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Management of enteroatmospheric fistula: A ten-year experience following fifteen years of learning. Surgery 2023; 173:1079-1085. [PMID: 36653234 DOI: 10.1016/j.surg.2022.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 11/20/2022] [Accepted: 12/11/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Enteroatmospheric fistulas are a serious complication of Open Abdomen. The goal of this study was to present the strategy and results of enteroatmospheric fistulas treatment during the last 10 years, after a long learning period. METHODS Seventy-seven patients with enteroatmospheric fistulas were treated and the data recorded between 2012 and 2021. For local treatment, 3 negative pressure methods were used, according to the wound characteristics. The results of conservative and surgical treatments were retrospectively identified and described, including nutritional recovery, morbidity and mortality. Predictors of spontaneous closure, as well as risk factors for the fistula's recurrence and mortality were analyzed. RESULTS Nutritional and clinical recovery was achieved in 66 patients (85.7%). Fourteen patients (18%) were healed without surgery after a median of 57 days (range 35-426 days). Unique lesions (13/46; P = .02, OR 10.23), initial output ≤700 mL/day (9/28; P = .0035, OR 3.79) and deep fistulas (9/12; P = .00001, OR 33.6) were encountered and acknowledged to be as spontaneous closure factors. Fifty-six patients (72.7%) required reconstructive surgery of the intestinal tract after a median of 187 days since last laparotomy (range: 63-455 days). There were 9 postoperative recurrences (16%), 5 of them closed with conservative treatment. No significant risk factors for recurrence nor postoperative mortality were found. Fistula complete closure was achieved in 63 of the 77 patients studied (81.8%), and 7 patients died (9%). CONCLUSION The combination of 3 vacuum methods used for enteroatmospheric fistula management was effective. Spontaneous closure of an enteroatmospheric fistula is unlikely but feasible when lesions are single, deep, with limited output, and when intestinal continuity is preserved. Surgical indications are well defined, although mortality and recurrence rates are still high.
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Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis? Surg Technol Int 2021. [PMID: 33844240 DOI: 10.52198/21.sti.38.gs1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis. METHODS We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition. RESULTS The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days). CONCLUSION NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer's instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.
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Alsubaie NM, Albdah AM, Alrushaid NR, Al-Abdullatif F, Aljamili GA. Vacuum-Assisted Closure in a Patient With Entero-Atmospheric Fistula: A Case Report. Cureus 2021; 13:e12777. [PMID: 33628649 PMCID: PMC7891799 DOI: 10.7759/cureus.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The entero-atmospheric fistula (EAF) is a recognized complication of open abdomen surgeries, which causes significant morbidity and mortality. This usually causes long hospitalizations and may require many surgical operations. While different methods of treatment for EAF are used, all different methods share the same goal, which is a proper closure of the fistula and the open abdomen to avoid recurrence and complications. We report a case of a 48-year-old female with a bowel perforation following an attempted open bilateral ovarian cyst drainage with cyst wall biopsy complicated by entero-atmospheric fistula treated by wound closure with vacuum-assisted pressure. In conclusion, the use of vacuum-assisted closure (VAC) to induce spontaneous healing of EAFs can provide a safe acceptable alternative to surgical treatment.
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Aguilar-Frasco J, Moctezuma-Velázquez P, Rodríguez-Quintero JH, Pastor-Sifuentes FU, Garcia-Ramos ES, Clemente-Gutierrez U, Morales-Maza J, Santes O, Hernández-Acevedo JD, Contreras-Jimenez E, Y Terán SM. Myths and realities in the management of the open abdomen with negative pressure systems. A case report and literature review. Int J Surg Case Rep 2019; 61:174-179. [PMID: 31376738 PMCID: PMC6677784 DOI: 10.1016/j.ijscr.2019.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/03/2019] [Accepted: 07/17/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The open abdomen is a useful resource for treating patients with abdominal hypertension and abdominal compartment syndrome. Currently, early closure assisted with negative pressure devices is considered standard of treatment, and its use has demonstrated favorable outcomes and a decreased rate of complications. PRESENTATION OF A CASE We present a case of a 32-year-old male patient with diagnosis of non-seminomatous germinal testicular tumor (Stage IIIB (T3-N3-M1), which was summited to surgery, as a complication he presented massive bleeding, that culminated in acute compartment syndrome. With the aforementioned findings the patient re entered the operating room and was managed with open abdomen combined with a medial retraction technique of the abdominal fascia. Currently, the patient has not presented recurrence or late complications after a year. DISCUSSION The use of negative pressure techniques for open abdomen management began to be generalized in 1995. Subsequently, this technique evolved to V.A.C therapy (Vacuum-assisted closure therapy). Currently, these negative pressure techniques have become the most used method for the temporary closure and management of open abdomen. Controversies continue to limit its widespread use and effectiveness. CONCLUSION Adequate application of negative pressure therapy in combination with techniques of medial retraction of the abdominal fascia, have proved to be useful in management for patients with open abdomen.
