Barry Weaver, RN.
Team Leader, Gloucester Ward, Private Practice Unit, Royal Free Hospital, LondonThis paper focuses on a 67-year-old male with a long history of Crohn's disease and underlying diabetes. Robert George was admitted to hospital for an elective sub-total colectomy and ileo-rectal anastomosis due to obstructive Crohn's ileo-colitis. But he had to return to theatre four times due to postoperative bleeding, bile leakage and failure of the anastomosis.
This paper focuses on a 67-year-old male with a long history of Crohn's disease and underlying diabetes. Robert George was admitted to hospital for an elective sub-total colectomy and ileo-rectal anastomosis due to obstructive Crohn's ileo-colitis. But he had to return to theatre four times due to postoperative bleeding, bile leakage and failure of the anastomosis.
This case study reports on the management of this difficult wound, which became contaminated, and the impact on Mr George.
Initial assessment and management
When Mr George arrived back in the ward from the intensive therapy unit his laparotomy wound began to gape, due to an outflow of bile. The origin of the bile leak could not be identified or sealed, despite returning to theatre.
The wound was assessed by the ward team leader and then the surgeons. There were no clinical signs of infection and bile erosion was thought to be the problem. The wound was filling with bile. After discussion with the surgeons, a decision was made to remove several of the wound closure clips, evacuate the wound's contents and assess the full extent of the problem. The wound opened completely from just below Mr George's sternum to his navel, and dark brown bile emanated from the top.
Bile is a complicated secretion made of many substances including acids and salts (Hargreaves, 1968).
At this point the main aim of wound care was to attempt to keep the wound free from contaminants such as the bile and prevent any further deterioration. Leakage of intestinal fluids can lead to wound infection, abscess and fistula formation, sepsis and even death, as well as having psychological effects on the patient caused by discomfort, poor body image and anxiety (Falconi and Perdozoli, 2001).
Mr George was referred to the tissue viability nurse team, who discussed with the consultant surgeon options for a dressing that could create the optimum conditions to aid wound healing: one that would facilitate a moist wound environment and would be impervious to bacteria (Voinchet and Magalon, 1996; Miller, 1998; Dyson et al, 1992). It was also important that it could manage the large amount of bile emanating from it - between 700 and 1200ml over 24 hours.
One option considered was vacuum-assisted closure (VAC) but because a small section of bowel was visible, the team leader, tissue viability nurse and consultant surgeon decided that VAC would present a high risk of bowel fistulation. The surgical, nursing and tissue viability teams decided to use Coloplast (Coloplast) wound manager bags to try to keep the wound surface free from contaminants until the wound was deemed more suitable for VAC therapy. Mr George was referred to the stoma-care team for supplies and advice.
The bags were the largest commercially available and two had to be stuck together to cover the wound. Creases and folds in Mr George's skin had to be sealed with stoma paste. It took nearly two hours each time to change the wound manager bags, and the team could find no way of stopping the flow of bile. This led to a cooling down of both the wound, which can have a detrimental effect on healing (Hartmann-Peterson et al, 2000), and Mr George's overall body temperature.
Mr George commented that during the bag changes he felt cold and exposed, and it took all day before he felt warm again. At the time of this case study, little could be offered to Mr George in the way of peri-wound protection except for stomahesive paste to protect any exposed skin. This problem has since been addressed, with the recent introduction of Cavilon barrier cream (3M) to the authors' trust.
Mr George's nutritional, electrolyte and fluid needs were met by use of total parenteral nutrition via a central line. A large wound such as this requires a high level of nutrients and fluid to repair (Goldstein et al, 1989). Mr George's underlying diabetes was managed with a sliding scale of insulin. Unfortunately this meant that his blood sugar needed checking every two hours, which interrupted his sleep pattern.
The size of the wound had a marked effect on Mr George's body image. He commented that until this admission there had been few problems with his health and his diabetes, and Crohn's disease had not been a problem. All of a sudden he found himself in hospital with a wound that he found shocking. Mr George recalled feeling horrified as the wound opened, and seeing what should have been a neat surgical incision turn into a massive hole, exposing his internal organs. He felt exhausted and developed a negative outlook for the future. He saw no end to his suffering.
