Management of Enterocutaneous Fistulas: To Pack or Not to Pack

Enterocutaneous fistulas should not be routinely packed, with management approach determined by the location and output of the fistula. 1

Fistula Management Based on Location and Output

Patients with distal (low ileal or colonic) fistulas with low output can receive nutritional support via the enteral route (generally as food) without requiring packing 1
Patients with proximal fistulas and/or very high output should receive nutritional support by partial or exclusive parenteral nutrition rather than packing 1
Management of enterocutaneous fistulas requires a multidisciplinary approach including gastroenterologists, surgeons, and dietitians 1, 2

For anorectal abscesses (which can lead to fistulas), the role of wound packing after drainage remains unproven despite being common practice 1, 3
A Cochrane review concluded it's unclear whether packing influences healing time, wound pain, fistula development, or abscess recurrence in anorectal abscesses 1, 3
A multi-center observational study found that packing of anorectal abscesses is costly and painful without providing clear benefits to the healing process 1, 3

Nutritional optimization is critical, as malnutrition (BMI <20 kg/m²) is an independent risk factor for complications 1
For high-output fistulas (>500 ml/day), management is more complex and challenging 2
Negative pressure wound therapy (NPWT) with appropriate interface protection may be beneficial for managing the surrounding wound while protecting exposed bowel 1, 4
An interface layer must be used to protect exposed organs and avoid adhesions between the bowel and abdominal wall when using NPWT 1

If a fistula is low and doesn't involve sphincter muscle (subcutaneous), perform fistulotomy at the time of abscess drainage 1, 3
If the fistula involves sphincter muscle, place a loose draining seton rather than packing 1, 3
Avoid probing to search for a non-obvious fistula to prevent iatrogenic complications 1, 3

Up to 70% of patients with fistulas have malnutrition, which significantly impacts spontaneous fistula closure 2
Early nutritional support, regardless of administration route, decreases the occurrence and severity of fistulas 1
For proximal or high-output fistulas, parenteral nutrition with gut rest may be more effective than enteral feeding 1, 5
Surgical correction is more likely to be successful if nutritional status is optimized preoperatively 1

Attempting to pack high-output proximal fistulas, which are better managed with parenteral nutrition and gut rest 1
Probing for non-obvious fistulas, which can create iatrogenic complications 1, 3
Neglecting nutritional status, which is a significant prognostic factor for spontaneous fistula closure 1, 2
Premature surgical intervention before adequate nutritional optimization 1, 6
Failing to distinguish between management approaches for different types of fistulas (proximal vs. distal, high vs. low output) 1