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A Modified “Fistula-VAC” Technique: Management of Multiple Enterocutaneous Fistulas in the Open Abdomen

Piazza, Rocco C., M.D.; Armstrong, Shannon D., M.D.; Vanderkolk, Wayne, M.D.; Eriksson, Evert A., M.D.; Ringler, Steven L., M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 453e-455e
doi: 10.1097/PRS.0b013e3181bcf6d4
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Grand Rapids Medical Education and Research Center, Michigan State University (Piazza, Armstrong)

Department of General Surgery (Vanderkolk)

Grand Rapids Medical Education and Research Center, Michigan State University (Eriksson)

Division of Plastic and Reconstructive Surgery, Department of General Surgery, Grand Rapids Medical Education and Research Center, Michigan State University, Grand Rapids, Mich. (Ringler)

Correspondence to Dr. Piazza, 53 Campau Circle, NW, Grand Rapids, Mich. 49503, rpiazzamd@gmail.com

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Sir:

Management of a high-output enterocutaneous fistula can be a labor-intensive and frustrating task for nursing staff, physicians, and the patient. In the presence of an open abdomen, wound management becomes extremely difficult, especially when effluent contaminates the granulating wound bed, delaying wound healing and prolonging hospital stay. The vacuum-assisted closure (V.A.C.; KCI, Inc., San Antonio, Texas) dressing has been used in patients with abdominal compartment syndrome and severe abdominal sepsis to aid in managing the open abdomen.1 Although the “fistula-VAC” technique has been described previously for exophytic fistula, our patient's fistulas were flush with the wound surface, making the dressing application more challenging.2 We present a case of an open abdomen complicated by two juxtaposed high-output enterocutaneous fistulas at the wound edge.

The patient is an obese but otherwise previously healthy 29-year-old man that sustained multiple gunshot wounds to the abdomen. He underwent laparotomy for control of hemorrhage and contamination. His abdomen remained open secondary to abdominal compartment syndrome and severe abdominal sepsis. Subsequently, he developed two high-output (2 to 3 liters/day) enterocutaneous fistulas in the proximal jejunum that were refractory to medical therapy (Fig. 1). The fistula output required three to four vacuum-assisted closure dressing changes daily.

Fig. 1.

Fig. 1.

A multidisciplinary approach enabled the development of our modified fistula-VAC dressing technique. The wound was first cleaned with saline irrigation. Suction was used to keep the continuously draining effluent off the wound bed. DuoDerm (ConvaTec, Skillman, N.J.) was placed on the normal skin adjacent to the fistulas. The perifistula area was dried using stoma powder, and a stoma flex ring was molded to the wound/skin junction. White vacuum-assisted closure nonadherent foam was then cut to fit the wound bed, excluding the fistulas and stoma flex ring (Fig. 2), and then covered by a black vacuum-assisted closure GranuFoam (KCI) (Fig. 3). A 2 × 2 gauze sponge was then placed over the fistulas and covered by the vacuum-assisted closure drape. The entire dressing was placed to 75 mmHg of suction. The 2 × 2 gauze pad was then cut out (Fig. 2), causing the dressing to lose suction; however, with placement of a vacuum-assisted closure drape and an additional stoma flex ring the seal is quickly reestablished (Fig. 4). The vacuum-assisted closure device is placed to intermittent suction at 75 mmHg. Lastly, the stoma appliance and bag were placed over the fistulas and connected to a Foley bag (Fig. 5). The dressing was changed every 3 days.

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

Fig. 4.

Fig. 4.

Fig. 5.

Fig. 5.

Open abdominal wounds are difficult to manage, especially when complicated by an enterocutaneous fistula. We describe a modified version of the fistula-VAC for enterocutaneous fistulas that are not matured, but instead are flush with the surrounding wound bed. Overall, time to complete healing was 5 weeks from the day of initiation of the modified fistula-VAC technique. We are confident that our method can be used to control enterocutaneous fistulas when the surrounding tissues are at differing heights around the wound bed. A multidisciplinary approach created the modified fistula-VAC technique, our solution to this complex wound-healing problem.

Rocco C. Piazza, M.D.

Shannon D. Armstrong, M.D.

Grand Rapids Medical Education and Research Center

Michigan State University

Wayne Vanderkolk, M.D.

Department of General Surgery

Evert A. Eriksson, M.D.

Grand Rapids Medical Education and Research Center

Michigan State University

Steven L. Ringler, M.D.

Division of Plastic and Reconstructive Surgery

Department of General Surgery

Grand Rapids Medical Education and Research Center

Michigan State University

Grand Rapids, Mich.

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ACKNOWLEDGMENTS

The authors thank Donald Scholten, M.D., professor, Grand Rapids Medical Education and Research Center, Department of General Surgery, Michigan State University; and Amanda M. McClure, B.S., Michigan State University College of Human Medicine, Grand Rapids, Michigan.

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DISCLOSURE

The authors have no disclosures with respect to this article.

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REFERENCES

1. Perez D, Wildi S, Demartines N, Bramkamp M, Koehler C, Clavien PA. Prospective evaluation of vacuum assisted closure in abdominal compartment syndrome and severe abdominal sepsis. J Am Coll Surg. 2007;205:586–592.
2. Goverman J, Yelon JA, Platz JJ, Singson RC, Turcinovic M. The “Fistula VAC,” a technique for management of enterocutaneous fistulae arising within the open abdomen: Report of 5 cases. J Trauma 2006;60:428–431; discussion 431.

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