Fistuloclysis--a valuable option for a difficult problem.

56 Despite the great advances in the management of high-output enterocutaneous fistulas (HOECFs), this condition remains a challenge for surgeons in both the developing and developed worlds. Since the early 1960s, nutritional support has been the mainstay of management that expedites the spontaneous healing of the fistula or, if healing does not occur, ensures that the patient is nutritionally optimised for surgical reconstruction. In most practices, the rapid and considerable metabolic and nutritional deficits that follow the development of a HOECF prompt the parenteral delivery of nutritional support , invariably via a central vein; however, enteral nutritional support alone has been reported to be equally effective in selective clinical situations. 6 The difficulty in delivering nutritional support because of access problems, high-output proximal enterocutaneous fistula or proximal enteric obstruction presents a clinical challenge. In such situations (as evident in this report), fis-tuloclysis (the delivery of nutrition via the fistula along the distal small bowel) is an attractive option. The patient, a 33-year-old woman without previous co-morbidity, had undergone laparotomy for pelvic peritonitis. At surgery, a right tubo-ovarian inflammatory mass was removed. On day 6 after surgery, the patient developed acute intestinal obstruction that warranted a re-laparotomy; adhe-siolysis was performed and a Bogota bag applied. A HOECF (daily output 1 500 ml) was diagnosed on day 5 after re-laparotomy. At this stage, the patient was ill-looking , nutritionally depleted with a serum albumin level of 17 g/l, and weighed 40 kg. Following the correction of fluid and electrolyte imbalances and appropriate blood transfusions, the patient was commenced on central total parenteral nutrition (TPN) and octreotide and kept nil per mouth. However, the fistula output still remained high (>1 500 ml/day); by day 15, the albumin level was 18 g/l and her weight 41 kg. Particularly challenging at this stage was a secondary throm-bophilic state that was diagnosed. Despite anticoagulant therapy, the patient continued to develop thrombi in major veins that made venous access for TPN difficult. On day 25 of TPN, the patient developed severe thrombo-phlebitis of her left subclavian vein following catheter-related sepsis; this was the last unoccluded major vein in the neck. Attempts to effect sustainable peripheral nutrition were unsuccessful on account of the thrombophilic state. This dilemma prompted consideration of fistuloclysis (feeding via the distal limb of the intestinal fistula). At this stage, the patient was noted to have a granulating laparostomy wound with the fistula demonstrating mucocutaneous …