Speaker 1In this class, we're going to discuss fistula management. Fistulas are a major challenge for ostomy nurses and wound nurses. So in this class, we're going to talk about what causes them. We're going to compare medical management and surgical intervention. We're going to talk about assessment guidelines, and we're going to focus particularly on assessment parameters that are indicative of very poor or no potential for spontaneous closure. And then finally, we'll discuss methods for fistula management. We will demonstrate these during Bridge Week. So what causes a fistula? How do you explain this to a patient? Well, you know what a fistula is, it's essentially a hole that should not be there, a channel between two organs or between the bowel and the skin. And the most common precipitating factor is intestinal surgery. So as you see here, whenever we do intestinal surgery, we are removing a section of bowel, and then typically we're doing an endoscopy. And then we're doing an endoscopy. a fistula has developed and I totally understand that because it's such a devastating complication and even though it has nothing to do with surgical technique what the surgeon realizes is now is a very difficult path forward. So sometimes the surgeon will be like well I'm going to come see I don't think it's a fistula it's probably not a fistula but then when they get to the bedside they're like okay well I'm going to order some tests. The test most commonly ordered is imaging like an MRI. The goal is to identify the point of origin for the fistula we already know the point of exit. Occasionally they'll order a fistulogram. Usually they order a fistulogram when the point of origin is not totally clear from the MRI. The way they do a fistula is they feed a narrow catheter into the fistula opening and then they inject contrast and do imaging studies to see if they can clearly identify the point of origin within the bowel. Initial workup also is designed to rule out any abscess formation so when they do the MRI they're looking to see is there any evidence of fluid accumulation abscess formation. If there is then typically they take the patient to interventional radiology and they insert a drain under radiologic guidance so that we can eliminate that fluid collection. Get it all drained out to promote ongoing healing of the anastomotic site and hopefully the fistula site. If there is significant intra-abdominal infection very occasionally they'll have to take the patient back to surgery to irrigate the abdominal cavity and to attempt to close the defect. That's done only if there is significant intra-abdominal contamination. Now at the time of original workup they'll also be looking for any evidence of distal bowel obstruction. So they want to know where does this fistula begin. They know where it empties. Then they want to look at the distal bowel to see is the distal bowel patent. If the distal bowel is patent then we can hope that appropriate management will promote spontaneous closure of the fistula opening. If the distal bowel is not patent that obstruction will have to be corrected before there's any potential for spontaneous healing. And then finally during initial workup they'll assess the patient in terms of fluid electrolyte balance and nutritional status. Because any hole in the bowel causes loss of nutrients, loss of fluids, loss of electrolytes. Those losses have to be addressed. A common question from the patient is what's going on why do I have all this drainage in my wound. So we're going to explain it looks like where we put your bowel back together. It looks like there's one little area that did not heal and we've got drainage from the bowel out through that hole and into your wound. So then your patient's next question is going to be well what are we going to do. Are they going to take me back to surgery. And the answer is they're not going to take you back to surgery right now. You may have to go back to surgery later. Right now we're going to do everything we can to see if we can get that little hole to close. So we're going to start with conservative management. That's always first line therapy. We will move to surgical closure if spontaneous closure does not occur. Now spontaneous closure is actually somewhat unlikely because you look at the statistics you look at the data. It only occurs in about 30% of fistulas. Most commonly in those low output fistulas where you have a relatively small hole. If the fistula is going to close spontaneously it will almost always do so in about six to eight weeks. So we watch this patient very carefully. We're watching the volume of output through the fistula tract. We're looking for stool output through the distal bowel to see are we making progress in getting this fistula to close. Surgical intervention is routinely delayed even if at the outset we're relatively confident that this patient is going to require surgery because we know at baseline they have 1500 milliliters out a day. We know that's a pretty good size defect that is very unlikely to close spontaneously. Still they're going to delay surgery typically for three to six months. Why? There's two reasons that apply to everyone and one reason that applies to patients with low output fistulas. So first of all this patient has just gone through a surgical procedure. They're in the process of trying to heal trying to recover from the operation they already had. If we take them back to surgery they are not going to heal normally because their body is still in recovery mode from their last procedure. So we have to allow them time to recover from the last operation. Also we want to do everything possible to maximize their potential for normal healing. If there are nutritional deficits we want to correct them. If the patient's been on steroids we want to try to wean the patient off steroids. If they have poorly controlled diabetes we need to address that. Comorbid conditions we need to address those conditions. So we want to do everything possible to put the patient in the best position. So we want to do everything possible to put the patient in the very best position to heal normally next time we take them to surgery. So we've got to give them time to recover from their previous surgery time for us to optimize their potential for healing. That's reason number one. Reason number two is equally important. Notice bullet point two it says we have to provide time for softening of the adhesions. So we want to do everything possible to put the patient in the best position to heal normally next time we take them to surgery. So if any of you have gotten the opportunity to observe abdominal surgery and if you've gotten the opportunity to observe a procedure where this was the first abdominal surgery and then to observe a surgical procedure on a patient who had had multiple abdominal procedures you already know what happens with scar tissue. For those of you who haven't had that opportunity I'm going to try to describe it. So when you watch surgery