A 54-year-old Hispanic female presented for a second gastric bypass surgery. At 5-foot, 1-inch and 289 pounds, she was more than twice her ideal weight. Significant history included hypertension, gastroesophageal reflux, nocturnal oxygen desaturation requiring home oxygen, degenerative joint disease, venous hypertension with ulceration, and degenerative joint disease. She denied smoking and drinking and did not have diabetes.
The patient had undergone gastric bypass surgery in 1994 via the Roux-en-Y procedure to reduce her weight after years of battling obesity. Her bypass was effective for 3 to 4 years. Then she began gaining weight again. Because of her decreasing ability to ambulate and failing self-esteem, she initiated another evaluation for a redo gastric bypass in early 2001.
An upper gastrointestinal (GI) series revealed a gastric fistula. This indicated the breakdown of her staple line, allowing an increased capacity for intake. After psychological evaluation and preoperative assessment, she underwent a second Roux-en-Y, a partial gastrectomy, a small bowel resection, and 2 enteroenterostomies on July 13, 2001. Her laboratory results at the time of admission reported a low albumin level of 2 mg/dL and hemoglobin and hematocrit levels of 11 and 33, respectively.
Postoperatively, the patient was transferred to the intensive care unit (ICU). An epidural catheter provided a route for morphine administration for pain relief. Two abdominal drains were inserted to prevent fluid collection in the abdominal tissue, and a nasogastric tube was utilized to minimize gastric contents to protect the gastric suture line. The patient retained 15 L of resuscitation fluids, adding more weight and workload to her heart, lungs, and kidneys. Patients with edematous tissue risk having complications of incisional breakdown, anastomotic leaks, and a prolonged ileus. 1
The following describes the postoperative condition of the patient's lungs, GI tract nutritional status, and abdominal wound. The events are reported by the intrinsic factors that impede wound healing in the obese patient, rather than chronologically, to better associate the cause and effect of each complication. As the physiologic insults to each organ system accumulated, the outcome for this patient became worrisome.
Postoperatively, the patient was extubated in the recovery room and placed on 100% oxygen via face mask. Obese people are chronically hypoxic because of hypoventilation due to restricted lung capacity. 2 This patient was known to require home oxygen therapy at night. On July 15, she became hypotensive (blood pressure 75/34 mm Hg), with shortness of breath, which raised concerns of a myocardial infarction (MI). The MI was ruled out, but a chest X-ray demonstrated bibasilar atelectasis.
The patient emergently returned to surgery on July 25 for repair of an incarcerated bowel that threatened the viability of the gut. She was kept heavily sedated on the ventilator to maximize oxygenation with minimal effort and to prevent straining of the suture lines. She developed pleural edema and worsening bibasilar air space on July 28 and remained on the ventilator until August 8. One day later she developed severe tachycardia, tachypnea, and a dramatic drop in her oxygen saturation levels. Pneumonia was confirmed, and she was once again placed on the ventilator. A tracheostomy was performed on August 17 to reduce complications from long-term endotracheal intubation. Chest X-rays continued to identify pneumonia, and attempts to wean her from the ventilator failed. Oxygenation to support wound healing, angiogenesis, and collagen formation remained compromised throughout the first 11/2 months after the original surgery.
Increased intra-abdominal pressure
The first sign of potential wound dehiscence appeared on July 17 with the leakage of a small amount of serous fluid at the distal end of the incision. Cooper 3 described serous drainage from the wound bed that occurs between the 5th and the 12th day postoperatively as a classic sign of pending dehiscence. On the 5th postoperative day (July 18), the patient complained of nausea and experienced several episodes of vomiting, which caused increased intra-abdominal pressure against the gastric and abdominal suture lines. An upper GI series indicated slow passage of contrast material. A computerized tomography (CT) scan confirmed an ileus, which added back-flow pressure to the suture lines; no bowel dilation or leaks were found.
On July 21, wound dehiscence was declared secondary to an abdominal abscess. The distal sutures were removed from the incision and 30 cm 3 of purulent drainage was collected. Two days later, the wound, ostomy, and continence nurse was called to assess the wound because greenish-yellow output had become part of the exudate. A small bowel fistula was evident.
