The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200-500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re-surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4-16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi-organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.

Cytotoxic activity of NK cells was estimated as related to IL-10 and TGF-β1 serum levels and Helicobacter pylori infection in gastric cancer patients. Moreover, we sought to determine whether human gastric adenocarcinoma cells in vitro release IL-10, TGF-β1 or factor(s) affecting NK cytotoxicity. The studies were conducted on 42 patients with gastric cancer (14 with I-II stage—group 1; 28 with III-IV stage—group 2) and on 20 healthy volunteers. The cytotoxicity was tested on NK cells isolated from peripheral blood. IL-10 and TGF-β1 levels were determined by ELISA. H. pylori was detected in cultures of gastric mucosa biopsies and in direct preparations. In 71.4% patients of group 1 NK cytotoxicity and IL-10 serum levels remained within a normal range while in 68% patients of group 2 a marked decrease was noted in cytotoxic function of NK cells, accompanied by increased levels of IL-10 in serum. In turn, in most patients of either group, independently of NK cytotoxicity and stage grouping in the patients, elevated serum levels of TGF-β1 were detected. Presence of H. pylori infection manifested no relationship with NK cytotoxicity, IL-10, or the TGF-β1 serum levels. In cultures of tumour cells presence of IL-10 and TGF-β1 was demonstrated. Nevertheless, supernatants of the cultures did not change cytotoxic activity of NK cells. Development of gastric carcinoma is accompanied by markedly decreased cytotoxic function of NK cells and by elevated IL-10 and TGF-β1 serum levels. Gastric carcinoma cells may release IL-10, the suppressive activity of which may in a secondary manner decrease NK cytotoxicity.

No abstract

Vacuum-assisted closure (VAC) therapy is a widely acknowledged method for chronic and traumatic wound healing. The feasibility of VAC therapy used for the treatment of intestinal fistulas is still a subject of debate. Complex postoperative wounds pose significant therapeutic problems, especially when there are several fistula openings in the wound area and other sites, usually at the site of previous drains. This paper describes the treatment of three patients in a critical condition, with complex postoperative wounds complicated by multiple fistulas. Vacuum-assisted closure therapy was based on effective drainage of the biggest fistula opening and ensuring conditions promoting the healing process of other fistulas and the wound. A considerable improvement in general condition and wound healing was noted within 2-4 weeks and both the number of fistulas and the volume of excreted contents decreased. After 5-7 weeks a significant improvement in wound healing was observed in all patients. Once the general condition of all patients was considered satisfactory (2-6 months), they underwent surgery aimed at restoration of the digestive tract continuity.In our opinion, VAC therapy used for the treatment of postoperative wounds with multiple fistulas in the wound area and other sites should aim mainly at the improvement of patients’ general condition, limitation of the number of fistulas as well as accelerated wound healing. This may lead to formation of one stoma-type fistula, which can be dressed and cared for by patients until the continuity of the digestive tract has been surgically restored.

Negative pressure wound therapy (NPWT) has become a standard in the treatment of chronic and difficult healing wounds. Negative pressure wound therapy is applied to the wound via a special vacuum-sealed sponge. Nowadays, the endoscopic vacuum-assisted wound closure system (E-VAC) has been proven to be an important alternative in patients with upper and lower intestinal leakage not responding to standard endoscopic and/or surgical treatment procedures. Endoscopic vacuum-assisted wound closure system provides perfect wound drainage and closure of various kinds of defect and promotes tissue granulation. Our experience has shown that E-VAC may significantly improve the morbidity and mortality rate. Moreover, E-VAC may be useful in a multidisciplinary approach – from upper gastrointestinal to rectal surgery complications. On the other hand, major limitations of the E-VAC system are the necessity of repeated endoscopic interventions and constant presence of well-trained staff. Further, large-cohort studies need to be performed to establish the applicability and effectiveness of E-VAC before routine widespread use can be recommended.