Management of a colocutaneous fistula in a large abdominal wound with a collapsible silicone fistula isolation device and negative pressure wound therapy with instillation therapy (NPWT-i)

Purpose: Management of large draining enterocutaneous fistula in a morbidly obese patient is a challenge.  Goals include containing effluent, protecting and promoting granulation of tissue mesh, preventing infection, optimizing nutritional status, promoting ostomy self-care, and wound closure with split thickness skin grafting.  Intubating the fistula and applying NPWT resulted in leakage of effluent from around the drain contamination of biological mesh increasing risk for wound infection.  Objective: Use a collapsible fistula isolation device to contain fistula effluent while using NPWT-i with installation of normal saline to cleanse the wound, promote granulation over biological mesh and prepare wound for split thickness skin graft (STSG).  Outcomes: A morbidly obese patient with grossly infected abdominal wall mesh with enterocutaneous fistula and giant recurrent ventral hernia underwent surgery for excision of infected mesh, exploratory laparotomy, lysis of adhesions, small bowel resection with primary anastomosis, excision of giant ventral hernia and abdominal wall reconstruction with 30cm x 20cm biologic mesh.  Her post-op course was complicated by a fluid collection and colocutaneous fistula managed by intubating the fistula with a large drain and using NPWT to promote granulation over the biological mesh.  The tube was removed due to leakage of fecal effluent three days after surgery and moist saline dressings were applied to the wound.  The patient was started on total parenteral nutrition.  A collapsible fistula isolation device to divert fistula effluent to an ostomy pouch was applied over the stoma and NPWT-i was used to irrigate the wound with normal saline, promote granulation and wound contraction.  Periodic sharp debridement was performed periodically.  Dressing changes were performed three times per week. The patient was ambulatory and able to tolerate a regular diet.  The fistula effluent was diverted through the device and contained in an ostomy pouch.  The patient learned how to empty her ostomy pouch.  The wound was closed with a STSG after ten weeks of therapy.