Systematic and Specific Treatment of Patients with Enteroatmospheric Fistulas: From Initial Conservative Treatment to Definitive Surgery.

INTRODUCTION: The open abdomen is a widespread therapeutic resource; however, it is also a source of complications, of which the enteroatmospheric fistulas (EAFs) pose one of the greatest problems. The objective of this study was to describe the implemented strategy for handling enteroatmospheric fistulas, and secondarily, to analyze the differential results based on a change in the conservative local treatment specifically designed for the stated complication. MATERIALS AND METHODS: From March 2002 to March 2014, patients treated for EAF were retrospectively analyzed. They were divided into 2 groups: Group 1 (G1: 2002 - 2007), treated with an occlusive vacuum device (SIVACO), similar to that used for other enterocutaneous fistulas, and Group 2 (G2: 2008 - 2014), covered in a specific modality for EAF. Results of conservative and surgical treatment were described and then the two groups were statistically compared. RESULTS: Study participants comprised 62 patients. Twelve cases (19.4%) healed with conservative treatment. This was statistically related with a baseline albumin level >3 g/dL, single lesions with no visible mucosa and baseline output <700 mL/d. In G1, the output fall was higher, while G2 required fewer wound dressing changes and enteral nutrition was feasible in a significantly higher number of patients. Forty-seven patients underwent reconstructive surgery. The mortality-associated variables were preoperative hypoalbuminemia and 2 or more anastomoses. Overall mortality was 8% (5 patients). In the multivariate model, only initial output (<700 mL/d) was an independent predictor for spontaneous closure, whereas 2 or more anastomoses and hypoalbuminemia were negative independent predictors. CONCLUSION: Systematic management of enteroatmospheric fistulas, following a rigorous protocol and a two-step specific treatment, resulted in a practical approach and yielded good results in healing and mortality.

Factors predictive of recurrence and mortality after surgical repair of enterocutaneous fistula.

Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17-81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.

Treatment of high-output enterocutaneous fistulas with a vacuum-compaction device. A ten-year experience.

BACKGROUND: Enterocutaneous fistulas arise as complications in 0.8%-2% of abdominal operations. The global mortality rate is 5%-37%, yet it may exceed 60% in the case of high-output fistulas and when sepsis and malnutrition are involved. The objective of this prospective cohort study with retrospective data analyses was to analyze our ten-year experience with a vacuum-compaction device for the management of high-output, postoperative enterocutaneous fistulas at the Department of General Surgery, E. Tornú Hospital, and the Intensive Care Unit, Churruca Hospital, Buenos Aires, Argentina. PATIENTS AND METHODS: Ninety-one patients presented 179 fistulas; 73 (69.2%) were men whose mean age was 48 years. Sepsis and malnutrition were present in 66 (72.5%). The mean initial fistula output was 1,485 ml/day. Conservative management was carried out according to diagnostic and therapeutic priority staging. A vacuum-compaction system (SIVACO; Spanish acronym) was used to control output. RESULTS: Output was entirely suppressed in 37 (40.7%) patients after 1-7 days of treatment, and reduced to less than 500 ml/day (average=138) in 52 (57.1%) patients. Spontaneous closure was achieved in 42 (46.2%) patients, whereas 37 (40.7%) patients did not improve after 20-380 (average=111) days of treatment. Those patients required surgical correction, which had an 83.8% success rate. Overall mortality was 16.5% (15 patients). CONCLUSIONS: The vacuum-compaction device proved effective for reducing fistula output in 89 of 91 patients (97.8%).

Oral glutamine in addition to parenteral nutrition improves mortality and the healing of high-output intestinal fistulas.

