Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg. 2008;32:445-453. [PMID: 18175171 PMCID: PMC2248608 DOI: 10.1007/s00268-007-9371-1]

An analysis of predictive factors for healing and mortality in patients with enterocutaneous fistulas

BACKGROUND

Most studies of enterocutaneous fistula report management and outcome. Few studies examine factors predicting healing and mortality.

AIM

To identify factors predicting healing and mortality in patients with ECF managed either with a definitive attempt at surgical closure or conservatively.

METHODS

The case notes of 277 patients with enterocutaneous fistula, treated at our institution over a 10 year period, were retrospectively reviewed. Patients were divided into those managed operatively or conservatively. Eleven factors were examined for their relationship to fistula healing and fistula-related mortality.

RESULTS

For patients treated operatively, successful enterocutaneous fistula closure related only to the complexity of the fistula (multiple fistula or presence of an internal abscess cavity) (P = 0.03), whereas fistula-related mortality related only to the presence of comorbidity (P = 0.02). In patients managed conservatively, a decreased likelihood of enterocutaneous fistula closure was associated with a high fistula output (P = 0.01), comorbidity (P = 0.03) and being referred from an external institution (P < 0.001). Fistula related-mortality in this group was related to a high output (P = 0.003) and an increased age (P = 0.001).

CONCLUSION

In patients managed operatively, fistula healing and fistula-related mortality are each associated with only one factor, whereas in patients managed conservatively healing and mortality are predicted by three and two factors, respectively.

Health-related quality of life in patients treated for enterocutaneous fistula

BACKGROUND

Patients with enterocutaneous fistulas undergo long intensive treatment. The aim of this study was to investigate the long-term health-related quality of life (HRQL) of these patients.

METHODS

Consecutive patients treated for enterocutaneous fistula between 1990 and 2005 were eligible for this retrospective study. The Karnofsky Performance Scale (KPS), Short Form 36 (SF-36) and the Inflammatory Bowel Disease Questionnaire were used to measure HRQL. The SF-36 was matched with results from healthy controls. Patients also gave information on concurrent medical illnesses.

RESULTS

Of 135 patients, 44 died, 14 were lost to follow-up and 12 refused to participate; of the remaining 65, 62 participated (response rate 81 per cent). HRQL was independent of patient characteristics during treatment. Scores for SF-36 domains were lower than in their matched controls (P < 0.050). Concurrent medical illness (cancer, depression and gastrointestinal disease) significantly reduced HRQL (for example with a 40 per cent reduction in vitality). The median KPS score was 80, indicating that activities could be performed with effort and patients had some signs of disease.

CONCLUSION

HRQL is lower in patients treated for enterocutaneous fistula than in matched controls, particularly in those with concurrent medical illnesses. Patients treated successfully have normal independence in daily functioning.

A rational approach to nutritional assessment

BACKGROUND & AIMS

Consensus regarding definitions of malnutrition and methods to assess nutritional state is lacking. We propose a definition and its operationalization.

METHODS

A definition was formulated on the basis of the pathophysiology of malnutrition, while reviewing the metabolic and physiological characteristics of different populations, considered to be malnourished. The definition was operationalized to yield measures to perform nutritional assessment.

RESULTS

Malnutrition was defined as "a subacute or chronic state of nutrition in which a combination of varying degrees of over- or undernutrition and inflammatory activity has led to a change in body composition and diminished function". Its operationalization led to four elements that may serve as the basis of nutritional assessment: (1) measurement of nutrient balance, (2) measurement of body composition, (3) measurement of inflammatory activity, and (4) measurement of muscle, immune and cognitive function. Most elements measured should be validated with gold standards; normal values should be obtained in different populations. Values obtained in people considered to be at nutritional risk should be related to outcome.

CONCLUSION

A definition is proposed that reflects the pathophysiology of malnutrition and that, when operationalized, will lead to measures reflecting this pathophysiology. Such an approach may yield comparable and reproducible rates and degrees of malnutrition in populations as well as in individuals.