Enteric Fistula Research Articles

Fistuloclysis as a method of nutritional management in a patient with high output enteroatmospheric fistula – a case report

Enteric fistula is a pathological communication between the small intestine and surrounding tissue. In case of communication with body surface it is called an enterocutaneous or enteroatmospheric fistula. There are many causes of enterocutaneous/enteroatmospheric fistula occurrence. A common result is malnutrition and organ dysfunction which leads to increased morbidity and mortality of the patients. Adequate nutritional support is a very important element in the management of patients with enterocutaneous/enteroatmospheric fistulas. One of the options of nutritional support is fistuloclysis which means administration of enteral nutrition formula to the distal fistula. We present the case of 76-year-old patient with a high-localized and high output enteroatmospheric fistula in whom we were able to reach adequate nutritional status using fistuloclysis, followed by closure of the fistula

Surgical Management of Complex Enteric Fistulas in Crohn's Disease

Crohn's disease is a chronic, inflammatory bowel condition that can affect the entire digestive tract and in many cases lead to enteric fistula formation. The management of enteric fistulas can be challenging and often requires a multidisciplinary approach.

Surgical Challenges in Management of Transected Pancreatic Duct in Blunt Trauma

Isolated blunt pancreatic injury with ductal involvement is rare following a motor vehicle collision, but correlates with significant morbidity and mortality. We reported a 15-year-old male who presented to emergency department after sustained motor vehicle collision. Post trauma, he appeared drowsy but hemodynamically stable. Abdominal examination was unremarkable but FAST scan was positive and he was subjected for CECT abdomen and showed pancreatic laceration at the body with suspicious of pancreatic duct injury. He was planned for emergency exploratory laparotomy and intra-operatively noted pancreatic head laceration with transected pancreatic duct. The case proceeded with ligation of pancreatic duct cephalic stump, and distal pancreaticogastrostomy. Post operatively, the patient recovered well and he was discharged home on day 6 post operatively. Upon follow up visit, he was asymptomatic with repeated ultrasonography of abdomen showed no evidence of intra-abdominal collection. Discussion: Pancreatic injuries with ductal disruption are of special significance. Apart from bleeding, the leak of enzyme rich of pancreatic juice incites vigorous inflammatory cascade that lead to catastrophic changes in patient metabolism and its sequelae including pancreatic necrosis, peripancreatic abscess, pseudocyst, enteric fistulae and organ failures. In a hemodynamically stable patient, CECT abdomen is the investigation of choice to detect pancreatic duct involvement. Pancreatic injury with ductal involvement require surgical management to prevent the complication of pancreatic enzyme leak. Non operative measure is found to be useful in selected patient. The criteria for nonoperative group are stable hemodynamically, a controlled leak wall off like pseudocyst, absent associated injury or pancreatic necrosis. Non-operative strategy requires multidisciplinary involvement with excellent nutritional support, expert endoscopist and interventional radiologist.

Types and implications of abdominal fluid collections following gastric cancer surgery

Background: Little data are available for abscess and non-abscess abdominal fluid collections (AFCs) after gastric cancer surgery and their clinical implications. We sought to analyse the natural history of such collections in a population of patients subject to routine postoperative imaging.Methods: From 1996 to 2012, 1381 patients underwent gastric resections and routine postoperative monitoring with abdominal ultrasound. As a unit protocol, examinations were carried out in all patients prior to drain removal, immediately before discharge, and at follow-up visits.Results: AFCs were diagnosed in 134 (9.7%) patients after a median time from surgery of seven days (interquartile range (IQR) 5–11 days). Sixty-four of the 134 AFCs (48%) were asymptomatic and resolved spontaneously after a median follow-up of 26.5 days (IQR 14–91 days). Seventy (52%) AFCs required interventional drainage. A stepwise logistic regression model demonstrated that interventional treatment was much more likely among patients with enteric fistula (odds ratio (OR) 9.542, 95% CI 1.418–46.224, p=.003) and pancreatic fistula (OR 7.157, 95% CI 1.340–39.992, p=.012).Conclusions: About one half of AFCs after gastric surgery were asymptomatic and eventually resolved spontaneously without any intervention. However, the need for interventional drainage was significantly increased by coexisting pancreatic or enteric fistula.

