A ten-year review of enterocutaneous fistulas after laparotomy for trauma. ACTA ACUST UNITED AC. 2009;67:924-928. [PMID: 19901649 DOI: 10.1097/TA.0b013e3181ad5463]

From penetrating abdominal injury to enterocutaneous fistula, a deadly outcome: A case report

Enterocutaneous fistula is a dreaded complication by most surgeons especially after emergency abdominal surgery. It can also occur spontaneously from an underlying disease. The pathology is demanding both mentally and physically and causes medical and nursing problems for the affected individual. In this case report we present a timeline of a young 4-year-old boy who sustained penetrating abdominal-perineal injury from a fall and later presented with peritonitis. His condition progressed to complicate into enterocutaneous fistula and succumbed unfortunately due to multifactorial reasons. This shows the impact and burden of the disease pathology not only on patients but also on the medical system as a whole.

Management of Enteroatmospheric Fistula (EAF) Using a Fistula-Vacuum Assisted Closure (VAC) in a Complicated Abdominal Trauma Case

Enteroatmospheric fistula (EAF) is a relatively rare complication of patients undergoing open abdomen (OA) for damage control surgery. Mortality rates are high due to the increased risk of peritonitis, intraabdominal abscess, sepsis, and new perforations. There are a wide range of EAF management therapies in the literature, however, there are limited options on cases involving fistula-vaccum assisted closure (VAC) therapy. This case describes the treatment course of a 57-year-old, male admitted for blunt abdominal trauma secondary to a motor vehicle accident. Upon admission the patient underwent damage control surgery. The surgeons elected to have the patient's abdomen open, applying a mesh to promote healing. After several weeks of hospitalization an EAF was discovered in the abdominal wound subsequently managed by utilizing a fistula-VAC technique. Based on the successful outcome of this patient, fistula-VAC was shown as an effective way to promote wound healing while reducing the chances of complications.

Treatment of enterocutaneous fistula: a systematic review and meta-analysis

BACKGROUND

Enterocutaneous fistula (ECF) is an abnormal communication between the gastrointestinal tract and skin, with a myriad of etiologies and therapeutic options. Management is influenced by etiology and specifics of the ECF, and patient-related factors. The aim of this study was to assess overall success, recurrence, and mortality rates of treatment for ECF.

MATERIALS

A systematic search of PubMed and Google Scholar was performed through October 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports, reviews, animal studies, studies not reporting outcomes, had no available English text, included patients < 16 years old or those assessing other abdominocutaneous/internal fistulas were excluded.

RESULTS

Fifty-three studies, between 1975 and 2020, incorporating 3078 patients were included. Patient age ranged between 16 and 87 years with a male:female ratio of 1.14:1. ECF developed postoperatively in 89.4%. Other common etiologies were inflammatory bowel disease, trauma, malignancy, and radiation. At least 28% of patients had complex fistulae (reported in 18 studies). Most common fistula site was small bowel. In 34 publications, 62.4% (n = 1371) patients received parenteral nutrition. In 45 publications, 72.5% underwent surgery to treat the fistula. Meta-analysis revealed an 89% healing rate; recurrence rate after initial successful treatment was 11.1%, and mortality rate was 8.5%. In a subgroup of patients who underwent combined ECF takedown and abdominal wall reconstructions (n = 315), 78% achieved fascial closure, mesh was used in 72%, hernia, and fistula recurrence rates were 19.7% and 7.6%, respectively.

CONCLUSIONS

Treatment of ECF must be individualized according to specific etiology and location of the fistula and the patient's associated conditions.

Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review

All abdominal wall reconstructions find themselves on a scale, varying between simple to highly complex procedures. The level of complexity depends on many factors that are divided into patient comorbidities, hernia characteristics, and wound characteristics. Preoperative identification of modifiable risk factors provides the opportunity for patient optimization. Because this so called prehabilitation greatly improves postoperative outcome, reconstructive surgery should not be scheduled before all modifiable risk factors are optimized to a point where no further improvement can be expected. In this review, we discuss the importance of preoperative risk factor recognition, identify modifiable risk factors, and utilize options for patient prehabilitation, all aiming to improve postoperative outcome and therewith long-term success of the reconstruction.

A core outcome set for damage control laparotomy via modified Delphi method

OBJECTIVES

Damage control laparotomy (DCL) remains an important tool in the trauma surgeon's armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while minimizing reporting bias.

METHODS

A modified Delphi study was performed using DCL content experts identified through Eastern Association for the Surgery of Trauma (EAST) 'landmark' DCL papers and EAST ad hoc COS task force consensus.

RESULTS

Of 28 content experts identified, 20 (71%) participated in round 1, 20/20 (100%) in round 2, and 19/20 (95%) in round 3. Round 1 identified 36 potential COS. Round 2 achieved consensus on 10 core outcomes: mortality, 30-day mortality, fascial closure, days to fascial closure, abdominal complications, major complications requiring reoperation or unplanned re-exploration following closure, gastrointestinal anastomotic leak, secondary intra-abdominal sepsis (including anastomotic leak), enterocutaneous fistula, and 12-month functional outcome. Despite feedback provided between rounds, round 3 achieved no further consensus.

CONCLUSIONS

Through an electronic survey-based consensus method, content experts agreed on a core outcome set for damage control laparotomy, which is recommended for future trials in DCL clinical research. Further work is necessary to delineate specific tools and methods for measuring specific outcomes.

LEVEL OF EVIDENCE

V, criteria.

