Review Scandinavian Journal of Surgery 96: 263271, 2007

Small bowel fiStulaS and the open abdomen

h. p. becker, a. willms, R. Schwab
Department of General, Abdominal and Thoracic Surgery, Central Military Hospital, Koblenz, Germany

abStRact

over the last 15 years, the contemporary strategies to treat the open abdomen have reduced the lethal complications. Systematic intensive care and modern wound management in conjunction with a plastic barrier to protect the viscera and topical negative pressure on the soft tissues have reduced the development of small bowel fistulas. The literature selected for this review shows that the surgical handling of the exposed bowel, the choice of the material for temporary coverage and early progressive closure of the defect are crucial for the prevention of fistulas. At present, surgeons worldwide have adopted these principles leading to an increase of primary or delayed closure rates. when a small fistula occurs, biological dressings like human acellular dermal matrix and fibrin glue may help to seal the orifice and to treat the patient conservatively. In case of a large fistula, vacuum-assisted wound management is recommended as well. Through a separate hole in the vacuum sponge matching to the fistula, the enteric contents are sucked off while the wound bed heals and is prepared for split thickness skin graft. Surgical resection of established fistula unresponsive to conservative measures should only be performed on patients well-nourished and free of infection with a delay of at least six months. for patients with an open abdomen, surgical expertise and a well-structured management plan offer the best chances to overcome this potentially devastating condition with or without fistula.
Key words: Fistula; small bowel; open abdomen; damage control; laparostomy; vacuum-assisted closure

InTRoDuCTIon open management of the peritoneal cavity has become a state of the art procedure in case of abdominal compartment syndrome, trauma, or massive intestinal sepsis (1). Although the open abdomen offers many advantages to patients in extremis like damage control, planned re-exploration, or prompt
Correspondence: Horst Peter Becker, M.D. Department of General, Abdominal and Thoracic Surgery Central Military Hospital Ruebenacher Strasse 170 D - 56072 Koblenz Germany Email: horstpeter.becker@t-online.de

drainage of the septic focus, it may be associated with serious complications. The formation of small bowel fistulas is the most critical one leading to a significant mortality and morbidity. Additionally, a fistula in an open abdomen means a logistical catastrophe because it needs enormous medical resources and extends the hospital stay. Despite all advances in the management of these patients, the crucial question arises whether today this specific complication has to be accepted as a nature driven course or whether it may be avoided by careful surgical technique. In recent review articles, the incidence of intestinal fistulas in connection with open abdomen is still reported between 5 and 75% (24). The rates differ extremely from author to author depending on the underlying disease and the various treatment modalities. Although the mortality continuously decreased over the years based on improved surgical techniques

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and better intensive care, the management of patients with fistulas remains difficult. The combination of three problems represents the challenge to the treating surgeon: the small bowel fistula itself with massive loss of fluid and electrolytes, the systemic septic morbidity, and the specific aspects of the open wound including the abdominal wall defect. In the last 15 years, there has been a progressive evolution in the management of the open abdomen especially with the advent of topical negative pressure in wound care (5). new concepts, e.g. the vacuum pack technique or vacuum assisted fascial closure including biological dressings, were published to further reduce the complications of the open abdomen (611). In the light of those modern treatment modalities, the primary purpose of this paper was to deliver an overview of the problems and the different treatment solutions associated with intestinal fistulas while managing the open abdomen. It continues to be of very much interest which mechanisms lead to small bowel fistulas and what kind of systematic precautions can be undertaken to prevent this serious and life threatening complication. Secondarily, we present recommendations with the important steps of performance in case of an arising fistula. METHoDS
A PubMed search (http://www.ncbi.nlm.nih.gov/sites/ entrez?db=pubmed) was conducted using the following strategy: [open abdomen treatment] and/or [open abdomen closure techniques] and/or [small bowel fistula]. In addition, the bibliographies of recent articles were examined to doublecheck the completeness of the Internet search. The search was stopped on october 30, 2007. All abstracts of the papers containing data on the open abdomen, strategy of treatment in general and management of small bowel fistula were considered for further research. Relevant original articles were carefully screened to eliminate double-published series under the same group of authors. under those aspects, a total of 152 articles were chosen for the final discussion of the problem. The most relevant publications were included in the bibliography of the present work.

DEFInITIon oF SMAll BowEl FISTulAS In THE oPEn ABDoMEn A gastrointestinal fistula is generally defined as a pathological communication or tract between two digestive organs or between the skin and a hollow organ (12). In contrast to enterocutaneous fistulas after surgery of inflammatory or cancer diseases, intestinal fistulas in an open abdomen are non-epitheliazed and expedite enteric contents directly to the peritoneal wound. Exactly defined, they are enteroatmospheric fistulas without a formal fistula tract and without overlying soft tissue (8). Spontaneous closure of those fistulas often associated with distal obstruction will not or only seldom occur because the intraluminal pressure of the aggressive fluids is too high. Therefore, they have to be considered as a subgroup of the gastrointestinal fistulas. This aspect may have impact on medical management because of treatment

