S J Dudrick1,2, L Panait3. 1. Department of Surgery, Saint Mary's Hospital, 56 Franklin Street, Waterbury, CT, 06706, USA. sdudrick@stmh.org. 2. Department of Surgery, Yale University School of Medicine, New Haven, CT, 06510, USA. sdudrick@stmh.org. 3. Department of Surgery, Saint Mary's Hospital, 56 Franklin Street, Waterbury, CT, 06706, USA.
Abstract
METHODS AND MATERIALS: The historical highlights of the management of fistulas of the gastrointestinal tract during the past century are presented briefly, together with the significant lessons learned from the studies published in the literature. DISCUSSION: The evolution from predominantly operative or technical approaches to comprehensive multidisciplinary management of metabolic and nutritional support, which are essential to optimal fistula closure, and morbidity and mortality outcomes are discussed. The importance of achieving hemodynamic stability, fluid and electrolyte homeostasis, fistula effluent control, protection of the skin, control of infection and sepsis, and cardiopulmonary and major organ support, preferably by specially trained and motivated teams in critical care units of institutions with the interest, resources, and skills in managing the metabolic consequences of gastrointestinal fistula patients, is emphasized. The current status of the nutritional and metabolic support of patients with gastrointestinal tract fistulas is outlined and discussed briefly. CONCLUSIONS: The optimal metabolic and nutritional management of patients with gastrointestinal tract fistulas is an extraordinary and daunting challenge which has yet to be perfected, demonstrated, and applied universally. Much education, research, motivation, proficiency, and concerted conscientious effort will be required in order to achieve this elusive but noble goal. Some suggestions for achieving success in this endeavor are proffered, consistent with the senior author's philosophy, which has evolved during a half-century of experience and endeavor in this vital area.
METHODS AND MATERIALS: The historical highlights of the management of fistulas of the gastrointestinal tract during the past century are presented briefly, together with the significant lessons learned from the studies published in the literature. DISCUSSION: The evolution from predominantly operative or technical approaches to comprehensive multidisciplinary management of metabolic and nutritional support, which are essential to optimal fistula closure, and morbidity and mortality outcomes are discussed. The importance of achieving hemodynamic stability, fluid and electrolyte homeostasis, fistula effluent control, protection of the skin, control of infection and sepsis, and cardiopulmonary and major organ support, preferably by specially trained and motivated teams in critical care units of institutions with the interest, resources, and skills in managing the metabolic consequences of gastrointestinal fistulapatients, is emphasized. The current status of the nutritional and metabolic support of patients with gastrointestinal tract fistulas is outlined and discussed briefly. CONCLUSIONS: The optimal metabolic and nutritional management of patients with gastrointestinal tract fistulas is an extraordinary and daunting challenge which has yet to be perfected, demonstrated, and applied universally. Much education, research, motivation, proficiency, and concerted conscientious effort will be required in order to achieve this elusive but noble goal. Some suggestions for achieving success in this endeavor are proffered, consistent with the senior author's philosophy, which has evolved during a half-century of experience and endeavor in this vital area.