Perioperative management of postoperative sigmoid colon cancer complicated by a large abdominal wall defect: A case report

Abstract

BACKGROUND

Large abdominal wall defect (LAWD) measures > 20 cm in width. LAWD can easily lead to intestinal necrosis, peritonitis, other complications, and even multiple organ dysfunction syndrome. Multiple intestinal fistulas are high-flow fistulas that can cause severe water–electrolyte imbalance and malnutrition, as well as inflammation, high metabolic status, and chronic intestinal failure caused by intestinal fluid corrosion in tissues around the orifice fistulas.

CASE SUMMARY

This article summarizes the nursing experience of a patient with sigmoid carcinoma who has LAWD with multiple intestinal fistula due to repeated operations for postoperative complications. The key points of care: Scientific assessment of nutritional status, dynamic adjustment of nutritional support programmes, comprehensive adoption of enteral nutrition, parenteral nutrition and combined nutrition of enteral and parenteral; taking good care of abdominal wall defects and intestinal fistulas; continuous flushing of the abdominal drainage tube and low negative pressure drainage; prevention of venous thrombosis; strengthening of physical exercise; implementation of positive psychological interventions.

CONCLUSION

After more than 7 months of careful care, the patient's physical fitness has been well recovered, local inflammation is well controlled, which wins the opportunity for the operation, and the postoperative recovery is good.

Key Words: Large abdominal wall defect; Multiple intestinal fistula; Perioperative period; Nursing; Tumor; Case report

Core Tip: Multiple intestinal fistulas are high-flow fistulas, which may lead to severe water and electrolyte disorder and malnutrition in patients. After nutritional support treatment, care of the abdominal wall defect and intestinal fistula, continuous irrigation of abdominal drainage tube and low negative pressure drainage and other active treatment and nursing measures, the patient's malnutrition, infection and other conditions were improved, which created the opportunity for surgery, so that the surgery was finally successfully operated.

INTRODUCTION

Large abdominal wall defect (LAWD) measures > 20 cm in width[1]. LAWD can easily lead to intestinal necrosis, peritonitis, other complications, and even multiple organ dysfunction syndrome[2,3]. Multiple intestinal fistulas are high-flow fistulas that can cause severe water-electrolyte imbalance and malnutrition, as well as inflammation, high metabolic status, and chronic intestinal failure caused by intestinal fluid corrosion in tissues around the orifice fistulas[4,5]. Although the co-occurrence of LAWD and fistulas in the same patient is rare, it can be life-threatening if not treated promptly.

CASE PRESENTATION

Chief complaints

A 78-year-old male patient who had sigmoid colon cancer with intestinal obstruction underwent "radical sigmoid resection + distal closure + proximal stoma (Hartmann’s operation)" on the first hospital day (July 12, 2018).

