Abdominal wall defect and enterocutaneous fistula treatment with the Vacuum-Assisted Closure (V.A.C.) system

Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.

How to isolate a high output enteroatmospheric fistula in the open abdomen with negative pressure therapy: an institution's step by step guide to the VAC donut

There is multiple evidence to suggest that isolation techniques of high output enteroatmospheric fistulas (EAF) in open abdomens can be advantageous in controlling fistula effluent while allowing time for abdominal wall to granulate. The large loss of proteins, electrolytes and fluid, and the distressing nature of the open abdomen for both patients and doctors, make managing these EAFs a clinical challenge. We present our experience with a high output mucosal protruding EAF and the creation of a 'VAC donut' allowing a successful diversion of the enteric content whilst promoting granulation of the tissue bed.

The successful management for long-term intractable enteroatmospheric fistula: A case report

Introduction

Efficacy of open abdomen management with negative pressure wound therapy for enteroatmospheric fistula has been performed. But, few reports have shown its utility for enteroatmospheric fistula several years after onset.

Presentation of case

A 46 year-old woman underwent total colectomy due to total ulcerative colitis in her twenties. Three years before the onset of enteroatmospheric fistula, she underwent simple total hysterectomy for uterine smooth muscle tumor. Small bowel obstruction occurred early and a small bowel bypass was performed. However, she had sudden abdominal pain and was diagnosed with anastomotic leakage of small bowel bypass. Although antibiotic treatment was initiated, infection was difficult to control, and a midline abdominal incision was performed, followed by the formation of enteroatmospheric fistula. She declined early surgical intervention and started receiving home parenteral nutrition with antibiotic treatment. Although central vein management was continued, catheter infection became frequent. Hence, surgical intervention was planned 30 months after the formation of enteroatmospheric fistula. Two-stage abdominal wall reconstruction using open abdomen management with negative pressure wound therapy was planned. The definitive abdominal wall reconstruction was performed 14 days after the initial operation. Finally, she was discharged without reoperation.

Discussion

Enteroatmospheric fistula has no overlying soft tissue and no real fistula tract. Besides these complications, there were complications of the scarred abdominal wall from intestinal fluid exposure for 30 months.

Conclusion

The strategy using open abdomen management with negative pressure wound therapy for long-term enteroatmospheric fistula will have a good postoperative outcome with the same as early intervention.

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Negative pressure wound therapy is effective in postonset enteroatmospheric fistula.

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It repairs abdominal wall skin damage from 30-month intestinal fluid exposure.

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Open abdominal management was able to control infection in the perioperative period.

Three Cases Describing Outcomes of Negative-Pressure Wound Therapy With Instillation for Complex Wound Healing

BACKGROUND

We describe 3 cases where negative-pressure wound therapy with instillation and dwell time (NPWTi-d) was used as an adjunctive therapy for 3 chronic wounds.

CASES

Three patients (2 males and 1 female), ranging in age from 28 to 53 years, presented with complex, infected wounds: (1) a diabetic foot ulcer with underlying infection, (2) a dehisced abdominal wound with enterocutaneous fistula, and (3) a large wound of the upper torso and axillary region resulting from soft tissue necrosis. Negative-pressure wound therapy with instillation and dwell time was initiated by instilling normal saline or an antiseptic solution; the solution was left in place for 3 to 10 minutes. Continuous negative pressure was then applied at -125 or -150 mm Hg; cycles were repeated every 1 or 3 hours. Treatment was applied for 5 to 44 days, and dressings were changed every 2 to 3 days. Granulation tissue developed in all 3 wounds; all closed after subsequent skin grafting.

CONCLUSIONS

Outcomes of these cases suggest that NPWTi-d may be used as an adjunctive treatment modality for a variety of chronic wounds.

Treatment Options in Gastrointestinal Cutaneous Fistulas

Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.

A systematic literature review on the use of vacuum assisted closure for enterocutaneous fistula

AIM

Enterocutaneous fistula (ECF) is considered to be one of the most challenging complications a general surgeon can encounter. The current mainstay of treatment is surgical closure, associated with significant morbidity and mortality. Vacuum assisted closure (VAC) has been successfully used for closure of persistent abdominal wounds for a number of years. This study aims to investigate whether current literature supports the use of VAC for ECF.

METHOD

A PubMed search of the search terms 'enterocutaneous fistula' and 'vacuum assisted closure/therapy' was performed in December 2014. Results were restricted to articles involving human subjects with an available abstract and full text written between 1950 and 2014. The end-points analysed included rate of fistula closure, duration of follow-up, and morbidity and mortality where available.