Incidence of gynecological fistula and its surgical treatment: A national registry-based study.

Gynecological fistula (affecting female genital organs) leads to involuntary loss of urine or feces. In industrialized societies, fistulas occur mostly as complications of surgery, radiation therapy or inflammatory bowel disease. We sought to determine the incidence of gynecological fistula and type of surgical treatment provided in Norway. This was a retrospective national cohort study of women treated for gynecological fistula (International Classification of Disease-10 code N82) during 2008-2014, identified from the mandatory Norwegian Patient Registry. To compare groups, we utilized Chi-square or non-parametric tests. In all, 1627 women (.06% of the female Norwegian population) had 4475 hospital admissions with a diagnosis of gynecological fistula. In total, 1214/1627 (75%) had fistula as the main diagnosis: 346 (29%) a urogenital fistula, 672 (55%) an enterogenital, 38 (3%) a genitocutaneous and 22 (2%) both urinary and enteral fistula. Surgery for gynecological fistula was performed in 723 women, an incidence rate of 4.2 per 100000person-years (95% confidence interval [CI] 4.2-4.3); gynecological procedures (mostly vaginal/perineal) were performed in 163 women (23%), urological in 43 (6%), enteral in 267 (37%) and surgery involving multiple pelvic compartments in 250 (35%). Women undergoing fistula surgery had a median of three hospital contacts (95% CI 3-3), for 370 women (52%), the procedure was performed by a gynecologist, and 212 of these (29%) were also operated by urologists or gastroenterologists. Gynecological fistula is rare in Norway, with an overall incidence of 6/10000 in the female population, whereas the incidence of surgically treated fistula is 4.2/100000. However, the condition represents considerable morbidity for the individual patient.

Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up

BackgroundThe aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence. MethodsConsecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas. ResultsAmong the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not. ConclusionsWith minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.

25 IDENTIFICATION OF PATHOGENIC BACTERIA IN SEVERE CROHN’S DISEASE

Despite great advancements in therapy, it remains unclear why inflammation in the digestive system of patients suffering Crohn’s Disease (CD) is progressive and leads to complications (e.g., enteric fistulas) that are only alleviated by surgical removal of the damaged bowel. By using a three-dimensional profiling method, we recently discovered that surgically removed CD bowels have complex 3D-networks of microscopic lesions that follow principles of ‘geological caverns’. Because such lesions contain purulent debris (pus), inflammatory cells, and bacterial DNA, their collective presence with that of bacteria could explain CD progression and recurrence. The main objective of this study was to use standard and novel culture methods to determine if bacteria previously identified by DNA methods can be found alive in such microscopic cavernous fistulous tract lesions (CavFT) and could induce intestinal inflammation in mice prone to CD (SAMP1/YitFc). Stereomicroscopic samples from the ileum from 5 CD patients undergoing surgery were obtained under strict aseptic conditions for incubation of anaerobic bacteria. Transplantation experiments of purulent debris and of pure bacterial isolates were conducted in adult (55-wk-old) and young (6-week-old) germ-free SAMP mice to determine acute and chronic intestinal inflammatory responses and gut microbial growth dynamics. In vitro growth assays were conducted to determine the effect of oxygen exposure on bacterial viability, inhibition, and resilience. Single colony 16S rRNA gene Sanger sequencing was used for bacterial speciation. A remarkable array of viable, and cultivable bacteria from the dissected CavFT lesions were revealed from the ilea of CD patients that underwent surgery, but not from paired control mucosa samples. All isolates, with one exception (e.g., Enterococcus faecalis) were strict anaerobes, with a predominance of Bacteroidetes(e.g., compared to Clostridium, 6:1 ratio). Among the Bacteroidetes, Parabacteroides distasonis was present in two patients that exhibited a consistent pattern of pro-inflammatory activity in SAMP mice (3D-cobblestone formation, histological inflammation), when compared to Alistipes finegoldii and Lactobacillus salivarius, which was present as a dominant microbe in mucosal ulcers of a colonic CD. P. distasonis, deemed a slow-growing bacterium, survived prolonged exposure to oxygen (room air), showed the ability to invade the gut wall of germ-free SAMP mice, and stimulate the growth of other specific CavFT bacteria in vitro. Findings support that bacteria inhabiting CavFT in CD could play a perpetuating pathogenic role in CD, by initiating liquefactive ‘sinkhole’ lesions on mucosal surfaces, and by perpetuating microscopic ‘cavernous fistulous tract’ lesions in deep gut muscle layers, which could lead to chronic fistulas.

