An enterocutaneous fistula (ECF) is an aberrant connection between the intra-abdominal gastrointestinal (GI) tract and skin/wound. Because of differences in management and significant preponderance of small intestinal and colonic fistulae, fistulae originating in the rectum, upper GI tract, or pancreas will not be discussed in this article.There are several ways in which ECF has been classified, including by output, etiology, and source.1-3 Most often, a high-output ECF is characterized as one with >500 mL/24 hours, low output <200 mL/24 hours, and a moderate output fistula between 200 and 500 mL/24 hours. While the great majority of ECFs are iatrogenic (75-85%), between 15 and 25% occur spontaneously. 3 Common causes of iatrogenic ECF are trauma; operations for malignancy, associated with extensive adhesiolysis, or in the setting of inflammatory bowel disease (IBD); and trauma. 1 With respect to postoperative small bowel fistulae, about half are from an anastomotic leak, with the other half occurring from inadvertent injury to the small bowel during dissection.3 Spontaneous fistulae occur from IBD (most common), malignancy, appendicitis, diverticulitis, radiation, tuberculosis/actinomycosis, and ischemia. 3Organ of origin is another classification used for ECF and is useful as well in the consideration of management options: type I (abdominal, esophageal, gastroduodenal), type II (small bowel), type III (large bowel), and type IV (enteroatmospheric, regardless of origin). 2Closure rates without operative intervention in the era of advanced wound care and parenteral nutrition (PN) vary considerably in reports 19 to 92%, 4,5 with most studies demonstrating closure rates in the 20 to 30% range. 5-11With historical wound care measures, 90% of spontaneous closure occurred in the first month after sepsis resolution, with an additional 10% closing in the second month, and none closing spontaneously after 2 months. 10 With vacuum assisted closure (VAC) and other negative pressure wound therapies (NPWT) therapy, there are case reports of fistulae closure well into the second and third month. ►Table 1 cites favorable and unfavorable prognostic factors for spontaneous fistula closure. 3,4,6,8,[12][13][14] Mortality rates in different series for patients with ECF are also markedly variable in distribution (5.5-33%), 4,7,15 with most deaths attributable to sepsis, malnutrition, and fluid/ electrolyte disturbances. 4,6,7,15,16 Factors that are predictive of high mortality are infectious and noninfectious complications, high-output fistula, 1,8,15,17 and age. 18 Cost of fistula care is significant and typically more than $500,000. 19 Approach to Enterocutaneous FistulaA common acronym used to describe ECF care protocol is "SNAP," which stands for management of skin and sepsis, nutrition, definition of fistula anatomy, and proposing a Keywords ► enterocutaneous fistula ► enteroatmospheric fistula ► spontaneous closure ► mortality ► timeline AbstractManagement of enterocutaneous fistula represents one of the most protracted and...

Background: Previous reviews and meta-analyses, which predominantly focused on patients treated before 2000, have reported conflicting evidence about the association between hospital/ surgeon volume and rectal cancer outcomes. Given advances in rectal cancer resection such as total mesorectal excision, it is essential to determine if volume plays a role in rectal cancer outcomes among patients treated since 2000. Objective: Determine if there is an association between hospital/surgeon volume and rectal cancer surgery outcomes among patients treated since 2000.

Obesity is a risk factor for colorectal cancer based on its molecular and metabolic effects on insulin and IGF-1, leptin, adipocytokines, and sex hormones. Obese men have a higher risk of colorectal cancer compared with normal weight men, but the association between obesity and rectal cancer is weaker than with colon cancer. There is a weaker association between obesity and colon cancer in women than in men, and no appreciable association between obesity and rectal cancer in women. Although obesity does not seem to have an effect on the number of lymph nodes harvested with resection, obesity does seem to be associated with more-aggressive colorectal cancers in a handful of studies. Survival and local recurrence studies are contradictory with no conclusive evidence that obesity predisposes to worse overall survival or increased recurrence in colon and rectal cancers. The literature is not definitive as far as overall morbidity and mortality rates in the obese are concerned, though obese rectal cancer patients seem to incur proportionally more morbidity and mortality. Preexisting steatosis or steatohepatitis in obese colorectal cancer patients or chemotherapy-induced liver dysfunction may lead to an increased mortality in obese patients with colorectal liver metastases. Diabetes may cause poorer response to neoadjuvant therapy in rectal cancer and contribute to higher mortality and recurrence in colon cancer.

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