Enterocutaneous Fistula Research Articles

Enterocutaneous fistula in thigh

Enterocutaneous fistula in thigh

Spontaneous groin enterocutaneous fistula following neglected inguinal hernia in 3-month infant spontaneous enterocutaneous fistula following neglected inguinal hernia leading to groin enterocutaneous fistula in 3-month infant

Hernia is defined as a protrusion of part or whole of a viscera through an abnormal opening in the wall of the cavity containing the viscera. Strangulation of the viscera within the hernial sac is a common complication in our environment, and this occurs in both adult and children. We study the presentation and management of a 3-month-old infant with groin enterocutaneous fistula following a neglected inguinal hernia. A 3-month-old infant presented late with perforated intestine in an inguinal hernia and managed by the resection and anastomosis of the small intestine. The outcome of a neglected inguinal hernia is still poor in our environment.

Spontaneous Enterocutaneous Fistula Formation and Closure on Anti- Vascular Endothelial Growth Factor (VEGF) Monoclonal Antibody Therapy Associated Adverse Effect during Adjuvant Chemotherapy on Advanced Stage Colonic Adenocarcinoma

Background: Bevacizumab as part of anti-VEGF is a humanized monoclonal antibody that targets vascular endothelial growth factor and is used in the standard adjuvant chemotherapy to treat metastatic colorectal cancer. Venous thromboembolism, delayed wound healing, spontaneous bowel perforation are the adverse events following bevacizumab treatment. According to the timing of fistula growth relative to operation and starting bevacizumab treatment, fistulas are possibly secondary to bevacizumab treatment rather than postoperative complications.

Simplified Model of Enterocutaneous Fistula in the Rat

Simplified Model of Enterocutaneous Fistula in the Rat

Complications of Intraperitoneal Mesh Techniques for Incisional Hernia - A Systematic Review.

Incisional hernia is considered to be one of the most frequent complication of abdominal surgery, with an incidence up to 20% or 35-50%. Given the latest focus on laparoscopic approach of any surgical pathology, there is a tendency in managing the incisional hernias in this particular manner, which impose intraperitoneal onlay mesh placement (IPOM). The aim of this review is to gather more information regarding the possible complications that can be associated with this technique. The study was conducted based on a bibliographic research using the databases: PubMed, Scopus and Web of Science. The work was reported in line with PRISMA guidelines. The study conducted shows that the short-term risks of intraperitoneal mesh placement for incisional hernia repair are not life-threatening and are comparable to other prosthetic surgical techniques. The most frequent complications can be devided in minor: seroma, hematoma and recurrent pain, and major: enterocutaneous fistula, mesh infection and Adhesions-Bowel obstruction. The high rate of unavailability for follow-up, especially regarding major complications that usually occur after a significant period of time, limits the results of the studies documented and they lack the quality-of-life assessment.

Laparoscopic management of ventral hernia repair using intraperitoneal synthetic mesh: A 10-year retrospective observational study

ObjectiveVentral hernia is an anterior abdominal wall hernia, with an incidence of 2%–13%. Laparoscopic ventral hernia repair is the preferred method worldwide with all the advantages of the laparoscopic technique proven to be an effective treatment option. This study aims to assess the long-term outcomes of laparoscopic management of ventral hernia repair using intraperitoneal onlay mesh (IPOM) or intraperitoneal onlay mesh with defect closure (IPOM PLUS) technique with the usage of variety of synthetic meshes intraperitoneally. MethodsA retrospective study of 821 patients of a single institution for a decade was conducted. Long-term outcomes such as pain, mesh infections, enterocutaneous fistula, bowel adhesions and recurrence were assessed. ResultsThere were 801 primary, 12 incisional, and 8 recurrent hernia cases, including 532 females and 289 males with a mean age of 45.62±9.37 years. IPOM PLUS were underwent in 674 (82.10%) cases. Polypropylene, dual, titanium, composite meshes were applied in 473 (57.61%), 208 (25.33%), 82 (9.99%), and 58 (7.06%) cases respectively. Intraoperative bleeding occurred in 3 (0.37%) cases, seroma in 8 (0.97%), wound infection in 4 (0.49%), stitch abscess in 2 (0.24%). Recurrence was found in 8 (0.97%) cases, with 5 used polypropylene mesh and 3 used dual mesh. Mesh infections were discovered in 6 (2.88%) cases used dual, and foreign body sensation in 4 (0.85%) cases used polypropylene. Three (0.37%) patients had suture site hernia, and 3 (0.37%) had chronic sinus. ConclusionIPOM or IPOM PLUS holds good in small or medium sized ventral hernias. The safety and efficacy of intraperitoneal polypropylene mesh is comparable to that of other synthetic meshes. A mesh overlap of minimum 5 cm beyond defect edge is must to minimise hernia recurrence. Absorbable suture can be considered as alternative to tackers.