He was offered access to a professional counsellor, but declined it, so it was left to the nursing staff to offer him support and encouragement.
Few authors do more than acknowledge the existence of altered body image and fail to offer advice to professionals on how to help the patient. Altered body image is a complex psychological concept, which is embedded in an individual's own perception of self, others and how individuals view each other. Price (1996) describes altered body image as 'A state of personal distress, defined by the patient, which indicates that the body no longer supports self-esteem, and which is dysfunctional to individuals, limiting their social engagement with others'.
Mr George told nurses he did not want to see anybody except his immediate family members, whereas before this trauma he had always been a confident, sociable person. He had a job in property development and had high self-esteem. Price (1996) continues: 'Altered body image exists when coping strategies (individual and social) to deal with changes in body reality, ideal or presentation, are overwhelmed by injury.'
Additional wound-management difficulties
The wound's location provided its own difficulties. The abdomen flexes and stretches during mobilisation, and this caused the seal between Mr George's skin and the bags to fail regularly, resulting in leakage. Mr George was afraid this body fluid would leak on his clothes, and he became reluctant to get out of bed. As he was in a supine position for most of the day and night, the wound was constantly bathed in bile, and little of it drained into the bags.
Lying supine increased his already high risk of pressure ulcers and the other complications of extended bed rest, such as deep vein thrombosis, constipation, chest infections, and so on. His Waterlow score was 26 on arrival from ITU (Waterlow, 1995). To reduce these risks an alternating Nimbus air mattress (Huntleigh) was used and his Waterlow score was reassessed at least weekly, sometimes daily. Other interventions included a minimum of two-hourly repositioning. encouraging the patient to change position using a monkey pole, protecting the patient's heels, chest physiotherapy and deep breathing and coughing exercises.
The wound was assessed daily and was found to be deteriorating. Within a week a deep fistula was observed near the top, and both the deep internal sutures and drain tubes were visible (Figure 1). The wound bed looked dirty. It was contaminated with green and brown body fluid staining, and there were thick clumps of slough in several areas. No signs of pink, healthy-looking granulation tissue could be seen. By now Mr George could not even look at his wound, and described it as like something from a horror film. He became passive and participated less in his self-care, preferring nursing staff to do almost everything for him.
Newell (2000), who examined first-hand accounts of people with disfigurements and their experiences, states: 'The work and social life of sufferers are affected, throughout the life cycle, and sufferers engage in such tactics as avoidance of social situations and avoidance of particular actions within these social situations.'
Mr George started refusing to see visitors or take telephone calls and became psychologically withdrawn. The consultant surgeon offered Mr George and his family psychological support by speaking to them all every day and keeping them informed of progress.
Wound reassessment and therapy change
Another multidisciplinary team meeting was held. The team decided Mr George needed a dressing that would allow complete evacuation of the wound from bile, and enable him to walk around without leaking. Since the rapid deterioration of the wound now outweighed the risk of bowel fistulation, VAC therapy (also known as topical negative pressure) was decided on. This method of wound repair uses the effects produced on a wound cavity by sub-atmospheric pressure.
A piece of polyvinyl foam is cut to the size and shape of the cavity and placed inside it. A length of piping with lateral perforations is placed in this, covered with an occlusive film, and a controlled level of vacuum is applied (Figure 2). This treatment could be classed both as a dressing and a therapy, or a combination of both.
Thomas (2001) states that VAC therapy accelerates debridement and promotes the healing process, and Voinchet et al (1996) states that VAC exerts a mechanical force which brings the wound edges together. It has been found to remove interstitial fluid and excess oedema, which increases blood flow and decreases bacterial levels (Thomas, 2001; Greer et al, 1999; Argenta and Morykwas, 1997; Mendez-Eastman, 1998). It is also believed to increase the rate of cell proliferation by deforming cells (Thomas, 2001).
VAC can cost more than £25 a day, including the hire or purchase of pumps and the cost of disposable equipment (Thomas, 2001), but Philbeck et al (1999) have calculated that this is still cost-effective compared to other treatments.
