Documente Academic
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Documente Cultură
DOI 10.1007/s00268-007-9304-z
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World J Surg (2008) 32:436–443 437
care facility. To cover a homogeneous group, only patients elective), serum albumin (g/dl), presence of malnutrition
with postoperative enterocutaneous fistulas (PEF) were and hydroelectrolytic imbalance at diagnosis or referral,
included. development of sepsis during the course of disease, and use
of octreotide.
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Table 1 Characteristics of patients and postoperative enterocutane- seals the edges of the dehisced wound and thus functions as
ous fistulas (n = 174) a skin protector. The wound is then covered with a plastic
Variable Number % sheet through which two tubes are placed; one is connected
to a suction device so as to evacuate fistula effluents and
Gender
the other allows entrance of air so as to prevent its collapse.
Male 105 60 For the remaining patients, ordinary methods of skin pro-
Female 69 40 tection and collection of gastrointestinal fluids were
Site of origin employed. Although we use vacuum-assisted closure (KCI,
Esophagus 6 3 San Antonio, TX) in selected patients, this system was not
Stomach 8 4 employed during the period of this study.
Duodenum 20 11 Antibiotic strategies varied during this long study per-
Jejunum 48 28 iod. The initial scheme was usually a combination of either
Ileum 42 24 a third-generation cephalosporin or a quinolone with an
Colon 50 29 antianaerobic agent, such as metronidazole or clindamycin.
Fistula output According to clinical course and results of cultures (when
High ([500 ml) 57 33 obtained), these regimens were later modified. Imipenem
Low (B500 ml) 117 67 cilastatin was frequently used as a second line agent. An-
Fistulous tract tifungals were added as needed.
Simple 159 91 Overall, PEF closure was obtained in 151 patients
Complex 15 9 (86%); a total of 65 (37%) had spontaneous closure, and
Number of fistulas the remaining 86 (49%) healed through operative means.
Multiple 32 18 Rates of total fistula closure (spontaneous and operative),
Single 142 82 as well as mortality, did not vary over time. Table 3 depicts
Initial (causative) operation these figures according to site of PEF origin within the
Urgent 124 71 gastrointestinal tract. Data regarding time intervals
Elective 50 29 between identification of the fistula and spontaneous clo-
Origin of patient sure or operative treatment for the different PEF sites is
Other hospital 134 77 shown in Table 4. It should be noted that because infor-
Same (our) hospital 40 23 mation from referring hospitals is frequently incomplete or
Sepsis inaccurate, identification of the fistula in patients referred
Yes 80 46 from other institutions was considered as the day of arrival
No 94 54 at our hospital.
Malnutrition
Yes 98 56
No 76 44
Spontaneous closure
Hydroelectrolytic imbalance
Univariate and multivariate analysis of factors related to
Yes 68 39
spontaneous closure are shown in Table 5. Jejunal site,
No 106 61
high output, multiple fistulas, and development of sepsis
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Table 3 Postoperative
Site of Number of Spontaneous closure Operative closure Total closure Deaths
enterocutaneous fistula
origin patients (n = 65) (n = 86) (n = 151) (n = 23)
outcomes in 174 patients
Number (%) Number (%) Number (%) Number (%)
according to location of the
fistula Esophagus 6 5 (83) 1 (17) 6 (100) 0 (0)
Stomach 8 3 (38) 4 (50) 7 (88) 1 (12)
Duodenun 20 10 (50) 9 (45) 19 (95) 1 (5)
Jejunum 48 7 (15) 27 (56) 34 (71) 14 (29)
Ileum 42 16 (38) 22 (52) 38 (90) 4 (10)
Colon 50 24 (48) 23 (46) 47 (94) 3 (6)
were identified through univariate analysis as factors that jejunal and high output PEF, compared to other sites of
precluded spontaneous closure. After multivariate analysis, origin and low output PEF, respectively. The only factor
multiple (versus single) PEF almost achieved statistical that favored spontaneous closure was that the fistula was
significance against spontaneous closure (p = 0.06); how- developed at our hospital. Often, patients with PEF that
ever, statistical significance prevailed only for high output originated at other institutions who were referred to our
and jejunal site. Odds ratios were calculated and chances institution did not experience spontaneous closure. Octre-
for spontaneous closure were 3.5 and 2.5 times lower for otide was used irregularly during our study period in a total
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of 52 patients (in *50% and *25% of the patients with jejunal PEF. Mortality according to location of PEF origin
high and low output PEF, respectively). This factor was is shown in Table 3. Several variables were significantly
analyzed as an independent variable, but it was not asso- associated with mortality through univariate analysis,
ciated with any of the dependent variables (outcomes). which included serum albumin \3 g/dl, hydroelectrolytic
imbalance at the moment of diagnosis or referral, devel-
opment of sepsis, jejunal site, high output, complex
Surgical treatment fistulous tract, and multiple fistulas. After multivariate
analysis, however, only jejunal site, multiple PEF, and
Overall, 102 patients (59%) required operative treatment; development of sepsis prevailed as independent significant
PEF closure was achieved in 86 (84%) of them. Indications factors. Odds ratios for these subgroups of patients
for surgery in these patients were PEF persistence without revealed that the chances of dying were 5, 6, and 16 times
sepsis in 36 (35%), source control in 29 (28%), eversion of higher compared to patients with other sites of PEF, single
mucosa in 23 (23%), distal obstruction in 10 (10%), and PEF, and those that did not develop sepsis, respectively
other causes in 4 (4%). Jejunal site, high output, and (Table 7). Probability of death increased with the number
multiple fistulas were identified through univariate analysis of risk factors identified through univariate analysis. Mor-
as factors that favored the need for operative treatment. tality rates for patients with 0–2, 3–4, and 5–7 factors were
After multivariate analysis, statistical significance pre- 2% (2 of 102 patients), 17% (9 of 54 patients), and 67% (12
vailed only for multiple PEF and high output PEF. Their of 18 patients), respectively.
odds ratios were 3 and 2.5 times higher, compared to single
PEF and low output PEF, respectively (Table 6).
