New application of intestinal obstruction catheter in enterocutaneous fistula:A case report

BACKGROUND Enterocutaneous fistula(ECF)is an abnormal connection between the gastrointestinal tract and the skin.ECF can lead to massive body fluid loss,hypercatabolism,and malnutrition.Therefore,nutritional support plays a crucial role in managing ECFs and promoting the healing of fistulas.For nutritional support,enteral nutrition(EN)is the preferred method when gastrointestinal function is recovering.Currently,various EN approaches have been applied for different anatomical positions of the ECF.However,the effectiveness of administering EN support for treating lower ECFs still needs further exploration and improvement.CASE SUMMARY We present the case of a 46-year-old male who underwent gastrointestinal stromal tumour resection.Six days after the surgery,the patient presented with fever,fatigue,severe upper abdominal pain,and septic shock.Subsequently,lower ECFs were diagnosed through laboratory and imaging examinations.In addition to symptomatic treatment for homeostasis,total parenteral nutrition support was administered in the first 72 h due to dysfunction of the intestine.After that,we gradually provided EN support through the intestinal obstruction catheter in consideration of the specific anatomic position of the fistula instead of using the nasal jejunal tube.Ultimately,the patient could receive optimal EN support via the catheter,and no complications were found during the treatment.CONCLUSION Nutritional support is a crucial element in ECF management,and intestinal obstruction catheters could be used for early EN administration.

Prevalence, Management and Outcomes of Enterocutaneous Fistulas in Buea Regional Hospital and Laquintinie Hospital of Douala. A Five Years Retrospective Study

Background: An Enterocutaneous fistula (ECF) is an abnormal connection between the intestinal tracts or stomach and the skin. They are a major catastrophe to the patient and surgeons and still have a high incidence of morbidity and mortality which varies between 6% - 33%;their management remains a big challenge. These patients frequently face complications, and a well-organized multidisciplinary approach must be implemented in their management to improve outcomes. Objectives: Our study aims to assess the prevalence, management and outcomes of enterocutaneous fistulas in Buea regional hospital and Laquintinie hospital of Douala over the past 5 years. Methods: This was a hospital-based retrospective study in Buea regional hospital and Laquintinie hospital of Douala. Records of patients who had enterocutaneous fistulas within the period of 1st January 2017 to 31st December 2020 in the surgical departments. Data included demographics, pre-operative diagnosis, comorbidities, type of fistula, management modality and means, the indication of operative treatment, length of stay in the hospital and outcomes. Data was analysed using SPSSv26. Results: The study constituted 1343 medical records of which 83 medical records of patients with enterocutaneous fistulas, giving a prevalence of 6.2%, female predominance at 59% (n = 49), 42.2% (n = 35) were referred cases from the periphery for better management. A vast majority (96.4%) occurred as post-operative complications with appendectomy the most common indication (18.8%). High output fistulas were predominant (43.4%). 59% (n = 47) were managed medically, 6% (n = 5) received both conservative and surgical modalities while 35% (n = 5) were managed surgically. 64.1% (n = 50) were placed on enteral nutrition while 35.9% (n = 28) were placed on parenteral nutrition. Peritonitis/infection 50% (n = 18) was the commonest indication of surgical treatment, followed by failure of medical treatment 25% (n = 9) then high output fistulas 16.7% (n = 6). Resection with end-to-end anastomosis was the preferred repaired work at 61% (n = 22). The mortality rate was 38.5% (n = 32), 29% (n = 24) healed after conservative treatment, 21.7% (n = 18) healed after surgery, 7.2% (n = 6) persisted after surgery while 3.6% (n = 3) persisted after conservative treatment. Anaemia, sepsis, electrolyte imbalance, dehydration and malnutrition were the commonest complications. Conclusion: The prevalence of enterocutaneous fistulas was high, with a female predominance and a mean age of 38 years. Most cases were seen as a referral from the periphery for better management. The greatest majority of fistulas occurred as a postoperative complications. Conservative management with enteral feedings was preferred, they had better outcomes and gave more chances of healing. The commonest indication of surgical treatment was an infection. Resection with end-to-end anastomosis was the preferred repaired work. The mortality rate was high, and anaemia, sepsis and electrolyte imbalance were the commonest complications.

3D-printed “fistula stent” designed for management of enterocutaneous fistula: An advanced strategy

Enterocutaneous fistulas(ECFs) are great challenges during the open abdomen. The loss of digestive juice, water-electrolyte imbalance and malnutrition are intractable issues during management of ECF. Techniques such as "fistula patch" and vacuumassisted closure therapy have been applied to prevent contamination of open abdominal wounds by intestinal fistula drainage. However, failures are encountered due to high-output fistula and anatomical complexity. Here, we report 3 D-printed patient-personalized fistula stent for ECF treatment based on 3 D reconstruction of the fistula image. Subsequent follow-up demonstrated that this stent was well-implanted and effective to reduce the volume of enteric fistula effluent.

