Fistula Output Research Articles

The gastrointestinal breach: understanding enterocutaneous fistula

The term "fistula" usually refers to abnormal communication between two epithelial surfaces and an enterocutaneous fistula (ECF) is an abnormal communication between any part of gastrointestinal (GI) tract and skin and lined by epithelium or granulation tissue. Common causes include trauma during abdominal surgery, inflammatory bowel disease, malignancy, infection, radiation etc. Sepsis and malnutrition are the leading causes of mortality. In cases of high-output fistula, it is essential to adequately replace the excessive fistula discharge. The patient's nutrition plays a crucial role in the successful management of ECFs. If the patient can tolerate oral or enteral feeding, it should be initiated promptly. However, if oral intake is not feasible, parenteral nutrition should be considered. Adequate wound care, including diligent skincare and timely drainage of localized abscesses, is necessary. Before conducting definitive investigations and initiating treatment, it is important to ensure proper resuscitation and stabilization of the patients. Surgical intervention should be approached in staged manner and should not be rushed to prevent failure in managing this complex condition. To conclude management of ECF is complicated and needs multidisciplinary approach. Initial focus for remedy is on treating fluid and electrolyte disturbances, comprehensive treatment of sepsis, management of fistula output, skin care and psychological support.

A prospective study on enterocutaneous fistula in a tertiary care centre: A single institution study

Background: Aberrant connection linking gastrointestinal tract and the skin is termed Enterocutaneous fistula. Enterocutaneous fistulas can lead to significant morbidity and mortality. Death pertaining to enterocutaneous fistulas remains enormous when juxtaposed with other surgeries. The treatment of Enterocutaneous fistula may be a significant challenge to surgeons and gastroenterologists. Method: After obtaining ethical committee clearance, a total of 25 patients of Enterocutaneous fistula who presented to Surgical department and Surgical Gastroenterology department were included in the study. The cause, site and output of fistula, clinical course and complications of fistula were studied. Patients were managed either surgically or conservatively depending on the output of the fistula, nutrition and metabolic profile. Results: 19 patients were managed conservatively and 6 patients were managed surgically. Amidst the conservative group, 16 out of 19 patients had spontaneous closure of fistula and remaining three had died as fistulas failed to close. Surgical closure was accomplished in 5 patients but failed in one patient and that patient died. 96% (24 out of 25) of patients in our study had developed fistula post operatively. Among 25 patients studied, nearly 44% each i.e., 11 out of 25 patients had colonic and small bowel fistula respectively followed by fistula at appendix accounting for 12% (i.e., Fistula Output: 11 (44%) fistulae were low output, 8 (32%) were medium output. Conclusion: Enterocutaneous fistulas are more common in postoperative period. Conservative treatment should be the mainstay in management of Enterocutaneous fistula.

Whole Model Path Planning-Guided Multi-Axis and Multi-Material Printing of High-Performance Intestinal Implantable Stent.

The problems of step effects, supporting material waste, and conflict between flexibility and toughness for 3D printed intestinal fistula stents are not yet resolved. Herein, the fabrication of a support-free segmental stent with two types of thermoplastic polyurethane (TPU) using a homemade multi-axis and multi-material conformal printer guided with advanced whole model path planning is demonstrated. One type of TPU segment is soft to increase elasticity, and the other is used to achieve toughness. Owing to advancements in stent design and printing, the obtained stents present three unprecedented properties compared to previous three-axis printed stents: i) Overcoming step effects; ii) Presenting comparable axial flexibility to a stent made of a single soft TPU 87A material, thus increasing the feasibility of implantation; and iii) Showing equivalent radial toughness to a stent made of a single hard TPU 95A material. Hence, the stent can resist the intestinal contractive force and maintain intestinal continuity and patency. Through implanting such stents to the rabbit intestinal fistula models, therapeutic mechanisms of reducing fistula output and improving nutritional states and intestinal flora abundance are revealed. Overall, this study develops a creative and versatile method to improve the poor quality and mechanical properties of medical stents.

Botulinum toxin infusion into the mesenteric artery has selective action on peristalsis in a rat model: experimental research.

