Route of Delivery

Because this patient has a high output fistula (700 cc/day), I will choose TPN as the route of feeding.  You 
really should not feed via the GIT when there is a high output fistula present- Total bowel rest is indicated 
to allow for the possibility of spontaneous closure, which if it is going to happen, will usually require at 
least 3 weeks.  The fact that it is likely that we will need to have the patient be on total bowel rest for 3 
weeks means that this will be a longer-term type of feeding, which makes it unwise to use a peripherally 
placed line.  A central line is indicated, and will allow us to provide optimal nutrition without having to 
worry about the osmolarity issues associated with PPN.  I will initiate TPN cautiously, with close 
monitoring of electrolytes and blood glucose, to allow the patient to adapt to the level of feeding gradually 
and to avoid the incidence of refeeding syndrome, given his compromised nutritional status.  

It is likely that the patient will be started on TPN  the hospital and stabilized before being sent home on TPN.  
I will start him on continuous feeding until he is tolerating it well, and
then depending upon planned date of discharge, will switch to a cyclic 
feeding that he will be on at home.  A home nutrition support service will
be arranged for followup post d/c.