RESULTS

Ten studies (all level IV) including 151 patients were examined. In all except one, surgery was the underlying aetiology with median number of fistulae per patient of one. The median rate of closure with VAC was 64.6% (7.7-100%) with healing occurring within 58 (12-90) days. Follow-up was only mentioned in three of the 10 studies, in which the patients were followed for 3, 20 and 28.5 months. No complications were reported in all but one of the studies, in which abdominal wall disruption and intestinal obstruction were identified in a minority of patients.

CONCLUSION

The included studies suggest that VAC therapy may be considered a safe treatment for ECF. The current evidence is generally of low level and characterized by heterogeneity. Definitive recommendations based on this information cannot therefore be made. Further studies are necessary to establish any proven benefit over standard surgical or conservative therapy.

Early Definitive Closure of the Open Abdomen: A Quiet Revolution

Contrary to the management strategy recommended only 2-3 years ago, temporarily covering the open abdomen with an absorbable mesh or a plastic sheath without preserving the peritoneal space is no longer considered in the patient's best interest. The use of the vacuum pack, in conjunction with vacuum-assisted wound management and new biological prostheses now offer patients with an open abdomen a better and simpler alternative to the giant "planned ventral hernia". With very few exceptions in the most critically ill patients, the survivors of damage control surgery or infected pancreatic necrosis should not be sent home with a huge defect only to undergo a complex reconstruction a year later. Simpler and better alternatives exist. The new concepts and technologies presented in this review, when widely adopted, will rapidly translate into safer and better management of the patient with an open abdomen.

Enterocutaneous Fistula: Proven Strategies and Updates

Management of enterocutaneous fistula represents one of the most protracted and difficult problems in colorectal surgery with substantial morbidity and mortality rates. This article summarizes the current classification systems and successful management protocols, provides an in-depth review of fluid resuscitation, sepsis control, nutrition management, medication management of output quantity, wound care, nonoperative intervention measures, operative timeline, and considerations, and discusses special considerations such as inflammatory bowel disease and enteroatmospheric fistula.

Vacuum-assisted closure of necrotic and infected cranial wound with loss of dura mater: A technical note

Background:

Complex cranial wounds can be a problematic occurrence for surgeons. Vacuum-assisted closure devices have a wide variety of applications and have recently been used in neurosurgical cases involving complex cranial wounds. There is only one report regarding the use of a vacuum-assisted closure device with loss of dura mater. We report a complicated case of a necrotic cranial wound with loss of dura mater.

Case Description:

A 68-year-old female underwent an evacuation of a subdural hematoma. Postoperatively, the patient developed a wound infection that required removal of the bone flap. The wound developed a wedge-shaped necrosis of the scalp with exposure of brain tissue due to loss of dura mater from previous surgeries. She underwent debridement and excision of the necrotic tissue with placement of a synthetic dural graft (Durepair®, Medtronic, Inc.) and placement of a wound vac. The patient underwent a latissismus dorsi muscle flap reconstruction that subsequently failed. After the wound vac was replaced, the synthetic dural graft was replaced with a fascia lata graft and an anterolateral thigh free flap reconstruction. We describe the technical nuances of this complicated case, how the obstacles were handled, and the literature that discusses the utility.

Conclusion:

We describe a case of a complex cranial wound and technical nuances on how to utilize a wound-vac with loss of dura mater.

Management of enteroatmospheric fistulae

A small-bowel enteroatmospheric fistula (EAF) is an especially challenging complication for patients with open abdomens (OAs) and their surgeons. Manipulation of the bowel during treatment (e.g. dressing changes) is one of the risk factors for developing these openings between the atmosphere and the gastrointestinal tract. Unlike enterocutaneous fistulae, EAFs have neither overlying soft tissue nor a real fistula tract, which reduces the likelihood of their spontaneous closure. Surgical closure is necessary but not always easy to do in the OA environment. Negative pressure wound therapy (NPWT) has been used successfully as an adjunct therapy to heal the wound around EAFs. This review discusses many aspects of managing EAFs in patients with OAs, and presents techniques that have been developed to isolate the fistula and divert effluent while applying NPWT to the surrounding wound bed.

Intestinal perforation after treatment of Burkitt's lymphoma: case report and review of the literature

Non-Hodgkin's Lymphoma (NHL) is the most common intestinal malignancy in children, and Burkitt's lymphoma is the most frequently encountered histologic subtype. In pediatric patients, intestinal involvement of the lymphoma is a common finding. As over half of these intestinal tumors are unresectable at the time of presentation, chemotherapy is the mainstay of treatment. However, as the tumor responds to chemotherapy, regression of the tumor in the bowel wall can result in intestinal perforation. We report a unique case of a pediatric patient with lymphoma-related intestinal perforation which was managed with a damage control laparotomy, discuss operative management strategies in these difficult cases, and provide a review of similar cases in the literature.

