[Prevention of small bowel fistulas during open abdominal treatment: lessons learned].

Background: Abdominal vacuum therapy has simplified the treatment of a laparostoma. But is that all that it can achieve? The role of abdominal vacuum therapy concerning the development of small bowel fistulas is still under discussion. Treatment of the bowel surface seems to be crucial for the prevention of fistulas. As military surgeons, we need a simple, standardised regimen, leading to reproducible good results and low complication rates. The question is: are we able to eliminate small bowel fistula during open abdominal treatment?
Patients and Methods: We analysed 28  consecutive patients with open abdominal treatment in the period of 2004 to 2009. From June 2006 on, we implemented an algorithm, using the KCI V.A.C.® Abdominal Dressing (Kinetic Concepts Inc., San Antonio, Texas, USA) and a vicryl mesh between the non-adherent layer and the foam to prevent fascial retraction. The patients treated -after the installation of the new algorithm were compared to a group treated from 2004 to May 2006 before its installation. Fistula rates, mortality, the fascial closure rate, the number of abdominal dressing changes and the duration of open -abdominal treatment were evaluated.
Results: After implementation of our new algorithm, the fistula rate decreased from 45 % to 0 %. The mortality during open abdominal treatment decreased from 45 % to 6 %. In addition, the duration of open abdominal treatment was reduced as well as the number of dressing changes. The primary fascial closure rate was 87 %.
Conclusion: We implemented a regimen, which is suitable for our mission in Afghanistan, as well as for medical evacuation and for the treatment of patients in our hospitals in Germany. It ensures a standardised treatment of the open abdominal cavity with an ideal protecting treatment of the bowel surface. Our algorithm utilises the advantages of the laparostoma while minimising the complications. The development of a small bowel fistula was eliminated in the evaluated patient group and mortality was clearly reduced.
(© Georg Thieme Verlag KG Stuttgart ˙ New York.)