Enterocutaneous Fistula Formation Research Articles

Enterocutaneous fistula from a perforated incarcerated Littre inguinal hernia in an infant

Inguinal hernia is a common surgical condition encountered of pediatric age group. Inguinal hernia may get incarcerated and if strangulated, it requires prompt intervention. Rarely incarcerated bowel can perforate leading to formation of entero-cutaneous fistula. Littre's hernia is the protrusion of a Meckel diverticulum through a potential abdominal opening. A one and half months old infant presented with an irreducible right inguino-scrotal swelling and faecal discharge from the scrotum for a month. Patient was passing stools from normal anal opening as well. Patient underwent exploratory laparotomy which revealed an incarcerated right inguinal hernia containing long ruptured Meckel's diverticulum of size 8 cm passing from deep inguinal ring to right hemiscrotum. Diverticulectomy with ileo-ileal end to end anastomosis with right herniotomy was done. The main complication of inguinal hernia is incarceration, which may result in bowel obstruction. Spontaneous intestinal-cutaneous fistula from incarcerated inguinal hernia with Meckel's diverticulum as content in neonates and infants is a rare occurrence and hitherto only one such case has been reported in the world literature. Prompt and early seeking of medical facility of patients with incarcerated inguinal hernias is necessary to reduce their morbidity and mortality.

Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma.

Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization. A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated. Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity. We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema. Systematic Review and Meta-Analysis; Level IV.

"Delayed-Immediate" Hernia Repairs in Infected Wounds: Clinical and Economic Outcomes.

Wound class in hernia repairs impacts surgical technique and outcomes. Hernia recurrence and complications are high when dirty wounds are treated in one stage. We hypothesize patients who undergo intentionally staged repairs are less likely to have adverse outcomes and associated costs. Patients were identified by retrospective chart review. Patient characteristics and outcome variables were collected. An economic analysis of cost variables was performed using medical records and published meta-analyses. There were 8 patients in the staged repairs group and 10 patients in the control group. Length of stay was 14.9days (±8.8), and 8.7 days (±6.4), respectively. Rate of hernia recurrence within 1year was 14.3% and 37.5%. Rate of mesh infection at 30days was 0% and 10%. Compared to controls, delayed-immediate repairs had a nearly 2-fold index surgical cost. Although there is an increased cost associated with delayed-immediate repairs, this cost may be offset by the decreased infection, seroma, dehiscence, enterocutaneous fistula formation, and hernia recurrence rate that necessitates future interventions. Further data collection is required to determine if clinical and economic benefit is seen long-term.

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.

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.

Assessment of button-type jejunostomy for nutritional management after esophagectomy in 201 cases

Many surgeons preferably place a trans-nasal feeding tube or a feeding enterostomy for post-operative nutritional management after esophagectomy. Various types of tubes (such as nasogastric, transgastric, transduodenal, or transjejunal tubes) have been used for enteral feeding; however, the appropriate enteral feeding routes have not yet been proposed. Therefore, this study aimed to evaluate the feasibility and safety of button-type jejunostomy. We reviewed 201 patients who underwent esophagectomy with placement of a button-type jejunostomy at the Jikei University Hospital (Tokyo, Japan) between 2008 and 2019. The analyzed variables included clinicopathological characteristics, operative data, jejunostomy-related characteristics, and postoperative complications. Postoperative bodyweight loss was examined 6 months and 1 year after the operation. Refractory enterocutaneous fistula and bowel obstruction occurred in 13 (6.5%) and 14 (7.0%) patients, respectively. The body mass index at button-type jejunostomy removal was significantly lower and the duration of button-type jejunostomy placement was significantly longer in patients with a refractory enterocutaneous fistula (p = 0.023 and p < 0.001, respectively). Bowel obstruction was significantly more likely to develop in patients with a non-squamous cell carcinoma (p = 0.021) and in patients who underwent open abdominal procedures (p < 0.001). After 1 year, the median bodyweight losses were 12.1% and 15.6% in patients with short and long jejunostomy placement durations (p = 0.642), respectively. A button-type jejunostomy is durable and allows easy self-management for maintaining the bodyweight without any adverse events. However, it is strongly recommended that the button be removed within a year to prevent refractory enterocutaneous fistula formation.

