New Technique to Protect Perineal Skin Grafts without a Diverting Ostomy at EAST Conference

David Dries, MD will present Massive Burns After Forge Explosion: New Technique to Protect Perineal Skin Grafts without a Diverting Ostomy at 4:06 PM EST on January 14th, 2021 during the Eastern Association for the Surgery of Trauma's Annual Scientific Assembly – Virtual.

One of the difficult aspects of maintaining good wound healing and perineal wounds is fecal contamination. Diverting colostomy and ileostomy are treatment options along with administration of materials which affect bowel motility.

Dr. Dries will present a new technique using a fecal collection circuit combined with an isolation device to avoid redirection of the fecal stream with the associated additional operative procedures of colostomy and ileostomy formation.  This Master Class Surgical Video presentation will illustrate a step-by-step application of this technique through case-study pictures and illustrations.

Isolation of Enteric Fistulas for Skin Graft Placement

The Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) has shared the case study poster Isolation of Enteric Fistulas to Allow Adjacent Skin Graft Placement.

Download the poster to see how Fistula Solution devices help manage intestinal effluent during the placement of skin grafts or artificial skin substitutes onto nearby wounds.

Belted Pouching with Fistula Solution Devices

A high-output enterocutaneous fistula or ostomy may produce two to seven liters of effluent per day which can be devastating to the skin and can cause pain, infection and emotional isolation.

Using a belted ostomy pouch with Fistula Solution devices can be a good effluent management option, particularly when:

  • The perifistula topography of a patients body, creases, or scars make adhesive pouching difficult, or
  • Ostomy pouches will not adhere to excoriated and weeping peristomal skin.

In these cases intestinal effluent can cause further irritation and wound formation of perifistula skin.  To seal and protect the skin from effluent, Fistula Solution devices can be compressed around the patient’s enteric fistula or ostomy with a belted pouching system.

The following "how-to" steps illustrate the use of the Fistula Funnel in these challenging situations.

belt 1

1. Tailor the Fistula Funnel by cutting along the exterior scribe line to form a skirt. The skirt will help form a good seal around the fistula or ostomy and protect the surrounding skin from effluent.

Scribe line

2. Check the fit of the tailored Fistula Funnel to ensure it will seal when compressed to the surface of the body.

The visible portion of the compression area is indicated by the yellow shape.

belt 3

3. Center fistula or stoma in opening and compress the device.  The fistula or stoma should be visible through the device opening after placement on the patient.

belt 2

4. Apply a belted ostomy pouch appliance to compress the device to seal and protect skin and capture intestinal effluent.

belt 4

This technique can be used to protect the skin from effluent and enable healing when other methods may not work and can dramatically improve quality of life for the patient.

High-output Fistula and Ostomy Effluent Containment

Managing effluent from a high-output fistula or ostomy can be a challenge.  Even large, high-output pouches can prove insufficient when a patient puts out 5 to 10 (or more) liters of effluent daily.

Pictured is a technique for managing high volumes of effluent.  A container is connected to the pouch using large bore corrugated tubing.  Then, as prescribed by the provider, intermittent wall suction is applied to the container to draw effluent out of the pouch.

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1. Connect and seal a suction tube near the top of a 3000 ml or other large container.  Do not extend the tube more than 3 inches / 6 cm inside the container.  Connect the free end of the tube to wall suction.

container 1

2. Connect and seal corrugated tubing to the top of the container.  Ensure tubing is long enough to reach from the floor to the patient's pouch.

container 2

3. Fasten the top to the container and place the container on the floor near the patient.

Note that the container inlets for corrugated tubing and wall suction are spaced apart.  This is so the effluent that is drawn into the container will drop to the bottom of the container and not be drawn into wall suction.

container 3

4. Connect and seal the free end of the corrugated tubing to the pouch drain.

As indicated by the healthcare provider, apply intermittent wall suction to draw excess effluent out of the pouch and through the corrugated tubing into the container.

container 4

This technique tip can help eliminate pouch clogs and effluent overfilling that can result in pouch adhesion failure and spills

The fill level of the large container should be monitored and the container can be emptied as needed.  When a patient needs to move the suction tube can be disconnected from the wall so the patient can take the container with them.