Vacuum-assisted closure for complex cranial wounds involving the loss of dura mater

The aim in this study was to describe the safety and efficacy of vacuum-assisted closure (VAC) in patients with complex cranial wounds with extensive scalp, bone, and dural defects who were not candidates for immediate free tissue transfer. Five patients (4 men and 1 woman) ages 24–73 years with complex cranial wounds were treated with VAC at Wake Forest Baptist Medical Center. Etiologies included trauma, squamous cell carcinoma, and malignant meningioma. Cutaneous wound defects measured as large as 15 cm in diameter. Four of the 5 patients had open skull defects with concomitant dural defects, and 1 patient had dural dehiscence. After surgical debridement, all 5 patients were treated with the direct application of a VAC device to a reapproximated dura mater (1 patient), to a pericranial flap (1 patient), or to a regenerative tissue matrix overlying CNS tissue (3 patients). In all cases involving open cranial wounds, the VAC device promoted granulation tissue formation over the dural substitute, prevented CSF leakage, and kept the wounds free from local infection. The duration of VAC therapy ranged from 16 to 91 days. Although VAC therapy was intended as a temporary measure until these patients could be stabilized for larger tissue transfer procedures or they succumbed to their primary pathology, 1 patient had a successful skin graft following VAC therapy. Hydrocephalus requiring shunt placement developed in 2 patients during VAC therapy. The VAC dressings applied to a tissue matrix or other barrier over brain tissue in extensive cranial wounds are safe and well tolerated, providing a functional barrier and preventing infection.

Controversies in the care of the enterocutaneous fistula

Enterocutaneous fistula and its variations are some of the most difficult problems encountered in the practice of general surgery. Reliable evidence that can be used to direct the care of patients afflicted with this malady is limited. There are controversies in several areas of care. This article addresses some of the gray areas of care for the patient with enterocutaneous fistula. There is particular attention directed toward the phenomenon of enteroatmospheric fistula, as well as prevention and abdominal wall reconstruction, which is often required in these individuals.

Vacuum-assisted closure therapy in patients with large postoperative wounds complicated by multiple fistulas

Vacuum-assisted closure (VAC) therapy is a widely acknowledged method for chronic and traumatic wound healing. The feasibility of VAC therapy used for the treatment of intestinal fistulas is still a subject of debate. Complex postoperative wounds pose significant therapeutic problems, especially when there are several fistula openings in the wound area and other sites, usually at the site of previous drains. This paper describes the treatment of three patients in a critical condition, with complex postoperative wounds complicated by multiple fistulas. Vacuum-assisted closure therapy was based on effective drainage of the biggest fistula opening and ensuring conditions promoting the healing process of other fistulas and the wound. A considerable improvement in general condition and wound healing was noted within 2-4 weeks and both the number of fistulas and the volume of excreted contents decreased. After 5-7 weeks a significant improvement in wound healing was observed in all patients. Once the general condition of all patients was considered satisfactory (2-6 months), they underwent surgery aimed at restoration of the digestive tract continuity.In our opinion, VAC therapy used for the treatment of postoperative wounds with multiple fistulas in the wound area and other sites should aim mainly at the improvement of patients' general condition, limitation of the number of fistulas as well as accelerated wound healing. This may lead to formation of one stoma-type fistula, which can be dressed and cared for by patients until the continuity of the digestive tract has been surgically restored.

Treatment of small-bowel fistulae in the open abdomen with topical negative-pressure therapy

BACKGROUND

An open abdomen (OA) can result from surgical management of trauma, severe peritonitis, abdominal compartment syndrome, and other abdominal emergencies. Enteroatmospheric fistulae (EAF) occur in 25% of patients with an OA and are associated with high mortality.

METHODS

We report our experience with topical negative pressure (TNP) therapy in the management of EAF in an OA using the VAC (vacuum asisted closure) device (KCI Medical, San Antonio, TX). Nine patients with 17 EAF in an OA were treated with topical TNP therapy from January 2006 to January 2009. Surgery with enterectomy and abdominal closure was planned 6 to 10 weeks later.

RESULTS

Three EAF closed spontaneously. The median time from the onset of fistulization to elective surgical management was 51 days. No additional fistulae occurred during VAC therapy. One patient with a short bowel died as a result of persistent leakage after surgery.