on a patient who's never had abdominal surgery before surgeons call that a virgin abdomen. Nobody's been there. And it literally looks like an anatomy textbook. When they make the incision open the abdominal wall you're like oh my gosh there's the greater omentum. There's the ascending colon transverse colon descending sigmoid. There's a small bowel in the stomach. Everything moves independently. Nothing is stuck together. The surgeon can go exactly where they need to go to do the repair for which the patient came to surgery. Whatever resection is required. Now once a patient has had surgery now they have scar tissue. They have adhesions. Patients who have had multiple surgical procedures may have extensive adhesions. And adhesions make it very difficult to get where you need to go in the abdomen. So I've tried to think how to explain this to patients to families to students. I can tell you what extensive adhesions look like. It looks almost like somebody threw a netting or laid down extensive cobwebs over all the intra abdominal organs. But that doesn't capture how sticky and thick and restrictive adhesions are. So I was talking to a nurse who was an operating room nurse for a long time. And I asked her if she had any insight as to a good analogy to explain the impact of adhesions on Repeat surgery. and to explain the impact of time on the softening of adhesion. So she said the analogy she had come up with was pasta. So she said this is what she'll tell a patient. Imagine that you're cooking pasta. We're going to say fettuccine. So you've just cooked up this big pot of fettuccine. And when you first dump that fettuccine into the colander, every strand moves independently. You can pick up a piece and test it. You can pick up a piece, throw it against the wall. All those strands move independently. But if you leave the fettuccine sitting in the colander without oil, without sauce, and you come back two hours later, what do you have? A wad of fettuccine where all those strands of fettuccine are all mixed in together and stuck together. That's what the loops of bowel are like. And if I gave you a scalpel and I said, "Okay, I want you to dissect out each strand of fettuccine and don't nick the fettuccine," you'd be like, "I can't do that." Time has the same impact on adhesions as oil or sauce and heat has on that water. So if you come back to that wad of fettuccine, you add oil or sauce, you put it in the microwave, you put it on the stove, you heat it gradually, what happens? All of those strands of fettuccine slither free. They all start to move independently again, and you're back at square one. With adhesions, the closest thing we have, to heat and sauce, is time. So over time, those adhesive bands start to thin, soften, stretch a little bit. So now I can kind of separate two loops of bowel and cut through. Separate and cut through. We don't know anything else that will soften and help to separate the loops of bowel, and help to separate the loops of bowel, and we don't know anything else that will soften and help to separate the loops of bowel, and we don't know anything else that will soften and help to separate the loops of bowel, other than time. So that's why we say you're going to have to wait three to six months. We have to give time for the scar tissue to soften and stretch, so that we can very carefully cut away the bands of scar tissue, and gradually get to the section of bowel where the fistula is, resect it, and do an end-to-end anastomosis. So the fistula is, resect it, and do an end-to-end anastomosis. The first reason we delay surgical intervention The first reason we delay surgical intervention The first reason we delay surgical intervention is so we can get the patient in the very best is so we can get the patient in the very best is so we can get the patient in the very best position to heal normally. The second reason we delay surgical intervention The second reason we delay surgical intervention The second reason we delay surgical intervention is because we have to have time is because we have to have time is because we have to have time to soften the adhesions to soften the adhesions to soften the adhesions to allow them to stretch enough to allow them to stretch enough to allow them to stretch enough for the surgeon to be able to find for the surgeon to be able to find for the surgeon to be able to find his or her way through the abdominal his or her way through the abdominal his or her way through the abdominal cavity to the area where the fistula cavity to the area where the fistula cavity to the area where the fistula is located. is located. is located. Now, the third reason applies only Now, the third reason applies only Now, the third reason applies only to patients with low-output fistulas, to patients with low-output fistulas, to patients with low-output fistulas, and that is if we do everything right and that is if we do everything right and that is if we do everything right with a low-output fistula, with a low-output fistula, with a low-output fistula, there's a pretty good chance there's a pretty good chance there's a pretty good chance that that fistula will close that fistula will close that fistula will close on its own and surgery will not be on its own and surgery will not be on its own and surgery will not be required. required. required. So I would share that with a patient So I would share that with a patient So I would share that with a patient with a low-output fistula. with a low-output fistula. If I had a patient with a high-output If I had a patient with a high-output If I had a patient with a high-output fistula at baseline, fistula at baseline, fistula at baseline, I'm not going to be talking to them I'm not going to be talking to them I'm not going to be talking to them about spontaneous closure because that is so unlikely for them. that is so unlikely for them. Instead, I'm going to explain that Instead, I'm going to explain that Instead, I'm going to explain that surgery probably will be required, surgery probably will be required, surgery probably will be required, but we have to delay it for but we have to delay it for but we have to delay it for typically at least three to six typically at least three to six typically at least three to six months so that we can get them in months so that we can get them in months so that we can get them in a really good position to heal, a really good position to heal, a really good position to heal, and we can provide time for the and we can provide time for the and we can provide time for the scar tissue to soften. scar tissue to soften. Now, sometimes we know early on Now, sometimes we know early on Now, sometimes we know early on that conservative management is that conservative management is that conservative management is going to fail and that the going to fail and that the going to fail and that the patient is going to require patient is going to require patient is going to require surgery, and the first is if we surgery, and the first