Abstract
Managing patients with severe fixation of intra-abdominal contents, known as frozen abdomen, often creates a vicious cycle of tissue injury that further prolongs open abdomen resolution. We share the management course of a 28-year-old male status post motor vehicle accident with traumatic pancreatitis and complex liver injury. Following multiple laparotomies for abdominal wash out, he developed a frozen abdomen and an entero-atmospheric fistula (EAF) through granulated bowel. The exposed granulated bowel, bilious leak and fistula limited options for abdominal closure and ostomy appliance placement. NovoSorb Biodegradable Temporizing Matrix (BTM) applied to the granulated bowel eventually allowed an ostomy appliance to be placed around the fistula on top of the non-absorbable layer of the BTM. Eventual fistula closure was achieved and appropriate granulation tissue had formed prior to autografting. This is the first report utilizing BTM to aid in the closure of open abdomen in the setting of frozen abdomen with EAF.
Introduction
Leaving an open abdomen (OA) during damage control laparotomy is a life-saving strategy for trauma patients with abdominal injuries, but it’s associated with visceral injury, abdominal infection, and/or large incisional hernia can arise [1–4]. Prolonged OA with repeat surgeries can often also leads to a profound inflammatory response [5, 6]. The Bjorck classification system for OA can be referenced to specify the degree intra-abdominal adhesions and contamination. The most severe category, Grade IV, is a frozen abdomen with an established entero-atmospheric fistula (EAF) [7]. Frozen abdomen (FA) is problematic because it leaves the abdominal contents exposed yet surgically inaccessible [1, 5]. Without control of enteric output, autografting is likely to fail, biologic mesh will rapidly dissolve, and synthetic mesh will leave the bowel incompletely protected or even contribute to additional fistula formation, and the risk of infection remains high [8, 9]. We present a patient with Bjorck Class III with a high output EAF managed with synthetic dermal matrix composed of bioabsorbable polyurethane and a non-biodegradable polyurethane sealing membrane, BTM Biodegradable Temporizing Matrix™ (BTM). To our knowledge, this is the first report utilizing this product to aid in the closure of a frozen abdomen with a EAF.
Case presentation
A 28-year-old male, restrained driver, rear-ended a semi-truck at 65 mph. CT imaging revealed a liver laceration and pancreatic head injury. Initially the patient was hypertensive, 170/97, and tachycardic at 120. Focused assessment with sonography for trauma was positive in all peritoneal compartments. Interventional radiology (IR) performed angiography for the liver laceration with hemoperitoneum. Angiograms of the visceral vessels demonstrated no apparent active extravasation, and the gastroduodenal artery was entirely occluded at its origin.
On hospital Day 2, the patient developed abdominal compartment syndrome and was taken for emergent exploratory laparotomy. Intraoperative findings included a pancreatic head injury with multiple areas of saponification, a dusky duodenum, and a laceration of liver lobe 4B with active bleeding and bile leakage controlled with cauterization and hepatic sutures. Following washout, the abdomen was left open with Bogota bag placement combined with negative pressure suction.
On hospital Day 11, after multiple reoperations the abdominal contents were notably frozen, and by hospital Day 18, a proximal small bowel EAF was appreciated (Fig. 1). On hospital Day 20, the patient developed hemorrhagic shock with bloody output from the nasogastric tube and hematochezia. Due to patient’s FA, decision was made to pursue endovascular intervention for suspected hepatobiliary arterial fistula. A supra-celiac arterial aortic occlusion balloon was placed in the intensive care unit, and visceral angiogram demonstrated frank hemorrhage into the bowel from the proper hepatic artery. Coil embolization from the left hepatic artery through the common hepatic artery was performed.
Frozen abdomen of the patient showing adhered loops of bowel and the lower lobe of the liver. The arrow represents the location where the patients fistula was located.
On hospital Day 31, BTM™ was placed on top of partially granulated intestine and liver. A hole on the BTM™ was trimmed to fit around the small bowel fistula and a Malecot™ drain placed to assist with fistula control (Fig. 2). A wound vacuum was applied on top of the BTM™ to keep it adherent to the granulated abdominal contents as well as fluid accumulation from non-granulated areas. When the BTM™ became sufficiently adherent to the abdominal content, the vacuum device was removed and an ostomy bag was placed directly to the BTM to control the output. With time the EAF resolved. Split thickness autograft was performed on hospital Day 68 (Fig. 3), and the patient was discharged after a total of 123 days. Figure 4 shows the healed image on the day of discharge.
Novosorb BTM on the abdomen with the laminte layer still on. The black arrow represents the location of the fistula.
Skin grafting of the Novosorb BTM.
The patients skin graft after complete epithilization.
Discussion
Definitive closure of an OA is performed through primary fascial closure with or without mesh reinforcement to prevent ventral hernia. However, neither primary fascial closure nor functional closure is appropriate in patients with underlying EAF [1]. In these situations, the primary goal of wound therapy is to control and reduce EAF output until fistula closure. Common techniques used to control EAF output include application of negative pressure wound device, stoma protection devices, or frequent wet-to-dry dressing changes. With diligent wound care, close management of fluids and electrolytes, nutritional support, and infection control, spontaneous EAF closure remains infrequent. In fact, most studies have reported spontaneous closure rates that are less than 30% with these standard wound therapy methods [8, 9]. The prolonged atmospheric exposure of granulated intestine increases the risk of additional formation of EAF.
Synthetic matrices, such as BTM™, have been used as temporary or permanent solutions for complex wounds. BTM™ is composed of two layers: a biodegradable polyurethane foam with a non-biodegradable polyurethane meshed protective top layer. The incorporation of the biodegradable polyurethane layer serves as the new dermis for skin grafting in two weeks. BTM™ is less likely to get infected or degrade in a contaminated field. Its indications for use include placement over fully debrided partial and full thickness wounds, pressure, venous, diabetic ulcers, surgical and draining wounds [10].
Available management of an OA with EAF include a combination of local wound care with or without vacuum assistance; absorbable or non-absorbable mesh like biologic, polyglactin 910 (Vicryl™), polypropylene (Marlex™) or polytetrafluoroethylene (Gor-Tex™); synthetic composite mesh; and eventual autograft. Autograft or biologic mesh would likely fail or breakdown given the inability to control enteric and bilious fistula output, and polyglactin 910 mesh would not allow an ostomy appliance to seal nor completely protect the bowel from further fistula formation. Current non-absorbable composite mesh with polypropylene would lead to continued inflammation with increased risk of additional EAFs without the ability to utilize omentum for bowel protection.
BTM™ provided durable coverage and protection of the exposed bowel and liver. The smooth protective top layer allowed placement of a vacuum assisted wound for fluid evacuation with product adherence and separate drainage of the EAF. Unlike autologous graft or biologic mesh, BTM™ was found to be resistant to EAF effluent breakdown, despite visible contamination and staining, while still facilitating the formation of underlying dermis and healthy granulation tissue. The temporizing coverage protected the abdominal content from additional injury as well as assist with EAF spontaneous closure since it was excluded from the vacuum dressing.
Conflict of interest statement
The authors declare there is no conflict of interest.
Funding
The research presented in this manuscript had no specific funding from any agency in the public, commercial or not-for-profit sectors.
Informed consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. Ethical approval was obtained from our institutional review board (IRB #23–01).
