Original Article
12473
Definitive surgical closure of enterocutaneous fistula:
outcome and factors predictive of increased postoperative
morbidity
P. Ravindran*†, N. Ansari*†, C. J. Young*† and M. J. Solomon*†
*Surgical Outcomes Research Centre (SOURCE), Royal Prince Alfred Hospital, University of Sydney and †Department of Colorectal Surgery, Royal
Prince Alfred Hospital, Sydney, New South Wales, Australia
Received 26 May 2013; accepted 16 August 2013; Accepted Article online 30 October 2013
Abstract
Aim Enterocutaneous fistula (ECF) presents a complex
management problem with significant mortality and
morbidity. The aim of this study was to assess the out-
come of patients undergoing surgical cure for ECF and
to predict factors that might relate to increased postop-
erative morbidity.
Method Medical records of all patients who underwent
definitive surgery for cure of an ECF within our colorec-
tal surgery unit between 2000 and 2010 were reviewed.
Results Forty-one patients (18 male) were identified, in
whom 44 definitive procedures were performed. The
median age was 54 (17–81) years. The median postop-
erative length of stay in hospital was 14 (2–213) days.
Half (50%) of the ECFs occurred as a postoperative
complication followed by spontaneous fistulation in
Crohn’s disease (36%). The interval to definitive surgery
was influenced by the aetiology of the fistula. The med-
ian time to surgery after formation of postoperative
fistula was 240 days (7.9 months). There was no 30-
day postoperative mortality. There were two (4.5%)
recurrences at 3 months. Thirty-eight (86%) patients
suffered postoperative morbidity as defined by the
Introduction
Enterocutaneous fistula (ECF) presents a difficult
dilemma to the surgeon. Historically, the combination
of aseptic technique, general anaesthesia and antibiotics
has increased the use of abdominal surgery. The
increase of major abdominal surgery by default has
increased the incidence of rare surgical complications
Correspondence to: Associate/Prof Christopher Young, Royal Prince Alfred
Hospital Medical Centre, Suite 415, 100 Carillon Ave, Newtown, New South
Wales 2042, Australia.
E-mail: cyoungnsw@aol.com
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218
doi:10.1111/codi.
Clavien–Dindo classification. High-grade morbidity
occurred in 32% of patients. On univariate analysis,
factors identified as being significantly associated with
high-grade morbidity included a fistula output of
> 500 ml/day (P = 0.004) in patients with postopera-
tive ECF, malnutrition at presentation (P = 0.04) and a
serum albumin value of < 30 g/l (P = 0.02) in patients
with spontaneous ECF due to Crohn’s disease.
Conclusion The majority of persistent complex ECFs
can be cured surgically with low mortality and recur-
rence in a multidisciplinary setting. Postoperative
morbidity, however, remains a significant burden.
Keywords Fistula, enterocutaneous fistula, sepsis, nutri-
tional support, morbidity
What does this paper add to the literature?
This study has defined peri-operative patient and fistula
factors that may predispose to increased morbidity fol-
lowing definitive surgery for enterocutaneous fistula. To
our knowledge this is the first paper to address factors
predisposing to high-grade postoperative morbidity
with past series focusing mainly on mortality and recur-
rence.
such as ECF [1]. Aetiological factors for spontaneous
fistulae include radiotherapy, malignancy, inflammatory
bowel disease, diverticular disease, trauma and retention
of foreign bodies [2]. Postoperatively, fistulae occur
after an anastomotic leak or unrecognized injury to the
bowel and comprise up to 80% of all ECFs [3]. The
increased use of electro-dissection over sharp dissection
and the increase of laparoscopic abdominal surgery may
also be factors associated with delayed ECF.
High levels of morbidity and mortality have long
been associated with ECF. Since the original observa-
tion of a 43% mortality rate by Edmunds et al. in 1960
209
Definitive surgical closure of enterocutaneous fistula
[4], mortality has progressively decreased over the dec-
ades with advancements in peri-operative care, particu-
larly parenteral nutrition. The principles of management
of ECF have been well defined. It has been recognized
for many years that the focus should be on non-opera-
tive care with peri-operative stabilization and nutritional
support and investigation of the underlying cause before
undertaking an attempt at surgical closure. Important
management principles include correction of water and
electrolyte imbalance, eradication of sepsis, nutritional
support, skin and wound care and psychological support
