Enterocutaneous fistulas (ECF) represent a complex condition. Management strategy is based on a combination of treatment of sepsis, correction of fluid and electrolyte imbalances, nutritional optimization, anatomical assessment, and management planning. The approach is necessarily multidisciplinary (nutritionists, enterostomal therapists, interventional radiologists, anesthesiologists, intensive care specialists, and surgeons). Fitting of skin prostheses remains a challenge and requires specialized enterostomal nursing expertise. Current nutritional recommendations are for 25–35 kcal/kg/day with 1.5 to 2.5 g/kg/day of protein, depending on the severity of muscle wasting. Parenteral nutrition plays a central role in the initial period. Re-instillation of chyme, when feasible (proximal and distal individualized fistula orifices), provides downstream intestinal stimulation, an ileal brake effect, improved liver function, and preparation for restoration of intestinal continuity. Enteral nutrition can be gradually increased as tolerated, and oral nutrition can even be considered in certain cases when the fistula is well controlled. This has real psychological benefits for the patient. Surgical management is most often delayed, but a recent study shows that early curative surgery ( < 4 months) is possible in certain selected patients. Main principles of curative surgery include complete viscerolysis, measurement of residual lengths, resection of the fistulated area, and most often, re-anastomosis. Parietal closure is sometimes difficult, requiring reconstructive techniques ranging from simple sutures to component separation or complex flaps. When the patient is eligible for curative surgery, the overall success rate for postoperative ECF is around 80%, with a recurrence rate of approximately 17% and a permanent stoma rate of nearly 10%. Success is highly dependent on the etiology. Current data suggest that center expertise, preoperative patient optimization, and careful patient selection are the determining factors for success. The economic and psychological impact of this condition should not be overlooked. An ECF doubles the cost of hospitalization on average. Clear and honest communication with the patient from the outset is essential.