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Octreotide and enterocutaneous fistula closure in neonates and children

Authors:
Noela Carrera-Guermeur
Noela Carrera-Guermeur
Noela Carrera-Guermeur
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Rosa martin crespo at Complejo Hospitalario de Toledo
Rosa martin crespo
Hilda J. Ramírez
Hilda J. Ramírez
Hilda J. Ramírez
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Ángel Pantoja
Ángel Pantoja
Ángel Pantoja
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Abstract and Figures

Enterocutaneous fistula and its conservative management still pose a challenge for the surgeon. The use of octreotide and somatostatin in neonates and children as adjunctive therapy in the conservative management of this condition, leads to major controversy regarding its efficacy. Therefore, we conducted an extensive literature review of published articles regarding the use of somatostatin and its analogues in the treatment of enterocutaneous fistula in neonates and children. Our review is then presented together with a case vignette and discusses the different practical aspects of the treatment with these drugs. Conclusion: The major diversity in treatment regimens among published studies makes outcomes difficult to compare. However, given the results of the different cases reported in the literature and of our own experience, we suggest a possible beneficial effect of octreotide and somatostatin on closure of enterocutaneous fistula in these patients. What is Known: • Enterocutaneous fistula in neonates and children is a very challenging condition. • Treatment of enterocutaneous fistula still remains controversial. What is New: • Octreotide and somatostatin may play a role in the closure of enterocutaneous fistula. • Our review will provide an updated source of information to guide management.
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... Licensed under a Creative Commons Unported License.Kannan NS et al. (14) no encontraron buenos resultados con la administración de octreótido. Noela Carrea et al.,(22) reportan que el tratamiento conservador con somatostatina y octreótido ayuda al cierre de la fístula, lo que controla las pérdidas hidroelectrolíticas y mejora el control local de la herida, permitiendo la eliminación temprana de la nutrición parenteral y el acceso venoso (22). Stevens P. Foulkes (23) en un metaanálisis concluye que la somatostatina y el octreótido mejoran el tiempo de cierre de la fístula. ...
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  • Apr 2021
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... Various medical treatments such as somatostatin or some of its analogues, such as octreotide, have proved beneficial as they reduce pancreatic enzyme secretion and intestinal motility, thus accelerating fistula closure. However, they do have cardiovascular and digestive side-effects, and the need for subcutaneous or intravenous administration is to be considered, since it impairs long-term use (2) . If the fistula is large and associated with partial abdominal cavity removal, it typically becomes chronic, while slowly closing the abdominal wall, thus adopting the shape of a "neostoma". ...
Combined treatment of enterocutaneous fistula with laser diode and embolization
Article
  • Jan 2021
Introduction: Enterocutaneous fistula treatment in patients undergoing multiple surgeries is complex and requires creative solutions. We present the case of an enterocutaneous fistula managed with laser diode and cyanoacrylates. Clinical case: 15-year-old patient, diagnosed with ulcerative colitis at 12 years of age, undergoing full colectomy with urgent ileostomy as a result of a flare-up refractory to medical treatment. Five months later, an ileoanal pull-through with pouch was carried out, leaving a protection ileostomy in place. However, postoperative evolution was poor, with pelvic infection, so two further urgent open surgeries were required for lavage and hemostasis purposes. Six months later, anastomotic stricture was noted. It was healed following various pneumatic dilations under ultrasound vision and at-home dilations using Hegar dilators. One year following this, ileostomy was closed, but one month later, abdominal distension occurred. It was associated with a fistula in the abdominal midline, which could be endoscopically guided, with its origin being located at the ileoanal anastomosis. Laser diode sessions were applied for treatment purposes, with partial improvement, but still with gas emission. One year later, embolization was performed by placing platinum coils and lipiodol-diluted cyanoacrylates, and clinical signs disappeared. 17 months following this surgery, the patient has no symptoms, with full day and night fecal continence and 3 daily stools, and the fistula is completely closed. Conclusion: Combined treatment with laser diode and platinum coil and cyanoacrylate embolization proves effective in the management of enterocutaneous fistula, with low morbidity.
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  • Jun 2018
Vascular Ehlers-Danlos syndrome (v-EDS) is a connective tissue disease resulting from mutations in COL3A1 gene, coding for type III procollagen, a major protein in vessel walls and hollow organs (1,2). Common clinical features include translucent skin, prominent superficial veins, abnormal facial appearance, easy bruising, and arterial, intestinal, and/or uterine fragility (1,2). In children, it usually presents with sigmoid perforation or vascular rupture (3). A history of chronic constipation with megacolon starting in adolescence can precede intestinal perforation (1). Intestinal failure (IF) requiring long-term parenteral nutrition (PN) has not been reported in children with v-EDS. We report a case of IF in a child with v-EDS because of multiple high-output enterocutaneous fistulae requiring longterm PN.