It can take a long time to apply the occlusive dressing over the sponge and tubing. The practitioner must ensure a good seal is present, or else vacuum is impossible, and this can lead to loss of temperature within the wound (Hartmann-Peterson et al, 2000). Staff must have the skills to apply and maintain the dressing, and many nurses felt uneasy about this apparently complicated technique of application. Several staff had never even heard of the therapy at the time, and whenever the dressing or canisters needed changing somebody had to be found who was familiar with the process. At times the tissue viability specialist nurses had to be contacted when they were off duty for advice, and sometimes the therapy had to be stopped until this advice was obtained.
Mr George commented that he felt dependent on the staff he knew were competent to change the dressing. He began to request to see the specialist staff if there was a problem with the dressing, such as air leaks causing loss of vacuum. A list of contact names and numbers was soon drawn up, and staff were offered training to ensure this would not complicate or compromise the wound-healing effects of this therapy.
Unfortunately, within 10 days of VAC starting, Mr George did develop a fistula at the visible area of his bowel and VAC therapy was discontinued.
It is debatable whether this fistula was a direct result of the VAC therapy, or a normal occurrence as 'postoperative gastrointestinal fistulae can occur after any abdominal procedure in which the gastrointestinal tract is manipulated' (Falconi et al, 2001).
Black (1995) takes a differing view in a review of wound-management products, stating that 'most fistulas developed spontaneously, and they were related to inflammatory diseases, only a minority being the result of postoperative complications'.
A capillary dressing
Vacutex (Pro-tex), a relatively new capillary dressing, was tried. This was in use in the trust as an experimental dressing and had produced favourable results in similar wounds in the past. It was placed into the wound in multiple layers to draw out exudates, and small strips of it were used as wicks, at both the bile leak and the bowel leak, and these were drained into stoma bags. Little research, except that from the manufacturer and its own studies (Pro-tex 2001), was available at this time.
This approach succeeded enough for the wound to show signs of granulation and the bowel fistula to form into a natural stoma, enabling it to be isolated with stoma bags (Figure 3).
VAC therapy was started again on the upper part of the wound, and the lower part was kept free of the vacuum using a barrier made from stomahesive paste, and managed with bags. This allowed the faecal fluid to be kept away from the wound without risking further fistulation (if the vacuum was to blame). Peri-wound protection was still only available at this time in the form of stoma paste.
As Mr George's bowel was now functioning well, he began eating and the parenteral nutrition and sliding-scale insulin could be discontinued.
Once he began eating, Mr George said that at last he felt he was on the road to recovery. He started engaging in the functions of normal social living. He took more responsibility for self-care, washing and dressing himself, and moving around. He saw more visitors, and began to eat meals with his family present.
Changes in his wound could now be seen on continued daily assessment and pink granulation tissue grew at a steady rate. Within a month his wound had regenerated enough healthy granulation tissue that skin grafting with a split-thickness graft taken from his left thigh was undertaken. Comparison between Figures 4 and 5 (taken 11 days apart) show an obvious and large improvement in both area of granulation tissue and wound contracture.
Three months after the initial dehiscence of the wound Mr George had a granulating wound with enough integrity for him to be discharged home. The community stoma care team assisted him with maintenance of his stoma at home, and the district nurses changed his abdominal dressings. The wound was fully healed after three months. Mr George has been re-admitted once during this time but this was due to problems with his stoma not functioning, and not because of his wound.
Wound manager bags alone were not a successful intervention as they leaked, discouraged Mr George from mobilising and kept the wound bathed in bile. The wound deteriorated rapidly during their use. The large size of the wound also complicated application, as two bags had to be stuck together, resulting in failure of the dressings.
Vacutex had a small but positive effect on the wound. It was easy to apply and encouraged the wound to improve until it reached a stage where the more effective VAC dressing could be used. It was useful in keeping the wound free from contaminant fluids, and most useful as a drainage wick from the wound into an isolating stoma bag, managing to cope well with the large amount of fluid produced. This fluid comprised bile, exudate and faecal fluid.
VAC therapy had a much more successful impact on the wound's regeneration. The argument remains as to whether or not this therapy caused the bowel fistulation, but the effect of a dressing that could keep the bile away from the wound bed was rapid regeneration of tissue.
The psychological effects on Mr George included withdrawal from his normal social and self-care routines, fear of the future, mistrust of unfamiliar members of staff, and dependence on familiar members of staff.
