OCTOBER 2004 •••••••••••••• Bariatric Skin & Care

CLINICAL MANAGEMENT extra : Impediment to Postsurgical

CME ce CATEGORY 1 ANCC/AACN 1 Hour 2.0 Contact Hours

Joyce A. Wilson, MSN, RN, CWOCN • Wound, Ostomy, Continence Consultant • Department of General Surgery • Wilford Hall Medical Center • Lackland Air Force Base • San Antonio, TX Jan J. Clark, BSN, RN, CWOCN • Wound, Ostomy, Continence Consultant • Department of General Surgery • Wilford Hall Medical Center • Lackland Air Force Base • San Antonio, TX The authors have disclosed that they have no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

PURPOSE To provide physicians and nurses with an overview of the impact of obesity on postoperative wound healing and how preplanning protocols can minimize skin and wound care problems in this patient population. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in reducing skin and wound care problems in their patients who are obese. OBJECTIVES After reading the article and taking the test, the participant will be able to: 1. Identify obesity-related changes in body systems and how these impede wound healing. 2. Identify complications of postoperative wound healing in obese patients and the assessments and intervention strategies that can reduce these complications. 3. Identify skin and wound care considerations for obese patients and the role of preplanning protocols in avoiding problems. ADV SKIN WOUND CARE 2004;17:426-35; QUIZ 442-3.

n 2000, 19.8% of adults in the United States were identified as son’s weight and height to gauge total body fat. BMI is calculated obese, a 61% increase since 1991.1 By the year 2000, a total of by dividing weight by height (squared). Obesity is indicated by a 38.8 million American adults met the classification of obesity, BMI of 30 or more; a BMI between 25 and 29.9 indicates that the I 1 2 according to the Centers for Disease Control and Prevention. person is overweight. Obesity and being overweight are different and are determined Providing health care for a population that is obese requires spe- by body mass index (BMI) scores. BMI is one of the most accurate cial equipment, skilled balancing of nutritional needs, professional ways to determine whether an adult is overweight. BMI uses a per- psychological skills, and expert knowledge of the physiologic

Adapted from Wilson JA, Clark JJ. Obesity: impediment to wound healing. Crit Care Nurs Q 2003;26:119-32.

ADVANCES IN SKIN & WOUND CARE • VOL.17 NO. 8 426 WWW.WOUNDCAREJOURNAL.COM demands of body systems. Obese persons regularly undergo and healthy subjects can usually accomplish that without signifi- surgery, experience trauma, and often developce chronic . A cant clinical interventions. Collagen synthesis requires oxygen, and major challenge for health care personnel caring for these individ- when oxygen at the tissue level is deficient, leukocyte and phago- uals after surgery is to achieve wound healing without complica- cytic activities are impeded.6 The processes of proliferation and tions, such as seroma, hematoma, , and wound separa- migration of cells, which eventually epithelialize a wound from the tion. Providing wound care for an obese patient requires an under- wound margins inward, are also oxygen-dependent. However, sig- standing of the intrinsic changes in body systems induced by obe- nificant hypoxia serves as a stimulating factor for angiogenesis, sity and how these changes impede wound healing. which initiates the process that builds granulating tissue. Wound healing factors are produced essentially by hypoxic conditions. PHYSIOLOGIC REQUIREMENTS These factors stimulate the actual cellular repair processes, which are oxygen-dependent.7 Cardiovascular In obese patients, the workload of the heart is frequently Nutrients increased by the strain of supplying oxygenated blood to all tis- All phases of wound healing depend on adequate supplies of sue. Wound healing depends on the circulatory system to pro- protein, carbohydrates, vitamins, and minerals. Proteins are the vide oxygen and nutrients to tissue. Ischemia, the deficiency of building blocks of cells. Wounds with exudate can lose protein, blood to tissue, may lead to tissue necrosis. Ischemia can be lowering albumin levels. Carbohydrates provide a source of caused by vessel constriction or obstruction, external pressure, cellular energy for the wound healing process. Vitamin C is or the failure of the heart to pump adequately. Adipose tissue essential to collagen synthesis. Vitamin A is required for an is poorly vascularized and known to be less tolerant of adequate inflammatory response and has been used to counter ischemia and hypoxia than the epidermis.3 the catabolic effect that glucorticosteroids exert on wound healing. Given its role in rapid tissue growth and protein syn- Respiratory thesis, zinc is thought to be involved in wound healing as well.8 Delivery of oxygen to cells in the body depends on lung ventilation, diffusion of oxygen from the alveoli into capillary blood, perfusion WOUND CLASSIFICIATON of systemic capillaries with oxygenated blood, and diffusion of oxy- Appropriate classification is a useful mechanism in under- gen from systemic capillaries into the cells.4 Hyperventilation is the standing and healing wounds (Table 1). The etiology of acute typical respiratory pattern of many obese patients5; the diaphragm wounds is either traumatic or iatrogenic. Examples of iatrogenic is unable to fully descend because of abdominal adipose tissue. wounds are incisions or grafts. Traumatic wounds include Chest expansion is impaired, and the resulting decreases in vital burns, stab or gunshot wounds, or other resulting from capacity and tidal function compromise tissue oxygenation, trauma. Acute wounds are usually a result of an that dis- adversely affecting wound healing. rupts blood vessels and initiates clotting, which stimulates the Fibroblasts need an oxygen pressure greater than 15 mm Hg for release of growth factors to initiate the wound healing cascade. adequate collagen formation. In patients who are not obese, the Chronic wounds are wounds with delayed healing, such as partial pressure of arterial oxygen (PaO2) has been found to be 60 pressure and vascular ulcers. Chronic wounds may result from to 90 mm Hg in the wound and near 0 mm Hg at the wound pathologic disease processes. Necrotic tissue, bacterial contam- 5 edges. From this, it would be reasonable to assume that the PaO2 ination, and local tissue ischemia are common in chronic of a wound in an obese patient would be lower due to avasculari- wounds. An acute wound that does not proceed to heal in an ty of adipose tissue.5 orderly manner, such as a dehisced incision, may become a Oxygen, like moisture, requires a balancing act to heal wounds, .