Failure of Abdominal Wall Closure: Prevention and Management

This article reviews evidence-based techniques for abdominal closure and management strategies when abdominal wall closures fail. In particular, optimal primary fascial closure techniques, the role of prophylactic mesh, considerations for combined hernia repair, closure techniques when the fascia cannot be closed primarily, and management approaches for fascial dehiscence are reviewed.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Enterocutaneous fistula after emergency general surgery: Mortality, readmission, and financial burden

BACKGROUND

The burden of enterocutaneous fistula (ECF) after emergency general surgery (EGS) has not been rigorously characterized. We hypothesized that ECF would be associated with higher rates of postdischarge mortality and readmissions.

METHODS

Using the 2016 National Readmission Database, we conducted a retrospective study of adults presenting for gastrointestinal (GI) surgery. Cases were defined as emergent if they were nonelective admissions with an operation occurring on hospital day 0 or 1. We used International Classification of Diseases, 10th Revision, code K63.2 (fistula of intestine) to identify postoperative fistula. We measured mortality rates and 30- and 90-day readmission rates censuring discharges occurring in December or from October to December, respectively.

RESULTS

A total of 135,595 patients underwent emergency surgery; 1,470 (1.1%) developed ECF. Mortality was higher in EGS patients with ECF than in those without (10.1% vs. 5.4%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.67-2.36) among patients who survived the index admission. Readmission rates were higher for EGS patients with ECF than without at 30 days (31.0% vs. 12.6%; OR, 3.12; 95% CI, 2.76-3.54) and at 90 days (51.1% vs. 20.1%; OR, 4.15; 95% CI, 3.67-4.70). Similar increases were shown in elective GI surgery.

CONCLUSIONS

Enterocutaneous fistula after GI EGS is associated with significantly increased odds of mortality and readmission, with rates continuing to climb out to at least 90 days. Processes of care designed to mitigate risk in this high-risk cohort should be developed.

LEVEL OF EVIDENCE

Prognostic and Epidemiological Study, Level III.

The impact of enteric fistulas on US hospital systems

BACKGROUND

There is limited characterization of patients with enteric fistula. Our objective is to determine the incidence of the disease, and characterize demographics, healthcare costs, co-diagnoses, and procedures in this population.

METHODS

The National Inpatient Sample database 2004-2014 was queried to identify patients with enteric fistula using ICD-9 code 569.81.

RESULTS

There were 317,000 admissions with a diagnosis of enteric fistula from 2004 to 2014, accounting for 230,000 hospital days annually. Costs totaled $500 million with charges of $1.5 billion annually. Inpatient mortality is 4.1%. Patients had significant comorbidities and 3 procedures or surgical interventions per admission.

CONCLUSIONS

This descriptive study elucidates the impact of enteric fistula on patients and hospitals by characterizing incidence, clinical associations, and admission characteristics. There is significant financial impact with 28,000 admissions and $500 million dollars in annual costs. This study lays the groundwork for future research by characterizing the impact of enteric fistula.

The Importance of Abdominal Wall Closure After Definitive Surgery for Enterocutaneous Fistula

INTRODUCTION

The coexistence of an enterocutaneous fistula (ECF) with large abdominal wall defects represent one of the most demanding situations seen by a surgeon. Simultaneous treatment of ECF closure with abdominal wall defect closure has been widely debated. Our objective was to determine if the type of abdominal wall closure was associated with fistula recurrence after definitive surgery for ECF.

MATERIALS AND METHODS

Consecutive patients submitted to fistula resection with primary anastomosis for ECF closure. Among several variables, total abdominal wall closure (primary independent variable) was assessed as a factor related to the recurrence of the ECF (dependent variable). Univariate and multivariate analyses were performed.

RESULTS

One-hundred and fourteen patients were included. Fistula recurred in 39 patients (34%). Total abdominal wall closure was done in 37 patients (32%). ECF recurred in 16% (6 of 37 patients) when abdominal wall closure was performed, compared to 43% (33 of 77 patients) when this was not (p < 0.02). After multivariate analyses, abdominal wall closure was found as a protective factor against recurrence (p < 0.02). Patients with total abdominal wall closure had one-fourth of risk for recurrence compared to patients without it. Other factors associated to recurrence of ECF were multiple fistulas (p < 0.05), intraoperative blood loss >325 mL (p < 0.05) and preoperative C-reactive protein >0.5 mg/dL (p < 0.01).

CONCLUSION

Our results suggest that total abdominal wall closure is a protective factor against fistula recurrence after definitive surgery for ECF.

Incisional hernia and enterocutaneous fistula in patients with chronic intestinal failure: prevalence and risk factors in a cohort of patients referred to a tertiary centre

AIM

This study aims to determine the prevalence of incisional hernia (IH) and enterocutaneous fistula (ECF) in patients with intestinal failure (IF) referred to a tertiary centre and to identify factors associated with their development.

METHOD

A retrospective case note review was undertaken of a prospectively maintained database of all patients on home parenteral nutrition between 2011 and 2016 at a UK tertiary referral centre for IF. Risk factors were identified using binary logistic regression.

RESULTS

The database search identified 447 patients, of whom 349 (78.1%) had surgery prior to developing IF. Eighty-one (23.2%) patients had an IH and 123 (35.2%) had an ECF at the time of referral. Of these, 51 (14.6%) had both IH and ECF. IH was associated with a high body mass index (P = 0.05), a history of a major surgical complication resulting in IF (P = 0.01), previous emergency surgery (P = 0.04), increasing number of operations (P = 0.02) and surgical site infection (SSI; P = 0.01). ECF was associated with complications relating to earlier surgery. (P ≤ .001), previous treatment with an open abdomen (P = 0.03), SSI (P = 0.001), intra-abdominal collection (P ≤ 0.001) and anastomotic leak (P = 0.02).

CONCLUSION

In this series, patients with IF had a prevalence of IH which was more than double that expected following elective laparotomy (about 10%) and one in three had an ECF. Risk factors for IH and ECF are discussed.

