Sink Into Quicksand

First law on holes: when you’re in one, stop digging!

Denis Healey

You are finishing your exhausting shift, waiting to go home. An enthusiastic surgeon in training is running towards you.

“Do you remember the patient we operated on ten days ago for a complicated ventral hernia? I told you, he had a wound infection and I have used negative pressure therapy for 48 hours. This is that patient today…”

“Do you think there is intestinal fluid on the wound? What should I do?”

And this is the precise moment when you feel your body sinking into quicksand… and you know that getting out of it will be difficult… but hope is still there…

Introduction

Enteroatmospheric fistula is a very complex pathology that occurs as a complication of previous abdominal surgery. Fortunately, it is very rare, but it carries a high mortality rate (close to 40%), as well as a significant economic and social impact on both the patient and the hospital. A high incidence associated with an open abdomen has been described; however, with the appropriate use of this technique, this high rate has been reduced to 8.9%.

This pathology consists of the opening of the intestinal surface to an open abdominal wound. It corresponds to grade IV of Björk’s classification of open abdomen. This represents a vicious cycle that causes the intestinal fluid to pour into the wound to contaminate the wound and prevent healing. Pertinent intervention is necessary to break this cycle.

Diagnosis

As you may think, you only need your eyes to make the diagnosis of this pathology. However, to have a deeper knowledge of it, you must define the following questions:

1. What is the daily output of the fistula?

Depending on the daily output  you can describe three types of fistula:

• High output: >500 cc;
• Medium output: 200-500 cc;
• Low output: <200 cc.

2. Is the fistula superficial or deep?

Superficial fistulas are those that open to the surface of the surgical wound. However, in a deep fistula, the opening of the intestine is located inside the abdominal cavity, making its management much more complex.

3. What intestinal segment is involved?

Depending on the intestinal defect involved, you may have:

– Proximal fistulas: stomach, duodenum, jejunum and proximal ileum;

– Distal fistulas: distal ileum and colon.

Proximal fistulas usually have a greater output and, therefore, their control is more difficult. Spontaneous fistula closure is less common in proximal fistulas. To determine the intestinal surface involved in the fistula, you can do a CT scan with oral contrast or serial radiology with water-soluble contrast (never with barium! Or you will turn the wound into a real mess).

4. Do I have one or more fistulous orifices? Which of them is the most proximal?

Determining the local anatomy of the wound is essential. Measure the wound in all diameters, as well as define all fistulous surfaces of the wound. Although, initially, it is difficult to determine which is the most proximal fistula if there are several fistulous surfaces, over time, you will easily identify which is the fistulous surface that provides the most intestinal content and, therefore, the most proximal.

5. Is there transit at the distal level? Is there an obstruction at the distal level?

Daily, you must ask the patient if their bowel is open and record it. When there is distal transit, the fistula is better controllable, has less output, and a greater opportunity for closure. Sometimes there are distal obstructions that perpetuate fistulas, and this can be defined through abdominal CT scan.

Objectives and Management

Initial objectives

At the initial moment, your goal should be to not do more damage and get the patient out of the septic situation.

• Don’t touch the wound. During the first 24-48 hours, clean the wound, and remove all material that could cause friction in the intestine, such as remains of mesh. Do not perform more friction on the intestine, do not try to introduce anything through the orifices. Place a window bag, go home, and think about how you are going to manage that injury in the coming months. Give the fistula time to define itself. Maybe the next day there will be no more intestinal fluid coming out of the wound… Probably not!

• Control the output of the fistula and nourish the patient. To achieve good control of the fistula, you will initially have to resort to parenteral nutrition. Remember to be accompanied by nutrition specialists who will help you optimize your patient. Measuring the input and output in the patient is complex but necessary (measure the output of each fistula, abdominal drains, ostomies, diuresis, and even the output of negative pressure therapy if you use it for local control of the fistula). This is necessary to know the exact contributions that the patient requires and to predict the behavior of the fistula with and without oral nutrition. You may be thinking about trying to add oral nutrition in the future. But not now!

