SURGEON AT WORK
Open Abdomen with Concomitant Enteroatmospheric Fistula: Attempt to Rationalize the Approach to a Surgical Nightmare and Proposal of a Clinical Algorithm Salomone Di Saverio, MD, Antonio Tarasconi, MD, Kenji Inaba, MD, FACS, Pradeep Navsaria, MBChB, FCS(SA), FACS, Federico Coccolini, MD, David Costa Navarro, MD, Matteo Mandrioli, MD, Pantelis Vassiliu, MD, FACS, Elio Jovine, MD, Fausto Catena, MD, Gregorio Tugnoli, MD circumstance. The aim of this study is to develop a flowchart designed to help guide the surgeons who are caring for this devastating complication choose the best approach on a case-by-case basis.
Development of an enteroatmospheric fistula (EAF) in the midst of an open abdomen represents a surgical nightmare, with an extremely challenging critical care problem set, including the full spectrum of surgical, metabolic, nutritional, and nursing issues. Spontaneous closure is rare, as there is no fistula tract, and there is a lack of wellvascularized overlying tissue. For these reasons, acute fistula management should aim to completely divert fistula output, protect the surrounding viscera, and allow for the granulation of exposed bowel. This is difficult to achieve because of the extreme frailty of the surrounding tissues, which are chronically injured by enteric fluids, and the multiple systemic derangements of the patient, driven by severe dehydration, electrolyte and acid/base disturbances, a hypercatabolic status, and ongoing sepsis. Despite the advancements in critical care and surgical management, EAFrelated mortality is still upwards of 40%.1 Significant heterogeneity in the surgical techniques described for EAF management remains, and there is no single approach that has proven to be ideal in every
ENTEROATMOSPHERIC FISTULA DEFINITION, CAUSE, AND MANAGEMENT Enteroatmospheric fistula is defined as the occurrence of an enteric fistula in the middle of an open abdomen. Specific characteristics defining EAF are the absence of a fistula tract, the lack of well-vascularized surrounding tissue, and location within an open abdomen resulting in spillage of enteric content directly into the open peritoneal cavity. Little is known about the risk factors associated with EAF development. A recent multicenter prospective observational study by Bradley and colleagues2 attempted to determine independent predictors for development of enterocutaneous fistula, EAF, and abdominal sepsis in patients undergoing damage-control laparotomy after trauma. Using the American Association for the Surgery of Trauma Open Abdomen registry, they identified patients who developed enterocutaneous fistula, EAF, or intra-abdominal sepsis during open abdomen management after damage-control laparotomy and compared the groups of patients with and without complications. Interestingly, their data showed that large-bowel resection, large-volume resuscitation, and an increasing number of re-explorations were statistically significant predictors for development of a fistula within an open abdomen after trauma. Another recent review of the available techniques for open abdomen management found a higher incidence of EAF occurring in septic open abdomen compared with nonseptic open abdomen (12.1% vs 3.7%, respectively). In addition, this review did not show any evidence of a relationship between use of negative-pressure wound therapy (NPWT) and fistula formation.3 For many years,
Disclosure Information: Nothing to disclose. Technique partially presented at the video session, 98th Clinical Congress of the American College of Surgeons, Chicago, IL, October 2012. Management Algorithm presented at the International Trauma & Emergency Surgery Week, Alicante, Spain, June 2014. Received September 5, 2014; Revised November 8, 2014; Accepted November 12, 2014. From the Maggiore Hospital, Bologna Local Health District, and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna (Di Saverio, Mandrioli, Jovine, Tugnoli), Department of Emergency and Trauma Surgery, Maggiore Hospital, Parma (Tarasconi, Catena), General and Emergency and Trauma Surgery, Hospital Papa Giovanni XXIII, Bergamo (Coccolini), Italy, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba), Trauma Center, Groote Schuur Hospital & University of Cape Town, South Africa (Navsaria), Department of Surgery, Alicante University General Hospital, Alicante, Spain (Costa Navarro), and Attikon University Hospital, Department of Surgery IV, Surgery and Traumatology, Athens, Greece (Vassiliu). Correspondence address: Salomone Di Saverio, MD, Maggiore Hospital, L.go Nigrisoli 2, Bologna, Italy. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
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Technique
Technique description
Pros
Cons
Feasible even in case of multiple fistulas Quick and easy to apply
Not applicable in case of fistulas larger than the teat
$$
Low
Quickest and easiest to apply Atraumatic Feasible even in case of multiple fistulas Quick and easy to apply
Does not provide effective fistula effluent diversion Teat easily displaced during nursing maneuvers
$$
Low
$$
Low
Adjustable to the dimension of the fistula Good seal
Very traumatic (running sutures can lacerate bowel wall)
$
High
Feasible even in case of multiple fistulas Quick and easy to apply
Risk of enlargement of fistula (there is no stop to catheter movements) Not applicable to fistulas larger than the catheter
$$
Low
Quick and easy to apply Atraumatic
Risk of pooling of enteric contents under sponge Large area around the fistula exposed to bowel content
$$
Low
Allows progressive abdominal Risk of pooling of enteric contents under the sponge wall closure Complex and time consuming Application of aspiration directly over the fistula
$$
High
When successful provides immediate closure of the fistula
$$$
High
Expensive Not applicable if ongoing peritonitis/sepsis
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A baby bottle nipple is placed over the fistula with a ring of colostomy paste. A Foley catheter is placed inside the fistula hole and pulled through the nipple tip. Everything is then kept in place with a commercial NPWT dressing. NPWT A simple, handmade NPWT dressing is placed over the open abdomen. Baby bottle nipple VAC A baby bottle nipple is placed over the fistula with a ring of colostomy paste. A Malecot catheter is pulled through the nipple tip. Everything is then kept in place with a commercial NPWT dressing. Floating stoma A plastic silo placed over the open abdomen and openings are created to fit the fistula. The edges of these openings are sutured to the margins of the fistula with a continuous polypropylene suture. A stoma bag is then placed over this “floating stoma.” Tube VAC Fistula is intubated with a Malecot catheter and the surface of the open abdomen is covered with petroleum jellye impregnated gauze. The wound is then covered with a polyurethane sponge and the Malecot catheters are pulled through it. Everything is then kept in place with a commercial NPWT dressing. Fistula VAC A sheet of Xeroform dressing is placed to protect the wound bed, with a hole cut for the enteric opening. The VAC sponge is placed over the Xeroform layer. An adherent polyurethane drape is eventually placed over the sponge and a hole is cut in this drape directly over the fistula, to allow placement of the appliance of an ostomy bag for collecting the fistula effluent. VAC chimney A chimney is created with a white sponge dressing. A plastic tube, shorter than the chimney, is then placed into the chimney itself, to avoid its collapse. Everything is then kept in place with a commercial NPWT dressing, placing the connector to the pump directly over the chimney. Biologic dressing Human acellular dermal matrix or cadaveric split-thickness skin graft are applied over small fistulas or deserosalization. Fibrin glue can improve the outcomes, keeping them in place and effectively sealing the fistula. Cyanoacrylates can be beneficial as an adjunct to primary suturing.
Estimated cost of the Technical equipment difficulty Di Saverio et al
Baby bottle nipple diversion
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Table 1. Fistula Management Techniques
Fistula plug
Medium
Not applicable to large fistulas Often fails to close the fistula
$
Low
Not applicable if ongoing peritonitis/sepsis Technically demanding Complex Difficult nursing care Risk of bowel obstruction
$
Very high
$
High
Not tested in case of ongoing peritonitis, or in case of multiple fistulas Must remain in situ until definitive fistula takedown
$
High
Applicable only if adjacent well vascularized dermis Traumatic to fistula edges
$
High
$, low cost range (approximately $1,500); NPWT, negative-pressure wound therapy; VAC, vacuum-assisted closure.
