Prevention of Enterocutaneous Fistula
To prevent enterocutaneous fistula formation, optimize nutritional status preoperatively (especially if BMI <20 kg/m²), provide early nutritional support in surgical patients, and implement specific intraoperative protective measures including early abdominal wall closure, bowel coverage with plastic sheets or omentum, avoidance of direct synthetic mesh contact with bowel, and deep burying of intestinal anastomoses. 1
Preoperative Nutritional Optimization
The most critical modifiable risk factor for fistula prevention is malnutrition, with BMI <20 kg/m² appearing as an independent risk factor for fistula formation. 1
For patients with Crohn's disease or inflammatory bowel disease:
- Assess nutritional status before any planned surgery 1
- Provide at least 5-7 days of preoperative nutritional support to reduce postoperative morbidity 1
- Use exclusive enteral nutrition (EEN) for 3-6 weeks preoperatively in high-risk patients, which has demonstrated:
- If enteral nutrition is not tolerated, use parenteral nutrition (PN) for at least 5 days preoperatively 1
The evidence strongly supports that early nutritional support in surgical patients decreases both the occurrence and severity of fistulas, independent of the route of administration. 1
Intraoperative Preventive Measures
During open abdomen procedures or high-risk abdominal surgeries, implement these imperative preemptive measures: 1
- Achieve early abdominal wall closure whenever physiologically possible 1
- Cover bowel loops with plastic sheets, omentum, or skin to prevent direct exposure 1
- Avoid direct application of synthetic prosthesis (polypropylene, PTFE, polyester) over bowel loops 1
- Never apply negative pressure wound therapy (NPWT) directly on viscera 1
- Bury intestinal anastomoses deeply under bowel loops to protect them 1
These measures are particularly critical in trauma patients, those with severe peritonitis, or any patient requiring damage control surgery. 1
Postoperative Early Nutritional Support
Initiate nutritional support early in the postoperative period for all surgical patients, as this independently decreases fistula occurrence and severity. 1
- For patients who can tolerate oral intake, advance diet as soon as possible 1
- If oral intake is not possible within one week after surgery, consider parenteral nutrition 1
- Monitor for signs of nutritional deprivation and implement standard precautions to prevent refeeding syndrome, particularly regarding phosphate and thiamine replacement 1
Special Considerations for Inflammatory Bowel Disease
In Crohn's disease patients with existing fistulas, proper nutritional management can facilitate fistula closure and prevent new fistula formation: 1
- For distal (low ileal or colonic) fistulas with low output, provide enteral nutrition 1
- For proximal fistulas or very high output fistulas, use partial or exclusive parenteral nutrition 1
- Short-peptide-based enteral nutrition for 3 months achieved successful closure in 62.5% of enterocutaneous fistulas in one study, likely due to improvement in inflammatory conditions and nutritional status 1
Critical Pitfalls to Avoid
Malnutrition: Failure to identify and correct malnutrition preoperatively significantly increases fistula risk. 1 Screen all surgical candidates and delay elective surgery if BMI <20 kg/m² until nutritional optimization is achieved. 1
Direct mesh-bowel contact: Placing synthetic mesh directly on bowel loops during open abdomen management is a major preventable cause of enteroatmospheric fistula formation. 1 Always interpose protective barriers. 1
Premature fascial closure: Attempting forced fascial closure under tension can lead to abdominal compartment syndrome and subsequent fistula formation. 1 Accept temporary open abdomen when necessary rather than risk ischemic bowel injury. 1
Delayed nutritional support: Waiting too long to initiate nutritional support postoperatively increases fistula risk. 1 Begin enteral or parenteral nutrition within the first week if oral intake is inadequate. 1