Quality of Life after Reconstructive Surgery for Intestinal Fistulas

BACKGROUND

This retrospective clinical study would like to objectively denote a quality of life of persons afflicted by an abdominal catastrophe and managed by an extensive surgery can be almost as well conformable as those of healthy people in a similar age group.

METHODS

A set of eighteen patients who were successfully surgically treated and cured enjoyed a relatively good convalescence after their surgery and returned to a satisfactory standard of life from the point of view of organ function and psychosomatic state. Statistical analysis of the data collected over a period of 1 to 6 years after this complex therapy using special questionnaire for QOL assessment SF-36 was performed.

RESULTS

Almost half of the patients evaluated their state similarly to the rest of the population of comparable age and general health status. The remainder of the patients declared significantly worse evaluations in the majority of the observed domains of the questionnaire.

CONCLUSION

Therapy of these patients was and must be complex: it included preparation for surgery at a special metabolic internal site, careful diagnostics of the digestive tract state, suitable surgery and good quality care after the surgery.

A Randomized Controlled Trial on Intra-Abdominal Irrigation during Emergency Trauma Laparotomy; Time for Yet Another Paradigm Shift

OBJECTIVE

To determine the optimal volume of abdominal irrigation that will prevent surgical site infections (both deep and superficial), eviscerations and fistula formations; and improve 30-day mortality in trauma patients.

METHODS

We conducted a three-arm parallel clinical superiority randomized controlled trial comparing different volumes of effluent (5, 10 and 20 liters) used in trauma patients (both blunt and penetrating) age 14 and above undergoing an emergency laparotomy between April 2002 and July 2004 in a busy urban Level 1 trauma center.

RESULTS

After randomization, a total of 204 patients were analyzed. All patient groups were comparable with respect to age, gender distribution, admission injury severity score, and mechanism of injury, estimated blood loss and degree of contamination. The mortality rate overall was 1.96% (4/204).No differences were noted with respect to contamination, wound infection, fistula formation, and evisceration. The twenty liter group (Group III) showed a trend toward an increased incidence of deep surgical site infections when compared to the five liter (Group I) (p=0.051) and ten liter (Group II) (p=0.057) groups. This did not however reach statistical significance.

CONCLUSION

The old surgical adage "the solution to pollution is dilution" is not applicable to trauma patients. Our results suggest that using more irrigation, even when large amounts of contamination have occurred, does not reduce post-operative complications or affect mortality; and it may predispose patients to increased incidence of abscess formation. (Trial registration number: ISRCTN66454589).

Spontaneous closure of multiple enterocutaneous fistula due to abdominal tuberculosis using negative pressure wound therapy: a case report

Enterocutaneous fistula (ECF) is one of the most challenging abdominal complications, for surgeons and other healthcare members, which involves significant morbidity and potentially mortality. Despite advancements in both operative and non-operative therapy, fistula-related complications are still unavoidable. Negative pressure wound therapy (NPWT) had been used years to treat chronic wound, to decrease tissue edema, improve circulation, promote healthy granulation tissue and inhibit bacterial growth. We report a 29-year-old male with complicated ECF due to abdominal tuberculosis, that was healed after treated using NPWT. This was the first ECF patient in our hospital treated using NPWT.

A Case of Small Bowel Obstruction and Enterocutaneous Fistulation Resulting from a Mesenteric Haematoma following Blunt Abdominal Trauma

A 23-year-old male with a history of previous abdominal surgery was involved in a road traffic accident. He was discharged after initial assessment but represented several days with small bowel obstruction secondary to a mesenteric haematoma. He underwent resection and recovered well but represented later on the day of discharge with a leaking surgical wound consistent with an enterocutaneous fistula. This was managed conservatively and closed spontaneously after ten days. This case serves to highlight that adhesions from previous surgery can tether the small bowel causing mesenteric injury following blunt-force trauma. It also demonstrates that postoperative ileus can result in an enterocutaneous fistula that has the appearance of an anastomotic breakdown but which resolves more rapidly.

The effect of damage control laparotomy on major abdominal complications: A matched analysis

INTRODUCTION

Damage control laparotomy (DCL) for trauma is thought to be associated with increased abdominal complications. The purpose of this study is to determine the effect of DCL on abdominal complications by comparing two groups of trauma patients: DCL patients who were prospectively adjudicated to potentially being closed at the primary laparotomy (potential DEF or pDEF) and those who underwent definitive laparotomy (DEF).

METHODS

The pDEF group was matched to DEF patients according to mechanism of injury, abdominal injury severity, operating room transfusions, and performance of a colon resection. The primary outcome was major abdominal complications (MAC), a composite variable.

RESULTS

No statistically significant difference in the primary outcome, major abdominal complications, were seen (pDEF 19% versus DEF 56%, p = 0.066). The pDEF group was more likely to have a fascial dehiscence (38% versus 0%, p = 0.018), and to be re-opened after fascial closure (38% versus 0%, p = 0.018).

CONCLUSION

Damage control laparotomy was associated with clinically but not statistically significant increase in rates of MAC. Increased numbers of patients to analyze in this fashion is needed.

Prognostic Factors for Enteroatmospheric Fistula in Open Abdomen Treated with Negative Pressure Wound Therapy: a Multicentre Experience

BACKGROUND

Reductions in mortality were reported with negative pressure wound therapy for laparostomy. However, some authors have voiced concern over an increased risk of enteroatmospheric fistulae. In this retrospective study, we hypothesized that surgical and metabolic derangements could increase the incidence of enteroatmospheric fistulae. We aimed to assess our experience and report long-term outcomes.

METHODS

A multicentre review of all patients with a laparostomy managed with negative pressure wound therapy between 2005 and 2015 was undertaken. Features associated with enteroatmospheric fistulae were included in multivariate logistic regression.

