Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study

The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200–500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re‐surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4–16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi‐organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.     

Management of fistula of ileal conduit in open abdomen by intra-condoit negative pressure system

INTRODUCTION

We aimed to present the management of a patient with fistula of ileal conduit in open abdomen by intra-condoid negative pressure in conjunction with VAC Therapy and dynamic wound closure system (ABRA).

PRESENTATION OF CASE

65-Year old man with bladder cancer underwent radical cystectomy and ileal conduit operation. Fistula from uretero-ileostomy anastomosis and ileus occurred. The APACHE II score was 23, Mannheim peritoneal index score was 38 and Björck score was 3. The patient was referred to our clinic with ileus, open abdomen and fistula of ileal conduit. Patient was treated with intra-conduid negative pressure, abdominal VAC therapy and ABRA.

DISCUSSION

Management of urine fistula like EAF in the OA may be extremely challenging. Especially three different treatment modalities of EAF are established in recent literature. They are isolation of the enteric effluent from OA, sealing of EAF with fibrin glue or skin flep and resection of intestine including EAF and re-anastomosis. None of these systems were convenient to our case, since urinary fistula was deeply situated in this patient with generalized peritonitis and ileus.

CONCLUSION

Application of intra-conduid negative pressure in conjunction with VAC therapy and ABRA is life saving strategies to manage open abdomen with fistula of ileal conduit.     

Use of negative pressure wound therapy in the management of infected abdominal wounds containing mesh: an analysis of outcomes

The purpose of this study was to examine the clinical outcomes of negative pressure wound therapy (NPWT) using reticulated open-cell foam (ROCF) in the adjunctive management of abdominal wounds with exposed and known infected synthetic mesh. A non randomised, retrospective review of medical records for 21 consecutive patients with infected abdominal wounds treated with NPWT was conducted. All abdominal wounds contained exposed synthetic mesh [composite, polypropylene (PP), or knitted polyglactin 910 (PG) mesh]. Demographic and bacteriological data, wound history, pre-NPWT and comparative post-NPWT, operative procedures and complications, hospital length of stay (LOS) and wound healing outcomes were all analysed. Primary endpoints measured were (1) hospital LOS prior to initiation of NPWT, (2) total time on NPWT, (3) hospital LOS from NPWT initiation to discharge and (4) wound closure status at discharge. A total of 21 patients with abdominal wounds with exposed, infected mesh were treated with NPWT. Aetiology of the wounds was ventral hernia repair (n = 11) and acute abdominal wall defect (n = 10). Prior to NPWT initiation, the mean hospital LOS for the composite, PP and PG meshes were 76 days (range: 21-171 days), 51 days (range: 32-62 days) and 19 days (range: 12-39 days), respectively. The mean hospital LOS following initiation of NPWT for wounds with exposed composite, PP and PG mesh were 28, 31 and 32 days, respectively. Eighteen of the 21 wounds (86%) reached full closure after a mean time of 26 days of NPWT and a mean hospital LOS of 30 days postinitiation of NPWT. Three wounds, all with composite mesh left in situ, did not reach full closure, although all exhibited decreased wound dimensions, granulating beds and decreased surface area exposure of mesh. During NPWT/ROCF, one hypoalbuminemic patient with exposed PP mesh developed an enterocutaneous fistula over a prior enterotomy site. This patient subsequently underwent total mesh extraction, takedown of the fistula and PP mesh replacement followed by reinstitution of NPWT and flap closure. In addition to appropriate systemic antibiotics and nutritional optimisation, the adjunctive use of NPWT resulted in successful closure of 86% of infected abdominal wounds with exposed prosthetic mesh. Patient hospital LOS (except those with PG mesh), operative procedures and readmissions were decreased during NPWT compared with treatment prior to NPWT. Future multi-site prospective, controlled studies would provide a strong evidence base from which treatment decisions could be made in the management of these challenging and costly cases.     

