Primary conservative management of external small-bowel fistulas. Changing composition of fistula series?

A primary conservative approach was used in treatment of 42 patients with 45 external small-bowel fistulas. Closure of fistula was achieved in 29 patients but failed in 13 (10 died and 3 discharged with open fistula). There was no time-related improvement in closure rate or mortality, probably because of a general shift towards more serious cases. To evaluate this concept more specifically, groups of simple (19) or complicated (23) fistula were distinguished. The 23 patients with complicated fistula were more severely ill, had more sepsis, e.g. intra-abdominal abscess, and were more often treated in the intensive care unit (p less than 0.01) than the 19 with simple fistula. The respective mortality rates were 7/23 and 3/19. All six patients who died of sepsis had complicated fistula. Mortality in the simple fistula group was related to the primary disease. Especially in cases of complicated fistula, further improvements in management of septic complications should be aimed for, to permit success in delayed definitive surgery.