How To Repair A Gi Fistula
Med Sci Monit. 2022; 25: 5445–5452.
Surgical Repair of Small Bowel Fistulas: Risk Factors of Complications or Fistula Recurrence
Andrzej Kluciński, 
1, A, B, C, D, Due east, F Marek Wroński,1, A, B, C, D, East Włodzimierz Cebulski,one, A, C, D Tomasz Guzel,1, B, Eastward Bartosz Witkowski,ii, C, East Marcin Makiewicz,i, B, E Andrzej Krajewski,ane, B, E and Maciej Słodkowski1, A, B, C, D, E
Andrzej Kluciński
1Department of General, Gastroenterological, and Oncological Surgery, Medical Academy of Warsaw, Warsaw, Poland
Marek Wroński
oneDepartment of General, Gastroenterological, and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
WÅ‚odzimierz Cebulski
1Department of General, Gastroenterological, and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
Tomasz Guzel
aneDepartment of General, Gastroenterological, and Oncological Surgery, Medical Academy of Warsaw, Warsaw, Poland
Bartosz Witkowski
iiHigher of Economical Assay, Partition of Probabilistic Methods, Warsaw School of Economics, Warsaw, Poland
Marcin Makiewicz
1Department of General, Gastroenterological, and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
Andrzej Krajewski
1Section of Full general, Gastroenterological, and Oncological Surgery, Medical Academy of Warsaw, Warsaw, Poland
Maciej SÅ‚odkowski
1Section of Full general, Gastroenterological, and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
Received 2022 November 25; Accepted 2022 Feb xi.
Abstract
Background
Definitive surgical repair of persistent fistulas of the small intestine remains a surgical challenge with a high rate of re-fistulation and mortality. The aim of this study was to evaluate the type and incidence of complications later on definitive surgical repair, and to identify factors predictive of severe postoperative complications or fistula recurrence.
Material/Methods
This was a retrospective study of 42 patients who underwent elective surgical repair of a persistent fistula of the pocket-size intestine. The analysis included preoperative and intraoperative parameters.
Results
The healing rate after definitive surgery was 71.four%. Postoperative complications developed in 88.1% of patients. The bloodshed charge per unit was 7.ii%. Fistula recurrence was recognized in 21.iv% of cases. Overall, 93 complications occurred in 37 patients. The most common complications were septic (48.0%). Hemorrhagic and digestive tract-related complications accounted for xix.0% and 15.0% of all complications, respectively. Severe complications (Clavien-Dindo class 3–V) fabricated up 28.0% of all complications. In univariate analysis, multiple fistulas (p=0.03), higher C-reactive protein level (p=0.01), and longer time interval from admission to definitive surgery (p=0.01) were associated with an increased risk of severe complications or fistula recurrence. In multivariate assay, but multiple fistulas were an independent risk factor for astringent complications or fistula recurrence (OR=viii.2, p=0.04).
Conclusions
Fistula complexity determines the risk of severe postoperative complications or fistula recurrence subsequently definitive surgical repair of the persistent small intestine fistulas. Inflammatory parameters should exist normalized earlier definitive surgery.
MeSH Keywords: Digestive System Surgical Procedures, Intestinal Fistula, Postoperative Complications, Risk Factors
Background
Gastrointestinal (GI) fistulas are i of the almost astringent complications after abdominal surgery. Betwixt 34.iv% and 65.0% of these fistulas originate from the modest intestine [i–eight]. Patients with abdominal fistulas require a specialized and multidisciplinary approach that frequently results in prolonged hospitalization and loftier costs. The initial management for abdominal fistulas is bourgeois and includes treatment of sepsis, nutritional support, control of fistula output, and peel care. Medical handling is successful in 15.half-dozen–69.9% of patients [5,nine–12]. Patients with persistent abdominal fistulas require surgical reconstruction. Definitive surgical repair of the small-scale intestine fistulas remains a real challenge, even for experienced surgeons. Re-fistulation later on definitive surgery reaches 31.0% [2–7,9,12–19]. The rate of postoperative mortality is relatively high and varies between iii.5% and fourteen% [12,xiv,xx]. However, there is a paucity of data on postoperative outcomes other than fistula recurrence or mortality following operative reconstruction of intestinal fistulas. In add-on, nigh studies study mixed example series comprising fistulas affecting different parts of the gastrointestinal tract [1–8].
