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126
E.K. Johnson
Fig. 8.11 A large fascial diastasis that has been bridged with a biologic mesh. While this is not optimal in terms of hernia repair, it may be
an acceptable option to obtain visceral coverage
ultimately did not occur in either. The use of this method
has also been reported to be successful in closing small
EAFs [ 35 , 36 ].
While nutritional optimization is central to the care of a
patient with a gastrointestinal fi stula, it is almost as important in the prevention of an EAF. A patient with an open
abdomen is in an extreme catabolic state with increased
nutritional requirements. The benefi ts of enteral nutrition
over parenteral nutrition are well established in surgical
patients, and the use of early (less than or equal to 4 days
after laparotomy) enteral nutrition has been shown to result
in a statistically signifi cant reduction in the rate of EAF formation, as well as a faster time to abdominal closure [ 37 ].
While no single strategy will prevent EAF in every patient
managed with an open abdomen, the above mentioned tools
may be tailored into the care for these patients to minimize
the risk of this devastating complication.
Problem: So You Have an EAF (The Early Phase)
Key Concept : In the early phase , the goals are to categorize
the EAF as superfi cial or deep to help defi ne an uncontrolled
infection , followed by implementation of sepsis control ,
nutritional therapy , and skin protection measures . Success
( or failure ) with each of these components has an interre-
lated effect on optimizing the others .
Diagnosis
Unfortunately, despite our best preventive efforts, some
patients will develop an enteroatmospheric fi stula (Fig.
8.12 ).
Recognition of this complication is not typically diffi cult, as
one will appreciate either stool or bilious material draining
from the open wound (Fig. 8.13 ). Once these signs are recog-
nized, one must determine if the EAF is deep or superfi cial. A
superfi cial fi stula is easy to see during physical examination
of the patient. Often a clearly visible enterotomy or colotomy
8.14 ) will be noted, but in many cases, defi nitive recog-
(Fig.
nition of the source may be more diffi cult. Irrigation of the
wound bed followed by focus on the region of the wound that
drainage appears to emanate from will often lead to localization of a pinhole enterotomy. Once a superfi cial source is confi rmed, focus can turn to early supportive care of the patient.
Superfi cial vs. Deep
Differentiation between superfi cial or deep EAF is important simply from the standpoint of uncontrolled sepsis. The
fi rst step in the early phase after recognition is control of any
septic focus. While the presence of an undrained abscess is
uncommon in the patient with an EAF, it is more common in
an individual with a deep fi stula source. The typical scenario
is an anastomotic leakage in a patient being managed with
an open abdomen. If the site of anastomosis lies deep within
the peritoneal cavity, undrained collections may be present despite the fact that some drainage is noted in the open
wound. Computed tomographic scanning is the best method
to demonstrate any intraperitoneal collection needing attention. A patient showing systemic signs of sepsis should be
treated with broad-spectrum antibiotics and undergo drainage
of any septic collection. In some cases this can be performed
percutaneously using CT guidance; however, in others this is
not possible due to lack of an intervening safe window of passage for needle and drain. It is this group of individuals that
may require early reoperation simply for control of sepsis.
In a small but fortunate subset of these individuals, the
problem of EAF may be addressed defi nitively at the reexploration through resection of the leaking segment of
bowel with reanastomosis, proximal diversion, or both
depending on the individual setting and sound surgical judgment. When considering the decision to perform an anastomosis in this setting, we must account for the fact that the
patient will likely continue to require management with an
open abdomen and that they initially developed the EAF/
leak in this very environment. The expectation that a new
anastomosis will heal in a worse environment is unlikely,
outside of the rare event of discovering an isolated identifi able and modifi able factor that led to the leak in the fi rst
place. Consideration of early proximal diversion in this
situation followed by the previously mentioned methods to
prevent re-fi stulization may shorten the course of this complication dramatically. Sadly this is not often possible, and
even when attempted, the result is often EAF recurrence.
