Management of Enterocutaneous Fistula: Outcomes in 276 Patients

Objective

To assess the outcomes of patients with type II intestinal failure due to enterocutaneous fistulae in a tertiary referral centre over a 15 year period.

Summary background

Intestinal failure secondary to enterocutaneous fistula (ECF) requires multidisciplinary management at significant cost. Mortality and morbidity are high.

Methods

Patients were identified from a prospectively collected database of patients requiring inpatient parenteral nutrition (1998–2013). Data collected included: demographics, mode of admission, pathological grouping and outcome.

Results

A total of 286 ECF were identified in 278 patients, mean age 64 years (20–96 years) with an equal gender distribution. In total, 112 fistulas developed following an emergency admission, 89 fistulas following an elective admission, and the remainder 85 were transferred from outlying district hospitals. In total, 246 ECF were as a result of previous surgery, 11 occurred following endoscopic procedures, with the remainder occurring spontaneously. All patients received parenteral nutrition (PN). Forty-seven patients overall died from sepsis/multiorgan failure. A total of 154 ECF resolved with aggressive non-operative management and 46 died prior to resolution of their fistula or surgery. 74.8% of patients with ECF proximal to the duodenal-jejunal flexure closed without surgery compared to 35.4% with disease distal to the flexure (p = 0.001). Nineteen early operations were performed, with 51 patients undergoing definitive surgery. In-hospital mortality was 19.1% (53/278), with 30-day post-operative mortality from definitive surgery being 9.8% (5/51).

Conclusion

Mortality remains high and is associated with sepsis. Fistulas proximal to the duodeno-jejunal flexure are more likely to close spontaneously. If the fistula fails to close spontaneously care is often prolonged and complex, requiring a dedicated nutrition team. In this series, spontaneous closure was more common in upper GI fistulas. Patients who are not able to be discharged in the interval between fistula formation and definitive surgery have a higher mortality risk.

     

Binding Versus Conventional Pancreaticojejunostomy After Pancreaticoduodenectomy: A Case-Matched Study

Background  

Postoperative morbidity of pancreaticoduodenectomy remains high and is mainly related to postoperative pancreatic fistula. Peng et al. (J Gastrointest Surg 2003;7:898–900; Am J Surg 2002;183:283–285; Ann Surg 2007;245:692–298) recently described binding pancreaticojejunostomy and reported a zero percent rate of pancreatic fistula. The aim of this study was to compare postoperative outcome of binding pancreaticojejunostomy and conventional pancreaticojejunostomy after pancreaticoduodenectomy.     

Does internal stenting of the pancreaticojejunostomy improve outcomes after pancreatoduodenectomy? A prospective study

Aim  

This study’s aim is to evaluate the effectiveness of using an internal stent when fashioning a duct-to-mucosa pancreatojejunostomy on preventing pancreatic fistula formation, as well as on the overall outcome for patients undergoing pancreaticoduodenectomy.     

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

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

Management of fistula of ileal conduit in open abdomen by intra-condoit negative pressure system

INTRODUCTION

We aimed to present the management of a patient with fistula of ileal conduit in open abdomen by intra-condoid negative pressure in conjunction with VAC Therapy and dynamic wound closure system (ABRA).

PRESENTATION OF CASE

65-Year old man with bladder cancer underwent radical cystectomy and ileal conduit operation. Fistula from uretero-ileostomy anastomosis and ileus occurred. The APACHE II score was 23, Mannheim peritoneal index score was 38 and Björck score was 3. The patient was referred to our clinic with ileus, open abdomen and fistula of ileal conduit. Patient was treated with intra-conduid negative pressure, abdominal VAC therapy and ABRA.

DISCUSSION

Management of urine fistula like EAF in the OA may be extremely challenging. Especially three different treatment modalities of EAF are established in recent literature. They are isolation of the enteric effluent from OA, sealing of EAF with fibrin glue or skin flep and resection of intestine including EAF and re-anastomosis. None of these systems were convenient to our case, since urinary fistula was deeply situated in this patient with generalized peritonitis and ileus.

CONCLUSION

Application of intra-conduid negative pressure in conjunction with VAC therapy and ABRA is life saving strategies to manage open abdomen with fistula of ileal conduit.     

Enterocutaneous fistula: analysis of clinical outcomes from a single Victorian tertiary referral centre

Background

Enterocutaneous fistulas (ECFs) are complex and can result in significant morbidity and mortality. The study aimed to evaluate ECF outcomes in a single tertiary hospital.