OBJECTIVE: Anastomotic leakage is one of the most important causes of morbidity and mortality in gastrointestinal surgery. We investigated the effect of oral glutamine on the healing of high-output intestinal fistula. SETTING: A tertiary Universitary Hospital of the University of Mato Grosso, Cuiaba, Brazil. PATIENTS AND METHODS: 28 patients (25 males and 3 females; median age = 45 [18-71] years old) admitted with high output post-operative small bowel fistulas (median volume in 24 h: 850 [600-2,200] mL) during a 4 years period were retrospectively studied. INTERVENTIONS: In the first two years 19 (67.9%) patients received only TPN as the initial nutritional support. In the last two years however, due to a change in the protocol for the nutritional support in cases of intestinal fistula 9 patients (32.1%) received oral glutamine (0.3 g/kg/day; 150 mL/day) in addition to TPN. Endpoints of the study were mortality, resolution of the fistula, and length of hospital stay (LOS). RESULTS: The overall mortality was 46.4% (13 patients). Fistula closure was observed in all other 15 patients (53.6%) that survived. In the subset of survived patients LOS was similar in those who received or not received glutamine. The multivariate regression analysis showed that resolution of the fistula was 13 times greater in patients that received oral glutamine (OR = 13.2 (95% CI = 1.1-160.5); p = 0.04) and 15 times greater in non-malnourished patients (OR = 15.4 [95% CI = 1.1-215.5]; p = 0.04). CONCLUSIONS: We conclude that oral glutamine accelerated the healing and diminished the mortality in this series of patients with post-operative high-output intestinal fistula receiving TPN.

[Enterocutaneous fistula in the pediatric population. Clinical experience]. / Fistula enterocutánea en la edad pediátrica. Experiencia clínica.

BACKGROUND: The presence of fistulous communications between the small bowel and the skin continues to be one of the most perplexing and challenging problems facing the surgeon today. Their occurrence is a major catastophe of surgical practice because are frequently a result of technical failure or errors in surgical judgement. MATERIAL, METHOD AND RESULTS: Thirty four patients with high-output enterocutaneous fistulae arising from the small intestine are reported. Fourteen were due to appendicitis and sixteen were infants. Fistula resection were performed in six patients. Spontaneous fistula closure occurred in twenty-eight. Six died. The treatment program included parenteral nutritition thorugh central venous line, local care and antibiotics. CONCLUSIONS: In recent years, more aggressive therapy accompanied by the development of high caloric parenteral alimentation shows promise of reducing the mortality and morbidity rates associated with these fistulas.

[Treatment results of enterocutaneous fistulae in patients with cancer]. / Resultados del tratamiento de fistulas enterocutáneas en pacientes con cancer.

BACKGROUND: Despite of advances obtained today, the enterocutaneous fistula has a mortality rate from 25 to 50%. The presence of cancer increases death frequency and makes difficult its treatment. OBJECTIVE: Evaluate the results of management of enterocutaneous fistula in cancer patients. METHODS: Seventy six cancer patients with average age of 56.8 +/- 13.5 years old and received curative primary treatment for malignancy at the Oncology Hospital, National Medical Center in Mexico who developed an enterocutaneous fistula between 1992 and 2002 were studied. RESULTS: Resolution of fistula was obtained in 52 patients (68.4%). Among these 52, 41 fistulae (53.9%) resolved spontaneously, and 11 required surgical treatment. All patients were treated with parenteral nutrition and octreotide. The meantime to fistula resolution, in those patients whose fistula was spontaneously resolved, was 20 days. Among the 24 patients who died, 21 had sepsis. Fistula-related mortality was highest in those patients with postoperative origin (82%; p = 0.024), of high output (57%; p = 0.001) and ileum site (45%; p = 0.04). CONCLUSIONS: The spontaneous closure is high and the surgical treatment is the best option. The mortality rate is moderate and sepsis the most frequent cause of death.

Fístulas gastroenterocutáneas posoperatorias: factores que influyen en la mortalidad / Postoperative gastroenterocutaneous fistulas: factors influencing on mortality

La mortalidad en las fístulas gastrointestinales externas posoperatorias ha sido relacionada con varios factores entre los que sobresalen la edad del paciente, el flujo, la localización, el número, la presencia o no de sepsis asociada y la malnutrición. El estudio de estas variables en 110 pacientes con tales fístulas demostró al emplear el modelo de regresión logística, que la posibilidad de muerte fue mayor en los enfermos que presentaron sepsis (p= 0,001), en los que tuvieron un flujo alto (p-0,016) y que aumentó con la edad (p= 0,016). La localización en el yeyuno estuvo cerca de la significación (p= 0,097)(AU)

The mortality in the postoperative external gastrointestinal fistulas has been related to some factors among which the age of the patient, the flow, the localization, the number, the presence or not of associated sepsis and malnutrition stand out. The study of these variables in 110 patients with such fistulas showed by using the logistic regression model that death possibility was higher in the patients that presented sepsis (p = 0.001), in those that had a high flow (p = 0.016), and that it increased with age (p = 0.016). The localization in the jejunum was close to significance (p = 0.097)(AU)

