Closure Of Enterocutaneous Fistula Research Articles

A Novel Technique For Enterocutaneous Fistula Closure- Local Transposition Flap

Enterocutaneous fistulae are one of the most dreaded complications of abdominal surgeries which may be due to the result of multiple causes like anastomotic failure, poor blood supply, or iatrogenic bowel injuries. These fistulae are classified based on their output. Most Low output fistulae usually close spontaneously but few remain patent and may require surgical intervention. We are presenting two of our cases where we have used the local transposition flap to cover the enterocutaneous fistulae successfully. It can serve as a good armour in the armamentarium of plastic surgeon.

Surgical treatment of enterocutaneous fistulas in patients with ventral incisional hernia

To determine the optimal surgical treatment in patients with enterocutaneous fistulas combined with ventral incisional hernia. There were 24 patients with enterocutaneous fistulas combined with ventral incisional hernia. Enterocutaneous fistula was noted in 19 cases, enteroatmospheric fistula - in 5 patients. Simultaneous fistula closure and abdominal wall repair were performed in 14 patients (mesh repair in 5 cases and local approximation of tissues in 9 cases). Postoperative complications occurred in 8 patients, hernia recurrence in long-term period developed in 7 people. Two-stage closure of abdominal wall defect was carried out in 10 patients. Fistula closure was followed by edge-to-edge anterior abdominal wall repair in 5 cases, skin edges were approximated by interrupted sutures or open wound management was performed. There were no postoperative complications and hernia recurrence in this group. Surgical treatment of patients with enterocutaneous fistulas combined with hernia should be performed in two stages, i.e. enterocutaneous fistula closure with subsequent hernia repair.

Enterocutaneous fistula closure using a balloon-assisted enteroscope preloaded with an over-the-scope clip - narrowing the gap.

Enterocutaneous fistula closure using a balloon-assisted enteroscope preloaded with an over-the-scope clip - narrowing the gap.

Medical Nutrition Therapy In Enterocutaneous Fistula: A Step-By-Step Approach

Enterocutaneous fistula (ECF) management is a challenge that requires a multidisciplinary team approach in achieving optimal clinical output. Nutrition as a component of management plays a vital role in determining the prognosis, both as a predictor of morbidity and mortality. Malnutrition can also occurs as a preceeding situation or complication of ECF caused by the underlying disease, decreased food intake, increased protein requirements associated with systemic inflammation, and increased nutrient loss associated with the amount of fistula output. Thus, nutrition management can act as prevention, therapy, or both. Nutritional medical therapy in ECF cases aims to adequately estimate nutritional needs, maintain fluid and electrolyte balance, and stimulate spontaneous ECF closure whenever possible. To achieve optimal outcome, nutrition needs analysis must be done individually by considering the etiology, anatomical location of the fistula, and the amount of output. In the following article, we will discuss a comprehensive step-by-step nutrition treatment, both from the nutritional routes consideration, macronutrient and micronutrient requirements, specific nutrients, pharmacotherapy, and monitoring and evaluation that need to be done to achieve optimal clinical outcomes.

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression.

The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.

The Importance of Abdominal Wall Closure After Definitive Surgery for Enterocutaneous Fistula

The coexistence of an enterocutaneous fistula (ECF) with large abdominal wall defects represent one of the most demanding situations seen by a surgeon. Simultaneous treatment of ECF closure with abdominal wall defect closure has been widely debated. Our objective was to determine if the type of abdominal wall closure was associated with fistula recurrence after definitive surgery for ECF. Consecutive patients submitted to fistula resection with primary anastomosis for ECF closure. Among several variables, total abdominal wall closure (primary independent variable) was assessed as a factor related to the recurrence of the ECF (dependent variable). Univariate and multivariate analyses were performed. One-hundred and fourteen patients were included. Fistula recurred in 39 patients (34%). Total abdominal wall closure was done in 37 patients (32%). ECF recurred in 16% (6 of 37 patients) when abdominal wall closure was performed, compared to 43% (33 of 77 patients) when this was not (p < 0.02). After multivariate analyses, abdominal wall closure was found as a protective factor against recurrence (p < 0.02). Patients with total abdominal wall closure had one-fourth of risk for recurrence compared to patients without it. Other factors associated to recurrence of ECF were multiple fistulas (p < 0.05), intraoperative blood loss >325mL (p < 0.05) and preoperative C-reactive protein >0.5mg/dL (p < 0.01). Our results suggest that total abdominal wall closure is a protective factor against fistula recurrence after definitive surgery for ECF.

