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In for the Long Haul: Managing the Consequences of Anastomotic Leak. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Percutaneous intestinal drainage for a refractory enterocutaneous fistula: A case report. Int J Surg Case Rep 2020; 72:564-568. [PMID: 32698289 PMCID: PMC7327875 DOI: 10.1016/j.ijscr.2020.06.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 11/30/2022] Open
Abstract
Treatment for enterocutaneous fistulas are essentially fasting, drainage, and adequate nutritional management. The effects of these drug treatments also depend on the fistula distance and the amount of discharge. Percutaneous intestinal drainage is possible to be very effective in improving skin erosion. Introduction Enterocutaneous fistulas (ECFs) that occur following gastrointestinal surgery require long-term hospitalization, and treatment may be difficult in rare cases. Although the morbidity and mortality associated with ECF have decreased with modern medical, the overall mortality is still surprisingly high, up to 30.4 %. Presentation of case The patient was a 79-year-old male who had undergone laparoscopic sigmoidoscopy for sigmoid colon cancer 5 years previously. He was newly diagnosed with sigmoid colon cancer 5 years following surgery. A laparoscopic high anterior resection was performed. On the 4th postoperative day, he was diagnosed with a suture failure which was treated conservatively; however, the fistula could not be closed, and ileostomy construction was performed. Intestinal fluid leaked from the median surgical incision, leading to the formation of a small intestinal fistula on the proximal side from the ileostomy. Conservative treatment did not improve the condition and skin erosion worsened. Two months after the stoma was constructed, a urethral balloon catheter was percutaneously inserted into the intestinal tract from the small intestinal fistula to drain the intestinal fluid. Following the maneuver, the problem of skin erosion was improved, with the resulting closure of the fistula. Discussion The basic principles underlying treatment for ECFs are essentially fasting, drainage, and adequate nutritional management. Some studies reported that the average period of negative pressure therapy was four weeks. It seems that four weeks is the breakpoint. Conclusion Percutaneous intestinal drainage for refractory ECFs following gastrointestinal surgery is minimally invasive and is likely to be extremely useful.
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Abstract
The development of new endoscopic techniques, such as gastrointestinal (GI) stenting, full-thickness suturing, clip application, and use of tissue adhesives, has had a significant impact on management of GI fistulae. These techniques have shown promising results, but further study is needed to optimize the efficacy of long-term closure. The advancement of endoscopic techniques, including the use of the lumen apposing metal stent (LAMS), has allowed for the deliberate creation of fistula tracts to apply endoscopic therapy that previously could not be achieved. This article examines the rapidly evolving area of endoscopic fistula closure and its relationship to LAMS.
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Affiliation(s)
- Jaehoon Cho
- Department of Internal Medicine, Los Angeles County and University of Southern California Medical Center, 2020 Zonal Avenue, IRD 620, Los Angeles, CA 90033, USA
| | - Ara B Sahakian
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, 1510 San Pablo Street, Los Angeles, CA 90033, USA.
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Coccolini F, Montori G, Ceresoli M, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Sartelli M, De Moya M, Velmahos G, Fraga GP, Pereira BM, Leppaniemi A, Boermeester MA, Kirkpatrick AW, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Martin-Loeches I, Sugrue M, Di Saverio S, Griffiths E, Soreide K, Mazuski JE, May AK, Montravers P, Melotti RM, Pisano M, Salvetti F, Marchesi G, Valetti TM, Scalea T, Chiara O, Kashuk JL, Ansaloni L. The role of open abdomen in non-trauma patient: WSES Consensus Paper. World J Emerg Surg 2017; 12:39. [PMID: 28814969 PMCID: PMC5557069 DOI: 10.1186/s13017-017-0146-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | | | - Rao Ivatury
- Trauma Surgery, Virginia Commonwealth University, Richmond, VA 23284 USA
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI 96813 USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, 15213 USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, 92103 USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Marc De Moya
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM) – Unicamp Campinas, São Paulo, Brazil
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, 98104 USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | | | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ewen Griffiths
- Upper Gatrointestinal Surgery, Birmigham Hospital, Birmigham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, MO 63130 USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | | | - Michele Pisano
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Trauma Surgery department, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy
| | - Jeffry L. Kashuk
- General Surgery department, Assuta Medical Centers, Tel Aviv, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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Effect of Oral ω3-Polyunsaturated Fatty Acids as a Complement Management to Control Fistula Output and Inflammation in Patients With Digestive Fistula. J Gastrointest Surg 2017; 21:453-462. [PMID: 27909869 DOI: 10.1007/s11605-016-3333-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/17/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The presence of digestive fistula involves chronic inflammation and fibrosis. It has been reported that ω3-polyunsaturated fatty acids stimulate the resolution of inflammation. AIM Determine if the administration of oral ω3 reduces fistula output and the time required for fistula closure. METHODS Forty-nine patients with postoperative fistula were randomly divided in two groups: 26 received conventional treatment and 23 received the conventional treatment supplemented with ω3 (540 mg eicosapentaenoic acid and 360 mg docosahexaenoic acid) for 35 days. Patients were monitored daily for fistula output and spontaneous closure. Additionally, serum pro-inflammatory cytokines and C-reactive protein were quantified in four patients with conventional and in seven patients with ω3 treatment. RESULTS Patients with ω3 had significantly decreased fistula output from days 2 to 27, compared to control (p < 0.05). Spontaneous fistula closure was achieved in 15 patients (65%) in the ω3 group and in 14 (54%) in the control group. ω3-polyunsaturated fatty intake also decreased the serum concentrations of interleukin-6 and C-reactive protein (p < 0.05). CONCLUSIONS Our results suggest that ω3 supplementation to conventional medical treatment decreases fistula output and reduces inflammation (interleukin-6 and C-reactive protein), and these effects may increase the efficiency of conventional medical treatment.
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Ashkenazi I, Turégano-Fuentes F, Olsha O, Alfici R. Treatment Options in Gastrointestinal Cutaneous Fistulas. Surg J (N Y) 2017; 3:e25-e31. [PMID: 28825016 PMCID: PMC5553539 DOI: 10.1055/s-0037-1599273] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/25/2017] [Indexed: 12/15/2022] Open
Abstract
Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.
