Abstract
Learning Objectives To discuss management of enterocutaneous fistula and describe enterocutaneous fistula repair using a porcine submucosa derived fistula plug. Background Enterocutaneous fistula (ECF) continues to be a serious surgical problem. The majority of ECF require a surgical procedure including adhesiolysis or resection of the fistulous tract and/or segment of bowel, which are associated with mortality rates of 5-20% and prolonged hospital stay. Less invasive treatments for ECF have been investigated, including fibrin glue, collagen plugs and gelfoam. The Cook Biodesign Advanced Tissue RepairTechnology (Cook Medical Inc., Bloomington, IN), a porcine submucosa derived fistula plug, is a novel treatment for ECF closure with documented overall clinical benefit of 42% and complete closure rate of 21%. Clinical Findings/Procedure Details Fistulography is performed to define the length, course and relationships of the fistula tract. A sheath is inserted into the cutaneous opening. A cytology brush is used to abrade the tract to denude the tract of granulation tissue. The tract is flushed and the delivery sheath is advanced over a stiff guide wire. The fistula plug is loaded into the sheath. Flange positioning is confirmed prior to plug deployment. The plug is withdrawn to the internal opening. Once appropriately positioned, the external portion of the plug is trimmed to length. Tethers are used to secure fistula plug to a Molnar disc at the site of the external fistula opening. Post procedural management includes no strenuous activity for at least 6 weeks, dietary restrictions and stool softeners. The flange is expected to remain in place for 2-4 weeks. If flange is retained beyond an 8-week period, the patient is monitored for bowel obstruction, erosion, perforation or flange migration. Additional potential complications include fistula recurrence, bleeding, plug migration, infection, abscess or seroma formation. Conclusion and/or Teaching Points 1. ECF remains a serious surgical problem associated with high morbidity and mortality. 2. The Cook Biodesign Advanced Tissue RepairTechnology: a porcine submucosa derived fistula plug, is a novel and feasible minimally invasive technique for fistula closure.
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