Systematic review of negative pressure wound therapy for head and neck wounds with fistulas: Outcomes and complications

Fistula formation in head and neck wounds is considered one of the most challenging complications that a head and neck reconstructive surgeon may encounter. The current mainstay of treatment is aggressive surgical debridement followed by vascularised soft tissue coverage. Negative pressure wound therapy (NPWT) has been successfully used for the closure of complicated wounds for decades. This study analysed the outcomes and complications of NPWT in the management of head and neck wounds with fistulas. A systematic search of studies published between January 1966 and September 2019 was conducted using the PubMed, MEDLINE, EMBASE, and SCOPUS databases and using the following key words: “negative pressure wound therapy,” “head and neck,” and “fistula.” We included human studies with abstract and full text available. Analysed endpoints were rate of fistula closure, follow‐up duration, and complications if present. Nine retrospective case series (Level IV evidence) that collectively included 122 head and neck wounds with orocutaneous fistulas, pharyngocutaneous fistulas, and salivary contamination were examined. The number of patients included in each study ranged from 5 to 64. The mode of NPWT varied among the included studies, with most adopting a continuous pressure of −125 mm Hg. Mean durations of NPWT ranged from 3.7 to 23 days, and the reported fistula closure rate ranged from 78% to 100%. To achieve complete wound healing, six studies used additional procedures after stopping NPWT, including conventional wound dressings and vascularised tissue transfer. Information regarding follow up was provided in only three of the nine studies, where patients were followed for 5, 10, and 18 months. No serious adverse events were reported. NPWT for head and neck wounds with fistulas may be considered a safe treatment method that yields beneficial outcomes with a low risk of complications. The current data originated mainly from studies with low levels of evidence characterised by heterogeneity. Therefore, definitive recommendations based on these data cannot be offered. Additional high‐quality trials are warranted to corroborate the findings of this systematic review.     

A prospective,randomized, controlled clinical trial on the efficacy of a single‐use negative pressure wound therapy system,compared to traditional negative pressure wound therapy in the treatment of chronic ulcers of the lower extremities

Multicenter, phase‐4, randomized, comparative‐efficacy study in patients with VLUs or DFUs comparing for noninferiority the percentage change in target ulcer dimensions (area, depth, and volume) a single‐use negative pressure wound therapy (s‐NPWT) system versus traditional NPWT (t‐NPWT) over a 12‐week treatment period or up to confirmed healing. Baseline values were taken at the randomization visit. Randomized by wound type and size, 164 patients with non‐infected DFUs and VLUs were included. The ITT population was composed of 161 patients (101 with VLUs, 60 with DFUs) and 115 patients completed follow‐up (64 in the s‐NPWT group and 51 in the t‐NPWT group) (PP population). The average age for all patients was 61.5 years, 36.6% were women, and treatment groups were statistically similar at baseline. Primary endpoint analyses on wound area reduction demonstrated statistically significant reduction in favor of s‐NPWT (p = 0.003) for the PP population and for the ITT population (p < 0.001). Changes in wound depth (p = 0.018) and volume (p = 0.013) were also better with s‐NPWT. Faster wound closure was observed with s‐NPWT (Cox Proportional Hazards ratio (0.493 (0.273, 0.891); p = 0.019) in the ITT population. Wound closure occurred in 45% of patients in the s‐NPWT group vs. 22.2% of patients in the t‐NPWT group (p = 0.002). Median estimate of the time to wound closure was 77 days for s‐NPWT. No estimate could be provided for t‐NPWT due to the low number of patients achieving wound closure. Device‐related AEs were more frequent in the t‐NPWT group (41 AEs from 29 patients) than in the s‐NPWT group (16 AEs from 12 patients). The s‐NPWT system met noninferiority and achieved statistical superiority vs. t‐NPWT in terms of wound progression toward healing over the treatment period. When NPWT is being considered for the management of challenging VLUs and DFUs, s‐NPWT should be considered a first choice over other types of NPWT.     

