Problem:  54 year old white female with a history of childhood pyelonephritis and ureteral reflux, end-stage renal disease and failed kidney transplant in 2005 returning to hemodialysis. After receiving a second kidney transplant February 2007, she developed a small bowel cutaneous fistula 10 days postop. Located transverse under the abdominal pannus within multiple skin folds, the wound drained a large amount of liquid effluent.   Objectives:  ●Contain effluent ●Protect periwound tissue ●Maintain accurate I&O ●Promote patient mobility ●Accommodate for consumption of solid food Past Management:  With limited success, past treatments included wound managers, ostomy pouches, negative pressure wound therapies, and combined pouching and wall suction.       An unsuccessful attempt to surgically close the enterocutaneous fistula resulted in a larger wound measuring 6x4x1cm with 2 pseudo stomas in the center. The distal pseudo stoma functioned. Current Clinical Approach:  ●Periwound skin protected with ostomy powder, ostomy cement, and skin barrier ●Creases filled with ostomy paste and strip paste ●Wound treated with NPWT ●Stoma isolated with a karaya barrier 1piece ostomy pouch with 3 convex rings attached to the barrier and an ostomy belt to secure ●Food consumption was accommodated by using blue nebulizer tubing connected to a suction canister to allow for food passage Outcomes: Using a relatively “old” type of colostomy pouch along with a “new” type of convex ring, “borrowing” a lot of ideas from WOCN and staff nurses, and a “blue” oxygen nebulizer tubing, we were able to construct an appliance that lasted 5 days and met our objectives.  Conclusion: After approximately 5 months in the acute care, the patient was discharged to an extended care facility. From there she was discharged to her home.  The wound has since healed and she is managing her enterocutaneous fistula in a similar manner.