WWW.WOUNDCAREJOURNAL.COM 427 ADVANCES IN SKIN & WOUND CARE • OCTOBER 2004 oxygen.12,14 Outcomes from different suturing techniques have Table 1. been studied in several prospective randomized trials. A con- WOUND CLASSIFICATION tinuous monofilament fascial closure technique, as opposed to ACUTE WOUNDS an interrupted technique, improves wound healing in morbid- Iatrogenic ly obese patients undergoing gastric operations.12,15 • Incisions • IV sites (puncture) Hematoma and seroma formation • Split skin removal (donor sites) Collection of pooled blood or serous fluid is an additional risk • Radiation burns for obese patients. The formation of hematomas and seromas • Graft sites Traumatic creates internal pressure and adds tension on sutured inci- • Stab wound sions. A review of the literature suggests that obese patients are • Bites more prone to hematoma formation, causing healing delays by • Burns reducing tissue oxygenation.9 A study on the effect of obesity • Lacerations on flap and donor-site complications in free transverse rectus • Degloving abdominis myocutaneous (TRAM) flap for breast reconstruc- • Amputations tion found that overweight patients had a significantly higher CHRONIC WOUNDS incidence of total flap loss, hematoma, seroma, and mastecto- • Pressure ulcers my skin flap necrosis.16 In addition, more donor-site , • Arterial ulcers donor-site seromas, and hernias were found in obese patients • Diabetic neuropathic ulcers than in normal-weight patients.16 Obese women undergoing • Venous ulcers • Ulcerated or fungating tumors cesarean delivery are considered to be difficult surgery cases • Nonhealing incisions because of the physical exertion associated with increased efforts at retraction and potential complications.The large pan- COMPLICATIONS nus predisposes patients to fluid accumulation, creating an environment conducive to seroma formation, infection, and 17 Infection wound edge separation or dehiscence.

The literature is replete with references to the higher incidence Pressure ulcers of infection among obese patients.5,9-12 Avascularity effectively With decreased vascularity in adipose tissue, the obese patient decreases the ability to combat infection: insufficient oxygen is at high risk for pressure ulcers. The difficulty or inability of impedes neutrophils from phagocytizing .5 Periopera- obese patients to reposition themselves or to help clinicians do tive complications were found to be significantly higher in so is a precursor to pressure-related injuries. Turning and repo- morbidly obese patients undergoing total knee arthroplasty.13 sitioning is a basic preventive intervention to reduce and It may be assumed that these complications can be easily relieve pressure from body tissue. Adipose tissue does not translated to other surgeries as well. Reasons for complications equate to padding. Two or more clinicians are often needed to in morbidly obese patients can be attributed to technical diffi- turn and reposition morbidly obese patients. Unfortunately, culties in operating on obese patients; operations taking more this intervention is risky on some hospital bed frames. Obese time, thus increasing the chances of contamination; more trau- patients have fears that hospital equipment will not safely ma; and even necrosis of the abdominal wall because of more accommodate their size, body configuration, or weight.18 As a forceful retraction during surgery. Suturing into the fat layer or result, they are frequently afraid to be repositioned. The imple- using 2 subcutaneous drains were investigated in the mid- mentation of bariatric beds resolves a safety/risk issue in addi- 1980s, but neither showed an advantage or reduced incidence tion to calming patient fears. Low-air-loss surfaces for bariatric of wound infections in obese patients.9 beds are an option to help reduce pressure. Moisture and incontinence are other risk factors predispos- Dehiscence ing patients to pressure ulcers. Skin folds on obese patients Explanations for the frequency of dehisced incisions among harbor microorganisms that thrive in moist areas and con- morbidly obese patients include increased tension on the fas- tribute to breakdown. Friction caused by skin on skin invites cial edges at the time of wound closure, thus increasing tissue ulceration. Edema caused by excessive fluid resuscitation may pressure and reducing microperfusion and the availability of be difficult to assess in an obese patient. This condition can

