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

Disclosures

Wounds. 2019;31(11):285-291. 

In This Article

Materials and Methods

The investigators conducted a retrospective analysis of all patients who underwent this 4-step technique for effluent control of EAF between January 2013 and December 2015 at the Hospital General Dr. Manuel Gea González (Mexico City, Mexico). Patients with incomplete data were excluded. This study was conducted in accordance with local audit, ethics, and governance protocols.

Data of patients regarding age, sex, and indication of the first emergency surgery and OA were analyzed. All EAFs recorded in this study were new fistulas that occurred following an emergency laparotomy performed in the authors' hospital. All EAFs included in this study had protruding visible mucosa. Enteroatmospheric fistula was defined as a pathological opening in the intestinal lumen directly into the atmosphere or an exposed fistula occurring in an OA with no overlying soft tissue.[1,2,5]

An initial stabilization phase including reanimation with fluids, sepsis control, electrolyte imbalance, and severe anemia correction was applied to all patients. A stepwise multidisciplinary team approach, including a nutritionist, infectious disease specialist, and ostomy specialist, were involved in patient care.

Based on previously described nutritional support interventions,[2,5–8] oral or enteral nutritional support was the preferred route of feeding. In patients with proximal fistulas, the authors introduced a feeding tube through it to provide enteral nutrition. Parenteral nutrition was employed in all patients in order to cover their energetic needs. Nutritional support followed the recommendations of the American Society for Parenteral and Enteral Nutrition[7] and the European Society for Parenteral and Enteral Nutrition.[8]

Effluent control was achieved with the surgical technique described in the next subsection. The purpose of this technique is to transform the EAF into a floating stoma and, after several dressing changes, transform this floating stoma into a "true" stoma ("ostomization of the fistula orifice"). In most instances, an elective operation for closure or resection and anastomosis was performed after correcting malnutrition status and maintaining well-balanced metabolic parameters as required. Nutritional status after nutritional support intervention (enteral and parenteral) was evaluated by clinical, biochemical (albumin, prealbumin, and transferrin), and anthropometric measurements (body mass index).[2,5–8]

The EAF variables included the number of fistulas, output volume, anatomic site of fistula (proximal or distal), and location inside the OA (either superficial or deep) and were described in each patient. Effluent characteristics were evaluated and classified in low (< 200 mL/day), moderate (200–500 mL/day), or high (> 500 mL/day) output volume.[5] The standard OA classification as proposed by Björck et al[9] was employed as well as the newest classification by Di Saverio et al.[1]

Surgical characteristics consisted of duration of OA with NPWT, number of dressing changes, time to fistula resection, and type of abdominal wall closure. In addition, the time in intensive care unit (ICU; days), overall hospital LOS, and 6-month mortality were evaluated. Rates of refistulization after the last surgery were included.

Data are presented as mean or median (minimum and maximum values, range) and presented. All data were analyzed using SPSS, version 22.0 (IBM Corp, Armonk, NY).

Surgical Technique

The aim of this 4-step technique is to control fistula drainage and protect the wound and surrounding skin while creating a floating stoma. At the final stage, the floating stoma is converted into a true stoma ("ostomization of the fistula"). This stoma facilitates subsequent management of the effluent and restores bowel continuity.

For patients with more than 1 EAF, the technique was applied to the fistula with the higher output, more proximal location, and largest fistula orifice (with protruded mucosa). The more distal, smaller, and lower output fistulas without protruding mucosa were controlled with primary suture closure and NPWT after covering with a patch of hydrophilic polyvinyl alcohol foam (V.A.C. WHITEFOAM Dressing; KCI, an Acelity Company, San Antonio, TX). For patients with more than 1 high-output and protruded mucosa fistula, a separate condom-fistula ring appliance was constructed for each EAF with the rest of the abdominal wound dressed with black NPWT foam (V.A.C. GRANUFOAM Dressing; KCI, an Acelity Company), thus bridging and connecting the negative pressure.

After completely debriding the wound, the 4-step surgical technique includes the following:

Step 1: Condom-EAF anastomosis (Figure 1). A condom (made of latex rubber) cut by the reservoir side according to the fistula size was utilized. The condom was anastomosed to the EAF opening with a running 4–0 nonabsorbable (polypropylene) suture, full-thickness bite. This is an important part of the procedure because the effluent will be diverted through the condom to the ostomy bag.

Figure 1.

Condom-enteroatmospheric fistula anastomosis with a running 4–0 nonabsorbable suture.

Step 2: Fistula ring creation (Figure 2). A fistula ring technique, as described by Verhaalen et al,[10] was performed. The fistula isolation "ring" was constructed with the black NPWT foam cut into a circular shape. The foam is completely encompassed with a drape (V.A.C. Drape; KCI, an Acelity Company). The fistula ring was placed surrounding the EAF and the condom.

Figure 2.

Fistula ring with black negative pressure wound therapy foam. The fistula ring was placed surrounding the enteroatmospheric fistula and condom.

Step 3: NPWT (Figure 3). After the condom was anastomosed to the fistula opening and isolated with the impermeable barrier provided by the fistula ring, the rest of the laparostoma was dressed applying black foam encompassed with the NPWT drape or dressed with the white foam (hydrophilic polyvinyl alcohol foam). Then, the occlusive drape was applied over the entire dressing area, with an orifice for the fistula ring and condom. Next, V.A.C. SensaT.R.A.C. (KCI, an Acelity Company) was placed onto the foam, away from the condom, with continuous negative pressure set at −125 mm Hg to −150 mm Hg.

Figure 3.

Laparostoma dressed with black foam encompassed with negative pressure wound therapy drape with an orifice for the fistula ring and condom.

Step 4: Ostomy bag (Figure 4). Once isolation of the effluent was achieved, a drainage or ostomy collection bag was placed over the ring. The condom was pulled through to the ostomy bag. For high-output EAFs, the authors introduced the tip of a flexible suction tube to the ostomy bag (secured with a suture or an adhesive tape) to recollect the effluent, facilitating quantification and avoiding premature dysfunction of the NPWT device.

Figure 4.

Ostomy bag with the condom pulled through to the ostomy bag.

The NPWT was changed on demand based on dysfunction of the system by obstruction or leakage (or at least once weekly). The condom was changed whenever the union with the fistula leaked effluent to the wound. In every change of the system, the authors closed the edges of the wound (at the top and bottom of the skin defect and, whenever possible, the fascial defect) to reduce the area of the wound with every change. Dressing changes were performed under regional anesthesia and sedation in the operating room. After several dressing changes, the EAF was converted to a true stoma; at the final stage, this stoma was surrounded by skin (Figure 5). Afterwards, patients followed up in the office. When nutritional and inflammatory statuses were corrected, patients were scheduled to a definitive surgery with restitution of bowel continuity and abdominal wall closure/reconstruction.

Figure 5.

Final step with the enteroatmospheric fistula converted into a true stoma.

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