Modified classification of intestinal fistulas

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Abstract

Introduction. Management of patients with intestinal fistulas is one of the most pressing and complex issues in abdominal surgery. It is accompanied by infectious complications, nutrient depletion, pronounced pain syndrome, and fluid and electrolyte disturbances. The lack of a unified, practice-oriented classification complicates diagnosis and treatment decisions.

Objective. To develop a practical, modified classification of intestinal fistulas suitable for routine clinical use and scientific standardisation with presentation of comprehensive and reduced versions.

Materials and Methods. A systematic literature search covering the period from 1945 to 2025 was conducted in international databases (PubMed/MEDLINE, Embase, Cochrane CENTRAL, Scopus, Web of Science) and Russian databases (eLIBRARY.ru, CyberLeninka, RSCI) using English- and Russian-language search strategies incorporating terms related to intestinal/enterocutaneous/enteroatmospheric fistulas and classification/staging. Deduplication, screening, full-text selection, extraction of classification features, and their comparison by axes were performed. Totally 6,119 records were identified; after deduplication, 254 records remained. Of these, 128 were selected based on titles and abstracts, and 102 articles underwent full-text analysis. Overall, 21 studies and 12 classification systems were included in the final review.

Results. Based on the data analysed, a modified classification of intestinal fistulas was proposed in two versions. The comprehensive version comprises nine criteria: etiology; location of the external opening; anatomical localisation; morphological features; degree of formation with the identification of types of non-formed (unformed) fistulas and their association with clinical variants of the "open abdomen" (degree of formation); functional status; amount of discharge (fistula output/flow/debit); single/multiple; mixed/combined; local and systemic complications. The reduced version is intended for standardised diagnostic reporting and includes six key parameters: location of the external opening, anatomical localisation, degree of formation, functional status, fistula output, and complications. The classification is based on national approaches, expanded and integrated with contemporary clinically relevant parameters.

Conclusion. The proposed modified classification provides a unified framework for describing intestinal fistulas, facilitates accurate diagnosis formulation, and supports the selection of staged treatment strategy. The reduced version is optimal for routine clinical documentation, whereas the comprehensive version is suitable for expert assessment and scientific research.

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About the authors

Vladimir Y. Struchkov

A.V. Vishnevsky National Medical Research Center of Surgery

Author for correspondence.
Email: doc.struchkov@gmail.com

Ph.D., Surgeon, Department of Abdominal Surgery, Head of the Accreditation and Simulation Center

Russian Federation, Moscow

Pavel V. Markov

A.V. Vishnevsky National Medical Research Center of Surgery

Email: pvmarkov@mail.ru

M.D., Head of the Department of Abdominal Surgery

Russian Federation, Moscow

Evgeny Y. Levchik

Ural State Medical University; Sverdlovsk Regional Clinical Hospital for War Veterans

Email: eylevchik@yandex.ru

M.D., Professor, Department of Surgery, Coloproctology and Endoscopy; Head of the Sverdlovsk Regional Center for the Management of Surgical Infections

Russian Federation, Yekaterinburg; Yekaterinburg

Andrey E. Demko

I.I. Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine; S.M. Kirov Military Medical Academy

Email: demkoandrey@gmail.com

M.D., Professor; Deputy Director for Research; Head of the Second Department of Advanced Surgical Training

Russian Federation, Saint Petersburg; Saint Petersburg

Ildar M. Batyrshin

I.I. Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine; S.M. Kirov Military Medical Academy

Email: onrush@mail.ru

M.D., Head of the Department of Surgical Infections; Lecturer, Second Department of Advanced Surgical Training

Russian Federation, Saint Petersburg; Saint Petersburg

Vladimir I. Belokonev

Samara State Medical University

Email: belokonev63@yandex.ru

M.D., Professor; Honored Physician of the Russian Federation; Head of the Department of Surgical Diseases No. 2

Russian Federation, Samara

Konstantin V. Atamanov

Novosibirsk State Medical University

Email: k_atamanov@hotmail.com

M.D., Associate Professor, Head of the Department of Faculty Surgery (Pediatric Faculty), Vice-Rector for Regional Development

