Executive Summary: Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) Nursing Best Practice Recommendations: Enterocutaneous Fistula and Enteroatmospheric Fistula.

Enterocutaneous fistulas (ECF) and enteroatmospheric fistulas (EAF) pose significant quality-of-life concerns for patients, and management challenges for the interprofessional healthcare team. In 2009, the Canadian Association for Enterostomal The developed best practice recommendations for the management of ECF. Over time, evidence and practice evolve, and the Nurses Specialized in Wound, Ostomy and Continence Canada performed a comprehensive review of the literature and revised the practice recommendation document. The revised recommendations provide evidence-based management guidance for ECF and EAF in the adult population whether in acute care, community/home care, or long-term/residential settings, and are specifically created for nurses. The revised recommendations include organizational support, assessment, nutrition, pharmaceutical management, education, and local fistula management. This article serves as an executive summary for this clinical resource; the full guideline is available at http://nswoc.ca/ecf-best-practices/.

Paciente con fístula enterocutánea e importante deterioro de la integridad cutánea / No disponible

Plan de cuidados individualizado para un paciente de 77 años que desarrolla una fístula enterocutánea de alto débito tras varias cirugías urgentes, debidas a complicaciones en el postoperatorio de una eventroplastia compleja y hemicolectomía derecha urgente por diagnóstico de suboclusión intestinal y eventración paraestomal. El manejo inicial se realizó con terapia de presión negativa. Debido al gran número de fugas e irritación de la piel, se optó por la bolsa de drenaje postquirúrgico Sistema para el manejo de Fístulas y Heridas Coloplast(R). El principal objetivo de los cuidados debe ser la protección de la piel frente al efecto corrosivo del efluente, para favorecer la epitelización, la disminución de la pérdida de la integridad cutánea y mejorar notablemente la calidad de vida percibida por el paciente. Una apropiada selección del material de curas y los cuidados individualizados permiten alcanzar estos objetivos

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Cuidados de la herida con fístula enterocutánea postoperatoria / No disponible

Las fístulas enterocutáneas son un problema mayor en la práctica quirúrgica. En general son secundarias a complicaciones postoperatorias. Hasta el 90% de los casos se desarrolla después de una cirugía. La morbilidad y la mortalidad continúan siendo muy elevadas a pesar de los avances en el manejo de esta patología. Las tres complicaciones principales de los pacientes con fístulas son desequilibrio hidroelectrolítico, desnutrición y sepsis, las cuales están en relación con la localización de la fístula, el gasto, las características bioquímicas y electrolíticas de la descarga y la condición patológica subyacente. El objetivo final en el manejo de los pacientes con fístulas es el cierre de la misma. En 1964, Chapman propuso un plan de tratamiento de los pacientes con base en cuatro prioridades. El propósito del tratamiento médico es el cierre espontáneo de la fístula o la preparación del paciente para cirugía. La instalación de un apoyo nutricional adecuado juega un papel esencial para el éxito del tratamiento. El control de la sepsis es una prioridad; la sepsis descontrolada debe ser atacada rápidamente ya que es la principal causa de muerte. El cierre espontáneo ha aumentado en los últimos años; sin embargo, es probable que todavía una gran parte de los pacientes necesite tratamiento quirúrgico, y éste debe ser realizado en el momento adecuado

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Considerations for the management of enterocutaneous fistula.

Enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and skin. Management includes early recognition and treatment of sepsis, reducing fluid and electrolyte homeostasis, nutrition support, wound management and a carefully timed surgical procedure. A multidisciplinary approach is required for successful management of these patients with one of the most challenging and resource-demanding aspects being local control of the effluent, requiring the skill and support of the specialist stoma care nurse. The inability to contain the fistula can be a source of morbidity for the patient, as they will experience pain and severe discomfort from the skin when leakages occur. Enterocutaneous fistula can result in intestinal failure, which is often fatal if not managed correctly.

A reflection on safeguarding in practice.

Safeguarding is about the protection of the most vulnerable people in our society. This article presents a case history of the author's experience of a patient with a colostomy and high-output abdominal fistula, who was involved in a safeguarding alert. It explores the roles and responsibilities of nurses, regardless of specialty, to increase their awareness, understanding and knowledge of safeguarding, and the processes in place to protect the most vulnerable people they care for.