Botulinum toxin type A (BoNT/A) reversibly blocks neurotransmission at voluntary and autonomic cholinergic nerve terminals, inducing paralysis. The aim of this study was to block panenteric peristalsis in rats through BoNT/A administration into the superior mesenteric artery (SMA) and to understand whether the toxin's action is selectively restricted to the perfused territory. Rats were infused through a 0.25-mm surgically inserted SMA catheter with different doses of BoNT/A (10 U, 20 U, 40 U BOTOX®, Allergan Inc.) or with saline for 24 h. Animals were free to move on an unrestricted diet. As a sign of bowel peristalsis impairment, body weight and oral/water intake were collected for 15 days. Statistical analysis was conducted with nonlinear mixed effects models to study the variation over time of the response variables. In three 40 U-treated rats, the selectivity of the intra-arterial delivered toxin action was studied by examining bowel and voluntary muscle samples and checking the presence of BoNT/A-cleaved SNAP-25 (the smoking gun of the toxin action) using the Immunofluorescence (IF) method through a specific antibody recognition. While control rats exhibited an increasing body weight, treated rats showed an initial dose-dependent weight reduction (p<0.001 control vs. treated) with recovery after Day 11 for 10 and 20 U-treated rats. Food and water intake over time showed significantly different half-saturation constants with rats treated with higher doses who reached half of the maximum achievable in a greater number of days (p<0.0001 control vs. treated rats). BoNT/A-cleaved SNAP-25 was identified in bowel wall NMJs and not in voluntary muscles, demonstrating the remarkable selectivity of arterially infused BoNT/A. Blockade of intestinal peristalsis, can be induced in rats by slow infusion of BoNT/A into the SMA. The effect is long-lasting, dose-dependent and selective. BoNT/A delivery into the SMA through a percutaneous catheter could prove clinically useful in the treatment of entero-atmospheric fistula by temporarily reducing fistula output.

Therapeutic Options in Postoperative Enterocutaneous Fistula-A Retrospective Case Series.

Objectives: The aim of the study was to present the results obtained in our experiment regarding the management of postoperative enterocutaneous fistulas (PECF). Materials and Methods: We conducted a retrospective study on 64 PECF registered after 2030 abdominal surgeries (1525 digestive tract surgeries and 505 extra-digestive ones) over a period of 7 years (1st of January 2014–31th of December 2020) in the 1st and 2nd Surgery Clinics, Clinical County Emergency Hospital of Craiova, Romania. The group included 41 men (64.06%) and 23 women (35.34%), aged between 21–94 years. Of the cases, 71.85% occurred in elderly patients over 65 years old. Spontaneous fistulas in Crohn’s disease, intestinal diverticulosis, or specific inflammatory bowel disease were excluded. Results: The overall incidence of 3.15% varied according to the surgery type: 6.22% after gastroduodenal surgery, 1.78% after enterectomies, 4.30% after colorectal surgery, 4.28% after bilio-digestive anastomoses, and 0.39% after extra-digestive surgery. We recorded a 70.31% fistula closure rate, 78.94% after exclusive conservative treatment and 57.61% after surgery; morbidity was 79.68%, mortality was 29.68%. Conclusion: PECF management requires a multidisciplinary approach and is carried out according to an algorithm underlying well-established objectives and priorities. Conservative treatment including resuscitation, sepsis control, output control, skin protection, and nutritional support is the first line treatment; surgery is reserved for complications or permanent repair of fistulas that do not close under conservative treatment. The therapeutic strategy is adapted to topography, morphological characteristics and fistula output, age, general condition, and response to therapy.

Single Institution Outcome of Minimally Invasive Enterocutaneous Fistula Management Utilizing the Biodesign® Fistula Plug.

To report the outcomes of the Biodesign Fistula Plug as an alternative treatment for enterocutaneous fistulae by presenting our institutional experience from 2013 to 2020. A retrospective review of all attempted fistula closures utilizing the Biodesign Fistula Plug at a single institution from 2012 to 2020 was performed under IRB approval and in compliance with HIPAA. Patient demographics were obtained including age at the time of the procedure, etiology, location of the fistula, history of malignancy, prior chemotherapy or radiation, and history of prior surgery or other interventions. Patient follow-up was performed through 7/2020 to evaluate for fistula closure, complications, or subsequent treatments. There were 25 patients who underwent 35 Biodesign Fistula Plug placements. Of these, 7 procedures were successful, defined as closure of the fistula, and 28 procedures were unsuccessful, defined as persistent fistula output or requiring further intervention on the EC fistula. There were 7 major complications, SIR classification D = 3, E = 2 and F = 2. No statistically significant risk factors were found predicting fistula plug failure although there was a trend towards patients with malignancy having unsuccessful outcome (p = 0.057). The average number of procedures for patients with successful closure was 1.4 versus 4.22 for those with unsuccessful closure. The average time to plug failure was 27.8days (range 3-163days), and the average time to fistula closure following plug placement was 21.4days (range 14-30). Enterocutaneous fistulae are complex and morbid with no good treatment options. These findings demonstrate the Biodesign Fistula Plug can be successful in select patients, however, should be used with great caution due to high rate of failure and complications including two patient deaths.