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Fistula suspension
$
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Fistula patch
Cons
Traumatic Risk of enlargement of fistula
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Pedicle flaps
Pros
When successful provides immediate closure of the fistula Quick Fibrin glue can improve the outcomes in adjunct to biologic When successful provides immediate closure of the dressings or primary suture. fistula Cyanoacrylates can be beneficial as an adjunct to primary Atraumatic suturing. Applicable as adjunct to primary suture or biologic dressings Different types of pedicle flaps are described in literature. When successful allows quick They should be designed and adapted according to the reconstruction of abdominal specific anatomy of every single case. wall Vicryl suture is passed through the center of a circular silicone Tight sealing of fistula output layer and then tied to a rubber band, with a bridge of foam- Promotes fistula closure covered aluminum. The silicone plug is then rolled and inserted into the fistula hole and the plug is hung on the bridge. The bridge is fixed to the abdominal wall. When the fistula is closed, the tread is cut off and the silicon plug is discharged at the time of defecation. Sutures are placed through the center of a gel lamellar circle Tight sealing of fistula output and are fixed to a drain tube placed across the fistula outside the bowel. The gel lamellar is then folded and pushed into the fistula, where it will unwrap, acting like a patch inside the bowel. The fistula patch remains in situ until the definitive fistula takedown operation. Fistula edges are gently mobilized and tacked to the lateral Artificial creation of a fistula tract aspect of the dermis. This allows the fistula to maturate into an ostomy. Negative pressure is applied to the granulating Allows reconstruction of abdominal wall open abdomen.
-, -
Cyanoacrylatesefibrin glue
Technique description
A usual suture is used to seal the fistula. Adjunct of cyanoacrylates and/or fibrin glue can improve outcomes.
No.
Primary suture
-,
Technique
Estimated cost of the Technical equipment difficulty
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Figure 1. From upper-left to lower-right: (A, B) application of colostomy paste underlining the nipple, (C) the complex nipple tube is held over the fistula hole with the aid of the paste layer, (D) the negative-pressure wound therapy drape is positioned and the nipple tube is extended through the exterior of the drape.
the application of negative pressure has been considered the primary cause of fistula formation, but additional studies have demonstrated that fistula formation rate can be as low as 5%,4,5 even with a handmade dressing, and that in a good proportion of cases the fistula can spontaneously heal during NPWT.6 In a recent relatively large series of EAFs in patients treated with an open abdomen for the management of abdominal sepsis, the incidence of EAF was 54.5% (18 of 33).7 In this series the rate of spontaneous closure with NPWT was 22% (4 of 18). Mean hospital length of stay was 88.89 days, median number of vacuumassisted closure (VAC) applications was 22.5, and median duration of VAC applications was 43.6 days. Mortality was as high as 44.4% (8 of 18). Many of the principles applied to enterocutaneous fistula management can be also considered in the management of the EAF. The latter, however, are often more difficult, as the unprotected bowel is friable and located within a “frozen abdomen,” precluding any possible surgical maneuvers or resection, with the added burden of peritonitis/sepsis due to the bowel content pooling directly within the exposed peritoneal cavity. Although the optimal option would be to perform a bowel resection or at least a proximal bowel diversion, this option is invariably not feasible for multiple reasons, including mesenteric retraction and edema, frozen abdomen, and loss of domain due to retraction of the abdominal wall.
As bowel resection or proximal diversion is not feasible, EAF management should aim to8-10: decrease fistula effluent: the use of total parenteral nutrition, somatostatin and its analogues,11-14 and a proton pump inhibitor15 can be effective in decreasing the bowel effluent; correct any fluid and electrolyte imbalances, acid/base derangements and reversal of the hypercatabolic state (collection, quantification, and characterization of bowel effluent are of key importance); interrupt or prevent ongoing sepsis; divert fistula output, allowing granulation of the exposed bowel; and if fistula closure is impossible, allow fistula to become chronic and controlled. The goal should be to control and limit the acute phase of care. Fistula takedown and abdominal wall reconstruction should be delayed optimally by at least 8 to 12 months to allow loosening of the visceral adhesions, and should be performed only when the patient is well nourished and satisfactory physiologic homeostasis has been achieved. Different methods for definitive fistula takedown and bowel reconstruction are described in the literature.16-20
TECHNIQUES FOR FISTULA EFFLUENT DIVERSION A wide spectrum of treatment options for effluent diversion has been described in the literature and is often used at the discretion of the attending surgeon, as a universally accepted management algorithm does not exist. The following techniques can be individualized to patients depending on their particular characteristics.
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Figure 2. From upper-left to lower-right: (A) the fistula hole is visible over the frozen viscera, (B) the baby nipple is cut and appropriately shaped to allow the passage of a Pezzer tube or a Foley catheter, (C) the Foley catheter can be inserted into the fistula hole through the nipple tip and the nipple itself is positioned around the fistula to drain the fistula leakage, (D) final result of the exterior isolated enteroatmospheric fistula after negative pressure application over the remaining abdominal viscera.
1. Negative-pressure wound therapy: The use of negative pressure in the open abdomen with handmade dressings is well described and some authors extended this technique to cases of EAF. This method is the easiest to apply and represents the foundation for many of the subsequent techniques. 2. Biologic dressing/fibrin glue or cyanoacrylates/primary suture21,22: The application of biologic dressings (ie, human acellular dermal matrix or cadaveric splitthickness skin graft) has been described with good results, particularly in case of a small-sized fistula or deserosalization. Fibrin glue can improve the outcomes of biologic dressings, helping to keep them in place and effectively sealing the fistula. Cyanoacrylates can be beneficial for small EAFs, especially as an adjunct to primary suturing.23 3. Floating stoma24: This is made with a plastic silo placed over the open abdomen, where openings are created to best fit the fistula opening; the edge of these openings are then sutured to the margins of the opening in the enteric loops with a continuous polypropylene suture. A stoma bag is then placed over this “floating stoma” to collect the enteric effluent. 4. Fistula VAC25: This method is easy and quick to apply, consisting of a single sheet of Xeroform dressing placed to protect the wound bed, with a hole cut
for the enteric opening. The VAC sponge is accurately tailored to fit the wound and to match the fistula opening, and is placed over the Xeroform layer. An adherent polyurethane drape is eventually placed over the sponge and a hole is cut in this drape directly over the fistula, to allow placement of the appliance of an ostomy bag for collecting the fistula effluent. A number of refinements to this technique are described in the literature, all attempting to obtain a better sealing of fistula area from the rest of the wound.26-28 5. Tube VAC29: The EAF is intubated with Malecot catheters and the surface of the open abdomen is covered with petroleum-impregnated gauge. The wound is then covered with a polyurethane sponge and the Malecot catheters are pulled through it. The entire device is then sealed with an occlusive dressing and continuous negative pressure is applied. 6. Baby Bottle Nipple VAC30-38: 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. A round layer of colostomy paste can be placed under the nipple to ensure a better seal. Petroleum jellye impregnated gauze or clear Telfa sheet is then placed over the bowel and the entire wound is covered by a
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8.
9.
10.
11.
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commercial VAC dressing. A small hole is shaped into the VAC sponge to hold the nipple in place. VAC chimney31: A chimney is created with a white sponge dressing, with the base of this construct covering the adjacent healthy tissue for an area of 2 to 3 cm, to avoid leakage of bowel effluent. A plastic tube, shorter than the chimney, is then placed into the chimney itself, to avoid its collapse. The open abdomen is then covered with a conventional VAC dressing, placing the connector to the pump directly over the chimney. Fistula patch32: A soft, flexible, gel lamellar is shaped into a round form. Sutures are then placed through the center of this circle and fixed to a drain tube placed across the fistula, outside of the bowel. The silica gel lamellar is then folded and pushed into the fistula. Once inside the bowel it will unwrap, acting like a patch inside the bowel. The fistula patch would then remain in situ until the definitive fistula takedown operation. Some authors have recently described a similar technique using a patch of hydrophilic polyvinyl alcohol foam to cover small fistulas, combined with NPWT used on the remaining abdominal surface.4 Fistula plug33: This is a plug designed to seal the EAF from inside, consisting of a circular disk of 1-mm thick silicone with a diameter of 2 to 5 cm. A Vicryl suture is passed through the center of the silicon circle and then tied to a rubber band, with a bridge of foam-covered aluminum. The silicone plug is then rolled and inserted into the fistula hole, the plug is hung on the bridge by means of the suspension suture and rubber band. The bridge is fixed to the abdominal wall using a self-adhesive plaster. Eventually, when the fistula is closed, the tread will be cut off and the silicon plug will be discharged at the time of defecation. Pedicled flap: Different types of flaps have been described in the literature.18,34-36 Although feasible and possibly effective, they are highly technically demanding and require a well-stabilized patient, without ongoing sepsis or physiologic derangements. For these reasons, flaps remain a good option for definitive management, after the acute phase has resolved. Suspension/stoma conversion36,37: In selected cases, when the fistula is located near the edge of the abdominal wound, the fistula edges can be gently mobilized and tacked to the lateral aspect of the dermis. This allows the fistula to maturate into a definitive ostomy, and negative pressure is applied to the granulating open abdomen, which is now protected from bowel effluent.