RESULTS

Fifty-seven patients were treated according to uniform protocol. Fourteen per cent (8/57) presented enteroatmospheric fistulae. Mesenteric ischaemia and preoperative arterial serum lactate >3.5 mmol/L were associated with a significantly increased risk of enteroatmospheric fistulae. Preoperative arterial serum lactate >3.5 mmol/L was an independent predictor of enteroatmospheric fistulae with an odds ratio of 12.41 (95% CI 1.54-99.99). All mesenteric ischaemia patients with anastomosis (5/15) presented enteroatmospheric fistulae. In-hospital mortality was 26.3% (15/57). One-year mortality was 33.3% (19/57). Incisional hernia rate was 5.2% (2/38) after 14.2 (2.4-56.3) months of follow-up.

DISCUSSION

Mesenteric ischaemia increases the risk of enteroatmospheric fistulae. Anastomosis should only be created in revascularized patients. When mesenteric vascularization is not restored, diversion is advised.

What is the effectiveness of the negative pressure wound therapy (NPWT) in patients treated with open abdomen technique? A systematic review and meta-analysis

BACKGROUND

The open abdomen technique may be used in critically ill patients to manage abdominal injury, reduce the septic complications, and prevent the abdominal compartment syndrome. Many different techniques have been proposed and multiple studies have been conducted, but the best method of temporary abdominal closure has not been determined yet. Recently, new randomized and nonrandomized controlled trials have been published on this topic. We aimed to perform an up-to-date systematic review on the management of open abdomen, including the most recent published randomized and nonrandomized controlled trials, to compare negative pressure wound therapy (NPWT) with no NPWT and define if one technique has better outcomes than the other with regard to primary fascial closure, postoperative 30-day mortality and morbidity, enteroatmospheric fistulae, abdominal abscess, bleeding, and length of stay.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions, an online literature research (until July 1, 2015) was performed on MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Library databases. The MeSH terms and free words used "vacuum assisted closure" "vac;", "open abdomen", "damage control surgery", and "temporary abdominal closure". No language restriction was made.

RESULTS

The initial systematic literature search yielded 452 studies. After a careful assessment of the titles and of the full text was obtained, eight articles fulfilled inclusion criteria. We analyzed 1,225 patients, of whom 723 (59%) underwent NPWT and 502 (41%) did not undergo NPWT, and performed four subgroups: VAC versus Bogota bag technique (two studies, 106 participants), VAC versus mesh-foil laparostomy (two studies, 159 participants), VAC versus laparostomy (adhesive impermeable with midline zip) (one study, 106 participants), and NPWT versus no NPWT techniques (three studies, 854 participants) in which it is not possible to perform an analysis of the different types of treatment. Comparing the NPWT group and the group without NPWT, there was no statistically significant difference in fascial closure (63.5% vs 69.5%; odds ratio [OR], 0.74; 95% confidence interval [CI], 0.27-2.06; p = 0.57), postoperative 30-day overall morbidity (p = 0.19), postoperative enteroatmospheric fistulae rate (2.1% vs 5.8%; OR, 0.63; 95% CIs, 0.12-3.15; p = 0.57), in the postoperative bleeding rate (5.7% vs 14.9%; OR, 0.58; 95% CIs, 0.05-6.84; p = 0.87), and postoperative abdominal abscess rate (2.4% vs 5.6%; OR, 0.42; 95% CI, 0.13-1.34; p = 0.14). On the other hand, statistical significance was found between the NPWT group and the group without NPWT in the postoperative mortality rate (28.5% vs 41.4%; OR, 0.46; 95% CI, 0.23-0.91; p = 0.03) and in the length of stay in the intensive care unit (mean difference, -4.53; 95% CI, -5.46 to 3.60; p < 0.00001).

CONCLUSION

The limitations of the present analysis might be related to the lack of randomized controlled trials, so there is a risk of selection bias favoring NPWT. For several outcomes, there were few studies, confidence intervals were wide, and inconsistency was high, suggesting that although there were no statistically significant differences between the groups, there was insufficient evidence to show that the outcomes were similar. We can conclude from the current available data that NPWT seems to be associated with a trend toward better outcomes compared to the use of no NPWT. It does reflect the evidence presented in the current systematic review; however, the data should be interpreted with substantial caution given a number of weaknesses (in particular, the lack of statistical significance and heterogeneity between studies, i.e., small sample size of the included studies, high variability between studies). We highlight the need for randomized controlled trials having homogeneous inclusion criteria to assess the use of NPWT for the management of open abdomen.

LEVEL OF EVIDENCE

Systemic review/meta-analysis, level III.

Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial

Background

Damage control laparotomy (DCL) is an abbreviated operation intended to prevent the development of hypothermia, acidosis, and coagulopathy in seriously injured patients. The indications for DCL have since been broadened with no high-quality data to guide treatment. For patients with an indication for DCL, we aim to determine the effect of definitive laparotomy on patient morbidity.

Method

This is a pragmatic, parallel-group, randomized controlled pilot trial. Emergent laparotomy is defined as admission directly to the operating room from the emergency department within 90 min of arrival. DCL indications excluded from the study include packing of the liver or retroperitoneum, abdominal compartment syndrome prophylaxis, to expedite interventional radiology for hemorrhage control, and the need for ongoing transfusions and/or continuous vasopressor support. When a surgeon determines a DCL is indicated, the patient will be screened for inclusion and exclusion criteria. Patients with any indication for DCL that is not excluded are eligible for randomization. Patients will be randomized intraoperatively to DCL (control) or definitive fascial closure of the laparotomy (intervention). The primary outcome will be major abdominal complication or death within 30 days. Major abdominal complication is a composite outcome including fascial dehiscence, organ/space surgical site infection, enteric suture line failure, and unplanned reopening of the abdomen. Outcomes will be compared using both frequentist and Bayesian statistics.

