Eur J Trauma Emerg Surg (2011) 37:241–250 DOI 10.1007/s00068-011-0108-3
REVIEW ARTICLE
Abdominal wall reconstruction in patients with enterocutaneous fistulas R. Latifi • M. Gustafson
Received: 17 February 2011 / Accepted: 4 April 2011 / Published online: 3 May 2011 Ó Springer-Verlag 2011
Abstract Enterocutaneous fistulas (ECFs) remain a feared complication of surgery, particularly in acute care and trauma patients. Despite advances in medical and surgical therapies, ECFs are associated with significant morbidity and mortality; in addition, significant health care resources are consumed in their treatment. Because of the frequency nowadays of open-abdomen and damage-control surgery, of aggressive treatment for abdominal compartment syndrome, and of necrotizing soft tissue infections of the abdominal wall, ECFs are becoming common; so are enteroatmospheric fistulas (EAFs), which represent a new entity where the lumen of the intestine is directly exposed to the outside environment and has no track through subcutaneous or cutaneous tissue. The surgical management of abdominal wall defects, including ECFs and/or EAFs, is often associated with major hernias and other complexities. Careful planning and advanced surgical techniques are required, often involving the use, alone or in combination, of biologic mesh and composite tissue transfer. The treatment of ECFs in patients with large abdominal wall defects is challenging, but with proper techniques, the results can be excellent. Biologic mesh is the mesh of choice in such patients.
R. Latifi (&) M. Gustafson Department of Surgery, Trauma, Surgical Critical Care and Emergency Surgery, University of Arizona, 1501 N. Campbell Avenue, Tucson 85724, AZ, USA e-mail: [email protected] R. Latifi Department of Surgery, Trauma and Surgical Critical Care, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
Keywords Abdominal trauma Emergency surgery Infection Plastic and reconstructive surgery Polytrauma
Introduction In the last few decades, significant advances in surgical techniques and technologies in the management of complex abdominal wall hernias have been achieved. Yet, despite all these advances, major abdominal wall defects remain a major worldwide challenge, in young and old patients with multiple comorbidities. How many abdominal wall defects are classified as complex is unknown, but ventral hernias and other abdominal wall defects clearly represent a significant surgical problem, and are associated with great morbidity and mortality [1]. Every year, in the United States alone, more than 250,000 abdominal incisional ventral hernias are repaired [1]. Of all large abdominal defects, the most complex are those associated with enterocutaneous fistulas (ECFs), enteroatmospheric fistulas (EAFs), and/or stomas, which are source a major morbidity and mortality, as well as poor quality of life (Fig. 1a, b). Most reports in the literature combine patients with abdominal wall hernias and fistulas, so it is unclear what percentage of patients with hernias have concomitant fistulas. It is also unclear what percentage of patients are treated for ECFs in concurrence with large abdominal wall defects, but in our practice, this number is about 20% (unpublished data). One can assume that most ECFs have some sort of abdominal wall defect through which they become evident. Few ECFs develop spontaneously; instead, they typically occur in the face of inflammatory bowel disease, malignancy, radiation, and diverticulitis. Most ECFs (75–85%) are postoperative. ECFs and EAFs develop in an open abdominal wound and
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Fig. 1 When the entire abdomen is a ‘‘fistula city’’! a A 28-year-old male status post shot gun wound to the right lower quadrant, which was complicated by right hip disarticulation and multiple fistulas. b A 24-year-old s/p gunshot wound with uncontrollable fistulas
may be caused by an anastomotic leak, exposed viscera, erosion of mesh into the bowel wall, an injury to the bowel during dressing changes, or tension from adhesions between the abdominal wall and the bowel (Fig. 2a, b) [2]. We have divided the care of these patients into preoperative, intraoperative, and postoperative phases.
Preoperative care The first steps in treating patients with ECFs and/or EAFs are sepsis control, electrolyte and fluid normalization, and the initiation and maintenance of parenteral nutrition support. In the last few decades, sepsis control has undergone significant changes. In critically ill patients, less invasive methods for treating intra-abdominal sepsis have become routine [3, 4]. The mainstay of therapy for intra-abdominal abscesses remains surgical or percutaneous drainage, but
R. Latifi, M. Gustafson
Fig. 2 Dealing with hostile abdomen. a Where does one start dissection (patient in Fig. 1b)? b Hostile abdomen with multiple fistulas despite treatment with total parenteral nutrition (TPN) and local wound care with wound vacuum-assisted closure (VAC) (patient in Fig. 1a)
broad-spectrum antibiotics may be initiated and subsequently tailored based on culture results. Spontaneous closure of ECFs is possible, but most fistulas, especially high-output fistulas, require surgical treatment [5–8]. Careful preparation of the patient for surgery is paramount, with continued attention on reversing sepsis, electrolyte and fluid disturbances, and malnutrition [9]. To help ensure that the surgical procedure succeeds, the patient’s preoperative condition must be optimized by the improvement of nutritional status and blood sugar levels, by cessation of smoking, and by reduction of the bioburden. Elective procedures should be postponed, if at all possible, in patients with a recent weight loss of 10–15%, with a serum albumin level \3 grams/deciliter (g/dL), with ongoing pelvic radiation treatment, and with ongoing systemic steroid or other immunosuppressant use. Hypovolemia and anemia should be corrected, either preoperatively or early intraoperatively, ensuring adequate
Abdominal wall reconstruction in patients with enterocutaneous fistulas
oxygen delivery and, thereby, minimizing anastomotic ischemia. Intraoperative and postoperative hypotension should be avoided. Bowel preparation may be indicated; immediately preoperatively, standard surgical skin preparations should be used and systemic antibiotics administered in order to minimize wound and intra-abdominal infections [10]. How long the surgeon should wait to take down ECFs is unclear. Certain anatomic factors favor spontaneous closure, including a gastrointestinal (GI) tract that remains in continuity; a bowel defect that is \1 cm long and a long tract ([2 cm) of bowel that originates from the esophagus, the duodenal stump, the jejunum, or the colon [11]. Whether or not fistula output affects spontaneous closure is debatable [6, 12]. However, high-output fistulas have been associated with significantly greater mortality [9, 13]. Somatostatin and its synthetic analog, octreotide, inhibit the secretion of many GI hormones and have been used to reduce fistula output, although the results have been inconsistent in the reduction of fistula output and in the time to closure [14–17]. However, they may prove to be useful for wound management in patients with high-output fistulas that are difficult to contain. Factors that contribute to the persistence of fistulas include the presence of a foreign body (such as synthetic mesh), radiation, infection, tract epithelialization, malignancy, distal obstruction, and the use of systemic steroids and other immunosuppressive agents. If such factors are not properly dealt with, fistulas often fail to resolve or recur after surgical intervention [11].
