Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery

Abstract

Objective: Recent experience with surgery for enterocutaneous fistulae (ECF) at a specialist colorectal unit is reviewed to define factors relating to a successful surgical outcome.

Summary background data: ECF cause significant morbidity and mortality and need experienced surgical management. Previous publications have concentrated on mortality resulting from fistulae, while factors affecting recurrence have not previously been a focus of analysis.

Methods: Records were reviewed of patients who had ECF surgery (1994-2001). Management strategy involved early drainage of sepsis and nutritional support prior to elective ECF repair, with selective defunctioning proximal stoma formation.

Results: A total of 205 patients were available (89 males, 43%; median age, 51 years; range, 16-86) years). ECF were related to Crohn's disease in 95, ulcerative colitis in 18, diverticular disease in 17, carcinoma in 25 (16 after radiotherapy), mesh ventral hernia repair in 21, and other causes in 29. Forty-one (20%) had undergone attempted fistula repair at other institutions. Initial management included CT-guided drainage of an intra-abdominal abscess in 23 patients, and total parenteral nutrition in 74 (36%). A total of 203 patients had definitive ECF repair. Forty-four had oversewing or wedge resection of the fistula, and 159 had resection and reanastomosis of the involved small bowel segment or ileocolic anastomosis. Ninety-day operative mortality was 3.5%. A total of 42 (20.5%) patients developed ECF recurrence within 3 months. Multivariate analysis demonstrated that recurrence was more likely after oversewing (36%) than resection (16%, P = 0.006).

Conclusions: A strategy of drainage of acute sepsis, maintenance of nutritional support prior to surgery, and selective use of PS allows for primary closure in 80% of complicated ECF. Resection should be performed when feasible.

FIGURE 1. Algorithm showing the initial surgical management of 205 patients requiring surgical treatment of ECF. The flowchart outlines procedures undertaken to deal with the fistula (drain only, oversewing, resection, or complex multiple resection with reanastomosis, nothing), requirement for anastomotic revision and reanastomosis, and stoma coverage (defunctioning proximal stoma, end ileostomy, stoma closure, or no stoma).

FIGURE 2. Relationship between number of definitive surgical procedures performed and probability of fistula recurrence relative to time since fistula onset (n = 203). Number of patients are represented by columns (left Y-axis) and recurrence by the black line (right Y-axis).