Small bowel enterocutaneous fistulae: the merits of early surgery

The treatment of patients with small bowel enterocutaneous fistulas is complex and a challenge for every surgeon. The mortality and morbidity associated with only conservative management is often high and expensive because most patients cannot afford prolonged parenteral nutrition which itself carries a high incidence of complications. Although operations are difficult if performed early they may be lifesaving in our situation. The focus of our study was to determine whether, in patients with fistulae, early intervention resulted in low mortality and morbidity rates and to identify prognostic factors for fistula closure and mortality.

Between August 1996 and July 2008 we treated 64 consecutive patients with small bowel enterocutaneous fistulae. There were 28 females and 36 males patients who had a mean age of 42.4 years. 49 (77%) of the fistulae resulted from surgical complications. Our policy was to intervene early once the patient was fit for a procedure.

In 4 patients (6.2%) the fistulae arose from the jejunum and in the remaining 94% from the ileum. Octreotide was administered in 49 (77%) patients. To maintain the nutrition of the patients enteral feeding was used in 47 (73%) while re-feeding of the proximal gut fistula output into the distal stoma was used in 7 patients. Spontaneous closure occurred in 10 patients (16%). There were 9 deaths (14%). Fifty-two patients (81%) required surgical intervention at some stage. A strong relationship was found between their preoperative albumin levels and and mortality.

Aggressive early surgical treatment with the judicious use of nutritional support, stoma care, octreotide, and control of sepsis results in a low mortality in patients with small intestinal fistulae. Preoperative hypoalbuminaemia is an important prognostic variable.