On July 23, a repeat CT scan indicated possible incarceration of the bowel within a large ventral hernia, an additional cause of increased bowel pressure. Surgery was performed to relieve it the following day. The bowel was found kinked and twisted, with necrosis and perforation. The incision (30 cm wide and 25 cm long) was left open to heal by secondary intention. The episodes of vomiting, the ileus, and the abscess were paramount issues in affecting the integrity of the abdominal and bowel suture lines.
Stress and pain management
Pain is a stressor to the healing process. According to Chang et al, 4 the body's reaction to stress causes vasoconstriction from the action of epinephrine, leading to decreased blood perfusion to all tissues including the wound. In an obese person, circulation is already compromised because adipose tissue is poorly vascularized. 2,5-7 When pain control was inadequate via her epidural catheter, the patient become agitated and hypertensive (190/100 mm Hg) due to vasoconstriction. Minimizing anxiety by anticipating her discomfort and medicating her appropriately were imperative to prevent the stress response. After the epidural was discontinued, she received a patient-controlled analgesia pump. This gave her the ability to manage her own pain, which allayed fears of waiting for pain medication to be delivered. The stress reaction decreased blood flow to the wound sites and negatively affected optimal healing.
Seepage of serous drainage appearing between the distal sutures on July 17 was the first sign of a wound complication. In obese patients, seromas and hematomas develop easily in the dead space of the fatty tissue, which is poorly perfused. 2,5,8 Despite placement of Jackson-Pratt drains during the initial and subsequent surgeries, this patient developed a seroma in the subcutaneous fatty tissue. On July 18, the lower sutures were removed so that the seroma could drain.
On July 25, the patient was returned to surgery for exploration of the surgical site. An abscess was located and intubated with a catheter to drain the pocket. The abscess fluid cultured Escherichia coli and the health care provider ordered the antibiotics piperacillin (Zosyn) and enoxaparin sodium (Lovenox). A bowel perforation and contamination caused peritonitis. Because of the infection and fistula output, the wound was left open to heal by secondary intention.
Over the next 2 months this patient had a Candida albicans infection and was treated with amphotericin B. Pseudomonas aeruginosa was found in the sputum and urine. A second abdominal abscess was identified in August and was treated with gentamicin sulfate (Garamycin). A methicillin resistant Staphylococcus aureus was detected at the central line insertion site on August 25 and the patient was placed in isolation.
During October, November, and December, Pseudomonas continued to be present in the urine and sputum. S aureus was still growing in the sputum and blood cultures just before discharge in December. The burden of infection compromised oxygenation and circulation early in the recovery period, causing necrosis of the bowel and fistula formation, failure of initial skin grafts to take, and wound dehiscence.
Protein provides the building blocks for tissue repair. 1 On admission, the patient had a low albumin of 2 g/dL (normal 3.5 to 5 g/dL). Albumin reflects the patient's nutritional status about 20 days prior to the blood draw. 1 By the second surgery on July 25, her albumin had dropped to 1.2 g/dL, depicting the utilization of proteins required during traumatic events to the body. 1 She had been NPO for 2 weeks after surgery and so tube feedings were attempted. Because of the ileus, increased fistula output, and leakage around the gastric tube, feedings were stopped and total parenteral nutrition was begun. A pre-albumin level was obtained, which provided a more current nutritional picture. 1 It measured a low 11.1 (normal 18 to 45).
The third surgery on August 11 was intended to close the fistula and apply skin grafts to the abdominal wound. Tube feedings were resumed on August 13, but were discontinued because of fistula recurrence. Progress to heal these body insults was interrupted by each surgery because the increased nutritional demands for healing were greater than her body's resources to build tissue. The patient was in a state of carbohydrate and protein malnutrition.
Initiatives for wound management
The patient's immediate postoperative plan of care progressed on schedule. She was out of bed with 2 abdominal binders in place on July 14. She started a gastric I diet. Then the difficulties began. The fecal material found in the exudate halted her oral intake. Temperature elevations caused excessive weakness, leaving her unable to perform daily personal care. Surgery performed on July 25 left a large open abdominal wound to heal by secondary intention.