The aim of this study was to evaluate the type and incidence of complications after surgical reconstruction of the pocket-sized intestine fistulas. We also attempted to place factors useful for prediction of severe postoperative complications or fistula recurrence.
Material and Methods
Patients
Between January 2004 and December 2022, 84 sequent patients with a small bowel fistula were treated at our institution. This report included patients with persistent fistulas of the small intestine who underwent a planned definitive surgical repair. The exclusion criteria were the post-obit: fistula not affecting the small intestine, need of emergent laparotomy, and historic period under eighteen years. All patients were initially managed conservatively. Medical treatment consisted of sepsis and fistula output control, nutritional back up, and wound management. Conservative therapy proved successful in 36 patients (43.3%). 3 patients died before definitive surgery could be performed. Another 3 patients underwent emergent surgery; ii of them died and 1 had fistula recurrence which healed on conservative handling. Patient selection for the written report is shown in Figure 1. Overall, 42 patients who underwent definitive surgical repair for persistent fistulas of the modest intestine were included in this report. The accomplice of patients was divided into Group I (25 patients who had but balmy or no complications), and Group II (17 patients who experienced postoperatively severe complications or fistula recurrence). The study was canonical by the Institutional Ideals Review Board on 12 November 2022.
The flowchart shows pick of patients with small bowel fistulas for the report.
Nomenclature of postoperative complications
This written report included the complications that occurred within the commencement 30 postoperative days. The severity of complications was classified co-ordinate to the Clavien-Dindo scale [21]. Clavien-Dindo course I and 2 complications were defined every bit mild, and Clavien-Dindo grades III through V were classified every bit severe complications. Fistula recurrence was regarded as failure to cure, and as such was not reported as a complication. The spectrum and incidence of postoperative complications according to the Clavien-Dindo scale are summarized in Tabular array 1. POSSUM and CR-POSSUM scores were calculated for each patient. In terms of POSSUM operative variables, all the operations were classified as major and elective. In addition, 1 point was assigned for elementary suture repair of the fistula, 4 points for partial resection of the minor intestine, and 8 points whenever a combined resection of the small and large intestines was performed.
Table ane
The blazon and incidence of postoperative complications co-ordinate to the Clavien-Dindo scale.
| Complication | Number |
|---|---|
| Grade I (34) | |
| SSI – bedside drainage | 27 |
| Wound hematoma – bedside evacuation | 4 |
| Eventration (dehiscence of all planes of the abdominal wall) | 1 |
| Urinary retention | one |
| Diarrhea | 1 |
| Grade 2 (33) | |
| Intestinal failure – TPN | 10 |
| Anemia – packed red cells transfusion | viii |
| SSI treated with antibiotics | 3 |
| Arrhythmias treated pharmacologically | 2 |
| Diabetes | 1 |
| Hematuria | ane |
| Hypothyroidism | i |
| Terminate-jejunostomy syndrome | 1 |
| Intraabdominal collection treated with antibiotics | one |
| Depression | i |
| Pneumonia treated with antibiotics | one |
| Ileus – resolved spontaneously | 1 |
| Deterioration of mental status | 1 |
| Gastrointestinal bleeding | 1 |
| Grade Iii (fifteen) | |
| Central venous catheter related infection (IIIa) | viii |
| Subileus – Miller-Abbott tube insertion (IIIa) | 1 |
| Intraabdominal hemorrhage – reoperation (IIIb) | 3 |
| Intraabdominal abscess or peritonitis – reoperation (IIIb) | 2 |
| Billiary fistula (IIIb) | one |
| Grade Iv (8) | |
| Respiratory failure (IVa) | ii |
| Cardiac failure (IVa) | 1 |
| Septic shock – single organ disfunction (IVa) | ane |
| Septic shock – multiple organ disfunction (IVb) | two |
| Multiple organ disfunction (IVb) | two |
| Grade V (3) | |
| Death | 3 |
Statistical analysis
The statistical analysis included preoperative and intraoperative parameters. Univariate analysis was performed using the Mann-Whitney U examination. The factors which were at p<0.one level in the univariate analysis were farther included in the multivariate analysis. Multivariate analysis was performed using backward stepwise logistic regression. Hypothesis testing was performed using 2-tailed α ≤0.05.
