Cost Comparison of Treatments Used on Recalcitrant Peristomal Skin Complications

Clinical Problem: 

Identifying cost-effective treatments for recalcitrant peristomal ulcers is challenging.  We present a 70-year old male with multiple peristomal ulcerations resistant to current best practice treatments.  His primary diagnosis is of radiation colitis injury from treatment for prostate cancer resulting in an anterior posterior resection and end ileostomy.  A comparison of seven peristomal ulcer treatment regimens was calculated for cost and effectiveness.

The patient is morbidly obese with a pendulous pannus, uncontrolled diabetes mellitus type II, and history of coronary artery disease. Complications following partial colectomy and colostomy resulted in an ileostomy and a graft closing a major abdominal defect.  He has developed an enlarging parastomal hernia resulting in recurrent mechanical and chemical peristomal skin ulcerations. Partial and full thickness ulcerations were identified as a result of pressure from an ill-fitted ostomy system. The patient was fitted with a flat flexible system. Skin complications included peristomal erythema, maceration, abnormal granulation, and fungal overgrowth.  Other complications included increased cost for ostomy supplies due to daily changes, and pain due to the ulcerations and wound care.

Clinical Approach:

Overall, peristomal ulcer management met with limited success despite multiple treatment regimens. Treatments included alginates, hydrocolloids, powdered polymer dressings, two collagen preparations, silver impregnated dressings and polyvinyl alcohol sponge with methylene blue and gentian violet.  Positive wound cultures were treated with appropriate systemic and topical antibiotics.  After following current best practices with limited success, treatment with 2-octyl cyanoacrylate monomer skin protection was initiated.  Progress toward deep tissue ulcers closure using the PUSH tool was seen within fourteen days and ostomy appliance wear-time increased to 3-5 days.

Conclusion:

A comparative cost analysis of dressing acquisitions, including ancillary supplies, and evidence of wound-healing progress over time was calculated. Significant cost advantage and progress toward healing was found with 2-octyl cyanoacrylate monomer skin protection application.