Mr Z was diagnosed with colon cancer at age 81 and was scheduled to have a colon resection at Hankensack University Medical Center on January 17, 2003. Before surgery, Mr Z was alert and oriented, ambulatory, and completely independent in terms of all his daily living activities. The patient was in relatively good health, but he did have 2 comorbid conditions: type 2 diabetes mellitus, which was controlled with the use of an oral hypoglycemic, and asthma, likely resulting from workplace exposure to asbestos years earlier, which did not require treatment at this time.
Before admission, Mr Z, was 5'9" tall and weighed 180 lb. After surgery, his postoperative course was uneventful until he developed an infection in his abdominal incision. On further examination, an anastomotic leak was discovered and further surgery was necessary. On January 22, 2003, Mr Z's anastomotic leak was repaired and a diverting colostomy was created.
Several days later, an infarct affecting Mr Z's entire abdominal incision line was diagnosed. Eschar was found proximal and distal to the stoma. Because the wound was dry and ostomy management successful, Mr Z was transferred to a subacute facility for rehabilitation and instruction on how to care for his ostomy. The wound then began to drain purulent material, which weakened the seal of the skin barrier. Feces would undermine the pouching system and contaminate the incisional wound. In sum, ostomy management soon became a problem for Mr Z, and on February 20, he was transferred back to the acute setting. Surgical debridement of the eschar was performed in the emergency room, followed by supportive care in the form of IV antibiotics, fluids, nutrition support, glucose management, and wound/ostomy care. The wound soon began to granulate, and after a course of antibiotics and a consultation with the in-house certified wound, ostomy, and continence nurse (CWOCN), it was determined that Mr Z could be sent home.
In collaboration with the physician, the hospital-based CWOCN developed an ostomy/wound management protocol. After thorough cleansing, Mr Z's wound was lightly packed with a calcium alginate. Then a large hydrocolloid cover was placed to prevent fecal contamination and provide a surface for pouching. Finally, a 2-piece pouching system was fashioned. This system lasted 1 to 2 days in the hospital setting.
On March 1, 2003, an eager Mr Z arrived home. At this time, he was ambulatory with a walker and weighed 160 lb. His blood sugars were stable (between 90 and 120), and he did not require oral hypoglycemic medication. His appetite was fair, and he supplemented his daily oral intake with 1-2 cans of Glucerna (Abbott Laboratories. Abbott Park, Ill). Although Mr Z required assistance with transfers and most activities associated with daily living, he was nonetheless happy to be in a comfortable familiar environment. Mr Z's enthusiasm quickly began to wane, however, when ostomy/wound management became a problem.
Even though the pouching system developed in the hospital was easily replicated at home, Mr Z's increasing activity resulted in his pouching system leaking within 24 hours after his arrival home. To compound matters, Medicare's coverage for homecare was intermittent and the costs of the homecare visits and supplies were adding up quickly, adding to the psychologic stress borne by Mr Z and his family. The physical demands on his elderly spouse, Mrs Z, were also proving to be not only physically demanding but also overwhelming; she was constantly disinfecting, doing laundry, and assisting her husband in managing fecal soiling and odor. It was evident that an alternative method of management was needed. Use of negative pressure wound therapy (NPWT) (V.A.C., KCI, San Antonio, Tex) was suggested in an effort to fashion a system that would provide a clean moist wound healing environment, a dry smooth surface on which to secure a pouching system, and a method to contain fecal and wound effluent separately. Indeed, although no literature was found to support this method of NPWT in an abdominal wound with an ostomy, this approach had been used safely and successfully on a previous patient with an ostomy in a dehisced abdominal wound. Mr Z, his physician, and his family agreed to this plan.
On May 3, 2003, NPWT was started. At that time, the wound was irregularly shaped and measured 23 cm long, 10 cm wide, and 4 cm deep. The wound bed was 90% granular, with 10% diffuse yellow slough. The stoma was viable, moderately protruding, and located toward the proximal end of the open full-thickness abdominal wound.
The goals of therapy were explained to Mr and Mrs Z, stressing that the top priorities should be aimed at wound management, containment of the feces, and containment of wound effluent so that the ostomy seal could be effectively maintained. In addition to wound healing, odor control, and preservation of periwound skin, decreasing the frequency of dressing changes was also stressed as an important goal. If all of these could be achieved, it was believed that Mr Z and his spouse would be better equipped to manage an extended recovery at home. Both Mr and Mrs Z were in agreement and were willing to try the new technology.
