Chronic Conditions

Chronic Abdominostomy With and Without Fistula

Chronic Conditions b
Chronic Conditions a
Patients may present with a previously unclosed fascial and skin defect which has granulated in.  This is often the result of the inability to close the fascia and thus the abdomen is left open and the wound covered with gauze dressings. The lack of fascial abdominal wall support causes a lack of external pressure on the abdominal viscera thereby allowing the bowel to adhere to and then perforate the abdominal wall.  Thus chronic fistulae are created.

Patients suffering from chronic fistulae have a significantly decreased quality of life and are often subjected to significant surgical intervention to address their problems.  Surgical exploration of these patients proves difficult, dangerous and time consuming because of adhesions and loss of tissue planes.

Chronic Conditions c
Bowel injury, perforations and bleeding are common complications of these explorations.  Often these patients are older and have co-morbidities – which is the reason they did not or could not undergo extensive fascial reconstruction at the time of original presentation.

A less invasive therapy to cover the chronic wound is to place a skin graft over the granulation tissue and exposed bowel.  While this therapeutic option offers a better solution than an open wound, it leaves many patients unhappy and with a remaining risk of herniation and fistula formation.  This scenario is rare but it does represent a problem for surgeons, patients and families.  Fortunately it has been successfully resolved with staged abdominal repair.

Frequency of Chronic Abdominostomies

Fascial Closure Rates
There are no data available describing the frequency of open abdomens that could not be closed.  Inferring from published data, the rate of failure to close the abdomen may be as high as 42%1.  In this meta-analysis in 1834 of 3169 “open abdomens” the fascia could not be closed.  The percentage of patients that go on to develop chronic open wounds without underlying fascial support is not known.

Of all patients treated for intra-abdominal infections about 12-15% fall in the category that require advanced operations such as STAR.

 

STAR for Chronic Abdominostomies

Although STAR was developed to treat acute abdominal problems this technique has also been applied to patients with chronic fascial defects and large, chronic open abdominal wounds.  Experience has shown that the fascial defects are often caused, at least in significant part, by lateral fascial retraction rather than actual loss of significant fascial tissue.  Approaching these patients with a staged abdominal repair technique couple with the use of the artificial bur to re-approximate the retracted fascial over time has shown to be a valid therapeutic option.

After optimizing nutrition and antimicrobial therapy, the entire abdomen must be explored, adhesions taken down, bowel loops separated, non-viable bowel and fistulae resected, and all viable bowel loops re-anastomosed.  While time consuming and tedious, this procedure is usually found to be less difficult than expected.  After addressing these intra-abdominal issues, the edges of the fascia are identified and the artificial burr sewn to it.  The abdomen is closed per the STAR technique.  After the first few re-explorations the fascial closure tension is kept somewhat lower so that intra-abdominal pressure does not impede anastomotic healing.  Once visual inspection of the anastomoses shows healing, artificial bur tension is guided by bladder pressure or airway pressure measurements.  Daily re-explorations with increasingly overlapping bur closures will eventually re-approximate the fascial edges to allow primary closure.

In the authors experience the fascia was eventually closed in all patients and all patients were discharged home.  No permanent mesh implants or skin grafts were necessary.  While the author’s limited number of cases are anecdotal evidence at best, this experience may still be helpful to other patients. The treated patients were uniformly grateful and satisfied with the outcome.  In the author’s opinion, the historically good results and grateful patients justify the time and effort risk involved in these cases where otherwise reasonably healthy patients are electively hospitalized, intubated and paralyzed for ten or more days.

Relevant Cases

 

Informing Patients with Chronic Abdominostomies

Dr. Wittmann has been performing the STAR procedure for chronic abdominal wall problems since the mid 1990’s.  Suffering patients presented with the desire to solve their chronic conditions – often “..at any price, Doctor!” 

Without available data and being presented with chronic open fistulae, patients were told that such procedures may carry a mortality rate up to 50%.  Patients and their families were informed that the patient would be in the ICU for ten or more days, be artificially ventilated and fed, be paralyzed to optimize fascial stretching and that the outcome could not be guaranteed.  Yet patients preferred that risk over their living with their open abdomens and chronic bowel leaks.

 

References

1 van Hensbroek PB,Wind J,Dijkgraaf MGW,Busch ORC,Goslings JC. Temporary Closure of the Open Abdomen: A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen. World J Surg; 2009;33(2):199-207