A Technique for Managing Enteric Fistula Closure Using Adjunctive Negative Pressure Wound Therapy

Traditional management of an abdominal fistula is pouching to collect effluent, while healing peri- fistula skin, until surgical closure can be attempted.  Utilizing Negative Pressure Wound Therapy (NPWT) as an initial treatment is another option for healing some abdominal fistulas.  Medical management of a fistula can take up to six months to spontaneously close.

NPWT was started within days of identifying the enteric fistula within an open abdominal wound.  Fistula opening was visualized at 12:00 position.   White poly-vinyl alcohol (PVA) foam was placed over the fistula, with the remaining wound bed filled with black polyurethane reticulated open-cell foam (ROCF).  Setting the machine at high NWPT pressures, the fistula was effectively closed in a few weeks. The entire dressing is changed every 2-3 days, maintaining a constant pressure to the fistula opening.  Within three months, this patient was able to start her chemo-therapy once the fistula had closed.  She did not have to wait the 4-6 months for the fistula to spontaneously close and then start the chemotherapy.

Key components for utilizing the NPWT for fistula closure:

1.      Place something over the visualized fistula opening that will not allow the free flowing of the effluent to pass through. 

2.      Fistula must be active for less than four weeks to achieve viable closure with this therapy.  

3.      Dead space at the entrance of the fistula should not be filled with the NPWT foam because the goal of the therapy is to have the walls of the space collapse inward.

4.      Amount of pressure directed downward onto the fistula opening should be high enough to effectively “plug” the fistula, anywhere from 150 – 200 mmHg/continuous.  

5.      Observe the fistula site to identify any adjustments that should be done to ensure an accurate seal when the NPWT therapy is reapplied.