Quality of Life Improvement in a Terminal Home Care Enterocutaneous FIstula Patient

A 63 year old female with terminal ovarian cancer was referred to home health care 7/15/09 for treatment of multiple high output enterocutaneous fistulae within a midline abdominal wound.  She had no other significant PMH. In addition, the patient had an ileostomy, a mucous fistula, a gastrostomy tube, and a surgical drain which also required care. Upon admission, her wound measured 14cm x 3.5cm x 1cm. It was pouched and connected to intermittent bedside suction which proved inadequate due to the amount of liquid output which contributed to leakage. Continuous suction was not available through local DME companies. The patient’s caregiver was willing but unable to re-pouch her when leakage occurred, at times necessitating multiple pouch changes per day per home care staff.  Negative pressure wound therapy (NPWT) utilizing gauze and a Wooding-Scott drain was initiated 8/21/11. Gauze was chosen over foam as previous attempts managing other enterocutaneous fistulae demonstrated that the output was too viscous to travel through the foam, instead, leaking from the edges which undermined the NPWT seal. This option was possible because the patient had private insurance (Medicare doesn’t cover NPWT for enterocutaneous fistulae at home). This system enabled her nursing visits to be decreased to three times per week for pouch changes. Her caregiver was able to manage canister changes between visits and a seal was maintained using gauze with a large bore surgical drain to continuous negative pressure. With the institution of continuous negative pressure therapy, her nursing visits were decreased to three times a week which made home care financially feasible and effective. Although her wound dimensions increased to 16cm x 5cm x 1cm due to tumor growth and her fistulae failed to close, this patient was maintained at home as per her wishes until her death 9/30/09.