536587
research-article2014
NCPXXX10.1177/0884533614536587Nutrition in Clinical Practice X(X)Yin et al
Clinical Observations
Is It Feasible to Implement Enteral Nutrition in Patients With Enteroatmospheric Fistulae? A Single-Center Experience
Nutrition in Clinical Practice Volume 29 Number 5 October 2014 656–661 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614536587 ncp.sagepub.com hosted at online.sagepub.com
Jianyi Yin, MD1; Jian Wang, MD, PhD1; Danhua Yao, MD1; Shaoyi Zhang, MD1; Qi Mao, MD, PhD1; Wencheng Kong, MD1; Lele Ren, MD1; Yousheng Li, MD, PhD1; and Jieshou Li, MD1
Abstract Background: Published experience in feeding patients with enteroatmospheric fistulae is scarce. This study aimed to determine if enteral nutrition (EN) could be safely delivered in the presence of enteroatmospheric fistula. Materials and Methods: This is a retrospective descriptive study from a major fistula treatment center in China. Medical records of patients who developed enteroatmospheric fistulae in the open abdomen after abdominal trauma were reviewed. The timing of initiation and achievement of full strength (25 kcal/kg/d) EN after enteroatmospheric fistula were noted, as well as the incidence of feeding-associated complications and weaning of parenteral nutrition (PN). The outcomes of open abdomen and enteroatmospheric fistula were also noted. Results: Nine patients were included in this study. EN was successfully implemented in all patients. The median timing of initiation and achievement of full strength of EN after enteroatmospheric fistula was 9 (interquartile range [IQR], 3–22) and 27 (IQR, 22–43) days, respectively. Feeding-associated complications developed in 1 (11.1%) patient. All patients were liberated from PN at hospital discharge. Split-thickness skin grafting was performed in all patients, of whom 5 underwent successful delayed abdominal closure, and 4 were awaiting definitive closure. Repair or resection of enteroatmospheric fistula occurred in 8 (88.9%) patients. Conclusion: This study showed that EN could be safely implemented in patients with enteroatmospheric fistulae without complicating the treatment of open abdomen and enteroatmospheric fistula. (Nutr Clin Pract. 2014;29:656-661)
Keywords abdominal injuries; intestinal fistula; open abdomen; enteroatmospheric fistula; enteral nutrition
Background The open abdomen treatment has become increasingly common in surgical practice during the past 2 decades. The technique is defined as nonclosure of abdominal fascia for the benefit of resultant open abdomen. Management of complex abdominal problems using the open abdomen technique has saved numerous lives of patients with trauma, intra-abdominal sepsis, and abdominal emergencies.1 However, the treatment itself is an iatrogenic complication of modern surgery and is associated with significant morbidity. Enteroatmospheric fistula (EAF) is one of the most devastating complications arising in the open abdomen.2 As a special subtype of enterocutaneous fistula occurring exclusively in patients with an open abdomen, an EAF is defined as an abnormal communication between the gastrointestinal (GI) tract and the atmosphere. Due to absence of skin or soft tissue around fistula opening, EAF presents a significant challenge in surgical management and is associated with considerable morbidity and mortality.3 Nutrition support is one of the most important predictors of outcomes in patients with an open abdomen. Enteral nutrition
(EN) is the preferred method of nutrition support due to its superiority over parenteral nutrition (PN) in preserving mucosal integrity and modulating immune response.4 However, it was initially uncertain whether administration of EN was feasible in patients with an open abdomen. With the accumulation of experience in managing open abdomen, there has been emerging evidence in recent years demonstrating the feasibility and safety of implementing EN in patients with an open abdomen.5-8 In a study of 23 patients with an open abdomen, Byrnes et al8 showed that EN could be successfully delivered at as early as 3.8 days after the initial laparotomy. Furthermore, From the 1Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China. Financial disclosure: This study was supported by grant numbers 81270945 and 81200327 from the National Natural Science Foundation of China. This article originally appeared online on June 11, 2014. Corresponding Author: Yousheng Li, MD, PhD, Department of Surgery, Jinling Hospital, 305 East Zhongshan Rd, Nanjing, 210002, China. Email: [email protected]
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in a cohort study enrolling patients undergoing open abdomen treatment after GI fistula and severe sepsis, early EN within 14 days of admission was associated with faster abdominal closure and lower mortality.9 However, experience in feeding patients with EAF is scarce. Patients with EAF represent one of the most complex subgroups of patients with an open abdomen. The presence of EAF further complicates the administration of EN, making these patients one of the most extreme examples of challenge in delivering EN. To our knowledge, few studies in the literature address enteral feeding in patients with EAF, leaving it unclear whether EN could be safely administered in these patients. In this study, we evaluated the nutrition practice in patients with EAF at a major fistula treatment center in China. We aimed to verify if EN could be safely implemented in the presence of EAF, identify its potential facilitating factors, and assess the clinical outcomes of these patients.