Laparostomías contenidas: experiencia en el Hospital San Juan de Dios / Contained laparostomy: experience of the Hospital San Juan de Dios

La laparostomía contenida (LC), surge a comienzos de la década pasada, como una técnica de excepción en los pacientes con sepsis abdominal grave. En Chile, la experiencia acumulada no supera los 200 pacientes en todas las series reportadas. Se revisan los archivos del servicio de cirugía desde agosto de 1988 hasta julio de 1998. La serie se compone de 45 pacientes, 27 varones. La edad promedio fue de 42 años, con un rango entre 15 y 77 años. Las patologías que originaron la indicación de LC fueron sepsis abdominal grave en 45 casos. Los cuadros apendiculares y de la región colorrectal, conforman el grupo mayoritario. La morbilidad médica se presentó en 32 pacientes (71,1 por ciento). Seis pacientes presentaron fístulas intestinales, ninguna de las cuales fue clínicamente atribuible a la técnica en sí, pero su presencia triplica la mortalidad general de la serie. En siete pacientes se realizó una técnica uniforme (15,5 por ciento) que se específica en el artículo original. La morbimortalidad es elevada, dado fundamentalmente por la patología de base que origina el cuadro séptico. La mortalidad global de la serie fue de 13,3 por ciento. Las técnicas para laparostomizar son variadas. Presentamos una técnica que es simple, económica y libre de complicaciones agregadas

O papel da U.T.I. no tratamento das fístulas entéricas / The role of Intensive Care Unit in the therapy of intestinal fistulas

As fístulas entéricas continuam representando complicaçöes pós-operatórias, extremamente graves e respondem por relevante mortalidade. Seu tratamento depende de um trabalho planificado, executado por equipe multiprofissional. Medidas clínicas e cirúrgicas se complementam, já que, apesar da prioridade para o tratamento conservador, as intervençöes cirúrgicas podem ser indispensáveis como medidas auxiliares, principalmente no combate à sepse. Ao longo do tratamento, o concurso do intensivista pode ser necessário, principalmente na fase inicial, quando o paciente pode apresentar importantes distúrbios hidroeletrolíticos, sépticos, ou cardiorrespiratórios. Em mais da metade dos pacientes, as fístulas se fecham espontaneamente com o tratamento conservador. O tratamento operatório definitivo, para o fechamento da fístula, fica reservado para os casos em que falharam os esforços para o fechamento espontâneo, mas só será realizado após o completo desaparecimento da sepse abdominal.

Nuevo enfoque en el tratamiento de las fístulas enterocutáneas postquirúrgicas / New approach in the treatment of the postoperative enterocutaneous fistulas

Entre 1985 y 1990 se trataron 14 pacientes con 27 fístulas enterocutáneas postcirugía, mediante un sistema original por vacío y compactación(SIVACO). Se basa en el uso de muy bajas presiones atmosféricas, que compacta una masa de fibras poliméricas(TFP) sobre el orificio, ocluyéndolo como una tapa o "pared dique". El sesgo grave de la población está dado por el alto caudal promedio de las fístulas (1500cc/día), una mortalidad esperada del 43% por APACHE II y por ser 7 pacientes con supuraciones peritoneales, 8 con desnutrición severa, 6 con m160s de una fístula y 12 con signos claros de sepsis. Los resultados fueron: el caudal cayó a 67cc/día a las 24 hs. y 0cc/día a los siete días. Este método resolvió las colecciones intraperitoneales sin punciones o cirugía. Siete de los ocho pacientes desnutridos recuperaron más del 55% del peso perdido a los 20 días. De las 27 fístulas tratadas 22 cerraron con este procedimiento y 4 con cirugía. El 93% de los pacientes se alimentaba por vía enteral, deambulaba y se encontraba sin vía venosa central a los 9 días de tratamiento. El tiempo de tratamiento fue de 14 a 365 días. Once enfermos curaron las fístulas entre 14 y 44 días, 2 con fístulas múltiples, algunas de ellas cerradas antes de los 90 días y que se reoperaron al año de las fístulas persistentes, con buen estado general y alta a los 15 y 20 días sin complicaciones. Trece pacientes fueron dados de alta curados. Uno falleció por bronconeumonía. La mortalidad del método fue 0

Nuevo enfoque en el tratamiento de las fístulas enterocutáneas postquirúrgicas / New approach in the treatment of the postoperative enterocutaneous fistulas

