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 negativepressure therapy. After sustaining an epigastric shot wound, a 33-year-old woman underwent three consecutive laparotomies, 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 nutrition 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
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 associated 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 closure (VAC) in the treatment of a recalcitrant post-traumatic 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 anastomosis 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 intravenous temocillin was given intravenously for four
weeks. Nevertheless, 10 weeks after the initial injury,
persistent leakage through the mersilene mesh was

noted. Abdominal radiology then conclusively revealed

one small bowel fistula distal to the oesojejunal anastomosis and one transverse colic fistula proximal to the
colostomy. Vacuum-assisted closure therapy was decided and applied for two weeks. It consisted of the placement 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 connected 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 demonstrated stable coverage without any leakage, while enteral 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 (200500 ml/24 h), or high (> 500 ml/24 h) (5). Outcome is
also influenced by the aetiology of the fistula, the concentration 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, distal 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
10

11

Age

Sex

Duration (days)

61
24
49
64
68
52
34
69
79
67
64
60
66
45
36
43
83
48
35
69
49
24
37
51
39

m
f
f
f
m
f
m
m
f
m
9m
6f

19
23
101
23
68
25
16
14
79
68
10
12
15
10

Follow-up (months)

Cure

yes
yes
yes
yes

mean 3

yes
yes
yes
yes
yes
yes

19
16
22
14
17

yes
yes
yes
yes
yes

10
9

yes
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 clinical studies. Its application in the management of enterocutaneous fistula has seldom been reported in the literature, 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 conservative management and were not amenable to surgical
treatment. Gunn et al. showed that VAC treatment outcome 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,

Improvement

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, previously 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 therapy (14).
Conclusion
This study, together with a literature review, depicts negative-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 highoutput 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 nutritional status before surgery. In such a particular indication, it does not seem to confer any additional morbidity 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