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

Abstract

ABSTRACTIntroductionThe 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.ObjectiveTo examine the influence upon GIF outcomes of nutritional practices adopted in the hospitals participating in the “Fistula Day” Project.Study designCohort 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 serieOne-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).MethodsThe 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.ResultsRate 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 %; andUse 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.ConclusionsIt 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.