30 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. Conclusions 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.

Peritonitis following unsafe abortion: a retrospective study in a tertiary health facility in North Central Nigeria.

Introductionsurgical complications following unsafe abortion (UA) are not uncommon and are associated with high morbidity and mortality in developing countries. The commonest need for the general surgeon following UA is after a diagnosis of peritonitis which can occur following use of sharp objects introduced through the vagina. This study aims to highlight the presentation, management types and outcome of patients who presented with peritonitis following UA.Methodsthis study is a retrospective review of cases of peritonitis following UA seen over 4 years from January 2015 to December 2019 in a tertiary health facility in North Central Nigeria.Resultsa total of 14 patients with peritonitis following UA were included in the study. The mean age of patients who presented was 27.4 years (19-40 years) with a mean estimated gestational age at abortion of 7.8 weeks. The average time from the UA procedure till presentation at the hospital was 8.6 days. There were 9 bowel injuries and 5 pelvic abscesses. A total of 3/9 patients had primary resection and anastomosis while 6/9 had stoma formed as part of their management. Pelvic abscesses were drained. In patients with bowel injury, those who had primary anastomosis had a 100% incidence of enterocutaneous fistula formation with associated sepsis requiring repeat exploration and formation of stoma. Mortality in this group was 67% (2/3) compared to the 0% (0/6) mortality rate seen in patients who had stoma. The overall mortality was four out of fourteen patients (28.6%).Conclusionperitonitis following UA is associated with marked morbidity and mortality as many of the patients present late. Initial preoperative resuscitation and stabilization should be followed by a swift laparotomy. Patients with bowel injury who had primary anastomosis had higher morbidity, reoperation rates and mortality than patients who had stomas.

2265 Umbilical Hernia Rupture Complicated by Enterocutaneous Fistula in 63-Year-Old Female With Decompensated NASH Cirrhosis

INTRODUCTION: Spontaneous umbilical hernia rupture, known commonly as Flood syndrome, is a rare complication of severe ascites in end stage liver disease. Leakage of ascitic fluid leads to skin ulceration and necrosis which poses a threat of infection in addition to risk of evisceration or incarceration of bowels. Surgical repair is often deferred due to high mortality risk in decompensated cirrhosis which further complicates management. CASE DESCRIPTION/METHODS: A 63-year-old female with decompensated NASH cirrhosis, type 2 diabetes, atrial fibrillation, chronic heart failure, and morbid obesity was admitted after she developed sudden rupture of umbilical hernia with large amount of fluid discharge after defecation. She was afebrile and normotensive and was found to have ulcerated, ruptured umbilical hernia with active leakage of yellow fluid. Labs were significant for thrombocytopenia (115 × 10^3/µL), mild creatinine elevation (1.11 mg/dl), hyperbilirubinemia (2.8 mg/dl) and hypoalbuminemia (2.2 mg/dl). CT of the abdomen and pelvis revealed large abdominal wall hernia containing large and small bowels with questionable low-grade partial small bowel obstruction. General Surgery was involved but as she didn’t want to undergo any invasive treatment and due to high surgical risk, conservative treatment was recommended. Two days later she became febrile and hypotensive, accompanied by acute kidney injury (1.40 mg/dl) and worsening bilirubin (3.5 mg/dl). Due to high likelihood of SBP, diuretics were held, and ceftriaxone and albumin were initiated. Her INR increased to 6.3 and thrombocytopenia progressed (56 × 10^3/µL). Blood cultures showed no growth, but ascitic fluid cultures revealed polymicrobial flora including Bacteroides fragilis raising concerns of enterocutaneous fistula. Fortunately, she improved with conservative management and was safely discharged. DISCUSSION: Flood syndrome is caused by increased intraabdominal pressure during coughing, vomiting or defecating, like in our patient. Treatment is challenging as surgical repair is associated with high mortality despite known benefits of hernia repair in cirrhotic patients, however, these studies did not include decompensated cirrhosis. Patients are at increased risk of intraperitoneal infection, which was likely the case in our patient, however formation of enterocutaneous fistula is extremely rare.