Use of negative pressure wound therapy for abdominal wounds in neonates and infants

BackgroundNegative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, but few large series reports exist in the literature.MethodsThe outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined.ResultsWe identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort.ConclusionNegative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.     

New technique for treating abdominal surgical site infection using CT woundgraphy and NPWT: A case report

IntroductionNegative pressure wound therapy (NPWT) for abdominal surgical site infection (SSI) is becoming increasingly common, although enterocutaneous fistula (ECF) has been reported as a complication. To avoid ECF, we used computed tomography (CT) woundgraphy to evaluate the relationship between the wound and the intestine, and then safely treated the abdominal SSI with NPWT.Case presentationFollowing a laparoscopic intersphincteric resection for low rectal neuroendocrine tumor and covering ileostomy, a 59-year-old woman underwent stoma closure. Six days after surgery, we diagnosed SSI. We suspected ECF, because the wound was deep and the pus resembled enteric fluid. However, CT woundgraphy showed that the wound was separated from the abdominal cavity and the intestine by the abdominal rectus muscle. Accordingly, we performed NPWT. SSI was cured and the wound was well granulated. Twenty-three days after surgery, the patient was discharged. Eventually, the wound was completely epithelialized.DiscussionAlthough successful NPWT has been reported for open abdominal wounds, ECF is a common complication. ECF can be prevented by separating the wound from the intestine by the omentum or muscle fascia, protecting the intestinal serosa during surgery, and applying low vacuum pressure. The relationships among the wound, the fascia, and the intestine must be evaluated before abdominal SSI treatment. One good method is CT woundgraphy, which evaluates wound extent and depth, closure of muscle fascia, and the relationship between the wound and the intestine.ConclusionWe report a case of CT woundgraphy before NPWT for abdominal SSI. CT woundgraphy is a good candidate for evaluating wound condition.     

Use of negative pressure wound therapy on malignant wounds – a case report and review of literature

The presence of malignancy is considered a contraindication to the use of negative pressure wound therapy (NPWT) because of concerns that it may promote tumourigenesis and expedite metastasis. This notion is extrapolated from studies evaluating NPWT in normal tissues. Despite the absence of direct evidence, the use of this technology in malignant wounds is widely considered a contraindication. We present the case of a patient with treatment‐resistant metastatic colon cancer, who developed a chronic abdominal wound with positive margins. A staged reconstruction using NPWT was performed and wound closure allowed the patient to meet eligibility criteria and enrol in a clinical trial for treatment of his oncological disease. Skin closure remained intact until the patient expired 6 months after the wound closure. This case, as well as others in the literature, demonstrated that the use of NPWT should not be considered an absolute contraindication in malignancy. Individualised approaches taking into account the patient's clinical scenario, the available evidence, as well as the risks and benefits of this technology are recommended.     

Management of complicated gastroschisis with porcine small intestinal submucosa and negative pressure wound therapy

Introduction

In almost all cases of gastroschisis, fascial closure may be achieved primarily or after silo reduction. Rarely, fascial and skin closure are impossible. We report our experience with visceral coverage in complicated cases of gastroschisis with porcine small intestinal submucosa (SIS) augmented by negative pressure wound therapy (NPWT).

Methods

Over a 3-year period, 55 infants with gastroschisis were managed. In 3 of these cases, fascia and skin could not be approximated safely after complete reduction of abdominal viscera with a spring-loaded silo. Visceral coverage in each case was achieved with 0.42-mm-thickness Surgisis ES (Cook Surgical, Bloomington, Ind) that was sewn to the fascial edges. Negative pressure wound therapy was then initiated at 75 mm Hg over the exposed SIS using vacuum-assisted closure.

Results

In each case, granulation tissue developed quickly and was followed by complete epithelialization. Two patients subsequently developed umbilical hernias.

