Guías Clínicas ASPEN-FELANPE: Terapia Nutricional en Pacientes Adultos con Fístulas Enterocutáneas / ASPEN-FELANPE Clinical Guidelines: Nutrition Support of Adult Patients with Enterocutaneous Fistula

INTRODUCCIÓN: el manejo de las fístulas enterocutáneas (FEC) es un reto que requiere un enfoque interdisciplinario y plantea un desafío importante. Las guías para optimizar el estado nutricional en estos pacientes están basadas en estudios que dependen de la experiencia individual y, ocasionalmente, institucional; que se focalizan en el tratamiento integral de las FEC, centrándose en el manejo médico y quirúrgico, mientras que la terapia nutricional se revisa solo superficialmente. Los requerimientos nutricionales, la vía de administración, el uso de inmunonutrición y el de análogos de la somatostatina en el tratamiento de estos pacientes no están bien definidos. El objetivo de esta guía clínica es desarrollar recomendaciones específicas para la terapia nutricional de los pacientes adultos con FEC. MÉTODO: revisión sistemática de la mejor evidencia disponible para responder a una serie de preguntas sobre la terapia nutricional de los adultos con FEC, evaluada utilizando la metodología GRADE. Se utilizó un proceso de consenso anónimo para desarrollar las recomendaciones de la guía clínica antes de la revisión por pares y la aprobación por las Juntas Directivas de ASPEN y FELANPE. Preguntas: 1) ¿Qué factores describen mejor el estado nutricional de los adultos con FEC? 2) ¿Cuál es la mejor vía para administrar la terapia nutricional (oral, nutrición enteral o parenteral)? 3) ¿Qué aporte energético y proteico proporciona mejores resultados clínicos? 4) ¿El uso de la fistuloclisis se asocia a mejores resultados? 5) ¿Las fórmulas inmunomoduladoras se asocian a mejores resultados? 6) ¿El uso de la somatostatina proporciona mejores resultados? 7) ¿Cuándo está indicada la terapia nutricional parenteral domiciliaria?

BACKGROUND: the management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to surgeons, gastroenterologists, intensivists, wound/stoma care specialists, and nutrition support clinicians. Available guidelines for optimizing nutritional status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual or institutional experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing nutrients, and use of somatostatin analogs in the management of patients with ECF remain a challenge for the clinician. The purpose of this clinical guideline is to develop recommendations for the nutritional care of adult patients with ECF. METHODS: a systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the A.S.P.E.N. and FELANPE Board of Directors. Questions: in adult patients with enterocutaneous fistula: 1) What factors best describe nutritional status? 2) What is the preferred route of nutritional therapy (oral diet, EN or PN)? 3) What protein and energy intake provide best clinical outcomes? 4) Is fistuloclysis associated with better outcomes than standard care? 5) Are immune-enhancing nutrients associated with better outcomes? 6) Does the use of somatostatin provide better outcomes than standard medical therapy? 7) When is home parenteral nutrition support indicated?

Nutrition Management of Home Parenteral Nutrition Among Patients With Enterocutaneous Fistula in the Sustain Registry.

BACKGROUND: Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of enterocutaneous fistula (ECF), yet little is known about how these patients are managed. This research compares nutrition management of adults with ECF as the indication for HPN therapy to those with other indications. METHODS: This is an analysis of data from adult HPN patients in the Sustain registry enrolled between August 2011 and February 2014 who have the diagnosis of ECF or other indication for HPN who served as the control group. Differences between the ECF and control group were assessed by t test, analysis of variance, or χ2 as appropriate. RESULTS: There were 141 HPN patients with ECF and 632 control patients. Patients with ECF were older (55 vs 50 years, P < .001), more frequently had a goal for future surgery (30% vs 15%, P = .010), had greater prevalence of overweight/obesity (33% vs 20%, P = .04), and had a lower serum albumin (2.98 ± 0.65 g/dL vs 3.16 ± 0.66 g/dL, P = .006) than controls. The diet order was more frequently nil per os (NPO) in patients with ECF (48% vs 22%, P < .001), and amino acid content of HPN was greater (111.90 ± 29.11 vs 102.06 ± 27.84, P < .001) than in controls. There were no differences in patterns of weight change by ECF or control groups, although underweight patients gained, normal-weight patients maintained, and overweight/obese patients lost weight and serum albumin increased similarly. CONCLUSIONS: The HPN management of patients with ECF is similar to other HPN patients other than greater provision of protein, more frequent NPO status, and a goal for future surgery.

