Outcome of reconstructive surgery for intestinal fistula in the open abdomen

OBJECTIVE: To determine factors which influence the outcome of surgical techniques to close enterocutaneous fistulas within the open abdomen. SUMMARY BACKGROUND DATA: Enterocutaneous fistulation within an open abdominal wound is associated with considerable morbidity and mortality. The factors that influence the outcome of reconstructive surgery are unclear. METHODS: Sixty-one patients undergoing 63 operations to close enterocutaneous fistulas associated with open abdominal wounds were referred to a national center for further management. Once sepsis had been eradicated, nutritional status restored and local conditions in the abdomen judged to be suitable, fistulas were resected and the abdominal wall reconstructed by suture repair with and without component separation, or by suture repair in combination with absorbable or nonabsorbable prosthetic mesh. Patients were followed up for 16 to 84 months postoperatively. RESULTS: There were 3 postoperative deaths (4.8%). Major complications, including postoperative respiratory and surgical site infection occurred in 52 of 63 (82.5%) procedures. Refistulation occurred in 7 cases (11.1%) but was more common when the abdominal wall was reconstructed with prosthetic mesh (7 of 29, 24.1%) than with sutures (0 of 34, 0%). Porcine collagen mesh was associated with a particularly high rate of refistulation (5 of 12, 41.7%). CONCLUSIONS: Simultaneous reconstruction of the intestinal tract and abdominal wall remains associated with a high complication rate, justifying the management of such patients in specialized units. Simultaneous reconstruction of the abdominal wall with prosthetic mesh is associated with a particularly high incidence of recurrent postoperative fistulation and should be avoided if possible.     

Enterocutaneous Fistulas and a Hostile Abdomen: Reoperative Surgical Approaches

Damage-control surgery and open-abdomen is an acceptable—and often lifesaving—approach to the treatment of patients with severe trauma, abdominal compartment syndrome, necrotizing soft tissue catastrophes, and other abdominal disasters, when closing the abdomen is not possible, ill advised, or will have serious sequelae. However, common consequences of open-abdomen management include large abdominal wall defects, enterocutaneous fistulas (ECFs), and enteroatmospheric fistulas (EAFs). Furthermore, in such patients, a frozen and hostile abdomen (alone or combined with ECFs) is not uncommon. Adding biologic mesh to our surgical armamentarium has revolutionized hernia surgery.     

Gangrenous pyoderma and enterocutaneous fistulas after ileal pouch-anal anastomosis

We describe the medical-surgical management of a patient with a complex inflammatory bowel disease who developed 2 acute episodes of pyoderma gangrenosum and enterocutaneous fistulas after ileal pouch-anal anastomosis for ulcerative colitis. The rarity of this postsurgical complication is emphasized. A good response to topical tacrolimus was achieved in cutaneous wounds. A less favorable response to infliximab was achieved in the abdominal fistulas, requiring surgical excision of the pouch.     

Surgical aspects of sclerosing encapsulating peritonitis

Sclerosing encapsulating peritonitis (SEP) is associated with the administration of beta-blocking agents as well as continuous ambulatory peritoneal dialysis. The predisposing factors in the latter group are recurrent peritonitis, presence of acetate in the dialysate, and antiseptics used during bag exchanges. We report a case of SEP following chronic ambulatory peritoneal dialysis and review the literature on this benign yet potentially lethal condition. Sclerosing encapsulating peritonitis frequently leads to intestinal obstruction, small-bowel necrosis, enterocutaneous fistulas, and malnutrition. There is a high incidence of anastomotic failure when a resection and primary intestinal anastomosis is performed in patients with SEP. Although SEP is not commonly reported in the surgical literature, its importance to surgeons is indicated by the fact that the overall mortality rate is close to 60% in patients with SEP who develop surgical complications.     

Experience with the use of vacuum dressings in the management of acute enterocutaneous fistulas

High-output enterocutaneous fistulas involving an open abdominal wound are a difficult management problem. We report our experience on the use of vacuum dressings. The potential benefits, problems and new recommendations for the use of vacuum dressings in the management of enterocutaneous fistulas are discussed.     

Surgical treatment of enteric 'bud' fistulas in contaminated wounds. A riskless extraperitoneal method using split-thickness skin grafts.

We describe methods and results of a local extraperitoneal method of repairing enterocutaneous "bud" fistulas in abdominal-wall defects. The method is performed with local anesthesia and involves an extraperitoneal closure with skin-graft coverage. Of the nine fistulas so treated, five healed. No patient's postoperative course was set back by the repairs that failed since the method precludes intraperitoneal entrance. Two of three high-output fistulas were successfully repaired with the extraperitoneal method, reversing an otherwise stormy clinical course. We conclude that for epithelialized enterocutaneous fistulas, little is lost if our method of repair fails and much is gained if it is successful in these critically ill patients.     

