Cath Lab Digest

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Abstract: Colocutaneous fistulas within laparotomy wounds are rare and difficult to treat. Surgical repair may be contraindicated or not desired and negative pressure wound therapy may not be successful. A simple device made from a silicone, flexi-aid hand exerciser was used to close a colocutaneous fistula within the laparotomy wound of a 50-year old man following surgery of an esophageal carcinoma and a surgical history of Whipple’s procedure for adenocarcinoma of the ampulla of Vater. His wound developed 9 days postoperatively, measured 8 cm x 3 cm x 2 cm, and was contaminated with fecal material. Initial efforts involving cleansing and the use of negative pressure wound therapy were unsuccessful and the patient refused additional surgery. In this patient, a silicone occlusion device, used in conjunction with a silver hydrofiber dressing, prevented fecal soiling and facilitated closure of the colocutaneous fistula and the laparotomy wound. He was discharged on postop day 22 and healed by postop day 64. This was the first time this approach was used. Studies to optimize nonsurgical management approaches of these complicated conditions are needed.

Key Words: colocutaneous fistula, esophageal carcinoma, esophageal reconstruction, laparotomy wound, nonsurgical management

Please address correspondence to: Dr. Ming-Ho Wu, 670 Chung-Te Rd, Tainan, Taiwan, 701 ROC; email: m2201@mail.ncku.edu.tw.

     A colocutaneous fistula resulting from leakage of the colocolostomy within the laparotomy wound after esophageal reconstruction is rare (in the authors’ facility, three colocutaneous fistula in 150 esophageal reconstructions, approximately 2%).¹ Because negative pressure therapy is not always successful in the treatment of open abdominal wounds and colocutaneous fistula,² a major laparotomy with intestinal resection as well as resection of the colocutaneous fistula often is necessary. Surgical treatment of these fistulas is difficult and associated with high morbidity and mortality rates.³ Fecal soiling from the colocutaneous fistula usually interferes with the patient’s daily activities.⁴ In consideration of these challenges, a nonsurgical modality for management of a colocutaneous fistula and laparotomy wound involving the design of an occlusion device is presented.

Case Report

     History. Four years before presenting to the authors, another surgeon performed a Whipple’s procedure for adenocarcinoma of the ampulla of Vater on 50-year-old Mr. H; subsequently, Mr. H received adjuvant chemoradiotherapy. More recently, Mr. H, who had no additional comorbidities, underwent a thoracoscopic subtotal esophagectomy and transverse colon interposition for squamous cell carcinoma of the esophagus. On postoperative day 9, a colocutaneous fistula developed at the upper middle portion of the laparotomy wound, which was an upper middle line incision. The wound, which measured 8 cm x 3 cm x 2 cm, was contaminated with stool from the fistula. Initial efforts (postoperative days 9 through 11) were directed toward cleansing and irrigation. To address drainage containment, negative pressure wound therapy (20 mm Hg) was administered on postoperative days 12 through 17 and throughout this period Mr. H required dressing changes every 2 to 3 hours, which disturbed his sleep. The periwound skin was irritated and painful. When he began oral intake of food, the drainage thickened and stool passed through the fistula, not the anus. Abdominal CT and colon study demonstrated the presence of a colocutaneous fistula within the laparotomy wound. Mr. H refused surgery to address the occurrence of the fistula in the laparotomy wound.

     Management.