L was stable enough to have the NPWT dressing changed at the bedside. Ischemia of the subcutaneous tissue was noted along with enteric drainage at the wound base.
Three days later, the NPWT dressing was changed at the bedside. The wound was 42 cm x 32 cm x 6 cm deep. Recurrence of the fistula was evidenced by enteric-type drainage and gas bubbles in the right side of the wound base. Because the wound was too large for conventional pouches, the NPWT dressing was continued at continuous mm Hg and PVA foam was applied over the acellular wound matrix.
Wide-mesh nonadherent gauze and PVA foam were placed over the area of the fistula and three large reticulated foam dressings were used to cover the remainder of the wound. Because the fistula was draining more than 1, mL daily, a red rubber catheter also was placed in the wound bed and connected to low continuous wall suction 80 mm Hg because the NPWT system was unable to contain the large amount of output.
Sixteen days after the last debridement, Mr. During this procedure, areas of loose acellular dermal matrix were removed. The fistula was intubated with a red rubber catheter. NPWT was continued with polyvinyl alcohol foam and reticulated foam dressing continuous 50 mm Hg. Two NPWT tubes were utilized to collect the large amount of drainage from the fistula. One of the tubes was placed directly over the red rubber catheter and a second tube was placed in the inferior aspect of the wound.
The abdominal wound began to granulate and 5 weeks after the initial trauma, split-thickness skin grafts were applied. Due to the drainage, some loss of the skin graft inferior to the fistula was anticipated, but the approach used was thought to be the best method to obtain final wound closure. Many variations of NPWT application were tried to manage the high fistula output and prevent loss of the skin graft, particularly on the inferior aspect of the wound.
This included use of NPWT in conjunction with an ostomy pouch over the fistula site. Simethicone drops were instilled through the tubing into the canister to reduce the bubbles. During this time, TPN was continued for nutritional support.
His social worker, case manager, pastoral care, and the nursing staff provided psychological support. Continuity of care was emphasized and a core of three to four nurses who took a personal interest in his case was routinely assigned.
Room decorations, humor, and casual conversations were part of his daily care, which provided distraction and emotional support. After 2 months, the goal became to increase Mr. Experienced WOC nurses tried various pouches, challenged by the changing contours of his abdomen with movement.
Fistula output remained high and ranged from 2, mL to 3, mL per day. Pouch adhesion was further complicated by the presence of moist granulation tissue at the wound base around the fistula. Because of the large amount of effluent, the pouch was attached to suction for the majority of the time but was connected to a straight drainage system when wall suction was disconnected for physical therapy activities.
This allowed Mr. L to experience a change in scenery and to go to the gym for physical therapy. Despite trying multiple pouches and modifying the application process, maximum pouch seal duration was usually less than 24 hours. After 10 days, frequent pouch leakage, subsequent skin irritation, and Mr. A modified T-tube was placed in the fistula stoma by the surgeon and connected to low continuous wall suction at 80 mm Hg to reduce the effluent going onto the wound.
Octreotide was tried, but little change in the volume of output was noted; therefore, it was discontinued after several weeks. Throughout this time, the skin graft was adherent superior to the fistula, but had not taken on the inferior aspect due to constant exposure to fistula effluent.
Almost 3 months after initial trauma, Mr. One week later, his NG tube was discontinued for the first time and an elemental tube feeding was started slowly via the jejunostomy tube.
Because Mr. L experienced several episodes of line sepsis, removal of invasive lines became another goal of care. Because many more epithelial cells had migrated over the wound bed by mid January, various pouching systems again were tried. Pectin skin barrier wafers also were continued over the area of maturing skin graft and Mr. A long-term acute care hospital or extended care facility was sought for the next stage of his recovery.
Caregivers from several institutions came to observe the pouch application and wound care procedures; most were overwhelmed by the complexity of Mr. After a 3-month stay, Mr. L was discharged to a long-term care facility with WOC nurses available. L could explain how to apply the pouch but was not able to do this independently due to the complexity of the system.
After his readmission, pectin-based skin barriers were continued over the skin graft and NPWT was resumed. However, the effluent was thicker and plugged the NPWT tubing. Pouch application was tried again. The major challenge continued to be the large area 12 cm x 18 cm x 1 cm deep of granulation tissue around the fistula stoma, thwarting product adherence.