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Affiliation(s)
- Itamar Ashkenazi
- Department of Surgery, Hillel Yaffe Medical Center, Hadera, Israel
| | | | - Oded Olsha
- Department of Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ricardo Alfici
- Department of Surgery, Hillel Yaffe Medical Center, Hadera, Israel
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Fukuchi S, Seeburger J, Parquet G, Rolandelli R. Nutrition Support of Patients With Enterocutaneous Fistulas. Nutr Clin Pract 2016. [DOI: 10.1177/088453369801300202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lyon JW, Hodde JP, Hucks D, Changkuon DI. First experience with the use of a collagen fistula plug to treat enterocutaneous fistulas. J Vasc Interv Radiol 2014; 24:1559-65. [PMID: 24070512 DOI: 10.1016/j.jvir.2013.05.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/16/2013] [Accepted: 05/17/2013] [Indexed: 11/28/2022] Open
Abstract
This report describes the authors' first experiences with the use of the Biodesign Enterocutaneous Fistula Plug (EFP). Six patients presented with intraperitoneal abscess and associated chronic bowel fistulas. The fistulas were treated by delivering an EFP by using radiologic guidance. The EFP placement procedure was successfully performed in all patients. All fistulas were closed within 2 weeks. Fistula recurrence occurred in two patients (33%) at 9 and 12 months after the procedure. One recurrence was associated with an adverse reaction to chemotherapy. The other was associated with the silicone flange migrating out of the bowel lumen. The Biodesign EFP offers a promising new approach for the treatment of enterocutaneous fistulas.
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Stevens P, Burden S, Delicata R, Carlson G, Lal S. Somatostatin analogues for treatment of enterocutaneous fistula. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Philip Stevens
- Salford Royal NHS Foundation Trust; Surgery; Stott Lane Salford UK M6 8HD
| | - Sorrel Burden
- University of Manchester; School of Nursing, Midwifery and Social Work; Room 6.32, Jean McFarlane Building, Oxford Road Manchester UK M13 9PL
| | - Raymond Delicata
- Gwent Healthcare NHS Healthboard ? Nevill Hall Hospital; General Surgery; Brecon Road Abergavenny UK NP7 7EG
| | - Gordon Carlson
- Salford Royal NHS Foundation Trust; General Surgery; Stott Lane Salford UK M6 8HD
| | - Simon Lal
- Salford Royal Foundation Trust; Intestinal Failure Unit; Salford UK M6 8HD
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Harris AG. Octreotide in the Treatment of Disorders of the Gastrointestinal System. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/bf03259208] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Polk TM, Schwab CW. Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach. World J Surg 2012; 36:524-33. [PMID: 22033622 DOI: 10.1007/s00268-011-1315-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The care and outcome of enterocutaneous fistula (ECF) have improved greatly over several decades due to revolutionary advances in nutrition, along with dramatic improvements in the treatment of sepsis and the critically ill. However, as the collective experience with damage control surgery has matured, the frequent development of enteroatmospheric fistula (EAF) in the "open abdomen" patient has emerged as an even more vexing problem. Despite our best efforts, ECF and especially EAF continue to be highly morbid conditions, and sepsis and malnutrition remain the leading causes of death. Aggressive nutritional and metabolic support is the most significant predictor of outcome with ECF and EAF. RESULTS Discussion of the historical advances in nutritional therapy and their impact on ECF, as well as review of the classification of ECF and EAF, provides a framework for the suggested phased strategy that specifically targets the nutritional and metabolic needs of the ECF/EAF patient. These three phases include (1) diagnosis, resuscitation, and early interval nutrition; (2) definition of fistula anatomy, drainage of collections, nutritional assessment and monitoring, and placement of feeding access; and (3) definitive nutritional management, including pharmacologic adjuncts. Early nutritional support with parenteral nutrition followed by transition to enteral nutrition is advocated, including the merits of delivery of enteral nutrition via the fistula itself, known as fistuloclysis. CONCLUSION Aggressive nutritional therapy is necessary to reverse the catabolic state associated with ECF/EAF patients. Once established, it allows proper time, preparation, and planning for definitive management of the fistula, and in many cases provides the support for spontaneous closure.
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Affiliation(s)
- Travis M Polk
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
Enteroatmospheric fistula (EAF), a special subset of enterocutaneous fistula (ECF), is defined as a communication between the gastrointestinal (GI) tract and the atmosphere. It is one of the most devastating complications of "damage control" laparotomy (DCL) and results in significant morbidity and mortality. The published incidence of EAF ranges from 5%-19% of patients who have undergone DCL and survived long enough to develop complications. Their etiology is complex and ranges from persistent abdominal infection, anastomotic leakage, adhesions of the bowel to itself or fascia, and repeated bowel manipulation during return trips to the operating room or dressing changes. Prevention is clearly the best treatment strategy but may be difficult to achieve. Once an EAF occurs, immediate management consists of treatment of sepsis if present; nutrition, fluid, and electrolyte support in the form of parenteral nutrition (PN); and wound/effluent control and protection of surrounding tissues and exposed bowel. It should be noted that EAF almost never close spontaneously, and definitive repair usually requires major surgical intervention and abdominal wall reconstruction 6 to 12 months after the original insult. Enteral feeding should be attempted once the anatomy of the EAF is defined and reliable enteral access is obtained. Most patients can tolerate some amount of enteral and even oral feeding and do not need to be maintained on PN alone. Professional judgment, experience, and teamwork are key to successfully managing the patient with EAF.
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Affiliation(s)
- Sarah Majercik
- Sarah Majercik, MBA, Department of Trauma and Surgical Critical Care, Intermountain Medical Center, Murray, UT 84157, USA.
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Degremont R, Brehant O, Fuks D, Sabbagh C, Dhahri A, Browet F, Mahjoub Y, Regimbeau JM. Management of supra-mesocolic peritonitis using the Levy helicoid drain (Hélisonde®). J Visc Surg 2011; 148:e291-e298. [PMID: 21872548 DOI: 10.1016/j.jviscsurg.2011.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Postoperative peritonitis arising in the upper abdomen requiring reoperative surgery has a mortality rate of up to 50%. One therapeutic modality for these patients is the use of the Hélisonde(®) drain, designed by Levy, the Levy Helical Drain (LHD), but it has not seen widespread use. In this paper, we describe our experience in managing supramesocolic peritonitis with this drain at the University Surgical Center at Amiens and we analyze our results. PATIENTS AND METHODS Between 2005 and 2010, we cared for 190 patients with supramesocolic peritonitis in our unit. Of these, 22 patients with gastric or duodenal fistula underwent transorificial intubation with the LHD. There were 12 men and 10 women with a mean age of 66 years. At surgery, the helical drain was screwed into the fistular orifice, two more flat drains were left adjacent to the fistula, and a jejunal feeding tube was placed. The mean interval between the initial surgery and the drainage procedure was 16.1 ± 14 days. RESULTS The mean APACHE II score was 20 (10-28). The Mannheim score averaged 28 (19-34). The LHD was completely removed at a mean interval of 35.5 ± 11 days. Six patients (27%) died postoperatively. Postoperative complications included intraperitoneal abscess (n = 3), pneumonia (n=1), and evisceration (n = 2). Two patients required reoperation. The average hospital stay was 70.7 days. Four patients had a persistent chronic fistula. CONCLUSION The LHD is a useful technical device in the treatment of supramesocolic peritonitis. Its management requires close oversight.