ADVANCES IN SKIN & WOUND CARE • VOL.17 NO. 8 428 WWW.WOUNDCAREJOURNAL.COM Figures 1-3. OBESE PATIENT WITH PRESSURE ULCERS

Skin-on-skin pressure from massive edema caused this full-thickness wound (left), a necrotic across the posterior waistline of an obese trauma patient. The same patient had a pressure ulcer covered with eschar on the right buttock (middle). The wound has been scored to allow penetration of a wound gel to initiate autolytic debridement. Following surgical debridement, 2 connecting Stage IV pressure ulcers with a deep cavity evolved. The photograph at right depicts improvement after 10 days of treatment with negative pres- sure wound therapy (V.A.C.; KCI, San Antonio, TX).

exacerbate the problem of pressure caused by skin on skin leukocytes are trapped due to sluggish blood flow, causing the (Figures 1 to 3). capillaries to become plugged and resulting in tissue Goals for treatment of obese patients include management ischemia.21 Falanga and Eaglstein have suggested that leaked of wound drainage, prevention or resolution of infections, macromolecules trap growth factors and matrix material, ren- healing of pressure ulcers, protection of periwound skin, and dering them unavailable to maintain normal tissue and repair enhancement of the patient’s comfort.18 wounded tissue.22 Management of venous ulcers includes compression wrap- Venous ulcers ping to reduce edema and local wound care to heal ulcers. Obesity can induce venous hypertension.19 Venous hyperten- However, the most important issue to address is the underly- sion results when incompetent valves in the lower extremities ing disease process and resulting comorbidities. prevent venous return, causing blood to pool and thus increas- ing the venous pressure. The failure of venous pressure to fall Stress response as the blood flows from the superficial veins to the deep veins Pain, anxiety, hypovolemia, and hypothermia trigger the stress creates a climate of venous hypertension.20 response, causing the release of epinephrine, norepinephrine, Obesity that prevents ambulation exacerbates venous hyper- and other catecholamines. This results in peripheral vasocon- tension because the calf muscle is not working to keep the striction, thus decreasing subcutaneous tissue oxygenation. veins pumping the blood out of the leg. Extra girth composed For example, norepinephrine is increased 3-fold in the early of adipose tissue and fluid contributes to venous hypertension postoperative hours, peaking with the patient’s first expression (Figure 4). of pain.23 Adrenocorticotrophic hormones secreted during The cause of leg ulcerations is not as clear in the literature. stress cause a decreased inflammatory response, the second Three theories are prominent: the fibrin cuff theory, the white phase of wound healing.21 Deficits in circulatory fluid volume blood cell trapping theory, and the trapping theory.19,20 The (hypovolemia) and decreases in venous return result in fibrin cuff theory originally proposed that fibrinogen leaked reduced cardiac output and systemic hypotension, further into dermal tissue; the fibrinogen hardened around capillaries, compromising tissue perfusion. Hypothermia is also common resulting in a barrier to oxygen and nutrients, causing tissue immediately postoperatively, causing increased oxygen death and ulceration.21 More recent studies, however, have demands and raising metabolism. shown that fibrin cuffs do not disturb transcutaneous oxygen levels and that venous ulcers can heal in the presence of fibrin Constipation cuffs.20 The white blood cell trapping theory suggests that Pain-relieving narcotics and immobility can cause constipation

WWW.WOUNDCAREJOURNAL.COM 429 ADVANCES IN SKIN & WOUND CARE • OCTOBER 2004 include skin discoloration at the incision site and vitals signs Figure 4. consistent with blood loss.5 PATIENT WITH VENOUS HYPERTENSION This morbidly obese male patient’s abdominal girth contributes to Nausea resistance to return of venous blood flow. Treatment of his multi- Assess for nausea if the patient has an abdominal incision— ple venous ulcers includes bilateral Unna’s boots. abdominal wounds in obese patients have excess tension due to adipose tissue and edema. Vomiting can add intra-abdomi- nal pressure at the incisional area. The patient may require a nasogastric tube or antiemetics, or he or she may need to be kept NPO until the nausea and vomiting subside.