Fístula duodenal tras gastrectomía: análisis retrospectivo de 13 nuevos casos / Duodenal fistula after gastrectomy: retrospective study of 13 new cases

Introducción: la fístula del muñón duodenal (FMD) es una de las complicaciones más agresivas tras una gastrectomía. Aunque la incidencia reportada en la literatura es baja, su asociación con una elevada morbimortalidad hace que sea una de las complicaciones más temidas por los cirujanos. Material y métodos: evaluamos de forma retrospectiva todas las FMD acaecidas en nuestro centro tras realizar una gastrectomía programada por neoplasia gástrica, en el periodo comprendido entre enero de 1997 y diciembre de 2014. Analizamos variables demográficas, oncológicas y quirúrgicas, así como la evolución posterior en términos de morbimortalidad y estancia hospitalaria. Resultados: en el periodo que comprende el estudio se realizaron 666 gastrectomías y observamos una FMD en 13 pacientes, lo que supone una incidencia del 1,95%. En 8 casos (61,5%) se efectuó un tratamiento quirúrgico, y en 5 casos (38,5%), un tratamiento conservador. La mortalidad postoperatoria asociada a una FMD fue del 46,2% (6 casos). En el grupo quirúrgico, 3 pacientes presentaron una sepsis grave con fracaso multiorgánico, 2 una hematemesis importante que requirió la realización de hemostasia endoscópica, una evisceración, y un absceso subfrénico que requirió drenaje percutáneo. Seis de los pacientes (75%) fallecieron a pesar del tratamiento quirúrgico, siendo 3 de las muertes en las primeras 24 horas tras la reintervención. Los 2 pacientes que consiguieron sobrevivir tras la reintervención presentaron una estancia de 45 y 84 días respectivamente. En el grupo de tratamiento conservador, la tasa de curación fue del 100%, no observándose complicaciones significativas y siendo la estancia media postoperatoria de 39,5 días (rango, 26-65 días). Conclusión: la FMD constituye una complicación poco frecuente pero asociada a una elevada morbimortalidad. En nuestra experiencia, el manejo conservador ha demostrado mejores resultados en cuanto a morbimortalidad en comparación con el tratamiento quirúrgico (AU)

Introduction: Duodenal stump fistula (DSF) after gastrectomy has a low incidence but a high morbidity and mortality, and is therefore one of the most aggressive and feared complications of this procedure. Material and methods: We retrospectively evaluated all DSF occurred at our hospital after carrying out a gastrectomy for gastric cancer, between January 1997 and December 2014. We analyzed demographic, oncologic, and surgical variables, and the evolution in terms of morbidity, mortality and hospital stay. Results: In the period covered in this study, we performed 666 gastrectomies and observed DSF in 13 patients (1.95%). In 8 of the 13 patients (61.5%) surgery was the treatment of choice and in 5 cases (38.5%) conservative treatment was carried out. Postoperative mortality associated with DSF was 46.2% (6 cases). In the surgical group, 3 patients developed severe sepsis with multiple organ failure, 2 patients presented a major hematemesis which required endoscopic haemostasis, 1 patient had an evisceration and another presented a subphrenic abscess requiring percutaneous drainage. Six patients (75%) died despite surgery, with 3 deaths in the first 24 hours of postoperative care. The 2 patients who survived after the second surgical procedure had a hospital stay of 45 and 84 days respectively. In the conservative treatment group the cure rate was 100% with no significant complications and an average postoperative hospital stay of 39.5 days (range, 26-65 days). Conclusion: FMD is an unusual complication but it is associated with a high morbidity and mortality. In our experience, conservative management has shown better results compared with surgical treatment (AU)

Fistuloclysis: An Interprofessional Approach to Nourishing the Fistula Patient.