similarities. Regardless of the cause, leakage of intestinal juices induces the same cascade of events: localized inflammation, systemic infection and loss of fluid and electrolytes. The hole in the gastrointestinal tract is either the result of an underlying pathology (e.g. a leaking anastomosis) or may develop as a consequence of the pathology of the open abdomen. The open abdomen has to be considered as a large healing wound with its own characteristics requiring a complex treatment (1). The challenge is the exposure of the unprotected bowel to the air. Thus, the bowel wall is in extreme danger of mechanical damage. Three principles lead to the wall defect and the formation of small bowel fistulas: First, any iatrogenic serosal laceration or tear during surgery. These weak spots may occur during the initial laparotomy while preparing the bowel or due to overseen defects after trauma. Second, adhesions gut-to-gut or gut to the sharp fascial edges may result in wall splitting, when the patient moves, breathes, and coughs. Third, the mechanical irritation to the serosal surface from frequent dressing changes or from adhesive material for temporary coverage of the abdomen eroding the viscera. Especially in the early phase of the open treatment, the bowel wall may come under tension because parts of the bowel may still periodically move, whereas others already stick to another or may adhere to applied meshes. The risk to develop a small bowel fistula is high before the bowel loops have granulated to the visceral block. A clinical classification is useful to come to a prognosis and therapeutical decisions as well. According to the amount of secretion, fistulas can be classified as low output (under 200 ml daily), moderate output (ranges between 200 and 500 ml) and high output (exceeds 500 ml per day) (13). Additionally, it makes sense to differentiate the fistulas according to their anatomical origin (Treitz ligament, jejunum, ileum). Investigations, such as fistulograms or computertomographic scans, are helpful to understand the nature of the small bowel fistulas and their location. Furthermore, it may be relevant whether the fistula arises from the surface or from the depth of the abdomen. Generally, the more proximal the small bowel fistula occurs, the larger is the amount of output and the more severe is the degree of electrolyte disturbance and malabsorption. A high-output fistula in the area of Treitz ligament has certainly a worse prognosis than a low-output one located more distally. Fistula output is an important factor in predicting the likelihood of spontaneous closure. other factors influencing the prognosis are sepsis, malnutrition, and the presence of malignancy. InCIDEnCE oF SMAll BowEl FISTulA AnD MoDERn TECHnIquES FoR TEMPoRARy CloSuRE The variability of the fistula incidence rates in an open abdomen derives from the heterogeneous nature of patients and from the different temporary closure techniques (Table 1). whereas some patients are young, well-nourished and sustain a non-complex

Small bowel fistulas and open abdominal treatment TABlE 1 Temporary closure techniques in patients with open abdomen. Group 1 2 Technique non-absorbable meshes, rough textile structure Polypropylene non-absorbable meshes, impervious surface Goretex Silicone 3 4 Staged management with absorbable meshes without vacuum assistance Topical negative pressure techniques Vacuum pack Vacuum assisted fascial closure with sponges Modified vacuum sandwich technique Vacuum assisted closure with PDS sutures providing constant fascial tension Vacuum assisted wound closure and mesh-mediated fascial traction Vacuum assisted closure in combination with biological dressings Authors nagy et al. 1996 (14) Ciresi et al., 1999 (38) Vertrees et al., 2006 (18) Howdieshell et al., 2004 (17) Jernigan et al., 2003 (15) Mayberry et al., 2004 (16) Brock et al., 1995 (5) Barker et al., 2000 (39) Barker et al. 2007 (6) Miller et al., 2004 (9) navsaria et al., 2003 (43) Cothren et al., 2006 (7) Petersson et al., 2007 (20) Scott et al., 2006 (10) Jamshidi and Schecter, 2007 (8)

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abdominal trauma, others are in poor nutritional status suffering from a disease like cancer or pancreatitis, may be septic and dehydrated, and may present with large abdominal wall defects and macerated skin. As many variables influence the development, the comparison of fistula rates is difficult and should be stratified to defined patient groups. Generally, most of the reported case series consist of small numbers of patients with eventually inadequate controls. The incidence of small bowel fistulas while managing the open abdomen strongly depends on the material used for temporary abdominal closure. non-absorbable meshes made of rough textures (e.g. nylon, polypropylene, or dacron) were generally associated with a high rate of fistula formation up to 75%, when the bowel surface was directly exposed to the device (14). used until a decade ago, the meshs surface causes an intense fibroblast response and the prosthesis becomes rapidly incorporated in the hosts granulation tissue. In this way, intestinal loops directly adhere to the material. The strong connection between bowel and mesh leads to serosal microtears either by bowel movements or mechanical damage during wound management. Therefore today, this rough material should be abandoned or only inserted with interposition of the greater omentum. Absorbable materials with good tensile strength (e.g., polyglactin, polyglycolic acid) have been applied to reduce the rate of small bowel fistulas especially in infectious situations. They allow medial traction of the fascial edges by pleating or resection and promote delayed closure of the abdomen (15, 16). However, substantial small bowel fistula rates have been reported when absorbable meshes are directly exposed to the bowel and being removed after the granulated visceral block has formed (15). Prolonged granulation is believed to contribute to the intestinal wall breakdown (15). Intestinal fistulization is much rarer if a tissue impervious material is inserted for maintaining the ab-

