Parenteral and enteral nutrition and the enterocutaneous fistula treatment. I. Investigations on fistula output, nutritional status complications.

Prospective evaluation were made of 45 patients with postoperative small bowel fistulas treated with total parenteral nutrition (TPN) and enteral nutrition (EN) between 1971-1988. The administration of TPN in the early treatment of enteric fistulas decreased the mean fistula output significantly (p < 0.05-0.001) and provided an effective tool in the control of high-output fistulas. The electrolyte contents of different fistula secretions were unchanged and the losses through the fistulas depended on the daily output. In patients with high-output fistulas acid-base balance disturbances had to be corrected. When comparing two parenteral nutrition regimens (carbohydrate+amino acids /CH + AA/ versus carbohydrate + amino acids + fat /CH + AA + F/) both facilitated the reduction of fistula secretion (in high-output fistulas. CH + AA = -50.2%; CH + AA + F = -49%). Positive nitrogen balance was achieved in non septic patients after 13 days of treatment. Improvement of serum protein and albumin occurred by the time of fistula healing. In non surviving patients significant decrease in protein synthesis was observed. Out 7 of 75 central venous catheters yielded positive bacterial cultures (9.3%). In 5 patients autopsy proved generalized sepsis. The use of parenteral and enteral nutrition proved to be a powerful method for controlling the enterocutaneous fistulas and maintaining the nutritional integrity of patients.

Parenteral and enteral nutrition and the enterocutaneous fistula treatment. II. Factors influencing the outcome of treatment.

An 18-year review of 64 patients treated with 71 postoperative enterocutaneous fistulas of the stomach /4/, duodenum /21/, jejunum /9/ and ileum /37/ was carried out to identify the factors affecting morbidity and mortality. Age, localization, output, inflammatory or malignant bowel disease, nutritional status and associated sepsis were analysed. The administration of total parenteral nutrition (TPN) or/and enteral nutrition (EN) as adjuvant therapy in the management of gastrointestinal fistulas increased the fistula closure rate (64%) and decreased mortality (33%). In patients over 65 years a rise in mortality rate (69%) was found. TPN and EN support yielded the best results in duodenal and jejunal fistula patients (closure rate 83% and 71%; respectively). In patients with high-output fistulas, inflammatory bowel disease and malignancy good results could be achieved with nutritional treatment. The presence of malnutrition had an adverse effect on the outcome in the non-TPN group with a mortality rate of 49%. In 43 patients severe septic complications occurred and 21 died due to septic multiple organ failure proved by autopsy. The overall mortality rate was 39%. Timing of fistula surgery had little impact on the fistula closure rate, but better results were obtained when reconstructive surgery was deferred beyond 6 weeks from fistula onset. Mortality has decreased since 1980. While many factors influence the outcome of fistula disease, adequate antiseptic treatment is assumed of primary importance. The nutritional therapy facilitated the spontaneous fistula healing and allowed the elective intestinal reconstruction to be scheduled at an optimal time.