A simple novel technique for enteroatmospheric fistulae: silicone fistula plug

Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.

Whole Model Path Planning-Guided Multi-Axis and Multi-Material Printing of High-Performance Intestinal Implantable Stent

The problems of step effects, supporting material waste, and conflict between flexibility and toughness for 3D printed intestinal fistula stents are not yet resolved. Herein, the fabrication of a support-free segmental stent with two types of thermoplastic polyurethane (TPU) using a homemade multi-axis and multi-material conformal printer guided with advanced whole model path planning is demonstrated. One type of TPU segment is soft to increase elasticity, and the other is used to achieve toughness. Owing to advancements in stent design and printing, the obtained stents present three unprecedented properties compared to previous three-axis printed stents: i) Overcoming step effects; ii) Presenting comparable axial flexibility to a stent made of a single soft TPU 87A material, thus increasing the feasibility of implantation; and iii) Showing equivalent radial toughness to a stent made of a single hard TPU 95A material. Hence, the stent can resist the intestinal contractive force and maintain intestinal continuity and patency. Through implanting such stents to the rabbit intestinal fistula models, therapeutic mechanisms of reducing fistula output and improving nutritional states and intestinal flora abundance are revealed. Overall, this study develops a creative and versatile method to improve the poor quality and mechanical properties of medical stents.

A 5 + 1-Axis 3D Printing Platform for Producing Customized Intestinal Fistula Stents

Tailored intestinal fistula stents with a hollow bent pipe structure prepared by using a three-axis bio-printing platform are often unsuitable due to low printing efficiency and quality caused by the unavoidable need for a supporting structure. Herein, a 5 + 1-axis 3D printing platform was built and developed for producing support-free intestinal fistula stents. A 3D model of the target stent shape and dimensions was treated by a dynamic slicing algorithm, which was then used to prepare a motion control code. Our printing method showed improved printing efficiency, superior stent surface properties and structure and ideal elasticity and mechanical strength to meet the mechanical requirements of the human body. Static simulations showed the importance of axial printing techniques, whereas the stent itself was shown to have excellent biocompatibility with wettability and cell proliferation tests. We present a customizable, efficient, and high-quality method with the potential for preparing bespoke stents for treating intestinal fistulas.

4D-printed bilayer hydrogel with adjustable bending degree for enteroatmospheric fistula closure

Recently, four-dimensional (4D) shape-morphing structures, which can dynamically change shape over time, have attracted much attention in biomedical manufacturing. The 4D printing has the capacity to fabricate dynamic construction conforming to the natural bending of biological tissues, superior to other manufacturing techniques. In this study, we presented a multi-responsive, flexible, and biocompatible 4D-printed bilayer hydrogel based on acrylamide-acrylic acid/cellulose nanocrystal (AAm-AAc/CNC) network. The first layer was first stretched and then formed reversible coordination with Fe³⁺ to maintain this pre-stretched length; it was later combined with a second layer. The deformation process was actuated by the reduction of Fe³⁺ to Fe²⁺ in the first layer which restored it to its initial length. The deformation condition was to immerse the 4D construct in sodium lactate (LA-Na) and then expose it to ultraviolet (UV) light until maximal deformation was realized. The bending degree of this 4D construct can be programmed by modifying the pre-stretched lengths of the first layer. We explored various deformation steps in simple and complex constructs to verify that the 4D bilayer hydrogel can mimic the curved morphology of the intestines. The bilayer hydrogel can also curve in deionized water due to anisotropic volume change yet the response time and maximum bending degree was inferior to deformation in LA-Na and UV light. Finally, we made a 4D-printed bilayer hydrogel stent to test its closure effect for enteroatmospheric fistulas (EAFs) in vitro and in vivo. The results illustrate that the hydrogel plays a role in the temporary closure of EAFs. This study offers an effective method to produce curved structures and expands the potential applications of 4D printing in biomedical fields.

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A novel strategy to fabricate 4D-printed multi-responsive bilayer hydrogels is proposed.

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The deformation mechanism relies on shrinkage anisotropy between two layers in lactate sodium solution and ultraviolet.

