Analysis of risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair

Objective To analyze the risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair. Methods The retrospective case-control study was conducted. The clinical data of 679 patients who underwent inguinal hernia free tension repair between January 2015 and September 2018 in Beijing Chao-Yang Hospital of Capital Medical University were collected. There were 646 males and 33 females, aged (65±12)years, with a range from 28 to 94 years. Observation indicators: (1) surgical situations of inguinal hernia free tension repair; (2) follow-up; (3) enterocutaneous fistula and its treatment; (4) risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair. Follow-up by outpatient examination and telephone interview was performed to detect the postoperative enterocutaneous fistula up to June 2019. Measurement data with normal distribution were represented as Mean±SD. Count data were described as absolute numbers. Univariate analysis and multivariate analysis were done using the chi-square test and Logistic regression model, respectively. Results (1) Surgical situations of inguinal hernia free tension repair: 679 patients underwent inguinal hernia free tension repair. Of 679 patients, 215 underwent plug repair or mesh-plug repair, including 9 cases undergoing Plug repair only, 50 undergoing Millikan procedure, and 156 undergoing Rutkow procedure, other 464 underwent non-plug surgery, including 181 undergoing Lichtenstein procedure, 53 undergoing transinguinal preperitoneal hernia repair (TIPP), and 230 undergoing transabdominal preperitoneal patch repair (TAPP) and total extraperitoneal inguinal hernia repair (TEP). Polypropylene mesh or plug were used in all 679 cases. The operation time and volume of intraoperative blood loss were (61±14)minutes and (10±7)mL. There were 580 of 679 patients treated with prophylactic antibiotics. (2) Follow-up: 679 patients were followed up for 15-86 months, with a median time of 51 months. There were 12 male patients with postoperative enterocutaneous fistula, aged (69±8)years, with a range from 57 to 79 years, twelve patients with enterocutaneous fistula developed symptoms within the time of (42±25)months. (3) Enterocutaneous fistula and its treatment: of 12 patients with enterocutaneous fistula, 11 underwent plug repair or mesh-plug repair, and 1 undergwent TAPP(enterocutaneous fistula secondary to invasion of preperitoneal patch to intestines). The fistulas were located at inguinal region, with a diameter of 0.5-1.0 cm. In the 12 patients, of the 5 patients with sigmoid fistula, 4 underwent intestinal resection around the fistula, 1 underwent distal bowel closure and proximal colostomy. Six patients had enteric fistula, including 5 secondary to invasion of plug to intestines and 1 due to preperitoneal patch in TAPP, and they underwent resection of intestines with fistula combined with side-to-side intestial anastomosis, or laparoscopic suture of all layers and seromuscular layer of enterocutaneous fistula. One patient with intestinal and vesical fistulas underwent resection of intestines with fistula, and had sutured and embeded them with 3-0 absorbable strings. Operation time of 12 patients was (126±40)minutes. Five patients received debridement and drainage for reoperation. Duration of hospital stay of 12 patients was (37±11)days. (4) Risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair: results of univariate analysis showed that surgical method was associated factor for postoperative enterocutaneous fistula after inguinal hernia free tension repair (χ2=17.601, P<0.05). Results of multivariate analysis showed that plug repair or mesh-plug repair was an independent risk factor for postoperative enterocutaneous fistula after inguinal hernia free tension repair (odds ratio=32.279, 95% confidence interval: 4.027-258.735, P<0.05). Conclusion The plug repair or mesh-plug repair is an independent risk factor for postoperative enterocutaneous fistula after inguinal hernia free tension repair. Key words: Hernia; Inguinal hernia; Tension free repair; Plug; Enterocutaneous fistula; Risk factors