Methods This is a retrospective descriptive study from a major fistula treatment center in China. For the purpose of this study, we first searched the database of abdominal trauma, which is one of the major etiologies of open abdomen. Subsequently, we reviewed the medical records of patients undergoing open abdomen treatment after major abdominal trauma between January 2008 and March 2013. Finally, adult patients with the development of 1 or multiple EAF in the open abdomen were identified, and all were included in this study. In this study, the indication of open abdomen treatment included damage control surgery and management of complex abdominal problems (eg, intra-abdominal bleeding, intra-abdominal sepsis) after trauma, and open abdomen was defined as the absence of skin and fascial approximation. The study protocol was approved by the ethics board of Jinling Hospital. Written informed consent was obtained from all included patients. Demographic characteristics, including age, sex, and body mass index (BMI), were collected. The size of the open wound and the technique of temporary abdominal closure were noted. Moreover, the timing of the occurrence of EAF after open abdomen treatment and its number, anatomic location, diameter, and effluent control method were noted. Daily nutrition support records in the intensive care unit (ICU) were reviewed and the following data were collected: presence of EN before development of EAF, timing of initiation and achievement of full-strength (25 kcal/kg/d) of EN after the development of EAF, enteral feeding access, EN formula, and presence of PN. Clinical outcomes of interest included in-hospital outcomes and outcomes of open abdomen and EAF. The in-hospital morbidity and mortality, duration of mechanical ventilation (MV) and continuous renal replacement therapy, and length of stay in the ICU and hospital were noted. Development of feeding intolerance (defined as the occurrence of at least 1 of the following
symptoms: abdominal distention, vomiting, diarrhea, or gastric residual volume >200 mL) and feeding-associated complications (aspiration, GI tract bleeding, or ileus) while implementing EN in the presence of EAF were also noted. In addition, the timing of split-thickness skin grafting, delayed abdominal closure, and treatment of fistula were recorded. An independent investigator checked the accuracy of collected data before analysis. Continuous variables are presented as median and interquartile (IQR). We used SPSS software (version 19.0; SPSS, Inc, an IBM Company, Chicago, IL) for statistical analysis.
Results A total of 36 patients undergoing open abdomen treatment after major abdominal trauma were identified between January 2008 and March 2013, of whom 9 developed EAF. Of the 9 patients included in this study, 7 were male. The median age and BMI were 35 (23–53) years and 23.0 (19.4–25.9), respectively. The size of the open wound ranged from 10 × 5 to 18 × 14 cm2 (Table 1). The modified sandwich-vacuum package technique was used for temporary abdominal closure in all patients.10 Sandwich-vacuum package dressing change was performed every 48 hours until split-thickness skin grafting. EAF developed 8 (0–47) days after open abdomen treatment (Table 2). There were a total of 12 EAFs, with 3 patients having 2 EAFs. The anatomic location of EAF was small bowel in 6 patients and stomach in 3 patients. The diameter of the EAF ranged from 0.5–1.8 cm. All fistulae were managed using suction drainage catheters before split-thickness skin grafting, which were either placed at the fistula opening or intubated for effluent control. There was considerable variability in the management of EAF after split-thickness skin grafting. This included use of a suction drainage catheter, ostomy bag, and fistuloclysis. In addition, the fistula patch technique using silicagel lamellar (Deyi, Suzhou, China) was applied in 3 patients (Figure 1).11 With respect to nutrition management, 4 patients were receiving EN before the occurrence of EAF. EN was successfully implemented in all 9 patients after the development of EAF. The median timing of initiation and achievement of fullstrength of EN after the occurrence of EAF was 9 (3–22) and 27 (22–43) days, respectively (Table 3). Variability existed in enteral feeding access, with 4 patients receiving EN via a nasojejunal feeding tube (NJT), 1 via a nasogastric feeding tube (NGT), 1 via a jejunostomy feeding tube (JFT), 1 via a combination of NJT and fistuloclysis (Figure 2), 1 via a combination of JFT and fistuloclysis, and 1 via fistuloclysis. Starter EN formula was Vivonex (Nestlé, Minneapolis, MN) in 5 patients and Peptisorb (Nutricia, Wuxi, China) in 4 patients. PN was administered in all patients before initiation of EN and was discontinued when one-half to two-thirds of full-strength EN was reached. All patients were liberated from PN at discharge.
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Table 1. Management of Open Abdomen. Patient No. 1 2 3 4 5 6 7 8 9
Size of Open Wound, cm2
Timing of First SplitThickness Skin Grafting, da
No. of Split-Thickness Skin Grafting Procedures
Timing of Delayed Abdominal Closure, da
15 × 10 10 × 8 12 × 7 18 × 4 20 × 8 18 × 10 18 × 14 20 × 10 10 × 5
36 47 14 54 41 30 65 24 18
6 1 1 2 2 1 1 1 1
199 340 NA 290 NA NA NA 143 66
NA, not achieved. a Calculated from the day of open abdomen treatment.
