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136
Figs. 8.28, 8.29, 8.30, 8.31,
and 8.32 (continued)
E.K. Johnson
Fig. 8.33 The “pinch” test that can be done to assess readiness for
reconstructive surgery
to attempted reconstruction of 311 days [ 65 ], 184 days [ 66 ],
and 585 days [ 67 ]. Due to the retrospective nature of these
studies, it is diffi cult to relate the success of a reconstructive
effort with the timing of surgery. What is clear, though, is
that a waiting period of 6 months or longer is common.
Contrary to these reports, another author suggests that a
delay of longer than 12 months may be associated with
increased loss of domain, thereby making a tension-free
repair more diffi cult leading to an increased recurrence [ 64 ].
It must be noted that these studies included many patients
that did not have EAFs and simply required abdominal wall
reconstruction after management with a planned ventral hernia strategy after an open abdomen. Regardless, any reconstructive attempt must be well planned, and the optimal
timing will be intimately related to resolution of infl ammation, softening of the surrounding tissues, improvement in
nutritional status, and overall fi tness of the patient. Surgical
judgment based on these multiple factors is likely the key to
success.
Optimization: Preparation for Surgery
Optimization of these factors prior to surgery can be achieved
through utilization of an appropriate delay, aggressive nutritional strategy, overall medical and physical re-conditioning,
and detailed planning. No matter what nutritional strategy is
employed, the patient’s overall nutritional status should be
assessed. This is likely best accomplished through the measurement of serum prealbumin levels, albumin and protein
levels. It is best to see a sustained achievement of normal
levels to ensure adequate nutritional status over time. Any
sudden decrease in the serum level of prealbumin should be
followed by measurement of serum C-reactive protein
(CRP), as any secondary infection or infl ammatory process
will lead to an acute phase response with a decrease in synthesis of prealbumin accompanied by an increase in CRP.
Sometimes this may be an early sign of line sepsis, pneumonia, or recurrent intra-abdominal abscess and should prompt
further investigation and avoidance of any extensive surgical
procedure. Any reconstructive procedure performed on a
8 Enteroatmospheric Fistula
137
malnourished patient is doomed to failure. This may be the
single most important factor to optimize prior to surgery.
Medical and physical optimization will require support
from a multidisciplinary team of providers including internists, medical subspecialists, physical therapists, and social
workers. Diligent preparation in these areas will ease recovery
from major reconstructive procedures and must be emphasized. Detailed planning for reconstruction starts fi rst with
obtaining an abdominopelvic CT scan utilizing IV and enteral
contrast. Imaging will assist in defi ning areas of potential
ongoing infl ammation and obstruction, as well as provide
detailed information about abdominal wall musculature and its
relation to underlying structures. The distance of rectus diastasis can be accurately measured, and a safe site of entry can
potentially be chosen. This information will assist the surgeon
in determining potential sizes and types of reinforcing materials that will have to be on hand and may in fact determine the
best approach to abdominal wall closure and reconstruction.
Staged vs. Non-staged Approaches
Key Concept : One or more extensive operations may be
required to achieve EAF and abdominal wall closure .
Planning for this involves setting well - defi ned goals , communicating these with the patient and their family , avoidance of overaggressive surgery , and knowledge of “ bail - out ”
strategies .
As previously stated, an individual that has been patiently
awaiting corrective surgery for an EAF will often push their
surgeon to achieve a quick single-stage solution to their
problem. The prospect of undergoing two or more major surgical procedures to correct all existing problems may not be
palatable to patient or family. Advocates of a single-stage
approach to this problem cite this advantage, as well as a
potential decrease in overall morbidity by avoiding multiple
procedures. A second approach to the problems of gastrointestinal tract fi stulae and coexisting abdominal wall defects
is to handle these issues remotely from one another at separate surgeries in order to improve the outcomes associated
with the abdominal wall reconstruction.
When using complex reconstructive techniques such as
component separation, [ 68 ] (Fig. 8.34 ) or fl aps, the fi rst
attempt will be the easiest and most likely to achieve success.