Conclusion

We have successfully used SIS augmented by NPWT in the management of 3 infants with complicated gastroschisis. In the rare situation in which fascial closure cannot be achieved, the combination of SIS and NPWT can provide a safe and effective means of abdominal wall closure.     

Clinical recommendations and practical guide for negative pressure wound therapy with instillation

Effective wound management involves a comprehensive assessment of the patient and the wound to determine an optimal wound treatment plan. It is critical to identify and address factors that may impair wound healing, prior to selecting the most appropriate therapy for each patient. Negative pressure wound therapy (NPWT) is a well‐established advanced therapy that has been successful in adjunctive management of acute and chronic wounds. In recent years, the introduction of topical wound solution delivery in combination with NPWT has provided further benefits to wound healing. A commercially available system now offers automated, volumetric control of instilled topical wound solutions with a dwell time in combination with NPWT (NPWTi‐d; V.A.C. VeraFlo? Therapy, KCI, an Acelity company, San Antonio, TX). This NPWTi‐d system differs from other instillation systems in that a timed, predetermined volume of topical wound solution is intermittently delivered (versus continuously fed) and allowed to dwell in the wound bed (without NPWT), for a user‐selected period of time before NPWT is resumed. This added accuracy and process simplification of solution delivery in tandem with NPWT have prompted use of NPWTi‐d as first‐line therapy in a wider subset of complex wounds. However, considerably more research is required to validate efficacy of NPWTi‐d in various wound types. The purpose of this review is to provide a relevant overview of wound healing, describe current literature supporting the adjunctive use of NPWTi‐d, propose a clinical approach for appropriate application of NPWTi‐d and conclude with case studies demonstrating successful use of NPWTi‐d. Based on this review, we conclude that either a large case series examining effects of NPWTi‐d on different wound types or possibly a large prospective registry evaluating NPWTi‐d with real‐world topical wound solutions versus immediate debridement and closure would be valuable to the medical community in evaluating the efficacy of this promising therapy.     

封闭式负压引流治疗内脏暴露且难以短期缝合的腹壁切口全层裂开的处理经验

目的报道采用封闭负压引流处理腹壁切口裂开小肠暴露的临床经过和治疗经验。方法 60岁男性患者因肾周脂肪肉瘤,外院行脂肪肉瘤切除+左肾切除+结肠切除,术后吻合口漏加做结肠造瘘。入院时腹腔感染、腹壁切口全层裂开并脏器暴露、皮下脓肿、感染性休克、全身多器官功能不全,在规范的全身系统治疗的基础上,使用改良的封闭式负压引流术,回收腹部渗液、保护外露脏器、保护术口周围的皮肤和治疗术口感染;在治疗过程中出现小肠瘘的并发症,通过在小肠内置入内引流管、硅胶封堵和负压引流,治疗小肠瘘的并发症,使患者能够不依靠肠外营养而生存;9月后行手术成功切除小肠瘘。结果患者全身感染症状、内环境及小肠功能在1个月之后好转,逐渐缝合术口。新出现的小肠瘘的并发症,依靠小肠内引流管和负压引流,患者可不依靠肠外营养支持生存,等待二次手术时机。9个月后手术切除小肠瘘,术口完全愈合。结论封闭式负压引流可用于严重的腹腔感染后难以短期缝合的术口全层裂开的治疗。     

Clinical evaluation of gauze‐based negative pressure wound therapy in challenging wounds

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze‐based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze‐based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult‐to‐heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline‐soaked antibacterial gauze‐based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23–97). In group I, average wound sizes of pre‐ and post‐treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm², respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre‐ and post‐treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm², respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze‐based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture‐negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow‐up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze‐based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.     

