Management of external gastrointestinal fistulas
Annals of Surgery
|October 1, 1978
Summary
Total parenteral nutrition (TPN) simplified nutritional management for patients with external gastrointestinal fistulas but did not change outcomes like mortality or spontaneous closure rates. Operative closure is recommended for persistent fistulas after sepsis control.
Area of Science:
- Gastroenterology
- Surgical Nutrition
- Clinical Outcomes Research
Background:
- External gastrointestinal fistulas present complex management challenges, impacting patient nutrition and recovery.
- Nutritional support, including TPN, has evolved as a key component in managing these patients.
- Previous studies have explored various interventions, but the specific impact of TPN on fistula outcomes requires further clarification.
Purpose of the Study:
- To evaluate the impact of TPN on the outcomes of patients with external gastrointestinal fistulas.
- To compare fistula-related mortality and spontaneous closure rates between groups with differing TPN utilization.
- To identify factors influencing spontaneous fistula closure and recommend optimal management strategies.
Main Methods:
- Retrospective analysis of 186 patients with external gastrointestinal fistulas treated between 1968 and 1977.
- Comparison of two groups: earlier (1968-1971) with 35% TPN use and later (1972-1977) with 71% TPN use.
- Analysis of fistula-related mortality, spontaneous closure rates, and influencing factors such as sepsis, comorbidities, and fistula characteristics.
Main Results:
- TPN use increased from 35% to 71% between the two study periods, simplifying nutritional management.
- Fistula-related mortality (11%) and spontaneous closure rates (32%) remained unchanged across the decade.
- Factors like malignancy, irradiation, Crohn's disease, or short fistula tracts reduced spontaneous closure likelihood (20% vs. 47%).
- Sepsis was a major determinant of mortality (68% of deaths) and delayed spontaneous closure.
- Most spontaneous closures occurred within one month post-sepsis eradication.
Conclusions:
- TPN primarily improved nutritional management convenience for gastrointestinal fistulas, without altering key clinical outcomes.
- Prompt control of sepsis is critical for enabling spontaneous fistula closure.
- Operative intervention, such as bowel excision and anastomosis or bypass, is recommended for fistulas persisting over one month after sepsis control.
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