High-output Enterocutaneous Fistula Research Articles

A130 RETROGRADE ENDOSCOPIC ULTRASOUND-GUIDED ENTERO-ENTEROSTOMY USING A LUMEN-APPOSING METAL STENT FOR THE MANAGEMENT OF A HIGH-OUTPUT ENTEROCUTANEOUS FISTULA AND ILEAL STRICTURE IN A COMPLEX SURGICAL ABDOMEN

Abstract Background A 26-year-old male sustained significant traumatic thoracoabdominal injuries following a gunshot. He underwent several laparotomies, small bowel resections, an extended left hemicolectomy with end-colostomy formation, and a flap to close the abdomen. He subsequently developed a high-output enterocutaneous fistula (ECF) and loss of colostomy output. CT imaging confirmed an ECF from the ileum to the anterior abdominal wall and a severe ileal stricture distal to the fistula. Aims In the context of his complex surgical abdomen and proximity of the ECF to the abdominal flap, surgical re-intervention was deemed high-risk. He was placed on total parenteral nutrition and referred for endoscopic management. Methods Under fluoroscopic guidance, we injected methylene blue & contrast dye from the skin side of the ECF. A dilated segment of small bowel was filled, with no downstream passage of contrast (Fig 1A). Retrograde ileoscopy was performed with an Olympus pediatric colonoscope via the patient’s colostomy. 90 cm from the ileocecal valve (ICV), we encountered a benign enteric stenosis that could not be traversed. Contrast was injected, with fluoroscopy revealing a 10 cm long tortuous stenosis (Fig 1B), extending to the previously filled loop of small bowel. Given the length and characterof the stricture, endoscopic balloon dilation and enteral stenting were technically infeasible. Results We proceeded to retrograde endoscopic ultrasound (EUS)-guided entero-enterostomy creation. With the aid of a guidewire, and under endoscopic, fluoroscopic and endosonographic guidance, a linear echoendoscope was advanced into the ileum via the colostomy, cecum and ICV. 50 cm from the ICV, we identified an adjacent dilated loop of small bowel (Fig. 1C). Water was instilled through the ECF, with the endosonographic view demonstrating filling, thus indicating this location to be upstream from the ECF. A 19-gauge needle was punctured through, with subsequent aspiration of methylene blue (Fig. 1D). We then created an EUS-guided entero-enterostomy using a 15mm lumen-apposing metal stent (Hot-AXIOS; Boston Scientific, Massachusetts, USA; Fig. 1E). Passage of methylene blue & contrast through the stent confirmed accurate deployment (Fig. 1F&G). With both the ECF & stricture bypassed, the patient’s colostomy output returned and ECF output diminished. Conclusions Electrocautery-enhanced lumen apposition with metal stenting is well established. It can facilitate the formation of an anchored anastomosis across non-adherent luminal structures in a single-step fashion. Herein, we have reported a novel application of this technique in the management of a complex post-surgical trauma patient with a high-output ECF and deep enteric stenosis. Figure 1: Retrograde EUS-guided entero-enterostomy Funding Agencies None

Isotonic solution for management of high output fistula and stoma

Enterocutaneous fistulae (ECF) is a common complication in open abdominal surgeries which is commonly fixed by creating a stoma. High-output ECF defined as production of fistulae more than 500 mL per day. It is one of the complications that can occur in the presence of a stoma, and it is associated with significant morbidity and mortality. Therefore, adequate management of high output ECF and stoma is important. Administration of isotonic solution is one of techniques proven to be beneficial in reducing stoma output and allowing persistent luminal stimulation. We reported a case of high-ileostomy and ECF output in which isotonic solution conveyed improvement in clinical outcome.

Prolapsed ileocolic intussusception in an infant: An uncommon presentation

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

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

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

Management of Duodeno-Jejunal Flexure Transection after Blunt Trauma - A Modified Approach.

