Enterocutaneous Fistula Repair Research Articles

OC-001 SINGLE-STAGED ABDOMINAL WALL RECONSTRUCTION IN CONJUNCTION WITH ENTEROCUTANEOUS FISTULA REPAIR WITH AND WITHOUT ACELLULAR DERMAL MATRICES: A SINGLE CENTRE OBSERVATIONAL COMPARISON OF SHORT-TERM OUTCOMES

Abstract Aim Single-staged abdominal wall reconstruction (AWR) with simultaneous enterocutaneous fistula (ECF) repair is safe. This study aims to evaluate short-term outcomes from AWR with ECF repair and compare short-term outcomes between two commonly used acellular dermal matrices (ADM) as well as suture repair alone, with focus on ECF recurrence. Methods Data were collected between 2011 and 2019 from a prospectively maintained operative database. A retrospective case-note review identifed patient demographics and post-operative outcomes. Kruskal-Wallis test was used for categorical variables and one-way ANOVA for continuous variables to evaluate between groups. Results One hundred and fifteen cases were performed in the study period: 70 primary suture repair, 28 Surgimend and 17 Strattice. Fifty-eight patients (50.4%) were female with a mean age of 55.3 years (SD 13.9), BMI of 26.9 (SD 5.18) and 75 (65.2%) had intestinal failure. Median length of stay was 25 days (range 7–176). Overall, fistula recurrence rate was 10.4% (12 cases). Of these, 9 (12.8%) occurred in the suture repair group, 2 (11.8%) where a Strattice mesh was used and 1 (3.6%) where a Surgimend mesh was used (p=0.54). Forty-six patients (40%) had a Clavien Dindo complication of >3 and 73 patients (53.2%) had an SSI. Mortality was low at 2.8%. Conclusion Single-staged AWR in conjunction with ECF repair remains a complex but safe undertaking. Initial experience suggests Surgimend is safe to use in the context of single-staged AWR and ECF recurrence rates are lower than with a comparable ADM with similar short-term outcomes.

Feasibility and Safety of Ambulatory Surgery as the Next Management Paradigm in Colorectal Resection Surgery.

Current clinical dogma favors universal inpatient admission after colorectal resection particularly in the presence of an anastomosis. We evaluate the feasibility and safety of ambulatory surgery in carefully selected patients undergoing colorectal resection/anastomosis. Between October 2020 and October 2021, all patients undergoing colorectal resection/anastomosis meeting specific criteria {no major comorbidity [American Society of Anesthesiologist (ASA) <4], not on therapeutic anticoagulation, compliant patient/family} were counseled preoperatively for ambulatory surgery (discharge <24h postsurgery). Complicated surgery (ileoanal pouch, enterocutaneous fistula repair, reoperative pelvic surgery, multiple resections) and/or ostomy creation (loop/end ileostomy, Hartmann's, abdominoperineal resection) were exclusions. Discharge was at 6 to 8 hours postoperatively if all predetermined factors (no ostomy teaching needed, ambulating comfortably, tolerating diet, stable vitals, and blood-work) were met and patients were willing, or was postponed to the next day at patient request. All discharged patients received phone checks the next day with the option also given for voluntary readmission if inpatient care was preferred by patient. Patients discharged <24 hours postop (AmbC) were compared to those staying on as inpatients admitted (InpC) and also to a comparable historical (October 2019-October 2020) group when ambulatory surgery was not offered (HistC). Of 184 abdominal colorectal surgery patients, 97 had complicated colorectal resection and/or ostomy. Of the remaining 87, 29 (33.3%) were discharged <24 hours postoperatively [7 (24%) patients at 8h]. Of these 29 AmbC patients, 4 were readmitted <30 days (ileus: 1, rectal bleeding: 2, nausea/vomiting: 1), 1 readmission was on first postdischarge day, none were voluntary post phone-check. AmbC and InpC (n=58) had similar age, sex, race, body mass index, and comorbidity. InpC had greater estimated blood loss (109 vs 34mL, P <0.001) while length of stay was expectedly significantly longer (109 vs 17 hours, P <0.001). There was no mortality in either group. AmbC and InpC had similar readmission, reoperation, anastomotic leak, ileus, and surgical site infection. Mean length of stay for HistC was 83 hours. AmbC and HistC had similar age, sex, race, body mass index, and ASA class. Complications including readmission, reoperation, anastomotic leak, ileus, and surgical site infection were also similar for AmbC and HistC. With careful patient selection, preoperative education, perioperative management, and postoperative follow-up, ambulatory surgery is feasible in up to a third of patients undergoing colorectal resection/anastomosis and can be performed with comparable safety to the time-honored practice of routine inpatient hospitalization. Refinements in inclusion/exclusion criteria and postoperative outpatient follow-up will allow a paradigm shift in how such patients are managed, which has huge implications for patient experience, care-giver workload and health care finances.

