Operative strategy in the treatment of enterocutaneous fistulas

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Abstract
An overall plan for the management of patients with enterocutaneous fistulas is presented. It comprises 4 sequential but frequently overlapping stages which include control of the fistula output, drainage of sepsis, intravenous nutrition, and excision of the fistula if there is no spontaneous closure.When the fistula persists, radiological investigations usually reveal the cause, and definitive surgery is required. This is conducted 6–8 weeks after all signs of sepsis have gone and the patient has been restored to nutritional health. For fistulas of the distal duodenum, jejunum, and ileum, the surgical procedure is a radical one involving complete dissection of the entire small intestine, resection of the segment of bowel involved, and primary anastomosis. Occasionally, especially when there has been abdominal irradiation, it is not possible to excise the diseased bowel, and bypass is preferred. Fistulas of the second part of the duodenum are treated by the serosal patch technique in which the jejunal wall is sutured directly to the opening of the fistula.Surgery is also often required early in the course of treatment when abscesses are drained and proximal diversion (with or without excision of the involved segment of bowel) may be required to control the fistula output. Definitive surgery at this stage frequently results in recurrence of the fistula and carries a high mortality rate.