Management of a Complex APR Wound Using a Thin Fenestrated Acellular Human Matrix

Statement of the Clinical Problem:  A 71 year old male with a reoccurrence of colon cancer underwent an APR and permanent colostomy.   Due to the anatomical involvement of the second tumor and courses of radiation in 2010 and 2013, an anastomosis was not a viable option.  Postoperatively patient developed an area of black eschar, involving the surgical incision, coccyx and sacrum.  The eschar demarcated, and was sharply debrided, at that time no bowel or bone was exposed in the wound bed.    Plastic surgery recommended a gracilis flap requiring multiple surgeries.   Concerned for the size of the wound and the small amount of muscle and skin available for the flap, the colorectal surgeon consulted wound care for possible alternatives.

Description of Past Management:   The skilled nursing facility packed the wound daily with an enzymatic debrider and saline moistened gauze.   Upon evaluation, the wound measured 18cm x 8cm x7cm. Sixty percent of the wound bed was necrotic.  Fractured coccyx and bowel were exposed in the base of the wound.   Patient had a 45lb weight loss since surgery, and was deconditioned.

Current Clinical Approach:  The patient was admitted to acute care for a comprehensive nutritional assessment, treatment for osteomyelitis and preparation of the wound bed with NPWT.   After one week, a thin, fenestrated acellular human dermal matrix was placed in the wound bed and NPWT applied.  The goal was to create protection for the bowel, stimulate healthy granulation tissue and minimize plastic surgery procedures.

Conclusions:  Bioengineered tissue may provide an alternative option for patients who are poor candidates for gracilis flaps.