Outcomes of gastrointestinal fistulas: Results from a multi-continent, multi-national, multi-center cohort

Garcí

et al. 2022

Preprint

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Introduction: The "Fistula Day" multicontinent, multinational, multicentered project has revealed a 14.7 % mortality rate in patients assisted for gastrointrestinal fistulas (GIF) in Latin American and European hospitals. Mortality associated with GIF might be explained for the clinical-surgical condition of the patient, the operational characteristics of the hospital, and the surgical practices locally adopted in the contention, treatment and resolution of GIF. Objective: To assess the influence of surgical practices adopted in the hospital upon GIF outcomes. Study design: Cohort-type study. Three cross-sectional examinations were done during the completion of the exercises of the "Fistula Day" project: on admission in the study serie, and at 30 and 60 days after admission. Study serie: One hundred seventy seven patients (Males: 58.2 %; Average age: 51.0 ± 16.7 years; Ages ≥ 60 years: 36.2 %) assisted in 76 hospitals of Latin America (13 countries) and Europe (4). Methods: Surgical practices adopted in the management of GIF were documented such as the use of computerized axial tomography (CAT) and oral ingestion of contrast for examination of the fistula path, the use of open abdomen and devices for temporary closure of the abdominal wall, the administration of somatostatin and analogs for promoting the closure of the fistula, reoperation for fistula closure, and admission in the ICU. Results: Usage rate of surgical practices was as follows: CAT + oral use of contrast: 39.5 %; Use of open abdomen: 31.1 %; Use of somatostatin and analogs: 22.6 %; Admission in the hospital ICU: 31.6 %; and Surgery for GIF closure: 33.9 %; respectively. Surgical practices were more frequently used in the treatment and containment of enteroathmosferic fistulas (EAF). Surgical practices adopted by participating hospitals did not imply a higher rate of GIF closure, but were associated instead with a higher mortality and prolongation of hospital stay. Conduction of surgical practices was independent from the guidelines followed by the medical teams in the management of GIF. Availability of surgical practices, and access of medical teams to them, were independent from the operational characteristics of the surveyed hospital. It is to be noticed the existence of a hospital unit dedicated to intestinal failure translated to a lower use of the techniques for open abdomen and temporary closure of the abdominal wall, which, in turn, translated to a higher likelihood of GIF spontaneous closure. Conclusions: Currently, the adoption of surgical practices for containment and resolution of GIF does not result in a higher GIF closure rate. It is likely the existence of a hospital unit specialized in the management of intestinal failure might bring about a higher rate of non-surgical closure of GIF.

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Surgical practices followed during containment, management and resolution of gastrointestinal fistulas. Results of a multicontinent, multinational, multicentric study

Garcí

et al. 2022

Preprint

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Influence of the hospital upon the outcomes of gastrointestinal fistulas: results of a multi-continent, multi-national, multi-center cohort