dominal integrity. non-absorbable devices (Bogota bag, GoreTex, ePTFE, silicone etc.) with non-adhesive, smooth surfaces to the bowel are meanwhile widely used for temporary closure in order to prevent the fascial edges from lateral distension (17, 18). The advent of the vacuum pack technique was the milestone in the treatment of the open abdomen. In 1995, Brock et al. described a method of temporary closure using a fenestrated polyurethane sheet between the abdominal viscera and anterior parietal peritoneum, then placing a moist laparotomy towel together with two silicone drains on top and closing the entire wound by a skin adhesive backed tape (5). Suction applied to the two drains created a vacuum and a rigid compression of the closure material. Meanwhile, various authors have modified this technique. Miller et al. substituted the surgical towel using a polyurethane sponge and developed thus the vacuum-assisted fascial closure technique (19). Cothren et al. covered the abdominal visceral with multiple white sponges overlapped like patchwork and put the fascia under moderate tension using PDS sutures (7). Then they placed another layer of black sponges on top and affixed the construction with an occlusive dressing. A new approach was described by Scott et al. using the combination of vacuum pack, vacuum assisted wound management and human acellular dermal matrix (10). Recently, Petersson et al. reported on vacuum assisted wound closure in combination with polypropylene mesh-mediated fascial traction (20). Jamshidi and Schecter applied a multilayer vacuum dressing for gradual closure of the abdominal wound and used biological dressings in case of intestinal fistula (8). The crucial aspect of the latter type of temporary wound closure is the perforated nonadhesive sheet placed like a barrier over the peritoneal viscera and beneath the peritoneum of the abdominal wall. It provides protection to the viscera against mechanical

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H. P. Becker, A. Willms, R. Schwab TABlE 2

Incidence rates of small bowel fistula in patients with open abdomen (only clinical studies of the last seven years with series over 50 patients). Authors, year of publication Total Indication for open number abdomen of patients 258 Mixed: trauma, intraabdominal sepsis, vascular surgery Mixed: trauma, intraabdominal sepsis, vascular surgery Abdominal trauma Intra-abdominal sepsis Abdominal trauma Abdominal trauma Abdominal trauma Mortality, early death rate 67/258 (26%) Temporary closure technique Small bowel fistula rate of survivors 13/191 (6,7%) Hospital mortality for patients with fistula

Barker et al. 2007 (6) Jamshidi and Schecter, 2007 (8)

Vacuum pack according to Brock Vacuum pack dressing and vacuum assisted fascial closure, biological dressing in case of fistula Mixed Vacuum pack Silicone sheeting, no vacuum Staged management using absorbable mesh Vacuum assisted fascial closure technique, polyethylene sheet combined with polyurethane sponge Mostly vacuum packing according to Brock, mixed

069

no report

7/69 (10,1%)

0 (0%)

Miller R.S. et al., 2005 (40) Adkins et al., 2004 (41) Howdieshell et al., 2004 (17) Mayberry et al., 2004 (16) Miller P.R. et al., 2004 (9)

344 081 088 140 053

68/344 (20%) 20/81 (25%) 17/88 (19%) 117/140 (16%) 8/53 (15%)

10/276 (3,6%) 12/61 (19,7%) 0/71 (0%) 10/117 (8,5%) 1/45 (2,3%) 5/12 (42%)

Tsuei et al., 2004 (42)

071

GI-sepsis = 25 Pancreatitis = 21 Trauma = 25

Trauma 5/25(20%) GI-sepsis 9/21(35%) Pancreat. 9/21 (43%) 108/274 (39%) 25 (45%)

Trauma 3/20 (15%) GI-sepsis 4/16 (25%) Pancreat. 6/12 (50%) overall 13/48 (27%) 10/166 (6%) 3/30 (10%) 1 (0,7%)

Jernigan et al., 2003 (15) navsaria et al. 2003 (43) Miller P.R. et al., 2002 (19)

274 055 148

Abdominal trauma Abdominal trauma

Staged management using absorbable mesh, no vacuum Modified sandwichvacuum technique Vacuum assisted fascial closure technique, polyethylene sheet combined with polyurethane sponge Mixed, no vacuum Vacuum pack technique

Blunt and perforating 65/148 (44%) abdominal trauma

Tremblay et al., 2001 (44) Barker et., 2000 (39)

181 112

Mixed, trauma, intraabdominal sepsis, pancreatitis Trauma

81/181 (45%) 29/112

26/100 (26%) 5/83 (6%)

