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.

Biliary phytobezoar resulting in intestinal obstruction

Phytobezoar is the most common type of bezoar.It is composed of indigestible vegetable matter and is usually found in the stomach.Biliary phytobezoar is extremely rare and difficult to diagnose preoperatively.The pathogenesis is not clear,and there have been only a few reports of biliary bezoars associated with sphincteric impairmentat the ampulla of Vater.Here,we present a report of biliary bezoar that resulted in jejunal obstruction.We were unable to identifythe bezoar in the extrahepatic bile duct until it obstructed the small bowel lumen.To our knowledge,this is the first report of small bowel obstruction resulting frommigration of a biliary bezoar.

Extracellular matrices for gastrointestinal surgery:Ex vivo testing and current applications

AIM:To assess the effects of bile and pancreatic juice on structural and mechanical resistance of extracellular matrices(ECMs) in vitro.METHODS:Small-intestinal submucosa(SIS),porcine dermal matrix(PDM),porcine pericardial matrix(PPM) and bovine pericardial matrix(BPM) were incubated in human bile and pancreatic juice in vitro.ECMs were examined by macroscopic observation,scanning electron microscopy(SEM) and testing of mechanical resistance.RESULTS:PDM dissolved within 4 d after exposure to bile or pancreatic juice.SIS,PPM and PDM retained their integrity for > 60 d when incubated in either digestive juice.The effect of bile was found to be far more detrimental to mechanical stability than pancreatic juice in all tested materials.In SIS,the loss of mechanical stability after incubation in either of the digestive secretions was less distinct than in PPM and BPM [mFmax 4.01/14.27 N(SIS) vs 2.08/5.23 N(PPM) vs 1.48/7.89 N(BPM)].In SIS,the extent of structural damage revealed by SEM was more evident in bile than in pancreatic juice.In PPM and BPM,structural damage was comparable in both media.CONCLUSION:PDM is less suitable for support of gastrointestinal healing.Besides SIS,PPM and BPM should also be evaluated experimentally for gastrointestinal indications.

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.

Postoperative negative-pressure drainage through a PEG tube can prevent pancreatic fistula after pancreatoduodenectomy

Postoperative pancreatic fistula(POPF)is a well-known complication after pancreatoduodenectomy[1].It is difficult to prevent due to a number of factors.The very placement and tightening of sutures in pancreatic tissue is challenging.Perfusion of the anastomosis edges is unpredictable.Another risk factor is the large amounts of fluids(comprising gastric and intestinal secretions,bile,and pancreatic juice)collected in the intestine near the pancreatic anastomosis,which increase the pressure in the first loop of the anastomosed intestine,and may ultimately rupture the pancreatoenteric anastomosis.Effective peristalsis,required to pass these fluids to subsequent sections of the intestine,takes time to return after such an extensive procedure.Increased pressure in the intestinal loop may also contribute to ischemia,by increasing the tension of the intestinal wall,constricting or even blocking its blood vessels.All these are aggravated by the chemical effects of intestinal contents.Any surgical errors may add the risk of POPF.

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.

Cholecystoenteric fistula with and without gallstone ileus: A case series

Background: A cholecystoenteric stula (CEF) is an uncommon complication of gallstone disease. The aim of this study was to present our experience of a series of patients with CEF, presenting with or without gallstone ileus, along with their surgical outcomes. Methods: From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution, of which 15 were diagnosed with a CEF. All electronic medical records were retrospectively reviewed. Results: Fifteen patients presented with CEF. Ten patients presented cholecystoduodenal stula, four pa- tients cholecystocolonic, and one patient cholecystogastric counterparts. Twelve patients were female. The median patient age was 61 years (range 33 86 years). Five patients presented with gallstone ileus treated by laparotomy and enterolithotomy. In ten patients, a laparoscopic approach was attempted, but conversion to open surgery was necessary for eight of them. The median operative time was 140 min (range 60 240 min), and the median operative blood loss was 50 mL (range 10600mL). The procedure-related morbidity and mortality rates were 13.3% and 6.7%, respectively. Conclusions: There is no consensus on the best treatment modality for a CEF, as the treatment outcome is mostly dependent on the surgeon’s expertise and the patient’s condition. Not all CEFs are accompanied by gallstone ileus. For such case, the main purpose is to resolve the intestinal obstruction and, unless necessary, avoidance of the gallbladder area.