García

et al. 2021

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SUMMARYRationalePrognosis and outcomes of gastrointestinal fistulas (GIF) might depend upon the operational characteristics of the hospital containing and caring for the patients.ObjectiveTo assess how selected operational characteristics of the hospital participating in the exercises of the “Fistula Day” Project (FDP) influence upon prognosis and outcomes of GIF.Study designCohort-type study. Enrolled patients were followed for 60 days. Three cross-sectional examinations were made during the completion of the exercises of the FDP, namely, upon admission of the patient in the study, and 30 and 60 days after admission.Study serieSeventy-six hospitals of Latin America (13 countries) and Europe (4).MethodsAssociations between survival of the patient, prolongation of hospital stay, and (likely) spontaneous closure of the fistula, on one hand; and selected operational characteristics of the participating hospital, on the other; were assessed.ResultsSpecialties hospitals prevailed. Most of the hospitals assisted between 1 – 2 GIF patients a month. Participating hospitals distributed evenly regarding the number of beds. Most of the hospitals had an intensive care unit. Similarly, three-quarters of the hospitals had a multidisciplinary unit dedicated to clinical and hospital nutrition. However, a unit dedicated to the management of intestinal failure and/or postoperative fistulas was present only in a fifth of them. Experience of the physician attending GIF was rated between “Expert” and “High” in one third of the hospitals. Number of hospitals beds associated with increased survival of GIF patients (χ2 = 5.997; p = 0.092), prolonged hospital stay (χ2 = 7.885; p < 0.05), and higher rate of spontaneous closure of the fistula (χ2 = 11.947; p < 0.05). In addition, rate of spontaneous closure of the fistula was (marginally) higher among patients assisted by a hospital unit specialized on intestinal failure (χ2 = 3.610; p = 0.0574). On the other hand, survival of the patient was dependent (also marginally) upon the number of patients assisted in a month (χ2 = 5.934; p = 0.0514).ConclusionsIt is likely number of hospital beds to determine prognosis and outcomes of GIF. Other operational characteristics of the hospital might exert a marginal influence upon survival of the patient and the likely spontaneous closure of the fistula.

On the nutritional practices followed during containment, management and resolution of gastrointestinal fistulas. Results of a multicontinent, multinational, multicentric study

Morales

et al. 2022

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Introduction: The multi-continent, multinational, multicenter "Fistula Day" Project has revealed a 14.7 % mortality rate in patients assisted for gastrointestinal fistulas (GIF) in hospitals of Latin America (LATAM) and Europe. GIF-associated mortality might be explained by the clinical-surgical condition of the GIF patient itself, the operational characteristics of the hospital, and surgical practices adopted locally in the containment, treatment and management of GIF. Given the hypermetabolic and cachectizing nature of GIF, it is then only natural to examine the nutritional practices adopted by medical teams in the care of GIF. Objective: To examine the influence upon GIF outcomes of nutritional practices adopted in the hospitals participating in the "Fistula Day" Project. Study design: Cohort study. During completion of the "Fistula Day" exercises 3 cross-sectional examinations were made: on admission in the study serie, and after 30 and 60 days after admission. Study serie: One-hundred and seventy-seven patients (Males: 58.2 %; Average age: 51.0 ± 16.7 years; Ages ≥ 60 years: 36.2 %) assisted in 76 hospitals of Latin America (13 countries) and Europe (4). Methods: The following nutritional practices adopted in the management of GIF were documented: assessment of the synthesis of hepatic secretory and acute phase proteins, patency of the oral route, administration of artificial nutrition, and use of glutamine as immunonutrient. Existence of a unit dedicated to clinical and hospital nutrition within the participating institution was also inquired. Impact of the documented nutritional practices upon survival of the patient, length of hospital stay, and spontaneous closure of the fistula was assessed. Results: Rate of usage of nutritional practices was as follows (in descending order): Determination of serum albumin: 95.5 %; Administration of artificial nutrition programs: 80.8 %; Existence of clinical and hospital nutrition unit: 71.2 %; Use of the oral route for sustaining the nutritional status of the patient: 70.1 %; Determination of C-reactive protein: 36.1 %; and Use of glutamine as immunonutrient: 23.2 %; respectively. Rate of usage of nutritional practices was higher in patients with an enteroatmospheric fistula (EAF). In all the examined instances type of fistula determined GIF outcomes: enterocutaneous fistulas (ECF) were associated with higher likelihoods of survival and spontaneous closure, although at the expenses of prolonged hospital stay. Administration of the assessed nutritional practices only resulted in the prolongation of hospital stay. Existence of a unit dedicated to clinical nutrition was associated with reduced mortality, prolonged hospital stay and (numerically) lesser chance for spontaneous (non-surgical resolution) of GIF. Conclusions: It is likely impact of the assessed nutritional practices to be mediated by the type of fistula, and that the benefit expected from a specified practice might be reduced (or even overruled) in patients assisted for EAF.