Metabolic and nutritional management of a patient with multiple enterocutaneous fistulas

INTERNATIONAL

WARD ROUNDS IN CLINICAL NUTRITION

ivutrition vol. 13, No.

5, 1997

CO-EDITORS: GEORGE L. BLACKBURN, MD, PHD Associate Professor of Surgery Harvard Medical School Director of Nutrition Support Services New England Deaconess Hospital Boston, Massachusetts, USA

GORDON L. JENSEN, MD, PHD Associate Physician Department of Gastroenterology and Nutrition Director of Nutrition Support Geisinger Medical Center Danville, Pennsylvania, USA

Metabolic and Nutritional Management of a Patient With Multiple Enterocutaneous Fistulas GAIL A. CRESCI,

RD, CNSD, AND ROBERT

G. MARTINDALE,

MD, PHD

From the Department of Surgery, The Medical College of Georgia, Augusta, Georgia, USA Date accepted: CASE REPORT

The patient is a 26-y-old male who sustained a close-range shotgun wound to the perineum. Following resuscitation at a community hospital in which an exploratory laparotomy with sigmoid loop colostomy was performed, he was transferred to a tertiary referral trauma center. Upon re-exploration, there was no evidence of viable rectum, and the wound was approximately lo- 14 cm in depth and extended from the base of the scrotum to the sacrum. Following several debridements, he was left with an end sigmoid colostomy with the open perineal and abdominal wounds to heal by secondary intention. Postoperatively, the patient’s stay was complicated by the development of multiple enterocutaneous fistulas all confined to the right lower quadrant. Initially these were treated conservatively with control of drainage, octreotide acetate, non per OS (NPO), and total parenteral nutrition (TPN) for nutritional support. Once stable he underwent split-thickness skin graft to his abdominal wounds following a brief course of human recombinant growth hormone (GH) in hopes of enhancing development of granulation tissue of the grafting bed. Approximately 2 mo into his hospital stay, contrast studies revealed the patient to have multiple enterocutaneous fistulas, the most proximal being 25-30 cm from the ligament of Trietz.

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Following the fistulogram, he began taking elemental formula orally and any fistula output was discarded. Enteral nutrition was tolerated well and TPN was discontinued, with the patient satisfying full nutritional needs with an oral elemental diet. He did require small volumes of intravenous fluid (IVF) to maintain fluid and electrolyte balance. Three weeks after oral feeding began, a feeding tube was inserted into the most distal fistula opening, and proximal fistula output was filtered and reinfused through this feeding tube. Once this recycling fistula output system was initiated, IVF was no longer required. The patient was advanced to a polymeric intact protein formula over a 3wk period with continued recycling of fistula output to facilitate discharge to home. At the time of discharge, roughly 4 mo post-trauma, the patient was comfortable with his own wound and colostomy care and feeding himself with the recycling system. Upon discharge his weight and visceral protein levels were stable and he was ambulating freely and not receiving any medications. DISCUSSION

Nutritional

Goals

Our first goal was to minimize the loss of lean body tissue that often occurs as a result of hypermetabolism after trauma.

Correspondence to: Gail A. Cresci, Surgical Nutrition Service, The Medical College of Georgia, Department of Surgery, Augusta, Georgia 309124004, USA.

Nutrition 13:446-449, 1997 OElsevier Science Inc. 1997 Printed in the USA. All rights reserved.

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TABLE I. METABOLIC PROGRESS Week of Adm

1

4

I

9

10

14

17

19

Parameter Body temperature (“C) Body weight (kg) WBC count (x 10%) Total bilirubin (mg/dL) Alkaline phosphatase (U/dL) Albumin (g/dL) Prealbumin (mg/dL)

3@ 70 16.0 1.0 160 2.1 8.6

31X 67 13.5 2.0 180 2.9 20.7

36h 62 10.3 2.2 182 3.0 26.1

315 61 11.8 2.0 187 3.0 30.6

Nitrogen balance (gm/d) APACHE II score

-6.1 12

-2.1 7

+1.0 N/A

+5.2 N/A

37’ 60 16.4 2.6 229 3.1 32.8 N/A N/A

37’ 60 6.0 2.4 247 3.7 42.0 N/A N/A

37” 57 6.1 I.1 225 3.4 27.4 N/A N/A

36’ 57 7.2 0.9 132 3.3 28 N/A N/A

WBC, white blood ceil.