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Figure 3. Patient 2. Complete baby bottle nipple diversion dressing for multiple fistulas.
The pros and cons, estimated cost, and technical difficulty of every approach are summarized in Table 1. Costs have been estimated because the prices of every device and surgical item vary widely between different countries and hospitals. An NPWT device rental price of 997.50 V was used for the estimates.
BABY BOTTLE NIPPLE DIVERSION We have developed a refinement38 of the technique described previously by Layton and colleagues,30 improving what we have found to be the practical downsides of this interesting management option for an EAF. This is called the baby bottle nipple diversion. First, the fistula is exteriorized as much as possible outside the abdominal cavity, creating a flat surface that will allow optimal nipple placement. At this time, irrigation and exploration of the abdominal cavity should be performed to reduce peritoneal contamination and decrease ongoing sepsis. After these preliminary steps, a baby bottle nipple of soft silicone is placed over the fistula (Video 1; available at: http://www.journalacs.org). The tip of the nipple is cut and a small-sized Pezzer tube is pulled through the hole of the rubber nipple and secured in place by a nonabsorbable stitch tied around the tip of the nipple (Video 1; available at: http://www.journalacs.org). To achieve a better seal, an underlying layer of colostomy paste (Fig. 1) can be placed around the fistula and under the nipple, which is then surrounded by petroleum jellyeimpregnated gauze, covering the bowel and excluding the area of the fistula. We have modified Layton’s technique to optimize the external diversion of the fistula and minimize nipple dislocation by inserting a small (10 F) Foley catheter (Fig. 2) into the fistula opening and inflating the
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Figure 4. Patient 1. At 3-year follow-up. (A) Frontal, (B) angled, and (C) lateral views.
balloon gently with 2 to 3 mL water. The Foley catheter is then passed through and secured to the silicone nipple neck. Finally, an NPWT dressing system is placed over the exposed viscera to promote surface granulation (Renasys; Smith & Nephew Corporate; Video 1; available at: http:// www.journalacs.org). The plastic drape is placed over the open abdomen and the nippleetube complex is passed through a hole shaped within the drape and the sponge. The plastic drape is then used to cover the sponge and shaped around the Pezzer tube. The negative pressure is used to compress the dressing, hold the nipple in place, and seal off the fistula (see Fig. 3) The baby bottle nipple diversion has the advantage of being effective even in cases of large, high-output fistulas and, unlike other techniques, can also be effective in case of multiple fistulas.
Clinical validation, patient 1 In October 2010, we applied this novel approach to the case of a 46-year-old male admitted for complete adhesive small bowel obstruction and strangulation of a parastomal hernia. On postoperative day 7, the patient had two ileal perforations develop within a completely frozen abdomen. These were initially treated with fibrin glue and an open abdomen with Bogota´ bag. After 6 days of NPWT therapy, a leak from one of the previously repaired perforations appeared. Another attempt at direct repair with Vicryl stitches and fibrin glue was not successful and the baby bottle nipple diversion was used. After 3 months of treatment with NPWT and baby bottle nipple diversion, the fistula output was diverted, effectively functioning as an ileostomy. The abdominal surface was almost completely covered by skin and subcutaneous tissue granulating from the edges of the
Figure 5. Patient 1. At 3-year follow-up. Computed tomography scan showing the evolution of the abdomen and the large herniation of intra-abdominal organs. Only a thin skin layer is covering the viscera.
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Figure 6. Patient 2. Intraoperative appearance demonstrating good granulation over the exposed bowel and an optimum diversion of bowel content.
abdominal wall (see CT scan in Video 2; available at: http://www.journalacs.org) and the patient was discharged to a rehabilitation facility. After 3 years of follow-up (Fig. 4A to C), the patient has returned to a normal active life with good quality of life. The previous EAF is functioning well as a natural ileostomy. The open abdomen has evolved into a large herniation of intraabdominal organs and only a thin skin layer is covering the viscera (Fig. 5; 3-year follow-up CT scan). Clinical validation, patient 2 In June 2013, we had to face a similar surgical nightmare: a 73-year-old male was admitted for acute bleeding from multiple angiodysplastic foci and underwent emergent right colonic resection. On postoperative day 7, the hospital course was complicated by evisceration and ileal nonanastomotic perforation. This was treated with ileal resection and primary anastomosis. Later, the patient underwent two subsequent relaparotomies for evisceration and small bowel perforations. This was complicated by a massive abdominal wall necrotizing fasciitis, which caused a great loss of tissue within the abdominal wall and required NPWT dressing. After 32 days and 14 NPWT dressing changes, two ileal EAFs appeared within a few centimeters of each other. At this point, the abdomen was frozen and completely inaccessible due to heavy matted adhesions. Based on the satisfactory results of our previous experience, the baby bottle nipple diversion technique was used, even in the presence of these multiple fistulas (Video 3; available at: http://www.journalacs.org). Two separate baby bottle nipples were placed over the fistulas,
Figure 7. Flowchart summarizing the various options available for enteroatmospheric fistula treatment. VAC, vacuum-assisted closure.
allowing effective and separate isolation of the two different EAFs (Fig. 3). After 4 dressing changes, both fistulas were well controlled and both their size and output had strongly decreased. The surrounding viscera were covered with Renasys dressing and treated with low pressure ( 60 to 80 mmHg) NPWT. In the absence of substantial enteric contamination, a clean granulation bed was formed. On postoperative day 65, the patient died of acute pulmonary edema, secondary to MI. At this stage, the fistulas were well controlled and the abdomen was clean and rapidly granulating (Fig. 6).
OUR PROPOSAL The management of an EAF is extremely challenging and should be tailored to the specific characteristics of each case. We believe that a systematic approach to the management of this devastating problem is required. Therefore, after performing a comprehensive review of the literature and analyzing the different options for EAF management, we have developed a flowchart, merging all the techniques described to date and including our experience and techniques (Fig. 7). This is one rational, practical method for approaching this surgical challenge. The acute management of an EAF should aim to divert the fistula output, preventing the spread of intestinal fluid into the peritoneal cavity; collect and quantify the fistula output to address and correct fluids and electrolyte imbalances; and protect and keep clean the surrounding granulating viscera.
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Table 2. Enteroatmospheric Fistula Classification Anatomic location Proximal Stomach, duodenum, jejunum, proximal ileus Distal Distal ileus, colon Output volume Low 500 mL/24 h Location inside the open abdomen Superficial Drains on top of a granulating abdominal wound Deep Drains intestinal content inside the peritoneal cavity
A thorough classification of EAF is essential for choosing the correct approach. According to the literature, an EAF can be classified based on anatomic location (proximal/distal); fistula output volume (low/moderate/ high), and location in the open abdomen (superficial/ deep)10,16,39 (Table 2). It is well known that distal and low-output fistulas have a higher spontaneous closure rate than those that are more proximal and with high output. For this reason, in the case of deserosalization and distal, small, or low-output fistulas, a first attempt at primary closure with sutures and sealants (fibrin glue, cyanoacrylates)21,23 should be made. If this first attempt fails, the fistula must be approached in the same manner as a proximal, large, or moderate/high-output fistulas. The latter fistula type is very unlikely to close with a glue/suture approach. The presence of ongoing peritonitis should be the factor that drives the choice of management technique. Biologic dressings and flaps or skin grafting should be avoided in these cases with ongoing uncontrolled peritonitis because of the high probability of failure (ie, graft rejection, flap necrosis, and lack of sepsis control). If there is ongoing peritonitis, the primary aim of treatment should be the diversion of fistula output, allowing improvement of the physiologic condition of the patient.
