Postoperative external small bowel fistulas: A study of a consecutive series of patients treated with intravenous hyperalimentation

Abstract

A consecutive series of 25 patients who developed external small bowel fistula within 2 weeks of abdominal surgery is described. Half the patients had a primary diagnosis of inflammatory bowel disease and the fistula arose usually as a result of direct trauma to the bowel or the breakdown of an anastomosis. All the patients were treated conservatively with total bowel rest and intravenous hyperalimentation. In 15 (60 per cent) spontaneous fistula closure occurred, in an average period of 32 days. In 8 patients the fistula failed to close and surgery was performed, but was effective in only 3 cases. Thus the fistula eventually closed in 18 patients. Five patients died, all from intra-abdominal sepsis. Of the 8 patients with a primary diagnosis of Crohn's disease, 3 died, 2 have a persistent fistula, 1 has a permanent ileostomy and spontaneous closure occurred in only 2.

Surgical Treatment of Crohn’s Disease

“…Enterocutaneous fistulae usually drain through a previous abdominal scar or through the umbilicus. 13 At times, they result from surgical incision and drainage of a subcutaneous abscess complicating severe intra-abdominal disease or from percutaneous drainage of an abdominal abscess. Patients may be reluctant to undergo surgical treatment when the enterocutaneous fistula has a minimal output and the underlying disease is under satisfactory control.…”

Nutrition and management of enterocutaneous fistula

“…Death related to enterocutaneous fistula remains disproportionately high compared with that associated with other surgical conditions. Studies reported over the past 30 years have shown mortality rates of 5–41 per cent1–25, with rates of 6–33 per cent in the most recent case series4, 13, 15, 17. Sepsis was the leading cause of death in all of these studies.…”

Treatment of External Gastrointestinal Fistulas by a Combination of Total Parenteral Nutrition and Somatostatin

“…In fact, the reported incidence of spontaneous fistula closure varies widely from 16% to 80%,3,6,13,37-39 and comparison between different series is difficult. The time taken for fistulas to close was very short in this series (1-14 days, mean 5.4), compared to that reported in the others, ranging from 20 to 35 days (mean duration).s, 6,37 In this retrospective study on a short and very heterogeneous series, no close correlation could be established between percent reduction in fistula output and spontaneous closure rate. Actually, the ideal cases for ST treatment, as well as responders, did not show a higher incidence of spontaneous closure than the other cases.…”