Our operative plan included PEF resection with primary Discussion
anastomosis in most cases; however, this was not feasible
in every patient. The type of operations included intestinal Enterocutaneous fistulas are one of the most difficult
or colonic resection with primary anastomosis in 64 complications that a surgeon can face [1–4]. In spite of
patients (63%), PEF resection with proximal enterostomy several advances in its management, mortality remains
or colostomy in 16 patients (16%), drainage of an abscess high. Even in successfully treated cases, inherent morbidity
in 12 patients (12%), and primary closure in 10 patients and the nature of the disease result in lengthy hospitaliza-
(10%). Surgical closure was achieved in 59 of the 64 tions [4]. Hospitals specializing in the management of
patients (92%) undergoing fistula resection and primary enterocutaneous fistulas usually receive their patients from
anastomosis, 13 of 16 (81%) after resection and a diverting other institutions [1, 5–7]. This type of referral improves
ostomy, 7 of 10 (70%) after primary PEF closure, and 7 of outcomes in terms of fistula closure, survival, and costs [6,
12 (58%) after abscess drainage. 8]. A potential explanation is that timely identification and
management of PEF within experienced facilities compares
quite favorably to delays and referral after all attempts to
Mortality control and treat the problem have failed.
Site of origin of the fistula also plays a crucial role.
A total of 23 patients (13%) died; 16 of them (70%) had Because they have higher output, proximal fistulas behave
been submitted to operative treatment, and 14 (61%) had more aggressively than distally located ones [4, 9–13]. Risk
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of hydroelectrolytic imbalance, malnutrition, and sepsis versus 25%, respectively) [12, 18, 22, 25]. This is in
increases in these patients [10, 14]. Moreover, probability contrast with our results (17% versus 38%, respectively)
and timing of spontaneous closure is also related to location and could be explained by the fact that 58% of our
of the fistula. Overall, small bowel fistulas have a lower patients with jejunal PEF had high output fistulas,
chance of spontaneous closure (*30%) and require longer compared to 26% of those with ileal fistulas. In any
courses of treatment before spontaneous closure (*50 days), case, our multivariate analysis disclosed that both high
compared to colonic fistulas (*85% and *35 days, output and jejunal site, were independent significant
respectively) [15]. Time intervals between identification of factors that precluded spontaneous closure. Our sponta-
the fistula and spontaneous closure or operative treatment for neous closure rate of 48% for colonic fistulas is in
the different PEF sites in our series are shown in Table 4. accordance with the findings of most authors [5, 9, 12,
These intervals, however, are only accurate in those 40 18, 20, 22].
patients whose PEF were originated at our hospital. Because Source control and elimination of sepsis are essential to
*80% of our patients were referred from other institutions, promote spontaneous closure [26]. In our group, sponta-
no conclusions can be drawn from these data. neous closure rates for patients without sepsis was almost
double the rate of those with sepsis (49% versus 26%,
respectively); these rates, however, significantly diminish
Spontaneous closure (\10%), if closure is not achieved 1 month after sepsis
control [12, 20].
Because spontaneous closure rates depend on many vari- Although use of octreotide was not significantly related
ables, a wide range, varying from 17% to 71% is reported to our dependent variables, no conclusions can be made
[1, 6, 8, 14, 16–24]. In our experience, 37% of PEF healed because of the number of patients and the irregular way in
without surgery. The known low rate of spontaneous clo- which it was used in our series. Recent reviews state that,
sure for small bowel fistulas was confirmed in our study; it even though management of enterocutaneous fistulas has
occurred in only 23 of 90 patients (25%). been aided by these hormones, results from randomized
Several authors report a higher rate of spontaneous controlled trials have not favoured including them as part
closure for jejunal fistulas than for ileal fistulas (*40% of the standard of care [27].
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‘‘unfriendly’’ abdomen. For these latter cases, and those in 11. Dudrick SJ, Maharaj AR, McKelvey AA (1999) Artificial nutri-
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Acknowledgments The authors acknowledge all members of the
and fourteen fistulas of the gastrointestinal tract treated with total
Department of General and Gastrointestinal Surgery, UMAE Hospital
parenteral nutrition. Surg Gynecol Obstet 163:345–350
de Especialidades, CMN Siglo XXI (IMSS), for allowing the inclu-
21. Prickett D, Montgomery R, Cheadle WG (1991) External fistulas
sion of their clinical experience.
arising from the digestive tract. South Med J 84:736–739
22. MacFadyen BV Jr, Dudrick SJ, Ruberg RL (1973) Management
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