This becomes the major challenge in the critically ill, even in patients well nourished prior to a traumatic incident.’ Due to the nature and location of the patient’s wound and massively edematous small bowel, TPN was the route of nutritional support initially chosen. Approximately 2 wk posttrauma, the development of multiple enterocutaneous fistulas required him to continue on TPN for several weeks until he was stabilized and the anatomy of the fistulas could be defined. Nutritional

Needs

The patient was presumed to have increased nutrient needs secondary to the recent trauma, multiple fistulas, and open abdominal cavity.’ His nutritional needs were estimated to be approximately 35 kcal *kg-’ * d-’ and 2 g protein *kg-’ * d-’ to be delivered parenterally.‘,’ These nutrients were provided as 52% carbohydrate, 23% protein, and 25% fat with a nutrient composition resulting in 84:l ratio of non-protein calorie to gram of nitrogen. While on TPN, the patient maintained normal electrolyte levels. Serum glucose levels ranged between 100 and 160 mg/ dL. Visceral protein markers were drawn biweekly, and gradually improved to within normal range as the patient improved metabolically. Liver function tests were also monitored biweekly, remaining normal to slightly elevated while on TPN (see Table I). The patient received standard multivitamin (MVI) supplement, with extra vitamin C, thiamin, and folate being added secondary to an ongoing trauma-service protocol. The patient had persistently large quantities of proximal enterocutaneous fistula output. This can often result in a deficiency of trace elements (e.g., zinc, copper), so as a precaution extra standard trace minerals were added daily.

tion, we chose to start the patient with an elemental formula that was flavored and consumed by mouth.4 The oral elemental enteral feeds were fully tolerated within 20 d of initiation and the TPN was then discontinued. Initially the patient had high fistula output (900- 1300 cc/ d), which was collected and discarded. With this delivery and collection method, the patient required additional IVFs with added electrolytes to maintain normal serum levels once the TPN was discontinued. Approximately 2 wk after the TPN was stopped, the patient’s fistula output increased to 2500-3000 cc/d and his visceral protein levels dropped. Rather than placing him back on TPN, we decided to attempt filtering and reinfusing the fistula output into the distal fistula to help prevent excessive fluid loss with resultant electrolyte disturbances, trace-element deficiencies, and protein loss. This recycling system proved to be successful and the IVF was discontinued. Attempts were made to advance the patient to a peptide formula for the added fat content after 14 d of enteral nutrition, but this was unsuccessful due to occurrence of nausea and vomiting. Due to the patient’s unexpected overall preference for the elemental formula, it was continued with the addition of corn oil and liquid MVI and trace minerals to prevent any deficiencies of essential fatty acids or vitamins/minerals. The patient consumed the elemental formula successfully for several weeks. Due to the patient’s minimal finances and the desire to discharge him home, a trial of polymeric intact protein formula was initiated. He tolerated the polymeric formula well with continuance of the fistula-recycling system. His visceral protein markers improved to normal levels, weight remained stable, and he maintained adequate fluid and electrolyte balance. Octreotide

Enteral Support

Once the patient was transferred from the intensive care unit to a surgical ward (hospital day 63), he was metabolically stable and fistula/ostomy care became the main concerns. The initial plan was to attempt to discharge the patient home with TPN. However, due to his lack of financial support, we were forced to attempt other means of providing nutrition in order to send him home. Contrast studies of the fistulas allowed defining the patient’s gastrointestinal (GI) anatomy. Following the fistulagram, enteral feeds were initiated. The patient had been NPO for approximately 76 d prior to initiation of enteral feeds. With multiple fistulas, a long period of nonutilization of the gut, and a desire to minimize GI stimula-

