Fístula enterocutánea en una hernia incisional / Enterocutaneous fistula in an incisional hernia

Introducción: Los defectos técnicos en el cierre de la laparotomía, como la utilización de suturas inadecuadas, muy apretadas o distancia incorrecta entre los puntos, presencia de cuerpos extraños, hematomas o la inclusión de un asa intestinal (pellizcamiento de esta), pueden provocar la aparición de una hernia incisional, y peor aún acompañarse de una fístula intestinal. Objetivo: Corroborar la importancia del cierre correcto y cuidadoso de la pared abdominal después de una laparotomía. Presentación del caso: Se trata de una paciente de 34 años de edad con antecedentes de tres cesáreas en un período de seis años, la última hace seis meses, que fue atendida en el Hospital Mnazi Mmoja, en Tanzania, refiriendo salida de contenido líquido amarillento a nivel de la cicatriz quirúrgica. Al examen físico se constata hernia incisional y un asa intestinal adherida a la piel con un orificio de menos de un cm por donde sale contenido intestinal amarillento. Se interviene con diagnóstico preoperatorio de hernia incisional y fístula enterocutánea; se realiza resección de 3 tres cm del íleon, anastomosis termino-terminal donde se encuentra el orificio fistuloso y hernioplastia mediante la técnica de Rives con utilización de malla de polipropileno. La evolución posoperatoria fue satisfactoria. Conclusiones: Se refuerza la afirmación que es de suma importancia el cierre correcto y cuidadoso de la pared abdominal después de una laparotomía, sobre todo si se realiza con urgencia(AU)

Introduction: In the closure of the laparotomy, technical defects such as the use of inadequate sutures, too tight or incorrect distance between stitches, the presence of foreign bodies, hematomas or the inclusion of an intestinal loop (pinching) can cause the appearance of an incisional hernia which, even worse, can be accompanied by an intestinal fistula. Objective: To corroborate the importance of the correct and careful closure of the abdominal wall after performing laparotomy. Case presentation: A 34-year-old patient with a history of three previous cesarean sections in a six-year period, the last one performed six months, was treated at the Mnazi Mmoja Hospital in Tanzania when she reported the release of a yellowish liquid content at the surgical scar level. Physical examination revealed an incisional hernia and an intestinal loop attached to the skin with a hole of less than one cm through which yellowish intestinal content was coming out. She was operated on with the preoperative diagnosis of incisional hernia and enterocutaneous fistula; a three-cm resection of the ileum, end-to-end anastomosis where the fistulous orifice was located, and hernioplasty were performed using the Rives technique with polypropylene mesh. The postoperative evolution was satisfactory. Conclusions: The assertion that correct and careful closure of the abdominal wall after laparotomy is of utmost importance, especially if it is performed urgently, is reinforced(AU)

Delayed presentation of enterocutaneous fistula after tubal ligation: a case report

A 50-year-old woman with a history of tubal ligation nine years earlier, presented with a complaint of discharge from the scar site. She was found to have an enterocutaneous fistula. The patient underwent an exploratory laparoscopy. The tract excised and primary repair of bowel done. A unique feature of the case is the formation of an enterocutaneous fistula after an extremely long latency due to gauze threads, which has not been previously reported in the literature.

Investigation of treatment and analysis of prognostic risk on enterocutaneous fistula in China: a multicenter prospective study / 中华胃肠外科杂志

