A Four-Step Technique for Effluent Diversion of Enteroatmospheric Fistulas

Adolfo Cuendis-Velázquez, MD; Mario Trejo-Avila, MD; Elisafat Arce-Liévano, MD; Eduardo Cárdenas-Lailson, MD; Carlos Sanjuan-Martínez, MD; Mucio Moreno-Portillo, MD


Wounds. 2019;31(11):285-291. 

In This Article

Abstract and Introduction


Background: Isolation of the enteroatmospheric fistula (EAF) opening and prevention of contamination of the rest of the wound by effluent are important factors in the management of EAF.

Objective: The aim of this study is to describe an easily reproducible technique for effluent control in patients with EAF.

Materials and Methods: A retrospective analysis was conducted on all patients who underwent the present technique between 2013 and 2015. The surgical technique included condom-EAF anastomosis, fistula ring creation, negative pressure wound therapy (NPWT), and adaptation of an ostomy bag.

Results: A total of 7 patients with a Björck grade 4 abdomen were included. All fistulas were located in the small bowel with a median number of 2 EAFs (range, 2–3) in each patient, and the majority had moderate output volume. The mean number of NPWT changes was 10 (range, 5–18), the mean time of NPWT use was 75.7 days (range, 60–120 days), and the mean length of stay was 108.2 days (range, 103–160 days). The mean time of ostomy formation to restitution of bowel continuity was 14.3 months (range, 8–20 months). Open anterior component separation was employed in all cases for closure of the abdominal wall. No mortality, ventral herniation, or refistulization was registered in the study. The mean follow-up time was 8.5 months (range, 6–12 months).

Conclusions: This is an easily reproducible and safe technique for effluent control in patients with Björk grade 4 abdomen with established EAF.


Enteroatmospheric fistula (EAF) is defined as the occurrence of an enteric fistula in the middle of an open abdomen (OA), consequently creating a communication between the gastrointestinal tract and external atmosphere.[1] Unique features that define EAF are the abscess of a fistula tract, lack of well-vascularized surrounding tissue, and location within an OA resulting in spillage of enteric content into the peritoneal cavity.[1]

Some of the etiologic factors associated with EAF are anastomotic leak, severe wound infection, burst abdomen, severe trauma, bowel ischemia, missed enterotomies, use of OA techniques (damage control surgery), and inflammatory bowel disease.[1,2] Open abdomen techniques and methods for temporary abdominal wall closure have been associated with an EAF development rate of 14% to 25%.[2,3] A higher incidence of EAF in septic OA compared with nonseptic OA (12.1% vs. 3.7%) has been reported.[1] Fistula formation rate related to negative pressure wound therapy (NPWT) can be as low as 5%, although Giudicelli et al[2] suggest the relationship between NPWT and EAF could be as high as 14.6%. The mortality rate due to EAF is reported to be between 36% and 64%.[1–5] In addition, the development of EAF increases the hospital length of stay (LOS) by 4-fold and hospital costs by 4- to 5-fold.[6]

There are several treatment options for EAF, reflecting the lack of uniform data, evidence-based results, and standard technique.[1–4] The isolation of the EAF opening and the prevention of the contamination of the rest of the wound by fistula effluent are important factors in the management of this entity.[4]

The aim of this study is to describe a novel, easily reproducible 4-step technique for effluent control in patients with EAF and the surgical outcomes of a series of patients treated with this method.