An ileostomy and enterocutaneous fistula lead to a voluntary assisted dying (VAD) application

An ileostomy and enterocutaneous fistula lead to a voluntary assisted dying (VAD) application

Spontaneous enterocutaneous fistula in a patient with femoral hernia: a case report

BackgroundEnterocutaneous fistula commonly occurs in the post-operative setting. However, a handful of cases have been reported to occur secondary to strangulation of hernia, mostly femoral due to the narrow femoral ring through which this type of hernia passes through.Case presentationWe encountered a case of spontaneous fecal fistula, which occurred in the setting of an incarcerated femoral hernia. The patient did not develop peritonism, or obstruction, throughout the course of the disease. The hernia ruptured on day 7 of incarceration. Exploratory laparotomy under epidural anesthesia revealed a femoral hernia with ileum as content, arising approximately 20 cm from the ileocecal junction. Reduction of the contents was done, and a resection performed along with repair of the hernia.ConclusionAs very few literature describe the formation of spontaneous fecal fistula, we discuss the presentation in this report.

New technique for abdominal wall procurement. Initial experience.

Difficulty in obtaining adequate abdominal wall closure due to loss of the abdominal domain is a frequent complication of multivisceral, isolated intestinal transplantation and in some cases of liver transplantation. Various methods for primary closure have been proposed, including the use of synthetic and biological meshes, as well as full-thickness abdominal wall and non-vascularized rectus fascia grafts. We describe a novel technique for abdominal wall procurement in which the graft is perfused synchronously with the abdominal organs and can be transplanted as a full-thickness wall or as a non-vascularized rectus fascia graft. We performed six transplants of non-vascularized rectus fascia in three intestinal transplants, one multivisceral transplant, and two liver transplants. The size of the covered abdominal wall defects ranged from 17cm × 7cm to 25cm × 20cm. Only one patient developed graft infection secondary to enterocutaneous fistula requiring surgical correction and removal of the fascia graft. This patient, as well as two other patients, died due to sepsis. Our procurement technique allows removal of the rectus fascia graft to cover the abdominal wall defect, providing a feasible solution for treatment of abdominal wall defects in recipients after abdominal organ transplantation.

P128 BOTULINUM TOXIN A IN CONJUNCTION WITH NEGATIVE PRESSURE WOUND THERAPY AND MESH-MEDIATED FASCIAL TRACTION PROVIDES HIGH RATE OF FASCIAL CLOSURE IN PATIENTS WITH OPEN ABDOMEN

Abstract Aim Presentation of our data on Vacuum-Assisted Wound Closure and Permanent Onlay Mesh-Mediated Fascial Traction (VAWCPOM) in combination with Botulinum Toxin A (BTX-A) injection in the lateral abdominal wall as a treatment of the open abdomen (OA). Material and Methods This is a retrospective case series including patients treated for OA from January 2017 till March 2021 with VAWCPOM and BTX-A. Patient records were collected from medical charts, incl. age, sex, body mass index (BMI), comorbidity, initial fascial defect size, time until fascial closure, complications and, when available, outpatient follow-up. Results A total of 33 patients with OA were included. The mean age was 62,5 years, male/female ratio was 15:18, with a mean BMI of 35,4 kg/m2. The mean width of the fascial defect was 13,5 cm (5 - 25cm). The rate of fascial closure was 96,9%, achieved within a mean of 22,7 days. Fascial closure was not attainable in one patient who developed enterocutaneous fistula under treatment. 22 patients experienced in-hospital complications. Short-term follow-up was conducted in 22 patients, with hernia recurrences in three. Conclusions Treatment of OA remains a surgical challenge. This case series shows promising results with a high rate of fascial closure using a combination of VAWCPOM and BTX-A and an acceptable rate of postoperative complications in this severely challenging patient group. The rate of primary closure indicates that this may be the future management of open abdomen.

