Nonoperative management of colonic fistulas in necrotizing pancreatitis can be effective for low-risk patients, reducing complications and length of stay without affecting survival.

• Among 47 patients with colonic fistulas, those managed nonoperatively had lower BISAP scores (1.0 vs. 3.0) and shorter hospital stays (10 vs. 39 days).
• High BISAP scores (≥3) were significantly associated with the need for operative management (odds ratio 6.1).

Surgeons should consider nonoperative strategies for patients with milder illness, reserving surgery for those with higher severity scores.