Discussion

In patients with an indication for DCL, this trial will determine the effect of definitive laparotomy on major abdominal complications and death and will inform clinicians on the risks and benefits of this procedure. Regardless of the study outcome, the results will improve the quality of care provided to injured patients.

Trial registration number

NCT02706041.

The Use of Latex Catheters to Close Enterocutaneous Fistulas: An Institutional Protocol and Retrospective Review

OBJECTIVE

The objective of our study was to retrospectively review an institutional protocol that uses latex catheters for the treatment of enterocutaneous fistulas (ECFs) that are resistant to simple drainage.

MATERIALS AND METHODS

Forty-six consecutive patients with ECFs that did not close with simple abscess drainage were treated with latex catheters. These patients' charts were retrospectively reviewed to determine treatment success rates and the relationship of treatment success to clinical characteristics.

RESULTS

ECFs in 26 of the 46 (56.5%) patients were treated successfully with latex catheters. On univariate analysis, the fistulas that originated from the stomach were statistically less likely to close (p = 0.03), whereas those originating from the small bowel were more likely to close (p = 0.01). The duration of treatment was significantly longer in patients for whom the treatment failed than in those who were successfully treated (p = 0.003). After a total treatment time of more than 116 days (odds ratio [OR], 9.8 [95% CI, 2.5-38.4]; p = 0.001) or latex catheter treatment time of more than 74 days (OR, 8.9 [95% CI, 2.2-35.0]; p = 0.002), the chance of ECF closure decreased significantly.

CONCLUSION

Treatment of ECFs that are resistant to simple abscess cavity drainage with a latex catheter is possible and decreases the need for surgery.

Vaizey CJ, Maeda Y, Barbosa E, Bozzetti F, Calvo J, Irtun Ø, Jeppesen PB, Klek S, Panisic-Sekeljic M, Papaconstantinou I, Pascher A, Panis Y, Wallace WD, Carlson G, Boermeester M. European Society of Coloproctology consensus on the surgical management of intestinal failure in adults

Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.

Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication

Background

Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances.

Method

A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR.

Results

From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16–110) after LT. Biliary reconstruction included duct‐to‐duct (n = 9) and hepatico‐jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in‐hospital death. In the follow‐up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well.

Conclusions

In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.

Ratio-driven resuscitation predicts early fascial closure in the combat wounded

BACKGROUND

Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy.

METHODS

Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure.

RESULTS

The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure.

CONCLUSION

Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Open abdomen in trauma patients: a double-edged sword

The use of open abdomen (OA) as a technique in the treatment of exsanguinating trauma patients was first described in the mid-19(th) century. Since the 1980s, OA has become a relatively new and increasingly common strategy to manage massive trauma and abdominal catastrophes. OA has been proven to help reduce the mortality of trauma. Nevertheless, the OA method may be associated with terrible and devastating complications such as enteroatmospheric fistula (EAF). As a result, OA should not be overused, and attention should be given to critical care as well as special management. The temporary abdominal closure (TAC) technique after abbreviated laparotomy was used to improve wound healing and facilitate final fascial closure of OA. Negative pressure therapy (NPT) is the most commonly used TAC method.

Short Bowel Syndrome and Malabsorption - Causes and Prevention

Background

The short bowel syndrome (SBS) is a condition caused by extensive intestinal resection for a variety of conditions. The etiology varies by age group. Necrotizing enterocolitis is the leading cause in infants. In older children, trauma and malignancies are most common. Postoperative SBS has become most common in adults, followed by mesenteric vascular disease and cancer/irradiation.

Methods

Systematic literature review.

Results

Prevention of SBS should be given high priority. Each of the etiologies has been evaluated and strategies to prevent extensive resection have been developed. These include a thoughtful approach to reoperation, early identification of complications, e.g. intestinal ischemia, reducing radiation enteritis, and bowel-conserving therapies in diseases such as Crohn's disease.

Conclusion

Several operative strategies to prevent SBS are useful. Timing and extent of reoperation need careful consideration. Minimizing intestinal resection, bowel-conserving techniques for complications such as fistula or strictures, and remodeling procedures are important.

Planned ventral hernia following damage control laparotomy in trauma: an added year of recovery but equal long-term outcome

PURPOSE

Significantly injured trauma patients commonly require damage control laparotomy (DCL). These patients undergo either primary fascial closure during the index hospitalization or are discharged with a planned ventral hernia. Hospital and long-term outcomes of these patients have not been extensively studied.

METHODS

Patients who underwent DCL for trauma from 2003 to 2012 at a regional Level I trauma center were identified and a comparison was made between those who had primary fascial closure and planned ventral hernia.

RESULTS

DCL was performed in 154 patients, 47% of whom sustained penetrating injuries. The mean age and injury severity score (ISS) were 40 and 25, respectively. Hospital mortality was 19%. Primary fascial closure was performed in 115 (75%) of those undergoing DCL during the index hospitalization. Of these, 11 (9%) had reopening of the fascia. Of the surviving patients, 22 (19%) never had primary fascial closure and were discharged with a planned ventral hernia. Patients with primary fascial closure and those with planned ventral hernia were similar in age, gender, ISS, and mechanism. Those with planned ventral hernias underwent more subsequent laparotomies (3.0 vs. 1.3, p < 0.001), and had more enteric fistulas (18.2 vs. 4.3%, p = 0.041) and intra-abdominal infections (46 vs. 15%, p = 0.007), and had a greater number of hospital days (38 vs. 25, p = 0.007) during the index hospitalization. Sixteen (73%) patients with a planned ventral hernia had definitive reconstruction (mean days = 266). Once definitive abdominal wall closure was achieved, the two groups achieved similar rates of return to work and usual activity (71 vs. 70%, p = NS).