Fasciocutaneous anterolateral thigh flaps for complex abdominal wall reconstruction after resection of enterocutaneous fistulas and the role of indocyanine green angiography: a pilot study

PurposeNo previous study reported the use of a fasciocutaneous anterolateral thigh (ALT) flap combined with a biological mesh for abdominal wall reconstruction (AWR) after enterocutaneous fistula (ECF) in a single-staged procedure and the use of Indocyanine Green Angiography (ICGA) intraoperatively. The purpose of this study was to determine the feasibility and safety of this procedure and to examine the added value of ICGA in minimizing postoperative complications.MethodsA single-institution review of a prospectively maintained database was conducted at Maastricht University Medical Center. To evaluate the feasibility and safety of this procedure, early (≤ 30 days) and late (> 30 days) postoperative complications were assessed. ECF recurrence was considered the primary outcome. To examine the added value of ICGA, complications in the ICGA group and the non-ICGA group were compared descriptively.ResultsTen consecutive patients, with a mean age of 66.7 years, underwent a single-staged AWR with fasciocutaneous ALT flaps. Mean follow-up was 17.4 months (4.3–28.2). Two early ECF recurrences were observed. Both restored without the need for reoperation. A lower rate of early complications was observed in the ICGA group compared to the non-ICGA group.ConclusionThe combination of a biological mesh and fasciocutaneous ALT flap is feasible and safe in AWR after ECF repair in a single-staged approach, with an acceptable complication rate in a cohort of complex patients operated in a dedicated center. ECF closure was achieved in all patients. ICGA seems to be of great added value in minimizing postoperative complications during AWR.

Enterocutaneous Fistula (ECF) Resolution with Isonitrogenous Parenteral Nutrition (PN), L-Carnitine (LC) and Ramped Infusion of Octreotide (Oct) (P12-054-19)

ObjectivesPN is a mainstay for ECF after pancreatoduodenectomy. LC has been studied for cutaneous wound healing. Oct lacks consistent evidence in ECF but may be beneficial with soft pancreatic texture or small ducts, as in pediatric patients. Prior experience suggests that intravenous Oct is superior for ECF than intermittent forms. This case demonstrates the value of isonitrogenous PN, LC and Oct infusion in ECF management. MethodsA 59-year-old male with familial adenomatous polyposis underwent pancreaticoduodenectomy. He returned to the OR after 4 weeks for abscess drainage, cholecystojejunostomy with transhepatic stent, and small bowel resection. The patient returned from rehabilitation 6 months later with persistent fistula output from recurrent ECF. We started on PN and subcutaneous Oct (100 mg TID). The PN amino acid content was guided based on nitrogen balance data. Carnitine levels were very low and LC (1000 mg) was added to the PN.The patient continued to have high volume fistula output and returned to the OR for closure of an anterior ECF, which was followed by development of a right-sided and left-sided ECFs. Continuous infusion of Oct was initiated at 250 mcg/d and gradually ramped-up by 250 mcg/d increments to 1500 mcg/d. ECF fluid output decreased with each step. Complete closure of ECFs was seen after 4 weeks. Oct drip was ramped downward by 250 mcg increments/d and discontinued. The patient advanced his diet and PN was discontinued. He was discharged to rehabilitation without re-emergence of ECF. ResultsThis case demonstrates the value of combination isonitrogenous PN, LC and continuous Oct for ECF. Nitrogen balance based amino acid intake ensured PN nutritional adequacy. Car was similarly based on actual patient data rather than empiric therapy. A continuous Oct ramping protocol enabled judgement of the beneficial effect and determine the need for further dosage increases. Continuous infusion was superior to the previous intermittent Oct. It is possible that the continuous infusion induced more significant suppression of gastrointestinal secretions than subcutaneous Oct administration, thereby improving its efficacy. ConclusionsCombination therapy with PN, Car continuous Oct could be an effective approach for ECF management for patients who have failed surgery and standard medical therapy. Funding SourcesNone.

