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


A total of 7 patients were included in the study. Table 1 presents the baseline characteristics, EAF features, and postoperative outcomes. All patients were previously healthy, with a mean age of 38.5 years (range, 23–67 years); 4 (57.1%) of the patients were male. The indications for primary surgery were abdominal sepsis in 5 patients (71.4%) and abdominal trauma in 2 (28.6%). In all patients, OA treatment was necessary after a complication of the index surgery (Table 1). Complications included anastomotic leaks (n = 4, 57.1%) and missed enterotomies (n = 3, 42.9%); all patients developed severe intra-abdominal sepsis (severe peritonitis). The indication for OA was the need for relaparotomy for lavage and drainage of collections/abscesses. The EAF developed as a complication of the OA in all patients.

All 7 patients were classified as Björck grade 4 (frozen OA with adherence/fixed bowel, impossible to close surgically, and with established fistula).[9] A total of 16 EAFs were registered in this series; all fistulas were located in the small bowel (proximal as per Di Saverio et al[1] classification) with a median number of 2 EAFs per patient (range, 2–3) and moderate output volume as the most frequent presentation (as per Di Saverio et al[1] classification). All EAF were located superficially (ie, draining on top of a granulating abdominal wound).[1] The 4-step technique was performed successfully in all 7 patients. Patients 5 and 7 required 2 separated condom-fistula ring appliances as previously described (Table 1). The mean number of NPWT changes was 10 (range, 5–18), mean time of NPWT use was 75.7 days (range, 60–120 days), and mean hospital LOS was 108.2 days (range, 103–160 days). No complications or new fistulas related to NPWT were recorded.

All patients included in this study underwent restitution of bowel continuity, with bowel resection (enterectomy) and primary anastomosis performed. Although the exact distance between each fistula was not recorded, the diseased bowel containing all active fistulas at the moment of restitution of bowel continuity was resected in all cases. 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 complications after restitution were found. No cases of short bowel were recorded. No mortality, ventral herniation, or refistulization was registered during the mean follow-up time of 8.5 months (range, 6–12 months).