Enteroatmospheric fistulas - the challenge of the open abdomen

Abstract

Introduction : In the past two decades, the open abdomen (OA) technique has gained wide popularity as an effective approach in the cases with severe peritonitis, abdominal compartment syndrome and critical trauma. However, it is still associated with high complication rate. Enteroatmospheric fistulas are the most devastating complication. Despite the numerous techniques described in the literature, their management remains a challenging task. Material and methods: The present study analyses the frequency of enteroatmospheric fistulas in two cohorts managed by open abdomen and discussed the results from their treatment in the V.A.C. group. The first cohort includes 69 consecutive patients temporarily closed by V.A.C. abdominal dressing, whereas the other one encompasses 83 patients treated by mesh-foil laparostomy. The fistula effluent was isolated by 10 ml syringe barrel according to the technique of Verhaalen. Results: Overall, 5/69 (7.2%) fistulas were identified. All were high output (>500 ml) small bowel fistulas. One patient died before fistula closure (25%, 1/5). A controlled enterocutaneous fistula was achieved in 2 patients and spontaneous closure in one. In one case an extensive small bowel resection due to intractable ileus was performed. The mean ICU and hospital stay in the fistula group were 15.2 (7-28) and 55.6 (32-84) days versus 8.2 (2-30) and 16.7 (3-84) respectively. Conclusion: The enteroatmospheric fistulas are the most dangerous complication of the open abdomen. The best treatment is their isolation combined with V.A.C. at the early stages and resection with primary anastomosis after 3-12 months.