Discussion
Isolation of enteric fluid from an enteric fistula deep within the abdomen or a deep subcutaneous space can be a challenging clinical problem. The goal for these wounds is to keep the wound clean and separate from the enteric drainage that inhibits healing through increased inflammation and bacterial load. Attempting to heal the subcutaneous tissue over a drainage device, such as a Jackson-Pratt surgical drain, was the authors' method to heal the midline abdominal incision while providing a separate portal for draining the thin enteric effluent. This unique technique provided a successful strategy that improved wound management. Some advantages in this case that the authors feel optimized success were: low-output fistula; thin enteric output; optimized nutrition with high-protein TPN; visible fascial sutures that prevented the sponge from making direct contact on the bowel; a deep subcutaneous layer that provided a large barrier between the effluent and skin; and an intact pliable outer abdominal wall skin needed for tension-free approximation and closure.
The low output and thin consistency of the enteric effluent was easily managed through a Jackson-Pratt drain. Higher fistula output volumes or thicker fluids may not have been able to pass through this type of drain and might have prevented this system from working. Also, nutrition is essential for wound healing. This patient had started on TPN 1 month prior to the development of her enterocutaneous fistula. Despite initially low serum albumin and prealbumin (1.6 g/dL and 10 mg/dL, respectively), this patient showed signs of quick healing. She had maximum protein in her TPN of 2.5 g/kg at first sight of the enteric fistula. Finally, her thick subcutaneous tissue provided an area that was able to granulate and provide a firm base for healing once the wound was approximated. A thinner subcutaneous layer may not have provided the depth necessary to approximate the wound to close without tension.
Attempting different wound management measures using a NPWT has allowed for innovative and creative wound care techniques for difficult-to-control abdominal fistulae. The negative pressure hastens wound granulation which allows for the development of a surface that could be approximated along the subcutaneous tissue. Approximation of the wound was completed with the use of a drape to provide a tension-free closure. Also, the negative pressure increases the blood flow at the level of the wound once it was approximated in order to allow for improved healing and closure.