Failing to adopt a systematic approach to management
A careful, methodical, systematic approach to management is what keeps a patient’s care pathway moving forward. Being systematic also prevents high-risk strategies (i.e. trying out the latest ‘flavour of the month’) from being pursued and ensures that the entire MDT has a safe, cohesive and structured approach. The optimal strategy for managing gastrointestinal fistulae that has stood the test of time is the ‘Sepsis-Nutrition-Anatomy-Plan’ or ‘SNAP’ approach (figure 1).1
Figure 1 | The ‘Sepsis-Nutrition-Anatomy-Plan’ or ‘SNAP’ approach to managing gastrointestinal fistulae.
Sepsis in patients with gastrointestinal fistulae is multifactorial in origin and may be low grade and indolent but can easily become life-threatening if not managed correctly. Typical sources of sepsis in this setting include central venous catheters (in patients receiving parenteral nutrition), intra-abdominal collections and respiratory or urinary infections. Identifying and managing sepsis is a crucial first step in the management of intestinal fistulae, to preserve life and to facilitate the switch from a catabolic to an anabolic state, so allowing recovery with nutritional support.
Nutritional support should be via the oral and/or enteral route whenever possible; however, if the patient has intestinal failure, parenteral nutrition may be required. Intestinal failure can occur in patients who have a proximal, ‘high output’ enterocutaneous or enteroatmospheric fistula, such that gastrointestinal absorption of nutrients is not sufficient to achieve optimal nutritional status. Maximising oral and/or enteral nutrition protects the integrity of the gut, provides psychological benefit to the patient and protects the liver from excessive parenteral feeding. Optimising oral and/or enteral intake, in combination with dietary and medical therapy, will aid control of the enteric output, facilitating the provision of effective nutrition. This effective nutrition and reduced output helps improve nutritional status and allow the preparation of the body for the healing process that will occur following surgery
Understanding an individual patient’s anatomy is essential for a successful outcome. So, once a patient is stable, extensive radiological examination of the gastrointestinal tract and abdominal cavity should, therefore, be undertaken. Such evaluation helps the surgeon decide the best strategy for the fistula repair prior to embarking on the operation and helps to determine how the patient may best receive nutrition in preparation for surgery and/or whether distal enteral tube feeding is feasible. Extensive contrast studies down, up and via the fistula plus cross-sectional imaging are required to determine the presence of any collections and extra-intestinal complications that may impact the success of surgery. The contrast studies provide information on quantity (i.e. how much intestine is above and below the fistula) and quality (e.g. the presence of obstructions, stenosis or dilatations).
The final management plan requires the correct information (e.g. the patient’s intestinal anatomy) to make use of the optimum environment created by the sepsis-nutrition-anatomy elements of the SNAP approach. For example, surgical repair can occur when the patient is nutritionally replete, medically optimised and psychologically ready. This approach helps ensure that the right operation is performed on the right patient at the right time, and that it is performed only once.
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