• Diagnose and manage possible abdominal sepsis. It is common that, in the beginning, the patient develops an intra-abdominal infection that complicates the condition. Manage this sepsis with broad-spectrum antibiotic therapy initially, order a CT scan of the abdomen to find out if there is any associated collection, and add percutaneous drainage to the treatment if necessary. As a last resort, take the patient to the operating room to resolve the sepsis. Remember that the possibility of committing new enterotomies in a reoperation is very high. These patients should not undergo surgery for at least 6 months after the last intervention unless it is strictly necessary.

Medium-term objectives

• Local wound control. Local wound control is complex to achieve due to its great clinical variability. Your goal when managing the wound is to ensure that the intestinal fluid is not in contact with the wound to achieve healing. For this, in 2002, the term “floating stoma” was defined by Subramaniam et al. Initially fashioned with bags sutured to the edges of the wound and the fistulous surface, this technique was recently upgraded through the use of negative pressure therapy systems. To generate this “new” floating stoma, you need to surround a device (e.g. a nipple, a commercial device, or a custom device) with negative pressure wound therapy (NPWT), in such a way that you get intestinal fluid to exit through that device into an ostomy bag. The rest of the wound is in contact with the negative pressure therapy. Does it seem easy? It is not! Use your patience and perseverance and you will achieve it.

• Control of the fistula output. Sometimes, the patient’s fasting is not enough to control the output of the fistula. A high-output fistula can influence the local control of the wound, leading to more complex wound healing due to the continuous outflow of intestinal fluid through the wound. On other occasions, you already have good local control of the fistula with a not high output and you want to try oral nutrition, but with this, the output of the fistula increases. For these cases, some drugs can help:
  • Somatostatin and its analog octreotide may help reduce gastrointestinal secretions. Practically, you should know about this drug that if it has not been effective within 48-72 hours, you can withdraw it. Try using somatostatin in parenteral nutrition to avoid a daily puncture in your patient’s arm. Sometimes these drugs cause very marked hypoglycemia and must be withdrawn. Pay attention to your patient!
  • Loperamide. Are you using loperamide at a dose of 2mg every 6 hours because you have read in its technical information that it is the maximum dose? Badly done! Update! The maximum dose in patients with intestinal failure (as patients with enteroatmospheric fistula frequently have) is much higher! Keep in mind that starting at 18 mg per day, you must monitor the patient’s QT on an EKG because alterations may occur.
  • Codeine. Codeine may also help reduce fistula output once you have reached the maximum dose of loperamide, or if the patient does not tolerate higher doses of loperamide. Likewise, check the maximum dose of this drug for intestinal failure.

• Don’t just nourish the patient, also nourish the enterocyte. Remember that the most physiological way to nourish the patient is enteral. If you can, add oral nutrition to the patient even if you are not going to be able to fully nourish him and still require parenteral nutrition. The intestine not only has a nutritional action but also an immune function. The cancellation of intestinal function causes the villi of the enterocytes to atrophy and prevent them from fulfilling their function. Whenever you can, nourish the enterocyte, orally but also by inserting a tube through the distal end of the fistula and introducing its nutrient-rich intestinal contents through its intestine. This is not easy, but there are new devices that help us easily perform this enteroclysis.

• Catheter infection prevention. Patients with enteroatmospheric fistula frequently have an intestinal failure that requires them to be nourished for months through parenteral nutrition. In these cases, it is vitally important to emphasize aseptic care of the catheter since catheter sepsis is one of the most important causes of mortality in these patients. Peripherally inserted central catheters (e.g. PICCs, Hitchman,…) are safer for these patients and can also be managed by the patient himself or his family member with the aim of the patient being discharged until the minimum time for definitive surgery has passed.
• Rehabilitates the patient physically and mentally. These patients usually have a long hospital stay, which results in significant detriment to their physical and mental state. Correct motor rehabilitation is essential to maintain optimal physical condition for definitive surgery. Likewise, mental health care in these patients is essential since this pathology carries a high emotional, economic, and social impact on the patient and his/her environment. For this, it is important to add physiotherapists, psychologists, and psychiatrists specifically focused on this pathology to your team.
• Send the patient home. The best place where the patient can rehabilitate physically and mentally and wait until definitive surgery is at home. Whenever possible, we should try to send the patient home. However, there are two fundamental limitations to this: the management of home parenteral nutrition and the local management of the ostomized fistula. Although initially the wound will be managed by the surgeon and specially trained nurses, over time, the wound will change, the cures will become simpler, and sometimes, the patient or a caregiver will be able to change the ostomy bag. A good team of nurses specialized in nutrition, as well as stoma therapists, can educate the patient or his/her family members to become more autonomous and leave the hospital.

