Enterocutaneous fistulas. Effects of total parenteral nutrition and surgery

Fifty patients with 68 enterocutaneous fistulas were retrospectively reviewed at Hennepin County Medical Center from 1967 to June 1981. Eleven of 28 patients, treated with total parenteral nutrition (TPN) as the initial therapy for their fistulas, had spontaneous closure of 22 of 44 fistulas (three gastroduodenal, 17 small-bowel, two colonic fistulas). There were 35 operative procedures resulting in the closure of 26 fistulas, ten of which had failed to close with TPN (two gastroduodenal, ten small-bowel, and fourteen colonic fistulas). Overall mortality was 22 per cent, with five postoperative deaths and four deaths of patients treated with TPN. Aggressive use of TPN has not obviated the need for surgical closure in the authors' experience, particularly low in the gastrointestinal tract. Management should include TPN for up to four weeks and surgery if there has been no improvement with conservative therapy.