Anatomy-based surgical strategy of gastrointestinal fistula treatment.

Anatomic delineation of a gastrointestinal fistula is essential in assessing the likelihood of spontaneous closure or to plan the surgical management. Computed tomography (CT) enterography and/or fistulograms provide invaluable information. The surgical strategy should carefully consider the when and how, as well as the special clinical situations that may arise following radiotherapy, the inaccessible or "frozen abdomen", and enteroatmospheric fistulas (EAFs). New operations like those performed in bariatric surgery, and the wide acceptance of the damage-control philosophy in severe trauma, have given rise to new types of fistulas and increased the occurrence of others. When confronted with this difficult complication, the surgeon must always exercise patience and restraint, and be open-minded about the different surgical alternatives to solve the problem.