CONCLUSIONS

Although previously considered a contraindication to TNP therapy, EAF can be managed successfully with TNP therapy. Surgical closure of EAFs is possible after several weeks.

Successful bridging treatment and healing of enteric fistulae by vacuum-assisted closure (VAC) therapy and targeted drainage in patients with open abdomen

PURPOSE

The object of this study was to investigate the bridging treatment of enteric fistulae by vacuum-assisted closure (VAC) therapy in patients with open abdomen.

METHODS

We retrospectively analyzed patients who have been treated between 1 January 2007 and 31 December 2008 at the intensive care unit of the Department of General Surgery, Medical University Vienna. Control of the fistula was established by VAC therapy to bridge the patients to the time of the fistula resection.

RESULTS

In the period of investigation, we treated nine (six men/three women) patients suffering from enteric fistulae with VAC therapy. The median age of the patients was 48 (range, 37-67) years. The median duration of VAC therapy was 76 (range, 53-128) days. The median length of stay in the intensive care unit was 44 (range, 25-127) days. The median APACHE II score was 23 (range, 18-25). The predicted mortality was 40%; the actual mortality was 11% (one patient). Primary fascial closure was achieved after median 91 (range, 89-92) days in three patients (33%) and secondary fascial closure after median 292 (range, 252-546) days in another three patients (33%). Fistulae were cured with VAC (five patients, 56%) and surgical resection (three patients, 33%). None of the patients developed a refistulation at the time of follow-up.

CONCLUSIONS

Control of enteric fistulae by VAC therapy can lead to spontaneous fistula closure and is associated with a low mortality.

Treatment of the open abdomen with topical negative pressure therapy: a retrospective study of 46 cases

The open abdomen is an ongoing challenge for professionals engaged in its treatment. The change in the integrity of the abdominal wall, the loss of fluids, heat and proteins and contamination of the wound are the main problems. The objective of this article is to describe our experience using the abdominal dressing vacuum-assisted closure therapy in treatment of the open abdomen. Since December 2006, all patients requiring treatment with the open abdomen technique have been treated with the abdominal dressing system and vacuum-assisted closure therapy (VAC(®) KCI, San Antonio, USA). The results obtained with this technique in non traumatic patients are analysed herein. The abdominal dressing system was used on 46 patients in the period between January 2006 and December 2009, with a mean 63 years old (29-80), with a gender distribution of 33 men (72%) and 13 women (28%). Closure of the abdominal wall was possible in 24 patients, 5 of which were primary in the recent postoperative phase, 5 had primary suture of the fascia and application of the supra-aponeurotic prosthesis and 14 had closure of the abdominal wall with a composite polytetrafluoroethylene (PTFE) and polypropylene mesh. Second intention closure took place in the remaining 22 patients (48%), as their conditions did not allow primary closure. The mean treatment time with abdominal dressing was 26 days (6-92) with an average of eight changes per patient. The abdominal dressing topical negative pressure system is a useful option for consideration in the event of needing to leaves the abdomen open. It stabilises the abdominal wall and quantifies and collects exudate from the wound, protects the intra-abdominal viscera and keeps the fascia intact and the cutaneous plane for subsequent closure of the wall.

Damage control in trauma and abdominal sepsis

Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.

Feasibility of negative pressure wound therapy during intercontinental aeromedical evacuation of combat casualties

OBJECTIVE

The objective of this study was to assess the feasibility of utilizing negative pressure wound therapy (NPWT) for the treatment of wartime soft-tissue wounds during intercontinental aeromedical evacuation.

BACKGROUND

Attempts to use NPWT during early phases of overseas contingency operations resulted in occasional vacuum system failures and potentially contributed to wound complications. These anecdotal episodes led to a perception that NPWT during aeromedical evacuation carried a high risk of wound complications and limited its use. As a result, NPWT was not frequently applied in the management of soft-tissue wounds before US casualty arrival in the continental United States (CONUS) for wounds sustained in the combat theaters. Concurrently, early NPWT on the traumatic wounds of host nation casualties not requiring aeromedical evacuation seemed to provide many benefits typically associated with the therapy such as decreased infection rates, earlier wound closure, and improved pain management.

METHODS

On a daily basis, study investigators reviewed the trauma in-patient census at Landstuhl Regional Medical Center, Germany, to identify patient candidates with soft-tissue extremity or torso wounds that required packing. Patient demographics, injuries, and previous wound treatments were recorded. Surgeons inspected wounds in the operating room and applied a NPWT dressing if deemed appropriate. NPWT was continued throughout the remainder of the patient's hospitalization and also during aeromedical evacuation to CONUS. A study investigator escorted the patient during aeromedical evacuation to educate the flight crews, to record the impact on crew workload, and to troubleshoot the system if necessary.

