What is the treatment for enterocutaneous fistula?

Treatment of Enterocutaneous Fistula

The treatment of enterocutaneous fistulas requires a multidisciplinary approach with low-volume fistulae potentially managed with immunomodulator and biological therapy, while high-volume fistulae usually require surgical intervention for symptom control. 1

Classification and Initial Assessment

• Enterocutaneous fistulae (ECF) are best classified based on their output: low (<200 ml/day), moderate (200-500 ml/day), and high (>500 ml/day) 1
• ECFs usually communicate with segments of active inflammation, often in the context of other complications including intra-abdominal abscess and luminal strictures, or with surgical anastomoses 1
• MRI is the preferred diagnostic tool for enteric fistulas, with the highest sensitivity and specificity 1

Initial Management (Stabilization Phase)

1. Fluid and Electrolyte Balance

• Immediate fluid resuscitation and electrolyte rebalancing is critical, especially for high-output fistulae 1, 2
• Monitor and replace losses, particularly in high-output fistulae which can lead to significant dehydration and electrolyte imbalances 1

2. Control of Sepsis

• Anti-TNF therapy should only be started after abscesses have been treated with antibiotics and, where possible, drainage 1
• Intra-abdominal abscesses should be treated initially with intravenous antibiotics and radiological drainage when possible 1
• Surgical drainage may be required but immediate resection should be avoided 1

3. Nutritional Support

• Nutritional optimization is essential before definitive management, particularly in high-output fistulae 1, 2
• Parenteral nutrition is often initially required, but enteral nutrition should be considered when possible 3
• In the context of a high output fistula with nutritional deficiency, a patient will require a period of nutritional and biochemical optimization before definitive surgical management 1

4. Skin Care

• Protect skin from fistula output to preserve peri-wound skin integrity 1
• Negative Pressure Wound Therapy (NPWT) may be used to manage output of fistulae and protect surrounding skin 1

Definitive Management

For Low-Volume Fistulae:

• Low-volume enterocutaneous fistulae may be controlled with immunomodulator and biological therapy 1
• If a fistula is associated with active inflammation, medical therapy with anti-TNF agents is worthwhile 1
• Anti-TNF therapy has shown limited success with approximately one-third of patients achieving fistula healing 1
• Medical therapy is unlikely to help postoperative fistulae 1

For High-Volume Fistulae:

• High-volume fistulae usually require surgery to achieve symptom control 1
• Surgery should be planned after stabilization through the four steps: fluid/electrolyte balance, control of sepsis, nutritional improvement, and skin care 1
• In a retrospective series, surgery was required in 54% of patients with enterocutaneous fistulae overall 1

Negative Pressure Wound Therapy (NPWT) Considerations:

• NPWT can be used to manage and divert fistula output away from the open abdominal wound 1
• For visible fistulae, a "floating stoma" approach using an ostomy bag with NPWT can be effective 1
• NPWT can help achieve secure bag adhesion and simultaneously manage adjacent wounds 1
• Once output is controlled and a granulating bed achieved, skin grafting may be considered 1

Special Considerations

Complexity Factors

• Complexity (multiple tracts) and associated stenosis reduce rates of healing with anti-TNF therapy and increase need for surgery 1
• Increasing complexity of the fistula is associated with adverse outcomes including mortality 1

Crohn's Disease-Related Fistulae

• If fistulae are associated with bowel stricture and/or abscess, surgery is strongly recommended 1
• In Crohn's disease, approximately two-thirds of ECFs require surgical intervention despite medical therapy 2

Outcomes

• Modern treatment approaches have significantly reduced mortality rates from ECF, from 44% in 1960 to as low as 3% in recent studies 3
• Surgical repair has been associated with 92% operative success in selected cases 3
• Spontaneous closure of fistulae with conservative management has been reported in 13 of 24 pediatric cases in one series 4

Pitfalls to Avoid

• Initiating anti-TNF therapy before adequate drainage of abscesses can worsen sepsis 1
• Immediate surgical resection without adequate preparation (nutritional optimization, sepsis control) leads to poorer outcomes 1
• Failure to address associated complications (strictures, abscesses) will reduce success rates of both medical and surgical interventions 1
• Neglecting skin care can lead to significant skin breakdown and additional morbidity 1