Objective@#To investigate the diagnosis and treatment for enterocutaneous fistula (ECF) in China, and to explore the prognostic factors of ECF.@*Methods@#A multi-center cross-sectional study was conducted based on the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections to collect the clinical data of ECF patients from 54 medical centers in 22 provinces/municipalities from January 1, 2018 to December 31, 2018. The clinical data included patient gender, age, length of hospital stay, intensive care unit (ICU) admission, underlying diseases, primary diseases, direct causes of ECF, location and type of ECF, complications, treatment and outcomes. All medical records were carefully filled in by the attending physicians, and then re-examined by more than two specialists. The diagnosis of ECF was based on the clinical manifestations, laboratory/imaging findings and intraoperative exploration.@*Results@#A total of 1521 patients with ECF were enrolled, including 1099 males and 422 females, with a median age of 55 years. The top three primary diseases of ECF were malignant tumors in 626 cases (41.2%, including 540 gastrointestinal tumors, accounting for 86.3% of malignant tumors), gastrointestinal ulcers and perforations in 202 cases (13.3%), and trauma in 157 cases (10.3%). The direct causes of ECF were mainly surgical operation in 1194 cases (78.5%), followed by trauma in 156 (10.3%), spontaneous fistula due to Crohn′s disease in 92 (6.0%), radiation intestinal injury in 41 (2.7%), severe pancreatitis in 20 (1.3%), endoscopic treatment in 13 (0.9%) and 5 cases (0.3%) of unknown reasons. All the patients were divided into three groups: 1350 cases (88.7%) with simple ECF, 150 (9.9%) with multiple ECF, and 21 (1.4%) with combined internal fistula. Among the patients with simple ECF, 438 cases (28.8%) were jejuno-ileal fistula, 313 (20.6%) colon fistula, 170 (11.2%) rectal fistula, 111 (7.3%) duodenal fistula, 76 (5.0%) ileocecal fistula, 65 (4.3%) ileocolic anastomotic fistula, 55 (3.6%) duodenal stump fistula, 36 (2.4%) gastrointestinal anastomotic fistula, 36 (2.4%) esophagogastric/esophagojejunal anastomotic fistula, 29 (1.9%) gastric fistula and 21 (1.4%) cholangiopancreatiointestinal. Among all the simple ECF patients, 991 were tubular fistula and 359 were labial fistula. A total of 1146 patients finished the treatment, of whom 1061 (92.6%) were healed (586 by surgery and 475 self-healing) and 85 (7.4%) died. A total of 1043 patients (91.0%) received nutritional support therapy, and 77 (6.7%) received fistuloclysis. Infectious source control procedures were applied to 1042 patients, including 711 (62.0%) with active lavage and drainage and 331 (28.9%) with passive drainage. Among them, 841 patients (73.4%) underwent minimally invasive procedures of infectious source control (replacement of drainage tube through sinus tract, puncture drainage, etc.), 201 (17.5%) underwent laparotomy drainage, while 104 (9.1%) did not undergo any drainage measures. A total of 610 patients (53.2%) received definitive operation, 24 patients died within postoperative 30-day with mortality of 3.9% (24/610), 69 (11.3%) developed surgical site infection (SSI), and 24 (3.9%) had a relapse of fistula. The highest cure rate was achieved in ileocecal fistula (100%), followed by rectal fistula (96.2%, 128/133) and duodenal stump fistula (95.7%,44/46). The highest mortality was found in combined internal fistula (3/12) and no death in ileocecal fistula. Univariate prognostic analysis showed that primary diseases as Crohn′s disease (χ2=6.570, P=0.010) and appendicitis/appendiceal abscess (P=0.012), intestinal fistula combining with internal fistula (χ2=5.460, P=0.019), multiple ECF (χ2=7.135, P=0.008), esophagogastric / esophagojejunal anastomotic fistula (χ2=9.501, P=0.002), ECF at ileocecal junction (P=0.012), non-drainage/passive drainage before the diagnosis of intestinal fistula (χ2=9.688, P=0.008), non-drainage/passive drainage after the diagnosis of intestinal fistula (χ2=9.711, P=0.008), complicating with multiple organ dysfunction syndrome (MODS) (χ2=179.699, P<0.001), sepsis (χ2=211.851, P<0.001), hemorrhage (χ2=85.300, P<0.001), pulmonary infection (χ2=60.096, P<0.001), catheter-associated infection (χ2=10.617, P=0.001) and malnutrition (χ2=21.199, P<0.001) were associated with mortality. Multivariate prognostic analysis cofirmed that sepsis (OR=7.103, 95%CI:3.694-13.657, P<0.001), complicating with MODS (OR=5.018, 95%CI:2.170-11.604, P<0.001), and hemorrhage (OR=4.703, 95%CI: 2.300-9.618, P<0.001) were independent risk factors of the death for ECF patients. Meanwhile, active lavage and drainage after the definite ECF diagnosis was the protective factor (OR=0.223, 95%CI: 0.067-0.745, P=0.015).@*Conclusions@#The overall mortality of ECF is still high. Surgical operation is the most common cause of ECF. Complications e.g. sepsis, MODS, hemorrhage, and catheter-associated infection, are the main causes of death. Active lavage and drainage is important to improve the prognosis of ECF.