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In the most recent review on the management of EAF, Tavusbay and colleagues7 proposed different techniques according to the size/output of the fistula. Small fistulas are first covered with a patch of hydrophilic polyvinyl alcohol foam and the entire abdominal wound is then covered with polyurethane foam to seal the open abdomen, preventing additional spillage of the enteric contents. The foam is covered with an adhesive drape and continuous negative pressure is applied. In case of large fistulas with protruding mucosa, Tavusbay and colleagues suggest that the open abdomen be covered with a perforated polyethylene sheet, cutting a hole in the polyurethane foam to match the fistula mouth, and the polyurethane foam is placed onto the polyethylene sheet. Patients with multiple fistulas provide an even more challenging situation. Most of the techniques described in the literature are complex and time consuming and often require a wide free surface to properly position the diverting device. In contrast, the baby bottle nipple diversion is quick and easy to apply, low in cost, and requires very little space, allowing its application in cases of multiple fistulas, whether they are far apart or in close proximity to each other. In our experience, the baby bottle nipple diversion approach offers the best chance of diverting the fistula output where there are multiple fistulas, either in close proximity or when located far from each other. This allows for effective control of ongoing sepsis and promotes clean granulation formation over the exposed bowel. It also allows exact quantification of the fistula output and assessment of its characteristics. Table 3 provides the appropriate take-home messages.
CONCLUSIONS To the best of our knowledge, an algorithm for EAF management has never been proposed or validated. The everexpanding variety of management techniques, as well as the increasing number of review articles16,40 attempting to summarize them, mirror the great confusion that accompanies the finding of an EAF and reflects the need for a rationale approach to EAF management.
Table 3. Take-Home Messages An enteroatmospheric fistula (EAF) is a major surgical complication that offers an extremely challenging range of critical care burdens, including the full spectrum of surgical, metabolic, nutritional, and nursing issues. Because spontaneous closure is extremely rare, the acute fistula management should aim to completely divert fistula output, protect the surrounding viscera, and allow the clean granulation of exposed bowel, promoting the fistula to become chronic and controlled; fistula takedown and abdominal wall reconstruction should be delayed optimally by at least 8 to 12 months. Considerably heterogeneity in the surgical techniques described for EAF management remains and there is no single approach that has proven to be ideal in every circumstance; a rationale approach to EAF management is needed. The baby bottle nipple diversion approach offers the best chance of diverting the fistula output in case of multiple fistulas, when located either in close proximity or far from each other.
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The proposed flowchart in Figure 7 is derived from our surgical experience managing the open abdomen and EAF and from an extensive review of the available literature. Given the rarity of this condition and the low likelihood of a controlled trial, our conclusions are not evidence based, rather, they are based on small case series and expert opinion. Because of the peculiarity of this field and the absolute lack of management guidelines, the opinion of expert surgeons is a major resource in EAF treatment. This flowchart can be an invaluable tool for those surgeons facing this surgical challenge. In addition, the standardization of the approach to an EAF can lead to a better understanding of the available literature. Speaking the same language all over the world is the first step to creating a rational approach to EAF management and, eventually, the promulgation of internationally accepted guidelines. Author Contributions Study conception and design: Di Saverio, Tarasconi, Tugnoli Acquisition of data: Di Saverio, Tarasconi, Jovine, Tugnoli Analysis and interpretation of data: Di Saverio, Tarasconi, Inaba, Navsaria, Coccolini, Costa Navarro, Mandrioli, Vassiliu, Catena Drafting of manuscript: Di Saverio, Tarasconi Critical revision: Di Saverio, Tarasconi, Inaba, Navsaria, Coccolini, Costa Navarro, Mandrioli, Vassiliu, Jovine, Catena, Tugnoli Final approval: Di Saverio, Tarasconi, Inaba, Navsaria, Coccolini, Costa Navarro, Mandrioli, Vassiliu, Jovine, Catena, Tugnoli REFERENCES 1. Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg 2007;96:263e271. 2. Bradley MJ, Dubose JJ, Scalea TM, et al. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry. JAMA Surg 2013;148:947e954. 3. Bruhin A, Ferreira F, Chariker M, et al. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen. Int J Surg 2014; 12:1105e1114. 4. Navsaria P, Nicol A, Hudson D, et al. Negative pressure wound therapy management of the “open abdomen” following trauma: a prospective study and systematic review. World J Emerg Surg 2013;8:4. 5. Navsaria PH, Bunting M, Omoshoro-Jones J, et al. Temporary closure of open abdominal wounds by the modified sandwichvacuum pack technique. Br J Surg 2003;90:718e722.
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6. Kirshtein B, Mizrahi S. Vacuum-assisted management of enteroatmospheric fistula within the open abdomen. Am Surg 2014;80:209e210. 7. Tavusbay C, Genc H, Cin N, et al. Use of a vacuum-assisted closure system for the management of enteroatmospheric fistulae. Surg Today 2014 Aug 28 [Epub ahead of print]. 8. Schecter WP. Management of enterocutaneous fistulas. Surg Clin North Am 2011;91:481e491. 9. Davis KG, Johnson EK. Controversies in the care of the enterocutaneous fistula. Surg Clin North Am 2013;93:231e250. 10. Evenson A, Fischer J. Current management of enterocutaneous fistula. J Gastrointest Surg 2006;10:455e464. 11. Coughlin S, Roth L, Lurati G, Faulhaber M. Somatostatin analogues for the treatment of enterocutaneous fistulas: a systematic review and meta-analysis. World J Surg 2012;36: 1016e1029. 12. Stevens P, Foulkes RE, Hartford-Beynon JS, Delicata RJ. Systematic review and meta-analysis of the role of somatostatin and its analogues in the treatment of enterocutaneous fistula. Eur J Gastroenterol Hepatol 2011;23:912e922. 13. Rahbour G, Siddiqui MR, Ullah MR, et al. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Ann Surg 2012; 256:946e954. 14. Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg 2006;93: 1045e1055. 15. Nightingale JM. The medical management of intestinal failure: methods to reduce the severity. Proc Nutr Soc 2003;62: 703e710. 16. Marinis A, Gkiokas G, Argyra E, et al. “Enteroatmospheric fistulae”dgastrointestinal openings in the open abdomen: a review and recent proposal of a surgical technique. Scand J Surg 2013;102:61e68. 17. Krpata DM, Stein SL, Eston M, et al. Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fistula takedown. Am J Surg 2013;205: 354e359. 18. Wind J, van Koperen PJ, Slors JF, Bemelman WA. Singlestage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique. Am J Surg 2009;197:24e29. 19. Dionigi G, Dionigi R, Rovera F, et al. Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience. Int J Surg 2008;6: 51e56. 20. Demetriades D. A technique of surgical closure of complex intestinal fistulae in the open abdomen. J Trauma 2003;55: 999e1001. 21. Girard S, Sideman M, Spain DA. A novel approach to the problem of intestinal fistulization arising in patients managed with open peritoneal cavities. Am J Surg 2002;184:166e167. 22. Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen: a preliminary report. Arch Surg 2007;142:793e796. 23. Bhat YM, Banerjee S, Barth BA, et al. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc 2013;78: 209e215. 24. Subramaniam MH, Liscum KR, Hirshberg A. The floating stoma: a new technique for controlling exposed fistulae in abdominal trauma. J Trauma 2002;53:386e388.