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.

Preoperative Sepsis Is Associated with Worse Outcomes in Patients Undergoing Enterocutaneous Fistula Repair

Aagaard Christensen, Mathias BS; Gaitanidis, Apostolos MD; Velmahos, George MD, FACS; Fawley, Jason MD Author Information

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

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

Adipose tissue imaging as nutritional predictors in patients undergoing enterocutaneous fistula repair.

The management of enterocutaneous fistulae (ECF) is complex, challenging, and often associated with metabolic, septic, and nutritional complications. Radiographic quantification of body composition such as fat or lean body mass distribution is a potentially valuable preoperative assessment tool to optimize nutritional status. The aim of this study was to investigate the correlation between total adipose tissue (fat) area (TFA), assessed by computed tomography and magnetic resonance imaging radiology tests, with body weight, body mass index (BMI), various biochemical parameters, need for nutritional support, and survival in patients undergoing ECF repair. Biochemical and anthropometric parameters at the time of ECF surgery were retrospectively collected for adult patients undergoing ECF repair at University College London Hospital, UK. Visceral and subcutaneous adiposity was measured at the level of the third lumbar vertebra (Image J) at computed tomography or magnetic resonance imaging. Statistical analysis included descriptives, univariate and multivariate analysis between TFA and various parameters, and their influence on postoperative survival. A complete set of data was available for 85 patients (51 women, 56.9 ± 14.5 y of age) who underwent ECF repair. ECF originated mainly as a surgical complication (86%) while 14% were undergoing a second ECF repair. Median BMI was 22.8 kg/m2 and mean TFA was 361 ± 174.9 cm2, with a higher visceral fat content in men than in women (183.8 ± 99.2 versus 99 ± 59.7 cm2, P < 0.001). BMI, body weight, and creatinine were significantly positively correlated with TFA (ρ=0.77, 0.73, and 0.50, respectively, P < 0.001); no correlation was noted between TFA and preoperative albumin levels. Patients in the low TFA group had a higher use of parenteral nutrition (P=0.049). Hospital length of stay was longer in patients receiving artificial nutrition support (70 versus 22 d, P < 0.001). A TFA cutoff point of 290 cm2 discriminated patients who required artificial nutrition versus no nutritional support with moderate sensitivity (75%) but poor specificity (45%). At multivariate analysis, only >60 y of age (hazard ratio [HR], 2.69, P < 0.02) and use of parenteral nutrition (HR, 3.90, P < 0.02) were associated with worse overall survival. Abdominal adiposity was strongly correlated with anthropometric parameters at the time of surgery. Earlier identification of patients requiring artificial nutrition at standard preoperative imaging might allow integration of nutritional optimization into initial clinical management plans reducing length of stay and improving clinical outcomes.

1690 Management of Non-Malignant Enterocutaneous Fistula Using Fully Covered Stent

INTRODUCTION: Postoperative enterocutaneous fistula (ECF) has a reported prevalence of 3.6% in general surgery, and up to 35% in Crohn disease-related surgery. ECFs can be of low-output, drain &lt; 200 mL/day, or of high-output, drain &gt; 500 mL/day, which unlikely to heal spontaneously. ECFs can cause metabolic disturbances, fluid loss, and malnutrition. CASE DESCRIPTION/METHODS: Case 1: A 54-year-old man with a history of colonic transmural necrosis status post multiple surgeries and end transverse colostomy placement, presented with a two-week history of passing stool from the lateral aspect of his peristomal incision, consistent with enterocutaneous fistula. The 2 fistulae ends were seen on the skin, laterally to the stoma (Figure 2c), and both other ends were identified in the stoma lumen. CT fistulogram confirmed the fistulae. After advancing the endoscope into the stoma, a 2 cm friable stenosis was seen (Figure 1a). The fistulae tracts were treated with silver nitrate and were injected with fibrin glue. A 20 mm × 6 cm fully-covered stent was placed (Figure 1b) and sutured in place. A month later the fistulae had healed (Figure 2d), with no recurrence reported. Case 2: A 64-year-old man with a history of metastatic mucinous appendiceal cancer status post multiple abdominal surgeries, referred for his recurrent ECF. CT scan showed air tracking outside the colon at the level of the cutaneous fistula site. Water-soluble contrast pushed through the rectum showed an occlusion with contrast extravasation is seen in the fistula (Figure 3e). Sigmoidoscopy confirmed the site of obstruction and the area of leakage. A fully covered stent was placed to relieve the obstruction and cover the fistula (Figure 3f). Initially, the fistula output resolved, but when the stent was removed a month later, the fistula output returned. So, a stent was placed again and was sutured to the colon. The patient is now asymptomatic and having normal bowel movements. DISCUSSION: ECF can cause significant morbidity and affect the quality of life. Surgical repair of ECF has a recurrence rate as high as 36% and is associated with high mortality especially in malnourished patients. Thus, endoscopic intervention using fully-covered stents can be helpful in healing the fistulae. In these 2 cases, the placement of a fully-covered stent relieved the coexisting obstruction, diverted the flow away from the fistula, and simultaneously covered the fistula end. The patients experienced relief of fistula symptoms and avoided them major surgical intervention. Watch the video: http://bit.ly/30BIvtw.

