Management of Septic Open Abdomen in a Morbid Obese Patient with Enteroatmospheric Fistula by Using Standard Abdominal Negative Pressure Therapy in Conjunction with Intrarectal One

Abstract

Introduction. Management of open abdomen (OA) with enteroatmospheric fistula (EAF) in morbid obese patient with comorbid disease is challenging. We would like to report the management of septic OA in morbid obese patient with EAF which developed after strangulated recurrent giant incisional hernia repair. We would also like to emphasize, in this case, the conversion of EAF to ileostomy by the help of second Negative Pressure Therapy (NPT) on ostomy side, and the chance of new EAF occurrence was reduced with intrarectal NPT. Case Presentation. 62-year-old morbid obese woman became an OA patient with EAF after strangulated recurrent giant hernia. EAF was converted to ostomy with pezzer drain by the help of second NPT on ostomy. Colonic distention was reduced with the third NPT application via rectum. Abdominal reapproximation anchor (ABRA) system was used for delayed abdominal closure. Conclusions. Using the 2nd NPT on ostomy side may help in the maturation of the ostomy created in a difficult condition in an open abdomen. Using the 3rd NPT through rectum may decrease the chance of EAF formation by reducing the pressure difference between intraluminal pressure and extraluminal pressure in hollow viscera.

1. Introduction

Incisional hernias (IH) are a frequent complication after all abdominal surgery, with an incidence of 10–23% [1, 2]. Obesity and chronic diseases are predisposing factors for developing IH with the potential complication of small bowel obstruction and other morbidities [3]. IH enlarge over time and can cause serious complications like bowel obstruction due to incarceration or strangulation. In strangulated IH, bowel perforation and fistula formation may rarely develop preoperatively. Large and complicated hernias are a challenge for surgeons [4].

Open abdomen (OA) management is a life-saving and challenging strategy in situations such as the abdominal compartment syndrome (ACS), damage-control surgery, and severe generalized peritonitis [5, 6]. Enteric fistulas are one of the most devastating abdominal complications in abdominal surgery [7]. Management of patients with an open abdomen and an enteroatmospheric fistula (EAF) is very challenging. The mortality of EAF was as high as 70% in the past decades but is currently approximately 40% due to advanced modern intensive care and improved surgical techniques [8].

We would like to report management of OA in morbid obese patient with EAF which developed after strangulated recurrent giant incisional hernia repair. We would like to also emphasize in this case that converting EAF to ileostomy was achieved with pezzer drain by the help of synchronized second NPT with abdominal NPT on ostomy side, and the chance of new EAF occurrence during long OA period was reduced by decreasing colonic distention with intrarectal NPT, first time in the literature (Figure 4).

2. Presentation of Case

62-year-old morbid obese woman was admitted to the emergency department with complaint of abdominal pain, distention, constipation, and vomiting. For the last 4 days, the severities of complaints have increased. Her levels of consciousness and orientation were also worsened. In her past history, she had hypertension, diabetes mellitus (DM), hyperlipidemia, chronic lung disease (CLD), and depression. Up to now, she was operated on 8 times from the same side of the abdomen. First of all, she was operated on for acute cholecystitis 15 years ago; 1 year after this operation, subcostal IH developed. She has been operated on 6 times for IH. She was also operated on for ileus. During the last 2 years, she had irreducible giant ventral hernia and she went to emergency department 3 times for the same complaint.

In physical examination, Body Mass Index (BMI) was 47. On her abdominal examination, there were giant hernia and distention. Rebound and rigidity were positive at all quadrants of abdomen. She underwent emergent operation. There was severe adhesion and septic abdomen. During exploration necrosis and perforation of 70 cm ileum segment which was 50 cm proximal to ileocecal valve was seen. At first operation, septic abdomen was irrigated, necrotized ileum segment was resected, and end to end anastomosis was done. Due to giant hernia and severe peritonitis, delayed abdominal closure with Bogota bag was performed. She was transferred to ICU with vasopressor support.

At postoperative 9th day, after EAF development, she was consulted and transferred to our clinic. Her general condition, consciousness, and orientation were not well. She was mechanically ventilated. Her vital parameters, intra-abdominal pressure (IAP), SOFA score, and estimated mortality rate were shown in Table 1. She was in septic shock and mild metabolic acidosis (Table 2). She underwent emergent reoperation. There was very wide OA wound ( cm in diameter) with high output enteric fistula and severe visceral adhesion. All intestine was very edematous and fragile and according to new modified Björck classification OA score of the patient was 2c score [9]. All the intra-abdominal content was irrigated with saline. Perforation point of ileum was seen at the previous anastomosis side (Figure 1). A pezzer drain was inserted in the EAF and redirected to the place where ileostomy was planned to open. Glycerin-impregnated gauze was used around EAF and pezzer drain tube to support segmentation of ostomy side from OA wound. Two NPT systems were applied; one was standard abdominal NPT (Figure 2), and the second one was performed on the ileostomy opening where the EAF was directed with pezzer tube. Synchronized negative pressure was applied to both NPTs [10]. The second NPT on ostomy place was changed 3-4 times a day.