2017 - CIRTA
6- Medical and Surgical Rehabilitation
20.12 - Autologous gastrointestinal reconstruction (AGR) for patients with enterocutaneous fistula - associated intestinal failure.
Presenter: Ruy, Cruz, Pittsburgh, United States
Authors: Ruy Cruz, Jenee McGurgan, William Stein, Laurie Butera, Armando Ganoza, Kristine Poloyac, Abhinav Humar
Autologous gastrointestinal reconstruction (AGR) for patients with enterocutaneous fistula - associated intestinal failure.
Ruy J. Cruz1,2, Jenee McGurgan1, William Stein1, Laurie Butera1, Armando Ganoza1, Kristine Poloyac1, Abhinav Humar1,2.
1Intestinal Rehabilitation and Transplant Center, Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; 2Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
Background: An enterocutaneous fistula (ECF) remains a challenging surgical problem. Recent advances in the fields of critical care, interventional radiology, wound care and, nutritional support have significantly decreased the mortality rate from 40% to 10%. Fewer than 25% of ECFs will close spontaneously with the remainder requiring surgical repair. A small number of patients with ECFs have associated short gut syndrome (SGS). We describe herein our recent experience on the surgical management of complex ECFs in patient with short gut syndrome (< 200cm).
Methods: We retrospectively reviewed 341 adult patients who were referred to our Center between January 2013 and December 2016.
Results: Fifty three patients with complex ECFs were evaluated and underwent surgical intervention in our center. Forty of them (75%) had SGS. Three of these patients are currently waiting for a definitive surgical procedure (most recent surgery < 6 months). The mean patient age at the time of operation was 55 years (range 24 to 79). ECFs were related to surgical complications (68%), Crohn’s disease (12%), and others causes (12%). All patients had high output fistulas (> 500 cc/day) and were on TPN at the time of operation. Mean residual bowel length was 105 cm (range 0 cm to 200 cm). Thirteen patients (35%) had definitive end ostomy and eight patients (22%) had ultra-short gut syndrome (< 50 cm). Three patients had combined ECFs and complex urinary fistulas requiring urologic reconstructive surgery (8%). Patients were weaned off TPN according to their postoperative GI tract anatomy and remaining small bowel length. After 3, 6 and 12 months 62%, 43% and 19% are still on TPN. There were no intraoperative or perioperative deaths (<28 days). Two patients underwent an uneventful isolated small bowel transplant and another three are listed for isolated intestinal transplantation. After 20 months median follow-up (range 2 to 47 months), thirty three patients are alive (89%).
Conclusion: In summary, patients with short bowel syndrome and complex ECFs can achieve full nutritional autonomy after autologous gastrointestinal reconstruction (AGR). Early referral to intestinal rehabilitation/transplant centers can expedite the adequate treatment for patients with ECF-associated intestinal failure and minimize postoperative morbidity and mortality. Intestinal transplantation should be reserved for patients who failed AGR.
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