ORIGINAL ARTICLE Management of orocutaneous fistulas using a vacuum-assisted closure system Brian Tian, MD, 1 Deborah Khoo, 1 Ai Choo Tay, RN, 2 Khee-Chee Soo, MD, 1 Ngian Chye Tan, MD, 1 Hiang Khoon Tan, MD, PhD, 1 N. Gopalakrishna Iyer, MD, PhD 1 * 1 Department of Surgical Oncology, National Cancer Centre Singapore, Singapore, 2 Department of Nursing, Singapore General Hospital, Singapore. Accepted 21 May 2013 Published online 4 June 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23393 ABSTRACT: Background. The vacuum-assisted closure (VAC) system has been used to manage complicated wounds. The purpose of this study was to describe a novel technique in using the VAC system for oro- cutaneous fistulas. Methods. A retrospective study was performed on 10 patients treated at the National Cancer Centre, Singapore, who developed postoperative oro- cutaneous fistulas. Hydrogum dental paste was used as a sealant together with the VAC system to close the fistulas. We used either the RENASYS or VAC ATS system with 50 mm Hg to 125 mm Hg continuous suction. Results. The 10 patients developed 11 fistulas. The median age of this cohort was 67 years (range, 33–80 years). Nine patients had successful closure of their fistulas with VAC therapy whereas 1 patient had unsuc- cessful VAC therapy and required flap reconstruction. The median time to fistula closure was 19 days (range, 6–36 days). The median time to radiotherapy after surgery was 46 days (range, 26–62 days). Conclusion. VAC therapy is an effective treatment option for orocutane- ous fistulas. V C 2013 Wiley Periodicals, Inc. Head Neck 36: 873–881, 2014 KEY WORDS: salivary fistula, pharyngocutaneous fistula, anasto- motic leak, postoperative complications, vacuum-assisted closure INTRODUCTION Orocutaneous fistulas tend to occur after extensive resec- tions for head and neck malignancies with a reported inci- dence ranging from 3% to 65%. 1 The formation of these is associated with several risk factors including the patients’ nutritional status and comorbidities, extent of surgery, reconstruction techniques, and prior irradiation. Notwithstanding, it is difficult to predict patients at risk or when fistulas will form. There is also little data sup- porting the role of additional procedures, such as flap coverage, in preventing fistula formation. 2,3 Once formed, these cause significant morbidity to most patients. Apart from extended hospital stays, difficulties in feeding, pain, and an overall increase in hospital expenses, there are technical issues with wound care and delays in adjuvant therapy. The latter can often compromise patients’ onco- logic outcome if treatment delay is beyond the period of time for maximal treatment benefit. Current treatment modalities focus on the basic princi- ples of fistula management: aggressive wound care, eradi- cation of sepsis, and reducing contamination by keeping the patient “nil per oral” while maintaining good overall nutrition via enteral feeding through either nasogastric or gastrostomy/jejunostomy tubes. 2,4–6 However, many still remain refractory to treatment, taking extended periods of time to heal. Apart from the obvious delay in patients’ subsequent treatment, there is also a reduced quality of life from having to deal with messy wounds, bulky dress- ings, patient inactivity, and psychological well-being. Eventually, when conservative methods fail, a surgical approach, often with flap reconstruction, is required in an already debilitated patient. 5 In 1993, Fleischmann et al 7 first described using nega- tive pressure to treat open or infected wounds. In 1997, based on Fleischmann’s earlier work, Argenta et al 8 and Morykwas et al 9 introduced the vacuum-assisted closure (VAC) system as a method of managing complicated wounds. The negative pressure applied by the VAC sys- tem improved perfusion of the dermal and subdermal tis- sues. It also reduced wound edema and facilitated growth of granulation tissue, while maintaining a relatively clean and isolated system. The VAC system also decreased the bacterial load on a wound. 9 Since then, the VAC system has been applied to the fields of plastic surgery, general surgery, orthopedic surgery, and obstetrics and gynecol- ogy. Most of these VAC-treated wounds had reduced healing times, improved outcomes, less dressing changes, and reduced hospital costs. However, despite the benefits of VAC therapy, its role in the treatment of orocutaneous fistulas has not been well studied. 10 The greatest chal- lenge in this scenario is the difficulty in applying the existing paraphernalia on a complex 3-dimensional wound, and the added difficulty to maintain a vacuum seal with inherent communication between these fistulas with the upper aerodigestive tract. The purpose of this study was to report our outcomes in using the VAC system in the treatment of orocutaneous *Corresponding author: N. G. Iyer, National Cancer Centre Singapore, 11 Hospital Drive, Singapore 169610. E-mail: gopaliyer@yahoo.com HEAD & NECK—DOI 10.1002/HED JUNE 2014 873