Enteric Fistula Management: Decision-Making Framework

Mary Anne R. Obst, BSN, RN, CWON, CCRN, CWS, asks the questions needed to manage enteric fistula.

This video is based on a poster presented at SAWC Spring 2022.

Transcript

Hi, my name is Mary Anne Obst. I'm the Complex Abdomen Specialist at Regions Hospital. We're a level one trauma center in St. Paul, Minnesota. Our poster, me and my colleagues­ - Maya Backstrom, Laura Gaglione, and Angela Smith - put together a decision-making framework in caring for enteric fistula patients, as this is really one of our biggest passions. One of the things in enteric fistula management is once you meet the patient, being able to decide on what direction to go with that patient with all the plethora of different devices out there for wound care and for fistula management and ostomy management. And so that's really what we're talking about in this particular poster is the management or the decision-making framework.

I'm going to put on my spectacles so I can read as I go through this, but most importantly, the fistula or enteric ostomy management is first you need to figure out, can you see the fistula? So if the fistula is hidden underneath the skin, it's very difficult for a wound care provider to take care of that. So if that's the case, do we need to take down soft tissue so we can expose the fistula to provide access to the wound care person so they can isolate it and contract and heal the wound around it? If the answer is that, no, it is not underneath the edge of the skin, then we're going to ask, do we need to heal a wound next to the skin? And if we do, what kind of wound healing device do we want to use? Do we want to use negative pressure? Do we want to use advanced wound dressings? And with that, how do we take care of the enteric contents? Because in wound management, generally speaking, you don't have stool coming into your wound bed?

So it's healing wounds, but it's also healing wounds with this added difficult factor. And so once we decide on what kind of dressing system we want to have, then we have to look at the surface that we're working, because when you work on the abdomen, if you don't know the layers of anatomy that the wound is over (is the fascia closed, you have muscle, is it just soft tissue loss?), you can actually cause harm. So you have to go back and read your imaging and understand your operative reports so that you can make that decision to have a really good wound management system. So once you figure that out, if, for example, you want to have negative pressure around your wound and isolate that fistula from the wound, what kind of system do you want to use and what pressures do you want to use? And that's all part of this decision-making framework that we have developed.

And then our ultimate goal in that situation is to get a patient ready for skin grafting, because we know that fistula management, if this fistula is stomatized, it's going to be a long haul for these patients, 12 to 18 months before we can do a surgical take down. And so a lot of times we're going to try and make them appear to be an ostomy patient. So we're going to heal the wound, skin graft up to the fistula as we need, and then put them in a standard ostomy pouch and send them home, or outside of the hospital to pre-habilitate, before we do this huge surgery where we put the bowel back together and reconstruct their abdominal wall. And so with that being said, I think that what we have found is that the multidisciplinary approach is really key.

It can't be just wound care nurses. It can't be just surgeons. You really need everyone in the group to be on the same plan. The surgeon needs to trust the wound care nurse. The wound care nurse needs the surgeon to help with soft tissue. A lot of times we have some of our advanced practice helping us with nutrition and medication management so that we don't overwhelm by the effluent. And all of this is to bring these fistula patients to an end point, an end journey of that big surgical take down where their fistula is no longer there. Their skin is closed and they go back to a normal life. And generally speaking, that's about an 18-month to cure program. And so you can imagine that's quite a few dressings. And so I hope this helps you in the decision making of enteric fistula, both the wound care and long-term care of the fistula patients.

Thank you for listening. I hope you have a great day.