title: Enterocutaneous fistula in patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Incidence, management and outcomes.
abstract: BACKGROUND
  Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for peritoneal carcinomatosis (PC) from multiple origins, however is associated with increased complications compared to conventional gastrointestinal surgery. The aetiology of enterocutaneous fistulas (ECF) in most cases is a result of various contributing factors and therefore remains a major clinical problem, occurring in 4-34% of patients post-CRS. The aim of this study was to analyze the incidence and outcome of ECF following CRS/HIPEC.
  
  
  METHODS
  From April 1999 to September 2015, 53 patients of 918 CRS/HIPEC procedures developed an ECF. Patient, operative and postoperative data were retrospectively analyzed to determine aetiology, classification outcome and possible contributing factors were reviewed on univariate and multivariate analysis.
  
  
  RESULTS
  We report a 5.8% ECF rate, diagnosed at a median of 13 days. The mortality rate was 5.7% and other morbidity was significantly increased (p = 0.0001). Twenty-five (47.2%), 8 (15.1%) and 20 patients (37.7%) had low, moderate and high output ECF respectively. Patients that had a CC2 cytoreduction, abdominal VAC or smoked had a higher risk of fistula (p = 0.004, p < 0.0001, p = 0.008). Spontaneous closure was achieved in 49.2% with conservative treatment (median 29 days) and 33.9% underwent surgical intervention. Preoperative serum albumin <35 g/L (p = 0.04), PCI>17 (p = 0.025) and operation >8.6 h s (p = 0.001) were independent risk factors on multivariate analysis. Overall and 5-year survival was significantly reduced (p < 0.0001,p = 0.016).
  
  
  CONCLUSIONS
  CRS/HIPEC remains an effective treatment modality for PC in selected patients with a comparable ECF incidence to reported elective gastrointestinal surgery rates. This study identifies multiple risk factors that should be considered in patients undergoing CRS/HIPEC.
authors: UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.
authors: Sarah J
authors: SJ
authors: Valle
authors: UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia; Al-Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia. Electronic address: nayefalhariri@hotmail.com.
authors: Nayef
authors: N
authors: Alzahrani
authors: UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.
authors: Saleh
authors: S
authors: Alzahrani
authors: UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.
authors: Thamer Bin
authors: TB
authors: Traiki
authors: UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia; Cancer Care Centre, St George Hospital, Kogarah, NSW, Australia.
authors: Winston
authors: W
authors: Liauw
authors: UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia. Electronic address: david.morris@unsw.edu.au.
authors: David L
authors: DL
authors: Morris
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001315:Australia / Q000453:epidemiology; D017024:Chemotherapy, Adjuvant; D010478:Chemotherapy, Cancer, Regional Perfusion / Q000009:adverse effects*; D003131:Combined Modality Therapy; D065426:Cytoreduction Surgical Procedures / Q000009:adverse effects*; D013505:Digestive System Surgical Procedures / Q000009:adverse effects*; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006979:Hyperthermia, Induced / Q000009:adverse effects*; D015994:Incidence; D007412:Intestinal Fistula / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010534:Peritoneal Neoplasms / Q000150:complications* / Q000473:pathology / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D015996:Survival Rate
keywords: Cytoreductive surgery (CRS); Enterocutaneous fistula (ECF); Hyperthermic intraperitoneal chemotherapy (HIPEC); Peritoneal carcinomatosis (PC); Peritoneal surface malignancy