Management of enterocutaneous fistulas

Owen RM, Love TP, Perez SD, Srinivasan JK, Sharma J, Pollock JD, Haack CI, Sweeney JF, Galloway JR. Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience. JAMA Surg. 2013 Feb;148(2):118-26.

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Figure 1. Causes of enterocutaneous fistula between 1987 and 2010. IBD indicates inflammatory bowel disease; other includes radiation, neoplasm, and trauma. Percentages may total more than 100% owing to the fact that some patients’ ECFs were secondary to multiple causes.

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Bhama AR. Evaluation and Management of Enterocutaneous Fistula. Dis Colon Rectum. 2019 Aug;62(8):906-910.

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“For fistulas that do not close, operative intervention is indicated.[10] Before embarking on operative intervention, it is imperative to time the operation appropriately. A general consideration is to wait at least 6 months, which is associated with decreased mortality following the operation.11 This also allows to time for intra-abdominal adhesions to soften and improves the safety of the operation; some patients require waiting additional time to allow the tissues to achieve a workable state. If there was a skin graft in place, a “pinch test” can be performed to evaluate if the intestines have separated from the anterior abdominal wall.[7] Also, in the case of an enteroatmospheric fistula with surrounding granulation tissues, allowing the granulation tissue to epithelialize may help with wound healing postoperatively (Fig. 4). An encouraging sign that an enteroatmospheric fistula is ready for operation is when the intestines begin to prolapse. After an appropriate waiting period, it is necessary to define the anatomy. Computed tomography scan and small-bowel follow-through will delineate the anatomy, and a retrograde contrast study or endoscopic evaluation will identify distal obstruction. In addition, the abdominal wall should be evaluated for hernia and may require the assistance of a general surgeon or plastic surgeon who specializes in abdominal wall reconstruction.[6]” (p. 907-908)


Lloyd DA, et al. Nutrition and management of enterocutaneous fistula. Br J Surg. 2006 Sep;93(9):1045-55.

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Results and conclusion: Management of enterocutaneous fistula should initially concentrate on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output. The routine use of somatostatin infusion and somatostatin analogues remains controversial; although there are data suggesting reduced time to fistula closure, there is little evidence of increased probability of spontaneous closure. Malnutrition is common and adequate nutritional provision is essential, enteral where possible, although supplemental parenteral nutrition is often required for high-output small bowel fistulas. The role of immunonutrition is unknown. Surgical repair should be attempted when spontaneous fistula closure does not occur, but it should be delayed for at least 3 months.

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