Background: Small bowel injuries are infrequent after blunt trauma and typically affect fixed segment. Untimely management of such injuries, results in high-output entero-cutaneous fistula which increases morbidity and mortality. Treatment of duodeno-jejunal flexure transection has been traditionally done by pyloric exclusion with gastrojejunostomy, but more recent evidence suggests that end-to-end anastomosis or primary closure may be equally effective in which duodeno-jejunal anastomosis is protected via an external tube duodenostomy. Objective: The objective of the study is to provide a modification to the technique of management of duodeno-jejunal flexure injury, avoiding external tube duodenostomy. Material and Methods: Patients admitted from July 1, 2015 to June 1, 2018 were identified and examined for duodeno-jejunal flexure transection. Non-accidental injury cases were excluded. Results: In the study period, a total of 10 patients were admitted with duodeno-jejunal flexure transection. All cases were admitted 24 hours after the injury and presented with shock. After fluid resuscitation and investigations, they were taken for urgent laparotomy. The whole of duodenum was mobilised, the transected ends were debrided and end-to-end duodenojejunal anastomosis was performed in two-layer fashion. An 18-French Nasojejunal (NJ) tube was placed beyond the anastomosis, and an 18-French nasogastric (NG) tube was placed in the stomach for gastric decompression. A feeding jejunostomy was performed in all cases. Both NG and NJ tubes were removed after bowel movements started and FJ was removed on first follow up. There was no incidence of duodenum related complications, and all were doing well on follow up. Discussion and conclusion: Placing the nasojejunal and nasogastric tube eliminates the need for duodenostomy and gastrostomy, respectively. This method protects the duodeno-jejunal anastomosis and decreases the incidence of duodenum-related complications.

SAT-483 Levothyroxine Absorption Test: A Potential Therapeutic Tool for Levothyroxine Malabsorption

INTRODUCTIONPersistent hypothyroidism (PH) even on high doses of levothyroxine is a common clinical problem and it is difficult to treat. Levothyroxine absorption test has been used to distinguish between pseudo-malabsorption and malabsorption as one of its causes. This test uses 1000 mcg of levothyroxine to calculate the percentage of levothyroxine absorbed. We present a case of malabsorption in which we used the levothyroxine absorption test to diagnose as well as treat malabsorption.Case:55-year-old male with history of papillary thyroid cancer status post total thyroidectomy, postsurgical hypothyroidism, recurrent small bowel obstruction, status post jejunal resection, complicated by high output entero-cutaneous fistula, distal high-grade obstruction status post placement of jejunal tube, chronic abdominal pain on narcotics, who initially presented with sepsis and was also found to be hypothyroid.The thyroid stimulating hormone (TSH) level was 45.25 with free thyroxine (FT4) level of 0.54. He was adherent to his levothyroxine (LT4) 175 mcg once daily which is given one hour after tube feeds have been stopped or one hour prior to any administration of other medications.Levothyroxine absorption test was done to distinguish between malabsorption versus pseudo-malabsorption. Three different doses of LT4 were used with results all consistent with malabsorption. The percentage of absorption with 175 mcg, 500 mcg, and 1000 mcg LT4 were 3.4%, 7.2%, and 18% respectively. The formula used to determine the percentage of absorption was (total T4 at 2 hour after LT4 administration - baseline total T4 prior to administration in mcg/L) x plasma volume in liter/dose of administered LT4 in mcg. The final prescription dose of 700 mcg once daily was then derived from the available data, which eventually corrected the patient’s hypothyroidism. Repeat testing after 2 weeks showed TSH of 0.17, FT4 of 1.29 and total T4 of 6.5. The suppressed TSH at this point was attributed to chronic narcotic use but FT4 and total T4 improved appropriately.Conclusion:There is no gold standard protocol for levothyroxine absorption test so we used a different protocol for LT4 dosing compared to the conventional regimen (1000 mcg of LT4). Our patient did show appropriate levothyroxine absorption on the calculated dose. Hence, the Levothyroxine absorption test may be used both as a diagnostic as well as a therapeutic tool for the patients with LT4 malabsorption causing PH.

