“Enteroatmospheric” Fistula: The Feared Complication of the. “Open Abdomen”. William Schecter, MD, FACS. Professor of Clinical Surgery. University of. An enteroatmospheric fistula (EAF) is a known, morbid complication of open abdomen (OA) treatment. Patients with EAF often require repeated operations and. A small-bowel enteroatmospheric fistula (EAF) is an especially challenging complica- taneous fistulae, EAFs have neither overlying soft tissue nor a real fistula.
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Enteroatmospheric fistula EAF is one of the most devastating complications in patients with an open abdomen and has associated morbidity and mortality rates. No gold standard therapy has been established for the treatment of EAF, and thus, treatment decision making is dependent on the experience of medical staff.
Nevertheless, treatment involves the following; 1 sepsis must be managed, 2 sufficient nutritional support must be provided, and 3 effluent must be isolated from skin and open viscera. Here the authors present the case of a year-old man who developed enteroatmospheric fistula after damage control laparotomy.
Management of an Entero-Atmospheric Fistula
As a result, the spontaneous healing of EAF is nearly impossible. A year-old male patient was admitted to trauma surgery department after a motorcycle accident. His mental status was alert but he was hypothermic.
Blood transfusion and warming were immediately instituted. Computed tomography revealed liver laceration, bleeding of mesentery, complete infarction of the ffistula kidney, multiple rib fractures, and a pelvic bone fracture Anterior Posterior Compression type III Fig.
Multiple perforations of small intestine and liver laceration were observed in operation. Temporary abdominal closure was performed after perihepatic gauze packing, resection of 50 cm of small intestine, and preperitoneal pelvic packing. External fixation of the pelvis was immediately followed by abdominal surgery.
After 1 day in hospital hospital enteroatmosphheric 1; HD1Continuous renal replacement therapy was implemented due to acute kidney injury. On HD2, right nephrectomy was performed due to complete infarction of the right kidney, but abdomen closure was unsuccessful due to severe bowel edema.
On HD4, the abdomen was closed using the component separation technique Fig. However, on HD10 enteroatmosphreic dehiscence occurred. On HD24, symptoms of peritonitis appeared and exploratory laparotomy was undertaken.
Perforation of right colon at the hepatic flexure was observed and right hemicolectomy with ileostomy was performed. On HD26, a perforation was observed 3 cm below the ileostomy. Ileostomy and the perforation were resected emergently and a stoma was created at midline Fisula. However, on HD44, the midline incisional wound necrotized ifstula wound dehiscence re-occurred. Subsequently, wound crown method was applied to divert effluent of EAF, 2 but failed because perforation sites adjoined the abdominal wall.
Then, a fistula plug was applied, but it was difficult to fix the plug in the EAF. A baby bottle nipple method was tried and quite successful somedays but fixation of the nipple on the EAF was not easy. Lastly, we applied a large colostomy bag or frequent gauze dressing.
Enteroatmospheric fistula: from soup to nuts.
The patient remained on total parenteral nutrition for 6 months and was then transferred to other hospital for definitive surgery. Segmental resection of the perforated bowel was performed successfully.
He enteroatmospherc in a bedridden state awaiting pelvic surgery. Considerable difficulty was experienced managing EAF in the described patient, primarily due to a lack of experience.
In retrospect, the Vaseline gauze barrier between the reticular foam of vacuum assisted closure VAC and open viscera was inadequate, and the sometimes high negative pressure mmHg applied to drain effluent resulted in injury and bleeding of serosa. EAF presents a huge challenge and requires a multidisciplinary – surgical, metabolic, nutritional, and nursing – approach. Initially, sepsis has to be managed and any fluid, electrolyte, and metabolic disorders need to be corrected.
Oral intake must be stopped until EAF was controlled and total parenteral nutrition introduced. Due to hypercatabolism and the losses caused by laparostomy and the fistula, appropriate calorie, protein, vitamin and microelement supplies must be ensured.
Recently, negative pressure wound fustula was introduced to manage OA. For many fistulq, the application of negative pressure wound therapy NPWT was considered enteroatkospheric increase the possibility of fistula formation, but additional studies have demonstrated that NPWT is safe. All techniques described aim to completely divert fistula output to protect entreoatmospheric viscera and allow clean granulation of exposed bowel, thus causing the fistula to become chronic and controlled.
