Management of Enterocutaneous Fistulas Worldwide: Challenges, Practices, and Outcomes

Enterocutaneous fistulas (ECFs) are among the most devastating complications in surgical practice. Management requires a multidisciplinary approach focused on sepsis control, nutritional optimization, fistula closure, and restoration of quality of life. A comprehensive review of PubMed and Google Scholar was conducted for the period from 2000 to 2025. Given the paucity of recent literature from low- and middle-income countries (LMICs), data from the past 25 years were included to capture broader insights into the topic. The Salford unit in the United Kingdom introduced the SNAP strategy (Sepsis, Nutrition, Anatomy, and Plan), which emphasizes infection control, nutritional support, anatomical definition, and surgical planning. While this structured approach has improved outcomes in high-income countries (HICs), its translation to LMICs remains challenging. Limited access to broad-spectrum antibiotics, advanced imaging, and modern wound care techniques hampers early management. Nutrition, which is central to fistula therapy, is optimized in HICs through tailored enteral and parenteral regimens. In contrast, LMICs often depend on modified oral or nasogastric feeding, which, although less effective, can provide reasonable outcomes when delivered consistently. Definitive management includes effluent control, skin protection, and surgical intervention. Advanced modalities such as negative pressure wound therapy (NPWT), octreotide, parenteral nutrition, and abdominal wall reconstruction with biological meshes are widely available in HICs. In LMICs, however, clinicians frequently rely on improvised NPWT systems, have limited access to pharmacological adjuncts and parenteral nutrition, and often resort to staged operations with fewer reconstructive options. This review highlights persistent management gaps in LMICs and emphasizes the urgent need for more robust data to better define challenges, guide policy, and adapt treatment strategies to resource-limited settings.