Successful treatment of complex traumatic and surgical wounds with a foetal bovine dermal matrix

A foetal bovine dermal repair scaffold (PriMatrix, TEI Biosciences) was used to treat complex surgical or traumatic wounds where the clinical need was to avoid skin flaps and to build new tissue in the wound that could be reepithelialised from the wound margins or closed with a subsequent application of a split‐thickness skin graft (STSG). Forty‐three consecutive cases were reviewed having an average size of 79·3 cm², 50% of which had exposed tendon and/or bone. In a subset of wounds (44·7%), the implantation of the foetal dermal collagen scaffold was also augmented with negative pressure wound therapy (NPWT). Complete wound healing was documented in over 80% of the wounds treated, whether the wound was treated with the foetal bovine dermal scaffold alone (95·2%) or when supplemented with NPWT (82·4%). The scaffold successfully incorporated into wounds with exposed tendon and/or bone to build vascularised, dermal‐like tissue. The new tissue in the wound supported STSGs however, in the majority of the cases (88·3%); wound closure was achieved through reepithelialisation of the incorporated dermal scaffold by endogenous wound keratinocytes. The foetal bovine dermal repair scaffold was found to offer an effective alternative treatment strategy for definitive closure of challenging traumatic or surgical wounds on patients who were not suitable candidates for tissue flaps.     

Pacifying the open abdomen with concomitant intestinal fistula: a novel approach

The management of the open abdomen, particularly when complicated by the presence of intestinal fistula, remains a significant challenge of modern trauma care. Although several approaches have been proposed, these varied and complex cases defy the application of a universal approach to local therapy. Ultimately, abdominal closure is desired but is not always possible. Accordingly, surgeons must be well versed in the application of a number of useful approaches that may serve to facilitate control of fistula drainage while permitting management of the surrounding open wound. We contribute a management approach that is simplistic in design, provides for effective fistula control, and permits the subsequent unhindered granulation of the surrounding wound in abdomens not amenable to delayed closure techniques.     

Negative pressure wound therapy for children with an open abdomen

Purpose

The utility of negative pressure wound therapy (NPWT) in the management of adults with an open abdomen has been well documented. We reviewed our experience with NPWT in the management of infants and children with this condition.

Methods

The records of all children who were treated with NPWT for an open abdomen between March 2005 and September 2009 at a single children’s hospital were reviewed.

Results

Twenty-five subjects were identified. They included children who developed abdominal compartment syndrome after a laparotomy (n?=?12) or in whom the abdomen could not be safely closed at the time of laparotomy (n?=?13). NWPT was accomplished with the vacuum-assisted closure (VAC®) system in all patients. The median duration for NPWT was 4.5 days. In 16 subjects, the abdomen was closed successfully after NPWT. In 14 children, the abdominal wall fascia was successfully approximated, and two children underwent a patch abdominal closure. But nine subjects died before an abdominal closure could be attempted. Only two (12.5%) children developed enterocutaneous fistulae.

Conclusions

NPWT is a reliable tool for infants and children with an open abdomen. Wound management was facilitated and abdominal wall closure was ultimately achieved in all survivors. Enterocutaneous fistulae developed in two children, however, these were likely due to underlying bowel injury and would have occurred despite variations in management of the open abdomen.     

Management of Open Abdomen After Trauma Laparotomy: A Comparative Analysis of Dynamic Fascial Traction and Negative Pressure Wound Therapy Systems