Results
The median historic period of patients was 56 years (IQR: 46–67). Males constituted 57% of all patients. The fistulas developed later a primary surgical intervention for ileus (23.eight%), complications of astute pancreatitis (23.8%), hernia (9.vi%), gastrointestinal perforation (9.vi%), and Crohn'due south disease (4.8%). In two patients (four.eight%) fistulas were internal and occurred spontaneously secondary to Crohn'southward disease. Forty patients had enterocutaneous fistulas, of which vii (18.9%) were high-output and 30 (81.1%) were low-output. Data on the amount of discharge were not available for 3 patients. Definitive surgery was performed later a median period of 38 days (IQR: 14–61) since access to our institution. The median operative time was 187.5 min (IQR: 160–235). The surgical procedures used for repair of the fistulas included partial resection of the small intestine in 15 (35.7%) patients, fractional resection of both the modest and large intestine in xv (35.7%) patients, and simple suture repair in 7 (xvi.six%) patients. In the remaining 5 (12%) cases, fractional resection of the small-scale and/or large intestine was combined with an boosted simple suture repair. Viii of 42 patients needed colostomy (n=three) or ileostomy (n=5). Colostomies were created after inadvertent full-thickness injury of the large bowel during dissection, whenever primary repair was regarded as loftier-risk for leakage. Abdominal wall defects in ix (21.4%) patients required mesh placement; a composite and polypropylene mesh were used in ane and 8 patients, respectively. Abdominal fistulas healed in 30 (71.iv%) patients afterward definitive surgery. Fistula recurrence was observed in nine (21.iv%) patients. The fistulas recurred after a median menstruation of 9 days (IQR: 7–23.5). Subsequent bourgeois treatment was successful in 5 of these patients. In 1 case, the fistula healed after another reoperation. Ii patients were discharged with residual low-output fistulas. One patient left the hospital with a high-out fistula confronting medical advice and was lost to follow-up. Three patients died (7.ane%). The postoperative course was uneventful in but 5 (xi.9%) patients. Postoperative complications occurred in 37 (88.1%) patients. Overall, 37 patients experienced 93 complications. A median of two complications per patient (IQR: 1–iii) was recorded. Well-nigh complications (72%) were mild and corresponded to Clavien-Dindo course I or II. Of these, 34 complications were grade I and 33 were course Two. Severe complications accounted for 28.0% of all complications, including xv cases of form III and viii cases of form IV. Postoperative death (i.e., Clavien-Dindo grade V complication) occurred in 3 cases. All the patients with fistula recurrence had at least 1 astringent complication postoperatively.
Septic complications were the nigh common and accounted for 48.0% of all complications. Surgical site infection was recognized in 32 (76.2%) patients after a median of 5 postoperative days (IQR: 5–eight). Thirty of these patients had superficial or deep surgical wound infections that were managed by wound irrigation and drainage; antibiotics were added in 3 of these patients. In 2 (4.8%) patients who had organ space surgical site infections, a relaparotomy was required; 1 patient manifested diffuse peritonitis on the third postoperative day and underwent peritoneal lavage for multiple intraperitoneal abscesses, and the other patient had surgical drainage of an intraabdominal abscess on the 28th postoperative twenty-four hour period. Central venous catheter-related infections requiring its removal occurred in 8 cases afterward a median fourth dimension of 21 days after operation (IQR: 7–27). Three patients developed septic shock postoperatively; 2 of these patients recovered on medical handling, and the 3rd patient underwent a relaparotomy due to diffuse peritonitis and at that place was an intestinal anastomotic leak intraoperatively. Hemorrhagic complications constituted 19.0% of all complications. Acute intraabdominal bleeding requiring emergent reoperation occurred in 3 patients; all these patients died afterwards reoperation. Eight patients required transfusion of packed red blood cells due to postoperative anemia. In iv patients, healing of the surgical incision was complicated past hematomas that needed bedside drainage. 1 patient experienced a transient hematuria that resolved spontaneously.