The importance of a holistic approach to stoma care: A case review

This case review discusses the importance of providing a holistic approach to the care of a patient with two stomas and an enterocutaneous fistula. In this case, the stomas and fistula significantly affected the patient; not just physically but emotionally and socially. The different challenges that arose in pouching a high-output ileostomy, enterocutaneous fistula and ileal conduit with Foley catheter in situ are explored. It also delves into the various options for discharging a patient with complex ostomy complications requiring different needs and resources. Finally, it aims to highlight the therapeutic comprehensive care the stomal therapy nurse provided to the patient and their family.

Creation of High Output Enterocutaneous Fistula From Self-Mutilation

Creation of High Output Enterocutaneous Fistula From Self-Mutilation

Duodenocutaneous fistula: An innovative management with triple tube drainage

Treatment of duodenocutaneous fistula is an expensive and time-consuming proposition, but in the absence of complicating factors, 74% of these fistulas close over a 9–12-week period of time. When complicated with sepsis, distal obstruction, and biliary peritonitis, the cost of treatment and length of hospital stay are increased along with high mortality associated with it. We present a patient who was reoperated with a technique using 3 tube (gastrostomy, duodenostomy, and feeding jejunostomy) which enhanced his recovery and speedy discharge from hospital at a lesser cost compared to traditional methods of treatment. Managing high output enterocutaneous fistula is difficult. Our technique ameliorates the nutrition, improves the fluid and electrolyte balance, decreases the morbidity, and evades the mortality when compared to existing management methods in literature.

Systematic review: pharmacotherapy for high-output enterostomies or enteral fistulas.

High-output enterocutaneous fistula or enterostomies can cause intestinal failure. There is a wide variety of options in medical management of patients with high output. To systematically review the literature on available pharmacotherapy to reduce output and to propose an algorithm for standard of care. Relevant databases were systematically reviewed to identify studies on pharmacotherapy for reduction in (high-) output enterostomies or fistula. Randomised controlled trials and within subjects controlled prospective trials were included. An algorithm for standard of care was generated based on the outcomes of the systematic review. Two studies on proton pump inhibitors, six on anti-motility agents, three on histamine receptor antagonists, one on an α2- receptor agonist and eight on somatostatin (analogues) were included. One study examined a proton pump inhibitor and a histamine receptor antagonist within the same patients. Overall, we found evidence for the following medical therapies to be effective: omeprazole, loperamide and codeine, ranitidine and cimetidine. On the basis of these outcomes and clinical experience, we proposed an algorithm for standard of care which consists of high-dose proton pump inhibitors combined with high-dose loperamide as the first step followed by addition of codeine in case of insufficient output reduction. So far, there is insufficient evidence for the standard use of somatostatin (analogues). The available evidence on the efficacy of medication to reduce enterostomy or enterocutaneous fistula output is hampered by low quality studies. We propose an algorithm for standard of care output reduction in these patients.

Endoscopic control of enterocutaneous fistula by dual intussuscepting stent technique.

