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Case Study
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Preventing diverting ostomy surgery in patients with extensive wounds in close proximity to the anal verge Jeffrey A. Niezgoda, MD, FACHM, FACEP, Mary Verhage, RN, BSN, CWOCN Interventions for complex wounds in the peri-rectal region are often complicated by the high risk of infection d/t contamination from feces and an over growth of flora that are endemic to the perineal region. Maintaining an occlusive dressing on wounds that are within close proximity to the mucocutaneous junction of the anal verge is nearly impossible for patients with intact bowel control and formed stool. Add the complication of fecal incontinence, frequent stooling, or antibiotic induced diarrhea and the chances of maintaining a dressing without wound contamination are nil. Wounds such as stage III and IV pressure ulcers of the sacrum and coccyx, Fournier's Gangrene, pelvic area burns, and excision of perineal hydradenitis supperativa are just a few of the complex wounds that often present this challenge. Until recently the procedure of choice to reduce the risk of repeated contamination and infection in these wounds was a diverting colostomy or ileostomy.. .Without fecal diversion, the standard wound management goals of bioburden control, granulation tissue formation and containment of exudate are not feasible. A common advanced wound care intervention, negative pressure wound therapy requires an occlusive seal in order to be effective; furthermore, a negative pressure dressing placed improperly in the peri-rectal region could potentially pull feces and contaminants into the wound bed continually exposing the tissue to pathogens. Flap or graft procedures to close these wounds definitively are threatened by bowel effluent, pressure, friction and shear forces This case series presents a unique combination of advanced therapies utilized to treat extensive wounds of the perineal and peri-rectal region which eliminated the need for diverting ostomy surgery and provided the required exudate control, bioburden reduction, and granulation tissue stimulation. The common interventions included a bowel management system, negative pressure wound therapy, and a topical infusion of an antimicrobial solution. Minasi JS. Clinical application of new bowel management system (BMS) on major burns. Case Report, 2003 Sibbald RG, Orsted H, Schultz GS, Coutts P, Keast D. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage 2003;49(11):23Ð51. |
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