NUTRITIONAL MANAGEMENT OF PATIENTS WITH GASTROINTESTINAL FISTULAS
Section snippets
ASSESSMENT OF THE PATIENT WITH GASTROINTESTINAL FISTULA
The role of nutritional support in the management of a patient with a gastrointestinal (GI) fistula is shown in Figure 1. It plays a key role in the comprehensive clinical management of GI fistulas discussed elsewhere in this issue.
RATIONALE FOR ASSESSING THE NUTRITIONAL STATUS OF A PATIENT WITH GASTROINTESTINAL FISTULA
The temporal course for the development of clinically evident malnutrition is summarized in Figure 3. Malnutrition has a deleterious effect on every major system in the body (Fig. 4), thus affecting structure and function. A link exists between deficient nutritional status (well nourished or malnourished) and poor operative outcome: GI, septic, and nonseptic complications, including death and prolonged hospital stay (Table 4). In the malnourished, the frequency of hospital-related complications
RATIONALE FOR THE USE OF NUTRITIONAL SUPPORT
In the 1960 landmark study by Edmunds et al,35 53% of the patients with gastric or duodenal fistulas, 74% with jejunal or ileal fistulas, and 20% with large bowel fistulas were malnourished; the overall mortality rates (with and without definitive therapy) were 62%, 59%, and 64%, respectively.
Four years later, Chapman et al22 emphasized the benefits of nutritional support in the management and outcome of patients with enterocutaneous fistulas. In 56 patients, 33% received optimal nutritional
NUTRITIONAL SUPPORT IN GASTROINTESTINAL FISTULAS
The role of nutritional support as either total parenteral nutrition (TPN) or enteral nutrition in fistula management is primarily that of supportive care* to prevent the further deterioration of malnutrition, thereby preventing further deterioration of the debilitated fistula patient. Furthermore, it has been suggested that nutritional support decreases or modifies the composition of GI and pancreatic secretions.33, 46, 102 Thus, it is
Water and Electrolyte Requirements
Of the different schemes devised to calculate maintenance fluid needs, water requirement based on caloric expenditure (1 mL/kcal/24 hr) is the most practical because, in general, 1 mL of water is needed for each calorie expended. Factors that significantly increase water and energy needs include loss of GI fluids, fever, and sepsis. Additional losses caused by external GI and fluid losses must be accurately measured and analyzed for major electrolyte content. The electrolyte content of the
Central Venous Cannulation.
Two routes are most commonly used: (1) the infraclavicular subclavian vein and (2) the supraclavicular internal jugular vein. Both routes are popular and permit the delivery of hypertonic nutrient solutions in a dependable manner. The indication for the use of either route is to provide nutrients for a period greater than 5 days when adequate nutrient intake to meet the patient's full nutrient requirements necessary for fistula-related treatment cannot be assured. The benefits of TPN via these
DURATION OF NUTRITIONAL SUPPORT AND SURGICAL OPTIONS
Once effective nutritional support is instituted and sepsis is controlled, spontaneous closure is achieved in 23% to 80% of the reported cases.* With the addition of somatostatin, DiCostanzo et al29 achieved 73% of spontaneous closure rate. If the four cases with complete anastomotic breakdown in that study are excluded, spontaneous closure occurred in 27 of 33 cases (82%).
Although progress is recognized when it occurs, as outlined in
ACKNOWLEDGMENT
We thank Maureen Galvin, MS, RD, for her technical assistance, and Darlene Thompson for diligent editorial assistance.
References (119)
Continuous montoring of critically ill patients with transcutaneous oxygen and carbon dioxide and conjunctival oxygen sensors
Ann Emerg Med
(1984)- et al.
Use of serum CPK-MM to monitor response to nutritional intervention in catabolic surgical patients
J Surg Res
(1987) - et al.
Guidelines on artificial nutrition versus hydration in terminal cancer patients
Nutrition
(1996) - et al.
The high frequency–low morbidity mechanical complications of tube feeding: A prospective study
Clin Nutr
(1992) - et al.