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The 4D shape-morphing hydrogel can adapt to intestinal curvature for enteroatmospheric fistula closure.

Application of a 3D-printed ”fistula stent” in plugging enteroatmospheric fistula with open abdomen: A case report

BACKGROUND

Open abdomen (OA) has been generally accepted for its magnificent superiority and effectiveness in patients with severe trauma, severe intra-abdominal infection, and abdominal compartment syndrome. In the meantime, OA calls for a mass of nursing and the subsequent enteroatomospheric fistula (EAF), which is one of the most common complications of OA therapy, remains a thorny challenge.

CASE SUMMARY

Our team applied thermoplastic polyurethane as a befitting material for producing a 3D-printed “fistula stent” in the management of an EAF patient, who was initially admitted to local hospital because of abdominal pain and distension and diagnosed with bowel obstruction. After a series of operations and OA therapy, the patient developed an EAF.

CONCLUSION

Application of this novel “fistula stent” resulted in a drastic reduction in the amount of lost enteric effluent and greatly accelerated rehabilitation processes.

Complete abdominal wound and anastomotic leak with diffuse peritonitis closure achieved by an abdominal vacuum sealing drainage in a critical ill patient: a case report

Background

Negative pressure wound therapy (NPWT) is a widely accepted technique to treat local infectious wounds of the skin, subcutaneous tissue, fascia, or muscle. Recently, several reports describing the efficacy of NPWT for various types of fistulas and anastomotic leaks have been published. We herein describe a patient with an open abdominal wound due to colonic anastomotic leakage and diffuse peritonitis, in whom abdominal vacuum sealing (AVS) as a modified NPWT was useful for the management of this complex wound.

Case presentation

A 32-year-old man was admitted to our hospital with late presenting traumatic diaphragmatic hernia and strangulated ileum complicated by necrosis of the ileum and transverse colon. He had a history of cervical spinal cord injury due to suicide attempt 14 years earlier and, as a result of cervical spinal cord injury, he was paralyzed in the lower body. The patient underwent an urgent hernia repair and bowel resection. Postoperatively, he developed severe septic shock. On postoperative day (POD) 6, wound dehiscence due to colonic anastomotic leakage with diffuse peritonitis was diagnosed, but he was unable to undergo re-operation because of refractory severe septic shock combined with neurogenic shock due to the cervical cord injury. The patient was treated with AVS therapy. He gradually recovered from septic shock, and the anastomotic leakage healed after a 2-month period. The wound dehiscence was also reduced. The patient resumed oral intake on POD 112 and was discharged on POD 190.

Conclusions

Although surgical repair would be the best method for the treatment of diffuse peritonitis due to gastrointestinal perforation or anastomotic leakage, our case suggests that AVS with ‘conventional’ drainage is a treatment of choice for open abdominal wounds even in the presence of diffuse peritonitis caused by intestinal anastomotic leakage, especially in patients with poor general medical condition.

Successful treatment of enteroatmospheric fistulas in combination with negative pressure wound therapy: Experience on 3 cases and literature review

Enteroatmospheric fistulas (EAF) are rare but challenging and morbid complications of abdominal surgery and require time- as well as resource-consuming management. Furthermore, they severely affect patients' quality of life. Several treatment modalities for EAF management are described in the literature. We describe 3 consecutive cases of EAF treatment by employing negative pressure wound therapy (NPWT) along with either a special silicone fistula adapter or a Silo-Vac-like system in another case to isolate the fistula from the remaining abdominal wound. Spontaneous fistula closure was achieved in 2 of the 3 cases, and surgical resection of the small bowel segment harbouring EAF opening was possible in a third case after wound conditioning. The rate of fistula closure was 100% (n = 3/3). Compartmentalisation of the contaminated area using NPWT accelerated healing of the open abdominal wound remarkably. In summary, we present a useful tool for the challenging management of EAF and review the literature on different treatment options of EAF available today.

Laparoscopically assisted treatment of entero-atmospheric fistula following abdominal wall repair of complex incisional hernia: Case report

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Laparoscopy is useful in approaching a complex abdominal cavity.