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Affiliation(s)
- R Degremont
- Service de chirurgie viscérale et digestive, CHU Nord-Amiens, université de Picardie, place Victor-Pauchet, 80054 Amiens cedex 01, France
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Degremont R, Brehant O, Fuks D, Sabbagh C, Dhahri A, Browet F, Mahjoub Y, Regimbeau JM. Prise en charge des péritonites sus-mésocoliques postopératoires par drainage de Lévy (drain Hélisonde®). JOURNAL DE CHIRURGIE VISCÉRALE 2011; 148:327-335. [DOI: 10.1016/j.jchirv.2011.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2025]
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Abstract
Management of enterocutaneous fistulas (ECFs) involves (1) recognition and stabilization, (2) anatomic definition and decision, and (3) definitive operation. Phase 1 encompasses correction of fluid and electrolyte imbalance, skin protection, and nutritional support. Abdominal imaging defines the anatomy of the fistula in phase 2. ECFs that do not heal spontaneously require segmental resection of the bowel segment communicating with the fistula and restoration of intestinal continuity in phase 3. The enteroatmospheric fistula (EAF) is a malevolent condition requiring prolonged wound care and nutritional support. Complex abdominal wall reconstruction immediately following fistula resection is necessary for all EAFs.
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Affiliation(s)
- William P Schecter
- Department of Surgery, University of California, San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, Ward 3A17, San Francisco, CA 94110, USA.
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Lewis RT, Maron DJ. Efficacy and complications of surgery for Crohn's disease. Gastroenterol Hepatol (N Y) 2010; 6:587-596. [PMID: 21088749 PMCID: PMC2976865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Patients with Crohn's disease commonly undergo surgery during their lifetime. Indications for surgical intervention include obstruction, intra-abdominal or perianal abscess, enterocutaneous fistulas, and complex perianal disease. As medical therapies continue to improve, it is important that surgical therapies are chosen carefully. This is particularly important in the treatment of perianal fistulas; combined surgical and medical therapy offer the best chance for success. In the treatment of small-bowel disease, bowel preservation is key. For the repair of short strictures, endoscopic dilatation is the preferred method when accessible; strictureplasty has been shown to be safe and effective for increasingly longer segments of disease. Intra-abdominal abscesses should be drained percutaneously, if possible. In the presence of colonic disease, segmental resection is recommended. Unfortunately, refractory disease still frequently requires complete proctectomy and permanent diversion.
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Affiliation(s)
- Robert T Lewis
- Dr. Lewis is a resident in the Department of Surgery in the University of Pennsylvania Health System in Philadelphia, Pennsylvania
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Taggarshe D, Bakston D, Jacobs M, McKendrick A, Mittal VK. Management of enterocutaneous fistulae: A 10 years experience. World J Gastrointest Surg 2010; 2:242-6. [PMID: 21160881 PMCID: PMC2999248 DOI: 10.4240/wjgs.v2.i7.242] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 07/13/2010] [Accepted: 07/20/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes of conservative vs surgical treatment of enterocutaneous fistulae (ECF) in a community teaching hospital over a decade.
METHODS: All cases of ECF between 1997 and 2007 were reviewed for management strategy.
RESULTS: Of the 83 patients with ECF, 60 (72%) were postoperative. Sixty-six patients (79.5%) were treated initially with conservative measures. Eighteen patients failed to respond to conservative treatment and required later (secondary) exploration; this group consisted of an equal number of low vs high output fistulae. Seventeen (20.5%) patients underwent initial (primary) definitive-surgery secondary to anastomotic leak and peritonitis. Surgical procedures included resection of ECF with anastomosis (24), exclusion (6) and direct-drainage (4). No significant difference was seen in the recurrence rate for conservative (10%) vs operative-treatment (20%).
CONCLUSION: Conservative treatment plays a pivotal role as an initial management in both low and high output fistulae. In selective cases only, early primary exploration is recommended.
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Affiliation(s)
- Deepa Taggarshe
- Deepa Taggarshe, Daniel Bakston, Michael Jacobs, Alasdair McKendrick, Vijay K Mittal, Department of Surgery, Providence Hospital and Medical Centers, 16001 West Nine Mile Road, Southfield, MI 48075, United States
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Abstract
Despite improvements in healthcare delivery, mortality rates for high-output fistulae remain unchanged. The pathophysiology and causes of fistulae are reviewed in this article. An overview of the diagnostic procedures to delineate fistulae and underlying bowel disease together with their complications is included. Management of high-output fistulae consists of assessment and stabilization of patients, followed by conservative management by a multidisciplinary team until spontaneous or surgical closure of fistulae.
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Affiliation(s)
- Naila Arebi
- Department of Medicine, St. Mark's Hospital, Harrow, Middlesex, United Kingdom
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Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM, Wexner SD, Dudrick SJ. Enteric fistulas: principles of management. J Am Coll Surg 2009; 209:484-91. [PMID: 19801322 DOI: 10.1016/j.jamcollsurg.2009.05.025] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 05/11/2009] [Accepted: 05/12/2009] [Indexed: 12/17/2022]
Affiliation(s)
- William P Schecter
- Department of Surgery, University of California-San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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Zarzour JG, Christein JD, Drelichman ER, Oser RF, Hawn MT. Percutaneous transhepatic duodenal diversion for the management of duodenal fistulae. J Gastrointest Surg 2008; 12:1103-9. [PMID: 18172607 DOI: 10.1007/s11605-007-0456-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 11/29/2007] [Indexed: 01/31/2023]
Abstract
PURPOSE The aim of this study was to determine the success of the nonoperative management of persistent duodenal fistulae (DF) with percutaneous transhepatic duodenal diversion (PTDD). METHODS Retrospective chart review identified six patients with DF managed by PTDD from 2006 to 2007. Patient outcomes and complications were assessed. RESULTS The etiology of DF included pancreatic surgery (three patients), gastrectomy (two patients), and Crohn's disease (one patient). PTDD was performed by interventional radiology at a median time of 37 days after fistula recognition. After PTDD, fistula drainage decreased from 775 cc/day (range 200 to 2,525 cc/day) to <50 cc/day at a median of 8 days. Patients were discharged 32 days (median) after PTDD. One patient with Crohn's disease required definitive surgical treatment. Of the remaining five patients, the PTDD tube was capped at 27 days (median) after placement and was removed on an outpatient basis at 79 days (median) after placement. There was no mortality, no fistula recurrence, or complications associated with PTDD placement. CONCLUSIONS We present an algorithm for the nonoperative management of persistent postoperative DF. In this limited series, PTDD was highly effective at definitively treating DF, especially in the acute setting. PTDD should be considered by surgeons facing the management of postoperative DF.