Predictive value of non-thyroidal illness syndrome before definitive operation on postoperative surgical site infection in patients with enterocutaneous fistula / 中华消化外科杂志

Objective To investigate the predictive value of non-thyroidal illness syndrome (NTIS) before definitive operation on postoperative surgical site infection (SSI) in patients with enterocutaneous fistula (ECF).Methods The retrospective case-control study was conducted.The clinical data of 264 ECF patients (181 with euthyroidism and 83 with NTIS) who underwent definitive operation in the Nanjing General Hospital of Nanjing Military Command between April 2014 and November 2016 were collected.After definitive operation,86 with SSI and 178 without SSI were respectively allocated into the SSI group and non-SSI group.Observation indicators:(1) risk factor analysis of postoperative SSI;(2) effect of preoperative NTIS on postoperative SSI;(3) predictive power of serum free triiodothyronine 3 (FT3) level on postoperative SSI.Measurement data with normal distribution were represented as x-± s and was analyzed using the t test.Count data were described as absolute number or percentage,and were analyzed using the chi-square test.The comparison of ordinal data was done by the nonparamentric test.The multivariate analysis was done using the logistic regression model.The receiver operating characteristic (ROC) curve was drawn,and area under the curve (AUC) was calculated for analyzing predictive power of serum FT3 level on postoperative SSI.Results (1) Risk factor analysis of postoperative SSI:cases with volume of preoperative intestinal fluid loss through fistula stoma ＜ 200 mL/24 hours,from 200 to 500 mL/24 hours and ＞ 500 mL/24 hours,preoperative hemoglobin (Hb) level,cases with surgical site located in stomach and duodenum,small intestine,ileocolon and colorectum,cases with open surgery and laparoscopic surgery were respectively 65,15,6,(119±36)g/L,5,50,31,36,58,28 in the SSI group and 135,27,16,(125±39)g/L,11,91,53,71,127,51 in the non-SSI group,with no statistically significant difference between groups (x2 =0.471,t =1.202,x2 =0.332,0.422,P＞0.05).Cases with preoperative single.and multiple fistula stoma,serum albumin (Alb) level,cases with preoperative NTIS,volume of intraoperative blood loss ＜ 300 mL and ≥ 300 mL,operation duration ＜ 3 hours and ≥ 3 hours were respectively 57,29,(35±.8)g/L,36,67,19,53,33 in the SSI group and 146,32,(37±9)g/L,47,161,17,140,38 in the non-SSI group,with statistically significant differences between groups (x2 =8.089,t =2.422,x2 =6.426,7.746,8.547,P＜0.05).Results of multivariate analysis showed that preoperative multiple intestinal fistula and NTIS were independent factors affecting occurrence of postoperative SSI in ECF patients (odds ratio =1.873,2.464,95％ confidence interval:1.052-2.671,1.120-4.392).(2) Effect of preoperative NTIS on postoperative SSI:incidence of preoperative multiple intestinal fistula,proportion of cases with preoperative enteral nutrition time ＞3 months,incidence of postoperative SSI,postoperative superficial and deep incision infection rates and organ/space infection rate were respectively 31.3％ (26/83),72.3％ (60/83),43.4％ (36/83),9.6％ (8/83),21.7％(18/83),7.2％ (6/83) in patients with NTIS and 19.3％(35/181),57.5％(104/181),27.6％(50/181),11.6％(21/181),3.9％(7/181),8.8％ (16/181) in patients with euthyroidism,with statistically significant differences in incidence of multiple intestinal fistula,proportion of cases with preoperative enteral nutrition time ＞ 3 months,incidence of postoperative SSI,superficial and deep incision infection rates (x2 =4.603,5.319,6.426,4.256,4.377,P＜0.05),and no statistically significant difference in organ/space infection rate (x2=0.193,P＞0.05).(3) Predictive power of serum FT3 level on postoperative SSI:the ROC curve showed that optimal cut-off point of serum FT3 predicting postoperative SSI was 3.5 pmol/L,AUC,sensibility and specificity were respectively 0.75,72.6％ and 68.7％.Conclusion The presence of NTIS is associated with occurrence of postoperative SSI in patients with ECF before definitive operation,and optimal cut-off point of serum FT3 predicting postoperative SSI is 3.5 pmol/L.

