Original article An 11-year experience of enterocutaneous fistula P. Hollington, J. Mawdsley, W. Lim, S. M. Gabe, A. Forbes and A. J. Windsor Department of Surgery, St Mark’s Hospital, Harrow, UK Correspondence to: Mr P. Hollington, c/o Colorectal Surgical Unit, Austin Hospital, 145-163 Studley Road, Heidelberg, Victoria 3084, Australia (e-mail: paul.hollington@bigpond.com) Background: Enterocutaneous fistula has traditionally been associated with substantial morbidity and mortality, related to fluid, electrolyte and metabolic disturbance, sepsis and malnutrition. Methods: A retrospective review of enterocutaneous fistula in 277 consecutive patients treated over an 11-year period in a major tertiary referral centre was undertaken to evaluate current management practice and outcome. Results: Most fistulas occurred secondary to abdominal surgery, and a high proportion (52·7 per cent) occurred in association with inflammatory bowel disease. A low rate of spontaneous healing was observed (19·9 per cent). The healing rate after definitive fistula surgery was 82·0 per cent, although more than one attempt was required to achieve surgical closure in some patients. Definitive fistula resection resulted in a mortality rate of 3·0 per cent. In addition, one patient died after laparotomy for intra-abdominal sepsis and an additional 24 patients died from complications of fistulation, giving an overall fistula-related mortality rate of 10·8 per cent. Conclusion: Early recognition and control of sepsis, management of fluid and electrolyte imbalances, meticulous wound care and nutritional support appear to reduce the mortality rate, and allow spontaneous fistula closure in some patients. Definitive surgical management is performed only after restitution of normal physiology, usually after at least 6 months. Presented to a meeting of the European Association of Coloproctology, Sitges, Spain, September 2003 and to the Royal Australasian College of Surgeons Annual Scientific Congress, Melbourne, May 2004; and published in abstract form as Colorectal Dis 2003; 5(Suppl 2): 6 and Aust N Z J Surg 2004; 74(Suppl): A53 Paper accepted 22 June 2004 Published online 25 October 2004 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4788 Introduction Enterocutaneous fistula is a feared complication of abdominal surgery. Such fistulas usually occur soon after surgery, although inflammatory bowel disease, diverticulitis, radiotherapy, trauma, ischaemic bowel and malignancy commonly contribute 1–6 . Favourable outcome relies on early control of sepsis, adequate nutritional support and skin protection 7,8 . Enterocutaneous fistulas have traditionally been associated with a high risk of morbidity and death, related to sepsis, malnutrition, and fluid, electrolyte or metabolic disturbances 1 . Reported mortality rates have, however, improved significantly, falling from 65 per cent to approximately 20 per cent 1,9–16 ; rates of less than 10 per cent are rare 17,18 . This study was a retrospective review of enterocutaneous fistula over an 11-year period in a major tertiary referral centre, undertaken to evaluate current management practice and outcome. Patients and methods The study included 277 patients with enterocutaneous fistula who were referred to or underwent definitive fistula surgery at St Mark’s Hospital from January 1992 to December 2002. Patients who developed fistula at this hospital were also included. Patients with enteroenteric, enterovesical, enterovaginal or peristomal fistulas were excluded. Some 93·1 per cent of the case notes were available for review. Enterocutaneous fistulas were classified with regard to anatomical site, output (high output was defined as a loss of at least 500 ml of enteric content over 24 h) and Copyright  2004 British Journal of Surgery Society Ltd British Journal of Surgery 2004; 91: 1646–1651 Published by John Wiley & Sons Ltd Downloaded from https://academic.oup.com/bjs/article/91/12/1646/6151172 by guest on 05 June 2022