Final objectives

• Fistula closure. Dreaming is free. It’s nice to think that the fistula can close spontaneously. This happens on very few occasions. However, in small fistulas, without associated prosthetic material, distal fistulas, with low output, and whose intestinal surface is covered by the edge of the fistula, dreaming of fistula closure may be a possibility. In most cases, we must assume that the best scenario is to transform an uncontrolled enteroatmospheric fistula into a controlled stoma (ostomization of the fistula).
• Ostomization of the fistula and reconstruction surgery. By performing a floating stoma with a device together with NPWT, you will gradually get the tissue surrounding the fistulous surface to granulate. Once this tissue is sufficiently granulated, you must promote epithelialization from the edges of the wound. Little by little, the fistula will become a type of stoma in which the patient or caregiver can more or less easily apply an ostomy bag. At this point, the patient can go home and recover for definitive surgery. The definitive surgery will be carried out at least 6 months after the last surgery, preferably within a year. The rate of fistula recurrence and mortality from surgery before 6 months is unacceptable. For reconstruction surgery, the patient must be well nourished, with minimal local inflammation at the level of the wound, without intra-abdominal abscesses, and with a Hb level above 13 g/dL. Moreover, if possible, the patient should be physically and mentally rehabilitated, convinced of performing the surgery, and well aware of its risks and possible results. It is a complex surgery that is recommended to be performed with two surgical teams: one team performs adhesiolysis, resects the fistula, and restores the normal bowel continuity, whereas the other team treats the hernia that these patients associate with.

Final Considerations

Initially, patients affected by this condition gain a lot of interest and attention from all the surgeons, nurses, and other specialists on the team. However, since these patients generally require a long hospitalization and a lot of care, all the attentions provided by the healthcare workers progressively fade away. To maintain interest and move forward with the patient, it is important to establish a final goal with an estimated therapy time and establish weekly objectives, so that the patient does not fall into oblivion. Remember to be empathetic with the patient and put yourself in their shoes. Take care of resolving all their doubts, try to be positive but realistic, try to understand what your concerns would be if you were in their place, and also take care of their family members who accompany and suffer with the patient. To achieve success in this pathology, you need perseverance, empathy and to be resourceful and creative in each stage the patient goes through. It is the only way to find hope.

Remember that treating these patients is the same as getting out of quicksand: be patient, have a plan, and move slowly… If you rush, you are only going to sink deeper, and it will be more and more difficult to come out…

Namasté

References

1. Coccolini F, et al. Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA). Injury 2019;50:160-6.
2. Durán Muñoz-Cruzado V, et al. Update on the management of enterocutaneous fistula and enteroatmospheric fistula. Cir Andal 2019;30:1-8.
3. Huang J, et al. Technique advances in eteroatmospheric fistula isolation after open abdomen: A review and outlook. Front Surg 2021;7:559443.
4. Subramaniam MH, et al. The floating stoma: a new technique for controlling exposed fistulae in abdominal trauma. J Trauma 2002;53:386-8.
5. Calero Castro FJ, et al. Pesonalized additive manufacturing of devices for the management of enteroarmospheric fistulas. Bioengineering & Traslational Medicine 2023;8:e10583.
6. Durán Muñoz-Cruzado V, et al. Using a bio-scanner and 3D printing to créate an innovative custom made approach for the management of complex entero-atmospheric fistulas. Sci Rep 2020;10:19862.

How to Cite This Post

Muñoz-Cruzado VD, Bellio G, Marrano E. Sink Into Quicksand. Surgical Pizza. Published on June 8, 2024. Accessed on May 15, 2025. Available at [https://surgicalpizza.org/rescue/sink-into-quicksand/].