Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes

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.