Vacuum-assisted closure in the treatment of enterocutaneous fistula a case report Dr. Marwan Abu Sada Dr. Ashraf Al Ashkar Dr. Hasan Aljaish

Background widely acknowledged method of chronic and traumatic wound healing. used for the first time in the1990s . In order to achieve negative pressure, a special polyurethane sponge is introduced to the wound bed and secured with an adhesive tape. This dressing, containing a drainage tube, is fitted tightly to a special device which produces constant or intermittent regulated negative pressure.

How does VAC work The mechanism of VAC therapy is complex and not very well understood ,but through observations of most authors It results in ….. decreased edema and wound exudates. It also promotes granulation tissue formation by arterial dilatation activates angiogenesis , and restores the integrity of capillary basement membranes. Another significant mechanism is a considerable reduction of the number of bacterial cultures ,which contributes to fewer infectious complications All these factors account for a greater percentage of recoveries, shorter time of wound healing as well as a reduction in the number of complications

Methodology We used V.A.C.Therapy Unit manufactured by KCI Inc. It contains V.A.C pump ,connecting system and polyurethane V.A.C. GranuFoam standard dressing Two patients presented with abdominal wounds with ECF that were treated in our department with V.A.C and their data were collected

First case A male pt. 33 y old , known case of M.S. for 6 y with history of peptic ulcer disease that led to perf. DU which was operated in 2010 Presented with 4 days history of generalized weakness , high grade fever ,nausea ,anorexia, and repeated non projectile vomiting Abd. Ex. epigastric pain radiating to the back with sudden onset that increased in intensity over the course of the past 4 days . CXR air under diaphragm

Management Diagnosed as a case of perf. DU Immediate laparotomy was done (large hole in the 1st part of duodenum ,sever induration and adhesions) Adhesiolysis ,formal abdominal inspection, peritoneal toileting ,distal gastrectomy with side to side gastrojujenostomy and duodenal diversion. High output enterocutaneous fistula developed on the 6th post op. day (about 1500 cc/24h)(most probably from duodenal stump )

The next 3 days conventional dressing was applied and Urinary cath The next 3 days conventional dressing was applied and Urinary cath. Was inserted into the fistula opening. From (9th post op. day) VAC dressing was started and changed 3 times within 21 dayes. nearly every week. TPN only before VAC (3000 Kcal)

Fistula discharge WBC HGB Renal F. Liver F. T.prot. Alb. 1st week 1300 cc/24h to 950 cc/24h 34.000 to 25.000 11.5 to 9.5 normal 4.7 to 5.5 2 to 2.6 2nd week 950cc/24h to 400cc/24h 25.000 to 15.000 9.5 to 10.7 5.5 t0 6.7 2.6 to 3.1 3rd week 400cc/24h to less than 10cc/24h 15.000 to 10.000 10.7 to 10.5 6.7 t0 6.4 3.1 to 3.2

Discharge Total in hospital stay 33 days Total VAC dressings 3 in 21 days Wound completely closed with no fistula discharge

First VAC dressing

Second case A 44 years old, male patient was referred to us from European Gaza hospital after suffering from a perforation in the transverse colon that was repaired with resection and anastomosis, for ICU monitoring due to his critical condition. While in the ICU he developed upper GI hemorrhage that required resuscitation. A trial of upper GI endoscopy was done twice and reveled a bleeding polyp with failure of endoscopic hemostasis techniques to arrest the bleeding.

Gastrotomy was done to arrest the bleeding in the OR and the patient returned to the ICU for monitoring, within two weeks he developed wound dehiscence with high output ECF. VAC was used to treat the fistula and resulted in decreased fistula output and improved general condition gradually over the course of 4 weeks with complete closure after 8 weeks.

Fistula discharge WBC HGB Renal F. Liver F. T.prot. Alb. 1st week 1800-1000 cc/24h 32.000 to 20.000 14.5 to 12 normal 4.5 to 5 2 to 2.2 2nd week 1000-700 20.000 to 14.000 12 to 10.5 5 to 6.5 2.2 to 2.7 3rd week 700-200 14.000 to 10.000 10.5 to 11.5 6.5 to 6.2 2.7 to 3.2 4th week 200- less than 10 cc/24h 11.5 to 12 6.5 3.2 to 3.5

Discharge Total in hospital stay 62 days Total VAC dressings 4 in 30 days Wound completely closed with no fistula discharge

Summary In both patients, the VAC protected the skin, improved the condition of the patient. Also, the VAC device promoted wound contracture and healing. There were no septic complications from the VAC, and fistula output decreased gradually.

Conclusion In our opinion Vacuum-assisted closure therapy positively influences the general condition of patients with chronic and traumatic wounds complicated by ECF. Application of this method may increase the survival rate and decrease the time of healing.

Conclusion cont. Also confirmed by observations of other authors, VAC therapy may also lower the overall costs of treatment ,reducing the number of surgical procedures, the costs of dressing materials and wound care . The fast subsiding inflammatory condition also limits the time of costly antibiotic therapy, particularly in case of the presence of opportunistic bacterial strains.

Thank you

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