A 47-year-old patient undergoing a complicated laparotomy for bowel obstruction develops a postoperative enterocutaneous fistula. Which of the following statement(s) is/are true concerning parenteral nutritional support in the postoperative period?

a. Oral intake can result in severe dehydration, electrolyte abnormalities, and perifistula skin injury

b. Total parenteral nutrition increases the spontaneous closure rate of intestinal fistula

d. The use of TPN better prepares the patient for surgery if surgical intervention proves necessary

Patients with gastrointestinal-cutaneous fistulas represent the classical indication for TPN. In such patients, oral intake of food almost invariably results in increased fistula output with associated metabolic disturbances, dehydration, skin breakdown, and death. Several comprehensive reviews have concluded that TPN clearly impacts on the treatment course of the disease in patients with GI fistulas. The following conclusions can be drawn from studies evaluating the use of TPN in patients with enterocutaneous fistula. First, TPN increases spontaneous closure rate of enterocutaneous fistulas but does not markedly decrease the mortality rate in patients with fistulas. Second, if spontaneous closure of the fistula does not occur, patients are better prepared for operative intervention because of the nutritional support they have received. Finally, certain fistulas are associated with a lower rate of spontaneous closure than others and should be treated more aggressively surgically after a defined period of nutritional support (unless closure occurs).