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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 95-99

Innovative technique for the abdominal wall reconstruction of complex enteroatmospheric fistula: A case report

Department of General Surgery, Queen Elizabeth Hospital, Adelaide, South Australia, Australia

Date of Submission12-Jul-2021
Date of Decision22-Jul-2021
Date of Acceptance07-Aug-2021
Date of Web Publication13-Nov-2021

Correspondence Address:
Dr. Victoria Kollias
Department of General Surgery, Queen Elizabeth Hospital, Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, Adelaide, SA 5011
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAWhs.ijawhs_48_21

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Enteroatmospheric fistula (EAF) is a rare and devastating surgical complication with significant management challenges. Abdominal wall reconstruction (AWR) at the time of definitive repair represents the major challenge in patients with large abdominal wall defects with associated loss of abdominal domain. Herein, we describe a case of EAF with significant loss of domain for which AWR was achieved using an innovative combined approach of preoperative botulinum toxin A (BTA), extensive transversus abdominal release (TAR), and abdominal reinforcement with biosynthetic mesh. This approach achieves primary abdominal closure, providing the option of a single definitive reconstructive procedure for EAF. Further studies with long-term follow-up are required to assess the long-term durability of this approach.

Keywords: Abdominal wall reconstruction, botulinum toxin A, enteroatmospheric fistula, posterior component separation, transversus abdominis release

How to cite this article:
Kollias V, Cribb BI, Ganguly T, Bierton C, Tonkin D. Innovative technique for the abdominal wall reconstruction of complex enteroatmospheric fistula: A case report. Int J Abdom Wall Hernia Surg 2022;5:95-9

How to cite this URL:
Kollias V, Cribb BI, Ganguly T, Bierton C, Tonkin D. Innovative technique for the abdominal wall reconstruction of complex enteroatmospheric fistula: A case report. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2023 Mar 20];5:95-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/2/95/330444

  Key Messages: Top

Abdominal wall reconstruction of enteroatmospheric fistula with associated large abdominal wall defects represents a significant surgical challenge. This can be safely achieved using an innovative combined approach of preoperative botulinum toxin A injection, extensive transversus abdominis release, and wide abdominal reinforcement with biosynthetic mesh.

  Introduction Top

Currently, there is no clear consensus on appropriate surgical approach for abdominal wall reconstruction (AWR) in definitive enteroatmospheric fistula (EAF) closure. This report describes a case of complex EAF with significant abdominal wall defect and loss of abdominal domain, for which AWR was achieved using a combined approach with botulinum toxin A (BTA) injection, transverse abdominus release, and biosynthetic mesh.

  Case History Top

A 39-year-old man was transferred from a regional center with complex EAF [Figure 1]. A Hartmann’s procedure was performed 3 months prior for perforated diverticulitis. This was complicated by leak from enterotomies, re-operations, and use of negative-pressure dressing resulting in further enterotomies. The patient was on total parenteral nutrition (TPN), without overt sepsis. Body mass index (BMI) at time of transfer was 31 kg/m2. Fistula output was several liters per day with healthy skin surrounding the EAF. The wound and EAF were managed with a large Eakin bag [Figure 2]. A multidisciplinary approach was employed, with fistula output control achieved using loperamide, codeine, and proton pump inhibitor.
Figure 1: Clinical photograph of the abdomen at time of patient admission showing the enteroatmospheric fistula. On the left side of the abdomen, an end colostomy is seen

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Figure 2: Clinical photograph of the abdomen showing the enteroatmospheric fistula with Eakin bag for skin protection

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Computed tomography (CT) with oral contrast and contrast via the enteric fistula revealed a relatively proximal fistula. The patient was managed conservatively for 12 months prior to definitive surgery. Preoperative CT showed a large abdominal wall defect measuring 20 cm in transverse diameter and roughly 450 cm2 in total area with shortened lateral musculature [Figure 3]. A total of 60 international units of BTA were injected, via ultrasound guidance, into the lateral musculature 4 weeks prior to surgery. Preoperative BMI was 29 kg/m2. [Figure 4] shows the EAF at time of operation.
Figure 3: Preoperative planning computed tomography axial image showing a 20-cm-wide abdominal wall defect

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Figure 4: Clinical photograph of the abdomen at time of operation showing the enteroatmospheric fistula

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At operation, approximately 20 cm of small bowel was resected with an associated cuff of nonviable skin. Two handsewn anastomoses re-established small bowel continuity and a stapled colonic anastomosis was performed.