Respiratory function Assess respiratory function and encourage use of inspiratory spirometers. Slow, deep breaths can help increase oxygen lev- els.Vigorous coughing can add intrathoracic pressure and more stress on the abdominal incision. Provide pillows to splint inci- sions when patients do cough.

Dressings Binders are helpful with abdominal incisions. Binders should in any postoperative patient. Straining causes intra-abdominal be released slowly and fastened gently. Abruptly ripping away pressure, which is known to disrupt wounds and cause dehis- tape over incisions can separate approximated edges and cause cence. Using stool softeners can prevent some problems. stripping damage to the skin. Use the press/lift technique of lifting tape with one hand while gently pressing the fingers of ASSESSMENT AND INTERVENTION the other hand on the skin and closely following the tape. Wet, soiled dressings should be removed. They indicate a Equipment draining and possibly dehisced wound, and they can be irritat- Initial assessment of an obese patient should include an inven- ing to the skin. Record the condition of the incisional wound, tory of special equipment needed to eliminate risk of injury to including the presence or absence of edema, induration, color, the patient and staff, such as: and drainage. It is important to note the approximation of • a bed wide enough for the patient to turn independently wound edges, or lack of it, and where separation is occurring. • a walker to support the weight for the first few postoperative days, if the patient is undergoing surgery Drains • an overhead trapeze to help the patient reposition himself or Closed wound suction devices, such as the Jackson-Pratt drain, herself should be checked frequently for proper functioning. The bulb • lifts for moving the patient safely is compressed to create negative pressure required to move air • a bedside commode.24 and secretions so that seromas or hematomas will not devel- It is important to convey to the patient that the clinician is op.5 Record amounts of drainage emptied from them and the skilled and knowledgeable in the use of special equipment; nature of the drainage. many obese patients fear injury to themselves or to their care- givers.18 Nutrition In addition to equipment, assess the need for and obtain any For wounds to heal, a patient must be in a state of positive special supplies, such as extra wound care dressings and nitrogen balance. Nitrogen balance is defined as the difference special-sized gowns.This will ensure that all patient care needs between nitrogen intake and nitrogen excretion. When a are met in an adequate and prompt manner. patient’s nitrogen intake exceeds his or her nitrogen excretion, the resultant “positive”nitrogen balance suggests the availabil- Incisions ity of protein for repair of nutritional deficits.8 Serum albumin Postoperatively, assess incision sites. Hematoma formation can is the major protein synthesized by the liver. It maintains plas- be caused by inadequate hemostasis. Signs and symptoms ma oncotic pressure and delivers metabolites, enzymes, drugs,

ADVANCES IN SKIN & WOUND CARE • VOL.17 NO. 8 430 WWW.WOUNDCAREJOURNAL.COM and hormones in the bloodstream. Albumin facilitates wound Obese patients present specific challenges to care. If clini- healing. During trauma, albumin synthesis decreases and uti- cians are knowledgeable about obese patients’ risks, they are lization of albumin increases at wound sites.8 Low serum albu- more able to intervene to eliminate or reduce potential prob- min values are an indicator of impaired wound healing. Any lems. Understanding basic wound care and the assessment obese patient should have a nutritional consult and discharge process is a precursor to identifying the special physiologic planning should include a follow-up for nutritional counseling. responses in postsurgical patients who are obese. ●

