What is the treatment for a controlled fistula?

From the Guidelines

The treatment for a controlled fistula should start with insertion of a seton to control sepsis and create a patent tract, followed by medical treatment, preferably anti-TNF therapy, as recommended by the most recent guidelines 1. This approach is based on the latest evidence from the ECCO guidelines on therapeutics in Crohn's disease, which emphasizes the importance of a combined medical and surgical approach in managing perianal fistulising Crohn's disease. The initial focus is on maintaining the controlled status by ensuring adequate drainage, protecting surrounding skin with barrier products, and managing output with collection devices. Nutritional support is crucial, often requiring high-protein diets, vitamin supplementation, and sometimes parenteral nutrition if enteral feeding is compromised. Medications may include antibiotics for infection, octreotide to reduce gastrointestinal secretions for digestive tract fistulas, and pain management as needed. Once the patient is stabilized with resolved infection and improved nutritional status, definitive closure can be considered, which may involve surgical intervention such as resection with primary anastomosis, advancement flaps, or placement of biological plugs depending on the fistula type. For some fistulas, especially small ones with low output, conservative management with continued drainage and wound care for 4-6 weeks may allow spontaneous closure, as supported by previous studies 1. However, the most recent and highest quality study 1 suggests that surgical closure under anti-TNF therapy can achieve MRI closure in up to 40% of cases, with no recurrences after long-term follow-up, making it a preferred approach for eligible patients. The treatment approach is individualized based on the specific characteristics of the fistula and the patient's overall condition, with the goal of achieving complete closure while minimizing complications. Key considerations include the location, size, and underlying cause of the fistula, as well as the patient's nutritional status, presence of infection, and overall health. By prioritizing a combined medical and surgical approach, healthcare providers can optimize outcomes for patients with controlled fistulas, reducing morbidity, mortality, and improving quality of life.

From the Research

Treatment for a Controlled Fistula

The treatment for a controlled fistula can vary depending on the type and location of the fistula.

• For a lymphatic fistula, treatment may include:
  • Total parenteral nutrition 2
  • Administration of subcutaneous octreotide or intravenous somatostatin to decrease lymph output 2, 3
  • Progressive withdrawal of abdominal drainage to promote healing 2
• For perianal fistulas in Crohn's disease patients, treatment may involve a multidisciplinary approach combining surgical and medical management, including:
  • Fistulotomy, fistulectomy, seton procedure, fistula plug insertion, video-assisted ablation of the fistulous tract, stem cell therapy, and proctectomy with stoma creation 4
  • Medical management with antibiotics, immunomodulators, and biologics including anti-tumor necrosis factor-alpha agents 4
• For enterocutaneous fistulas, treatment may involve:
  • An interdisciplinary approach with nutrition care, wound/stoma care, and pharmacists 5
  • Optimization of nutrition status, with consideration of immune-enhancing formulas and somatostatin analogues 5
• For anal fistulas, surgical treatment options may include:
  • Fistulotomy for simple intersphincteric anal fistulas 6
  • Sphincter-saving techniques such as ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps for complex anal fistulas 6
  • Novel techniques such as fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) 6