OSTOMY CARE The Suction Pouch for Management of … · The Suction Pouch for Management ... colon...

Copyright © 2010 by the Wound, Ostomy and Continence Nurses Society J WOCN ■ July/August 2010 387

Copyright © 2010 Wound, Ostomy and Continence Nurses Society. Unauthorized reproduction of this article is prohibited.

OSTOMY CARE

The Suction Pouch for Management of Simple or Complex Enterocutaneous FistulaeChristoph Franklin

Containing effluent from an enterocutaneous fistula (ECF) re-quires expertise, critical thinking skills, and creativity. Using acombination of products readily available to WOC nurses prac-ticing in the United States, I have designed a suction pouch thatreliably contains fistula output. A standard ostomy pouch canbe converted into a suction pouch by adding a large, single-lumen catheter into the pouch, sealing it, and connecting theassembly to low continuous suction. The resulting pouch can beused by itself to drain effluent from an ECF or it can be used incombination with wound dressings, or a negative pressurewound therapy system. Application of a suction pouch extendsthe integrity of the appliance and diverts succus away from thewound bed or the newly applied skin graft with increasedreliability. This article describes the technique used to create asuction pouch, followed by 4 brief case descriptions thatdemonstrate feasibility of its use for the management of ECFs.

■ Background

An enterocutaneous fistula (ECF) is an abnormal passagebetween the lumen of the gastrointestinal tract and theskin.1 It can be classified as simple or complex. A simplefistula presents as a short, direct tract connecting boweland skin. In contrast, complex fistulae are associated withan abscess (type 1), or they occur as an opening into awound (type 2). An ECF often requires prolonged hospi-talization and ongoing management by a multidiscipli-nary team. The WOC nurse plays a crucial role in selectingand customizing dressings needed to manage an abdomi-nal wound and associated fistula.

Approximately 75% of ECFs are iatrogenic and 25% arespontaneous. Factors associated with iatrogenic ECFs in-lude reoperation requiring extensive lysis of adhesions,cancer, inflammatory bowel disease, prior radiation ther-apy, trauma, and emergency abdominal surgery. Factorsassociated with spontaneous ECFs include intrinsic in-testinal disease and external trauma. The management ofan ECF can be taxing for the patient, family, and healthcare team. Nursing goals for fistula care include protectionof the perifistular skin, containment of effluent, control of

odor, comfort, maximization of mobility, ease of care, andcost containment.1

Patients with a simple ECF can usually be managedwith a number of commercially available ostomy orwound management pouches. In contrast, those withcomplex ECF often require an individualized system fordressing the abdominal wound and evacuating effluent.Designing such a system requires critical thinking by theWOC nurse acting in consultation with other members ofthe multidisciplinary care team. Methods reported includethe use of a modified vacuum-assisted closure dressing,2,3

closed wound systems using wall suction,4,5 the “Tube-VAC,”6 a wound VAC inserted into the fistula,7 variouscustom-made, large ostomy pouches, and a compactionchamber with high negative pressure.8 Each system re-quires complex wound dressing techniques, and many in-volve negative pressure wound therapy (NPWT).

For example, the “fistula VAC” is a modified, vacuum-assisted closure dressing2,3 (VAC; KCI International, SanAntonio, Texas). It combines NPWT with ostomy pouchesin order to manage an ECF within an open abdominalwound. A standard wound VAC dressing is applied overthe wound with a cutout over the fistula. An ostomypouch is then applied over the cutout on top of the dress-ing to collect effluent. An alternative method for contain-ing effluent from a fistula in an open abdominal wound isa closed wound system consisting of wet gauze and aBioclusive dressing (Opsite, Smith and Nephew, Largo,Florida, or Ioban; 3M Cavilon, St Paul, Minnesota) with ei-ther a drainage bag to gravity or a catheter to wall suctionfor longer wear time. The reported frequency of dressingchanges is every 12 to 20 hours for the drainage bag and 2to 3 days for the version using wall suction.4,5 Potentiallimitations of this technique include limited patient

J Wound Ostomy Continence Nurs. 2010;37(4):387-392.Published by Lippincott Williams & Wilkins

� Christoph Franklin, RN, WOCN, Wound Care Nurse Manager,Vibra Specialty Hospital, Vibra Specialty Hospital, Portland, Oregon.Correspondence: Christoph Franklin, RN, WOCN, Vibra SpecialtyHospital, 10300 NE Hancock St, Portland, OR 97220 ([email protected])

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388 Franklin J WOCN ■ July/August 2010


mobility following system placement and dressing failurewith interruption of suction.

