SKIN CARE MANAGEMENT OF GASTROINTESTINAL FISTULAS

doi:10.1016/S0039-6109(05)70499-0

Surgical Clinics of North America

Volume 76, Issue 5, 1 October 1996, Pages 1095-1109

https://doi.org/10.1016/S0039-6109(05)70499-0 Get rights and content

The development of a cutaneous gastrointestinal (GI) fistula creates a challenge for skin care management. The effects of continuous moisture on the skin and the degree of chemical irritation of effluent (depending on where the fistula originates in the GI tract) can severely compromise skin integrity. These factors may also lead to infection or impair wound healing if draining within an open wound.4, 5, 6, 7

The ongoing scenario for the patient with a draining fistula usually consists of odor, wetness, burning pain, and discomfort secondary to skin erosion. These conditions necessitate frequent dressing changes, which also create additional discomfort for the patient. Alteration in skin integrity not only impacts overall patient well-being and comfort but also medical-surgical and nursing management goals for the patient.

Section snippets

GOALS OF SKIN CARE MANAGEMENT

The goals of skin care management are to maintain skin integrity and to contain the effluent. The ability to contain the effluent and divert it from the perifistular skin protects and heals irritated skin and surrounding wounds. Further, the ability to contain the effluent allows for accurate measurement of fluid and electrolyte losses and thus for the timely replacement of fluids and electrolytes and the maintenance of nutritional balances. Good mechanical control of a high-output fistula and

ASSESSMENT AND PLAN

The patient with a GI fistula must have an individualized plan determining which methods and materials are appropriate for optimal skin care management. In addition, availability of products, cost, knowledge of products, time, creativity, and technical skills of the caregiver must also be taken into account.

Irrang and Bryant⁴ developed a fistula assessment guide that identifies four major components to assess when determining skin care options for a patient with a GI fistula.

1
Origin of the

INTERVENTIONS AND METHODOLOGY

The decision of which method or product to use for each patient with one or several GI cutaneous fistulas may initially require a trial-and-error period and a period of close re-evaluation and modifications.

Bryant² states that a good rule of thumb to follow when dressings are used to contain effluent and require changing more often than every 4 hours is to consider application of a pouch system. When dressings are being used to contain effluent, a protective skin barrier, either in wafer or

SUMMARY

The basic objectives of skin care management of GI fistulas are the prevention and management of skin breakdown and the promotion of healing of an open wound with a draining fistula by the containment of effluent. Skin or wound care management is one component of the overall medical-surgical management of patients with GI fistulas. This component plays a significant role in promoting patient comfort and well-being and mechanical control of unwanted drainage on the skin. When these objectives

References (11)

B. Blaylock et al.
A jejunal fistula in a granulating wound and jejunal refeeding
Ostomy/Wound Manag
(1992)
R. Bryant
Management of drain sites and fistulas
M. Hanlon
Options in practice
Wound, Ostomy and Continence Nursing
(1994)
S. Irrang et al.
Management of the enterocutaneous fistula
Journal of Enterostomal Therapy
(1984)
K. Jeter et al.
Managing draining wounds and fistulae: New and established methods

There are more references available in the full text version of this article.

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Complex Colorectal Fistulas
2012, Colorectal Surgery
Enteric Fistulas: Principles of Management
2009, Journal of the American College of Surgeons
Citation Excerpt :
Duodenal or pancreatic fistulas can require HCO3− replacement as well, and electrolyte measurement of the fistula fluid can help guide replacement. Control of the effluent is critical not only to protect the skin from the corrosive effects of the enteric content, but also to facilitate nursing care of the patient.25 The skin protection components and regimen must be tailored to the specific anatomic circumstances of each fistula.26
Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: Single center experience
2008, International Journal of Surgery
Citation Excerpt :
Moreover, drainage from entero-cutaneous fistulae is associated with severe inflammatory skin reactions such as maceration and erythema. In our experience, successful and simple techniques of external control of the fistula included “laparostoma” and the VAC system.20,21 These devices allow quantification and characterization of the enteric drainage, improved wound care, permit continuous irrigation, prevent desiccation of exposed loops of bowel, simplify subsequent fluid and electrolyte management.20,21
Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects.
Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present.
All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800 ml/day (range 400–1600 ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20–2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis.
After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.
Pancreatocutaneous fistula secondary to postoperative pancreatitis after laparoscopic duodenal switch
2004, Cirugia Espanola
El cruce duodenal por laparoscopia (CDxLP) es una variante de la derivación biliopancreática y representa un tratamiento eficaz para la obesidad mórbida. A pesar de los buenos resultados aportados en la pérdida de peso del paciente, esta técnica bariátrica no está exenta de complicaciones postoperatorias derivadas sobre todo del efecto malabsortivo intestinal y de la dehiscencia anastomótica. En muy escasas ocasiones se han descrito casos de complicación pancreática secundaria a este tipo de cirugía.
Presentamos un caso de obesidad mórbida intervenida por CDxLP que desarrolló en el postoperatorio un episodio de pancreatitis edematosa y que se inició con una fistulización externa cutánea a través del trayecto labrado por los trocares de laparoscopia.
Laparoscopic duodenal switch is a variant of biliopancreatic diversion and is an effective treatment for morbid obesity. Although this bariatric procedure provides excellent weight loss results, it produces postoperative complications, mainly due to the effect of intestinal malabsorption and anastomotic dehiscence. In a very few patients, pancreatic complications due to these bariatric techniques have been reported.
We report a case of morbid obesity with postoperative edematous pancreatitis following laparoscopic duodenal switch that presented as cutaneous fistulization through the route followed by the laparoscopic trocars.
Management of an ileostomy and mucous fistula located in a dehisced wound in a patient with morbid obesity
2003, Journal of Wound, Ostomy and Continence Nursing
Enterocutaneous fistulas: Current diagnosis and management
2000, Current Surgery

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: Address reprint requests to Jean L. Dearlove, CNS, RNC, CETN, Department of Surgery, State University of New York Health Science Center, 750 East Adams Street, Syracuse, NY 13210

^*: From the Department of Surgery, State University of New York Health Science Center, Syracuse, New York

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SKIN CARE MANAGEMENT OF GASTROINTESTINAL FISTULAS

Section snippets

GOALS OF SKIN CARE MANAGEMENT

ASSESSMENT AND PLAN

INTERVENTIONS AND METHODOLOGY

SUMMARY

A jejunal fistula in a granulating wound and jejunal refeeding

Ostomy/Wound Manag

Management of drain sites and fistulas

Options in practice

Wound, Ostomy and Continence Nursing

Management of the enterocutaneous fistula

Journal of Enterostomal Therapy

Managing draining wounds and fistulae: New and established methods