Minimally Invasive Treatment of High Output Isolated Biliary Fistula after Hepato-Biliary Surgery

Introduction: Post-hepatectomy leakage from major bile ducts, excluded from the rest of the biliary tree, will result in high output biliary fistulas, with no chance of spontaneous healing. Radical treatment of this condition includes liver resection and/or bilio-enteric anastomosis, with high risk of complications. Minimally invasive procedures such as bile duct ablation (BDA) and percutaneous transhepatic portal vein embolization (PTPE) have been reported in case reports with mixed outcome. We decided to test a combination of PTPE and BDA for treatment of High Output Isolated Biliary Fistulas (HOIBF). Method: HOIBF is diagnosed by Primovist® enhanced MRI. After identifying the leaking bile duct the following procedure is initiated: • Percutaneous placement of a catheter in the leaking bile duct • Selective PTPE in the corresponding segmental portal vein • No earlier than 2 weeks later ablation is performed, using 3-5 cc of pure alcohol, instilled in the excluded bile duct. The alcohol is aspirated 5 minutes later • Repetition of the ablation procedure every 3rd day, until fistula output is < 25 cc/24 hours and/or bilirubin concentration of the drain fluid is < 50 μmol/l • The biliary catheter is removed Results: From July 2019 to March 2021 four patients with HOIBF were treated with this new procedure. Details of the location, output and treatment of the HOIBF appear from Table 1. All fistulas were closed successfully without complications. No recurrence occurred in the 3-16 month observation period. Conclusion: Radical treatment of HOIBF with staged combination of PTPE and BDA seems to be efficient and safe.

Isolated Right Hepatic Duct Stricture: A Management Dilemma

Isolated injury to the right hepatic duct(RHD) during cholecystectomy is rare, but may occur in patients with low lying primary biliary confluence. We report the therapeutic challenges owing to difficulty in accessing the proximal duct for anastomoses as well as decision dilemmas in asymptomatic patients. A 41-year-old female underwent laparoscopic cholecystectomy at an outside hospital. Intra-operatively, the RHD was clipped and divided, resulting in a bile leak. The injury was recognised and a drain was placed. Following initial management, she presented to our centre with a fistula draining ∼50-75 ml bile/ day and normal liver function tests (LFTs). She was managed conservatively and the fistula output gradually reduced. She was evaluated with an MRCP which showed the presence of an isolated RHD stricture with a loss of 1.2cm segment with the secondary biliary confluence being just formed (Fig1). The patient had normal LFTs except increased ALP and GGT. Though there was no evidence of cholangitis, since an untreated main RHD stricture would lead to atrophy of the entire right lobe, hence the patient was planned for a Roux-en-y hepaticojejunostomy to RHD. A PTC was placed pre-operatively to aid in the identification. A wide Roux-en-y hepaticojejunostomy was performed after a hepatotomy. The patient had an uneventful post-operative course and was discharged onPOD7. She is doing well at 36 months follow with normal LFTs and ultrasound. The case illustrates a rare form of biliary injury owing to aberrant anatomy and successful management using a combination of preoperative PTC and bilio-enteric anastomoses.

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.

Spontaneous Internal Pancreatic Fistulae Complicating Acute Pancreatitis.