Proponents of the staged procedure cite several advantages.
Given the contaminated nature of these cases performed in
patients with fi stulae and/or intestinal stomas, infectious
complications may be decreased, as well as improving overall closure rates, and decreasing the rates of recurrent hernia
by performing the abdominal wall reconstruction after the
EAF has been addressed. Aside from the risk of infection,
the nutritional status of these patients may be far superior
after repair of their fi stula and complete reliance on enteral
feeding utilizing the entire GI tract.
There are no prospective studies that have randomized
patients to a staged vs. non-staged approach to these prob-
Fig. 8.34 A unilateral traditional “Ramirez” component separation.
Unilateral fascial release may be all that is needed in some cases to get
approximation of the rectus fascia at the midline
lems. There are several small retrospective analyses of
patients that required surgical management of both fi stulae
(not all EAF) and large abdominal wall defects, some of
which took a staged approach [ 66 ] and some of which did
not [ 69 , 70 ]. One retrospective review of 19 patients with
high-output EAFs associated with large abdominal wall
defects revealed a 31.5 % re-fi stulization rate after the initial
procedure performed to repair the digestive tract fi stula [ 66 ].
The investigators used a staged approach to abdominal wall
reconstruction employing the use of fl ap procedures, but
unfortunately did not report the results of the reconstruction
in their manuscript. It is certainly reasonable to assume that
the cases where re-fi stulization occurred would have likely
failed any abdominal wall reconstructive attempt had the
procedures been performed concomitantly.
A retrospective study of 32 patients that had either intestinal stomas or enterocutaneous fi stulae in the presence of
large abdominal wall defects who subsequently underwent
single-stage closure of the gastrointestinal tract and their
abdominal wall defect using a component separation technique reported a 28 % rate of wound complications, 21 %
recurrence of hernia, and 26 % recurrence of fi stulae with a
median follow-up of 20 months [ 69 ]. The authors concluded
that the rates of hernia recurrence and re-fi stulization were
acceptable, although the defi nition of acceptable is certainly
open for debate. Because of the diffi culty associated with the
care of these patients, the United Kingdom has established
specialized intestinal failure units to assist in, and potentially
improve the care of these diffi cult cases [ 70 ]. The standard
management in one of these units has been to perform repair
of the fi stula with concomitant abdominal wall closure/
reconstruction after initial optimization of the patient’s overall condition—focusing mainly on nutritional support and
control of sepsis. Sixty-one patients underwent 63 operations
138
E.K. Johnson
to close digestive tract fi stulae associated with open abdominal wounds. They used primary suture repair, with and without component separation, or suture repair in combination
with absorbable or nonabsorbable prosthetic mesh to reconstruct the abdominal wall in these individuals. The observed
postoperative mortality rate was 4.8 %, with respiratory or
surgical site infections occurring in 82.5 %. Re-fi stulization
occurred in 11.1 % of the group but was more common when
prosthetic mesh was used (24.1 %). Porcine collagen mesh
was associated with a particularly high rate of re-fi stulization
at 41.7 %. These authors discourage the concomitant repair
of fi stulas with abdominal wall reconstruction and suggest
avoiding the use of prosthetic mesh [
70 ].
