D. J. Gross1, B. Zangbar1, K. Chang1, E. H. Chang1, P. Rosen1, L. Boudourakis2, M. Muthusamy2, V. Roudnitsky2, T. Schwartz2 2Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA 1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NEW YORK, USA
Introduction:
With the popularization of damage control surgery and the use of the open abdomen, a new permuation of fistula arose, the entero-atmospheric fistula(EAF); an opening of exposed intestine splling ucontrollably into the peritoneal cavity. EAF is the most devastating complication of the open abdomen. We describe and analyze a single institution's experience in controlling high-output deep exposed (entero-atmospheric) fistulas (DEFs) in patients with peritonitis in an open abdomen.
Methods:
We analyzed 189 consecutive procedures to achieve and maintain definitive control of 24 DEFs in 13 patients between 2006 – 2017. DEFs followed surgery for either trauma (7 patients, 53%) or non-traumatic abdominal conditions (6 patients, 46%). All procedures were mapped onto an operative timeline and analyzed for: success in achieving definitive control, number of reoperations, and feasibility of bedside procedures in the SICU. The end point was controlled enteric drainage through a healed abdominal wound (superficial exposed fistula) that was no longer life threatening.
Results:
There was a mean delay of 8.5 days (range 2 – 46 days) from the index operation until the DEF was identified. Most DEFs required several attempts (mean: 2.7 per patient, range 1 – 7) until definitive control was achieved. Reoperations were then required to maintain control (Table). While the most effective techniques were endoscopic (clipping and stenting) and proximal diversion, these were applicable only in select circumstances. A "floating stoma" where the fistula edges are sutured to an opening in a temporary closure device, while technically effective, required multiple reoperations in the OR. Tube drainage through a negative pressure dressing (Tube Vac) required the most maintenance usually through bedside procedures. Primary closure almost always failed [18/20]. Twelve of the 13 patients survived
Conclusion:
A DEF is a unique and highly complex surgical challenge. Successful source control of the potentially lethal ongoing peritonitis requires tenacity and tactical flexibility. The appropriate control technique is often found by trial and error, and must be creatively tailored to the individual circumstances of the patient.