There are also instances where proximal diversion is desired
but impossible due to mesenteric foreshortening and bowel
immobility. In cases such as this, the only option available
may be to widely drain a leak with multiple closed suction or
sump-type drains. Elimination of oral/enteral intake may be
required to achieve effective control of drainage.
8 Enteroatmospheric Fistula
127
Fig. 8.12 Algorithm depicting methods useful in managing an
enteroatmospheric fi stula after it is initially discovered. EAF entero-
atmospheric fi stula, NPWT negative-pressure wound therapy, OR
operating room, NPO nothing per os, TPN total parenteral nutrition,
VAC vacuum-assisted closure device
Fig. 8.13 Image showing a NPWT system that has been overwhelmed
by a high-output EAF. This dressing was placed less than 1 day prior to
this photo
Fig. 8.14 A superfi cial coloatmospheric fi stula
128
E.K. Johnson
Control of Sepsis and Resuscitation
Once it is recognized that there will be no rapid solution to
the problem of EAF, the surgeon and patient will embark
upon the long journey involved in treating this process. The
tation, nutritional support, control of output, protection of
surrounding skin, and creation of a plan for the subacute and
chronic management of this problem. Resuscitation occurs
simultaneously with diagnosis and control of sepsis. In the
earliest phase, it is often sepsis that drives resuscitative needs,
though a high-output fi stula (>500 mL/day) will lead to substantial fl uid and electrolyte loss requiring replacement. The
type of fl uid required for replacement therapy is dictated by
the site of fi stula origin, with normal saline + 10 mEq/L KCL
being effective for most EAFs. Very proximal small bowel
or duodenal fi stulas may require bicarbonate replacement as
well. Until the situation begins to stabilize, frequent analysis
of serum electrolytes will be required to correct any necessary defi ciencies. Basic principles of fl uid resuscitation apply
to these patients as they would to any postsurgical patient.
Yes
Early Nutrition
Sound and effective nutritional support is central to the care
of the EAF patient either to provide the highest chance of
nonoperative closure or to optimize the patient for eventual
surgery (Fig. 8.15 ). The question of enteral vs. parenteral
nutrition is always simple for the nutritionist—with enteral
almost always being the preferred route—but is much more
complex for patient, surgeon, and nurse caring for the patient.
Because of diffi culty with control of effl uent, enteral nutrition is rarely an option in the early phase of EAF management. Even a “low”-output fi stula may not be suitable for the
enteral route of replacement, as they will often convert to a
high-output fi stula when the gut is used for feeding.
Parenteral nutrition via a central venous catheter will likely
be the best option in this phase. With the majority of these
patients in a profoundly catabolic phase, the standard postoperative nutritional recommendations of 20 nonprotein
kcal/kg and 1.5 g/kg of protein may not be suffi cient. The
patient may require up to 30 nonprotein kcal/kg and 2.5 g/kg
of protein with supplementation of zinc, vitamins, trace
Early EAF
No
Success
Continue
enteral
feeding
Fistula VAC,
tubes, drains
other methods
of control
Consider
enteral
feeding
High output
or difficult
control
NPO, TPN
Failure
Yes
Proximal
origin
TPN, NPO
Output
controlled
NPO, TPN
octreotide?
Fistulogram
Feed afferent
limb,
fistuloclysis
No
Distal
origin
NPO, TPN vs
wound manager
and eneral
feeding
Fig. 8.15 Algorithm illustrating a feeding strategy to be used early after discovery of an EAF. EAF enteroatmospheric fi stula, NPO nothing per
os, TPN total parenteral nutrition, VAC vacuum-assisted closure device
8 Enteroatmospheric Fistula
129
elements, and fi ve to ten times the standard recommendation
of vitamin C [
13 ]. Additional copper, folic acid, and vitamin
B12 are often also needed [ 38 ].