is if we surgery, and the first is if we see that fistula turn into a see that fistula turn into a see that fistula turn into a stoma. Some people call this a stoma. Some people call this a pseudostoma. Others say that the pseudostoma. Others say that the problem is that it's not problem is that it's not problem is that it's not going to turn out well. going to turn out well. But I want you to see, let me see But I want you to see, let me see But I want you to see, let me see if I go back one. if I go back one. if I go back one. So, I want you to notice here. If you could look inside the If you could look inside the If you could look inside the abdominal cavity when a fistula abdominal cavity when a fistula abdominal cavity when a fistula first forms, this is what you first forms, this is what you first forms, this is what you would see. would see. would see. You can see that the fistula is You can see that the fistula is You can see that the fistula is on the anastomosis, and that on the anastomosis, and that on the anastomosis, and that fluid is leaking out, following fluid is leaking out, following fluid is leaking out, following the line of the incision out the line of the incision out the line of the incision out into the open wound. into the open wound. into the open wound. But I also want you to notice But I also want you to notice But I also want you to notice that at this point, the bowel that at this point, the bowel that at this point, the bowel wall and the abdominal wall are wall and the abdominal wall are wall and the abdominal wall are completely separate. completely separate. completely separate. They are not attached. Now you see a change. Now that bowel wall has become Now that bowel wall has become Now that bowel wall has become adherent to the abdominal wall. adherent to the abdominal wall. The bowel has become attached The bowel has become attached The bowel has become attached to the abdominal surface, to the abdominal surface, to the abdominal surface, has turned back on itself has turned back on itself has turned back on itself to form a stoma. to form a stoma. to form a stoma. Stomatization of the fistula Stomatization of the fistula Stomatization of the fistula is a very negative finding is a very negative finding is a very negative finding because it means this is not because it means this is not because it means this is not going to close spontaneously. going to close spontaneously. Stomas don't just go away. If we do a temporary stoma If we do a temporary stoma If we do a temporary stoma and the patient no longer needs it, and the patient no longer needs it, and the patient no longer needs it, what do we do? what do we do? what do we do? We bring them back, We bring them back, We bring them back, take them to surgery, take them to surgery, take them to surgery, disconnect the bowel disconnect the bowel disconnect the bowel from the abdominal wall. from the abdominal wall. Same thing here. Same thing here. Same thing here. Once there's evidence that Once there's evidence that Once there's evidence that the bowel wall has become the bowel wall has become the bowel wall has become adherent to the abdominal wall, adherent to the abdominal wall, adherent to the abdominal wall, we know surgical intervention we know surgical intervention we know surgical intervention will be required to close will be required to close will be required to close this fistula. this fistula. this fistula. We might not be ready We might not be ready We might not be ready to take them back. to take them back. to take them back. We might have to wait We might have to wait We might have to wait three more months. three more months. three more months. But once we see stoma formation, But once we see stoma formation, But once we see stoma formation, we know surgical closure we know surgical closure we know surgical closure of the fistula. of the fistula. of the fistula. That is another That is another That is another negative prognostic finding. negative prognostic finding. So most high output fistulas So most high output fistulas So most high output fistulas do not close on their own. do not close on their own. Most of them will require Most of them will require Most of them will require surgical intervention. surgical intervention. It's not quite the black It's not quite the black It's not quite the black and white of stomatization. and white of stomatization. Stomatization is black and white. If it is not stomatized, If it is not stomatized, If it is not stomatized, it will not close on its own. it will not close on its own. That patient will require That patient will require That patient will require surgical intervention surgical intervention surgical intervention to close the fistula. to close the fistula. High output, not a complete High output, not a complete High output, not a complete predictor, but fairly significant. predictor, but fairly significant. So that if you have high output So that if you have high output So that if you have high output at baseline, you know already at baseline, you know already at baseline, you know already that that fistula is unlikely that that fistula is unlikely that that fistula is unlikely to close on its own because to close on its own because to close on its own because there's a big hole in the there's a big hole in the there's a big hole in the bowel wall. bowel wall. bowel wall. If the patient has had radiation If the patient has had radiation If the patient has had radiation to the area in the past, we know to the area in the past, we know to the area in the past, we know that healing is going to be that healing is going to be that healing is going to be compromised because of ischemic compromised because of ischemic compromised because of ischemic changes to the tissues. changes to the tissues. So we know that healing is So we know that healing is So we know that healing is unlikely to occur and if there's unlikely to occur and if there's unlikely to occur and if there's malignancy in the area, malignancy in the area, malignancy in the area, healing is extremely unlikely healing is extremely unlikely healing is extremely unlikely to occur. to occur. to occur. We are the ones that do the We are the ones that do the We are the ones that do the ongoing assessment of the ongoing assessment of the ongoing assessment of the patient with a fistula. patient with a fistula. So we are the ones at any given So we are the ones at any given So we are the ones at any given time who can tell you, time who can tell you, time who can tell you, is this patient making progress is this patient making progress is this patient making progress in terms of spontaneous closure in terms of spontaneous closure in terms of spontaneous closure of the fistula tract? of the fistula tract? So the things we're always So the things we're always So the things we're always assessing, what's the volume assessing, what's the volume assessing, what's the volume of output through the fistula of output through the fistula of