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Factors Predictive of Recurrence and Mortality after Surgical Repair of Enterocutaneous Fistula


Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17–81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.

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  1. Martinez JL, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo F. Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World J Surg 2008;32:436–443

    Article  PubMed  Google Scholar 

  2. Draus JM Jr, Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula: are treatments improving? Surgery 2006;140:570–576

    Article  PubMed  Google Scholar 

  3. Wainstein DE, Fernandez E, Gonzalez D, Chara O, Berkowski D. Treatment of high-output enterocutaneous fistulas with a vacuum-compaction device. A ten-year experience. World J Surg 2008;32:430–435

    Article  PubMed  Google Scholar 

  4. Visschers RG, Olde Damink SW, Winkens B, Soeters PB, van Gemert WG. Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg 2008;32:445–453

    Article  PubMed  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

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

    PubMed  CAS  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  8. Fischer JE. The pathophysiology of enterocutaneous fistulas. World J Surg 1983;7:446–450

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  10. Joyce MR, Dietz DW. Management of complex gastrointestinal fistula. Curr Probl Surg 2009;46:384–430

    Article  PubMed  Google Scholar 

  11. Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen after trauma and abdominal sepsis: a strategy for management. J Am Coll Surg 2006;203:390–396

    Article  PubMed  Google Scholar 

  12. Schein M. Postoperative small bowel leak. Br J Surg 1999;86:979–980

    Article  PubMed  CAS  Google Scholar 

  13. Hill GL, Operative strategy in the treatment of enterocutaneous fistulas. World J Surg 1983;7:495–501

    Article  PubMed  CAS  Google Scholar 

  14. Hollington P, Mawdsley J, Lim W, Gabe SM, Forbes A, Windsor AJ. An 11-year experience of enterocutaneous fistula. Br J Surg 2004;91:1646–1651

    Article  PubMed  CAS  Google Scholar 

  15. Lynch AC, Delaney CP, Senagore AJ, Connor JT, Remzi FH, Fazio VW. Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg 2004;240:825–831.

    Article  PubMed  Google Scholar 

  16. Brenner M, Clayton JL, Tillou A, Hiatt JR, Cryer HG. Risk factors for recurrence after repair of enterocutaneous fistula. Arch Surg 2009;144:500–505

    Article  PubMed  Google Scholar 

  17. Wind J, van Koperen PJ, Slors JF, Bemelman WA.Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique. Am J Surg. 2009;197:24–9.

    Article  PubMed  Google Scholar 

  18. Gyorki DE, Brooks CE, Gett R, Woods RJ, Johnston M, Keck JO, Mackay JR, Heriot AG.Enterocutaneous fistula: a single-centre experience .ANZ J Surg. 2010;80:178–81.

    Article  PubMed  CAS  Google Scholar 

  19. McIntyre PB, Ritchie JK, Hawley PR, Bartram CI, Lennard-Jones JE. Management of enterocutaneous fistulas: a review of 132 cases. Br J Surg 1984;71:293–296

    Article  PubMed  CAS  Google Scholar 

  20. Reber HA, Roberts C, Way LW, Dunphy JE. Management of external gastrointestinal fistulas. Ann Surg 1978;188:460–467

    Article  PubMed  CAS  Google Scholar 

  21. Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen: a preliminary report. Arch Surg 2007;142:793–796

    Article  PubMed  Google Scholar 

  22. Fischer JE. The importance of reconstruction of the abdominal wall after gastrointestinal fistula closure. Am J Surg 2009;197:131–132

    Article  PubMed  Google Scholar 

  23. Sarfeh IJ, Jakowatz JG. Surgical treatment of enteric ‘bud’ fistulas in contaminated wounds. A riskless extraperitoneal method using split-thickness skin grafts. Arch Surg 1992;127:1027–1030

    Article  PubMed  CAS  Google Scholar 

  24. Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM, Wexner SD, Dudrick SJ. Enteric fistulas: principles of management. J Am Coll Surg 2009;209:484–491

    Article  PubMed  Google Scholar 

  25. Connolly PT, Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL. Outcome of reconstructive surgery for intestinal fistula in the open abdomen. Ann Surg 2008;247:440–444.

    Article  PubMed  Google Scholar 

  26. Mastboom WJ, Kuypers HH, Schoots FJ, Wobbes T. Small-bowel perforation complicating the open treatment of generalized peritonitis. Arch Surg 1989;124:689–692.