Assessment of nutritional adequacy should also begin in
the early phase with twice weekly measurements of serum
prealbumin. The serum C-reactive protein level is also often
helpful in determining whether or not the patient remains in
the acute infl ammatory phase or has ongoing sepsis. No
matter how much nutritional support is provided, it is diffi cult to make measurable gains in the nutritional status of
an actively septic individual. This again illustrates the
importance of sepsis control in optimizing a patient’s
chance to heal an EAF nonoperatively or at least provide
favorable conditions for a future required surgical
procedure.
E f fl uent Control and Skin Protection
It is worth repeating that the poorly controlled EAF is a
nightmare for the patient and everyone involved in their
care. It is a source of embarrassment and discomfort for
the patient, frustration for the surgeon, and results in the
consumption of a tremendous amount of nursing and
disposable medical resources. Early control of EAF output is therefore critical, as contact between the skin and
drainage will result in signifi cant skin damage that may
limit options for subsequent control. A sound fi rst step is
to stop any and all oral intake. Bowel rest will likely not
eliminate EAF output, but will signifi cantly reduce the
quantity. Use of a nasogastric tube on intermittent suction may also aid in reducing the quantity of effl uent. In
the majority of cases, the use of NPWT will have already
been employed, and simple continuation of this will be
all that is needed to obtain early effl uent control. EAFs
that result in higher effl uent output will often overwhelm
NPWT systems resulting in the requirement for dressing changes on a daily basis or even more frequently.
This again can overwhelm both manpower and resources
requiring advanced methods of control (Figs.
and
8.18 ). The involvement of an enterostomal therapist or
8.16 , 8.17 ,
experienced wound care team cannot be overemphasized
[ 39 ]. If the patient is being cared for in a facility without
these resources, transfer to a higher level of care should
certainly be considered.
There are several available options for skin protection
using any of a variety of topical skin barriers. Again, the
enterostomal therapist/wound care team will be familiar with
the available options, and use of these materials should be
employed early. Advanced method of effl uent management
as well as pharmacologic adjuncts to the management of
EAF will be discussed in the next section.
Fig. 8.16 The “fi stula VAC.” The EAF has been isolated from the rest
of the wound bed allowing the benefi ts of NPWT while controlling
effl uent using and ostomy appliance
Fig. 8.17 Use of a large custom fi t wound appliance. This technique is
useful when NPWT fails to adequately control fi stula effl uent
Intermediate Phase
Key Concept : Once the patient has stabilized , the focus shifts
to using enteral nutrition , defi ning the fi stula anatomy , identifying potential sources hindering EAF resolution , and
mobilization or discharge of the patient through advanced
wound protection . This may allow the EAF to close spontaneously or prepare the patient for surgery .
130
E.K. Johnson
Fig. 8.18 Use of baby bottle nipples with Malecot drains inserted in
them to isolate two EAFs from the wound bed so NPWT could be used
The intermediate phase in the care of the EAF patient is
characterized by anatomical defi nition of the fi stula, obtaining durable feeding access or employing alternate feeding
strategies, use of advanced wound care and control techniques, and tailored management toward defi ned goals of
spontaneous closure vs. future surgical closure. Psychiatric
and social support of the individual with EAF cannot be
overstated. It is this phase of management where the patient,
their family, and nursing will apply pressure to the surgeon
in hope of a quick fi x. Unfortunately, there is no easy way
out of this complication, and patience with well-defi ned
goal-directed management must be employed. Surgeons
must resist pressure to attempt surgical intervention too
soon, as the error of early surgical intervention often results
in secondary complications potentially worse than the original problem.
D e fi ning Anatomy
Defi nition of EAF anatomy can be helpful in determining
prognosis, in preoperative planning, and in creating a feeding strategy. While it may be obvious whether an EAF is of
colonic or small bowel origin on simple inspection of the
wound bed, in some cases (especially with deep EAF), this
distinction is diffi cult to make. Fistulas that originate more
distally in the small bowel or those from the colon are often
more likely to close spontaneously. Deep EAFs are also
more likely to close, as long as sepsis is controlled, given the
length of the fi stula tract. While these statements are diffi cult
to support directly with evidence, one can extrapolate from
evidence that reveals lower spontaneous closure rates in fi stulas with proximal origin or high output [
40 ]. There is also
some evidence to suggest that ECFs that have developed in
trauma patients may be more likely to close than in others;
however, it is unknown if this association applies to those
with an EAF [
41 ]. Knowledge of the likelihood of spontane-
ous closure will affect the goal-directed management plan as
well as provide reasonable expectations for the patient and
others involved in their care. Site of origin may also directly
impact upon the decision to feed enterally or parenterally.
