Investigation of treatment and analysis of prognostic risk on enterocutaneous fistula in China: a multicenter prospective study

Tao Zheng; Haohao Xie; Xiuwen WU; Qiang Chi; Feng Wang; Zhenhua Yang; Chaowu Chen; Wei Mai; Suming Luo; Xiaofei Song; Shimin Yang; Wei Zhou; Haiyan Liu; Xinjian XU; Zheng Zhou; Chuanyuan Liu; Lian′an Ding; Kai Xie; Gang Han; Hongbin Liu; Jianzhong Wang; Shichen Wang; Peige Wang; Gefei Wang; Guosheng GU; Jian′an Ren

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Investigation of treatment and analysis of prognostic risk on enterocutaneous fistula in China: a multicenter prospective study

VernacularTitle: 全国多中心肠外瘘诊治情况调查及预后风险因素分析
Author: Tao ZHENG ¹ ; Haohao XIE ¹ ; Xiuwen WU ¹ ; Qiang CHI ² ; Feng WANG ³ ; Zhenhua YANG ⁴ ; Chaowu CHEN ⁵ ; Wei MAI ⁶ ; Suming LUO ⁷ ; Xiaofei SONG ⁸ ; Shimin YANG ⁹ ; Wei ZHOU ¹⁰ ; Haiyan LIU ¹¹ ; Xinjian XU ¹² ; Zheng ZHOU ¹³ ; Chuanyuan LIU ¹⁴ ; Lian′an DING ¹⁵ ; Kai XIE ¹⁶ ; Gang HAN ¹⁷ ; Hongbin LIU ¹⁸ ; Jianzhong WANG ¹⁹ ; Shichen WANG ²⁰ ; Peige WANG ²¹ ; Gefei WANG ¹ ; Guosheng GU ¹ ; Jian′an REN ¹
Author Information

1. Research Institute of General Surgery, East War Zone Hospital of PLA, Nanjing 210002, China
2. Department of General Surgery, The Second Affiliated Hospital, Harbin Medical University, Harbin 150086, China
3. Department of Gastrointestinal Surgery, Affiliated Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China
4. Department of General Surgery, The First College of Clinical Medical Science, China Three Gorges University, Hubei Yichang 443000, China
5. Department of Gastrointestinal Surgery, Hunan Provincial People′s Hospital, Changsha 410005, China
6. Department of Gastrointestinal Surgery, The People′s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, China
7. Department of Emergency Trauma Surgery, The People′s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, China
8. Department of Gastrointestinal Surgery, Henan Provincial People′s Hospital, Medical College of Henan University, Zhengzhou 450003, China
9. Department of Gastrointestinal Surgery, The Nankai Hospital, Nankai University, Tianjin 300100, China
10. Department of General Surgery, Sir Run Run Shaw Hospital, Medicine of School, Zhejiang University, Hangzhou 310016, China
11. Department of Emergency Surgery, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450000, China
12. Department of Pancreatic Surgery, The First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China
13. Department of Gastrointestinal Surgery, The First Affiliated Hospital, Division of Life Sciences And Medicine, University of Science and Technology of China, Hefei 230001, China
14. Department of Gastrointestinal Surgery and Hernia Surgery, Ganzhou People′s Hospital of Jiangxi Province, Jiangxi Ganzhou 341000, China
15. Department of Gastrointestinal Surgery, Affiliated Hospital, Qingdao University, Shandong Qingdao 266003, China
16. Department of General Surgery, Chest Hospital of Nanyang City of Henan Province, Henan Nanyang 473000, China
17. Department of Gastrointestinal Surgery, The Second Hospital of Jilin University, Changchun 130041, China
18. Department of GeneralSurgery, The 940th Hospital, Joint Logistics Support Force of Chinese PLA, Lanzhou 730050, China
19. Department of Gastrointestinal Surgery, The First Affiliated Hospital, Gannan Medical College, Jiangxi Ganzhou 341000, China
20. Department of General Surgery, The 901th Hospital, Joint Logistic Support Force of PLA, Hefei 230031, China
21. Department of Emergency Surgery, Affiliated Hospital, Qingdao University, Shandong Qingdao 266003, China
Publication Type:Journal Article
Keywords: Enterocutaneous fistula; Prognostic factors; Multicenter study
From: Chinese Journal of Gastrointestinal Surgery 2019;22(11):1041-1050
CountryChina
Language:Chinese
Abstract: Objective:To investigate the diagnosis and treatment for enterocutaneous fistula (ECF) in China, and to explore the prognostic factors of ECF.
Methods:A multi-center cross-sectional study was conducted based on the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections to collect the clinical data of ECF patients from 54 medical centers in 22 provinces/municipalities from January 1, 2018 to December 31, 2018. The clinical data included patient gender, age, length of hospital stay, intensive care unit (ICU) admission, underlying diseases, primary diseases, direct causes of ECF, location and type of ECF, complications, treatment and outcomes. All medical records were carefully filled in by the attending physicians, and then re-examined by more than two specialists. The diagnosis of ECF was based on the clinical manifestations, laboratory/imaging findings and intraoperative exploration.
Results:A total of 1521 patients with ECF were enrolled, including 1099 males and 422 females, with a median age of 55 years. The top three primary diseases of ECF were malignant tumors in 626 cases (41.2%, including 540 gastrointestinal tumors, accounting for 86.3% of malignant tumors), gastrointestinal ulcers and perforations in 202 cases (13.3%), and trauma in 157 cases (10.3%). The direct causes of ECF were mainly surgical operation in 1194 cases (78.5%), followed by trauma in 156 (10.3%), spontaneous fistula due to Crohn′s disease in 92 (6.0%), radiation intestinal injury in 41 (2.7%), severe pancreatitis in 20 (1.3%), endoscopic treatment in 13 (0.9%) and 5 cases (0.3%) of unknown reasons. All the patients were divided into three groups: 1350 cases (88.7%) with simple ECF, 150 (9.9%) with multiple ECF, and 21 (1.4%) with combined internal fistula. Among the patients with simple ECF, 438 cases (28.8%) were jejuno-ileal fistula, 313 (20.6%) colon fistula, 170 (11.2%) rectal fistula, 111 (7.3%) duodenal fistula, 76 (5.0%) ileocecal fistula, 65 (4.3%) ileocolic anastomotic fistula, 55 (3.6%) duodenal stump fistula, 36 (2.4%) gastrointestinal anastomotic fistula, 36 (2.4%) esophagogastric/esophagojejunal anastomotic fistula, 29 (1.9%) gastric fistula and 21 (1.4%) cholangiopancreatiointestinal. Among all the simple ECF patients, 991 were tubular fistula and 359 were labial fistula. A total of 1146 patients finished the treatment, of whom 1061 (92.6%) were healed (586 by surgery and 475 self-healing) and 85 (7.4%) died. A total of 1043 patients (91.0%) received nutritional support therapy, and 77 (6.7%) received fistuloclysis. Infectious source control procedures were applied to 1042 patients, including 711 (62.0%) with active lavage and drainage and 331 (28.9%) with passive drainage. Among them, 841 patients (73.4%) underwent minimally invasive procedures of infectious source control (replacement of drainage tube through sinus tract, puncture drainage, etc.), 201 (17.5%) underwent laparotomy drainage, while 104 (9.1%) did not undergo any drainage measures. A total of 610 patients (53.2%) received definitive operation, 24 patients died within postoperative 30-day with mortality of 3.9% (24/610), 69 (11.3%) developed surgical site infection (SSI), and 24 (3.9%) had a relapse of fistula. The highest cure rate was achieved in ileocecal fistula (100%), followed by rectal fistula (96.2%, 128/133) and duodenal stump fistula (95.7%,44/46). The highest mortality was found in combined internal fistula (3/12) and no death in ileocecal fistula. Univariate prognostic analysis showed that primary diseases as Crohn′s disease (χ²=6.570, P=0.010) and appendicitis/appendiceal abscess (P=0.012), intestinal fistula combining with internal fistula (χ²=5.460, P=0.019), multiple ECF (χ²=7.135, P=0.008), esophagogastric / esophagojejunal anastomotic fistula (χ²=9.501, P=0.002), ECF at ileocecal junction (P=0.012), non-drainage/passive drainage before the diagnosis of intestinal fistula (χ²=9.688, P=0.008), non-drainage/passive drainage after the diagnosis of intestinal fistula (χ²=9.711, P=0.008), complicating with multiple organ dysfunction syndrome (MODS) (χ²=179.699, P<0.001), sepsis (χ²=211.851, P<0.001), hemorrhage (χ²=85.300, P<0.001), pulmonary infection (χ²=60.096, P<0.001), catheter-associated infection (χ²=10.617, P=0.001) and malnutrition (χ²=21.199, P<0.001) were associated with mortality. Multivariate prognostic analysis cofirmed that sepsis (OR=7.103, 95%CI:3.694-13.657, P<0.001), complicating with MODS (OR=5.018, 95%CI:2.170-11.604, P<0.001), and hemorrhage (OR=4.703, 95%CI: 2.300-9.618, P<0.001) were independent risk factors of the death for ECF patients. Meanwhile, active lavage and drainage after the definite ECF diagnosis was the protective factor (OR=0.223, 95%CI: 0.067-0.745, P=0.015).
Conclusions:The overall mortality of ECF is still high. Surgical operation is the most common cause of ECF. Complications e.g. sepsis, MODS, hemorrhage, and catheter-associated infection, are the main causes of death. Active lavage and drainage is important to improve the prognosis of ECF.