Factors Predictive of Recurrence and Mortality After Definitive Surgical Repair of Enterocutaneous Fistula
Jose L. Martinez*, Enrique Luque-De-LEóN
Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional SXXI, Mexico DF, Mexico
Background: Most enterocutaneous fistulae (ECF) require operative treatment. Although recent advances have widened therapeutic options, recurrence after surgical repair has not changed substantially. Assessment of outcomes specifically regarding recurrence and mortality after surgical repair has not been studied extensively.Aim: To determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF.Material and Methods: We analyzed prospectively collected databases on all consecutive patients submitted to surgical repair of ECF during a 5 year period. Several patient, disease and operative variables were assessed as factors related to recurrence and mortality. Univariate statistical (UA) comparisons were made using Students T Test for continuous variables and Fischers exact test for categorical variables. Multivariate analyses (MA) were also performed.Results: A total of 71 patients were included. Median age was 52 y. (range, 17-81). Operative indications included ECF persistence (38), sepsis (17), eversion of mucosa (12), and others (4). Surgical treatment included resection and anastomosis (37), resection and ostomy (21), oversew (4), bypass (3), and catheter placement (2). ECF recurred in 22 patients (31%). Medical treatment was established in 9 (with ECF closure in 7); surgical repair was re-attempted in 13 others (attained in 11). Thus, management of 22 patients with recurrent ECF was successful in 18 (82%). UA disclosed non-colonic ECF origin (p=0.04) and high output (p=0.001) as risk factors for recurrence. This latter was the only one that prevailed after MA (p=0.01). Although not statistically significant, management with an open abdomen (p=0.06) and enteroatmosferic fistulae (p=0.07) had a tendency to favor recurrence. A total of 14 patients died (20%). UA revealed several risk factors for mortality measured at diagnosis or referral including malnutrition (p=0.03), sepsis (p=0.01), hydroelectrolytic imbalance (p=0.001), and serum albumin < 3 g/dl (p=0.02). Other significant variables were interval from diagnosis to operation ≤ 20 weeks (p=0.03), preop. serum albumin < 3 g/dl (p=0.001), and age ≥ 55 years (p=0.03). Only the latter two remained significant after MA. A slight tendency was observed for female gender (p=0.07) and non-colonic ECF origin (p=0.09). Interestingly recurrence after surgical treatment was not associated with mortality (p=0.75).Conclusions: Among several studied variables, recurrence was only independently associated with high output. Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series (closure rate of 82%). Mortality was associated to previously reported bad prognostic factors at diagnosis or referral. Timing of operation (> 20 weeks) seems relevant in order to optimize patients functional and nutritional status.
Back to 2011 Program