We are often required to perform some sort of radiographic study to make a defi nitive determination of the
site of fi stula origin. There are several options available to
the surgeon for this purpose. The fi stulogram is the classic
study to assist in this purpose. Performance of a fi stulogram
involves intubation of the fi stula tract from the outside using
various tubing or catheter devices that will facilitate direct
contrast instillation into the tract. A scout radiograph should
be obtained prior to any contrast administration. This will
assist in visualizing any clips or anastomotic staples in the
area of question that may be related to the process of fi stulization. Contrast should be administered gently under low
pressure while visualizing the area of interest using fl uoroscopy. The use of a balloon tipped catheter infl ated with
low pressure may assist in maintaining intraluminal contrast
thereby improving the image. A well-performed fi stulogram
of a deep EAF will defi ne the tract, its length, the origin,
and any associated abscess cavity. Fistulograms performed
on superfi cial EAFs may assist in determination of how
proximal or distal the origin of the fi stula is in the GI tract.
Water- soluble contrast should be used when performing
these studies. While barium tends to provide greater detail,
water- soluble contrast material works well and alleviates the
risk of peritonitis related to barium extravasation in some
circumstances. Any barium retained in the GI tract tends to
form concretions that can be very diffi cult to clear and may
hinder further radiographic evaluations. As a general rule,
barium is simply best avoided in these patients. A fi stulogram may also aid in the identifi cation of distal obstruction
as well as adjacent or associated foreign bodies—both factors that will tend to preclude spontaneous fi stula closure.
Alternatively, a small bowel follow-through after ingestion
of oral water- soluble contrast may also be helpful in identifying the discussed fi ndings.
Computed tomography scanning is probably the most
useful modality for imaging a patient with an EAF to determine if there are other associated intraperitoneal abnormalities. When oral and IV contrast are used, one may in fact
achieve direct visualization of the origin of the EAF, as well
as information related to tract length, associated abscess,
adjacent infl ammation, presence and relation of foreign
body, and any potential distal obstruction. Cross-sectional
imaging with CT also provides the obvious advantage of
facilitating percutaneous drainage of intra-abdominal fl uid
collections. MRI and ultrasound examination may also be
helpful in select circumstances but are less frequently
employed methods of imaging in these patients.
8 Enteroatmospheric Fistula
131
Nutrition
As mentioned, the purpose of imaging is to defi ne the situation anatomically such that an intervention can be undertaken to improve outcome, if possible. Intervention may be
direct, as in the case of abscess drainage, or indirect such as
implementation of an enteral feeding plan based on anatomy.
In cases where fi stulas are located distally, it may be possible
to provide all nutritional intake by mouth without substantially increasing fi stula output to a level where control
becomes diffi cult. In cases where the fi stula origin is very
proximal, enteral feeding can often be achieved via a tube
inserted into the efferent portion of the tract. The majority of
intestinal absorptive surface can be utilized, and high volume biliopancreatic secretions can be re-fed into the distal
bowel [ 13 ]. Some patients will simply not be candidates for
enteral nutrition (although it should always be the fi rst
choice) and will require extended administration of total parenteral nutrition (TPN). These individuals will require durable central venous access in some form. Line sepsis and
TPN-associated liver disease remain major morbidities in
those who require this form of nutritional therapy. While
debatable, when fi stula anatomy is favorable for a higher
likelihood of spontaneous closure, some physicians prefer
the parenteral route alone in order to keep effl uent output
low. If spontaneous closure seems unlikely, which is often
the case, feeding enterally may be the best way to boost
nutritional status in preparation for future surgery.
