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


The OA complicated with EAFs results in a complex wound with persistent inflammation of the surrounding granulation tissue or skin because of persistent soiling and chemical irritation by intestinal content, local infection, sepsis, electrolyte imbalance, and nutritional depletion.[11]

With the advent of damage control surgery for the treatment of abdominal trauma and sepsis, OA has emerged as a common treatment modality. Another indication of OA is prevention or treatment of intra-abdominal hypertension/compartment syndrome. Although OA has its role in acute care surgery, it is associated with significant complications, including fluid and protein loss, loss of bowel function, loss of abdominal wall domain, prolonged hospital LOS, and, the most feared complication, fistula formation.[6]

The fistulogenic nature of the OA was recognized due to increasing rates of incidence; it is thought to be a consequence of the continuous exposition of the bowel to desiccation and frequent dressing changes.[11] Spontaneous closure of this type of fistula (EAF, high-output, and with protruding mucosa) is unlikely,[3] thus controlling the fistula effluent and protecting the wound and skin are the biggest challenges in managing these patients.[11]

Fistula management should aim to completely divert the fistula output.[1] Perhaps one of the most important advances in managing EAF is the introduction of NPWT as an adjunct for managing effluent and wound complications. Early case reports and small case series have been published since 2000 on the treatment of fistulas with NPWT.[12–16] These reports recognized the advantage of using NPWT in enterocutaneous fistula but not in the context of OA. D'Hondt et al[11] used NPWT to collect the effluent, protect the surrounding skin, and promote granulation tissue formation. Transferring this knowledge to the OA complicated with EAF (once considered a contraindication) has been slow but with increasing evidence that NPWT can be employed successfully in this scenario.

In addition, NPWT not only provided effluent control but also contributed to increased granulation, wound contraction, microenvironment control, and accelerated wound healing.[4] Some of the previously described techniques for effluent diversion and their disadvantages that differ from the present technique include NPWT with handmade dressings (does not provide effective fistula effluent diversion);[1] floating stoma (very traumatic and technically difficult);[17] fistula NPWT (risk of pooling of effluent under the sponge, area around the fistula exposed to bowel content);[18] tube NPWT (risk of enlargement of fistula, not applicable to fistulas larger than the catheter);[19] NPWT chimney (risk of pooling of effluent under the sponge, complex and time consuming);[20] baby bottle nipple NPWT (small fistula only);[21] fistula patch (not tested in peritonitis, must remain until fistula takedown);[22] fistula suspension (technically difficult, only if adjacent to well-vascularized dermis);[23] biologic dressing (expensive, not applicable if sepsis);[1] and fistula plug (complex device, difficult care, risk of obstruction).[1]

Some advantages of the present technique (4 steps with condom) that differ from the others are that it is a quick, easy technical application; has a low cost; has accessible materials; is applicable with ongoing sepsis or peritonitis; provides effective fistula effluent diversion and easy quantification; has a good seal; avoids cannulization of the orifice; is applicable to any size of EAF orifice (especially with large protruding mucosa); allows progressive abdominal wall closure; protection of spillage of enteric contents under the sponge to avoiding early dysfunction of NPWT; and is feasible in cases of multiple fistulas. The drawbacks of the 4-step technique include, in some cases, trauma due to laceration of the bowel with the sutures and risk of enlargement of the fistula. This technique is unique because it combines the benefits of abdominal NPWT plus the isolation of the fistula with the condom-fistula ring complex, providing excellent outcomes regarding effluent control and wound healing and transforming EAF into a more manageable ostomy.

Results of different series treating OA complicated by EAF with NPWT are listed in Table 2.[5,11,17,18,22,24] In comparison with previously published work, this study adds the rate of refistulization and rate of ventral herniation during follow-up to the literature, which the authors consider an important variable in these cases.

In 2011, D'Hondt et al[11] proposed the treatment of small bowel fistulas in the OA with topical NPWT. They covered the abdomen with 3 layers of nonadherent paraffin gauze and the entire wound was covered with black NPWT foam and received −125 mm Hg continuous pressure. Small fistulas without protruding mucosa were covered with polyvinyl alcohol foam; a hole was cut in the black foam for larger fistulas with protruding mucosa. The dressings were changed every 4 days.[11]

One of the most recent large case series was published in 2017 by Bobkiewicz et al.[5] This series included 10 patients with 12 EAFs with protruding mucosa that were treated with a Foley catheter placed directly into the intestine lumen; in cases with moderate- or high-output fistulas, they implemented the fistula NPWT technique.[5]

Also, in 2017, Yetisir et al[24] reported a new technique called "fistula isolation by suturing the penrose drain to mucosa of orifice of EAF"; after suturing the drain, they placed NPWT foam and administered NPWT at −75 mm Hg. They achieved isolation of the fistula with Adapt Skin Barrier Paste (Hollister, Libertyville, IL).[24]

Regarding the optimal time to close or resect the fistula and repair the abdominal wall defect, Demetriades[25] reported that ideally it should be performed 4 to 6 months after treatment in patients with an EAF, but a later publication[1] reported that fistula takedown and abdominal wall reconstruction should be delayed optimally by at least 8 to 12 months.