The wound was managed with gauze impregnated with petrolatum to keep the wound bed moist and protected from the fistula effluent. The enterocutaneous small bowel fistula was located above the bottom rim of the wound at 6 o'clock. A large Malecot catheter was swaddled in moist saline gauze and placed beneath the active fistula to draw the drainage out of the wound. The wound area was much too large to pouch with a wound manager, and so the entire site was packed with moist normal saline Kerlix (Tyco Healthcare/Kendall, Mansfield, MA) and covered with Ioban (3M Health Care, St. Paul, MN), a larger, thicker transparent film dressing found in the operating room. The periwound skin was protected from this adhesive dressing by applying a hydrocolloid platform around the entire wound margin. This sealed system was connected to low wall suction.
After 3 attempts, skin grafting succeeded in covering the majority of the wound, allowing the use of a pouching system to collect the output (Figures 1 and 4). Skin Bond Cement (Smith & Nephew, Largo, FL) was applied to the skin grafted area of the abdomen and the backs of the wafer pieces. Containment of the output was complicated by the narrow gully between the stoma at 6 o'clock and the lower skin margin. Coloplast Strip Paste (Coloplast Corp., Marietta, GA) was used as a filler along the rim. To enhance the wafer seal, Hollister SoftFlex skin barrier rings (Hollister Incorporated, Libertyville, IL) were used to fill the gap below the fistula and the rim of the lower wound margin until it was at the level of the abdominal skin (Figure 2). A Durahesive wafer (ConvaTec, Skillman, NJ) with a convex insert was used to contain the main fistula (Figure 3).
|Figure 1. SKIN GRAFTSSkin grafts cover the wound surface. A gully is seen at 6 o'clock below the fistula. A small fistula is seen in the upper center of the wound.|
|Figure 2. SITE PREPARATIONThe site is prepared with Skin Bond Cement, Strip Paste (to fill the ridge), and Soft Flex barrier rings (to fill the gully). The barrier rings were cut to fit and layered until level with the skin.|
|Figure 3. FISTULA CONTAINEDA Durahesive wafer with a convex insert and urostomy pouch was used to contain the main fistula.|
|Figure 4. FISTULA POUCHEDThe upper fistula was pouched with Stomahesive flexible wafer and urostomy pouch to prevent undermining of the lower wafer.|
The mucous fistula above and central of the bowel fistula produced copious amounts of thin, mucus-like output. It was also pouched to prevent undermining of the larger fistula's wafer (Figure 4). After placement of pouches, the wafer margins around the main fistula were extended with Stomahesive wafer strips (ConvaTec, Skillman, NJ) to ensure contact to healthy skin for stability.
Wearing time for the system was unpredictable and ranged from 2 to 7 days. Her husband was instructed in many problem-solving tricks to maintain the seal. He helped maintain the pouching system at the rehabilitation center and at home. He was a wonderful source of encouragement to his wife and his ability to manage the collection system gave her confidence in going to the rehabilitation center.
After 52 days in ICU and 168 days (more that 5 months) in the hospital, this patient was sent to a rehabilitation center. When pouching failures became more frequent after the wound margins became less pronounced, the husband was given a Hollister Drainable Fecal Incontinent Collector (Hollister Incorporated, Libertyville, IL) to serve as the fistula pouch. The large pouch capacity, along with a drain spout that was attached to a bedside drainage bag at nighttime, was an improvement.
Following 3 months of rehabilitation, the patient went home. She was seen in the enterostomal therapy clinic for special supply acquisition. At that time, she was increasing her activities at home, was well dressed, and had been to the hair salon. Her attitude about recovery continued to be optimistic.
Three weeks after her discharge, however, she developed lower back pain and fever and was readmitted to the hospital. Within 8 hours, she was found to have a spinal abscess that quickly caused lower extremity paralysis. She was placed on a bariatric bed frame and a rotating pressure relief mattress to assist in respiratory toileting. An increasing temperature and respiratory distress sent her to the ICU. She developed sepsis and respiratory failure, and she died of her complication only 10 months after her second elective bypass surgery.