Single Center Experience with Gastrostomy Insertion in Pediatric Patients: A 10-Year Review / 대한소아소화기영양학회지

PURPOSE: This study was performed to review the outcomes of gastrostomy insertion in children at our institute during 10 years. METHODS: A retrospective chart review was performed on 236 patients who underwent gastrostomy insertion from October 2005 to March 2015. We used our algorithm to select the least invasive method for gastrostomy insertion for each patient. Long-term follow-up was performed to analyze complications related to the method of gastrostomy insertion. RESULTS: Out of 236 patients, 120 underwent endoscopic gastrostomy, 79 had laparoscopic gastrostomy, and 37 had open gastrostomy procedures. The total major complication rates for endoscopic gastrostomy insertion, laparoscopic gastrostomy insertion, and open gastrostomy were 9.2%, 8.9%, and 8.1%, respectively. The most common major complication was gastroesophageal reflux requiring Nissen fundoplication (3.8%), and other complications included peritonitis (1.3%), hiatal hernia (1.3%), and bowel perforation (0.8%). Gastrostomy removal was successful in 8.6% and 5.0% of patients in the endoscopic and surgical gastrostomy groups, respectively. Gastrocutaneous fistula occurred in 60% of surgically inserted cases, requiring a second operation. CONCLUSION: This retrospective study was performed to review the outcome of gastrostomy insertion, as well as to introduce an algorithm that can be used for future cases. Further studies should be conducted to make a consensus on choosing the most appropriate method for gastrostomy insertion.

<b>Otsujito Found Effective in Enterocutaneous Fistula after Trying Other Kampo T</b><b>reatments</b> / 日本東洋医学雑誌

<p>Otsujito is a well-known Kampo medicine for treatment of hemorrhoidal diseases. In the current report, we present end results for a case of enterocutaneous fistula treated with Kampo medicine in accordance with traditional “sho” indications.<br>An 81 year-old female developed abdominal wall-intestinal fistula right immediately following partial colectomy due to ischemic sigmoid colic perforation 12 years previously. Two years later, she had a fistulectomy and repair using intraperitoneal mesh for abdominal recruitment. Eight years after repair of the enterocutaneous fistula, she had peritonitis caused by the tardive intraperitoneal mesh infection. Since then, she has had frequent repeated ileus and received conservative treatment for two years. Several local operations and abdominal drainages were performed after transfer to Aizu Medical Center. Kigikenchuto was provided for wound healing for approximately 1 year, and one fistula was finally identified. Otsujito dramatically decreased the leakage of intestinal juice and closed her enterocutaneous fistula.<br>Angelicae Radix as an anti-inflammatory agent, and Cimicifugae Rhizoma as originally indicated, may have played pivotal roles in this case with Otsujito.</p>

Guía de manejo para las fístulas enterocutáneas / Enterocutaneous fístula management guideline

La fístula enterocutánea (FE) es una patología de difícil manejo que requiere la intervención de un equipo multidisciplinario . El objetivo del estudio es recopilar y revisar la mejor y más reciente información sobre la presentación clínica, el diagnóstico y el tratamiento de la FE y dar recomendaciones para su manejo basadas en la mejor evidencia disponible.

Enterocutaneous Fistula (EF) is a challenging pathology that requires a multdisciplinary approach. The aim of this study was to gather and review thebest available evidence about clinical features, diagnosis and treatment of EF in order to provide evidence-based recommendatons.

Nutritional Management in Enterocutaneous Fistula. What is the evidence?