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Affiliation(s)
- J Aguilar-Frasco
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico.
| | - P Moctezuma-Velázquez
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - J H Rodríguez-Quintero
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - F U Pastor-Sifuentes
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - E Sanchez Garcia-Ramos
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - U Clemente-Gutierrez
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - J Morales-Maza
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - O Santes
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - J D Hernández-Acevedo
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - E Contreras-Jimenez
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - S Mier Y Terán
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
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Li Y, Li PY, Sun SJ, Yao YZ, Li ZF, Liu T, Yang F, Zhang LY, Bai XJ, Huo JS, He WB, Ouyang J, Peng L, Hu P, Zhu YA, Jin P, Shao QF, Wang YF, Dai RW, Hu PY, Chen HM, Wang GF, Wang YG, Jin HX, Zhu CJ, Zhang QY, Shao B, Sang XG, Yin CL. Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review. Chin J Traumatol 2019; 22:1-11. [PMID: 30850324 PMCID: PMC6529401 DOI: 10.1016/j.cjtee.2018.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/12/2018] [Accepted: 01/12/2019] [Indexed: 02/07/2023] Open
Abstract
Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chinese Trauma Surgeon Association organized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries. Eleven questions regarding the use of VSD in abdominal surgeries were addressed: (1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions? (2) Can VSD be preventively used for a high-risk abdominal incision with primary suture? (3) Can VSD be used in severely contaminated/infected abdominal surgical sites? (4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome? (5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage? (6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula? (7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess? (8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects? (9) Does VSD increase the risk of bleeding? (10) Does VSD increase the risk of intestinal wall injury? (11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.
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Affiliation(s)
- Yang Li
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Pei-Yuan Li
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Shi-Jing Sun
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Yuan-Zhang Yao
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Zhan-Fei Li
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Tao Liu
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Fan Yang
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Lian-Yang Zhang
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China.
| | - Xiang-Jun Bai
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Jing-Shan Huo
- Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangzhou Province, China
| | - Wu-Bing He
- Fujian Provincial Hospital, Fuzhou, China
| | - Jun Ouyang
- Emergency Surgery of the First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang Autonomous Region, China
| | - Lei Peng
- The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Ping Hu
- Chongqing Emergency Medical Center, Chongqing, China
| | - Yan-An Zhu
- Taizhou Hospital of Zhejiang Province, Taizhou, Zhejiang Province, China
| | - Ping Jin
- Yuyao People's Hospital of Zhejiang Province, Yuyao, Zhejiang Province, China
| | - Qi-Feng Shao
- Ninth People's Hospital of Zhengzhou, Zhengzhou, China
| | | | - Rui-Wu Dai
- Chengdu Military General Hospital, Chengdu, China
| | - Pei-Yang Hu
- Tiantai County People's Hospital, Tiantai, Zhejiang, China
| | - Hai-Ming Chen
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ge-Fei Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong-Gao Wang
- Department of Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Hong-Xu Jin
- Shenyang Military General Hospital, Shenyang, China
| | - Chang-Ju Zhu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi-Yong Zhang
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Biao Shao
- The First People's Hospital of Kunming, Kunming, China
| | | | - Chang-Lin Yin
- The First Affiliated Hospital of Third Military Medical University, Chongqing, China
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Misky A, Hotouras A, Ribas Y, Ramar S, Bhan C. A systematic literature review on the use of vacuum assisted closure for enterocutaneous fistula. Colorectal Dis 2016; 18:846-51. [PMID: 27088556 DOI: 10.1111/codi.13351] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 02/15/2016] [Indexed: 02/08/2023]
Abstract
AIM Enterocutaneous fistula (ECF) is considered to be one of the most challenging complications a general surgeon can encounter. The current mainstay of treatment is surgical closure, associated with significant morbidity and mortality. Vacuum assisted closure (VAC) has been successfully used for closure of persistent abdominal wounds for a number of years. This study aims to investigate whether current literature supports the use of VAC for ECF. METHOD A PubMed search of the search terms 'enterocutaneous fistula' and 'vacuum assisted closure/therapy' was performed in December 2014. Results were restricted to articles involving human subjects with an available abstract and full text written between 1950 and 2014. The end-points analysed included rate of fistula closure, duration of follow-up, and morbidity and mortality where available. RESULTS Ten studies (all level IV) including 151 patients were examined. In all except one, surgery was the underlying aetiology with median number of fistulae per patient of one. The median rate of closure with VAC was 64.6% (7.7-100%) with healing occurring within 58 (12-90) days. Follow-up was only mentioned in three of the 10 studies, in which the patients were followed for 3, 20 and 28.5 months. No complications were reported in all but one of the studies, in which abdominal wall disruption and intestinal obstruction were identified in a minority of patients. CONCLUSION The included studies suggest that VAC therapy may be considered a safe treatment for ECF. The current evidence is generally of low level and characterized by heterogeneity. Definitive recommendations based on this information cannot therefore be made. Further studies are necessary to establish any proven benefit over standard surgical or conservative therapy.
