[Gastrocolic fistula as infrequent cause of chronic diarrhea in a patient with percutaneous radiological gastrostomy]. / Fístula gastrocólica como causa infrecuente de diarrea persistente en un paciente portador de gastrostomía radiológica percutánea.

Introduction: Introduction: gastrocolic fistula is an infrequent but severe complication of percutaneous gastrostomy. Clinical suspicion in the presence of chronic diarrhea of unknown etiology manifesting after percutaneous radiological gastrostomy (PRG) tube replacement is key to early detection and treatment. Case report: we report the case of a patient with PRG that began with chronic diarrhea after tube replacement and developed severe malnutrition. Initial treatment was not effective, studies were extended with the finding of this complication in a CT image. The use of this tube was discontinued with resolution of diarrhea and a favorable nutritional outcome. Discussion: this case report shows the importance of considering gastrocolic fistula in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.

Introducción: Introducción: la fístula gastrocólica supone una complicación infrecuente pero potencialmente grave de las sondas de gastrostomía. La sospecha clínica ante una diarrea de origen incierto que comienza tras el recambio de la sonda es clave para la detección y el tratamiento precoces. Caso clínico: se presenta el caso de un paciente portador de gastrostomía radiológica percutánea (PRG) que comienza con diarrea persistente tras el primer recambio de la sonda y desnutrición grave secundaria. Tras el fracaso de las medidas terapéuticas iniciales se amplían los estudios, con hallazgo de esta complicación en la imagen de TC. Se suspende el uso de esta sonda con resolución de la diarrea y evolución nutricional favorable. Discusión: este caso pone de manifiesto la importancia de incluir la fístula gastrocólica en el diagnóstico diferencial de la diarrea persistente en un paciente portador de sonda de gastrostomía.

Injectable Nanoengineered Adhesive Hydrogel for Treating Enterocutaneous Fistulas.

Enterocutaneous fistula (ECF) is a severe medical condition where an abnormal connection forms between the gastrointestinal tract and skin. ECFs are, in most cases, a result of surgical complications such as missed enterotomies or anastomotic leaks. The constant leakage of enteric and fecal contents from the fistula site leads to skin breakdown and increases the risk of infection. Despite advances in surgical techniques and postoperative management, ECF accounts for significant mortality rates, estimated between 15-20%, and causes debilitating morbidity. Therefore, there is a critical need for a simple and effective method to seal and heal ECF. Injectable hydrogels with combined properties of robust mechanical properties and cell infiltration/proliferation have the potential to block and heal ECF. Herein, we report the development of an injectable nanoengineered adhesive hydrogel (INAH) composed of a synthetic nanosilicate (Laponite®) and a gelatin-dopamine conjugate for treating ECF. The hydrogel undergoes fast cross-linking using a co-injection method, resulting in a matrix with improved mechanical and adhesive properties. INAH demonstrates appreciable blood clotting abilities and is cytocompatible with fibroblasts. The adhesive properties of the hydrogel are demonstrated in ex vivo adhesion models with skin and arteries, where the volume stability in the hydrated internal environment facilitates maintaining strong adhesion. In vivo assessments reveal that the INAH is biocompatible, supporting cell infiltration and extracellular matrix deposition while not forming fibrotic tissue. These findings suggest that this INAH holds promising translational potential for sealing and healing ECF.

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.

Adipose tissue-derived stem cells as a therapeutic strategy for enterocutaneous fistula: an experimental model study.

PURPOSE: Enterocutaneous fistula (ECF) is a condition in which there is an abnormal connection between the intestinal tract and the skin. It can lead to high morbidity and mortality rates despite the availability of therapeutic options. Stem cells have emerged as a potential strategy to treat ECF. This study aimed to evaluate the effect of adipose tissue-derived stem cells (ASC) on ECF in an experimental model. METHODS: ECF was induced in 21 Wistar rats, and after one month, they were divided into three groups: control group (C), culture medium without ASC group (CM), and allogeneic ASC group (ASC). After 30 days, the animals underwent macroscopic analysis of ECF diameter and histopathological analysis of inflammatory cells, tissue fibrosis, and vascular density. RESULTS: The study found a 55% decrease in the ECF diameter in the ASC group (4.5 ± 1.4 mm) compared to the control group (10.0 ± 2.1 mm, p = 0.001) and a 59.1% decrease in the CM group (11.0 ± 4.3 mm, p = 0.003). The fibrosis score in the ASC group was 20.9% lower than the control group (p = 0.03). There were no significant differences in inflammation scores among the three groups. CONCLUSIONS: This study suggests that ASC treatment can reduce ECF diameter, and reduction in tissue fibrosis may be a related mechanism. Further studies are needed to understand the underlying mechanisms fully.

Early oral hydration in patients with high enterocutaneous fistula.