Table 2. Management of EAF. Patient Timing of Development No. of EAF, da
No. of EAF
Anatomic Location of EAF
Diameter of EAF, cm
Management of EAF
Treatment of EAF
1
0
2
Small bowel
0.8, 1
2 3 4 5 6 7
0 8 33 71 0 79
1 2 1 1 1 2
Stomach Small bowel Small bowel Stomach Stomach Small bowel
0.8 0.5 1.5, 1.5 0.8 0.7 0.5, 1.8
Suction drainage catheter, ostomy bag, and fistuloclysis Suction drainage catheter, fistula patch Suction drainage catheter, fistula patch Suction drainage catheter, fistuloclysis Suction drainage catheter Suction drainage catheter Suction drainage catheter, ostomy bag
8 9
13 2
1 1
Small bowel Small bowel
1 1.5
Suction drainage catheter, fistula patch Suction drainage catheter, fistuloclysis
Resection Resection NA Resection Resection Repair Repair and resection Resection Resection
EAF, enteroatmospheric fistula; NA, not achieved. a Calculated from the day of open abdomen treatment.
Table 3. Nutrition Management. Patient No. 1 2 3 4 5 6 7 8 9 Figure 1. Use of a fistula patch technique in a patient with a gastroatmospheric fistula. Black arrow: fistula patch.
Route of EN JFT and fistuloclysis NJT NGT NJT and fistuloclysis JFT NJT NJT NJT Fistuloclysis
Timing of Initiation of EN After EAF, d
Timing of Full-Strength EN After EAF, d
21
57
2 23 4
22 27 42
8 9 19 0 29
16 24 44 21 34
EAF, enteroatmospheric fistula; EN, enteral nutrition; JFT, jejunostomy feeding tube; NGT, nasogastric tube; NJT, nasojejunal tube.
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659 from NGT and JFT, and administration of somatostatin) and short-term disruption of EN. Split-thickness skin grafting was performed in all 9 patients, with 4 undergoing 2 or more split-thickness skin grafting procedures. The first split-thickness skin grafting occurred 36 (21–51) days after open abdomen treatment. Delayed abdominal closure was achieved in 5 patients. This was completed 199 (105–315) days after open abdomen treatment. The remaining 4 patients were awaiting definitive abdominal closure and abdominal wall reconstruction (Table 1). EAFs were repaired or resected along with adjacent bowel segments or partial stomach in 8 patients, with a median time of 293 (157–336) days after open abdomen treatment. The remaining 1 patient was awaiting definitive treatment of EAF (Table 2).
Discussion
Figure 2. Use of fistuloclysis in a patient with 2 enteroatmospheric fistulae. White arrow: fistuloclysis catheters. Black arrow: suction drainage catheter. Table 4. In-Hospital Complications. Complication
No. (%)
Sepsis Intra-abdominal abscess Pneumonia Acute kidney injury Intra-abdominal hemorrhage Enterocutaneous fistula Biliary fistula Ileus Duodenal ulcer Gastrointestinal tract hemorrhage
6 (66.7) 6 (66.7) 5 (55.6) 5 (55.6) 3 (33.3) 3 (33.3) 1 (11.1) 3 (33.3) 1 (11.1) 1 (11.1)
Major in-hospital complications are summarized in Table 4. All 9 patients were discharged alive. The median duration of MV and continuous renal replacement therapy was 67 (29–87) and 4 (0–21) days, respectively. The median length of stay in the ICU and hospital was 102 (45–130) and 116 (54–136) days, respectively. Feeding intolerance occurred in 5 patients, and feeding-associated complication arose in 1 patient who had ileus during administration of EN. The complication was relieved by conservative treatment (including fluid resuscitation, drainage
Published experience of feeding patients with EAF is scarce. This case study provided single-center experience in feeding patients with EAF, showing that EN can be safely implemented in these patients without complicating the management of open abdomen and EAF. First, this case study demonstrated the feasibility and safety of implementing EN in patients with EAF. Patients with EAF represent one of the most extreme examples of difficulty in delivering EN. In this study, we included 9 patients developing EAF following open abdomen treatment after major abdominal trauma, and we showed that EN could be successfully initiated in the presence of EAF in all. Furthermore, full-strength EN was achieved in all, leading to weaning of PN. With regard to adverse effects of enteral feeding, the incidence of feeding intolerance was moderate (55.6%), and the occurrence of feeding-associated complications was rare (11.1%). These results indicated the practicality and safety of implementing EN in patients with EAF. The general outcomes of patients in this study were satisfactory. All patients were alive at hospital discharge, making the overall mortality lower than the results of previous studies.12,13 All patients underwent split-thickness skin grafting, and delayed abdominal closure was either achieved or planned. Treatment of EAF was achieved in 8, and the remaining 1 patient was awaiting definitive treatment. These results were satisfactory compared with those of previous studies.14 We were following several principles of nutrition practice in managing patients with EAF. First, resuscitation and stabilization should be implemented before initiating EN. This includes restoration of blood volume, correction of fluid/electrolyte and acid/base imbalance, and treatment of local and systematic infections. Second, systematic evaluation of EAF and the GI tract is crucial. The number, anatomic location, size, and output of fistula should be identified. This is particularly important for patients with multiple fistulae, in whom accurate assessment of the afferent/efferent sequencing of each fistula limb is essential in deciding enteral feeding access. Moreover,