A rare complication of prosthetic mesh repair of a ventral incisional hernia: erosion and enterocutaneous fistula formation

Recurrence of hernia has significantly reduced with mesh repair. But mesh is a foreign material which has its own complications like haematoma, infection, sinus formation, mesh migration and erosion. Mesh migration and erosion although rare, is a challenging complication which requires surgical intervention. There are very few such mesh related complications reported in the literature. Authors report a case of mesh erosion resulting in chronic infection and formation of enterocutaneous fistula following incisional hernia repair 5 years after surgery. In this case small bowel segment containing mesh was resected and primary anastomosis was done. Migration of mesh also depends on the nature of mesh (biomaterial) and type of fixation. Although many techniques of hernia repair have been described (open or laparoscopic) care must be taken to fix the mesh to abdominal wall for prevention of delayed complications. Different techniques of repair, types of meshes have been discussed to prevent such complications.

Enteral and Parenteral Nutrition

Alternative routes of nutrient administration are available for patients who are unable to eat or digest sufficient food to prevent malnutrition. These routes include enteral (administered through the gastrointestinal tract) and parenteral (administered intravenously). This review details the clinical consequences of malnutrition, nutritional assessment, the benefits of nutrition support therapy, determining the nutrient prescription, special considerations in nutrition support therapy, aspects of obtaining enteral or parenteral access, monitoring of patients receiving nutrition support therapy, and complications and ethical issues associated with enteral and parenteral nutrition. Figures include algorithms showing the identification of malnutrition, the nutrition support decision process, and the approach to gastric residual monitoring; nasogastric tube displacement leading to pneumothorax; proper placement of a long or “midline” catheter versus a peripherally inserted central catheter; and photographs of a 43-year-old man with Crohn disease complicated by enterocutaneous fistula formation, distal small bowel obstruction, and evisceration of the small bowel after developing a pelvic abscess. Tables list acute illness- or injury-related malnutrition; chronic disease−related malnutrition; social or environmental circumstances−related malnutrition; indications and contraindications to enteral and parenteral nutrition; selected examples of predictive equations; electrolyte provision in parenteral nutrition; parenteral vitamin and trace element requirements; complications associated with enteral and parenteral nutrition; and indications, contraindications, and complications of gastrostomy tube placement. This review contains 6 highly rendered figures, 11 tables, and 167 references.

Fistulating Richter’s Hernia of Groin with Necrotizing Soft Tissue Infection: A Lethal Combination

Strangulation of groin hernia can result in significant morbidity and mortality. Spontaneous external fistulation following strangulation is rare and typically occurs with Richter's hernia. Spreading Necrotizing Soft Tissue Infection (NSTI) secondary to Enterocutaneous Fistula (ECF) is an ominous sign, further worsening its prognosis. Early diagnosis and prompt surgical treatment is crucial to improve outcome. Herewith the authors are presenting a case of neglected inguinal hernia. It was complicated with ECF formation and rapidly spreading NSTI of flank. He underwent resection and anastomosis of the gangrenous bowel, anatomical repair of the hernia along with soft tissue debridement of flank region. This patient however succumbed to sepsis with multi organ dysfunction. Significant delay in seeking medical care led to dismal outcome.