Spontaneous pancreatic fistula (PF) is a rare but challenging complication of acute pancreatitis (AP). The fistulae could be internal (draining into another viscera or cavity, e.g., pancreaticocolonic, gastric, duodenal, jejunal, ileal, pleural, or bronchial) or external (draining to skin, i.e., pancreaticocutaneous). Internal fistulae constitute the majority of PF and will be discussed in this review. Male sex, alcohol abuse, severe AP, and infected necrosis are the major risk factors for development of internal PF. A high index of suspicion is required to diagnose PF. Broad availability of computed tomography makes it the initial test of choice. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography have higher sensitivity compared with computed tomography scan and also allow for assessment of pancreatic duct for leak or disconnection, which affects treatment approaches. Certain complications of PF including hemorrhage and sepsis could be life-threatening and require urgent intervention. In nonurgent/chronic cases, management of internal PF involves control of sepsis, which requires effective drainage of any residual pancreatic collection/necrosis, sometimes by enlarging the fistula. Decreasing fistula output with somatostatin analogs (in pancreaticopleural fistula) and decreasing intraductal pressure with endoscopic retrograde cholangiopancreatography or endoscopic ultrasound/interventional radiology-guided interventions or surgery are commonly used strategies for management of PF. More than 60% of the internal PF close with medical and nonsurgical interventions. Colonic fistula, medical refractory-PF, or PF associated with disconnected pancreatic duct can require surgical intervention including bowel resection or distal pancreatectomy. In conclusion, AP-induced spontaneous internal PF is a complex complication requiring multidisciplinary care for successful management.

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.

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

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

Outcome and management of postoperative enterocutaneous fistula

Background: Approximately 75% of enterocutaneous fistula (ECF) occur following surgery. Due to the high morbidity and mortality associated with ECF, prompt and effective treatment is important. This study was conducted to study the outcome and management of patients with enterocutaneous fistula.Methods: Total 40 patients developing the enterocutaneous fistula following surgery were included. All patients were treated either conservatively or operatively by various means and varying period of time. Treatment was focused on the correction of dehydration, controlling sepsis, management of electrolyte imbalance and nutritional support.Results: Overall 40 patients were included in this observational study, comprising 26 were males and 14 were females. About 97.5% of ECF were postoperative. Ileum was found to be the most common site of ECF. Also, 42.5% of fistulas were high output and 57.5% were low output. Serum albumin levels correlated significantly with fistula healing and mortality. Surgical intervention was required in 37.5% of patients.Conclusions: Conservative management with emphasis on improvement of nutrition, control of sepsis, management of fluid and electrolyte balance and control of fistula output is first line of management. Operative intervention must be done in selectively after cases after aggressive and targeted measures for improvement of nutritional status and control of infection.

Gastrointestinal Stomas and Fistulas: What is Lost and What to Do?

Abnormal connections between gastrointestinal tract (GIT) and skin are called enterocutaneous fistulas (ECFs). Presence of ECF is associated with significant morbidity and mortality. A stoma refers to a surgically created opening in the abdomen to divert feces or urine to the outside of the body, to compensate for partial or complete loss of bowel function. Gastrointestinal (GI) stomas and postoperative ECFs present a unique challenge to the intensivist due to development of malnutrition, dehydration, and sepsis leading to high morbidity and mortality. This review focuses on the basic concepts about the type of fistula and stomas, their indications and complications, and management. Principles of clinical management include replacement of fluid and electrolyte losses, control of sepsis along with reducing fistula output, prevention of malnutrition and psychological support, and skin care.How to cite this article: Pande RK, Gupta A. Gastrointestinal Stomas and Fistulas: What is Lost and What to Do? Indian J Crit Care Med 2020;24(Suppl 4):S175–S178.

Vacuum assisted closure system in the management of postoperative complex enterocutaneous fistulae: Postoperative Cohort Study‎

Background: There is controversy in the use of vacuum assisted closure therapy (VAC) in management of enterocutaneous fistula (ECF). Due to the increased risk of new fistula formation, its use was contraindicated, but then several studies reported successful closure, fistula effluent control and healing of excoriated skin by keeping it dry. Objectives: The aim of this study is to evaluate the efficacy of VAC in treatment of the complex postoperative ECF. Patient and Methods: Patients with postoperative ECF were enrolled in this prospective study in the period from January 2018 to June 2019. Full history, examination and investigations were done for all patients. Patients had VAC. After one month, responses to VAC in terms of time from fistula to VAC, general condition, fistula output, fistula closure, wound size, skin condition, time to start oral feeding, need to segregate, complications and mortality were recorded. On follow-up, time to complete closure, type of closure and cost were recorded. Results were then analyzed. Results: 60 patients with ECF were enrolled. General condition was improved in 32 patients while ECF output was improved in 52 patients. Early start of Oral feeding had occurred with the use of VAC. Complications as pain, new fistula formation, pulmonary embolism or ongoing sepsis occurred in 40 patients while mortality occurred in 12 patients. Conclusion: VAC is feasible in complex postoperative enterocutaneous fistulae. It enhances the survival, improves the general condition and the perifistular skin and reduces the fistula output and wound size.

