Objective: The purpose of this study was to analyze the course and outcome of patients with combined entero-atmospheric fistulas in open abdomen treatment. Methods: In this retrospective observational study, we collected data on 214 patients with open abdomen complicated by entero-atmospheric fistulas admitted to Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School from January 2012 to January 2021. We collected their basic characteristics, aetiology, treatment plan, and prognosis, including the durations of hospitalization and open treatment, time to resumption of enteral nutrition, duration and prognosis of definitive surgery, and overall prognosis. Results: Of the 214 patients with open abdomen complicated with entero-enteral fistulas, 23 (10.7%) died (11 of multiple organ failure caused by abdominal infection, five of abdominal cavity bleeding, four of pulmonary infection, one of airway bleeding, one of necrotizing fasciitis, and one of traumatic brain injury). The remaining 191 underwent definitive surgery at our hospital. The patients who underwent definitive surgery were predominantly male (156 patients, 81.7%); their age was (46.5±2.5) years. Trauma and gastrointestinal tumors (120 cases, 62.8%) predominated among the primary causes. The reasons for abdominal opening were, in order, severe abdominal infection (137 cases, 71.7%, damage control surgery (29 cases, 15.2%), and abdominal hypertension (25 cases, 13.1%). Temporary abdominal closure measures were used to classify the participants into a skin-only suture group (104 cases) and a skin-implant group (87 cases). Compared with the skin-implant group, in the skin-suture-only group the proportion of male patients was lower (74.7% [65/87] vs. 87.5% [91/104], χ2=5.176, P=0.023), the mean age was older ([48.3±2.0] years vs. [45.0±1.9] years, t=-11.671, P<0.001), there were fewer patients with trauma (32.2% [28 /87] vs. 58.7% [61/104), χ2=13.337, P<0.001), intensive care stays were shorter ([8.9±1.0] days vs. [12.7±1.6] days, t=19.281, P<0.001), total length of stay was shorter ([29.3±2.0] days vs. [31.9±2.0] days, t=9.021,P<0.001), there was a higher percentage of colonic fistulas (18.4% [16/87] vs. 8.7% [9/104], χ2=3.948, P=0.047), but fewer multiple fistulas (11.5% [10/87] vs. 34.6% [36/104], χ2=14.440, P<0.001). As to fistula management, a higher percentage of fistula sealing methods using 3D-printed intestinal stents were implemented in the skin-only suture group (60.9% [53/87] versus 43.3% [45/104], χ2=5.907, P=0.015). Compared with the implant group, the skin-only suture group had a shorter mean time to performing provisional closure ( [9.5±0.8] days vs. [16.0±0.6] days, t=66.023, P<0.001), shorter intervals to definitive surgery ( [165.0±10.7] days vs. [198.9±8.3] days, t=26.644, P<0.001), and less use of biopatches (56.3% [49/87) vs. 71.2% [74/104], χ2=4.545, P=0.033). Conclusions: Open abdomen complicated with entero-enteral fistulas is more common in male, and is often caused by trauma and gastrointestinal tumor. Severe intra-abdominal infection is the major cause of open abdomen, and most fistulae involves the small intestine. Collection and retraction of intestinal fluid and 3D-printed entero-enteral fistula stent sealing followed by implantation and skin-only suturing is an effective means of managing entero-enteral fistulas complicating open abdominal cavity. Earlier closure of the abdominal cavity with skin-only sutures can shorten the time to definitive surgery and reduce the rate of utilization of biopatches.
目的： 探讨腹腔开放患者并发肠空气瘘的临床诊治特点。 方法： 采用观察性研究方法。对南京大学医学院附属金陵医院（东部战区总医院）暨全军普通外科研究所2012年1月至2021年1月期间，收治的腹腔开放并发肠空气瘘患者的临床资料进行回顾性分析。观察指标主要为患者的基本信息、原发病、腹腔开放原因、肠空气瘘的瘘口位置及其瘘口管理策略（三套管近端肠管收集肠液，远端回输；或使用3D打印肠瘘支架进行封堵）、腹腔开放治疗时间、确定性手术（切除瘘段肠管后，采取腹壁组织层次分离技术并根据缺损大小及腹壁顺应性，选择放置生物补片行肠道重建和腹壁修补）等待时间及腹壁缺损处理方法、入住重症监护室（ICU）和总住院时间等。根据腹腔开放创面临时关腹的措施分为创面植皮组和单纯缝合皮肤组，并分析比较两组患者的临床特征和治疗情况。 结果： 共计收治214例腹腔开放并发肠空气瘘的患者，除去23例死亡（11例多器官功能衰竭，5例腹腔出血，4例肺部感染，气道出血、坏死性筋膜炎及外伤致颅脑损伤各1例）外，191例实施确定性手术的患者纳入分析。男性156例（81.7%），年龄（46.5±2.5）岁。原发病中外伤89例（46.6%），胃肠肿瘤31例（16.2%），消化道穿孔22例（11.5%），肠梗阻17例（8.9%），急性胰腺炎和其他32例（16.8%）。腹腔开放原因依次为严重腹腔感染（137例，71.7%）、损伤控制性手术（29例，15.2%）和腹腔高压（25例，13.1%）。瘘口位置：胃15例（7.8%），小肠105例（55.0%），结肠25例（13.1%），多发瘘46例（24.1%）。单纯缝合皮肤组104例，创面植皮组87例。相较创面植皮组，单纯缝合皮肤组男性患者占比更低［74.7%（65/87）比87.5%（91/104），χ2=5.176，P=0.023］，年龄更大［（48.3±2.0）岁比（45.0±1.9）岁，t=-11.671，P<0.001］，外伤患者占比更少［32.2%（28/87）比58.7%（61/104），χ2=13.337，P<0.001］；重症监护住院时间更短［（8.9±1.0）d比（12.7±1.6）d，t=19.281，P<0.001］，总住院时间更短［（29.3±2.0）d比（31.9±2.0）d，t=9.021，P<0.001］；结肠瘘占比更高［18.4%（16/87）比8.7%（9/104），χ2=3.948，P=0.047］，但是多发瘘更少［11.5%（10/87）比34.6%（36/104），χ2=14.440，P<0.001］。瘘口管理方面，与创面植皮组比较，单纯缝合皮肤组使用3D打印肠管支架封堵方法占比更高［60.9%（53/87）比43.3%（45/104），χ2=5.907，P=0.015］，实施临时关腹时间更短［（9.5±0.8）d比（16.0±0.6）d，t=66.023，P<0.001］，确定性手术时间间隔更短［（165.0±10.7）d比（198.9±8.3）d，t=26.644，P<0.001］，生物补片使用率更低［56.3%（49/87）比71.2%（74/104），χ2=4.545，P=0.033］。 结论： 腹腔开放并发肠空气瘘以男性患者多发，创伤和胃肠肿瘤为常见病因，严重腹腔感染为腹腔开放的主要原因；瘘口位置以小肠多见。肠液收集回输及3D打印肠瘘支架封堵后行创面植皮及单纯缝合皮肤法是处理腹腔开放并发肠空气瘘的有效方法，更早地进行单纯缝合皮肤法关腹可缩短确定性手术等待时间及减少生物补片使用率。.