Methods

A retrospective study of all patients treated with ECF between the period of January 2009 and June 2014 was conducted. Baseline demographic data assessed included the primary aetiology of the fistula, site of the fistula and output of the fistula. Outcomes measures assessed included re‐fistulation rate, return to theatre, wound complications, fistula closure rate and death over the study period.

Results

A total of 16 patients with ECF were recorded within the study period. Mean age of the patient cohort was 55.8 ± 11.8 years with a female predominance (11 females, 5 males). Primary aetiology were Crohn's disease (31%), post intra‐abdominal surgery not related to bowel neoplasia (50%) and post intra‐abdominal surgery related to bowel neoplasia (19%). Majority of the fistulas developed from the small bowel (75%) and had low output (63%). Operative intervention was required in 81% of patients with an overall closure rate of 100%. Median operations required for successful closure was 1.15 operations. Mean duration between index operation and curative operation was 8 ± 12.7 months.

Conclusion

Appropriate bundle of care (perioperative care, surgical timing and surgical technique) can produce excellent results in patients with ECF.     

Primary fascial closure after damage control laparotomy: Sepsis vs haemorrhage

Objective

To compare the outcomes of patients undergoing damage control laparotomy (DCL) for intra-abdominal sepsis vs intra abdominal haemorrhage. We hypothesize that patients undergoing DCL for sepsis will have a higher rate of septic complications and a lower rate of primary fascial closure.

Settings and patients

Retrospective study of patients undergoing DCL from December 2006 to November 2009. Data are presented as medians and percentages where appropriate.

Results

111 patients were identified (55 men), 79 with sepsis and 32 with haemorrhage. There was no difference in age (63 vs 62 years), body mass index (BMI, 27 vs 28), diabetes mellitus (13% vs 9%), or duration of initial operation (125 vs 117 min). Patients with sepsis presented with a lower serum lactate (2.2 vs 4.7 mmol/L, p < 0.01), base deficit (4.0 vs 8.0, p ≤ 0.01) and ASA score (3.0 vs 4.0, p < 0.01). There was no statistical difference in overall morbidity (81% vs 66), mortality (19% vs 22%), intra-abdominal abscess (18% vs 16%), deep wound infection (9% vs 9%), enterocutaneous fistula (ECF) (8% vs 6%) and primary fascial closure (58% vs 59%). Multivariable analysis demonstrated that intra-abdominal abscess (OR 4.26, 95% CI 1.06–19.32), higher base deficit (OR 1.14, 95% CI 1.00–1.31) and more abdominal explorations (OR 1.54, 95% CI 1.23–2.07) were associated with lack of primary fascial closure, but BMI (OR 1.00, 95% CI 0.94–1.07), ECF (OR 2.02, 95% CI 0.23–19.98), wound infection (OR 0.93, 95% CI 0.15–5.27), amount of crystalloids infused within the first 24 h (OR 1.00, 95% CI 0.99–1.00) and intra-abdominal sepsis (OR 1.14, 95% CI 0.35–3.80) were not.

Conclusions

There was an equivalent rate of septic complications and primary fascial closure rates regardless of cause for DCL. Intra-abdominal abscess, worse base deficit and higher number of abdominal explorations were independently associated with the lack of primary fascial closure.     

Repair of vesicovaginal fistula by the transabdominal route: outcome at a north Indian tertiary hospital

Introduction and hypothesis  

The purpose of this study is to present the outcome of management of vesicovaginal fistula (VVF) by the transabdominal route.     

Malignant Transformation in Perianal Fistulas of Crohn’s Disease: a Systematic Review of Literature

Introduction  

Malignant transformation of perineal fistula in Crohn’s disease has rarely been reported. The aim of this study is to define the patient’s characteristics and clinical presentation of this rare disease.     

Determination of protein phosphatase type 2A in monocytes from multiple trauma patients: a potential biomarker for sepsis

Background

Protein phosphatase type 2A (PP2A) can downregulate c-Jun N-terminal kinase (JNK) expression in monocytes stimulated by lipopolysaccharide. However, this effect has not been evaluated in patients with sepsis. We sought to determine whether PP2A/JNK pathway is involved in sepsis and whether PP2A expression can be associated with patient outcome.

Materials and methods

We measured PP2A, c-Jun, and JNK protein as well as PP2A and c-Jun messenger RNA in monocytes from trauma patients with (n = 24) or without (n = 22) sepsis 1 and 7 d after major trauma and from healthy volunteers (n = 15) by Western blotting and quantitative real-time polymerase chain reaction. Patient outcomes, including intensive care unit length of stay, Sequential Organ Failure Assessment score, and Multiple Organ Dysfunction score were compared between groups. Correlations between PP2A and c-Jun/JNK expression as well as patient outcomes were analyzed. Receiver operating characteristic analysis was performed to determine the diagnostic efficiency of PP2A for sepsis.