The “Tube-VAC” uses Malecot catheters inserted intothe fistulae to drain effluent via gravity.6 A polyurethanesponge is applied around the catheters, sealed with an oc-clusive dressing and connected to continuous negativepressure at –100 mmHg to stabilize the catheters. Potentialadverse side effects with this system include bowel traumawith catheter movement and residual leakage suckedthrough the foam dressing.

Nienhuijs and colleagues7 reported successful out-comes by inserting VAC foam directly into the fistula tractand applying negative pressure (�125 mmHg). Wainsteinand coinvestigators8 reported spontaneous closure of ECFwith negative pressures of �600 mm Hg applied in a com-paction chamber with unwoven polyester fibers and apolyethene film. They analyzed results of their 10-yearexperience with the vacuum compaction device, which tomy knowledge is not available in the United States.Ninety-one patients who developed 179 fistulae weretreated with the vacuum compaction system and sponta-neous closure was achieved in 42 (46.2%). At least oneauthor9 warns about the possibility of creating a fistula byusing NPWT and further research is needed before it ispossible to determine the role of these techniques in themanagement of ECF.

In order to achieve consistent separation of effluentfrom wound drainage in patients with ECF, I recommendthe use of a version of the “fistula VAC “ combined withthe use of a suction pouch. Four cases are presented thatillustrate the application of this system for the manage-ment of patients with complex ECF.

■ Technique

Similar to the “fistula VAC” technique described earlier,2,3

I apply a wound VAC dressing with a generous cut createdover the fistulae, enabling the placement of a dam con-structed of petrolatum gauze. I construct the dam usingtwo 3 � 36-in Vaseline-impregnated gauze strips (KendallHealth Care Products, Mansfield, Massachusetts) fash-ioned into a tube and smoothed on both ends. After ap-plying Stomahesive powder (Convatec, Princeton, NewJersey) to dry the wound bed surrounding the fistula andsealing the powder with a barrier film (No-Sting barrierfilm, 3M Cavilon), the petrolatum dam is inserted into the cutout in the foam dressing, around the fistulae.Stomahesive paste (Convatec) can be added to the ends foradditional sealant, if desired. The clear drape is appliedover the completed assembly and connected to NPWT. I typically use a setting of �50 mm Hg for the NPWT por-tion with this dressing application. Once the desired neg-ative pressure is reached, the drape can be cut away withinthe dam without losing suction in the remaining dressingover the wound. I then attach an ostomy or wound pouchover the opening to collect effluent without contamina-

tion of the wound or dressing (Figure 1). Eakin Cohesiveseals (Convatec) are then applied to securely attach thepouch to the clear drape. For additional security, a large 30French single-lumen catheter is inserted into the ostomypouch and connected to wall suction or a portable suctiondevice creating a “suction pouch.” The suction in thepouch should not exceed �80 mm Hg but should behigher than the negative pressure in the surroundingdressing. The suction keeps the pouch empty of effluentand increases the reliability of the dressing by reducing theweight of the pouch and creating a pressure gradient.

The resulting arrangement comprises 2 closed negativepressure systems: a wound VAC and a suction pouch.Negative pressures can be regulated independently in the 2systems. When managing a high-output ECF, I prefer the ap-plication of higher negative pressure in the suction pouchand a lower negative pressure in the wound dressing. For ex-ample, I often select a pressure of �50 mm Hg for the VACdressing and a pressure of �80 mm Hg for the suction pouch.Establishing a pressure gradient away from the wound andtoward the suction pouch helps to keep effluent out of thewound bed. I have found that effluent may leak under thedam after a few days, but this system ensures that wounddrainage leaks into the suction pouch rather than the ontothe wound bed. This is especially helpful when a skin graft isapplied to the wound and a dressing is left in place for 7 daysor more. In this case, effluent is collected in a 1- or 2-L wallsuction container, allowing for convenient and accuratemeasurement of effluent volume. This system is particularlydesirable because it separates drainage collected in thewound VAC canister from fistular effluent, which is collectedin the wall suction container. The separated system is alsouseful when managing a split-thickness skin graft. We areable to collect more than 2 L of effluent per day from the fis-tula without leakage onto the skin graft.

FIGURE 1. The Completed Dressing With a Wound Vac andSuction Bag. The Suction Bag Is Continuously Emptied ofSuccus and the Pressure Gradient Ensures Complete DiversionAway From the Newly Applied Skin Graft.

