Management of enteroatmospheric fistula: A ten-year experience following fifteen years of learning.

BACKGROUND: Enteroatmospheric fistulas are a serious complication of Open Abdomen. The goal of this study was to present the strategy and results of enteroatmospheric fistulas treatment during the last 10 years, after a long learning period. METHODS: Seventy-seven patients with enteroatmospheric fistulas were treated and the data recorded between 2012 and 2021. For local treatment, 3 negative pressure methods were used, according to the wound characteristics. The results of conservative and surgical treatments were retrospectively identified and described, including nutritional recovery, morbidity and mortality. Predictors of spontaneous closure, as well as risk factors for the fistula's recurrence and mortality were analyzed. RESULTS: Nutritional and clinical recovery was achieved in 66 patients (85.7%). Fourteen patients (18%) were healed without surgery after a median of 57 days (range 35-426 days). Unique lesions (13/46; P = .02, OR 10.23), initial output ≤700 mL/day (9/28; P = .0035, OR 3.79) and deep fistulas (9/12; P = .00001, OR 33.6) were encountered and acknowledged to be as spontaneous closure factors. Fifty-six patients (72.7%) required reconstructive surgery of the intestinal tract after a median of 187 days since last laparotomy (range: 63-455 days). There were 9 postoperative recurrences (16%), 5 of them closed with conservative treatment. No significant risk factors for recurrence nor postoperative mortality were found. Fistula complete closure was achieved in 63 of the 77 patients studied (81.8%), and 7 patients died (9%). CONCLUSION: The combination of 3 vacuum methods used for enteroatmospheric fistula management was effective. Spontaneous closure of an enteroatmospheric fistula is unlikely but feasible when lesions are single, deep, with limited output, and when intestinal continuity is preserved. Surgical indications are well defined, although mortality and recurrence rates are still high.

Systematic and Specific Treatment of Patients with Enteroatmospheric Fistulas: From Initial Conservative Treatment to Definitive Surgery.

INTRODUCTION: The open abdomen is a widespread therapeutic resource; however, it is also a source of complications, of which the enteroatmospheric fistulas (EAFs) pose one of the greatest problems. The objective of this study was to describe the implemented strategy for handling enteroatmospheric fistulas, and secondarily, to analyze the differential results based on a change in the conservative local treatment specifically designed for the stated complication. MATERIALS AND METHODS: From March 2002 to March 2014, patients treated for EAF were retrospectively analyzed. They were divided into 2 groups: Group 1 (G1: 2002 - 2007), treated with an occlusive vacuum device (SIVACO), similar to that used for other enterocutaneous fistulas, and Group 2 (G2: 2008 - 2014), covered in a specific modality for EAF. Results of conservative and surgical treatment were described and then the two groups were statistically compared. RESULTS: Study participants comprised 62 patients. Twelve cases (19.4%) healed with conservative treatment. This was statistically related with a baseline albumin level >3 g/dL, single lesions with no visible mucosa and baseline output <700 mL/d. In G1, the output fall was higher, while G2 required fewer wound dressing changes and enteral nutrition was feasible in a significantly higher number of patients. Forty-seven patients underwent reconstructive surgery. The mortality-associated variables were preoperative hypoalbuminemia and 2 or more anastomoses. Overall mortality was 8% (5 patients). In the multivariate model, only initial output (<700 mL/d) was an independent predictor for spontaneous closure, whereas 2 or more anastomoses and hypoalbuminemia were negative independent predictors. CONCLUSION: Systematic management of enteroatmospheric fistulas, following a rigorous protocol and a two-step specific treatment, resulted in a practical approach and yielded good results in healing and mortality.

Effect of intestinal pressure on fistula closure during vacuum assisted treatment: a computational approach.