Jernigan and colleagues [ 64 ] reviewed their experience
with a 3-stage approach to complex abdominal wall defects
in 274 patients over 8 years. They did not specifi cally address
individuals with fi stulae, but all patients were critically ill
and were managed with open abdomens. Their management
scheme was as follows: stage 1, absorbable mesh insertion
for temporary closure (with mesh pleating and delayed closure if edema resolved within 3–5 days); stage 2, mesh
removal after 2–3 weeks and formation of a planned ventral
hernia through placement of a split-thickness skin graft over
granulation tissue or a full-thickness skin closure over viscera; and stage 3, defi nitive abdominal wall reconstruction
after 6–12 months using the modifi ed component separation
technique. Of note, 39 % of the patients died during stage 1
secondary to shock. Of the 166 patients who lived and had
absorbable mesh placed, 22 % underwent delayed fascial
closure. In the stage 2 group, there were nine deaths from
multisystem organ failure, with 96 % of the remaining 120
patients having a skin graft placed over the viscera. A total of
14 fi stulae occurred (8 % of survivors). To date, 73 of the 120
have undergone defi nitive abdominal wall reconstruction
with no deaths and a 5 % rate of recurrent hernia at a mean
follow-up of 24 months. This large, retrospective study demonstrates nicely how a well thought-out and staged reconstructive plan can result in low mortality with good long-term
results. Application of these results to the patient with an
EAF must be done cautiously, however, as these patients
were not analyzed separately as a specifi c group.
Abdominal Wall Reconstruction (AWR)
Key Concept : Reconstruction of the abdominal wall may be
the most diffi cult aspect of the case , fraught with high complication rates . Expertise is crucial to successful results and
may require a multidisciplinary approach along with use of
mesh , fl a p , or tissue transfer techniques .
Reconstruction of the abdominal wall can be a complex
and high-risk procedure. When performing defi nitive surgery
for EAF, one immediate goal is to obtain closure of the abdomen over the visceral repair (Fig. 8.35 ). Exposure of bowel to
the environment is one factor that likely led to formation of an
EAF to begin with and must be avoided at this stage at all
costs. The approach to closure of the abdominal wall will be
dictated in part by the decision to stage the repair or not.
There is no ideal technique or simple approach to AWR.
Component separation techniques (CST) and fl ap reconstructions tend to be technically demanding and can be associated
with an increased incidence of wound problems depending on
the approach used; however, they can provide a functional
abdominal wall reconstruction. Simple mesh underlay closure
of fascial defects will result in an acceptable hernia repair, but
often leaves the patient with a large area of laxity on the anterior abdominal wall. The lack of a functional anterior abdominal wall may limit their physical activity in the future, and the
fi nished appearance may be cosmetically inferior. It is important to consider a patient’s functional status and expectations
when determining which approach to use for abdominal wall
reconstruction and hernia repair (Figs.
The CST originally popularized by Ramirez in 1990 [
8.36 and 8.37 ).
68 ]
involves separating the rectus muscle from the posterior rectus sheath and the external oblique muscle from the internal
oblique, thereby resulting in medial advancement of approximately 5 cm at the epigastrium, 10 cm at the waistline, and
3 cm in the suprapubic region unilaterally (Fig. 8.38 ). This can
be coupled with mesh reinforcement and restores a dynamic
and functional abdominal wall. There are several reports in the
literature on the success of CST in the management of large
ventral hernias, revealing rates of hernia recurrence from 6 to
52 % [ 68 , 71 – 83 ]. It may seem intuitive, but it is worth stating
that larger hernia defects are more likely to recur and they are
more likely to require mesh-bridging techniques whether or not
CST is used. Ideally, CST is used to facilitate full re-approximation of the rectus complex in the midline with some sort of
mesh buttress. Some defects are so large that bridging will still
be required even after performance of component separation.
One can expect higher recurrence rates in these scenarios.
A randomized comparison of CST to prosthetic mesh closure with an expanded PTFE patch in 39 patients [ 78 ] showed
that wound complications were more frequent in the prosthetic group and 38 % of the patients closed with mesh
required its removal later because of infectious complications. Recurrent hernia was noted in 52 % of those undergoing CST and in 36 % of those with prosthetic repair. While it
is diffi cult to draw defi nitive conclusions from this small
study, the two methods were statistically equivalent in this
group. Several minor modifi cations of the CST technique
have been reported in the literature with varying success rates
[ 74 , 75 , 81 , 84 ]. All of these reports involved either single
cases or very small groups of patients. More recently there
has been a surge of interest in the use of the posterior CST,
81 ] likely related to the ability to exploit the retro-rectus
[
space for placement of mesh reinforcement. Many of those
who were major proponents of the classic anterior CST have
shifted to the posterior approach.