11/26 (42%)

damage on repeat exploration and allows the abdominal wall to be advanced to the midline under subsequent application of negative pressure. The low fistula rate of several authors using the vacuum technique certainly relies to the nonadhesive material on the bowel. Interpreting the published results of the actual literature, it makes sense to look at series over 50 patients collected within a recent, limited time frame (Table 2). Those papers reported on high hospital mortality rates, in selected series of up to 50%, dem-

onstrating that patients with open abdomen are critically ill. The indication for open abdomen revealed three groups: trauma, intraabdominal sepsis and pancreatitis. This separation results in different overall rates for small bowel fistulas as there are up to 15% for trauma, up to 25% for sepsis, and the highest rates up to 50% for pancreatitis patients. Mortality of patients with fistula can be still high up to 42% according to the listed publications. looking at the trauma group alone, it becomes evident that hospitals with a high volume of patients

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267 TABlE 3

have greater experience with open abdomen resulting in lower fistula rates (Table 2). Furthermore, surgeons who routinely use vacuum assisted closure techniques have lower rates than those with a mixture of treatment modalities. In the year of 2007, the combination of an inert plastic sheet in contact with the viscera and the application of subatmospheric pressure on the wound seem to be the most effective combination to maximize the prospects of delayed primary closure while minimizing the risk of fistula and ventral hernia. PATHoPHySIoloGICAl ConSEquEnCES oF THE FISTulA Patients with an open abdomen have their own pathophysiology driven by acidosis, coagulopathy, and hypothermia or the consequences of compartment syndrome and sepsis respectively. In addition, they undergo the stages of a systemic inflammatory response syndrome and the risks from protein-calorie malnutrition including poor healing and infections. Especially with the onset of the open abdomen, gastrointestinal dysfunction ends up in an ileus. Swelling and distention of the gut cause gastrointestinal reflux, may eventually not tolerate enteral feeding and thus, malabsorption deteriorates the patients status. The configuration of the large open wound with the leakage of intestinal juices persistently amplifies the negative sequelae of the underlying disease (Table 3). This is obvious in patients with highoutput duodenal and jejunal fistulas, which may initially drain as much as 3000 ml of fluid daily. Primarily, this non-anatomical expedition of enteric contents produces abnormal dehydration, electrolyte disturbance and acid-base imbalance. Secondarily, resorption of electrolytes and nutrients are impaired or even impossible especially when long segments of the bowel are bypassed beyond the fistula leading to malnutrition. The third consequence is a great variety of skin and wound problems around the fistula. TREATMEnT RECoMMEnDATIonS The treatment of patients with open abdomen with small bowel fistulas covers two main areas: the systemic medical management including all aspects of nutrition and the surgical handling of the abdominal wound. Considering treatment similarities in patients with enterocutaneous fistulas, several objectives have to be addressed (1, 8, 12, 2123): 1. Restoration of blood volume and correction of fluid/electrolyte losses and acid-base imbalances. 2. Early recognition and treatment of infection and sepsis respectively with appropriate antibiotics, evaluation and drainage of abscesses, preferably percutaneously. 3. Initiation of a regimen of alimentary tract rest, gastric acid secretory inhibition, pancreatic and intestinal secretory inhibition, and short-term nasogastric suction.

Pathophysiological consequences of small bowel fistula in patients with open abdomen. Abnormal fluid losses dehydration hypovolemia Electrolyte disturbance hyponatriaemia hypokalaemia hypochloridaemia hypomagnesaemia hypophosphataemia Acid-base imbalance metabolic acidosis or alkalosis Malnutrition hypoalbuminaemia hypoproteinaemia vitamin and trace element deficiencies Skin and wound problems around the fistula excoriation autodigestion bacterial infection secondary fungal invasion impaired healing

TABlE 4 Clinical-instrumental methods used for diagnosis of small bowel fistula (adapted from Falconi and Pederzoli, (13)).

Monitor fistula output volume aspect of the fistula output (color, clear, purulent etc.) water-electrolyte balance biochemical analysis of effluent (amylase. lipase, bilirubin etc.) infection status nutritional/anabolic status Methylene blue test Digestive tract X-rays with water soluble contrast medium Fistulography with water soluble contrast medium Computerized axial tomography Magnetic resonance imaging

4. Beginning and maintaining optimal nutrition by total parenteral nutrition or enteral nutrition by tube feeding distal to a high fistula or administering a low-residue readily absorbed, chemically defined diet above the fistula. 5. Control of the fistula exit site by separation/suction of the intestinal contents, measuring the output per 24 hours. 6. General wound care around the fistula, skin protection. 7. Closure of the fistula, either conservatively or properly timed by surgical resection. Once a small bowel fistula arises, the first step to therapy is a thorough examination of the patients status using all available clinical-instrumental methods to characterize the pathological effluent as far as possible (Table 4). For example, it is an important

