The Art of Fistuloclysis: Nutritional Management of Enterocutaneous Fistulas

CASE In June 2009, a 40-year-old male was admitted to an outside institution after developing a partial small bowel obstruction secondary to multiple abdominal incisional hernias that required repair; recovery was complicated by the development of multiple intraabdominal abscesses. His history was significant for a motor vehicle crash dating back to 2002 where he sustained multiple orthopedic and intra-abdominal injuries that required numerous surgical interventions. Before transfer to our facility, he underwent lysis of adhesions, repair of multiple hernias and resection of a loop of small bowel with a primary anastomosis after a bowel perforation. At this point he was admitted to our facility with a deep wound infection, necrotizing fasciitis and abdominal sepsis. On July 30th a laparotomy was performed for retroperitoneal abscess drainage and debridement of necrotic tissue due to abdominal wall infection. On August 16th, a computerized tomography (CT) scan suggested enterocutaneous fistulas, and by August 25th the fistulas had epithelialized. One fistula drained significant volume indicating it was the more proximal fistula; the other drained scant mucous and was therefore deemed a mucous fistula. A fistulogram via the mucous fistula showed significant length of bowel above the ileocecal valve, no leaks or communications with the other more proximal fistula, and unobstructed flow to the large bowel. It was determined that the NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #87