(CS-002) ECM and Polyvinyl Alcohol Foam with Methylene Blue and Gentian Violet in Conjunction with NPWT for a Complex Fournier's Gangrene Wound with Tunnels

Introduction: 58-year-old male admitted with Fournier's Gangrene with new onset of diabetes mellitus and severe sepsis. Emergent surgical debridement resulted in a large wound to the peri-rectal, perineum and groin region. Hartmann's procedure was completed to protect wound. This wound required complex wound care to treat. Wound measured 19.0 x 10.0 x 10.0cm with tunnels at groin measuring 6.0cm at 11 and 1 o'clock. The intact skin circumferential to the rectum needed to be preserved. An additional concern was present for the healing to follow the anatomical curves to allow for pain free sitting without pain or tension.

Methods: Wound was cleansed with hypochlorous acid for a period of 10 minutes. Wound perimeter was cleansed then sealed with a skin barrier wipe. Tunnels were packed with dense version of polyvinyl alcohol foam with methylene blue and gentian violet for antimicrobial benefits. A stoma ring was used around the intact peri rectal skin to facilitate Negative Pressure Wound Therapy (NPWT) seal and preserve skin. NPWT at 125mmHg was completed with dressing changes every Monday, Wednesday and Friday. At week 2, an Ovine extracellular matrix was initiated over the wound base to facilitate granulation with a contact layer and NPWT. The patient was discharged to home at 2 weeks and continued with outpatient wound care dressing changes three times per week. By week 4, the frequency was reduced to twice a week. Polyvinyl alcohol foam with methylene blue and gentian violet was used on edges which were starting to roll or over areas with hyper-granulation. By week 7.5 the wound measured 11.0 x 1.3 x 1.5cm and tunnels were now closed. The NPWT was discontinued at 13 weeks and wound fully resolved at 15 weeks. Patient continued with colostomy with the option for reversal after one year.

Results: The combination of using hypochlorous acid, polyvinyl alcohol foam with methylene blue and gentian violet, ovine extracellular matrix and NPWT allowed for this patient to heal without the need for a skin flap, without scarring and with pain free return of functional mobility with standing, sitting and walking.

Discussion: Attention to detail including wound bed preparation, management of edge advancement and creative use of advance products to achieve the desired goals was essential to close this wound. It is always a team effort from everyone involved especially the surgeon, hospitalist and the infectious disease doctor.