Catastrophic Abdominal Wall After Repair of Enterocutaneous Fistula

Repair of an enterocutaneous fistula (ECF) is challenging, particularly when complications occur. This case describes the use of negative pressure wound therapy (NPWT) and microadhesive dressings with polyabsorbent fibers and an acrylic core, with and without lipidocolloid and nano-oligosaccharide factors, in the management of a patient with a large abdominal wound and ECF. An 84-year-old woman underwent abdominoperineal resection with colostomy, hysterectomy, and subsequent chemotherapy and radiotherapy for colorectal cancer. She experienced complications, ultimately resulting in ECF of the jejunum. Initial management with NPWT was used to promote abdominal wound healing, while protecting exposed bowel loops proved challenging because of leakage of stoma effluent that impeded the formation of granulation tissue. In order to promote wound healing and prevent infection, we applied a microadhesive dressing composed of polyabsorbent fibers with an acrylic core and lipidocolloid and nano-oligosaccharide factors that facilitated autolytic debridement and healing. Use of NPWT with the microadhesive dressing proved successful in the management of this complex and challenging ECF.

Computed Tomography-Measured Psoas Density Predicts Outcomes After Enterocutaneous Fistula Repair.

Low muscle mass and quality are associated with poor surgical outcomes. We evaluated computed tomography (CT)-measured psoas muscle density as a marker of muscle quality and physiologic reserve and hypothesized that it predicts poor outcomes after enterocutaneous fistula repair (ECF). We conducted a retrospective cohort study of patients 18-90 years old with ECF who failed nonoperative management, requiring elective operative repair at The Ohio State University (2005-2016), and who received preoperative abdomen/pelvis CT scan with intravenous contrast within 3 months of the operation. Psoas Hounsfield unit average calculations were measured at the L3 level. One-year leak rate, mortality (90 days, 1 years, and 3 years), complication risk, length of stay, dependent discharge, and 30-day readmission were compared with Hounsfield unit average calculation (HUAC). One hundred patients met inclusion criteria. Patients were stratified into interquartile ranges based on HUAC. The lowest HUAC interquartile was our low muscle quality (LMQ) cutoff, which was associated with 1-year leak (relative risk [RR] = 2.10, P < .005), 1-year mortality (RR = 2.22, P < .04) and 3-year mortality (RR = 2.13, P < .007), complication risk (RR = 1.54, P < .001), and dependent discharge (RR = 2.50, P < .004) compared to patients without LMQ. Psoas muscle density is a significant predictor of poor outcomes in ECF repair. This readily available measure of physiologic reserve can identify patients with ECF who have increased risk and may benefit from additional interventions and recovery time before operative repair.

Inflammatory Bowel Disease Clinical

Inflammatory Bowel Disease Clinical

Complex abdominal wall reconstruction in the setting of active infection and contamination: a systematic review of hernia and fistula recurrence rates

Minimal evidence exists to guide surgeons on the risk of complications when performing abdominal wall reconstruction (AWR) in the presence of active infection, contamination or enterocutaneous fistula. This study aims to establish the outcomes of contaminated complex AWR. Analysis was conducted according to PRISMA guidelines. Systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on single-staged repair of contaminated complex AWR were included. Pooled data were analysed to establish rates of complications. Sixteen studies were included, consisting of 601 contaminated complex AWRs, of which 233 included concurrent enterocutaneous fistula repair. The average follow-up period was 26.7months. There were 146 (24.3%) reported hernia recurrences. When stratified by repair method, suture repair alone had the lowest rate of recurrence (14.2%), followed by nonabsorbable synthetic mesh reinforcement (21.2%), biological mesh (25.8%) and absorbable synthetic mesh (53.1%). Hernia recurrence was higher when fascial closure was not achieved. Of the 233 enterocutaneous fistula repairs, fistula recurrence was seen in 24 patients (10.3%). Suture repair alone had the lowest rate of recurrence (1.6%), followed by nonbiological mesh (10.3%) and biological mesh reinforcement (12%). Forty-six per cent of patients were reported as having a wound-related complication and the mortality rate was 2.5%. It is feasible to perform simultaneous enterocutaneous fistula repair and AWR as rates of recurrent fistula are comparable with series describing enterocutaneous fistula repair alone. Hernias recurred in nearly a quarter of cases. This analysis is limited by a lack of comparative data and variability of outcome reporting.

