Enteric Fistula Management Decision Making Framework
Introduction: Enteric fistulas and poorly sited ostomies can challenge patients and providers on multiple fronts. Caring for adjacent wounds, controlling effluent, preventing leaks, and maintaining a positive attitude can all be problematic. Furthermore, these wound types can many times leave the patient bound to a care facility, with skin breakdown related to effluent leakage resulting in moisture-associated skin damage and readmission to an acute care hospital.
Methods: We present a decision framework used by the complex abdominal reconstruction service (CARS) to help providers determine the appropriate therapy when faced with a challenging enteric fistula or ostomy. Because patient presentation changes over time due to complications and/or wound healing this framework is reviewed periodically to determine when there should be a change in therapy.
Results: The cross-functional CARS team including a surgeon and CWON assesses patients according to the SNAP methodology: Skin and Sepsis, Nutrition, Anatomy, and planned surgical
Procedures: The team assessment also includes the presence of adjacent wounds and patient pouchability. These factors are all considerations in the decision hierarchy presented here. Patient assessments considering the decision framework results in one of three therapy decisions: Negative Pressure Wound Therapy (NPWT) using a fistula isolation device, Bolstered touching, Soft tissue revision and skin grafting around the stoma
Discussion: We present enteric fistula and ostomy patient cases illustrating the application of the decision making tool providing a structured approach and the therapies applied. Therapies presented include NPWT, pouching, and skin grafting. In all cases the patients were assessed by the CARS team and therapies were applied based on the decision making framework. This framework highlights the need for a multidiscipline approach for managing enteric fistulas. Applying the decision making tool with team-based assessment to improve patient quality of life, decrease hospital stays and enable patients to return to home.
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