[3]. A fistula that does not close with non-operative
management should be considered for operative cure.
Healing rates following surgical closure of between 75%
and 90% are reported [5–7].
This study aimed to determine the end-points of
attempted surgical closure including mortality, high-
grade morbidity, recurrence and healing in a series of
patients with ECF.
Method
Patients
The medical records and surgeon office notes of all
patients who underwent definitive surgery for cure of
an ECF in the colorectal unit of Royal Prince Alfred
Hospital (a tertiary referral hospital) between 1 Janu-
ary 2000 and 31 December 2010 were reviewed.
ECF was defined as a fistulous communication to the
skin originating from the small bowel, colon or an
anastomosis. Patients with an internal or perianal fis-
tula were excluded. The patient population was identi-
fied using consultant surgeon operative databases.
Four colorectal surgeons contributed patients to the
study, of whom two performed most of the ECF
repairs (20 and 16). All patients were followed up at
6–8 weeks after discharge from hospital and thereafter
as indicated.
Management approach
Preoperative treatment involved early control of sepsis,
aggressive correction of water and electrolyte balance,
and optimization of nutritional status. Management
was delivered by a multidisciplinary team from medical
staff, radiology, intensive care, dietitians and stomather-
apy. Multiple imaging modalities were employed to
define the anatomy and to demonstrate the potential
cause of the ECF. Contrast studies including CT and
fluoroscopy, aided by fistulograms when appropriate, as
well as other modalities such as endoscopy were uti-
lized to assess the fistula. Septic sources were identified
210 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218
P. Ravindran et al.
and treated within the first 24–48 h using percutaneous
drainage of intra-abdominal collections when necessary.
Accurate daily records of oral intake, stoma and fistula
outputs and regular blood and nutritional assessments
were carried out. A stomatherapist was engaged to pro-
vide advice on skin protection.
Dietitian assessment defined malnutrition using
anthropometric data, biochemical parameters, and either
the Mini Nutritional Assessment – Short Form for
patients aged ≥ 65 years or the Subjective Global
Assessment of Nutritional Status for patients < 65 years
[8,9]. Total parenteral nutrition (TPN) was commenced
in patients with a demonstrated malnutrition and in
patients at high risk of malnutrition due to inadequate
caloric intake and high fistula output. TPN was deliv-
ered via central venous access and monitored by a dedi-
cated TPN team. High fistula output (> 500 ml/day)
was controlled with titrating doses of antimotility
agents, including loperamide up to 24 mg daily and
codeine up to 90 mg daily. The majority of patients on
TPN also continued on enteral nutrition provided fis-
tula outputs remained stable. In patients with a very
high fistula output of > 1000 ml/day, octreotide
(100 lg subcutaneously three times daily) was trialled
for 5 days in conjunction with a strict regimen of nil by
mouth to control losses. If there was no significant
reduction in fistula output, octreotide was ceased.
If conservative management failed, surgical resection
was undertaken. This study excluded patients whose
ECF closed with conservative management. Postopera-
tive fistulae were defined as either early (diagnosed in
the first 10 postoperative days) or late (diagnosed
between 10 days and 4 weeks postoperatively). Our
unit’s preference in relation to fistulae diagnosed in the
postoperative setting is a period of waiting for at least
6–8 weeks from the time of control of sepsis and com-
mencement of parenteral nutrition before any attempt
at curative resection. This allows for a reasonable chance
of operative closure as well as permitting the acute post-
operative inflammatory reaction to settle.
A number of different surgical approaches were uti-
lized depending on patient and fistula characteristics.
The procedure was classified as ‘resection’ if the area of
bowel containing the ECF was resected, with primary
anastomosis not assumed. The procedure was classified
as ‘wedge resection’ if any area less than the circumfer-
ence of the bowel was resected and anastomosed or the
edges of the fistula were simply debrided and closed.
‘Anastomotic revision’ refers to resection and revision
of any previous anastomosis (e.g. ileocolic) and for the
purposes of this analysis was considered a subset of
resection. If multiple ECFs were present and multiple
resections were performed along with wedge resections,
P. Ravindran et al.