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aspect to know whether the secretion is a purulent discharge from an abscess, intestinal contents or pancreatic fluid. The restoration of homeostasis and the correction of the electrolyte/fluid imbalances follow the rules of modern intensive care. Precise measurement of all intake and output are essential, and frequent assessment of central venous pressure and clinical appraisal of hydration may be helpful. Once the fistula has been confirmed, the daily output volume should be measured and biochemical and microbiological evaluations should be performed. Large water deficits may require more than a day to replenish, especially when cardio-pulmonary function is compromised. Hematocrit and hemoglobin, plasma albumin and total protein should be regulated to normal levels. Derangements of calcium, magnesium, phosphorus, and other electrolytes are corrected by administration of the appropriate replacement salts. Sepsis is the most common complication often associated with intraperitoneal abscesses or secondary skin infection due to the bacterial contents of the small bowel fistula. Sepsis may be influenced or even caused by poor nutrition status compromising patients immunity and ability to heal. A problem may be the recurrent superinfection of the central venous access with prolonged sepsis. Concomitant infections of the respiratory or urinary tract can complicate the clinical status. The blood, the abdominal wound, the fistula output, urine and sputum, and the catheter tip should be cultured in case of permanent sepsis. Thereafter, a broad-spectrum antibiotic regimen should be initiated and modified, as necessary once specific sensitivities have been determined. It is crucial to identify the possible sources of sepsis and to take aggressive measures. Any pathological fluid collections or abscesses have to be drained CT-guided percutaneously or even surgically removed. With the onset of a small bowel fistula, it is important to put the alimentary tract at rest in order to get control of the fistula output. If it is low or under control, the wound treatment and the skin protection of the fistula site is facilitated which promotes the healing around. oral intake is stopped; a nasogastric tube is placed with occasional suction of the gastric contents decreasing the fistula output. Gastrointestinal secretions can be temporarily inhibited by administration of proton pump inhibitors and anticholinergic agents, and somatostatin and its analogues. The indication for total parenteral nutrition include the following: fistula output over 500 ml/24 hours, persisting ileus, inability of enteral nutrition, and multiple other adverting factors. The total parenteral nutrition not only helps to overcome the systemic deficits, but also induces small bowel and pancreatic rest. However, the implication of somatostatin and its analogues on the outcome of small bowel fistulas is controversially discussed. Somatostatin, a naturally occurring 15-amino acid peptide, has been shown to inhibit gastric, pancreatic, biliary, and enteric secretions (23). Furthermore, it reduces several gastrointestinal hormones and diminishes gut motility. In patients with enterocutaneous fistulas, its use together with total parenteral nutrition has been well

documented reporting spontaneous closure rates up to 80% (23). In a recent paper on the administration of octreotide, Draus et al. reported a only 30% success rate declining the fistula output in 8 of 24 patients with enterocutaneous small bowel fistula (21). Various other papers on gastrointestinal fistulas confirmed that somatostatin and its analogues had beneficial effects with regard to fistula closure rate and hospital stay. However, the effects were statistically insignificant and routine application was not recommended (2, 2426). To our knowledge, there is no specific data for the use of somatostatin and its analogues in patients with open abdomen. At present, somatostatin and its analogues may be recommended as a trial in a stable patient. The indication should be the temporary reduction of fistula output to promote wound healing around the orifice or to seal the fistula by biological dressings (8, 21). While treating patients with high-output fistulas, an important goal is to minimize the development of the catabolic state. Despite aggressive nutritional support, malnutrition continues to be a major clinical problem. Malnutrition has to be considered in case of substantial body weight loss and concomitant hypoproteinaemia. Malnutrition in patients with small bowel fistulas is mainly due to the inadequate nutrient intake, to hypercatabolism associated with sepsis, to the loss of protein-rich gastrointestinal secretions, and to other consumptive factors related to the underlying disease. The serum albumin level is of predictive importance for mortality and fistula closure. The treatment of malnutrition, even though difficult to perform, includes the following strategies: total parenteral nutrition, aggressive measures against sepsis, the attempt of enteral feeding, and meticulous wound care around the fistula. Total parenteral nutrition is usually started via central venous catheter. The regimen consists of water, proteins, and caloric fractions calculated on the patients characteristics and specific needs. In addition to standardized, pre-fabricated solutions, the crystalloid nutrient formulation including vitamins and trace elements is tailored to the requirements of the individual patient. Measurements of the important blood parameters are performed every two or three days. Enteral nutrition is often difficult or impossible to administer in presence of a small bowel fistula because of ileus, sepsis, or inadequate absorptive capacity. However, it can be accomplished in selected stable patients. A recent study of Collier et al. has shown that early enteral feeding of patients with open abdomen has several advantages (27). The rationale for enteral feeding comprises prevention from acute calorie malnutrition, modulation of immune response, and promotion of gastrointestinal structure (28). If at least 4 feet of functioning bowel exists between the ligament of Treitz and the fistula, oral, nasogastric, or nasoduodenal tube feedings are possible administering highly absorbable, low-residue nutrients. This advantage has to be balanced against the fact that enteral nutrition increases the fistula output and may detoriate the wound situation around the fistula site. In absence of distal obstruction, a small, blockable