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25. Goverman J, Yelon JA, Platz JJ, et al. The “fistula VAC,” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma 2006;60:428e431. 26. D’Hondt M, Devriendt D, Van Rooy F, et al. Treatment of small-bowel fistulae in the open abdomen with topical negative-pressure therapy. Am J Surg 2011;202. e20ee24. 27. Piazza R, Armstrong S, Vanderkolk W, et al. A modified “fistula-VAC” technique: management of multiple enterocutaneous fistulas in the open abdomen. Plast Reconstruct Surg 2009;124:453ee455e. 28. Pang TC, Morton J, Pincott S. Novel technique for isolating and dressing enteroatmospheric fistulae. ANZ J Surg 2012;82:747e749. 29. Al-Khoury G, Kaufman D, Hirshberg A. Improved control of exposed fistula in the open abdomen. J Am Coll Surg 2008; 206:397e398. 30. Layton B, DuBose J, Nichols S, et al. Pacifying the open abdomen with concomitant intestinal fistula: a novel approach. Am J Surg 2010;199:e48ee50. 31. Rekstad LC, Wasmuth HH, Ystgaard B, et al. Topical negative-pressure therapy for small bowel leakage in a frozen abdomen. J Trauma Acute Care Surg 2013;75:487e491. 32. Wang G, Ren J, Liu S, et al. “Fistula patch”: making the treatment of enteroatmospheric fistulae in the open abdomen easier. J Trauma Acute Care Surg 2013;74:1175e1177.
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33. Ozer MT, Sinan H, Zeybek N, Peker Y. A simple novel technique for enteroatmospheric fistulae: silicone fistula plug. Int Wound J 2014;11[Suppl 1]:22e24. 34. Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R. Operative management of small bowel fistulae associated with open abdomen. Asian J Surg 2006;29:1e7. 35. Stephensen B, Brown J, Lambrianides A. A novel method for managing enterocutaneous fistulae in the open abdomen using a pedicle flap. J Surg Case Rep 2012;2012:5. 36. Al-Nahawi M. A rare approach to entero-atmospheric fistula. Am J Case Rep 2013:476e480. 37. Clark CE, Walker T, Bacon L, et al. Staged suspension of an enteroatmospheric fistula: a novel surgical approach. Am Surg 2013;79:E139eE140. 38. Di Saverio S, Villani S, Biscardi A, et al. Open abdomen with concomitant enteroatmospheric fistula: validation, refinements, and adjuncts to a novel approach. J Trauma 2011;71: 760e762. 39. Schecter WP, Hirshberg A, Chang DS, et al. Enteric fistulas: principles of management. Am Coll Surg 2009;209: 484e491. 40. Terzi C, Egeli T, Canda AE, Arslan NC. Management of enteroatmospheric fistulae. Int Wound J 2014;11[Suppl 1]: 17e21.
Open Abdomen with Concomitant Enteroatmospheric Fistula: Attempt to Rationalize the Approach to a Surgical Nightmare and Proposal of a Clinical Algorithm Salomone Di Saverio, MD, Antonio Tarasconi, MD, Kenji Inaba, MD, FACS, Pradeep Navsaria, MBChB, FCS(SA), FACS, Federico Coccolini, MD, David Costa Navarro, MD, Matteo Mandrioli, MD, Pantelis Vassiliu, MD, FACS, Elio Jovine, MD, Fausto Catena, MD, Gregorio Tugnoli, MD circumstance. The aim of this study is to develop a flowchart designed to help guide the surgeons who are caring for this devastating complication choose the best approach on a case-by-case basis.
Development of an enteroatmospheric fistula (EAF) in the midst of an open abdomen represents a surgical nightmare, with an extremely challenging critical care problem set, including the full spectrum of surgical, metabolic, nutritional, and nursing issues. Spontaneous closure is rare, as there is no fistula tract, and there is a lack of wellvascularized overlying tissue. For these reasons, acute fistula management should aim to completely divert fistula output, protect the surrounding viscera, and allow for the granulation of exposed bowel. This is difficult to achieve because of the extreme frailty of the surrounding tissues, which are chronically injured by enteric fluids, and the multiple systemic derangements of the patient, driven by severe dehydration, electrolyte and acid/base disturbances, a hypercatabolic status, and ongoing sepsis. Despite the advancements in critical care and surgical management, EAFrelated mortality is still upwards of 40%.1 Significant heterogeneity in the surgical techniques described for EAF management remains, and there is no single approach that has proven to be ideal in every
ENTEROATMOSPHERIC FISTULA DEFINITION, CAUSE, AND MANAGEMENT Enteroatmospheric fistula is defined as the occurrence of an enteric fistula in the middle of an open abdomen. Specific characteristics defining EAF are the absence of a fistula tract, the lack of well-vascularized surrounding tissue, and location within an open abdomen resulting in spillage of enteric content directly into the open peritoneal cavity. Little is known about the risk factors associated with EAF development. A recent multicenter prospective observational study by Bradley and colleagues2 attempted to determine independent predictors for development of enterocutaneous fistula, EAF, and abdominal sepsis in patients undergoing damage-control laparotomy after trauma. Using the American Association for the Surgery of Trauma Open Abdomen registry, they identified patients who developed enterocutaneous fistula, EAF, or intra-abdominal sepsis during open abdomen management after damage-control laparotomy and compared the groups of patients with and without complications. Interestingly, their data showed that large-bowel resection, large-volume resuscitation, and an increasing number of re-explorations were statistically significant predictors for development of a fistula within an open abdomen after trauma. Another recent review of the available techniques for open abdomen management found a higher incidence of EAF occurring in septic open abdomen compared with nonseptic open abdomen (12.1% vs 3.7%, respectively). In addition, this review did not show any evidence of a relationship between use of negative-pressure wound therapy (NPWT) and fistula formation.3 For many years,
Disclosure Information: Nothing to disclose. Technique partially presented at the video session, 98th Clinical Congress of the American College of Surgeons, Chicago, IL, October 2012. Management Algorithm presented at the International Trauma & Emergency Surgery Week, Alicante, Spain, June 2014. Received September 5, 2014; Revised November 8, 2014; Accepted November 12, 2014. From the Maggiore Hospital, Bologna Local Health District, and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna (Di Saverio, Mandrioli, Jovine, Tugnoli), Department of Emergency and Trauma Surgery, Maggiore Hospital, Parma (Tarasconi, Catena), General and Emergency and Trauma Surgery, Hospital Papa Giovanni XXIII, Bergamo (Coccolini), Italy, Department of Surgery, University of Southern California, Los Angeles, CA (Inaba), Trauma Center, Groote Schuur Hospital & University of Cape Town, South Africa (Navsaria), Department of Surgery, Alicante University General Hospital, Alicante, Spain (Costa Navarro), and Attikon University Hospital, Department of Surgery IV, Surgery and Traumatology, Athens, Greece (Vassiliu). Correspondence address: Salomone Di Saverio, MD, Maggiore Hospital, L.go Nigrisoli 2, Bologna, Italy. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
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Technique
Technique description
Pros
Cons
Feasible even in case of multiple fistulas Quick and easy to apply
Not applicable in case of fistulas larger than the teat
$$
Low
Quickest and easiest to apply Atraumatic Feasible even in case of multiple fistulas Quick and easy to apply
Does not provide effective fistula effluent diversion Teat easily displaced during nursing maneuvers
$$
Low
$$
Low
Adjustable to the dimension of the fistula Good seal
Very traumatic (running sutures can lacerate bowel wall)
$
High
Feasible even in case of multiple fistulas Quick and easy to apply
Risk of enlargement of fistula (there is no stop to catheter movements) Not applicable to fistulas larger than the catheter
$$
Low
Quick and easy to apply Atraumatic
Risk of pooling of enteric contents under sponge Large area around the fistula exposed to bowel content
$$
Low
Allows progressive abdominal Risk of pooling of enteric contents under the sponge wall closure Complex and time consuming Application of aspiration directly over the fistula
$$
High
When successful provides immediate closure of the fistula
$$$
High
Expensive Not applicable if ongoing peritonitis/sepsis
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A baby bottle nipple is placed over the fistula with a ring of colostomy paste. A Foley catheter is placed inside the fistula hole and pulled through the nipple tip. Everything is then kept in place with a commercial NPWT dressing. NPWT A simple, handmade NPWT dressing is placed over the open abdomen. Baby bottle nipple VAC A baby bottle nipple is placed over the fistula with a ring of colostomy paste. A Malecot catheter is pulled through the nipple tip. Everything is then kept in place with a commercial NPWT dressing. Floating stoma A plastic silo placed over the open abdomen and openings are created to fit the fistula. The edges of these openings are sutured to the margins of the fistula with a continuous polypropylene suture. A stoma bag is then placed over this “floating stoma.” Tube VAC Fistula is intubated with a Malecot catheter and the surface of the open abdomen is covered with petroleum jellye impregnated gauze. The wound is then covered with a polyurethane sponge and the Malecot catheters are pulled through it. Everything is then kept in place with a commercial NPWT dressing. Fistula VAC A sheet of Xeroform dressing is placed to protect the wound bed, with a hole cut for the enteric opening. The VAC sponge is placed over the Xeroform layer. An adherent polyurethane drape is eventually placed over the sponge and a hole is cut in this drape directly over the fistula, to allow placement of the appliance of an ostomy bag for collecting the fistula effluent. VAC chimney A chimney is created with a white sponge dressing. A plastic tube, shorter than the chimney, is then placed into the chimney itself, to avoid its collapse. Everything is then kept in place with a commercial NPWT dressing, placing the connector to the pump directly over the chimney. Biologic dressing Human acellular dermal matrix or cadaveric split-thickness skin graft are applied over small fistulas or deserosalization. Fibrin glue can improve the outcomes, keeping them in place and effectively sealing the fistula. Cyanoacrylates can be beneficial as an adjunct to primary suturing.