8 Enteroatmospheric Fistula
Yes
EAF and AW
defect, cannot
get midline
closed
139
No
EAF takedown
Visceral
coverage
Absorbable
mesh
Adequate skin
coverage
No
NPWT
keep moist
Fig. 8.35 Algorithm illustrating a strategy for abdominal wall reconstruction in EAF patients. EAF enteroatmospheric fi stula, AW abdominal wall,
AWR abdominal wall reconstruction, CST component separation technique, NPWT negative-pressure wound therapy
Biological
mesh
Yes
Close skin
over drains
Staged repair?
No
EAF takedown
with biologic
bridge
Candidate
for AWR?
Yes
EAF takedown
and CST
Reinforce CST,
primary closure
with biologic
mesh
Utilization of CST may assist in AWR by increasing
abdominal domain. Comparisons of preoperative and postoperative CT scans of the abdomen and pelvis after CST
repair of large abdominal wall hernias with associated loss of
domain have shown signifi cant increases in the intraabdominal volume without any signifi cant change in diaphragmatic height [ 85 ]. It may be possible to restore lost
domain without the unfavorable result of pulmonary compromise secondary to a loss of thoracic volume.
One of the major criticisms of the anterior CST approach
is the large bilateral skin fl aps that result from the dissection
necessary for exposure during the procedure. Flap complications comprise the majority of wound occurrences noted
with this procedure. Several approaches have been devised
to avoid the seroma and potential infections that can be common. The use of fi brin sealant has been shown to reduce
seroma and wound infection rates in patients undergoing
traditional anterior CST [ 82 ]. Placing numerous “quilting”
mattress sutures has been described to eliminate dead space
with the potential decrease in seroma formation but has
not been studied prospectively. Rosen et al. [ 83 ] described
the use of a laparoscopic component separation technique
in seven patients that altogether eliminates the large fl aps
created using the open technique. The technique is similar
to that used in TEPP laparoscopic inguinal hernia repair.
Release of Scarpa’s fascia should also be performed with this
approach, although care must be taken not to divide the linea
semilunaris itself. After performance of the CST portion of
the case laparoscopically, the midline may be reconstructed
using either a laparoscopic or open approach—a requirement
in all EAF patients treated with a single-stage procedure.
Short- term follow-up of patients treated with this technique
has shown acceptable outcomes. Laparoscopic CST has been
shown to be inferior with regard to mobility in a porcine
model, as it yielded only 86 % of the medial mobilization
of the rectus that was achieved with the open technique [ 86 ].
In cadaveric testing the two have been shown to be equivalent [ 87 ]. Another minimally invasive method of achieving a
lateral release has been described by creating small tunnels
from the midline incision instead of large fl aps [
88 ]. While
this technique is approached through a large midline incision, it avoids the creation of large fl aps with their attendant
140
E.K. Johnson
Figs. 8.36 and 8.37 These images show a young patient after a functional abdominal wall reconstruction. Note the obvious positioning of
the rectus back in the midline as well as his ability to perform a sit-up
wound morbidity, potentially making it ideal in the case of
single-stage repair of EAF. Laparoscopic and other minimally invasive approaches to component separation are relatively new, and to date, no randomized comparisons of these
techniques with traditional techniques have been undertaken.
Biologic or Synthetic Mesh
Key Concept : Choice of mesh involves factors ranging from
the risk of infection , strength and durability to incorporation ,
to personal preference . Regardless of choice , primary myofascial apposition along with the mesh vs . using a mesh
“ bridge ” results in decreased hernia formation .
AWR performed at the time of EAF repair will occur in a
contaminated or potentially grossly infected environment.