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Successful management of enterocutaneous fistula in a preterm infant by a simple negative pressure wound therapy technique
Article
  • Apr 2021
Enterocutaneous fistula (ECF) is a serious complication with problems of nutritional maintenance, infection control and wound management. A preterm baby (birth weight 690g) developed ECF after surgery for necrotizing enterocolitis. Conservative treatments including parental nutrition and wound care were ineffective initially, until negative pressure wound therapy technique (a colostomy bag and a suction tube connected to negative pressure) was applied. Among the various beneficial effects of negative pressure wound therapy, we believe the most obvious one is the rapid removal of the corrosive intestinal fluid from the wound.
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«Risks and Сhances» of Development of Adverse Events at Treatment of Enteric Fistula
Article
Full-text available
  • Oct 2019
Relevance. The basis of a solution of the problem of treatment of enteric fistula is made by the termination of current of contents on the formed pathological course. For this purpose use sandostatin or its analogs which efficiency needs objectification and statistical justification. Purpose: to define possibilities of a method of mathematical modeling of risk and weighing of chances at assessment of emergence of an adverse event during a disease depending on a way of treatment of enteric fistula. Materials and methods. Results of treatment of 65 patients with enteric fistula who were in a surgical department of hospital of N.A. Semashko of Yaroslavl during the period from 1988 to 2017 are analyzed. At treatment of 41 patients we adhered to traditional tactics. Sandostatin was included in a complex of therapeutic measures at 24 people. For identification of predictive value of clinical symptomatology, clinical laboratory indicators of blood, urine and haemo biochemical parameters carried out the statistical analysis according to Friedman of 352 options 112 of the estimated variables. At the same time assessment procedure of risk and weighing of chances of emergence of such events, adverse events as need of an operative measure for elimination of fistula (the first model) and a lethal outcome (the second model) is realized. Results. On each of three investigation phases from 27 to 55 determined parameters indicating a high probability of the fact that against the background of use of traditional medical measures carrying out operation with the purpose of treatment of fistula is required are revealed. The quantity of the indicators connected with use of an octreotide at the first two investigation phases was minimum, and by 28 their days did not become at all that testified to high performance of the used means excluding need in a surgical grant during the entire period of observation. At the second statistical model in the conditions of traditional tactics throughout all research the number of parameters was notable higher. Meant it that the practiced complex of treatment of an intestinal fistula was ineffective. When using an octreotide total number of the integrated signs at the first and second investigation phases was minimum, and to the third stage of observation of similar parameters did not become at all that indicated high performance of treatment of enteric fistula, excepting the predicted risk of a lethal outcome. Conclusion. The technique of statistical modeling allows to reveal well-being of medical process concerning enteric fistula. The mathematical analysis which is carried out at the same time gives the chance to define significantly changing variables. Unlike traditional tactics at early operational stages of an octreotide chances of development of adverse events decrease, and need of surgical intervention is completely leveled later and the probability of a lethal outcome decreases that correlates with clinical effectiveness of the practiced measures (reduction of lethality by 2.5 times).
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A Meta-analysis of Outcomes Following Use of Somatostatin and Its Analogues for the Management of Enterocutaneous Fistulas
Article
Full-text available
  • Aug 2012
  • ANN SURG
Objective: Several randomized control trials (RCTs) have compared somatostatin and its analogues versus a control group in patients with enterocutaneous fistulas (ECF). This study meta-analyzes the literature and establishes whether it shows a beneficial effect on ECF closure. Methods: We searched MEDLINE, EMBASE, CINAHL, Cochrane, and PubMed databases according to PRISMA guidelines. Seventy-nine articles were screened. Nine RCTs met the inclusion criteria. Statistical analyses were performed using Review Manager 5.1. Results: Somatostatin analogues versus control. Number of fistula closed: A significant number of ECF closed in the somatostatin analogue group compared to control group, P = 0.002.Time to closure: ECF closed significantly faster with somatostatin analogues compared to controls, P < 0.0001.Mortality: No significant difference between somatostatin analogues and controls, P = 0.68.Somatostatin versus control. Number of fistula closed: A significant number of ECF closed with somatostatin as compared to control, P = 0.04.Time to closure: ECF closed significantly faster with somatostatin than controls, P < 0.00001.Mortality: No significant difference between somatostatin and controls, P = 0.63 Conclusions: Somatostatin and octreotide increase the likelihood of fistula closure. Both are beneficial in reducing the time to fistula closure. Neither has an effect on mortality. The risk ratio (RR) for somatostatin was higher than the RR for analogues. This may suggest that somatostatin could be better than analogues in relation to the number of fistulas closed and time to closure. Further studies are required to corroborate these apparent findings.