BACKGROUND: Enteric fistulas can be classified as enterocutaneous and/or enteroatmospheric. Both are devastating complications of bowel disease, abdominal surgery, and/or open abdomen. Enteric fistulas are associated with a mortality rate varying from 1% to 33%; the main cause of death is sepsis. Coordinated and skillful efforts of an interprofessional team are required in customizing successful treatment regimens appropriate to each patient's unique clinical scenario. CASE STUDY: A 65-year-old white woman experienced an enteroatmospheric fistula patient after ventral hernia repair. Care of this patient was based on the complementary relationship between professionals from 2 disciplines: the wound and ostomy continence nurse (WOC nurse) and the nutrition support registered dietitian/nutritionist. Working together, they developed a comprehensive wound, ostomy, and nutritional plan. Initially, the patient received parenteral nutrition exclusively. After the fistula tract was clearly defined, a feeding tube was placed into the distal limb of the fistula, and she received nourishment via a fistuloclysis (ie, enteral feedings administered via the fistula). A special wound management system was created to contain fistula output while allowing feeding through the distal limb of the fistula. CONCLUSION: Enterocutaneous and enteroatmospheric fistulas originating from the small bowel present a management challenge to the entire healthcare team. WOC nurses are often called upon to meet the challenge of maintaining skin health while promoting dignity and function. Nutrition support via registered dietitian/nutritionists play a critical role in managing the nutrition regimen for these patients. In this case, the use of fistuloclysis met the patient's nutritional needs while avoiding the risks associated with parenteral nutrition.

Experience of living with an enterocutaneous fistula.

AIMS AND OBJECTIVES: The purpose of this study was to describe patients' experiences of living with an enterocutaneous fistula. BACKGROUND: An enterocutaneous fistula is a complex and serious illness that usually occurs as a complication from surgery or spontaneously as a result of an underlying disease. The illness is demanding both physically and mentally and causes substantial medical and nursing problems for the afflicted individual. DESIGN: A descriptive design with a qualitative approach. METHODS: In-depth interviews were performed with nine participants who had experiences of living with an enterocutaneous fistula. The analysis was conducted using descriptive phenomenology according to Giorgi. RESULTS: The essence of this study was that living with an enterocutaneous fistula is about handling an illness that causes several limitations in daily life and the following five themes emerged from the data: restrictions in daily life, approaches to illness, emotions, dependence and need of support. A constant fear of leakage from the fistula appliance, being dependent on intravenous fluids and being dependent on health care professionals caused isolation and social restriction. CONCLUSIONS: The participants had many strategies for handling their illness. By being well trained, engaged and having a positive and understanding approach, health care professionals can encourage hope, motivation and self-care. This can lead to decreased dependence and help the patient to better handle their illness. RELEVANCE TO CLINICAL PRACTICE: The competence of health care professionals is essential in the care of patients with an enterocutaneous fistula.

Intestinal failure and the ward nurses: causes, assessment and management.

In order to manage intestinal failure (IF), a complex regimen of care is required to manage fluid intake and electrolyte balance. In the majority of cases ward nurses will bare the responsibility of managing patients with these specific needs, with the support of the nutritional multidisciplinary team. Therefore, nurses need to ensure they have expert knowledge of each area of IF management. This article defines IF and outlines how it can be managed surgically and medically. The author discusses the role of the ward nurse in monitoring and managing therapy, and states the importance of providing emotional and psychological care.

Supporting patients with enterocutaneous fistula: from hospital to home.

The aim of this article is to discuss the care of patients with enterocutaneous fistula (ECF) requiring long-term support in the community. The discussion of what ECF are and aspects of nutrition will support the knowledge required to care for this group of patients effectively in their homes. This article focuses on the management of ECF appliances and gives a basic guide of skin care and how to reduce the prevalence of appliance leaks.

Bedside management of an abdominal wound containing an enteroatmospheric fistula: a case report.