A pouch, applied over the fistula, was connected to low continuous wall suction at 80 mm Hg and NPWT at mm Hg continuously was applied over the remainder of wound see Figure 2. This system maintained a seal for 24 hours. L was fed a full liquid diet plus tube feeding.
His prealbumin was One week following his readmission, the surgeon inserted a button g-tube to stent open the buckled posterior wall of the fistula and allow distal passage of stool. This tube was connected to low continuous wall suction at 80 mm Hg. The following week, tube feedings were discontinued and a pureed diet was ordered. L did not find this palatable, and even though pureed, his transit time was extremely rapid; plus, due to his previous gastric bypass surgery, solid food particles would plug drainage tubes.
His food then was blenderized several times to eliminate any food particles. Managing complex, high-output, enterocutaneous fistulas: a case study. Author information: 1 Mercy St. Following diagnosis, management strategies may have to be adapted frequently to address changes in fistula output, surrounding skin or wound condition, overall patient clinical and nutritional status, mobility level, and body contours.
The use of CT, however, within the first week after surgery is associated with the expected presence of postoperative air within the abdominal cavity and thus may be difficult to interpret. Obviously, extravasation of intraluminal contrast on CT examination is diagnostic of perforation. CT and ultrasound are useful adjuncts when an intraabdominal abscess is suspected [ 51 ]. Significant fluid collections should be drained, preferably under CT or ultrasound guidance via a percutaneous route, and an indwelling catheter left in the cavity.
This permits subsequent examination of the cavity under fluoroscopy with water-soluble contrast to assist in delineation of the fistula tract [ 50 ]. Therefore, the false-negative results must be considered as a possibility. In cases where no sepsis is found, the fistulography is an important test to determine the origin of the fistula, as yet undiscovered, documenting intestinal continuity and verify the presence of distal obstruction [ 53 ].
Additionally, ongoing losses must be anticipated and prevented. Malnutrition is easier to prevent than correct. Once established, malnutrition is difficult to correct, especially in the face of continuing sepsis. After the initial stabilization period, including control of sepsis and establishment of nutritional support, management can be divided into phases, starting with determination of the anatomy of the fistula and the likelihood of spontaneous closure [ 54 ].
This may then be followed by definitive surgical therapy for a fistula that does not close spontaneously, but a waiting period of at least 6 weeks is usually required. The final process is healing. The critical points in successful management of gastrointestinal fistulas are recognition of the fistula, control of infection and further contamination, restoration of fluid and electrolyte losses, and reestablishment of a positive nutritional balance before undertaking major definitive corrective procedures [ 56 ].
Management of a gastrointestinal fistula is a difficult and complex process. However, a systematic approach can lead to treatment that becomes manageable and potentially rewarding. In general, management can be compartmentalized into five stages: stabilization, investigation, decision, definitive therapy, and healing [ 57 ]. As outlined earlier, the first step in the management of any intestinal fistula is stabilization of the patient, to be accomplished within the first hours of management.
These patients are typically in a vulnerable state of health. Patients typically require correction of obligate third-space losses, as well as emesis, fistula output, urine output, or a combination of these and other causes. Initial efforts should be directed toward intravenous fluid resuscitation, control of infection, ongoing measurement of fistulous and urine output, and protection of the surrounding skin [ 58 ].
For surgical treatment of patients with intestinal fistula must be carried nutritional recovery, replacement and stabilization of electrolytes, identification of the fistulous path, drainage adjacent and along the fistula and abscess to allow full closure thereof and the abdominal wall [ 59 , 60 ].
Depending on the site of the fistula, replacement of fistula output varies. Moderate-output and low-output fistulas are associated with low mortality rates and higher spontaneous closure rates. Small bowel, pancreatic, and biliary losses are isotonic. Colonic losses may be hypotonic, and gastric fistulas may be associated with the classic hypokalemic, hypochloremic metabolic alkalosis [ 62 ].
The natural course of an improperly managed high-output fistula is dehydration, electrolyte abnormalities, malnutrition, infection and sepsis, renal failure, and death. Initial management should address any existing hypovolemia; anemia; hypoalbuminemia; sodium, chloride, or potassium depletion; bile salt losses, and acid-base disorders [ 1 ].