CONCLUSIONS

Following DCL for trauma, patients with a planned ventral hernia have definitive reconstruction nearly 9 months after the initial injury. Once definitive abdominal wall closure has been achieved; patients with primary fascial closure and those with planned ventral hernia have similar rates of return to usual activity.

Efficacy and safety of damage control in experimental animal models of injury: protocol for a systematic review and meta-analysis

BACKGROUND

Although abbreviated surgery with planned reoperation (damage control surgery) is now widely used to manage major trauma patients, the procedure and its component interventions have not been evaluated in randomized controlled trials (RCTs). While some have suggested the need for such trials, they are unlikely to be conducted because of patient safety concerns. As animal studies may overcome several of the limitations of existing observational damage control studies, the primary objective of this study is to evaluate the efficacy and safety of damage control versus definitive surgery in experimental animal models of injury.

METHODS/DESIGN

We will search electronic databases (Medline, Embase, PubMed, Web of Science, Scopus, and the Cochrane Library), conference abstracts, personal files, and bibliographies of included articles. We will include RCTs and prospective cohort studies that utilized an animal model of injury and compared damage control surgery (or specific damage control interventions or adjuncts) to definitive surgery (or specific definitive surgical interventions). Two investigators will independently evaluate the internal and external/construct validity of individual studies. The primary outcome will be all-cause mortality. Secondary outcomes will include blood loss amounts; blood pressures and heart rates; urinary outputs; core body temperatures; arterial lactate, pH, and base deficit/excess values; prothrombin and partial thromboplastin times; international normalized ratios; and thromboelastography (TEG) results/activated clotting times. We will calculate summary relative risks (RRs) of mortality and mean differences (for continuous outcomes) using DerSimonian and Laird random effects models. Heterogeneity will be explored using subgroup meta-analysis and meta-regression. We will assess for publication bias using funnel plots and Begg's and Egger's tests. When evidence of publication bias exists, we will use the Duval and Tweedie trim and fill method to estimate the potential influence of this bias on pooled summary estimates.

DISCUSSION

This study will evaluate the efficacy and safety of damage control in experimental animal models of injury. Study results will be used to guide future clinical evaluations of damage control surgery, determine which animal study outcomes may potentially be generalizable to the clinical setting, and to provide guidelines to strengthen the conduct and relevance of future pre-clinical studies.

Polymorphism of heat shock protein 70-2 and enterocutaneous fistula in Chinese population

AIM

To investigate whether the heat shock protein 70-2 (HSP70-2) polymorphism is associated with enterocutaneous fistulas in a Chinese population.

METHODS

This study included 131 patients with enterocutaneous/enteroatmospheric fistulas. Patients with inflammatory bowel disease or other autoimmune diseases were excluded from this study. All patients with enterocutaneous/enteroatmospheric fistulas were followed up for three months to observe disease recurrence. In addition, a total of 140 healthy controls were also recruited from the Jinling Hospital, matched according to the sex and age of the patient population. Genomic DNA was extracted from peripheral blood from each participant. The HSP70-2 restriction fragment length polymorphism related to the polymorphic PstI site at position 1267 was characterized by polymerase chain reaction (PCR). First PCR amplification was carried out, and then PCR products were digested with PstI restriction enzyme. The DNA lacking the polymorphic PstI site within HSP70-2 generates a product of 1117 bp in size (allele A), whereas the HSP70-2 PstI polymorphism produces two fragments of 936 bp and 181 bp in size (allele B).

RESULTS

The frequency of the HSP70-2 PstI polymorphism did not differ between patients and controls; however, the A allele was more predominant in patients with enterocutaneous fistulas than in controls (60.7% vs 51.4%, P = 0.038, OR = 1.425, 95%CI: 1.019-1.994). Sixty-one patients were cured by a definitive operation, drainage operation, or percutaneous drainage while 52 patients were cured by nonsurgical treatment. There was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who had surgery compared to those who did not (P = 0.437, OR = 1.237, 95%CI: 0.723-2.117). Moreover, 11 patients refused any treatment for economic reasons or tumor burden, and 7 patients with enterocutaneous fistulas (5.8%) died during the follow-up period. However, there was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who survived compared to those who died (P = 0.403, OR = 0.604, 95%CI: 0.184-1.986).

CONCLUSION

The A allele of the HSP70-2 PstI polymorphism was associated with enterocutaneous fistulas in this Chinese population.

The open abdomen: temporary closure with a modified negative pressure therapy technique

The most common indications for an open abdomen (OA) are abdominal compartment syndrome, damage control surgery, diffuse peritonitis and wound dehiscence, and often require a temporary abdominal closure (TAC). The different TAC methods that are currently available include skin closure techniques, mesh products and negative pressure therapy (NPT) systems. For this study, we retrospectively reviewed records of 115 OA patients treated with the commercially available NPT systems (V.A.C.(®) Abdominal Dressing System and ABThera™ Open Abdomen Negative Pressure Therapy System) using a new method of applying the system - the narrowing technique - over a 5-year period. Endpoints included fascial closure and 30-day mortality rates and presence of enteroatmospheric fistulas. Secondary closure of the fascia was obtained in 92% (106/115) of the patients with a mortality rate of 17% (20/115) and a fistula rate of 3·5% (4/115). The use of the narrowing technique to apply NPT may explain the high closure rates observed in the patient population of this study. Further studies are necessary to compare the different methods and to evaluate the long-term outcomes.