the operation was classified as a ‘resection’. Finally, all
operations were divided into ‘defunctioned’ or ‘not de-
functioned’ depending on whether a stoma remained
after the operation, irrespective of the reason. All wedge
resections and closures were performed using hand-
sewn techniques and all resections were either hand
sewn or stapled according to the discretion of the pri-
mary operator.
Outcome
Successful closure was defined as all ECFs remaining
closed for at least 3 months. Recurrence was defined as
reappearance of the ECF within those 3 months. Mor-
tality was defined as death within 30 days after surgery.
Morbidity was defined according to the Clavien–Dindo
classification of postoperative morbidity [10] (Table 1).
Morbid events occurring prior to definitive surgical clo-
sure were not considered part of the postoperative
course and thus were not included in this study. High-
grade morbidity was defined as being Clavien–Dindo
Grade 3 and above.
Predictive factors
A literature review identified a number of factors that
may be predictive of the presence and grade of morbidity
Table 1 Clavien–Dindo classification of surgical complications
[10].
Grade Definition
Grade I Any deviation from the normal postoperative
course without the need for pharmacological
treatment or surgical, endoscopic and
radiological intervention
Allowed therapeutic regimens are drugs as
anti-emetics, antipyretics, analgetics, diuretics,
electrolytes and physiotherapy. Also includes
wound infections opened at the bedside
Grade II Requiring pharmacological treatment with
drugs other than such allowed for Grade I
complications
Blood transfusions and TPN are also included
Grade III Requiring surgical, endoscopic or radiological
intervention
Grade IIIa Intervention not under general anaesthesia
Grade IIIb Intervention under general anaesthesia
Grade IV Life-threatening complication requiring
intensive care unit management
Grade IVa Single organ dysfunction (including dialysis)
Grade IVb Multi-organ dysfunction
Grade V Death of a patient
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218
Definitive surgical closure of enterocutaneous fistula
using studies that identified predictors of spontaneous
closure and mortality [6,7,11–16]. Along with patient
demographics, fistula characteristics and surgical proce-
dure data were collected. Comorbid conditions affecting
the study population were rated using the Charlson
comorbidity index [17]. Detailed data relating to possi-
ble factors that may predict mortality, recurrence and
postoperative morbidity were also collected.
Statistical analysis
Statistical analysis was performed using SPSS computer
software (SPSS, Chicago, Illinois, USA). Numerical val-
ues are expressed as median (and range) unless other-
wise specified. All variables were stratified around the
median value and classified accordingly. The Student’s
t-test was utilized to perform comparisons between
continuous values. Categorical variables were compared
using Pearson’s chi-squared test or Fisher’s exact test
where appropriate. All comparisons were two-tailed
probabilities. Significance was determined using 95%
confidence interval (95% CI, P < 0.05). To determine
risk factors for morbidity, significant variables were
identified using univariate analysis. Because of our
small cohort, we were unable to perform a multivariate
analysis.
Results
Patient and fistula characteristics
Forty-one patients (23 women) were identified. There
were 44 presentations in total, with two patients pre-
senting with a new ECF at 3 and 6 years after initial
presentation and one re-presenting with recurrence
within 3 months who required a second operation for
closure. The median age was 54 (17–81) years. The
median postoperative length of stay in hospital was 14
(2–213) days. Twenty-one (51%) patients were referred
to our facility from other units or institutions. The aeti-
ology of ECF for the majority of patients was postoper-
ative (52%), followed by Crohn’s disease (36%). With
respect to postoperative ECF, six (27%) patients were
diagnosed in the early postoperative period of < 10 days
and five of these were referred from other institutions.
The sites of ECF were ileum (55%), jejunum (16%),
ileocolic anastomosis (14%), ileal J-pouch (2%) and
colon (25%). Five patients had an ECF that involved
more than one anatomical site. The majority (82%) of
patients had a low fistula output of < 500 ml/day.
Details of patient characteristics, nutritional status at
time of presentation and fistula characteristics are pre-
sented in greater detail in Table 2.
211
Definitive surgical closure of enterocutaneous fistula P. Ravindran et al.