A Retrospective, Observational Study of Enteral Nutrition in Patients with Enteroatmospheric Fistulas.

Enteroatmospheric fistulas (EAFs) represent a challenging problem in patients with an open abdomen (OA). A retrospective, descriptive study was conducted to evaluate the effects of enteral alimentation on wound status and management and nutrition. All patients with an EAF in an OA treated between October 2012 and December 2014 at a university hospital in Germany were included without criteria for exclusions. Demographic and morbidity-related data collected included age, gender, surgeries, OA grading, body mass index (BMI), serum albumin, and serum creatinin. Underlying diseases and time between the index operation and the formation of the OA and EAFs were analyzed in relation to the initiation of enteral nutrition (EN), which can aggravate and contaminate the OA due to intestinal secretions necessary for digestion. The OA was described in size and area of the fascia defect and classified according to the Björck Scale. The number and location of the fistulas and the duration of negative pressure wound therapy (NPWT) were documented. Outcome parameters included fistula volume, wound management (eg, dressing change frequency, need for wound revision), feeding tolerance, systemic impact of nutrition, nutrition status at discharge, and mortality. Data were analyzed using primary descriptive statistics. The Mann-Whitney test was used to evaluate changes in fistula volume and BMI; categorical data were compared using Fisher's exact test. A P value less than 0.05 was considered significant. Ten (10) patients (8 women, median age of participants 55.4 [range 44-71] years) were treated during the study time period. Seven (7) patients had the first fistula orifice in the upper jejunum (UJF); 8 had more than 1 fistula. EN was initiated with high caloric liquid nutrition and gradually increased to a 25 kcal/kg/day liquid or solid nutrition. All patients were provided NPWT at 75 mm Hg to 100 mm Hg. EN was not followed by a significant increase of median daily fistula volume (1880 mL versus 2520 mL, P = 0.25) or the need for more frequent changes of NPWT dressings (days between changes 2.6 versus 2.9, P = 0.19). In 9 patients, the severity of wound complications such as inflammation or skin erosion decreased both in frequency and magnitude (eg, affected area). All patients achieved a sufficient oral intake, but only 3 were discharged from the hospital without parenteral nutrition. In this study, EN did not cause additional problems in wound management but did not provide sufficient alimentation in patients with a UJF. Prospective studies are needed to clarify associations between EN, nutrition, and wound management.

Terapia nutricia en fístula enterocutánea; de la base fisiológica al tratamiento individualizado / Nutrition therapy in enterocutaneous fistula; from physiology to individualized treatment

La fístula enterocutánea es la forma más común de las fístulas intestinales. Es una patología que obliga la estancia hospitalaria prolongada debido a complicaciones como desequilibrio hidroelectrolítico, desnutrición, desajustes metabólicos y sepsis. El apoyo nutricio es parte esencial en el manejo, ya que favorece la función intestinal, inmune, promueve la cicatrización y disminuye el catabolismo. Aunque se ha reconocido la importancia del apoyo nutricio no existen ensayos clínicos sobre su manejo integral, lo cual puede resultar limitante al establecer estrategias específicas. Se desconoce el desajuste metabólico que ocasiona una fístula. Para fístulas de bajo gasto, se recomienda cubrir el gasto energético en reposo, con un aporte de 1,0 a 1,5 g/kg/d de proteína; mientras que en fístulas de alto gasto puede aumentar hasta 1,5 veces su requerimiento, con un aporte de proteína de 1,5 y hasta 2,5 g/kg. Se recomienda el aporte del doble del requerimiento de vitaminas y elementos traza y entre 5 y 10 veces el de Vitamina C y Zinc, especialmente para fístulas de alto gasto. La decisión de elegir entre la vía enteral o parenteral dependerá de la evaluación de cada paciente, del tipo y localización de la fístula, estado nutricio previo, entre otros. Siempre que sea posible debe preferirse la vía enteral; y cuando no se pueda cubrir el requerimiento por esta vía, combinar con nutrición parenteral. Otras estrategias de tratamiento nutricio en fístulas podrían incluir el uso de inmunomoduladores e incluso el manejo de estrés (AU)

