Surgical Treatment for Enterocutaneous Fistula
When Surgery is Indicated
Surgery for enterocutaneous fistula should be reserved for high-output fistulas (>500 ml/day), fistulas associated with bowel stricture or abscess, and those failing conservative management after adequate medical optimization—typically requiring 3-12 months of preparation including nutritional support, sepsis control, and allowing fibrous adhesions to lyse. 1, 2
Absolute Indications for Surgery
- High-volume fistulas (>500 ml/day) that cannot be controlled medically 1, 2
- Associated bowel stricture and/or intra-abdominal abscess 1, 2
- Failure of conservative management after adequate trial (typically 3+ months) 1, 2
- Complex fistulas with multiple tracts that reduce healing rates with anti-TNF therapy 1, 2
- Postoperative fistulas, where medical therapy is unlikely to help 1
Relative Indications
- Moderate-output fistulas (200-500 ml/day) failing medical therapy after 3-6 months 1
- Symptomatic fistulas causing significant quality of life impairment despite optimal medical management 3
Preoperative Optimization (Critical for Success)
Timing: The "Wait and Optimize" Approach
- Delay surgery 3-12 months after initial diagnosis or previous laparotomy to allow lysis of fibrous adhesions 4
- Never perform immediate resection at time of abscess drainage—this leads to poor outcomes 1, 2
Four-Step Preparation Protocol
Fluid and electrolyte balance: Aggressive IV resuscitation with normal saline (2-4 L/day), replace sodium losses (100 mmol/L per liter of output), restrict oral hypotonic fluids to <1000 ml/day 1, 2
Sepsis control: Treat abscesses with IV antibiotics and radiological drainage first; surgical drainage only if percutaneous approach fails 3, 1
Nutritional optimization:
Skin care: Protect peristomal skin with barrier products; consider negative pressure wound therapy to manage output and preserve skin integrity 2
Surgical Technique
Operative Principles
- Complete fistula tract excision with resection of involved bowel segment 4
- Primary anastomosis in healthy, well-vascularized bowel after adequate debridement 4
- Avoid multiple strictureplasties in close proximity—single resection is preferable if adequate bowel length remains 3
- Diverting ostomy may be necessary for complex cases or when primary anastomosis is high-risk 3
Expected Outcomes
- Operative success rate: 92% in modern series with proper patient selection and preparation 6
- 54% of enterocutaneous fistulas ultimately require surgery despite initial conservative management 1
- In-hospital mortality: 3% with modern multimodal approach (down from 44% in 1960) 6
Special Considerations
Crohn's Disease-Related Fistulas
- Attempt anti-TNF therapy first if associated with active inflammation (not postoperative fistulas) 3, 1
- Only one-third achieve fistula healing with anti-TNF therapy 1, 2
- Complexity and stenosis reduce medical therapy success—proceed to surgery earlier in these cases 1, 2
- Control proctitis medically before and after surgery to prevent recurrence 3
Low-Output Fistulas (<200 ml/day)
- Trial of conservative management for 3-6 months with enteral nutrition and skin care 1, 2
- Consider anti-TNF therapy if Crohn's-related 1, 2
- Approximately one-third close spontaneously with medical treatment alone 4
Critical Pitfalls to Avoid
- Never start anti-TNF therapy before draining abscesses—this worsens sepsis (one-third of patients developed abscesses on anti-TNF) 1, 2
- Never operate immediately without nutritional optimization and sepsis control—leads to poor outcomes and high mortality 1, 2
- Never neglect skin care—breakdown causes significant additional morbidity and complicates surgical planning 2
- Never operate during active inflammation in Crohn's disease—medically control disease first 3
Multidisciplinary Team Requirements
Surgery should only proceed after coordination between gastroenterology, surgery, interventional radiology, nutrition, and wound care specialists 4, 6