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Systematic Management of Postoperative Enterocutaneous Fistulas: Factors Related to Outcomes

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Abstract

Background

Most enterocutaneous fistulas are postoperative in origin. Sepsis, malnutrition, and hydroelectrolytic deficit are still the most important complications to which patients with postoperative enterocutaneous fistulas (PEF) are exposed. Knowledge of prognostic factors related to specific outcomes is essential for therapeutic decision-making processes.

Methods

We reviewed files of all consecutive patients with PEF treated in our hospital during a 10-year period. Our aim was to identify factors related to spontaneous closure, need for operative treatment, and mortality. Univariate and multivariate analyses were performed.

Results

A total of 174 patients were treated. The most frequent site of origin was the small bowel (90 patients: 48 jejunal, and 42 ileal), followed in frequency by the colon (50 patients). Postoperative enterocutaneous fistula closure was achieved in 151 patients (86%), being spontaneous in 65 (37%) and surgical in 86 (49%). Factors that significantly precluded spontaneous closure were jejunal site, multiple fistulas, sepsis, high output, and hydroelectrolytic deficit at diagnosis or referral. Origin of PEF at our hospital was the only factor significantly associated with spontaneous closure. The most frequent operative indication was PEF persistence without sepsis. Factors significantly associated with the need for operative treatment were high output, jejunal site, and multiple fistulas. Closure was achieved in 84% of patients who underwent operation. A total of 23 patients died (13%). Factors associated with mortality were serum albumin <3.0 g/dl (at diagnosis or referral), high output, hydroelectrolytic deficit, multiple fistulas, jejunal site, sepsis, and a complex fistulous tract.

Conclusions

In spite of advances in management of PEF, the associated morbidity and mortality remain high. Among several variables influencing outcome, our multivariate analysis disclosed high output, jejunal site, multiple fistulas, and sepsis as independent adverse factors related to non-spontaneous closure, need for operative treatment, and/or death.

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References

  1. Halversen RC, Hogle HH, Richards RC (1969) Gastric and small bowel fistulas. Am J Surg 118:968–972

    Article  PubMed  CAS  Google Scholar 

  2. Nassos TP, Braash JW (1971) External small bowel fistulas. Current treatment and results. Surg Clin North Am 51:687–692

    PubMed  CAS  Google Scholar 

  3. Hollender LF, Meyer C, Avet D, et al. (1983) Postoperative fistulas of the small intestine: therapeutic principles. World J Surg 7:474–480

    Article  PubMed  CAS  Google Scholar 

  4. Martineau P, Schwed JA, Denis R (1996) Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure? Am J Surg 172:386–395

    Article  PubMed  CAS  Google Scholar 

  5. Kuvshinoff BW, Brodish RJ, McFadden DW, et al. (1993) Serum transferrin as a prognostic indicator of spontaneous closure and mortality in gastrointestinal cutaneous fistulas. Ann Surg 217:615–623

    Article  PubMed  CAS  Google Scholar 

  6. Lévy E, Frileux P, Cugnenc PH, et al. (1989) High-output external fistulae of the small bowel: management with continuous enteral nutrition. Br J Surg 76:676–679

    Article  PubMed  Google Scholar 

  7. Schein M, Decker GAG (1991) Postoperative external alimentary tract fistulas. Am J Surg 161:435–438

    Article  PubMed  CAS  Google Scholar 

  8. Campos ACL, Andrade DF, Campos GMR, et al. (1999) A multivariate model to determine prognostic factors in gastrointestinal fistulas. J Am Coll Surg 188:483–490

    Article  PubMed  CAS  Google Scholar 

  9. Edmunds LH Jr, Williams GM, Welch CE (1960) External fistulas arising from the gastrointestinal tract. Ann Surg 152:445–471

    Article  PubMed  Google Scholar 

  10. Foster CE, Lefor AT (1996) General treatment of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances. Surg Clin North Am 76:1037–1052

    Google Scholar 

  11. Dudrick SJ, Maharaj AR, McKelvey AA (1999) Artificial nutrition support in patients with gastrointestinal fistulas. World J Surg 23:570–576

    Article  PubMed  CAS  Google Scholar 

  12. Reber HA, Roberts C, Way LW, et al. (1978) Management of external gastrointestinal fistulas. Ann Surg 188:460–467

    Article  PubMed  CAS  Google Scholar 

  13. Rubelowsky J, Machiedo GW (1991) Reoperative versus conservative management for gastrointestinal fistulas. Surg Clin North Am 71:147–157