The treatment of high enterocutaneous fistula with surgical drainage and total parenteral nutrition

High enterocutaneous fistulas occurred in 17 malnourished patients after abdominal surgery, performed in most cases for serious primary disease, and were treated with emergency surgical drainage, in 15 cases, early resuturation, in six patients, and total parenteral nutrition (12.6 MJ) in all cases. No elective reconstructions were carried out. The fistulas healed in 27 +/- 20 days, except in three patients, with carcinoma of the stomach or necrosis of the pancreas, who died in sepsis.     

Systematic Management of Postoperative Enterocutaneous Fistulas: Factors Related to Outcomes

Background Most enterocutaneous fistulas are postoperative in origin. Sepsis, malnutrition, and hydroelectrolytic deficit are still the most important complications to which patients with postoperative enterocutaneous fistulas (PEF) are exposed. Knowledge of prognostic factors related to specific outcomes is essential for therapeutic decision-making processes. Methods We reviewed files of all consecutive patients with PEF treated in our hospital during a 10-year period. Our aim was to identify factors related to spontaneous closure, need for operative treatment, and mortality. Univariate and multivariate analyses were performed. Results A total of 174 patients were treated. The most frequent site of origin was the small bowel (90 patients: 48 jejunal, and 42 ileal), followed in frequency by the colon (50 patients). Postoperative enterocutaneous fistula closure was achieved in 151 patients (86%), being spontaneous in 65 (37%) and surgical in 86 (49%). Factors that significantly precluded spontaneous closure were jejunal site, multiple fistulas, sepsis, high output, and hydroelectrolytic deficit at diagnosis or referral. Origin of PEF at our hospital was the only factor significantly associated with spontaneous closure. The most frequent operative indication was PEF persistence without sepsis. Factors significantly associated with the need for operative treatment were high output, jejunal site, and multiple fistulas. Closure was achieved in 84% of patients who underwent operation. A total of 23 patients died (13%). Factors associated with mortality were serum albumin <3.0 g/dl (at diagnosis or referral), high output, hydroelectrolytic deficit, multiple fistulas, jejunal site, sepsis, and a complex fistulous tract. Conclusions In spite of advances in management of PEF, the associated morbidity and mortality remain high. Among several variables influencing outcome, our multivariate analysis disclosed high output, jejunal site, multiple fistulas, and sepsis as independent adverse factors related to non-spontaneous closure, need for operative treatment, and/or death.     

Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds

Chronic postoperative pouch-vaginal and vesicovaginal fistulas after hysterectomy and irradiation to treat advanced cervical cancer do not respond to conventional treatment because of the low vascularity in the irradiated area. We present the successful repair of these complications in a female patient, in whom several vaginal and abdominal approaches had been tried and had resulted not only in failure but also in tissue loss and fibrosis and persisting fistulas. First, a synchronous vaginoabdominal approach using a vertical myocutaneous distally based rectus abdominis myocutaneous flap was used successfully to close a pouch-vaginal fistula and simultaneously reconstruct the posterior vaginal wall. In a second approach, the persisting vesicovaginal fistula was closed by a right rectus abdominis myocutaneous flap while simultaneously reconstructing the anterior vaginal wall, closing the enterocutaneous stoma and performing an appendicovesicostomy as a continence channel for catheterization. Despite unfavorable local wound situations, including an enterocutaneous stoma through the rectus abdominis and various previous incision lines, the transfer of axially well-vascularized tissue can solve these problem wounds. Consecutive bilateral use of the rectus abdominis flap may be necessary to deal with extensive pelvic wounds. This technique should be considered as one repair modality in irradiated pelvic wounds with fistulas. Previous enterostomy is not a contraindication to the use of this flap.     

Artificial Nutritional Support in Patients with Gastrointestinal Fistulas

Gastrointestinal (GI) fistulas allow abnormal diversions of GI contents, digestive juices, water, electrolytes, and nutrients from one hollow viscus to another or to the skin, potentially precipitating a wide variety of pathophysiologic effects. Mortality rates have decreased significantly during the past few decades from as high as 40% to 65% to 5.3% to 21.3% largely as a result of advances in intensive care, nutritional support, antimicrobial therapy, wound care, and operative techniques. The primary causes of death secondary to enterocutaneous fistulas have been, and continue to be, malnutrition, electrolyte imbalances, and sepsis, especially in high-output fistulas, which continue to have a mortality rate of about 35%. Priorities in the management of GI fistulas include restoration of blood volume and correction of fluid, electrolyte, and acid-base imbalances; control of infection and sepsis with appropriate antibiotics and drainage of abscesses; initiation of GI tract rest including secretory inhibition and nasogastric suction; control and collection of fistula drainage with protection of the surrounding skin; and provision of optimal nutrition by total parenteral nutrition (TPN) or enteral nutrition (EN) (or both). The role of nutrition support in the management of enterocutaneous fistulas as either TPN or EN is primarily one of supportive care to prevent malnutrition, thereby obviating further deterioration of an already debilitated patient. It has been shown in several studies that TPN has substantially improved the prognosis of GI fistula patients by increasing the rate of spontaneous closure and improving the nutritional status of patients requiring repeat operations. Moreover, other studies have shown that nutritional support decreases or modifies the composition of the GI tract secretions and is thus considered to have a primary therapeutic role in the management of fistula patients. Finally, if a fistula has not closed within 30 to 40 days, or if it is unlikely to close because of a variety of collateral or compounding pathophysiologic conditions, consideration must be given to operative resection of the fistula while continuing to maintain the previous nutritional and metabolic support. The morbidity and mortality rates in such unfortunate patients remain high despite the many recent advances in surgical and metabolic technology.     