History of present illness

Postoperative pathology showed a moderately differentiated adenocarcinoma of the sigmoid colon. On July 20, 2018, the stoma fistula was found to be retracted into the abdominal cavity, and fecal-like liquid leaked around the left lower abdominal drainage tube and incision. Therefore, the patient underwent emergency “exploratory laparotomy + abdominal irrigation + colostomy reconstruction.” Intraoperatively, the original colostomy had retracted to the peritoneal layer, and a large amount of fecal-like liquid accumulated in the left side of the colon sulcus. The paracolic groove was flushed using a large amount of iodophor + metronidazole + warm saline. After a part of an intestinal segment of the original colostomy was resected, colostomy was performed again. On postoperative day 6, purulent exudates were found in the abdominal incision. The drainage fluid of the left paracolic sulcus and pelvic cavity was cloudy and smelly, and angiography detected an intestinal fistula. After continuous irrigation of the pelvic drainage tube with low negative-pressure suction, the patient’s body temperature fluctuated repeatedly, and pulmonary infection occurred. On August 30, 2018, the patient’s abdominal drainage tube drained a large amount of bloody fluid. Hence, emergency “exploratory abdominal section + enterostomy” was performed. During the operation, a small intestinal rupture (1 cm in diameter) was found under the original incision. After adhesion separation, the segment of the small intestine was pulled out, and double-tube stomy was performed. Postoperatively, the lung infection worsened, with cough and sputum production becoming more frequent; high fever was also repeated. On September 20, 2018, the incision had an acute dehiscence with no definite cause, and fecal water was leaking around the incision and small intestine stoma. Thus, emergency "incision debridement and suture surgery" was performed. Intraoperatively, the small intestine was found to be perforated; thus, it was sutured. However, incision infection occurred postoperatively. On October 8, 2018, the patient underwent “incision debridement and suture + small intestine double-tube stomy distal closure surgery” again because of another incision dehiscence. Unfortunately, the incision was infected again and separated postoperatively, and the feces flowed out around the incision and small intestine stomy, resulting in serious abdominal cavity contamination. On October 19, 2018, the patient was treated in a different hospital where abdominal irrigation and drainage were performed, surgical sutures were removed, abdominal wound was opened, dressing was changed, wound protection was performed, scalp skin was removed, and the abdominal wall was skin-grafted. On November 28, 2018, the patient was admitted to the Gastrointestinal Surgery Department of Hefei First People’s Hospital for further treatment and was diagnosed with LAWD with multiple intestinal fistulas and sigmoid colon cancer after surgery.

History of past illness

The patient has a history of appendectomy (1996) and coronary heart disease for over a month, but has not taken any medication orally.

Personal and family history

The patient's family has no history of similar diseases or familial genetic illnesses.

Physical examination

The patient’s clear consciousness, poor mental state, moderate malnutrition (height 175 cm, body weight 50 kg, body mass index (BMI) 16.3 kg/m². NRS2002 nutritional risk screening score is 5 points), no obvious yellowing of the skin and sclera, no enlargement of superficial lymph nodes throughout the body, soft neck, coarse respiratory sounds in both lungs, no obvious dry and wet rales heard, regular heart rhythm, no obvious pathological murmurs.

The patient had stable vital signs and moderate malnutrition (175 cm height, 50 kg body mass, BMI 16.3 kg/m²). The score of NRS2002 nutritional risk screening table was 5 points)[6]. There was an open wound of 22 cm × 18 cm in the middle abdomen, with the visible intestinal wall, bright red in color, good blood supply, no active bleeding, and a small part of relatively thin skin graft covering the surface. There were one stoma on the upper side and one on the left side of the wound, which were red in color, with good blood circulation, and without stenosis or slip. There were yellow formed stools discharged from the left stoma, and four intestinal fistula could be seen on the intestinal wall of the wound, with yellow feces discharged. The patient was placed with drainage tubes on the upper and lower sides of the left abdomen and subjected to continuous low-pressure flushing (Figure 1). There is no obvious edema in both lower limbs.

Figure 1  Abdominal condition on admission.

Laboratory examinations

Blood routine: White blood cell count 6.62 × 10⁹/L, neutrophil percentage 71.7%, red blood cell count 3.78 × 10¹²/L, hemoglobin 112 g/L, platelets 179 × 10⁹/L, C-reactive protein 51.83 mg/L. Urine routine: PH 5, 42 red blood cells/μL, 1842 white blood cells/μL, 42 fungi/LPF. Blood biochemistry test: Liver function: Albumin 34.1 g/L, prealbumin 113 g/L, glutamyl transpeptidase 182 μL, cholinesterase 1389 u/L, all other values are within normal range. Renal function is normal. Carbon dioxide binding capacity is 19.9 mmol/L, glucose (non fasting) is 6.8 mmol/L, and cystatin C is 1.96 mg/L. Electrolytes are within the normal range. Myocardial enzyme examination: Creatine kinase 29.64 μ/L, lactate dehydrogenase 606 μ/L, and high-sensitivity troponin 126.4 μg/L. Blood B-type natriuretic peptide measurement: 228.9 pmol/L. Sputum culture: Klebsiella pneumoniae. Urine culture: Smooth Candida resistant. Coagulation function: Antithrombin III 64.9%, fibrin degradation products 10.97 μg/mL, D-dimer 2.31 mg/L.