Entre 1985 y 1990 se trataron 14 pacientes con 27 fístulas enterocutáneas postcirugía, mediante un sistema original por vacío y compactación(SIVACO). Se basa en el uso de muy bajas presiones atmosféricas, que compacta una masa de fibras poliméricas(TFP) sobre el orificio, ocluyéndolo como una tapa o "pared dique". El sesgo grave de la población está dado por el alto caudal promedio de las fístulas (1500cc/día), una mortalidad esperada del 43% por APACHE II y por ser 7 pacientes con supuraciones peritoneales, 8 con desnutrición severa, 6 con m160s de una fístula y 12 con signos claros de sepsis. Los resultados fueron: el caudal cayó a 67cc/día a las 24 hs. y 0cc/día a los siete días. Este método resolvió las colecciones intraperitoneales sin punciones o cirugía. Siete de los ocho pacientes desnutridos recuperaron más del 55% del peso perdido a los 20 días. De las 27 fístulas tratadas 22 cerraron con este procedimiento y 4 con cirugía. El 93% de los pacientes se alimentaba por vía enteral, deambulaba y se encontraba sin vía venosa central a los 9 días de tratamiento. El tiempo de tratamiento fue de 14 a 365 días. Once enfermos curaron las fístulas entre 14 y 44 días, 2 con fístulas múltiples, algunas de ellas cerradas antes de los 90 días y que se reoperaron al año de las fístulas persistentes, con buen estado general y alta a los 15 y 20 días sin complicaciones. Trece pacientes fueron dados de alta curados. Uno falleció por bronconeumonía. La mortalidad del método fue 0

Fístulas enterocutâneas: complicaçöes / Small bowel fistulas: complications

Säo apresentados 17 casos de fístulas de intestino delgado tratados entre janeiro de 1982 e janeiro de 1988, no Hospital Nossa Senhora das Graças, com o uso de nutriçäo parenteral total. Houve fechamento espontâneo em 58,8% dos pacientes, necessidade de reintervençäo cirúrgica em 17,7% e óbitos durante a evoluçäo clínica em 23,5%. Os autores demonstram a importância do emprego da nutriçäo parenteral total no manejo de pacientes portadores de fístulas enterocutâneas

The management of aortoenteric and paraprosthetic fistulae.

Aortoenteric and aortic paraprosthetic fistulae are devastating complications. Most authors recommend total excision of the graft and revascularization of the lower extremities by extra-anatomic bypass. We reviewed the University of Pittsburgh experience with these fistulae in 15 patients between 1977 and 1987. There were 9 aortoenteric fistulae (AEF) and 6 paraprosthetic fistulae (PPF). Seven of the 9 AEF had no abscess surrounding the graft, but communication of the intestine with the aortic anastomosis. One patient died during operation. Six patients underwent a local repair or in situ replacement of the graft. All 6 of those patients survived operation without limb loss. Two of the 9 patients with AEF had evidence of graft infection and underwent total excision of the graft and extra-anatomic reconstruction. Both patients died, one of sepsis and one of aortic stump rupture. All 6 patients with PPF had clinical and operative evidence of overt graft infection and underwent total graft excision and extra-anatomic bypass. Two of these patients died secondary to sepsis. We conclude that AEF, without evidence of graft infection, were safely treated by local repair. Patients with PPF had infected grafts requiring graft removal with significant morbidity and mortality.

Fístulas enterocutáneas: tratamiento quirúrgico / Enterocutaneous fistulas: surgical treatment

Entre 1971 y 1986 se atendió en el Instituto Nacional de Pediatría a 55 niños con diagnóstico de fístulo enterocutánea; la edad de los sujetos iba de tres a 17 años. El 80% de los pacientes fueron enviados de otros hospitales para tratamiento. Los factores desencadenantes más frecuentes fueron: apendicitis perforada, perforación intestinal pos Salmonella, enfermedad isquémica intestinal, vólvulo por Ascaris e invaginación intestinal. En 38 enfermos se diagnóstico fístula de gasto alto y en 17, de gasto bajo. De los 55 pacientes, en 41 se dió tratamiento conservador con dieta elemental, alimentación parenteral, o ambas, y en 30 (73%) se logró cierre espontáneo. En los 14 restantes se requirió intervención quirúrgica y se logró el cierre en 12 (86%). La mortalidad fué de 25% por septisemia y sus complicaciones; los enfermos que murieron tenían fístulas de gasto alto