Complications related to enterocutaneous fistulas are common and include sepsis, malnutrition, and fluid or electrolyte abnormalities. Intestinal failure is one of the most feared complications of enterocutaneous fistula management and results in significant patient morbidity and mortality. The authors review emerging trends in the medical and surgical management of patients with intestinal failure.KEYWORDS: Enterocutaneous fistula, intestinal failure, short bowel syndrome, intestinal transplantationObjectives: Upon completion of this article, the reader should: (1) be familiar with the etiology and pathophysiology of intestinal failure in patients with enterocutaneous fistulas; (2) be able to summarize the current and emerging medical treatment options for patients with intestinal failure; and (3) be able to summarize the surgical treatment options and results of small bowel transplantation for intestinal failure.Enterocutaneous fistulas (ECFs) are associated with considerable morbidity and mortality. Recent case series suggest a mortality rate of 6 to 33%, with sepsis and concomitant malnutrition being the most common causes of death. 1 Increased mortality has been shown to be associated with high fistula output and the presence of infectious complications. 2 Edmunds et al identified the classic triad of complications of enterocutaneous fistulas as sepsis, malnutrition, and fluid or electrolyte abnormalities. 3 Septic complications related to ECFs include localized abscess, soft tissue infection, generalized peritonitis, or frank sepsis. Early control of fistula output, drainage of localized collections, and appropriate antibiotic therapy are the keys to early management of these patients.Postoperative ileus, sepsis, loss of bowel integrity and absorptive surface area, and the external loss of protein-rich enteric contents all contribute to the malnutrition and fluid and electrolyte abnormalities seen in patients with enterocutaneous fistulas. 4 Early correction of fluid and electrolyte abnormalities and the provision of nutrition (parenteral or enteral) are of paramount importance in minimizing or avoiding these complications altogether. In a significant number of patients with enterocutaneous fistulas, however, intestinal failure can ensue as a consequence of the natural history of the disease or as a consequence of attempted surgical management. The focus of this review is to summarize the diagnosis and management of intestinal failure in patients with ECFs.