P.5 CORRELATION BETWEEN NUTRITIONAL STATUS, ITS VARIATION DURING TPN ~D SPONTANEOUS CLOSURE OF DIGESTIVE FISTULAS. F. Bozzetti, G. Bonfanti, M.G. Bonalumi, M.G. Inglese, A. Scott|, M. Ammatuna. Istituto Nazionale Tumor|, via Venezian |, 20133 Milan, Italy.

Spontaneous closure of digestive fistulas in patients receiving TPN has been generally attributed to the improvement of the nutritional status (NS), to the bowel rest or both. To evaluate the role of the nutritional status in the outcome of patients with digestive fistulas receiving TPN, a retrospective analysis has been performed at the Istituto Na- zionale Tumor| on 62 patients having post-surgical (45), or postirradiatory (|O), or pa- thological (6) - neoplastic or inflammatory - fistulas. The outcome of these patients (spontaneous closure vs surgical closure or total failure) was analyzed in relation to the NS, evaluated before and after TPN and to the etiology, site and number of fistulas. Nutritional parameters included body weight, serum albumin (SA), transferrin, cholineste- rase and lymphocytes/mm 3. A preliminary evaluation (chi-square test) showed that post- surgical fistulas close spontaneously more frequently than post-irradiatory (P = 0.006) and pathological ones (P = 0.002). The statistical analysis within homogeneous groups of patients with postsurgical fistulas showed that single fistulas close more frequently than multiple ones (P = 0.008) and no pre TPN or post TPN parameter of NS is significan- tly correlated to the outcome, except SA. SA increased significantly only in patients with spontaneous healing. Furthermore duration of TPN was significantly shorter in pat- ients with spontaneous closure. We conclude that spontaneous recovery with TPN of pat- ients with digestive fistulas in mainly related to the bowel rest and the only purpose of TPN is to allow minimal peristalsis and minimal digestive secretion for a period of time necessary for the spontaneous healing. Furthermore, change in 8A is a predictor of the outcome of the fistula.

P.6 RESULTS OF 6 WEEKS PRE-OPERATIVE TREATMENT WITH TOTAL PARENTERAL NUTRITION IN PATIENTS WITH SEVERE CROHN'S DISEASE D.J.Gouma, P.C.M.de Jong, R.l.C.Wesdorp, J.M. Greep, P. Pop, E. Hardy and P.B. Soeters (St. Annadal Hospital, Un ivers i ty of Limburg, Dpt of Surgery, Maastr icht, The Netherlands).

The use of pre-operative nu t r i t i ona l support in the treatment of pat ients with Crohn's disease is s t i l l controvers ia l . The duration and the decision to feed entera l ly and/or parentera l ly d i f f e r from center to center. Of the 22 patients wi th severe Crohn's disease referred to our department for surgical treatment, 4 patients could be treated without operation, whi le the remaining 18 patients were operated. They a l l had an act ive disease with an abdominal mass, in te rna l - or exter- nal cutaneous f i s t u l a s , and signs of obstruct ion (mean Crohn's disease a c t i v i t y index was 332). Based on commonly used parameters (albumin and percentage of weight loss) , they a l l were severe malnourished and were pre-operat ively treated wi th to ta l parenteral n u t r i t i o n (TPN). The mean pre-operative period of TPN was 6 weeks. In th is period, the general con- d i t ion improved, body weight increased with a mean of 6.2 kg, mean serum albumin increa- sed s i g n i f i c a n t l y ( 26 g/ l > 34 g / l ) and 74% of the f i s t u l as closed spontaneously. There was no post-operative mor ta l i t y (in-house mor ta l i ty ) in th is group of patients and a very low morbidity with only two minor skin in fec t ions. Twenty-seven catheters were used in these patients ( i i Broviac R and 16 VygonR). Catheter related sepsis was seen in 2 patients during 973 catheter days. At the operation, a l imi ted resection of diseased bowel was performed. A l l resected gut specimens contained a stenot ic i r r eve rs ib l y f ib ros- ed segment. From the above data we may conclude that pre-operative TPN decreased post- operative complications in severe Crohn's disease and that a l imi ted resection of the stenosed gut is essent ia l .