Enterocutaneous Fistula: a Tanzanian Experience in a Tertiary Care Hospital

Background: Enterocutaneous fistulae pose a therapeutic challenge to general surgeons all over the world and contribute significantly to high morbidity and mortality. The aim of this study was to describe our experience in the management of enterocutaneous fistulas; outlining the causes; fistula characteristics; treatment outcome and prognostic factors for fistula closure and mortality in our local setting. Methods: A prospective study of patients with enterocutaneous fistulae was conducted at Bugando Medical Centre between December 2007 and November 2009. After informed written consent for the study and HIV testing; all patients who met the inclusion criteria were consecutively enrolled into the study. Data were collected using a pre-tested; coded questionnaire and analyzed using SPSS software version 11.5. Results: Ninety two patients were seen during the study. There were 54 males (58.7) and 38 (41.3) females (M: F ratio = 1.4:1). Post-operative complication was the commonest cause of enterocutaneous fistulae in 91.3of cases. The majority of patients (63.0) had high output fistulae and the jejuno-ileum was commonly affected (60.9). The complication rate was 34.8and sepsis was the most common complication. Sixteen patients (17.4) had HIV infection. Fistula closure was successfully achieved in 64 patients (69.6). Of these; 42 patients (65.6) had spontaneous closure and 22 patients (34.4) underwent surgical closure. Mortality rate was 30.4. Using multivariate logistic regression; the cause of fistula; fistula output; presence of complications and institutional origin of the patient were found to be significant predictors of spontaneous closure (p-value 0.001); where as surgical closure was significantly associated with presence of complications and pre-morbid illness (p-value 0.001). Fistula output; institutional origin of the patient; presence of complications and premorbid illness; HIV positivity and CD4 count were significant predictors of mortality. Conclusion: Enterocutaneous fistulae pose a therapeutic challenge at BMC and contribute significantly to high morbidity and mortality. A multidisciplinary approach focusing on fluid resuscitation; nutritional supplementation; electrolyte replenishment; control of sepsis; containment of effluent; skin integrity and surgery at appropriate time is necessary to lessen morbidity and mortality with a higher fistula closure rate. The high rate of postoperative enterocutaneous fistulae resulting from anastomotic breakdown in patients referred from peripheral hospitals calls for urgent surgical skill training course in this region. The high rate of HIV infection in these patients needs further studies

Improving outcome in patients of high output small bowel fistula.

Early and effective control of sepsis is the most important factor determining the outcome in patients with enterocutaneous fistulae (ECF). From a retrospective analysis of the hospital records (published data), ongoing contamination of the peritoneal cavity by the faecal stream was the most important factor leading to sepsis and occurred in 75% of patients. The mortality figure in patients with high-output ECF was 54.5% and in the presence of sepsis it was 63%. In an attempt to reduce these high mortality rates, we conducted a prospective study to evaluate the role of the routine use of ileostomy as an ancillary surgical procedure for diversion of the faecal stream in patients with high-output small bowel fistulae. Data were collected prospectively over a period of 3 years for 31 patients with high-output small bowel fistulae. On the appearance of the first signs of a leak, a laparotomy incision was opened in part or entirely and the abdominal collections were drained. Atthe time of exploration ileostomy was performed. There were 19 males and 12 females with a age range of 15-34 years (mean 30.1 years). All the fistulae were postoperative. Enteric fever was the most common aetiology (39%), followed by tuberculosis (35.5%). In 26 patients (84%), ileostomy could be done while 5 (16%) were received in moribund state and could not be operated on. Nine patients were operated on within 24 hours of the leak and 7 (77%) survived. Fifteen patients were operated on between 2 and 5 days, and 13 (87%) survived. The remaining 2 patients were operated on after 7 days of the leak and both died. All 5 patients who were not operated on died. The overall mortality in patients with high-output small bowel ECFwas 35.5%, which was significantly less than themortality figure of 54.5% in a similar group in our retrospective study. The mortality in patients undergoing ileostomy was 23%. In the postoperative period, surgical wound infection occurred in 100% of patients with partial or complete wound dehiscence. Two patients required secondary suturing while the remaining healed by secondary intention. Routine use of ileostomy for diverting the faecal stream in patients with high-output small bowel fistulae was effective in bringing down mortality rates.