Enterocutaneous Fistula: Guidelines for an Evolving Problem

Importance: The care and outcome of enterocutaneous fistula (ECF) have improved greatly over several decades due to revolutionary advances in nutrition, along with dramatic improvements in the treatment of sepsis in the critically ill. However, as the collective experience with damage control surgery has matured, the frequent development of enteroatmospheric fistulas (EAF) in the open abdomen patient has emerged as an even more vexing problem. Despite our best efforts, ECFs and especially EAFs continue to be highly morbid conditions, and sepsis and malnutrition remain the leading causes of death. Aggressive nutritional, metabolic support and multidisciplinary approach is the most significant predictor of outcome with ECFs and EAFs. Observations: Discussion of the historical advances in therapy and their impact on ECFs, as well as review of the classification of ECFs and EAFs, provides a framework for the suggested phased strategy that specifically targets the nutritional and metabolic needs of the ECF/EAF patient. These three phases include (1) diagnosis, resuscitation, and early interval nutrition; (2) definition of fistula anatomy, drainage of collections, nutritional assessment and monitoring, and placement of feeding access; and (3) definitive operative management. Conclusion: The successful management of GI fistula requires a multidisciplinary team approach including a gastroenterologist, interventional radiologist, enterostomal therapist, dietician, social worker and surgeons. With this coordinated approach, EC fistula can be controlled with acceptable morbidity and mortality.