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Enterocutaneous Fistulas and a Hostile Abdomen: Reoperative
Surgical Approaches
R. Latifi
•
B. Joseph
•
N. Kulvatunyou
•
J. L. Wynne
•
T. O’Keeffe
•
A. Tang
•
R. Friese
•
P. M. Rhee
Published online: 6 October 2011
Ó Socie
´
te
´
Internationale de Chirurgie 2011
Abstract Damage-control surgery and open-abdomen is
an acceptable—and often lifesaving—approach to the
treatment of patients with severe trauma, abdominal com-
partment syndrome, necrotizing soft tissue catastrophes,
and other abdominal disasters, when closing the abdomen
is not possible, ill advised, or will have serious sequelae.
However, common consequences of open-abdomen man-
agement include large abdominal wall defects, enterocu-
taneous fistulas (ECFs), and enteroatmospheric fistulas
(EAFs). Furthermore, in such patients, a frozen and hostile
abdomen (alone or combined with ECFs) is not uncom-
mon. Adding biologic mesh to our surgical armamentarium
has revolutionized hernia surgery.
Introduction
For patients with complex abdominal wall hernias and
other abdominal wall defects, significant advances in sur-
gical techniques have been made, and new materials (both
synthetic and biologic) have become available. Yet major
abdominal wall defects remain a worldwide problem. In
the United States alone, more than 250,000 abdominal
incisional ventral hernias are repaired each year [1]. Of
all large abdominal defects, the most complex are those
associated with enterocutaneous fistulas (ECFs), enteroat-
mospheric fistulas (EAFs), and/or stomas, as well as those
involving a loss of abdominal wall domain and/or morbid
obesity [2, 3]. The number of patients who have concom-
itant fistulas and a large abdominal wall defect is unclear,
but their care is complex and surgeons face serious ques-
tions: When should we operate in patients with a hostile
abdomen? How long should we wait until we think it is the
optimal time to operate? What should we tell the patient?
How do we know that ‘‘things will get better with time’’ in
an abdomen that looks like one large ‘‘stoma city’’? What
surgical technique(s) should we use in approaching and
repairing a massive abdominal defect? What kind of mesh
should we use, and how should we place and fix the mesh?
The answers to such questions regarding a ‘‘disastro-
ma,’’ or hostile abdomen, are not straightforward [2–4].
Clearly, multiple factors affect a surgeon’s decisions to
adopt one or another technique, one or another mesh, and
one or another waiting time. To name just a few, factors to
be considered include the individual patient’s anatomy,
physiology, and religious beliefs, and the particular sur-
geon’s expertise, hospital resources, and support staff. A
special issue that in itself affects the patient, the family,
and the surgeon, is the overall ability to cope with the
pathology at hand.
For this review, we assume that patients have overcome
the acute phase of their disease; that intra-abdominal sepsis
has been controlled; that electrolyte and fluid normalization
have been achieved; that total parenteral nutrition (TPN) is
being maintained in patients unable to eat and use their
gastrointestinal (GI) tract; that patients are in a ‘‘status
quo’’ surgical condition; and that large abdominal wall
defects are open to air or have been covered with healed-
over skin grafts (Fig. 1a–d) [4–7]. Because most fistulas,
especially high-output fistulas, require surgical treatment
R. Latifi (&) B. Joseph N. Kulvatunyou
J. L. Wynne T. O’Keeffe A. Tang R. Friese P. M. Rhee
Division of Trauma, Surgical Critical Care, and Emergency
Surgery, Department of Surgery, University of Arizona,
1501 N. Campbell Avenue, Tucson, AZ 85724, USA
e-mail: rlatifi@email.arizona.edu
R. Latifi
Department of Surgery, Trauma Section, Hamad Medical
Corporation, Doha, Qatar
123
World J Surg (2012) 36:516–523
DOI 10.1007/s00268-011-1306-1
[8–13], patients with this condition need to be prepared for
surgery. During this preoperative period continuous
meticulous attention must be paid to avoid or at least
minimize sepsis (such as catheter-related sepsis in patients
receiving TPN), to minimize electrolyte and fluid distur-
bances, and to overcome malnutrition [5, 6].
