A clinical study on identification of factors affecting spontaneous closure of postoperative enterocutaneous fistula

INTRODUCTION

Enterocutaneous (EC) fistula is defined as an abnormal communication between the mucosal epithelium of the gastrointestinal tract and the skin surface.¹ Management of these EC fistulas provides a surgeon with multiple challenges; we should consider about the complications - fluid and electrolyte abnormalities, malnutrition, sepsis, abdominal wall and wound abnormalities and other complications.²

MATERIAL AND METHODS

This study is a retrospective analysis conducted in the Department of General Surgery at a tertiary care center. The study included a population of 28 patients and spanned a duration of 21 months, from November 2022 to July 2024. Patients with postoperative enterocutaneous fistula at the center were included, while those with inflammatory bowel disease or on high doses of steroids for other causes were excluded. The collected data were tabulated and analyzed using the Chi-square test of independence, with the significance level set at 0.05.

Table 1 illustrates the categorization of host factors into modifiable and non-modifiable factors. Modifiable factors include hemoglobin levels, serum albumin levels, and the presence or absence of sepsis. Non-modifiable factors comprise the age and gender of the patient. The collected data are systematically tabulated and represented in the table.

In Table 2, fistula factors are categorized into modifiable and non-modifiable factors. Modifiable factors include the presence or absence of intra-abdominal collection. Non-modifiable factors include the site of the fistula, the length of the fistula tract, the output of the fistula, and the presence or absence of distal obstruction. The collected data are systematically tabulated and represented.

In Table 3, the results were analyzed using the Chi-square test of independence, with a p-value less than 0.05 considered statistically significant. The achievement of spontaneous closure was taken as the end result, and the corresponding p-values are depicted.

In Table 4, with active interventions targeting modifiable factors, spontaneous closure can be achieved despite the inability to change the most significant non-modifiable factor, which is the site of the fistula. The success percentage results are presented in the table.

RESULTS

Out of 28 patients, 22 patients have attained spontaneous closure, and 6 patients have not attained spontaneous closure (4 patients were re-operated on, and 2 patients died even after intervention).

DISCUSSION

The most common site of EC fistulas is the small bowel.³ Distal fistulas (jejunal and colonic) are more likely to close without operative intervention.⁴

In contrast, proximal fistulas (gastric, lateral duodenal) are more likely to require surgical correction.

Ileal fistulas usually take longer durations to heal and may need surgical intervention.

Other anatomical factors decreasing the likelihood of non-operative closure are complete disruption of GI continuity, adjacent abscess, strictured or diseased bowel, foreign bodies, or distal intestinal obstruction.⁵

CONCLUSION

Management of postoperative enterocutaneous fistulas involves consideration of various factors, and treatment is comprehensive.

With this study, we have categorized the factors affecting spontaneous closure into modifiable and nonmodifiable ones, host factors, and fistula factors per sepsis. We propose a proactive strategy to identify such factors and effectively manage them by providing ICU care, improving anemia and hypoalbuminemia, correcting fluid and electrolyte imbalances, providing nutritional support, managing sepsis, and timely guided interventions.

This results in qualitative improvement in the outcome of EC fistulas and benefits to the patient.