Myositis and osteomyelitis due to radiotherapy-related fistulae in locally advanced cervical cancer

Enteric and urinary fistulae secondary to chemoradiation for carcinoma of the uterine cervix are devastating uncommon conditions with a significant impact in quality of life. They can also originate multiple disturbances and complications, mainly recurrent infections. We present two women with locally advanced cervical cancer treated with radiation who presented myositis and osteomyelitis secondary to pelvic infections due to radiation-induced fistulae. Recognizing and managing these complications need a high level of suspicion. Treatment is based on a multimodal approach which includes antimicrobial therapy, nutritional support, and surgical intervention. Revision of the literature is presented.

Gallstone Ileus: An Uncommon Cause of Acute Abdomen

Gallstone ileus is a rare cause of acute abdomen, representing less than 1% of intestinal obstruction. It is due to mechanical small bowel obstruction (SBO) by a migrated gallstone. we report this observation to illustrate the imaging findings especially in CT scan. A 62-year-old woman was admitted to emergency for acute bowel obstruction. The CT scan has confirmed jejunal bowel distension with fluid levels upstream endoluminal formation which was rounded and well limited, measuring 5 cm of long axis. This training was slightly hyperdense with hypodense areas of fat density. Moreover, there was aerobilia with multiple fistulas between the duodenum (D1) and gallbladder, which was empty. The triad of aerobilia, small bowel obstruction and migrant gallstone was suggestive of gallstone ileus diagnosis. The patient was operated with good evolution. Gallstone ileus is an uncommon presentation of gallstone disease. It is frequently observed in elderly patients with a history of cholelithiasis or cholecystitis. Early diagnosis is crucial and would avoid morbidity and mortality related to this disease. CT scan shows the classical triad of Rigler with pneumobilia, an ectopic stone and mechanical ileus. CT may improve the diagnosis providing important information regarding the exact number, size, and location of ectopic stones and the site of intestinal obstruction or direct visualization of a biliary–enteric fistula, to help clinicians in the therapeutic management of patients.

Transplantation of Human Intestine Into the Mouse: A Novel Platform for Study of Inflammatory Enterocutaneous Fistulas.

Enteric fistulas represent a severe and medically challenging comorbidity commonly affecting Crohn's disease [CD] patients. Gut fistulas do not develop in animal models of the disease. We have used transplantation of the human fetal gut into mice as a novel platform for studying inflammatory enterocutaneous fistulas. Human fetal gut segments were transplanted subcutaneously into mature SCID mice, where they grew and fully developed over the course of several months. We first analysed the resident immune cells and inflammatory response elicited by systemic lipopolysaccharide [LPS] in normal, fully developed human gut xenografts. Thereafter, we used immunostaining to analyse fully developed xenografts that spontaneously developed enterocutaneous fistulas. Resident human innate and adaptive immune cells were demonstrated in gut xenografts during steady state and inflammation. The expression of human IL-8, IL-1β, IL-6, TNF-α, A20, and IkBα was significantly elevated in response to LPS, with no change in IL-10 gene expression. Approximately 17% [19/110] of fully developed subcutaneous human gut xenografts spontaneously developed enterocutaneous fistulas, revealing striking histopathological similarities with CD fistula specimens. Immunohistochemical analyses of fistulating xenografts revealed transmural lymphocytic enteritis associated with massive expansion of resident human CD4+ lymphocytes and their migration into the intraepithelial compartment. Regionally, mucosal epithelial cells assumed spindle-shaped mesenchymal morphology and formed fistulous tracts towards chronic non-healing wounds in the host mouse skin overlying the transplants. Inflammation and fistulas developed in human gut xenografts lacking IL-10 gene response. This novel model system will enable systematic studies of the inflamed and fistulating human gut in live animals.

