NUTRITIONAL MANAGEMENT OF PATIENTS WITH GASTROINTESTINAL FISTULAS

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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.

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    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

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