Management of the post-traumatic open abdomen (OA) using negative pressure wound therapy (NPWT) alone is associated with low rates of primary fascial closure. The abdominal reapproximation anchor (ABRA) system exerts dynamic medial fascial traction and may work synergistically with NPWT to facilitate primary fascial closure. Patients with an OA following trauma laparotomy between 2009 and 2018 were identified from a prospectively maintained institutional database. Patients treated with ABRA in conjunction with NPWT (ABRA) versus NPWT alone (NPWT) were compared in terms of primary fascial closure rate, number of surgeries to closure, tracheostomy duration, length of stay and incidence of entero-atmospheric fistula. Multivariable linear regression was performed to identify predictors of tracheostomy duration. We identified 48 patients [ABRA, 12 and NPWT, 36]. The ABRA group was significantly younger (25 vs. 37 years, p = 0.027) and included a lower proportion of males (58% vs. 89%, p = 0.032). Groups were similar with respect to the incidence of hollow viscus injury, injury severity score and abdominal abbreviated injury score. Compared to the NPWT group, the ABRA group had a significantly higher rate of primary fascial closure (100% vs. 28%, p < 0.001), fewer surgeries to abdominal closure (2 vs. 2.5, p = 0.023) and shorter duration of tracheostomy (15.5 vs. 36 days, p = 0.008). There were no differences in length of stay or incidence of entero-atmospheric fistula. On multivariable linear regression, ABRA placement was an independent predictor of shorter tracheostomy duration, after adjusting for covariates (β = − 0.294, p = 0.036). For the post-traumatic OA, ABRA coupled with NPWT achieves a higher rate of primary fascial closure compared to NPWT alone, while requiring fewer surgeries and a shorter duration of tracheostomy.     

Genitourinary fistulas of obstetric origin

Objective: To review the results of management of 42 cases of genitourinary fistulas of obstetric origin.Settings: Department of urology, Nishtar Hospital, Multan. Pakistan.Methods: Forty two cases of genitourinary fistulas (36 vesicovaginal, 2 vesicouterine, one ureterovaginal and 3urethrovaginal) were repaired from 1st December, 1999 to 31st May, 2002). All fistulas were repaired three months or more after formation. Transabdominal and vaginal repair of vesicovaginal fistulas was undertaken in 29 and 7 patients respectively. Two patients had trans-abdominal closure of vesicouterine fistulas. Ureteroneocystostomy with antireflux mechanism was performed for uretereovaginal fistula. For three urethrovaginal fistulas transvaginal layered repair was carried out.Results: Overall success rate for all types of fistula was 85.7% (36 pts).Conclusion: The surgical treatment of genitourinary fistulas will depend upon the type, size and location of fistula. Acceptable results can be achieved by adhering to the surgical principles of fistula repair i.e. optimal tissue conditions, adequate exposure and tension free closure.     

Role of negative pressure wound therapy in treating peripheral vascular graft infections

Wound complications involving large subcutaneous vessels can cause significant challenges for surgeons. Negative pressure wound therapy (NPWT) has been increasingly used for treating complex wounds in vascular surgery, including groin infections, either as a bridge to surgical closure or as a primary wound treatment modality. Although a growing body of evidence exists for managing various problematic wounds, such as diabetic foot ulcers and open abdominal wounds, the role of NPWT in wounds involving large blood vessels or wounds complicating infected vascular grafts has not been well defined. A multidisciplinary advisory panel reviewed the literature relevant to wounds related to vascular surgical procedures and complications, focusing on large subcutaneous or infected vascular conduits. The results supported by the literature and the clinical practice of the consensus panel suggested that NPWT can be a useful adjunct to the management of vascular groin infections and dehiscences but must be used with caution.     

胆总管下端术后十二指肠瘘19例治疗分析

目的：了解胆总管下端手术后十二指肠瘘发生的原因及处理。方法：回顾性分析1975－2002年收治的19例胆总管下端手术后十二指肠瘘发生的原因，诊断和治疗。十二指肠瘘经确诊后均经手术治疗。治疗方式：脓肿引流13例，十二指肠修补5例，胃大部切除幽门旷置胃空肠吻合，空肠造口1例。结果：十二指肠瘘治愈15例，死亡4例，死亡原因：消化道大出血2例，腹膜后严重感染1例，并发重症胰腺炎1例。结论：行胆总管下端探查操作时应谨慎，避免发生医源性损伤。十二指肠后早期诊断尤为重要，十二指肠瘘手术以引流为主，并予以充分的肠内营养支持。