Enterocutaneous fistula is the most common of all intestinal fistulas. Is a condition that requires prolonged hospital stay due to complications such as electrolyte imbalance, malnutrition, metabolic disorders and sepsis. Nutritional support is an essential part of the management; it favors intestinal and immune function, promotes wound healing and decreases catabolism. Despite the recognition of the importance of nutrition support, there is no strong evidence on its comprehensive management, which can be limiting when establishing specific strategies. The metabolic imbalance that a fistula causes is unknown. For low-output fistulas, enegy needs should be based on resting energy expenditure, and provide 1.0 to 1.5 g/kg/d of protein, while in high-output fistulas energy requirement may increase up to 1.5 times, and provide 1.5 to 2.5 g/kg of protein. It is suggested to provide twice the requirement of vitamins and trace elements, and between 5 and 10 times that of Vitamin C and Zinc, especially for high-output fistulas. A complete nutritional assessment, including type and location of the fistula, are factors to consider when selecting nutrition support, whether is enteral or parenteral nutrition. The enteral route should be preferred whenever possible, and combined with parenteral nutrition when the requirements cannot be met. Nutritional treatment strategies in fistulas may include the use of immunomodulators and even stress management (AU)

Intestinal failure and the ward nurses: causes, assessment and management.

In order to manage intestinal failure (IF), a complex regimen of care is required to manage fluid intake and electrolyte balance. In the majority of cases ward nurses will bare the responsibility of managing patients with these specific needs, with the support of the nutritional multidisciplinary team. Therefore, nurses need to ensure they have expert knowledge of each area of IF management. This article defines IF and outlines how it can be managed surgically and medically. The author discusses the role of the ward nurse in monitoring and managing therapy, and states the importance of providing emotional and psychological care.

Nutritional management of enterocutaneous fistulas.

Enterocutaneous fistulas (ECF) may be challenging to manage due to the large volume of fluid losses, that may result in severe dehydration, electrolyte imbalances, malnutrition and sepsis. It is imperative that this group of patients receive adequate nutrition, as malnutrition and sepsis are the leading cause of death. ECF treatment is complex and based on various assessments, treatment can be medical/conservative management or surgical. Depending on the site of the fistula and the nutritional status of the patient, clinicians have to decide whether parenteral nutrition or enteral nutrition should be established. Fistuloclysis is a relatively novel procedure in which nutrition is provided via an enteral feeding tube placed directly into the distal lumen of a high output fistula. Although fistuloclysis is not feasible for all patients with ECF, for those that are eligible, the method appears to be an acceptable and safe method of maintaining and improving nutritional status.

[Staged treatment of patients with external small bowel fistulas].

Results of staged treatment of small bowel fistulas in 115 patients were analyzed. Staged treatment of 21.7% of patients resulted in healing the fistulas without operations. Modern methods of nutritional maintenance were shown to allow surgical restorative treatment to be performed in the optimal period in 82.2% of patients. The number of postoperative complications and lethality rate were reduced to 5.6%, general lethality to 7.8%.

Oral glutamine in addition to parenteral nutrition improves mortality and the healing of high-output intestinal fistulas / Glutamina oral en adición a nutrición parenteral mejora la mortalidad y la cicatrización de fístulas intestinales de alto débito

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 University 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% (13patients). Fistula closure was observed in all other 15patients (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

