A case study demonstrating the Wound Crown ® to isolate an Entero-atmospheric fistula within the use of Topical Negative Pressure.
Gill Devaney -Tissue Viability Nurse, Jo Burdett Tissue Viability Nurse, Emma Privett, Tissue Viability Clinical Support.
University Hospitals of Leicester NHS Trust.
Entero-atmospheric fistula (EAF) within an open abdomen is one of the most dreaded complications of surgery, as this causes many life threatening risks such as sepsis and severe dehydration.
EAF is defined as a communication between the gastrointestinal tract and the atmosphere. (Majerick et al 2012)
It is extremely difficult to manage this type of wound, and this type of fistula involves multidisciplinary working. Complications from poor fistula management can result in severe excoriation of peri-wound skin, and as a result, this further challenges the effective application of wound manager bags to contain effluence. This in turn leads to dissatisfaction for the patient, and sometimes a decrease in mobility as they become afraid to move for fear of leakage. This can impact patients physically, psychologically, socially and emotionally as well as increasing the length of stay. This can have cost implications to the National Health Service (NHS) (Posnett et al 2009).
This purpose of this case study was to establish if using of the Wound Crown®, (KCI), a collapsible isolation device, to isolate the fistula whilst utilising Topical Negative Pressure (TNP) to manage the wound would be more beneficial than the current method of managing the wound, whilst still producing effective clinical outcomes.
The patient was a 53 year old male who had undergone an elective Aorto-femoral bypass graft; post operatively he developed complications of multi-organ failure, liver and bowel ischaemia and developed a compartment syndrome. He had a laparotomy and his open abdomen was managed with Topical Negative pressure (TNP) using KCI Vacuum Assisted Closure (VAC®) unit, with the ABThera ™ open abdomen dressing.
He had multiple V.A.C. ® dressing changes in theatre and this was discontinued as he had developed an EAF of the small bowel. The wound was subsequently managed by a wound manager bag.
A referral was made to the Tissue Viability Team the following day as staff were finding it very difficult to maintain the integrity of the bag and effluent matter was leaking onto his skin. This was causing great distress to the patient.
At initial assessment the findings were a large open abdomen, 30cm x 23cm, with a fistula visible at the right lower wound edge. He had severe excoriation to the peri-wound skin, which extended down to groins, inner thighs and his genital area. This was causing the patient severe pain.
The biggest challenge was how to control and contain the effluent matter, whilst promoting wound healing and allowing patient to mobilise confidently.
After a discussion with his Consultant, it was agreed that we would proceed with V.A.C .® therapy with isolation of the fistula as per KCI guidance (KCI clinical guidelines 2015) .This was a very time consuming procedure as he had a high output fistula requiring control by wall suction. If this occurred it proved very difficult for us to produce an effective seal. At the first review after application of fistula isolation V.A.C. ® an improvement in the peri wound skin had been noted. This method was continued for several weeks.
The TV team were then informed and made aware of the Wound Crown ®, which is a one piece compressible device made of Thermoplastic elastomer, which had been shown to be effective for fistula effluent diversion.
This was then used as an alternative to the previous method, as per KCI guidance to isolate the fistula; in conjunction with V.A.C. ® therapy to manage the wound. The dressing was changed twice weekly. Pain and peri-wound skin was monitored at each change
During this case study the key objectives were achieved:
- Easy to handle and apply
- Reduced the length of time spent on dressing changes as it’s a one piece device
- Allowed wound healing with V.A.C. ® therapy whilst containing effluent matter within the stoma bag.
- The patient felt reassured as leakage was not as often.
After 4 dressing changes, wound improvement was noted.
The Wound Crown® was easier to use, however, we did notice that the plastic ring left an indentation on the wound bed. However this did not have any detrimental effect on the wound. It reduced dressing time as it was easier to handle that the Jelonet and hydrocolloid rings. The Wound Crown ® did sometimes leak under the V.A.C. ® dressing.
Although this case study focused on one patient, it has highlighted the potential of the Wound Crown ® and it now utilised more within our team. It reduced the time each dressing took.
Majerick S, Kinikini M, White T (2012) Entero-atmospheric Fistula: from soup to nuts. Nutrition in clinical Practice 27 (4):507-512
POSNETT J, GOTRUPP F, LUNDGREN H, SAAL G. (2009) The resource impact of wounds on health-care providers in Europe, Journal of wound care, 18(4) pp.154-61
V.A.C. Therapy clinical guidelines (2015) 56-57
Wound Crown® is a trademark of Fistula Solution Corporation. KCI an Acelity company is the exclusive distributor of the Fistula isolation Device.