This precludes the placement of a permanent prosthetic or
alloplastic mesh as a bridge or reinforcement secondary to
risk of infection requiring prosthetic removal. The advent of
biologic prosthetic meshes has provided one more tool for
the care of these complex patients. While these materials can
still get infected in 0–40 % of cases [ 29 , 30 , 89 – 106 ], they
appear to be more suitable for placement in contaminated
operative fi elds than do permanent synthetic prosthetics.
There are currently numerous biologic mesh products
available on the market, the discussion of which is beyond the
scope of this chapter. The majority of products are collagenbased, and this collagen can be either cross-linked or noncross-linked. They are all somewhat different in the way they
are processed, and all products claim to support normal host
fi broblast and vascular ingrowth. Each manufacturer claims
that their product is either integrated into or replaced by
host tissue. There is a paucity of high-quality data to support any of these claims, but what appears certain is that
these materials can be used safely in complicated scenarios
to assist in the achievement of abdominal wall closure and
visceral coverage when permanent synthetic options cannot
be used. Cross-linked biologic prosthetics tend to be stronger
and have higher bursting strengths, while non-cross- linked
biologic prosthetics allow for more host cellular ingrowth
and “resorb” faster in vivo. It is the author’s experience that
cross-linked prosthetics become encapsulated as opposed to
incorporated into host tissues. This may or may not be desirable to the operating surgeon. It is important to note that a
completely cross-linked prosthetic will not incorporate into
host tissues at all, while partially cross-linked prosthetics
will incorporate to some degree.
The majority of data available for biologic mesh use
in AWR involves three products: AlloDerm ® (LifeCell
Corporation, Branchburg, NJ) [ 29 , 30 , 96 – 106 ], Surgisis ®
(Cook Biotech, West Lafayette, IN) [ 93 – 95 ], and Permacol™
(Covidien Surgical, Mansfi eld, MA) [ 89 – 92 ]. AlloDerm
studies included between 10 and 144 patients revealing hernia recurrence rates between 0 and 100 % with variable follow- up. There is unfortunately a fair amount of heterogeneity
in the approach to reconstruction within each study, making it
diffi cult to draw defi nitive conclusion from the data. Reports
of Permacol™ use include between 1 and 28 patients with
hernia recurrence rates of 0–15 % with variable length of
follow-up [ 89 – 92 ]. Several studies on the use of Surgisis ®
to repair both ventral and inguinal hernia defects in contaminated environments have been published [ 93 – 95 ]. These
studies have included between 20 and 53 patients with mean
follow-up periods of 14–19 months and showed hernia recurrence rates of 0–30 %. All ventral repairs completed in these
studies were performed using a fascial-bridging technique.
One study of the use of a non-cross-linked porcine dermal
scaffold in the abdominal wall reconstruction of 16 patients
reported a 7 % hernia recurrence rate after 16.5 months of
follow -up [
105 ]. Importantly, the majority of these patients
8 Enteroatmospheric Fistula
ab
cd
ef
141
Fig. 8.38 These drawings depict the anatomy of the rectus and oblique
muscles on one side of the anterior abdominal wall. The traditional
“Ramirez” anterior component separation is shown. Release of the
external oblique is performed and the space between the external and
underwent CST, and they achieved complete apposition and
closure of the rectus muscles in 88 %. The porcine matrix
was used as a reinforcing underlay in the majority of these
patients but was used as a bridge graft in those where rectus
apposition could not be achieved. The only recurrence was
noted in a patient who was “bridged” (Fig. 8.39 ).