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the length and function of residual bowel segments should be assessed to ensure adequate absorption of enteral nutrients and avoid ileus due to bowel immobility. The evaluation may be accomplished based on characteristics of fistula effluent, surgical findings, and radiological imaging findings such as computed tomography scans and fistulograms. Third, PN is required to maintain nutrition status when EN is not feasible. In this study, the median timing of initiation of EN after EAF was 9 (3–22) days. All patients were relying on PN before implementation of EN. This is similar to our previous finding that a combination of PN and EN was required in most (76%) patients with enterocutaneous fistulae.15 Establishment of enteral feeding access in patients with EAF can be challenging. The access should be easy to establish and maintain, using as many small bowel segments for absorption as possible. Moreover, establishment of enteral feeding access must be tailored to the individual patient according to illness severity, GI tract function, and characteristics of EAF, particularly the anatomic location of the fistula. For patients with gastroatmospheric fistulae, nasojejunal or jejunostomy feeding tubes are safe. Nasogastric or postpyloric feeding can be achieved in patients with ileoatmospheric fistulae provided effective fistula effluent control. Potential feeding routes for patients with jejunoatmospheric fistula include passage of the feeding tube distal to the fistula and fistuloclysis. The utilization of fistuloclysis in patients with enterocutaneous fistulae has been reported by several authors,16,17 but there are no reports of using this technique to feed patients with EAF. In this study, fistuloclysis was implemented in 3 patients, including 2 with multiple fistulae. In brief, the proximal fistula opening was intubated with a Foley’s balloon catheter, which was advanced approximately 5 cm in the lumen. Then, the balloon was inflated by infusing 10 mL of water, and the catheter was fixed on the skin using suturing or tape. To prevent leakage, the fistula opening might be surrounded by surgical gauze. The catheter was then connected to a continuous infusion pump. Similarly, the distal fistula opening was intubated and connected to the pump. In this way, the effluent of the proximal fistula opening was passaged to the distal fistula opening. This technique facilitated implementation of EN and allowed the longest bowel segments for absorption. Full-strength EN was achieved in all 3 patients undergoing fistuloclysis, and no complications associated with the technique were observed. A major risk of implementing EN in the presence of EAF is a dramatic increase in fistula output, which may contaminate surrounding tissues and complicate the management of open abdomen. As such, effective effluent control is the prerequisite for providing EN in patients with EAF. A number of effluent control techniques have been described in the literature, but none has shown definitive benefit.18-21 In this study, we managed EAF with suction drainage catheters before split-thickness skin grafting. This method was simple and useful in controlling fistula output, but it required frequent dressing
changes and good fixation of the catheter. Split-thickness skin grafting significantly facilitated the management of EAF and open abdomen. It provided the base for ostomy devices and effective protection to the open wound as well. Furthermore, the fistula patch was useful in managing EAF and significantly facilitated administration of EN. It allowed continuity of the GI tract, avoided loss of fistula effluent, and simplified open wound management. This study has several limitations. First, the sample size was small, which might be explained by the low incidence of EAF14 and inclusion of only patients undergoing open abdomen treatment after abdominal trauma. Second, techniques for temporary abdominal closure and fistula management may determine the outcomes of patients with EAF. Hence, the use of the modified sandwich-vacuum package technique and suction drainage catheters, rather than vacuum-assisted closure devices20,22 for the management of open abdomen and EAF, should be taken into consideration when interpreting the results of this study. Finally, this study showed the feasibility of EN support in patients with EAF, but we were not able to demonstrate the potential benefits of EN. This merits further investigation.
Conclusion This study demonstrated that EN could be successfully implemented in patients with EAF and did not complicate the management of open abdomen and EAF.
References 1. Diaz JJ Jr, Cullinane DC, Dutton WD, et al. The management of the open abdomen in trauma and emergency general surgery: part 1-damage control. J Trauma. 2010;68(6):1425-1438. 2. Majercik S, Kinikini M, White T. Enteroatmospheric fistula: from soup to nuts. Nutr Clin Pract. 2012;27(4):507-512. 3. Yin JY, Li YS, Wang J, Zhao BC, Li JS. Development of two enteroatmospheric fistulae after split-thickness skin grafting: a case report. Ostomy Wound Manage. 2013;59(6):48-51. 4. Weissenfluh GM, Brundage SI, Spain DA. Early enteral nutrition after abdominal trauma: effects on septic morbidity and practicality. Nutr Clin Pract. 2006;21(5):479-484. 5. Tsuei BJ, Magnuson B, Swintosky M, et al. Enteral nutrition in patients with an open peritoneal cavity. Nutr Clin Pract. 2003;18(3):253-258. 6. Dissanaike S, Pham T, Shalhub S, et al. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg. 2008;207(5):690-697. 7. Cothren CC, Moore EE, Ciesla DJ, et al. Postinjury abdominal compartment syndrome does not preclude early enteral feeding after definitive closure. Am J Surg. 2004;188(6):653-658. 8. Byrnes MC, Reicks P, Irwin E. Early enteral nutrition can be successfully implemented in trauma patients with an “open abdomen.” Am J Surg. 2010;199(3):359-363. 9. Yuan Y, Ren J, Gu G, Chen J, Li J. Early enteral nutrition improves outcomes of open abdomen in gastrointestinal fistula patients complicated with severe sepsis. Nutr Clin Pract. 2011;26(6):688-694. 10. Yuan Y, Ren J, Yuan K, Gu G, Wang G, Li J. The modified sandwich-vacuum package for fascial closure of the open abdomen in septic patients with gastrointestinal fistula. J Trauma Acute Care Surg. 2013;75(2):266-272.