Large high-output enterocutaneous fistulas pose great difficulties, especially in the setting of recent surgery and compromised skin integrity. This video demonstrates a new technique of endoscopic control of enterocutaneous fistula by using two covered overlapping stents. In brief, the two stents are each inserted endoscopically, one proximal, and the other distal to the fistula with 2cm of each stent protruding cutaneously. Following this, the proximal stent is crimped and intussuscepted into the distal stent with an adequate overlap. A prolene suture is passed through the anterior wall of both stents to prevent migration. The two stents used were evolution esophageal stents-10cm long, fully covered, double-flared with non-flared and flared diameters being 20 and 25mm, respectively (product number EVO-FC-20-25-10-E, Cook Medical, Bloomington, IN, USA). The patient featured in this video developed a high-output enterocutaneous fistula proximal to a loop ileostomy, which was created following a small bowel leak after a curative surgery for bladder cancer. Using the technique featured in this video (schematic depicted in Fig.1), the patient was nutritionally optimized with oral feeds from albumin of 0.9-3.4g/dl within 2months despite prior failure to achieve nutrition optimization and adequate skin protection with combination of oral and/or parenteral nutrition. Three months after stenting, following nutritional optimization and improvement of skin coverage, definitive procedure consisted of uncomplicated fistula resection with primary stapled side-to-side functional end-to-end anastomosis. The stents were not completely incorporated into the mucosa and were rather easily pulled through the residual fistula opening just prior to the surgery. Only minimal fibrosis was noted and less than 20cm of involved small bowel needed to be resected. Had the fistula have closed completely, the options would have included (1) proceeding to bowel resection with removal of the stents regardless of closure, or (2) cutting the securing prolene stitch and observation. Considering the placement of the stents in mid-small bowel, their endoscopic retrieval would have been difficult unless they were to migrate into the colon. Although a prior attempt at managing an enterocutaneous fistula with a stent deployed through a colostomy site was previously reported [1], there is no published account of bridging an enterocutaneous fistula with overlapping endoscopic stents through the fistula itself. This video serves as a proof of concept for temporizing enterocutaneous fistulas with endoscopic stenting.

Enterocutaneous fistula in patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Incidence, management and outcomes

BackgroundCytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for peritoneal carcinomatosis (PC) from multiple origins, however is associated with increased complications compared to conventional gastrointestinal surgery. The aetiology of enterocutaneous fistulas (ECF) in most cases is a result of various contributing factors and therefore remains a major clinical problem, occurring in 4–34% of patients post-CRS. The aim of this study was to analyze the incidence and outcome of ECF following CRS/HIPEC. MethodFrom April 1999 to September 2015, 53 patients of 918 CRS/HIPEC procedures developed an ECF. Patient, operative and postoperative data were retrospectively analyzed to determine aetiology, classification outcome and possible contributing factors were reviewed on univariate and multivariate analysis. ResultsWe report a 5.8% ECF rate, diagnosed at a median of 13 days. The mortality rate was 5.7% and other morbidity was significantly increased (p = 0.0001). Twenty-five (47.2%), 8 (15.1%) and 20 patients (37.7%) had low, moderate and high output ECF respectively. Patients that had a CC2 cytoreduction, abdominal VAC or smoked had a higher risk of fistula (p = 0.004, p < 0.0001, p = 0.008). Spontaneous closure was achieved in 49.2% with conservative treatment (median 29 days) and 33.9% underwent surgical intervention. Preoperative serum albumin <35 g/L (p = 0.04), PCI>17 (p = 0.025) and operation >8.6 h s (p = 0.001) were independent risk factors on multivariate analysis. Overall and 5-year survival was significantly reduced (p < 0.0001,p = 0.016). ConclusionCRS/HIPEC remains an effective treatment modality for PC in selected patients with a comparable ECF incidence to reported elective gastrointestinal surgery rates. This study identifies multiple risk factors that should be considered in patients undergoing CRS/HIPEC.

PTH-198 Preoperative parenteral nutrition in crohn’s disease patients requiring abdominal surgery

