Negative Pressure Wound Therapy for Fistula Management?

Abdominal wounds with fistulas present a challenge to patients, surgeons, and clinical staff even in an advanced practice setting with a multitude of treatment options.  This particular patient, 72 year female, presented to our clinic with a chronic draining abscess of the abdominal wall secondary to ventral hernia repair and retained mesh. The patient was given the options of basic wound and skin care with suppressive antibiotics versus excision of the pathological material (and eventual abdominal wall reconstruction).  The patient opted for a non-operative approach but soon developed increased drainage, pain, and inflammation. This was due to erosion of the mesh into small bowel.  The resulting wound after debridement was 5 x 13 x 3 cm with jejunal fistulas. As she was still ineligible for major curative surgery, management was based on total parenteral nutrition, pharmaceuticals to minimize bowel fluids, and wound and skin care based on periwound skin protectants and silver based topicals.  Ostomy appliances to collect fistula output were difficult to maintain for more than a day, resulting in frequent bag and dressing changes, and persistent dermatitis.  Negative Pressure Wound Therapy (NPWT) was tried as a means of managing the drainage, but when done using conventional polyurethane sponges, they became occluded and ineffective in capturing all of the drainage, resulting in persistent leaks and dermatitis.  However, an alternative NPWT* device was now on the market which offered various tube sizes, larger lumens, and a cotton gauze interface to the wound, resulting in less frequent tube clogging. Once this new NPWT* device was initiated, drainage and dermatitis were controlled, and over a three month period, the wound contracted and healed to the edges of the fistula.  Although this was a complex dressing, on a complex wound, we found promise with the new NPWT* device for fistula management.