Octreotide acetate is a long-acting somatostatin analogue with known GI inhibitory properties. It inhibits endocrine and exocrine function and decreases splanchnic blood flo~.‘,~ It has been used in patients in conjunction with TPN for the reduction of fistula output and to aid in the rate of spontaneous fistula closure.5s6 We utilized octreotide in this patient in hopes of reducing his fistula output and perhaps aiding in fistula closure, although spontaneous closure was not expected. By controlling fistula output, we hoped to gain better skin protection, nitrogen balance, fluid, electrolyte, and trace-mineral management. When octreotide was initiated, we noted a reduction in fistula output from about 2000 cc to 1000 cc/d. However, once the patient

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was skin grafted and the exposed fistulas were well controlled with drains and ostomy bag coverage, octreotide was discontinued since it was evident the patient’s fistulas were not going to close spontaneously. Upon discontinuation of somatostatin, fistula output ranged from 900- 1300 cc/d until oral feeds were initiated. Then output ranged from 1700-3000 cc/d, which was collected and reinfused.

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CONCLUSION

With some ingenuity, patients with multiple enterocutaneous fistulas can be fed enterally once their anatomy is defined. Providing nutrient delivery to the remaining viable GI tract allows the mucosa to remain healthy by supporting the wellknown benefits of enteral nutrition and perhaps minimizing surgical risk and speedy patient recovery. REFERENCES

Growth Hormone Human recombinant GH is now commercially available. In this clinical setting, GH was used to complement nutritional support by promoting systemic anabolism.7m9 GH has several metabolic effects, one of which is a lipolytic response allowing the organism to better utilize adipose tissue as an energy source, thereby allowing protein-sparing effects.7-9 As GH is an insulin antagonist, another side effect noted with its use can be persistent hyperglycemia.8 In several prospective studies in burned children with large open wounds, GH has been shown to be advantageous for enhancing rates of wound healing.“-” GH at 10 mg/d was administered for 5 d prior to the skin grafting to maximize recipient granulation tissue. At this time, the patient was medically stable, but continued with a negative nitrogen balance and suboptimal visceral protein markers. Due to short-term administration of GH and the patient’s lack of hyperglycemia, caloric distribution and provision were not adjusted. OUTCOME

Six months after the patient’s traumatic injury, he was readmitted to the hospital in excellent nutritional status (serum albumin 4.7 g/dL; weight 56 kg and returned to the operating room where he underwent reconstruction of the abdominal wall and excision of the multiple small-bowel fistulas with primary anastomosis, leaving him with approximately 200 cm of small bowel. A feeding tube was placed at surgery, and he was started on 20 cc/h elemental formula 8 h postoperatively. Four days later, the patient began to drink the elemental formula with flavor packets, and on post-operative day 12 he began a regular diet.

Editorial on Case Study: Patient with Multiple Enterocutaneous Fistulas Postoperative gastrointestinal fistulas occur infrequently but represent a dreaded and challenging problem for the general surgeon. Small-bowel enterocutaneous fistulas in particular often result in profound fluid losses, electrolyte imbalances, and sepsis. Malnutrition, patient disability, prolonged hospitalization, and enormous financial and societal cost can also result. The goals of therapy in this clinical setting are to limit such morbidity and eventually reestablish intestinal continuity.’ Nutrition and, in selected patients, surgery play essential supportive and therapeutic roles in achieving these goals in patients with enterocutaneous fistulas. Ideally, patients with such complex problems should be managed by a surgical team well versed in contemporary multimodal approaches combining