从围手术期外科之家角度审视复杂肠外瘘的手术治疗

复杂肠外瘘病人常经历2次以上腹部手术,且瘘发生后多有严重的腹腔感染,以及重要器官的功能损害.复杂肠外瘘手术常涉及全腹部多个脏器,剥离面大、手术应激反应重、手术时间长,且常对原有手术部位再次手术,更增加了手术的复杂性.因此,肠外瘘手术与一般腹部外科操作既有共性,又有其特殊性与复杂性.复杂肠外瘘的围手术期处理要求明显高于一...     

Laparoscopic management of enterocutaneous fistula

Enterocutaneous fistulas develop in settings of prior abdominal surgery, inflammatory bowel disease, diverticulitis, radiation or malignancy. Traditional surgical management requires laparotomy with bowel resection and anastomosis and is associated with a high incidence of wound infection. Recent advances in instrumentation and accumulation of experience has allowed minimally invasive surgery to become an alternative and often preferred approach to handling complex surgical problems. We present a case of successful laparoscopic management of an enterocutaneous fistula that developed in the setting of prior colectomy and laparoscopic inguinal hernia repair with prosthetic mesh. Laparotomy and its attending complications were avoided facilitating recovery and return to work.     

Local and surgical management of enterocutaneous fistulas.

Intensive nutritional treatment is now recognized as the single most important factor in achieving closure of enterocutaneous fistulas, replacing attempts at early surgical closure. Operation in the early stages of management should be confined to the drainage of abscesses, the defunctioning of diseases or disrupted bowel and the formation of feeding enterostomies. In those few cases where spontaneous closure of the fistula does not occur, definitive surgical operation can be carried out when malnutrition has been corrected. The combination of nutritional treatment, skin protection and judicious surgery can reduce the mortality to below 10 per cent.     

Nonthyroidal illness syndrome in enterocutaneous fistulas

Background

The aim of this study was to investigate the incidence, etiology, clinical outcomes, and prognosis of nonthyroidal illness syndrome (NTIS) in patients with enterocutaneous fistulas.

Methods

We prospectively collected 226 patients with enterocutaneous fistulas. Demographics, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment scores, C-reactive protein, body mass index, albumin, and thyroidal hormones were evaluated for each patient.

Results

The incidence of NTIS was 57.5% in patients with enterocutaneous fistulas. Age and the APACHE II and Sequential Organ Failure Assessment scores were significantly higher, whereas albumin was lower in the NTIS group compared with those in the euthyroid group. A decreased sum activity of deiodinases and a reduced ratio of total thyroxin/free thyroxin and total triiodothyronine/free triiodothyronine were observed in the NTIS group. Patients with NTIS suffered longer durations in the intensive care unit and higher possibilities of mechanical ventilation. The cumulative survival rate was significantly lower in the NTIS group.

Conclusions

NTIS was common, and patients with NTIS displayed worse clinical outcome and prognosis. A hypodeiodination condition and a potential thyroid hormone–binding dysfunction may play a role in the etiology of NTIS. A low serum albumin concentration and a high APACHE II score were risk factors of NTIS in enterocutaneous fistulas.     

Practical Approaches to Definitive Reconstruction of Complex Abdominal Wall Defects

With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify “complex” are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.     

Somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized controlled trials

BACKGROUND: The aim of this study was to evaluate, through systematic review, the effectiveness of somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of established enterocutaneous pancreatic fistulas. METHODS: Electronic databases, including Medline and EMBASE, were searched systematically by using keywords including 'somatostatin', 'octreotide', 'fistula' and 'randomiz(s)ed controlled trial'. In addition, citations of relevant primary and review articles were examined. Particular authors were contacted when necessary. Data on patient recruitment, intervention and outcome were extracted from the included trials and analysed. RESULTS: Use of somatostatin or octreotide for the prevention of postpancreatectomy complications, including pancreatic fistulas, was identified in 14 randomized controlled trials, including one abstract and one conference proceeding, involving a total of 1686 patients. Use of somatostatin or octreotide for the treatment of established enterocutaneous pancreatic fistulas was identified in ten trials involving a total of 301 patients. Significant heterogeneity was found among the identified trials with regard to the definition of fistula, dosage of octreotide, starting time and duration of the treatment, among other factors. CONCLUSION: There was major disagreement between the studies on whether use of the drugs in question is of value in preventing postoperative complications. This analysis suggests that, in units where the postoperative fistula rate following pancreaticoduodenectomy for neoplasia and other pancreatic conditions exceeds 10 per cent, somatostatin or octreotide administered before operation may significantly reduce the rate of major postoperative complications, particularly pancreatic fistulas. The identified evidence also suggests that there may be a limited role for such drugs in the treatment of established postoperative enterocutaneous pancreatic fistulas. A major conclusion is that further clarification of the roles of these drugs is still required through large, high-quality, randomized trials.     

Intraperitoneal polypropylene mesh repair of incisional hernia is not associated with enterocutaneous fistula

BACKGROUND: Incisional hernia repair with prosthetic material is followed by fewer recurrences than primary repair. Polypropylene is the most commonly used prosthetic material but may cause entero- cutaneous fistulas. The aim of this study was to determine whether enterocutaneous fistulas developed after incisional hernia repair with polypropylene mesh and to evaluate clinical outcome after incisional hernia repair. METHODS: A retrospective analysis of the outcome of incisional hernia repair with polypropylene mesh between 1982 and 1998 was conducted. Follow-up data were obtained from medical records and questionnaires. RESULTS: Polypropylene incisional hernia repair was performed in 136 patients. Median follow-up was 34 months. No enterocutaneous fistulas developed. Wound infection occurred in 6 per cent. Wound sinus formation occurred in two patients. No mesh was removed because of infection and no persisting infection of the mesh occurred. CONCLUSION: Enterocutaneous fistula formation appears to be very rare after incisional hernia repair with polypropylene mesh, regardless of intraperitoneal placement, omental coverage or closing of the peritoneum.     

Treatment of 27 postoperative enterocutaneous fistulas with the long half-life somatostatin analogue SMS 201-995.

Twenty-seven patients with postoperative enterocutaneous fistulas were treated with parenteral nutrition and SMS 201-995 (100 micrograms/8 hours, subcutaneously), a long half-life somatostatin analogue. At the time SMS 201-995 was started, 11 patients had low output fistulas (less than 1000 ml/48 hours), 11 patients had high output fistulas (above 1000 ml/48 hours), and 5 patients had fistulas sitting in large abdominal wall defects. Within 24 hours of treatment, a mean reduction of 55% of the fistula output was observed. Fistula site or output before treatment had no influence on the magnitude of output reduction. Spontaneous closure was achieved in 77% of the patients after a mean of 5.8 +/- 2.7 days of treatment with this drug. Two patients died (7.4%). Pain at the injection site was referred by 15% of the patients but no other side effects were observed. Glucose intolerance was not observed. SMS 201-995 has been shown to be very useful in the conservative treatment of enterocutaneous fistulas because of its ability to rapidly reduce fistula output and accelerate spontaneous closure.     

Laparoscopic repair of an internal strangulated supravesical hernia

Traditional surgical management of a chronic enterocutaneous fistula requires laparotomy, but the optimal site of incision is unclear. Laparoscopy and adhesiolysis may offer an alternative approach. Two cases of non-healing enterocutaneous fistula within chronic, granulating wounds are described. The laparoscope was placed subcostally using the Hasson technique with additional ports placed under direct vision. After clearing the anterior abdominal wall of all but the fistula-containing bowel, an incision was made circumferentially around the granulation bed. Resection and primary anastomosis was performed in standard fashion. Lateral component separation allowed primary wound closure. Both patients were discharged without sequelae and doing well at last follow-up (mean 12 months). A laparoscopic approach to non-healing enterocutaneous fistulas seems safe and technically feasible. When combined with lateral component separation, it may result in reduction of inadvertent enterotomies and optimal management of the wound without the use of prosthetic mesh. Presented at the annual meeting of the Society of American Gastrointestinal Surgeons, Los Angeles, CA, USA, 12–15 March 2003. This article contains the opinions of the authors only and does not represent the opinions of the United States Department of Defense or the United States Army.     

No enterocutaneous fistula development in a cohort of 695 patients after incisional hernia repair using intraperitoneal uncoated polyproylene mesh

Hernia - To determine the incidence of enterocutaneous fistulas (ECFs) developed after elective incisional hernia (IH) repair using intraperitoneal uncoated polypropylene (PPE) mesh. This is a...