S4121 Nutritional Challenges in a Patient With Multiple Entero-Enteric and Enterocutaneous Fistulas Complicated by Intraabdominal Abscess

Introduction: The management and successful closure of entero-enteric fistulas (EEF) and enterocutaneous fistulas (ECF) can be challenging in post–Roux-en-Y gastric bypass (RYGB) patients. Due to the complexity and low incidence of ECFs, there is a lack of widely accepted guidelines on their management. Nonetheless, nutrition management to provide adequate nutrient requirements, maintain fluid and electrolyte balance, and enhance appropriate fistula healing is attainable. Whether enteral (EN), parenteral (TPN), or oral nutrition is provided it’s important to maximize protein intake. Expert consensus recommends 1.5-2 gm/kg/day, increasing to as high as 2.5 gm/kg/day for high output fistulas. Case Description: We describe our experience with a 62-year-old woman status post-RYGB, complicated by (c/b) gastro-gastric fistula (GGF) and dilated gastro-jejunal (GJ) pouch, status post (s/p) laparoscopic GGF takedown, redo-GJ, remnant gastrostomy tube (G-tube) placement c/b GJ leak s/p laparoscopic washout due to intraabdominal abscess at GJ, s/p interventional radiology drain. Patient initially was tolerating tube feeds (TFs) via G-tube in her remnant stomach, but course was c/b persistent GJ leak. Patient was diagnosed with unspecified protein-calorie-malnutrition in the context of acute illness, given prolonged hypocaloric intake and mild-to-moderate muscle wasting on nutrition-focused physical examination. TPN was initiated when patient was unable to consistently receive goal EN due to intolerance, persistent GJ-leakage, intraabdominal abscess, and multiple ECFs. Endovacuum therapy was instituted for fistulous tract healing. Based on healing and output control, TFs were reintroduced slowly. Careful interplay of nutrition management with TPN alternating with EN with variable daily rates based on daily clinical progression were paramount in the course. Discussion: Nutritional and metabolic management in complex multiple EEF or ECF is challenging and associated with high morbidity and mortality. Patient outcomes can be improved by adjusting the nutrition regimen frequently based on daily fluid, protein, and electrolyte losses. Overall goal is closure of fistula and resumption of an oral diet. While some patients achieve this, others require home nutrition support for chronic fistulas. Intensive and complex nutritional and metabolic support creates a favorable basis for spontaneous closure of ECFs, improving ECF prognosis. However, reducing the treatment duration, decreasing incidence of complications, and preventing further recurrence are still the areas for future research.