Estimated cost of the Technical equipment difficulty Di Saverio et al
Baby bottle nipple diversion
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Fistula plug
Medium
Not applicable to large fistulas Often fails to close the fistula
$
Low
Not applicable if ongoing peritonitis/sepsis Technically demanding Complex Difficult nursing care Risk of bowel obstruction
$
Very high
$
High
Not tested in case of ongoing peritonitis, or in case of multiple fistulas Must remain in situ until definitive fistula takedown
$
High
Applicable only if adjacent well vascularized dermis Traumatic to fistula edges
$
High
$, low cost range (approximately $1,500); NPWT, negative-pressure wound therapy; VAC, vacuum-assisted closure.
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Fistula suspension
$
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Cons
Traumatic Risk of enlargement of fistula
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Pedicle flaps
Pros
When successful provides immediate closure of the fistula Quick Fibrin glue can improve the outcomes in adjunct to biologic When successful provides immediate closure of the dressings or primary suture. fistula Cyanoacrylates can be beneficial as an adjunct to primary Atraumatic suturing. Applicable as adjunct to primary suture or biologic dressings Different types of pedicle flaps are described in literature. When successful allows quick They should be designed and adapted according to the reconstruction of abdominal specific anatomy of every single case. wall Vicryl suture is passed through the center of a circular silicone Tight sealing of fistula output layer and then tied to a rubber band, with a bridge of foam- Promotes fistula closure covered aluminum. The silicone plug is then rolled and inserted into the fistula hole and the plug is hung on the bridge. The bridge is fixed to the abdominal wall. When the fistula is closed, the tread is cut off and the silicon plug is discharged at the time of defecation. Sutures are placed through the center of a gel lamellar circle Tight sealing of fistula output and are fixed to a drain tube placed across the fistula outside the bowel. The gel lamellar is then folded and pushed into the fistula, where it will unwrap, acting like a patch inside the bowel. The fistula patch remains in situ until the definitive fistula takedown operation. Fistula edges are gently mobilized and tacked to the lateral Artificial creation of a fistula tract aspect of the dermis. This allows the fistula to maturate into an ostomy. Negative pressure is applied to the granulating Allows reconstruction of abdominal wall open abdomen.
-, -
Cyanoacrylatesefibrin glue
Technique description
A usual suture is used to seal the fistula. Adjunct of cyanoacrylates and/or fibrin glue can improve outcomes.
No.
Primary suture
-,
Technique
Estimated cost of the Technical equipment difficulty
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Figure 1. From upper-left to lower-right: (A, B) application of colostomy paste underlining the nipple, (C) the complex nipple tube is held over the fistula hole with the aid of the paste layer, (D) the negative-pressure wound therapy drape is positioned and the nipple tube is extended through the exterior of the drape.
the application of negative pressure has been considered the primary cause of fistula formation, but additional studies have demonstrated that fistula formation rate can be as low as 5%,4,5 even with a handmade dressing, and that in a good proportion of cases the fistula can spontaneously heal during NPWT.6 In a recent relatively large series of EAFs in patients treated with an open abdomen for the management of abdominal sepsis, the incidence of EAF was 54.5% (18 of 33).7 In this series the rate of spontaneous closure with NPWT was 22% (4 of 18). Mean hospital length of stay was 88.89 days, median number of vacuumassisted closure (VAC) applications was 22.5, and median duration of VAC applications was 43.6 days. Mortality was as high as 44.4% (8 of 18). Many of the principles applied to enterocutaneous fistula management can be also considered in the management of the EAF. The latter, however, are often more difficult, as the unprotected bowel is friable and located within a “frozen abdomen,” precluding any possible surgical maneuvers or resection, with the added burden of peritonitis/sepsis due to the bowel content pooling directly within the exposed peritoneal cavity. Although the optimal option would be to perform a bowel resection or at least a proximal bowel diversion, this option is invariably not feasible for multiple reasons, including mesenteric retraction and edema, frozen abdomen, and loss of domain due to retraction of the abdominal wall.
As bowel resection or proximal diversion is not feasible, EAF management should aim to8-10: decrease fistula effluent: the use of total parenteral nutrition, somatostatin and its analogues,11-14 and a proton pump inhibitor15 can be effective in decreasing the bowel effluent; correct any fluid and electrolyte imbalances, acid/base derangements and reversal of the hypercatabolic state (collection, quantification, and characterization of bowel effluent are of key importance); interrupt or prevent ongoing sepsis; divert fistula output, allowing granulation of the exposed bowel; and if fistula closure is impossible, allow fistula to become chronic and controlled. The goal should be to control and limit the acute phase of care. Fistula takedown and abdominal wall reconstruction should be delayed optimally by at least 8 to 12 months to allow loosening of the visceral adhesions, and should be performed only when the patient is well nourished and satisfactory physiologic homeostasis has been achieved. Different methods for definitive fistula takedown and bowel reconstruction are described in the literature.16-20
TECHNIQUES FOR FISTULA EFFLUENT DIVERSION A wide spectrum of treatment options for effluent diversion has been described in the literature and is often used at the discretion of the attending surgeon, as a universally accepted management algorithm does not exist. The following techniques can be individualized to patients depending on their particular characteristics.
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Figure 2. From upper-left to lower-right: (A) the fistula hole is visible over the frozen viscera, (B) the baby nipple is cut and appropriately shaped to allow the passage of a Pezzer tube or a Foley catheter, (C) the Foley catheter can be inserted into the fistula hole through the nipple tip and the nipple itself is positioned around the fistula to drain the fistula leakage, (D) final result of the exterior isolated enteroatmospheric fistula after negative pressure application over the remaining abdominal viscera.