Intraoperative care Once the patient is preoperatively prepared for surgery (with sepsis controlled and nutritional, electrolyte, and fluid status improved), the anatomy of the fistula must be delineated [18–21]. Complex ventral hernias, ECFs, and/or EAFs must be identified, by whatever methods the surgeon thinks best: a fistulogram, a computed tomography (CT) scan, or an upper GI (UGI) study with small bowel followthrough. On many occasions, it is prudent to order a barium or Gastrografin enema in order to study the distal segment of the rectum and/or colon and ensure patency, such as in patients with previous diverticulitis and/or colostomies. The surgeon must consider and decide on the surgical approach, the type and technique of the repair, and the material to use to repair the hernia, always keeping in mind the expected improvement in the patient’s quality of life. The main surgical goals are to establish GI tract continuity and to minimize the recurrence of ECFs, EAFs, hernias, and wound infections. Creativity and a combination of different techniques and repairs are often required.
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The abdominal wall of most patients with ECFs and/or EAFs is hostile; the surgeon may find that even entering the cavity itself presents a significant challenge. When possible, the surgeon should avoid going through the same incision used in prior operations, instead attempting to enter from non-violated areas of the abdominal wall (such as the superior epigastric region or just over the pubic region). However, doing so is usually not possible, especially in patients with prior major operations (such as laparotomy for trauma). An alternative method of entering the abdomen through a transverse incision has been advocated, although we have not used that method in our practice [11]. Fistula excision For resecting the fistulous portion of the bowel, the best scenario is when multiple fistulas are in close proximity to each other; the surgeon can then resect the segment of fistulous tract ‘‘en masse’’ (Fig. 3a–c). For re-establishing intestinal continuity, the hand-sewn double-layer technique (and not staplers) should be used [19]. Adjunct procedures such as strictureplasty can be used to avoid removing a large amount of bowel, because these patients are at high risk for developing short gut syndrome. The surgeon should mobilize the entire bowel from the ligament of Treitz to the rectum. Doing so is tedious and time-consuming, given previous abdominal surgeries and intraabdominal inflammatory processes [11]. If the integrity of the anastomosis is questionable, it is reasonable to revise it or to create a proximal diverting ostomy. Operative treatment with the takedown of ECFs is successful in 80–90% of patients [22]. Patients with ECFs whose abdominal content is covered with a split-thickness skin graft (STSG) and who have large abdominal wall defects require special attention. In this subgroup, before the skin graft is excised, the ‘‘neoskin’’, when pinched between the surgeon’s thumb and forefinger, should be able to be easily elevated from the underlying tissue. Some surgeons do not attempt to excise the skin graft at all, but close the abdomen over it. When excision is attempted while the skin graft is adherent, dissection is likely to result in enterotomies and to risk recurrent fistula formation [19]. Identifying all of the fistulas and the entire GI tract is the key issue at hand. The surgeon must be attentive to technical issues, in order to avoid enterotomies; any inadvertent enterotomies and serosal tears must be repaired. Excessive trimming of the mesentery, tension on the anastomosis, and inclusion of diseased bowel in the anastomosis must all be avoided [10]. Utmost care must be taken to avoid injury to the underlying bowel during fascial closure. Meticulous adhesiolysis must be performed and the entire GI tract identified from the ligament of Treitz to the recto-sigmoid
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Fig. 4 Dealing with a large abdominal defect. a Large abdominal wall defect after gastrointestinal (GI) tract reconstituted. b At the completion of resection and anastomosis and re-establishing GI tract continuity
Fig. 3 Intraoperative decisions. a Resection of an entire block of ‘‘fistula city’’! b Excision of the fistulas and lysis of the adhesions. c Fistulous tract resected
junction. The establishment of diverting stoma is an option and this should be at the discretion of the surgeon. One should never promise the patient that he/she will not have a stoma, at least a temporary one. Abdominal wall reconstruction Definitive surgery for ECFs and/or EAFs entails simultaneous fistula excision and abdominal wall reconstruction.