When the equipment arrived, Mr Z and his spouse were allowed to handle the V.A.C. unit to familiarize themselves with it. They were encouraged to practice the insertion and removal of the canister, which contained the wound effluent. They were also instructed how to navigate the equipment's screen and buttons and were provided tips on "troubleshooting" if and when alarms went off. All of their questions were answered by the CWOCN and reassurances provided. As well, emergency telephone numbers were given in case problems arose after hours.
Now it was time for application of the dressing system. After the wound was irrigated with normal saline, the periwound skin was cleansed and dried thoroughly. Skin barrier film was applied to the periwound skin for protection. Additional protection was also supplied by draping the periwound area to avoid maceration. Next, the black sponge was cut to fit the different sections of the abdominal wound, ensuring a fit that allowed the sponges to communicate so that the negative pressure would benefit all the wounds (Figure 1). This was accomplished by bridging. Before anchoring the sponges with the drape, a thick bead of stoma paste was applied around the stoma. Then strips of drape were positioned around it to seal. Rather than using one big sheet, experience showed that it was easier to apply the drape in smaller pieces and overlap them. At this point, the track pad with connective tubing was positioned over the lower portion of the wound where the larger sponge was located; a secure seal was attained by applying light pressure around the stoma using both hands, as the unit was turned on.
Once the prescribed pressure of 125 mmHg was reached, the pouching system could be fashioned on top of the sponge and drape. Although the stoma was protruding, peristomal irregularities made it necessary to use a convex skin barrier (Center Point Lock convex skin barrier, Hollister, Libertyville, Ill). In addition, use of a strip, paste, and belt were important to maintaining a seal that would last 2 to 3 days (Figure 2).
By the end of the visit, Mr Z and his spouse were able to demonstrate changing of the pouch and replacing the canister. Consequently, nursing visit frequency was decreased to 3 times a week. The entire setup was refitted every Monday, Wednesday, and Friday. It should be mentioned here that a newer model for delivering NPWT (V.A.C. Freedom, KCI, San Antonio Tex) was used. This model is compact, portable, and lightweight (3 lb), which allows patients to increase their activity as they heal. Two staff nurses at the home health agency were also taught the procedure so that coverage was always available. The staff nurses soon became quite proficient and were able to redress the wound and stoma in less than an hour.
According to agency policy, wounds are assessed at each dressing change and measured weekly. Mr Z's wound responded well to the negative pressure therapy. Approximately 2 months after the start of therapy, his wounds were dramatically smaller. So much healing had occurred that 2 separate well-defined areas were present. On May 9, 2003, the proximal wound measured 1.5 x 1 cm and the distal one measured 5 x 2.5 cm. Both wounds were superficial in depth (Figure 3).
Progress continued, and on June 4, the proximal wound was completely healed and the distal wound measured 4 x 2 cm (Figure 4). In addition to wound healing, the patient's overall physical condition had improved substantially. Mr Z was now able to walk without assistance and was even able to prepare light meals. Mr Z's increasing independence lifted the burden of care off his wife's shoulders, allowing her more time for rest and relaxation. Both also stated that they felt encouraged, because they could see for themselves how well the wound was healing at each dressing change.
On June 30, the remaining wound was almost completely epithelialized. A thin irregular opening of 3 x 1 cm was visible. The surgeon was notified, and after an office visit, Mr Z was scheduled for surgery. Just before July 4, 2003, Mr Z went to the operating room to undergo an operation to close the ostomy.
Negative pressure therapy proved to be an effective means of managing Mr Z's colostomy in the center of a full-thickness abdominal wound in the homecare setting. During the 4 months that it took to achieve wound closure, the nursing staff was able to effectively contain the ostomy effluent. All wound and ostomy management goals were met, enabling Mr Z and his spouse to enjoy the comforts of their home and family.
ACKNOWLEDGMENTS
The author thanks C. Fahey, RN, and M. Anthony, RN, for their photographic assistance; E. Conway, RN (Team Leader), and M. Seeley, RN (Primary RN), for their clinical skills; and R. Ryan, RN, for her computer skills.