Enteroatmospheric fistulae (EAF) - unnatural connections between the bowel and the outside environment - are a feared complication of major abdominal operations. EAF pose a life-threatening risk to patients already weakened by surgical insult by altering fluid and electrolyte balance and fostering malnutrition. The authors describe a method of wound management for a 64-year-old morbidly obese woman with a history of coronary artery disease, diabetes mellitus, and bipolar disorder who developed a large abdominal wound containing multiple high-output EAF after an incarcerated abdominal hernia repair, wound infection, and subsequent laparotomy and lysis of adhesions followed by graft placement and negative pressure wound therapy. The volume, consistency, and location of the EAF caused commercial negative pressure devices to fail and simple gauze dressings were ineffective in maintaining a clean wound base and containing odor. Effluent collection and wound healing was achieved utilizing a modified method of EAF management that included two connecting rubberized catheter drains and continuous wound irrigation with wall suction and cotton gauze for debridement. Surgical EAF closure was successful after 6 months of care. This method provided a satisfactory balance between the diagnosis of EAF and the readiness to meet the physiologic demands of definitive surgical treatment.

Management of an enterocutaneous fistula in a patient with a gastrointestinal stromal tumor.

BACKGROUND: Gastrointestinal stromal (GIS) tumors are rare malignancies that affect the esophagus, stomach, gallbladder, liver, small intestine, colon, or rectum. These tumors are often refractory to treatment with radiotherapy and chemotherapy and usually treated with a combination of surgery and imatinib mesylate, a tyrosine kinase inhibitor. CASE: This case study describes the management of an enterocutaneous fistula in a patient with a rare GIS tumor who ultimately required radical excision of the mesenteric GIS tumor by enteroenterostomy and colocolostomy. He subsequently developed an enterocutaneous fistula within his dehisced surgical wound. This fistula along with the wound required various dressings and pouching modifications to meet treatment goals and enable the patient to be discharged from the hospital. CONCLUSION: Although rare, WOC nurses may care for a patient with GIS tumors. Fistulas may occur due to the disease or as a result of treatment. The use of a fistula pouching system, combined with individualized and detailed education, may allow patients to maintain a quality of life despite the poor prognosis associated with this malignancy.

[Nurse's experience caring for a patient with malignant fungating wound with enterocutaneous fistula].

This report describes a nurse's experience treating a metastatic skin lesion with draining enterocutaneous fistula located in the right posterolateral abdominal wall. The period of nursing care ran from April 22nd through June 25th, 2006. In studying the nursing process, Gordon's assessment tools were used to gather subjective and objective data to establish critical care issues, which included chronic pain, sleep pattern disturbance, impaired tissue integrity, and disturbed body image. The focus of care was to manage the pain and irritation caused by the fistula of enterocutaneous. Targeting the issue of impaired tissue integrity, we developed and applied various methods to decrease the wound macerated from fecal, control odor, maintain patient comfort and improve patient quality of life. We helped the patient achieve her wish to end her life in peace. This nursing experience may provide a reference in caring for such cases in the clinic.

A cost-effectiveness analysis of fistula treatment in the abdominal region using a new integrated fistula and wound management system.

OBJECTIVE: To evaluate wear time and costs of a new fistula and wound management system (FWMS) compared to standard fistula treatments. METHODS: Data were collected from 22 patients with an abdominal fistula recruited from 5 sites in the United States. This economic evaluation was based on a cost-effectiveness analysis with wear time, material costs, and labor costs taken into account. RESULTS: A longer wear time for each pouch as well as simpler handling by nurses amounted to an average lower cost of $83 per day of treatment with the FWMS. A large variation was observed in the collected data. However, the sensitivity analysis showed that 77% of patients achieved a cost reduction when changing to the FWMS. CONCLUSION: The FWMS was less costly than traditional methods for managing abdominal fistula, probably due to longer wear time and less time spent on each pouching session.

Management of intestinal failure and high-output stomas.

Intestinal failure and a high faecal output from a stoma or fistula are rare gastrointestinal complications. Intestinal failure occurs when the intestine fails to absorb sufficient fluids and nutrients to maintain life, and can result from bowel resection or malabsorption. The management of these conditions raises many issues which nurses caring for affected patients need to consider. This article will discuss those relating to feeding, appliances and medication. Two methods of feeding that can be useful in patients with intestinal failure, namely parenteral nutrition (intravenous feeding) and fistuloclysis (feeding via an intestinal fistula), will be explored. Finally, a short case study will be presented to highlight the effects of some of these interventions and the problems that they can cause for patients.