Successful outcome of combined surgical and negative pressure therapy in complex enterocutaneous fistulas: a case report

**Background:** Enterocutaneous fistula (ECF) is an abnormal communication between the small intestine and the skin, leading to leakage of digestive contents and potentially severe complications including infection, dehydration, malnutrition, and death. Causes include Crohn's disease, cancer, injury, and surgical complications. Approximately one-third of ECFs close spontaneously with conservative measures, particularly low-output fistulas in the proximal small intestine. For refractory cases, negative pressure wound therapy (NPWT) using vacuum-assisted closure (VAC) devices has been proposed to isolate the wound from intestinal material and promote healing, though its use in small bowel ECF remains debated and lacks official international guideline support.

**Methods:** This is a single-patient case report. The patient was an 81-year-old woman with a history of Hartmann surgery and intestinal transit reconstruction for perforated diverticulitis (15 years prior) and incisional hernia treated with hernioplasty and polypropylene mesh (10 years prior). She had chronic serous-purulent discharge from a low-volume surgical wound since the mesh surgery. She presented to the digestive surgery service with abdominal pain and fever. Physical examination revealed a surgical wound with fetid odor and color changes. Abdominal CT showed an abscess in the abdominal wall adjacent to the previous mesh measuring 12 × 4.0 × 13.0 cm. Laboratory tests showed mild elevation of C-reactive protein (70.9 mg/L) with normal white blood cell count, renal function, and electrolytes. Initial treatment included antibiotic therapy (ampicillin + sulbactam) and surgical drainage of the abscess with mesh debris removal, which revealed an entero-atmospheric labial fistula. Due to severity and limited options, surgery was performed to transform the fistula into a stoma by approximating skin and subcutaneous tissue. Persistent drainage and extravasation complicated by chemical dermatitis led to a second surgical intervention with an external aspiration probe, which had limited success.

**Key Results:** A vacuum dressing was placed at 70 mmHg and later increased to 100 mmHg. After 3 weeks, the dressing was removed. A karaya bag was placed with vacuum therapy and stomahesive for skin protection. The patient was started on a soft diet with gradual reduction of parenteral nutrition. The patient had reduced fistula drainage and was discharged with a healed surgical wound, no chemical dermatitis, and an oriented fistula. CT follow-up showed decreased collection in the subcutaneous tissue of the umbilical region compared with the previous scan. The mean duration of vacuum therapy was 12 days without need for additional treatments. The authors note that a systematic review of 151 patients reported a median closure rate with VAC of 64.6% (range 7.7–100%), with healing occurring within 58 days (range 12–90 days).

**Clinical Implications:** This case demonstrates that NPWT with VAC devices can be an effective adjunct in managing complex ECFs that fail conventional therapy, achieving wound healing and fistula control without requiring additional surgical interventions. The patient's rapid response (12 days of therapy) compares favorably with the systematic review median of 58 days. However, the authors acknowledge concerns in the literature about VAC therapy potentially causing recurrent ECFs and wounds in the abdominal cavity, as well as reports of increased mortality, though these remain debated. The case supports the need for further research and potential development of formal guidelines for NPWT use in small bowel ECF, as no officially recognized international guidelines currently recommend this approach.