Managing ‘Adhesive Small Bowel Obstruction’ in Tanzania: A Single Center Retrospective Review of Treatment Approach and its Outcomes

Background The management of adhesive small bowel obstruction has evolved significantly in high income countries with improvements in diagnosis and treatment, from conservative to minimally invasive approaches. In Tanzania, like in many low and middle income economies, these developments have not been herald. Addressing adhesive small bowel obstruction in this setting is therefore vital to improve outcomes. This study aimed to explore current treatment modalities and their outcome among patients with ‘adhesive small bowel obstruction’ at Muhimbili national hospital. Methodology A descriptive retrospective, cross-sectional study was conducted at Muhimbili National Hospital covering the period 2014 to 2016. Patients with a documented diagnosis of adhesive Small Bowel Obstruction were sought from medical records. Using a predefined data capture sheets, age, sex, type of management, complications, mortality and time to feeding (among patients who were managed conservatively) were captured. The study had 80% power to detect a mortality rate of 8.7% at 95% confidence interval. Descriptive statistics were populated and summarized as proportions while mortality between the operated versus the conservative group compared using chi square test with significant value set at p value of <5%. Results A total of 127 patients with diagnosis of adhesive small bowel obstruction were identified. The mean age was 40.5±17.6 and a slight male predominance at a ratio of 1.6:1. Operative approach was predominant over conservative at ratio of 1.7:1. One third of the surgical group had bowel resection and anastomosis performed. In 18.8% of the operated cases, a complication was reported with Enterocutaneous fistula and surgical site infection being the most common. Overall mortality was 8.7% being higher in the operated group at 10%. Conclusion Open surgical approach is the predominant management approach in patients with Adhesive Small Bowel Obstruction. One in three of surgically managed required bowel resection signifying late presentation. Managing adhesive small bowel obstruction carries high morbidity and mortality. There is no standardized protocol for the management of these patients at the tertiary level. Recommendation Locally adoptable protocol for diagnosis and treatment of adhesive small bowel obstruction is needed. This should maximize on resources that are available even at district level facilities with much consideration of the role of surgery.

Prolapsed ileocolic intussusception in an infant: An uncommon presentation

Intussusception is a common pediatric emergency, although a prolapsed intussusception is a rare entity, often misdiagnosed as a rectal prolapse. We report a 10-month-old female baby who presented with a three week history of a mass protruding per anus and vomiting, and a 2 week history of bloody diarrhoea. A clinical diagnosis of a prolapsed intussusception was made and no imaging studies were ordered to avoid a delay in management. The patient underwent an emergency laparotomy, where a dual reduction was done and the bowels were found to be ischemic hence a right hemicolectomy was performed with end-to-end ileo-transverse anastomosis. Unfortunately, 2 weeks post laparotomy, the patient presented with a high output enterocutaneous fistula. Another emergency laparotomy was performed, with findings of intestinal adhesions and an anastomotic leak. Adhesiolysis was done along with re-freshening of the ileo-transverse anastomosis. Intussusceptions presenting in the form of a prolapse through the anus is a rare condition indicating a serious sign and is often mistaken for a rectal prolapse. A digital rectal examination can help differentiate the two from each other. Surgery is the mainstay treatment for a prolapse intussusception, and should not be delayed.

EP.FRI.616 Novel Technique of Gastrojejunostomy Tube Insertion to Control Retracted Proximal Stoma

Abstract Introduction Extensive small bowel resection for ischaemia can require formation of a proximal jejunostomy. Depending on length of remaining jejunum, a major potential complication is stoma retraction with resultant peritonitis, intra-abdominal sepsis and enterocutaneous fistula formation. We describe a case using a novel technique of inserting a retrograde gastrojejunostomy tube to gain control of an acutely retracted stoma in a 61 year old patient who developed an enterocutaneous fistula shortly after major resection due to ischaemia. Method Under fluoroscopic guidance, the retracted proximal limb of the jejunostomy was cannulated antegradely by guide wire. A gastro-jejunostomy tube was inserted retrograde over the guide wire and the tip placed within the stomach. The proximal tube fenestrations were sited within the duodenum and the balloon was inflated to limit enteric content spilling into the peritoneal cavity. Conclusion This technique enabled drainage of gastroduodenal fluid, minimised spillage into the peritoneal cavity, reduced fistula output and controlled sepsis. This allowed time for nutritional optimisation, better glycaemic control and endovascular revascularisation in preparation for restoration of intestinal continuity at an appropriate time. This method offered a useful alternative to surgery, in a patient for whom emergency re-exploration of the abdomen would carry significant risk of morbidity or mortality.