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feeding tube may be inserted below the fistula in the alimentary tract. Sometimes, a great part of creativity is needed in the devastating situation of a small bowel fistula. Enteral feeding is suggested if the patient can tolerate it and if enteral feeds do not increase the fistula output. From the decision on to leave the peritoneal cavity open, technique and experience with temporary closure are the crucial points. The dressing used should not only simply contain the visceral mass within the abdomen, but also protect the small bowel surface from any damage. At present, a perforated polyethylene sheet with or without sponge provides the best method to separate bowel from the abdominal wall and to avoid adhesions and fistula formation. Additionally, vacuum-assisted management of the soft tissue on top improves the chances of reclosure the abdominal cavity. When an enteroatmospheric fistula arises, vacuumassisted wound management is recommended as well. Suture of the bowel wall is not possible because of the concomitant peritonitis. Generally, two treatment strategies are promising. A small fistula which has no visible mucosa on examination can be closed either by negative-pressure dressings (29) or an attempt can be made to seal the fistula orifice applying human acellular dermal matrix and fibrin glue (8, 30). Gunn et al. reported on overall closure rate of 73% in 15 patients with a fistula by use of vacuum assisted wound care alone (29). If a large fistula with grossly visible mucosa is present, the fistula VAC technique by Goverman et al. is recommended (31). The difference to conventional vacuum assisted wound management consists in separate suction of the enteric contents through a hole in the vacuum sponge matching the fistula orifice. This procedure creates a barrier between the abdominal wound bed and the enteric opening. Even though technically demanding, diversion of the enteric contents is the key principle to allow normal wound granulation around the fistula and thereby prepare the bed for eventual split thickness skin grafting. Split skin grafts may be placed incorporating the fistulas. As the skin grafts mature, ostomy bags can be used to manage the fistula output. Local control of the fistula drainage reduces the local wound problems like skin irritation and bacterial infection. As shown above, a new promising tool available to the surgeon in case of massive abdominal wall defect and small bowel fistula is the use of biological dressings. In 2002, Girard et al. proposed an idea which led to a good understanding of the wanted repair mechanisms (30). They reported first on the application of human acellular tissue matrix on the fistula using fibrin glue. Meanwhile various authors showed that this technique led to fistula closure without surgical resection in a selected group of patients (8, 10, 32). Human acellular dermal matrix is a biologic tissue grafting material created by decellularization of donated human skin. The material, having been excessively tested in animals and already used in humans, carries none of the cellular components that elicit rejection phenomenon or inflammatory reaction (32, 33). It is especially suitable to situations with local

wound infection. The evaluation of the final role of the acellular dermal matrix either as a seal of fistula or as bridging material is under way. Consideration must be given to surgical resection of the small bowel fistula by removing the segment of the involved bowel if the fistula has not closed within 30 to 40 days. Surgeons have come to recognize that resuscitation of patients with a fistula, wound care, and restoration of the anabolic status take initial priority, and that surgical treatment should be delayed to allow for decrease of the inflammatory response and the adhesions within the abdomen. Generally, it is recommended an interval between the onset of fistula and surgical treatment of at least several months (8). The operative plan should include lysis of all adhesions from the ligament of Treitz to the rectum, segmental resection of the fistula-bearing bowel with end-to-end anastomosis of strong, healthy vascularized bowel. Several options exist for the closure of the large gap between the fascial edges of the abdominal wall. Traditional techniques include all variations of midline hernia reparation like sublay or onlay mesh repair, the components separation technique (34, 35), or myocutaneous flaps (36). A new approach is the introduction of non-absorbable biologic prostheses made of allogenic acellular dermal matrix. Experimental studies with this new material have been promising and the first clinical reports have come out (8, 10, 33). DISCuSSIon The actual standard approach to patients with an open abdomen comprises restoration of homeostasis, control of sepsis, optimal wound care, and the reclosure of the abdomen as soon as possible. These basic principles have undergone a quiet revolution over the years with the result that mortality and complications have decreased in critically ill patients (1). Comparing recent clinical studies with reports a decade ago, the incidence of small bowel fistulas has significantly decreased especially in trauma patients (6, 14). Due to increasing expertise and research, it has been demonstrated that enteroatmospheric fistulas are not inevitable. Besides optimal intensive care, the adequate wound management is the key factor to early closure of the abdomen. while taking advantage of the open abdomen, primary attention has to be paid to prevention of serosal trauma to the exposed bowel and to efficient treatment of the soft tissue. The best protection is achieved by placing a large, perforated polyethylene sheet around the entire visceral mass. It prevents the bowel from formation of adhesions to the abdominal wall and hereby delays the onset of the frozen, non-accessible abdomen. on top of the sheet, vacuum-assisted management gives optimal care to the pathology of the open abdomen. The application of a controlled vacuum force has positive effects to the peritoneal cavity and to the abdominal wall by edema egression, amelioration of perfusion and cellular activity, all leading to enhanced granulation tissue formation and

