Factors influencing the outcome of treatment of small bowel cutaneous fistula

Abstract

Abstract A 20‐year review of 174 external fistulas of the jejunum and ileum led to the identification of factors affecting morbidity and mortality. The mortality rate for jejunal fistulas was higher as compared to ileal fistulas, whether treated by nonoperative means (41.7% and 29.4%, respectively), conservative surgical means (70% and 21%, respectively) or by radical, i.e., resectional surgical techniques (21.7% and 12.2%, respectively). Overall mortality rate in the series was 22.4% (39 patients). Respective mortality rates for high‐output (greater than 200 ml/day) and low‐output fistulas were 30.3% and 4.8%; where the presence or absence of significant intra‐abdominal sepsis could be clearly established on chart review, mortality rates were 29.6% and 0%, respectively. The presence of anemia, hypoalbuminemia, and malnutrition adversely affected outcome, with mortality rates of 30.7%, 41.9%, and 31.8%, as compared to the outcome when these features were absent (8.2%, 0%, and 3.0%, respectively). Etiological factors were also examined. High mortality rates were observed for fistulas arising due to radiation effect (45.4%), gangrenous intestine or evisceration (52.4%), and those secondary to surgery for ulcerative colitis (33.3%). Timing of fistula surgery had little impact on rates of fistula cure, but survival was highest when such surgery could be deferred beyond 6 weeks from fistula onset. Improvement in survival has been noted since 1970. While many factors influence mortality rates, inadequately treated sepsis assumes primary importance. In favorable circumstances, intestinal resection and anastomosis is the procedure of choice. However, staging procedures such as resection of the fistula‐bearing segment without anastomosis or enterostomy with wide drainage of associated sepsis should be considered when local conditions in the abdomen indicate a likelihood of anastomotic breakdown. These local conditions invariably improve with adequate drainage and prevention of further contamination; total parenteral nutrition has provided a mechanism of sustaining the patient while this improvement occurs, allowing for elective intestinal reconstruction.