Digestive tract-related complications constituted 15.0% of all complications. Ten patients required prolonged parenteral diet postoperatively, 2 of these patients had short bowel syndrome and i patient manifested an end-jejunostomy syndrome divers every bit metabolic disturbances associated with a loftier-output end stoma. One patient suffered protracted diarrhea, and two patients experienced ileus that resolved on medical treatment and after Miller-Abbot tube insertion.
Eight of 42 patients (xix.0%) developed organ failure after surgical repair of the small intestine fistula. In 2 patients, prolonged mechanical ventilation was required due to respiratory failure. One patient had cardiac failure on the outset postoperative day and required pharmacological support. In add-on, 3 patients adult organ failure secondary to sepsis and ii had an intraabdominal hemorrhage.
Univariate analysis, including the preoperative factors, is shown in Tabular array 2. More than than 1 fistula (p=0.029) and an elevated level of C-reactive protein (p=0.014) were significantly associated with risk of severe complications or fistula recurrence. Moreover, this adventure was college with a longer duration of hospitalization before definitive surgery (p=0.011). Other preoperative and intraoperative parameters in the univariate analysis did not influence the adventure of astringent complications or fistula recurrence (Tables 2, iii).
Tabular array 2
Risk factors of severe complications or fistula recurrence – univariate analysis: preoperative parameters.
| Parameter | Patients with mild or no complications (due north=25) Group I | Patients with severe complications or fistula recurrence (due north=17) Group II | p-Value |
|---|---|---|---|
| Fistula parameters | |||
| Fistula output on the day before surgery, ml/twenty-four hour period; median (IQR) | 100 (300–50) | 150 (600–100) | 0.231 |
| Fistula output on the solar day earlier surgery, >500 ml/day; n (%) | 2 (8) | 5 (29) | 0.068 |
| Number of fistulas; median (IQR) | one (one–2) | ii (4–i) | 0.029 |
| Number of fistulas >1, n(%) | 8 (32) | 11 (65) | 0.038 |
| Clinical parameters | |||
| Age, years; median (IQR) | 61.0 (67.0–47.0) | 55.0 (59.0–45.0) | 0.204 |
| Time since terminal operation, days, median (IQR) | 150.0 (332.0–73.0) | 85.5 (123.0–52.5) | 0.091 |
| Time since admission to definitive surgery, days median (IQR) | 23.0 (42.0–8.0) | threescore.0 (89.0–34.0) | 0.011 |
| Systolic blood pressure, mmHg, median (IQR) | 120 (130–110) | 125 (130–110) | 0.725 |
| Mean claret pressure <70 mmHg, n (%) | 1 (4) | 1 (6) | 0.781 |
| Laboratory parameters | |||
| WBC >eleven×ten9/50, n (%) | 2 (8.0) | 4 (23.5) | 0.058 |
| RBC <3.8×1012/l, northward (%) | 13 (52.0) | ten (58.eight) | 0.666 |
| HGB <10 grand/dl, northward (%) | 8 (32.0) | vii (41.i) | 0.547 |
| HCT <thirty%, n (%) | 11 (44.0) | 7 (41.i) | 0.857 |
| PLT ×109/l, median (IQR) | 208 (351.0–208.0) | 348 (441.0–195.0) | 0.343 |
| Fibrinogen mg/dl, median (IQR) | 503 (564.0–395.5) | 558 (672.0–369.0) | 0.386 |
| Sodium <135 mmol/fifty, n (%) | half dozen (24.0) | 7 (41.1) | 0.242 |
| Urea >48 mg/dl, n (%) | five (xx.0) | 3 (17.6) | 0.850 |
| Creatinine >ane.1 mg/dl, north (%) | 5 (twenty.0) | i (5.eight) | 0.204 |
| Proteins <6.ii 1000/dl, n (%) | 7 (28.0) | 5 (29.4) | 0.852 |
| Albumins <3.0 yard/dl, n (%) | 7 (28.0) | 9 (52.nine) | 0.117 |
| Albumins g/dl, median (IQR) | 3.one (3.4–2.7) | two.eight (3.5–ii.5) | 0.411 |
| Bilirubin >1.2 mg/dl, n (%) | 1 (four.0) | 1 (v.8) | 0.768 |
| AST > forty U/l, n (%) | 6 (24.0) | five (29.iv) | 0.696 |
| ALT >56 U/l, due north (%) | five (20.0) | two (11.7) | 0.479 |
| CRP mg/50, median (IQR) | 7.6 (36.ii–three.three) | 46.55 (89–xi.4) | 0.014 |
| Scales | |||
| ASA III–IV, north (%) | 8 (32.0) | 9 (52.ix) | 0.180 |
| APACHE II, median (IQR) | 8 (10–5) | 6 (seven–4) | 0.053 |
Table 3
Risk factors of severe complications or fistula recurrence – univariate analysis: intraoperative parameters.