RESULTS

Thirty enrolled patients with 41 separate wounds flew from Germany to CONUS with a portable NPWT system (VAC Freedom System; Kinetic Concepts Incorporated, San Antonio, TX). All 30 patients arrived at the destination facilities with intact and functional systems. No significant in-flight complications were identified, impact on flight crew workload was negligible, and subjective feedback from both flight crews and patients was uniformly positive. For 29 patients, the NPWT dressing was replaced (frequently with serial exchanges) during initial surgical treatment in CONUS; the 30th patient underwent delayed primary closure of his right forearm fasciotomy. Receiving care teams reported no complications attributable to NPWT during aeromedical evacuation.

CONCLUSIONS

NPWT is feasible during intercontinental aeromedical evacuation of combat casualties without an increase in wound complications or a significant impact on air crew workload. Further studies are indicated to evaluate the efficacy of NPWT in combat wounds compared with other wound care techniques.

Vacuum-assisted closure of laparostomy wounds: a critical review of the literature

Vacuum-assisted closure (VAC) reduces the burden for carers of laparostomy wounds but evidence from randomised trials is lacking. This review analyses the evidence for the VAC abdominal wound management system (KCI, San Antonio, TX) in the open abdomen. Three prospective studies provide level III evidence that VAC allows delayed primary fascial closure in the majority of these wounds up to 21 days after occurrence, but not where duration of VAC was less than 9 days or if vacuum pack techniques were used in place of VAC. Fistulae occurred in a minority of wounds complicated by multi-organ failure or sepsis and could not be attributed to VAC itself. Two retrospective analyses suggested VAC may reduce re-operation rate and length of stay in complex wounds. Whilst randomised controlled trials remain the gold standard of evidence for effectiveness of health care interventions, contemporaneous level III evidence supports the hypothesis that VAC increases the rate of primary fascial closure. Whilst enterocutaneous fistula formation is reported in the most complex of these wounds, there is no more evidence that these are consequential to as opposed to coincident with VAC use.

V.A.C. Therapy in the management of paediatric wounds: clinical review and experience

Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.

Management of ileocutaneous fistulae using TNP after surgery for abdominal malignancy

Enteric fluids produced by enterocutaneous fistulae can cause severe inflammation in the surrounding skin. By removing these corrosive fluids, topical negative pressure can help maintain skin integrity and promote spontaneous closure.

Surgical management of abdominal compartment syndrome; indications and techniques

The indications for surgical decompression of abdominal compartment syndrome (ACS) are not clearly defined, but undoubtedly some patients benefit from it. In patients without recent abdominal incisions, it can be achieved with full-thickness laparostomy (either midline, or transverse subcostal) or through a subcutaneous linea alba fasciotomy. In spite of the improvement in physiological variables and significant decrease in IAP, however, the effects of surgical decompression on organ function and outcome are less clear. Because of the significant morbidity associated with surgical decompression and the management of the ensuing open abdomen, more research is needed to better define the appropriate indications and techniques for surgical intervention.

Biliogastric diversion for the management of high-output duodenal fistula: report of two cases and literature review

High-output duodenal fistula occurs as a result of a duodenal wall defect caused by gastroduodenal surgery, endoscopic sphincterotomy, duodenal injury, and tumors with high morbidity and mortality rate. A new technique for its management is reported along with literature review. This procedure consists of transection of the duodenum 2 cm distally to the pylorus, transection of the common bile duct, and end duodenostomy with or without suturing the duodenal wall defect. The continuity of the alimentary tract is reinstated by an end-to-end duodenojejunostomy, end-to-side choledochojejunostomy, and end-to-side Roux-en-Y jejunojejunostomy, obtaining biliogastric diversion from the duodenum and closure of the fistula. This technique was performed in two patients with excellent results.

Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds

Over the past two decades, topical negative pressure (TNP) wound therapy has gained wide acceptance as a genuine strategy in the treatment algorithm for a wide variety of acute and chronic wounds. Although extensive experimental and clinical evidence exists to support its use and despite the recent emergence of randomised control trials, its role and indications have yet to be fully determined. This article provides a qualitative overview of the published literature appertaining to the use of TNP therapy in the management of acute wounds by an international panel of experts using standard methods of appraisal. Particular focus is applied to the use of TNP for the open abdomen, sternal wounds, lower limb trauma, burns and tissue coverage with grafts and dermal substitutes. We provide evidence-based recommendations for indications and techniques in TNP wound therapy and, where studies are insufficient, consensus on best practice.