EP.FRI.337 Active management of the open abdomen in non-trauma catastrophes, including use of negative pressure wound therapy, is associated with high primary fascial closure rates

Abstract Aims Deliberate use of the open abdomen (OA) following emergency laparotomy (EL) may be life-saving in the non-trauma abdominal catastrophe (NTAC) and damage control surgery (DCS) can reduce the risk of abdominal compartment syndrome in compromised patients. Controversy exists over optimum management of the abdominal wall. An audit was undertaken of negative pressure wound therapy (NPWT) in OA patients. Methods All patients who underwent OA management of NTAC from 1st Jan 2019 to 31st Dec 2020 were identified. Data on patient demographics, indication for OA and clinical outcomes were analysed. Results Eighteen patients (median age 65.5 years; M:F9 each) underwent OA following EL. The indications were: bowel ischaemia (8), intra-abdominal sepsis (5), grossly distended bowel (3) and intra-abdominal haemorrhage (2). In all cases, ABTHERATM dressings (KCI/Acelity) were used. Mean ICU stay was 7.4 days (range 1-15) and mean hospital stay 33 days (range 2-61). Four patients died, 3 within 24 hours of initial EL. Relook laparotomy was performed within 48 hours in the remaining 15 patients; 3 patients required 2 relooks and 1 patient had three. Primary fascial closure (PFC) was achieved within five days in 13/14 (93%) survivors. Eight patients had SSIs with 2 intra-abdominal collections and all were treated conservatively. One patient developed an enterocutaneous fistula. Conclusions The use of commercially-available NPWT dressings in OA management is associated with high PFC rates within one week of initial EL. This practice is consistent with World Society of Emergency Surgery guidance recommending planned re-look laparotomy within 48 hours.

Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications.

Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.

1431 Stoma Intubation, Isolation and Negative Pressure Wound Therapy for Complex Stoma-Associated Wounds: New Technique and Case Series

Abstract Background The use of negative pressure wound therapy (NPWT) in colorectal surgery has been demonstrated for treating perineal defects, enterocutaneous fistula and stoma dehiscence. Here we describe a technique for closure of complex stoma-associated wounds using a novel commercial intubation device alongside NPWT to protect the surrounding wound from the stoma effluent. The device has previously described for use with enterocutaneous fistula. We present two cases that have been successfully treated with this technique. Technique and Cases The first case is of 88-year-old women with a retracted loop ileostomy and the second a 48 year-old male with a retracted end colostomy. Both patients underwent significant emergency peristomal debridement and in both cases the commercial device was deployed to intubate the stoma. VAC foam and standard adhesive dressings were used to form a quality seal and the pressure set to 125mmHg. In both cases near complete healing was achieved to the point that standard stoma bags and management could be used. Conclusions This is the first description of the use of an isolation device in complex stoma associated wounds. We have found the Fistula Funnel to be highly effective in this context.

477 Surgical Solutions and Problems in An Adult Patient with VACTERL Association

Abstract Background We report an adult patient with features of VACTERL - oesophageal and anal atresia, with cardiac malformation. In infancy he underwent colonic interposition for oesophageal atresia using the transverse colon as a conduit. As a teenager he underwent formation of a Koch continent ileostomy after previous stoma formation for anal atresia. Eventual failure of the Koch pouch nipple valve necessitated a laparotomy for attempted refashioning. Unfortunately, this operation was beset by life-threatening complications and a protracted post-operative course. He presented to our hospital with a laparostomy, high output enterocutaneous fistulae (ECF) necessitating home total parenteral nutrition (TPN), severe cachexia and deconditioning. Method Conservative therapy was utilised to improve the nutritional and physiological status of the patient. Simultaneously, attempts were made to define the anatomy of his abdomen in relation to previous surgery. However, operation notes for the original procedures (oesophageal reconstruction and Koch pouch formation) were lost due to closure of the hospital which he attended at the time. A laparotomy was subsequently performed to manage the ECFs. Most of the small intestine was unsalvageable due to multiple fistulae and adhesions, leaving 35cm of small bowel terminating in an end ileostomy. A cholecystectomy was performed to mitigate gallstone formation. Conclusions Efficient communication is imperative in the management of complex patients. The loss of original operation notes made interpretation of subsequent imaging and planning of surgery troublesome. In contrast, efficient communication between teams involved in his peri-operative care, particularly the respiratory and intensive care teams facilitated a smooth post-operative course and successful discharge from hospital.

