Management of a High-Output Postoperative Enterocutaneous Fistula with a Vacuum Sealing Method and Continuous Enteral Nutrition SUNG H. HYON,*† JORGE A. MARTINEZ-GARBINO,† MARIO L. BENATI,* MARCELO E. LOPEZ-AVELLANEDA,* NICOLAS A. BROZZI,* AND PABLO F. ARGIBAY*† A postoperative enterocutaneous fistula is one of the most complex medical problems. Its treatment may become long- lasting, wearisome, and its outcome often is disappointing. Here, we describe the use of a novel device to treat a 67- year-old patient with a postoperative, high-output enterocu- taneous fistula. A semipermeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic polymer covered with a self-adherent surgical sheet. To set up the system, we constructed a vacuum chamber equipped with precision instruments that supplied subatmospheric pressures between 350 and 450 mm Hg. The intestinal content was, thus, kept inside the lumen, restoring bowel transit and phys- iology. The fistula output was immediately reduced from a median of 800 ml/day (range, 400 –1,600 ml/day), to a me- dian of 10 ml/day (range, 0 –250 ml/day), which was readily collected by the apparatus. Oral feeding was reinitiated while both parenteral nutrition and octreotide were withdrawn. No septic complications occurred, and the perifistular skin stayed protected from irritating intestinal effluents. Both the fistula orifice and the wound defect fully healed after 50 days of treatment. We believe this method may serve as a useful tool to treat selected cases of high-output enterocutaneous fistulas without the need for octreotide or parenteral nutri- tion. ASAIO Journal 2000; 46:511–514. E nterocutaneous fistulas most commonly arise as a compli- cation of surgical procedures on the gastrointestinal tract. Other known causes are radiation therapy, inflammatory bowel disease, trauma, and cancer. 1 Conventional, nonsurgi- cal therapy is the first choice and consists of total parenteral nutrition (TPN), administration of somatostatin analogues (oc- treotide), bowel rest, prevention of sepsis, and local wound care. The rate of spontaneous closure with the above-men- tioned strategy ranges from 60 to 78% of affected patients. 2–4 Those who do not heal may require one or more re-operations, but precise timing and patient selection seems to be of para- mount importance. Other less conventional strategies, such as fluoroscopically guided percutaneous catheterization of the fistula tract, endo- scopic sealing with fibrin, or coverage of the bowel defect by extra-peritoneal surgical maneuvering of local tissue, have been reported with promising results. 5–8 We investigated the use of a nonsurgical approach, adapted from previously de- scribed methods, 9 –11 in which a semipermeable barrier is created over the fistula orifice by applying high levels of subatmospheric pressure in a vacuum tight system. The purpose of this communication is to describe the design and function of the system and to report on its performance in the treatment of a patient with a high output (500 ml/day), jejunoileal enterocutaneous fistula. Materials and Methods Two distinct components make up the system: a vacuum chamber with its precision instruments attached and a vacu- um-tight seal fixed over the fistula on the patient. Noncollaps- ible light-weight tubing connects both components. The Vacuum Chamber As depicted in Figure 1, vacuum is first accumulated in a custom made, stainless steel rigid chamber with capacity for 40 L. The variation of subatmospheric pressure inside the chamber is continuously displayed by a precision vacuometer (Weksler Glass Thermometer Corp., Boca Raton, FL) attached to one of its sides. Upper and lower limits of vacuum may be set by the operator with a vacuostat (Danfoss, Nordborg, Den- mark), which is connected to an electronic solenoid valve (Jefferson S.A., Buenos Aires, Argentina). The valve, interposed between the chamber and the vacuum source, opens when the lower limit is reached (increasing vacuity inside the chamber) and closes once the upper limit attained. Two disposable fluid collection flasks (Medi-Vac, Baxter HealthCare Corp., Valen- cia, CA.), serially connected at the patient outlet, are intended to prevent entrance of liquid into the chamber. Either a central vacuum line or an electric vacuum pump (Westinghouse/Lammert Pump, Sargent Welch Scientific Co., Addison, IL) may serve as the source of subatmospheric pres- sure. When a pump is used, its activation is controlled by the vacuostat, which simultaneously opens the solenoid valve and switches the engine on, or closes the valve and switches the engine off. Patient Components To set up the vacuum-tight seal on the patient (Figure 2), the fistula orifice is covered by completely filling the depth of the From the *Department of Surgery and the †Unit of Experimental Medicine, Hospital Italiano de Buenos Aires, Argentina. Submitted for consideration June 1999; accepted for publication in revised form December 1999. Reprint requests: Pablo F. Argibay, MD PhD, Department of Surgery, Hospital Italiano de Buenos Aires, Gascon 450, Buenos Aires 1181, Argentina. ASAIO Journal 2000 511