    Article  PubMed  CAS  Google Scholar 

  27. Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R. Operative management of small bowel fistulae associated with open abdomen. Asian J Surg 2006;29:1–7

    Article  PubMed  Google Scholar 

  28. Schein M, Decker GA. Gastrointestinal fistulas associated with large abdominal wall defects: experience with 43 patients. Br J Surg 1990;77:97–100.

    Article  PubMed  CAS  Google Scholar 

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Dr. Jose L. Martínez is a CONACYT (México) Doctoral Fellow (Registration 224708) at Universidad Autónoma Metropolitana-Iztapalapa.

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Correspondence to Jose L. Martinez.

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Dr. Stuart G. Marcus, MD (Bridgeport, CT, USA): I would like to commend Drs. Martinez and Luque-de-Leon on their dedication to this difficult population of patients and also for presenting a large amount of data in a clear and concise manner. These results, which are among the best reported in the literature, reflect excellent decision making and a clear understanding of the need to withhold surgery until the patient is in the best possible physical condition. The outstanding management and results of an average of one new patient approximately every 2 weeks over a 5-year period set a benchmark for others to meet in the surgical care of enterocutaneous fistulas.

I have several questions for the authors:

1. You mention that 22 patients, or 31%, were treated with Octreotide. This was not factored into your analysis. Can you tell us what effect, if any, Octreotide had on ECF recurrence and mortality after surgery?

2. You clearly point out the importance of restoring nutrition, controlling sepsis and correcting electrolyte imbalance to achieve your excellent results. Another factor also considered important in patients with ECF is maintaining skin integrity. Can you tell us some lessons learned in this area?

3. In your manuscript, you conclude that sepsis continues to be the most important factor related to mortality. Seventeen of your patients were operated on due to sepsis and 12 died with sepsis, yet on multivariate analysis sepsis is not found to be a significant factor. How do you explain this discrepancy?

I would like to thank the authors and the SSAT for the opportunity to discuss this paper.

Closing Discussant

Drs. Jose L. Martinez and Enrique Luque-de-Leon:

1. We did analyze Octreotide use as an independent variable and did not find any relationship with recurrence or mortality. The nonprotocolized form of its use (in regards to indications, duration, dosage, etc.) made us decide not to include it in our final presentation and manuscript. We are planning to standardize its use and include it in future protocols with specific patient populations.

2. Skin care is undoubtedly one of the cornerstones in the management of these patients. Since more than 80% of our patient population are referred from other hospitals, we have been faced with a wide range of skin derangements and problems. Our stoma care unit was established in 1998, and has been a great asset not only for patients with stomas, but also for those with ECF and those managed with an open-abdomen. In general, once ECF control is achieved, skin integrity is maintained with transparent films without alcohol (i.e., proshell, adapt and stomadhesive) or karaya. Treatment of those referred patients with diverse skin lesions starts with its classification (discoloration erosion tissue growth, DET); hydrocolloid and alginate wound dressings and powder as well as transparent films are part of the armamentarium for their management.

3. As shown in our tables, our analysis was based on patients that had sepsis at admission or referral (19) and those that developed it prior to surgical treatment (6); 10 of these 25 patients died for p values of 0.004 (univariate) and 0.761 (multivariate). As Dr. Stuart points out, there are however other ways to look at the numbers. For example, sepsis was the surgical indication in 17 patients (which are part of the 25 patients mentioned above). The fate of these 17 patients included death in 8 due to abdominal sepsis (4), pulmonary sepsis (3), and pulmonary thromboembolism (PTE; 1). The results are similar if the analysis is based in these numbers (p values of 0.003 and 0.57, respectively). Perhaps a greater sample would confirm sepsis as an independent factor related to mortality.

Overall, 14 patients died; causes included abdominal sepsis (6), pulmonary sepsis (6), PTE (1, who had sepsis during course of disease) and acute myocardial infarction (1). Thus, only this latter patient’s dismissal was completely unrelated to sepsis. This only confirms presence or development of sepsis as a major factor related to outcome.

DDW 2011. SSAT Plenary Session V. May 9th, 2011. Chicago, IL, USA.

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Martinez, J.L., Luque-de-León, E., Ballinas-Oseguera, G. et al. Factors Predictive of Recurrence and Mortality after Surgical Repair of Enterocutaneous Fistula. J Gastrointest Surg 16, 156–164 (2012).

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  • Intestinal fistula
  • Intestinal fistula surgery
  • Intestinal fistula recurrence
  • Enterocutaneous fistula
  • Surgical complications