Treatment Strategies in 135 Consecutive Patients with Enterocutaneous Fistulas

Abstract

Background Enterocutaneous fistulas (ECF) pose a major challenge to every gastrointestinal (GI) surgeon. Based on earlier studies, a standardized treatment guideline was implemented. The focus of the present study was to assess that guideline and determine prognostic factors for outcome of patients with ECF, and to define a more detailed therapeutic approach including the convalescence time before restorative surgery. Methods All patients with ECF treated between 1990 and 2005 were included. Management consisted of controlling Sepsis, Optimization of nutritional state, Wound care, assessment of fistula Anatomy, Timing of surgery, and Surgical strategy (the SOWATS guideline). Prognostic factors were assessed by way of multiple logistic regression analysis. Results A total of 135 patients were treated at our unit. Overall closure was achieved in 118 patients (87.4%). Restorative operations for fistula closure were performed after a median of 53 days (range: 4-270 days). Restorative operations were successful in 97/107 patients (90.7%). Thirteen patients (9.6%) died. An abdominal wall defect was the most predominant negative prognostic factor for Conclusions Application of the SOWATS guideline allowed a favorable outcome after a short convalescence period. Abdominal wall defects and preoperative hypoalbuminemia are important prognostic variables.

Management of acute intestinal failure

“…Visschers et al (22) report a mortality rate of 9 . 6% for management of patients with enterocutaneous fistula.…”

“…It is sometimes necessary to perform a defunctioning loop jejunostomy in the left upper-abdominal quadrant to divert enteric contents from the fistula (7,23) . Definitive surgery for non-healing enterocutaneous fistulas requires elimination of sepsis (22) , restoration of nutrition, delineation of anatomy (by oral and per-fistula contrast studies) and a planned procedure after a period of 3-6 months (34) or when there is evidence of reduction of adhesions (softening of abdominal wall, development of hernia or prolapse of fistula) (20) . Although recovery of these patients takes a long time (SLOW STUFF) and some interventions are slow to have an effect (restoration of nutrition, management of open abdomen, recovery of disturbed liver function), other actions of the clinical team need to be taken promptly (correction of fluid and electrolyte abnormalities; elimination of sepsis).…”

Treatment Options in Gastrointestinal Cutaneous Fistulas

“…Thus, retrospective data purporting to show an association between total parenteral nutrition and fistula closure should be interpreted with caution. 48 Prolonged total avoidance of enteral nutrition is discouraged. Enteral nutrition promotes bowel trophism and may prevent bacteremia in selected patients.…”

Enterocutaneous Fistula: Medical and Surgical Management Including Patients with Crohn's Disease

“…Those not associated with malignancy or radiation enteritis include ECFs with a low daily output (<500 mL/day), distal location, or single opening, and patients without malnutrition (serum albumin >3 g/dL) and those with intact intestinal continuity. [7][8][9] When the surgeon has concluded that the ECF is unlikely to spontaneously close, the decision as to when surgical intervention is required should be based on a clinical impression with consideration of the individual patient's nutritional status, absence of sepsis, and condition of the abdominal wound. My preference is to wait until the 3-to 6-month time frame following development of the ECF to allow for the acute inflammatory process to subside, when possible.…”