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Any standard drainable ostomy pouch or wound pouchcan be converted to a suction pouch by placing a catheterthrough the tail end of the pouch and sealing it with EakinCohesive seal. Additional holes are cut in the sides of thecatheter to allow removal of effluent throughout the appli-ance. To keep the holes from getting plugged and to protectthe fistula or exposed wound bed from damage caused bydirect suction, I wrap the catheter with Mepitel One(Mölnlycke Health Care US, LLC, Norcross, Georgia). Theporous structure of Mepitel One allows exudate to pass intothe catheter while preventing suctioning of exposed tissues.

■ Case 1

Mr A is a 74-year-old man who was referred to our hospitalfor application of a split-thickness skin graft to an openabdominal wound with ECF. He had suffered a perforatedcolon during colonoscopy, followed by intra-abdominal sep-sis. His wound was initially managed with absorptive pads,and ostomy pouches were applied over the fistula. However,he experienced frequent leakage that rendered his woundcare both labor-intensive and uncomfortable. Because of he-modynamic instability, Mr A’s surgery was delayed. Duringthis period, his abdominal wound was managed with awound VAC dressing and an ostomy pouch was adapted foruse as a suction pouch. Mr A stabilized after 3 days, and asplit-thickness skin graft was applied to the wound. The graftwas then protected with a layer of Adaptic, and white VACfoam was applied over the protective layer, followed by alayer of black foam. With the guidance of the WOC nurse,the petrolatum dam was inserted around the fistula and theclear drape was applied over the assembly. The VAC wasengaged at a pressure of �50 mm Hg. Next, the drape was cutaway within the fistula dam without losing pressure in theremaining dressing and the suction pouch was attached towall suction at a pressure of �80 mm Hg (Figure 2).

Approximately 10 L of effluent were collected in thesuction pouch during the 8-day period that the dressingremained in place. In contrast, the wound VAC canisteraccumulated no drainage during the first 4 days the systemremained in place, and it accumulated only 25 mL ofserosanguineous drainage after 8 days (Figure 3). A newdressing was applied using the same technique that func-tioned well for an additional 4 days. After this point, theECF was managed with a convex ostomy pouch and thepatient was discharged.

■ Case 2

Mr B is a 42-year-old man with history of HIV and inflam-matory bowel disease. He experienced a bowel perforationwith sepsis, resulting in creation of a colostomy withHartmann’s pouch in 2006. Leakage from the Hartmann’spouch and abdominal sepsis complicated the healingprocess, and he eventually required a split-thickness skingraft. In 2008, a takedown of the ostomy with a herniarepair was undertaken at the patient’s urging. Duringsurgery, an enterostoma was created and repaired, but therepair broke down and an ileostomy site was created forfecal diversion. Mr B’s abdominal wound dehisced and anECF formed. Initially, the wound was managed with awound VAC and it was ultimately closed with a split-thick-ness skin graft. The fistula was surrounded by irregularareas of full-thickness skin loss, the ileostomy site, a patchof transposed mucosa (mucosal cells migrated along a su-ture line to the skin) and severely scarred skin wastroughed (Figure 4). Attempts to pouch this high-outputfistula failed because there was not enough room to placea regular pouch within the complex perifistular surfacesand because mucus production from the transposed mu-cosal tissue further impaired adherence.

FIGURE 2. Dressing Removal After 8 Days. The Vaseline DamStayed Intact Without Leaks. Adaptic and White Foam WereUsed to Protect the Graft.

FIGURE 3. A Complex Enterocutaneous Fistula and AbdominalWound Photographed After the Removal of the Dressing onDay 8 and Before Cleaning the Wound. Note the Absence ofGraft Contamination and Approximately 90% Take.

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After consulting with the physician, a suction pouchwas constructed from a neonatal ostomy pouch (Hollister3778; Hollister, Libertyville, Illinois) and a 30-Frenchcatheter. I was able to fit the small wafer of the pouchwithin the problem areas and secure it with half of anEakin Cohesive seal. The tail end of the pouch was cut offto enable catheter insertion and sealed with the remaininghalf of the cohesive seal. Wall suction was applied at apressure of �80 mm Hg; it kept the pouch empty at alltimes. The average output from the fistula was 2 L per day,and the suction pouch was changed twice weekly (Figure 5).The patient’s fistula was managed with the suction bag forseveral months after which an attempt was made to repairthe ECF. Unfortunately, this procedure resulted in an openabdominal wound with subsequent development of mul-tiple new fistulae. Mr B was again managed with a combi-nation of suction pouches and NPWT for several months.During this time, he was transferred to a long-term acute

care hospital where management of his abdomen was con-tinued in the same manner under the care of a wound spe-cialist. A final attempt to repair his bowel was successful.Currently, Mr B lives with a temporary divertingileostoma, with the goal of reconnection as soon as an-other procedure is deemed feasible.