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11. Wang G, Ren J, Liu S, Wu X, Gu G, Li J. “Fistula patch”: making the treatment of enteroatmospheric fistulae in the open abdomen easier. J Trauma Acute Care Surg. 2013;74(4):1175-1177. 12. Adkins AL, Robbins J, Villalba M, Bendick P, Shanley CJ. Open abdomen management of intra-abdominal sepsis. Am Surg. 2004;70(2):137-140. 13. Tremblay LN, Feliciano DV, Schmidt J, et al. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg. 2001;182(6):670-675. 14. Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg. 2007;96(4):263-271. 15. Li J, Ren J, Zhu W, Yin L, Han J. Management of enterocutaneous fistulas: 30-year clinical experience. Chin Med J (Engl). 2003;116(2):171-175. 16. Teubner A, Morrison K, Ravishankar HR, Anderson ID, Scott NA, Carlson GL. Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula. Br J Surg. 2004;91(5):625-631.
17. Polk TM, Schwab CW. Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach. World J Surg. 2011;36(3):524-533. 18. Al-Khoury G, Kaufman D, Hirshberg A. Improved control of exposed fistula in the open abdomen. J Am Coll Surg. 2008;206(2):397-398. 19. Girard S, Sideman M, Spain DA. A novel approach to the problem of intestinal fistulization arising in patients managed with open peritoneal cavities. Am J Surg. 2002;184(2):166-167. 20. Goverman J, Yelon JA, Platz JJ, Singson RC, Turcinovic M. The “Fistula VAC,” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma. 2006;60(2): 428-431. 21. Ramsay P, Mejia V. Management of enteroatmospheric fistulae in the open abdomen. Am Surg. 2010;76(6):637-639. 22. Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg. 2012;36(3):497-510.
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research-article2014
NCPXXX10.1177/0884533614536587Nutrition in Clinical Practice X(X)Yin et al
Clinical Observations
Is It Feasible to Implement Enteral Nutrition in Patients With Enteroatmospheric Fistulae? A Single-Center Experience
Nutrition in Clinical Practice Volume 29 Number 5 October 2014 656–661 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614536587 ncp.sagepub.com hosted at online.sagepub.com
Jianyi Yin, MD1; Jian Wang, MD, PhD1; Danhua Yao, MD1; Shaoyi Zhang, MD1; Qi Mao, MD, PhD1; Wencheng Kong, MD1; Lele Ren, MD1; Yousheng Li, MD, PhD1; and Jieshou Li, MD1
Abstract Background: Published experience in feeding patients with enteroatmospheric fistulae is scarce. This study aimed to determine if enteral nutrition (EN) could be safely delivered in the presence of enteroatmospheric fistula. Materials and Methods: This is a retrospective descriptive study from a major fistula treatment center in China. Medical records of patients who developed enteroatmospheric fistulae in the open abdomen after abdominal trauma were reviewed. The timing of initiation and achievement of full strength (25 kcal/kg/d) EN after enteroatmospheric fistula were noted, as well as the incidence of feeding-associated complications and weaning of parenteral nutrition (PN). The outcomes of open abdomen and enteroatmospheric fistula were also noted. Results: Nine patients were included in this study. EN was successfully implemented in all patients. The median timing of initiation and achievement of full strength of EN after enteroatmospheric fistula was 9 (interquartile range [IQR], 3–22) and 27 (IQR, 22–43) days, respectively. Feeding-associated complications developed in 1 (11.1%) patient. All patients were liberated from PN at hospital discharge. Split-thickness skin grafting was performed in all patients, of whom 5 underwent successful delayed abdominal closure, and 4 were awaiting definitive closure. Repair or resection of enteroatmospheric fistula occurred in 8 (88.9%) patients. Conclusion: This study showed that EN could be safely implemented in patients with enteroatmospheric fistulae without complicating the treatment of open abdomen and enteroatmospheric fistula. (Nutr Clin Pract. 2014;29:656-661)
Keywords abdominal injuries; intestinal fistula; open abdomen; enteroatmospheric fistula; enteral nutrition
Background The open abdomen treatment has become increasingly common in surgical practice during the past 2 decades. The technique is defined as nonclosure of abdominal fascia for the benefit of resultant open abdomen. Management of complex abdominal problems using the open abdomen technique has saved numerous lives of patients with trauma, intra-abdominal sepsis, and abdominal emergencies.1 However, the treatment itself is an iatrogenic complication of modern surgery and is associated with significant morbidity. Enteroatmospheric fistula (EAF) is one of the most devastating complications arising in the open abdomen.2 As a special subtype of enterocutaneous fistula occurring exclusively in patients with an open abdomen, an EAF is defined as an abnormal communication between the gastrointestinal (GI) tract and the atmosphere. Due to absence of skin or soft tissue around fistula opening, EAF presents a significant challenge in surgical management and is associated with considerable morbidity and mortality.3 Nutrition support is one of the most important predictors of outcomes in patients with an open abdomen. Enteral nutrition
(EN) is the preferred method of nutrition support due to its superiority over parenteral nutrition (PN) in preserving mucosal integrity and modulating immune response.4 However, it was initially uncertain whether administration of EN was feasible in patients with an open abdomen. With the accumulation of experience in managing open abdomen, there has been emerging evidence in recent years demonstrating the feasibility and safety of implementing EN in patients with an open abdomen.5-8 In a study of 23 patients with an open abdomen, Byrnes et al8 showed that EN could be successfully delivered at as early as 3.8 days after the initial laparotomy. Furthermore, From the 1Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China. Financial disclosure: This study was supported by grant numbers 81270945 and 81200327 from the National Natural Science Foundation of China. This article originally appeared online on June 11, 2014. Corresponding Author: Yousheng Li, MD, PhD, Department of Surgery, Jinling Hospital, 305 East Zhongshan Rd, Nanjing, 210002, China. Email: [email protected]
