From an Enteroatmospheric to an Enterocutaneous Fistula Using a Condom

Abstract

An enteroatmospheric fistula (EAF) is one of the most feared complications of damage control laparotomy. Its management is highly challenging, often requiring multiple surgeries and prolonged hospitalization. It is a serious condition, and despite significant improvements in mortality rates due to advancements in intensive care, the rate remains substantial. We describe the case of a 75-year-old male who presented to the emergency department with abdominal pain one day after being discharged from another hospital following an elective converted cholecystectomy. He underwent emergency median relaparotomy, revealing fecal peritonitis and jejunum leakage. Following the jejunal segmental resection with mechanical anastomosis, we chose to leave the abdomen open. Eight days later, an EAF was established, and the abdomen was classified as grade 4 according to Bjork (classification of 2016). To manage this complication a four-step technique was employed: latex condom-EAF anastomosis, fistula ring creation, negative pressure wound therapy (NPWT), and adaptation of an ostomy bag. Nine weeks later, the wound was fully healed, and the stoma completely matured. Several recent reports have discussed the treatment of this condition. Techniques employing a baby bottle nipple, silicon plug, and floating stoma have shown promising results. NPWT was considered to increase the risk of fistula formation for many years, but additional studies have demonstrated its safety. No gold standard therapy has been established for EAF treatment; therefore, decisions rely on the surgical staff's experience. This technique for effluent control in patients with a Björk grade 4 abdomen and established EAF is easily reproducible and safe.

Keywords: condom technique; enteroatmospheric fistula; enterocutaneous fistula; negative pressure wound therapy; open abdomen.

Figure 1. CT scan revealing pneumoperitoneum

Figure 2. CT scan image revealing fat stranding and a small volume of loculated fluid suggesting a collection approximately 30 mm in diameter

Figure 3. Frozen abdomen and anastomotic leak

Figure 4. Condom-fistula anastomosis

Figure 5. Condom-fistula anastomosis with leveling paste to minimize leakage

Figure 6. Protective ring and negative pressure wound therapy application

Figure 7. Ostomy bag application

Figure 8. Secondary anastomosis between the enteroatmospheric fistula opening and a rubber drain to reduce leaks

Figure 9. Ostomy plate applied directly around the condom

Figure 10. Negative pressure wound therapy foam applied in the remaining wound area

Figure 11. Enterocutaneous fistula (true stoma)