The management of Enterocutaneous fistula (ECF) is challenging. It remains associated with morbidity and mortality, despite advancements in medical and surgical therapies. Early nutritional support using parenteral, enteral or fystuloclysis routs is essential to reverse catabolism and replace nutrients, fluid and electrolyte losses. This study aims to review the current literature on the management of ECF. Fistulae classifications have an impact on the calories and protein requirements. Early nutritional support with parenteral, enteral nutrition or fistuloclysis played a significant role in the management outcome. Published literature on the nutritional management of ECF is mostly retrospective and lacks experimental design. Prospective studies do not investigate nutritional assessment or management experimentally. Individualising the nutritional management protocol was recommended due to the absence of management guidelines for ECF patients.

A clinical efficacy study of interventional catheter drainage combined with ozone therapy for the management of postoperative enterocutaneous fistula / 实用医学杂志

Objective To evaluate the efficacy of interventional catheter drainage combined with ozone therapy for the management of postoperative enterocutaneous fistula. Method A total of 70 patients with postoperative enterocutaneous fistula were enrolled and divided into group A (35, conventional surgical treatment) and group B (35, interventional catheter drainage and ozone therapy). Clinical efficiency, hospital stays, hospital expenses and complications were compared. Follow-up observations of the infection score in 2 groups before and after treatment (3 days, 1 week, 2 weeks and 1 month) were also compared. Results 30 cases in group A recovered (85.7%), and 28 cases in group B recovered (80.0%), the result of which shows no statistic significance. The hospital stays and expense in group B were significantly lower than those in group A. 4 cases of group A suffered from incision complications , 2 intra-abdominal hemorrhage , 1 severe pneumonia and 1 septic shock. 2 cases in group B suffered from stomachache. The differences can be shown significantly. The infection score between the two groups shows no significant difference, but the score was found to be obviously lower after treatment than before. The infection score decreased by an average of 19.9 in group A and 23.5 in group B,indicating a better anti-infective effect in group B. Conclusion Interventional catheter drainage combined with ozone therapy for the management of postoperative enterocutaneous fistula is safe and effective, with lower hospital stays and expense.

Enterocutaneous Fistula of the Scrotum.

Inguino-scrotal hernia is a very common surgical entity. Though much common in pediatric population, yet no age is exempted. Enterocutaneous fistula in an inguino-scrotal hernia is a very rare surgical entity in both developing as well as developed countries. Comparatively commoner in pediatric age group but no age is exempt, the information gathered from few cases available in the surgical literature. About 08 cases in pediatric age group and 06 cases in adult population are available in the literature that could be revealed from Pubmed/Medline as well as medical library shelf search. We report here two rare cases of scrotal enterocutaneous fistula in an adult in inguinoscrotal hernia.

Enfermedad de Crohn fistulizante: manejo actual y su aplicabilidad en la realidad nacional / Fistulizing Crohn’s disease, current management and its applicability in the national reality

The development of fistulas during the evolution of Crohn’s Disease represents a severe situation that affects quality of life and requires a multidisciplinary care approach that involving gastroenterologists, surgeons and radiologists. Fistulizing Crohn’s disease can be divided in perianal and not perianal disease. Perianal disease can also be divided in simple or complicated disease depending on the fistula’s characteristics that will guide the clinical and therapeutic approach. Fistulizing not perianal disease can be internal when it communicates the bowel with other organs (colovesical, rectovaginal or enteroenteric fistulas), and external when it communicates the bowel with the abdominal wall (enterocutaneous fistula), either as a spontaneous or post-surgical phenomenon. Given the variety of fistula presentation, it is necessary to give an individualized approach, taking into account the fistula’s route, the inflammatory bowel activity, the presence of abscesses, and the nutritional status of the patient. This review is focused on the current management of fistulizing Crohn’s disease in our country.