| Parameter | Patients with balmy or no complications (north=25) Group I | Patients with severe complications or fistula recurrence (north=17) Grouping Ii | p-Value |
|---|---|---|---|
| Operative time, min; median (IQR) | 180 (225–155) | 210 (240–180) | 0.066 |
| Operative time >iv hours, n (%) | 2 (8) | 4 (23) | 0.163 |
| Length of the resected intestine, cm; median (IQR) | 30 (45–15) | 50 (85–3) | 0.232 |
| Duration of the systolic blood pressure level within 80–100 mmHg, min; median (IQR) | 50 (70–20) | seventy (100–20) | 0.368 |
| Duration of the systolic claret pressure <80 mmHg, min; median (IQR) | 0 (xv–0) | 10 (l–0) | 0.178 |
| Intestinal resection, northward (%) | 22 (88.0) | fourteen (82.3) | 0.612 |
| Stoma, due north (%) | 4 (16.0) | 4 (23.5) | 0.546 |
| Scales | |||
| POSSUM, median (IQR) | 36 (42–33) | 40 (43–32) | 0.797 |
| Physiological points, median (IQR) | 20 (24–17) | 22 (25–xvi) | 0.887 |
| Operative points, median (IQR) | 16 (18–14) | 18 (18–xiv) | 0.527 |
| CR-POSSUM, median (IQR) | 16 (17–15) | 15 (17–xiv) | 0.103 |
| Physiological points, median (IQR) | nine (ten–8) | eight (8–seven) | 0.056 |
| Operative points, median (IQR) | 7 (viii–7) | 7 (7–7) | 0.497 |
Multivariate analysis, including the preoperative parameters, showed that the presence of more than 1 fistula was an independent take chances factor of severe complexity or fistula recurrence. The odds of severe complications or fistula recurrence were approximately viii times higher in patients with more than than 1 fistula (p=0.044) (Table 4). The intraoperative parameters, including the POSSUM scores, were not associated with a higher hazard of astringent complications or fistula recurrence.
Table 4
Chance factors of severe complications or fistula recurrence – multivariate analysis.
| Variable | Odds ratio | 95% confidence interval | p-value |
|---|---|---|---|
| Preoperative parameters | |||
| Number of fistulas >one | 8.xx | 1.05–63.83 | 0.044 |
| Fistula output on the solar day before surgery >500 ml/twenty-four hour period | 2.84 | 0.25–31.77 | 0.395 |
| WBC > 11×10nine/l | 7.34 | 0.18–286.29 | 0.286 |
| Fourth dimension since admission to definitive surgery | 1.01 | 0.97–1.04 | 0.488 |
| APACHE II score | 0.79 | 0.57–1.09 | 0.161 |
| Time since last performance | 0.99 | 0.99–one.00 | 0.434 |
| Intraoperative parameters | |||
| Duration of the systolic blood pressure <eighty mmHg | one.03 | 0.99–1.08 | 0.084 |
| Operative fourth dimension | 1.00 | 0.98–1.02 | 0.827 |
| Sum of physiological points on CR-POSSUM scale | one.16 | 0.48–2.81 | 0.728 |
Give-and-take
This is one of the start studies reporting type, frequency, and severity of complications after definitive surgical repair of small bowel fistulas. In dissimilarity to other studies, which reported a example-mix of fistula locations with 67–88% of cases originating from the small intestine [5–seven,thirteen], our series included just fistulas involving the small intestine. The rate of fistula recurrence after definitive performance was comparable to that reported in other studies [3,six,7,9,12–14,nineteen,20]. Similarly, postoperative mortality of approximately 7.0% vicious within the range reported by other groups [14,20]. A contempo meta-analysis by Vries et al. [22] constitute that the weighted pooled recurrence charge per unit after reconstructive surgery for enteric fistula was nineteen% (95% CI xv–24) with a mortality rate of 3% (95% CI 2–5). In our study, the majority of patients suffered at least i complication, whereas only 12% of patients had an uneventful postoperative course. In comparing, Owen et al. [vii] observed complications in 87.vi% of patients. Similarly, the morbidity charge per unit reported past Ravindran et al. [xviii] was 86%. Such a high rate of postoperative complications after repair of the small intestine fistulas reflects both the difficult operative field and the complexity of surgical procedures in already debilitated and fragile patients.