There is some controversy as to whether or not bridging a fascial defect with a biologic prosthetic is an adequate hernia repair. A retrospective review of 11 patients
that had large complex hernias bridged with human acellular dermal matrix found an 80 % hernia recurrence rate
at a mean follow-up of 24 months and a cost of $5,100 per
patient [ 29 ]. The manuscript title asserts that bridging
with a biologic may simply result in an expensive hernia
sac. Another study showed that a biologic mesh-reinforced
primary repair (involving CST in most) had only a 20 %
recurrence, while 80 % of patients who were bridged with
the same biologic mesh-reinforced primary repair had
hernia recurrence [ 96 ]. The obvious confounder in this
study is that patients who were bridged had larger defects
that were more likely to recur in any case. Comparison of
biologic reinforcement of CST with historical controls
internal obliques is developed out to the fl ank. The posterior rectus fascia is also released. Arrows indicate the direction of dissection, ( a – f )
indicate the order of dissection, 1 – 4 indicate the layers of the abdominal
wall and muscles
Fig. 8.39 A bridge repair with a biologic mesh
who were not reinforced shows a decreased recurrence
rate in hernias that did not require bridging [
97 ]. There
have been other reports that surgical site infection is more
common with larger biologic implants [
103 ] and that
142
E.K. Johnson
hernia recurrence in those treated with biologic implants
is more common in women, increased body mass index,
prior failed repair [
104 ], and with use of the ultra-thick
form of human acellular dermal matrix as opposed to the
thick variety [ 100 ].
Another controversy that exists regarding the use of biologics in abdominal wall reconstruction is the issue of what
defi nes a recurrent hernia vs. simple abdominal wall laxity. Unfortunately, the difference between these two, if one
exists, is often not addressed in manuscripts that discuss hernia recurrence rates. In one study that does address this issue
[ 101 ], the authors comment that bridging was performed in 9
of the 27 patients in their study group who underwent repair
of large abdominal hernias using AlloDerm as an underlay in
combination with CST. Two of the 9 patients also had a polypropylene mesh onlay constructed over the biologic. Laxity
was seen at 1-year follow-up in 7 of the 9 that did not have a
polypropylene mesh onlay performed. Others report laxity or
hernia recurrence in 100 % of those bridged with AlloDerm ®
at 1 year follow-up [ 30 ]. AlloDerm ® in particular has been
associated with abdominal wall laxity with long-term follow up, and this is believed to be related to the elastin content in
the graft. The manufacturer suggests pre-stretching the graft
and placing it under some tension to minimize this complication. LifeCell Corporation also now markets Strattice™, a
non-cross-linked porcine dermal product, specifi cally for the
purpose of AWR given its lack of elastin content.
In the situation of a staged abdominal wall reconstruction
in a patient that has previously undergone EAF repair with
simple visceral coverage, a synthetic prosthetic mesh may be
appropriate to use (for a clean wound class I). The issue of
bridging vs. complete myofascial re-approximation is pertinent in the select patient population with complex abdominal
wall defects. While the idea of tension-free hernia repair has
made its way from use in the inguinal region to use in ventral
hernia repair; it may be that this concept is fundamentally
fl awed. It is obvious that bringing a patient’s fascia together
in the midline under extreme tension increases the risk of
failure; however, a certain amount of tension on a repair is
desired. When surgeons place a piece of prosthetic mesh as
an underlay to bridge a fascial defect, a degree of tension is
intentionally placed upon the underlay mesh to fascia interface. A prosthetic placed with no tension at all results in a
palpable bulge or soft spot at the location of the fascial defect.
This is undesirable to patients both physically and cosmetically. Either the mesh should likely be placed under some tension to fl atten abdominal contour or a component separation
should be performed to achieve complete myofascial approximation and a functional abdominal wall reconstruction. This
issue is controversial and is not strongly supported by data;
however, a 2005 review of 188 patients with large abdominal
hernias showed a recurrence rate of 31 % in patients treated
with a fascial-bridging synthetic prosthetic vs. 9 % in those
that had complete restoration of myofascial continuity of
the abdominal wall [ 106 ]. It is the author’s recommendation
that primary fascial closure be performed whenever possible
while using a prosthetic underlay to reduce hernia recurrence.
This applies to both synthetics and biologics but is certainly
more important when using a biologic with the intention of
performing a durable hernia repair.