Persistent inflammation-immunosuppression catabolism syndrome, a common manifestation of patients with enterocutaneous fistula in intensive care unit

BACKGROUND

Persistent inflammation-immunosuppression catabolism syndrome (PICS) is a newly proposed concept that has replaced late multiple-organ failure and prolongs surgical intensive care unit (ICU) duration. Enterocutaneous fistula (ECF) is one of the most challenging complications in the practice of surgery. However, no studies have been performed connecting PICS with ECF.

METHODS

A total of 130 ECF patients admitted to ICU between January 2011 and January 2012 were retrospectively studied. Two residents of our center collected data (including demographics, clinical manifestation, underlying disease, Acute Physiology and Chronic Health Evaluation II score, therapeutic schedules, laboratory test reports, and clinical outcomes) from electronic medical records for each patient. We further investigated the prevalence of PICS in patients with ECF and compared the demographics, disease severity, complications, clinical outcomes, and prognosis between PICS and non-PICS patients.

RESULTS

The overall incidence of PICS in ECF was 43.1%. The mortality rates of non-PICS and PICS groups were 7.1% and 28.3%, respectively. Compared with the non-PICS group, the PICS group showed an increased age, a higher fistula output, but a lower body mass index and albumin level. However, the Acute Physiology and Chronic Health Evaluation II score did not differ between the two groups. During the whole treatment course, the PICS group showed a higher risk of developing pneumonia and catheter-related blood stream infection compared with the non-PICS group. Although the overall incidences of sepsis were similarly, the risk of developing sepsis after the first 7 days of admission was significantly higher in the PICS group (67.9% vs. 38.6%, p = 0.002). Moreover, the PICS group experienced longer stays in the ICU, higher hospital charges, and higher probabilities of mechanical ventilation compared with the non-PICS group.

CONCLUSION

PICS is a common manifestation of patients with ECF. ECF provides an excellent clinical model to study PICS owing to the pathophysiologic characteristics of ECF itself.

LEVEL OF EVIDENCE

Prognostic study, level III.

Use of Damage Control and the Open Abdomen in Combat

Despite the well-documented use of damage control laparotomy (DCL) in civilian trauma, its use has not been well described in the combat setting. Therefore, we sought to document the use of DCL and to investigate its effect on patient outcome. Prospective data were collected on 1603 combat casualties injured between April 2003 and January 2009. One hundred seventy patients (11%) underwent an exploratory laparotomy (ex lap) in theater and comprised the study cohort. DCL was defined as an abbreviated ex lap resulting in an open abdomen. Patients were stratified by age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), mechanism of injury, and blood product administration. Multivariate regression analyses were used to determine risks factors for intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and the need for DCL. Mean age of the cohort was 24 ± 5 years, ISS was 21 ± 11, and 94 per cent sustained penetrating injury. Patients with DCL comprised 50.6 per cent (n = 86) of the study cohort and had significant increases in ICU admission ( P < 0.001), ICU LOS ( P < 0.001), HLOS ( P < 0.05), ventilator days ( P < 0.001), abdominal complications ( P < 0.05), but not mortality ( P = 0.65) compared with patients without DCL. When compared with the non-DCL group, patients undergoing DCL required significantly more blood products (packed red blood cells, fresh-frozen plasma, platelets, and cryoprecipitate; P < 0.001). Multivariate regression analyses revealed blood transfusion and GCS as significant risk factors for DCL ( P < 0.05). Patients undergoing DCL had increased complications and resource use but not mortality compared with patients not undergoing DCL. The need for combat DCL may be different compared with civilian use. Prospective studies to evaluate outcomes of DCL are warranted.

Damage control abdomen: single-stage reconstruction using a vicryl mesh buttress

PURPOSE

Damage control laparotomy has become an accepted approach for patients with life-threatening abdominal conditions. This method compromises fascial integrity creating functionally and aesthetically debilitating hernias. The purpose of this study is to present our technique and outcomes with these complex abdominal wall reconstructions.

METHODS

A retrospective review was conducted on 56 patients with previous damage control laparotomies who underwent elective single-stage abdominal wall reconstruction between 1999 and 2006. Mean age was 42 years. Reconstruction consisted of a double-layer, subfascial Vicryl mesh buttress, combined with components separation and rectus muscle turnover flaps. Hernia recurrence and function were evaluated by clinical examinations and telephone surveys.

RESULTS

The major etiologies of abdominal hernias were gunshot wounds, motor vehicle accidents or blunt trauma, and sepsis or perforated bowel. The mean abdominal wall defect was 865 cm, and the average interval time to definitive repair was 17 months. The average length of follow-up was 29 months. Most patients (88%) had successful repair of their abdominal wall, with no hernia recurrence. There were 7 cases of hernia. Of these, 2 cases were from reopening of abdomen because of compartment syndrome that was not repaired, 3 were small asymptomatic hernias for which patients elected not to undergo further repair. Other complications include superficial skin dehiscence, all of which healed secondarily with daily wound care 12% (7 patients) and abdominal compartment syndrome 7.1% (4 patients), resulting in 2 postoperative mortalities in the initial part of the series. There were no mesh exposures, seromas, or fistulas. In all, 29% or 52% of patients were reached by telephone. Of those, 90% surveyed and who worked full-time prior to injury returned to their jobs, and 92% were functioning at premorbid activity levels.

CONCLUSION

Massive abdominal hernia following damage control laparotomy poses a great challenge to the reconstructive surgeon. This patient population is at significant risk for mortality and morbidity. We believe the use of a Vicryl mesh buttress is an important adjunctive tool in complex abdominal wall reconstruction. Functional results are excellent with most returning to work and preinjury activity levels.

The open abdomen and temporary abdominal closure systems--historical evolution and systematic review

AIM

Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end-points included delayed fascial closure and in-hospital mortality. The secondary end-points were intra-abdominal complications.

RESULTS

The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%).

CONCLUSION

Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.

The use of temporary abdominal closure in low-risk trauma patients: helpful or harmful?

