Difficult question! It depends on the situation and the time! If you have an early fistula, perhaps early reintervention with resection and anastomosis is an option after complete adhesiolysis. If the situation is more complex after the second/third reintervention or after HIPEC after neoadjuvant treatment totally conservative treatment with only drainage placement nearby might be an valuable option, too. You have to differntiate the risks of reintervention versus "conservative" treatment. A simple or standard treatment Regime is not possible!

First question is the patency of the loops below the fistula; second TPN, and eventually VAC

Reoperation should be considered only in case of early detection, no R1-2 for cancer surgery, few comorbidity (medium to high life-expectacy not correlated to the fistula). Any other case is to be treated on-demand, no guidelines could be provided. During the wait and see time, TPN is mandatory. An attempt to spontaneous healing is an option, while VAC therapy could be of some help. A second look operation is the last choice, removing any foreign bodies (i.e: prosthesis).

All above mentioned treatment options are feasible, and as stated by the colleagues it greatly depends on the specific situation. Variables that need to be taken into account are current status of the patients: e.g. cancer status, R0 vs. tumor progress, infection signs, nutrition status and patients wish. In addition, the local situation needs to be considered: high vs. low output fistula, conditions of the surrounding tissue and time from previous operations.

Agree with all of the above. Non-op tx with TPN is usually best initial method of treatment. In an entero-atmospheric fistula, use of a wound manager (like a big colostomy bag) will help protect the skin and has a suction port at the inferior portion to remove the succus. These difficult patients will usually require 6 months of TPN, with attention to enteric losses and replacement. If you wait 6 months, your chance of restoring enteric continuity and resecting the fistula sites is best.

I would recomend TPN and a trial of conservative treatment however high output fistulas will need aggressive operative management. There seems to be a remote chance for resection as there is almost no place of resection and anastamoses but palliative procedures with a laprostomy may work

Enterocutaneous fistulas following adhesiolysis in hostile abdomen with small bowel obstruction.

If there is bowell obstruction, it is mandatory to solve it because the fistula will never closed. In most cases that means a new surgical intervention. The key is to find the right time. First of all we need a patient in good nutritional state, with no active infections, phisically active, and to take care of the skin around the fistula ; we need a good map of the fistulae, and the possible points of bowell obstruction. And we have to tell the patient the risks of the surgery: short bowell, ostomies, new fistulae, TPN at home, ... Then you have to arrange a long lasting operation day and perform a deliberate and reflexive surgery.

This is a very challenging situation even for experienced surgeons.

The problem with timing in most of these cases is the surgeon: often the impatience of the surgeon seems to have the priority. All conservative measures as mentioned above should be taken and then almost every patient can reach an anabolic status. Waiting time can be 6 to 12 months.

The biggest challenge to the surgeon in the developing world that makes him impatient are the spiraling costs of surpportive treatment and the absence of a universal comprehensive medical insurance scheme.

It is a challenge.Conservative line of management ,NBM,TPN,skin protection are important .Once the fistula matures,cect will guide us to resect.Glue injections if the fistulous opening is small can be tried.Overall it is a long process,special care units are

very helpful.In hostile abdomen surgical interventions make things worse.

If you are dealing with a high output fistula/as, any type of medical and conservative treatments have the only function of improving the nutritional and metabolic state of the patient in order to prepare him/her to an unavoidable new surgical procedure, which quite often is difficult, needs great experience in abdominal surgery, and in the majority of these cases I always recommended a delayed primary closure of the abdomen just to be sure of the tightness of the anastomoses and the absence of any septic foci. The medical treatment to improve the patient's conditions should not last more than one month, and the final closure of the abdomen should be performed after 2-3 revisions of the cavity during the first post-operative week.

The treatment in such scenario is as follow:

1. NPO and maintain nutrition by TPN.

2. Control of sepsis by antibiotics.

3. Skin protection and control of fistula affluents.

4. You may use VAC therapy cautiously as this may cause mor fistulae to develop.

5. In case of high output you may try somatostatin.

6. Make sure there is no distal bowel obstruction as this will preclude fistula closure.

7. Majority will close but after 6-8 weeks, surgical intervention is contemplated if no signs of closure.

I am sorry, I don't entirely agree that high output fistulas "in the majority of the cases" will close. Moreover, I don't think there is any evidence that somatostatin is able to turn a high output fistula into a low output fistula, and if this treatment is just a try it's an expensive and often an useless try.

I never saw an high output fistula that was significantly influenced with somatostatin or sandostatin - despite many attempts. As Renzo stated all conservative therapy in high output fistula has the aim to improve the patients general and nutritional status preoperative.

These are difficult patients to manage. There is a physical and psychological dimension that their care needs to address. I agree with many of the comments. Ideally patients should be managed within a multidisciplinary team and with involvement of the nutrition team. The patient's expectations need careful consideration. An anatomy 'roadmap', good nutrition and adequate time for the peritoneal cavity to 'mature' are important considerations. Thought should be given to whether the abdomen can be closed primarily or alternative closure strategies need to be considered. Obstuction, poor nutrition, ongoing sepsis, occult malignancy or prior radiation therapy are significant predictors of a poor outcome

I think that the most important thing is how's the patient: is the fistula completely drained without signs of peritonitis? if this is the scenario wait and see could be the correct choice even for a long time. Obviously we have to manage properly the patient during the waiting period. In our experience if the fistulas is completely drained the chance of healing is high but if the output is high we'll have a stoma and the outcome for the patient is mostly due where this stoma is.

Like Dr Abdul-Wahed remarked, I've had bad experience using VAC when there is evidence of a fistula. Seems to worsen prognosis.

Management of a high output fistula can be quite challenging. Octreotide, NWPD and supportive measures including nutrition all have a role to play. The degree of tissue elasticity which depends on local factors like sepsis and tumor spread will decide on whether or when to intervene surgically. There is no hard and fast rule. The patients characteristics and the local wound state would guide in making this important decision. My experience with NWPD or VAC has been good so far.

The real issue is the presence of a enteral fistulization inside of an open abdomen. This fact reduces the treatment options. Applying a negative pressure dressing will increased the fistula output, so actually the problem is how to transform an entero-atmospheric fistula in an entero-cutaneous one. The 2nd one is more easy to manage and allows to apply some negative pressure dressing, favoring the abdominal closure, and then more comfortably handle the enteric fistula.