Topical Management of Enterocutaneous and Enteroatmospheric Fistulas: A Systematic Review.

A systematic literature review was conducted to identify topical management interventions used in ECF/EAF care and to explore the role of these interventions in fistula closure and long-term fistula management. A search of PubMed, the Cumulative Index of Nursing and Allied Health Literature, and Scopus was conducted to identify English-language articles published from January 2004 to January 2019. The keywords enterocutaneous fistula, enteroatmospheric fistula, negative pressure wound therapy, NPWT, vacuum-assisted closure, VAC, pouch or pouching, troughing, bridging, collection device, dressing, and wound care were used to identify all publications pertaining to the topical management of adult and mixed adult/pediatric patients with an ECF or EAF. Single-person case studies, exclusively pediatric studies, surgical treatment-based, and duplicate publications were excluded. Abstracts were screened for relevance to the research questions, and eligible publications were abstracted and categorized using The Oxford Centre for Evidence-Based Medicine Levels of Evidence. The Joanna Briggs Institute (JBI) critical appraisal checklist for case series was used to assess each article for risk of bias and methodological quality. Outcomes of interest included patient demographics, closure rates, fistula classification (type of fistula, fistula output, fistula origin), type of topical treatment, adverse events (pain, new fistula formation, fistula recurrence, mortality), follow-up, long-term management, perifistula skin protection, effluent management, dressing change frequency, and quality of life. Descriptive statistics were presented; no statistical analysis was performed. Of the 983 articles identified, 57 underwent critical appraisal using the JBI checklist for case series. Forty-two (42) did not meet the inclusion criteria, leaving 15, level IV, case-based publications (N = 410 patients). No randomized controlled trials were found. All studies included some form of negative pressure wound therapy. JBI results found that each study was at high risk of bias in more than 2 domains. Interventions were categorized as intubation, occlusion, or isolation of the fistula. Of the 559 fistulas treated, spontaneous closure was reported in 164 cases, with rates ranging from 0% to 100%. Adverse events to treatment included pain (n = 33 patients), new fistula formation (n = 12), and fistula recurrence (n = 1). Sepsis was the leading cause of mortality (n = 29), with reported rates ranging from 0% to 44%. Due to the high risk of study bias and low quality of evidence, the exact contribution of any one intervention could not be established. Results also suggest a high risk of publication bias, and patient-centered outcomes were reported in only 1 study. Although topical management might play a role in fistula closure, it is only as part of a comprehensive plan of care. Future research should focus on developing and using standardized reporting tools, classifications, and outcomes and include patient-centered outcomes such as acceptance, tolerability, pain, and quality of life relating to any one intervention. At this time, the evidence base for management recommendations is limited, suggesting that interventions should mainly be based on practical considerations such as resources and clinician skill.

Nursing Process of Enterocutaneous Fistula Patient with Severe Acute Malnutrition in Pediatric Surgical Ward

&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;This case study aims to prove the effectiveness of nursing intervention, particularly management of nutrition, fluid and electrolyte, ostomy care, and risk for infection management, at managing enterocutaneous fistula patient with severe acute malnutrition in pediatric surgical ward.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This case study was performed by giving nursing care of enterocutaneous fistula patient with severe acute malnutrition for about 13 days based on the patient’s length of stay.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;The target for weight gain in malnourished children was ≥ 50 grams/kg/week. Within thirteen days, weight of the patient rose 450 grams from 4700 grams to 5150 grams. Patient’s weight gain target was 470 grams in 14 days, this condition showed that increase in body weight was quite appropriate. Fistula output was decreased day by day and feces that came out from from anus has better solid consistency than before.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;Nutrition management aims to increase body weight during the preoperative period of the client. Hospital treatment managed to increase weight, the child did not experience vomiting and diarrhea from the first day of treatment, and appetite continued to increase every day. This is in accordance with the outcome criteria that has been established for the main problem of imbalanced nutrition: less than the body requirement. Furthermore, children are advised to get follow up care with regular weekly control obligations.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Keywords: &lt;/strong&gt;child; enterocutaneous; fistula; malnutrition; nursing&lt;/p&gt;

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.