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Affiliation(s)
- Jessica G Zarzour
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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22
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Colak T, Dag A, Turkmenoglu O, Polat A, Comelekoglu U, Bagdatoglu O, Polat G, Akca T, Sucullu I, Aydin S. The effect of octreotide on healing of injured colonic anastomosis with immediate postoperative intraperitoneal administration of 5-Fluorouracil. Dis Colon Rectum 2007; 50:660-9. [PMID: 17216142 DOI: 10.1007/s10350-006-0810-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to investigate the effect of octreotide on side effects of immediate usage of 5-fluorouracil after colonic anastomosis. METHODS Forty male Wistar rats were randomly assigned into four groups and underwent standardized left colonic anastomosis. The rats served as control or received intraperitoneal 5-fluorouracil (20 mg/kg daily), subcutaneous octreotide (20 mug/kg daily), or both. Diarrhea and wound complications were noted during the experiment. The colonic anastomoses were assessed for healing on postoperative Day 7 by determining the anastomotic bursting pressure, performing histologic examination, and measuring the tissue hydroxyproline content, serum malondialdehyde, and nitric oxide levels. Intraperitoneal adhesions and anastomotic leakage were also noted. RESULTS No statistical significant difference was found between the control and octreotide groups for each of the parameters measured. Immediate 5-fluorouracil use resulted with higher adhesion score (P = 0.002), significant depression in anastomotic bursting pressure (P = 0.0001), histopathologic score (P = 0.0001), hydroxyproline content (P = 0.0001), and increasing nitric oxide (P = 0.0001) and malondialdehyde levels (P = 0.0001) compared with the control group. Diarrhea was seen in 80 percent of the 5-fluorouracil group but in neither the control nor octreotide groups (P = 0.0001 for each comparison). However, all these parameters were ameliorated by use of concomitant octreotide and 5-fluorouracil (P = 0.019, P = 0.023, P = 0.0001, P = 0.006, P = 0.0001, and P = 0.013, respectively). In addition, diarrhea was found to be prevented (P = 0.0001). CONCLUSIONS The results of this study showed that concomitant octreotide use might prevent the side effects of 5-fluorouracil, such as diarrhea, postoperative adhesion, and delaying the anastomotic healing parameters. In addition, it might reduce tissue damage and inflammation.
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Affiliation(s)
- Tahsin Colak
- Faculty of Medicine, Department of General Surgery, Mersin University, Tip Fakultesi Hastanesi, Zetinlibahce C., Mersin, 33097, Turkey.
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23
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Gunn LA, Follmar KE, Wong MS, Lettieri SC, Levin LS, Erdmann D. Management of Enterocutaneous Fistulas Using Negative-Pressure Dressings. Ann Plast Surg 2006; 57:621-5. [PMID: 17122546 DOI: 10.1097/01.sap.0000228966.13979.1c] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Fifteen patients with enterocutaneous fistulas (ECFs) not amenable to surgical treatment were treated with negative-pressure dressings over the abdominal wound and ECF. Closure of the ECF and time to closure were examined. In 11 patients who had no visible intestinal mucosa on examination, the closure rate was 100%, with a mean time to closure of 14 days. In 4 patients who did have grossly visible intestinal mucosa, no closure occurred. This represents an overall closure rate of 73%. Fistula output rate did not have a significant effect on outcome. These results confirm the efficacy of negative-pressure dressings in the closure of ECFs. Presence or absence of visible intestinal mucosa is the single most important clinical factor when considering the use of a negative-pressure dressing in the management of a patient with ECF.
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Affiliation(s)
- Laura A Gunn
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
BACKGROUND The management of enterocutaneous fistula is challenging, with significant associated morbidity and mortality. This article reviews treatment, with emphasis on the provision and optimal route of nutritional support. METHODS Relevant articles were identified using Medline searches. Secondary articles were identified from the reference lists of key papers. RESULTS AND CONCLUSION Management of enterocutaneous fistula should initially concentrate on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output. The routine use of somatostatin infusion and somatostatin analogues remains controversial; although there are data suggesting reduced time to fistula closure, there is little evidence of increased probability of spontaneous closure. Malnutrition is common and adequate nutritional provision is essential, enteral where possible, although supplemental parenteral nutrition is often required for high-output small bowel fistulas. The role of immunonutrition is unknown. Surgical repair should be attempted when spontaneous fistula closure does not occur, but it should be delayed for at least 3 months.
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Affiliation(s)
- D A J Lloyd
- The Lennard-Jones Intestinal Failure Unit, St Mark's Hospital and Academic Institute, Harrow, UK.
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25
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Draus JM, Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula: are treatments improving? Surgery 2006; 140:570-6; discussion 576-8. [PMID: 17011904 DOI: 10.1016/j.surg.2006.07.003] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2006] [Accepted: 07/10/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND We studied the etiology, treatment, and outcome of enterocutaneous fistulas in 106 patients to evaluate our current practice and the impact of newer therapies-octreotide, wound vacuum-assisted closure (VAC), and fibrin glue-on clinical outcomes. Review of the literature and our own 1990 study indicate a mortality rate of 5% to 20% for enterocutaneous fistula, and a healing rate of 75% to 85% after definitive surgery. METHODS We reviewed all cases of gastrointestinal-cutaneous fistula from 1997 to 2005 at 2 large teaching hospitals. We identified 106 patients with enterocutaneous fistula; patients with irritable bowel disease and anorectal fistulas were excluded. RESULTS The origin of the fistula was the small bowel in 67 patients, colon in 26, stomach in 8, and duodenum in 5. The etiology of the fistula was previous operation in 81 patients, trauma in 15, hernia mesh erosion in 6, diverticulitis in 2, and radiation in 2. Of the 106 patients in the study, 31 had a high output fistula (greater than 200 mL/day), 44 had a low output fistula, and, in 31 patients, the fistula output was low but there was no record of volume. Initial treatment was nonoperative except for patients with an abscess who needed urgent drainage. In 24 patients, the effect of octreotide was monitored: in 8 patients, fistula output declined; in 16 patients, octreotide was of no benefit. Fibrin glue was used in 8 patients and was of benefit to 1. The wound VAC was used in 13 patients: 12 patients still required operative repair of the fistula, whereas the fistula was healed in 1 patient. The main benefit of the VAC system was improved wound care in all patients before definitive surgery. Total parenteral nutrition was used in most patients to provide nutritional support. Operative repair was performed in 77 patients and was successful in 69 (89%), failing in 6 patients with persistent cancer or infection. Nonoperative treatment was used in 29 patients and resulted in healing in 60%. Of 106 patients, 7 (7%) died of fistula complications. The cause of death was persistence or recurrence of cancer in 4 patients and persistent sepsis in 3. CONCLUSION Enterocutaneous fistula continues to be a serious surgical problem. The wound VAC and fibrin glue had anecdotal successes (n = 2), and one-third of patients responded to octreotide. We believe that octreotide should be tried in most patients and that the wound VAC has a role in selected patients. Although 7% overall mortality is lower than in previous studies, the number managed without operation (27%) remains the same. In addition to early control of sepsis, nutritional support, and wound care, a well-timed operation was the most effective treatment.