Effects of recombinant human growth hormone on enterocutaneous fistula patients

AIM： To explore the effects of recombinant human growth hormone （rhGH） on intestinal mucosal epithelial cell proliferation and nutritional status in patients with enterocutaneous fistula. METHODS： Eight patients with enterocutaneous fistulas received recombinant human growth hormone （10 ug/d） for 7 d. Image analysis and immunohistochemical techniques were used to analyse the expression of proliferating cell nuclear antigen （PCNA） in intestinal mucosal epithelial cells in biopsy samples from the patients who had undergone an endoscopic biopsy through the fistula at day 0, 4 and 7. Body weights, nitrogen excretion, serum levels of total proteins, albumin, prealbumin, transferrin and fibronectin were measured at day 0, 4 and 7. RESULTS： Significant improvements occurred in the expression of PCNA in the intestinal mucosal epithelial cells at day 4 and 7 compared to day 0 （24.93 ± 3.41%, 30.46 ± 5.24% vs 12.92 ± 4.20%, p 〈 0.01）. These changes were accompanied by the significant improvement of villus height （500.54 ± 53.79 um, 459.03 ± 88.98um vs 210.94 ± 49.16 um, P 〈 0.01）, serum levels of total proteins （70.52 ± 5.13 g/L, 74.89 ± 5.16 g/L vs 63.51 ± 2.47 g/L, P 〈 0.01）, albumin （39.44 ± 1.18 g/L, 42.39 ± 1.68 g/L vs 35.74 ± 1.75 g/L, P 〈 0.01） and fibronectin （236.3 4- 16.5 mg/L, 275.8± 16.9 mg/L vs 172.5 ± 21.4 mg/L, P 〈 0.01） at day 4 and 7, and prealbumin （286.38 ± 65.61 mg/L vs 180.88 ± 48.28 mg/L, P 〈 0.05）, transferrin （2.61 ± 0.12 g/L vs 2.41 ±0.14 g/L, P 〈 0.05） at day 7. Nitrogen excretion was significantly decreased at day 7 （3.40 ± 1.65 g/d vs 7.25 ± 3.92 g/d, P 〈 0.05）. No change was observed in the body weight. CONCLUSION： Recombinant human growth hormone could promote intestinal mucosal epithelial cell proliferation and protein synthesis in patients with enterocutaneous fistula.

Reduction of the closure time of postoperative enterocutaneous fistulas with fibrin sealant

AIM: To assess whether the use of fibrin sealantshortens the closure time of postoperative enterocutaneous fistulas (ECFs). METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application directly through the external hole. Outcome variables included closure time, time to resume oral feeding and morbidity related to nutritional support. RESULTS: There were no differences in mean age, fistula output, and follow-up. Closure-time for all patients of the study group was 12.5 ± 14.2 d and 32.5 ± 17.9 d for the control group (P < 0.001), and morbidity related to nutritional support was 8.6% and 42.5%, respectively (P < 0.01). In patients with colonic fistulas, complete closure occurred 23.5 ± 19.5 d after the first application of fibrin glue, and spontaneous closure was observed after 36.2 ± 22.8 d in the control group (P = 0.36). Recurrences were observed in 2 patients because of residual disease. One patient of each group died during follow-up as a consequence of septic complications related to parenteral nutrition. CONCLUSION: Closure time was significantly reduced with the use of fibrin sealant, and oral feeding was resumed faster. We suggest the use of fibrin sealant for the management of stable enterocutaneous fistulas.

Necrotizing fasciitis secondary to enterocutaneous fistula:Three case reports

Necrotizing fasciitis(NF)is an uncommon,rapidly progressive,and potentially fatal infection of the superficial fascia and subcutaneous tissue.NF caused by an enterocutaneous fistula has special clinical characters compared with other types of NF.NF caused by enterocutaneous fistula may have more rapid progress and more severe consequences because of multiple germs infection and corrosion by digestive juices.We treated three cases of NF caused by postoperative enterocutaneous fistula since Jan 2007.We followed empirically the principle of eliminating anaerobic conditions of infection,bypassing or draining digestive juice from the fistula and changing dressings with moist exposed burn therapy impregnated with zinc/silver acetate.These three cases were eventually cured by debridement,antibiotics and wound management.

Polymorphism of heat shock protein 70-2 and enterocutaneous fistula in Chinese population

AIM: To investigate whether the heat shock protein 70-2 (HSP70-2) polymorphism is associated with enterocutaneous fistulas in a Chinese population.

