Chronic Enterocutaneous Fistula Research Articles

ESPEN guideline on chronic intestinal failure in adults – Update 2023

Background & aimsIn 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. MethodsThe grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. ResultsThe recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is “strong consensus” for 148 (99.3%) and “consensus” for one (0.7%) recommendation. The grade of consensus for the statements is “strong consensus” for 14 (87.5%) and “consensus” for two (12.5%). ConclusionsIt is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

A052 Creation of esophagojejunostomy after chronic enterocutaneous fistula from sleeve gastrectomy leak

A052 Creation of esophagojejunostomy after chronic enterocutaneous fistula from sleeve gastrectomy leak

Chronic enterocutaneous fistula: management in the community setting.

Despite being aggravating and potentially embarrassing, enterocutaneous fistulas can be successfully managed, with patients being able to resume many of their normal daily activities while the fistula continues to drain. Nevertheless, the management of enterocutaneous fistulas in the community can pose many challenges to nurses, the most common being peri-fistula moisture-associated skin damage. This article presents fistula management plans, which can facilitate the long-term support of these patients, promoting patient comfort and adherence to treatment.

Laser Ablation Facilitates Closure of Chronic Enterocutaneous Fistulae

This report describes the use of laser ablation for treatment of chronic enterocutaneous fistulae (ECFs) after failure of conservative therapy. Three patients underwent laser ablation for treatment of 8 ECFs. Mean duration of fistula patency was 28 months with mean fistula output of 134 mL/day. The initial technical success was 100% with no major or minor complications. Three ECFs required repeat treatment. At mean follow-up of 53 days, 7 of the fistulae were occluded. One fistula showed a markedly reduced output of 10 mL/day.

Chronic Infection and Enterocutaneous Fistula Secondary to Mesh Migration and Erosion into the Small Bowel

Abstract Background: The use of prosthetic mesh is associated with a lower risk of hernia recurrence and hence is used commonly in hernia repair. Mesh migration and erosion into the gastrointestinal tract, albeit rare, is one of the most serious and challenging complications of hernia operations. Timely surgical intervention is an essential part in the management of this condition. Case Presentation: A 55-year-old Caucasian female was admitted with severe abdominal pain and chronic abdominal wall infection nine years after an incisional hernia repair with mesh. Computed tomography (CT) scan of the abdomen revealed mesh eroded into the small bowel with a surrounding abscess and a fistulous tract. Surgery involved resection of the small bowel segment containing the mesh followed by primary anastomosis and complete excision of the remaining mesh. An adnexal pelvic mass was also excised. Despite a post-operative surgical site infection the patient was well at follow-up. Conclusion: This report emphasizes the ...

Combination of hypertonic saline and fibrin glue: Another selection to treat chronic enterocutaneous fistula

Gastrointestinal tract fistula is a frequent complication of surgery or disease. In general, cases involving failure to manage fistulae after 5–6 weeks of nonoperative treatment possibly require surgery. Here, we report a case involving a chronic enterocutaneous fistula (ECF) for 24 months that was treated using hypertonic saline injection within the duodenal mucosa and use of fibrin glue as an adhesive to ensure rapid closure. This technique is a simple and effective method for treating an ECF. The procedure is easy to perform, carries minimal surgical risk, and features the advantages of reduced hospitalization or home nursing care and expenses compared with traditional therapy.

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

To determine the incidence of enterocutaneous fistulas (ECFs) developed after elective incisional hernia (IH) repair using intraperitoneal uncoated polypropylene (PPE) mesh. 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. 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 59months. Four (0.5%) patients required additional surgery due to intestinal occlusion. Neither acute nor chronic ECFs were encountered during follow-up in 695 patients. 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.

Assessment of Microbiota and Their Drug Resistance in Chronic Fistulous Tracts.

