Current role of surgery in the treatment of digestive fistulas

Surgery is the main treatment of digestive fistulas (DF) but its role has changed over the last 40 years. The aim of this review is to analyze the surgical management of DF paying attention to timing and type of surgery. We performed a review considering the following electronic databases: Medline, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, EMBASE and the reference lists of the key papers. Literature searches were carried out using the following medical subject headings: "digestive fistula"; "gastrointestinal fistula"; "enterocutaneous fistula"; 'AND surgery"; "AND surgical treatment". Because the absence of randomized studies, we have considered the larger series or original techniques. Surgical treatment of DF has two indications: to treat complications due to DF juice action such as peritonitis, abscesses, gangrene, bleeding; and when a fistula fails to heal. In this case the surgical indication is often difficult to establish, because of the risk of making an inconclusive act. Indications to surgery, timing and choice of operation cannot often be standardized because they depend on a mixture of DF and patient characteristics. In specific cases, involvement of nutritionist and plastic surgeon is required.