Introduction The benefits of parenteral nutrition (PN) in Crohn’s Disease (CD) prior to abdominal surgery remains debatable, with two recent studies suggesting preoperative PN given to patients with moderate to severe CD minimises the risk of early postoperative complications. Method Retrospective cohort study of consecutive CD patients who received PN prior to abdominal surgery, from January 2013 to January 2015. Total days of PN received prior to surgery, changes in weight and BMI, and changes to CRP and albumin in all patients receiving PN were analysed. Adverse events related to PN, including line-related complications, and post-operative complications were also recorded. Results Of 62 operations performed for CD over the study period, 6 patients (4 male) received pre-operative PN. PN was administered via a PICC line with a dedicated lumen in all patients. All patients continued PO liquid intake and existing CD medications. 5 patients had stricturing and penetrating disease (3 with ileocaecal disease, and 2 with colonic disease). 2 of these patients had phlegmons, 2 had complex peri-anal fistulising disease, and 1 had a high output entero-cutaneous fistula. A further patient had isolated ileocolic stricturing disease. 4 patients required ileocaecal resection, 1 required panproctocolectomy and 1 sub-total colectomy. Pre-operative PN was administered for a mean of 41 days. Weight and BMI increased in all 6 patients (mean weight increased from 51.2 kg to 57.7 kg, mean BMI from 17.5 kg/m2to 19.8 kg/m2). The weight gained was maintained at routine follow-up after surgery. Mean CRP improved from 35.5 to 18.3, and albumin from 35.5 g/L to 38.3 g/L. Mean post-operative stay was 12 days, and diversion stoma was not required in 80% (4 patients). Line complications (catheter related infection/thrombosis) were not seen. One patient (16.7%) required PN withdrawal 2 days before planned surgery for suspected line sepsis not confirmed on blood cultures. No serious post-operative complications occurred, and only a single patient required antibiotics post-operatively for a small collection (not requiring surgical or radiological intervention). Conclusion In this small group of complex CD patients who received pre-operative PN, sustained weight gain and improvement in inflammatory markers was observed. Two recent studies suggest favourable postoperative outcomes, and our findings are in keeping with this. The role of optimisation with PN warrants further investigation and randomised controlled studies are required. Disclosure of interest None Declared.

A Combination of Local Flap Transfer and Negative Pressure Wound Therapy for Management of High-output Enterocutaneous Fistula

A Combination of Local Flap Transfer and Negative Pressure Wound Therapy for Management of High-output Enterocutaneous Fistula

A modified approach to decompression of primary repair of the duodeno-jejunal flexure transection after blunt trauma

Small bowel injuries in general are uncommon after blunt abdominal trauma and are usually due to high-energy deceleration injuries, often in relation to motor vehicle accidents and affect fixed segments such as duodenum, duodeno-jejunal (DJ) flexure, proximal jejunum and terminal ileum. High morbidity and mortality are associated with this type of injury when the diagnosis is delayed. Untimely management of such injuries, especially transection of the DJ flexure, results in high-output entero-cutaneous fistula. In total, eight cases of DJ flexure transection with/without associated multiple injuries were reviewed retrospectively. For DJ flexure transection in all cases, the flexure was adequately mobilised, and end-to-end duodenojejunostomy performed with two-layer interrupted sutures. A large calibre nasojejunal tube was placed through the anastomotic site before completion to protect the anastomotic area from the proteolytic action of large volumes of upper gastrointestinal secretions. In case of associated injuries, appropriate procedures were done. In DJ flexure transection, a timely management by end-to-end anastomosis with administration of nasojejunal tube beyond the site of anastomosis is an alternate, simple and safe procedure in comparison to difficult procedures such as pyloric exclusion and gastrojejunostomy in patients with delayed presentation.

Management of patients with high output stomas and enterocutaneous fistulae: Do proton pump inhibitors really help?

Summary Background and aims Patients with high output stomas and enterocutaneous fistulae are prone to fluid and electrolyte abnormalities, particularly dehydration, hyponatraemia and hypomagnesaemia. As well as medication to prolong transit time and aid absorption, proton pump inhibitors (PPIs) have been advocated to reduce gastrointestinal losses. Recent, reports in other clinical areas have linked long-term PPI use to hypomagnesaemia. We wondered whether PPIs used to reduce stoma losses may paradoxically be aggravating hypomagnesaemia in these patients? Our aim was to audit the effect of stopping PPIs, used solely for reduction of gastrointestinal losses, in a cohort of patients with high stoma losses. Methods Nine patients (8 high output stomas: 1 enterocutaneous fistula) were regularly attending a dedicated clinic for supervision and management of fluid and electrolytes during October 2012. Stoma outputs, blood and urine results were recorded before and after stopping their PPI. Results There was a significant reduction in average daily stoma outputs when the PPI was stopped. Before PPI cessation, mean daily stoma volume was 1550 mls (SE:147.67) compared to mean of 1344 mls after (SE:130.29, t(8) = 2.11, p Conclusion Our findings do not support current thinking with regard to PPIs reducing enteric losses in patients with high stoma losses. The PPI effect on hypomagnesaemia in this cohort is uncertain but cessation should be considered in resistant hypomagnesaemia.