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Affiliation(s)
- John M Draus
- Department of Surgery, University of Louisville, KY, USA
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26
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Ramón Rábago L, Moral I, Delgado M, Guerra I, Quintanilla E, Castro JL, Llorente R, Martínez Veiga JL, Gea F. [Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:390-396. [PMID: 16938253 DOI: 10.1157/13091451] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We summarize our experience of endoscopic treatment of gastrointestinal fistulas with fibrin glue. PATIENTS AND METHOD We retrospectively reviewed the outcome of 30 patients with gastrointestinal fistulas (9 internal and 21 external) refractory to standard conservative treatment for at least 10 days. Once the fistula was endoscopically located, 4 to 8 ml of reconstituted fibrin glue (Tissucol 2.0) at 37 degrees C was injected through a Duplocath catheter on a weekly basis. RESULTS The mean age was 59 years (32-87) and 63% were men. A total of 21.9% of the patients had high output fistulas. We were able to find all fistular orifices what were located close to the surgical anastomosis. Healing time was 17 days (4-90); 2.8 sessions were required per patient (1-5) but only 2.3 sessions were required in responders. Complete sealing of fistulas was achieved in 75%; (80% in low-output, 25% in high-output and 55.5% in internal fistulas). The frequency of fistula recurrence was 3.3%. No complications related to the sealing procedure were found. Overall mortality was 10%, but only 6.6% was related to persistence of the fistula. CONCLUSIONS Endoscopic treatment of fistulas with biological glue has a high success rate in sealing without complications, helping to speed up the healing process and reduce costs, particularly in low-output enterocutaneous fistulas.
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Affiliation(s)
- Luis Ramón Rábago
- Sección de Digestivo. Hospital Severo Ochoa. Leganés. Madrid. España.
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27
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Abstract
Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.
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Affiliation(s)
- Choon-Kiat Ho
- Department of General Surgery, University of HeidelbergGermany
| | - Jörg Kleeff
- Department of General Surgery, University of HeidelbergGermany
| | - Helmut Friess
- Department of General Surgery, University of HeidelbergGermany
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28
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de Castro SMM, Busch ORC, Gouma DJ. Management of bleeding and leakage after pancreatic surgery. Best Pract Res Clin Gastroenterol 2004; 18:847-64. [PMID: 15494282 DOI: 10.1016/j.bpg.2004.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pancreatic surgery has advanced considerably during the past decades. Recent studies report reduced morbidity rates and virtually no mortality after resection. However, postoperative complications are still a formidable menace. In this chapter we discuss the management of postoperative bleeding and leakages which are considered the most feared complications, and discuss the advent of minimal invasive methods for management of these complications. Patients who develop postoperative bleeding almost always present with septic complications and a sentinel bleed before onset of bleeding. These patients should undergo early diagnostic angiography followed by embolisation. If this does control the bleeding an emergency laparotomy should be performed as last resort. Patients who develop pancreatic leakage are generally managed conservatively by means of percutaneous drainage. Aggressive surgery should be performed at the first sign of severe sepsis. The condition of the pancreatic remant found during reoperation dictates the type of surgical intervention best performed.
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Affiliation(s)
- S M M de Castro
- Department of Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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29
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Yildiz S, Uluutku H, Gunay A, Yildirim I, Yildirim S, Gurbuz AK. The effect of hyperbaric oxygen therapy on the adverse effects of octreotide on wound healing. Eur J Gastroenterol Hepatol 2004; 16:475-8. [PMID: 15097040 DOI: 10.1097/00042737-200405000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Octreotide, a long-acting somatostatin analogue, has been used in the treatment of various disorders. Octreotide has significant detrimental impacts upon wound healing. We tested the hypothesis that hyperbaric oxygen therapy may overcome octreotide-mediated suppression of wound healing. DESIGN Prospective, randomised, parallel-group animal study. METHODS Operated rats were divided into four groups: (1) controls, (2) octreotide therapy, (3) hyperbaric oxygen therapy and (4) combination of octreotide and hyperbaric oxygen therapy. Wound healing was assessed by breaking-strength measurements, hydroxyproline levels and fibrosis scores. RESULTS Octreotide decreased the breaking-strength measurements, hydroxyproline levels and fibrosis scores to 72%, 88% and 55%, respectively, of the control group. In the combination group, hyperbaric oxygen therapy increased breaking-strength measurements and hydroxyproline levels to 137% and 126%, respectively, of the control group. In the combination group, hyperbaric oxygen therapy tended to increase the fibrosis scores to 111% of the control group, but without statistical significance. CONCLUSION Hyperbaric oxygen therapy tends to reverse the octreotide-induced impairment of wound healing.
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Affiliation(s)
- Senol Yildiz
- Department of Sea and Underwater Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey.
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30
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Affiliation(s)
- Janice B Heikenen
- Department of Pediatrics, Marshfield Clinic, Marshfield, Wisconsin 54449, USA.
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31
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Schultz DJ, Brasel KJ, Spinelli KS, Rasmussen J, Weigelt JA. Porcine small intestine submucosa as a treatment for enterocutaneous fistulas. J Am Coll Surg 2002; 194:541-3. [PMID: 11949759 DOI: 10.1016/s1072-7515(02)01119-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- David J Schultz
- Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA
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32
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Abstract
There are two common types of adult patient with a short bowel, those with jejunum in continuity with a functioning colon and those with a jejunostomy. Both groups have potential problems of undernutrition, but this is a greater problem in those without a colon, as they do not derive energy from anaerobic bacterial fermentation of carbohydrate to short chain fatty acids in the colon. Patients with a jejunostomy have major problems of dehydration, sodium and magnesium depletion all due to a large volume of stomal output. Both types of patient have lost at least 60 cm of terminal ileum and so will become deficient of vitamin B12. Both groups have a high prevalence of gallstones (45%) resulting from periods of biliary stasis. Patients with a retained colon have a 25% chance of developing calcium oxalate renal stones and they may have problems with D (-) lactic acidosis. The survival of patients with a short bowel, even if they need long-term parenteral nutrition, is good.
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Affiliation(s)
- J M Nightingale
- Gastroenterology Centre, Leicester Royal Infirmary, United Kingdom.