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Therapeutic Applications of Octreotide in Pediatric Patients
Article
Full-text available
  • Mar 2012
  • Saudi J Gastroenterol
We report our experience with the use of octreotide as primary or adjunctive therapy in children with various gastrointestinal disorders. A pharmacy database identified patients who received octreotide for gastrointestinal diseases. Indications for octreotide use, dosing, effectiveness, and adverse events were evaluated by chart review. A total of 21 patients (12 males), aged 1 month to 13 years, were evaluated. Eleven received octreotide for massive gastrointestinal bleeding caused by portal hypertension-induced lesions (n=7), typhlitis (1), Meckel's diverticulum (1), and indefinite source (2). Blood transfusion requirements were reduced from 23 ± 9 mL/kg (mean ± SD) to 8 ± 15 mL/kg (P<0.01). Four patients with pancreatic pseudocyst and/or ascites received octreotide over 14.0 ± 5.7 days in 2 patients. In 3 children, pancreatic pseudocyst resolved in 12 ± 2 days and pancreatic ascites resolved in 7 days in 2. Three patients with chylothorax received octreotide for 14 ± 7 days with complete resolution in each. Two infants with chronic diarrhea received octreotide over 11 ± 4.2 months. Stool output decreased from 85 ± 21 mL/kg/day to 28 ± 18 mL/kg/day, 3 months after initiation of octreotide. The child with dumping syndrome responded to octreotide in a week. Adverse events developed in 4 patients: Q-T interval prolongation and ventricular fibrillation, hyperglycemia, growth hormone deficiency, and hypertension. Octreotide provides a valuable addition to the therapeutic armamentum of the pediatric gastroenterologist for a wide variety of disorders. Serious adverse events may occur and patients must be closely monitored.
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Non-Surgical Management of a Ruptured Posttraumatic Pancreatic Pseudocyst in a Child
Article
Full-text available
  • Oct 2008
Generally speaking, isolated pancreatic injuries are rare after abdominal blunt trauma. However, the incidence of pancreatic injuries in children has risen in recent decades. Pancreatic pseudocyst represents a typical complication after acute pancreatitis due to blunt abdominal trauma. Spontaneous rupture of pseudocysts leading to acute abdominal pain has been described, however, it rarely occurs, especially in pediatric patients. We report the successful non-surgical management of a ruptured pancreatic pseudocyst in a 5-year-old girl which occurred 27 days after trauma. The traumatic acute pancreatitis was due to a handlebar injury.
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Management of postoperative enterocutaneous fistulae in children: A decade experience in a single centre
Article
  • Jan 2012
  • Afr J Paediatr Surg
Enterocutaneous fistula (ECF) in children poses a lot of management challenges due to sepsis, malnutrition, fluid and electrolyte deficits, which are frequent complications. Knowledge of prognostic factors of postoperative ECF is essential for therapeutic decision-making processes. This study examined the variables that relate to the outcomes of management of ECF in children. Consecutive children who were managed for postoperative ECF in our unit between 2000 and 2009 were evaluated. Data were analysed for clinical features, management and its outcome. A total of 54 patients were managed for ECF. Majority of the fistulas were due to operation for infective causes, with typhoid intestinal perforation ranking the highest. Overall, spontaneous closure without operative intervention occurred in 29 (53.7%) patients. Twenty-one (38.9%) patients required restorative operations to close their fistulas, which was successful only in 12 (22.2%) patients. There was a strong correlation between high-output fistulas (jejunal location) and surgical closure (P<0.001). Hypoalbuminaemia and jejunal location profoundly resulted in non-spontaneous closure of ECF (P<0.001) and were associated with high morbidity (P<0.001). Thirteen (24.1%) patients died due to hypokalaemia, sepsis and hypoproteinaemia/hypoalbuminaemia. Majority of the ECF in children closed spontaneously following high-protein and high-carbohydrate nutrition. Hypoalbuminaemia and jejunal location were important prognostic variables resulting in non-spontaneous closure, while hypokalaemia, sepsis and hypoproteinaemia/hypoalbuminaemia were associated with high mortality in children with ECF.