Imaging examinations

Head, chest, and abdomen computed tomography scan: (1) Postoperative absence of part of the left lower abdominal wall following sigmoid colon cancer surgery, with a tube shadow in the left lower abdominal wall, and residual contrast agent visible in the right hemicolon; (2) Multiple nodular lesions in both lungs, considered as possible fibroproliferative lesions metastatic tumors to be excluded; please compare with old images, and a follow-up is recommended; (3) Inflammation in the upper lobe of the left lung and both lower lobes; (4) Right pleural effusion with atelectasis of the right lower lung lobe, and thickening and adhesion of the left pleura; (5) Multiple lymph node shadows in the mediastinum; (6) Multiple cysts in the liver and both kidneys; (7) Enlargement of the prostate with an irregular anterior margin; follow-up and re-examination are advised; (8) Age-related brain changes; and (9) Sphenoid sinusitis.

FINAL DIAGNOSIS

The final diagnosis was multiple intestinal fistulas, abdominal infection, LAWD with abdominal opening, and moderate malnutrition secondary to incisional laceration and debridement, autologous skin transplantation status, radical resection of the sigmoid colon cancer, enterostomy, colostomy, and appendectomy. He was also diagnosed with coronary heart disease. After admission, a personalized nutrition program was formulated, providing mixed enteral nutrition (EN) and parenteral nutrition (PN) to the patient. In addition, the peritoneal drainage tube was continuously lavished with isotonic saline, followed by low negative-pressure drainage. The wound was well managed (Figure 2), and anti-infective medications were administered. Subsequently, the patient’s physical condition gradually improved. After 7 months, he underwent "complex intestinal fistula (4 places) excision + intestinal anastomosis + colostomy" under general anesthesia (Figures 3 and 4), and the operation was successful. Postoperatively, medical care measures such as anti-infection treatment, intravenous nutrition combined with EN, and wound and orifice fistula skin specialist nursing were provided. Eventually, the patient recovered smoothly. The abdominal wound was dry and had no exudation, with no reports of discomfort after eating. Thus, the patient was discharged (Figure 5). A 3-year postoperative outpatient review and regular telephone follow-ups revealed that the patient recovered well.

Figure 2  Abdominal condition before the 7^th operation.

Figure 3  Situation of the 7^th surgical exploratory procedure.

Figure 4  Postoperative specimen anatomy.

Figure 5  Abdominal condition before discharge.

TREATMENT

Scientific assessment of nutritional status

Infection, homeostasis imbalance, and malnutrition are the three major pathophysiological changes in patients with intestinal fistulas, and these changes interact with each other. Malnutrition-related sepsis is the primary cause of death in patients with external intestinal fistulas. Active nutritional support can help reduce the incidence and mortality of complications[4]. Therefore, patients’ nutritional status must be correctly assessed to provide the proper nutritional support treatment. The patient in this case was an older adult and had undergone several operations in a short period of time. Furthermore, owing to LAWD and multiple intestinal fistulas, he suffered from infections, internal homeostasis imbalance, and high energy consumption, resulting in a poor nutritional condition. Apart from the low body mass and BMI and high NRS2002 score, his hemoglobin and albumin levels were 118 and 34.1 g/L, respectively. The diagnosis of moderate malnutrition was made through consultation with the nutrition department, and nutritional intervention was required. A targeted nutritional support plan had been developed according to the patient’s nutritional status and disease condition. His nutritional status was assessed weekly, focusing on his albumin and hemoglobin levels. EN and PN methods were then comprehensively adopted, and nutritional measures were dynamically adjusted.