1201. A Prolonged Multispecies Outbreak of Carbapenemase-Producing Enterobacteriaceae Due to Transmissible Plasmid With Carbapenemase Gene

BackgroundIn 2010, a multispecies outbreak of IMP type carbapenemase-producing Enterobacteriaceae (IMP-CPE) occurred at a large acute care hospital in Japan. The outbreak continued for years involving more than 100 patients mainly in surgical wards.MethodsBecause of the long period of the outbreak, investigation were focused on hospitalized patients whose clinical samples were positive for IMP-CPE between July 2013 and March 2014. A case–control study was conducted for cases who underwent abdominal surgery with controls from whom meropenem-susceptible Enterobacteriaceae were isolated. Pulsed-field gel electrophoresis (PFGE) was used for molecular typing. To evaluate genetic relationship among IMP-CPE isolates of different species, plasmid analysis using S1 nuclease to separate plasmid and chromosomal DNA followed by plasmid DNA extraction and whole-genome sequencing (WGS) was conducted.ResultsDuring the study period, 22 cases were identified and 22 IMP-CPE isolates which consisted of eight Escherichia coli, five Klebsiella oxytoca, five Enterobacter cloacae, three Klebsiella pneumoniae and one Enterobacter aerogenes were obtained. All five isolates of K. oxytoca had similar PFGE profiles which suggested clonal transmission. However, PFGE profiles of E. coli, E. cloacae and K. pneumoniae isolates were diverse. Plasmid analysis revealed that all 22 isolates shared ca. 50 kb IncN plasmid with blaIMP-6 which implies interspecies transmission of it The case–control study which adjusted by days of hospitalization with 11 cases and 24 controls revealed that pancreato-duodenectomy (adjusted odds ratio (aOR) = 6.4, 95% confidence interval (CI) 1.3–32.4) and enteric fistula (aOR = 8.0, 95% CI 1.5–41.9) were associated with IMP-CPE acquisition. Use of endoscopy within the past six months was not associated with IMP-CPE (aOR = 0.8 95% CI 0.2–4.2). With a bundled infection control with Osaka City Public Health Office, the outbreak was contained in July 2016.ConclusionDissemination of carbapenemase gene by transmissible plasmid can play a critical role to complicate epidemiology of CPE outbreak and made it difficult to control. Plasmid analysis using WGS technology is a promising tool to untangle it.Disclosures All authors: No reported disclosures.

Morbidity and Mortality Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Data from the DGAV StuDoQ Registry with 2149 Consecutive Patients.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are performed for well-selected patients with peritoneal surface malignancies. This combined treatment is potentially associated with an increased rate of complications. The aim of this paper was to analyze the morbidity and mortality of CRS and HIPEC in the German national registry. We present a retrospective analysis of 2149 consecutive patients from 52 hospitals. The data were prospectively documented in the DGAV StuDoQ Registry between February 2011 and December 2016. Almost two-thirds of all patients had a colorectal malignancy; therefore, the most frequently performed resections were colectomies (54%) and rectal resections (30%). Only 36.2% of all patients had no anastomosis, and fewer than 20% of all patients were older than 70years of age (16.4%). Enteric fistula and anastomotic leaks occurred in 10.5% of all cases. The reoperation rate was 14.6% (95% confidence interval [CI] 11.51-18.1). Major grade 3 and 4 complications (Clavien-Dindo classification) occurred in 19.3% of all patients, half of which were due to surgical complications. The overall 30-day postoperative hospital mortality was 2.3% (95% CI 1.02-3.85). Multivariate analysis showed an increased risk for morbidity associated with pancreatic resections (odds ratio [OR] 2.4), rectal resection (OR 1.5), or at least one anastomosis (OR 1.35), and mortality with reoperation (OR 8.7) or age > 70years (OR 3.35). CRS and HIPEC are associated with acceptable morbidity and low mortality. These results show that CRS and HIPEC can be safely performed nationwide when close mentoring by experienced centers is provided.