Endoscopic technique for closure of enterocutaneous fistulas.

Endoscopic over the scope clip (OTSC) closure represents a new technique for endoscopic management of enteric bleeding and tissue defects such as anastomotic leaks and enterocutaneous (EC) fistulas. We aim to describe our technical approach for OTSC closure of EC fistulas and convey our outcomes. This retrospective review includes ten patients who underwent OTSC application for EC fistulas by surgical endoscopists at a US tertiary care hospital from July 2015 to October 2017. Demographic data, along with type of defect, location, duration of lesion, success or failure of OTSC, and nutritional status were compiled. The ACS NSQIP surgical risk calculator was used to project the risk of mortality, complications, length of stay, and risk of readmission had our patients undergone surgical correction of their fistula. Overall success for EC fistula closure was 70%. Acute fistulas were closed with a success rate of 86%. Chronic fistulas were closed successfully in only 33% of cases. Of patients successfully closed, NSQIP-predicted rates of mortality, any complication, and median length of stay were 21.1%, 34.5%, and 9.5days, respectively. With OTSC, these patients experienced 0 mortalities, 0 complications, and had a median length of stay of 4days. OTSC is an effective adjunctive measure to improving rates of successful closure of EC fistulas and compromised anastomosis. OTSC conveys a markedly improved procedural risk profile as compared to standard surgical correction.

A systematic review on the use of vacuum assisted closure therapy for the closure of enterocutaneous fistulae

A systematic review on the use of vacuum assisted closure therapy for the closure of enterocutaneous fistulae

Predictive value of preoperative serum C-reactive protein for recurrence after definitive surgical repair of enterocutaneous fistula

BackgroundRecurrence rates after surgical repair of enterocutaneous fistula (ECF) have not changed substantially. Serum C-reactive protein (s-CRP) has been used as an indicator of postoperative complications in abdominal surgery. ​ The aim of this study was to determine the predictive value of preoperative s-CRP for recurrence after definitive surgical repair of ECF. MethodsFifty consecutive patients with ECF persistence submitted electively to definitive surgical repair (ECF resection with primary anastomosis) were included. Among several variables, preoperative s-CRP (primary independent variable) was assessed as a factor related to recurrence (dependent variable). Univariate and multivariate analyses were performed. ResultsECF recurred in 19 patients (38%). Univariate and multivariate analyses disclosed operative blood loss greater than 325 mL (P < .05) and preoperative s-CRP greater than .5 mg/dL (P < .01) as the only risk factors for recurrence. ECF recurrence rates were significantly higher for patients with preoperative s-CRP above this level (53% vs 11%, P < .01). After conservative and surgical management, overall ECF closure was attained in 40 patients (80%). ConclusionsOur results suggest that s-CRP may serve as a useful parameter to predict potential failure (recurrence) in patients submitted to definitive closure of ECF.

Adjunctive Hyperbaric Oxygen Therapy promotes successful healing in patients with refractory Crohn's disease.

To investigate de adjunctive effect of Hyperbaric Oxygen Therapy in a group of patients with refractory Crohn's disease. A total of 29 subjects with refractory Crohn's disease were submitted to daily sessions of Hyperbaric Oxygen Therapy, in a 2800 Sechrist Monoplace Hyperbaric Chamber (Sechrist, USA) pressurized to 2.4 ATA. Each session lasted 2 hours. The endpoint was closure of enterocutaneous fistulas and complete healing of Pyoderma Gangrenosum and perineal Crohn's disease. A total of 829 HBOT sessions were performed and no complications were noted. Overall success rate was 76% (22 cases). Pyoderma Gangrenosum and enterocutaneous fistulas had the highest successful healing rates (100% and 91%, respectively). Perineal Crohn's disease healing rate was 65%. Adjunctive Hyperbaric Oxygen Therapy promoted satisfactory healing in a group of patients with refractory Crohn's disease.