Stop Pouch Attachment Leakage

Leaks can happen at the interface of a pouch appliance and Fistula Solution device.  Usually leaks are because the pouch opening is cut too small or because of poor pouch adhesion.

The goal is to direct ALL effluent into the pouch appliance with no leaks.  These technique tips will help assure success.

Drop x

Click here for a detailed pouching video that demonstrates these technique tips.

1. Add a thin ostomy barrier ring to the top flange of the of the Fistula Solution device.  This landing zone is where the high output ostomy pouch or wound manager will be placed.

Pouch 1

2. Cut the opening in the high output ostomy pouch or wound manager generously.  Make the opening diameter about 1 cm larger than the Fistula Solution device opening.  Then place the pouch appliance on the landing zone.

Pouch 2

3. Bridge the gap between the opening of the pouch appliance and the landing zone with another ostomy barrier ring.  A barrier ring can be cut and applied in segments as shown in the image to the right.

Work the pouch appliance into the barrier rings. Have the patient lay quietly for 30 minutes or more to allow the pieces to warm up and adhere to each other.

Pouch 3

These technique tips can help stop leaks from happening at the interface of the pouch appliance and Fistula Solution device, and ensure all effluent goes into the pouch where it belongs.

Protect Perineal Burns and Wounds without a Diverting Ostomy

A common mitigation approach to fecal contamination of perineal wounds and skin grafts is to create an ileostomy or colostomy.   However, the Fistula Funnel can be paired with standard fecal management systems to isolate burns and wounds to the perineum without surgical redirection of the fecal stream.

Fistula Funnel anal isolation

This illustration depicts how the Fistula Funnel can be employed to isolate a fecal management system. The "how-to" steps to assemble the devices follow.

Click here to see a video that demonstrates this technique.

1. Tailor the Fistula Funnel and create a skirt by cutting along the scribe line.   The skirt is intended to seal and protect the perineum from fecal management system leakage.

Scribe line

2. Disinfect the Fistula Funnel with skin or wound cleaning solution, then pull the fecal management system through the Fistula Funnel opening.

FMS isolation

3. Apply dressings to Fistula Funnel, ensuring the skirt around the base of the Fistula Funnel opening faces toward the anus.

4. Apply an ostomy barrier ring to the base of Fistula Funnel to help form a seal between the skin and the device.

Compress the prepared Fistula Funnel against the skin around the fecal management drain to seal and protect the perineum.

Stabilize PEG Tubes and Wound Drains to Reduce Insertion Site Leakage

Gastric fluid leakage or wound drainage around medical tubes is an unfortunate occurrence. The leaked fluid can cause skin irritation, infection, reduced healing times, and general patient discomfort.  Leakage often occurs because patient movement rubs the tube against the insertion site and widens the incision over time

peg 3

The Fistula Funnel can be used to stabilize tubes and reduce tube friction on the insertion site.  The "how-to" steps follow.

1. As shown, place the bottom half of the Fistula Funnel around the tube prior to tube placement if possible.

If the tube is already in place, tailor the Fistula Funnel by cutting as indicated by the dotted line so it can be placed around the tube.

PEG tube cutting

2. Place a contact layer followed by a flat ostomy barrier ring on the perimeter skin. Notch the flange to allow the device to flex, then place it around the tube so that the notched flange rests on the ostomy barrier ring.

Funnel 4 placed

3. Fasten the Fistula Funnel to the patient by placing adhesive strips on top of the base flange. Use zip ties or tape to fasten the Fistula Funnel to the tube.  The stabilized tube should stand perpendicular to the patient's body.

Funnel 5 placed

This technique can stabilize PEG tubes and wound drains in order to reduce tube rubbing on the insertion site and mitigate incision widening.  The Fistula Funnel and companion dressings can also help seal and protect the skin from leakage when applied as shown.