Management of Enterocutaneous Fistulas

Abstract

An enterocutaneous (EC) fistula is defined as an abnormal connection between the gastrointestinal (GI) tract and the skin. The majority of EC fistulas are iatrogenic due to a missed enterotomy or anastomotic leak, and are generally defined based on their etiology, location and daily output. Patients may present either with drainage of enteric contents from the surgical site/abdominal wall or with abdominal pain, ileus, fevers, malaise, and computer tomography (CT) findings consistent with an intraabdominal abscess. Regardless of etiology, initial management requires a multidisciplinary approach consisting of fluid resuscitation, characterization of EC fistula and intraabdominal collections with cross-sectional imaging, control of sepsis, nutritional support, and local wound care. Spontaneous closure occurs in about one third of patients in the first 4–6 weeks after formation. Risks factors for nonspontaneous closure include high fistula outputs, distal obstruction, ongoing infection, inflammatory bowel disease, epithelialized or short (<2 cm) fistulous tract, retained foreign body such as mesh, and presence of underlying neoplasia. Definitive surgical management should be deferred at least 12 weeks from fistula formation in patients whose nutrition has been maximally optimized and sepsis has been completely controlled. Surgical management consists of lysis of adhesions and takedown of EC fistula with resection of affected bowel and may require complex abdominal wall repair.