Search

Background: Enterocutaneous fistula has traditionally been associated with substantial morbidity and mortality, related to fluid, electrolyte and metabolic disturbance, sepsis and malnutrition., Methods: A retrospective review of enterocutaneous fistula in 277 consecutive patients treated over an 11-year period in a major tertiary referral centre was undertaken to evaluate current management practice and outcome., Results: Most fistulas occurred secondary to abdominal surgery, and a high proportion (52.7 per cent) occurred in association with inflammatory bowel disease. A low rate of spontaneous healing was observed (19.9 per cent). The healing rate after definitive fistula surgery was 82.0 per cent, although more than one attempt was required to achieve surgical closure in some patients. Definitive fistula resection resulted in a mortality rate of 3.0 per cent. In addition, one patient died after laparotomy for intra-abdominal sepsis and an additional 24 patients died from complications of fistulation, giving an overall fistula-related mortality rate of 10.8 per cent., Conclusion: Early recognition and control of sepsis, management of fluid and electrolyte imbalances, meticulous wound care and nutritional support appear to reduce the mortality rate, and allow spontaneous fistula closure in some patients. Definitive surgical management is performed only after restitution of normal physiology, usually after at least 6 months., (Copyright 2004 British Journal of Surgery Society Ltd.)

The contrasting results of treatment of patients with postoperative enterocutaneous fistulae reflect the heterogeneity of the disease and depend on the patient's condition and the characteristics of the fistulae. For this reason, the use of a prognostic index, which enables such patients to be classified according to their risk of death, could be useful. In this study we propose a prognostic index based on a logistic regression analysis, obtained by using two (APACHE II score and serum albumin concentration) of the eight risk factors that have been retrospectively analysed in a series of 70 patients with postoperative enterocutaneous fistulae treated in our surgical department since 1981. The logistic regression equation indicates that patients with a probability of dying of less than 0.35 have a good prognosis, with a sensitivity of 90 per cent, a specificity of 90 per cent, a negative predictive value of 79 per cent, a positive predictive value of 96 per cent and an accuracy of 90 per cent. The predictive performance of the index has also been evaluated in a group of 17 patients studied prospectively, and this confirms the sensitivity and specificity of the model. This postoperative enterocutaneous fistulae index could be a helpful tool in clinical trials and surgical audit.

A series of 75 patients with 87 postoperative enterocutaneous fistulas (PEF) is reported. All received parenteral nutrition after the diagnosis of PEF was made. There were 16 deaths (21.3 per cent) and 62 fistulas (71.2 per cent) closed spontaneously. A classification of PEF is proposed according to the results obtained. The therapeutic approach cannot be uniform in all types of PEF. We feel that parenteral nutrition has substantially improved the prognosis of fistulous patients by increasing the rate of spontaneous closure and improving the nutritional status of patients needing repeated operations. Comparison between series of patients to establish the usefulness of parenteral nutrition is bound to yield inconclusive data due to marked differences in patient populations. We suggest that proper information be obtained by studying series of homogeneous patients, namely those who develop oesophageal, gastric or intestinal fistulas after surgery.

Three hundred and thirty-five patients with high-output enterocutaneous fistulae arising from the small intestine are reported. Median fistula output was 1350 ml/24 h. Eighty-two per cent of patients were referred from other institutions. The fistula opening was associated with evisceration in 165 cases (49 per cent). One or more severity factors were present in 75.5 per cent of the patients. Patients were divided into three groups according to their initial therapy: 21 patients (6 per cent) referred in a moribund state were not operated on (non-intervention); 80 patients (24 per cent) were operated on as an emergency, and the fistula was either exteriorized or defunctioned; 234 patients (70 per cent) were initially managed conservatively. Appropriate local care and nutrition were provided in all cases. Enteral nutrition was the exclusive nutritional support in 285 patients (85 per cent). In 92 cases with proximal fistulae, methods limiting the fistula output or allowing reinfusion of chyme were required. The overall mortality rate was 34 per cent: 100 per cent in the non-intervention group, 55 per cent after emergency surgery, and 19 per cent after conservative treatment. In the latter group, spontaneous closure was obtained in 88 patients (38 per cent). Overall mortality rate was reduced to 19 per cent in patients treated since 1980. Enteral nutrition with appropriate local care may be used in the majority of high-output enterocutaneous fistulae, with an acceptable rate of spontaneous closure. Conservative management is the treatment of choice in the initial period. Emergency surgery should be restricted to the treatment of haemorrhage or intra-abdominal abscesses associated with uncontrolled systemic sepsis.