BACKGROUND

Temporary abdominal closure (TAC) has become a widely used technique in severely injured patients. However, there is growing concern that TAC is being overutilized. We sought to identify less severely injured patients who underwent TAC and to compare their outcomes with patients managed with a single-stage laparotomy (SSL).

METHODS

This is a analysis of all trauma patients who underwent immediate laparotomy from 2005 to 2009. Risk modeling identified TAC patients who met all low-risk criteria: systolic blood pressure >90, no severe head injury, no combined solid + hollow viscus injury, or vascular injury. The low-risk cohort (LR-TAC) was compared with a matched similarly injured cohort managed with SSL using univariate and multivariate regression analysis.

RESULTS

Among the 282 patients undergoing TAC, 62 (22%) met low-risk criteria and were included in the LR-TAC group. There were 566 patients identified in the SSL group. There was no significant difference between groups for age, mechanism, Injury Severity Scores, associated injuries, base deficit, temperature, blood transfusion, solid organ injury, or bowel resection. The LR-TAC group had more hospital and ventilator days and increased complications rates (all p < 0.05). This included a higher rate of bowel ischemia/perforation with LR-TAC (7% vs. 0.7%). The use of TAC in the low-risk group was independently associated with increased complications (odds ratio 3.0, p = 0.01) and prolonged hospital stays (odds ratio 9.6, p < 0.01).

CONCLUSIONS

TAC was associated with increased morbidity and resource utilization when applied to less severely injured patients. Further study is indicated to clarify populations that may be harmed or benefitted by TAC.

LEVEL OF EVIDENCE

: III, therapeutic study.

Abdominal compartment syndrome: risk factors, diagnosis, and current therapy

Abdominal compartment syndrome's manifestations are difficult to definitively detect on physical examination alone. Therefore, objective criteria have been articulated that aid the bedside clinician in detecting intra-abdominal hypertension as well as the abdominal compartment syndrome to initiate prompt and potentially life-saving intervention. At-risk patient populations should be routinely monitored and tiered interventions should be undertaken as a team approach to management.

[Open abdomen 2009. A national survey of open abdomen treatment in Germany]

BACKGROUND

Open abdomen (OA) treatment has been established worldwide. This survey examines the current status of OA treatment in Germany.

MATERIAL AND METHODS

A national survey was conducted between October 2008 and September 2009 by questionnaires sent to 1,219 surgical departments. Data were evaluated descriptively.

RESULTS

The response rate was 38% overall and 69% for university departments. Open abdomen treatment is used by 94% of all respondents. Most commonly used are staged abdominal lavage (87%), a commercial abdominal dressing system (82%), planned ventral hernia (69%), and other intra-abdominal dressings (e.g. vacuum pack 15%, Bogotá bag 5%). Nearly half of the respondents (46%) indicated a modification of their strategy towards vacuum techniques during the last 5 years.

CONCLUSIONS

Open abdomen procedures are widely used in German surgical departments. This survey indicates a shift of treatment strategies towards vacuum techniques but even though predominant, the effectiveness and safety of these techniques must still be confirmed by prospective controlled trials. This survey helps to identify relevant clinical questions and enables focused trial networking.

Surgical management of enterocutaneous fistula

Enterocutaneous (EC) fistula is an abnormal connection between the gastrointestinal (GI) tract and skin. The majority of EC fistulas result from surgery. About one third of fistulas close spontaneously with medical treatment and radiologic interventions. Surgical treatment should be reserved for use after sufficient time has passed from the previous laparotomy to allow lysis of the fibrous adhesion using full nutritional and medical treatment and until a complete understanding of the anatomy of the fistula has been achieved. The successful management of GI fistula requires a multi-disciplinary team approach including a gastroenterologist, interventional radiologist, enterostomal therapist, dietician, social worker and surgeons. With this coordinated approach, EC fistula can be controlled with acceptable morbidity and mortality.

A national survey on temporary and delayed abdominal closure in Norwegian hospitals

Introduction

Temporary abdominal closure (TAC) is included in most published damage control (DC) and abdominal compartment (ACS) protocols. TAC is associated with a range of complications and the optimal method remains to be defined. The aim of the present study was to describe the experience regarding TAC after trauma and ACS in all acute care hospitals in a sparsely populated country with long transportation distances.

Material and methods

A questionnaire was sent to all 50 Norwegian hospitals with acute care general surgical services.

Results

The response rate was 88%. A very limited number of hospitals had treated more than one trauma patient with TAC (5%) or one patient with ACS (14%) on average per year. Most hospitals preferred vacuum assisted techniques, but few reported having formal protocols for TAC or ACS. Although most hospitals would refer patients with TAC to a trauma centre, more than 50% reported that they would perform a secondary reconstruction procedure themselves.

Conclusion

This study shows that most Norwegian hospitals have limited experience with TAC and ACS. However, the long distances between hospitals mandate all acute care hospitals to implement formal treatment protocols including monitoring of IAP, diagnosing and decompression of ACS, and the use of TAC. Assuming experience leads to better care, the subsequent treatment of these patients might benefit from centralization to one or a few regional centers.

Enterocutaneous fistulas: an overview

Enterocutaneous fistulas remain a difficult management problem. The basis of management centers on the prevention and treatment of sepsis, control of fistula effluent, and fluid and nutritional support. Early surgery should be limited to abscess drainage and proximal defunctioning stoma formation. Definitive procedures for a persistent fistula are indicated in the late postoperative period, with resection of the fistula segment and reanastomosis of healthy bowel. Even more complex are the enteroatmospheric fistulas in the open abdomen. These enteric fistulas require the highest level of multidisciplinary approach for optimal outcomes.

Damage control in trauma and abdominal sepsis

Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.