output through the fistula tract? tract? tract? What's the volume of output What's the volume of output What's the volume of output through the distal bowel? through the distal bowel? And has the fistula stomatized? So here's what I want to see. I want to see progressive I want to see progressive I want to see progressive reduction in the amount of output reduction in the amount of output reduction in the amount of output through the fistula and through the fistula and through the fistula and progressive increase in the volume progressive increase in the volume progressive increase in the volume of output through the distal of output through the distal of output through the distal bowel, either the rectum or a bowel, either the rectum or a bowel, either the rectum or a distal stomach. distal stomach. distal stomach. If I see that, fistula output If I see that, fistula output If I see that, fistula output coming down, distal bowel output coming down, distal bowel output coming down, distal bowel output going up, it's like, okay, the going up, it's like, okay, the going up, it's like, okay, the fistula is getting smaller. fistula is getting smaller. More and more of the stool is More and more of the stool is More and more of the stool is going through the primary path going through the primary path going through the primary path out the rectum or out the stoma. out the rectum or out the stoma. A great prognostic finding. I'm always alert to foreign I'm always alert to foreign I'm always alert to foreign bodies, so if I see long sutures, bodies, so if I see long sutures, bodies, so if I see long sutures, I'm going to alert the surgical I'm going to alert the surgical I'm going to alert the surgical team, ask them if that can be team, ask them if that can be team, ask them if that can be removed, anything that could removed, anything that could removed, anything that could interfere with healing. interfere with healing. And of course, I'm going to be And of course, I'm going to be And of course, I'm going to be very alert to stoma formation. very alert to stoma formation. So if I see any evidence that So if I see any evidence that So if I see any evidence that the fistula has stomatized, the fistula has stomatized, the fistula has stomatized, I will alert the surgical team I will alert the surgical team I will alert the surgical team because that changes the because that changes the because that changes the management plan. management plan. management plan. We know the patient will have to We know the patient will have to We know the patient will have to go back to surgery. So now let's talk about the details So now let's talk about the details So now let's talk about the details of conservative management. of conservative management. So that's where we're going to So that's where we're going to So that's where we're going to start, almost always. start, almost always. And goal number one is to minimize output through the fistula tract. We want this tract to close. So if we can minimize output through the fistula tract, that's a benefit. How do we do that? Well, first of all, we restrict oral or enteral intake. So in the past, we would make patients NPO. We learned that was not a good thing to do because when you make a patient NPO, the villi in the small bowel mucosa flatten out. Then you get a very thin atrophic mucosal layer. It's very easy for bacteria to penetrate that thinned out mucosal layer. And then you can end up with a patient with sepsis. So we learned that we need to keep patients on low volume oral or enteral intake. To keep the mucosal layer healthy and to prevent sepsis. So today, most patients are allowed clear liquids, allowed to sip on small amounts throughout the day, and encouraged to take in some high protein fluids such as Juven so that we are keeping the bowel wall healthy. Also, you will see most patients are placed on a trial of NPO. So we're going to do a little bit of a test. We're going to do a little bit of a test. We're going to do a little octreotide or sandostatin and you know that that is an analog of a GI hormone that reduces GI secretions. When you think about the fluid in the GI tract it was either produced by intestinal glands or swallowed. So we restrict oral intake to limit swallowed food and fluids and we give octreotide to reduce the volume of fluids produced by the intestinal glands. And the goal is to minimize what's going out the fistula tract so that hopefully if it's a low output fistula by reducing the volume of output through the fistula tract we're hoping we can get it to close. Minimally even if we don't get it to close spontaneously with facilitated management by reducing output. So that's almost always the first intervention is to limit oral and enteral intake. And then the second thing is okay we're not feeding the patient but we have to maintain positive nutritional status in order to support granulation tissue formation and fistula closure. So almost always patients are placed on TPN. The vast majority of fistulas are located in the middle portion of the small bowel. The only way to adequately support those individuals nutritionally without tremendously increasing fistula output is TPN. And I actually happened to graduate from nursing school the last year before we had TPN available. I was working on a general surgical unit and I saw how devastating fistulas were. Almost all of our patients died. We had no way to get those fistulas to heal. Either we kept feeding the patient and tried to increase their nutrient intake which increased their fistula output or we made them NPO which reduced fistula output but eliminated nutritional support for healing we couldn't win. With TPN we can win. Because we can provide them with the protein, calories, the micronutrients to support healing while minimizing oral and enteral intake. Our third goal is to partially or totally collapse the fistula tract. And that's why we sometimes use negative pressure wound therapy. So you should know that the data supporting use of negative pressure wound therapy and fistula management is limited to anecdotal reports. Now here's what we know. Most fistulas drain into open wounds and we do know that negative pressure will promote granulation tissue in open wounds. So will it support wound healing? Yes we know that. Will negative pressure facilitate management of the fistula output itself? Absolutely. The fistula output will track through the sponge, through the foam, through the suction control pad into the canister. So we know absolutely for sure that if we use negative pressure we'll promote wound healing and we'll facilitate fistula management. And we know that it might promote fistula closure. What we're hoping is that the negative pressure will pull the edges of the defect together and hold them there until fistula healing is complete. But we don't have randomized controlled trials to prove that that's true. These trials are very difficult to do, very expensive. Even if you're in a major medical center, you