E f fl uent Control and Skin Protection
In the intermediate phase, control of fi stula effl uent remains
extremely diffi cult. As patients regain strength, simple mobilization and, eventually, life beyond the hospital become a
reality. This poses challenges to the effl uent control aspect of
care. In order to re-feed biliopancreatic secretions, they must
be effectively controlled and collected. While possible
through use of nasogastric tubes and NPWT systems, this is
a much more diffi cult task in practice. High-output EAFs
will tend to overwhelm NPWT systems requiring extremely
frequent dressing changes and resulting in high cost. For
those without as much experience in dealing with this situation, it should be highlighted that an EAF that arises in the
setting of the open abdomen often actually gets worse before
it starts to get better (Figs. 8.19, 8.20, 8.21, and 8.22 ). Control
of effl uent and protection of surrounding skin present a true
challenge in this period. Poor control of gastrointestinal
secretions will lead to a frustrated patient and nursing staff.
Aggressive effort toward the above goals is warranted
immediately and may require considerable thought. Several
authors have developed methods and systems, simply out of
need, to address these concerns [
42 – 48 ]. Creation of a “fl oat-
ing stoma” has even been reported and may be useful in specifi c circumstances [
49 ]. All of these methods address a few
simple ideas: “dam off” the EAF from surrounding bowel or
granulation tissue, provide NPWT to surrounding tissues to
assist with healing and exudate control, protect the surrounding skin to assist with dressing adherence and use in future
surgery, and prevention of trauma to underlying viscera to
eliminate the potential for additional EAF formation
8.23, 8.24, 8.25, and 8.26 ). Any system that can
(Figs.
address all of these concerns will be effective, but none specifi cally designed for the purpose of EAF control has been
marketed. It therefore requires considerable effort from the
care team to design a custom device for a particular patient
and to ensure its effective use on a daily basis. This is where
a competent enterostomal therapist or wound care team is
worth their weight in gold.
In cases where effl uent control is simply impossible with
NPWT-based wound care systems, the only remaining option
may be the use of what amounts to a large stoma appliance
or wound manager (Fig. 8.27 ) [ 48 ]. These devices can be
custom cut to the size and shape of the open wound and function much like a standard ostomy appliance. They come in a
variety of sizes and are marketed by at least two companies
currently. If the surrounding skin is in good shape, a watertight seal can be maintained with effective collection of
effl uent in a large pouch. Despite continued contact with
gastrointestinal secretions, granulation tissue will somewhat
surprisingly continue to form over the underlying viscera,
and the wound will contract over time (Figs.
8.28, 8.29, 8.30,
8.31, and 8.32 ). The wound appliance should be replaced
with a fresh one as needed or ideally every 4–5 days, much
like an ostomy appliance is managed. As a general rule,
changes should be as infrequent as possible to limit trauma
to the underlying skin.
Pharmacologic Therapy
Key Concept : Several pharmacological agents including
octreotide , somatostatin , acid - reducing medications , and
antimotility drugs aid in decreasing EAF effl uent volume and
ultimately help in EAF control , volume and electrolyte
abnormalities , wound care , and closure .
Ultimately, the goal remains for either spontaneous EAF
closure, provision of an acceptable wound bed for performance of split-thickness skin grafting (STSG), or optimization of the overall situation in preparation for future surgery.
Optimal control of fi stula output is key to achieving these
goals but, as stated, can often be diffi cult in execution. In this
case, pharmacologic adjuncts assist in reduction of fi stula
output and aid in EAF effl uent control. The most widely utilized and studied adjunct is octreotide. Octreotide is the
long-acting synthetic analogue of somatostatin, a naturally
occurring hormone that reduces gastrointestinal, biliary, and
pancreatic secretions while increasing intestinal electrolyte
and water absorption [ 50 ]. These effects are understandably
benefi cial in the patient with an EAF. Though often not
stated, the drug also has the potentially negative effects of
132
E.K. Johnson
Figs. 8.19, 8.20, 8.21, and 8.22 This series of images shows an EAF
patient as they progress through the phases of management. The fi rst
image shows a large poorly controlled EAF associated with a wound that
decreasing the release of growth hormone and thyroid stimulating hormone [ 51 ].