Delayed interventions and mortality in trauma damage control laparotomy

In damage control laparotomy, operative principles include hemorrhage and contamination control. However, required components of initial damage control laparotomy are unknown, and nonemergency injury repair is sometimes delayed for resuscitation, angiography, or nonabdominal operations. The frequency and effects of delayed interventions are unknown. A retrospective review of patients undergoing damage control laparotomy at a single, urban trauma center was performed. Interventions initially performed at the second laparotomy were considered delayed interventions. In the study, 330 damage control laparotomy patients survived to reoperation. Of all interventions, 13.9% were first performed at the second laparotomy, including 11.9% of visceral interventions and 27.2% of vascular interventions. Overall, 29.7% of patients underwent an unplanned re-exploration, and 21.8% of patients underwent re-exploration for hemorrhage control. There was no significant increase in mortality (33.3% vs 23.9%, P=.09), intra-abdominal infection (37.9% vs 28.0%; P=.10), anastomotic leak (8.0% vs 5.8%, P=.45), or enterocutaneous fistula formation (9.2% vs 9.1%, P=1.00) with delayed interventions overall. However, mortality was increased in patients undergoing delayed vascular interventions (59.1% vs 22.8%, P=.003), unplanned re-exploration (45.9% vs 18.1%, P<.001) and re-exploration for hemorrhage control (50.0% vs 19.8%, P<.001). Delayed interventions are common in damage control laparotomy, with abdominal interventions often spread over multiple explorations. Mortality is increased in patients undergoing emergent re-exploration and with delayed repair of major vascular injuries. Ideal treatment of damage control laparotomy patients may include addressing injuries more completely at the first laparotomy instead of deferring care for other priorities.

Pyloro-duodenal hernia with formation of enterocutaneous fistula in a buffalo calf following a dog attack

A body wall hernia entrapping abomasum and concurrent duodenal fistula in a buffalo calf aged about 8 months, secondary to a dog bite was successfully treated by closure of fistulous orifice and ventro lateral herniorrhaphy.

A Rare Complication of Composite Dual Mesh: Migration and Enterocutaneous Fistula Formation.

Introduction. Mesh is commonly employed for abdominal hernia repair because it ensures a low recurrence rate. However, enterocutaneous fistula due to mesh migration can occur as a very rare, late complication, for which diagnosis is very difficult. Presentation of Case. Here we report the case of an enterocutaneous fistula due to late mesh migration in a mentally retarded, diabetic, 35-year-old male after umbilical hernia repair with composite dual mesh in 2010. Discussion. Mesh is a foreign substance, because of that some of the complications including hematoma, seroma, foreign body reaction, organ damage, infection, mesh rejection, and fistula formation may occur after implantation of the mesh. In the literature, most cases of mesh-associated enterocutaneous fistula due to migration involved polypropylene meshes. Conclusion. This case serves as a reminder of migration of composite dual meshes.

Fascial closure after open abdomen: Initial indication and early revisions are decisive factors – A retrospective cohort study

Background: The surgical treatment method in which the peritoneal cavity is opened anteriorly and deliberately left open, hence often called “open abdomen” has become the standard of care in damage-control procedures as well as in the management of intra-abdominal hypertension and in severe intra-abdominal sepsis. Whereas open abdomen has been closed in two stages traditionally, a modern trend is to close the fascial layers within the initial hospitalization to avoid complications like enterocutaneous fistula and hernia formation. The aim of this study was to determine crucial factors influencing the possibility of fascial closure after open abdomen. Methods: Between 2003 and 2013, 355 adult patients were treated with open abdomen in our institution. Their data were collected and retrospectively analyzed. They were divided into two groups depending on fascial closure or not (fascial closure, n = 137 (39%) vs. non-fascial closure, n = 218 (61%)). Results: The patients who reached fascial closure had a significantly higher rate of initially performed open abdomen (97 patients (71%) vs. 118 (54%), p = 0.002) and the periods of time until a second and a third look operation were significantly shorter (2.7 ± 2.5 vs. 4.2 ± 6.6 days, p = 0.021 and 5.6 ± 3.7 vs. 8.5 ± 8.6 days, p = 0.006). Furthermore, the presence of peritonitis (64 patients (47%) vs. 83 patients (38%), p = 0.023) and large bowel resection (74 patients (54%) vs. 90 patients (41%), p = 0.022) were significantly higher in this group. Rates of in-hospital mortality (97 patients (44%) vs. 38 patients (28%), p = 0.002) and the presence of pancreatitis (19 patients (9%) vs. 3 patients (2%), p = 0.013) were significantly higher in the non-fascial closure group. Conclusions: The probability to reach fascial closure after open abdomen seems to increase when open abdomen is performed initially and when early second and third look operations are performed. The presence of pancreatitis seems to be the only negative prognostic marker concerning fascial closure.