The AWR was performed with a retrorectus dissection and bilateral transversus abdominis release (TAR) with extensive dissection in this plane to the retroperitoneum. The posterior layer was closed in the midline with continuous 2/0 PDS suture. A 50 cm × 50 cm Phasix mesh was cut to size and placed in the retrorectus plane with interrupted 1/0 PDS at the mesh periphery. Two nineteen French Blakes drains were placed anterior to the mesh [Figure 5]. The anterior fascia was closed by placing multiple lengths of continuous loop 1 PDS sutures and progressively ratcheting this layer closed, which required significant tension. The skin was closed with staples and interrupted nylon [Figure 6]. The total operating time was 300 minutes. The patient was kept intubated for 24 h postoperatively in the intensive care unit and extubated the following day. There were no signs of abdominal compartment syndrome. An abdominal binder was used.
Figure 5: Intraoperative photograph showing the retrorectus placement of large Phasix mesh prior to anterior fascial closure

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Figure 6: Clinical photograph after abdominal wound closure

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The patient had an uncomplicated recovery and was discharged after 2 weeks. At 9-month follow-up, the patient had made a full recovery without any ongoing concerns. [Figure 7] shows the follow-up CT of the reconstructed abdominal wall.
Figure 7: Postoperative axial computed tomography image postoperatively showing the reconstructed abdominal wall musculature with midline fascial closure

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  Discussion Top

EAF is a rare condition that usually occurs following iatrogenic bowel injury or anastomotic leak and subsequent burst abdomen. Initial management requires a multidisciplinary approach, with aggressive fluid resuscitation, electrolyte replacement, early sepsis control, skincare and effluent drainage, and specialist dietician input to address nutritional deficiencies.[1]

The goals of surgical EAF closure are to resect the fistula, establish bowel continuity, and reconstruct the abdominal wall.[2],[3] Delaying surgery for up to 12 months allows resolution of sepsis and inflammation, wound maturation, nutritional optimization, and softening of intra-abdominal adhesions.[1],[4]

Achieving primary abdominal wall closure in EAF with large abdominal wall defects is a significant challenge with limited surgical options available. Delayed closure techniques such as laparostomy with mesh-mediated fascial traction, often combined with negative-pressure wound therapy, have been described, but may place patients at greater risk of ventral hernia and potential fistula recurrence.[5] Interposition mesh as a definitive repair is not recommended due to the risks of infection, as well as abdominal wall laxity, which limits physical activity and may result in poor cosmesis.[4]

A single-stage approach may prevent the need for multiple operations; reducing hospitalization costs and anesthetic risk.[6] Component separation is usually required where there are large abdominal wall defects. Anterior component separation has been advocated.[2],[3],[7] Wind et al.[7] reported a fascial closure rate of 85% in their series of 32 patients; however, the postoperative complication rate was 50%, with the majority being local wound issues. The authors attributed this to the requirement for large bilateral skin flaps. This predisposes to potential seroma formation, flap necrosis, and infection.[4],[7],[8] Furthermore, it can result in recurrent lateral hernia. Posterior component separation with TAR has since been used in EAF repair,[3],[9] with fascial closure rates of up to 95% reported by Krpata et al. Although the respective authors have not yet reported comprehensive long-term outcomes, TAR confers a number of advantages over anterior component separation in this setting. It enables greater myofascial release with sparing of the neurovascular bundles, avoids subcutaneous tissue undermining, and allows a large space for mesh placement with good lateral coverage.[8] Extensive dissection to the retroperitoneum facilitates closure of the posterior and anterior layers of the abdominal wall. Although this technique potentially limits options in case of hernia recurrence, reported hernia recurrence rates are lower compared to other techniques such as interposition mesh placement and anterior component separation.[8]

In this case, preoperative BTA injection was used to address loss of domain secondary to lateral abdominal wall contraction. BTA use is associated with greater fascial closure, lower postoperative infection rates, and decreased long-term hernia recurrence.[10] Although there are currently no published studies reporting the use of BTA in EAF repair, in this case, it provided a safe and effective means of facilitating successful fascial closure of a complex EAF.

