A fistula after CRS/HIPEC comes up often in the Appendicure community. I went looking for research on the day-to-day part of living with one, and for newer treatments surgical teams are using.

Most of the treatment research comes from fistulas after other abdominal operations, not appendix cancer surgery alone. I’ve tried to say clearly which studies include appendix cancer patients and which don’t.

Types of fistula after CRS/HIPEC

A fistula is an opening that forms where it shouldn’t. With an enterocutaneous fistula, bowel contents leak out through an opening in the skin of the abdomen. Digestive fluid is harsh on skin, so the leak also becomes a wound care problem.

Other kinds happen too. A pancreatic leak can follow removal of the spleen, and I cover that further down. Leaks in the pelvis can also reach the bladder or the vagina.

These fistulas are hard to talk about. In a 2026 review of women with a rectovaginal fistula after rectal cancer surgery, many described embarrassment, shame, worry about their partner’s reaction, and pulling back from work, friends, and intimacy. A Swedish study of people with anal fistulas found the same thing, with many telling only their closest family. A fistula is a complication of a very big surgery. It isn’t something you caused, and your surgical team has seen it before. Telling them early gets you care sooner.

How common is it?

One study focused only on PMP. It comes from Beijing Aerospace Center Hospital in China and followed 668 PMP patients treated with CRS and heated chemotherapy between 2014 and 2020, and 91.5% of them had tumors that started in the appendix. Sixteen (2.4%) developed an intestinal fistula and five (0.7%) developed a leak where two pieces of bowel had been joined. That hospital’s patients differ from many in the U.S. and Europe. Only about a third had all visible tumor removed, and most also got several days of chemotherapy into the abdomen after surgery.

A larger study from St George Hospital in Sydney, Australia, looked at 918 CRS/HIPEC operations from 1999 to 2015 across several cancer types. Fifty-three patients (5.8%) developed a fistula to the skin, usually found about two weeks after surgery. I was only able to read the summary of this paper, not the full text.

In Sydney, fistulas were more likely with low albumin before surgery (below 35 g/L), a PCI score above 17 (PCI, the peritoneal cancer index, is a score describing how much disease is in the abdomen and where), and an operation lasting longer than 8.6 hours. Smoking and incomplete tumor removal were also linked to more fistulas. In Beijing, low albumin and low hemoglobin before surgery went along with more serious complications overall. Albumin is a blood protein that is strongly affected by inflammation and illness, so on its own it can’t tell whether someone is malnourished. A dietitian can look at what you’re eating, weight changes, and muscle loss as part of getting ready for surgery. My post on prehab before surgery covers that preparation. None of this means a fistula is something a patient caused.

Daily care for a fistula after CRS/HIPEC

Protecting the skin

Getting drainage into a pouch quickly matters because bowel contents are corrosive. A practice guideline from Vanderbilt University Medical Center calls for immediate pouching and an early visit from a wound, ostomy, and continence (WOC) nurse. Fitting a pouch around a fistula is hard and takes specialized nursing skill. If the pouch keeps leaking or the skin around it is raw and burning, ask the wound nurse to reassess the pouching system and your skin. If a WOC nurse hasn’t seen you, ask for a referral.

Tracking drainage and urine

Your team will want to know how much drains from the fistula over each 24 hours. The Vanderbilt guideline counts more than 500 mL a day as high output. Ask your team exactly how they want you to measure and record the drainage, and whether they also want you to track how much urine you pass. A drop in urine can be an early sign of dehydration.

Fistula fluid carries salts and minerals out of the body. The same guideline lists low sodium, low potassium, and low magnesium as common problems, and they need to be replaced. Expect regular blood tests while the fistula is draining.

Drinking the right things

If a fistula drains a lot, drinking more plain water isn’t always the answer. Cambridge University Hospitals in the U.K. gives patients with a high-output stoma or fistula a leaflet that asks them to limit water, tea, coffee, juice, and fizzy drinks to an amount their team sets, and to drink an oral rehydration solution instead. The leaflet says sports drinks like Gatorade and Powerade are not a suitable replacement for a proper rehydration solution. It lists thirst, weakness, dizziness, nausea, and headaches as signs of dehydration.

Please don’t cut back on fluids on your own. The right plan depends on where the fistula is and how much it drains, and some people need IV fluids. Ask your team to write down how much you should drink, what kind, and when to call.

Eating, tube feeding, and IV nutrition

Whether you can eat depends on where the fistula is, how much it drains, and whether your body can absorb enough nutrition and fluid. Some patients can eat or receive tube feeding. Others need IV nutrition (often called TPN), sometimes alongside feeding through the gut. The 2023 European guideline on intestinal failure (ESPEN) notes that research has not shown that withholding gut feeding by itself improves fistula closure, and that good nutrition and wound care may steady a fistula and give it a chance to close on its own. Your team may still limit eating for a while if it makes drainage hard to manage or keeps you from staying hydrated. Follow your own feeding plan, and ask when it will be reassessed.