Bacteria colonizing an enterocutaneous fistula tract have not been clarified. The aims of this study were to investigate the pathogen spectra of fistulous tracts and their resistance to antibiotics in patients with chronic fistulas. We conducted a one-year prospective single-center study. In the absence of significant sepsis, consecutively stabilized patients with chronic enterocutaneous fistula were included. Microbiology and antimicrobial susceptibility of isolates from the tracts were analyzed. The correlations between the existence of bacteria and various clinical values were investigated further. Forty-one patients were enrolled, of whom eight had a negative culture. A total of 48 bacterial strains were harvested, including 42 strains of gram-negative bacteria and six strains of gram-positive bacteria, most of which were multiple-drug-resistant. The three bacteria cultured most often were Escherichia coli (11 strains; 22.9%), Pseudomonas aeruginosa (eight strains; 16.7%), and Klebsiella pneumoniae (eight strains). Binary logistic regression analysis with forward (conditional) stepwise selection found that fistula length correlated with positive bacterial results (p=0.018). Other variables, namely entire length of hospitalization and fistula duration and location, were unrelated to the presence of micro-organisms in fistula tracts. Multiple-drug-resistant gram-negative bacteria were the main pathogens colonizing chronic fistula tracts. Fistula length was significantly associated with the presence of pathogens in a multivariable logistic regression model.

Giant squamous cell carcinoma as a complication of a chronic enterocutaneous fistula: complex parietal reconstruction

Treatment of an enterocutaneous fistula is complex and may require multidisciplinary management, especially when associated with a neoplastic process. Here, we describe the case of a 59-year-old patient with a squamous cell carcinoma that had invaded the abdominal wall through a chronic enterocutaneous fistula identified 30 years ago. We combined parietectomy with small intestine and colon resection and inguinal lymphadenectomy in order to obtain clear surgical margins. At the same time, plastic surgery involved the implementation of a large bioprosthesis and coverage with a vastus lateralis muscle free flap.

Unpredictable Absorption of Oral Opioid Medications in a Quadriplegic Patient With Chronic Enterocutaneous Fistulas

ABSTRACTAlthough there is an abundance of literature on the acute management of enterocutaneous fistulas, there is a paucity of data on the chronic management of enterocutaneous fistulas. Their impact on oral pharmacotherapy, including their effect on the bioavailability of oral medications, is poorly understood. This case describes a 23-year-old quadriplegic male with a complex history of multiple abdominal surgeries presented with three persistent enterocutaneous fistulas. Diazepam and furosemide were among the patient's oral medications and had sufficient bioavailability to show efficacy on anxiety and pedal edema, respectively. Conversely, oral oxycodone and methadone were ineffective in controlling chronic pain despite high doses and aggressive titration. Due to inadequate pain control, the patient supplemented opioid medications with high doses of lorazepam and diazepam to augment psychological comfort. A trial of subcutaneous morphine successfully produced immediate analgesia, causing a marked reduction in benzodiazepine use. Enterocutaneous fistulas may reduce the bioavailability of oral medications to various degrees depending upon the medication. Further research is needed to elucidate the effect chronic enterocutaneous fistulas have on the bioavailability of oral medications. It is therefore important for clinicians to question the bioavailability of medications in the setting of enterocutaneous fistulas and poor clinical response.

Percutaneous embolization of persistent low-output enterocutaneous fistulas

To present and retrospectively evaluate the technique of percutaneous embolization of chronic enterocutaneous fistulas (ECFs) using n-butyl-2-cyanoacrylate and Lipiodol under fluoroscopic guidance. Six patients with a total of seven post-operative low-output ECFs of the large intestine were treated. After fistulography a hydrophilic guide wire and a catheter were advanced through the ECF into the intestine. After dilation of the bowel with saline and contrast medium, the catheter was withdrawn into the enteric orifice and glue together with Lipiodol was injected while simultaneously pulling the catheter. Complete closure of all seven fistulas was achieved. There were no peri-procedural complications. In one patient 1 month following embolization a low-output enteric discharge was observed, but the ECF spontaneously healed 5 days later. In one patient 18 months after the embolization a new perforation due to diverticulitis close to the embolization site occurred and resection of the sigmoid colon was performed. One patient needed reoperation due to a recurrence of rectal carcinoma. In our series of patients, the presented technique of percutaneous embolization proved to be efficacious and easy to perform. It may have potential as a first-line treatment of low-output ECFs but a prospective study with a larger series of patients and a longer follow-up is required.