Intravenous Warfarin and Heparin-Induced Thrombocytopenia

To describe the diagnosis, management, and monitoring of a patient with heparin-induced thrombocytopenia (HIT) with thrombosis and simultaneous bleeding risk treated with argatroban and transitioned to intravenous (IV) warfarin secondary to the inability to administer enteral medications. A 71-year-old man was admitted to the surgical intensive care unit (SICU) following aortic valve repair, coronary artery bypass, and ascending aortic aneurysm repair. On postoperative day 9, he was found to have a pulmonary embolism, and therapeutic heparin was started. The following day, his platelet count was found to have dropped precipitously. HIT was diagnosed, heparin was discontinued, and argatroban was initiated. On postoperative day 22, anticoagulation was discontinued because of massive gastrointestinal bleeding. On postoperative day 35, multiple venous thromboses were found, and argatroban was restarted. The patient developed a high-output enterocutaneous fistula, eliminating the option of enteral route of medication administration. The multidisciplinary SICU team transitioned the patient from argatroban to IV warfarin for long-term anticoagulation. The international normalized ratio was monitored and remained therapeutic throughout his admission without further thrombotic complications. HIT occurs when antibodies develop to heparin-platelet factor 4 complexes, causing simultaneous hypercoagulability and thrombocytopenia. It is diagnosed based on both clinical factors and laboratory testing. Treatment includes discontinuation of all forms of heparin; initiation of a nonheparin anticoagulant, such as argatroban; and transition to warfarin. IV warfarin is a therapeutic option for patients with malabsorption issues. A multidisciplinary team in an intensive care setting optimizes cost-effective, patient-centered, and safe care.

Managing high-output stomas: module 2 of 3

All patients with short bowel should be provided with some lumenal source of nutrition if it is safe to do so. Dietary needs are very complex, and support and education through a dedicated dietetics team is pivotal and will improve clinical outcome (Culkin et al, 2009). Energy requirements are higher than in normal people if patients are to be maintained on enteral nutrition alone. These requirements can be met by eating highenergy food, having oral sip feeds, or high-energy enteral feeds at night via a naso-gastric or gastrostomy tube. If increasing the enteral intake fails to meet the requirements or leads to an unacceptable amount of diarrhoea/stoma output, parental nutrition (PN) is indicated (Nightingale and Woodward, 2006). Enteroclysis or fistuloclysis, which is the infusion of enteral feed into the distal limb of a loop stoma or enterocutaneous fistula, might be a viable alternative in some cases (Levy et al, 1988; Teubner et al, 2004). Dietary advice will differ according to the intestinal anatomy that the patient has. There are three main categories of patients with short bowel syndrome: mid-ileal resection, jejunocolic anastomosis and jejunostomy (or high-output enterocutaneous fistula) (Figure 1). Patients with a mid-ileal resection rarely run into nutritional or fluid balance problems. Vitamin B12 is absorbed in the terminal ileum and this will need to be supplemented in these patients. Bile acid malabsorption can also be a cause of Simon Gabe

Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature

Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.

The parachute design as a new extraperitoneal method of closing a recalcitrant high-output enterocutaneous fistula: report of a case

We introduce a new method for closure of a recalcitrant high-output jejunal enterocutaneous fistula. First, a transposed rectus abdominis muscle is sutured into the fistula opening using a parachuting technique, then the muscle is covered with a skin graft and temporarily immobilized to the fistula wall and abdominal wall with a negative pressure device. This extraperitoneal method provides tension-free closure of the fistula with well-vascularized tissue, without compromising the intestinal lumen. No bowel is resected. This new technique allows for early mobilization and recommencement of enteral nutrition.