Pain REFERENCES Pain assessment and intervention are paramount to successful 1. Centers for Disease Control and Prevention. 1991-2001 prevalence of obesity among U.S. adults, by characteristics. Available at http://www.cdc.gov/nccdphp/dnpa/obesity/ recovery. One study found that obese patients given epidural trends/prev_char.htm; accessed August 3, 2004. morphine were more able to sit, stand, ambulate, and tolerate 2. American Obesity Association. What is obesity? Available at http://www.obesity.org/ more vigorous physiotherapy postoperatively than obese subs/fastfacts/obesity_what2.shtml; accessed August 3, 2004. 3. Maklebust J, Sieggreen MY. Pressure Ulcers: Guidelines for Prevention and Nursing patients who received intramuscular morphine. There were Management, 2nd ed. Springhouse, PA: Springhouse Corporation; 1996. fewer pulmonary complications in the patients receiving 4. Brashers VL, Davey SS. Alterations of pulmonary function. In: McCance KL, Huether SE, epidurals, and wound healing was unimpaired.25 editors. Pathophysiology: The Biologic Basis for Disease in Adults and Children, 3rd ed. St. Louis, MO: Mosby; 1998. p 1158-1200. 5. Groszek DM. Promoting wound healing in the obese patient. AORN J 1982;5:1132-8. Pressure ulcer prevention 6. Jacobson TM. Obesity and the surgical patient: nursing alert. Ostomy Wound Manage The Braden Scale for Predicting Pressure Sore Risk is a cumu- 1994;40(2):56-8, 60-3. 7. Van Meter K. Systemic hyperbaric oxygen therapy as an aid in resolution of selected lative score from 6 subscales to determine risk for development chronic problem wounds. In: Krasner D, Kane D, editors. Chronic Wound Care: A Clinical of pressure ulcers.26 A score is assigned to each subscale: sen- Source Book for Professionals, 2nd ed. Wayne, PA: Health Management Publications Inc.; sory, nutrition, mobility, moisture, activity, and friction and 1997. p 260-75. 8. Pinchofsky-Devin G. Nutritional assessment and intervention. In: Krasner D, Kane D, edi- shear. Some critics claim that this risk assessment tool leaves tors. Chronic Wound Care: A Clinical Source Book for Professionals, 2nd ed. Wayne, PA: out factors, such as circulation, that would make it more bene- Health Management Publications Inc.; 1997. p 73-83. ficial in the critical care setting,27 where most obese postsurgi- 9. Armstrong M. Obesity as an intrinsic factor affecting wound healing. J Wound Care 1998;7:220-1. cal patients are managed. Some have proposed adaptations or 10. Johnson RG, Cohn WE, Thurer RL, McCarthy JR, Sirois CA, Weintraub RM. Cutaneous clo- alternative risk assessment tools more customized to intensive sure after cardiac operations: a controlled, randomized, prospective, comparison of intra- care units (ICUs). One study designed the Heel Pressure Ulcer dermal versus staple closures. Ann Surg 1997;226:606-12. 11. Printen KJ, Paulk SC, Mason EE. Acute postoperative wound complications after gastric Risk Assessment Tool, a 3-part risk assessment/prevention tool surgery for morbid obesity. Am Surg 1975;41:483-5 specifically for patients in ICUs.28 Regardless of what the crit- 12. Derzie AJ, Silvestri F, Liriano E, Benotti P. Wound closure technique and acute wound ics say, the important point is that any risk assessment scale is complications in gastric surgery for morbid obesity: a prospective randomized trial. J Am Coll Surg 2000;191:238-43. intended to identify risks and prompt interventions to reduce 13. Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone those risks (such as using a moisture barrier in skin folds to Joint Surg Am 1998;80:1770-4. prevent friction-induced ulcers). 14. Hopf H, Hunt T, West J, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg 1997;132:997-1004. Turning patients at least every 2 hours—more if indicated by 15. Israelsson LA, Jonsson T. Overweight and healing of midline incisions: the importance of the patient’s condition—is a standard intervention to prevent suture technique. Eur J Surg 1997;163:175-80. pressure ulcers. In the ICU, however, many patients cannot be 16. Chang DW, Wang B, Robb GL, et al. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast turned. Instead, positional changes of legs and arms are bene- Reconstr Surg 2000;105:1640-8. ficial. Heels should always be “floated.”Heel ulcers are the only 17. Houston MC, Raynor BD. Postoperatiave morbidity in the morbidly obese parturient pressure ulcers that are preventable, yet the heels consistently woman: supraumblilical and low transverse abdominal approaches. Am J Obstet Gynecol 2000;182:1033-5. appear in the literature as the second most common site of 18. Murphy K, Gallagher S. Care of an obese patient with a pressure ulcer. J Wound Ostomy pressure ulcers.29,30 Continence Nurs 2001;28:171-6. 19. Davis JM, Crawford PS. Persistent leg ulcers in an obese patient with venous insuffi- ciency and elephantiasis. J Wound Ostomy Continence Nurs 2002;29:55-60. SUMMARY 20. Falanga V. Venous ulceration: assessment, classification and management. In: Krasner D, A team approach, in which goals are mutually established and Kane D, editors. Chronic Wound Care: A Clinical Source Book for Professionals, 2nd ed. the patient is a cooperative participant, is considered to be Wayne, PA: Health Management Publications Inc.; 1997. p 165-171. 21. Doughty DB, Waldrop J, Ramundo J. Lower-extremity ulcers of vascular etiology. In: most effective means of managing an obese patient. A frank, Bryant R, editor. Acute and Chronic Wounds: Nursing Management, 2nd ed. St. Louis, MO: nonjudgmental discussion should be conducted about the Mosby; 2000. p 265-300. effects of obesity on the outcomes of wound healing, as well as 22. Falanga V, Eaglstein WH. The “trap” hypothesis of venous ulceration. Lancet 1993;341:1006-8. therapeutic options. 23. West JM, Gimbel ML. Acute surgical and traumatic wound healing In: Bryant R, editor.

