Features and choice of surgical strategy in patients with gastrointestinal fistulas

Abstract

To evaluate the features and choice of surgical strategy in patients with gastrointestinal fistula based on classification of their types. There were 398 patients with gastrointestinal fistula. Fistula type 1 was found in 126 (31.7%) cases, type 2 - 38 (9.6%) cases, type 3 - 73 (18.3%) cases, type 4 - 26 (6.5%) patients, type 5 - 135 (33.9%) cases. One-stage and two-stage treatment was applied in patients with fistula type 1, two-stage treatment only - for fistula type 2. In patients with fistula type 3, treatment strategy depended on timing of fistula formation, its level and amount of intestinal chymus loss. In case of fistula type 4, radical treatment is difficult. However, surgery is safer when adhesions between intestinal loops are not yet dense enough. Indeed, dissection is associated with less risk of their damage. Reconstructive procedures were applied for fistula type 5 depending on its localization. The causes of gastrointestinal fistula were complications after surgery for acute ileus in 73 patients (17 ones died), blunt abdominal trauma in 81 (8), open abdominal trauma with cold weapons in 39 (6) and firearms in 11 cases (2), mesenteric thrombosis in 33 patients (8), pancreatic necrosis in 25 cases (9), abdominal hernia in 15 cases (4), acute appendicitis in 40 patients (3), colonic diverticulosis in 24 patients (1), urological diseases in 5 cases, colon perforation by a foreign body in 3 cases, colonoscopy in 5 patients, Hirschsprung's disease in 2 patients, Crohn's disease in 11 cases (3), colon polyps in 4 patients, intestinal tuberculosis in 1 case (1), small bowel resection for obesity in 1 patient and gynecological diseases in 25 patients (2). Fistulas type 1 and 4 were followed by the highest postoperative mortality since these interventions are associated with the most severe changes in abdominal cavity. Low mortality was observed in patients with fistula type 5, no abdominal inflammation and normalized intestinal passage. The overall mortality in patients with gastrointestinal fistulas was 16.1%. Treatment strategy in patients with gastrointestinal fistula primarily depends on the type of fistula that requires emergency, urgent, delayed or reconstructive surgery. Staged approach in patients with gastrointestinal fistulas can improve treatment outcomes.