Open Abdomen after Severe Acute Pancreatitis

The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2-3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9-12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.

Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis

BACKGROUND

Open abdomen treatment because of severe abdominal sepsis and abdominal compartment syndrome remains a difficult task. Different surgical techniques are available and are often used according to the surgeon's personal experience. Recently, the abdominal vacuum-assisted closure (VAC) system has been introduced, providing a new possibility to treat an open abdomen. In this study, we evaluate the role of this treatment option.

STUDY DESIGN

This prospective observational cohort study includes 37 consecutive patients who were temporarily treated with VAC for severe abdominal sepsis or abdominal compartment syndrome, or both. Patients with abdominal trauma were excluded from the study. Thirty-seven patients undergoing major elective laparotomy and primary abdominal closure served as control group. Primary end points were fascial closure rate, physicoemotional recovery, and appearance outcomes 1 year after closure. Secondary end points included mortality, duration of open abdomen, length of ICU stay, and hospitalization time.

RESULTS

Abdomens were left open for 23 days (range 3 to 122 days) with 3.8 dressing changes (range 1 to 22) per patient. Abdominal closure was achieved in 70% (n = 26), with no marked relation to duration of open abdomen treatment (p > 0.05). After 3 months, patients with VAC treatment recovered to a physical and mental health status similar to patients in the control group (p > 0.05). This status remained stable until the end of the study. Aesthetic outcomes (according to the Vancouver Scar Scale) were considerably poorer in the VAC group compared with controls (p < 0.01).

CONCLUSIONS

Treatment of laparostomy with VAC for abdominal sepsis and abdominal compartment syndrome results in a high rate of successful abdominal closure. In addition, patients recover more rapidly, although hypertrophic scars might interfere with body perception. We recommend abdominal VAC system as first option if open abdomen treatment is indicated.

Mesh repair for postoperative wound dehiscence in the presence of infection: is absorbable mesh safer than non-absorbable mesh?

OBJECTIVE

In patients with postoperative wound dehiscence in the presence of infection, extensive visceral oedema often necessitates mechanical containment of bowel. Prosthetic mesh is often used for this purpose. The aim of the present study was to assess the safety of the use of non-absorbable and absorbable meshes for this purpose.

METHOD

All patients that had undergone mesh repair of abdominal wound dehiscence between January 1988 and January 1998 in the presence of intra-abdominal infection were included in a retrospective cohort study. All surviving patients had physical follow-up in February 2001.

RESULT

Eighteen patients were included in the study. Meshes consisted of polyglactin (n = 6), polypropylene (n = 8), polyester (n = 1), or a combination of a polypropylene mesh with a polyglactin mesh on the visceral side (n = 3). All patients developed complications, consisting mainly of mesh infection (77%), intra-abdominal abscess (17%), enterocutaneous fistula (17%), or mesh migration through the bowel (11%). Mesh removal was necessary in eight patients (44%). Within four months postoperatively, six patients (33%) had died because of progressive abdominal sepsis. The incidence of progressive abdominal sepsis was significantly higher in the group with absorbable polyglactin mesh than in the group with nonabsorbable mesh (67 vs. 11%, p = 0.02) After a mean follow-up of 49 months, 63% of the surviving patients had developed incisional hernia. Absorbable meshes did not yield better outcomes than nonabsorbable meshes in terms of complications and mortality rate.

CONCLUSION

Synthetic graft placement in the presence of intra-abdominal infection has a high risk of complications, regardless of whether absorbable (polyglactin) or non-absorbable mesh material (polypropylene or polyester) is used, and should be avoided if possible.

Vacuum Effects over the Closing of Enterocutaneous Fistulae: A Mathematical Modeling Approach

Enterocutaneous fistulae are pathological communications between the intestinal lumen and the abdominal skin. Under surgery the mortality of this pathology is very high, therefore a vacuum applying system has been carried previously on attempting to close these fistulae. The objective of this article is the understanding of how these treatments might work through deterministic mathematical modelling. Four models are here proposed based on several assumptions involving: the conservation of the flow in the fistula, a low enough Reynolds number justifying a laminar flow, the use of Poiseuille law to model the movement of the fistulous liquid, as well as phenomenological equations including the fistula tissue and intermediate chamber compressibility. Interestingly, the four models show fistulae closing behaviour during experimental time (t<60 sec). To compare the models, both, simulations and pressure measurements, carried out on the vacuum connected to the patients, are performed. Time course of pressure are then simulated (from each model) and fitted to the experimental data. The model which best describes actual measurements shows exponential pumping flux kinetics. Applying this model, numerical relationship between the fistula compressibility and closure time is presented. The models here developed would contribute to clarify the treatment mechanism and, eventually, improve the fistulae treatment.