Strict intake and output measurements are essential and central venous pressure monitoring and urinary catheterization are especially helpful with high-output fistulas.
Invasive monitoring is often necessary because it is usually difficult to estimate antecedent fluid deficits accurately [ 2 ]. A central venous catheter can be extremely useful in this capacity and provides the additional benefit of supplying access for parenteral nutrition. The patient's urine output should be restored to greater than 0. Ongoing fluid losses should be fully replaced, and potassium, calcium, phosphorus, and magnesium deficits should be corrected [ 3 ].
These electrolyte deficits may take time to correct because the measured serum levels incompletely reflect massive depletion of intracellular ions. Sodium bicarbonate administration may be required to correct the metabolic acidosis that develops with a high-output or proximal fistula. There is no specific hemoglobin or hematocrit level that requires transfusion; rather, transfusion should be based on the patient's overall hemodynamic status, oxygen-carrying capacity, and oxygen delivery [ 4 ].
More importantly, however, the patient is in a state of nutritional emergency. For this patient to be stabilized and to potentially heal the fistula, positive nitrogen balance must be achieved. If nutritional therapy is not started early, these patients are at greater risk [ 14 ]. Parenteral nutrition, however, had no impact on fistula mortality; maintenance of adequate nutrition with more conventional methods was equally effective [ 17 ].
Parenteral nutrition has greatly simplified the nutritional management of patients with gastrointestinal fistulas. Even though these patients often have abdominal abscesses and bacteremia, parenteral nutrition is safe and the overall incidence of catheter-related septic complications is no greater than that in other clinical situations [ 34 ].
Enteral nutrition is not without complications, however, and the process should be closely monitored. Complications such as diarrhea, aspiration, and bowel ischemia are not uncommon without careful clinical monitoring [ 20 ]. Enteral nutrition can be given for upper gastrointestinal fistulas, especially when the feeding tube can be placed beyond the fistula e.
In general, when possible feeding tubes should be placed beyond the ligament of Treitz to decrease the potential risk for aspiration.
If at least 4 feet of functional bowel exists between the ligament of Treitz and the external site of the fistula, enteral feedings of highly absorbable, low-residue nutrients may be administered [ 22 ]. Because both enteric and parenteral feeding has advantages and disadvantages, the source of nutritional supplementation should depend on the individual patient and the surgeon's preference and experience.
In most cases, parenteral nutrition should be instituted as soon as possible [ 41 ]. Thereafter, steps to localize the fistula and control infection can be taken. Normal intestinal motility and function generally return once abdominal sepsis is controlled and fluid and electrolyte imbalances are corrected.
If the fistula location is such that enteric access and alimentation are possible, enteral nutrition can be instituted and parenteral nutrition phased out [ 59 ].
By using a combination of approaches, adequate nutrition can be maintained throughout the patient's course [ 1 ]. It is advised to begin provision of nutritional support as soon as the patient is stabilized. Full caloric and nitrogen replacement can be provided within a few days of instituting nutritional support.
Nutrition can be given by several routes [ 34 ]. Usually, either enteral tube feeding or parenteral nutrition will be required. The choice of which to use depends on the fistula anatomy.
It is advantageous to provide at least a portion of the calories through the enteral route because the gastrointestinal tract is a much more efficacious way of providing nutrition, maintaining the intestinal mucosal barrier and immunologic integrity, and stimulating hepatic protein synthesis, which has been found to be essential in determination of the outcome in patients [ 3 ].
Thus, whenever possible, enteral nutrition is preferable to parenteral nutrition and probably decreases the incidence of multisystem organ failure and sepsis if administered appropriately [ 28 ]. Uncontrolled sepsis remains the major factor contributing to mortality in patients with small intestinal fistulas. Aggressive management of all ongoing infections and careful surveillance for new septic foci are necessary for successful management.
Tachycardia, persistent fever, and leukocytosis usually portend inadequate control of the fistula or abscess formation. Frequent physical examination and judicious use of ultrasonography and computed tomography CT are mandatory [ 33 ]. Malnutrition in the presence of uncontrolled sepsis cannot be treated without effective surgical drainage of the septic source.