1339 Gastro-Colic Fistula: A Delayed Complication of Whipple's Procedure for Tropical Pancreatitis

INTRODUCTION: Gastrointestinal (GI) fistula is a serious condition that can lead to electrolyte disturbance, severe debility and even death. It occurs as a complication of gastrointestinal surgery mostly involving malignancies. We present a case of a gastro-colic fistula (GCF) occurring six years after Whipple's procedure. CASE DESCRIPTION/METHODS: A 58 years old Guyanese male with current alcohol abuse was admitted for 2 months of diarrhea. He reported more than 2 dozen watery bowel movements a day including nocturnal episodes, fecal incontinence, chills and a 15 lbs weight loss. Lab work showed significant hypoalbuminemia, hypokalemia and normal anion gap metabolic acidosis. He reported a history of tropical pancreatitis complicated by acute necrotizing pancreatitis followed by Whipple's procedure 6 years ago. Patient underwent CT abdomen which showed diffuse wall thickening of the ascending colon while colonoscopy revealed circumferential ulcerated mucosa in the same area. The colonoscope was not advanced further due to high risk of perforation. Biopsies from ulcer base and margin showed benign colonic mucosa with regenerative changes. An EGD was performed that revealed a 3 cm peri-anastomotic gastric ulcer and a large GCF in ulcer base. Fecal material was found in stomach and fistula was easily traversed with gastroscope. Patient was put on TPN and underwent exploratory laparotomy with partial greater omentectomy, distal gastrectomy with Roux-en-Y gastrojejunostomy, transverse colectomy with end colostomy, long Hartmann's pouch and a partial small bowel resection. Post-procedure he was slowly advanced to a regular diet with resolution of his diarrhea. DISCUSSION: GCF happens most commonly in surgeries involving GI malignancies. Imaging of choice is barium enema with barium seen in the stomach via a pressure gradient created from the colon to the stomach. GCF can be diagnosed endoscopically but may be missed if the fistula opening is small or obscured by adjacent mucosal changes as we encountered during colonoscopy in this case. Risk factors for developing GCF after Whipple's procedure include infection, sepsis, breakdown of intestinal anastomosis due to ischemia, tension in anastomotic tissue, distal obstruction hypoproteinemia, radiation injury and underlying IBD. Controlling fistula output by keeping patient NPO, proton pump inhibitors and maintaining adequate nutrition are key factors in healing GCF. Endoscopic or surgical approaches for fistula closure should be considered on individual basis.

P2.52: Complete Jejunal Exclusion: A novel method to manage Enterocutaneous Fistulas in the background of short bowel syndrome

Introduction: Management of enterocutaneous fistulas (ECF) in patients with short bowel syndrome (SBS) is challenging. High output fistulas are unlikely to close spontaneously; however, the success rate of surgical intervention is limited due to poor nutrition, inflammation, limited bowel length and lack of abdominal wall integrity. Here, we describe 8 cases of utilizing complete jejunal exclusion at the ligament of Treitz with a gastrostomy tube drainage to manage the ECF as a temporary measure for subsequent bowel reconstruction or transplant. To our knowledge, this is the first report of this approach. Methods: Eight patients who underwent jejunal exclusion at our institution were retrospectively reviewed. In all cases, the jejunum was divided 1–2 inches distal to the ligament of Treitz. Both ends were oversewn. A gastrostomy tube was placed for retrograde decompression of proximal enteric secretions without pyloroplasty. In 4 cases of active ECF’s, we accessed the ligament of Treitz via a left subcostal incision to avoid the fistula. Results: The procedure was done for active ECFs (n=4), impending fistulas (n=1), bridge to transplant following desmoid tumor resection in Gardner’s syndrome (n=2), and after graft enterectomy (n=1). Four cases of active ECFs were managed elsewhere without success. All patients were discharged home on TPN. Of the 4 ECF cases, the fistula output decreased substantially in all patients and closed entirely in 2 cases. Two underwent successful reconstruction and 2 are awaiting reconstruction. One who had secondary biliary cirrhosis due to biliary obstruction and TPN induced liver disease died while waiting for multivisceral transplant (MVT). Of the desmoid tumor cases, one underwent MVT, is alive and well 8 years after transplant, while the other refused to undergo MVT and is living with TPN and g-tube decompression 6 years after the procedure. The patient who underwent graft enterectomy is listed for MVT-this patient developed acute pancreatitis after the jejunal exclusion and required G-J tube decompression. Conclusions: Jejunal exclusion is an effective and generally well tolerated option in the management of intractable ECF in patients with SBS. Associated complications include pancreatitis and liver failure. This procedure should be considered as a bridge to intestinal rehabilitation or transplantation in patients with ECFs that fail to close with medical or traditional surgical management. Table:Picture: