Enterocutaneous fistula: a Tanzanian experience in a tertiary care hospital

Abstract

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 91.3% of cases. The majority of patients (63.0%) had high output fistulae and the jejuno-ileum was commonly affected (60.9%). The complication rate was 34.8% and 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.