An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis

Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n= 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n= 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P= .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P=.999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P= .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P= .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P= .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P= .039). In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.

The long-term outcomes of early abdominal wall reconstruction by bilateral anterior rectus abdominis sheath turnover flap method in critically ill patients requiring open abdomen

BackgroundIn a previous study, we reported the usefulness of early abdominal wall reconstruction using bilateral anterior rectus abdominis sheath turnover flap method (turnover flap method) in open abdomen (OA) patients in whom early primary fascial closure was difficult to achieve. However, the long-term outcomes have not been elucidated. In the present study, we aimed to evaluate the procedure, particularly in terms of ventral hernia, pain, and daily activities.MethodsBetween 2001 and 2013, 15 consecutive patients requiring OA after emergency laparotomy and in whom turnover flap method was applied were retrospectively identified. The long-term outcomes were evaluated based on medical records, physical examinations, CT imaging, and a ventral hernia pain questionnaire (VHPQ).ResultsThe turnover flap method was applied in 2 trauma and 13 non-trauma patients.In most of cases, primary fascial closure could not be achieved due to massive visceral edema. The turnover flap method was performed for abdominal wall reconstruction at the end of OA. The median duration of OA was 6 (range 1–42) days. One of the 15 patients died of multiple organ failure during initial hospitalization after the performance of the turnover flap method. Fourteen patients survived, and although wound infection was observed in 3 patients, none showed enteric fistula, abdominal abscess, graft infection, or ventral hernia during hospitalization. However, it was found that 1 patient developed ventral hernia during follow-up at an outpatient visit. Nine of 14 patients were alive and able to be evaluated with a VHPQ (follow-up period: median 10 years; range 3–15 years). Seven out of nine patients were satisfied with this procedure, and none complained of pain or were limited in their daily activities.ConclusionsBased on the results of this study, early abdominal reconstruction using the turnover flap method can be considered to be safe and effective as an alternative technique for OA patients in whom primary fascial closure is considered difficult to achieve.

