SACSTM: Studio Alterazioni Cutanee Stomali; NPWT: Negative Pressure Wound Therapy; L: Lesion; T: Topography

The occurrence of a complex peristomal lesion in an ostomy patient [1-3] implies many issues [4]. It exacerbates the already severe clinical condition, especially because managing the stoma becomes harder and the wound’s healing is delayed.

Although advanced medications are commonly effective for this kind of lesions, sometimes no method yields positive results. The patient suffered a range of negative symptoms, from the loss of her ostomy device to skin degradation and overall bad quality of life. The necessity of trying new approaches led us to a change of strategy. After consulting with other colleagues and briefly researching the use of NPWT in ostomy patient [5,6], we decided to use this device with our patient. We waited 20 days while we managed the lesion with traditional treatment before starting the NPWT for a period of 12 days. This had never been tried before in our surgical setting.

The target of this case study was to estimate the effectiveness of the Negative Pressure Wound Therapy (NPWT) into managing a complex peristomal skin complication in a patient with a urostomy. At the beginning we had difficulties with attaching any ostomy device because of the skin condition, so we needed to improve the conditions of the skin in order to manage the ostomy correctly with the appropriate equipment.

The patient was an elderly woman of 72 years who suffered from a malignant metastatic bladder cancer. She had a complex medical case: urostomy (Wallace 2), overweight, arterial hypertension, diabetes, impaired mobility. The patient had a severe peristomal skin lesion L4- TV, according to the SACSTM Classification (Figure 1). Skin complications treatment was a priority in order to manage the ostomy with the appropriate medical device.

Figure 1: Peristomal Skin Lesion L4-TV (S.A.C.S. Classification).

In the first phase after an appropriate wound bed preparation and debridement the patient was treated with advanced dressings according to the current protocols. Also the excess of exudate and urine leakage forced us to admit the patient in a hospital setting because of the impossibility of managing the ostomy device properly from home. We used Hydrofiber, Alginates, Hydrocolloids, Stomahesive Protective Powder, Stomahesive Paste and Polyurethane Foam skin barriers, but after 20 days of continuous medication unfortunately we observed no improvement in the patient’s clinical conditions.

In the second phase the patient was treated with Negative Pressure Wound Therapy. We will now show you step by step how we treated the patient are wound.

Step 1: We started protecting the periwound skin with sterile grease gauze, in order to preserve the area from Negative Pressure (Figure 2).

Figure 2: Positioning of the non-adherent dressing to protect the skin.

Step 2: Then we applied the Stomahesive Paste to flatten and protect peristomal skin from urine leakages (Figure 3).

Figure 3: Application of the Stomahesive Paste in order to protect the lesion from the urine.

Step 3: As we experienced some challenges in adapting the Polyurethane Foam to the peristomal area, we decided to protect the skin with sterile gauze (Figure 4).

Figure 4: Application of the antimicrobial gauze.

Step 4: The last step was applying the NPWT Therapy; we used a Foley Catheter in order to reduce urine leakage, placed directly inside the urinary ostomy (Figure 5). This innovative set-up allowed us to reduce significantly the risks of detaching the NPWT device.

Figure 5: Foley catheter and VAC Therapy application.

The patient was treated with a new wound dressing every 72 hours. The device used in this case study is The RENASYS GOTM, an electronic NPWT pump (Figure 6), that can offer flexibility in treating a wide variety of wounds in acute and home care settings, and it combines portability and ease of operation in order to maximize patient comfort, mobility, and convenience. This device was chosen because it allowed us to continue the treatment at the patient’s home. The decision was made with the patient in order to best meet her needs.

Figure 6: The RENASYS GO™ NPWT Smith and Nephew GmbH Medication Kit (UK).

In each follow-up visit, we assessed a constantly improving condition of peristomal skin. The patient was treated with NPWT for 12 days. After this time we could already observe a significant improvement of the lesion. The skin condition, initially rated L4, improved to L3; the extension of the skin lesion also reduced from TV to TI-TIV (Figure 7).

Figure 7: (a) Skin lesion at Time 0 of Vac Therapy, (b) After 72 hours from the first use of the Vac Therapy, (c) After 12 days the lesion had a significant improvement to L3 / TI-TIV (S.A.C.S. Classification).

This reduction allowed an appropriate management of the stoma with an ostomy device and allowed the patient to be discharged from hospital with self-management of the ostomy and stomacare. After discharge the lesion was treated with zinc oxide until complete healing and tissue restoration occurred in about one week.

This was the first time that NPWT was used for this kind of lesion in our setting. Even if no one ever tried to manage a complex peristomal lesion like this, we discussed this case with the patient and colleagues and decided to try this new approach. Our goal was to allow correct stomacare for the patient and improve her quality of life. NPWT has been the perfect choice for this. It allowed connecting wound edges together, cleaning the wound from any infected material, and favouring granulation. The technique is secure, efficient, moneysaving and comfortable for patients.

This case made us realize that NPWT is a great alternative also as treatment for complex peristomal skin complications [7-9]. The treatment was well received by the patient; neither negative effects nor intolerance occurred.

The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

Not consulted.

Written informed consent was obtained from the patient for publication of this case study and any accompanying images.

No financial support received.

All authors equally contributed in writing the case and giving care to the patient.