INTRODUCTION: Enterocutaneous fistula is defined as an abnormal connection between the gastrointestinal tract and the skin. In addition to the early recognition and treatment of sepsis, nutritional support, wound management, the adequate replacement of lost fluids with a properly set and timely rehydration treatment, together with the control of fistula production represent the first steps in treatment management. MATERIAL AND METHODS: The authors present an overview of oral rehydration therapy, describing the properties and effects of individual solutions on fistula. The absorption of fluids and electrolytes into the gastrointestinal tract is performed by the group of sodium-dependent glucose cotransporters (sodium-glucose linked transporter, SGLT1). DISCUSSION: The water and electrolyte absorption mechanisms described in the article can be used in the treatment of a patient with a high fistula. The amount of administered hypotonic fluids (water, tea) should not exceed 500 ml/day. The remaining volume, depending on fistula loss, must be supplemented with isoosmolar fluids. With a good tolerance of oral rehydration solutions and compliance with the other steps of treatment, it is possible to remain on oral intake during the entire duration of treatment without the need to prohibit it completely, thus improving the patient's overall comfort. CONCLUSION: Reducing the intake of hypotonic fluids (tap water, tea) and administering an isotonic solution help to reduce the production of the fistula, thereby contributing to its spontaneous closure.

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.

Route delivery of nutrition in patients with enterocutaneous fistula.

Malnutrition is one of the most frequent effects of an enterocutaneous fistula (ECF). There are some factors that contribute to it including inadequate intake, fluid loss via fistula and underlying disease. The role of nutrition is very important as a part of ECF therapy to give adequate nutrition, maintain fluid and electrolyte state and increase the likelihood of fistula closure spontaneously. Therefore, it is anticipated that adequate nutrition management will lower morbidity and mortality while enhancing clinical results. Nutritional requirements and nutritional route, whether oral, enteral and parenteral nutrition in ECF management, are influenced by the anatomical, physiological and aetiology of the fistula. The purpose of this review was to highlight the evidence based on nutritional therapy in ECF patients by calling attention to nutritional route selection based on the anatomy and physiology fistula to prevent malnutrition.

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.

[Fistuloclysis - A useful tool in patients with intestinal failure]. / Fistuloclisis: una herramienta útil en pacientes con falla intestinal.

Introduction: Introduction: fistuloclysis is a technique described by Teubner et al. whereby a fistula is used as a route of nutritional administration. This procedure is an alternative to the management of patients with intestinal failure receiving parenteral nutritional support. Case reports: we present two clinical cases of patients with different medical histories but who coincided in malnutrition, abdominal sepsis with fistulas, and their awaiting intestinal reconnection. In both cases nutritional support was administered with parenteral nutrition and enteral nutrition through fistuloclysis. Discussion: enteral nutrition through fistuloclysis improves function of the intestinal barrier, reduces the rate of intrahospital infection in critically ill patients, improves immune function, prevents atrophy of the intestinal mucosa, and that is why as soon as an enteral access is located we must take advantage of this route so that our patients may experience the benefits of fistuloclysis regardless of caloric intake.

Introducción: Introducción: la fistuloclisis es una técnica descrita por Teubner y cols. donde se utiliza una fístula como vía de administración nutricional. Este procedimiento es una alternativa al manejo de los pacientes con fallo intestinal que reciben soporte nutricional por vía parenteral. Casos clínicos: presentamos dos casos clínicos de pacientes con antecedentes médicos distintos pero que coincidían en cuanto a cuadro de desnutrición, sepsis abdominal con fistulas y espera de reconexión intestinal. En ambos casos se administró apoyo nutricional con nutrición parenteral y nutrición enteral a través de fistuloclisis. Discusión: la nutrición enteral a través de fistuloclisis mejora la función de la barrera intestinal, reduce la tasa de infección intrahospitalaria en los pacientes críticos, mejora la función inmunológica, evita la atrofia de la mucosa intestinal y es por ello que tan pronto podamos localizar un acceso enteral deberemos aprovechar esta vía para que nuestros pacientes puedan experimentar los beneficios de la fistuloclisis, independientemente del aporte calórico administrado.

Evaluation of Comfort in Patients with Intestinal Fistula and Analysis of Influencing Factors.

Objective: To analyze the comfort and influencing factors in patients with enterocutaneous intestinal fistula (ECF) on hospital admission and propose targeted nursing intervention countermeasures. Methods: A total of 193 patients with EDF admitted to Hunan Provincial People's Hospital in China from May 2018 to February 2021 were selected for this study. Basic patient data were collected upon admission and the Kolcaba Comfort Scale was used to score comfort status. Univariate and multivariate analysis methods were used to analyze the influencing factors. Results: Patients with ECF have low comfort scores; the social, psychological, physiological and environmental dimensions were affected by 8, 7, 4 and 2 factors, respectively. The number of fistulas and skin condition in patients with ECF were the main physiological factors affecting patients. Conclusion: Paying attention to the fistula and surrounding skin care and strengthening psychological counseling can improve the comfort of patients with ECF.

Chinese consensus on open abdomen therapy (2023 edition) / 中华胃肠外科杂志

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.

[Conservative treatment of patients with small bowel fistula]. / Konservativnoe lechenie patsientov s tonkokishechnymi svishchami.

OBJECTIVE: To describe conservative treatment of patients with small bowel fistula. MATERIAL AND METHODS: We report 3 patients with small bowel fistula. CONCLUSION: A personalized approach in patients with small bowel fistula and a modified treatment technique were effective for conservative treatment. Moreover, this approach was valuable to avoid surgical intervention.

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.