Open abdomen managementに合併したenteroatmospheric fistulaの1例(A case of enteroatmospheric fistula followed by the open abdomen management)

• Published in: Nihon Kyūkyū Igakkai zasshi 2017-03, Vol.28 (3), p.94-99
• Main Authors: (Takashi Iwamura), 岩村 高志, (Futoshi Nagashima), 永嶋 太, (Miho Oota), 太田 美穂, (Ryota Sakurai), 櫻井 良太, (Hiroyuki Koami), 小網 博之, (Yuichiro Sakamoto), 阪本 雄一郎, (Satoshi Inoue), 井上 聡
• Format: Article
• Language: English
• Subjects: damage control surgery; negative pressure wound therapy; planned ventral hernia; temporary abdominal closure; ダメージコントロール手術; 一時的閉腹; 陰圧閉鎖療法
• ISSN: 1883-3772; 1883-3772
• DOI: 10.1002/jja2.12161

要旨 Enteroatmospheric fistula（EAF）は，open abdomen management（OAM）に伴う致死的合併症の一つで，開腹術創部に直接開口する消化管瘻を指す。43歳の男性が交通事故に伴う多発外傷で長期のOAMを余儀なくされた。早期閉腹のためfascial traction法を用いて腹壁の退縮を予防し，第20病日，component separation法を試みたが閉腹困難であり，第30病日に小腸のEAFを発症した。EAF管理に際しては，ストーマ化による瘻孔排液の分離に難渋し漏れが頻発したが，陰圧閉鎖療法を併用した物理的な瘻孔圧迫や腸管縫合による閉鎖が腸内容物の排液量制御に有用であった。但し，完全な閉鎖は困難で時間を要するため，栄養吸収に問題がなければ早期の植皮術・ストーマ管理が入院期間の短縮に有用と考えた。 ABSTRACT Enteroatmospheric fistula (EAF), the digestive tract fistula opening directly to the laparotomy wound is one lethal complication associated with open abdomen management. A 43–year–old man who sustained severe multiple abdominal trauma due to a traffic accident required long–term open abdomen management. In order to perform early fascial closure, the fascial traction method was used in combination with negative pressure wound therapy (NPWT) to prevent fascial retraction. On the 20th hospital day, the component separation method was tried for fascial closure, but was unsuccessful. On the 30th hospital day, EAF in the small intestine was confirmed. In EAF management, being unable to drain intestinal fluid from the fistula caused frequent leakage, which resulted in adjacent skin erosion. Physical compression to the fistula on top of NPWT and simple intestinal closure decreased the amount of fistula output. The complete closure of chronic EAF is extremely difficult and time–consuming. Therefore, if the patient’s nutritional absorption is normal, the early stoma management with a split thickness skin graft should be considered to reduce the length of hospital stay.