3 The procedure
3.1 A variety of techniques have been described for insertion of a collagen plug to close an enterocutaneous fistula, most being carried out with the patient under sedation. The fistula track is visualised using fluoroscopy and may need dilatation to allow passage of the plug. The track is then debrided to improve incorporation of the plug. A guide wire is inserted from the skin surface through the track into the bowel lumen and a delivery sheath is put in place. Once the delivery sheath is in position, the collagen plug is passed through the track, under fluoroscopic guidance. The delivery sheath is then taken out. The collagen plug is secured in place with absorbable sutures and a Molnar disc (a disc which lies against the skin at the external opening of the fistula, to help keep the device in place). A radiopaque flange (footplate) attached to the internal end of the plug creates a seal to help stop enteric fluids from entering the fistula track, and allows visualisation of the plug during placement. The collagen plug fills the fistula track and acts as a scaffold for tissue growth, allowing the fistula to become filled with tissue and to heal. The patient is usually kept in hospital for a few days of strict bed rest, to prevent displacement of the plug and to encourage its incorporation.
3.2 Various plugs are available for this procedure.