don't get enough fistulas to permit this kind of trial. So all we have in support of negative pressure to promote fistula closure, all we have are anecdotal reports. I think it helped with this patient. Now if we're going to use negative pressure to promote wound healing, to manage fistula output, and to hopefully promote fistula closure, we have to be very careful with our technique. We do not want to risk formation of additional fistulas. And any time you have one fistula, you know there are loops of bowel very close to the surface. And you know if you put your granular foam directly against granulation tissue or on a thin layer of tissue that's covering loops of bowel, the risk is that that tissue will grow into the foam, become apparent to the foam, and that when you remove the foam, you'll un-roof a loop of bowel and cause a fistula. We never ever want to do that. And when you look at the guidelines from the manufacturers of negative pressure wound therapy, they all say if there are organs, loops of bowel, blood vessels, critical structures close to the wound surface, you must use a contact layer and/or a dense, less porous foam, the white foam. So here's what you should be doing. Here's what we should be doing if we're using negative pressure. We should be putting a contact layer or white foam or both down into the wound bed over the fistula, over the entire wound bed. We do not put a contact layer or a white foam on the fistula. We do not put a contact layer or white foam in the fistula tract. We want the tract to close. So we're not going to do anything to hold the tract open. Typically, we begin negative pressure at somewhere between minus 150 and minus 200. If I start at minus 150 and it essentially eliminates enteric drainage, perfect. I'll hold it there. If I'm still having enteric drainage at minus 150, I'll go to minus 175 and then minus 200. That's as high as you can go. And then I monitor to see what's happening. Now, what I'm hoping for is a marked reduction in fistula output. If I see a marked reduction or elimination of the enteric drainage, perfect. Then I'm going to keep that patient on negative pressure, continuing to put the contact layer on. And then I'm going to put the contact suction at my established level typically for at least two to three weeks to allow granulation tissue to form. And then I would very gradually step down my use of negative pressure. So I might go from minus 175 to minus 150 to make sure I don't see any increase in enteric drainage. Then minus 125. Then minus 100. Okay, looking good. Now I feel as if I can safely discontinue the negative pressure if I no longer need it for wound care. Now occasionally what we need to do is we need to apply negative pressure to the open wound to promote granulation tissue in the open wound. Okay. But we need to isolate the fistula. We need to separate the stomatized fistula from the foam and we need to put a pouch over that area. When is that even possible? Well, if my fistula has stomatized and I have protrusion and the stomatized fistula is sticking up out of the wound bed, then it is usually possible to create isolation between the fistula and the rest of the wound and the foam. When do I need to do it? I only need to separate the fistula output from the wound bed if the drainage from the fistula is too thick to flow readily through the suction control pad and into the canister. So if I'm having frequent issues with blockage alarms, I'm having to redo my dressing all the time, that is when I think about isolating the stomatized fistula, separating that from the wound with the negative pressure wound therapy. Now here's how you do it and we will review this during Bridge Week. So you could use a commercial device. The companies that make negative pressure have commercial isolators, crowns, different things you can use, but I'm going to walk you through how to do it and how you can do it just with barrier rings. So what you would do first, you're going to irrigate your wound, then you're going to take your contact layer dressing. It could be Mepi-Tel, Mepi-Tel 1, Versatel Adaptic. You're going to cut it to fit the wound bed. You're going to put it across the entire wound bed, including the stomatized fistula. Once you get your contact layer down, now you're going to take a barrier ring and you're going to put the barrier ring around the stomatized fistula on top of your contact layer. Then you're going to take your black foam and you're going to cut out an opening that is going to accommodate the stomatized fistula. And it should be at least a quarter of an inch larger than the stomatized fistula. So if the stomatized fistula is bigger than the stomatized fistula, it should be at least a quarter of an inch larger than the stomatized fistula. So if the stomatized fistula is bigger than the stomatized fistula, So if the stomatized fistula is bigger than the stomatized fistula, it should be at least a quarter of an inch in diameter. So if the stomatized fistula is an inch in diameter, the opening in the foam should be one and a quarter inches in diameter. So now I put my foam down. Then I'm going to take a second barrier ring and put it on top of the first barrier ring. And my goal is to catch the foam between the outer aspect of the two rings and to have the two rings pinched together right next to the stomatized fistula so that I'm separating the stomatized fistula from the foam. And again, we'll show this to you when you're on site. Once I've done that, I'm going to put my drape down. I'm going to attach my suction control pad. I'm going to activate my negative pressure. Once it's sucked down, I'll cut the drape away over my stomatized fistula and attach a pouch. And the goal is to have the fistula output go into the pouch and have the wound fluid go into the canister. Okay, let's talk about surgical closure. So let's say we've had the patient on conservative management. They have not healed with conservative management. And or they now have a stomatized fistula. So we know that they're going to have to have surgery. The surgeon is going to determine the timing. We know they usually have to wait for three to six months. In the interim, our focus is manage the output, protect the skin, continue nutritional support because they still have a hole in their gut. Now, typically, we will liberalize their diet a little bit at this point because we know they're going to have to have surgery. We know they're going to have to have surgery. We know they're going to require surgical closure. And it seems cruel to keep them just on clear liquids. But you want to be very careful about the message you give them. I did this wrong so many times. So I would say to the patient, so the bad news is you're going to have to have surgery. But the good thing is you can kind of eat what you want until that point. Well, they took me at my word. They ate what they wanted. I had massive volumes of fish oil output that were very difficult to manage. Sometimes they were eating high