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Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.
Necrotizing soft tissue infections represent a spectrum of diseases characterized by extensive necrosis involving the skin, subcutaneous tissues, fascia or muscles. These infections are generally severe and rapidly progressive, often accompanied by sepsis, septic chock, multiple organ failure and, ultimately, death. Several classifications have been developed based on multiple parameters, such as the anatomical location of the disease, the depth of the lesion or the microbiology. Numerous clinical factors predispose individuals to the development of necrotizing soft tissue infections. The clinical presentation is not always characterized by local signs and systemic symptoms of infection, which can lead to delays in both diagnosis ad treatment. Broad-spectrum antibiotic directed at the likely organisms is essential early in the treatment course, but do not substitute surgical management. Antibiotic therapy should be subsequently tailored to the etiologic micro-organism. Rapid recognition and early surgical intervention form the mainstay of management of necrotizing soft tissue infections. Initial surgical debridement should be promptly performed preferably at the presenting hospital, when adequate infrastructure and personnel are available. Transfer to a referral center may be necessary for definitive surgical and complex wound care. Most patients require more than one debridement. A multidisciplinary approach is also essential to improve the results in the treatment of these patients.
Background: Abdominal muscle injuries after blunt trauma are rare but increasingly recognized. The overall incidence in all traumatic admissions is 0.2%–0.9%, which rises to 9.2% in patients who underwent abdominal/pelvis CT scan. The aim of this systematic review is to evaluate the incidence, type, management, and outcomes of abdominal wall injuries following blunt trauma. Methods: We performed a systematic review according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement to identify articles reporting abdominal wall injuries following blunt abdominal trauma. Only the papers focusing on abdominal wall injuries following abdominal trauma among the adult population were included. Preoperative variables and outcomes were analyzed. Results: A total of 49 papers of the 568 initially identified were included for analysis. This represented a total of 759 patients, with the majority of papers being retrospective case reports/series. No prospective studies were retrieved. According to the Dennis et al. classification of traumatic abdominal wall injuries, type V (151) was the most common traumatic abdominal wall hernia, followed by type IV (71), type III (20), and type VI (9). Acute repair was performed in 333 patients (43.9%). As a whole, the use of mesh to repair the abdominal wall defect was specified in 183 patients. A minimally invasive approach was reported in eight papers. Conclusion: Patients with traumatic blunt injury to the abdominal wall are rarely reported and often overlooked by both radiologists and trauma surgeons. Nowadays, complex abdominal wall reconstruction has become a specific topic of interest for dedicated surgeons. In light of the five pillars of acute care surgery, we believe that a modern trauma team should include surgeons specifically trained in abdominal wall reconstruction techniques.