Appropriate mesh choice in the setting of EAF repair remains controversial.[6] Given the clean-contaminated nature of the surgery and potential for infection, permanent synthetic mesh is best avoided.[3],[11] Biologic mesh provides a safe alternative in contaminated fields.[6],[11] The concern with biological mesh is inadequate strength to the repair and uncertainty regarding long-term durability.[11] Biosynthetic mesh such as Phasix mesh provides the remodeling characteristics of biological mesh with the strength of synthetic mesh, has antimicrobial characteristics, and is less inflammatory than other meshes.[12] Although evidence regarding long-term outcomes of biosynthetic compared to biologic and permanent synthetic mesh is still evolving,[9] in this case, it was a suitable choice, providing sufficient abdominal wall reinforcement with no complications at 9-month follow-up.

  Conclusion Top

Complex EAF management often requires AWR. This case report details an innovative combined approach with BTA injection and biosynthetic mesh that appears safe and effective in achieving primary closure of complex EAF. Benefits of this approach are that it is a single, definitive procedure that facilitates patient recovery, return to home and daily activities, and restoration of quality of life. There remains uncertainty regarding the durability of repair and further studies assessing long-term outcomes of this approach are required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical approval

Ethics approval for the publication of this case report was sought from the Central Adelaide Local Health Network Human Research Ethics Committee (Reference Number 14782).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Di Saverio S, Tarasconi A, Walczak DA, Cirocchi R, Mandrioli M, Birindelli A, et al. Classification, prevention and management of entero-atmospheric fistula: A state-of-the-art review. Langenbecks Arch Surg 2016;401:1-13.  Back to cited text no. 1
Latifi R Practical approaches to definitive reconstruction of complex abdominal wall defects. World J Surg 2016;40:836-48.  Back to cited text no. 2
Krpata DM, Stein SL, Eston M, Ermlich B, Blatnik JA, Novitsky YW, et al. Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fistula takedown. Am J Surg 2013;205:354-8; discussion 358-9.  Back to cited text no. 3
Davis KG, Johnson EK Controversies in the care of the enterocutaneous fistula. Surg Clin North Am 2013;93:231-50.  Back to cited text no. 4
Rasilainen SK, Viljanen M, Mentula PJ, Leppäniemi AK Enteroatmospheric fistulae in open abdomen: Management and outcome––single center experience. Int J Surg Open 2016;5:44-9.  Back to cited text no. 5
Hodgkinson JD, Maeda Y, Leo CA, Warusavitarne J, Vaizey CJ Complex abdominal wall reconstruction in the setting of active infection and contamination: A systematic review of hernia and fistula recurrence rates. Colorectal Dis 2017;19:319-30.  Back to cited text no. 6
Wind J, van Koperen PJ, Slors JF, Bemelman WA Single-stage closure of enterocutaneous fistula and stomas in the presence of large abdominal wall defects using the components separation technique. Am J Surg 2009;197:24-9.  Back to cited text no. 7
Jones CM, Winder JS, Potochny JD, Pauli EM Posterior component separation with transversus abdominis release: Technique, utility, and outcomes in complex abdominal wall reconstruction. Plast Reconstr Surg 2016;137:636-46.  Back to cited text no. 8
Fafaj A, Tastaldi L, Alkhatib H, Zolin SJ, Rosenblatt S, Huang LC, et al. Management of ventral hernia defect during enterocutaneous fistula takedown: Practice patterns and short-term outcomes from the Abdominal Core Health Quality Collaborative. Hernia2021;25:1013-20.  Back to cited text no. 9
Deerenberg EB, Elhage SA, Shao JM, Lopez R, Raible RJ, Kercher KW, et al. The effects of preoperative botulinum toxin A injection on abdominal wall reconstruction. J Surg Res 2021;260:251-8.  Back to cited text no. 10
Rosen MJ, Krpata DM, Ermlich B, Blatnik JA A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann Surg 2013;257:991-6.  Back to cited text no. 11
Mellia JA, Othman S, Naga HI, Messa CA, Elfanagely O, Byrnes YM, et al. Outcomes of poly-4-hydroxybutyrate mesh in ventral hernia repair: A systematic review and pooled analysis. Plast Reconstr Surg Glob Open 2020;8:e3158.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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