A 2026 review of fistula care by French surgeons describes IV nutrition as central early on, with eating considered once the fistula is well controlled, and it notes real psychological benefits for patients who can eat. Needing IV nutrition for a while doesn’t mean you’ll never eat normally again.

For some fistulas high in the small bowel, specialist centers collect the digestive fluid that drains out and feed it back into the bowel below the leak through a tube. This is called chyme reinfusion. The French review says it keeps the lower bowel working, helps liver function, and prepares the gut for being reconnected later, and ESPEN lists it as an option for certain high-output fistulas. It only works when the bowel below the fistula is open and healthy.

Treatments your team may try

Some of these have been used for years and a few are newer. The studies below don’t show how well any of them work after CRS for appendix cancer specifically.

Octreotide and similar drugs. These reduce digestive secretions. A 2025 pooled analysis of 9 randomized trials with 442 patients did not find a statistically significant improvement in closure rates or a drop in the need for surgery. In the studies that reported timing, fistulas that closed did so about 6 days sooner on average.

Fibrin glue. A sealant is placed into the fistula tract. In a 2010 study from Mexico, 23 patients with carefully selected fistulas (draining less than 500 mL a day, with a tract longer than 2 cm and no local complications) got fibrin glue and were compared with 47 treated without it. Fistulas in the glue group closed in about 12 days on average, compared with about 33 days. The study was not randomized, and its results don’t apply to large, infected, or complicated fistulas.

Endoscopic clips. A doctor passes a scope inside the bowel and clamps the inner opening shut with a special clip. In a 2019 study of 10 patients, 7 fistulas closed. Newer fistulas did much better than old ones, with 86% of acute fistulas closing compared with 33% of chronic ones. This was a very small study.

Vacuum therapy placed with a scope. A 2026 study of 44 patients with fistulas after surgery used a small vacuum device placed through the skin with a scope. The treatment succeeded in 30 of the 44. Fourteen needed surgery, and 10 of those healed afterward. Most patients received more than one endoscopic treatment. Just over half (24 of 44) had bowel-to-skin fistulas, and the study was not about CRS patients.

Wound vacuums on the abdomen. Specially designed wound-vacuum systems can help manage drainage and the wound around a fistula. Evidence that they close the fistula itself is limited. These setups need an experienced team.

Pancreatic leaks after spleen removal

This section is for anyone whose surgery included removing the spleen. Clearing PMP from the upper left abdomen often means taking out the spleen, and the tail of the pancreas sits right against it. A 2021 study from St George Hospital in Sydney looked at 1,141 CRS/HIPEC patients across several cancer types. Sixty-five (5.7%) developed a pancreatic leak. Patients who had their spleen removed had about four times the odds of a leak, and 12% of them developed one. Removing or stripping part of the pancreas was linked to about twenty times the odds.

In that study, most patients with a pancreatic leak got octreotide and IV nutrition, 48 of the 65 needed a drain placed by a radiologist, and 23 needed another operation. The average hospital stay was 43 days, compared with 26 days for patients without a leak. If your surgery may include removing your spleen, it’s fair to ask your surgeon how often they see pancreatic leaks and what the plan is if one happens.

Waiting, healing, and repair surgery

In the Sydney fistula study, 49% of fistulas closed with care alone. Among those, the typical time to close was about a month. About a third of patients needed surgery. That’s one center’s experience, not a prediction for any one person.

Repair surgery usually waits. The Vanderbilt guideline says patients with a new fistula rarely benefit from an immediate operation, and that surgery is considered after other treatment hasn’t worked and nutrition has recovered. Infection has to be controlled first. The French review says the best timing is still debated, from around 3 to 4 months at some centers to 6 to 8 months or longer at others, and that repair should happen at an expert center after careful preparation. For patients able to have definitive repair surgery, it reports success around 80%, with the fistula returning in about 17% and a permanent stoma in nearly 10%. Those numbers come from broad fistula populations and don’t predict an individual outcome after CRS. If you’re facing a repair, ask what milestones you need to reach and how the timing fits with your cancer follow-up.

For caregivers

A 2023 study from Linköping University in Sweden followed seven patients with an enterocutaneous fistula and one family member of each, before and after repair surgery. All seven patients depended on IV fluids or IV nutrition before surgery. The pairs described life being put on hold, with constant leakage, pain, and fatigue for the patient and practical support from the family member. Being tied to IV fluids left people socially isolated, and that brought mood swings and depressed feelings. The researchers recommend that every patient have their own contact nurse, a care plan built around the person, and an offer of psychological support.

Before discharge, get names and phone numbers for who teaches pouch changes, who orders supplies, who handles IV nutrition if it’s needed, and who answers at night and on weekends. Ask for one named contact nurse if possible, and ask about counseling for both the patient and the caregiver. Caregivers need a backup person too, because this can go on for months.