As long as uncontrolled sepsis persists, the patient's condition will continue to deteriorate [ 39 ]. The stabilization phase often involves control of a septic source. Typically, drainage of an intraabdominal abscess is required, which is ideally accomplished in an image-guided, percutaneous fashion. In addition, fistula drainage must be controlled and the skin of the abdominal wall protected.
Local control is an extremely important component of the early management of a fistula [ 40 ]. The best treatment is prevention of complications with any surgical procedure. Intraoperative risk factors and factors related to the patient intervention is possible and better control to avoid deiscences [ 2 ]. As a general rule, the type I fistulas require resection of the diseased segment, while the type II fistulas have potential spontaneous closure as conservative treatment [ 17 ].
Conservative treatment for late dehiscence and low output fistulas includes adequate percutaneous drainage replacement of fluids and electrolytes, nutritional support and antibiotic therapy for patients with signs of systemic or local inflammation with pain.
About a third of enterocutaneous fistulas will close spontaneously with care [ 3 ]. The insertion of a catheter allows control of debt and exchange, in the case of fistula, catheter progressively smaller caliber with treatment, follows the path of healing and the evolution of the case [ 58 ].
Enteral nutrition should be initiated as soon as possible in patients with a risk factor for fistula, since it constitutes a protective factor [ 59 ].
For early anastomotic dehiscence and great debt fistulas, the surgical management is the best option. Surgery gives a definitive diagnosis and institute treatment before a new complication develops [ 60 - 62 ].Sodium bicarbonate administration may be required to correct the metabolic acidosis that develops with a high-output or proximal fistula. This system has a cutting surface of 8 inches x He was wearing a seatbelt at the time of his accident and sustained a severe external seatbelt injury to his abdomen in addition to his internal injuries. Thereafter, steps to localize the fistula and control infection can be taken. L was stable enough to have the NPWT dressing changed at the bedside. Hemostasis must be achieved, incidental enterotomies avoided, and serosal injuries identified and repaired. Negative pressure wound therapy NPWT has been utilized to contain the effluent and promote wound healing when a. If at least 4 feet of functional bowel exists patients with gastrointestinal fistulas. Parenteral nutrition has greatly simplified the nutritional management of the fistula, replacement of Arid related words for hypothesis output varies. The albumin level may take 14 days to return to normal when depleted.
An area of abdominal skin and soft tissue, approximately 45 cm x 40 cm x 5 cm deep, also was removed due to devitalized fat and a degloving injury. He was attentive during the pouch change procedure and he could verbalize the proper steps and needed supplies. This permits subsequent examination of the cavity under fluoroscopy with water-soluble contrast to assist in delineation of the fistula tract [ 50 ]. More commonly, anemia develops chronically and is associated with slow blood loss from a friable fistula tract [ 24 ]. In general, when possible feeding tubes should be placed beyond the ligament of Treitz to decrease the potential risk for aspiration. Cirocchi R, Trastulli S, Morelli U The treatment of anal fistulas with biologically derived products: is innovation better than conventional surgical treatment?
The major challenge continued to be the large area 12 cm x 18 cm x 1 cm deep of granulation tissue around the fistula stoma, thwarting product adherence. The surgery included an exploratory laparotomy with resection of infarcted mid-jejunum 53 cm , end-to-end anastomosis, repair of a mesenteric laceration, lysis of adhesions, and repair of ventral hernia and enterotomy.
Concerning etiology, the fistulas are classified into Type I or Primary fistulas resulting from an underlying disease affecting the gastrointestinal wall. Fistulograms are performed by inserting a soft catheter into the fistula and instilling contrast media. Because many more epithelial cells had migrated over the wound bed by mid January, various pouching systems again were tried. Surgery gives a definitive diagnosis and institute treatment before a new complication develops [ 60 - 62 ]. Although prealbumin levels may decrease in the presence of inflammation and zinc deficiency, as well as in the immediate postoperative period, these levels do not decrease with dehydration and may increase during prednisone therapy.
Drainage can be contained using gauze dressings, pouches, and suction catheters. As outlined earlier, the first step in the management of any intestinal fistula is stabilization of the patient, to be accomplished within the first hours of management. The location of the fistula — within an incision or in an area of abdominal creases — may complicate pouch application. Curr Probl Surg
Patients who develop wound dehiscence postoperatively present lower functional outcomes to other patients undergoing digestive surgeries with losses in their quality of life.