In our study, severe complications occurred in 40.5% of patients. The almost mutual were septic complications, which accounted for about half of all adverse postoperative events. Similarly, Owen et al. [7] reported septic episodes in 35.iii% of patients managed surgically for gastrointestinal fistulas. In our serial, infection usually involved the surgical wound (76.2%), whereas 4.viii% of patients had an organ abscess or adult septic daze (7.1%). In contrast, Owen et al. [7] reported wound and organ infection afterward definitive surgical fistula repair in 16.4% and xiv.4% of patients, respectively. The second most frequent septic complication in our report group was infection of the central venous catheter, which occurred in 19% of patients. Similarly, Owen et al. [7] found this complexity in 26.1% of patients undergoing definitive surgery for enterocutaneous fistulas. Moreover, Visschers et al. [9] reported infection of the fundamental venous catheter in 18.v% of patients with gastrointestinal fistulas; withal, their series included patients treated both conservatively and surgically. The 2nd most frequent postoperative complications in our study were hemorrhagic. Although a majority of patients required just transfusion of packed red blood cells, 3 patients underwent emergent relaparotomy for acute haemorrhage, and none of them survived. In comparison, Owen et al. [seven] reported that 71.two% of patients after definitive surgery of gastrointestinal fistula in their study received blood products. The frequent demand for blood transfusions in patients with enterocutaneous fistulas during the postoperative period might be attributed to extensive surgical dissection in already chronically ill people and anemic patients. In our report, approximately 1-3rd of patients had a preoperative hemoglobin level beneath 10 k/dl. In such patients, even moderately complex operations will require blood transfusion, and acute bleeding might be life-threatening. Although digestive tract-related complications were less common and usually mild, some of them event in long-term sequelae. 2 of our patients (four.8%) developed curt bowel syndrome due to extensive intestinal resection. Both patients continue parenteral nutrition at habitation at 9 and 10 years following the definitive operation, respectively. Surprisingly, to the best of our knowledge, the charge per unit of short bowel syndrome afterwards definitive surgery for modest bowel fistulas has non been reported in the literature.
One of the goals of this study was to decide which factors are predictive of severe complications or fistula recurrence after definitive surgery for minor intestine fistula. Our statistical models included but pre- and intraoperative factors. We hypothesized that knowledge of these factors would allow adequate patient preparation for surgery, and would guide the surgeon's determination making at the time of functioning. In contrast to other authors, we decided non to include any postoperative factors in the assay, because these should, in our opinion, exist considered as complications. In this study, only the presence of multiple fistulas was independently associated with severe complications or fistula recurrence. Similarly, Mawdsley et al. [8] establish out that fistula healing after definitive surgery was related simply to the complexity of the fistula. In their study, the complex fistulas, which were divers as having several channels, affecting multiple intestinal loops, or passing through an abscess cavity, had a decreased likelihood of closure (OR=0.24; 95%CI 0.16–0.81; p=0.03). In comparing, Rahbour et al. [17] observed an increased risk of fistula recurrence in patients with comorbidities (OR=0.ten; 95% CI: 0.02–0.49; p=0.02) and in patients who adult the fistula outside a specialist heart (OR=0.14; 95% CI 0.03–0.67; p=0.01).