1. Negative-pressure wound therapy: The use of negative pressure in the open abdomen with handmade dressings is well described and some authors extended this technique to cases of EAF. This method is the easiest to apply and represents the foundation for many of the subsequent techniques. 2. Biologic dressing/fibrin glue or cyanoacrylates/primary suture21,22: The application of biologic dressings (ie, human acellular dermal matrix or cadaveric splitthickness skin graft) has been described with good results, particularly in case of a small-sized fistula or deserosalization. Fibrin glue can improve the outcomes of biologic dressings, helping to keep them in place and effectively sealing the fistula. Cyanoacrylates can be beneficial for small EAFs, especially as an adjunct to primary suturing.23 3. Floating stoma24: This is made with a plastic silo placed over the open abdomen, where openings are created to best fit the fistula opening; the edge of these openings are then sutured to the margins of the opening in the enteric loops with a continuous polypropylene suture. A stoma bag is then placed over this “floating stoma” to collect the enteric effluent. 4. Fistula VAC25: This method is easy and quick to apply, consisting of a single sheet of Xeroform dressing placed to protect the wound bed, with a hole cut
for the enteric opening. The VAC sponge is accurately tailored to fit the wound and to match the fistula opening, and is placed over the Xeroform layer. An adherent polyurethane drape is eventually placed over the sponge and a hole is cut in this drape directly over the fistula, to allow placement of the appliance of an ostomy bag for collecting the fistula effluent. A number of refinements to this technique are described in the literature, all attempting to obtain a better sealing of fistula area from the rest of the wound.26-28 5. Tube VAC29: The EAF is intubated with Malecot catheters and the surface of the open abdomen is covered with petroleum-impregnated gauge. The wound is then covered with a polyurethane sponge and the Malecot catheters are pulled through it. The entire device is then sealed with an occlusive dressing and continuous negative pressure is applied. 6. Baby Bottle Nipple VAC30-38: 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. A round layer of colostomy paste can be placed under the nipple to ensure a better seal. Petroleum jellye impregnated gauze or clear Telfa sheet is then placed over the bowel and the entire wound is covered by a
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8.
9.
10.
11.
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commercial VAC dressing. A small hole is shaped into the VAC sponge to hold the nipple in place. VAC chimney31: A chimney is created with a white sponge dressing, with the base of this construct covering the adjacent healthy tissue for an area of 2 to 3 cm, to avoid leakage of bowel effluent. A plastic tube, shorter than the chimney, is then placed into the chimney itself, to avoid its collapse. The open abdomen is then covered with a conventional VAC dressing, placing the connector to the pump directly over the chimney. Fistula patch32: A soft, flexible, gel lamellar is shaped into a round form. Sutures are then placed through the center of this circle and fixed to a drain tube placed across the fistula, outside of the bowel. The silica gel lamellar is then folded and pushed into the fistula. Once inside the bowel it will unwrap, acting like a patch inside the bowel. The fistula patch would then remain in situ until the definitive fistula takedown operation. Some authors have recently described a similar technique using a patch of hydrophilic polyvinyl alcohol foam to cover small fistulas, combined with NPWT used on the remaining abdominal surface.4 Fistula plug33: This is a plug designed to seal the EAF from inside, consisting of a circular disk of 1-mm thick silicone with a diameter of 2 to 5 cm. A Vicryl suture is passed through the center of the silicon circle and then tied to a rubber band, with a bridge of foam-covered aluminum. The silicone plug is then rolled and inserted into the fistula hole, the plug is hung on the bridge by means of the suspension suture and rubber band. The bridge is fixed to the abdominal wall using a self-adhesive plaster. Eventually, when the fistula is closed, the tread will be cut off and the silicon plug will be discharged at the time of defecation. Pedicled flap: Different types of flaps have been described in the literature.18,34-36 Although feasible and possibly effective, they are highly technically demanding and require a well-stabilized patient, without ongoing sepsis or physiologic derangements. For these reasons, flaps remain a good option for definitive management, after the acute phase has resolved. Suspension/stoma conversion36,37: In selected cases, when the fistula is located near the edge of the abdominal wound, the fistula edges can be gently mobilized and tacked to the lateral aspect of the dermis. This allows the fistula to maturate into a definitive ostomy, and negative pressure is applied to the granulating open abdomen, which is now protected from bowel effluent.
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Figure 3. Patient 2. Complete baby bottle nipple diversion dressing for multiple fistulas.
The pros and cons, estimated cost, and technical difficulty of every approach are summarized in Table 1. Costs have been estimated because the prices of every device and surgical item vary widely between different countries and hospitals. An NPWT device rental price of 997.50 V was used for the estimates.
BABY BOTTLE NIPPLE DIVERSION We have developed a refinement38 of the technique described previously by Layton and colleagues,30 improving what we have found to be the practical downsides of this interesting management option for an EAF. This is called the baby bottle nipple diversion. First, the fistula is exteriorized as much as possible outside the abdominal cavity, creating a flat surface that will allow optimal nipple placement. At this time, irrigation and exploration of the abdominal cavity should be performed to reduce peritoneal contamination and decrease ongoing sepsis. After these preliminary steps, a baby bottle nipple of soft silicone is placed over the fistula (Video 1; available at: http://www.journalacs.org). The tip of the nipple is cut and a small-sized Pezzer tube is pulled through the hole of the rubber nipple and secured in place by a nonabsorbable stitch tied around the tip of the nipple (Video 1; available at: http://www.journalacs.org). To achieve a better seal, an underlying layer of colostomy paste (Fig. 1) can be placed around the fistula and under the nipple, which is then surrounded by petroleum jellyeimpregnated gauze, covering the bowel and excluding the area of the fistula. We have modified Layton’s technique to optimize the external diversion of the fistula and minimize nipple dislocation by inserting a small (10 F) Foley catheter (Fig. 2) into the fistula opening and inflating the
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Figure 4. Patient 1. At 3-year follow-up. (A) Frontal, (B) angled, and (C) lateral views.
balloon gently with 2 to 3 mL water. The Foley catheter is then passed through and secured to the silicone nipple neck. Finally, an NPWT dressing system is placed over the exposed viscera to promote surface granulation (Renasys; Smith & Nephew Corporate; Video 1; available at: http:// www.journalacs.org). The plastic drape is placed over the open abdomen and the nippleetube complex is passed through a hole shaped within the drape and the sponge. The plastic drape is then used to cover the sponge and shaped around the Pezzer tube. The negative pressure is used to compress the dressing, hold the nipple in place, and seal off the fistula (see Fig. 3) The baby bottle nipple diversion has the advantage of being effective even in cases of large, high-output fistulas and, unlike other techniques, can also be effective in case of multiple fistulas.
Clinical validation, patient 1 In October 2010, we applied this novel approach to the case of a 46-year-old male admitted for complete adhesive small bowel obstruction and strangulation of a parastomal hernia. On postoperative day 7, the patient had two ileal perforations develop within a completely frozen abdomen. These were initially treated with fibrin glue and an open abdomen with Bogota´ bag. After 6 days of NPWT therapy, a leak from one of the previously repaired perforations appeared. Another attempt at direct repair with Vicryl stitches and fibrin glue was not successful and the baby bottle nipple diversion was used. After 3 months of treatment with NPWT and baby bottle nipple diversion, the fistula output was diverted, effectively functioning as an ileostomy. The abdominal surface was almost completely covered by skin and subcutaneous tissue granulating from the edges of the
Figure 5. Patient 1. At 3-year follow-up. Computed tomography scan showing the evolution of the abdomen and the large herniation of intra-abdominal organs. Only a thin skin layer is covering the viscera.