The role of octreotide in the management of EAF has not
been specifi cally investigated; however, numerous studies of
the drug’s use in patients with enterocutaneous fi stulas exist
[ 50 , 52 – 61 ]. Claims that octreotide and somatostatin reduce
fi stula output and result in a higher rate of spontaneous fi stula
closure are controversial. A 2011 meta-analysis of the role of
these drugs in patients with enterocutaneous fi stulas concluded that both drugs shorten the time to fi stula closure, but
only somatostatin improved the rate of spontaneous closure
[
52 ]. There are several analyses that show a reduction in fi s-
tula output with the use of these medications [
55 – 57 , 59 , 61 ],
while others show questionable or no benefi t [ 50 , 53 , 60 ].
A single center study of 60 ECF patients showed no benefi t
actually gets wider initially and is controlled with a wound appliance.
Over time the wound bed granulates and contracts ultimately leaving the
patient with a very small open wound with two mature fi stulas
to the use of octreotide, though did show an increase in septic
and thrombotic complications in those in which the drug was
used [ 58 ]. Another randomized controlled trial of the use of
these drugs in 2004 showed that both somatostatin and
octreotide reduced time to ECF closure as well as overall
hospital costs [ 54 ]. Given the mixed nature of reports in the
literature, the use of these pharmacologic adjuncts should be
individualized in EAF patients, keeping in mind the potential
negative effects and complications associated with their use.
Drugs such as proton-pump inhibitors and histamine-2
receptor blockers have been shown to be benefi cial in patients
with short-gut syndrome [
62 ]. The benefi t is at least in part
related to a reduction in upper gastrointestinal secretions.
While most EAF patients will be receiving one of these
drugs given the nature of their disease, there may be a benefi t,
8 Enteroatmospheric Fistula
133
Figs. 8.23, 8.24, 8.25, and 8.26 This series of images depicts
construction of a “fi stula VAC.” A “donut” is constructed out of sponge
and nonporous drape. This is utilized to dam off the EAF from the
although unproven, in reducing EAF output. Patients with
more distal fi stulas may benefi t from the use of loperamide
to control effl uent, although there is no data to support this
drug’s use for this purpose.
Psychiatric Implications of EAF
Key Concept : The psychiatric toll on both the patient and
surgeon is tremendous . Open discussion between all parties ,
including airing of frustrations , anger , or concerns , is benefi cial . Managing expectations and the involvement of mental health specialists can aid in this process .
surrounding wound. Stoma paste and powder can be used to facilitate this. The remaining wound bed is covered with sponge and drape.
A fi stula appliance is placed over the EAF to control effl uent
Dealing with an EAF presents numerous challenges
to the patient and their family. There are signifi cant psychiatric implications associated with this disease process.
Unfortunately, EAF is a problem with no rapid solution. In
the best cases a fi stula may close nonoperatively after a signifi cant amount of time (i.e., months) and intensive care management. Patient activity is typically severely limited during
the early and intermediate phases of disease. Diffi culties
with effl uent control can prevent a patient from ambulating
any signifi cant distance and may completely eliminate the
ability to perform normal activities of daily living. Problems
134
E.K. Johnson
Fig. 8.27 Wound appliance in place
with body image occur as a direct result of the physical
appearance of the abdomen, the smell of the EAF effl uent,
and the potential or actual leakage around wound appliances that can be devastating for a patient’s psyche. Even if
a patient becomes stable enough to leave the hospital, they
often become homebound and reclusive, with limited mobility, while they await spontaneous closure or corrective surgery. Because of this, patients and family will often pressure
the surgical team for a quick solution. While no published
data addresses the issue in EAF patients specifi cally, depression is clearly a major problem faced by these individuals.