Table 2 Characteristics of ECFs and complications. for patients on TPN who started TPN preoperatively
was 33.0 (20–44) g/l.
Presentations
Five patients were commenced on a trial of octreo-
(n, total 44) Percentage
tide with two demonstrating a significant decrease in
fistula output and both were kept on octreotide until
Aetiology of ECF
Postoperative 22 50
definitive surgery took place at 269 and 105 days.
< 10 days 6 Before carrying out any definitive procedure, 25 (57%)
> 10 days 16 patients required open drainage, percutaneous drainage
Crohn’s disease 16 36 or a combination of both for control of sepsis. Details
Diverticular 2 5 are included in Table 2.
Neoplasm 1 2
Ischaemia 1 2
Radiation 1 2 Operative management
Hernia 1 2 Forty-one patients had 44 definitive procedures, includ-
Systemic complication at presentation
ing one patient who required further surgical closure of
Sepsis 28 64
a recurrence. The time to definitive surgery was signifi-
Malnourished 21 48
Electrolyte imbalance 10 23
cantly influenced by the aetiology of the fistula. Median
Fistula site time to operation following diagnosis of ECF in fistulae
Ileum 24 55 that were not postoperative was 26.5 (1–1462) days,
Jejenum 7 16 whereas for postoperative fistulae it was 240 (5–810)
Ileocolic anastomosis 6 14 days. The median interval from diagnosis to definitive
Ileal J-pouch 1 2 surgery for postoperative ECFs diagnosed after 10
Colon 11 25 postoperative days was 250 (98–810) days. For ECFs diag-
Fistula output nosed in the early postoperative period (< 10 days), the
Low (< 500 ml/day) 36 82 median time to definitive surgery was 74 (9–296) days.
High (> 500 ml/day) 8 18
Twelve (27%) patients had an intra-abdominal or
Procedures prior to definitive procedure
pelvic collection identified during the definitive surgical
CT guided drainage 13 30
of collection
procedure, seven of whom already had previous
Drainage of abdominal 9 20 CT-guided drainage. Twelve patients had multiple fistu-
wall abscess lous openings identified at the time of definitive sur-
Open drainage of pelvic/ 3 7 gery. Of the 42 resections that occurred, 18 (41%)
abdominal abscess involved resection with anastomosis. There were a
Defunctioning stoma 2 5 further two patients who had a wedge resection
Intra-abdominal/pelvic 12 27 performed. These were patients with a colocutaneous
abscess at operation fistula involving the transverse colon partly incarcerated
in a hernia and a postoperative ileal-cutaneous fistula to
the midline laparotomy wound. Both ECFs that under-
went wedge resection had small mural defects intra-
Preoperative management
operatively with associated healthy bowel and were
The median albumin level at diagnosis of ECF was 31 managed successfully with a more limited approach.
(14–53) g/l. Twenty-three (52%) patients required Four patients had a history of being managed at some
intravenous nutrition (TPN) to maintain nutritional stage with an open abdomen, two of whom were trans-
status. All but four of these began TPN preoperatively. ferred from other institutions with an open abdomen.
Twenty-one patients were classified as malnourished on Of 44 procedures, 24 had either an end or a loop
presentation based on detailed dietitian and TPN team stoma with 21 stomas being newly created or revised.
assessment. The median albumin level at diagnosis for Thirteen of these stomas were created for the purpose
patients who started TPN preoperatively was 28.5 of defunctioning (Fig. 1).
(22–31) g/l. Two patients developed short gut post- The duration of the operation performed for definitive
operatively and required life-long TPN following dis- surgical closure was a median of 195 (20–539) min. The
charge. For the remainder of the patients, the median median American Society of Anesthesiologists (ASA)
duration of utilization of TPN was 32.5 (9–370) days. score of the patients at definitive surgical closure was 2
Median preoperative albumin level in all patients had (1–4). Intensive care unit admission was required in 14
increased to 35.5 (20–50) g/l, while the median level (32%) patients postoperatively and blood transfusion

