Ali Imran Amjad, Saqib Hamid Qazi, Zafar Nazir.
Enterocutaneous fistulae in children – a management challenge.
J Coll Physicians Surg Pak Jan ;18(8):526-7.

We report a case series of seven children with EF to highlight the difficulties encountered in management in developing world. Seven patients (age ranging from 14 days to 13 years; mean 7.1 years) with EF were admitted to paediatric surgical service at the Aga Khan University Hospital (AKUH), Karachi, from January 2003 to December 2006. Patients were self-referred after an initial treatment at other healthcare facilities. Important clinical features of patients are summarized in Table I. At presentation, 6 out of the 7 patients had fluidelectrolyte imbalance and sepsis (positive blood cultures). Initial management included correction of fluid-electrolyte imbalance and control of sepsis (drainage of intra-abdominal abscesses under CT or ultrasound guidance in four children and broadspectrum antibiotics). All patients were malnourished (weight loss >10%, low serum albumin; ranging from 1.2 to 2.3 g/dl) and received Total Parenteral Nutrition (TPN) for a mean duration of 32.5 days (ranging from 16 to 55 days). Somatostatin analogue (10 mcg/kg subcutaneously every 12 hours) was used in 2 patients, which reduced the fistula output substantially. None of the fistulae healed spontaneously. Six patients underwent surgical procedures including adhesiolysis (n=6), closure of perforation (n=3), and resection and anastomosis of small bowel (n=3). The operative time ranged from 7 to 10 hours (mean 8.8 hours) due to extensive intra-abdominal and inter-loop fibrotic adhesions. One patient died of uncontrolled sepsis (multi-drug resistant Pseudomonas aeruginosa) and liver dysfunction (total bilirubin 8.8 mg/dl) and albumin 1.2 g/dl) before surgery during the initial stabilization phase. Six patients were discharged after 23 to 93 days (mean 56 days) of hospitalization. The treatment costs ranged from PKR 325,435 to PKR 744,430 (US$ 5,388 to US$ 12,325). These figures, however, do not include the personal expenses by the family on illness before presenting to the hospital.

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