Spontaneous closure of stoma.

Intestinal loop stoma is a common surgical procedure performed for various benign and malignant abdominal problems, but it rarely undergoes spontaneous closure, without surgical intervention. Two male patients presented to our emergency surgical department with acute abdominal pain. One of them was diagnosed as having rectosigmoid perforation and underwent diversion sigmoid loop colostomy after primary closure of the perforation. The other was a known case of carcinoma of the rectum who had already undergone low anterior resection with covering loop ileostomy; the patient underwent second loop ileostomy, this time for complicated intestinal obstruction. To our surprise, both the loop colostomy and ileostomy closed spontaneously at 8 weeks and 6 weeks, respectively, without any consequences. Spontaneous stoma closure is a rare and interesting event. The exact etiology for spontaneous closure remains unknown, but it may be hypothesized to result from slow retraction of the stoma, added to the concept of a tendency towards spontaneous closure of enterocutaneous fistula.

Su1783 Risk of Intestinal Malignancy in Patients With Short Bowel Syndrome

S A T A b st ra ct s had gastroplasty. The most common cause of short bowel syndrome was bowel resection due to volvulus (48%), 24% (n=6) patients had internal hernia, 12 % (n=3) had bowel obstruction from adhesions and 16% (n=4) patients had mesenteric ischemia. Mean residual short bowel lengthwas 48 cm (range 9 cm to 128 cm). All patients were on parenteral nutrition on presentation. Five patients were treated nonsurgically with intestinal rehabilitation TPN weaning program. Twenty patients underwent surgical procedures. Eight reconstructive bowel anastomoses surgeries, 1 tapering enteroplasy, 1 STEP procedure, 3 G/J tube insertions, 3 adhesiolysis, 6 bypass revision, 3 enterocutaneous fistula closure and 2 stoma takedowns were performed. Five patients needed reconstruction of abdominal wall, with or without biological mesh. Four patients (16%) underwent isolated small bowel transplant. The most common indications for transplant were multiple severe line infections, and non-reconstructable GI tract, respectively. Two patients (8%) receivedmulti-visceral abdominal allograft (liver/pancreas and small bowel) due to TPN induced liver failure. The 1 year graft survival rate for isolated small bowel and multi-visceral transplant was 75% and 50%, respectively. Currently 9 patients remain TPN-dependent, 3 have died, and 13 are off TPN. Conclusions: Patients with short bowel syndrome after bariatric surgery should be treated by dedicated multispecialty teams at intestinal rehabilitation and transplant centers. Corrective reconstructive surgery remains a safe and feasible option in majority of patients, while some patients require isolated small bowel or multi-visceral transplant.

Enterocutaneous Fistula: Different Surgical Intervention Techniques for Closure along with Comparative Evaluation of Aluminum Paint, Karaya Gum (Hollister) and Gum Acacia for Peristomal Skin Care.

Gastrointestinal fistulas are serious complications and are associated with high morbidity and mortality rates. In majority of the patients, fistulas are treatable. However, the treatment is very complex and often multiple therapies are required. These highly beneficial treatment options which could shorten fistula closure time also result in considerable hospital cost savings. This study was planned to study aetiology, clinical presentation, morbidity and mortality of enterocutaneous fistula and to evaluate the different surgical intervention techniques for closure of enterocutaneous fistula along with a comparative evaluation of different techniques for management of peristomal skin with special emphasis on aluminum paint, Karaya gum (Hollister) and Gum Acacia. This prospective observational study was conducted in the Department of Surgery, M.L.N. Medical College, Allahabad and its associated hospital (S.R.N. Hospital, Allahabad) for a period of five years. Majority of enterocutaneous fistula were of small bowel and medium output fistulas (500-1000 ml/24hours). Most of the patients were treated with conservative treatment as compared to surgical intervention. Large bowel fistula has maximum spontaneous closure rate compare to small bowel and duodenum. Number of orifice whether single or multiple does not appear to play statistically significant role in spontaneous closure of fistula. Serum Albumin is a significantly important predictor of spontaneous fistula closure and mortality. Surgical management appeared to be the treatment of choice in distal bowel fistula. The application of karaya gum (Hollister kit), Gum Acacia and Aluminum Paint gave similar outcome. Postoperative fistulas are the most common aetiology of enterocutaneous fistula and various factors do play role in management. Peristomal skin care done with Karaya Gum, Gum Acacia and Aluminum Paint has almost equal efficiency in management of skin excoriation. However, role of Gum Acacia was found to be good with inflamed, excoriated and ulcerative skin in comparison to Aluminum Paint and as efficacious as Karaya Gum but at much lower cost.

