The Management of the Entero-Atmospheric Fistula (EAF)
The open abdomen is an available tool utilized in the management of damage control laparotomy (DCL) as well as emergency general surgery intra-abdominal sepsis. Despite its theoretical usefulness, open abdomen has definite associated complications includi
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The Management of the Entero-Atmospheric Fistula (EAF) Narong Kulvatunyou and Peter Rhee
Background The concept of open abdomen was popularized in the era of damage control laparotomy (DCL) for trauma (Fig. 25.1). The concept has been applied to an emergency general surgery and intra-abdominal sepsis as well. In trauma, however, the pendulum has now swung toward performing less DCL. This will probably lead to a lower incidence of open abdomen-related complications, i.e., ventral hernia and enteric fistula. Prior reported incidence of open abdomen-related fistula may be as high as 21 % [1]. In this clinical presentation, the fistula presented is termed an “enteroatmospheric fistula” (EAF). It is a fistula without an epithelialized tract and the opening is exposed to air (hence the term “atmosphere”) instead of skin. This type of fistula is very different from the traditionally discussed entero-cutaneous fistula (ECF), because EAF presents a much more clinical challenge in terms of patient’s critical illness, controlling fistula effluence, and the unlikely spontaneous closure of the fistula. However, there have been several prior case reports of spontaneous fistula closure of the EAF using various techniques [2–4]. These will be further discussed later.
N. Kulvatunyou (&) P. Rhee Division of Acute Care Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave., Room 5411, PO Box 245603, Tucson, AZ 85727-5063, USA e-mail: [email protected] P. Rhee e-mail: [email protected] © Springer International Publishing Switzerland 2017 J.J. Diaz and D.T. Efron (eds.), Complications in Acute Care Surgery, DOI 10.1007/978-3-319-42376-0_25
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Fig. 25.1 Budding mucosa (arrow) below the VICRYL mesh in an open abdomen
Etiology Etiology for EAF is somewhat different from ECF, which often discussed in terms of intrinsic versus extrinsic factors. Intrinsic factors included conditions such as an inflammatory bowel disease and diverticulitis. Extrinsic factors included postoperative anastomotic leak and iatrogenic bowel injury. On the contrary, EAF arises mostly from extrinsic factors, usually in association with open abdomen. For example, the fistula can arise from an unrecognized iatrogenic bowel injury that is delay detected during a postoperative course (Fig. 25.2), an anastomotic leak (Fig. 25.3), a significant trauma that is associated with significant loss of abdominal wall domain (Fig. 25.4), or a complication of open abdomen from desiccation (our case scenario). Therefore, whether the open abdomen is intentional or unintentional, the open abdomen is definitely a risk factor for EAF development.
Classification In ECF, a general classification of fistula is often based on effluent output per 24 h. A high output is 500 cc per 24 h, while a low output is less than 200 cc, and a moderate output is between 200 and 500 cc. The classification can also be based on the anatomical location such as gastric versus small bowel versus large bowel. These classifications may have som
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