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Multidisciplinary approach and well-planned surgery improved the EAF treatment.

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Different forms of tube drainage inside or around the fistula are proposed.

Introduction

Entero-atmospheric fistula (EAF) is an uncommon complication. Its timing and surgical management could be extremely challenging because extensive adhesions may heavily affect the approach to the abdominal cavity.

Presentation of case

We hereby report a case of EAF in a 70 year-old man. In order to control the fistula output and the surrounding tissue damage from enteric content, the patient was managed conservatively using different technical solutions. Finally, the patient underwent surgery that started with a laparoscopic approach in order to avoid the hostile abdomen.

Discussion

Due to the lack of guidelines, treatment of EAF requires a multidisciplinary approach and different technical options based on the experience and inventiveness of the surgeon. Among others, the vacuum assisted wound management proved to be a useful support andlaparoscopy demonstrated to be valuable in approaching the abdominal cavity.

Conclusion

According to our experience the success of the treatment of EAF may be improved adopting a multidisciplinary approach and well-planned surgery in referral centers.

Enteroatmospheric fistula management by endoscopic gastrostomy PEG tube

Management of small-bowel fistulas which are in an open abdomen and have no soft tissue overlay or a fistula tract involves many complications and challenges. Controlling the local leakage of enteric contents has a central role in the success of medical treatment. There are several methods to deal with fistula discharge but unfortunately, the technical solutions only partially address such problems and a definitive management of fistula discharge still remains an insoluble challenge. We describe a simple and cheap method to control fistula leakage by using a percutaneous endoscopic gastrostomy tube.

Classification, prevention and management of entero-atmospheric fistula: a state-of-the-art review

BACKGROUND

Entero-atmospheric fistula (EAF) is an enteric fistula occurring in the setting of an open abdomen, thus creating a communication between the GI tract and the external atmosphere. Management and nursing of patients suffering EAF carries several challenges, and prevention of EAF should be the first and best treatment option.

PURPOSE

Here, we present a novel modified classification of EAF and review the current state of the art in its prevention and management including nutritional issues and feeding strategies. We also provide an overview on surgical management principles, highlighting several surgical techniques for dealing with EAF that have been reported in the literature throughout the years.

CONCLUSIONS

The treatment strategy for EAF should be multidisciplinary and multifaceted. Surgical treatment is most often multistep and should be tailored to the single patient, based on the type and characteristics of the EAF, following its correct identification and classification. The specific experience of surgeons and nursing staff in the management of EAF could be enhanced, applying distinct simulation-based ex vivo training models.

Use of Vacuum-assisted closure in management of open abdominal wound with multiple enterocutaneous fistulae during chemotherapy: A case report

INTRODUCTION

Vacuum-assisted closure (VAC) is useful for treating complex wounds because it promotes granulation. In the present report, a successful case of VAC used for an open abdominal wound with enterocutaneous fistulae after multiple intestinal perforations during chemotherapy is described.

PRESENTATION OF CASE

A 73-year-old man was admitted to our hospital with severe abdominal pain. He underwent surgical resection for ascending colon cancer 4 years ago and was administered chemotherapy with bevacizumab for recurrence. Physical examination and computed tomography revealed perforation of the intestine, and an emergency operation was performed. Following this procedure, other intestinal perforations occurred, resulting in an open abdominal wound at postoperative day (POD) 10. To isolate enteric contents and promote granulation, VAC was applied to the abdominal wound with enterocutaneous fistulae. Oral intake started at POD 21 and the wound size became smaller. Further, an ostomy bag was directly attached to the most oral perforation site. The patient recovered from life-threatening events without severe infection and was transferred to another hospital close to his home at POD 180.

DISCUSSION

Gastrointestinal perforation is known to be one of the fatal adverse events of bevacizumab. In this case four gastrointestinal perforations were observed. Isolation of enteric contents is important to heal the wound and VAC is an effective therapy for the management of open abdominal wounds even with enterocutaneous fistulae.

CONCLUSION

Innovative VAC use for the management of open abdominal wounds can improve the nutritional status and overall wound healing of the patient.