Recurrent incisional hernia, enterocutaneous fistula and loss of the substance of the abdominal wall: plastic with organic prosthesis, skin graft and VAC therapy. Clinical case.

Surgical wounds dehiscence is a serious post-operatory complication, with an incidence between 0.4% and 3.5%. Mortality is more than 45%. Complex wounds treatment may require a multidisciplinary management. VAC Therapy could be an alternative treatment regarding complex wound. VAC therapy has been recently introduced on skin's graft tissue management reducing skin graft rejection. The use of biological prosthesis has been tested in a contaminated field, better than synthetic meshes, which often need to be removed. The Permacol is more resistant to degradation by proteases due to its cross-links. Surgery is still considered the best treatment for digestive fistula. A 58 years old obese woman come to our attention, she was operated for an abdominal hernia. She had a post-operatory entero-cutaneous fistula. She was submitted to bowel resection, the anastomosis has been tailored and the hernia of the abdominal wall has been repaired with biological mesh for managing such condition. She had a wound dehiscence with loss of substance and the exposure of the biological prosthesis, nearly 20 cm diameter. She was treated first with antibiotic therapy and simple medications. In addiction, antibiotic therapy was necessary late associated to 7 months with advanced medications allowed a small reduction's defect. Because of its, treatment went on for two more months using VAC therapy. Antibiotic's therapy was finally suspended. The VAC therapy allowed the reduction of the gap, between skin and subcutaneous tissue, and the defect's size preparing a suitable ground for the skin graft. The graft, managed with the vac therapy, was necessary to complete the healing process.

Virtual ileostomy following rectal cancer surgery: a good tool to avoid unusefull stomas?

BACKGROUND/AIMS: Anastomotic leak is a life threatening complication following surgery for rectal cancer below peritoneal reflection. Colostomy or ileostomy following colorectal or coloanal anastomosis protect the patients from general peritonitis or sepsis secondary to anastomotic leak. METHODOLOGY: In this paper the experience of the last 100 cases of rectal cancer below the peritoneal reflection treated from 2004 to 2010 was reviewed. RESULTS: In 79 cases, primary anastomosis was performed. In 44/79 cases virtual ileostomy was prepared and in 35/79 cases, based on risk factors and intraoperative decision of the surgeon, an open ileostomy was performed. In 8/44 cases virtual ileostomy was opened, thus avoiding in 35/79 cases a second operation. CONCLUSIONS: The goal for a good clinical outcome of patients with virtual ileostomy is a strict postoperative follow-up focused on fever onset and quality of drainage discharge. In our experience virtual ileostomy is a good tool to avoid open ostomy at time of primary colorectal or coloanal anastomosis in a good number of cases.