WWW.WOUNDCAREJOURNAL.COM 431 ADVANCES IN SKIN & WOUND CARE • OCTOBER 2004 Acute and Chronic Wounds: Nursing Management, 2nd ed. St. Louis, MO: Mosby; 2000. p tion. Am J Crit Care 1995;4:361-367. 189-96. 28. Blaszczyk J, Majewski M, Sato F. Make a difference: standardize your heel care practice. 24. Gallagher S. : An important tool for treatment and weight loss of the Ostomy Wound Manage 1998;44(5):32-40. obese patient. Xtra-Wise 2001;3(1):3. SIZEWise Rentals, Prairie Village, KS. 29. Carlson EV, Kemp MG, Shott S. Predicting the risk of pressure ulcers in critically ill 25. McCaffery M, Pasero C. Pain: Clinical Manual, 2nd ed. St. Louis, MO: Mosby; 1999. patients. Am J Crit Care 1999;8:262-9. 26. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure 30. Cuddiggan J, Ayello EA, Sussman C, editors. Pressure Ulcers in American: Prevalence, Sore Risk. Nurs Res 1987;36:205-10. Incidence, and Implications for the Future. Reston, VA: National Pressure Ulcer Advisory 27. Jiricka MK, Ryan P, Carvalho MA, Bukvich J. Pressure ulcer risk factors in an ICU popula- Panel; 2001.

CASE REPORT: Complications of Gastric Bypass Surgery

A 54-year-old Hispanic female presented for a second gastric room and placed on 100% oxygen via face mask. Obese peo- bypass surgery. At 5-foot, 1-inch and 289 pounds, she was more ple are chronically hypoxic because of hypoventilation due to than twice her ideal weight. Significant history included hyperten- restricted lung capacity.2 This patient was known to require sion, gastroesophageal reflux, nocturnal oxygen desaturation home oxygen therapy at night. On July 15, she became requiring home oxygen, degenerative joint disease, venous hyper- hypotensive (blood pressure 75/34 mm Hg), with shortness of tension with ulceration, and degenerative joint disease. She breath, which raised concerns of a myocardial infarction (MI). denied and drinking and did not have . The MI was ruled out, but a chest X-ray demonstrated bibasi- The patient had undergone gastric bypass surgery in 1994 lar atelectasis. via the Roux-en-Y procedure to reduce her weight after years of The patient emergently returned to surgery on July 25 for battling obesity. Her bypass was effective for 3 to 4 years. Then repair of an incarcerated bowel that threatened the viability of she began gaining weight again. Because of her decreasing abili- the gut. She was kept heavily sedated on the ventilator to ty to ambulate and failing self-esteem, she initiated another evalu- maximize oxygenation with minimal effort and to prevent ation for a redo gastric bypass in early 2001. straining of the suture lines. She developed pleural edema and An upper gastrointestinal (GI) series revealed a gastric fis- worsening bibasilar air space on July 28 and remained on the tula. This indicated the breakdown of her staple line, allowing ventilator until August 8. One day later she developed severe an increased capacity for intake. After psychological evalua- tachycardia, tachypnea, and a dramatic drop in her oxygen tion and preoperative assessment, she underwent a second saturation levels. Pneumonia was confirmed, and she was Roux-en-Y, a partial gastrectomy, a small bowel resection, and once again placed on the ventilator. A tracheostomy was per- 2 enteroenterostomies on July 13, 2001. Her laboratory results formed on August 17 to reduce complications from long-term at the time of admission reported a low albumin level of endotracheal intubation. Chest X-rays continued to identify 2 mg/dL and hemoglobin and hematocrit levels of 11 and 33, pneumonia, and attempts to wean her from the ventilator respectively. failed. Oxygenation to support wound healing, angiogenesis, Postoperatively, the patient was transferred to the inten- and collagen formation remained compromised throughout the 1 sive care unit (ICU). An epidural catheter provided a route for first 1 ⁄2 months after the original surgery. morphine administration for pain relief. Two abdominal drains were inserted to prevent fluid collection in the abdominal tis- Increased intra-abdominal pressure sue, and a nasogastric tube was utilized to minimize gastric The first sign of potential wound dehiscence appeared on July contents to protect the gastric suture line. The patient retained 17 with the leakage of a small amount of serous fluid at the distal 15 L of resuscitation fluids, adding more weight and workload end of the incision. Cooper3 described serous drainage from the to her heart, lungs, and kidneys. Patients with edematous tis- wound bed that occurs between the 5th and the 12th day post- sue risk having complications of incisional breakdown, anasto- operatively as a classic sign of pending dehiscence. On the 5th motic leaks, and a prolonged ileus.1 postoperative day (July 18), the patient complained of nausea The following describes the postoperative condition of the and experienced several episodes of vomiting, which caused patient’s lungs, GI tract nutritional status, and abdominal wound. increased intra-abdominal pressure against the gastric and The events are reported by the intrinsic factors that impede abdominal suture lines. An upper GI series indicated slow pas- wound healing in the obese patient, rather than chronologically, sage of contrast material. A computerized tomography (CT) scan to better associate the cause and effect of each complication. As confirmed an ileus, which added back-flow pressure to the the physiologic insults to each organ system accumulated, the suture lines; no bowel dilation or leaks were found. outcome for this patient became worrisome. On July 21, wound dehiscence was declared secondary to an abdominal abscess. The distal sutures were removed from the Cardiopulmonary incision and 30 cm 3 of purulent drainage was collected. Two Postoperatively, the patient was extubated in the recovery days later, the wound, ostomy, and continence nurse was called

