Outpatient follow – up discovery of stoma site recurrence. A case study

Ms Melanie Perez1, Anne Mamo1
1St. George Public Hospital, Hebersham, Australia

This case study involves discovering stoma site recurrence in patients being reviewed in the outpatient setting. The aim is to show the importance of follow- up review in identifying unusual growth and nodules around the stoma. Routine follow- up involves the assessment of the stoma which provides the opportunity to detect minor changes that is potentially indicative of sinister occurrence. In order determine and classify the unusual growth, direct referral to the treating surgeon is essential for a definitive diagnosis. Hence, this paper also highlights the significance of collaboration and teamwork with the surgeon in providing timely intervention and management. As timely intervention and management of stoma recurrence is crucial as it directly impacts the pouching, the output, prognosis and the quality of life of the patient.


Biography:

I am currently working  as a Clinical Nurse Specialist in the Stomal Therapy department at St. George Public Hospital. I also work as a part- time Registered Nurse in the gastro, liver, peritonectomy surgical ward. Working as a Stomal therapy nurse and a ward nurse has given me the opportunity to appreciate the different challenges that comes from the ward and the stomal therapy department. The uniqueness and complexities of every case I encounter inspires me to be innovative, patient- centered and focus on improving patient care and experience.

The use of Negative Pressure Wound Therapy on the perineal incision following an abdominoperineal resection.  Can time to wound healing be reduced?

Mrs Trish Doherty1, Dr Kim-Chi Phan-Thien2
1Hurstville Private Hospital, Hurstville, Australia, 2Sydney Colorectal Associates, Hurstville, Australia

Background: Complications with the healing of perineal wounds following abdominoperineal resection are common.₁ These include infection, dehiscence, perineal sinuses, and abscesses.₁  Negative pressure wound therapy (NPWT) is a  treatment used to increase blood flow to the wound, encourage the development of granulation tissue, control exudate and decrease the amount of oedema in the area.₂  The use of a NPWT device on an incision can improve healing, decrease wound dehiscence and prevent infections.₁

Aims: The aim of this audit was to determine if the use of a NPWT device on the perineal incision site, as prophylactic wound management,  reduced the time to wound healing in patients following abdominoperineal resection.

Methods: This is a retrospective review of patients who underwent abdominoperineal resections. The medical records of patients who had negative pressure wound therapy applied to the perineal wound were assessed and compared to patients who had standard dressings applied in the postoperative periods.

Results: There were no differences in BMI, comorbidities, adjuvant therapy in those who did or did not have NPWT applied. Preliminary results show that healing time in the patients who had the NPWT applied had an average healing time of 25.25 days, compared to those with a standard dressing, average healing time of 82.71 days (p=0.118).

Conclusion: Our early data show no significant difference in the time to healing with and without NPWT. These data are limited by the small number and should be interpreted with caution. Further data will be collected and the results will be updated.


Biography:

Trish Doherty is a Clinical Nurse Specialist in stomal therapy, continence and wound care with extensive experience in a large tertiary teaching hospital as well as a smaller but busy colorectal surgical hospital in Sydney. Her current role involves working closely with a team of colorectal surgeons in their rooms and also in the hospital. This unique situation allows for continuity of care for colorectal / stoma patients from diagnosis to community follow-up.  Trish also works one day per week in the anorectal physiology laboratory which has given her knowledge in the management of functional bowel disorders, antegrade colonic irrigation and sacral nerve neuromodulation.

Trish has an enormous passion for stomal therapy, wound and continence care and is keen to develop her research skills in these areas.

Management of a growing Desmoid tumour in the setting of familial adenomatous polyposis with an existing ileostomy and active fistula in a nursing home setting

Mrs Rebecca Hook1, Ms Kirralee Foster
1University Hospital Geelong, Geelong West, Australia

We will follow the journey of 49 year old Mrs K who has a history of Familial adenomatous Polyposis.  This condition has subsequently resulted in a rapidly changing desmoid tumour.

The tumour was intially internal and has since become external.

She has an existing ileostomy and faecal fistula resulting in issues with the management of faecal output from both the fistula and the ileostomy. She resides in a nursing home and relies on nursing staff for all pouch changes and on going care.

Management was initially achieved with the use of small coloplast wound pouches but as the tumour grew and changed over the following 18 months, the use of various sized Eakin wound pouches were required to achieve some degree of tumour, fistula and stoma management due to the close proximity of all of the above. The tumour size has varied from 8cm x 8 cm to 36cm x 34cm.

Palliative care are involved with ongoing care, however with an unknown disease progression, and the nature of the ever changing tumour size,  stomal therapy involvement continues to be intermittent but ongoing.