Closure of a Large Chronic Enterocutaneous Fistula Following Transcutaneous Endoscopic Placement of Two Overlapping Enteral Stents

Closure of a Large Chronic Enterocutaneous Fistula Following Transcutaneous Endoscopic Placement of Two Overlapping Enteral Stents

Heterotopic mesenteric ossification as a cause of persistent enterocutaneous fistula: overview of the literature and addition of a new case*

BACKGROUND: Heterotopic mesenteric ossification (HMO) is rare condition with unclear multifactorial etiology. When presented with enterocutaneous fistulae, HMO may be devastating for the patient. METHODS: We herein present the case of a 59-year-old woman with persistent enterocutaneous fistula secondary to heterotopic mesenteric ossification, which developed after a complicated gynecologic laparoscopic oophorectomy, abdominal sepsis, multiple small-bowel resections, and skin grafting for an open abdomen. RESULTS: Nonoperative management with nil per os status and total parenteral nutrition of her fistulae was unsuccessful. The patient subsequently underwent en masse resection of her mesenteric ossification with associated small and large intestine. CONCLUSIONS: This case represents a rare occurrence of chronic enterocutaneous and/or enteroatmospheric fistulae secondary to heterotopic mesenteric ossification. Diagnosis, treatment, and histologic appearance of heterotopic mesenteric ossification are discussed in a review of the literature.

Percutaneous Gelfoam Embolization of Chronic Enterocutaneous Fistulas: Report of Three Cases

A relatively simple radiologically guided method for the treatment of enterocutaneous fistula by gelfoam embolization is described. Three cases of chronic enterocutaneous fistula are presented. In each case, a sheath was positioned with its tip at the enteric opening of the fistula. Gelfoam was injected to occlude the fistula at its enteric opening. In each case, there was successful closure of the fistula. Radiologically guided embolization with gelfoam is a safe, relatively simple procedure, which may be useful in the treatment of chronic enterocutaneous fistula.

Clinical Observations and Experimental Studies of New Therapy for Chronic Enterocutaneous Fistulae: T-Tubes and Bridging Stents

Clinical Observations and Experimental Studies of New Therapy for Chronic Enterocutaneous Fistulae: T-Tubes and Bridging Stents

Direct Percutaneous Endoscopic Jejunostomy: Outcomes in 307 Consecutive Attempts

Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ. To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution. Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed. Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics (23) or persistent site pain (14). DPEJ was associated with a moderate or severe complication in approximately 10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved.

The Frequency, Severity, and Spectrum of Adverse Events Associated with Direct Percutaneous Endoscopic Jejunostomy (DPEJ)