fiber foods that didn't drain well through my pouching setup. So I learned to say the bad news is you're going to have to have surgery. The good news is you can eat small amounts of selected foods. You can't have salads. You can't have pills. You can't have nuts. But if everyone's having birthday cake and you want birthday cake, you can have a small piece. If everybody's having ice cream and you want a little bit, you can have a little bit. So you need to be very careful. The more you eat, the more difficulty we're going to have managing this. But we do want you to be able to eat small amounts for pleasure. Okay, so what are our options? Well, first of all, if you're eating small amounts of fish oil, you're going to have to eat a lot of fish oil. And if you're eating a lot of fish oil, you're going to have to Most of the time we end up using wound managers or fistula pouches. And you can see from the illustrations on this slide what the advantages of those pouches are. Almost all of them have a spout, which makes it easier to empty and also gives you the option to connect to bedside drainage. Connecting to bedside drainage is tremendously helpful when you have high output fistula output. So that's one advantage. Most of them also have an access cap. So you can open the access cap, go inside the pouch to add paste all the way around the edges for skin protection, to assess the wound, whatever. Now things that will improve your pouch seal. There are ways in which fistula pouching differs from stoma pouching. So typically when you're pouching a stoma, you cut the opening to fit pretty snugly around the stoma. The one exception is if you have a skin level stoma and you cut it a little bit wide. Well here, when you're pouching a fistula, it's very much like pouching a skin level stoma. Everything comes out at skin level. So you make your pattern, but then when you go to cut your pouch out, you cut outside the line. And typically you're aiming for about 1/4 inch clearance all the way around the edge of the wound. Then you're going to use a flat layer of paste to protect the exposed skin. So I'm going to walk you quickly through the pouching procedure. We'll go through this again when you're here for Bridgeway. So you're going to clean skin with water, pat it dry. If you have any damaged skin, you're going to use that crusting procedure that you know very well at this point. Dust on ostomy powder, dust off the excess. You can use alcohol-free liquid barrier spray or wipes on top of the powder if desired. You're going to make the pattern of the wound, and you're going to cut the opening in the pouch wider than the pattern. So, you're going to cut the opening in the pouch wider than the pattern. So that you get clearance all the way around the edges, and you get a secure seal. You can use paste, either strip paste or tube paste to fill any little defects or dimples. Then you're going to use gauze or a tampon or wall suction to control fistula output while you get ready to put your pouch in place. So, I've got my pouch all ready. I'm holding my gauze here then I'm going to quickly move my gauze, put my pouch down. And once I get my pouch down, then I'm going to go on the inside edge and add my paste to caulk my edge and to protect my skin. The challenge in pouching a fistula, as many of you already know, is it seems like they never stop. Just as you're about to put the pouch on, you'll have a gush of fluid. So it's, and usually you're by yourself, so it's like, okay, absorb the drainage, swap out your gauze, swap out your gauze, okay, I'm going for it. I'm going to move my gauze and put my pouch down. So ideally, I have a pouch with an access cap. I can hold my gauze in place, clean the skin, swap out my gauze, treat any damaged areas, swap out my gauze, make sure my skin is clean and dry, swap out my gauze, pick up my pouch, move my gauze, put my pouch down, and then go on the inside. If you're using a pouch that does not have an access cap, then you have to put down all the protective paste before you apply the pouch. It's much more difficult. Now, what about the impact of the fistula output on the wound itself? Patients are going to ask you this, family members will ask you this, staff will ask you this, sometimes residents ask me this, what are we going to do about that fistula output? What are we going to do about that fistula output? Patients are going to ask you this, family members will ask you this, what are we going to do about that fistula output? Running over the wound bed, running through the foam into the negative pressure canister or running into the pouch, don't we need to do something to protect the wound bed? So here's what you need to know. In general, you do not need to protect the wound bed and that's because the enzymes in small bowel fluid have no impact on the collagen and granulation tissue. So the wound will continue to granulate even though small bowel fluid is running over that wound bed 24/7. No negative impact on the collagen. Granulation tissue continues to form. Then people worry about, well what about infection? Because that's liquid stool. But remember that bacterial counts in small bowel fluid are low and this is an open wound. So infectious risk are very, very low. Now once that wound granulates to the surface and begins to epithelialize, yes the enzymes will attack that epithelium. So once you start to lay down epithelium, you have to protect the new epithelium with a hydrocolloid, with paste, with something. You don't want any of that drainage running over new epithelium. What about colonic drainage? We see many fewer colonic fistulas, but colon drainage has no enzymes. So again, no risk to the granulation tissue. Colonic drainage does have higher bacterial counts. But again, with an open wound, infection is rarely an issue. So is it safe to pouch around a wound with a fistula? Yes, it is. Is it safe to use negative pressure for a wound with a fistula? Yes, it is. Now I'm going to briefly review some other strategies for managing fistula output. I'm going to go through them quickly. We'll talk about them in more detail when you're on site, because it helps to see some of these things. The first procedure I'm going to address is a closed suction procedure. This is a great option if you have a patient with an open wound, large amounts of drainage, so long as that patient is bed bound or chair bound, because this procedure is suction dependent. So the patient has to be close to wall suction at all times. But the advantages are, it's very simple, it's low cost, it works really well for a large number of patients. So you're going to treat any damaged skin. You can do a bead of paste all the way around the wound edge for additional protection, or you can use strip paste, or you can just use your liquid skin barrier. So that bead of caulk of paste is optional. Now you're going to use suction catheters to control the drainage, and you're going to place suction catheters in the wound. You do not want to cause