Commentary by Barbara Hocevar
This case demonstrates an all-too-common challenge faced by WOC nurses on a daily basis: an ostomy near or within an open surgical wound. In an extensive review of the literature, no data concerning the occurrence of stomas located in a surgical wound was found. Incidences of abdominal would dehiscence range from 0.2% to 6%,1 with associated mortality rates of 9-44%.1-3 Four articles examining factors influencing wound dehiscence were reviewed. Riou et al1 found that significant factors influencing wound dehiscence include age greater than 65, wound infection, pulmonary disease, hemodynamic instabilities, and ostomies in the incision. Significant systemic factors include hypoproteinemia, systemic infection, obesity, uremia, hyperalimentation, malignancy, ascites, steroid use, and hypertension. Riou et al1 also found that 30% of patients with at least 5 significant risk factors developed dehiscence, and all patients with more than 8 risk factors developed wound dehiscence. Col et al2 found the following factors to be significantly associated with wound dehiscence: hypoproteinemia, nausea/vomiting, fever, wound infection, abdominal distension, type of suture material used, 2 or more abdominal drains, and surgeon experience. They also found that the number of patients with wound dehiscence increased with an increase in the number of risk factors the patient had, reaching 100% for those with 8 risk factors. Makela et al3 found hypoalbuminemia, anemia, malnutrition, chronic lung disease, and emergency procedures to be significantly associated with wound dehiscence. In addition, postoperative factors that were significant include vomiting, prolonged intestinal paralysis, repeated urinary retention, and increased coughing. When the number of risk factors increased from 0-5, there was a significant increase in wound dehiscence. Penninckx et al4 found that the following factors predispose patients to wound dehiscence: male, greater than 64 years old, complicated neoplastic and inflammatory diseases, emergency interventions, and bleeding and noncomplicated inflammatory diseases, with the exception of appendicitis. To the extent possible, all groups believed that risk factors should be controlled before operation (eg, hypoproteinemia corrected and hypertension normalized). The use of retention sutures or extra preventative measures taken by the surgeon at time of wound closure was advocated when 5 or more,1 3 or more,3 and 2 or more4 risk factors are identified preoperatively.
Mr Z had several of the predisposing factors for wound dehiscence mentioned: age, malignancy, lung disease, wound infection, colostomy in the incision, and a postoperative catabolic state. As such, it is not surprising he experienced a breakdown of his surgical wound. As this case illustrates, pouching and wound care are fairly routine when wounds are covered with eschar, but as autolytic debridement occurs beneath the skin barrier of the pouching system, management becomes more difficult and complex. The management methods chosen must reflect the changes to the stoma and peristomal tissues that occur as postoperative edema subsides, as well as the evolution of the wound from necrotic tissue to a clean granulating wound. In addition, improvement in patient status, particularly from less mobile to full ambulation, influences the type of pouching system/wound management methods required. As is often the case, the systems and methods that work extremely well in the hospital require maximum modification in the home setting.
Case reports detail the use of a variety of management methods for stomas or fistulae located within open abdominal wounds: closed suction,5-10 conventional ostomy pouch and/or collectors,7,8 custom-made systems (such as 1-piece adhesive backed pouch with skin barrier),11 food-storage bag with skin barrier,9 bowel isolation bag with skin barrier,12 and skin protection with dressings.11 At the commentator's institution, all of these have been used, depending on patient status, stoma/wound presentation, and availability of product. Recently, one patient, NB, challenged the staff's capabilities to the fullest.
On April 27, NB, a 58-year-old white female, had a total abdominal colectomy, loop end ileostomy with oversew of the rectal stump for mucosal ulcerative colitis. Comorbid conditions included coronary artery disease, hypertension, type 1 diabetes mellitus, hypothyroidism, depression, morbid obesity (the patient's panniculus at time of operation measured 13 cm deep), history of hyperlipidemia, status after quadruple bypass, angioplasty, and total abdominal hysterectomy. Ischemic changes to the stomal mucosa were noted on postoperative day 3. Surgical service examined the stoma, and the ischemic changes were believed to be above fascial level, so no surgical intervention was planned. The patient was discharged on postoperative day 6.