Crohn’s disease complicated by multiple stenoses and internal fistulas clinically mimicking small bowel endometriosis

We report a 31-year-old woman with Crohn's disease complicated by multiple stenoses and internal fistulas clinically misdiagnosed as small bowell endometriosis, due to the patient's perimenstrual symptoms of mechanical subileus for 3 years; at first monthly, but later continuous, and gradually increasing in severity. We performed an exploratory laparotomy for small bowel obstruction, and found multiple ileal strictures and internal enteric fistulas. Because intraoperative findings were thought to indicate Crohn's disease, a right hemicolectomy and partial distal ileum resection were performed for obstructive Crohn's ileitis. Histopathology of the resected specimen revealed Crohn's disease without endometrial tissue. The patient made an uneventful recovery from this procedure and was discharged home 10 d post-operatively. The differential diagnosis of Crohn's diease with intestinal endometriosis may be difficult pre-operatively. The two entities share many overlapping clinical, radiological and pathological features. Nevertheless, when it is difficult to identify the cause of intestinal obstruction in a woman of child-bearing age with cyclical symptoms suggestive of small bowel endometriosis, Crohn's disease should be included in the differential diagnosis.

A combined pig model to determine the net absorption of volatile fatty acids in the large intestine under different levels of crude fiber

Background:This study aimed to develop a combined model to quantify the net absorption of volatile fatty acids(VFA)in the large intestine(LI)of pigs.Methods:Fifteen female growing pigs(Duroc×Large White×Landrace)were ranked by body weight(30±2.1 kg)on day 0 and assigned to one of three treatments,namely the basal diet containing different crude fiber(CF)levels(LCF:3.0%CF,MCF:4.5%CF,and HCF:6.0%CF).The pigs were implanted with the terminal ileum fistula and the cannulation of the ileal mesenteric vein(IMV),portal vein(PV),and left femoral artery(LFA)from days 6 to 7.[13 C]-Labeled VFA and P-aminohippuric acid were constantly perfused into the terminal ileum fistula and the cannulation of the IMV(day 15),respectively.Blood samples were collected from the PV and the LFA during perfusion(5 h),and LI samples were collected.Results:The net flux of[12 C]-acetic acid in the PV was greater for LCF versus MCF(p=0.045),but no difference was observed in the net flux of[12 C]-propionic acid(p=0.505)and[12 C]-butyric acid(p=0.35)in the PV among treatments.The deposition of[12 C]-acetic acid in the LI was greater for LCF versus MCF(p=0.014),whereas the deposition of[12 C]-propionic acid(p=0.007)and[12 C]-butyric acid(p=0.037)in the LI was greater for LCF versus HCF.Conclusions:In conclusion,this pig model was found conducive to study the net absorption of VFAs in the LI,and LCF had more net absorption of VFAs in the LI than MCF and HCF.

Endoscopic treatment of primary aorto-enteric fistulas:A case report and review of literature

BACKGROUND Primary aorto-enteric fistula(PAEF)is a rare condition,traditionally treated in the acute,bleeding phase with open surgery or endovascular repair.However,these approaches have high morbidity and mortality,indicating a need for new methods.With advances in endoscopic techniques and equipment,haemoclipping of fistulas has now become feasible.Therefore,we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping.CASE SUMMARY A 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools.An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum.Afterward,a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm.Based on the clinical presentation and the combined endoscopic and radiographic findings,we argue that this is a case of a PAEF.CONCLUSION Endoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF,serving as a bridge to final therapy.

