Optimising the treatment of upper gastrointestinal fistulae.

A three stage strategy is generally employed in the management of gastrointestinal fistulae which can form due to surgery, disease, or trauma. The condition is investigated leading to diagnosis, conservative treatment is initiated to stabilise the patient, followed by specific surgical treatment measures in complicated cases, or in the absence of spontaneous closure. Conservative management of fistulae is based on parenteral nutrition and bowel rest, as well as on control of infection, electrolytic disturbances, and local care of the fistula tract. Surgical treatment may be required although generally only in particularly serious cases. Somatostatin-14 has been used in addition to parenteral nutrition to further reduce the volume and enzymatic activity of the fluid output through the fistula tract, generally with good results. The majority of reports have shown a beneficial effect, and randomised studies have demonstrated a reduction in closure time and morbidity. However, due to a combination of the seriousness and rarity of the condition and the difficulties inherent in trial design, data from large scale, double blind, randomised, controlled studies investigating the use of pharmacotherapy in the treatment of established gastrointestinal fistulae are lacking. Nevertheless, preliminary data from initial trials suggest that somatostatin-14 and its analogue octreotide considerably improve the conservative treatment of gastrointestinal fistulae in the absence of distal obstruction. In addition, reduction of the concentration of caustic enzymes in the discharge will benefit both wound healing and nutritional losses. With reduced closure time, the period of hospitalisation will be shortened with potentially considerable economic reductions and improvements in quality of life for the patient.