Russian Federation, Novosibirsk

Valery M. Luft

I.I. Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine

Email: vm_aspep@mail.ru

M.D., Professor, Head of the Clinical Nutrition Laboratory

Russian Federation, Saint Petersburg

Amiran S. Revishvili

A.V. Vishnevsky National Medical Research Center of Surgery; Russian Medical Academy of Continuous Professional Education Ministry of Health of the Russian Federation

Email: vishnevskogo@ixv.ru

M.D., Academician of the Russian Academy of Sciences, Professor, Director General; Head of the Department of Angiology, Cardiovascular, Endovascular Surgery and Arrhythmology (named after Academician A.V. Pokrovsky)

Russian Federation, Moscow; Moscow

References

  1. Mel'nikov AV, Dzhanelidze YuYu. Klinika i profilaktika Mel'nikov A.V. Klinika i profilaktika svishchei zheludka i kishechnika u ranenykh v bryushnuyu polost'. L.: VMMA. 1947; 460. (in Russ.)
  2. Hatchimonji JS, Passman J, Kaufman EJ. Enterocutaneous fistula after emergency general surgery: mortality, readmission, and financial burden. Journal of Trauma and Acute Care Surgery. 2020;89(1):167–172. https://doi.org/10.1097/TA.0000000000002673.
  3. Ortiz LA, Zhang B, McCarthy MW, Kaafarani HMA, Fagenholz P, King DR, De Moya M, Velmahos G, Yeh DD. Treatment of Enterocutaneous Fistulas, Then and Now. Nutrition in Clinical Practice. 2017;32(4):508–515. https://doi.org/10.1177/0884533617701402
  4. Базаев А.В., Пузанов А.В., Петров С.В., Захаров А.Г. Лечение множественных свищей желудочно-кишечного тракта. Нижегородский медицинский журнал. 2005;4:119–120.
  5. Байчоров Э.X., Вафин А.З., Куджева Ф.А. Комплексное лечение несформированных тонкокишечных свищей. Медицинский вестник Северного Кавказа. 2006(3):7–9. [Baichorov E.Kh., Vafin A.Z., Kudzheva F.A. Complex treatment of
  6. Li J, Ren J, Zhu W, Yin L, Han J. Management of enterocutaneous fistulas: 30-year clinical experience. Chinese Medical Journal (Engl). 2003;116(2):171–175. http://doi.org/10.1117/12.538864
  7. Demko AE, Batyrshin IM, Shlyapnikov SA, Ostroumova YuS, Sklizkov DS, Fomin DV, Pichugina GA. A step-by-step approach in the treatment of patients with unformed intestinal fistulas. Khirurgiya. Zhurnal im. N.I. Pirogova. 2020;(11):66–73. https://doi.org/10.17116/hirurgia202011166 (in Russ.)
  8. Vorobyov SA, Levchik EY. Stage-by-stage treatment of patients with external small intestinal fistulas. Vestnik khirurgii im. I.I. Grekova. 2008;167(6):114–118. (in Russ.)
  9. Krieger AG, Kubyshkin VA, Berelavichus SV, Gorin DS, Kaldarov AR, Gogia BSh, Ikramov RZ, Akhtanin EA, Matushevskaya VN, Sokolova EA. Surgical treatment of patients with small intestinal fistulas. Khirurgiya. Zhurnal im. N.I. Pirogova.2015;12:86–95. https://doi.org/10.17116/hirurgia20151286-95 (in Russ.)
  10. Struchkov VYu, Berelavichus SV, Akhtanin EA, Gorin DS, Dvukhozhilov MV, Goev AA, Burmistrov AI, Markov PV, Krieger AG. Two-stage treatment of small intestinal fistulas. Russian Journal of Gastroenterology, Hepatology, and Coloproctology. 2023;33(4):58–69. https://doi.org/10.22416/1382-4376-2023-33-4-58-69 (in Russ.)
  11. Hаrle K, Lindgren M, Hallbооk O. Experience of living with an enterocutaneous fistula. Journal of Clinical Nursing. 2015;24(15-16):2175–83. doi: 10.1111/jocn.12857.
  12. Visschers RG, Olde Damink SW, van Bekkum M, Winkens B, Soeters PB, van Gemert WG. Health-related quality of life in patients treated for enterocutaneous fistula. British Journal of Surgery. 2008;95(10):1280–6. doi: 10.1002/bjs.6326. PMID: 18763244.