Anti-tumor Necrosis Factor Therapy for Crohn Disease: Friend or Foe to the Surgeon?

Anti-tumor Necrosis Factor Therapy for Crohn Disease: Friend or Foe to the Surgeon?

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

Background aimsSurgical treatment for enterocutaneous fistulas (EF) frequently fails. Cell therapy may represent a new approach to treatment. Mesenchymal stromal cells (MSCs) have high proliferative and differentiation capacity. This study aimed to investigate whether MSCs could adhere to suture filament (SF), promoting better EF healing. MethodsMSCs, 1 × 106, from adipose tissue (ATMSCs) were adhered to a Polyvicryl SF by adding a specific fibrin glue formulation. Adhesion was confirmed by confocal and scanning electron microscopy (SEM). A cecal fistula was created in 22 Wistar rats by incising the cecum and suturing the opening to the surgical wound subcutaneously with four separate stitches. The animals were randomly allocated to three groups: control (CG)—five animals, EF performed; injection (IG)—eight animals 1 × 106 ATMSCs injected around EF borders; and suture filament (SG): nine animals, sutured with 1 × 106 ATMSCs attached to the filaments with fibrin glue. Fistulas were photographed on the operation day and every 3 days until the 21st day and analyzed by two observers using ImageJ Software. ResultsConfocal and SEM results demonstrated ATMSCs adhered to SF (ATMSCs-SF). The average reduction size of the fistula area at 21st day was greater for the SG group (90.34%, P < 0.05) than the IG (71.80%) and CG (46.54%) groups. ConclusionsATMSCs adhered to SF maintain viability and proliferative capacity. EF submitted to ATMSCs-SF procedure showed greater recovery and healing. This approach might be a new and effective tool for EF treatment.

Enterocutaneous Fistula Plug Placement as a Successful Endoscopic Intervention for Management of a Refractory Gastrocutaneous Fistula: ACG Clinical Vignette Award Presidential Poster

Introduction: Chronic gastrocutaneous fistulae (GCF) can tremendously impact patients’ health and quality of life. Multiple endoscopic interventions have been reported to assist in GCF closure including clips, cyanoacrylate, tissue adhesives, and endoscopic suturing. Porcine small intestine submucosa (SIS) Biodesign® Enterocutaneous Fistula Plug (EFP) (Cook Medical, Bloomington, IN) is designed to assist with the closure of enterocutaneous fistulae. We report this case to share our experience of using this device for the closure of a refractory GCF. Methods: A 46-year-old female developed a splenic abscess 7 months after sleeve gastrectomy, requiring laparotomy with splenectomy and percutaneous drain placement that led to formation of a GCF. A partially covered esophageal stent was placed at an outside hospital to aid with closure. Retrieval attempt 2 months later was unsuccessful due to robust tissue ingrowth. Upon referral to our medical center, 2 overlapping fully covered stents were placed inside the partially covered stent with 1-2 cm of overlap on the distal and proximal ends with the intent of causing pressure necrosis on ingrown tissue to facilitate removal of the partially covered stent. All 3 stents were removed after 2 weeks; the fistula was observed in the proximal stomach about 15 mm distal to the GEJ. Surgical consultation was obtained but surgical repair was declined. At a subsequent EGD, the GCF tract was abraded with a brush and treated with Argon Plasma Coagulation for de-epithelialization. Over-the-scope clip (OTSC, Ovesco Endoscopy USA, Los Gatos, CA) closure was then performed with apparent technical success. Unfortunately, the fistula continued to drain and this persisted for few months; as such, closure with the Biodesign EFP was elected. After tract dilation, a 22 Fr Wilson Cook Biodesign® EFP was passed over the guidewire and deployed into the tract, with good seating of the internal retention disk confirmed endoscopically. Results: The patient had no further fistula drainage and the external aspect of the fistula was noted to be well-healed at a follow-up office visit one month later. Conclusion: Leaks leading to formation of fistulous tracts are a known complication after bariatric surgery. Insertion of porcine SIS to facilitate closure has been reported in cases of refractory enterocutanoeous and perinanal fistulae. A SIS product developed specifically for enterocutaneous fistulae has recently been developed and FDA approved. In our case, this wire-guided SIS EFP was successful in closing a chronic GCF when other modalities had failed.

