Analysis of risk factors related to gastrointestinal fistula in patients with severe acute pancreatitis: a retrospective study of 344 cases in a single Chinese center

Hua et al. BMC Gastroenterology (2017) 17:29 DOI 10.1186/s12876-017-0587-8 RESEARCH ARTICLE Open Access Analysis of risk factors related to gastrointestinal fistula in patients with severe acute pancreatitis: a retrospective study of 344 cases in a single Chinese center Zhipeng Hua1, Yongjie Su1, Xuefeng Huang1, Kang Zhang2, Zhengyu Yin1,2, Xiaoming Wang1,2 and Pingguo Liu1,2* Abstract Background: Gastrointestinal fistula (GIF) in severe acute pancreatitis (SAP) is considered as a sparse episode and studied sporadically in the literature. There is paucity of data on the prediction of the effect on risk of GIF in patient with SAP. This study was aimed to investigate risk factors related to GIF in the development of SAP. Methods: The clinical data of 344 patients with SAP from 2011 to 2016 were reviewed retrospectively. All patients were divided into the GIF group and the non-GIF group, and their data analyzed with respect to 15 parameters were applied to explore potential risk factors for GIF in patients with SAP. Results: Of the 344 eligible patients, 52 (15.12%) progressed to GIF. Only occurrence of infected pancreatic and extra-pancreatic necrosis (IPN) (P = 0.004, OR = 3.012) and modified CT severity index (MCTSI) (P = 0.033, OR = 1.183) were proved to be independent risk factors for GIF in patients with SAP, and blood type B (P = 0.048, OR = 2.096, 95% CI: 0.748–3.562) indicated weaker association of risk factor for GIF. The early (48–72 h after admission) enteral nutrition (EEN) (P = 0.016, OR = 0.267) acted as a protective factor. Conclusions: Occurrence of IPN and high MCTSI are independent risk factors for the development of GIF in patients with SAP, blood type B reveals a potential correlation with GIF in patients with SAP. EEN is helpful to prevent the progression of GIF secondary to SAP. Keywords: Severe acute pancreatitis, Gastrointestinal fistula, Risk factor, Infected pancreatic necrosis, MCTSI, EEN, Blood type B Background Severe acute pancreatitis (SAP) is a devastating disease that is characterized by a high mortality rate (ranging from 15% to as high as 85%) due to the development of pancreatic and extra-pancreatic necrosis infection, and multisystem organ failure (MOF) [1, 2]. The management of SAP is complicated because of the incomplete understanding of the pathogenesis and multi-causation of the * Correspondence: 1 Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Hubing South Road, Xiamen, Fujian, China 2 Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma (Xiamen University Affiliated ZhongShan Hospital), Xiamen, China disease, uncertainties in predicting outcome and limited effective treatment modalities [2, 3]. Gastrointestinal fistula (GIF) is a well-recognized complication secondary to SAP, although the incidence of GIF in SAP is low and sporadically reported in the literature. As previously reported, GIF is one of the most fatal and intractable complications after SAP, and associated with other major complications and serious clinical consequences, such as hemorrhage and exacerbation of infection which can lead to a fatal outcome [4–7]. The etiology and pathogenesis of GIF in patients with SAP involve complex processes, which are far from fully understood. Indeed, the management of GIF in SAP is complicated and controversial, © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hua et al. BMC Gastroenterology (2017) 17:29 which could lead to a prolonged hospital course, and significant morbidity and mortality [8, 9]. The sites of fistula may involve the stomach, duodenum, jejunum, ileum, and colon, either in localization or diffusion. GIF may result from direct erosion from digestive enzymes excreted by the inflamed pancreas on the adjacent gastrointestinal (GI) tract, or it could occur as a consequence of intestinal necrosis due to vascular thrombosis in an area of inflammation and infection. In addition, GIF may be associated with iatrogenic intervention [10–12]. It has been reported that GIF may cause none of additional symptoms in some cases, which are usually detected incidentally on radiologic imaging or during surgical intervention [10, 13–15]. The resulting events of GIF we observed also confused us frequently, which led to either further complications or spontaneous resolution. Interestingly, more of GIF often tended to relatively facile resolution rather than thorny complications, especially serious GIF, such as the case of multiple or diffuse. Little data exists regarding the risk factors for this complication, and few publications provide precise and adequate predictions of the risk for GIF in patients with SAP. Therefore, the early prediction of GIF and specific targeted interventions are imperative to reduce GIF-related mortality [16, 17]. In this retrospective study we analyzed the data from patients with SAP to determine the risk factors for developing GIF. Moreover, we also studied the different clinical characteristics and outcomes of GIF in the setting of SAP. Methods Patient enrollment From January 2011 to January 2016, patients with a primary diagnosis of SAP admitted to Departments of Emergency, Hepatopancreatobiliary Surgery, Gastroenterology, Surgical Intensive Care Units of Zhongshan Hospital (Xiamen, China) within 72 h from the onset of the disease were screened for enrollment, and including some critical patients confirmed SAP who transferred from other facilities. Demographic and clinical characteristics of patients were collected at the time of admission. Our criteria are consistent with that recommended in the Revised Atlanta Classification (RAC-2013) [18] and the revised guidelines of the Italian Association for the Study of the Pancreas (AISP-2014) [9]. To ensure the inclusion of only eligible patients with SAP, only those with an acute inflammatory process of the pancreas associated with variable severity were included, such as the presence of organ failure and local/systemic complications. Patients who met the following criteria were excluded: (1) patients developed GIF after iatrogenic intervention or surgical management;(2) younger than 18 years old age; (3) previous diagnosis of chronic liver and gastrointestinal disease; (4) pregnancy or severe immune system disorders; (5) Page 2 of 8 end-stage chronic disease; (6) patients with incomplete data (e.g., deceased within 24 h after ad (...truncated)