Artificial nutritional support in patients with gastrointestinal fistulas

Gastrointestinal (GI) fistulas allow abnormal diversions of GI contents, di gestive juices, water electrolytes, and nutrients from one hollow viscus to another or to the skin, potentially precipitating a wide variety of pathop hysiologic effects. Mortality rates have decreased significantly during the past few decades from as high as 40% to 65% to 5.3% to 21.3% largely as a result of advances in intensive care, nutritional support, antimicrobial th erapy, wound care, and operative techniques. The primary causes of death se condary to enterocutaneous fistulas have been, and continue to be, malnutri tion, electrolyte imbalances, and sepsis, especially in high-output fistula s, which continue to have a mortality rate of about 35%. Priorities in the management of GI fistulas include restoration of blood volume and correctio n of fluid, electrolyte, and acid-base imbalances; control of infection and sepsis with appropriate antibiotics and drainage of abscesses; initiation of GI tract rest including secretory inhibition and nasogastric suction; co ntrol and collection of fistula drainage with protection of the surrounding skin; and provision of optimal nutrition by total parenteral nutrition (TP N) or enteral nutrition (EN) (or both). The role of nutrition support in th e management of enterocutaneous fistulas as either TPN or EN is primarily o ne of supportive care to prevent malnutrition, thereby obviating further de terioration of an already debilitated patient. It has been shown in several studies that TPN has substantially improved the prognosis of GI fistula pa tients by increasing the rate of spontaneous closure and improving the nutr itional status of patients requiring repeat operations. Moreover, other stu dies have shown that nutritional support decreases or modifies the composit ion of the GI tract secretions and is thus considered to have a primary the rapeutic role in the management of fistula patients. Finally, if a fistula has not dosed within 30 to 40 days, or if it is unlikely to close because o f a variety of collateral or compounding pathophysiologic conditions, consi deration must be given to operative resection of the fistula while continui ng to maintain the previous nutritional and metabolic support. The morbidit y and mortality rates in such unfortunate patients remain high despite the many recent advances in surgical and metabolic technology.