Review Nutrition and management of enterocutaneous fistula D. A. J. Lloyd 1 , S. M. Gabe 1,2 and A. C. J. Windsor 3 1 The Lennard-Jones Intestinal Failure Unit, St Mark’s Hospital and Academic Institute, Harrow, 2 Division of Surgery, Oncology, Reproductive Biology and Anaesthetics, Imperial College, London and 3 Department of Surgery, University College Hospital, London, UK Correspondence to: Dr D. A. J. Lloyd, The Lennard-Jones Intestinal Failure Unit, St Mark’s Hospital and Academic Institute, Watford Road, Harrow HA1 3UJ, UK (e-mail: dajl@btinternet.com) Background: The management of enterocutaneous fistula is challenging, with significant associated morbidity and mortality. This article reviews treatment, with emphasis on the provision and optimal route of nutritional support. Methods: Relevant articles were identified using Medline searches. Secondary articles were identified from the reference lists of key papers. Results and conclusion: Management of enterocutaneous fistula should initially concentrate on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output. The routine use of somatostatin infusion and somatostatin analogues remains controversial; although there are data suggesting reduced time to fistula closure, there is little evidence of increased probability of spontaneous closure. Malnutrition is common and adequate nutritional provision is essential, enteral where possible, although supplemental parenteral nutrition is often required for high-output small bowel fistulas. The role of immunonutrition is unknown. Surgical repair should be attempted when spontaneous fistula closure does not occur, but it should be delayed for at least 3 months. Paper accepted 7 June 2006 Published online 27 June 2006 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5396 Introduction Enterocutaneous fistulas are abnormal communications between the gastrointestinal tract and the skin. Although rare, they are associated with considerable morbidity and mortality. Death related to enterocutaneous fistula remains disproportionately high compared with that associated with other surgical conditions. Studies reported over the past 30 years have shown mortality rates of 5–41 per cent 1–25 , with rates of 6–33 per cent in the most recent case series 4,13,15,17 . Sepsis was the leading cause of death in all of these studies. Increased mortality has been shown to be associated with high initial fistula output and the presence of complications 4 ; logistic regression analysis by Altomare et al. 26 identified increased Acute Physiology And Chronic Health Evaluation II scores and low serum albumin concentrations as predictors of mortality. Similar multivariable logistic regression analyses of retrospective data from St Mark’s Hospital identified high initial fistula output and the presence of patient co-morbidity as factors increasing the risk of death (unpublished observations). The management of enterocutaneous fistula continues to present a considerable challenge to surgeons, gastroen- terologists and allied professionals, and this has resulted in a variety of different management strategies. Patients have frequently undergone several operative procedures, and their physiological and nutritional reserves are often severely compromised. Management should focus initially on correction of fluid and electrolyte disturbances, aggres- sive treatment of sepsis and control of fistula output. Nutritional requirements must be addressed and atten- tion paid to skin care and psychological support. Only after these issues have been dealt with adequately, and if the fistula persists after conservative measures, should further surgery be contemplated. This article reviews the management of fistulas arising from the small intestine and colon, with particular emphasis on the provision and optimal route of nutritional support. Where possible, the article explores the evidence basis behind management protocols. However, much of the literature concerning enterocutaneous fistula is in the form of retrospective reviews, usually originating from large Copyright  2006 British Journal of Surgery Society Ltd British Journal of Surgery 2006; 93: 1045–1055 Published by John Wiley & Sons Ltd