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Figure 6. Patient 2. Intraoperative appearance demonstrating good granulation over the exposed bowel and an optimum diversion of bowel content.
abdominal wall (see CT scan in Video 2; available at: http://www.journalacs.org) and the patient was discharged to a rehabilitation facility. After 3 years of follow-up (Fig. 4A to C), the patient has returned to a normal active life with good quality of life. The previous EAF is functioning well as a natural ileostomy. The open abdomen has evolved into a large herniation of intraabdominal organs and only a thin skin layer is covering the viscera (Fig. 5; 3-year follow-up CT scan). Clinical validation, patient 2 In June 2013, we had to face a similar surgical nightmare: a 73-year-old male was admitted for acute bleeding from multiple angiodysplastic foci and underwent emergent right colonic resection. On postoperative day 7, the hospital course was complicated by evisceration and ileal nonanastomotic perforation. This was treated with ileal resection and primary anastomosis. Later, the patient underwent two subsequent relaparotomies for evisceration and small bowel perforations. This was complicated by a massive abdominal wall necrotizing fasciitis, which caused a great loss of tissue within the abdominal wall and required NPWT dressing. After 32 days and 14 NPWT dressing changes, two ileal EAFs appeared within a few centimeters of each other. At this point, the abdomen was frozen and completely inaccessible due to heavy matted adhesions. Based on the satisfactory results of our previous experience, the baby bottle nipple diversion technique was used, even in the presence of these multiple fistulas (Video 3; available at: http://www.journalacs.org). Two separate baby bottle nipples were placed over the fistulas,
Figure 7. Flowchart summarizing the various options available for enteroatmospheric fistula treatment. VAC, vacuum-assisted closure.
allowing effective and separate isolation of the two different EAFs (Fig. 3). After 4 dressing changes, both fistulas were well controlled and both their size and output had strongly decreased. The surrounding viscera were covered with Renasys dressing and treated with low pressure ( 60 to 80 mmHg) NPWT. In the absence of substantial enteric contamination, a clean granulation bed was formed. On postoperative day 65, the patient died of acute pulmonary edema, secondary to MI. At this stage, the fistulas were well controlled and the abdomen was clean and rapidly granulating (Fig. 6).
OUR PROPOSAL The management of an EAF is extremely challenging and should be tailored to the specific characteristics of each case. We believe that a systematic approach to the management of this devastating problem is required. Therefore, after performing a comprehensive review of the literature and analyzing the different options for EAF management, we have developed a flowchart, merging all the techniques described to date and including our experience and techniques (Fig. 7). This is one rational, practical method for approaching this surgical challenge. The acute management of an EAF should aim to divert the fistula output, preventing the spread of intestinal fluid into the peritoneal cavity; collect and quantify the fistula output to address and correct fluids and electrolyte imbalances; and protect and keep clean the surrounding granulating viscera.
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Table 2. Enteroatmospheric Fistula Classification Anatomic location Proximal Stomach, duodenum, jejunum, proximal ileus Distal Distal ileus, colon Output volume Low 500 mL/24 h Location inside the open abdomen Superficial Drains on top of a granulating abdominal wound Deep Drains intestinal content inside the peritoneal cavity
A thorough classification of EAF is essential for choosing the correct approach. According to the literature, an EAF can be classified based on anatomic location (proximal/distal); fistula output volume (low/moderate/ high), and location in the open abdomen (superficial/ deep)10,16,39 (Table 2). It is well known that distal and low-output fistulas have a higher spontaneous closure rate than those that are more proximal and with high output. For this reason, in the case of deserosalization and distal, small, or low-output fistulas, a first attempt at primary closure with sutures and sealants (fibrin glue, cyanoacrylates)21,23 should be made. If this first attempt fails, the fistula must be approached in the same manner as a proximal, large, or moderate/high-output fistulas. The latter fistula type is very unlikely to close with a glue/suture approach. The presence of ongoing peritonitis should be the factor that drives the choice of management technique. Biologic dressings and flaps or skin grafting should be avoided in these cases with ongoing uncontrolled peritonitis because of the high probability of failure (ie, graft rejection, flap necrosis, and lack of sepsis control). If there is ongoing peritonitis, the primary aim of treatment should be the diversion of fistula output, allowing improvement of the physiologic condition of the patient.
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In the most recent review on the management of EAF, Tavusbay and colleagues7 proposed different techniques according to the size/output of the fistula. Small fistulas are first covered with a patch of hydrophilic polyvinyl alcohol foam and the entire abdominal wound is then covered with polyurethane foam to seal the open abdomen, preventing additional spillage of the enteric contents. The foam is covered with an adhesive drape and continuous negative pressure is applied. In case of large fistulas with protruding mucosa, Tavusbay and colleagues suggest that the open abdomen be covered with a perforated polyethylene sheet, cutting a hole in the polyurethane foam to match the fistula mouth, and the polyurethane foam is placed onto the polyethylene sheet. Patients with multiple fistulas provide an even more challenging situation. Most of the techniques described in the literature are complex and time consuming and often require a wide free surface to properly position the diverting device. In contrast, the baby bottle nipple diversion is quick and easy to apply, low in cost, and requires very little space, allowing its application in cases of multiple fistulas, whether they are far apart or in close proximity to each other. In our experience, the baby bottle nipple diversion approach offers the best chance of diverting the fistula output where there are multiple fistulas, either in close proximity or when located far from each other. This allows for effective control of ongoing sepsis and promotes clean granulation formation over the exposed bowel. It also allows exact quantification of the fistula output and assessment of its characteristics. Table 3 provides the appropriate take-home messages.
CONCLUSIONS To the best of our knowledge, an algorithm for EAF management has never been proposed or validated. The everexpanding variety of management techniques, as well as the increasing number of review articles16,40 attempting to summarize them, mirror the great confusion that accompanies the finding of an EAF and reflects the need for a rationale approach to EAF management.
Table 3. Take-Home Messages An enteroatmospheric fistula (EAF) is a major surgical complication that offers an extremely challenging range of critical care burdens, including the full spectrum of surgical, metabolic, nutritional, and nursing issues. Because spontaneous closure is extremely rare, the acute fistula management should aim to completely divert fistula output, protect the surrounding viscera, and allow the clean granulation of exposed bowel, promoting the fistula to become chronic and controlled; fistula takedown and abdominal wall reconstruction should be delayed optimally by at least 8 to 12 months. Considerably heterogeneity in the surgical techniques described for EAF management remains and there is no single approach that has proven to be ideal in every circumstance; a rationale approach to EAF management is needed. The baby bottle nipple diversion approach offers the best chance of diverting the fistula output in case of multiple fistulas, when located either in close proximity or far from each other.
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The proposed flowchart in Figure 7 is derived from our surgical experience managing the open abdomen and EAF and from an extensive review of the available literature. Given the rarity of this condition and the low likelihood of a controlled trial, our conclusions are not evidence based, rather, they are based on small case series and expert opinion. Because of the peculiarity of this field and the absolute lack of management guidelines, the opinion of expert surgeons is a major resource in EAF treatment. This flowchart can be an invaluable tool for those surgeons facing this surgical challenge. In addition, the standardization of the approach to an EAF can lead to a better understanding of the available literature. Speaking the same language all over the world is the first step to creating a rational approach to EAF management and, eventually, the promulgation of internationally accepted guidelines. Author Contributions Study conception and design: Di Saverio, Tarasconi, Tugnoli Acquisition of data: Di Saverio, Tarasconi, Jovine, Tugnoli Analysis and interpretation of data: Di Saverio, Tarasconi, Inaba, Navsaria, Coccolini, Costa Navarro, Mandrioli, Vassiliu, Catena Drafting of manuscript: Di Saverio, Tarasconi Critical revision: Di Saverio, Tarasconi, Inaba, Navsaria, Coccolini, Costa Navarro, Mandrioli, Vassiliu, Jovine, Catena, Tugnoli Final approval: Di Saverio, Tarasconi, Inaba, Navsaria, Coccolini, Costa Navarro, Mandrioli, Vassiliu, Jovine, Catena, Tugnoli REFERENCES 1. Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg 2007;96:263e271. 2. Bradley MJ, Dubose JJ, Scalea TM, et al. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry. JAMA Surg 2013;148:947e954. 3. Bruhin A, Ferreira F, Chariker M, et al. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen. Int J Surg 2014; 12:1105e1114. 4. Navsaria P, Nicol A, Hudson D, et al. Negative pressure wound therapy management of the “open abdomen” following trauma: a prospective study and systematic review. World J Emerg Surg 2013;8:4. 5. Navsaria PH, Bunting M, Omoshoro-Jones J, et al. Temporary closure of open abdominal wounds by the modified sandwichvacuum pack technique. Br J Surg 2003;90:718e722.
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