■ Case 3

Mr C is a 57-year-old plumber who fell off a ladder and sus-tained a fracture of his right hip and left upper arm. Duringhis hospital course, he developed Ogilvie’s syndrome (anacute intestinal pseudo-obstruction caused by intestinaldilation secondary to severe surgical or medical stress) withileus and subsequent bowel perforation. A colectomy withileostomy and mucous fistula was performed. He suffered astroke during the postoperative period and developedabscesses in the abdomen, which required multiple surg-eries. This left him with an open abdominal wound, severalECFs, jejunostomy, and ileostomy. He experienced high-volume output, especially from the 2 ECFs in his abdomi-nal wound. In contrast, the remaining fistulae and the 2 ostomies produced only a modest amount of mucus. Initialmanagement with a wound VAC and a medium-size EakinFistula and Wound pouch worked reasonably well, but fre-quent leaks and dressing changes proved frustrating toboth the patient and staff. After consultation with the sur-geon, the wound pouch was converted to a suction pouchby adding a 30-French catheter through the tail end andsealing it with 1 Eakin Cohesive seal. The catheter was con-nected to wall suction. Following the addition of a suctionpouch, the frequency of dressing changes was reduced to 3times weekly and the frequency of leaks declined consider-ably despite several liters of effluent per day from the 2ECFs. The patient was placed on total parenteral nutritionto lower the amount of output and to provide nutrition. Asplit-thickness skin graft was applied to the wound bedwith a 90% take. We continued to use the suction pouch inconjunction with the wound VAC to prevent damage fromthe ECF drainage to the new graft. After 2 weeks, the graftwas strong enough to discontinue the wound VAC and thefistulae were managed with the suction pouch alone. Withthe total parenteral nutrition and only minimal oral in-take, output stabilized at 2 L per day, with twice weeklypouch changes. The patient’s spouse was taught how tofabricate, apply, and manage the suction pouch. A mobileVAC with a 1-L collection container was ordered and con-nected to the catheter. The patient was discharged homeafter a hospital stay of 128 days.

In my experience, patients with similarly complexabdominal wounds with ECF may require hospitalizationfor up to 1 year before a repair can safely be attempted.However, the use of the suction pouch, along with strongfamily support and good community resources, allowedthis man to be managed as an outpatient, with clinic visits on a monthly basis (Figures 6-8). Mr D successfullyFIGURE 5. High-Output Fistula With a Neonatal Suction Bag.

FIGURE 4. Abdomen With a High-Output Fistula. The Openingof the Fistula Is a Tiny Hole Barely Visible Above the 5-cmMark of the Ruler.

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underwent surgery to repair his bowel 220 days afterdischarge home, which was almost a year after the origi-nal accident.

■ Case 4

D is a 1-year-old boy who developed an open abdomen andmultiple fistulae. He had Denys Drash syndrome, a rare mu-tation of chromosome 11. The syndrome is characterized bya triad of defects, including congenital nephropathy, Wilmstumor, and sexual development disorder. Initially, his ab-domen was managed by surgical staff with a wound VAC,but effluent from the ECF frequently clogged the foam andwet-to-moist gauze dressings were started. D subsequentlydeveloped moisture-associated skin damage of the perifis-tular skin, and a consultation with the WOC service wasinitiated by the bedside nurse (Figure 9).

The inflamed periwound skin was protected with inaddition, Stomahesive powder (Convatec) and No-Stingbarrier spray (3M Cavilon) that was applied in several al-ternating layers by using a crusting technique. In addition,a hydrocolloid was used to cover the irritated skin.Stomahesive paste was applied into the skin fold on thecaudal wound border to avoid leaks. A suction pouch wasfabricated using a small Eakin Fistula pouch, a 30-Frenchcatheter with extra holes was cut into the side, and EakinCohesive seals were placed around the perimeter of thecutout. The catheter was placed into the pouch and con-nected to wall suction at a negative pressure of –50 mmHg. The pouch opening was sealed with Eakin Cohesiveseal around the catheter (Figures 10 and 11).

