Combined approach with negative pressure wound therapy and biological mesh for treatment of enterocutaneous fistula after synthetic mesh repair of incisional hernia. A case report

AIM: Enterocutaneous fistula is a rare but severe complication of prosthetic incisional hernia repair. Management requires re-exploration with intestinal repair/resection and mesh removal. Repair of the parietal defect in this contaminated field is challenging. MATERIAL OF STUDY: A 58-years male patient presented to our department one year after synthetic mesh repair of large incisional hernia with mesh infection and enterocutaneous fistula. The diagnosis was confirmed by ultrasound guided drainage and CT scans with oral contrast. A multiple-step surgical approach has been adopted: first, the mesh was removed, intestinal resection performed and posterior fascial closure obtained by bilateral transversus abdominis release (TAR) and supra-fascial NPWT (negative pressure wound therapy) was positioned and maintained for one week; second, a definitive repair was obtained by a biological prothesis fixed to posterior fascia and covered by anterior fascia closure. Then, new NPWT was positioned and maintained for 6 days on the skin closure. At 18-months follow-up, the patient showed no clinical or radiological signs of recurrence or reinfection. DISCUSSION: Surgical strategies to face enterocutaneous fistula after prosthesis ventral hernia repair are not standardized. After bowel fistula treatment and mesh removal, the challenge of abdominal wall closure stay unsolved because of the high rate of complication and failure of a new prosthetic repair. A case-by-case management plan, often with the use of a multi-step strategy, may be an option. CONCLUSION: This is a single recovery multiple-step strategy combined approach using NPWT and biological prothesis to manage a case of mesh infection by an enterocutaneous fistula. This unique approach has revealed safe and effective for the treatment of parietal defect in infected field resulting from a mesh removing procedure. KEY WORDS: Biological prosthesis, Bowel mesh erosion, Enterocutaneous fistula, Negative Pressure Wound Therapy, Open incisional hernia repair.

La fistola enterocutanea è una complicanza rara ma assai temuta legata all’utilizzo di reti per la plastica del laparocele. Non essendoci ancora una tecnica standardizzata, abbiamo descritto un caso clinico di rilevanza: maschio, 58 anni, a distanza di 1 anno dall’essere stato sottoposto a plastica per un voluminoso laparocele con utilizzo di rete sintetica, mostrava segni e sintomi clinici di infezione della protesi con presenza di una fistola enterocutanea. La diagnosi veniva confermata da ecografia, col drenaggio dell’ascesso e TC con mdc per os. Data la complessità del caso, abbiamo adottato una strategia multi-step: in primo luogo, rimozione della protesi, resezione intestinale e chiusura della fascia posteriore dei muscoli retti con associata TAR (transversus abdominis release) e posizionamento di dispositivo NPWT soprafasciale per 1 settimana; successivamente, chiusura definitiva con protesi biologica fissata tra la fascia posteriore ed anteriore dei muscoli retti, ancora con NPWT a protezione della cute per ulteriore 6 giorni. Il decorso postoperatorio è stato privo di eventi avversi e il paziente, ad un follow-up clinico-radiologico di 18 mesi, non presenta segni di recidiva o reinfezione. Questo approccio multi-step si è rivelato sicuro ed efficace nel nostro caso, e data la mancanza di standardizzazione per una patologia poco frequente, rappresenta una concreta possibilità terapeutica.