NB was monitored in the outpatient clinic but was again hospitalized on May 12 when she presented with increased wound drainage and induration. NB returned to surgery on May 13 and underwent a resection of ileostomy and terminal ileum with neo-loop end ileostomy, oversew/resection of sigmoid cutaneous fistula, drainage of abdominal wall abscess, closure of abdomen with retention sutures and dental rolls, and insertion of drain. Not unexpectedly, a mucocutaneous separation developed postoperatively; this was conservatively managed using skin barrier powder, skin barrier paste, skin barrier washer, and a soft flat pouching system. The patient was discharged home with homecare follow-up on May 21. On May 24, NB was once again admitted with questionable fistula from the midline incision. Consults were placed to infectious disease, nutritional support team, and peripherally inserted central catheter (PICC) line team. The ileostomy in the lower right quadrant was recessed approximately 2.5 cm, had a circumferential mucocutaneous separation with slough present, and measured from 2.5 cm to 7.5 cm deep. It communicated with the midline wound and was the "fistula source." Retention sutures were removed from the lower wound, and negative pressure wound therapy (V.A.C. by KCI, San Antonio, Tex) was applied. The mucocutaneous separation was packed lightly with alginate rope, covered with skin barrier powder and paste, and pouched with a skin barrier washer and flat flexible pouch. Minor "tweaking" to the system was required until an every-other-day change schedule was obtained.
As the slough cleared, more effluent diverted into the wound; a decision was made to take the patient to surgery. On June 7, a subcutaneous lipectomy, complex ileostomy revision with rotation skin flap, and drainage of the subcutaneous space were performed. To assist effluent collection, an indwelling catheter was placed into the proximal lumen of the stoma. Peristalsis kept pushing the catheter out, however, so it was abandoned on postoperative day 3. The ileostomy was pouched with a 2-piece system with skin barrier washer, and the wound was packed with normal saline-moistened gauze roll. By postoperative day 6, the stoma was retracted with a full-thickness mucocutaneous separation from 2-12 o'clock. Effluent was again leaking into the midline wound. The wound measured 9 cm from wound edge to the edge of the mucocutaneous separation, with tracking beneath the skin bridge, an external midline opening 5.5 cm x 6 cm, and with undermined area at 12 o'clock, extending 9 cm cephalad. External serosa of the ileum was visible along the lateral edge of the wound.
The V.A.C. system was again implemented. Vaseline gauze was placed to cover the exposed bowel; white foam was used in the undermined cavity with black foam to the remaining wound. Periwound skin was protected with skin sealant and pieces of skin barrier. After wound care was completed, the ileostomy was pouched using skin barrier wedges, skin barrier paste, powder, and a soft-backed 1-piece pouching system. The majority of ileostomy effluent was collected in the pouch, with minimal wound contamination. The patient was discharged to a subacute facility (she had refused discharge to a subacute facility previously) and was eventually discharged to home July 16.
Throughout all of this, NB's husband, an engineer by profession, provided emotional support and encouragement. He actively participated with his wife's wound and ostomy care and was able to make and implement ideas that assisted in making a more effective seal. "Let's add a wedge here or make this wedge bigger," are such examples of his input.
Throughout the next month, NB was readmitted to the hospital twice for dehydration, adrenal insufficiency, and infection of her PICC line. During her second return, NB voiced her discouragement/exasperation with the management method. The V.A.C. alarmed every 1-2 hours for no apparent reason, the system leaked, and the change schedule was unpredictable. Modifications were made with no success, so the decision was made to pouch the stoma and wound together. At this time (August 3), the wound measured 10 cm x 5 cm deep. The wound bed was red and clean with granulation deposition in the mucocutaneous separation. A large skin barrier with an adhesive-backed pouch, skin barrier powder, and paste were used as the pouching system. Minor variations to this, such as the addition of more skin barrier wedges and changing the pattern used, were made because the wound had granulated and contracted, causing abdominal and peristomal contour changes. At her last outpatient visit on October 12, NB's wound had decreased to 6.5 cm in length. The pouching system was changed to a 1-piece soft flexible wound management pouch, skin barrier wedges, skin barrier paste, and cement.
As a patient's ostomy/wound changes, so to must his or her management systems. Although similar management options were used in the cases presented, the timing for when they were "best used" was different. For Mr Z, pouching with wound dressings worked best in the in-patient setting and the V.A.C. system allowed for scheduled changes, wound healing progression, and increased freedom of movement in the home setting. NB's situation, on the other hand, was just the opposite. These two case studies reinforce the need for ongoing ostomy/wound assessment and evaluation and modification of the management plan.
ACKNOWLEDGMENTS
The commentator thanks her fellow colleagues who, along with herself, have provided care to NB: Brenda Stenger, MEd, BSN, CWOCN; Judy Landis-Erdman, BSN, CWOCN; Denise Groh, BSN, CWOCN; Valerie Green, BSN, CWOCN; M. Colleen Neely, BSN, COCN, CWCN; and Coleen Potts, BSN, CWOCN.
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