Patients and their family members may be at risk for acute
stress disorder as well as post-traumatic stress disorder [ 63 ].
Depression and anxiety also remain real threats to family
members of EAF patients. The tremendous volume of care
required by EAF sufferers may prevent family members from
keeping normal work schedules and often can result in the need
for family members to completely change their daily life to
provide support to a loved one. Awareness of the psychological
impact of this disease on patient and family is critical for the
surgeon. Referral for psychiatric care will often be required.
Most importantly, the surgeon must not allow pressure from
the family or patient to have a negative impact on the long-term
plan of care. Rushing to the operating room to solve a “perceived” problem may result in worsening of the “real” problem
as well as the potential of burned bridges for the future.
Late/Chronic Phase
Key Concept : Failure of spontaneous closure leads to a
period of preparation prior to surgical intervention . This process lasts several months and is dictated by the individual ’ s
nutritional , overall health , and overlying skin and EAF status . Optimization of these factors and extensive planning that
includes both the reestablishment of gastrointestinal tract
continuity and abdominal wall reconstruction is required .
In the late phase of care, realistic treatment goals have
been established and management is driven to best prepare
the patient to meet these goals. If there was a realistic expectation of spontaneous closure, but it has not occurred by
12 weeks, it is unlikely to occur. A shift toward preparation
for eventual surgery is probably best in these individuals. In
the majority of EAF cases, this will have been determined
early in the intermediate phase and preparation for surgical
treatment will be in full swing. An incisional hernia will by
defi nition coexist with the EAF. Many of these abdominal
wall defects can be quite large and are often associated with
a signifi cant loss of abdominal domain. When planning, you
will be faced with a multifaceted problem: when and how to
approach the fi stula, how to repair the associated hernia,
whether or not to reconstruct a functional abdominal wall,
and whether or not to perform repair of the fi stula and the
abdominal wall concomitantly or in a staged fashion.
These cases will be categorized as wound classes II–IV
since the gastrointestinal tract is open and will have to be
violated during the procedure. The wounds are often contaminated with bacteria or are grossly infected. Often these
patients will have gastrointestinal tract stomas in place,
which may require takedown at the time of fi stula repair,
while others may require temporary proximal diversion to
protect a high-risk anastomosis. All of these variables make
the decision to address the abdominal wall a challenging one
in terms of timing of repair, choice of prosthetic material
used in reconstruction, and the decision to embark on a
staged vs. non-staged approach. From this, two major questions always lurk: when do you re-operate and on whom do
you attempt surgery?
Timing of Surgery
This area is controversial at best and there is no level I data
to support any specifi c period of delay prior to an attempt at
closure of an EAF or abdominal wall reconstruction. Most
experienced surgeons would agree that a period of at least
3 months after the initial laparotomy or fi stula formation
would be advised before any attempt at operative repair.
This allows time for intra-abdominal adhesions to soften,
for infl ammatory processes to resolve, and reduces risk of
iatrogenic bowel injury during the reparative procedure.
In patients who have had split-thickness skin grafting directly
over bowel, defi nitive surgery is routinely deferred until the
graft is no longer adherent to the underlying viscera. This
can be determined with a simple “pinch” test (Fig. 8.33 ) by
pinching the skin graft between the index fi nger and thumb
to see if it lifts freely from the intestine underneath. In general, this takes longer than 3 months and can take up to a year
before conditions are ideal for proceeding with surgery.
Various authors have reported delays that range between
2 and 929 days from initial temporary abdominal closure to
attempted defi nitive reconstruction [
64 – 67 ], with mean times
8 Enteroatmospheric Fistula
135
Figs. 8.28, 8.29, 8.30, 8.31, and 8.32 This series of images shows a
poorly controlled deep EAF with resulting skin irritation and an adjacent
loop ileostomy. This individual was managed with a wound appliance,
and despite chronic contact of the wound bed with fi stula effl uent, the
wound contracted nicely over time with resultant spontaneous closure of
the deep EAF. The ostomy was taken down and the patient did well