I. Gianotti L, Nelson JL, Alexander JW, et al. Post injury hypermetabolic response and magnitude of translocation: prevention by early enteral nutrition. Nutrition 1994; lo:225 DC, Omert LA, Badellino MM, et al. Correlation 2. Frankenfield between measured energy expenditure and clinically obtained variables in trauma and sepsis patients. JPEN 1994; 18:398 and 3. Kemper M, Weissman C, Hyman AL. Caloric requirements supply in critically ill surgical patients. Crit Care Med 1992; 20:344 4. DeChicco RS, Matarese LE. Selection of nutrition support regimens. Nutr Clin Pratt 1992;7:239 5. Sitger-Serra A, Guirao X, Pereira JA, et al. Treatment of gastrointestinal fistulas with Sandostatin. Digestion 1993;54( suppl I):38 et al. Somatostatin in the 6. Torres AJ, Landa JI, Moreno-Azcoita, management of gastrointestinal fistulas: a multicenter trial. Arch Surg 1992; 127:97 I. Wong WK, Soo KC, Nambiar R, et al. The effect of recombinant growth hormone on nitrogen balance in malnourished patients after major abdominal surgery. Aust NZ J Surg 1995;65:109 of recom8. Ziegler TR, Rombeau J, Young LS, et al. Administration binant human growth hormone enhances the metabolic efficacy of parenteral nutrition: a double-blind, randomized, controlled study. J Clin Endocrinol Metab 1992;74:865 9. Bryne TA, Morrissey TB, Gatzen C, et al. Anabolic therapy with growth hormone accelerates gain in lean tissue in surgical patients requiring nutritional rehabilitation. Ann Surg 1993;218:400 10. Hemdon DN, Barrow RE, Kunkle KR, et al. Effects of recombinant human growth hormone on donor site healing in severely burned children. Ann Surg 1990;212:424 11. Sherman SK, Demling RH, LaLonde C, et al. Growth hormone enhances reepithelialization of human split skin graft donor sites. Surg Form 1989;40:37 12. Gilpin DA, Barrow RE, Rutan RL, et al. Recombinant human growth hormone accelerates wound healing in children with large cutaneous bums. Ann Surg 1994;220: 19

skillful nutrition and surgical support. Indeed, this case report of small-bowel enterocutaneous fistula development after laparotomy for penetrating trauma demonstrates such an approach. Early nutritional support with total parenteral nutrition (TPN) and cessation of oral intake, both of which were done in this case, are most appropriate. While eventual enteral nutrition is always desirable, early TPN can hasten recovery by decreasing fistula output, thereby promoting the best environment for spontaneous fistula closure while providing metabolic and nutritional support. Adjuvant therapies such as octreotide acetate can reduce fistula output but have not been shown to increase the rate of fistula closure in randomized prospective studies.’ The recycling of proximal fistula drainage, as demonstrated in this report, represents a good management strategy, as it permits adequate enteral nutritional support and liberation from intravenous hydration.

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The adjunctive use of growth hormone to promote skin graft donor-site healing and anabolism represents a cutting-edge approach to the control of the catabolic response to injury.’ Growth hormone administration has many potential benefits such as improved nitrogen balance, redistribution of total body water resulting in increased lean body mass, and acceleration of skin graft donor-site healing.‘-’ Its use in a critically ill patient population requires special skills to prevent hypercalcemia and hyperglycemia. Growth hormone, however, has not been shown to date to improve overall outcome in randomized prospective trials. Additionally, it is expensive. While the benefits of its use are certainly intriguing, cost-effectiveness and improved outcome need to be demonstrated in randomized trials before it is routinely administered to critically ill patients. JEFFREY A. STERNBERG, MD GEORGE L. BLACKBURN, MD, PHD Nutrition/Metabolism Laboratory,

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Cancer Research Institute and the Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA REFERENCES 1. Fischer J. Enterocutaneous fistula. In: JL Cameron. Currenf surgical rherapy, 4th ed. St. Louis: B. C. Decker, 1992:1102 2. Foster C, Lefor A. General management of gastrointestinal fistulas. Surg Clin North Am 1996; 1019:33 illness. N Engl J Med 1991;325:695 M, Kimbrough T, Jacobs D, Wilmore D. Growth hormone attenuates the abnormal distribution of body water in critically ill surgical patients Surgery 1992; 112: 181 5. Byrne T, Monissey T, Gatzen C, et al. Anabolic therapy with growth hormone accelerates protein gain in surgical patients requiring nutritional rehabilitation. Ann Surg 1993: 2 18:400

3. Wilmore D. Catabolic 4. Gatzen C, Scheltinga

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