What is the management of an enterocutaneous fistula?

Management of Enterocutaneous Fistula

The management of enterocutaneous fistulas (ECFs) requires a multidisciplinary approach with treatment tailored based on fistula location and output, with proximal or high-output fistulas requiring parenteral nutrition while distal or low-output fistulas can often be managed with enteral nutrition. 1

Initial Assessment and Classification

• ECFs are best classified based on output volume: low (<200 ml/day), moderate (200-500 ml/day), and high (>500 ml/day) 2
• ECFs typically communicate with segments of active inflammation, often with complications including intra-abdominal abscess and luminal strictures, or with surgical anastomoses 1
• MRI is the preferred diagnostic tool for defining fistula anatomy with highest sensitivity and specificity 2

Initial Management (First Phase)

Control of Sepsis

• Intra-abdominal abscesses should be treated with intravenous antibiotics and radiological drainage when possible 1
• Surgical drainage may be required but immediate resection should be avoided 1
• Anti-TNF therapy should only be started after abscesses have been adequately treated to avoid worsening sepsis 2

Fluid and Electrolyte Management

• Immediate fluid resuscitation and electrolyte rebalancing is critical, especially for high-output fistulae 2
• Monitor and replace losses, particularly in high-output fistulae which lead to significant dehydration 2
• High-output fistulas require restriction of hypotonic/hypertonic fluids to <1000 ml daily 3

Nutritional Support

• Nutritional assessment and optimization is essential for all patients with ECF 1
• For distal (low ileal or colonic) fistula with low output, enteral nutrition is appropriate 1
• For proximal fistula and/or very high output, partial or exclusive parenteral nutrition is recommended 1
• Surgical correction is more likely to be successful if nutritional status is optimized preoperatively 1
• Be vigilant for refeeding syndrome in patients with prolonged nutritional deprivation 1

Skin and Wound Care

• Protect skin from fistula output to preserve peri-wound skin integrity 2
• Negative Pressure Wound Therapy (NPWT) may help manage output and protect surrounding skin 2
• NPWT can secure bag adhesion and simultaneously manage adjacent wounds 2

Definitive Management (Second Phase)

Medical Therapy

• If a fistula is associated with active inflammation (particularly in Crohn's disease), medical therapy with anti-TNF agents should be attempted 1
• Anti-TNF therapy has shown limited success with approximately one-third of patients achieving fistula healing 1, 2
• A study of short-peptide-based enteral nutrition for three months showed successful closure of ECFs in 62.5% of Crohn's disease patients 1
• Medical therapy is unlikely to help postoperative fistulae 1

Surgical Management

• Surgery should be delayed for at least 3 months to allow for spontaneous closure and optimization 4
• High-volume fistulae usually require surgery for definitive management 2
• Complexity (multiple tracts) and associated stenosis reduce rates of healing with anti-TNF therapy and increase need for surgery 1
• Surgery was required in 54% of patients with enterocutaneous fistulae in a retrospective series 1
• If fistulae are associated with bowel stricture and/or abscess, surgery is strongly recommended 2

Special Considerations

Crohn's Disease-Related ECFs

• Treatment should involve a multidisciplinary team including gastroenterologist, surgeon, and dietitian 1
• Anti-TNF therapy may be more effective for inflammatory rather than postoperative fistulae 1
• One-third of patients treated with anti-TNF therapy developed intra-abdominal abscess, highlighting the need for careful monitoring 1

Postoperative ECFs

• Conservative approaches can be attempted but have limited success 1
• Surgical intervention is often necessary but should be performed after adequate preparation 1

Pitfalls to Avoid

• Initiating anti-TNF therapy before adequate drainage of abscesses can worsen sepsis 2
• Immediate surgical resection without adequate preparation leads to poorer outcomes 2
• Neglecting skin care can lead to significant skin breakdown and additional morbidity 2
• Failure to address associated complications (strictures, abscesses) will reduce success rates of both medical and surgical interventions 2