Once the continuity of the GI tract has been established, as described above, creating a new abdominal wall may represent a serious surgical challenge. Multidisciplinary approaches and advanced surgical techniques may be necessary to cover the exposed viscera (Fig. 4a, b). Whatever technique is used, the goal is to establish coverage of the abdominal cavity with native abdominal wall; if doing so is not possible, biologic or prosthetic mesh should be used, which will eventually serve as the new abdominal wall. In most patients, some sort of combination of reconstruction will be done. If native tissue can be used without undue tension, then that should be the primary step. But if midline tissue cannot be easily approximated, or if mesh reinforcement is needed (as it is in almost all abdominal wall defects larger than 6 cm), then other techniques must be considered. For example, if midline tissue cannot be easily approximated, then lateral components need to be released and a neo-abdominal wall created. In our practice, we most commonly use tissue transposition of myocutaneous flaps through lateral component separation, as described previously (Fig. 5a, b) [23]. Component separation results in the medial advancement of intact
Abdominal wall reconstruction in patients with enterocutaneous fistulas
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Fig. 5 Lateral component separation. a Artist depiction (used with permission from LifeCellTM Corporation). b One can obtain up to 10–12 cm of relaxation in the middle of the abdomen
rectus myofascial units bilaterally, closing defects of up to 10 cm in the upper abdomen, 20 cm in the mid abdomen, and 6–8 cm in the lower abdomen [23, 24]. The component separation technique is based on an enlargement of the abdominal wall surface by the separation and advancement of the muscular layers (Fig. 5b). Other techniques used for abdominal wall reconstructions that have been described include the use of tissue expanders, the use of autogenous pedicle demucosalized small intestinal sheets, and other highly sophisticated plastic surgery operations [25–32]. In our practice, the three most common techniques used to place mesh during abdominal wall reconstruction are onlay placement (Fig. 6), underlay placement (Fig. 7a–c), and interposition or bridge (Fig. 8) placement. At the beginning of our practice, we used mostly onlay placement; however, in recent years, we have changed almost entirely to underlay placement. Underlay placement is more
involved, but once it is learned and perfected, it does not add significant operative time. We prefer underlay placement in order to minimize the incidence of seromas associated with the repair of abdominal wall defects. Either open or laparoscopic surgical techniques can be used to repair abdominal wall defects, but in patients with ECFs and/or EAFs, the open approach is more common. Closed suction drainage prevents seromas, which have the potential to become infected and, thereby, jeopardize the integrity of the closure. If an open abdomen is used, the risk of EAF development can be decreased by placing omentum between the bowel and mesh, by placing skin grafts as soon as possible, by using nonadherent barriers, and by performing vacuum-assisted fascial closure [33, 34]. The lowest EAF rate has been achieved by using inert plastic nonadherent barriers between the visceral and parietal peritoneum, in combination with applying subatmospheric pressure [34].
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Fig. 6 Artist depiction of lateral compartment release, primary approximation (reproduced with permission from LifeCellTM Corporation)
Choice of mesh By definition, patients with ECFs, EAFs, and/or stomas have contaminated wounds. Synthetic mesh has been used in the past, but it was associated with high rates of wound infection (often necessitating the removal of infected mesh for the source control of infection) and with other complications (such as newly created fistulas) [34–38]. Most recently, biologic mesh has become standard in high-risk patients with contaminated and dirty–infected wounds [38]. Most of the published studies using biologic mesh (all of the references mentioned) to repair complex abdominal wall defects do not provide the exact number of concomitant fistulas, with one exception: a recent multicenter, prospective, cohort study of 80 patients with clean–contaminated and dirty–infected wounds reported that only seven of them (9%) had fistulas [36]. To this end, one may conclude, however, that the use of biological mesh for abdominal wall reconstruction in patients with ECFs and/or EAFs should be a standard approach, although there is a need for level I evidence. In a recent study at our center, 60 patients underwent acellular dermal matrix (ADM) implantation for abdominal wall reconstruction from January 2006 through December 2009. Of the 60 patients, four were lost to follow-up. In the remaining 56 patients, we used two brands of ADM: AlloDerm (LifeCell Corporation, Branchburg, NJ) in 38 patients (68%) and Strattice (LifeCell Corporation) in 18 patients (32%). A total of nine patients had concomitant ECFs and/or EAFs. For the nine patients with ECFs and/or EAFs, we used underlay placement in four (44%) and interposition or bridge placement in five (56%) (Table 1). We found that the abdominal wall reconstruction results in patients with versus without concomitant ECFs and/or EAFs did not statistically differ, in terms of the rates of overall complications, of recurrence, and of infectious complications [37]. Others have also reported that ADM implantation can be safely used to repair large and complex ventral hernia
Fig. 7 Underlay technique placement of Strattice, before closing the fascia. Center image artist depiction
Fig. 8 Reconstruction of the abdominal wall using Strattice using the bridge technique. Due to multiple previous surgeries, the patient was not a candidate for other repairs
Abdominal wall reconstruction in patients with enterocutaneous fistulas Table 1 Etiology of fistulas, mesh utilized, and techniques employed in repairs Etiology of fistula ECF
Number (n = 9) 1
% 11
EAF
8
89
Trauma open abdomen
5
67
Gunshot wound
3
33
Number of fistulae Range
1–5
Mean Mesh
2
AlloDerm
8
89
Strattice
1
11
Component separation
5
56
Onlay
0
0
Underlay
4
45
Bridge
5
55
Technique
defects in patients with clean–contaminated or dirty– infected wounds [36, 38]. In the same study, of patients who underwent ADM implantation with either AlloDerm or Strattice, 35 had contaminated fields as defined by the presence of intraabdominal or soft tissue infection, stoma, or fistula [37]. Of those 35, most of them—26 (74%)—were Grade 4, as per a hernia grading system outlined in Table 2 [1]. These studies suggest that biologic mesh implantation is a valid option for complex abdominal wall reconstruction in the high-risk trauma and acute care surgery population. At least one group have suggested staged care in patients with giant abdominal wall defects, without the use of permanent mesh [39]. In their reported study of 274 patients, absorbable mesh implantation with component separation for definitive abdominal wall reconstruction provided effective temporary abdominal wall defect coverage with a low fistula rate. But most surgeons attempt to complete abdominal wall reconstruction at the time of hernia repair or at the time of takedown of ECFs and/or EAFs, even in contaminated fields [34–37]. In our practice, we aim to complete the
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definitive procedure in one operation. On occasion, we have used the principle of damage control, returning the next day or so to complete, if at all possible, the operation. For the last 8 years, in all of our patients with clean– contaminated or dirty–infected wounds, we have used biologic mesh, primarily AlloDerm and Strattice. Our experience with other biologic mesh products, such as Surgisis (Cook Biotech, Inc., West Lafayette, IN) and Veritas (Synovis, St. Paul, MN), has not been good; we have not used Surgisis or Veritas for the last 5–6 years. We prefer underlay placement, which we believe makes seroma formation less likely (even though there are no published data to support this). When mesh is used as a bridge, and when there is no skin or subcutaneous tissue to cover the mesh, then we use wound vacuum-assisted closure (VAC) with continuous irrigation, which keeps the mesh moist and speeds the process of granulation for later skin grafting (Fig. 9a, b). When there is native tissue to cover the mesh, we use four to five drains that stay in for 10–15 days. With underlay placement, we use one large drain between the mesh and fascia, and then three to four drains over the fascia and under the skin and subcutaneous tissue; to avoid drain displacement, we fix all of the drains to tissue with fine chromic sutures. Very recently, a grading system was created to classify patients by their risk for infectious complications, in order to help surgeons decide on the technique and, potentially, on the mesh to be used [1]. Grade 1 refers to patients at low risk for infections or complications who have no history of wound infections; Grade 2 refers to patients with comorbidities such as smoking, diabetes, obesity, a suppressed immune system, and chronic obstructive pulmonary disease (COPD); Grade 3 refers to patients with previously contaminated wound infections, stomas, or intraoperative violations of the GI tract; and Grade 4 refers to patients with infected mesh and septic foci. Obviously, Grades 3 and 4 present serious medical and surgical challenges for the patient and for the health care team, whether led by a general surgeon, trauma surgeon, or plastic surgeon. But even Grade 2 means that patients may harbor a significant risk and need to be thoroughly evaluated preoperatively, otherwise significant problems could arise post operatively.