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in a cohort study enrolling patients undergoing open abdomen treatment after GI fistula and severe sepsis, early EN within 14 days of admission was associated with faster abdominal closure and lower mortality.9 However, experience in feeding patients with EAF is scarce. Patients with EAF represent one of the most complex subgroups of patients with an open abdomen. The presence of EAF further complicates the administration of EN, making these patients one of the most extreme examples of challenge in delivering EN. To our knowledge, few studies in the literature address enteral feeding in patients with EAF, leaving it unclear whether EN could be safely administered in these patients. In this study, we evaluated the nutrition practice in patients with EAF at a major fistula treatment center in China. We aimed to verify if EN could be safely implemented in the presence of EAF, identify its potential facilitating factors, and assess the clinical outcomes of these patients.
Methods This is a retrospective descriptive study from a major fistula treatment center in China. For the purpose of this study, we first searched the database of abdominal trauma, which is one of the major etiologies of open abdomen. Subsequently, we reviewed the medical records of patients undergoing open abdomen treatment after major abdominal trauma between January 2008 and March 2013. Finally, adult patients with the development of 1 or multiple EAF in the open abdomen were identified, and all were included in this study. In this study, the indication of open abdomen treatment included damage control surgery and management of complex abdominal problems (eg, intra-abdominal bleeding, intra-abdominal sepsis) after trauma, and open abdomen was defined as the absence of skin and fascial approximation. The study protocol was approved by the ethics board of Jinling Hospital. Written informed consent was obtained from all included patients. Demographic characteristics, including age, sex, and body mass index (BMI), were collected. The size of the open wound and the technique of temporary abdominal closure were noted. Moreover, the timing of the occurrence of EAF after open abdomen treatment and its number, anatomic location, diameter, and effluent control method were noted. Daily nutrition support records in the intensive care unit (ICU) were reviewed and the following data were collected: presence of EN before development of EAF, timing of initiation and achievement of full-strength (25 kcal/kg/d) of EN after the development of EAF, enteral feeding access, EN formula, and presence of PN. Clinical outcomes of interest included in-hospital outcomes and outcomes of open abdomen and EAF. The in-hospital morbidity and mortality, duration of mechanical ventilation (MV) and continuous renal replacement therapy, and length of stay in the ICU and hospital were noted. Development of feeding intolerance (defined as the occurrence of at least 1 of the following
symptoms: abdominal distention, vomiting, diarrhea, or gastric residual volume >200 mL) and feeding-associated complications (aspiration, GI tract bleeding, or ileus) while implementing EN in the presence of EAF were also noted. In addition, the timing of split-thickness skin grafting, delayed abdominal closure, and treatment of fistula were recorded. An independent investigator checked the accuracy of collected data before analysis. Continuous variables are presented as median and interquartile (IQR). We used SPSS software (version 19.0; SPSS, Inc, an IBM Company, Chicago, IL) for statistical analysis.
Results A total of 36 patients undergoing open abdomen treatment after major abdominal trauma were identified between January 2008 and March 2013, of whom 9 developed EAF. Of the 9 patients included in this study, 7 were male. The median age and BMI were 35 (23–53) years and 23.0 (19.4–25.9), respectively. The size of the open wound ranged from 10 × 5 to 18 × 14 cm2 (Table 1). The modified sandwich-vacuum package technique was used for temporary abdominal closure in all patients.10 Sandwich-vacuum package dressing change was performed every 48 hours until split-thickness skin grafting. EAF developed 8 (0–47) days after open abdomen treatment (Table 2). There were a total of 12 EAFs, with 3 patients having 2 EAFs. The anatomic location of EAF was small bowel in 6 patients and stomach in 3 patients. The diameter of the EAF ranged from 0.5–1.8 cm. All fistulae were managed using suction drainage catheters before split-thickness skin grafting, which were either placed at the fistula opening or intubated for effluent control. There was considerable variability in the management of EAF after split-thickness skin grafting. This included use of a suction drainage catheter, ostomy bag, and fistuloclysis. In addition, the fistula patch technique using silicagel lamellar (Deyi, Suzhou, China) was applied in 3 patients (Figure 1).11 With respect to nutrition management, 4 patients were receiving EN before the occurrence of EAF. EN was successfully implemented in all 9 patients after the development of EAF. The median timing of initiation and achievement of fullstrength of EN after the occurrence of EAF was 9 (3–22) and 27 (22–43) days, respectively (Table 3). Variability existed in enteral feeding access, with 4 patients receiving EN via a nasojejunal feeding tube (NJT), 1 via a nasogastric feeding tube (NGT), 1 via a jejunostomy feeding tube (JFT), 1 via a combination of NJT and fistuloclysis (Figure 2), 1 via a combination of JFT and fistuloclysis, and 1 via fistuloclysis. Starter EN formula was Vivonex (Nestlé, Minneapolis, MN) in 5 patients and Peptisorb (Nutricia, Wuxi, China) in 4 patients. PN was administered in all patients before initiation of EN and was discontinued when one-half to two-thirds of full-strength EN was reached. All patients were liberated from PN at discharge.