Long-term outcome of enterocutaneous fistula in patients with Crohn's disease treated with anti-TNF therapy: a cohort study from the GETAID.

Although anti-tumor necrosis factor (TNF) therapy is the treatment of choice for perianal fistulizing Crohn's disease (CD), the efficacy and safety of anti-TNF therapy in enterocutaneous fistula (ECF) remains unclear. Between January 2008 and December 2009, we retrospectively reviewed the outcomes of all CD patients with ECF (excluding perianal fistula) treated with anti-TNF therapy followed up in Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif (GETAID) centers. ECF closure and tolerance of anti-TNF therapy were studied using univariate and multivariate analyses. Forty-eight patients (twenty-six women; median age 34.6 (interquartile range=25.0-45.5) years) were included in this study. The median follow-up period was 3.0 (2.0-6.6) years. The fistula was located in the small bowel (n=38), duodenum (n=1), and colon (n=9). The fistula has been developed in ileocolonic anastomosis in 17 (35%) cases. Sixteen patients (33%) had complex fistulas with multiple tracts and eleven patients (23%) had a high ECF output (if wearing an ostomy bag). Complete ECF closure was achieved in 16 (33%) patients, of whom eight relapsed during the follow-up period. In multivariate analysis, complete ECF closure was associated with the absence of multiple ECF tracts and associated stenosis. An abdominal abscess developed in 15 (31%) patients. ECF resection was needed in 26 (54%) patients. One patient died after surgery owing to abdominal sepsis. In CD patients with ECF, anti-TNF therapy may be effective in up to one-third of patients, especially in the absence of stenosis and complex fistula. A careful selection of patients is mandatory to prevent treatment failure and improves the safety.

PIODERMA GANGRENOSO GIGANTE DE CURSO FULMINANTE ASOCIADO A ENFERMEDAD INFLAMATORIA INTESTINAL

Abstract Giant pyoderma gangrenosum associated with an inflammatory bowel disease Background: Pyoderma gangrenosum (PG) is an uncommon neutrophilic dermatosis that presents as an inflammatory and ulcerative disorder of the skin. Case report : We report a 23 years old male subjected to a total colectomy and ileostomy due to a toxic megacolon associated with an inflammatory bowel disease. Ten months later, he suffered an infected abdominal wall dehiscence after a surgical intervention for a bowel obstruction. The patient presented confluent ulcerated skin lesions surrounding the ileostomy and drainage sites, associated with severe malaise and without response to antimicrobial treatment. Presuming the presen-ce of a giant and fulminant pyoderma gangrenosum associated with Crohn’s disease, the patient was treated with adrenal steroids and immunosuppressive agents. One month later an enterocutaneous fistula appeared. Thereafter the patient experienced a slow but progressive recovery with a complete healing of the skin lesion and closure of enterocutaneous fistula after four years of immunosuppressive and anti-tumor necrosis factor treatment. The basis of the treatment of this patient was the use of immunosuppressive agents.