Analysis of mechanical response of fistula plug for structure optimization

Anal fistula is one of the three greatest anorectal diseases with a high prevalence. The traditional treatments（e.g., surgery） for fistula have limitations due to damage to the internal anal sphincter of patients. With recent advances in biomaterials, treatments based on biomaterial filling （e.g., scleraprotein injection, fistula plug） have emerged as novel therapies for fistula. The anal fistula plug （e.g., based on small intestinal submucosa （SIS）） has attracted increasing attention because of short term healing rate and biocompatibility. However, challenges remain for this method such as plug falling as observed in clinics. To address this, this paper analyzes the case of SIS falling under physiological condition from mechanical point of view using ANSYS simulation. It then proposes three new geometrical structures for fistula plug and compares their mechanical behavior （e.g., axial stress, reaction of constraint） with that of clinically used structure （cone shape）. Based on the simulation, it optimizes the geometric parameters of fistula plug. The approach developed here can help to improve the design of fistula plug for better clinical treatments.

超声在克罗恩病并发症诊断中的应用

克罗恩病的并发症主要包括狭窄、肠瘘及脓肿等,给克罗恩病患者带来极大的痛苦,尤其是肠瘘及纤维性狭窄的形成更是外科手术的主要适应证,早期诊断并进行干预有助于改变克罗恩病远期临床结局。超声作为一种实时、经济、简便、有效的检查方式,在克罗恩病诊断中发挥重要作用,且各种超声技术的发展也给克罗恩病并发症的诊断带来更加积极的作用。本文就超声的各种技术在克罗恩病并发症诊断中的应用作一综述。

1例小肠双腔造瘘合并急性胰腺炎超高龄患者的营养支持护理

报道1例小肠双腔造瘘合并急性胰腺炎超高龄患者的营养支持护理经验。护理要点包括以营养状况评估、个体化的营养支持方案、使用肠内营养耐受性评估管理工具和中医适宜技术为主的营养支持护理,辅以功能锻炼和小肠双腔造口护理。患者急性胰腺炎期经过积极治疗,早期鼻空肠营养,及时调整营养支持方案为改良式(轻断食)喂养,现已恢复正常鼻饲量,营养状态良好。目前,小肠双腔造瘘合并急性胰腺炎的营养支持护理的相关报道较少,现将该患者的护理过程整理报道,以期为更多患者提供借鉴。

小儿继发性肠狭窄及闭锁伤口造瘘口护理方法分析

目的:探讨小儿继发性肠狭窄及闭锁伤口造瘘口的有效护理方法,为临床治疗提供依据。方法:选取宁夏医科大学总医院2022年1月—2023年12月收治的继发性肠狭窄及闭锁患儿70例作为研究对象,随机分为观察组和对照组,各35例。观察组采用新型护理方案,对照组采用传统护理方案。比较两组患儿瘘口情况、排泄及感染情况及并发症发生率。结果:观察组瘘口愈合时间短于对照组,观察组护理后视觉模拟评分法评分低于对照组,差异有统计学意义(P<0.001);观察组排泄不佳率、感染率均低于对照组,差异均有统计学意义(P<0.05);观察组并发症总发生率低于对照组,差异有统计学意义(P=0.040)。结论:相较于传统护理方法,新型护理方案在小儿继发性肠狭窄及闭锁伤口造瘘口护理中的优势显著,能够有效缩短瘘口愈合时间,降低感染率及并发症发生率,改善排泄情况,减轻患儿瘘口疼痛程度。