PS02.205: MALIGNANCY DEVELOPING IN CORROSIVE INJURED ESOPHAGUS

Abstract Background Malignancy developing in a corrosive injured esophagus has been described in the literature. Though the possibility of malignancy developing in a corrosive esophagus is expected to be around 1000 fold no team has managed large numbers. The aim of this study is to analyse the pattern of presentation and problems encountered in managing these difficult patients. Methods 13 patients with corrosive malignancy encountered between 1991 and 2016 were included in this study. Patients basic demographic profile, incidence, time interval between ingestion of corrosive and occurrence of malignancy, site of malignancy, symptoms at presentation, stage, management and survival were analysed. Results There were 10 males and 3 females. The age at presentation was between 35 and 52 years. The time taken between ingestion to presentation with cancer was between 13 and 29 years. The commonest presentation was dysphagia in 11, TEF in 1, UGI bleed in 1 patient. Most common site of malignancy is upper cervical esophagus (53.8%) either at the anastamotic site after coloplasty or at post cricoid region followed by middle (30.7%) and lower esophagus (7.75%) and OG junction (7.75%). 6 of them underwent definitive chemo RT, 3 were unwilling for any sort of management, 1 died within 24 hours due to aorto enteric fistula, 3 underwent THE and gastric pull up. Of these 9 patients only seven were under regular follow up. The survival in 3 patients who underwent THE respectively were 3.8, 5.5,7 years. The survival in patients who underwent Chemo RT was between 3 months and 15 months. Conclusion There were 10 males and 3 females. The age at presentation was between 35 and 52 years. The time taken between ingestion to presentation with cancer was between 13 and 29 years. The commonest presentation was dysphagia in 11, TEF in 1, UGI bleed in 1 patient.. Most common site of malignancy is upper cervical esophagus (53.8%) either at the anastamotic site after coloplasty or at post cricoid region followed by middle (30.7%) and lower esophagus (7.75%) and OG junction (7.75%). 6 of them underwent definitive chemo RT, 3 were unwilling for any sort of management, 1 died within 24 hours due to aorto enteric fistula, 3 underwent THE and gastric pull up. Of these 9 patients only seven were under regular follow up. The survival in 3 patients who underwent THE respectively were 3.8, 5.5,7 years. The survival in patients who underwent Chemo RT was between 3 months and 15 months. Disclosure All authors have declared no conflicts of interest.

ESTIMATION OF EFFICIENCY OF COLLAGEN AND BIOLOGICAL GLUE AT DUODENAL FISTULA IN EXPERIMENT

Introduction. One of the worst complication of different surgical diseases of abdominal cavity organs and of performed, on that regard, operational interventions, are intestinal festulas including without limitation deodenum fistulas. Longterm experience of surgical treatment of patients with unformed duodenal and high enteric fistulas show that it is feasible to have a clear surgical tactics with account of location level and type of fistulas, their quantity, volume of sarcous reduction, peritonitis and multi-organ failure syndrome. In this regard, the objective of this research is to find optimal surgical tactics and to determine the most effective method of treating duodenum fistulas of various causation.Materials and methods. Experimental work was carried out under conditions of experimentally formed intestinal fistula in rabbits of “Shinshilla” breed. After formation of fistula the animals were divided into 3 groups based on the method of removing artificially installed duodenal fistula: sealing through Albert — Schmieden — Lembert suture without fastening of suture line; sealing through fastening of intestinal suture with biological surgical glue; sealing through fastening with swine dermal collagen. Mechanical constancy of the sutures was measured with pneumocompression of sealed intestinal tract areas as well as with morphological study of surgical wound edges.Results. The results of histological study show that experiments with application of bio-implant demonstrated less vascular congestion and interstitial swelling. Phologistic infiltration also responded more efficiently both quantitatively (manifestation rate) and qualitatively (quick change of cell elements) in the group that used bio-implant.Conclusion. Results of morphological studies and pneumocompression data under modelling of duodenal fistulas in experimental animals show that application of bio-implant helps to earlier restore microcirculatory abnormality.

Complications in pediatric intestine transplantation in the absence of peri‐operative donor or recipient bowel decontamination

This study reports the clinical complication and infection rates of an active pediatric IT program that has never utilized bowel decontamination in either the donor or the recipient. All patients undergoing IT from 2003 to 2015 at a single pediatric IT center were reviewed. Post-transplant surgical, infectious, and immunosuppressive complications are reported. There were 52 patients who underwent IT during the study period. Among these patients, 4% developed a postoperative abscess, one developed an enteric fistula (2%), and one had an enteric or anastomotic leak (2%). The rate of any bacterial infection was 90% in the first year, with a wound infection rate of 23%. Any fungal infection occurred in 25% of patients. Any viral infection occurred in 75% of patients. Gastrointestinal viruses were diagnosed in 52% of patients, and cytomegalovirus infections occurred in 17%. Rejection rates were 39% at any time post-transplant (isolated 44% and 35% for multivisceral patients). At this center in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. These findings suggest bowel decontamination may provide no significant benefit in this population of high-risk transplant patients.