ADVANCES IN SKIN & WOUND CARE • VOL.17 NO. 8 432 WWW.WOUNDCAREJOURNAL.COM to assess the wound because greenish-yellow output had During October, November, and December, Pseudomonas become part of the exudate. A small bowel fistula was evident. continued to be present in the urine and sputum. S aureus On July 23, a repeat CT scan indicated possible incarcera- was still growing in the sputum and blood cultures just before tion of the bowel within a large ventral hernia, an additional discharge in December. The burden of infection compromised cause of increased bowel pressure. Surgery was performed to oxygenation and circulation early in the recovery period, caus- relieve it the following day. The bowel was found kinked and ing necrosis of the bowel and fistula formation, failure of initial twisted, with necrosis and perforation. The incision (30 cm skin grafts to take, and wound dehiscence. wide and 25 cm long) was left open to heal by secondary intention. The episodes of vomiting, the ileus, and the abscess Nutrition were paramount issues in affecting the integrity of the abdomi- Protein provides the building blocks for tissue repair.1 On nal and bowel suture lines. 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 Stress and pain management about 20 days prior to the blood draw.1 By the second surgery Pain is a stressor to the healing process. According to Chang et al,4 on July 25, her albumin had dropped to 1.2 g/dL, depicting the the body’s reaction to stress causes vasoconstriction from the utilization of proteins required during traumatic events to the 1 action of epinephrine, leading to decreased blood perfusion to all tis- body. She had been NPO for 2 weeks after surgery and so sues including the wound. In an obese person, circulation is already compromised because adipose tissue is poorly vascularized.2,5-7 Figure 1. When pain control was inadequate via her epidural catheter, the SKIN GRAFTS patient become agitated and hypertensive (190/100 mm Hg) due to Skin grafts cover the wound surface. A gully is seen at 6 vasoconstriction. Minimizing anxiety by anticipating her discomfort o’clock below the fistula. A small fistula is seen in the upper and medicating her appropriately were imperative to prevent the center of the wound. stress response. After the epidural was discontinued, she received a patient-controlled analgesia pump. This gave her the ability to man- age 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.

Infection 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 per- fused.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 Figure 2. sutures were removed so that the seroma could drain. SITE PREPARATION On July 25, the patient was returned to surgery for explo- The site is prepared with Skin Bond Cement, Strip Paste (to fill ration of the surgical site. An abscess was located and intu- the ridge), and Soft Flex barrier rings (to fill the gully). The bar- bated with a catheter to drain the pocket. The abscess fluid rier rings were cut to fit and layered until level with the skin. cultured Escherichia coli and the health care provider ordered the 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 abdom- inal abscess was identified in August and was treated with gen- tamicin 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.

WWW.WOUNDCAREJOURNAL.COM 433 ADVANCES IN SKIN & WOUND CARE • OCTOBER 2004 CASE REPORT: Complications of Gastric Bypass Surgery (Continued)