Mr George has commented that he feels the support offered to him by nursing staff and the consultant surgeon - with whom he had built close relationships - was more beneficial to him than a professional counsellor would have been.
The surprising thing is that the turning point for him was not when the wound began to improve but when the parenteral nutrition was discontinued, and he was able to eat. The importance of this as a function of social interaction is often forgotten in a clinical environment.
Use of a multidisciplinary approach and specialists (tissue viability, stoma care nurse, surgical consultant and team, and so on) were a key factor in the care delivered to Mr George. Good relationships and a healthy respect for each of the specialist skills and knowledge of all involved enabled different approaches to be tried to overcome each of the new problems at an early stage.
Daily assessment of the wound and risk assessments of pressure area care helped avoid further complications with skin integrity. A holistic approach to Mr George's care was an integral part of his progress.
There were, however, a few limitations to his care. Practitioners had limited knowledge and skills in relation to some of the specialist equipment used. Some staff were anxious about using VAC and Mr George worried when staff he did not know needed to deal with the treatment; he only allowed the specialist staff he knew to treat him.
Several important lessons for the staff involved arose out of this complex case study, including:
- The negative impact of wound contaminants, such as bile or faecal fluid, and how they not only can prevent integrity of a wound, but also cause a relatively minor wound to become a major or even life-threatening condition
- The impact of this cascade of terrifying events on the patient, Mr George, and how this altered his perception of his body image
- How rapidly even such a large wound as this one can heal, despite a complex underlying pathology and further complications, if thorough assessment and a close multidisciplinary teamwork approach are adopted.
The patient's name has been changed.
Argenta, L.C., Morykwas, M.J. (1997)Vacuum assisted closure: a new method for wound control and treatment: clinical experience. Annals of Plastic Surgery 38: 6, 563-577.
Black, P.K. (1995)Caring for large wounds and fistulas. Journal of Wound Care 4: 1, 23.
Dyson, M., Young, S.R., Lynch, J.A., Lang, S. (1992)Comparison of the effects of moist and dry conditions on dermal repair. Journal of Investigative Dermatology 6: 729-733.
Falconi, M., Perdozoli, P. (2001)The relevance of gastro-intestinal fistulae in clinical practice: a review. Gut 49: (suppl 4), 2-10.
Goldstein, S.A., Elwyn, D.H. (1989)The effects of injury and sepsis on fuel utilization. Annual Review of Nutrition 9: 445-473.
Greer, S.E., Duthie, E., Cartolano, B. et al. (1999)Techniques for applying subatmospheric pressure dressing to wounds in different regions of anatomy. Journal of Wound Ostomy Continence Nursing 26: 5, 250-253.
Hargreaves, T. (1968)The Liver and Bile Metabolism. Amsterdam: North Holland Publishing Company.
Hartmann-Peterson, R., Walmond, P.S., Berezin, A. et al. (2000)Individual cell motility studied by time-lapse video recording: influence of experimental conditions. Cytometry 40: 4, 260-270.
Mendez-Eastman, S. (1998)Negative pressure wound therapy. Plastic Surgery Nursing 18: 1, 27-29, 33-37.
Miller, M. (1998)Moist wound healing: the evidence. Nursing Times 94: 45, 74-76.
Newell, R. (2000)Body Image and Disfigurement Care. London and New York: Routledge.
Philbeck, T.E.Jr., Whittington, K.E., Millsap, M.H. et al. (1999)The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare Medicare patients. Ostomy Wound Management 45: 1, 41-50.
Price, R. (1996)Assessing altered body image. Journal of Psychiatric and Mental Health Nursing 2: 196-197.
Pro-tex. (2001)Independent report on a UK-wide clinical review assessing performance of the capillary wound dressing, Vacutex, on acute and chronic wounds. Available from: Hampshire, UK: Pro-tex Capillary Dressings.
Thomas, S. (2001)An Introduction to the Use of Vacuum Assisted Closure. Bridgend: Surgical Materials Testing Laboratory.
Voinchet, V., Magalon, G. (1996)Vacuum assisted closure: wound healing by negative pressure. Annual Chirugical Plastic Esthetics 41: 5, 83-589.
Waterlow, J. (1995)A risk assessment card. Nursing Times 81: 48-55.