trauma to the underlying tissue. So first you protect the wound bed with several layers of damp gauze. You could also use mepital or adaptic. Damp gauze is almost always available, very conformable, so you can just grab a roll of curlix or cling, moisten it, put down several layers to protect the wound bed. Then you're going to take your suction catheter, and you're going to place your suction catheter inferior to the fistula opening. Now in the illustrations you see here, you see a latex catheter placed inferior to the fistula opening. You also see a white catheter. The surgeon was using that for installation of a medication, so you can just ignore that. Focus on the large bore latex suction catheter. You could use any large bore catheter. You can take your scissors and add additional holes along the side so that you have multiple suction points. If you have very high volume output, you might need to add two suction catheters, one to each side of the wound bed. And then once you put the suction catheter where it goes, then you stabilize that catheter. You cover it with multiple layers of damp gauze. That holds the suction catheter in place and makes sure that the drape you use to seal the wound doesn't occlude the eye holes of the suction catheter. So now you take opsyte, tegaderm, negative pressure drape, you seal the entire wound, you seal around the suction catheter, you attach the suction catheter to wall suction. Typically we use low to medium intermittent suction. If you have very high volume drainage, you might have to do low to medium continuous. And you're going to change it every one to two days, so you can see it's very straightforward. It's something you could teach the staff to do. The next procedure probably will not make sense to you until you come on site, practice it during bridge week. This is the trough procedure. And this is indicated for fistula's draining into open wounds, especially when you have a large irregular wound, you're having a lot of difficulty maintaining a pouch seal, or you have a dehisc wound with a fistula and practically no surface for pouch application. So you think sometimes people come back from surgery, they have an incision one inch away, they have a GJ tube, they have an ileostomy, they have a devol drain, they have a surgical drain. If that incision dehiscs and they develop a fistula, you don't have room for a pouch. But you could do the troughing procedure, because all you have to be able to do is seal all the way around the wound with a transparent adhesive drape. So those are some situations when troughing can be advantageous. When you can't get a seal with a regular pouch, there's not enough surface for a regular pouch. The surface is very irregular and you keep losing your seal. But you should be aware it's appropriate only for wounds that run from top to bottom with a vertical orientation, because it is predicated on forcing the draining down to the bottom of the wound into a pouch. So it doesn't work well for wounds that run horizontally. This was actually developed by a wound and ostomy nurse in Florida, Chris Martin. And he developed it as an alternative for fistula management when you had, you were using large pouches that weren't working. So he said, okay, goal number one, I've want to protect my peri-wound skin. Now when he developed this, we had relatively few options for peri-wound skin protection. So what he chose to use were overlapping strips of hydrocolloid barrier. So he cut a piece to fit around the base of the wound and put that down. And then he took a strip and overlapped the base strip by an inch and put that down and then overlapped that strip. Chris Martin: So he had all these overlapping strips that can move independently. And he theorized that this would reduce the incidence of leakage. And he was right. But you don't have to do that. We now have many options for peri-wound skin protection. You could use strip paste. You could use a bead of tube paste, or you could simply spray the surrounding skin with a liquid skin barrier. Chris Martin: And then you're going to prepare your bottom strip of transparent adhesive drape. So you're going to take negative pressure wound drape or or tegaderm, you're going to cut a little starter hole, you're going to take your pouch, you're going to put your pouch, attach your pouch to the front of that piece of drape. So now your pouch and your opside or tegaderm or negative pressure wound drape are one entity. And once you have them stuck together, you're going to enlarge the opening in your drape-pouch combination until that opening is wider than the wound at the bottom, because you want everything to flow into the wound. And again, you're going to practice this. So here you can see that they have the pouch-drape combination in place along the base of the wound, and now we've added overlapping strips of our adhesive drape until the entire wound is sealed, just like we do with negative pressure. We seal the entire wound. But in this situation, the entire wound is sealed, but the bottom piece of drape has a big hole in it and a pouch on top. So the drainage comes down to the bottom of the wound and into the pouch. And then we can connect the pouch to drainage, to wall suction, whatever. We really want you to know how to do the trough procedure. You will have situations when you need to know that skill, and we will have you practice that when you're here for Bridge Week. The last technique I'm going to talk about is bridging. And this is something that you can do when you have a large wound with two separate areas. So let's say that I have a large wound. Maybe it runs from the xiphoid to the symphysis in a morbidly obese patient. So it's a huge wound. At the bottom of the wound I have a fistula. None of my pouches are big enough to accommodate the whole wound, but I really only need to pouch the bottom. The top part I can manage just with moist wound healing. So the question is, how can I create a partition halfway down so that I can dress the top half of the wound and pouch the bottom half? So we're going to show you how we did this. In this case, your model patient has a wound running from the right mid axillary line all the way across the abdomen to the left mid axillary line. She had a fistula on the right, a biliary fistula draining about five to six hundred milliliters a day. So the question was, could we find a way to pouch her? We're like, well if we could somehow create a partition and figure out a way to pouch just this area, that's what we need to do. So we decided we would try to build a bridge. We picked a narrow area proximal to our fistula. And the way we did our bridge is we took hydrocolloid strips. We put one in the base, another one on top, another one, another one, another one. Until we reached skin level. And then once we reached skin level, we added two additional strips of the hydrocolloid barrier so that we created a wedge that came up a little bit over skin level. So we filled the wound at that point and