Enterocutaneous fistula in the setting of ventriculoperitoneal shunt extrusion through the skin and perforation through the small bowel

The authors report a case of a 2-year-old boy with postinfectious hydrocephalus, managed with a ventriculoperitoneal (VP) shunt and complicated by shunt extrusion through the cranial skin. The shunt was removed due to concern for infection, and the child was found to have an enterocutaneous fistula (ECF) communicating along the shunt track between the small bowel and a clavicular sinus. Self-closure of the ECF was anticipated. Thus, the fistula was managed expectantly with dressing changes of the clavicular sinus, while the patient's malnutrition was managed in accordance with World Health Organization protocols. The presentation, prognosis and management of ECFs, including the likelihood of self-resolution and the role of expectant management, are discussed. Additionally, proposed mechanisms of ECF formation in the setting of a VP shunt are discussed, with an emphasis on the roles of infection and malnutrition.

Suspected Behçet's disease presenting with enterocutaneous fistula formation and lower gastrointestinal bleeding after appendectomy

Behçet's disease (BD) is a form of vasculitis which is believed to be an autoimmune disease. The disease can be categorized as “intestinal Behçet's disease” with its predominant gastrointestinal symptoms and intestinal ulcerations. If a patient first presents with complicated BD, it is difficult to diagnose because the gastrointestinal symptoms are nonspecific. We report a case of a 22-year-old man with no previous medical history who presented with intermittent right lower quadrant pain 2 days after an appendectomy. Intra-abdominal abscess formation was suspected first and treated medically. Then, the disease progressed to produce an enterocutaneous fistula and lower gastrointestinal bleeding. The diagnosis of BD was made 2 months after the patient's first visit.

Rectopopliteal fecal fistula developed through an intra-abdominal adhesion

Background: A number of etiological factors may result in an enterocutaneous fistula formation. Some fistulas may drain from long and unexpected tracts. Case Presentation: A 58-year-old female patient who had undergone radical cystectomy with ileal pouch reconstruction surgery two years earlier for urinary bladder carcinoma was admitted for septic clinical condition and a rectopopliteal fecal fistula formation. Patient was improved with a diversion surgery with Hartmann closure and proper wound care. This case is unique by being the sole enterocutaneous fistula which is developed through an intra-abdominal adhesion. Rectopopliteal enteroatmospheric fistulas are rare clinical conditions. Conclusion: Enterocutaneous fistulas may complicate any intra-abdominal condition, especially in comorbid patients who have had a major abdominal surgery. A septic clinical presentation with erythema and subcutaneous emphysema is suggestive of enteric fistula formation.

Enterocutaneous Fistula Formation of Meckel's Diverticulum via the Urachal Cyst in an Adult Patient: A Case Report and Literature Review

Meckel's diverticulum (MD) is the most common congenital anomaly of small intestine. It is the most common end result of the spectrum of omphalomesenteric duct anomalies, which also include umbilicoileal fistula, umbilical sinus or cyst, and a fibrous cord connecting the ileum to the umbilicus. Besides this, abnormal remnants of the urachus can present as patent urachus, vesicourachal diverticulum, urachal sinus or urachal cyst (UC). Urachal cysts represent an incomplete closure of the urachus, a cord-like structure connecting the primitive bladder to the umbilicus in early embryonic formation. Primary aim of this study was to present and share an orginal case of enterocutaneous fistula formation of MD via the UC in an adult patient, which is the first in literature. A 39-year-old male applied to the emergency surgery service with complaints of increasing abdominal pain, nausea, vomiting and fecal discharge from the umbilicus. Laparotomy was carried out with a suspicion of intrabdominal mass and enterocutaneous fistula formation. The surgical exploration revealed enterocutaneous fistula formation of MD via the UC. The patient was treated successfully with resection of UC and MD, and had an uneventful postoperative recovery. We conducted a literature review of studies published in the English language on