University College Hospital, London, England.
Dis Colon Rectum. 2010 Feb;53(2):192-9. doi: 10.1007/DCR.0b013e3181b4c34a.
Enterocutaneous fistula associated with type 2 intestinal failure is a challenging condition that involves a multidisciplinary approach to management. It is suggested that complex cases should only be managed in select national centers in the United Kingdom.
Over an 18-month period, we prospectively studied all patients referred to us with established enterocutaneous fistulas. Patients followed standardized protocols. Eradication of sepsis, appropriate wound management, establishment of nutritional support, and restoration of normal physiology were attempted. Definitive surgical management was deferred for at least 6 months after the last abdominal surgical intervention. Follow-up was for a minimum of 6 months.
Of 55 patients, 10 were internal referrals and 45 were from institutions elsewhere. The mean age was 50 years. Nine patients had colonic fistulas. Forty-six had small bowel fistulas; 19 of these (35%) were associated with inflammatory bowel disease. Patients had undergone a median of 3 previous operations. Four fistulas (7%) healed spontaneously. Thirty-five patients (63%) underwent definitive surgery. Recurrent fistula occurred in 4 patients (13%); 1 required further surgery, and 3 healed spontaneously. The overall mortality rate was 7% (4/55 patients), with 3 patients dying before definitive surgery and 1 patient dying postoperatively.
Our results compare favorably with data from designated national centers (overall mortality, 9.5%-10.8%; operative mortality, 3%-3.5%), suggesting that these patients can be effectively managed in regional units that have sufficient expertise, interest, and volume of patients. Rationalization of funding and referral of patients with type 2 intestinal failure to regional centers may allow national centers to conserve their scarce resources.
与 2 型肠衰竭相关的肠外瘘是一种具有挑战性的疾病，需要多学科方法进行管理。有人建议，复杂的病例应仅在英国的一些指定国家中心进行治疗。
在 18 个月的时间里，我们前瞻性地研究了所有向我们转诊的患有已确诊肠外瘘的患者。患者遵循标准化方案。尝试消除败血症、进行适当的伤口管理、建立营养支持和恢复正常生理机能。在最后一次腹部手术干预后至少 6 个月才进行确定性手术治疗。随访时间至少为 6 个月。
55 例患者中，有 10 例为院内转科，45 例来自其他机构。平均年龄为 50 岁。9 例为结肠瘘，46 例为小肠瘘；其中 19 例（35%）与炎症性肠病有关。患者的中位手术次数为 3 次。4 例（7%）瘘自行愈合。35 例（63%）患者接受了确定性手术。4 例（13%）患者出现复发性瘘，其中 1 例需要再次手术，3 例自行愈合。总的死亡率为 7%（4/55 例），其中 3 例在确定性手术前死亡，1 例术后死亡。
我们的结果与指定国家中心的数据相比（总死亡率为 9.5%-10.8%；手术死亡率为 3%-3.5%）相当，表明这些患者可以在具有足够专业知识、兴趣和患者数量的区域单位得到有效治疗。将 2 型肠衰竭患者的资金和转诊合理化，以便将患者转诊到区域中心，可能使国家中心能够节省其稀缺资源。
