Management of Complex Hepatobiliary Surgical Patients with Post-operative Wound Dehiscence and Fistulas

The management of fistulas in a dehisced surgical wound is always challenging for the WOC nurse.  Hepatobiliary patients who are  post-Whipple procedures have compromised nutrition, impaired digestion, and other co-morbidities which add to difficult healing.  Many develop wound dehiscence and some type of fistula.

Our purpose/objective was to contain the high biliary and small bowel fistula output while still providing for therapeutic wound healing in the remainder of the wound.  Current methods of management have included wound managers/ostomy pouches and gauze dressing changes.  Both allow the drainage to remain in the wound bed and gauze requires frequent dressing changes.  Slough often develops in the wound bed and the dressing changes are very time consuming for the nurse.  Skin integrity is easily impaired by the effluent pH and enzymes present in the drainage.  Patients also find frequent dressing changes painful and psychologically upsetting.  We developed a method to isolate the fistula utilizing ostomy barrier rings, petrolatum gauze, and a red rubber catheter to wall suction.  We combined this with the use of negative pressure wound therapy to the remainder of the wound, performing dressing changes three times per week.

Outcomes we achieved included containment of fistula output, a granulating wound bed, efficient wound management for the bedside nurse, intact periwound skin, patient satisfaction and comfort, and the ability to quantify fistula output.  In addition, the secure dressing allows for the patient to get out of bed and move in the room, decreasing immobility risks.  Our surgeons are pleased with the techiniques and patients go on to full healing and closure as their nutrition improves.