Biography:

Rebecca has been a qualified Stomal therapy Nurse for 10 years and has a background in colorectal nursing. She works 3 days a week in the Stomal Therapy department at University Hospital Geelong. Kirralee is a recently qualified Stomal therapy nurse and is the third member of the stomal therapy team in Geelong.  They look after over 120 new stomas per year.

Anorectal trauma associated with sodium phosphate enema leading to Fournier’s gangrene requiring extensive debridement and diverting colostomy

Ms Fiona (Lee) Gavegan1, MS Karen Shedden1, Ms Annelise Cocco1, Dr James W.T. Toh1
1Stoma Therapy, Department of Surgery, Westmead Hospital, Sydney, Australia,

Fournier’s gangrene is a devastating life-threatening condition which is poorly understood. In today’s context, the most common cause of Fournier’s gangrene is perianal abscess followed by urological source – often in elderly, immunocompromised or diabetic patients with significant co-morbidities. However, the first documented genitalia gangrene reported by Baurienne in 1764 described a 14-year old male was gored by an ox, and subsequent early case reports also documented necrotizing perineal sepsis in young healthy men associated with trauma. In this case series, we revisit perianal trauma as a cause for Fournier’s gangrene. More specifically, trauma from administration of phosphate enemas inadvertently leading to Fournier’s gangrene. Within the literature, there have been only a handful of small case series of rectal necrosis associated with phosphate enemas, and rare case reports of Fournier’s gangrene associated with phosphate enema administration. Here we present a 51 year old male who was not diabetic or immunocompromised, and an 84 year old male who was diabetic who developed Fournier’s gangrene after traumatic enema administration. Both patients required extensive debridement of the perineum and scrotum and a diverting colostomy. We review the symptoms, diagnosis, management and sequelae of phosphate enema induced Fournier’s gangrene.


Biography:

Lee Gavegan and Karen Shedden are senior stomal therapists at Westmead Hospital, Sydney, Australia. Dr Annelise Cocco is a senior registrar at Westmead Hospital. Dr James W. T. Toh is a colorectal surgeon at Westmead Hospital and Clinical Senior Lecturer, Westmead Campus, The University of Sydney.

Necrotising soft tissue infection and management of a stoma after extensive abdominal wall soft tissue loss

Ms Colleen Mendes1
1Royal Prince Alfred Hospital, Camperdown, Australia

Background: Extensive loss of abdominal wall soft tissue creates a complex and challenging situation where a stoma is formed in the absence of abdominal wall skin or subcutaneous tissue.  This case study describes a 64 year old male who was admitted  in acute septic shock with a perineal mass and necrotising soft tissue infection extending over the abdominal wall. He underwent surgical debridement of the affected tissue, perineal proctectomy with wide excision of the anal sphincter and formation of colostomy.

Aim: The aim of this presentation is to describe a technique for isolation of a stoma that has been formed onto abdominal wall fascia, surrounded by negative pressure wound therapy dressing.

Method: The fascia surrounding the stoma was covered with a silicone dressing and a mouldable seal before a fistula isolation device was applied. The negative pressure dressing foam was cut to fit between the two bridges of the fistula isolation device. The abdominal defect was covered with foam dressing. With the negative pressure applied, the consitina in the fistula isolation device contracted down around the stoma and a bag was able to be applied.

Conclusion: The use of the fistula isolation device successfully separated the newly formed stoma from the negative pressure dressing allowing stoma maturation, complex abdominal wound management and avoidance of enteric contamination of the wound.


Biography:

Colleen Mendes is a Clinical Nurse Consultant in Stomal therapy at Royal Prince Alfred Hospital, Sydney, She has a 25 year nursing career, with 10 years specialising in this field. Colleen has extensive experience in stoma, wound, continence, antigrade colonic irrigation, sacral nerve neuromodulation programming and anorectal physiology.

AASTN

This conference is proudly hosted by the Australian Association of Stomal Therapy Nurses: www.stomaltherapy.com

One of the Association's major objectives is the promotion of quality care for a wide range of people with specific needs. These needs may be related to ostomy construction, urinary or faecal incontinence, wounds with or without tube insertion and breast surgery.

Patients/clients across the life span are provided with preventative, acute, rehabilitative and continuing care as required. Another objective is the maintenance and improvement of professional standards in relation to Stomal Therapy Nursing Practice to the highest degree possible. Recognition of the need for and encouragement of the development of specialist expertise in the field of Stomal Therapy Nursing underpins the Standards for Stomal Therapy Nursing Practice.

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