High Output Fistulas within Abdominal Wounds of Patients having Atypical Habitus-The Ultimate Challenge!

Introduction:

Small bowel fistulas produce caustic effluent which must be contained to protect the skin from erosion. A patient with a rotund or irregularly shaped abdomen with a small bowel fistula within a wound creates a challenging situation because pouch failure is a frequent problem.

Rationale:

A system that will promote wound closure while containing small bowel output is needed. Traditional wound/fistula managers alone may not maintain a seal.

Methodology:

Negative Pressure Wound Therapy (NPWT) utilizing the Wooding-Scott fistula manager kit was used on two patients with small bowel fistulas within abdominal wounds. Gauze was used until the wound granulated, at which time a fistula/wound manager pouch was used in combination with the Wooding-Scott drains and NPWT.

Results:

In both patients the system stayed intact for 48 to 72 hours. The wounds regranulated in 14 and 17 weeks respectively with intact periwound skin, preparing the patient to return to surgery for reduction of the fistulas.

Patient #1 is a 56 y/o female with multiple previous abdominal surgeries and hernia repairs. She was admitted for removal of infected mesh and closure of abdomen with a biologic graft. On day 2 post-op she was had significant pain and nausea and was found to have a small bowel fistula. The distal end of incision at pubis was in line with her hips and created an ‘overhang’ on each side of her belly.

Patient#2 is a 64 y/o female with infected mesh at hernia repair site. After failure of conservative management, she was admitted for removal of mesh and closure with biologic graft. Several days post op she was found to have staining under graft and subsequent small bowel fistula. Her abdomen was rotund and was extremely mobile when moving side to side. Without a waistline an ostomy belt was not an option.