“The abdominal catastrophe”

Abstract

An open abdomen with multiple small intestinal fistulas is a highly challenging situation for the entire treating team and, in some cases, ultimately requires small bowel transplantation. In May 2015, a 55-year-old female patient was transferred to our department for evaluation for small bowel transplantation. Following appendectomy in childhood, the patient had had a complicated course with consecutive loss of small bowel. In May 2014, an even more complicated perforated sigma diverticulitis followed. The consequence was a small bowel high-output stoma with concomitant short-bowel syndrome. In March 2015, an attempt to reconstruct the passage failed and ended in an open abdomen with eight small intestinal fistulae, a contracted ileostomy and a defunctioned descendostomy. We firstly mobilized the stoma and conditioned the wound with almost daily changing of a vacuum dressing system (VAC®, KCI, International) by using a children’s pacifier. At 6 months after the previous abdominal operation, extensive adhesiolysis and conglomerate resection plus a jejunoileostomy and new installation of the descendostomy was performed. Approximately 80 cm of small intestine, 50 cm of colon plus the ileocecal valve could be preserved. The abdominal wall was closed cutaneously only. After 168 days of hospitalization, the patient was discharged with oral alimentation and supplementary parenteral nutrition only by night. With considerable nursing and surgical effort, the need for intestinal transplantation with all its complications can be avoided in selected cases. A children’s pacifier can help to make vacuum-assisted closure of the wound possible.