Entero-Atmospheric Fistula: The Evolution of Complex Wound Management

Background: Enteroatmospheric (EAF) fistulae pose tremendous challenges to patients, physicians, and nursing staff.  We present a successful strategy of fistula containment and skin graft repair of a complex EAF based on previous descriptions, and discuss our experience and the lessons learned.

RP is a 62 year old female with ovarian cancer, status post cytoreductive surgery, which was complicated by a dehiscence and multiple (12) ECFs.  Conventional management was unsuccessful resulting in a large abdominal wound with multiple EAFs.

Methods: The EAFs were individually secured to condom catheters, penrose drains, and a sterile bag, a split-thickness skin graft (STSG) placed to the wound, and V.A.C. (KCI, USA) dressing placed. After 5 days of negative pressure therapy the V.A.C. was removed revealing a healthy STSG with >95% take. The drains had been dislodged resulting in succus spillage threatening the viability of the STSG.  Only the bag remained secure to its EAF without leak.  Due to the tenuous nature of the young STSG, we sewed bags to each EAF, placed them to gravity drainage, and repeated the V.A.C. dressing for another week.  After this period, the STSG around the fistulae had completely taken shape, allowing a fitted ostomy appliance for proper drainage of the the EAF contents.

Results: After fistula containment surgery and successful skin grafting RP was able to tolerate a regular diet with appropriate management of the ECF output.  She was able to become ambulatory with a secure ostomy appliance and was discharged home.

Conclusion: Management of complex abdominal wounds with intestinal fistulae is an evolving therapeutic challenge.  Intuitively, centers that have standardized protocols have shown improved outcomes in small series. Controlling fistula output with a “silo” technique has shown promise in protecting the wound from further injury, while allowing a STSG to mature and nutritional status to be replenished.