EN aspect

EN helps prevent intestinal atrophy, maintain intestinal function, and support immune function[7]. If conditions permit, EN should be used as much as possible. The patient was admitted to the hospital with a nutritional tube, and yellow formed stools were leaking from both the stoma and the intestinal fistula. Considering that the patient’s gastrointestinal tract maintained to be partially functional, 1500 mL of EN suspension was administered daily through a gastrointestinal nutritional tube after heating and dripping. This EN suspension was the enteral nutrition suspension (SP), a short peptide-type EN preparation that is directly absorbed in the intestine without digestion. It is especially suitable for patients with gastrointestinal functions but without the ability to take in conventional food to meet the nutritional needs of the body receiving EN therapy; thus, it was suitable for the patient in this case. During the EN support period, the following "six degrees" should be considered at all times: The nutrient solution’s temperature is moderate, the concentration is gradually increasing (the speed should be from slow to fast), the patient should start to adapt from 50 mL/h in the process of using SP and then gradually transition to 150 mL/h, the head of the bed should be raised at least 30°, the cleanliness of the bed unit should be maintained, and the patient’s comfort level should be timely evaluated. Three bottles of SP can provide 1500 kcal of energy and 60 g of protein, thereby meeting all the daily energy needs of the patient. Meanwhile, the appropriate use of alanyl glutamine injection combined with compound amino acid injection can promote positive nitrogen balance and intestinal mucosal repair and reduce the incidence of infection complications.

PN aspect

During the EN period, owing to abdominal pain, vomiting, and diarrhea, the patient experienced significant fluctuations in body temperature, reaching 39.2 ℃. At one point, his plasma albumin and hemoglobin levels decreased to 22.13 and 109 g/L, respectively. After consultation with the nutrition department, the patient was considered to have intestinal nutrition tolerance disorders; hence, the nutrition plan was adjusted. EN was changed to PN using a fully integrated PN mixture (50% glucose, 250 mL; 10% glucose, 250 mL; 10% potassium chloride, 40 mL; 10% sodium chloride, 40 mL; multi-trace elements injection (II), 10 mL; 50% glucose, 100 mL; water-soluble vitamin, 10 mL; insulin, 32 units; 11.4% compound amino acid, 500 mL; 20% fat emulsion, 250 mL; liposoluble vitamin, 10 mL; 20% alanyl glutamine injection, 100 mL; and sodium glycerophosphate injection, 10 mL). The total amount of nutrient solution was 1550 mL, with a total nitrogen content of 12.32 g (heat: Nitrogen, 106:1; sugar: Fat, 800:500; sugar: Insulin, 6.25:1), providing 1350 kcal for energy and 65 g of amino acids. The patient was injected through a central venous catheter (CVC) at an infusion rate of 100 mL/h. Continuous infusion was required for 11 days, during which 20 g of albumin was administered intravenously once a day. The following precautions should be taken to prevent catheter infection while infusing the nutrient solution: (1) Disinfecting the catheter and replacing the film twice weekly; (2) Prohibiting blood drawing and transfusion from the venous channel for PN; and (3) Using 20 mL of isotonic saline to flush the tube every 8 hours during PN infusion. During the PN process, changes in liver and kidney functions, blood glucose level, blood lipid level, and coagulation function were monitored weekly to observe the balance of patients’ intake and outflow.

PN combined with EN

After the gastrointestinal symptoms such as abdominal pain and diarrhea were eliminated and the body temperature normalized, PN was gradually transitioned to EN under the guidance of the nutrition department according to the patient’s condition, to stimulate the growth of intestinal mucosal epithelial cells and prevent intestinal mucosal atrophy. The abovementioned PN formula should be halved, and adding 1000 mL of SP, which should be heated and dripped through a nutrient tube, per day was necessary. As the gastrointestinal function improved, the patient was progressively transitioned to total EN, discontinuing the PN infusion.

After more than half a year of nutritional support treatment, before the 7^th operation in Hefei First People’s Hospital, the patient’s albumin level, hemoglobin count, BMI, and NRS2002 score were 37.1 g/L, 128 g/L, 18.7 kg/m², and 2 points, respectively, which laid a good foundation for subsequent surgical treatment.