In the univariate assay, severe complications or fistula recurrence were significantly associated with multiple fistulas (p=0.003), elevated CRP (p=0.01), and longer hospitalization preceding surgical handling (p=0.01). Martinez et al. [23] found that a preoperative CRP level greater than 0.5 mg/dl was an contained risk cistron of fistula recurrence after definitive surgery. Increased CRP level might indicate smoldering intraperitoneal infection, which warrants preoperative treatment; otherwise, information technology may exist a source of infection postoperatively. In our study, 28.half-dozen% of patients had clinically silent interloop abscesses found intraoperatively. Similarly, Visschers et al. [9] showed that patients with sepsis developed recurrence of the fistula afterward definitive surgery more than often than those who were not septic (16.0% vs. 1.ix%; p=0.017).
The optimal timing of definitive surgery for enterocutaneous fistulas remains unclear. Brenner et al. [13] showed that operations performed before the vithursday week or between the 13th and 36th weeks afterwards fistula formation were associated with the everyman recurrence rates (8% and ten%, respectively), whereas no fistula recurrence was observed if surgical intervention took identify within the first 2 weeks. Furthermore, fistula recurrence rates increased up to 36% and 27% if operations were performed later 36 weeks or betwixt the 7thursday and 12th weeks, respectively. In multivariate analysis, delay in surgical intervention of more than than 36 weeks significantly increased the take a chance of fistula recurrence (OR=5.4; 95% CI: one.8–sixteen.4; p=0.003). Interestingly, patients with severe complications or fistula recurrence in our study were hospitalized longer prior to definitive surgery. Worse outcomes in this subgroup probably reverberate the fact that more than complex fistulas required longer periods of preoperative training.
In this report, the selected prognostic scales did non show whatever value for prediction of astringent postoperative complications or fistula recurrence. Owen et al. [7] showed that ASA grade did non influence the chance of fistula recurrence, simply patients with ASA form 4 had an increased 1-year take chances of death (OR=3.02; 95% CI one.47–half-dozen.24; p=0.003). Similarly, Lynch et al. [xiv] found that ASA form did not predict fistula recurrence.
This report has some limitations. First, it was retrospective and the patient population was limited. Second, fistula recurrence was regarded as failure to cure and every bit such we did not assign it any Clavien-Dindo grade. Failure to cure corresponds to the situation when the primary purpose of the operation is not accomplished. Accordingly, recurrence of a fistula later on definitive surgery should not be classified every bit a complication. Arguably, a postoperative fistula after other surgical procedures would be considered a complication.
Conclusions
Definitive surgery in patients with small bowel fistulas results in a loftier rate of postoperative morbidity. Presence of multiple fistulas determines the risk of severe postoperative complications or fistula recurrence after definitive surgical repair of persistent small intestine fistulas. Inflammatory parameters should preferably be normalized before definitive operation. ASA, APACHE Two, POSSUM, and CR-POSSUM scales did not show any utility in prediction of severe postoperative complications.
Footnotes
Source of support: Departmental sources
Disharmonize of involvement
None.
References
1. Draus JM, Jr, Huss SA, Harty NJ, et al. Enterocutaneous fistula: Are treatments improving? Surgery. 2006;140(4):570–76. [PubMed] [Google Scholar]
2. Gyorki DE, Brooks CE, Gett R, et al. Enterocutaneous fistula: A single-centre feel. ANZ J Surg. 2010;80(3):178–81. [PubMed] [Google Scholar]
3. Hollington P, Mawdsley J, Lim W, et al. An eleven-year feel of enterocutaneous fistula. Br J Surg. 2004;91(12):1646–51. [PubMed] [Google Scholar]
4. Li J, Ren J, Zhu W, et al. Management of enterocutaneous fistulas: thirty-year clinical experience. Chin Med J (Engl) 2003;116(2):171–75. [PubMed] [Google Scholar]
v. Martinez JL, Luque-de-Leon E, Mier J, et al. Systematic management of postoperative enterocutaneous fistulas. Factors related to outcomes. World J Surg. 2008;32(3):436–43. [PubMed] [Google Scholar]
