Management of Enterocutaneous Fistulas Worldwide: Challenges, Practices, and Outcomes

Abstract

Enterocutaneous fistulas (ECFs) are among the most devastating complications in surgical practice. Management requires a multidisciplinary approach focused on sepsis control, nutritional optimization, fistula closure, and restoration of quality of life. A comprehensive review of PubMed and Google Scholar was conducted for the period from 2000 to 2025. Given the paucity of recent literature from low- and middle-income countries (LMICs), data from the past 25 years were included to capture broader insights into the topic. The Salford unit in the United Kingdom introduced the SNAP strategy (Sepsis, Nutrition, Anatomy, and Plan), which emphasizes infection control, nutritional support, anatomical definition, and surgical planning. While this structured approach has improved outcomes in high-income countries (HICs), its translation to LMICs remains challenging. Limited access to broad-spectrum antibiotics, advanced imaging, and modern wound care techniques hampers early management. Nutrition, which is central to fistula therapy, is optimized in HICs through tailored enteral and parenteral regimens. In contrast, LMICs often depend on modified oral or nasogastric feeding, which, although less effective, can provide reasonable outcomes when delivered consistently. Definitive management includes effluent control, skin protection, and surgical intervention. Advanced modalities such as negative pressure wound therapy (NPWT), octreotide, parenteral nutrition, and abdominal wall reconstruction with biological meshes are widely available in HICs. In LMICs, however, clinicians frequently rely on improvised NPWT systems, have limited access to pharmacological adjuncts and parenteral nutrition, and often resort to staged operations with fewer reconstructive options. This review highlights persistent management gaps in LMICs and emphasizes the urgent need for more robust data to better define challenges, guide policy, and adapt treatment strategies to resource-limited settings.

Keywords

• Developing countries
• enterocutaneous fistula
• intestinal fistula
• negative-pressure wound therapy
• nutrition therapy
• sepsis

Dünya Çapında Enterokütanöz Fistül Yönetimi: Zorluklar, Uygulamalar ve Sonuçlar

Abstract

Enterokütanöz fistüller (EKF), cerrahi pratiğin en yıkıcı komplikasyonları arasında yer almaktadır. Yönetim; sepsis kontrolü, beslenmenin optimizasyonu, fistülün kapatılması ve yaşam kalitesinin yeniden sağlanmasına odaklanan multidisipliner bir yaklaşım gerektirir. 2000–2025 dönemini kapsayan kapsamlı bir PubMed ve Google Scholar taraması yapılmıştır. Düşük ve orta gelirli ülkelerden (LMIC) güncel literatürün sınırlı olması göz önünde bulundurularak, konuya daha geniş bir bakış açısı kazandırmak amacıyla son 25 yılın verileri dahil edilmiştir. Birleşik Krallık’taki Salford ünitesi, enfeksiyon kontrolü, beslenme desteği, anatomik tanımlama ve cerrahi planlamayı vurgulayan SNAP stratejisini (Sepsis, Nutrition, Anatomy, Plan) geliştirmiştir. Bu yapılandırılmış yaklaşım yüksek gelirli ülkelerde (HIC) sonuçları iyileştirmiş olsa da, LMIC’lere uyarlanması çeşitli güçlükler taşımaktadır. Geniş spektrumlu antibiyotiklere, ileri görüntüleme yöntemlerine ve modern yara bakımına sınırlı erişim erken dönemde yönetimi zorlaştırmaktadır. Fistül tedavisinin merkezinde yer alan beslenme, HIC’lerde özelleştirilmiş enteral ve parenteral rejimlerle optimize edilmektedir. Buna karşın LMIC’lerde sıklıkla modifiye oral veya nazogastrik beslenmeye başvurulmakta olup, bu yöntemler daha az etkili olsa da düzenli uygulandığında makul sonuçlar sağlayabilmektedir. Kesin tedavi; fistül akıntısının kontrolünü, cilt korunmasını ve cerrahi girişimi kapsamaktadır. Negatif basınçlı yara tedavisi (NPWT), oktreotid, parenteral beslenme ve biyolojik greftlerle abdominal duvar rekonstrüksiyonu gibi ileri modaliteler HIC’lerde yaygın olarak uygulanmaktadır. Ancak LMIC’lerde klinisyenler çoğunlukla doğaçlama NPWT sistemlerine başvurmakta, farmakolojik adjuvanlara ve parenteral beslenmeye erişimleri sınırlı kalmakta ve rekonstrüktif seçeneklerin daha kısıtlı olduğu aşamalı operasyonlara yönelmektedir. Bu derleme, LMIC’lerde süregelen yönetim boşluklarını vurgulamakta ve zorlukların daha iyi tanımlanabilmesi, politikaların yönlendirilmesi ve tedavi stratejilerinin kaynak kısıtlı ortamlara uyarlanabilmesi için daha güçlü verilere duyulan acil ihtiyacın altını çizmektedir.

Keywords

• Beslenme tedavisi
• enterokütanöz fistül
• intestinal fistül
• negatif basınçlı yara tedavisi
• sepsis

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