it came up a little bit higher than the skin so that when we put our covering barrier strip, which you see on bottom, I'm hoping that from the angle you can see that that hydrocolloid wedge is slightly thicker than the wound at that point. And that our cover strip was actually creating a very slight pressure dressing effect and holding our bridge in position. And then we did the trough procedure and as you can see, drainage is going into the pouch. Now today, if I did this, I probably would not do all of those hydrocolloid strips just because it takes a long time. I probably would cut a piece of white foam to fill the wound at the point where I wanted my bridge and I would put that down into the wound. And then I would take a piece of black foam and put it on top because we all know nothing sticks to white foam. So I would have white foam, then black foam, then my covering strip. And then I could pouch or trough. So during bridge week, you're going to have a chance to ask questions. And we'll go through this procedure again. And you can ask any questions so you get clarity as to exactly what we're talking about. Because most of you will need to do this at some point. A couple of final points. We're almost to the end, so hang in there. You will occasionally have patients with rectovaginal or enterovaginal or vescovaginal fistulas. Most of the time, these patients either have pelvic malignancies that have created these fistulas, sometimes they're end of life, but rectovaginal fistulas can also incur in women who have had pelvic surgery, like vaginal hysterectomy, where there was inadvertent creation of a communicating channel between the vagina and the rectum. Now, rectovaginal fistulas are typically managed with colostomy. The goal is divert the stool, let that fistula tract heal, and then close the colostomy. If you have a patient who's not a surgical candidate, then what you can do is you can focus on stool consistency. You want to bulk up the stool so you never have pellets, you never have mush, you never have liquids, you always have solid logs. And if you do that, you won't have stool tracking into the vaginal vault. You will still have bacteria draining into the vaginal vault, but you won't have stool tracking there. So if for some reason, they're having to look at the vaginal vault, they're going to focus on stool consistency, they're going to focus on the vaginal vault. So if you're having to live with this fistula instead of getting it fixed, you focus on fiber and fluid to control stool consistency. And then you can talk to the surgeon about ordering an antimicrobial vaginal gel to reduce bacterial counts, to eliminate odor. And you can tell the patient, just wear a mini pad because you're not going to have much drainage. Interesting. So what you want to do is you want to divert the liquid stool or urine through a balloon-tipped catheter placed in the vaginal vault. And then you can tell the patient, just wear a mini pad because you're not going to have bacterial counts, to eliminate odor. And you can tell the patient, just wear a mini pad because you're not going to have bacterial counts, to eliminate odor. And then you can tell liter balloon. That works great if I have a very narrow opening. If it's a wider opening, maybe I need a catheter with a 30 milliliter balloon. Occasionally, we'll use a bowel management system. Most of the time, that balloon's too big, but if we need a larger balloon, we could use a bowel management system, or we could feed a catheter through a baby nipple. Use the baby nipple to occlude the vaginal opening. The catheter sits within the baby nipple and drains the stool or urine to the bedside bag. You never want to manage them just with absorptive products. That just makes their skin worse. So you figure out what kind of catheter setup would provide diversion of most of the drainage. Some of us sometimes encounter a fistula that we can't pouch. We've done everything we can think of. We can't come up with anything that works. The patient's constantly having to go through pouch changes. They're really worried about going home. What am I going to do? How am I going to manage this? I don't have anybody who can be there all the time to do this. I know the home health nurse can't just come out however many times a day I need them. How else can I manage? So in that situation you go back to your primary goals, which are protect the periwound skin and manage the drainage. So the easiest thing to do is to coat the periwound skin with zinc oxide. Take a super absorptive baby diaper. Fold it so it contours to the wound, absorption side down, and fit it into the wound. And then secure it with a binder so that there's light pressure against the baby diaper. So you're holding the baby diaper against the wound surface. You're forcing the drainage into that superabsorbent material in the diaper. And then you can tell the patient, every two to three hours, open the binder, take out the soiled diaper, reinforce the zinc oxide, replace the diaper. Okay, you finally got to the summary slide. So fistulas are holes that shouldn't be there. They're very difficult to manage, very frustrating for the patient. First, we have to determine what's going to happen to the baby diaper. And then we're going to take out the diaper. Where does it originate? We know where it terminates. So they'll do an MRI or a fistulogram. They're also looking to rule out abscesses that need to be drained and to assure that the distal bowel is patent. Management, two pathways, non-surgical, surgical. We know that surgery is going to be required for about 70 percent of patients. But it's typically delayed for at least three to six months so that the patient has time to recover from the previous surgery so that we can optimize their potential for healing and so that the adhesions have time to soften and stretch so that the surgeon can get where he or she is going. Medical management is the rule of thumb until we take the patient back to surgery. It involves very low volume oral and enteral feedings, primarily clear liquids, TPN for nutritional support, frequently negative pressure wound therapy to promote wound healing and facilitate fistula management, and hopefully to promote fistula closure. Any patient who fails conservative management, any patient who develops a stomatization or a spondylitis fistula goes on to the surgical track. Surgery will be done three to six months later. They'll resect the component of the bowel with the fistula and do an end-to-end anastomosis. In the interim, it's our job to manage the drainage, protect the skin, support the patient. Typically we use pouching. If that's not working well, we think about closed suction, we think about troughing, we think about how do you think would it help to bridge, or do I need to back off and just do skin care and absorptive products? And again, we'll come back to this whole discussion when you're on site for Bridge Weight. Thanks.
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