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Affiliation(s)
- A Misky
- University College London Medical School, London, UK
| | - A Hotouras
- North-East London Deanery, University College London Hospital, London, UK
| | - Y Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, Terrassa, Barcelona, Spain
| | - S Ramar
- King's College Hospital, London, UK
| | - C Bhan
- Department of Colorectal Surgery, Whittington Health NHS Trust, University College London, London, UK
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Abstract
BACKGROUND A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.
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Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Int J Surg 2014; 12:1105-14. [PMID: 25174789 DOI: 10.1016/j.ijsu.2014.08.396] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 08/11/2014] [Accepted: 08/19/2014] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Negative Pressure Wound Therapy (NPWT) is widely used in the management of the open abdomen despite uncertainty regarding several aspects of usage. An expert panel was convened to develop evidence-based recommendations describing the use of NPWT in the open abdomen. METHODS A systematic review was carried out to investigate the efficacy of a range of Temporary Abdominal Closure methods including variants of NPWT. Evidence-based recommendations were developed by an International Expert Panel and graded according to the quality of supporting evidence. RESULTS Pooled results, in non-septic patients showed a 72% fascial closure rate following use of commercial NPWT kits in the open abdomen. This increased to 82% by the addition of a 'dynamic' closure method. Slightly lower rates were showed with use of Wittmann Patch (68%) and home-made NPWT (vac-pack) (58%). Patients with septic complications achieved a lower rate of fascial closure than non-septic patients but NPWT with dynamic closure remained the best option to achieve fascial closure. Mortality rates were consistent and seemed to be related to the underlying medical condition rather than being influenced by the choice of dressing, Treatment goals for open abdomen were defined prior to developing eleven specific evidence-based recommendations suitable for different stages and grades of open abdomen. DISCUSSION AND CONCLUSION The most efficient temporary abdominal closure techniques are NPWT kits with or without a dynamic closure procedure. Evidence-based recommendations will help to tailor its use in a complex treatment pathway for the individual patient.
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Affiliation(s)
- A Bruhin
- Department of Trauma and Visceral Surgery, Luzern, Switzerland
| | - F Ferreira
- Hospital Pedro Hispano, Matosinhos-Porto, Portugal
| | - M Chariker
- Aesthetic Plastic Surgery Institute, Louisville, KY, USA
| | | | - N Runkel
- Department of General Surgery, Black Forest Hospital, Villingen-Schwenningen, Germany; University of Freiburg, Germany
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Novel Techniques Using Negative Pressure Wound Therapy for the Management of Wounds With Enterocutaneous Fistulas in a Long-term Acute Care Facility. J Wound Ostomy Continence Nurs 2013; 40:481-8. [DOI: 10.1097/won.0b013e3182a21c08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Buote NJ, Havig ME. The Use of Vacuum-Assisted Closure in the Management of Septic Peritonitis in Six Dogs. J Am Anim Hosp Assoc 2012; 48:164-71. [DOI: 10.5326/jaaha-ms-5755] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to describe the appropriate surgical technique, postoperative monitoring, and complications encountered with use of vacuum-assisted closure (VAC) in six dogs with confirmed septic peritonitis. Initial diagnosis of septic peritonitis was performed by measuring either the blood-to-fluid lactate ratio and glucose concentration differences or cytologic verification of intracellular bacteria. After appropriate surgical procedures were performed to manage the primary cause of peritoneal sepsis, a VAC was performed. Serum and abdominal fluid protein levels were measured, and all complications were noted during the postoperative period. Three of the six dogs (50%) survived to the secondary closure and were subsequent discharged, which is similar to previous studies where the abdomen was either closed primarily or treated with open abdominal drainage. No major complications occurred with bandage management during hospitalization. The results of this study support VAC as a feasible technique for managing septic peritonitis.
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Affiliation(s)
| | - Marc E. Havig
- Surgery Department, The Animal Medical Center, New York, NY
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