腹腔镜根治术治疗胃癌的疗效及对肿瘤标志物及氧化应激反应的影响

目的 探讨腹腔镜根治术治疗胃癌的临床效果及对患者肿瘤标志物及氧化应激水平的影响。方法 选取78例胃癌患者,按随机数字表法分为2组,各39例。对照组行开腹根治术治疗,观察组行腹腔镜根治术治疗。比较两组手术情况、肿瘤标志物、氧化应激水平、炎症水平及并发症发生情况。结果 观察组手术、排气及住院时间分别为(221.52±13.25)min、(1.52±0.39)d、(10.98±2.04)d,较对照组[(257.63±14.13)min、(2.38±0.43)d、(14.39±2.18)d]短,出血量为(209.63±12.43)ml,低于对照组的(296.87±15.38)ml,有统计学差异(P<0.05);观察组术后癌胚抗原(CEA)、糖类抗原199(CA199)、糖类抗原125(CA125)水平分别为(14.63±2.08)ng/ml、(34.35±3.82)U/ml、(37.25±3.96)U/ml,较对照组[(18.28±2.24)ng/ml、(40.16±4.02)U/ml、(42.58±4.23)U/ml]低,有统计学差异(P<0.05);观察组术后超氧化物岐化酶(SOD)、谷胱甘肽过氧化物酶(GSH-Px)水平分别为(67.85±6.14)U/ml、(218.96±23.52)pg/ml,高于对照组的(55.73±6.05)U/ml、(186.74±19.68)pg/ml,丙二醛(MDA)水平为(25.37±3.19)U/L,低于对照组的(30.82±3.57)U/L,有统计学差异(P<0.05);观察组术后C反应蛋白(CRP)、白介素-6(IL-6)及肿瘤坏死因子-α(TNF-α)水平分别为(20.41±2.86)mg/L、(25.96±3.12)ng/L、(69.85±5.37)ng/L,低于对照组的(26.93±3.12)mg/L、(31.52±3.45)ng/L、(78.52±6.05)ng/L,并发症发生率低于对照组,有统计学差异(P<0.05)。结论 腹腔镜根治术治疗胃癌效果优于开腹根治术,能降低CA199、CEA、CA125水平,减轻机体创伤,抑制氧化应激反应,阻止炎症因子活化,减少并发症发生,值得广泛应用。

肠外瘘的外科阶段治疗策略

目的:总结肠瘘不同阶段的治疗经验及分期手术策略在肠瘘确定性手术治疗中的应用。方法:采用回顾性病例数据,收集2016年1月—2019年12月清华大学附属北京清华长庚医院收治的255例肠瘘患者的临床资料,包括患者年龄、性别、原发疾病、致瘘原因、瘘的部位、瘘的数量、瘘的性质、瘘发生到就诊时间、肠瘘诊断评估方式、营养风险、营养支持方式、入院感染状态等进行初步总结。根据肠瘘病理生理特点进行肠瘘阶段治疗:肠瘘急性阶段-肠瘘稳定阶段-肠瘘确定性手术阶段。肠瘘确定性手术分期治疗:I期手术和分期手术。并分析各个阶段治疗策略和治疗效果。结果:肠瘘急性阶段(141例),局部感染患者与严重感染患者之间的腹腔脓肿处理方式有明显差异(P=0.023),损伤控制外科手术适合严重感染患者。141例均进入肠瘘稳定阶段,其中112例患者接受全过程治疗,28例放弃,1例死亡。112例完整治疗患者中,75例治愈(治愈率83.7%),37例保守无效进入肠瘘确定性手术阶段;联合114例外院保守无效肠瘘患者;共计151例进入肠瘘确定性手术阶段;其中134例行Ⅰ期手术,17例行分期手术。151例患者手术治疗的总体结局,138例治愈(治愈率为91.4%)。结论:根据肠瘘患者的发生和病理生理,正确归入肠瘘急性阶段、肠瘘稳定阶段或肠瘘确定性手术阶段并进行相应的治疗至关重要。另外,合理的手术时机和分期手术策略也是手术治疗肠瘘的关键所在。

负压辅助冲洗引流在肠外瘘伤口管理中的应用效果

目的探讨负压辅助冲洗引流在肠外瘘伤口管理中的应用效果。方法对南昌市第一医院2012年8月至2023年8月收治的22例采用负压辅助冲洗引流进行伤口管理的肠外瘘患者的临床资料进行回顾性分析。结果22例患者经负压辅助冲洗引流治疗后治愈19例(86.4%),其中瘘口自行闭合9例、经手术治疗痊愈10例;死亡2例,其中1例为高流量瘘、1例因肿瘤复发自发肠外瘘。22例患者治疗后白细胞、中性粒细胞计数均较治疗前显著降低(P<0.01)。结论负压辅助冲洗引流能有效管理肠外瘘伤口,促进感染恢复。