Timing of the operation
In an attempt to reduce the frequency of leaving our
patients with an open abdomen, surgeons in the trauma
community in particular have changed our mindset and our
approach toward open abdomen. Evidence is mounting that
this vital procedure, once overused, is being used less often
[14–17].We have all departed from a ‘‘leave it open’’ to a
‘‘sew it up’’ strategy as soon as it is technically and
physiologically is possible to close the abdomen [14, 15].
After the open-abdomen approach, complications such as
ECFs are a major problem. In one study, the most common
fistula site was the colon (69%), followed by the small
bowel (53%), the duodenum (36%), and the stomach
(19%). In the same study 56% of ECF patients had multiple
hollow viscus injuries. The development of an ECF was
associated with a significant increase in the intensive care
unit (ICU) length of stay (28.5 ± 30.5 days with an ECF
vs. 7.6 ± 9.3 days without an ECF; P = 0.004), in the
hospital length of stay (82.1 ± 100.8 vs. 16.2 ± 17.3
days; P \ 0.001), and in hospital charges ($539,309 vs.
$126,996; P \ 0.001) [17].
To avoid such sequelae, different surgical techniques to
aid in closing the abdomen have been reported, such as
progressive abdominal closure, vacuum-assisted closure,
the use of biologic mesh at an early stage, and/or tissue
transfer [16–23]. The most essential question is this: When
do we ‘‘attack’’ a frozen abdomen and an ECF? The answer
is uncertain. Surgeons have wrestled with the question of
when to operate and how to succeed for years [20]. Certain
anatomic factors are known to affect the closure, such as
the length of the fistulous tract and the anatomic location of
the fistula [22–26]. Ideally, the anatomy of complex ventral
hernias, ECFs, and EAFs can properly be identified (pre-
operatively, if at all possible). Any previous operative
reports for a given patient should be obtained and studied.
On many occasions, however, the surgeon must make a
difficult decision and embark on operation even without
completely discerning the anatomy, without having a sur-
gical road map to follow. In such situations the surgeon can
only hope that, intraoperatively, the anatomy will become
clear.
Overall, there are two camps of surgeons: those who
wait until things have ‘‘settled down’’ and those who
choose to operate early [20]. At our institution, we choose
to operate early, although ‘‘early’’ has not been defined
clearly in the literature. Rather, the decision is clinical,
based on the individual patient.
One recent study that looked at early planned operations
in patients with ECF reported a 21% mortality rate from
multiple-organ system failure and a 17% complication rate
[26]. But other recently reported mortality rates are as low
Fig. 1 ‘‘Status quo’’ surgical
condition. a A 51-year-old
female status post catastrophic
laparoscopic cholecystectomy
with multiple injuries to the
large intestines not recognized
at the time of operation. Now
she is in a ‘‘status quo’’ surgical
condition. Multiple EAF, skin
graft, ‘‘ileostomy’’ insisting on
definitive reconstruction.
b Intraoperative view, after
fistulas were taken down, and
GI tract continuity was
established. c Large piece of
Strattice was used to cover the
abdominal content. Wound
VAC is applied (d)
World J Surg (2012) 36:516–523 517
123
as 7% [23], much better than the historical mortality rate of
43% reported in 1960 [9]. Some authors have suggested
waiting 4–5 weeks before operating, just long enough to
make sure that patients are nutritionally sound and that
sepsis is controlled [27]. Most surgeons, however, wait
3–6 months and others wait 12 months or longer.
In preparation for the operation, key clinical and labo-
ratory issues must be addressed. For example, blood sugar
levels must be controlled. Patients must stop smoking for at
least a month before the surgery. The bioburden must be
reduced through application of vacuum-assisted closure
(VAC) of the wound or through other modalities, including
stoma protection techniques. Hypovolemia and chronic
anemia must be corrected. A complete biochemical profile
(including levels of trace elements, vitamins, and essential
fatty acids) must be obtained and any problems resolved.
