Management of Two patients with Enterocutaneous Fistula After Open Abdomen Requiring Split-Thickness Skin Grafting

Abstract

We present the cases of Patient A, a 71-year-old female, and Patient B, a 74-year-old male, who underwent successful management of enterocutaneous fistulas after having open abdomens requiring split-thickness skin grafting. Enterocutaneous fistulas are one of the most challenging problems in abdominal surgery with a high morbidity and mortality. Most studies demonstrate a 20%-30% closure rate. With the use of appropriate dressings, many of the fistulas that will close spontaneously do so within the first month. Principles of management include initial resuscitation, nutrition, wound care, and control of effluent. In this case series, we discuss wound management and effluent control. Patient A initially underwent liposuction complicated by colonic perforation and necrotizing fasciitis. Patient B initially presented with adhesive small bowel disease complicated by intraabdominal hemorrhage and abdominal compartment syndrome post-operatively. Both patients had prolonged hospital courses requiring multiple trips to the OR resulting in partially closed abdomens requiring skin grafts. During the period of open abdomen with known concern of entero-atmospheric fistula development, oil emulsion and white foam were used under negative pressure wound therapy (NPWT). Areas of concern were able to be closed down in this fashion. Once adequate granulation tissue had formed, a split-thickness skin graft was applied. After removing operative dressings, a lipidocolloid^‡ was applied over the skin graft while a hydroconductive dressing* was applied over the fistula covered by a hydrocellular foam^†. Collagen/oxidized regenerated cellulose˚ was utilized to promote ingrowth to remaining lesions. With this method, wound care could be performed twice weekly, allowing patients to be managed outside the hospital. The cost comparison between continued NPWT and this dressing, excluding extended hospitalization charges, was also reduced from approximately $90/day to around $4/day. With these two patients, we are able to demonstrate optimal outcomes, but need a larger population and continued evaluation to draw further conclusions.

Trademarked Items (if applicable):
‡UrgoTul, Urgo Medical North America, Fort Worth, Texas, USA
*Drawtex®, Urgo Medical North America, Fort Worth, Texas, USA
†Allevyn Gentle Border, Smith & Nephew, Inc., Fort Worth, Texas, USA
˚Promogran Prisma™Matrix, 3M Acelity, Inc., San Antonio, Texas, USA