Can skin graft next to an outlet of acid & proteolytic enzymes survive
This case study examines the use of Eakin Cohesive® Seals to aid wound closure, sited close to a gastric fistula.
Author: Naomi Houston. RN Grad Dip FHC (Family Health Care),MPHC (Masters in Primary Health Care), Clinical Nurse Specialist – Stomal Therapy, Nepean Hospital. Western Area Health Service. Sydney. NSW.
Mrs X had a long and complicated history. Following multiple surgeries for a bowel obstruction and infected mesh, Mrs X’s abdominal wound dehisced and a gastric fistula developed. Through the use of skin graft, her wound was closed. However there were grave concerns of it dissolving due to its proximity to the gastric fistula.
It was anticipated the corrosive gastric contents of hydrochloric acid with a pH similar to battery acid and proteolytic enzymes designed to break down protein, the graft and the surrounding perifistular skin would become macerated, excoriated and digested.
The challenge was on!
Prior to the eventual surgical closure, could we save this graft ‘against all odds’? Could we maintain healthy perifistular skin, reduce and minimize complications of pain, unnecessary dressing changes and patient distress?
Photo A shows the impact of contact irritant dermatitis denuding the skin of the perifistular area and the overflow of gastric secretions that were affecting the graft to the left. (A yanker sucker is being used to suction the copious production of corrosive acid and enzymes found in the gastric secretions prior to applying a system that would cope with the problem. Please note the yanker sucker tip indicates the fistular orifice flush with the skin).
We applied large Eakin Cohesive® Seals as our skin /graft barrier (Photo B). We chose Eakin as it is not only reliable in providing first class adhesion and enhances wound healing but it is also hypoallergenic, easy to apply, atraumatic to remove and is flexible and mouldable.
Photo A shows the impact of contact irritant dermatitis denuding the skin of the perifistular area
Photo B shows Large Eakin Cohesive® Seals as a skin/graft barrier
In this situation, we used one and a half pre-warmed large Eakin Cohesive® Seals (Eakins cut into halves). Although Eakin Seals are well known for being flexible/mouldable, not requiring scissors, we did use scissors in this situation, i.e., primarily as we wanted to work quickly to give the graft/perifistular skin the best chance of adhesion.
Skin was cleaned and dried. Carboxymethylcellulose powder was puffed on with excess removed whilst secretions were suctioned through the use of a yanker sucker. We then applied the first prewarmed half Eakin Cohesive® Seal to the most prominent and vulnerable part of the graft, followed by one half Eakin Seal at the top of the graft/perifistular and then finally we placed the last half at the fistula orifice. In this way we found that we were able to protect the destruction of the graft, create healing of denuded tissue, prevented unnecessary pain and patient distress.
Please note the Percutaneous Endoscopic Jejunostomy (PEJ) feeding tube to the right of the photo. Despite the gastric balloon and the external bolster, we had difficulties in maintaining correct anchorage without leakage. The balloon (like an ‘alien’) would pop out of the gastric fistula and no amount of movement of the bolster to create a snug fit would assist in preventing spillage of gastric fluid and the consequence of corroded skin.
To manage this problem, we used Eakin again. Either we would use the last half of the 2nd large Eakin Cohesive® Seal (used for the perifistular) and wrap it around the PEJ tube under the external bolster/disk or we would use a small Eakin Cohesive® Seal – which we would break in half and again wrap under the disk.
In Photo C the perifistular skin, especially near the gastric orifice, is healthy with no signs of dermal toxicity due to effects of the gastric effluent.
In Photo C the perifistular skin, especially near the gastric orifice, is healthy with no signs of dermal toxicity due to effects of the gastric effluent. The graft is healing well: more than 70% ‘taken’. This 70% meant a good outcome for the final wound closure.
Against all odds, the graft next to an acid outlet of HCL and the digesting proteolytic enzymes survived! Mrs X, thanks to the Large Eakin Cohesive® Seals, had successful closure to her wound and was spared many a complication.