Surgical wound case studies with the versatile 1 wound vacuum system for negative pressure wound therapy

Negative pressure wound therapy consists of a wound dressing, a drainage tube inserted into the dressing, an occlusive transparent film, and a connection to a vacuum source that supplies the negative pressure. A new product called the Versatile 1 Wound Vacuum System (BlueSky Medical, La Costa, Calif) is available for negative pressure wound therapy. This article describes the application, management, and effectiveness of the Versatile 1 in 3 cases where the patients have all undergone surgical debridement.

Experience with the use of vacuum dressings in the management of acute enterocutaneous fistulas

High-output enterocutaneous fistulas involving an open abdominal wound are a difficult management problem. We report our experience on the use of vacuum dressings. The potential benefits, problems and new recommendations for the use of vacuum dressings in the management of enterocutaneous fistulas are discussed.

The Sandwich Design

Fistulas draining through large abdominal wall defects are exceptionally difficult to treat and are associated with a very high mortality. This case report describes a new method for closure of these fistulas where prior conservative and surgical treatment had failed. Initial use of a vacuum-assisted closure (VAC) system optimized wound care and led to coverage of the exposed intestines with granulation tissue. The serratus muscle of a composite free latissimus dorsi-serratus flap was used to close the fistula, while the large abdominal wall defect was closed with the musculocutaneous latissimus dorsi flap. Temporary placement of a VAC system between the serratus muscle and the latissimus dorsi muscle immobilized the serratus to the fistula and counteracted changes in abdominal pressure. The layering of muscle, VAC system, and muscle resembles a sandwich. The advantage of the sandwich design is an extraperitoneal approach that provides tension-free closure of the fistula and abdominal wall, with well-vascularized tissue.

Use of porcine dermal collagen graft and topical negative pressure on infected open abdominal wounds

This article reports on two cases in which porcine dermal collagen grafts were used successfully alongside topical negative pressure therapy in order to close open abdominal wounds in which severe infection was present.

Vacuum-assisted closure therapy in ureteroileal anastomotic leakage after surgical therapy of bladder cancer

BACKGROUND

Vacuum-assisted closure (VAC) is an acknowledged method of treating wound healing disorders, but has been viewed as a contraindication in therapy of intraabdominal fistulas.

CASE PRESENTATION

We present the case of an 83-year old patient with ureteroileal anastomotic insufficiency following cystectomy and urinary diversion by Bricker ileal conduit due to urothelial bladder cancer. After developing an open abdomen on the 16th postoperative day a leakage of the ureteroileal anastomosis appeared that cannot be managed by surgical means. To stop the continued leakage we tried a modified VAC therapy with a silicon covered polyurethane foam under a suction of 125 mmHg. After 32 days with regularly changes of the VAC foam under general anesthesia the fistula resolved without further problems of ureteroileal leakage.

CONCLUSION

We present the first report of VAC therapy successfully performed in urinary tract leakage after surgical treatment of bladder cancer. VAC therapy of such disorders requires greater care than of superficial application to avoid mechanical alterations of internal organs but opens new opportunities in cases without surgical alternatives.

Pelvic exenteration affords safe and durable treatment for locally advanced rectal carcinoma

BACKGROUND

Treatment of locally advanced rectal carcinoma (LARC) often involves exenterative surgery, which can be associated with high perioperative morbidity and mortality. To assist in patient selection for radical surgery, we sought to determine clinicopathologic factors influencing recurrence and disease-free survival (DFS) of LARC.

METHODS

Consecutive patients with LARC undergoing exenterative surgery were retrospectively identified in our institutional database. Factors evaluated included age, sex, primary versus recurrent tumors, neoadjuvant or adjuvant chemoradiotherapy, resection margin status, recurrence, time to recurrence, and survival. The primary outcome was DFS. Secondary outcomes were overall survival and perioperative morbidity.

RESULTS

A total of 72 patients were identified; median age was 52 years, and median follow-up time was 30 months. The overall complication rate was 43%; rates were similar among the patients with primary (47%) or recurrent (37%) LARC. Primary or recurrent tumor status was the only factor significantly predictive of outcome after exenteration. Local recurrence rates were lower in the primary group (primary 22%, recurrent 52%, P = .05). A significant difference in 5-year DFS was found between primary and recurrent tumor (52% vs. 13%; P < .01). The median time to recurrence was longer in the patients with primary LARC (17 months vs. 8 months; P < .01).