867 A Novel Use for Silicone Expanders: Reducing Pelvic Dead Space and Preventing Bowel Herniation When Managing Radical Exenterative Surgery Complications

Abstract Aim To date, there is no clear consensus regarding the best way to obliterate the pelvic dead space, as seen in patients treated for recurrent perineal herniation and entero-cutaneous fistuli following total pelvic exenteration (TPE) for locally advanced rectal cancer. We present a novel technique using saline-filled breast expander to fill the dead space and create an artificial pelvic floor using the implant capsule, thus preventing intestinal herniation and fistuli formation in the multi-operated and irradiated pelvis scenario. Method We present 2 patients who initially had TPE, IGAP flap perineal reconstruction and neoadjuvant chemoradiotherapy. Patient 1 had 2 laparotomies for persistent enteroperineal fistulae in the 2-year postoperative period. Patient 2 had persistent wound discharge 2 years post TPE and underwent an enterocutaneous fistula repair and wound debridement. Both cases were complicated by perineal herniation and re-presented with persistent fistulation. A Becker 25 breast expander was placed into the pelvis and inflated with 150 ml of saline, to help contain the small bowel in the abdomen and reduce the risk of perineal re-herniation and fistulae. Results The silicone device was removed at 7-12 months, preserving its capsule, by the time the wound had healed. The wounds remained healed at post-operative follow up without any further perineal wound complications, herniation or fistuli Conclusions Addressing the dead pelvic space by using a breast expander may treat this particular TPE complication. The capsule created following placement of breast implant, facilitates artificial pelvic floor.

Enterocutaneous Fistula and Abscess Diagnosed with Point-of-care Ultrasound.

Case PresentationA 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain. The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension. The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control.DiscussionA rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications.

S794 In-Hospital Outcomes and Healthcare Burden of Fistulizing Crohn’s Disease Requiring Parenteral Nutrition

Introduction: The transmural inflammation characteristic of Crohn’s disease (CD) predisposes patients to the formation of enterocutaneous fistulas (ECF), which is a major cause of morbidity and worse outcomes. Parenteral nutrition (PN) is frequently prescribed to provide bowel rest in efforts for closure, however PN might be associated with an increased risk of adverse events. We sought to analyze the burden and outcomes related to ECF and CD with PN and without PN use. Methods: A retrospective cohort study of the 2016-2017 National Inpatient Sample database was performed, using ICD10-CM/PCS codes to identify patients discharged with a primary diagnosis ECF with CD and those receiving PN. Primary endpoint was in-hospital mortality. Secondary endpoints were length of stay (LOS), in-hospital complications and advanced therapy, hospital related charges. Multivariate regression analysis model to adjust for patient and hospital characteristics, was performed for both primary and secondary outcomes. Results: Of 10,230 admitted with ECF and CD, 10.4% (1,065) received supplemental PN. These patients were more likely to belong to a higher income bracket (21.3% vs 28.2%; P = 0.02), and less likely to be self-pay (4.3% vs 0.1%; P < 0.01). They were more likely to abuse opiates (2.2% vs 6.1%; P < 0.01), have moderate or severe protein-caloric malnutrition (17.5% vs 68.5%; P < 0.01), vitamin D deficiency ( 4.2% vs 7.0%; P = 0.05), hypovolemic hyponatremia ( 4.9% vs 13.2; P < 0.01), hypokalemia (12.7% vs 22.5%; P < 0.01), hypophosphatemia (2.2% vs 11.3%; P < 0.01), upper GI bleeding (0.1% vs 0.5%; P < 0.01) and required transfusion of blood products ( 4.6% vs 13.6%; P < 0.01). On multivariate analysis LOS was longer [6.87 Days; (P < 0.01)] in patients receiving PN, they also had higher healthcare burden including charges [50,732 US$; (P < 0.01) and costs [14,022 US$; (P < 0.01)]. We found higher rates of endotracheal intubation [OR 10.25; (P < 0.01)], prolonged mechanical ventilation (>96 hours) [OR 7.90; (P = 0.02)] and tracheostomy requirement [OR 4.17; (P < 0.01)], however no difference in in-hospital mortality was found [OR 1.25; (P = 0.82)]. Conclusion: PN use in CD with ECF, is not associated with higher in-hospital mortality. However, we found an increased overall in hospital burden, including LOS, healthcare utilization, and prolonged intensive care resource utilization. Further studies are needed to assess why those differences occur between the two groups.Table 1.: Availability of Six FDA-Approved Agents in Commercial vs Governmental Formularies