Surgical approach
Either open or laparoscopic surgical techniques can be used
to repair abdominal wall defects. But in patients with a
frozen or a hostile abdomen and with ECFs and/or EAFs,
the open approach is standard. Each surgeon will use cre-
ativity and a combination of different techniques and
repairs, depending, primarily, on the mission at hand. If the
goals of the operation are to take down fistulas, establish GI
tract continuity, and concomitantly repair abdominal
defects, then things become more complicated, and the
surgeon should plan accordingly [2, 3, 20, 23]. Preopera-
tively, surgeons should assume that all patients with ECFs
and/or EAFs have a frozen abdomen or a hostile abdomen,
and that entering the abdominal cavity will be extremely
challenging. Proper mental preparation is essential—for the
surgeon as well as for the patient and family. When pos-
sible, the surgeon should avoid going through the same
incision used in prior operations. Instead, attempts should
be made to enter the abdomen from nonviolated areas of
the abdominal wall. But doing so may not always be pos-
sible, especially in patients who have previously undergone
laparoscopy for trauma or other major operations. Some
authors have suggested alternative methods of entering the
abdomen through a transverse incision [11, 20]. At our
institution, we have rarely used a transverse incision in
such patients. Instead, when a frozen abdomen is covered
with a skin graft, we prefer meticulous dissection on either
side, using the medial edges of muscle. During fascial
closure, utmost care must be taken to avoid injury to the
underlying bowel: the consequences of inadvertent enter-
otomies are not trivial. In one study, patients with inad-
vertent enterotomies had a significantly higher rate of
postoperative complications (P \ 0.01) and of urgent rel-
aparotomies (P \ 0.001), a higher rate of admission to the
ICU (P \ 0.001) and of parenteral nutrition use
(P \ 0.001), and an increased postoperative hospital length
of stay (P \ 0.001) [28]. If an enterotomy is recognized, it
should be either repaired at once or marked with a silk
suture for later identification. Most authors agree that
surgeons should mobilize and identify the entire GI tract,
from the gastroesophageal (GE) junction to the rectosig-
moid junction. Identifying all of the fistulas and the entire
GI tract is pivotal. Marking free segments of bowel with
silk sutures helps to locate the ‘‘free segment’’ of the
intestines for proper anastomosis. Resecting multiple fis-
tulas as one segment en masse is preferable, but this may
not be possible if the fistulas are located at a distance from
one another (Fig. 2). Thus, difficult decisions must often be
made during the course of the operation: Should more than
two or three anastomoses be created, running the risk of a
leak or an ECF? Or, should the number of anastomoses be
minimized? Should large segments of small bowel be
resected, potentially creating GI-crippled patients with
possible short gut syndrome? Or should one create more
anastomoses? Only the operating surgeon can make that
judgment. It is important to recognize that intestines look
shorter than they in fact are in the abdomen that has been
operated previously. If at least 20–25 cm of bowel can be
left between anastomoses, a hand-sewn double-layer
technique should be used. A stapler, however, should not
be used [22]. To avoid resecting a large amount of bowel,
adjunct procedures (such as a modified strictureplasty)
can be used in certain fistulas. If the integrity of the
Fig. 2 ‘‘En mass’’ resection of multiple fistulas. Difficult questions:
How much do you resect and how many anastomoses do you create?
518 World J Surg (2012) 36:516–523
123
anastomoses or anastomosis is questionable, revision is
reasonable, as is creation of a proximal diverting ostomy.
Surgeons should not promise their patients that they will
not have a stoma, temporary or otherwise. These operations
can take a long time, so surgeons should consider stopping
and returning the next day to complete the anastomosis or
to reconstruct the abdominal wall. We have called this
‘‘damage control on demand.’’ During the interim period,
patients can be resuscitated, coagulation and acidosis can
be corrected, and the surgeon and surgical team can get
some much-needed rest before performing the definitive
surgery.