CONCLUSIONS

The complication rates for pelvic exenteration remain high, but the morbidity can typically be managed without a clinically important increase in hospitalization. In primary LARC, an aggressive surgical approach provides most patients 5-year DFS. Select patients with recurrent LARC will also benefit from pelvic exenteration.

Abdominal Wall Reconstruction in a Trauma Setting

According to the World Health Organization "Global burden of disease study", future demographics of trauma are expected to show an increase in morbidity and mortality. In the past few decades, the field of trauma surgery has evolved to provide global and comprehensive care of the injured. While the modern day trauma surgeon is well trained to deal with multitrauma patients with injuries involving several systems, the ever-increasing nature and variety of multitrauma has left lacuna in certain areas. One such area is the management of abdominal wall injuries, which has been the domain of both plastic and reconstructive and general surgeons. The trauma surgeon is adept at treating the contents of the abdomen but not always the container. If not managed properly complications associated with abdominal wall injuries can lead to increased morbidity and mortality. In considering reconstruction of the abdominal wall in multitrauma patients proper evaluation, scrupulous planning, appropriate, and meticulous technique improve the chances for success with minimal complications. In the present article, we provide a brief description of the most commonly used procedures, and more importantly we outline the principles and guidelines applied to abdominal wall reconstruction in order to inform the trauma surgeon of different available treatment options. In doing so, we hope that this review will assist trauma surgeons in their overall care of patients that present with abdominal injuries.

Management of Enterocutaneous Fistulas Using Negative-Pressure Dressings

Fifteen patients with enterocutaneous fistulas (ECFs) not amenable to surgical treatment were treated with negative-pressure dressings over the abdominal wound and ECF. Closure of the ECF and time to closure were examined. In 11 patients who had no visible intestinal mucosa on examination, the closure rate was 100%, with a mean time to closure of 14 days. In 4 patients who did have grossly visible intestinal mucosa, no closure occurred. This represents an overall closure rate of 73%. Fistula output rate did not have a significant effect on outcome. These results confirm the efficacy of negative-pressure dressings in the closure of ECFs. Presence or absence of visible intestinal mucosa is the single most important clinical factor when considering the use of a negative-pressure dressing in the management of a patient with ECF.

Enterocutaneous fistula: are treatments improving?

BACKGROUND

We studied the etiology, treatment, and outcome of enterocutaneous fistulas in 106 patients to evaluate our current practice and the impact of newer therapies-octreotide, wound vacuum-assisted closure (VAC), and fibrin glue-on clinical outcomes. Review of the literature and our own 1990 study indicate a mortality rate of 5% to 20% for enterocutaneous fistula, and a healing rate of 75% to 85% after definitive surgery.

METHODS

We reviewed all cases of gastrointestinal-cutaneous fistula from 1997 to 2005 at 2 large teaching hospitals. We identified 106 patients with enterocutaneous fistula; patients with irritable bowel disease and anorectal fistulas were excluded.

RESULTS

The origin of the fistula was the small bowel in 67 patients, colon in 26, stomach in 8, and duodenum in 5. The etiology of the fistula was previous operation in 81 patients, trauma in 15, hernia mesh erosion in 6, diverticulitis in 2, and radiation in 2. Of the 106 patients in the study, 31 had a high output fistula (greater than 200 mL/day), 44 had a low output fistula, and, in 31 patients, the fistula output was low but there was no record of volume. Initial treatment was nonoperative except for patients with an abscess who needed urgent drainage. In 24 patients, the effect of octreotide was monitored: in 8 patients, fistula output declined; in 16 patients, octreotide was of no benefit. Fibrin glue was used in 8 patients and was of benefit to 1. The wound VAC was used in 13 patients: 12 patients still required operative repair of the fistula, whereas the fistula was healed in 1 patient. The main benefit of the VAC system was improved wound care in all patients before definitive surgery. Total parenteral nutrition was used in most patients to provide nutritional support. Operative repair was performed in 77 patients and was successful in 69 (89%), failing in 6 patients with persistent cancer or infection. Nonoperative treatment was used in 29 patients and resulted in healing in 60%. Of 106 patients, 7 (7%) died of fistula complications. The cause of death was persistence or recurrence of cancer in 4 patients and persistent sepsis in 3.

CONCLUSION

Enterocutaneous fistula continues to be a serious surgical problem. The wound VAC and fibrin glue had anecdotal successes (n = 2), and one-third of patients responded to octreotide. We believe that octreotide should be tried in most patients and that the wound VAC has a role in selected patients. Although 7% overall mortality is lower than in previous studies, the number managed without operation (27%) remains the same. In addition to early control of sepsis, nutritional support, and wound care, a well-timed operation was the most effective treatment.