One operation, two challenges: systematic review and single arm proportional meta-analysis of concurrent enterocutaneous fistula takedown and ventral hernia repair.

backgroundEnterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and skin, often arising postoperatively or due to inflammatory diseases, malignancies, trauma, or radiation. Based on etiology, anatomical factors, and patient conditions, their management can differ. Patients with ECF frequently present with concurrent ventral hernia. Repairing the hernia during ECF takedown is debated due to contamination, dense adhesions, and prior operations that raise complication and recurrence risks. This study aims to analyze the treatment of ventral hernia in patients with ECF focusing on postoperative complications, including surgical site infection, hernia recurrence, fistula recurrence, reoperation, and mortality.

methodsThe study was conducted following a comprehensive search in PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science. A search strategy was performed until its conclusion in March 2025. Studies including patients ≥ 18 years with ECF and ventral, or incisional hernia were eligible. Data on patient demographics, ECF etiology, treatment strategies, surgical outcomes, recurrence and mortality were extracted and analyzed individually. Single-arm proportional meta-analyses were performed in R. Mortality was pooled with a binomial GLMM (logit). Surgical Site Infection (SSI), hernia recurrence, fistula recurrence, and reoperation used inverse-variance random-effects models on the logit scale. Results are reported as pooled proportions with 95% CIs. Quality assessment was evaluated with the ROBINS-I tool.

resultsThe initial search provided 1,115 studies, and 9 met the inclusion criteria after screening and full-text analysis. A total of 697 patients were analyzed in the included studies, with a mean age of 57 years (standard deviation of 14.9), 55.1% male, and an average body mass index of 28.5 kg/m2 (SD 7.3). All patients underwent simultaneous ECF treatment and abdominal wall repair. Mesh was used in 476 patients (68.3%), including 265 biologic (38%), 169 synthetic (24.2%), 42 biosynthetic (6.1%). Pooled rates were: SSI 41% (95% CI: 0.28–0.56; I² = 85.6%), hernia recurrence 27% (95% CI: 0.19–0.37; I² = 81.4%), fistula recurrence 9% (95% CI: 0.05–0.16; I² = 71.8%), reoperation 14% (95% CI: 0.07–0.26; I² = 86.6%), and mortality 2% (95% CI: 0.01–0.06; I² = 12.4%). Follow up varied from 1 to 153 months across the studies.

conclusionThe management of ECF in the context of abdominal wall repair remains challenging, with high rates of SSI, hernia and fistula recurrence. Mesh reinforcement, predominantly in a sublay position, was used in most cases, yet recurrence rates highlight the need of a better timing for a proper surgical repair.