Innovative Use of Negative Pressure Wound Therapy on an Exposed Duodenostomy, Pancreatic, and Biliary Ducts in Complex Open Abdominal Wound

Innovative Use of Negative Pressure Wound Therapy on an Exposed Duodenostomy, Pancreatic, and Biliary Ducts in Complex Open Abdominal Wound.

___________________________________________________________________________________________

Clinical Problem: Caucasian adult male admitted to academic Midwestern United States hospital with bowel ischemia following emergent cholecystectomy resulting in total enterectomy.  Patient presented for small bowel transplant evaluation and non-healing midline incision.  Initial consult from Intestinal Transplant Team (ITT) requested WOC nurses to contain exudate and preserve peri-wound skin with wound healing.  WOC nurse assessment revealed an undermined, non-healing midline incision complicated by duodenostomy, with pancreatic and biliary ducts at base, causing erosion of mucocutaneous junction of stoma and tunneling to PEG tube. 

Comorbidities: Heavy smoker, heavy alcohol use, TPN dependency, arterial thrombosis, compromised labs, and severe malnutrition.  

Past Management:  WOC nurses’ attempts to segregate stoma from wound by pouching failed. Separate stoma pouching and gauze-based Negative Pressure Wound Therapy (NPWT) failed.

Clinical Dilemma:  Continued erosion of wound and complete separation of mucocutaneous junction resulted in large, undermined open wound with open tract to PEG tube and severely denuded peri-wound skin.  ITT reluctant to open wound sutures fearing patient’s inability to heal. Daily erosive leaks and changes caused patient much pain and suffering from severely denuded skin limiting patient ability to participate in therapies necessary for transplant consideration.  Patient removed from transplant list.

Current Management:  ITT removed all midline sutures and debrided necrotic tissue to allow for NPWT, with black foam, to be applied over entire wound. The stoma was protected with several layers of petrolatum-infused gauze. This system eliminated impediments to wound healing.  

Outcome: Patient’s wound healed and he is independent with stoma pouching. Patient is back on transplant list.

Conclusion:  Including the stoma in NPWT application while protecting bowel with layers of petrolatum-infused gauze eliminated impediments to wound healing.