdominal e se optou pela enterectomia seguida de enteroanastomose término-terminal. Após 16 dias sem intercorrências, o animal apresentou sinais de dor abdominal não responsível aos analgésicos. No 21o dia de internação, o animal veio a óbito. Ao exame necroscópico, constataram-se aderências envolvendo íleo, ceco e musculatura abdominal, necrose de alças intestinais e de abscesso. Apesar da escassez da literatura sobre o tema abordado, concluiu-se que o caso relatado se tratava de uma fístula enterocutânea resultante de uma hérnia umbilical.(AU)

Guía de manejo para las fístulas enterocutáneas / Enterocutaneous fístula management guideline

La fístula enterocutánea (FE) es una patología de difícil manejo que requiere la intervención de un equipo multidisciplinario . El objetivo del estudio es recopilar y revisar la mejor y más reciente información sobre la presentación clínica, el diagnóstico y el tratamiento de la FE y dar recomendaciones para su manejo basadas en la mejor evidencia disponible.

Enterocutaneous Fistula (EF) is a challenging pathology that requires a multdisciplinary approach. The aim of this study was to gather and review thebest available evidence about clinical features, diagnosis and treatment of EF in order to provide evidence-based recommendatons.

Mesenchymal stromal cells from adipose tissue attached to suture material enhance the closure of enterocutaneous fistulas in a rat model.

BACKGROUND AIMS: Surgical treatment for enterocutaneous fistulas (EF) frequently fails. Cell therapy may represent a new approach to treatment. Mesenchymal stromal cells (MSCs) have high proliferative and differentiation capacity. This study aimed to investigate whether MSCs could adhere to suture filament (SF), promoting better EF healing. METHODS: MSCs, 1 × 10(6), from adipose tissue (ATMSCs) were adhered to a Polyvicryl SF by adding a specific fibrin glue formulation. Adhesion was confirmed by confocal and scanning electron microscopy (SEM). A cecal fistula was created in 22 Wistar rats by incising the cecum and suturing the opening to the surgical wound subcutaneously with four separate stitches. The animals were randomly allocated to three groups: control (CG)-five animals, EF performed; injection (IG)-eight animals 1 × 10(6) ATMSCs injected around EF borders; and suture filament (SG): nine animals, sutured with 1 × 10(6) ATMSCs attached to the filaments with fibrin glue. Fistulas were photographed on the operation day and every 3 days until the 21st day and analyzed by two observers using ImageJ Software. RESULTS: Confocal and SEM results demonstrated ATMSCs adhered to SF (ATMSCs-SF). The average reduction size of the fistula area at 21st day was greater for the SG group (90.34%, P < 0.05) than the IG (71.80%) and CG (46.54%) groups. CONCLUSIONS: ATMSCs adhered to SF maintain viability and proliferative capacity. EF submitted to ATMSCs-SF procedure showed greater recovery and healing. This approach might be a new and effective tool for EF treatment.

Enfermedad de Crohn fistulizante: manejo actual y su aplicabilidad en la realidad nacional / Fistulizing Crohn’s disease, current management and its applicability in the national reality

The development of fistulas during the evolution of Crohn’s Disease represents a severe situation that affects quality of life and requires a multidisciplinary care approach that involving gastroenterologists, surgeons and radiologists. Fistulizing Crohn’s disease can be divided in perianal and not perianal disease. Perianal disease can also be divided in simple or complicated disease depending on the fistula’s characteristics that will guide the clinical and therapeutic approach. Fistulizing not perianal disease can be internal when it communicates the bowel with other organs (colovesical, rectovaginal or enteroenteric fistulas), and external when it communicates the bowel with the abdominal wall (enterocutaneous fistula), either as a spontaneous or post-surgical phenomenon. Given the variety of fistula presentation, it is necessary to give an individualized approach, taking into account the fistula’s route, the inflammatory bowel activity, the presence of abscesses, and the nutritional status of the patient. This review is focused on the current management of fistulizing Crohn’s disease in our country.

El desarrollo de fistulas durante la evolución de la enfermedad de Crohn es una situación grave que condiciona una peor calidad de vida, así como mayor complejidad en el enfrentamiento, debiendo involucrar la colaboración multidisciplinar entre gastroenterólogos, cirujanos y radiólogos. La enfermedad fistulizante se divide en aquella que afecta la zona perianal (enfermedad perianal) y en aquella que no afecta la zona perianal. La enfermedad perianal a la vez se dividirá en simple o compleja dependiendo de las características de las fistulas, lo cual condiciona variaciones en el enfrentamiento y tratamiento. La enfermedad fistulizante no perianal se divide en interna cuando comunica al intestino con otros órganos (fistulas entero-vesicales, entero-vaginales, entero-entérico) y externas cuando se comunica al intestino con la pared abdominal (fistulas entero-cutáneas) tanto de forma espontánea como postquirúrgica. Debido a la gran diversidad de presentación de las fistulas es necesario individualizar cada grupo de trayectos fistulosos, valorar la asociación a actividad inflamatoria luminal, descartar la presencia de abscesos y valorar el estado nutricional de los pacientes para definir el manejo integral adecuado. Este artículo se centra en el manejo actual de la enfermedad de Crohn fistulizante en nuestro país.