Posttransplant complications in adult recipients of intestine grafts without bowel decontamination

BackgroundSelective digestive decontamination is commonly used to decrease lumenal bacterial flora. Preoperative bowel decontamination may be associated with a lower wound infection rate but has not been shown to decrease risk of intra-abdominal abscess or lower leak rate for enteric anastomoses. Alternatively, the decontamination disrupts the normal flora of the gastrointestinal tract and may affect normal physiology, including immunologic function. This study reports complication rates of an intestine transplant program that has never used bowel decontamination. MethodsAll adult patients who underwent intestine transplant from 2003 to 2015 at a single center were reviewed. Posttransplant complications included intra-abdominal abscess, enteric fistula, and leak from the enteric anastomosis. Viral, fungal, and bacterial infections in the first year after transplant are reported. ResultsThere were 184 adult patients who underwent deceased donor intestine transplant during the study period. Among these patients, 30% developed an infected postoperative fluid collection, 4 developed an enteric fistula (2%), and 16 had an enteric or anastomotic leak (8%). The rate of any bacterial infection was 91% in the first year, with a wound infection rate of 25%. Fungal infection occurred in 47% of patients. Rejection rates were 55% at 1 y for isolated intestine patients and 17% for multivisceral (liver inclusive) patients. ConclusionsAmong this population of intestine transplant patients in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. Bowel decontamination provides no identifiable benefit in intestine transplantation.

Surgical treatment of chronic radiation enteropathy

Chronic radiation enteropathy(CRE) represents a latent intestinal injury resulting from abdominal-pelvic radiotherapy. Severe complications like refractory bleeding, intestinal obstruction, perforation and fistula may occur during CRE progression. Surgical treatment is the most effective way to handle these complications. Since radiotherapy has become an important and common way to relieve or even cure many malignant tumors, the incidence of severe complications of CRE is likely to rise. Thus the value of surgical treatment in managing severe complications of CRE should gain more attention. Through the literature review combined with our clinical experience, this paper analyzes the preoperative management and surgical treatment of five long-term complications of CRE, including obstruction, enteric fistula, rectovaginal fistula, perforation and bleeding. Also we propose that when managing patients with severe complications of CRE, clinicians should carefully master the surgical indications, consummate perioperative management, design personal surgical plan according to patient's condition and make improving the quality of life of patients the ultimate purpose of surgical treatment for CRE while assuring its safety.

Negative pressure wound therapy in pediatric surgery: How and when to use.

Negative pressure wound therapy (NPWT) has been widely adopted to treat laparostomy, abdominal compartment syndrome (ACS) and complicated wounds associated with tissue loss. The method presents specific aspects, advantages and indications in Pediatrics. Our aim is to review the evidence available about NPWT in children. Active search for papers about NPWT in Pediatric patients. Papers referring to orthopedic problems, wound complications after Cardiac Surgery or burns were excluded. The method shows good results to treat ACS, complicated wounds and abdominal wall malformations in neonates, including prematures. Periwound skin protection, monitoring of fluid losses and fine tuning of negative pressure levels according to age are necessary. Less pain, quicker recovery, less frequent dressing changes, possible recovery of exposed surgical hardware, granulation and shrinkage of the wound are advantages of the method over other kinds of dressing. NPWT is contraindicated over blood vessels and exposed nerves. Debridement is needed before usage over necrotic areas. Enteric fistulae are not contraindications. Complications are rare, mainly foam retention and dermatitis/skin maceration. The possibility of fistulae being caused by NPWT remains debatable. NPWT is widely used in Pediatrics, including neonates and premature, but the evidence available about the method is scarce and low quality. Complications are uncommon and mostly manageable. A possible causal relationship between NPWY and enteric fistula remains unclear. Adult devices and parameters have been adapted to children's use. Extra care is needed to protect the delicate tissues of Pediatric patients. Comparative research to define differential costs, indications and advantages of the method, specific indications and limits of NWTP in Pediatrics is needed. Review. IV.