老年原发性胃癌患者腹腔镜手术后肠瘘发生的相关影响因素

目的研究老年原发性胃癌患者接受腹腔镜手术治疗后发生肠瘘的相关影响因素。方法择取150例老年原发性胃癌患者作为研究对象。所有患者均接受腹腔镜手术治疗,依据术后是否发生肠瘘进行分组,将发生肠瘘的40例患者纳入观察组,将未发生肠瘘的110例患者纳入对照组。对2组患者的资料数据展开比对分析,针对有统计学意义的单因素开展多元回归分析,以明确导致患者术后发生肠瘘的影响因素。结果观察组年龄≥75岁、糖尿病、肝硬化、术前营养不良患者占比均高于对照组,其消化道重建方式为BillroNhⅠ患者占比亦高于对照组(P<0.05);多元回归分析中,糖尿病、肝硬化、术前营养状态以及消化道重建方式为术后发生肠瘘的主要影响因素。结论老年原发性胃癌患者接受腹腔镜手术治疗后并发肠瘘与糖尿病、肝硬化、手术前营养状态以及消化道重建方式等因素有关。

paired Coagulation Status in the Crohn＇s Disease Patients Complicated with Intestinal Fistula

Background： Intestinal fistula is one of the common complications of Crohn＇s disease （CD） that might require surgical treatment. The clinical characteristics and outcomes of CD with intestinal fistula are much different from CD alone. This study was to investigate whether the coagulation status of CD is changed by intestinal fistula. Methods： Data were retrospectively analyzed for 190 patients with a definitive diagnosis of CD who were registered at the Jinting Hospital between January 2014 and September 2015. Baseline clinical characteristics and laboratory indices of initial admission and 7 days after intestinal fistula resections were collected. Student＇s t-test and the Wilcoxon rank-sum test were used to compare differences between the two groups. Results： Compared with CD patients without intestinal fistula, prothrombin time （PT） in patients with intestinal fistula was significantly longer （12.13 ± 1.27 s vs. 13.18± 1.51 s,P〈0.001 in overall cohort： 11.56± 1.21 svs. 12.61 ±0.73 s,P 0.001 in females： and 12.51± 1.17 s vs. 13.37± 1.66 s, P - 0.003 in males）. Platelet （PLT） count was much lower in intestinal fistula group than in nonintestinal fistula group （262.53 ± 94.36 × 109/L vs. 310.36 ± 131.91× 109/L, P = 0.009）. Multivariate logistic regression showed that intestinal fistula was significantly associated with a prolonged PT （odds ratio [OR] 1.900, P 〈 0.001 ）, a reduced amount of PLT （OR = 0.996, P = 0.（124）, and an increased operation history （OR = 5.408, P 〈 0.001 ）. Among 65 CD patients receiving intestinal fistula resections, PT was obviously shorter after operation than baseline （ 12.28 ± 1.16 s vs. 13.02 ± 1.64 s, P = 0.006）. Conclusions： Intestinal fistula was significantly associated with impaired coagulation status in patients complicated with CD. Coagulation status could be improved after intestinal fistula resections.

Enteral fistula as initial manifestation of primary intestinal lymphoma

To the Editor:Enteral fistula(EF)is a rare complication mostly caused by inflammatory bowel disease and in some cases by duodenal ulcer,intestinal tuberculosis,intestinal lymphoma,abdominal surgery,or necrotizing enterocolitis.[1,2]Perforative complications including perforation and EF are major complications of primary intestinal lymphoma(PIL).Vaidya et al[2]reported that in a cohort of 1062 patients with gastrointestinal lymphoma,bowel perforation occurred in 9%of the patients,and among them,the small intestine was the most common site(81%).Furthermore,perforation events occurred as the initial presentation in 51%of these patients.