Team Collaboration and Creative Approaches in the Management of a Lateral Enteroatmospheric Fistula

Problem: A 36-year-old male developed necrotizing fasciitis after a radiofrequency ablation of L3-L5 in APR2015 for his history of chronic pain. The infection involved his back and left flank and required numerous surgical procedures including extensive resection and reconstruction. He underwent an elective flank hernia repair and pedicled muscle flap in APR2017 which was complicated by wound dehiscence and fistula formation. The periwound skin was delicate, uneven and, as a result of multiple surgical repairs, had a “glassy” appearance. The fistulas were difficult to manage, had high-volume output and became severely prolapsed.

Clinical Approach: Initial dehiscence was managed with negative pressure (NPWT), which proved ineffective and resulted in moisture-related skin breakdown from enzymatic effluent. Partial success was achieved by crusting areas of weeping skin, filling uneven areas with strip paste, moldable rings and cohesive seals and applying fistula managers. This technique was also performed intra-operatively over tie-over bolsters to fresh autograft in conjunction with NPWT. Once the patient’s mobility increased, the addition of “petaling” with a hydrocolloid skin barrier and change to a post-operative pouch improved patient comfort and mobility. Wear-time ranged from 1 day to 3 days, depending on the level of activity.

Outcome: As the perifistular skin healed, wear-time was successfully extended to ≥3 days using the post-operative pouch. The WOC team encouraged the spouse to participate in the patient’s care. Once she was able to demonstrate independence with his complex wound care, the patient was able to discharge home in JUL2017. Fistula take-down and closure was planned for NOV2017.

Conclusion: Fistula development presents numerous wound management challenges and may become frustrating for the patient, family and multidisciplinary team. The WOC team plays a vital role within the multidisciplinary team in managing fistulas, developing complex wound management solutions, education and facilitating transition from the acute care facility.