A modern multidisciplinary approach to the treatment of enterocutaneous fistulas in Crohn’s disease patients

ABSTRACT

Introduction

Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn’s disease (CD) that is challenging to treat and has considerable morbidity and mortality rates.

Areas covered

This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients.

Expert opinion

Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-α therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting.

KEYWORDS:

• Enterocutaneous fistula
• crohn’s disease
• sepsis
• enteral nutrition
• anti-TNF-α

Article highlights

• Enterocutaneous fistulas (ECFs), although rarer than perianal fistulas, are among the most feared manifestations of penetrating CD since they are associated with significant morbidity and mortality

• The treatment of ECFs in CD patients is a challenge for physicians and requires a multidisciplinary approach to obtain satisfactory results and minimize consequences and recurrences

• Sepsis resolution is the most important prognostic factor for the healing of ECFs; thus, intensive treatment is mandatory.

• The correction of malnutrition and prevention of specific nutrient deficiency by the adoption of effective nutritional support is of paramount importance in patients with ECFs.

• The psychological support of patients with ECFs must necessarily complement conventional therapies, nutrition and nursing care. The optimal timing of surgery for ECFs is crucial for subsequent outcomes, such as postoperative morbidity, recurrence and mortality.

• The control of fistula output should be attempted as far as possible since the amount of enteric loss is a crucial prognostic factor for ECF healing.

• The psychological support of patients with ECFs must necessarily complement conventional therapies, nutrition and nursing care.The optimal timing of surgery for ECFs is crucial for subsequent outcomes, such as postoperative morbidity, recurrence and mortality.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This paper was not funded.