[Diagnostic and therapeutic guidelines for entero-cutaneous fistulas. Personal experience and literature review].
The entero-cutaneous fistulas (ECF) are abnormal communications between intestine and abdominal skin. They can occur spontaneously, or after an injury or a surgical procedure. They are associated with a high rate of morbidity and mortality. Spontaneous fistulas can mainly occur in patients affected by cancer, inflammatory bowel disease, diverticulitis, appendicitis, as a result of radiotherapy or injuries. Surgical procedures, carried out in case of neoplastic diseases, inflammatory bowel disease, adhesions removal, represent the primary cause in the development of a postoperative fistulas. Malnourishment, poor general conditions of the patient, high output fistula along with anatomical site of development, and the presence of abscesses, represent the negative factors influencing the spontaneous healing of fistulas. The experience reported here is about three ECF cases occurred after surgery and treated only with medical therapy. The first case is a woman in good general conditions who underwent surgery to remove a recurrent retroperitoneal myxoid liposarcoma situated in the right lower quadrant. The patient had never undergone surgery for an intestinal resection. The other two patients analyzed were affected by sepsis and metabolic unbalance and had developed a fistula after colonic resection. Fluids and electrolytes adjustments and sepsis management have preceded any other kind of therapy. Continuous infusion with somatostatin, fast, proton pump inhibitors and loperamide have been taken up to decrease secretions and intestinal motility. Total parenteral nutrition has been essential to recover nutritional status and improve patients' general conditions. In order to heal and protect peri-fistula skin we have used sterile washing solutions, absorbable ionic exchange resin, silver and polyurethanes based medications and colostomy bags adhesive systems. Since surgical treatment of ECF is associated with high rates of morbidity and mortality, conservative treatment should always be taken into consideration. When conservative treatment fails, delayed surgical intervention has been related to a higher rate of success. The purpose of this study is to describe diagnostic and therapeutic guidelines to general surgeons, like ourselves, whenever they have to deal with ECF cases.
Candela
G
G
VII Divisione di Chirurgia Generale, Facoltà di Medicina e Chirurgia, Seconda Università di Napoli, Napoli, Italy.
Di Libero
L
L
Varriale
S
S
Manetta
F
F
Giordano
M
M
Lanza
M
M
Argenziano
G
G
Pizza
A
A
Sciascia
V
V
Napolitano
S
S
Riccio
M
M
Esposito
D
D
Santini
L
L
D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000930:Antidiarrheals / Q000627:therapeutic use; D003125:Colostomy / Q000009:adverse effects; D004202:Disinfectants; D004359:Drug Therapy, Combination; D005260:Female; D006728:Hormones / Q000627:therapeutic use; D006801:Humans; D007412:Intestinal Fistula / Q000175:diagnosis* / Q000188:drug therapy* / Q000209:etiology / Q000628:therapy; D008139:Loperamide / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009236:Myxosarcoma / Q000601:surgery; D011140:Polyurethanes; D017410:Practice Guidelines as Topic; D054328:Proton Pump Inhibitors; D012186:Retroperitoneal Neoplasms / Q000601:surgery; D012307:Risk Factors; D018805:Sepsis / Q000150:complications / Q000628:therapy; D013004:Somatostatin / Q000627:therapeutic use; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D000930:Antidiarrheals; D004202:Disinfectants; D006728:Hormones; D011140:Polyurethanes; D054328:Proton Pump Inhibitors; D013004:Somatostatin; D008139:Loperamide