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Challenge of uncontrolled enteroatmospheric fistulas
  1. Daniel Jonathan Gross1,
  2. Michael C Smith2,
  3. Bardiya Zangbar-Sabegh3,
  4. Kenneth Chao4,
  5. Erin Chang1,
  6. Leon Boudourakis3,
  7. Muthukumar Muthusamy3,
  8. Valery Roudnitsky3,
  9. Tim Schwartz3
  1. 1Surgery, State University of New York Downstate Medical Center, Brooklyn, New York, USA
  2. 2Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  3. 3Surgery, Kings County Hospital Center, Brooklyn, New York, USA
  4. 4Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, New York, USA
  1. Correspondence to Dr Daniel Jonathan Gross, Surgery, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; daniel.gross{at}


Introduction With the popularization of damage control surgery and the use of the open abdomen, a new permutation of fistula arose; the enteroatmospheric fistula (EAF), an opening of exposed intestine spilling uncontrollably into the peritoneal cavity. EAF is the most devastating complication of the open abdomen. We describe and analyze a single institution’s experience in controlling high-output EAFs in patients with peritonitis.

Methods We analyzed 189 consecutive procedures to achieve and maintain definitive control of 24 EAFs in 13 patients between 2006 and 2017. EAFs followed surgery for either trauma (seven patients) or non-traumatic abdominal conditions (six patients). All procedures were mapped onto an operative timeline and analyzed for: success in achieving definitive control, number of reoperations, and feasibility of bedside procedures in the surgical intensive care unit. The end point was controlled enteric drainage through a healed abdominal wound.

Results There was a mean delay of 8.5 days (range 2–46 days) from the index operation until the EAF was identified. Most EAFs required several attempts (mean: 2.7 per patient, range 1–7) until definitive control was achieved. Multiple reoperations were then required to maintain control (mean: 13). While the most effective techniques were endoscopic (1) and proximal diversion (1), these were applicable only in select circumstances. A ‘floating stoma’ where the fistula edges are sutured to an opening in a temporary closure device, while technically effective, required multiple reoperations. Tube drainage through a negative pressure dressing (tube vac) required the most maintenance usually through bedside procedures. Primary closure almost always failed. Twelve of the 13 patients survived.

Conclusion An EAF is a highly complex surgical challenge. Successful source control of the potentially lethal ongoing peritonitis requires tenacity and tactical flexibility. The appropriate control technique is often found by trial and error and must be creatively tailored to the individual circumstances of the patient.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Presented at 14th Academic Surgical Congress. Houston,Texas 2019

  • Contributors DJG, TS, MM, VR, LB, and MCS contributed to the design of this study and the editing of the article. DJG, KC, BZS, and EC contributed to data acquisition, analysis and assembly of the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Author note We would like to thank Asher Hirshberg MD for his guidance and pioneering work on this subject

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