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Resolution of a Posttraumatic Pancreatic Pseudocyst with Octreotide Acetate in a Pediatric Patient
Article
  • Sep 2011
  • PHARMACOTHERAPY
A pancreatic pseudocyst is a complication of abdominal trauma in pediatric patients. Octreotide acetate is an effective adjunct therapy used in combination with traditional surgical approaches. We describe a 19-month-old boy with a pancreatic pseudocyst secondary to blunt abdominal trauma who was successfully managed with octreotide acetate in combination with percutaneous drainage and the placement of a pancreatic stent. Octreotide acetate 1 μg/kg/hour was administered as a continuous intravenous infusion for 24 hours, followed by 2.5 μg/kg/dose every 12 hours subcutaneously for 11 days. The patient was discharged after the pseudocyst had resolved and oral feeding was restored. He had no recurrence of the pseudocyst. The published literature regarding octreotide acetate therapy for pediatric pancreatic pseudocysts is limited. Previously reported cases demonstrated successful resolution of pancreatic pseudocysts with varying doses of intravenous and subcutaneous octreotide acetate within 23-30 days; however, with our patient's regimen, along with surgical interventions, the pseudocyst resolved within 11 days. In addition, our patient's regimen involved higher doses of octreotide acetate given more frequently than those reported in the literature. This case report illustrates that use of higher octreotide acetate dosages may be a potential adjunct therapy to surgical interventions for the management of pancreatic pseudocysts in children.
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Systematic review and meta-analysis of the role of somatostatin and its analogues in the treatment of enterocutaneous fistula
Article
  • Aug 2011
Somatostatin analogues may help pancreatic fistula although it remains unclear whether they help nonpancreatic fistula. This study involved meta-analysis of somatostatin analogues for treatment of enterocutaneous fistula. Meta-analysis of studies was undertaken, to estimate the effect of somatostatin analogues on spontaneous closure, time to closure and mortality. Results showed significant associations between somatostatin and both spontaneous closure rate [odds ratio (OR) 6.61, 95% (CI) confidence interval 1.35-32.43] and time to closure (standardized mean difference -0.80, 95% CI: -1.34 to -0.26). Octreotide reduced closure time (standardized mean difference -0.57, 95% CI: -0.95 to -0.20) but not spontaneous closure (OR: 1.74, 95% CI: 0.64-4.76). Lanreotide also improved time to closure (mean of 17 days vs. 26 days, standard deviation not stated) but not spontaneous closure (OR: 0.94, 95% CI: 0.42-2.12). Somatostatin, octreotide and lanreotide did not significantly affect mortality (OR: 0.30, 0.82, and 0.48; 95% CI: 0.03-3.47, 0.38-1.78, and 0.04-5.07 respectively). Somatostatin and octreotide improved fistula closure time but only somatostatin improved spontaneous closure rate.
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Necrotizing enterocolitis in neonates receiving octreotide for the management of congenital hyperinsulinism
Article
Laje P, Halaby L, Adzick NS, Stanley CA. Necrotizing enterocolitis in neonates receiving octreotide for the management of congenital hyperinsulinism. The somatostatin analog octreotide was used for the first time in the treatment of an infant with congenital hyperinsulinism in 1986. Since then, it is commonly used in the management of congenital hyperinsulinemic hypoglycemias. Despite a wide variety of potential adverse reactions, octreotide is generally well tolerated. It has been extensively demonstrated that octreotide reduces the splanchnic blood flow in a dose-dependent manner, affecting the entire gastrointestinal tract, and some concern has been recently raised regarding the potential implications of this effect in the development of necrotizing enterocolitis in neonates receiving octreotide for the management of congenital hyperinsulinism. The aim of this report is to present a series of patients treated at our institution in which we observed this association, and review the current related literature.
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Enterocutaneous fistulas of the small bowel in children (25 cases)
Article
  • Mar 1978
During the past 5 yr, 25 children ranging in age from 10 days to 14 yr have been treated for single or multiple severe enterocutaneous fistulas. There were two deaths. In 24 cases out of 25, initial treatment was nonsurgical and consisted of nutritional support (by total parenteral nutrition in 20, and constant rate enteral feeding in 4) and was associated with local treatment. Successful closure was achieved without surgery in 13 cases, and 11 secondary operations were performed, with success in 9. The addition of nutritional methods has completely changed the prognosis of enterocutaneous fistula.
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