Review of 404 Patients with Gastrointestinal Fistulas Impact of Parenteral Nutrition

Abstract

This paper represents an extensive review, spanning 30 years of experience with 404 patients with gastrointestinal fistulas. It includes the first period (1945-1960) during the introduction of antibiotics, the second period (1960-1970) which saw rapid improvements in parasurgical care including, respiratory support, perfection of antibiotics, some introduction of nutritional support and improved monitoring, and the third period which saw the introduction of parenteral nutrition specifically central venous hyperalimentation using hypertonic glucose and amino acids (1970-1975) in the treatment of patients with fistulas. The principal causes for mortality in the historical sense were malnutrition, sepsis and electrolyte imbalance. Mortality among patients with gastrointestinal cutaneous fistulas decreased between the first and second periods from approximately 48 to 15%. Surprisingly, mortality did not decrease further in the "hyperalimentation period" although spontaneous closure of gastrointestinal fistulase increased. The results suggest that the improvement in mortality in patients with gastrointestinal cutaneous fistulas is mostly due to the introduction of improved parasurgical care. It is acknowledged that nutritional support was practiced in the 1960's although this was generally not in the form of hyperalimentation. The addition of hyperalimentation in large scale to the treatment of gastrointestinal cutaneous fistulas has improved spontaneous closure and is a valuable part of the armamentarium. The decrease in mortality however, cannot be attributed to parenteral nutrition.

Enterocutaneous Fistulas: A Look at Causes and Management

“…Careful monitoring of the character and volume of output of a fistula can guide resuscitation and nutrition support efforts. There have been several series studying the relationships between output and mortality as well as likelihood of spontaneous closure suggesting increased mortality and decreased spontaneous closure rate in high output fistulas [13,[16][17][18][19]. Other physiological factors that predict spontaneous fistula closure include a well-maintained nutritional status and absence of sepsis (Table 3).…”

“…Common causes include IBD, radiation enteritis, diverticular disease, appendicitis, perforated ulcers, malignancy, intra-abdominal sepsis, pancreatitis, ischemia, and trauma. Ability to correct or treat the underlying cause bears heavily on the non-operative closure rate [18,26].…”

“…The traditional starting point has been the Harris-Benedict equation, but more recently, the use of indirect calorimetry has allowed the assessment of respiratory quotient and macronutrient balance [11,27]. The use of parenteral nutrition has classically been a well-established part of the management of ECF [18]. Whether used independently or in conjunction with enteral feeding, institution of parenteral nutrition can help meet the nutritional demands of the patient while allowing for minimization of enteric flow through the fistula.…”

“…One study confirms this opinion [5], and it is also supported in discussion with other experts in the field. Many series have demonstrated higher recurrence rates when surgical correction involves over-sewing the fistula versus resection with primary anastomosis [4,18,54 • ]. Staged approaches involving resection of the fistula bearing bowel without anastomosis or proximal diversion of the anastomosis have been advocated by some to decrease recurrence of the fistula but expose the patient to the risk of additional surgery [59].…”

A Clinical Study of Enterocutaneous Fistula and Management Options

“…[2] 5. Conclusions  Small bowel is the most common site of fistula, of which terminal ileal fistulas are more common  Most of the fistulas occurring in emergency surgeries(76%)  Appendiceal and colonic fistulas hace a better prognosis when compared with patients with gastric and small bowel fistulas  High output fistulas are associated with poor prognosis  The presence of sepsis is associated with a poor prognosis and seems to be the most important cause of death in these patients  Grade III and IV fistulas are associated with increased mortality  Age and sex of the patient does not affect the outcome in patients with enterocutaneous fistula…”