When to call your team

Cleveland Clinic tells people with an enterocutaneous fistula to contact their healthcare provider about fever, pain or discomfort in the abdomen, and new leakage or infection near the wound, because these can mean the fistula is getting worse or coming back. Signs of dehydration, a sudden jump in drainage, or much less urine also need a call. Ask your team for a written list of what needs an urgent call, and keep it where everyone in the house can find it.

A pouch that keeps leaking is a problem for your wound nurse, so call them promptly rather than waiting for the next visit. If someone is very ill, confused, or faints, get emergency care.

What these studies don’t answer

I didn’t find a study that tracks fistula care and healing only in appendix cancer patients. The Beijing study is mostly appendiceal PMP but comes from one hospital with practices that differ from many Western centers. The Sydney studies mix several cancer types, and I read only the summary of the fistula paper. The treatment and caregiver studies come from fistulas after many kinds of surgery. None of these studies breaks results out for LAMN, HAMN, mucinous adenocarcinoma, goblet cell adenocarcinoma, or signet ring cell carcinoma. Use this as background for questions to ask your own team.

Frequently asked questions

How common is a fistula after CRS/HIPEC?

In a study of 668 PMP patients, most with appendix-origin tumors, 2.4% developed an intestinal fistula. A mixed-cancer study of 918 CRS/HIPEC operations in Sydney found 5.8% developed a fistula to the skin.

Will a fistula close on its own?

Some do. In the Sydney study, 49% closed without surgery, and those typically closed in about a month. About a third of patients needed another operation.

Should I drink more water if my fistula drains a lot?

Not without your team’s advice. Some hospitals ask patients with a high-output fistula to limit plain drinks and use an oral rehydration solution instead. Sports drinks are not a substitute.

Can I eat with a fistula?

Sometimes. It depends on how much the fistula drains and where it is. Some people need a combination of eating, tube feeding, and IV nutrition, and the plan changes as the fistula changes.

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Sources

Zhang X, Gao SC. Analysis of risk factors for major post-operative complications following intraperitoneal hyperthermic perfusion for pseudomyxoma peritonei. J Minim Access Surg. Read the study
Valle SJ, et al. Enterocutaneous fistula in patients with peritoneal malignancy following CRS/HIPEC. Surgical Oncology, 2016. Read the study
Pastier C, Collard MK, et al. Enterocutaneous fistula: Update in 2026. Journal of Visceral Surgery, 2026. Read the review
Pironi L, et al. ESPEN guideline on chronic intestinal failure in adults, update 2023. Read the guideline
Gadomski S, Smith MC. Practice management guidelines: acute presentation of new enterocutaneous fistula. Vanderbilt University Medical Center. Read the guideline
Evans DC, et al. The use of visceral proteins as nutrition markers: an ASPEN position paper. Nutrition in Clinical Practice, 2021. Read the paper
Matar A, et al. Postoperative pancreatic fistula after CRS and HIPEC. Anticancer Research, 2021. Read the study
Ghanipour L, et al. Anastomosis versus rectal stump procedure in CRS-HIPEC. Colorectal Disease, 2025. Read the study
Dsouza R, Akbar H, Menon G. Colovesical and other enterovesical fistulas. StatPearls, updated 2026. Read the reference
Lachowska K, et al. Rectovaginal fistulas after radiation therapy: treatment options and outcomes, a narrative review. Frontiers in Oncology, 2026. Read the review
Guida AM, et al. Iatrogenic rectovaginal fistula after rectal cancer surgery: a comprehensive review. Discover Oncology, 2026. Read the review
Adamo K, et al. “You cannot be yourself”: identity disruption, stigma, and the lived experience of anal fistula. PLOS One, 2026. Read the study
Somatostatin-based therapies for external gastrointestinal fistulas: updated meta-analysis of randomized clinical trials. World Journal of Gastrointestinal Pharmacology and Therapeutics, 2025. Read the study
Avalos-González J, et al. Reduction of the closure time of postoperative enterocutaneous fistulas with fibrin sealant. World Journal of Gastroenterology, 2010. Read the study
Roy J, et al. Endoscopic technique for closure of enterocutaneous fistulas. Surgical Endoscopy, 2019. Read the study
Kantowski et al. Percutaneous endoscopic vacuum therapy for patients with postoperative enterocutaneous fistulas. Techniques and Innovations in Gastrointestinal Endoscopy, 2026. Read the study
Härle K, et al. Putting life on hold: living with an enterocutaneous fistula before and after reconstructive surgery. Journal of Clinical Nursing, 2023;32:4663-4676. Read the study
Cleveland Clinic. Enterocutaneous fistula: causes, treatment and complications. Read the page
Cambridge University Hospitals. Diet and fluid advice for a high volume stoma or fistula. Read the leaflet