Results

PP2A protein and messenger RNA expression were significantly higher in septic patients compared with nonseptic patients or healthy volunteers. Conversely, the expressions of JNK and c-Jun were significantly reduced in septic patients and correlated inversely with PP2A expression. Furthermore, PP2A expression was positively associated with LOS, Sequential Organ Failure Assessment and Multiple Organ Dysfunction score at day 1 and day 7. Receiver operating characteristic curve yielded a high sensitivity (87.5%) of PP2A in discriminating septic versus nonseptic patients.

Conclusions

PP2A may serve as a negative regulator of the JNK pathway and a biomarker for sepsis.     

Outcome and functional prognosis of pelvic sepsis after ileal pouch-anal anastomosis in patients with ulcerative colitis

Purpose

Restorative proctocolectomy with ileal pouch-anal anastomosis is a surgical procedure for ulcerative colitis, but pouch failure or pelvic sepsis still occurs in some patients. We conducted this study to investigate the cause of pouch failure and evaluate defecatory function after pelvic sepsis.

Methods

A total of 234 patients who underwent restorative proctocolectomy were enrolled. We analyzed the cause of pouch failure, as well as defecatory function and manometric outcomes, with and without the complication of pelvic sepsis.

Results

Pelvic sepsis developed in 29 (12.3%) of the 234 patients who underwent restorative proctocolectomy (pelvic sepsis group). The pelvic sepsis led to pouch failure in two of these patients (as a vaginal fistula in one and ileo-anal anastomotic leakage in one). Of the remaining majority of patients who did not suffer pelvic sepsis (control group), nine suffered pouch failure (as vaginal fistula in four, perianal abscess in two, pouch-spinal marrow fistula in one, and chronic pouchitis in two). There were no significant differences in defecatory function or manometric outcomes between the two groups. In the pelvic sepsis group, stool frequency was significantly correlated with white blood cell count (P = 0.01) and the duration until onset of pelvic sepsis (P < 0.01).

Conclusions

Pelvic sepsis after restorative proctocolectomy for ulcerative colitis does not affect defecatory and manometric function, but control of the inflammation caused by pelvic sepsis is integral for defecatory function.

     

Does Increased Experience with Isolated Limb Infusion for Advanced Limb Melanoma Influence Outcome? A Comparison of Two Treatment Periods at a Single Institution

Background  

Isolated limb infusion (ILI) with cytotoxic drugs has been used since 1992 to treat advanced melanoma confined to a limb. Over this time the technique has undergone progressive modification. In this study we evaluated our experience with ILI by analyzing outcome and toxicity from an “early” and a “late” treatment period.     

Five years experience of ureterovaginal fistulae following obstetric or gynecological intervention in Ethiopia

Objectives  

To study the etiology, presentation and outcome of women presenting to the Addis Ababa Fistula Hospital with an ureterovaginal fistula.     

Recovery from paraplegia after the treatment of spinal dural arteriovenous fistula: case report and review of the literature

Background  

Spinal dural arteriovenous fistula (SDAVF) is a rare and enigmatic disease. Functional outcome is particularly uncertain for the small group of patients that are unable to stand at the time of diagnosis (grade 5 gait disturbance on the Aminoff-Logue scale, ALS). The objective of this study is to examine the final functional outcome of patients with SDAVF in grade 5 gait ALS before treatment.     

CD16 inhibition increases host survival in a murine model of severe sepsis

Background

To investigate the therapeutic effect of monoclonal antibody (mAb)–induced CD16 (FcγRIII) inhibition in a murine model of high-grade (severe) sepsis.

Materials and methods

In a prospective controlled animal study, 2 μg of CD16/32 (FcγRIII/FcγRII) or the same volume of normal saline was administered intraperitoneally to BALB/c FcγRII^−/− mice at the time of cecal ligation and puncture (CLP) in a murine model of high-grade sepsis. Subcutaneous administration of CD16/32 (0.5 μg/24 h) or normal saline continued for 7 d. Survival was evaluated, and the underlying therapeutic mechanism of mAb-induced CD16 inhibition was investigated.

