GETTING THE BEST OUTCOME FOR A PATIENT WITH AN OPEN ABDOMINAL WOUND AND ACUTE ENTERIC FISTULAE
Fleur Tresize, Clinical Nurse Consultant, Surgery/ Wound Management.Background:
This 77yo patient was admitted to hospital for an elective right hemi-colectomy and fashioning of an end loop ileostomy following an incidental finding of Ca colon after a colonoscopy. He has a past medical history of (L) THR, hypertension and ischaemic heart disease.
On Day 10 post-operatively the abdominal wound dehisced and the patient returned to theatre for a repair of the abdominal wound dehiscence, repair of enterotomy x 2 and division of adhesions.
The wound, complicated by MRSA infection, broke down again and the challenge now was to provide a wound management solution that would stabilise the abdominal area, manage an acute enteric fistulae, contain or control the output and provide protection to the peri-wound area.Management:
A fistula as a result of an open abdomen can be a difficult and frustrating management challenge. Effective control of fistulae in granulation tissue can also be difficult due to the problems associated with obtaining a seal and preventing leakage.Fig 1
In the acute phase of management for this patient, we chose to implement negative pressure wound therapy, (VAC) in an attempt to close the acute enteric fistula that had formed in the proximal end of the abdominal wound. Following guidelines provided by KCI relating to the management of acute enteric fistulae using VAC Therapy, this treatment was initiated. It soon became clear, however, that the output was too high and it was not possible to achieve pressure directed closure of the fistula.
Our management strategy now changed to determining how to isolate the fistula to allow for drainage, yet still apply negative pressure wound therapy to the rest of the wound. Eakin Cohesive was chosen to isolate the fistula and protect the proximal portion of the abdominal wound and surrounding skin. Its ability to mould and adhere to a moist surface, namely the open abdomen, allowed us to continue using negative pressure wound therapy (VAC) to the distal portion of the wound and pouch to proximal end. The application of the Eakin Seal enabled us to effectively divide the wound and manage each half as separate wounds.
We now had a wound regime in place that managed the fistula output, protected the surrounding wound area, prevented leakage and could remain insitu for up to three days between dressing changes. With this regime in place the patient no longer experienced constant leakage, discomfort or significant skin excoriation.
Fig 5Fig 4
A second fistula formed in the wound, which resulted in a modification to the application of Eakin Cohesive (see Fig 4) and Eakin Fistula Pouch (Fig 5).
Fig 7Fig 6
The distal portion of the wound was granulating well with the negative pressure wound therapy and within a period of four weeks this was ceased and the entire wound was managed with Eakin Cohesive and Eakin Fistula Pouches.
Six weeks since this management commenced, the open abdominal wound and enteric fistulae continue to be managed with the Eakin Cohesive Seals and Eakin Fistula Pouch (Fig 7).
The fistula output remains at between 300-450mls per day. The loop ileostomy is currently non-functioning. Output is well contained, the peri-wound skin is in good condition and now the appliances and Eakin cohesive are changed only on leakage. We are able to achieve up to four days wear time, the patient is comfortable, the wound is stable and the nursing staff are happy.