Table 2 Hernia grading system adapted from reference [1] Grade 1 Low risk
Grade 2 Comorbid
Grade 3 Potentially contaminated
Grade 4 Infected
Low risk for complications
Currently smoking
Previous wound infection
Infected mesh
No history of wound infection
Obesity
Stoma present
Septic dehiscence
No significant comorbidities
Diabetic
Violation of the gastrointestinal tract
Immunosuppressed COPD
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Fig. 10 The final outcome of the patient in Fig. 1a
Fig. 9 Final abdominal wall reconstruction. a Patient in Fig. 1b several months after abdominal wall reconstruction with AlloDerm and skin graft. b Following several weeks of application of wound VAC, finally skin graft, and the final ‘‘product’’. The patient has now resumed fully p.o. intake and is off TPN
Postoperative care The postoperative care of patients after major exploratory laparotomy with takedown of fistulas and abdominal wall reconstruction is as complex as the operation itself. When reoperation is required in the immediate perioperative period, one can open the biological mesh and perform the exploration (Fig. 10). These patients will require continuation of parenteral nutrition, supplemented with massive doses of vitamin C. In our practice, we administer 2 g of vitamin C intravenously every 4 h for at least 1 week, as well as vitamin E, zinc, selenium, and, when appropriate, vitamin A, above and beyond the standard doses in total parenteral nutrition (TPN), until GI tract function returns to normal and patients resume oral intake. Prolonged ileus calls for extreme patience. Careful examination of the wound site is mandatory and should be done by the surgeon who performed the operation. The
Fig. 11 Opening of the biological mesh 36 h after the reconstruction. The mesh was salvaged and closed up primarily
mortality rate can be as high as 50% [22]. The potential for morbidity is also significant, including wound infections and other surgical site complications (20–45%), hernia recurrence (up to 20%), fistula recurrence (up to 47%), depending on the type of mesh used, small bowel obstructions, and pain [31, 40]. Nonetheless, successful completion of ECF takedown and reconstruction of the abdominal wall improves patients’ quality of life significantly (Fig. 11). Comorbidities that increase the risk of infection after hernia repair include smoking, diabetes, COPD, coronary artery disease, malnutrition, a suppressed immune system, chronic corticosteroid use, obesity, and advanced age. According to a National Surgical Quality Improvement Program database, all of those comorbidities, in particular, chronic corticosteroid use, were significant independent predictors of wound infections in a large group of patients [41]. Findings from other studies suggest that advanced age and obesity are also independent predictors of infectious complications in these complex surgical patients [42].
Abdominal wall reconstruction in patients with enterocutaneous fistulas Conflict of interest Dr. Latifi, serves as Speaker for LifeCell Corporation.