Postoperative nutrition

The patient underwent the 7^th operation of "complex intestinal fistulectomy + colostomy" in Hefei First People’s Hospital. Four small intestinal fistulas were completely removed, and anastomosis of the small intestine end was performed. Furthermore, the original colostomy orifice was removed, and the transverse colon stump was dragged out of the abdominal wall again for stomy. Then, a drainage tube was placed in the left paracolic trench. On postoperative day 2, PN support was started (50% glucose, 250 mL; 5% glucose sodium chloride, 500 mL; 10% potassium chloride, 40 mL; 10% calcium gluconate, 10 mL; 25% magnesium sulfate, 5 mL; multi-trace elements injection (II), 10 mL; water-soluble vitamin, 10 mL; insulin, 24 units; 11.4% compound amino acid, 500 mL; sodium glycerophosphate injection, 10 mL; 20% fat emulsion, 250 mL; and liposoluble vitamin, 10 mL), with a total ammonia content of 9.12 g/day, and a total nutrient solution of 1600 mL/day (heat: Nitrogen, 111:1; sugar: Fat, 510:500; and sugar: Insulin, 6.25:1). The infusion route was the CVC. The combined PN and EN was administered one week after the surgery; then, PN was gradually reduced and EN was increased. The transition to EN was completed on the fourth week after surgery.

Nursing of the LAWD and intestinal fistula

On admission, the patient had LAWD measuring 22 cm × 18 cm in the midabdomen, with a bright red intestinal wall, good blood supply, and no active bleeding. Part of the intestinal wall surface was covered with gray and white skin grafts, which were discontinuous and patchy, and the skin flap was relatively thin. One stoma was found on the upper side and another on the left side of the wound, appearing red and displaying a good blood supply, without stenosis or detachment. Additionally, yellow formed stools expelled from the left stoma. Four intestinal fistulas were also observed in the intestinal wall of the affected area, also discharging yellow stools. The skin around the defect area was red, swollen, and eroded, indicating inflammation, owing to the long-term exposure to intestinal content leakage. After admission, the following nursing measures were taken after consultation with a wound ostomy specialist. First, the dressing should be changed timely to remove the necrotic tissue. The color of the intestinal mucosa should be monitored closely, and the necrotic tissue from the LAWD should be removed to promote wound healing. After 12 days of treatment, the redness and swelling of the surrounding tissue of the LAWD clearly subsided, and the inflammation improved. Second, the skin around the fistula should be protected. The patient had multiple intestinal fistulas, which were high-flow fistulas. The spilled intestinal fluid could easily corrode the adjacent tissues and the abdominal wall skin, causing serious tissue edema. Therefore, the spilled intestinal fluid should be sucked by a negative-pressure suction device in time. The surrounding skin should also be washed with warm water, and ostomy skin care powder should be applied. Antibiotic ointment or zinc oxide ointment may be applied as needed to reduce intestinal fluid irritation to the skin and keep the surrounding skin dry. Third, tissue repair should be promoted. After the LAWD is cleaned, it should be sprayed with recombinant fibroblast growth factor (Befuji) to accelerate the growth of skin grafts in the defect. Before discharge, the exposed area of the LAWD was reduced from 20 cm × 20 cm to 15 cm × 3 cm.

OUTCOME AND FOLLOW-UP

At the follow-up visit after 63 postoperative days, the skin graft had completely covered the wound.

DISCUSSION

Continuous flushing of peritoneal drainage tube with isotonic saline and low negative-pressure drainage. The patient had multiple intestinal fistulas and a large amount of leakage, which may cause serious abdominal infection if the drainage was incomplete. Negative-pressure drainage could be used in abdominal wall defects with severe contamination or infection within the abdominal cavity, or as a transitional treatment before clear repair and reconstruction of such defects. It could significantly reduce intra-abdominal pressure, alleviate edema, enable granulation tissue for better and faster formation, and strengthen the coverage of abdominal wall defects[8]. During admission, the abdominal drainage tubes were placed in the upper and lower parts of the left abdomen and were continuously flushed with isotonic saline combined with low negative-pressure suction (irrigation speed within 60-80 drops/min; negative drainage pressure between -110 and -95 mmHg). The negative-pressure drainage tube drew the flushing fluid, exudates, and necrotic tissue out of the wound, promoting wound healing. After the inflammation was controlled, the irrigation rate was changed to 40 drops/min, and the negative-pressure drainage was adjusted between −80 and −55 mmHg. After 10 weeks of treatment, the abdominal infection was controlled and the skin inflammation subsided.