6. Taggarshe Deepa BD, Jacobs M, McKendrick A, Mittal 5. Management of enterocutaneous fistuale: A 10 years experience. World J Surg. 2010;2(7):242–46. [PMC free article] [PubMed] [Google Scholar]
7. Owen RM, Dear TP, Perez SD, et al. Definitive surgical handling of enterocutaneous fistula: Outcomes of a 23-year experience. JAMA Surg. 2013;148(ii):118–26. [PubMed] [Google Scholar]
eight. Mawdsley JE, Hollington P, Bassett P, et al. An analysis of predictive factors for healing and bloodshed in patients with enterocutaneous fistulas. Aliment Pharmacol Ther. 2008;28(ix):1111–21. [PubMed] [Google Scholar]
9. Visschers RG, Olde Damink SW, Winkens B, et al. Handling strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg. 2008;32(3):445–53. [PMC complimentary article] [PubMed] [Google Scholar]
10. Haffejee AA. Surgical management of high output enterocutaneous fistulae: A 24-year experience. Curr Opin Clin Nutr Metab Intendance. 2004;7(3):309–sixteen. [PubMed] [Google Scholar]
11. Campos Air conditioning, Andrade DF, Campos GM, et al. A multivariate model to determine prognostic factors in gastrointestinal fistulas. J Am Coll Surg. 1999;188(5):483–90. [PubMed] [Google Scholar]
12. Gupta M, Sonar P, Kakodkar R, et al. Small bowel enterocutaneous fistulae: The merits of early surgery. Indian J Surg. 2008;70(six):303–7. [PMC free article] [PubMed] [Google Scholar]
13. Brenner M, Clayton JL, Tillou A, et al. Risk factors for recurrence later repair of enterocutaneous fistula. Arch Surg. 2009;144(half-dozen):500–five. [PubMed] [Google Scholar]
14. Lynch AC, Delaney CP, Senagore AJ, et al. Clinical result and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg. 2004;240(5):825–31. [PMC free commodity] [PubMed] [Google Scholar]
fifteen. Martinez JL, Luque-de-Leon East, Ballinas-Oseguera G, et al. Factors predictive of recurrence and bloodshed after surgical repair of enterocutaneous fistula. J Gastrointest Surg. 2012;sixteen(1):156–63. [PubMed] [Google Scholar]
16. Mawdsley JE, Gibson P, Forbes A, Gabe SM. Technical report: Per-oral epitome-guided insertion of a jejunostomy feeding tube. Clin Radiol. 2004;59(10):951–53. [PubMed] [Google Scholar]
17. Rahbour G, Gabe SM, Ullah MR, et al. Seven-year experience of enterocutaneous fistula with univariate and multivariate analysis of factors associated with healing: Development of a validated scoring system. Colorectal Dis. 2013;15(nine):1162–70. [PubMed] [Google Scholar]
xviii. Ravindran P, Ansari Due north, Young CJ, Solomon MJ. Definitive surgical closure of enterocutaneous fistula: Outcome and factors predictive of increased postoperative morbidity. Colorectal Dis. 2014;16(three):209–18. [PubMed] [Google Scholar]
19. Runstrom B, Hallbook O, Nystrom PO, et al. Event of 132 consecutive reconstructive operations for intestinal fistula-staged functioning without chief anastomosis improved outcome in retrospective analysis. Scand J Surg. 2013;102(3):152–57. [PubMed] [Google Scholar]
20. Rinsema W, Gouma DJ, von Meyenfeldt MF, et al. Primary conservative management of external pocket-size-bowel fistulas. Irresolute composition of fistula serial? Acta Chir Scand. 1990;156(6–7):457–62. [PubMed] [Google Scholar]
21. Dindo D, Demartines North, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13. [PMC free article] [PubMed] [Google Scholar]
22. de Vries FEE, Atema JJ, van Ruler O, et al. A systematic review and meta-analysis of timing and outcome of intestinal failure surgery in patients with enteric fistula. Earth J Surg. 2018;42(3):695–706. [PMC free commodity] [PubMed] [Google Scholar]
23. Martinez JL, Luque-de-Leon E, Ferat-Osorio Due east, Estrada-Castellanos A. Predictive value of preoperative serum C-reactive protein for recurrence afterwards definitive surgical repair of enterocutaneous fistula. Am J Surg. 2017;213(i):105–11. [PubMed] [Google Scholar]
Articles from Medical Scientific discipline Monitor : International Medical Journal of Experimental and Clinical Research are provided here courtesy of International Scientific Information, Inc.
How To Repair A Gi Fistula,
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668489/
Posted by: montgomeryletyle.blogspot.com
0 Response to "How To Repair A Gi Fistula"
Post a Comment