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249 20. Draus JM Jr, Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula: are treatments improving? Surgery 2006;140:570–6 (discussion 576–8). 21. Lynch AC, Delaney CP, Senagore AJ, Connor JT, Remzi FH, Fazio VW. Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg. 2004;240: 825–31. 22. Martinez JL, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo F. Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World J Surg 2008; 32:436–43. 23. Ramirez OM, Ruas E, Dellon AL. ‘‘Components separation’’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconst Surg. 1990;86:519–26. 24. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast Reconstr Surg. 2000;105:731–8. 25. Rodriguez ED, Bluebond-Langner R, Silverman RP, Bochicchio G, Yao A, Manson PN, Scalea T. Abdominal wall reconstruction following severe loss of domain: the R Adams Cowley Shock Trauma Center algorithm. Plast Reconstr Surg. 2007;120:669–80. 26. Liu L, Li JS, Li N, Ren JA, Zhao YZ. Reconstruction of infected complex abdominal wall defects with autogenous pedicled demucosalized small intestinal sheet. Surgery. 2009;145:114–9. 27. Kushimoto S, Yamamoto Y, Aiboshi J, Ogawa F, Koido Y, Yoshida R, Kawai M. Usefulness of the bilateral anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management. World J Surg. 2007;31:2–8 (discussion 9–10). 28. Szczerba SR, Dumanian GA. Definitive surgical treatment of infected or exposed ventral hernia mesh. Ann Surg. 2003;237: 437–41. 29. Samson TD, Buchel EW, Garvey PB. Repair of infected abdominal wall hernias in obese patients using autologous dermal grafts for reinforcement. Plast Reconstr Surg. 2005;116:523–7 (discussion 528). 30. Connolly PT, Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL. Outcome of reconstructive surgery for intestinal fistula in the open abdomen. Ann Surg. 2008;247:440–4. 31. Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg. 2005;116:1263–75 (discussion 1276–7). 32. Matthews MS. Abdominal wall reconstruction with an expanded rectus femoris flap. Plast Reconstr Surg. 1999;104:183–6. 33. Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg. 2007;96:263–71. 34. Patton JH Jr, Berry S, Kralovich KA. Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions. Am J Surg. 2007;193:360–3. 35. Kim H, Bruen K, Vargo D. Acellular dermal matrix in the management of high-risk abdominal wall defects. Am J Surg. 2006;192:705–9. 36. Awad S, Baumann D, Bellows C et al. Prospective multicenter clinical study of single-stage repair of infected or contaminated abdominal incisional hernias using StratticeTM reconstructive tissue matrix. (RICH study) Poster Presentation at the American College of Surgeons 2010 Clinical Congress, Washington, DC, 3–7 October 2010. 37. Chavez L, Latifi R, O’Keefe K et al. Are biologic mesh repairs the answer for complicated abdominal wall defects and for patients with enterocutaneous fistulae? In: Oral presentation at the 11th European Congress of Trauma and Emergency Surgery, Brussels, Belgium, 18 May 2010.
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REVIEW ARTICLE
Abdominal wall reconstruction in patients with enterocutaneous fistulas R. Latifi • M. Gustafson
Received: 17 February 2011 / Accepted: 4 April 2011 / Published online: 3 May 2011 Ó Springer-Verlag 2011
Abstract Enterocutaneous fistulas (ECFs) remain a feared complication of surgery, particularly in acute care and trauma patients. Despite advances in medical and surgical therapies, ECFs are associated with significant morbidity and mortality; in addition, significant health care resources are consumed in their treatment. Because of the frequency nowadays of open-abdomen and damage-control surgery, of aggressive treatment for abdominal compartment syndrome, and of necrotizing soft tissue infections of the abdominal wall, ECFs are becoming common; so are enteroatmospheric fistulas (EAFs), which represent a new entity where the lumen of the intestine is directly exposed to the outside environment and has no track through subcutaneous or cutaneous tissue. The surgical management of abdominal wall defects, including ECFs and/or EAFs, is often associated with major hernias and other complexities. Careful planning and advanced surgical techniques are required, often involving the use, alone or in combination, of biologic mesh and composite tissue transfer. The treatment of ECFs in patients with large abdominal wall defects is challenging, but with proper techniques, the results can be excellent. Biologic mesh is the mesh of choice in such patients.
R. Latifi (&) M. Gustafson Department of Surgery, Trauma, Surgical Critical Care and Emergency Surgery, University of Arizona, 1501 N. Campbell Avenue, Tucson 85724, AZ, USA e-mail: [email protected] R. Latifi Department of Surgery, Trauma and Surgical Critical Care, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
Keywords Abdominal trauma Emergency surgery Infection Plastic and reconstructive surgery Polytrauma
Introduction In the last few decades, significant advances in surgical techniques and technologies in the management of complex abdominal wall hernias have been achieved. Yet, despite all these advances, major abdominal wall defects remain a major worldwide challenge, in young and old patients with multiple comorbidities. How many abdominal wall defects are classified as complex is unknown, but ventral hernias and other abdominal wall defects clearly represent a significant surgical problem, and are associated with great morbidity and mortality [1]. Every year, in the United States alone, more than 250,000 abdominal incisional ventral hernias are repaired [1]. Of all large abdominal defects, the most complex are those associated with enterocutaneous fistulas (ECFs), enteroatmospheric fistulas (EAFs), and/or stomas, which are source a major morbidity and mortality, as well as poor quality of life (Fig. 1a, b). Most reports in the literature combine patients with abdominal wall hernias and fistulas, so it is unclear what percentage of patients with hernias have concomitant fistulas. It is also unclear what percentage of patients are treated for ECFs in concurrence with large abdominal wall defects, but in our practice, this number is about 20% (unpublished data). One can assume that most ECFs have some sort of abdominal wall defect through which they become evident. Few ECFs develop spontaneously; instead, they typically occur in the face of inflammatory bowel disease, malignancy, radiation, and diverticulitis. Most ECFs (75–85%) are postoperative. ECFs and EAFs develop in an open abdominal wound and
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Fig. 1 When the entire abdomen is a ‘‘fistula city’’! a A 28-year-old male status post shot gun wound to the right lower quadrant, which was complicated by right hip disarticulation and multiple fistulas. b A 24-year-old s/p gunshot wound with uncontrollable fistulas
may be caused by an anastomotic leak, exposed viscera, erosion of mesh into the bowel wall, an injury to the bowel during dressing changes, or tension from adhesions between the abdominal wall and the bowel (Fig. 2a, b) [2]. We have divided the care of these patients into preoperative, intraoperative, and postoperative phases.