Objetivo: La fístula anastomótica es una de las principales causas de morbilidad y mortalidad en cirugía general. Investigamos el efecto de la glutamina oral en la cicatrización de fístulas intestinales de alto débito. Ámbito: Una unidad terciaria de un Hospital Universitario de la Universidad Federal de Mato Grosso, Cuiabá, Brasil. Pacientes y métodos: 28 pacientes (25 M y 3 F; edad mediana = 45 [18-71] años) admitidos con fístulas pos-operatorias del intestino delgado de alto débito (volumen mediano en 24 h: 850 [600-2.200] mL) durante un período de 4 años fueron retrospectivamente estudiados. Intervenciones: En los dos primeros años 19 pacientes (67,3%) recibieron únicamente TPN como suporte nutricional. En los últimos dos años sin embargo, debido a un cambio del protocolo para el suporte nutricional en casos de la fístula intestinal 9 pacientes (32,1%) recibieron glutamina oral (0,3 g/kg/día; 150 mL/día) además de TPN. Las variables de resultado del estudio fueron la mortalidad, la resolución de la fístula, y el tiempo de hospitalización (LOS).Resultados: La mortalidad fue de 46,4% (13 pacientes). La cicatrización de la fístula fue observada en 15 pacientes (53,6%) que sobrevivieron. Entre los pacientes que sobrevivieron la permanencia hospitalaria fue similar en aquellos que recibieron o no recibieron glutamina. El análisis multivariante mostró que la resolución de la fístula fue 13 veces mayor en los pacientes que recibieron glutamina oral (OR = 13,2(95% CI = 1,1-160,5); p = 0,04) y 15 veces mayor entre los pacientes no desnutridos (OR = 15,4 [95% CI = 1,1-215,5]; p = 0,04). Conclusiones: La glutamina oral acelera la cicatrización y disminuyó la mortalidad en nuestros pacientes con fístula intestinal de alto débito que recibieron TPN

Fístula gastrocutánea resuelta mediante inyección endoscópica de cola biológica / Closure of gastrocutaneous fistula using endoscopic biological glue injection

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The nursing care of a patient with enterocutaneous faecal fistulae.

This article discusses the nursing care given to a patient with a large abdominal, enterocutaneous faecal fistula. It highlights classification, signs, symptoms and some causal factors related to fistulas. Fistulas are rare and there is minimal evidence-based knowledge on the subject. However, incorporating knowledge from other specialties, such as tissue viability, can assist in caring for this client group. Diagrams illustrate the extent of the problems and assist with understanding the appliance techniques. There are many problems that may be encountered in the care of fistulas that are not encountered with planned stomas. Difficulties may include containment of the faecal matter within a wound, problems associated with skin care, leakage and dietary issues. The author's methods of confronting and coping with these problems in this case study are discussed, with the aim of assisting other nurses in similar situations.

Does rich fiber diet accelerate the healing process of low-output colorectal fistulas?

The occurrence of an anastomotic leakage is a major therapeutic concern in colorectal surgery. Considering the outflow level of the fistula, a defunctioning stoma may be necessary to obtain closure. When the outflow is low and the intestinal transit is not interrupted, a colostomy is not mandatory but the healing process can be long. Here the author presents three consecutive cases of low output fistula treated by feeding with an enriched fiber diet. Closure of the fistulae occurred in a few days. The rationale of this alternative treatment is discussed.

Manejo con nutrición parental total de las fístulas enterocutáneas complicadas / Management of complicate enterocutaneous fistulas with total parenteral nutrition

Objetivo. Presentar nuestra experiencia con Nutrición Parenteral Total (NPT) en pacientes con fístulas enterocutáneas complicadas con sepsis abdominal y abdomen abierto. Sede. Departamento de Cirugía General. Clínica de Apoyo Nutricional. Hospital General Dr. Manuel Gea González. Diseño y análisis estadístico. Estudio prospectivo, de 3 años. Se emplearon media, error estándar de la media (media ñ SEM), homogeneidad de varianza, prueba de Wilcoxon, Chi cuadrada y coeficiente de regresión lineal. Se tomó como significativa p<0.06. Pacientes y métodos. Pacientes adultos con fístulas enterocutáneas complicadas con sepsis abdominal y abdomen abierto. Se utilizaron 3 a 4 g/kg/día de Dextrosa, 0.5 a 1 g/kg/día de lípidos y 0.1 a 0.9 g/kg/día de aminoácidos. Se evlauron gasto de la fístula, albúmina sérica, transferrina sérica, cuental total de linfocitos y cicatrización de la pared abdominal. Resultados. Siete pacientes completaron el estudio. La tasa de cierre espontáneo fue del 57.14 por ciento entre la 4a y la 10a semnas. La mortalidad fue del 28.5 por ciento. La albúmina se elevó de 2.199 ñ 0.2 mg/dl a 3.09 ñ 0.3 mg/dl. La transferrina se llevó de 201 ñ 32.7 a 242 ñ 27.15 mg/dl y la cuenta linfocitaria se incrementó de 1392 ñ 338.22 células/ a 2619 ñ 716 células/mm3. Las complicaciones fueron: colestasis 14.2 por ciento, sepsis por catéter 42.7 por ciento. La cicatrización de la pared abdominal fue en 85.7 por ciento de los casos. Conclusión. La NPT es efectiva para controlar el estado séptico y mejorar el estado nutricional de pacientes con fístulas enterocutáneas complicadas con sepsis abdomianal, favorece el cierre espontáneo y la cicatrización de la pared abdominal