First report of colonoscopic closure of a gastrocolocutaneous PEG migration with over-the-scope-clip-system

Percutaneous endoscopic gastrostomy(PEG) is a common practice for long-term nutrition of patients who are unable to take oral food. We report of an 85-year old man with a history of recurrent larynx carcinoma and hemicolectomy many years ago due to unknown reason. Laryngectomy was indicated. Preoperatively a PEG was inserted endoscopically after an abdominal ultrasonography without abnormal findings. Few months after PEG insertion, the patient was evaluated for diarrhea and insufficient feeding without signs of infection or peritonism. An upper endoscopy and computed tomography scan confirmed a buried bumper syndrome with migration of the PEG tube into the colon as a rare complication. He underwent successful colonoscopic removal of the internal bumper and closure of the colonic orifice of the fistula with the over-the-scope-clip system(OTSC). OTSC is an endoscopic device for treatment of bleeding, perforation, leak and fistula in the gastrointestinal tract. To the best of our knowledge, this is the first report of the use of OTSC for colonoscopic closure of a gastrocolocutaneous fistula due to a buried bumper syndrome with transcolonic PEG tube migration.

Management of the enteroatmospheric fistula:A case report

BACKGROUND Enteroatmospheric fistula(EAF)is a catastrophic complication that can occur after open abdomen.EAFs cause severe body fluid loss,hypercatabolism,and wound complications,leading to adverse clinical outcomes.CASE SUMMARY A 72-year-old female patient underwent ventral hernia repair.Five days after the surgery,she exhibited severe abdominal pain with septic shock.Exploratory laparotomy revealed extensive intestinal adhesions and severe intraperitoneal contamination.Since the patient was hemodynamically unstable,a salvage operation rather than definite surgery was needed,and three surgical open drains were inserted into the peritoneal cavity.Postoperative EAFs developed,and it was almost impossible to isolate and reduce the fistula output despite the use of vacuum-assisted closure dressings and endoscopic stent insertion.Finally,we anastomosed two vascular grafts to the openings of each EAF to restore enteric continuity.The inserted vascular grafts showed acceptable patency,and the patient could receive optimal nutritional support with elemental enteral feeding.She underwent EAF resection 76 d after graft implantation.CONCLUSION Control of the enteric effluent are key elements in achieving favorable clinical conditions which should precede definite surgery for EAFs.

Meckel's diverticulum manifested by a subcutaneous abscess

This case report describes an extremely rare complication of a Meckel's diverticulum:enterocutaneous fistula of the diverticulum.The presence of Meckel's diverticulum is a well known entity,but subcutaneous perforation of the diverticulum is very rare.Here we report the case of a patient with the complaint of a right lower quadrant abscess,preoperatively diagnosed as enterocutaneous fistula,which was determined intraoperatively to be a fistula resulting from Meckel's diverticulum.

Cecocutaneous fistula diagnosed by computed tomography fistulography:A case report

BACKGROUND Enterocutaneous fistula(ECF) is an abnormal communication between the skin and the gastrointestinal tract and is associated with considerable morbidity and mortality. To diagnose ECF, X-ray fistulography and abdominal computed tomography(CT) with intravenous or oral contrast are generally used. If the anatomic details obtained from CT are insufficient, CT fistulography may help diagnose and determine the extent of the abnormal channel. However, CT fistulography is seldom performed in patients with insufficient evidence of a fistula.CASE SUMMARY A 35-year-old man with a prior appendectomy presented with purulence over the abdominal wall without gastrointestinal tract symptoms or a visible opening on the abdominal surface. His history and physical examination were negative for nausea, diarrhea, muscle guarding, and bloating. Local abdominal tenderness and redness over a purulent area were noted, which led to the initial diagnosis of cellulitis. He was admitted to our hospital with a diagnosis of cellulitis. We performed a minimal incision on the carbuncle to collect the pus. The bacterial culture of the exudate resulted positive for Enterococcus sp. ECF was thus suspected, and we arranged a CT scan for further investigation. CT images before intravenous contrast administration showed that the colon was in close contact with the abdominal wall. Therefore, we conducted CT fistulography by injecting contrast dye into the carbuncle during the CT scan. The images showed an accumulation of the contrast agent within the subcutaneous tissues, suggesting the formation of an abscess. The contrast dye tracked down through the muscles and peritoneum into the colon, delineating a channel connecting the subcutaneous abscess with the colon. This evidence confirmed cecocutaneous fistula and avoided misdiagnosing ECF without gastrointestinal tract symptoms as cellulitis. The patient underwent laparoscopic right hemicolectomy with re-anastomosis of the ileum and transverse colon.CONCLUSION CT fistulography can rule out ECF in cases presenting as cellulitis if examinations are suggestive.

Management of post-operative complications in open ventral hernia repair

Hernia repair is the most common general surgical procedure performed in the United States;however,historically,there has been a surprising lack of consensus regarding hernia complications and their management.The development of international,prospectively-collected databases such as the Americas Hernia Society Quality Collaborative has introduced a new era of evidence-based practice around the prevention and management of these complications.This review seeks to equip surgeons with evidence-based techniques for prevention and management of the most common complications of open ventral hernia repair.