212 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218
P. Ravindran et al. Definitive surgical closure of enterocutaneous fistula

Patients (41)

Procedures
(44)

Wedge
Resection
Resection
(42)
(2)

Not No
Anastomosis
Defunctioned Anastomosis
(40)
(2) (2)

Not
Defunctioned Defunctioned
Defunctioned
(11) (2)
(29)

End Loop
Loop End
jejunostomy jejunostomy
Figure 1 Flow diagram of the fate of 41 ileostomy (8) Colostomy (2)
(2) (1)
patients with enterocutaneous fistula.

(given to patients with postoperative haemoglobin Table 3 Division of major and minor morbidity by events and
< 70 g/dl or 80 g/dl if they had a background of ischae- time.
mic heart disease) was required in 18 (41%) in the first
Number of
72 h postoperatively.
Morbidity patients (%)

Outcome All morbidity 38 (86)

Patients with Clavien Grade ≥ III 14 (32)
There was no 30-day mortality following any of the 44 Patients with Clavien Grade I and II 24 (55)
definitive procedures, and to our knowledge there was Total morbid events 70
no overall mortality that was fistula-related from any of Early (< 30 days) 62 (89)
our surgically closed ECFs. Of 44 definitive closures, Late (> 30 days) 8 (11)
there were two (4.5%) recurrences at 3 months, one of
which required further surgical closure and the other
closed on conservative management. Both recurrences
Risk factors associated with poor peri-operative
occurred in patients with Crohn’s disease.
outcome
There was a high morbidity. Of the 44 definitive
closures, 38 (86%) patients had a postoperative complica- As there was no 30-day mortality and few recurrences,
tion. There were 70 morbid events, which have been clas- we were unable statistically to analyse factors that may
sified in Table 3, 89% of which occurred in the first influence mortality or recurrence. Univariate analysis,
30 days and are classified as early postoperative. High- however, was applied to high-grade morbidity. Patients
grade morbidity, defined as a Clavien–Dindo morbidity with spontaneous ECF secondary to Crohn’s disease and
grade of III or more, occurred in 32% of patients. Table 3 patients with postoperative ECF were analysed sepa-
summarizes the division of major and minor morbidity. rately. Factors identified as being significantly associated

Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218 213
Definitive surgical closure of enterocutaneous fistula
with high-grade morbidity in patients with Crohn’s ECF
were a serum albumin level at presentation > 30 g/l
(P = 0.02) and malnutrition at presentation (P = 0.04).
In patients with postoperative ECF, the only factor sig-
nificantly associated with high-grade morbidity was a
high fistula output > 500 ml/day (P = 0.004). A num-
ber of other variables were analysed including blood
transfusion ≥ 2 units, time to definitive surgery, ASA
grade, presence of intra-abdominal sepsis and site of fis-
tula. None of these reached statistical significance for
predicting high-grade morbidity (Tables 4 and 5).
Discussion
Brenner et al. [18] compared 10 series and found that
operative mortality has markedly improved over time,
probably due to advances in imaging, percutaneous
drainage and wound care technology. Recurrence rates,
meanwhile, have remained relatively stable between 10%
and 20%. We had no 30-day mortality and a recurrence
rate of 4.5%. Furthermore, among our surgically closed
ECFs, we have not had any fistula-related mortality in
this 10-year period. These results compare favourably
with other recent published series [11,19–22].
The timing of surgery has been noted to be a pre-
dictor of outcomes in the past. Fazio et al. [23] found
that patients operated on within 10 days or after
6 weeks of original operations had mortality rates of
11%–13% while patients requiring re-laparotomy within
this period had a mortality rate of 21%. The peritoneal
cavity undergoes an intense reaction with the formation
of perilous inflammatory adhesions after a laparotomy
that last up to 10 weeks postoperatively. This may be
further exacerbated by the presence of an ECF and sep-
sis. Most authors have reported their best results in
patients where surgery has been delayed for at least
3–6 months and this is our standard practice when pos-
sible [3,6,8]. Visschers et al. [22] demonstrated that
prolonging the period of convalescence for patients
with ECF improves spontaneous closure and reduces
recurrence rates when comparing groups undergoing
definitive surgery after a median time period of 53
compared with 101 days. The 6-month time course is
commonly utilized in groups with experience in
treating fistulae, with the St Mark’s group delaying
definitive surgery for a median of 8 months after
occurrence of fistulization [24]. The median time to
definitive surgery for patients in our unit diagnosed
with postoperative ECF after 10 postoperative days was
250 days. This is in contrast to the group of six
patients diagnosed in the early postoperative period
(< 10 days) where the median time to definitive surgery
was 74 days.
214 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218
P. Ravindran et al.
Several factors were found to predict high-grade
postoperative morbidity (Clavien–Dindo Grade > III)
on univariate analysis including high fistula output, mal-
nutrition on presentation and low serum albumin. Of
these, malnutrition has been accepted to contribute to
poor wound healing and is associated with higher inci-
dences of postoperative complications and mortality in
patients undergoing abdominal surgery [3]. A retro-
spective review of 771 medical and surgical patients
revealed that malnutrition was associated with a three-
fold increase in both minor and major complications
and a four-fold increase in mortality [25]. Low preoper-
ative serum albumin has also been associated with
increased postoperative morbidity and mortality in
numerous studies. In one large-scale study, Gibbs et al.
[26] demonstrated, in of 54 215 patients without
cardiac disease undergoing major surgery, that preoper-
ative albumin was the strongest predictor of 30-day
morbidity and mortality out of 61 other possible preop-
erative risk factors. A number of authors have shown
that albumin is an important predictor of mortality in
ECF [21,22,27,28]. Lu et al. [29] suggested that an
improvement in serum albumin levels following TPN
was a vital prognostic factor for healing of the ECF in
postoperative gastrointestinal cancer patients. Our study
is in line with these observations.
High fistula output has been identified as a predictor
of recurrence and mortality by a number of other
authors [7,13,23,28]. Multivariate analysis of data from
188 consecutive patients with ECF over a 10-year per-
iod indicated that spontaneous closure was significantly
more likely in patients with a low-output fistula [12].
In our analysis, high fistula output was the only factor
significantly related to high-grade postoperative morbid-
ity. Four-fifths (84%) of the non-resolving ECFs man-
aged in our unit had an average output of < 500 ml/
day and this may have contributed to the low recur-
rence rate in the present study.
There are few studies that have investigated postop-
erative morbidity after surgery for ECF and it should be
borne in mind that the factors investigated such as mor-
tality and recurrence are unique to the institution. For
example, Lynch et al. [11] found that wedge resection
was an independent risk factor for recurrence, while
Brenner et al. [18] showed that the location of a fistula
in the small intestine, inflammatory bowel disease, inter-
val from diagnosis to operation of 36 weeks or longer
and resection with stapled anastomosis were all variables
affecting ECF recurrence independently.
Optimal management of complex ECF requires sur-
gical experience and a multidisciplinary approach to pro-
vide peri-operative support with respect to nutrition,
intensive care and wound management. Our colleagues
P. Ravindran et al. Definitive surgical closure of enterocutaneous fistula

Table 4 Univariate analysis of factors

Predictive factors in patients Clavien ≥ III Clavien < III Fisher
associated with major morbidity defined
with spontaneous Crohn’s ECF (n = 14) (n = 30) exact test
as Clavien Grade 3 or more in patients
with spontaneous Crohn’s ECF.
Age, years, mean (SD) 40.2 (8.4) 35.0 (14.1) P = 0.46
Fistula output
> 500 ml/day 0 1 P = 1.00
< 500 ml/day 5 10
Time from presentation to 15.6 (27.7) 208.6 (429.5) P = 0.34
definitive closure, days,
mean (SD)
Operative time 150.6 (63.7) 172.1 (48.2) P = 0.47
Number of ECFs
≥2 1 2 P = 1.00
1 4 9
Albumin at presentation
> 30 g/l 1 9 P = 0.02
≤ 30 g/l 4 1
Malnourished at presentation
Yes 1 9 P = 0.04
No 4 2
Septic at presentation
Yes 4 8 P = 1.00
No 1 3
Intra-abdominal abscess at definitive closure
Yes 2 8 P = 0.30
No 3 3
Preoperative albumin
> 30 g/l 4 10 P = 1.00
≤ 30 g/l 1 1
ASA score
≥2 3 11 P = 0.08
≤1 2 0
Blood transfusion
> 1 unit 3 1 P = 0.06
≤ 1 unit 2 10
Defunctioned
Yes 4 9 P = 1.00
No 1 2
Location of fistula
Large bowel 2 1 P = 0.24
Small bowel 3 9
Referral from other institution
Yes 5 6 P = 0.12
No 0 5
Charlson comorbidity index
≥2 0 1 P = 1.00
≤1 5 10
Cardiovascular risk factors
Yes 0 1 P = 1.00
No 5 10