The family disconnected the wall suction intermit-tently and plugged the catheter in order to leave the roomwith the child. Fortunately, this did not compromise thedressing and the bag was emptied upon return by

FIGURE 6. Abdomen with 4 Fistulae, Jejunostomy, andIleostomy. An Abscess Marked by the Cotton-Tip DrainedLarge Amounts of Pus but Eventually Closed.

FIGURE 8. The Suction Pouch in Place. The Force of the SuctionHelps Seal the Bag to the Abdomen.

FIGURE 9. Effluent-Associated Skin Damage in a 1-Year-OldChild With Denys Drash Syndrome.

FIGURE 7. The Wound Manager Is Converted Into a SuctionPouch With a Catheter and Eakin Seal. During DressingChanges, a Yankaur Is Used to Manage the Fistula Output.

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reconnecting to wall suction. The periwound skin recoveredwithin 1 week of management with the suction pouch.

■ Discussion

In my clinical experience, the addition of a suction pouchextends the wear time of complex abdominal ECF dressingand drainage systems. While application of a suctionpouch, especially in combination with NPWT, typicallyrequires the advanced skills of a WOC nurse and consid-erable time to apply, it greatly reduces the need for unex-pected dressing changes. Because WOC nursing servicesare usually not available around the clock, I have foundthat the added reliability of the suction pouch is appreci-ated by both caregivers and patients.

I have also observed that the suction pouch appears toenhance successful take of a split-thickness skin graft andreduce total hospital stay. The suction pouch is also usefulfor the management of denuded perifistular skin becauseit diverts effluent from even a high-output ECF.

■ Conclusion

The suction pouch is one of several options for the treat-ment of ECF. Similar to other techniques described in theliterature, it is a complex dressing requiring the expertiseof a wound care specialist to successfully construct andapply. In my experience, the suction pouch adds reliabil-ity and durability to the abdominal dressing with an ECFwhile reducing unscheduled dressing changes. The suctionpouch is made of products readily available to WOCnurses. I continue using the suction pouch in my practicewith good feedback from patients, families, and caregivers.Further research is needed to more accurately comparevarious solutions for the management of ECF and the roleof the suction pouch.

✔ A suction pouch adds reliablity and durability to an ECFdressing.

✔ A suction pouch reduces unscheduled dressing changes.

✔ The suction pouch is made of material readily available toWOC nurses.

■ References1. Bryant R, Rolstad S. Management of drain sites and fistulas. In:

Acute & Chronic Wounds. Current Management Concepts. 3rd ed.2007;490-516, Management of Drain Sites and Fistulas. Mosby,Elsevier.

2. Goverman J, Yelon J, Platz J, Singson R, Turcinovic M. The “fis-tula VAC,” a technique for management of enterocutaneousfistulae arising within the open abdomen: report of 5 cases. J Trauma. 2006;60:428-431.

3. Reed T, Economon D, Wiersema-Bryant L. Colocutaneous fis-tula management in a dehisced wound: a case study. OstomyWound Manag. 2006;52(4):60-66.

4. Geiger Jones E, Harbit M. Management of an ileostomy andmucous fistula located in a dehisced wound in a patient withmorbid obesity. J Wound Ostomy Continence Nurs. 2003;30:351-356.

5. Kordasiewicz L. Abdominal wound with a fistula and largeamount of drainage status after incarcerated hernia repair. JWound Ostomy Continence Nurs. 2004;31:150-153.

6. Al-Khoury G, Kaufman D, Hirschberg A. Improved control ofexposed fistula in the open abdomen. J Am Coll Surg. 2007;206:397-398.

7. Nienhuijs S, Manupassa R, Strobbe L, Rosman C. Can topicalnegative pressure be used to control complex enterocutaneousfistulae? J Wound Care. 2003;12(9):343-345.

8. Wainstein D, Fernandez E, Gonzalez D, Chara O, Berkowski D.Treatment of high-output enterocutaneous fistulas with a vac-uum-compaction device. A ten-year experience. World J Surg.2008;32:430-435.

9. Fischer J. A cautionary note: the use of vacuum-assisted closuresystems in the treatment of gastrointestinal coetaneous fistulamay be associated with higher mortality from subsequentfistula development. Am J Surg. 2008;196:1-2.

KEY POINTS

FIGURE 10. Skin Protection With Crusting and Hydrocolloid.

FIGURE 11. The Suction Pouch in Place.

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