Enterocutaneous Fistulas

As surgeons we are deeply affected by our postoperative complications, no matter how minor some may initially seem. We are also not infrequently called upon to personally treat or to help colleagues manage difficult clinical situations, whether as a result of the underlying disease process or from therapeutic endeavors. Although many are easily remedied, others leave us pondering as to how to proceed. Enterocutaneous fistulas (ECF), unfortunately, too often tend to fall into this latter group. With their wide-ranging etiology and variety of clinical factors potentially affecting management, each is extremely challenging in diverse aspects for both patient and physician alike.

Confounding the situation, patients with ECF may present in a wide array of physiologic states spanning from a chronic draining wound to florid sepsis. As such, clinicians caring for these patients must possess a sound, and often stepwise, approach for evaluation and treatment. In this issue of Clinics in Colon and Rectal Surgery, our objective was to fully explore the complex nature of caring for patients with ECFs to help optimize patient outcomes in what is likely an already problematical state of affairs.

Drs. Lundy and Fischer set the stage for the issue by providing an overview of ECF, including a fascinating look at the historical perspectives of this condition. Drs. Bleier and Hedrick discuss the metabolic support of the fistula patient including superb guidance on the initial goals of sepsis control, nutritional support, and available adjuncts for supportive care. Following patient stabilization, Drs. Lee and Stein present an in-depth review of the evaluation of fistula anatomy through both radiographic and endoscopic studies. The authors highlight the importance of detailing ECF anatomy to aid in successful outcomes, as well as the emerging role of minimally invasive alternatives for treatment. As a crucial component of the initial goals of ECF care, Drs. Hoedema and Suryadevara outline the principles of wound care along with the various techniques and tools available for enterostomal therapy to enhance patient comfort, recovery, and facilitate fistula healing.

As the presence of ECF in assorted clinical settings can have a major impact on both diagnostic and therapeutic considerations, the authors have compiled a comprehensive review with respect to the patient's underlying condition. Dr. Orangio begins with a thorough summary detailing the importance of a multidisciplinary approach to ECF care, the surgeon's role as the leader within that team, as well as some technical aspects with emphasis on those patients with Crohn's disease. Drs. de Campos-Lobato and Vogel tackle the difficult scenario of ECF management in those patients with underlying malignancy and prior radiation therapy, while Drs. Dubose and Lundy explore ECF management in the critically ill, posttraumatic, and thermally injured patient with an open abdomen including techniques to optimize fistula prevention. Dr. Ross provides insight into the principles of operative and reoperative surgery for ECF, highlighting technical details, timing considerations, and thoughts on how to proceed with recurrent fistulas following fistula surgery. Rounding out this issue, Drs. Johnson and Tushoski present an extensive evaluation of the described techniques of abdominal wall reconstruction in ECF patients including pitfalls with the various options. Finally, Drs. Williams, Zolfaghari, and Boushey review the complications associated with ECF management including emerging trends in the medical and surgical management of patients with perhaps one of the most feared complications, intestinal failure.

The authors of each of these articles are experts in their respective fields, and it has been my privilege and pleasure to work with them in developing this issue. I would like to personally thank each one of them for taking time out of their busy schedules to provide the most up-to-date management on these topics. It is my wish that this issue serve as a guide for surgeons who find themselves faced with this taxing and unfortunate situation. In closing, I would like to extend my gratitude to Dr. David Beck for allowing me to serve as a Guest Editor on this important topic.