tube feedings were attempted. Because of the ileus, increased Initiatives for wound management fistula output, and leakage around the gastric tube, feedings The patient’s immediate postoperative plan of care progressed were stopped and total parenteral nutrition was begun. A pre- on schedule. She was out of bed with 2 abdominal binders in place on July 14. She started a gastric I diet. Then the difficul- Figure 3. ties began. The fecal material found in the exudate halted her FISTULA CONTAINED oral intake. Temperature elevations caused excessive weak- ness, leaving her unable to perform daily personal care. A Durahesive wafer with a convex insert and urostomy pouch Surgery performed on July 25 left a large open abdominal was used to contain the main fistula. 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 cov- ered with Ioban (3M Health Care, St. Paul, MN), a larger, thicker transparent film found in the operating room. The peri- wound skin was protected from this adhesive dressing by apply- ing a hydrocolloid platform around the entire wound margin. This Figure 4. sealed system was connected to low wall suction. FISTULA POUCHED After 3 attempts, skin grafting succeeded in covering the majority of the wound, allowing the use of a pouching system The upper fistula was pouched with Stomahesive flexible to collect the output (Figures 1 and 4). Skin Bond Cement wafer and urostomy pouch to prevent undermining of the (Smith & Nephew, Largo, FL) was applied to the skin grafted lower wafer. 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 mar- gin. 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). The mucous fistula above and central of the bowel fistula pro- duced copious amounts of thin, mucus-like output. It was also pouched to prevent undermining of the larger fistula’s wafer (Figure albumin level was obtained, which provided a more current 4). After placement of pouches, the wafer margins around the main nutritional picture.1 It measured a low 11.1 (normal 18 to 45). fistula were extended with Stomahesive wafer strips (ConvaTec, The third surgery on August 11 was intended to close the Skillman, NJ) to ensure contact to healthy skin for stability. fistula and apply skin grafts to the abdominal wound. Tube Wearing time for the system was unpredictable and ranged feedings were resumed on August 13, but were discontinued from 2 to 7 days. Her husband was instructed in many problem- because of fistula recurrence. Progress to heal these body solving tricks to maintain the seal. He helped maintain the pouching insults was interrupted by each surgery because the increased system at the rehabilitation center and at home. He was a wonder- nutritional demands for healing were greater than her body’s ful source of encouragement to his wife and his ability to manage resources to build tissue. The patient was in a state of carbo- the collection system gave her confidence in going to the rehabilita- hydrate and protein malnutrition. tion center.

ADVANCES IN SKIN & WOUND CARE • VOL.17 NO. 8 434 WWW.WOUNDCAREJOURNAL.COM Summary sent her to the ICU. She developed sepsis and respiratory failure, After 52 days in ICU and 168 days (more that 5 months) in the hos- and she died of her complication only 10 months after her second pital, this patient was sent to a rehabilitation center. When pouching elective bypass surgery. ● failures became more frequent after the wound margins became less pronounced, the husband was given a Hollister Drainable References Fecal Incontinent Collector (Hollister Incorporated, Libertyville, IL) to 1. Pinchofsky-Devin G. Nutritional assessment and intervention. In: Krasner D, Kane D, serve as the fistula pouch. The large pouch capacity, along with a editors. Chronic Wound Care: A Clinical Source Book for Professionals, 2nd ed. Wayne, drain spout that was attached to a bedside drainage bag at night- PA:Health Management Publications Inc.; 1997. p 73-83. 2. Groszek DM. Promoting wound healing in the obese patient. AORN J 1982;5:1132-8. time, was an improvement. 3. Cooper D. Wound assessment and evaluation of healing. In: Bryant R, editor. Acute and Following 3 months of rehabilitation, the patient went home. Chronic Wounds: Nursing Management. St. Louis, MO: Mosby Year Book; 1992. p 69-90 She was seen in the enterostomal therapy clinic for special supply 4. Chang N, Goodson W, Gottrup F, Hunt T. Direct measurement of wound and tissue oxy- acquisition. At that time, she was increasing her activities at home, gen tension in postoperative patients. Ann Surg 1983;197:470-8. was well dressed, and had been to the hair salon. Her attitude 5. Armstrong M. Obesity as an intrinsic factor affecting wound healing. J Wound Care 1998;7:220-1. about recovery continued to be optimistic. 6. Johnson RG, Cohn WE, Thurer RL, McCarthy JR, Sirois CA, Weintraub RM. Cutaneous Three weeks after her discharge, however, she developed closure after cardiac operations: a controlled, randomized, prospective, comparison of lower back pain and and was readmitted to the hospital. intradermal versus staple closures. Ann Surg 1997;226:606-12. Within 8 hours, she was found to have a spinal abscess that quick- 7. Falanga V.Venous ulceration: assessment, classification and management. In: Krasner D, Kane D, editors. Chronic Wound Care: A Clinical Source Book for Professionals, 2nd ly caused lower extremity paralysis. She was placed on a bariatric ed. Wayne, PA: Health Management Publications Inc.; 1997. p 165-171. bed frame and a rotating pressure relief mattress to assist in respi- 8. Printen KJ, Paulk SC, Mason EE. Acute postoperative wound complications after gas- ratory toileting. An increasing temperature and respiratory distress tric surgery for morbid obesity. Am Surg 1975;41:483-5

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