  13. Kumpf VJ, de Aguilar-Nascimento JE, Diaz-Pizarro Graf JI. ASPEN-FELANPE Clinical Guidelines. Journal of Parenteral and Enteral Nutrition. 2017;41(1):104–112. https://doi.org/10.1177/0148607116673053.
  14. Vitsyn BA, Blagitko EM. Sformirovannye i nesformirovannye kishechnye svishchi. Novosibirsk: Nauka. 1983; 143. (in Russ.)
  15. Bognitskaya TN. Naruzhnye kishechnye svishchi pri ostrykh khirurgicheskikh zabolevaniyakh i povrezhdeniyakh organov bryushnoi polosti: Avtoref. diss. d-ra med. nauk. M. 1977; 24. (in Russ.)
  16. Atamanov VV, Atamanov KV, Vayner YuS, Levchik EY. Multi-stage treatment of a patient with multiple fistulas of the small intestine. Neotlozhnaya khirurgiya im. I.I. Dzhanelidze. 2024;(3):8–15. https://doi.org/10.54866/27129632_2024_3_8 (in Russ.)
  17. Akhtanin EA, Markov PV, Goev AA, Struchkov VYu, Martirosyan TA, Shukurov KU. Drainage methods in patients with unformed intestinal fistulas in preparation for surgical treatment. Klinicheskaya praktika. 2023;14(4):65–74. https://clinpractice.ru/jour/article/view/567849 (in Russ.)
  18. Levchik EYu, Atamanov KV, Demko AE. Modern approaches to obturation of unformed small intestine fistulas (clinical lecture). Neotlozhnaya khirurgiya im. I.I. Dzhanelidze. 2023;(4):175–189. https://doi.org/10.54866/27129632_2023_4_175. (in Russ.)
  19. Tonolini M, Magistrelli P. Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and MRI. Insights Imaging. 2017;8(6):537–548. doi: 10.1007/s13244-017-0572-3.
  20. Berelavichus SV, Struchkov VYu, Akhtanin EA. Management of patients with enterocutaneous fistulae. Pirogov Russian Journal of Surgery. 2020;(6):98–103. https://doi.org/10.17116/hirurgia202006198 (in Russ.)
  21. Levchik EYu, Vorobyev SA. Reconstructive operations in patients with external small intestinal fistulas against the common peritoneal adhesions. Neotlozhnaya khirurgiya im. I.I. Dzhanelidze. 2022;(4):8–13. https://doi.org/10.54866/27129632_2022_4_8 (in Russ.)
  22. Belokonev VI, Pushkin SYu, Kovaleva ZV. Features and choice of surgical strategy in patients with gastrointestinal fistulas. Khirurgiya. Zhurnal im. N.I. Pirogova. 2021;(5):58–62. https://doi.org/10.17116/hirurgia202105158 (in Russ.)
  23. Demko AE, Zinovev EV, Pogosov NV, Batyrshin IM, Soloshenko VV, Fomin DV, Krainyukov EP. Skin reconstructive plastic surgery in patients with unformed intestinal fistulas. Military Medical Journal. 2021;342(4):31–38. https://doi.org/10.17816/rmmj82614 (in Russ.)
  24. Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reporting items for systematic reviews and meta—analyses: the PRISMA statement. PLoS Med. 2009; 6.
  25. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Systematic reviews. 2021;10(1):89. https://www.equator-network.org/reporting-guidelines/prisma/
  26. Rebrova OYu, Fediaeva VK. Meta-analyses and Assessment of Their Methodological Quality. Russian Version of AMSTAR Questionnaire. Medical Technologies. Assessment and Choice. 2016;1(23):10–16. (in Russ.)
  27. Omel'yanovskii V.V., Sukhorukikh O.A., Luk"yantseva D.V., Fedyaeva V.K., Zhuravleva N.I., Shabashov A.E. Metodicheskie rekomendatsii po provedeniyu otsenki nauchnoi obosnovannosti vklyuchaemoi v klinicheskie rekomendatsii informatsii. FGBU «TsEKKMP» Minzdrava Rossii. Moskva. 2019; 81. (in Russ.)
  28. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et all. Cochrane Hand-book for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane. 2022. https://training.cochrane.org/handbook/current
