The pathophysiology of enterocutaneous fistulas

The patient with an enterocutaneous fistula represents a high-risk situation with overall mortality rates of up to 20%, depending on the series. Treatment of these patients to a successful outcome requires attention to detail and, if necessary, meticulous operative technique. For convenience, care of these patients is divided into 5 phases:

1. Stabilization. Resuscitation with crystalloid colloid and/or blood. Drainage of only obvious abscesses. Beginning of local wound care. Initiation of nutritional support.
2. Investigation. Radiographic investigation of local fistula area, principally by sinography and, if necessary, other contrast studies. Purpose of these studies is to determine likelihood of spontaneous closure with nutritional support.
3. Decision. Is operation indicated and, if so, when? A decision must be made as to the necessity for operative closure in situations in which the fistula appears anatomically favorable but shows no signs of closure.
4. Definitive therapy—either spontaneous closure or operation. If the latter, careful preparation is required. Resection and end-to-end anastomosis gives the best results.
5. Healing phase. Nutritional support should not be discontinued too soon for fear of breakdown of newly laiddown protein.

With experience and proper management, relatively high success rates can be achieved.