Impact of Surgihoney Reactive Oxygen on surgical site infection (SSI) after complex abdominal wall reconstruction (AWR) of grade 3 and 4 ventral Hernias: A single arm pilot study

IntroductionFollowing Abdominal Wall Reconstruction (AWR) wound infections occur in over one third of patients and rates can be even higher in entero-cutaneous fistula repair. A novel antimicrobial gel has been engineered by microbiologists called Surgihoney Reactive Oxygen (SHRO). SHRO gel will be applied to a group of patients. We aim to conduct a pilot case series with the hope to show a reduction in local wound complications after SHRO application. Methods and analysisA single arm pilot study of AWR patients will be carried out on patients with grade 3 and 4 (VHWG grade) ventral hernias. Patients’ pre-operative wounds will be graded according to the CDC classification scale. Post operatively the wounds will be classified according to the Wilson surgical site infection classification. Intervention: SHRO will be applied after abdominal fascial closure and before skin closure through a standardised method. Our results from the series will be compared to our retrospective standard wound care results. Data will be collected from 01.03.2017 to 01.11.2017. Primary outcome: Surgical site infection within 30days of surgery, assessed by clinicians at 5, 15 and 30days and by patient’s self-report for the intervening period. Secondary outcomes include other SSOs (haematoma, seroma, wound dehiscence, skin necrosis), duration of stay in hospital, reported side effects from local treatment and other systemic postoperative complications. We will aim for a cohort of 40 patients. ConclusionsThis study will provide an assessment of methods and feasibility of recruiting and following up patients who are treated with SHRO. On the basis of this pilot trial, a full trial may be proposed in the future which will provide additional, robust evidence on the clinical and cost effectiveness of SHRO in wound management following AWR. This may act as a model for the management of wounds in complex patients undergoing AWR.

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

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

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

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

PWE-230 The exaggerated inflammatory response to large incisional hernia and enterocutaneous fistula repair with biological mesh

Introduction Biological meshes are increasingly used in the repair of complex, large incisional hernias, particularly in the context of a contaminated surgical field. In our centre it was noted that patients displayed an exaggerated and prolonged inflammatory response on post-operative blood results in comparison to other similar surgical procedures. This study aims to investigate the post-operative inflammatory response in patients undergoing placement of large biological meshes for the repair of large incisional hernias or enterocutaneous fistulae. Method Post-operative white blood cell count (WCC) and complement reactive protein (CRP) levels were recorded on the first five post-operative days for a consecutive cohort of patients following repair of large ventral or incisional hernias with or without repair of enterocutaneous fistulae. The mesh size and the presence of component separation was also recorded. Post-operative WCC and CRP data was collected for a size-matched contemporaneous, consecutive control group of patients undergoing open colorectal resections for a diagnosis of colorectal cancer. Post-operative inflammatory responses were compared. Results 41 patients underwent a large ventral hernia repair using biologic mesh, of which 16 (39.0%) underwent simultaneous repair of an enterocutaneous fistula. 27 (65.9%) underwent component separation. Post-operative CRP was significantly higher in patients in the hernia group on the third (188 vs. 133) and fourth (188 vs. 117) post-operative days (p < 0.01). There was no significant difference in WCC on either day. The CRP response was not significantly different between groups by the fifth post-operative day. Repair of enterocutaneous fistulae was associated with significantly increased CRP levels on the third and fourth post-operative day when compared to hernia repair alone. There was a positive correlation between mesh area (mean area = 183cm2) and CRP level on the third post-operative day (Pearson’s r = 0.42). Conclusion Patients undergoing large ventral hernia repairs using biological mesh display an exaggerated and prolonged inflammatory response in comparison to open colorectal cancer resections. The inflammatory response is no different between groups by the fifth post-operative day. This data suggests that an exaggerated inflammatory response should be expected in such procedures and that normalisation of inflammatory markers ought to be expected by the fifth post-operative day. Disclosure of interest None Declared.

