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

  • 2011 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

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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Acknowledgments

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

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Authors and Affiliations

  1. Department of General and Gastrointestinal Surgery, UMAE Hospital de Especialidades–Centro Médico Nacional Siglo XXI (IMSS), Av.Cuauhtémoc 330, 3er piso, Colonia Doctores, Delegación Cuauhtémoc, México, DF, CP 06725, Mexico

    Jose L. Martinez, Enrique Luque-de-León & Guillermo Ballinas-Oseguera

  2. Programa de Doctorado de Ciencias Biológicas y de la Salud, Universidad Autonoma Metropolitana-Iztapalapa, México City, Mexico

    Jose L. Martinez

  3. Unidad de Investigación Médica en Enfermedades Metabólicas, UMAE Hospital de Especialidades, Centro Médico Nacional Siglo XXI (IMSS), México City, Mexico

    José D. Mendez

  4. Facultad de Medicina, Universidad Nacional Autónoma de México, México City, Mexico

    Marco A. Juárez-Oropeza

  5. División Ciencias Biológicas y de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, México City, Mexico

    Ruben Román-Ramos

Authors
  1. Jose L. Martinez
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  2. Enrique Luque-de-León
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  3. Guillermo Ballinas-Oseguera
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  4. José D. Mendez
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  5. Marco A. Juárez-Oropeza
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Corresponding author

Correspondence to Jose L. Martinez.

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Discussant

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). https://doi.org/10.1007/s11605-011-1703-7

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  • DOI: https://doi.org/10.1007/s11605-011-1703-7

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