Preoperative care The first steps in treating patients with ECFs and/or EAFs are sepsis control, electrolyte and fluid normalization, and the initiation and maintenance of parenteral nutrition support. In the last few decades, sepsis control has undergone significant changes. In critically ill patients, less invasive methods for treating intra-abdominal sepsis have become routine [3, 4]. The mainstay of therapy for intra-abdominal abscesses remains surgical or percutaneous drainage, but
R. Latifi, M. Gustafson
Fig. 2 Dealing with hostile abdomen. a Where does one start dissection (patient in Fig. 1b)? b Hostile abdomen with multiple fistulas despite treatment with total parenteral nutrition (TPN) and local wound care with wound vacuum-assisted closure (VAC) (patient in Fig. 1a)
broad-spectrum antibiotics may be initiated and subsequently tailored based on culture results. Spontaneous closure of ECFs is possible, but most fistulas, especially high-output fistulas, require surgical treatment [5–8]. Careful preparation of the patient for surgery is paramount, with continued attention on reversing sepsis, electrolyte and fluid disturbances, and malnutrition [9]. To help ensure that the surgical procedure succeeds, the patient’s preoperative condition must be optimized by the improvement of nutritional status and blood sugar levels, by cessation of smoking, and by reduction of the bioburden. Elective procedures should be postponed, if at all possible, in patients with a recent weight loss of 10–15%, with a serum albumin level \3 grams/deciliter (g/dL), with ongoing pelvic radiation treatment, and with ongoing systemic steroid or other immunosuppressant use. Hypovolemia and anemia should be corrected, either preoperatively or early intraoperatively, ensuring adequate
Abdominal wall reconstruction in patients with enterocutaneous fistulas
oxygen delivery and, thereby, minimizing anastomotic ischemia. Intraoperative and postoperative hypotension should be avoided. Bowel preparation may be indicated; immediately preoperatively, standard surgical skin preparations should be used and systemic antibiotics administered in order to minimize wound and intra-abdominal infections [10]. How long the surgeon should wait to take down ECFs is unclear. Certain anatomic factors favor spontaneous closure, including a gastrointestinal (GI) tract that remains in continuity; a bowel defect that is \1 cm long and a long tract ([2 cm) of bowel that originates from the esophagus, the duodenal stump, the jejunum, or the colon [11]. Whether or not fistula output affects spontaneous closure is debatable [6, 12]. However, high-output fistulas have been associated with significantly greater mortality [9, 13]. Somatostatin and its synthetic analog, octreotide, inhibit the secretion of many GI hormones and have been used to reduce fistula output, although the results have been inconsistent in the reduction of fistula output and in the time to closure [14–17]. However, they may prove to be useful for wound management in patients with high-output fistulas that are difficult to contain. Factors that contribute to the persistence of fistulas include the presence of a foreign body (such as synthetic mesh), radiation, infection, tract epithelialization, malignancy, distal obstruction, and the use of systemic steroids and other immunosuppressive agents. If such factors are not properly dealt with, fistulas often fail to resolve or recur after surgical intervention [11].
Intraoperative care Once the patient is preoperatively prepared for surgery (with sepsis controlled and nutritional, electrolyte, and fluid status improved), the anatomy of the fistula must be delineated [18–21]. Complex ventral hernias, ECFs, and/or EAFs must be identified, by whatever methods the surgeon thinks best: a fistulogram, a computed tomography (CT) scan, or an upper GI (UGI) study with small bowel followthrough. On many occasions, it is prudent to order a barium or Gastrografin enema in order to study the distal segment of the rectum and/or colon and ensure patency, such as in patients with previous diverticulitis and/or colostomies. The surgeon must consider and decide on the surgical approach, the type and technique of the repair, and the material to use to repair the hernia, always keeping in mind the expected improvement in the patient’s quality of life. The main surgical goals are to establish GI tract continuity and to minimize the recurrence of ECFs, EAFs, hernias, and wound infections. Creativity and a combination of different techniques and repairs are often required.
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The abdominal wall of most patients with ECFs and/or EAFs is hostile; the surgeon may find that even entering the cavity itself presents a significant challenge. When possible, the surgeon should avoid going through the same incision used in prior operations, instead attempting to enter from non-violated areas of the abdominal wall (such as the superior epigastric region or just over the pubic region). However, doing so is usually not possible, especially in patients with prior major operations (such as laparotomy for trauma). An alternative method of entering the abdomen through a transverse incision has been advocated, although we have not used that method in our practice [11]. Fistula excision For resecting the fistulous portion of the bowel, the best scenario is when multiple fistulas are in close proximity to each other; the surgeon can then resect the segment of fistulous tract ‘‘en masse’’ (Fig. 3a–c). For re-establishing intestinal continuity, the hand-sewn double-layer technique (and not staplers) should be used [19]. Adjunct procedures such as strictureplasty can be used to avoid removing a large amount of bowel, because these patients are at high risk for developing short gut syndrome. The surgeon should mobilize the entire bowel from the ligament of Treitz to the rectum. Doing so is tedious and time-consuming, given previous abdominal surgeries and intraabdominal inflammatory processes [11]. If the integrity of the anastomosis is questionable, it is reasonable to revise it or to create a proximal diverting ostomy. Operative treatment with the takedown of ECFs is successful in 80–90% of patients [22]. Patients with ECFs whose abdominal content is covered with a split-thickness skin graft (STSG) and who have large abdominal wall defects require special attention. In this subgroup, before the skin graft is excised, the ‘‘neoskin’’, when pinched between the surgeon’s thumb and forefinger, should be able to be easily elevated from the underlying tissue. Some surgeons do not attempt to excise the skin graft at all, but close the abdomen over it. When excision is attempted while the skin graft is adherent, dissection is likely to result in enterotomies and to risk recurrent fistula formation [19]. Identifying all of the fistulas and the entire GI tract is the key issue at hand. The surgeon must be attentive to technical issues, in order to avoid enterotomies; any inadvertent enterotomies and serosal tears must be repaired. Excessive trimming of the mesentery, tension on the anastomosis, and inclusion of diseased bowel in the anastomosis must all be avoided [10]. Utmost care must be taken to avoid injury to the underlying bowel during fascial closure. Meticulous adhesiolysis must be performed and the entire GI tract identified from the ligament of Treitz to the recto-sigmoid
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Fig. 4 Dealing with a large abdominal defect. a Large abdominal wall defect after gastrointestinal (GI) tract reconstituted. b At the completion of resection and anastomosis and re-establishing GI tract continuity
Fig. 3 Intraoperative decisions. a Resection of an entire block of ‘‘fistula city’’! b Excision of the fistulas and lysis of the adhesions. c Fistulous tract resected
junction. The establishment of diverting stoma is an option and this should be at the discretion of the surgeon. One should never promise the patient that he/she will not have a stoma, at least a temporary one. Abdominal wall reconstruction Definitive surgery for ECFs and/or EAFs entails simultaneous fistula excision and abdominal wall reconstruction.
