Despite advances in antimicrobial chemotherapy, nutritional support, and perioperative
critical care, the development of an enterocutaneous fistula continues to represent
a major therapeutic challenge, with appreciable morbidity and mortality. Specific
problems that must be addressed for the successful management of patients with enterocutaneous
fistulas are the control of sepsis, maintenance of adequate fluid and electrolyte
balance, provision of adequate and complication-free nutritional support, and skin-stoma
care. In addition, many patients with postoperative intestinal fistulation suffer
from significant psychological morbidity, which must be addressed during often prolonged
periods of rehabilitation. The complex nature of the care required for successful
management of patients with enterocutaneous fistulas mandates a multidisciplinary
team approach, with specialist nurses, dieticians, pharmacists, radiologists, physicians,
and surgeons all having important roles to play.
KEYWORDS
Sepsis - parenteral nutrition - fistuloclysis - laparostomy
REFERENCES
- 1 Gomella L G, Lefor A T. Surgery on Call. Norwalk, CT; Appleton-Lange 1990
- 2 Nightingale J MD. The short bowel. In: Nightingale JMD Intestinal Failure. London;
Greenwich Medical Media 2001: 177-198
- 3
Nightingale J MD, Walker E R, Farthing M JG, Lennard-Jones J E.
Effect of omeprazole on intestinal output in the short bowel syndrome.
Aliment Pharmacol Ther.
1991;
5
405-412
- 4
Paran H, Neufeld D, Kaplan O, Klausner J, Freund U.
Octreotide for treatment of postoperative alimentary fistulas.
World J Surg.
1995;
19
430-433
- 5
Soeters P B, Ebeid A M, Fischer J E.
Review of 404 patients with gastrointestinal fistulas: impact of parenteral nutrition.
Ann Surg.
1979;
190
189-202
- 6
Shaw J HF, Koea J B.
Metabolic basis for the management of the septic surgical patient.
World J Surg.
1993;
17
154-164
- 7
Streat S J, Beddoe A H, Hill G L.
Aggressive nutritional support does not prevent protein loss despite fat gain in septic
intensive care patients.
J Trauma.
1987;
27
262-266
- 8
Carlson G L.
Surgical management of intestinal failure.
Proc Nutr Soc.
2003;
62
711-718
- 9 Carlson G L, Irving M H. Infection: recognition and management of infection in surgical
patients. In: Hanson G Critical Care of the Surgical Patient-A Companion to Bailey
and Loves' Surgery. London; Chapman & Hall Medical 1997: 273-290
- 10
Schein M, Decker G A.
Postoperative external alimentary tract fistulas.
Am J Surg.
1991;
161
435-438
- 11
Levy E, Frileux P, Cugnenc P H, Honiger J, Ollivier J M, Parc R.
High-output external fistulae of the small bowel: management with continuous enteral
nutrition.
Br J Surg.
1989;
76
676-679
- 12
Fazio V W, Coutsoftides T, Steiger E.
Factors influencing the outcome of treatment of small bowel cutaneous fistula.
World J Surg.
1983;
7
481-488
- 13
Bone R C, Balk R A, Cerra F B et al..
Definitions for sepsis and organ failure and guidelines for the use of innovative
therapies in sepsis.
Chest.
1992;
101
1644-1655
- 14
Thomas H A.
Radiological investigation and treatment of gastrointestinal fistulas.
Surg Clin North Am.
1996;
76
1081-1094
- 15
Gerzof S G, Oates M E.
Imaging techniques for infections in the surgical patient.
Surg Clin North Am.
1988;
68
147-166
- 16 Carlson G L. Surgical causes and management. In: Nightingale JMD Intestinal Failure. London;
Greenwich Medical Media 2001: 39-49
- 17
McLauchlan G J, Anderson I D, Grant I S, Fearon K C.
Outcome of patients with abdominal sepsis treated in an intensive care unit.
Br J Surg.
1995;
82
524-529
- 18
Shackley D C, Brew C J, Bryden A A et al..
The staged management of complex entero-urinary fistulae.
BJU Int.
2000;
86
624-629
- 19
Anderson I D, Fearon K C, Grant I S.
Laparotomy for abdominal sepsis in the critically ill.
Br J Surg.
1996;
83
535-539
- 20
Agwunobi A O, Carlson G L, Anderson I D, Irving M H, Scott N A.
Mechanisms of intestinal failure in Crohn's disease.
Dis Colon Rectum.
2001;
44
1834-1837
- 21
Mughal M M, Bancewicz J, Irving M H.
Laparostomy. A technique for the management of intractable abdominal sepsis.
Br J Surg.
1986;
73
253-259
- 22
Hedderich G S, Wexler M J, McLean A P, Meakins J L.
The septic abdomen: open management with Marlex mesh with a zipper.
Surgery.
1986;
99
399-408
- 23
Wittmann D H.
Operative and nonoperative therapy of intraabdominal infections.
Infection.
1998;
26
335-341
- 24 Hughes S, Myers A, Carlson G. Care of intestinal stoma and enterocutaneous fistula. In:
Nightingale JMD Intestinal Failure. London; Greenwich Medical Media 2001: 51-63
- 25
Scripcariu V, Carlson G, Bancewicz J, Irving M H, Scott N A.
Reconstructive abdominal operations after laparostomy and multiple repeat laparotomies
for severe intra-abdominal infection.
Br J Surg.