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H. P. Becker, A. Willms, R. Schwab C, Schumpelick V: Temporary closure of the abdominal wall. Hernia 2002;6:155162 Brock wB, Barker DE, Burns RP: Temporary closure of abdominal wounds: the vacuum pack. Am Surg 1995;61:3035 Barker DE, Green JM, Maxwell RA, Smith Pw, Mejia VA, Dart Bw, Cofer JB, Roe SM, Burns RP: Experience with vacuumpack temporary abdominal wound closure in 258 trauma and general and vascular surgical patients. J Am Coll Surg 2007;204: 784792 Cothren CC, Moore EE, Johnson Jl, Moore JB, Burch JM: one hundred percent fascial approximation with sequential abdominal closure of the open abdomen. Am J Surg 2006;192:238 242 Jamshidi R, Schecter wP: Biological dressings for the management of enteric fistulas in the open abdomen. Arch Surg 2007;142:793796 Miller PR, Meredith Jw, Johnson J C, Chang MC: Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced. Ann Surg 2004;239:608614 Scott BG, welsh FJ, Pham Hq, CArrick MM, liscum KR, Granchi TS, wall MRJ, Mattox Kl, Hirshberg A: Early aggressive closure of the open abdomen. J Trauma 2006;60:1722 Suliburk Jw, Drue nw, Balogh Z, McKinley BA, Cocanour CS, Kozar RA, Moore FA: Vacuum-assisted wound closure achieves early fascial closure of open abdomens after severe trauma. J Trauma 2003;55:11551160 Evenson RA, Fischer JE: Current management of enterocutaneous fistula. J Gastrointest Surg 2006;10:455464 Falconi M, Pederzoli P: The relevance of gastrointestinal fistulae in clinical practice: a review. Gut 2002;49 (SuPPl. IV): iv.2iv10 nagy KK, Fildes JJ, Mahr C, Roberts RR, Krosner SM, Joseph KT, Barrett J: Experience with three different prosthetic material in temporary abdominal wall closure. Am Surg 1996; 62:331335 Jernigan Tw, Fabian TC, Croce MA, Moore n, Pritchard FE, Minard G, Bee TK: Staged management of giant abdominal defects. Ann Surg 2003;238:349354 Mayberry JC, Burgess EA, Goldman RK, Pearson TE, Brand D, Mullins RJ: Enterocutaneous fistula and ventral hernia after absorbable mesh prosthesis closure for trauma: the plain truth. J Trauma 2004;57:157163 Howdieshell TR, Proctor CD, Sternberg E, Cuew JI, Mondy JS, Hawkins Ml: Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen. Am J Surg 2004;188:301306 Vertrees A, Kellicut D, ostman S, Peoples G, Shriver C: Early definitive abdominal closure using serial closure technique on injured soldiers returning from Afghanistan and Iraq. J Am Coll Surg 2007 2006;202:762772 Miller PR, Thompson JT, Faler BJ, Meredith Jw, Chang MC: late fascial closure in lieu of ventral hernia: the next step in open abdomen management. J Trauma 2002;53:843849 Petersson u, Acosta AS, Bjorck M: Vacuum-assisted wound closure and mesh-mediated fascial traction-a novel technique for late closure of the open abdomen. world J Surg 2007; ahead of print Draus JM, Huss SA, Harty nJ, Cheadle wG, larson GM: Enterocutaneous fistula: are treatments improving? Surgery 2006; 140:570578 Dudrick SJ, Maharaj AR, McKelvey AA: Artificial nutritional support in patients with gastrointestinal fistula. World J Surg 1999;23:570576 Makhdoom ZA, Komar MJ, Still CD: nutrition and enterocutaneous fistulas. J Clin Gastroenterology 2000;31:195204 Haffejee AA: Surgical management of high ouptut enterocutaneous fistulae: a 24-year experience. Curr Opin Clin Nutr Metab Care 2004;7:309316 Jamil M, Ahmed u, Sobia H: Role of somatostatin analogues in the management of enterocutaneous fistulae. J Coll Physicians Pak 2004;14:237240 lloyd DA, Gabe SM, windsor AC: nutrition and management of enterocutaneous fistula. Br J Surg 2006;93:10451055 Collier B, Guillamondegui o, Cotton B, Donahue R, Conrad A, Groh K, Richman J, Vogel T, Miller R, diaz JJ: Feeding the open abdomen. J Parenter Enter nutr 2007;31:410415 Todd SR, Kozar RA, Moore FA: nutrition support in adult trauma patients. nutr Clin Pract 2006;21:421429