Once the continuity of the GI tract has been established, as described above, creating a new abdominal wall may represent a serious surgical challenge. Multidisciplinary approaches and advanced surgical techniques may be necessary to cover the exposed viscera (Fig. 4a, b). Whatever technique is used, the goal is to establish coverage of the abdominal cavity with native abdominal wall; if doing so is not possible, biologic or prosthetic mesh should be used, which will eventually serve as the new abdominal wall. In most patients, some sort of combination of reconstruction will be done. If native tissue can be used without undue tension, then that should be the primary step. But if midline tissue cannot be easily approximated, or if mesh reinforcement is needed (as it is in almost all abdominal wall defects larger than 6 cm), then other techniques must be considered. For example, if midline tissue cannot be easily approximated, then lateral components need to be released and a neo-abdominal wall created. In our practice, we most commonly use tissue transposition of myocutaneous flaps through lateral component separation, as described previously (Fig. 5a, b) [23]. Component separation results in the medial advancement of intact
Abdominal wall reconstruction in patients with enterocutaneous fistulas
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Fig. 5 Lateral component separation. a Artist depiction (used with permission from LifeCellTM Corporation). b One can obtain up to 10–12 cm of relaxation in the middle of the abdomen
rectus myofascial units bilaterally, closing defects of up to 10 cm in the upper abdomen, 20 cm in the mid abdomen, and 6–8 cm in the lower abdomen [23, 24]. The component separation technique is based on an enlargement of the abdominal wall surface by the separation and advancement of the muscular layers (Fig. 5b). Other techniques used for abdominal wall reconstructions that have been described include the use of tissue expanders, the use of autogenous pedicle demucosalized small intestinal sheets, and other highly sophisticated plastic surgery operations [25–32]. In our practice, the three most common techniques used to place mesh during abdominal wall reconstruction are onlay placement (Fig. 6), underlay placement (Fig. 7a–c), and interposition or bridge (Fig. 8) placement. At the beginning of our practice, we used mostly onlay placement; however, in recent years, we have changed almost entirely to underlay placement. Underlay placement is more
involved, but once it is learned and perfected, it does not add significant operative time. We prefer underlay placement in order to minimize the incidence of seromas associated with the repair of abdominal wall defects. Either open or laparoscopic surgical techniques can be used to repair abdominal wall defects, but in patients with ECFs and/or EAFs, the open approach is more common. Closed suction drainage prevents seromas, which have the potential to become infected and, thereby, jeopardize the integrity of the closure. If an open abdomen is used, the risk of EAF development can be decreased by placing omentum between the bowel and mesh, by placing skin grafts as soon as possible, by using nonadherent barriers, and by performing vacuum-assisted fascial closure [33, 34]. The lowest EAF rate has been achieved by using inert plastic nonadherent barriers between the visceral and parietal peritoneum, in combination with applying subatmospheric pressure [34].
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Fig. 6 Artist depiction of lateral compartment release, primary approximation (reproduced with permission from LifeCellTM Corporation)
Choice of mesh By definition, patients with ECFs, EAFs, and/or stomas have contaminated wounds. Synthetic mesh has been used in the past, but it was associated with high rates of wound infection (often necessitating the removal of infected mesh for the source control of infection) and with other complications (such as newly created fistulas) [34–38]. Most recently, biologic mesh has become standard in high-risk patients with contaminated and dirty–infected wounds [38]. Most of the published studies using biologic mesh (all of the references mentioned) to repair complex abdominal wall defects do not provide the exact number of concomitant fistulas, with one exception: a recent multicenter, prospective, cohort study of 80 patients with clean–contaminated and dirty–infected wounds reported that only seven of them (9%) had fistulas [36]. To this end, one may conclude, however, that the use of biological mesh for abdominal wall reconstruction in patients with ECFs and/or EAFs should be a standard approach, although there is a need for level I evidence. In a recent study at our center, 60 patients underwent acellular dermal matrix (ADM) implantation for abdominal wall reconstruction from January 2006 through December 2009. Of the 60 patients, four were lost to follow-up. In the remaining 56 patients, we used two brands of ADM: AlloDerm (LifeCell Corporation, Branchburg, NJ) in 38 patients (68%) and Strattice (LifeCell Corporation) in 18 patients (32%). A total of nine patients had concomitant ECFs and/or EAFs. For the nine patients with ECFs and/or EAFs, we used underlay placement in four (44%) and interposition or bridge placement in five (56%) (Table 1). We found that the abdominal wall reconstruction results in patients with versus without concomitant ECFs and/or EAFs did not statistically differ, in terms of the rates of overall complications, of recurrence, and of infectious complications [37]. Others have also reported that ADM implantation can be safely used to repair large and complex ventral hernia
Fig. 7 Underlay technique placement of Strattice, before closing the fascia. Center image artist depiction
Fig. 8 Reconstruction of the abdominal wall using Strattice using the bridge technique. Due to multiple previous surgeries, the patient was not a candidate for other repairs
Abdominal wall reconstruction in patients with enterocutaneous fistulas Table 1 Etiology of fistulas, mesh utilized, and techniques employed in repairs Etiology of fistula ECF
Number (n = 9) 1
% 11
EAF
8
89
Trauma open abdomen
5
67
Gunshot wound
3
33
Number of fistulae Range
1–5
Mean Mesh
2
AlloDerm
8
89
Strattice
1
11
Component separation
5
56
Onlay
0
0
Underlay
4
45
Bridge
5
55
Technique
