Fistula and wound management
This case looks at the use of Eakin Wound Pouches to manage a fistula and abdominal wound.
By Wendy McNamara Royal Perth Hospital
Mr A is a 33 year old male with Ehlers – Danlos syndrome who lives in rural Australia. Ehlers-Danlos is a genetic disorder affecting the connective tissue which provides support to the muscles, ligaments and skin (EDNF , 2016) . Characteristics include abnormal clotting , soft easily bruised skin and internal organ and vascular fragility (EDNF, 2016). This genetic disorder was passed on to Mr A by his mother. Mr A had previously suffered from multiple arterial dissections which included infra-renal abdominal aortic dissection, internal carotid, hepatic artery, renal artery, splenic artery and gastric artery which were all treated with stents and embolisations.
Mr A later suffered abdominal trauma from a motorbike accident requiring open evacuation of retro-peritoneal haematoma and embolisation of hepatic arteries. The post - operative course was complicated by intra-abdominal sepsis, left internal capsule stroke, left pulmonary embolus, pleural effusion, bile leakage and enterocutaneous fistula of his ileum. Mr A was later discharged with community nurses to conservatively manage his fistula and wound dehiscence with a wound bag at home as this was the common goal for George and his family , however this was complicated with daily leaks and issues related to frequent appliance failure and, as a result effluent and odour were not effectively managed.
During this discharge Mr A had taken methamphetamines which caused drug-induced psychosis. He had later been diagnosed with an organic bipolar disorder.
Mr A did not heal and needed further surgeries to attempt reversing his fistula. Contributing factors were his Ehlers – Danlos syndrome, drug use, and malnutrition due to malabsorption of nutrients due to his high output fistula and was referred to a colorectal surgical team at a tertiary hospital in May 2015. It was this time he was introduced to the Stomal Therapy Service. His wound was able to be isolated from the fistula and the output managed with an Eakin Wound Pouch. He was discharged home in September 2015 with home total parental nutrition (TPN) and able to manage his fistula care with the assistance and support of his wife and achieving an average of 6-8 days wear out of his appliance.
In July 2016 he was re-admitted to attempt to resect and repair his multiple (5) entero-cutaneous fistulae. Resection was initially achieved and abdomen was closed. Mr A subsequently was passing flatus per rectum and had his bowels open. Ten days later he was noted to have a tense abdomen, faecal content in his penrose drain and went back to theatre for re-laparotomy and oversewing of a perforation.
Mr A's abodomen subsequently broke down further. Output is between 1-1.6 L per day. At present, maturation of fistulae are not visible. Patient has been nil by mouth until September 2016 where he is now permitted small amounts of clear fluids. TPN has had additional Vitamin C in the view that this may improve his Ehlers-Danlos Syndrome and improve wound healing. There is also an ongoing discussion regarding the trial of systemic stem cells
His open abdominal wound and fistulae are being managed very effectively with the large Eakin Wound pouch (839265) and achieving 5 days wear time. Pouch changes are being attended electively rather than because of leakage due to the complexity of the wound and potential skill mix of the ward staff after hours when there is no Stomal Therapy Service and he requires entonox for pain relief during the pouch change.
Because of the fragility of his peri-wound skin, paste and pouch are all that is used (no medical adhesives) and the pouch is bordered with frames and placed on straight drainage. There is now noticeable evidence of healthy granulation tissue over the mesh in the wound bed.
The Ehlers-Danlos National Foundation (EDNF) 2016, EDS types, 9th Sept 2016, http://www.ednf.org/eds-types