Summary Pearls
EAF patients will present a multitude of challenges to the
surgeon. In a typical case, the surgeon will be confronted
with a complex fi stula, a hostile peritoneal cavity, a complex
and large abdominal wound, the possible presence of or need
for a stoma, a diffi cult abdominal contour, and the presence
of old contaminated prosthetic mesh—all potentially in an
initially septic patient. Each of these elements must be factored into the operative plan to optimize the chance for success. Something as simple as gaining entrance to the
peritoneal cavity must be given thoughtful consideration.
Fortunately, many of these patients are quite remote from the
index procedure and have developed adjacent incisional hernias that may facilitate ease of entry into the abdomen.
Preoperative CT scan may show this and physical examination will be confi rmatory. The presence of adjacent hernia
sac provides a site of entrance that will be free of adhesions.
Take advantage of this if it is present. If not, one may be
forced to enter in the midline where dense adhesions between
the bowel and anterior abdominal wall will create diffi culty
and potentially enterotomies. Lateral entry into the abdomen
should be avoided as it may limit the options for CST during
the reconstructive portion of the procedure.
Performing a complete adhesiolysis during laparotomy is
tempting and can certainly be achieved in some circumstances. Yet, if there are no signs of bowel obstruction either
clinically or radiographically, it is likely best to limit adhesiolysis to areas of necessity. The risk of enterotomy is high,
and the likelihood of re-fi stulization increases with every
enterotomy created. Fistulas should be resected and the
remaining bowel re-anastomosed. The temptation to free an
area of fi stulized bowel followed by primary closure should
be reserved for situations where it is the only possibility.
These repairs tend to break down and are discouraged.
The patient with an ostomy presents an additional challenge. The surgeon must fi rst consider if the stoma should be
closed or left in place. The length of remaining bowel, continence status, presence of a parastomal hernia, and potential
for the need to perform a high-risk distal anastomosis must all
be considered. If the need for a stoma remains, it is easiest to
leave the existing stoma in place. If AWR is performed at the
time of EAF closure, it is likely that the abdominal wall contour will change to some degree. A stoma site that was prime
preoperatively may be completely unsuitable after AWR.
This is especially important with high-output stomas and
8 Enteroatmospheric Fistula
143
Fig. 8.40 A patient previously operated upon where “incorporated”
polypropylene mesh was left in place. She suffered midline wound
breakdown and bowel fi stulization through the mesh. Ultimately this
mesh was excised and she underwent AWR with a good result
ileostomies. If this situation is encountered, the best course of
action is to re-site the stoma. You won’t have the luxury of
selecting an appropriate site preoperatively, so familiarity
with the concepts of selecting an optimal stoma site is critical. The stoma can be delivered through a keyhole in any
mesh used as reinforcement, and should be located through
the rectus muscle. Parastomal hernias can be repaired using
the Sugarbaker technique or can also be addressed via relocation of the stoma and primary closure with mesh reinforcement. High-risk or distal colorectal/coloanal anastomoses
should be covered with a proximal stoma. You have one good
shot at helping these patients, and clinical sequelae of a leaking anastomosis will destroy any chance of success. If any
previous mesh is encountered during the procedure, remove it
completely (Fig. 8.40 ). The old adage that “incorporated
mesh” is fi ne to leave behind is a terrible pitfall. While controversial, it is this author’s opinion that leaving old and
potentially infected mesh behind is a recipe for failure.
Finally, often in the profession of surgery, true wisdom
involves knowing when to say when. There are some EAF
patients that, despite our best efforts and intentions, simply
cannot be helped with surgery. Unfortunately there is no surgical “crystal ball” that will allow us to reliably make this
assessment. Though it may sound obvious, these procedures
are extremely stressful on the patient, and those in poor medical condition with severe cardiopulmonary disease may not
tolerate this stress. Some patients will learn to live harmoniously with an EAF over time. In some, the fi stula simply
becomes a poorly sited stoma that can be effectively controlled with an appliance and wound care products. An
elderly patient with signifi cant comorbidities and a wellcontrolled EAF may be best left alone. Give this considerable thought and ensure adequate counseling of the patient
prior to making the commitment to surgical repair.
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