Fibre, diabetes and risk of bezoar
Lancet
(1980) - et al.
Management of intestinal fistulas
Am J Surg
(1964) Foods high in fiber and phytobezoar formation
J Am Diet Assoc
(1987)Intravenous catheters and infection
Surg Clin North Am
(1972)- et al.
External intestinal fistulas: Nursing care and surgical procedures
Clin Gastroenterol
(1982) - et al.
Determination of resting energy expenditure utilizing the thermodilution pulmonary artery catheter
Chest
(1987)
Glucose or fat as a nonprotein energy source? A controlled clinical trial in gastroenterological patients requiring intravenous nutrition
Gastroenterology
Nutrition support in surgical practice: Current knowledge and research needs
Am J Surg
Nutritional support in cancer
Lancet
Quantitative tip culture methods and the diagnosis of central venous catheter–related infections
Diagnos Microbiol Infect Dis
A new approach to the management of Broviac catheter infection
J Hosp Infect
Use of chemically defined diets in the management of patients with high output gastrointestinal cutaneous fistulas
Am J Surg
Septic complications of total parenteral nutrition. A five year experience
Am J Surg
Efficacy of tube feeding in supplying energy requirements of hospitalized patients
JPEN
The role of hyperalimentation in therapy of gastrointestinal cutaneous fistulae
Ann Surg
Intestinal Fistulas
Influence of total parenteral nutrition on fuel utilization in injury and sepsis
Ann Surg
Effects of total parenteral nutrition on gas exchange and breathing patterns [abstract]
Crit Care Med
Reduction of catheter-associated sepsis in parenteral nutrition using low-dose intravenous heparin
Br Med J
Evaluation of lysis centrifugation system for recovery of yeasts and filamentous fungi from blood
J Clin Microbiol
Comfort measures for the terminally ill: Is dehydration painful?
J Am Geriatr Soc
Blood culture as a guide for the diagnosis of central venous catheter sepsis
JPEN
Prevention and treatment of central venous catheter sepsis by exchange via a guide wire
Ann Surg
Glucose requirements following burn injury
Ann Surg
The Caval Catheter
On feeding the dying
Hastings Center Rep
Home enteral nutrition via gastrostomy in advanced head and neck cancer patients
Head Neck
The clinical use of total nutritional admixtures
Nutrition
Standardized enteral orders attain caloric goals sooner: A prospective study
JPEN
Assessing the efficacy of intravenous nutrition in general surgical patients: Dynamic nutritional assessment with plasma proteins
JPEN
Delayed reconstructive surgery for complex enterocutaneous fistulas
Am Surg
Small intestine cutaneous fistulas
Surg Gynecol Obstet
Fungal septicemia in patients receiving parenteral hyperalimentation
N Engl J Med
Cannulation of the inferior vena cava for long term central venous access: Techniques and results
Surg Gynecol Obstet
Effect of operation and nutrient intake of muscle function and enzymes
Surg Forum
Treatment of external gastrointestinal fistulas by a combination of total parenteral nutrition and somatostatin
JPEN
New centrifugation blood culture device
J Clin Microbiol
Quantitative blood cultures for diagnosis and management of catheter-related sepsis in pediatric hematology and oncology patients
Intens Care Med
Ethics, law and nutritional support
Arch Intern Med
Spontaneous closure of traumatic pancreatoduodenal fistulas with total parenteral nutrition
J Trauma
Jejunal variceal hemorrhage: An unusual complication of needle catheter jejunostomy
JPEN
External fistulas arising from the gastrointestinal tract
Ann Surg
Incidence and prevention of thrombosis of the subclavian vein during total parenteral nutrition
Surg Gynecol Obstet
Factors influencing the outcome of treatment of small bowel cutaneous fistulas
World J Surg
Evaluating total parenteral nutrition
Nutrition
Cited by (0)
Address reprint requests to Michael M. Meguid, MD, PhD, Department of Surgery, University Hospital, State University of New York, 750 East Adams Street, Syracuse, NY 13210