Optimising the treatment of upper gastrointestinal fistulae

A three stage strategy is generally employed in the management of gastroint estinal fistulae which can form due to surgery, disease, or trauma. The con dition is investigated leading to diagnosis, conservative treatment is init iated to stabilise the patient, followed by specific surgical treatment mea sures in complicated cases, or in the absence of spontaneous closure. Conse rvative management of fistulae is based on parenteral nutrition and bowel r est, as well as on control of infection, electrolytic disturbances, and loc al care of the fistula tract. Surgical treatment may be required although g enerally only in particularly serious cases. Somatostatin-14 has been used in addition to parenteral nutrition to further reduce the volume and enzyma tic activity of the fluid output through the fistula tract, generally with good results. The majority of reports have shown a beneficial effect, and r andomised studies have demonstrated a reduction in closure time and morbidi ty. However, due to a combination of the seriousness and rarity of the cond ition and the difficulties inherent in trial design, data from large scale, double blind, randomised, controlled studies investigating the use of phar macotherapy in the treatment of established gastrointestinal fistulae are l acking. Nevertheless, preliminary data from initial trials suggest that som atostatin-14 and its analogue octreotide considerably improve the conservat ive treatment of gastrointestinal fistulae in the absence of distal obstruc tion. In addition, reduction of the concentration of caustic enzymes in the discharge will benefit both wound healing and nutritional losses. With red uced closure time, the period of hospitalisation will be shortened with pot entially considerable economic reductions and improvements in quality of li fe for the patient.