Combined surgical and negative pressure therapy to treat multiple enterocutaneous fistulas and abdominal abscesses: A case report

Abstract

Introduction We report the case of a successful management with combined aggressive surgery and negative pressure therapy, to treat a severely ill-septic patient, affected by multiple chronic enterocutaneous fistulas. Presentation of case A 26-year-old female patient presented with multiple pelvic and intra-abdominal abscesses, enterocutaneous fistulas and central venous catheter-related bacteraemia in extremely poor general conditions. The patient underwent both an abdominal CT which showed multiple digestive loops stuck and apparently fistulised and an abdominal-pelvic MRI, confirming the CT findings, and demonstrating a third fistula involving the Pouch and responsible for a pelvic and retroperitoneal chronic abscess. Given the patient's septic condition, despite several attempts of conservative therapies, an aggressive surgical approach was adopted. After temporary abdominal wall closure, the patient underwent Vacuum Assisted Closure therapy in order to close the abdominal wall and drain the residual abscess. The patient was discharged at the 35th post-operative day in good general conditions. Discussion This case is about a complex, long-lasting clinical scenario, progressively leading a young woman to death despite several attempts of conservative therapy, sometimes allowed to treat enterocutaneous fistulas. The use of negative pressure therapy to manage open abdomen is still controversial. Patients affected by enterocutaneous fistulas are in need of adequate nutritional support due to their hypercatabolic state, secondary both to the fluid loss and the concomitant inflammatory status. Conclusion When conservative management fails and the patient shows septic complications, a multidisciplinary aggressive approach, including surgery, negative-pressure therapy and hyperbaric oxygen therapy is required to treat this life-threatening condition.

Enterocutaneous Fistula Management and Clinical Nutrition in Sepsis of Abdominal Wall Incisional Hernia. Tips, Tricks and Literature Revision

“…Seventy-one-old-years septic male patient, in 2005, January underwent a median xiphoid to pubis laparotomy for aneurysmectomy (a surgical procedure performed to repair a weak area in the Aorta, upper kidney arteries to bifurcation with common iliac arteries (aortoperipheral bypass) and implantation of aorto-bifurcated Dacron woven prosthesis [22]. Moreover, the lower polar right kidney artery was reimplanted.…”

“…"The challenge of caring for patients with ECF is not merely the management of the underlying conditions leading to ECF or the correct provision of appropriate nutrition (TPN or Enteral Nutrition NE) or both the prevention of complications, whether pulmonary thromboembolism (thrombosis of portal vein IF-associated to liver disease) or metabolic bone disease and central venous catheter-related bloodstream infection" [21]. This report looks at the role of the EN, "the multidisciplinary team, and novel therapies, including hormonal treatment" of ECF, but also surgical options [22]. "One of the most significant advances in the treatment of ECF was the development of TPN in the 1960s by Dudrik [23,24].…”

“…Much controversy surrounds nearly every aspect of caring for these patients. The overall incidence of ECF is unknown [22,25]. The prevalence of case reports and case series is due to the scarcity of homogeneous patient populations and randomized clinical trials, making this situation unlikely to change soon.…”

“…Bacteremia risk by CVC is high. The Enteral Nutrition (EN) treatment results are not well-known and popular among surgeons [22]. Insufficient evidence demonstrates that TPN is superior to EN in spontaneous closure rates.…”

“…Concern that EN contributes to or worsens fistula production is probably unfounded [26]. EN has indeed demonstrated no infections and a lower rate of fistula formation in trauma patients well managed with an open abdomen [22,31]. For nutritional support in patients with ECF, EN should be the first choice unless there is a clear contraindication.…”