Nutritional management of external gastrointestinal fistulas

From July 1969 to December 1975, 86 patients with 100 fistulas required one or a combination of three modern nutritional aids: central intravenous hyperalimentation; the peripheral intravenous, lipid-amino acid-carbohydrate system; and elemental, nutritionally complete liquid diets. Of the fistulas, 81 closed spontaneously, and in 11 operative closure was attempted; 89 fistulas healed. Eight patients died (9.3%). Before 1969, in an earlier comparable group of patients who had not received such nutrition, the mortality was 40.0%. Fistula drainage and sepsis were controlled. Abscesses were drained. Skin was protected. The most successful way of identifying the nature and origin of a fistula was by instillation of radiopaque liquid into the external opening. Prolonged fistula drainage occurred with distal bowel narrowing and inflammation; previous irradiation to the area; underlying granulomatous bowel disease; bowel adjacent to skin; and foreign bodies in the fistulous tract. Operative closure (resection) was necessary only for distal obstruction and wide breakdown or complete disruption of an anastomosis. Patients who did require operation were in a better nutritional state to withstand operation after receiving specialized nutritional support. Adequate calories and amino acids afforded healing and secretory and mechanical rest for the gastrointestinal tract.