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Table 1. Management of Open Abdomen. Patient No. 1 2 3 4 5 6 7 8 9
Size of Open Wound, cm2
Timing of First SplitThickness Skin Grafting, da
No. of Split-Thickness Skin Grafting Procedures
Timing of Delayed Abdominal Closure, da
15 × 10 10 × 8 12 × 7 18 × 4 20 × 8 18 × 10 18 × 14 20 × 10 10 × 5
36 47 14 54 41 30 65 24 18
6 1 1 2 2 1 1 1 1
199 340 NA 290 NA NA NA 143 66
NA, not achieved. a Calculated from the day of open abdomen treatment.
Table 2. Management of EAF. Patient Timing of Development No. of EAF, da
No. of EAF
Anatomic Location of EAF
Diameter of EAF, cm
Management of EAF
Treatment of EAF
1
0
2
Small bowel
0.8, 1
2 3 4 5 6 7
0 8 33 71 0 79
1 2 1 1 1 2
Stomach Small bowel Small bowel Stomach Stomach Small bowel
0.8 0.5 1.5, 1.5 0.8 0.7 0.5, 1.8
Suction drainage catheter, ostomy bag, and fistuloclysis Suction drainage catheter, fistula patch Suction drainage catheter, fistula patch Suction drainage catheter, fistuloclysis Suction drainage catheter Suction drainage catheter Suction drainage catheter, ostomy bag
8 9
13 2
1 1
Small bowel Small bowel
1 1.5
Suction drainage catheter, fistula patch Suction drainage catheter, fistuloclysis
Resection Resection NA Resection Resection Repair Repair and resection Resection Resection
EAF, enteroatmospheric fistula; NA, not achieved. a Calculated from the day of open abdomen treatment.
Table 3. Nutrition Management. Patient No. 1 2 3 4 5 6 7 8 9 Figure 1. Use of a fistula patch technique in a patient with a gastroatmospheric fistula. Black arrow: fistula patch.
Route of EN JFT and fistuloclysis NJT NGT NJT and fistuloclysis JFT NJT NJT NJT Fistuloclysis
Timing of Initiation of EN After EAF, d
Timing of Full-Strength EN After EAF, d
21
57
2 23 4
22 27 42
8 9 19 0 29
16 24 44 21 34
EAF, enteroatmospheric fistula; EN, enteral nutrition; JFT, jejunostomy feeding tube; NGT, nasogastric tube; NJT, nasojejunal tube.
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659 from NGT and JFT, and administration of somatostatin) and short-term disruption of EN. Split-thickness skin grafting was performed in all 9 patients, with 4 undergoing 2 or more split-thickness skin grafting procedures. The first split-thickness skin grafting occurred 36 (21–51) days after open abdomen treatment. Delayed abdominal closure was achieved in 5 patients. This was completed 199 (105–315) days after open abdomen treatment. The remaining 4 patients were awaiting definitive abdominal closure and abdominal wall reconstruction (Table 1). EAFs were repaired or resected along with adjacent bowel segments or partial stomach in 8 patients, with a median time of 293 (157–336) days after open abdomen treatment. The remaining 1 patient was awaiting definitive treatment of EAF (Table 2).
