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Surgical techniques for the management of enteroatmospheric fistulae.

BACKGROUND
An intestinal fistula in the "open abdomen" is called "enteroatmospheric" and is a great challenge for the surgeon because of the high mortality and morbidity rates associated with it. This report is a study of the surgical strategy for treating patients with enteroatmospheric fistulae.


METHODS
During a 3-year period (2005-2007), two males and one female patient with a mean age of 63 years were referred to our surgical department for management of enteroatmospheric fistulae that developed after operations carried out for severe peritonitis, which was a consequence of sigmoid diverticulum rupture in two cases and disruption of an entero-enteric Roux-en-Y anastomosis after total gastrectomy for cancer in one.


RESULTS
All patients were appropriately supported in a surgical intensive care unit, with administration of total parenteral nutrition and appropriate antibiotics to eliminate secondary infections. Several re-operations were necessary to treat the enteroatmospheric fistulae. Eventually, all patients were discharged after a lengthy hospital stay (45-145 days).


CONCLUSIONS
The essential principles of our operative strategy are: (1) early intervention; (2) a lateral surgical approach via the circumference of the open abdomen to avoid further damage to the exposed viscera; (3) excision of the involved bowel loop with an end-to-end anastomosis; (4) temporary abdominal closure and coverage of the open abdomen with an absorbable mesh, promoting tissue granulation; (5) skin grafting attempts; and (6) selective use of vacuum-assisted closure.