Results after Definitive Surgical Treatment in Patients with Enteroatmospheric Fistula

Abstract

As enteroatmospheric fistulas (EAF) lack healthy overlying tissue, spontaneous healing is very unlikely. Our aim was to identify risk factors for recurrence and mortality after definitive surgical treatment for EAF. Sixty-two consecutive patients with a diagnosis of EAF were submitted to definitive surgical repair (fistula resection and primary anastomosis) during a 6-year period. Several patient, disease, and operative variables were assessed as risk factors associated to our endpoints: recurrence and mortality. All patients were followed-up until hospital discharge or death. Univariate and multivariate analysis were performed. There were 24 females and 38 males with a median age of 53 years (interquartile ranges 43–63). EAF recurred in 23 patients. Univariate analysis identified several risk factors for recurrence which included performing more than one anastomosis (20 vs 52%, P = 0.013), failure of achieving total abdominal closure (16 vs 47%, P = 0.025), intraoperative hemorrhage >400 cc (28 vs 65%, P = 0.007), presence of multiple fistulas (25 vs 61%, P = 0.008), and preoperative C-reactive protein >0.5 mg/dL (54 vs 82%, P = 0.029). The latter two remained significant after multivariate analysis. Final EAF closure was attained in 47 patients (76%) and 8 more (13%) had a low-output (<50 mL/day) enterocutaneous fistula. Timing of surgery was not related to fistula recurrence. Eight patients died (13%), and fistula recurrence was the only risk factor found related to mortality both through univariate (26 vs 5%, P = 0.043) and after multivariate analysis. EAF management represents a rather challenging problem. Timing for surgical treatment is controversial and is based mostly on patient status and surgeon's criteria. Recurrence is associated to EAF characteristics and an inflammatory state; it was also the only factor associated to mortality.

Failure to Rescue (FTR) and Pitfalls in the Management of Complex Enteric Fistulas (CEF): From Rescue Surgery to Rescue Strategy

“…In their series of 79 patients, 49 required surgeries after a median time of 101 days (IQR 7-163 days). In our series, definitive surgery was performed after a median time of 120 days (IQR 34-231 days), similar to that suggested by Demetriades [34] and by Martinez et al (median time 106 days; IQR 76-165 days) [36]. In patients undergoing ostomy, the median time to surgery was 236 days (IQR 148.5-328.5 days), longer than that suggested by Visschers et al [35].…”

“…The median number of anastomoses per patient was one (IQR 1-2). We followed another study demonstrating that performing more than one anastomosis is a significant predictor of fistula recurrence [36]. Hand-sewn anastomoses were preferred over stapled anastomoses because evidence shows that anastomotic failures are more than twice as likely with stapled anastomoses than with hand-sewn anastomoses in case of friable or repeatedly manipulated bowel tissue, even when controlling for markers of preoperative nutrition [38].…”

“…If component separation is insufficient to reapproximate the fascial edges, biological or biosynthetic meshes can be used as a bridge (inlay position). The use of non-cross-linked biological or biosynthetic prostheses should be advocated in all patients treated for CEF due to contamination of the surgical field [17,36,40]. The disadvantages of non-cross-linked meshes positioned inlay include a 40-50% rate of recurrent hernia and abdominal wall laxity [17].…”

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression

“…Fortunately, up to one third of all ECFs will close spontaneously, whereas most EAFs will require surgery for definitive closure ( 17 , 18 ). The surgeon must also recognize the tremendous catabolism that occurs with peritonitis and a huge open wound and treat with appropriate nutrition support.…”