Acta chir belg, 2007, 107, 703-705

Vacuum-assisted Closure of Enterocutaneous Fistula

K. Boulanger, V. Lemaire, D. Jacquemin
Department of Plastic and Reconstructive Surgery, University Hospital Liege.

Key words. Vacuum-assisted closure ; enterocutaneous fistula.

Abstract. The authors report their experience in the treatment of a posttraumatic enterocutaneous fistula with negative-
pressure therapy. After sustaining an epigastric shot wound, a 33-year-old woman underwent three consecutive laparo-
tomies, which eventually led to an open abdomen with the interposition of a surgical mesh. Enterocutaneous fistulae
were subsequently documented and Vacuum-Assisted Closure therapy was instituted along with total parenteral nutri-
tion and systemic antibiotics. Development of a suitable granulation bed and closure of the fistulae were noted after two
weeks of treatment and a split-thickness skin graft was applied to the wound. Follow-up at 8 months showed stable
coverage and a return to normal enteral feeding.

Introduction noted. Abdominal radiology then conclusively revealed

Enterocutaneous fistulae are mostly encountered in
Crohns disease and after digestive surgery (75 to 85%
of the cases) (1). Its incidence has been reported to be
7.1% after an emergent laparotomy (2). It is still associ-
ated with high mortality, ranging between 16 and
80% (3). Conventional management consists of fasting,
fluid control, total parenteral nutrition, and octreotide
(4). We report our experience with vacuum-assisted clo-
sure (VAC) in the treatment of a recalcitrant post-trau-
matic digestive fistula.
Case report
A 33-year-old woman was admitted to our emergency
department after sustaining an epigastric shot wound
with a fragmentation bullet. Exit wounds were multiple
and were situated in the back. Medical history is relevant
for Crohns disease. Emergent surgery consisted of colic
resection up to the transverse colon with subsequent
colostomy, partial small bowel resection, splenectomy,
and raphy of a perforated stomach. Surgical revision
with total gastrectomy and omega oesojejunal anasto-
mosis was required at postoperative day 5 due to gastric
leakage with subsequent septic shock. A transverse colic
fistula was demonstrated at day 7 and was treated with
raphy and biologic glue. Primary closure of this third
laparotomy was impossible and a mersilene mesh was
applied and draped with sterile gauzes. Bacteriological
cultures were positive for an escherichia coli and intra-
venous temocillin was given intravenously for four
weeks. Nevertheless, 10 weeks after the initial injury,
persistent leakage through the mersilene mesh was
one small bowel fistula distal to the oesojejunal anasto-
mosis and one transverse colic fistula proximal to the
colostomy. Vacuum-assisted closure therapy was decid-
ed and applied for two weeks. It consisted of the place-
ment of a foam sponge (VAC, Kinetic Concepts, Inc,
San Antonio, Texas) over the mersilene mesh that was
draped with an adhesive, with the tubing system con-
nected to a negative pressure pump (125 mm Hg).
Moreover, it was continuously irrigated with lactated
Ringers solution through a perfusion tube that was
inserted between the foam sponge and the polyurethane
adhesive drape dressing. This system was changed each
72 hours. Total parenteral nutrition and co-amoxiclav
and metronidazole antibiotherapy were continued for
three weeks. Afterwards, good granulation tissue was
achieved (Table 1) and a split-thickness skin graft was
applied with success. Follow-up at 8 months demon-
strated stable coverage without any leakage, while enter-
al feeding was re-started and well tolerated through a
persistent colostomy.
Discussion
Intestinal fistulae are commonly classified following
their output as mild (< 200 ml/24 h), moderate (200-
500 ml/24 h), or high (> 500 ml/24 h) (5). Outcome is
also influenced by the aetiology of the fistula, the con-
centration of trypsin, and possible infection. With
adjuncts such as somatostatin analogues, conservative
treatment leads to high rates of spontaneous healing
(close to 75%) but residual cancer, Crohns disease, dis-
tal obstruction, and severe sepsis are known hindrance
factors (4). Surgery is indicated in cases of failed
704 K. Boulanger et al.

Table 1
Achievement of good-quality granulation tissue after 2 weeks of VAC therapy
Reference Age Sex Duration (days) Follow-up (months) Cure Improvement
10 61 m 19
24 f 23
49 f 101 yes
64 f 23 yes
68 m 68 yes
52 f 25
34 m 16 yes
69 m 14
79 f 79 yes
67 m 68 yes
11 64 9m 10 mean 3 yes
60 6f 12 yes
66 15 yes
45 10 yes
36
43 19 yes
83 16 yes
48 22 yes
35 14 yes
69 17 yes
49
24
37
51 10 yes
39 9 yes

conservative treatment, but resection of the diseased
intestinal segment is not always feasible.
Vacuum therapy has gained wide acceptance during
the past ten years and its indications broaden with clini-
cal studies. Its application in the management of entero-
cutaneous fistula has seldom been reported in the litera-
ture, with only seven studies existing, involving
45 patients (3, 6-11). Mean age was 55 years with a sex
ratio of 0.95. Negative-pressure dressings were applied
for a mean of 30 days. Complete healing of the fistula
was achieved in 64% of the patients and improvement
was noted in 21%. There was no recurrence of the
healed fistulae, within a mean follow-up of 3 months.
Moreover, there was no adverse effect to this treatment.
These encouraging results are to be analysed in the light
of the particular population studied. Indeed, most of
these patients had multiple previous failures of conserv-
ative management and were not amenable to surgical
treatment. Gunn et al. showed that VAC treatment out-
come did not seem to be correlated to the fistula output
rate and that non-closure could be anticipated in the
presence of visible digestive mucosa in the wound (11).
Surgeons could be reluctant to use VAC therapy in
enterocutaneous fistulae since its use in abdominal
wounds with exposed bowels has been reported to
induce intestinal fistula formation in about 20% of
cases (12). It is our belief that interposition of material,
such as a mersilene mesh, ensures an effective barrier
that can prevent direct trauma to the gut and subsequent
fistula formation. The same practice is applied by
authors who advocate the use of non-adherent dressings
between vascular anastomosis and the VAC sponge (13).
Moreover, it could appear implicit that suction would
enhance the output rate of the fistula. However, previ-
ously depicted studies have shown the contrary and large
studies dealing with the direct insertion of a Foley
catheter into the fistula tract, with the application of
high-level negative pressure, have shown this method to
yield better results than standard conservative thera-
py (14).
Conclusion
This study, together with a literature review, depicts neg-
ative-pressure therapy as an effective adjunct treatment
in the management of enterocutaneous fistula. It
improves skin integrity around the fistula and lowers
requirements in dressing changes, especially in high-
output fistulae. It achieves closure in 64% of the cases
where conservative treatment is ineffective and, in the
other cases, is helpful in improving the patients nutri-
tional status before surgery. In such a particular indica-
tion, it does not seem to confer any additional morbidi-
ty or any risk of new fistula formation.
VAC in Enterocutaneous Fistula
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Pr. D. Jacquemin
Department of Plastic and Reconstructive Surgery
University Hospital Lige
Sart Tilman 1B
B-4000 Lige, Belgium