improved wound healing parameters (37). Meanwhile available as a commercially prepacked system, the VAC abdominal dressing provides the modern standardized approach to the problems of open peritoneal cavity also for lesser-experienced surgeons. Continuous downsizing of the abdominal wall defect by cranio-caudal and latero-medial progressive closure is another important factor to reduce the morbidity of the exposed bowel especially fistulas. Progressive means to keep the fascial edges under reasonable tension, Scott et al. even call this approach aggressive (10). while the soft tissue edema evades under influence of the vacuum system, the suction slowly advance the fascial edges towards the midline. Thus, the vacuum technique itself effectively works against lateral retraction of the musculo-fascial layer. Additionally, a wide variety of techniques for progressive closure has been published to actively support this process (10, 15, 20). They all rely on the principle that medial traction is brought on the fascial edges by means of different meshes. Progressive fascial advancement by interrupted sutures starting at the apices helps to close the defect as soon as possible. If an enteroatmospheric fistula occurs in the midst of the open abdomen, only a few helpful measures come into consideration. Basically, the vacuum-assisted wound management should be continued and an attempt should be made to seal the fistula below the vacuum sponge by using fibrin glue and human acellular dermal matrix (8). When the fistula output is too large, the enteric contents should be diverted through a separate hole in the sponge (fistula VAC) preparing the site around the fistula for split-thickness skin graft for the application of ostomy bags (31). Although the vacuum may not close the fistula sooner, it significantly improves the local wound healing around. Surgical resection of established fistulas unresponsive to conservative measures is a maneuver for patients well-nourished and free of infection, which may require a delay of at least six months. The key word on fistula management is patience and well-planned management. The experiences with biological dressings are limited but promising. only a few authors have reported on the clinical use of human acellular dermal matrix grafts (8, 10, 32). However, as Scott et al. pointed out, this non-absorbable biological prosthesis can be implanted in the eventually hostile environment of septic abdomen and may be of great help to support the healing of fistulas and bridging large abdominal wall defects (10). Future research is absolutely necessary to clarify the final role of this material. REFEREnCES
01. Scott BG, Feanny MA, Hirshberg A: Early definitive closure of the open abdomen: a quiet revolution. Scand J Surg 2005;94:9 14 02. Evenson RA, Fischer JE: Treatment of enteric fistulae in the open abdomen. Chirurg 2006;77:594601 03. DeCosta A: Making a virtue of necessity: managing the open abdomen. AnZ J Surg 2006;76:356363 04. Schachtrupp A, Fackeldey V, Klinge u, Hoer J, Tittel A, Toens

05. 06.

07.

08. 09.

10. 11.

12. 13. 14.

15. 16.

17.

18.

19. 20.

21. 22. 23. 24. 25. 26. 27. 28.

Small bowel fistulas and open abdominal treatment 29. Gunn lA, Follmar KE, wong MS, lettieri SC, levin lS, Erdmann D: Management of enterocutaneous fistulas using negative pressure dressings. Ann Plast Surg 2006;57:621621 30. Girard S, Sideman M, Sain DA: A novel approach to the problem of intestinal fistulization in patients with open peritoneal cavities. Am J Surg 2002;184:166167 31. Goverman J, yelon JA, Platz JJ, Singson RC, Turcinovic M: The Fistula VAC, a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 case. J Trauma 2005;60:42831 32. Hirsch EF: Repair of an abdominal wall defect after a salvage laparotomy for sepsis. J Am Coll Surg 2004;198:324328 33. An G, walter RJ, nagy K: Closure of abdominal wall defects using acellular dermal matrix. J Trauma 2004;56:12661275 34. Shestak KC, Edington HJ, Johnson RR: The separation of anatomic components technique for the reconstruction of midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast Reconstr Surg 2000;105:731738 35. Vries Reilingh TS, van Goor H, Rosman C, Bemelmans MH, de Jong D, van nieuwenhoven EJ, van Engeland MI, Bleichrodt RP: Components separation technique for the repair of large abdominal hernias. J Am Coll Surg 2003;196:3237 36. Mathes SJ, Steinwald PM, Foster RD, Hoffman wy, Anthony JP: Complex abdominal wall reconstruction: a comparison of flap and mesh closure. Ann Surg 2000;232:586596 37. Banwell PE, Musgrave M: Topical negative pressure therapy: mechanisms and indications. Int wound J 2004;1:95106

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38. Ciresi Dl, Cali RF, Senagore AJ: Abdominal closure using nonabsorbable mesh after massive resuscitation prevents abdominal compartment syndrome and gastrointestinal fistula. Am Surg 1999;8:720725 39. Barker DE, Kaufman HJ, Smith lA, Ciraulo Dl, Richart Cl, Burns RP: Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma 2000;48:201206 40. Miller RS, Morris JAJ, Diaz JJJ, Herring MB, May AK: Complications after 344 damage-control open celiotomies. J Trauma 2005;59:13651371 41. Adkins Al, Robbins J, Villalba M, Bendick P, C. S: open abdomen management of intra-abdominal sepsis. Am Surg 2004;70:137140 42. Tsuei BJ, Skinner JC, Bernard AC, Kearney PA, Boulanger BR: The open peritoneal cavity: etiology correlates with the likelihood of fascial closure. Am Surg 2004;70:652656 43. navsaria PH, Bunting M, omoshoro-Jones J, nicol AJ, Kahn D: Temporary closure of open abdominal wounds by the modified sandwich-vacuum pack technique. Br J Surg 2003;90:718 722 44. Tremblay ln, Feliciano DV, Schmidt J, Cava RA, Tchorz KM, Ingram wl, Salomone JP, nicholas JM, Rozycki GS: Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg 2001;182:670675

Received: october 30, 2007