Tu1805 Predictive Value of Preoperative Serum C-Reactive Protein for Recurrence After Definitive Surgical Repair of Enterocutaneous Fistula

Tu1805 Predictive Value of Preoperative Serum C-Reactive Protein for Recurrence After Definitive Surgical Repair of Enterocutaneous Fistula

Educational Exhibit Abstract No. 336 - Enterocutaneous fistula closure with porcine submucosa derived fistula plug: a novel minimally invasive closure technique

Learning Objectives To discuss management of enterocutaneous fistula and describe enterocutaneous fistula repair using a porcine submucosa derived fistula plug. Background Enterocutaneous fistula (ECF) continues to be a serious surgical problem. The majority of ECF require a surgical procedure including adhesiolysis or resection of the fistulous tract and/or segment of bowel, which are associated with mortality rates of 5-20% and prolonged hospital stay. Less invasive treatments for ECF have been investigated, including fibrin glue, collagen plugs and gelfoam. The Cook Biodesign Advanced Tissue RepairTechnology (Cook Medical Inc., Bloomington, IN), a porcine submucosa derived fistula plug, is a novel treatment for ECF closure with documented overall clinical benefit of 42% and complete closure rate of 21%. Clinical Findings/Procedure Details Fistulography is performed to define the length, course and relationships of the fistula tract. A sheath is inserted into the cutaneous opening. A cytology brush is used to abrade the tract to denude the tract of granulation tissue. The tract is flushed and the delivery sheath is advanced over a stiff guide wire. The fistula plug is loaded into the sheath. Flange positioning is confirmed prior to plug deployment. The plug is withdrawn to the internal opening. Once appropriately positioned, the external portion of the plug is trimmed to length. Tethers are used to secure fistula plug to a Molnar disc at the site of the external fistula opening. Post procedural management includes no strenuous activity for at least 6 weeks, dietary restrictions and stool softeners. The flange is expected to remain in place for 2-4 weeks. If flange is retained beyond an 8-week period, the patient is monitored for bowel obstruction, erosion, perforation or flange migration. Additional potential complications include fistula recurrence, bleeding, plug migration, infection, abscess or seroma formation. Conclusion and/or Teaching Points 1. ECF remains a serious surgical problem associated with high morbidity and mortality. 2. The Cook Biodesign Advanced Tissue RepairTechnology: a porcine submucosa derived fistula plug, is a novel and feasible minimally invasive technique for fistula closure.

Feasibility of NOTES omental plug repair of perforated peptic ulcers: results from a clinical pilot trial

Ulcer perforation carries up to a 30 % 1-year mortality rate. Intervention-related adverse events are among statistically significant predictors of 1-year mortality. A natural orifice transluminal endoscopic surgical (NOTES) approach may be less invasive and may decrease procedure-related adverse events by diminishing the so-called second hit, thus leading to decreased morbidity and mortality. We sought to assess the feasibility of an endoscopic transluminal omental plug technique in patients with perforated gastroduodenal ulcers under laparoscopic guidance. Patients with suspected acute gastroduodenal ulcer perforations were offered participation in this prospective pilot study. Closure of the perforation was attempted using the NOTES omental plug technique. Demographic, clinical, endoscopic, and radiographic data were abstracted, as were data for morbidity, mortality, and pilot data regarding quality of life (QOL). From February 2010 through February 2012, a total of 17 patients presented to a tertiary care center with clinically suspected perforated ulcer. Of seven patients (mean age 79 years, range 64-89 years) who consented to the study, three underwent the study procedure. All patients had multiple comorbidities. Two patients presented with 4-6 mm perforated peptic ulcers and underwent successful laparoscopic-assisted NOTES omental and falciform ligament patch closure, respectively. Postoperative radiographic contrast studies showed no leak, and patients were discharged home on postoperative days 3 and 4. The third patient had undergone enterocutaneous fistula repair with herniorrhaphy 6 weeks before. Although a transluminal endoscopic approach was feasible, the omentum was under too much tension to be secured. This procedure was converted to an open omental patch repair. For all but one patient who provided consent, obtaining QOL data was feasible. Initial results from a laparoscopic-assisted NOTES approach for closure of perforated peptic ulcers appear promising and enable swift recovery in selected patients. This is especially important in elderly and/or immunocompromised patients. Technical details and patient selection criteria continue to evolve.

Regenerative Surgery for the Definitive Surgical Repair of Enterocutaneous Fistula

Regenerative Surgery for the Definitive Surgical Repair of Enterocutaneous Fistula

Factors Predictive of Recurrence and Mortality after Surgical Repair of Enterocutaneous Fistula

Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17–81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.