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33
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Hesse U, Ysebaert D, de Hemptinne B. Role of somatostatin-14 and its analogues in the management of gastrointestinal fistulae: clinical data. Gut 2001; 49 Suppl 4:iv11-21. [PMID: 11878789 PMCID: PMC1766896 DOI: 10.1136/gut.49.suppl_4.iv11] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Somatostatin-14 and its analogue octreotide both exert inhibitory effects on gastrointestinal secretions and may therefore be beneficial in the treatment of gastrointestinal fistulae. There are no studies that have compared these two drugs directly and hence this paper aims to review studies that are available for each drug. There are only six controlled studies that have examined the effects of somatostatin-14 and octreotide on fistula output reduction, three for each drug. All studies compared conservative therapy and the drug in combination with conservative therapy. Of the somatostatin-14 studies, two showed a significant effect on output (p<0.05) and the other demonstrated an output reduction on day 1 that was twice that in the control group (NS). Of the octreotide studies, one showed a significant effect (p<0.01) and the other two showed no effect of the drug on output. No study with either drug has demonstrated an increase in the number of patients that have achieved closure. However, a positive effect on the time to achieve closure has been found. Of the five controlled studies with somatostatin-14, all showed a significant reduction in time to closure. Of the two controlled studies with octreotide, one showed a significant reduction (p=0.002) and the other showed no difference. Due to the limited number of trials, a definitive evaluation of the efficacies of somatostatin-14 and octreotide in the treatment of gastrointestinal fistulae is not possible. However, currently available information seems to suggest a considerable benefit of somatostatin-14 when administered in association with standard conservative treatment, but this needs to be confirmed in a large prospective controlled study.
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Affiliation(s)
- U Hesse
- Department of Surgery, Ghent University Hospitals, Heelkundige Kliniek, Universitair Ziekenhuis, Gent, Belgium.
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34
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Rodríguez Santiago J, Targarona EM, Ros E, Martínez J, Poca E, Vela M, Massó J, Nadal A, Marco C, Trias M. [Increased bile lithogenicity after simultaneous total parenteral nutrition and octrotide. A model of calcium palmitate Gallstones]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:321-6. [PMID: 11481065 DOI: 10.1016/s0210-5705(01)70186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Gallbladder stasis and gallstone formation are well-known complications of both fasting-associated total parenteral nutrition (TPN) and long-term treatment with octreotide. Additive noxious effects to hepatobiliary function may develop when both therapies are given together as treatment of enteric fistulae. The aim of this study was to assess the risk of gallstone formation during treatment with TPN and octreotide separately and in combination. We studied four groups of New Zealand rabbits (n = 32) during a 2-week intervention period: 14 chow-fed controls; 6 fasted and TPN-fed; 6 chow-fed and administered octreotide, and 6 fasted and treated with both TPN and octreotide. After treatment, the bile duct was cannulated and the gallbladder and liver tissue were obtained for histological analysis. Hepatic and gallbladder bile were retrieved for microscopic examination and measurement of biliary lipids, bilirubin, calcium, total protein, and cholesterol nucleation time. The chemical composition of gallstones was also analyzed. The results of the study suggest that simultaneous administration of these two therapies in rabbits has additive effects on gallbladder stasis and bile lithogenicity. The administration of both treatments can play an important role in the formation of calcium palmitate gallstones in these animals.
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Affiliation(s)
- J Rodríguez Santiago
- Servicio de Cirugía General, Hospital Mutua de Terrassa, Universidad de Barcelona, Spain
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35
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Sales JP, Gayral F. [Role of somatostatins in the preventin of pancreatic fistulae and the treatment of digestive fistulae]. ANNALES DE CHIRURGIE 2000; 125:929-35. [PMID: 11195921 DOI: 10.1016/s0003-3944(00)00401-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Somatostatin and analogues exert an extraordinary range of inhibitory effects which eventually may have a variety of therapeutic applications. Treatment of intestinal and pancreatic fistula are the main targets in general and digestive surgery. The perioperative and prophylactic application of somatostatin or octreotide in patients who undergo major pancreatic surgery reduces the postoperative complication rate. This prevention seems indicated following Whipple procedure in patients with soft pancreatic tissue. The efficacy of somatostatin or analogues in the treatment of intestinal or pancreatic fistulae is still in debate. Fistula output frequently decreases but closure rate, healing time and complications rate are not reduced. The treatment and care of patients with high output fistulae may be simplified by somatostatin or analogues if a positive effect on output is obvious in the first days of treatment.
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Affiliation(s)
- J P Sales
- Service de chirurgie générale, CHU de Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France.
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36
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Abstract
Enterocutaneous fistulas (ECFs) are a complex topic in terms of classification. ECF-related morbidity and mortality can be high due to fluid loss and electrolyte imbalance, sepsis, and malnutrition. Most prognostic factors influencing the outcome of ECF are now well-known. ECF treatment is complex; and, based on various situations, it can be surgical or conservative/ medical. Depending on fistula site and nutritional status, clinicians have to decide whether total parenteral or enteral nutrition should be established. In cases where total parenteral nutrition alone for 7 days has failed to influence the high output fistulas, overall data support the use of adjuvant drug, somatostatin, or its synthetic analogue, octreotide. Somatostatin 250 microg/d and octreotide 300-600 microg/d have been tried along with total parenteral nutrition to decrease the healing time of ECFs and to reduce the number of complications.
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Affiliation(s)
- Z A Makhdoom
- Section of Gastroenterology/Nutrition, Penn State Geisinger Medical Center, Danville, Pennsylvania 17822, USA.
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37
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Hyon SH, Martinez-Garbino JA, Benati ML, Lopez-Avellaneda ME, Brozzi NA, Argibay PF. Management of a high-output postoperative enterocutaneous fistula with a vacuum sealing method and continuous enteral nutrition. ASAIO J 2000; 46:511-4. [PMID: 10926156 DOI: 10.1097/00002480-200007000-00028] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A postoperative enterocutaneous fistula is one of the most complex medical problems. Its treatment may become long-lasting, wearisome, and its outcome often is disappointing. Here, we describe the use of a novel device to treat a 67-year-old patient with a postoperative, high-output enterocutaneous fistula. A semipermeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic polymer covered with a self-adherent surgical sheet. To set up the system, we constructed a vacuum chamber equipped with precision instruments that supplied subatmospheric pressures between 350 and 450 mm Hg. The intestinal content was, thus, kept inside the lumen, restoring bowel transit and physiology. The fistula output was immediately reduced from a median of 800 ml/day (range, 400-1,600 ml/day), to a median of 10 ml/day (range, 0-250 ml/day), which was readily collected by the apparatus. Oral feeding was reinitiated while both parenteral nutrition and octreotide were withdrawn. No septic complications occurred, and the perifistular skin stayed protected from irritating intestinal effluents. Both the fistula orifice and the wound defect fully healed after 50 days of treatment. We believe this method may serve as a useful tool to treat selected cases of high-output enterocutaneous fistulas without the need for octreotide or parenteral nutrition.