Intraoperatively, these patients need to be resuscitated
just like trauma patients. Adequate oxygen delivery and
maintenance of normal tissue perfusion and adequate body
temperature are mandatory. Fluid status should be moni-
tored. Hypotension should be avoided, especially if the
patient underwent preoperative bowel preparation.
Reconstruction of abdominal wall defects
The goal of the operation in patients with ECFs and/or
EAFs is to definitively correct the problem. Operative
treatment with takedown of ECFs or fistula excision and
abdominal wall reconstruction is successful in 80–90% of
patients [12, 22]. Once GI tract continuity has been
established (as described above), the next big step is to
cover the intraperitoneal content. But doing so can be a
serious surgical challenge. To cover the abdominal cavity
and create the ‘‘new’’ abdominal wall, native tissue and
prosthetic mesh should be used. No one technique has been
reported to be superior to others. Many authors have
described a combination of different approaches, based on
the location and the type of defects. Using a combination of
different techniques and a preplanned algorithm based on
careful analysis of the defect and location, a 92% rate of
successful closure of this complex of defects has been
reported [28]. In most patients, some combination of
reconstruction will be done. If native tissue can be used
without undue tension, then using it should be the primary
step. But if midline tissue cannot be easily approximated,
or if mesh reinforcement is needed (as it is in almost all
abdominal wall defects larger than 6 cm), then other
techniques must be considered. A detailed summary of
tissue transfer techniques is beyond the scope of this
review. In brief, if midline tissue cannot be easily
approximated, then separation of lateral components or
some sort of tissue transposition needs to be done, as
originally described by Albanese in 1951 [29] and popu-
larized later [30]. Component separation results in medial
advancement of intact rectus myofascial units bilaterally,
closing defects of up to 10 cm in the upper abdomen, of up
to 20 cm in the mid-abdomen, and of 6–8 cm in the lower
abdomen. Different techniques [31–37] for abdominal wall
reconstruction include the use of tissue expanders or other
highly sophisticated plastic surgery tools and operations, as
described elsewhere in this issue of World Journal of
Surgery by Leppaniemi and Tukianen [35].
Choice of mesh
Is biologic mesh the new answer to an old problem? In
recent years, the need for biological mesh in the surgical
repair of complex, contaminated, or potentially contami-
nated abdominal defects has become evident [38–48]. Its
use is becoming common and is supported by a whole new
industry and data, although long-term studies are still
lacking. According to a hernia grading system developed
by the Ventral Hernia Working Group [1], in patients
whose risk is classified as either grade 3 or grade 4, syn-
thetic mesh should be avoided because of the fear (borne
out by substantial evidence) of high wound infection rates
(often necessitating removal of infected mesh for source
control) and of other complications (such as newly created
fistulas) (Fig. 3a, b).
Most recently, the use of biologic mesh has become
standard in high-risk patients with contaminated and dirty-
infected wounds [43–50]. One multicenter study of 242
patients who were followed for slightly less than a year
(317 days) found that human acellular dermal matrix
(ADM) is a suitable alternative for complex ventral hernia
repair in a compromised surgical field [43]. The overall
mortality rate in that study was 2.9% and the hernia
recurrence rate was 17.1% (41 patients). Repair of a fistula
or stoma was associated with hernia recurrence (P = 0.03)
and with fistula recurrence (
P \ 0.001). Logistic regression
analysis showed that a surgical site infection and a body
mass index of greater than 30 were independent risk factors
for hernia recurrence. Another recent multicenter, pro-
spective, cohort study of 80 patients with clean-contami-
nated and dirty-infected wounds reported similar results
[44].
Definitive abdominal wall reconstruction at the time of
hernia repair or at the time of takedown of ECFs and/or
EAFs, even in contaminated fields, should be attempted.