Discussion
Figure 2. Use of fistuloclysis in a patient with 2 enteroatmospheric fistulae. White arrow: fistuloclysis catheters. Black arrow: suction drainage catheter. Table 4. In-Hospital Complications. Complication
No. (%)
Sepsis Intra-abdominal abscess Pneumonia Acute kidney injury Intra-abdominal hemorrhage Enterocutaneous fistula Biliary fistula Ileus Duodenal ulcer Gastrointestinal tract hemorrhage
6 (66.7) 6 (66.7) 5 (55.6) 5 (55.6) 3 (33.3) 3 (33.3) 1 (11.1) 3 (33.3) 1 (11.1) 1 (11.1)
Major in-hospital complications are summarized in Table 4. All 9 patients were discharged alive. The median duration of MV and continuous renal replacement therapy was 67 (29–87) and 4 (0–21) days, respectively. The median length of stay in the ICU and hospital was 102 (45–130) and 116 (54–136) days, respectively. Feeding intolerance occurred in 5 patients, and feeding-associated complication arose in 1 patient who had ileus during administration of EN. The complication was relieved by conservative treatment (including fluid resuscitation, drainage
Published experience of feeding patients with EAF is scarce. This case study provided single-center experience in feeding patients with EAF, showing that EN can be safely implemented in these patients without complicating the management of open abdomen and EAF. First, this case study demonstrated the feasibility and safety of implementing EN in patients with EAF. Patients with EAF represent one of the most extreme examples of difficulty in delivering EN. In this study, we included 9 patients developing EAF following open abdomen treatment after major abdominal trauma, and we showed that EN could be successfully initiated in the presence of EAF in all. Furthermore, full-strength EN was achieved in all, leading to weaning of PN. With regard to adverse effects of enteral feeding, the incidence of feeding intolerance was moderate (55.6%), and the occurrence of feeding-associated complications was rare (11.1%). These results indicated the practicality and safety of implementing EN in patients with EAF. The general outcomes of patients in this study were satisfactory. All patients were alive at hospital discharge, making the overall mortality lower than the results of previous studies.12,13 All patients underwent split-thickness skin grafting, and delayed abdominal closure was either achieved or planned. Treatment of EAF was achieved in 8, and the remaining 1 patient was awaiting definitive treatment. These results were satisfactory compared with those of previous studies.14 We were following several principles of nutrition practice in managing patients with EAF. First, resuscitation and stabilization should be implemented before initiating EN. This includes restoration of blood volume, correction of fluid/electrolyte and acid/base imbalance, and treatment of local and systematic infections. Second, systematic evaluation of EAF and the GI tract is crucial. The number, anatomic location, size, and output of fistula should be identified. This is particularly important for patients with multiple fistulae, in whom accurate assessment of the afferent/efferent sequencing of each fistula limb is essential in deciding enteral feeding access. Moreover,
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the length and function of residual bowel segments should be assessed to ensure adequate absorption of enteral nutrients and avoid ileus due to bowel immobility. The evaluation may be accomplished based on characteristics of fistula effluent, surgical findings, and radiological imaging findings such as computed tomography scans and fistulograms. Third, PN is required to maintain nutrition status when EN is not feasible. In this study, the median timing of initiation of EN after EAF was 9 (3–22) days. All patients were relying on PN before implementation of EN. This is similar to our previous finding that a combination of PN and EN was required in most (76%) patients with enterocutaneous fistulae.15 Establishment of enteral feeding access in patients with EAF can be challenging. The access should be easy to establish and maintain, using as many small bowel segments for absorption as possible. Moreover, establishment of enteral feeding access must be tailored to the individual patient according to illness severity, GI tract function, and characteristics of EAF, particularly the anatomic location of the fistula. For patients with gastroatmospheric fistulae, nasojejunal or jejunostomy feeding tubes are safe. Nasogastric or postpyloric feeding can be achieved in patients with ileoatmospheric fistulae provided effective fistula effluent control. Potential feeding routes for patients with jejunoatmospheric fistula include passage of the feeding tube distal to the fistula and fistuloclysis. The utilization of fistuloclysis in patients with enterocutaneous fistulae has been reported by several authors,16,17 but there are no reports of using this technique to feed patients with EAF. In this study, fistuloclysis was implemented in 3 patients, including 2 with multiple fistulae. In brief, the proximal fistula opening was intubated with a Foley’s balloon catheter, which was advanced approximately 5 cm in the lumen. Then, the balloon was inflated by infusing 10 mL of water, and the catheter was fixed on the skin using suturing or tape. To prevent leakage, the fistula opening might be surrounded by surgical gauze. The catheter was then connected to a continuous infusion pump. Similarly, the distal fistula opening was intubated and connected to the pump. In this way, the effluent of the proximal fistula opening was passaged to the distal fistula opening. This technique facilitated implementation of EN and allowed the longest bowel segments for absorption. Full-strength EN was achieved in all 3 patients undergoing fistuloclysis, and no complications associated with the technique were observed. A major risk of implementing EN in the presence of EAF is a dramatic increase in fistula output, which may contaminate surrounding tissues and complicate the management of open abdomen. As such, effective effluent control is the prerequisite for providing EN in patients with EAF. A number of effluent control techniques have been described in the literature, but none has shown definitive benefit.18-21 In this study, we managed EAF with suction drainage catheters before split-thickness skin grafting. This method was simple and useful in controlling fistula output, but it required frequent dressing
changes and good fixation of the catheter. Split-thickness skin grafting significantly facilitated the management of EAF and open abdomen. It provided the base for ostomy devices and effective protection to the open wound as well. Furthermore, the fistula patch was useful in managing EAF and significantly facilitated administration of EN. It allowed continuity of the GI tract, avoided loss of fistula effluent, and simplified open wound management. This study has several limitations. First, the sample size was small, which might be explained by the low incidence of EAF14 and inclusion of only patients undergoing open abdomen treatment after abdominal trauma. Second, techniques for temporary abdominal closure and fistula management may determine the outcomes of patients with EAF. Hence, the use of the modified sandwich-vacuum package technique and suction drainage catheters, rather than vacuum-assisted closure devices20,22 for the management of open abdomen and EAF, should be taken into consideration when interpreting the results of this study. Finally, this study showed the feasibility of EN support in patients with EAF, but we were not able to demonstrate the potential benefits of EN. This merits further investigation.
Conclusion This study demonstrated that EN could be successfully implemented in patients with EAF and did not complicate the management of open abdomen and EAF.
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