1994;
81
1475-1478
- 26 Carlson G L, Little R A. Insulin resistance and tissue fuels. In: Kinney JM Organ
Metabolism and Nutrition: Ideas for Critical Care. New York; Raven Press 1994: 49-69
- 27
Chandran V P, Sim A J.
Nutritional support in acute intestinal failure.
Bailllieres Clin Gastroenterol.
1991;
5
841-860
- 28 Carlson G L, Little R A. The pathophysiology and pattern of the hormonal response
to severe sepsis. In: Boles JM Endocrine Consequences of Critical Illness. Paris;
Arnette 1992: 57-69
- 29
Allard J P, Jeejheebhoy K N, Whitwell J, Pashutinski L, Peters W J.
Factors influencing energy expenditure in patients with burns.
J Trauma.
1988;
28
199-202
- 30
Askanazi J, Carpentier Y A, Elwyn D H et al..
Influence of total parenteral nutrition on fuel utilization in injury and sepsis.
Ann Surg.
1980;
291
40-46
- 31
Arnold J, Shipley K A, Scott N A, Little R A, Irving M H.
Thermic effect of parenteral nutrition in septic and nonseptic individuals.
Am J Clin Nutr.
1989;
50
853-860
- 32
Arnold J, Shipley K A, Scott N A, Little R A, Irving M H.
Lipid infusion increases oxygen consumption similarly in septic and nonseptic patients.
Am J Clin Nutr.
1991;
53
143-148
- 33
Arnold J, Leinhardt D, Carlson G, Gray P, Little R A, Irving M H.
Thermogenic and hormonal responses to amino acid infusion in septic humans.
Am J Physiol.
1992;
263
E129-E135
- 34
Carlson G L, Gray P, Arnold J, Little R A, Irving M H.
Thermogenic, hormonal and metabolic effects of intravenous glucose infusion in human
sepsis.
Br J Surg.
1997;
84
1454-1459
- 35
Askanazi J, Rosenbaum S H, Hyman A I, Silverberg P A, Milic-Emili J, Kinney J M.
Respiratory changes induced by the large glucose loads of total parenteral nutrition.
JAMA.
1980;
243
1444-1447
- 36 Carlson G L. Nutrient induced thermogenesis. In: Wernerman J, Little RA Clinical
Endocrinology & Metabolism: Energy Metabolism in Trauma. London; Balliere-Tindall
1998: 603-615
- 37 Fleming C R, Remington M. Intestinal failure. In: Hill GL Nutrition and the Surgical
Patient. New York; Churchill Livingstone 1981: 219-235
- 38
Scott N A, Leinhardt D J, O'Hanrahan T, Finnegan S, Shaffer J L, Irving M H.
Spectrum of intestinal failure in a specialised unit.
Lancet.
1991;
337
471-473
- 39
Williams N, Carlson G L, Scott N A, Irving M H.
Incidence and management of catheter-related sepsis in patients receiving home parenteral
nutrition.
Br J Surg.
1994;
81
392-394
- 40
Williams N, Wales S, Irving M H.
Prolonged peripheral parenteral nutrition with an ultrafine cannula and low osmolality
feed.
Br J Surg.
1996;
83
114-116
- 41
May J, Murchan P, MacFie J et al..
Prospective study of the aetiology of infusion phlebitis and line failure during peripheral
parenteral nutrition.
Br J Surg.
1996;
83
1091-1094
- 42
Plusa S M, Horsman R, Kendall-Smith S, Webster N, Primrose J N.
Fine bore cannulas for peripheral intravenous nutrition: polyurethane or silicone?.
Ann R Coll Surg Engl.
1998;
80
154-156
- 43
Tighe M J, Wong C, Martin I G, McMahon M J.
Do heparin, hydrocortisone and glyceryl trinitrate influence thrombophlebitis during
full intravenous nutrition via a peripheral vein?.
J Parenter Enteral Nutr.
1995;
19
507-509
- 44
Teubner A, Farrer K, Ravishankar H, Anderson I, Scott N.
Fistuloclysis can successfully replace parenteral feeding in the nutritional support
of patients with enterocutaneous fistulas.
Br J Surg.
2004;
31
625-631
- 45
Levy E, Frileux P, Sandrucci S et al..
Continuous enteral nutrition during the early adaptive stage of the short bowel syndrome.
Br J Surg.
1988;
75
549-553
- 46
Tassiopoulos A K, Baum G, Halverson J D.
Small bowel fistulas.
Surg Clin North Am.
1996;
76
1175-1181
- 47
Van Der Krabben A A, Dijkstra F R, Nieuwenhuijzen M, Reijnen M M, Schaapveld M, Van
Goor H.
Morbidity and mortality of inadvertent enterotomy during adhesiotomy.
Br J Surg.
2000;
87
467-471
- 48
Niggebrugge A H, Trimbos J B, Hermans J, Steup W H, Van De Velde C J.
Influence of abdominal-wound closure technique on complications after surgery: a randomised
study.
Lancet.
1999;
353
1563-1567
- 49
Malik R-A, Scott N A.
Double near and far prolene suture closure: a technique for abdominal wall closure
after laparostomy.
Br J Surg.
2001;
88
146-147
- 50
Diebel L N, Dulchavsky S A, Wilson R F.
Effect of increased intra-abdominal pressure on mesenteric arterial and intestinal
mucosal blood flow.
J Trauma.
1992;
33
45-48
Mr.
G L Carlson
Department of Surgery, Hope Hospital
Salford M6 8HD, United Kingdom
eMail: gcarlson@fs1.ho.man.ac.uk