Cyanoacrylates can be beneficial for small EAFs, especially as an adjunct to primary suturing. This flexible device is designed to create a channel for effluent while maintaining the integrity and beneficial aspects of the NPWT dressing. This is a plug designed to seal the EAF from inside, and consists of a circular disk of 1-mm thick silicone of diameter of 2 to 5 cm Fig.
A Vicryl suture is passed through the center of the silicon circle and then tied to a rubber band attached to bridge of foam-covered aluminum. The silicone plug is then rolled and inserted into the fistula, the plug is hung on the bridge using a suspension suture and the rubber band.
The bridge is fixed to the abdominal wall enteroatmispheric a self-adhesive plaster. Eventually, when the fistula is closed, the suture is cut off and the silicon plug is discharged at time of defecation. A baby bottle rubber nipple is placed over the fistula opening and a Pezzer tube, Malecot, or Foley catheter is placed through a small hole cut into the tip of the nipple Fig.
A layer of colostomy paste can be placed under the nipple to ensure a better seal.
Petroleum impregnated gauze or clear Telfa sheet is then placed over the bowel and the entire wound is covered using a commercial VAC dressing. A small hole is shaped into the VAC sponge to hold the nipple in place. The AAST American Association for the Surgery of Trauma Open Abdomen Study Group reported that large-bowel resection, large-volume resuscitation, and a greater number of re-explorations were significant predictors of development of a fistula within an open abdomen after trauma.
The number of patients with EAF is expected to increase when the trauma centers are activated. All of these methods may result in good outcomes but all require appropriate experience. When treating patients with risk factors, efforts should be made to prevent EAF development and devise better techniques for diverting effluent.
Pelvic AP scan showing anteroposterior compression type 3 pelvic fracture A. Coronal view abdominal CT scan showing complete infarction of the right kidney B and mesenteric bleeding C. Component separation technique using an anterior rectus sheath turnover A.
Lateral incisions were made to close skin at the midline incision B.
Management of enteroatmospheric fistulae.
Previously made Ileostomy site white arrownewly made stoma black arrowpin site of the external fixator black arrow headand the incision made for preperitoneal pelvic packing white arrowhead. Search for Search All Journals. Kang Kook Choi, M. Abstract Other Sections Abstract I. Discussion Figure Reference Enteroatmospheric fistula EAF is one of the most devastating complications in patients with an open abdomen and has associated morbidity and mortality rates.
Enteroatmospheric fistula, Open abdomen, Negative pressure wound therapy. Introduction Other Sections Abstract I. Discussion Figure Reference A year-old male patient was admitted to trauma surgery department after a motorcycle accident. Discussion Other Sections Abstract I.
Discussion Figure Reference Enteroatmosphric difficulty was experienced managing EAF in the described patient, primarily due to a lack of experience.
Other Sections Abstract I. Discussion Figure Reference Figures Fig. References Fistul Sections Abstract I. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: Collapsible enteroatmospheric fistula isolation device: J Am Coll Surg ; Eastern Association for the Surgery of Trauma: World J Emerg Surg ;8: What is the effectiveness of the negative pressure wound therapy NPWT in patients treated with open abdomen technique?
A systematic review and meta-analysis. J Trauma Acute Care Surg ; Negative-pressure wound therapy for critically ill adults with open abdominal wounds: Small bowel fistulas and the open abdomen.
Scand J Surg ; Open abdomen with concomitant enteroatmospheric fistula: Attempt to rationalize the approach to a surgical nightmare and proposal of enteroattmospheric clinical algorithm.
Sand Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen: A simple novel technique for enteroatmospheric fistulae: Int Wound J ; Pacifying the open abdomen with concomitant intestinal fistula: Open Abdomen Advisory Panel. Management of the open abdomen: Quality of life after abdominal wall reconstruction following open abdomen. Comparison of outcomes between early fascial closure and delayed abdominal closure in patients with open abdomen: Gastroenterol Res Pract ; Enteeoatmospheric31 enferoatmospheric.