    PubMed  CAS  Google Scholar 

  14. Fazio VW, Coutsoftides T, Steiger E (1983) Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg 7:481–488

    Article  PubMed  CAS  Google Scholar 

  15. Berry SM, Fischer JE (1994) Enterocutaneous fistulas. Curr Prob Surg 31:483–566

    Article  Google Scholar 

  16. Fischer JE (1983) The pathophysiology of enterocutaneous fistulas. World J Surg 7:446–450

    Article  PubMed  CAS  Google Scholar 

  17. Chapman R, Foran R, Dunphy JE (1964) Management of intestinal fistulas. Am J Surg 108:157–164

    Article  PubMed  CAS  Google Scholar 

  18. Aguirre A, Fischer JE, Welch CE (1974) The role of surgery and hyperalimentation in therapy of gastrointestinal-cutaneous fistulae. Ann Surg 180:393–401

    Article  PubMed  CAS  Google Scholar 

  19. McIntyre PB, Ritchie JK, Hawley PR, et al. (1984) Management of enterocutaneous fistulas: a review of 132 cases. Br J Surg 71:293–296

    Article  PubMed  CAS  Google Scholar 

  20. Rose D, Yarborough MF, Canizaro PC, et al. (1986) One hundred and fourteen fistulas of the gastrointestinal tract treated with total parenteral nutrition. Surg Gynecol Obstet 163:345–350

    PubMed  CAS  Google Scholar 

  21. Prickett D, Montgomery R, Cheadle WG (1991) External fistulas arising from the digestive tract. South Med J 84:736–739

    PubMed  CAS  Google Scholar 

  22. MacFadyen BV Jr, Dudrick SJ, Ruberg RL (1973) Management of gastrointestinal fistulas with parenteral hyperalimentation. Surgery 74:100–105

    PubMed  Google Scholar 

  23. Sitges-Serra A, Jaurrieta E, Sitges-Creus A (1982) Management of postoperative enterocutaneous fistulas: the roles of parenteral nutrition and surgery. Br J Surg 69:147–150

    Article  PubMed  CAS  Google Scholar 

  24. Draus JM Jr, Huss SA, Harty NJ, et al. (2006) Enterocutaneous fistula: are treatments improving? Surgery 140:570–578

    Article  PubMed  Google Scholar 

  25. Berry SM, Fischer JE (1996) Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am 76:1027–1036

    Article  Google Scholar 

  26. Sancho JJ, di Costanzo J, Nubiola P, et al. (1995) Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistula. Br J Surg 82:638–641

    Article  PubMed  CAS  Google Scholar 

  27. Evenson AR, Fischer JE (2006) Current management of enterocutaneous fistula. J Gastrointest Surg 10:455–464

    Article  PubMed  Google Scholar 

  28. Sheldon GF, Gardiner BN, Way LW, et al. (1971) Management of gastrointestinal fistulas. Surg Gynecol Obstet 133:385–389

    PubMed  CAS  Google Scholar 

  29. Soeters PB, Ebeid AM, Fischer JE (1979) Review of 404 patients with gastrointestinal fistulas. Ann Surg 190:189–202

    Article  PubMed  CAS  Google Scholar 

  30. Hill GL (1983) Operative strategy in the treatment of enterocutaneous fistulas. World J Surg 7:495–501

    Article  PubMed  CAS  Google Scholar 

  31. Lorenzo G. Beal JM (1969) Management of external small bowel fistulas. Arch Surg 99:394–396

    Google Scholar 

  32. Lynch AC, Delaney CP, Senagore AJ, et al. (2004) Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg 240:825–831

    Article  PubMed  Google Scholar 

  33. Altomare DF, Serio G, Pannarale OC, et al. (1990) Prediction of mortality by logistic regression analysis in patients with postoperative enterocutaneous fistulae. Br J Surg 77:450–453

    Article  PubMed  CAS  Google Scholar 

  34. Hollington P, Mawdsley J, Lim W, et al. (2004) An 11-year experience of enterocutaneous fistula. Br J Surg 91:1646–1651

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors acknowledge all members of the Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades, CMN Siglo XXI (IMSS), for allowing the inclusion of their clinical experience.

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Authors and Affiliations

  1. General and Gastrointestinal Surgery, Centro Médico Nacional, Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Cuauhtémoc #330, Col. Doctores, Deleg. Cuauhtémoc, 06725, México, D.F, México

    Jose L. Martinez, Enrique Luque-de-Leon, Juan Mier, Roberto Blanco-Benavides & Felipe Robledo

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  1. Jose L. Martinez
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  2. Enrique Luque-de-Leon
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  3. Juan Mier
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  4. Roberto Blanco-Benavides
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Correspondence to Jose L. Martinez.

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Martinez, J.L., Luque-de-Leon, E., Mier, J. et al. Systematic Management of Postoperative Enterocutaneous Fistulas: Factors Related to Outcomes. World J Surg 32, 436–443 (2008). https://doi.org/10.1007/s00268-007-9304-z

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