(p. 889) Management of the open abdomen and abdominal fistulae in the critically ill 

Management of the open abdomen and intestinal fistulae remains a significant challenge. Leaving the abdomen open when it is possible to close it confers no benefit and may increase morbidity. The abdomen may be left open as part of a ‘damage control’ strategy in an unstable patient with abdominal trauma, or in other conditions in which it may be impossible to close because swollen intestinal loops, retroperitoneal haematoma, or oedema may lead to abdominal compartment syndrome. It may also be inappropriate to close the abdomen when there has been infection that cannot be readily controlled. Intestinal fistulae are associated with considerable morbidity and mortality. Management is described by the four ‘R’s of resuscitation, restitution, reconstruction and rehabilitation. Eradication of sepsis, improved wound and skin care, safe nutritional support and appropriate timing of surgical intervention have reduced mortality related to enterocutaneous fistulae from 65 to <10% over the last 30 years. However, mortality from enteroatmospheric fistulae remains high. Fifty to eighty per cent of enterocutaneous fistulae close spontaneously, compared with only 10% of colonic fistulae. Refistulation rates are high despite operative repair.