El desarrollo de fistulas durante la evolución de la enfermedad de Crohn es una situación grave que condiciona una peor calidad de vida, así como mayor complejidad en el enfrentamiento, debiendo involucrar la colaboración multidisciplinar entre gastroenterólogos, cirujanos y radiólogos. La enfermedad fistulizante se divide en aquella que afecta la zona perianal (enfermedad perianal) y en aquella que no afecta la zona perianal. La enfermedad perianal a la vez se dividirá en simple o compleja dependiendo de las características de las fistulas, lo cual condiciona variaciones en el enfrentamiento y tratamiento. La enfermedad fistulizante no perianal se divide en interna cuando comunica al intestino con otros órganos (fistulas entero-vesicales, entero-vaginales, entero-entérico) y externas cuando se comunica al intestino con la pared abdominal (fistulas entero-cutáneas) tanto de forma espontánea como postquirúrgica. Debido a la gran diversidad de presentación de las fistulas es necesario individualizar cada grupo de trayectos fistulosos, valorar la asociación a actividad inflamatoria luminal, descartar la presencia de abscesos y valorar el estado nutricional de los pacientes para definir el manejo integral adecuado. Este artículo se centra en el manejo actual de la enfermedad de Crohn fistulizante en nuestro país.

Analysis of pathogen spectra and their drug resistance in patients with enterocutaneous fistula complicated with abdominal infection / 中华消化外科杂志

Objective To study the pathogen spectra in patients with enterocutaneous fistula complicated with abdominal infection and their resistance to antibiotics. Methods The abdominal pus was collected from 226 patients with enterocutaneous fistula complicated with abdominal infection for bacterial culture and antibiotic susceptibility test. Results A total of 520 bacterial strains were harvested, including 333 strains of gram-negative bacteria, I 80 strains of gram-positive bacteria and 7 strains of fungi. The top 10 bacteria cultured were Escherichia coli (131 strains), Staphylococcus aureus (62 strains), Enterococcus (59 strains), Pseudomonas aeruginosa (50 strains), Klebsiella pneumoniae (23 strains), Acinetobacter baumannii (18 strains), Enterobacter cloacae (17 strains), Proteus mirabilis (15 strains), Morganella morganii (15 strains) and Enterococcus faecalis (12 strains). The extended spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae were 102 and 17 strains, respectively. Methicillin-resistant Staphylococcus aureus were 60 strains. Conclusions Gram-negative bacteria were the main pathogens in patients with enterocutaneous fistula complicated with abdominal infection. The positive rate of the extended spectrum beta-lactamase is high. Most of the Staphylococcus aureus were resistant to Methicillin.

Management of Enterocutaneous Fistula

PURPOSE: The aim of this study was to help access the treatment of enterocutaneous fistula patients. METHODS: We experienced 35 cases of enterocutaneous fistulas at Seoul Red Cross Hospital from January 1993 to December 1997 and we reviewed the patient's charts retrospectively. RESULTS: The ratio of men and women was 1.7 : 1. The most prevalent age group was the 7th decade (12 cases, 34.3%). The most frequent site of the enterocutaneous fistula was the large colon (11 cases,31.4%). The etiology of the all cases was postoperative complication. The most common underlying disease was malignancy (11 cases, 31.4%). The latent period of the fistula after an operation was most commonly 6 to 10 days (18 cases, 51.4%). Fistulography was the most accurate diagnostic method (90.9%). According to the amount of daily drainage, high output fistulas occurred in 10 cases (28.6%), and low output fistulas in 25 cases (71.4%). Twenty five (25) patients (71.4%) were treated conservatively, 10 patients (28.6%) were treated surgically. The methods of operation were bowel resection and anastomosis (6 cases), an fistulectomy (2 cases), and a bypass procedure (2 cases). The overall mortality was 3 cases (8.6%). The most common cause of death was sepsis and multiple organ failure. CONCLUSION: Prevention of an enterocutaneous fistula is of utmost importance, but once it occurs early detection, which is essential to improve the patient's general condition, avoidance of infection, and proper judgment as to the time of operation are important to the survival rate.

Closure of enterocutaneous fistulas using fibrin sealant / 解放军医学杂志

Objective To study the method of promoting spontaneous closure of enterocutaneous fistula with fibrin sealant. Methods In twenty-seven patients with enterocutaneous fistula the selective fibrin sealant occlusion method was applied, and fistulagraphy was used to confirm closure. Results Fistula occlusion was attained within 2 weeks in 25 of the 27 patients, and there had been no sign of recurrence over a follow-up period of 1-15 months (average 5.6 months). Conclusion Selective fibrin sealant occlusion is highly effective for the closure enterocutaneous fistula.