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Affiliation(s)
- S H Hyon
- Department of Surgery, Hospital Italiano de Buenos Aires, Argentina
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38
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Cunningham JD, Weyant MT, Levitt M, Brower ST, Aufses AH. Complications requiring reoperation following pancreatectomy. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1998; 24:23-9. [PMID: 9746886 DOI: 10.1007/bf02787527] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CONCLUSIONS In this series, the overall reoperative rate following pancreatic surgery is 9%. Complications following pancreatectomy that require reoperation fall into four categories: hemorrhage, infectious, delayed gastric emptying, and anastomotic leak. A delay in the management of these types of complications can be fatal. BACKGROUND Despite the improvement in the morbidity and mortality rates associated with pancreatic resection, complication still arise that require surgical intervention. This study reviews the pancreatic surgical experience at a major medical center to determine the overall reoperative complication rate. STUDY DESIGN From 1985 to 1995, 107 patients underwent pancreatic resection. There were 50 pancreaticoduodenectomies, 20 total pancreatectomies, and 37 distal pancreatectomies for 102 periampullary or pancreatic cancers and five for chronic pancreatitis. The operative mortality rate was 6.5% and the morbidity rate was 43%. Ten patients (9%) developed complications that required reoperation. RESULTS Re-exploration was performed in five patients for hemorrhage. Four patients had bleeding intra-abdominally and one had a suture line bleed. One patient developed a wound infection and fascial necrosis which necessitated reoperation. Three patients were explored for sepsis and one was found to have a pancreatic leak. One patient had persistent gastric outlet obstruction and he required conversion of the gastrojejunostomy to a Roux-en-y anastomosis. The mortality rate for re-exploration was 3/10 (30%).
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Affiliation(s)
- J D Cunningham
- Department of Surgery, Mount Sinai Medical Center, One Gustave Levy Place, New York, NY, USA
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39
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Türkçapar AG, Demirer S, Sengül N, Ersöz S, Kuterdem E, Renda N, Kuzu I. The adverse effects of octreotide on the healing of colonic anastomoses in rats. Surg Today 1998; 28:279-84. [PMID: 9548309 DOI: 10.1007/s005950050121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Octreotide, a long-acting somatostatin analogue, is widely used in gastrointestinal hypersecretory states and also for endocrine tumors in an attempt to inhibit the paracrine hormones. Although it is well known that octreotide inhibits trophic and anabolic hormones, no research has been conducted on its adverse effects on wound healing. In the present study, groups of rats were given 20 mcg/kg/day octreotide and 100 mg/kg/day hydrocortisone, the latter being the negative control group, starting 5 days preoperatively. The colonic anastomoses were assessed for healing on postoperative days (PODs) 5 and 8 by determining the bursting pressure of the anastomoses, performing histopathological analysis, and measuring the hydroxyproline content of the anastomotic tissues. Octreotide was found to affect anastomotic healing negatively on both PODs 5 and 8, but the negative effect of hydrocortisone was significant only on POD 8. No significant difference was found between the adverse effects of the two agents on POD 8. These findings indicated that octreotide has an adverse effect on the healing of colonic anastomoses in rats.
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Affiliation(s)
- A G Türkçapar
- Department of General Surgery, Ankara University Medical School, Sihhiye, Turkey
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40
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Rolandelli R, Roslyn JJ. Surgical management and treatment of sepsis associated with gastrointestinal fistulas. Surg Clin North Am 1996; 76:1111-22. [PMID: 8841366 DOI: 10.1016/s0039-6109(05)70500-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The development of sepsis associated with a GI fistula can be a catastrophic complication of any surgical procedure in the vicinity of the abdominal cavity. The predominant sites of infection directly associated with GI fistulas are in the surgical wound and within the abdominal cavity. Some patients present with florid signs of sepsis, whereas others may have minimal signs of infection. CT scanning is the main diagnostic method for intra-abdominal collections. Often, it also provides a means of treatment by percutaneous placement of catheters. Patients who develop extensive cellulitis or necrotizing fasciitis, intra-abdominal collections incompletely drained by percutaneously placed catheters, multiple intra-abdominal collections not amenable to percutaneous drainage, dissociation of the ends of an anastomosis with flow of enteric contents into the peritoneal cavity, large intra-abdominal hematoma, or a septic course without identifiable source should be taken to the operating room on an urgent basis. The operative approach varies with the particular situation and extends from incision and drainage of the wound, extraperitoneal drainage of an abscess, and formal exploratory laparotomies, to the placement of tube enterostomies for decompression and drainage. The overall mortality of fistulas has decreased owing to better fluid and electrolyte replacement and the proper use of parenteral nutrition. However, patients continue to die from fistulas, and the cause of death is nearly always infection. The burden is on the surgeon to expeditiously diagnose and treat sepsis associated with GI fistulas.
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Affiliation(s)
- R Rolandelli
- Department of Surgery, MCP Hahnemann School of Medicine, Allegheny University of the Health Sciences, Philadelphia, Pennsylvania, USA
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Abstract
The treatment of small bowel fistulas remains a difficult problem. Spontaneous closure rates of 30% are currently being achieved after 4 to 6 weeks of conservative therapy with bowel rest, TPN, octreotide, and control of sepsis. Resection of the fistulous bowel is warranted if fistula closure has not occurred by 4 to 6 weeks.
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Affiliation(s)
- A K Tassiopoulos
- Department of Surgery, State University of New York Health Science Center, Syracuse, USA
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Martineau P, Shwed JA, Denis R. Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure? Am J Surg 1996; 172:386-95. [PMID: 8873537 DOI: 10.1016/s0002-9610(96)00193-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Octreotide is a long-acting analogue of somatostatin that exhibits good subcutaneous absorption. It reduces gastrointestinal and pancreatic secretions as well as relaxes the intestinal musculature. It has been hypothesized that octreotide could decrease fistula output, thus facilitating fluid and electrolytes management and possibly hasten fistula closure. DATA SOURCES Relevant articles were identified from a MEDLINE search of the literature. Because of the scarcity of well-designed studies on the use of octreotide to promote enterocutaneous and pancreaticocutaneous fistulas closure, all case series and controlled trials were reviewed. CONCLUSIONS Octreotide as an adjuvant to standard fistula management diminishes fistula output, but its shortening of the time to fistula closure remains to be proven by well-designed comparative trials. For recent onset fistulas (less than 8 days old), octreotide does not seem better than the recommended management, including parenteral nutrition. Octreotide can effectively prevent postoperative complications and fistula formation in patients undergoing elective pancreatic resection.
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Affiliation(s)
- P Martineau
- Faculté de Pharmacie, University of Montreal, Quebec, Canada
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Frizelle FA, Pfiefer MV. Paraneoplastic hypoglycaemia treated with somatostatin analogue SMS 201-995. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1996; 22:546-7. [PMID: 8903503 DOI: 10.1016/s0748-7983(96)93317-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- F A Frizelle
- University of Otago Medical School, Dunedin, New Zealand
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Foster CE, Lefor AT. General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances. Surg Clin North Am 1996; 76:1019-33. [PMID: 8841362 DOI: 10.1016/s0039-6109(05)70496-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.
