Title: Vacuum Assisted Closure (VAC) of Recalcitrant Enterocutaneous Fistulas
Authors: Michael S. Wong, MD, Salvatore C. Lettieri, MD
Background: Enterocutaneous fistulas (ECFs) are a challenging problem that may complicate the postoperative course of patients with solid or visceral abdominal cancers or those having undergone multiple abdominal surgeries.1 Uncontrolled ECFs can lead to or worsen existing malnutrition and macerate surrounding skin and soft tissues, making wound healing and closure more difficult. Traditionally accepted treatment of ECFs consists of bowel rest and somatostatin to decrease fistula output in conjunction with parenteral nutrition to provide the necessary energy required for optimal wound healing. This is also combined with local measures to protect the skin from the irritating affects of fistulous drainage.
The wound VAC is a self-contained vacuum system attached to a polyurethane sponge that is being increasingly utilized in the management of a variety of difficult wounds. The manufacturer lists several contraindications to the use of the wound VAC including untreated osteomyelitis, residual necrotic tissue in the wound, malignancy in the wound and fistulas to organs or body cavities.2 Despite the latter, we have begun treating patients with persistent ECFs in order to aid in controlling the fistulous drainage from the surrounding skin.
Materials and Methods: Over an 8 month period, VAC was used in 9 patients, 5 males and 4 females, ages 32-72 years (average = 60.1 4.8 years, mean sem) with ECFs following abdominal surgery that had not responded to traditional therapy. Four patients had advanced malignancy. This included pancreatic cancer in two patients, metastatic gastric cancer in one patient, and another patient with advanced stage cervical cancer. Four patients had diabetes mellitus. All patients were malnourished with the average albumin of our patients being 2.2 0.2 mg/dl (range 1.4-3.4 mg/dl). VAC treatment averaged 21.1 5.2 (9-32) days.
Results: Complete closure of 3 ECFs was achieved with VAC treatment alone while an additional ECF was surgically closed 16 days following VAC treatment. Seven months later, this patient refistulized and again was successfully closed surgically. Among the 4 ECFs that closed, patient albumin averaged 1.97 0.47 mg/dl and the two diabetics had well controlled blood sugars (< 140 mg/dl). Among the 5 ECFs that did not close, their albumin averaged 2.34 0.30 mg/dl and the 2 diabetics had persistantly elevated blood sugars (> 200 mg/dl) during their hospitalization. Six of the 9 patients treated with VAC demonstrated signs of decreased inflammation and excoriation of the surrounding skin. Failure to obtain control in the remaining 3 patients was due to difficulty maintaining a vacuum seal around ostomies and patient noncompliance.
Conclusion: This preliminary experience suggests that VAC is a helpful adjunct in managing complicated ECFs. It can simplify dressing changes from 2-3 times per day to 3 times per week. VAC can control fistulous drainage and decrease the irritation to the surrounding skin in the compliant patient in which a vacuum seal can be maintained. It can serve as a bridge to surgical repair, and even result in fistula closure. Albumin levels did not appear to predict closure while good control of blood sugars was associated with ECF closure.
References:
1. Hiyama DT, Zinner MJ: Surgical Complications, Schwartz SI (ED): Principles of Surgery, Sixth Edition, New York, McGraw-Hill, Inc., 1994, Chapter 11, pp. 455-87.
1. Hiyama DT, Zinner MJ: Surgical Complications, Schwartz SI (ED): Principles of Surgery, Sixth Edition, New York, McGraw-Hill, Inc., 1994, Chapter 11, pp. 455-487.
2. KCI USA, Inc.: V.A.C. Recommended Guidelines for Use: Physician & Caregiver Reference Manual, 1999, p. 3.
Picture 1:
A close-up view of succus entericus draining from an enterocutaneous fistula at the superior portion of an abdominal wound.
Picture 2:
The same abdominal wound as in Picture 1, covered by a polyurethane foam sponge connected to the VAC device.