defects in patients with clean–contaminated or dirty– infected wounds [36, 38]. In the same study, of patients who underwent ADM implantation with either AlloDerm or Strattice, 35 had contaminated fields as defined by the presence of intraabdominal or soft tissue infection, stoma, or fistula [37]. Of those 35, most of them—26 (74%)—were Grade 4, as per a hernia grading system outlined in Table 2 [1]. These studies suggest that biologic mesh implantation is a valid option for complex abdominal wall reconstruction in the high-risk trauma and acute care surgery population. At least one group have suggested staged care in patients with giant abdominal wall defects, without the use of permanent mesh [39]. In their reported study of 274 patients, absorbable mesh implantation with component separation for definitive abdominal wall reconstruction provided effective temporary abdominal wall defect coverage with a low fistula rate. But most surgeons attempt to complete abdominal wall reconstruction at the time of hernia repair or at the time of takedown of ECFs and/or EAFs, even in contaminated fields [34–37]. In our practice, we aim to complete the
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definitive procedure in one operation. On occasion, we have used the principle of damage control, returning the next day or so to complete, if at all possible, the operation. For the last 8 years, in all of our patients with clean– contaminated or dirty–infected wounds, we have used biologic mesh, primarily AlloDerm and Strattice. Our experience with other biologic mesh products, such as Surgisis (Cook Biotech, Inc., West Lafayette, IN) and Veritas (Synovis, St. Paul, MN), has not been good; we have not used Surgisis or Veritas for the last 5–6 years. We prefer underlay placement, which we believe makes seroma formation less likely (even though there are no published data to support this). When mesh is used as a bridge, and when there is no skin or subcutaneous tissue to cover the mesh, then we use wound vacuum-assisted closure (VAC) with continuous irrigation, which keeps the mesh moist and speeds the process of granulation for later skin grafting (Fig. 9a, b). When there is native tissue to cover the mesh, we use four to five drains that stay in for 10–15 days. With underlay placement, we use one large drain between the mesh and fascia, and then three to four drains over the fascia and under the skin and subcutaneous tissue; to avoid drain displacement, we fix all of the drains to tissue with fine chromic sutures. Very recently, a grading system was created to classify patients by their risk for infectious complications, in order to help surgeons decide on the technique and, potentially, on the mesh to be used [1]. Grade 1 refers to patients at low risk for infections or complications who have no history of wound infections; Grade 2 refers to patients with comorbidities such as smoking, diabetes, obesity, a suppressed immune system, and chronic obstructive pulmonary disease (COPD); Grade 3 refers to patients with previously contaminated wound infections, stomas, or intraoperative violations of the GI tract; and Grade 4 refers to patients with infected mesh and septic foci. Obviously, Grades 3 and 4 present serious medical and surgical challenges for the patient and for the health care team, whether led by a general surgeon, trauma surgeon, or plastic surgeon. But even Grade 2 means that patients may harbor a significant risk and need to be thoroughly evaluated preoperatively, otherwise significant problems could arise post operatively.
Table 2 Hernia grading system adapted from reference [1] Grade 1 Low risk
Grade 2 Comorbid
Grade 3 Potentially contaminated
Grade 4 Infected
Low risk for complications
Currently smoking
Previous wound infection
Infected mesh
No history of wound infection
Obesity
Stoma present
Septic dehiscence
No significant comorbidities
Diabetic
Violation of the gastrointestinal tract
Immunosuppressed COPD
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Fig. 10 The final outcome of the patient in Fig. 1a
Fig. 9 Final abdominal wall reconstruction. a Patient in Fig. 1b several months after abdominal wall reconstruction with AlloDerm and skin graft. b Following several weeks of application of wound VAC, finally skin graft, and the final ‘‘product’’. The patient has now resumed fully p.o. intake and is off TPN
Postoperative care The postoperative care of patients after major exploratory laparotomy with takedown of fistulas and abdominal wall reconstruction is as complex as the operation itself. When reoperation is required in the immediate perioperative period, one can open the biological mesh and perform the exploration (Fig. 10). These patients will require continuation of parenteral nutrition, supplemented with massive doses of vitamin C. In our practice, we administer 2 g of vitamin C intravenously every 4 h for at least 1 week, as well as vitamin E, zinc, selenium, and, when appropriate, vitamin A, above and beyond the standard doses in total parenteral nutrition (TPN), until GI tract function returns to normal and patients resume oral intake. Prolonged ileus calls for extreme patience. Careful examination of the wound site is mandatory and should be done by the surgeon who performed the operation. The
Fig. 11 Opening of the biological mesh 36 h after the reconstruction. The mesh was salvaged and closed up primarily
mortality rate can be as high as 50% [22]. The potential for morbidity is also significant, including wound infections and other surgical site complications (20–45%), hernia recurrence (up to 20%), fistula recurrence (up to 47%), depending on the type of mesh used, small bowel obstructions, and pain [31, 40]. Nonetheless, successful completion of ECF takedown and reconstruction of the abdominal wall improves patients’ quality of life significantly (Fig. 11). Comorbidities that increase the risk of infection after hernia repair include smoking, diabetes, COPD, coronary artery disease, malnutrition, a suppressed immune system, chronic corticosteroid use, obesity, and advanced age. According to a National Surgical Quality Improvement Program database, all of those comorbidities, in particular, chronic corticosteroid use, were significant independent predictors of wound infections in a large group of patients [41]. Findings from other studies suggest that advanced age and obesity are also independent predictors of infectious complications in these complex surgical patients [42].
Abdominal wall reconstruction in patients with enterocutaneous fistulas Conflict of interest Dr. Latifi, serves as Speaker for LifeCell Corporation.
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