Nutrición en situaciones especiales (Insuficiencia hepática y fistula intestinal) / Nutrition in special situation (Liver failure and intestinal fistula)

Se revisan diferentes causas de enfermedad hepática, sus complicaciones nutricionales, la etiología de la encefalopatia hepática,y se dan sugerencias de como manejar al paciente en insuficiencia hepática desde el punto de vista general y nutricional, haciendo énfasis en el uso de aminoácidos de cadena ramificada. Se discuten los conceptos más importantes, etiología, y principios generales del manejo de las fístulas eterocutáneas

[Correction of homeostasis indices in unformed small intestine fistulas]. / Korrektsiia nekotorykh pokazatelei gomeostaza pri nesformirovannykh tonkokishechnykh svishchakh.

Problems of the correction of indices of protein and water-electrolyte metabolism in unformed fistulas of the small intestine were studied in 44 patients. The authors show that the use of the Alvesin "Novyi" amino acid mixture in parenteral feeding is more promising than the use of preparations of protein hydrolysates. For correction of water metabolism the authors give tea infusion per os.

[Status of elemental diets in the therapy of Crohn disease in childhood]. / Stellung von Elementardiäten in der Therapie des Morbus Crohn im Kindesalter.

Since the seventieth low molecular weight formulas, "elemental diets", are applied in acute Crohn's disease in addition to drug therapy. In small bowel involvement, therapeutic efficiency in active disease is as good as salazosulfapyridine combined with corticosteroids. Physiological changes under elemental diet have been reported: decrease of gastric and pancreatic secretion, changes of bacterial bowel flora and in patients with Crohn's disease decreased fecal bile acid excretion and decreased intestinal losses of lymphocytes were described. Further, the absence of allergens in the formula and the quick and complete resorption are discussed to be important to clinical improvement in Crohn's disease. Indications for elemental diet are acute small bowel disease, intestinal obstruction, malnourishment and growth retardation. Further studies are needed to examine if elemental diets are effective in gastrointestinal fistulas and extraintestinal symptoms in Crohn's disease.

[Nitrogen balance of children with fistulae of the small intestine kept on a diet with a protein enteral feeding formula]. / Issledovanie azotistogo balansa u detei so svishchami tonkoi kishki pri vkliuchenii v ratsion belkovogo énpita.

Sixteen children with small bowel fistulas receiving hospital diets and 9 children with the same condition kept on the diets including products for enteral nutrition were examined over time. The use of the hospital diets alone brought about the lowering of the patients' body weight, high protein excretion via fistulas, negative nitrogenous balance, and protracted clinical course of the disease. After the patients were placed on the diet including products for enteral nutrition, the protein content amounting up to 50%, the body weight gain, a 2-times reduction in protein losses with the chyme, establishment of the positive nitrogenous balance, increase in the total blood protein, and a more favourable clinical course of the disease were recorded.

[Postoperative high digestive-cutaneous fistula. Advantages of nutritional treatment]. / Fistole digestivo-cutanee alte postoperatorie. Vantaggi del trattamento nutrizionale.

Twenty-four patients (18 male and 6 female) with high post-surgery digestive fistulas (8 pancreatic-cutaneous, 7 duodenal-cutaneous, 4 jejunum-cutaneous, 4 ileal-cutaneous, 1 gastric cutaneous) were treated with T.P.N. and/or E.N. between 1980-1983. 17 patients (71%) recovered with spontaneous healing of fistulas in 9-92 (average 39) days. 3 patients underwent a second operation. 3 patients (12.5%) died: 2 for sepsis, 1 for cachexia. A.E. and T.P.N. were able to improve serious catabolic state and to get a better prognosis.