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Affiliation(s)
- C E Foster
- Department of Surgery, University of Maryland Medical System, Baltimore, USA
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Paran H, Neufeld D, Kaplan O, Klausner J, Freund U. Octreotide for treatment of postoperative alimentary tract fistulas. World J Surg 1995; 19:430-3; discussion 433-4. [PMID: 7639001 DOI: 10.1007/bf00299182] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Eighteen patients with postoperative fistulas of the gastrointestinal tract were treated with the somatostatin analog octreotide between November 1989 and November 1992. Fourteen patients had enterocutaneous fistulas: seven from the duodenum and seven from the ileum. Another three patients had pancreatic fistulas, and one patient had a biliary fistula. Within 24 hours of octreotide treatment, a mean reduction of 52% in the intestinal fistulas' output, 40% in the pancreatic fistulas, and 30% in the biliary fistula was noted. In the intestinal fistulas group the closure rate was 72% after a mean of 11 days. Early closure (mean 6 days) was achieved in all three pancreatic fistulas. In the patient with the biliary fistula a 30% reduction was observed twice following the administration of octreotide, and an increase occurred when it was withheld. The reduction rate of the secretions in high-output intestinal fistulas (> 500 ml/day) was higher than in the low-output fistulas (63 +/- 8% versus 39 +/- 4%, p < 0.05). Fistula output and the initial response to octreotide treatment had no value in predicting spontaneous healing. In conclusion, octreotide is a valuable tool for the conservative treatment of fistulas of the digestive tract. It is especially valuable for management of high-output enteric fistulas and pancreatic fistulas.
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Affiliation(s)
- H Paran
- Department of Surgery A, Meir Hospital, Kfar Saba, Israel
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Sancho JJ, di Costanzo J, Nubiola P, Larrad A, Beguiristain A, Roqueta F, Franch G, Oliva A, Gubern JM, Sitges-Serra A. Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistula. Br J Surg 1995; 82:638-41. [PMID: 7613936 DOI: 10.1002/bjs.1800820521] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Somatostatin and octreotide both enhance closure of gastrointestinal fistulas. The present trial was undertaken to test whether early combined treatment with parenteral nutrition and octreotide 100 micrograms every 8 h by subcutaneous injection had a beneficial effect compared with parenteral nutrition plus placebo. Thirty-one patients with post-operative gastrointestinal or pancreatic fistula were randomly assigned to receive parenteral nutrition plus octreotide (14 patients) or placebo (17) within 8 days of fistula onset. The percentage reduction in output and rate of spontaneous closure within 20 days were analysed. Mean(s.d.) reduction in output was similar after octreotide and placebo at 24 h (66(43) versus 68(47) per cent, P = 0.9), 48 h (60(46) versus 57(43) per cent, P = 0.8) and 72 h (62(50) versus 66(49) per cent, P = 0.9) after starting the combined treatment. Closure within 20 days was observed in eight of 14 fistulas in patients given octreotide and in six of 17 in those receiving placebo (P = 0.4). Administration of octreotide, within 8 days of fistula onset, associated with parenteral nutrition does not significantly increase the spontaneous fistula closure rate compared with parenteral nutrition plus placebo.
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Affiliation(s)
- J J Sancho
- Department of Surgery, Hospital Universitari del Mar, Universitat Autònoma de Barcelona, Spain
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Yamaner S, Buğra D, Müslümanoğlu M, Bulut T, Cubukçu O, Ademoğlu E. Effects of octreotide on healing of intestinal anastomosis following small bowel obstruction in rats. Dis Colon Rectum 1995; 38:308-12. [PMID: 7882799 DOI: 10.1007/bf02055609] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Octreotide is an analog of somatostatin, with the same biologic effects but a longer half-life than somatostatin. The purpose of this experimental study was to search the effects of octreotide on the healing of bowel anastomosis and to observe the anatomic and physiologic changes in the obstructed bowel. METHODS Two groups of ten male Wistar albino rats (average weight, 250 grams) were used in this study. One group was the octreotide group, and the other was the control group. In both groups, the basal diameters of jejunum were measured before ligation of the bowel 20 cm from the duodenum. Octreotide was administered subcutaneously (7 micrograms/kg/day, in two equal doses) in the first group, and the same volume of saline was used in the control group. Diameters of the obstructed segments were measured, and sodium and potassium levels, obtained from the luminal fluid of the obstructed bowel, were recorded 48 hours following the first operation. Dilated segments were resected, and end-to-end intestinal anastomoses were performed. In rats sacrificed on the fourth and seventh days following the second operation, bursting pressures of the anastomotic and hydroxyproline levels in tissue samples taken from the anastomosis were measured. RESULTS The diameter of the obstructed bowel increased significantly in the control group (P < 0.05). Sodium and potassium losses were significantly less in the octreotide group (P < 0.001 for sodium; P < 0.01 for potassium). In histopathologic examination, ischemic changes were more evident in the control group (P < 0.05). Anastomotic bursting pressure differences were not significant on the fourth postoperative day (P > 0.05), but differences were significant on the seventh postoperative day (P < 0.05). Anastomotic tissue hydroxproline synthesis on the fourth and seventh postoperative days of the octreotide and control groups did not show significant difference (P > 0.05). CONCLUSION In this experimental model, it appears that octreotide attenuates the ischemic changes and electrolyte losses in the obstructed bowel.
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Affiliation(s)
- S Yamaner
- Department of General Surgery, Istanbul Medical School, Turkey
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Carlson GL, Scott NA, Irving MH, Sancho JJ, Sitges-Serra A. Somatostatin in gastroenterology. More studies needed. BMJ (CLINICAL RESEARCH ED.) 1994; 309:604-5. [PMID: 7993463 PMCID: PMC2541434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Octreotide, an analogue of somatostatin with a more favorable pharmacokinetic profile, is a new drug that may offer some advantages in the palliative care setting. It has been used with favorable results in the management of some gastrointestinal disorders, such as gastrointestinal hemorrhage, diarrhea, short-bowel syndrome, fistula, and intestinal occlusion in the palliative care setting. These favorable results occurred without important side effects, underlining the potential role of this drug. The cost-benefit ratio of this expensive drug must be considered, however.
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Affiliation(s)
- S Mercadante
- Department of Anesthesia and Intensive Care, Buccheri La Ferla Fatebenefratelli Hospital, SAMOT, Palermo, Italy
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50
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Spiliotis J, Gouttebel MC, Briand D, Louer B, Saint-Aubert B, Joyeux H. A drug adjunct for postoperative external alimentary tract fistulas. Am J Surg 1994; 168:71. [PMID: 8024102 DOI: 10.1016/s0002-9610(05)80075-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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