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TREATMENT OF ENTEROTMOSPHERIC FISTULAS IN THE OPEN ABDOMEN MANAGEMENT USING NEGATIVE PRESSURE WOUND THERAPY. A MULTICENTER OBSERVATIONAL STUDY
Adam Bobkiewicz*1, Dominik Walczak2, Adam Studniarek1, Jacek Szmeja1, Tomasz Banasiewicz1
1Department of General, Endocrinological Surgery and Gastroenterological Oncology , Poznan University of Medical Sciences, Poznan, Poland; 2Department of General Surgery, John Paul II Memorial Hospital, Belchatow, Poland
Introduction
An enteroatmospheric fistula (EAF) in the open abdomen (OA) management is an extremely challenging complication. The introduction of NPWT has significantly improved the wound healing and increased spontaneous EAF closure. The main goal of this study was to evaluate our experience with NPWT in the management of EAF in the OA.
Material and Methods
Retrospectively, sixteen patients with a total of thirty-one enteroatmospheric fistulas in OA were managed with NPWT in four referral centers between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies. Based on the output, EAF were classified as followed: low (< 200ml/day), moderate (200-500ml/day) and high (>500 ml/day) output fistulas.
Results
The study group comprised of 5 women and 11 men with the mean age of 52,6± 11,9 years. The majority of patients (11/16 patients) were referred from other hospitals with the mean number of re- laparotomies of 3,7±2,2 due to acute pancreatitis (n=3), bowel malignancy (n=3) and bowel obstruction (n=3) as the most common indications for primary surgery since NPWT was implemented.
Twenty- five of EAFs were located within the small bowel, four in the colon and three at the anastomotic site. EAFs were classified as followed: thirteen as low output (41,9%), two as moderate (6,5% ) and sixteen as high output (51,6%) fistulas. An overall spontaneous EAF closure rate was 61,3% within the mean time of 46,7 (SD 43,4) days of NPWT. EAFs closure rate was 50% in both high and moderate output fistulas, whereas 76,9% of low output EAFs closed spontaneously. Analyzing the cycle of negative pressure therapy, surprisingly we found that spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure whereas in group of patients treated with continuous pressure 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3,3; range 4-16). In all EAFs without fistula closure (n=12), a protruding mucosa was present. In two patients treated with NPWT, an iatrogenic EAF was revealed. The mortality rate was 18,8% (n=3).
Conclusions
NPWT is a safe and efficient method for OA management with concomitant EAF. Although, closure of EAF is challenging, we found NPWT as a useful technique for spontaneous EAF closure. Based on our experience, low output fistulas as well as no mucosal protrusion positively influence on higher EAF spontaneous closure rate in OA using NPWT.
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