Stoma or fistula takedown at the time of complex hernia
repair has been reported to be associated with significant
complications [49]. These studies suggest that biologic
mesh implantation is a valid option for complex abdominal
wall reconstruction in high-risk trauma and acute care
surgery patients. As previously described, in our practice,
the three most common techniques used to place mesh
during abdominal wall reconstruction are onlay placement
(Fig. 4a, b), interposition or bridge (Fig. 5a, b), underlay
World J Surg (2012) 36:516–523 519
123
Fig. 3 a Infected synthetic mesh placed onlay in a diabetic woman following ventral hernia repair that required excision. There were no signs of
active infection at the time of implantation of the mesh. b Following excision of the synthetic mesh 2 weeks later
Fig. 4 Overlay mesh placement. a Primary closure of fascia followed by overlay mesh reinforcement. b Illustration of the mesh placed, before it
is fixed tightly to reduce seromas
Fig. 5 a Bridge interposition of biological mesh in a patient that
despite component separation, we were unable to approximate the
native abdominal wall tissue. After multiple drains are placed (not
shown) skin and adipose tissue is closed over the mesh. b Patient from
above picture undergoing bridge graft interposition. When possible
skin and subcutaneous tissue should cover the underlying mesh.
Feeding jejunostomy tube may be required as in this case
520 World J Surg (2012) 36:516–523
123
placement (Fig. 6a, b), and placement—or a combination
of the three (Fig. 7a, b) [2].
In 9 patients with ECFs and/or EAFs, previously
reported we used underlay placement in 4 (44%) and
interposition or bridge placement in 5 (56%) [2]. In the
same series of patients who underwent ADM implantation
with either AlloDerm or Strattice, 35 had contaminated
fields as defined by presence of intra-abdominal or soft
tissue infection, stoma, or fistula. Of those 35, most of
them—26 (74%)—were grade 4, per a hernia grading
system [1]. There were no differences in terms of the rates
of overall complications, recurrence, and of infectious
complications between patients with ECFs and/or EAFs
and those without concomitant ECFs and/or EAFs.
When mesh is used as a bridge, and when there is no
skin or subcutaneous tissue to cover the mesh, then we use
wound vacuum-assisted closure with continuous irrigation,
which keeps the mesh moist and speeds the process of
granulation for later skin grafting [2]. Whenever possible,
we use 4 to 5 drains that stay in place for 10–15 days or
until drainage from the individual drain measures less than
25 ml/24 h. To minimize the drain displacement, we fix all
of the drains to tissue with fine chromic sutures.
Perioperative morbidity
There is significant potential morbidity when we operate in
patients with ECF in need for concomitant abdominal wall
reconstruction [3, 49–52]. In one study of 62 patients,
major complications, including postoperative respiratory
and surgical site infection occurred in 82.5% of the patients
[3]. Fistula reocurred in 7 cases (11.1%) but was more
common when the abdominal wall was reconstructed with
prosthetic mesh (7 of 29, 24.1%) than with sutures (0 of 34,
0%). Porcine collagen mesh was associated with a partic-
ularly high rate of fistula recurrence (5 of 12, 41.7%) [4].
Despite all of these complications, abdominal wall recon-
struction offers the only possible option to significantly
improve the quality of life in this group of patients.
Summary
Surgical treatment of patients with ECFs and a hostile
abdomen and other complex abdominal defects is chal-
lenging and expensive; it requires significant resources,
both surgical and financial. Careful planning and advanced
surgical techniques are required, often involving the use
(alone or combined) of biologic mesh and composite tissue
Fig. 6 Underlay biological mesh placement (Strattice was used in this case). a Mesh is stretched laterally to cover the lateral edge of the
component separation. b Fascia is closed over the underlay mesh. Skin and subcutaneous tissue is closed over multiple drains (not shown)
Fig. 7 Interposition mesh used as a bridge and ‘‘underlay.’’ Attempt
is made to fix the mesh under the fascia at least 5–6 cm lateral from of
the edge of the muscles
World J Surg (2012) 36:516–523 521
123
transfer. With careful planning and proper surgical tech-
niques, using biologic mesh may be the only viable choice
and could offer excellent results. Furthermore, while
abdominal reconstruction in patients with fistulas and
abdominal defects is challenging and complex, and is
associated with significant morbidity and potential mor-
tality, abdominal wall reconstruction offers the only pos-
sible option to significantly improve the quality of life of
this group of patients.
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