BACKGROUND: Enterocutaneous fistulae, pathological communications between the intestinal lumen and the abdominal skin, can arise as serious complication of gastrointestinal surgery. A current non-surgical treatment for this pathology involves topical application of sub-atmospheric pressure, also known as vacuum assisted closure (VAC). While this technique appears to be promising, surgeons report a number of cases in which its application fails to achieve fistula closure. Here, we evaluate the fistula's physical properties during the vacuum assisted closure process in a computational approach exploring the relevance of intraluminal intestinal pressure. METHODS: A mathematical model formulated by differential equations based on tissue elasticity properties and principles of fluid mechanics was created and forcing functions were integrated to mimic intestinal pressure dynamics. A software to solve equations and to fit the model to experimentally obtained data was developed. This enabled simulations of vacuum assisted fistula closure under different intestinal pressure. RESULTS: The simulation output indicates conditions, in which fistula closure can or cannot be expected suggesting favoured or impeded healing, respectively. When modifications of intestinal pressure, as observed in fistula accompanying pathologies, are integrated, the outcome of fistula closure changes considerably. Rise of intestinal pressure is associated with delay of fistula closure and temporary fistula radius augmentation, while reduction of intestinal pressure during sub-atmospheric pressure treatment contributes to a faster and direct fistula closure. CONCLUSION: From the model predictions, we conclude that administration of intestinal pressure decreasing compounds (e.g. butylscopolamine, glucagon) may improve VAC treatment, while intestinal pressure increasing drugs should be avoided.

Management of external small bowel fistulae: challenges and controversies confronting the general surgeon.

BACKGROUND: External small bowel fistulae (ESBF) are serious complications that represent a major challenge for general surgeons. They are still associated with significant morbidity and mortality. This article reviews the management of ESBF with emphasis on the treatment using sub-atmospheric pressure as well a timing, strategies and techniques of reconstructive surgery. METHODS: Relevant articles from 1960 to 2010 were identified using various electronic databases to review randomized controlled trials, prospective observational studies, retrospective studies and case reports and highlight key references. CONCLUSIONS: External small bowel fistulae require multidisciplinary management and multimodal approaches with a primary essential focus on early recognition and diminishment of mortality factors such as sepsis and malnutrition. In most cases, the initial treatment is conservative, including clinical and nutritional recovery, output control and extensive local wound care. At this stage, the application of local negative pressure is highly effective. This procedure also allows for a spontaneous closure in many patients. Other cases require careful consideration of surgical reconstruction, knowing that success rates are variable and largely dependent on the patient's condition as well as on local aspects of the lesion. Best surgical results are obtained via intra-peritoneal access with extensive enterolysis, resection of the bowel segment from which the fistulae originate and direct abdominal wall closure.

Complicaciones de la cirugía laparoscópica: tratamiento por relaparoscopía, a propósito de tres casos / Complications of laparoscopic surgery: relaparoscopic treatment, our experience

En la mayoría de las series de complicaciones de la cirugía laparoscópica se hallan presentes las colecciones abdominales postoperatorias. Ante este suceso, el drenaje percutáneo es actualmente el tratamiento de elección. Sin embargo cuando dicho método fracasa, o bien no tiene indicación precisa, la laparotomía se impone. En este trabajo se presentan tres pacientes operados por vía laparoscópica que presentaron este tipo de complicaciones y fueron resueltos con una reintervención también por vía laparoscópica. Los resultados obtenidos fueron satisfactorios. Los autores consideran que la relaparoscopía puede ser, en este capítulo, una alternativa terapéutica previa a la laparotomía, no excluyente de la misma incluso en el mismo acto quirúrgico (AU)

Complicaciones de la cirugía laparoscópica: tratamiento por relaparoscopía, a propósito de tres casos / Complications of laparoscopic surgery: relaparoscopic treatment, our experience

En la mayoría de las series de complicaciones de la cirugía laparoscópica se hallan presentes las colecciones abdominales postoperatorias. Ante este suceso, el drenaje percutáneo es actualmente el tratamiento de elección. Sin embargo cuando dicho método fracasa, o bien no tiene indicación precisa, la laparotomía se impone. En este trabajo se presentan tres pacientes operados por vía laparoscópica que presentaron este tipo de complicaciones y fueron resueltos con una reintervención también por vía laparoscópica. Los resultados obtenidos fueron satisfactorios. Los autores consideran que la relaparoscopía puede ser, en este capítulo, una alternativa terapéutica previa a la laparotomía, no excluyente de la misma incluso en el mismo acto quirúrgico