T. Wild

Successful bridging treatment and healing of enteric fistulae by vacuum-assisted closure (VAC) therapy and targeted drainage in patients with open abdomen

PurposeThe object of this study was to investigate the bridging treatment of enteric fistulae by vacuum-assisted closure (VAC) therapy in patients with open abdomen.MethodsWe retrospectively analyzed patients who have been treated between 1 January 2007 and 31 December 2008 at the intensive care unit of the Department of General Surgery, Medical University Vienna. Control of the fistula was established by VAC therapy to bridge the patients to the time of the fistula resection.ResultsIn the period of investigation, we treated nine (six men/three women) patients suffering from enteric fistulae with VAC therapy. The median age of the patients was 48 (range, 37–67) years. The median duration of VAC therapy was 76 (range, 53–128) days. The median length of stay in the intensive care unit was 44 (range, 25–127) days. The median APACHE II score was 23 (range, 18–25). The predicted mortality was 40%; the actual mortality was 11% (one patient). Primary fascial closure was achieved after median 91 (range, 89–92) days in three patients (33%) and secondary fascial closure after median 292 (range, 252–546) days in another three patients (33%). Fistulae were cured with VAC (five patients, 56%) and surgical resection (three patients, 33%). None of the patients developed a refistulation at the time of follow-up.ConclusionsControl of enteric fistulae by VAC therapy can lead to spontaneous fistula closure and is associated with a low mortality.

Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced

The open abdomen has become commonplace in abdominal and trauma surgery, a concept that was refused by most trauma surgeons 20 years ago. Developing damage control surgery for trauma and understanding the abdominal compartment syndrome have resulted in those principles changing in the last years. Abbreviated operations in injured patients, especially when they show the often lethal combination of acidosis, coagulopathy and hypothermia, are aimed at stopping bleeding and limiting contamination, leaving the abdomen open [1]. This requires one or more reoperations. Also visceral and retroperitoneal edema as a consequence of shock and reperfusion that could lead to organ dysfunction must be handled with an open abdomen. Many coverage techniques have been developed protecting and allowing access to the viscera, yet primary fascial closure cannot be achieved after 7–10 days because of retraction of the abdominal wall and adhesions of the viscera [2–4]. The vacuum-assisted fascial-closure (VAFC) technique is supposed to close the fascia even after this time period [5]. Miller et al. describe a VAFC technique used in patients who had open abdomen management after undergoing laparotomies due to traumatic abdominal injuries and abdominal compartment syndrome. The method is performed after using a vacuum dressing with a surgical towel until resolving of the edema. A perforated polyethylene sheet is placed over the bowel and under the edges of the abdominal wall to avoid adhesions in the subsequent days and weeks. Over this a sponge is placed stabilized by a suture on the skin edges. After that, suction tubing, occlusive dressing and suction are applied which shrinks the sponge pulling the edges of the abdominal wall to the middle line. After changing the dressing every 3 to 5 days, the fascia may be closed in a secondary operation as the edges meet [5]. Miller et al. have contributed another important study in the management of the open abdomen with the VAFC. They investigated 53 patients who required open abdomen management; that is 25% of 212 laparotomies that were performed during a 19-month period (November 1 2001 through May 31, 2003). For 43 patients, VAFC was attempted and fascial closure rate was 88% (38) after a mean time of 9.5 days. This is a significantly higher rate compared to the last study (69%) when the technique was developed. Closure rate, time to closure and abdominal complications including fistula, abscess and dehiscence as well as postoperative incidence of ventral hernia were examined. 45 (78%) of the 53 patients looked at survived until abdominal closure (mean age, 36 ± 15 years). 43 underwent VAFC which was successful in 38 (88%). Mean time until fascial closure was 9.6 days (range, 1–21) with a mean number of 3.4 dressing changes in the closed group (range, 1–9). VAFC allows for fascial closure weeks after initial laparotomy with 21 patients (48%) undergoing late closure (>9 days). The reason for failure of the therapy in 5 patients (12%) is unclear due to the fact that the groups do not significantly differ. Investigating abdominal complications, one enterocutaneous fistula was developing under vacuum dressing therapy and therefore VAFC was discontinued. 2 patients (4.6%) developed wound dehiscence and were successfully reclosed and 1 patient (2.3%) developed a ventral hernia that was repaired.