• Georgi Popivanov, Roberto Cirocchi, Dimitar Penchev, Kirien Kjossev, Marina Konaktchieva, and Ventsislav Mutafchiyski.
• Department of Surgery, Military Medical Academy, "Sv. G. Sofiiski" Str. 3, 1606 Sofia, Bulgaria.
• Medicina (Kaunas). 2022 Jan 28; 58 (2).

AbstractEnteroatmospheric fistulas (EAFs) are still the worst complication of the open abdomen. They lead to a significantly prolonged intensive care unit and hospital stay and to high mortality. Despite the various techniques described in the literature EAFs remain "a nightmare" for the patient, the surgeon, and the hospital. Here we describe a case of right colectomy for obstructing Crohn's disease in a 26-year-old. On the 19th postoperative day, he developed a superficial EAF. Due to the frozen abdomen, neither resection of the anastomosis, nor implementation of the known techniques for treatment of EAFs were possible. This prompted us to modify the Pepe technique. The EAF was isolated from the upper and lower parts of the wound through deep-skin and subcutaneous sutures and the application of two small pieces of non-adherent plastic foil. The lower holes of a single drain, put through a piece of black foam, were placed over the fistula. The upper holes, which were enveloped with the foam, remained in contact with the wound. The drain was connected to a negative pressure of 125 mmHg. NPWT (negative pressure wound therapy) was also applied by two separate sponges and drains in the upper and lower part. The mainstay of EAF treatment is the isolation of the EAF from the abdominal cavity and subcutaneous tissue, supported by control of the sepsis and adequate nutrition. The proposed technique is applicable in cases with a single, superficial EAF on the background of the frozen abdomen with minimal lateral fascial retraction. As of today, due to the rarity of the condition and lack of randomized trials, EAFs still represents a unique challenge often requiring improvisation.

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