The pivotal role of negative pressure wound therapy in the management of enteroatmospheric fistula: a year-long "obstacle marathon".

Abstract

Background: Enteroatmospheric fistula (EAF) is an abnormal communication between the gastrointestinal tract and the atmosphere. This phenomenon is still considered one of the most significant challenges faced by general surgeons after abdominal surgery. Primary goals of managing EAF include controlling and diverting intestinal contents outside the abdominal cavity, protecting surrounding tissues from retraction, and promoting wound healing. Achieving these goals is not easy. EAF has a 40% mortality rate. Several techniques have been proposed for managing this problem, including negative pressure wound therapy. The use of bladder catheters, nipples, endoscopic stents, vascular grafts, and fistula funnel, among other options, in the management of EAF has also been described.

Case report: The patient in the current report underwent Hartmann reversal surgery. On postoperative day (POD) 5, he had an anastomotic leak with ischemia of the descending colon and the transverse colon. Resection of the ischemic colon was performed, followed by creation of a terminal ileostomy on the last ileal loop on the right side. The first small orifice of EAF appeared on POD 23, the second on POD 28, and the third on POD 45. On POD 253, the patient underwent resection of the fistulated loop, extensive vitreolysis of the entire small intestine, and mechanical jejunojejunal laterolateral anastomosis to reestablish the canalization toward the previous terminal ileostomy on the right side. Complete closure of the skin was evident on POD 358.

Conclusion: There is no ideal treatment approach that is valid for all cases of EAF. Spontaneous closure of an EAF is unlikely but feasible in the setting of a single, deep lesion with limited output and when intestinal continuity is preserved.