Results

CD16 expression was significantly increased on peripheral blood CD14⁺ monocytes from mice with high-grade sepsis compared with non–septic control mice (1579.40 ± 217.75 versus 461.10 ± 36.13; P < 0.05). CD16/32 mAb treatment increased the survival of mice with high-grade sepsis (P < 0.05) and significantly decreased their elevated levels of serum tumor necrosis factor α (36.70 ± 9.97 versus 52.60 ± 10.69; P < 0.05) and interleukin 1β (1149.40 ± 244.09 versus 2605.60 ± 353.74; P < 0.05) at 6 and 24 h after CLP, respectively. Moreover, CD16/32 mAb-treated mice with high-grade sepsis had fewer bacteria in their blood and peritoneal lavage than mice just treated with normal saline at 24 h after CLP (P < 0.05).

Conclusions

CD16/32 mAb-induced CD16 inhibition increased the survival of mice with high-grade sepsis, which may have been because of the concomitant suppression of tumor necrosis factor α and interleukin 1β as well as the enhancement of monocyte phagocytosis. Thus, targeted inhibition of CD16 can potentially improve the outcome of selected patients with severe sepsis.     

Duration of Time on Intensive Insulin Therapy Predicts Severe Hypoglycemia in the Surgically Critically Ill Population

Background  

Hypoglycemia has emerged as a barrier to the practice of intensive insulin therapy. Current literature suggests that hypoglycemia occurs at variable rates and has different effects on outcomes in surgical and medical populations. We sought to determine the incidence, independent predictors, and effect on outcome of severe hypoglycemia (≤ 40 mg/dl) in a surgical population.     

C-reactive protein as predictor for poor outcome after aneurysmal subarachnoid haemorrhage

Background  

Aneurysmal subarachnoid haemorrhage (SAH) is a severe disease with high case-fatality and morbidity rates. After SAH, the value of C-reactive protein (CRP)—an acute phase sensitive inflammatory marker—as a prognostic factor has been poorly studied, with conflicting results. In this prospective study, we tested whether increased CRP levels increase independently the risk for cerebral infarct and poor outcome.     

Treatment Strategies in 135 Consecutive Patients with Enterocutaneous Fistulas

Background Enterocutaneous fistulas (ECF) pose a major challenge to every gastrointestinal (GI) surgeon. Based on earlier studies, a standardized treatment guideline was implemented. The focus of the present study was to assess that guideline and determine prognostic factors for outcome of patients with ECF, and to define a more detailed therapeutic approach including the convalescence time before restorative surgery. Methods All patients with ECF treated between 1990 and 2005 were included. Management consisted of controlling Sepsis, Optimization of nutritional state, Wound care, assessment of fistula Anatomy, Timing of surgery, and Surgical strategy (the SOWATS guideline). Prognostic factors were assessed by way of multiple logistic regression analysis. Results A total of 135 patients were treated at our unit. Overall closure was achieved in 118 patients (87.4%). Restorative operations for fistula closure were performed after a median of 53 days (range: 4–270 days). Restorative operations were successful in 97/107 patients (90.7%). Thirteen patients (9.6%) died. An abdominal wall defect was the most predominant negative prognostic factor for spontaneous closure (odds ratio [OR] = 0.195, confidence interval [CI] 0.052–0.726, p = 0.015). A strong relation was found between preoperative albumin level and surgical closure (p < 0.001) and mortality (p < 0.001). Conclusions Application of the SOWATS guideline allowed a favorable outcome after a short convalescence period. Abdominal wall defects and preoperative hypoalbuminemia are important prognostic variables.     

Low-frequency sampling for PRx calculation does not reduce prognostication and produces similar CPPopt in intracerebral haemorrhage patients

Background  

The cerebral pressure reactivity index (PRx) correlates with the outcome in intracerebral haemorrhage (ICH) patients and has been used to define an autoregulation-oriented “optimal cerebral perfusion pressure” (CPPopt). PRx has been calculated as a moving correlation coefficient between mean arterial pressure (MAP) and intracranial pressure (ICP) averaged over 5-10 s, using a 2.5- to 5-min moving time window, in order to reflect changes in MAP and ICP within a time frame of 20 s to 2 min. We compared PRx with a different calculation method [low-frequency PRx (L-PRx)], where rapid fluctuations of MAP and ICP are cancelled (waves with frequencies greater than 0.01 Hz).     

TVT-O versus Monarc after a 2–4-year follow-up: a prospective comparative study

Introduction and hypothesis  

The aim of this study was to compare outcome and quality of life of tension-free vaginal tape “inside-out” (TVT-O) and Monarc transobturator tapes after 2–4 years.