Background: DPEJ is increasingly utilized as a method for obtaining enteral access. Though it has been described for more than 15 years, scant data exists regarding the safety profile of DPEJ. Aims: To describe the frequency and type of complications associated with DPEJ. Methods: Institutional databases identified 316 attempted DPEJ placements at Mayo Clinic Rochester from 1996 to August 2004. All but 9 patients had consented to have their records used for research. These records were abstracted with attention to adverse events (AEs). Severe AEs were defined as those requiring urgent surgery or endoscopy or seriously threatening a patient's health. Moderate AEs were defined as those requiring non-urgent surgery or endoscopy, or any hospitalization (not meeting criteria for severe). All other AEs were categorized as mild. Mean follow-up (f/u) time was 251 days, median f/u time was 88 days, and 91% of patients had at least 48 hours of f/u. Results: 307 attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%) and 98 failed (32%). Overall, 89 AEs were associated with DPEJ placement or removal in 73 (23.7%) of the cases, with a clear causal relationship in 65 cases. In 16 cases more than one AE occurred. There were 13 serious AEs (4.2% of all cases), 18 moderate AEs, and 58 mild AEs. Serious AEs included 7 bowel perforations, 3 cases of jejunal volvulus, and 3 major bleeding events. The only death in this group was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 8 chronic enterocutaneous fistulae that required surgical or endoscopic closure and 2 significant site infections requiring hospitalization for IV antibiotics and/or abscess drainage. Many of the mild AEs were site infections requiring oral antibiotics (22/58) or persistent site pain (14/58). Conclusions: DPEJ was associated with a moderate or severe complication in 29/307 (9.4%) of cases. While DPEJ is a useful technique to gain enteral access that often obviates the need for surgery and is more reliable than percutaneous endoscopic gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved. Given incomplete follow-up in many patients, these complication rates may be an underestimate.

Lithotripsy of an impacted calcified stone in the cystic duct accompanied by cholecystitis in severe Crohn's disease.

A 35 year old women patient with Crohn's disease and previous multiple abdominal operations presented with a calcified stone of 12 mm diameter in the cystic duct giving rise to cholecystitis. The surgeons declined to operate because of extensive intra-abdominal adhesions caused by multiple intestinal resections and chronic enterocutaneous fistulas. It was possible to fragment the stone in three lithotripsy sessions. The fragments were excreted spontaneously through the ductus choledochus and the cholecystitis was cured by antibiotic treatment. The patient remained symptom free after 12 months.

Intraabdominal abscess in Crohn's (ileo) colitis

Operations for intraabdominal abscess were performed in 46 (20 percent) of 230 patients with Crohn's colitis and ileocolitis treated at the Mount Sinai Hospital during the decade 1964 to 1974. Internal and external fistulas, intestinal obstruction, and abdominal mass occurred significantly more often in patients with intraabdominal abscess, while only overt bleeding was significantly less common. Abscesses were equally divided between 23 patients who had undergone previous surgery and 23 cases of spontaneous onset. In ileocolitis, the most frequent site of origin was the terminal ileum with right lower quadrant abscess, as opposed to a sigmoid origin in colitis with presentation in the left lower quadrant. There was no mortality among 24 patients treated with simple drainage, usually for superficial abscess, but enterocutaneous fistulas persisted in 5 of these patients (21 percent). Four of 11 patients (35 percent) died after undergoing bypass or ileostomy diversion. Among the 31 patients surviving either of these procedures, 18 (60 percent) required subsequent resection of the diseased bowel. By contrast, among 11 patients treated with primary en bloc resection plus drainage, there was only 1 death (9 percent) and no abscess recurrence or chronic enterocutaneous fistula formation during a follow-up period of 1 to 4 years. The high mortality rate after bypass may be explained by the more serious nature of the disease and the preexisting deep intraabdominal abscess and postoperative sepsis. Simple extraperitoneal drainage is a safe procedure associated with an extremely low mortality; however, when feasible, resection of the diseased bowel seems to be the treatment of choice for abscess in patients with Crohn's colitis and ileocolitis.

Persistent enterocutaneous fistula associated with intraperitoneal metallic mercury.

The case of a patient in whom the formation of a chronic recurrent enterocutaneous fistula possibly related to metallic mercury free in the peritoneal cavity has been reported. The mercury originated from a ruptured Cantor tube. This is a rarely reported phenomenon and the first in which the diagnosis was suggested by finding elemental mercury at the time of biopsy via a sigmoidoscope. The mercury was also grossly visible on histological sections. This report emphasizes the adverse effects of metallic mercury when it gains entrance to the peritoneal cavity through a break in the mucosa of the intestinal tract.