  29. Rebrova OYu, Fediaeva VK. The Questionnaire to Assess the Risk of Systematic Bias in Non-Randomized Comparative Studies: the Russian-Language Version of the Newcastle—Ottawa Scale. Medical Technologies. Assessment and Choice. 2016;3:14–19. (in Russ.)
  30. Bjоrck M, Bruhin A, Cheatham ML, Hinck D, Kaplan MJ, Manca G, Wild T, Windsor A. Classification—Important Step to Improve Management of Patients with an Open Abdomen. World Journal of Surgery. 2009;33:1154–1157. https://doi.org/10.1007/s00268-009-9996-3.
  31. Belokonev VI, Izmailov EP. Diagnostika i lechenie svishchei zheludochno-kishechnogo trakta: monografiya. Samara: Perspektiva; 2005; 238. (in Russ.)
  32. Bogdanov AV. Svishchi pishchevaritel'nogo trakta v praktike obshchego khirurga. M.: IM. 2001; 196. (in Russ.)
  33. Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surgical Clinics of North America. 1996;76(5):1009–1018. https://doi.org/10.1016/S0039-6109(05)70495-3.
  34. Kolchenogov PD. Naruzhnye kishechnye svishchi i ikh lechenie. M.: Meditsina. 1964. 235. (in Russ.)
  35. Evenson AR, Fischer JE. Current management of enterocutaneous fistula. Journal of Gastrointestinal Surgery. 2006;10(3):455–464. https://doi.org/10.1016/j.gassur.2005.08.001.
  36. Danilov IN, Neimark AE, Solonitsyn EG, Nasedkin DB, Ivanikha EV, Salov MA, Kovalev AA, Bogdanova VL, Nasedkina EA. Experience of using a vacuum wound therapy system in the treatment of a high external small intestinal fistula. Rany i ranevye infektsii. Zhurnal im. prof. B. M. Kostyuchenka. 2018; 5 (2): 80–89.(in Russ.)
  37. Bazaev AV. klassifikatsii kishechnykh svishchei. Sbornik nauchnykh trudov «Izbrannye stranitsy istorii i aktual'nye voprosy sovremennoi khirurgii». 2013;3(8):39–41.
  38. Luft VM, Demko AE, Kelbetova BR, Batyrshin IM, Fomin DV, Lapitsky AV, Pichugina GA, Sergeeva AM, Usenov KK. Problems of nutritional and metabolic therapy in patients with intestinal fistulas. Zhurnal im. N.V. Sklifosovskogo «Neotlozhnaya meditsinskaya pomoshch'». 2025;14(1):155–165. https://doi.org/10.23934/2223-9022-2025-14-1-155-165
  39. Struchkov VYu, Sharapov IE, Mamoshin AV, Burmistrov AI, Markov PV. A modern approach to nutritional support for patients with intestinal fistulas. Vestnik eksperimental'noi i klinicheskoi khirurgii. 2025;18(4):291–303. https://doi.org/10.18499/2070-478X-2025-18-4-291-303. https://vestnik-surgery.com/index.php/journal/article/view/2845
  40. Sitges-Serra A, Jaurrieta E, Sitges-Creus A. Management of postoperative enterocutaneous fistulas: the roles of parenteral nutrition and surgery. British Journal of Surgery. 1982;69(3):147–150. https://doi.org/10.1002/bjs.1800690310.
  41. Schein M, Decker GA. Postoperative external alimentary tract fistulas. American Journal of Surgery. 1991;161(4):435–8. doi: 10.1016/0002-9610(91)91107-t.

Supplementary files

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2. Fig. 1. PRISMA diagram for publication selection.

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3. Fig. 2. Main criteria of intestinal fistula classifications.

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4. Fig. 3. External, incomplete, moderate small intestinal fistula. Stage 1 fistula dermatitis, stage 1 protein-energy malnutrition.

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5. Fig. 4. External, unformed (type 3b), complete small intestinal fistulas, extremely high-output. Stage 3 fistula dermatitis, stage 1 protein-energy malnutrition, sepsis.

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