in Melbourne, Australia, argue that centralization of There are several limitations to this study including
management of ECF may have a better outcome [30]. its retrospective nature. Given the variations in mor-
This may be pertinent in a setting with a large geo- bidity and mortality in the literature, and given our
graphical area and a small population such as Australia. own small sample, referral to publications from higher

Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218 215
Definitive surgical closure of enterocutaneous fistula P. Ravindran et al.

Table 5 Univariate analysis of factors

Predictive factors in patients Clavien ≥ III Clavien < III Fisher
associated with major morbidity defined
with postoperative ECF (n = 14) (n = 30) exact test
as Clavien Grade 3 or more in patients
with postoperative ECF.
Age, years, mean (SD) 62.1 (7.8) 52.1 (19.3) P = 0.20
Fistula output
> 500 ml/day 5 1 P = 0.004
< 500 ml/day 2 14
Time from presentation to 180.4 (77.1) 242.7 (304.1) P = 0.60
definitive closure, days, mean (SD)
Time between operations in 250.0 (70.4) 369.5 (426.4) P = 0.51
postoperative ECFs, days, mean (SD)
Operative time 315.1 (123.7) 246.3 (138.0) P = 0.28
Number of ECFs
≥2 5 5 P = 0.17
1 2 10
Albumin at presentation
> 30 g/l 2 6 P = 0.64
≤ 30 g/l 4 6
Malnourished at presentation
Yes 3 9 P = 0.65
No 4 6
Septic at presentation
Yes 3 8 P = 1.00
No 4 7
Intra-abdominal abscess at definitive closure
Yes 7 11 P = 0.26
No 0 4
Preoperative albumin
> 30 g/l 3 1 P = 0.08
≤ 30 g/l 4 14
ASA score
≥2 7 12 P = 0.52
≤1 0 3
Blood transfusion
> 1 units 5 5 P = 0.17
≤ 1 units 2 10
Defunctioned
Yes 4 9 P = 1.00
No 3 6
Location of fistula
Large bowel 0 4 P = 0.28
Small bowel 6 11
Referral from other institution
Yes 2 5 P = 1.00
No 5 10
Charlson comorbidity index
≥2 4 6 P = 0.65
≤1 3 9
Cardiovascular risk factors
Yes 3 11 P = 0.34
No 4 4

volume centres may represent better the rates associ- management approaches, lack of standardization of
ated with surgical treatment of this condition. Fur- documentation of the peri-operative outcome and het-
thermore, variability in surgeon experience and erogeneity of the disease itself and its many causes

216 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 209–218
P. Ravindran et al.
further contribute to difficulties in collecting and
interpreting data.
ECF is a difficult condition for patient and doctor.
With a delayed operative approach combined with mod-
ern advances in imaging, percutaneous drainage and
wound care combined with nutritional and intensive
care support, the surgical management of a persisting
ECF can be achieved with minimal mortality and recur-
rence albeit with a high morbidity. The next logical
addition to the management algorithm of ECFs is early
identification and correction of factors that predispose
to high-grade morbid events in an effort further to
improve the outcome.
Author contributions
Praveen Ravindran was involved in conception and
design, acquisition of data, analysis and interpretation of
data, drafting the article. Nabila Ansari was involved in
conception and design, acquisition of data, analysis and
interpretation of data, drafting the article and revising
the article critically for important intellectual content.
Christopher J. Young was involved in conception and
design, revising the article critically for important intel-
lectual content and final approval of the version to be
published. Michael J. Solomon was involved in concep-
tion and design, revising the article critically for impor-
tant intellectual content and final approval of the
version to be published.
Conflict of interests
None.
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