Prevention of venous thrombosis

On admission, the patient’s Autar deep vein thrombosis (DVT) risk score was 13, and he could not get out of bed and move outside because of his illness, thereby at risk of developing DVT. The nurse instructed the patient to execute bed activities daily, assisted the patient to turn over, regularly massaged the leg muscles, encouraged the use of lower-limb compression elastic socks, and provided lower-limb pressure therapy (30 minutes/session), ankle pump exercises of both lower limbs, knee extension and bending exercises, hip-lifting exercises, and others. After the patient had recovered his strength, he was encouraged to get out of bed in time, and the blood coagulation index was monitored twice a week. Anticoagulant drugs were used when necessary. After active prevention, the patient did not develop DVT during hospitalization.

Physical exercise

Physical exercise can promote patients’ intestinal peristalsis and overall muscle strength recovery, contribute to the gradual restoration of the intestinal function, and prevent and control pulmonary complications[9]. After patient admission, the physicians immediately began to establish a physical exercise plan with his family according to his condition. Initially, the "four escorts" should be performed at bedside, that is, providing morning and evening care for patients, conducting passive activities in bed, and massaging the limbs and muscles. After 10 days, the patient’s mental state improved, and his physical strength partially recovered. The patient was encouraged to gradually engage in active exercises, such as moving the limbs and sitting up in bed. On the 37^th day, the patient began to sit on the edge of the bed gradually. He began to stand beside the bed momentarily after 48 days, could walk by the bed or in the corridor with assistance after 93 days, and tried to walk independently after 158 days. During discharge, the patient could walk independently for 20 minutes.

Psychological nursing

The patient was an older adult, and his condition had fluctuated repeatedly since the disease onset. He had undergone multiple surgeries and dressing changes in a short period of time. The wound surface was large, and the condition was serious, resulting in changes in external appearance and bowel movements. The secondary infection after the operation, wound pain, worries regarding the disease prognosis, and the burden on the family and other situations had led to his unstable mental state, as manifested by depression, unwillingness to communicate, pessimistic attitude toward disease development and prognosis, and deep concern about his future life. Considering his psychological state, the supervising physician, nurse, and wound specialist nurse all showed understanding and provided supportive psychological intervention. Through clear explanation of the disease condition, support from family and wardmates, and encouragement to increase confidence in treatment and care, the patient’s negative emotions improved. The medical team conducted timely patient psychological assessments and continuously praised the patient’s support and cooperation in treatment and nursing work, as well as every progress in the condition. As the condition improved and the wound recovered, the patient gradually developed confidence about his prognosis and became proactive until being discharged. The follow-up after discharge showed that the patient quickly participated in normal social activities.

CONCLUSION

In this case, the patient had LAWD accompanied with multiple intestinal fistulas. On admission, he had poor nutritional status, severe intra-abdominal infection, and evident inflammation and edema in the abdominal wall, exposed tissue, and surrounding tissue of the LAWD. Through multidisciplinary consultation preoperatively, the medical team formulated individualized diagnosis and treatment plan according to the patient’s condition, corrected the patient’s nutritional status, and significantly improved the skin status around the fistula. Consequently, the patient’s tissue, organ, and immune functions reached the best state, laying a good foundation for a smooth operation and patient’s recovery. However, some lessons worth rethinking were realized in the course of managing this patient. Continuous EN would pose challenges to the patient’s gastrointestinal functional tolerance, and the patient once developed EN tolerance disorder. Moreover, the patient was weak, and his nutritional status deteriorated again; thus, he was forced to transition to PN, which prolonged the recovery time. For DVT prevention, physical exercise, and other nursing measures, patient’s and his family’s full informed consent and active cooperation, and repeated education and encouragement were required in the process. In addition, positive psychological intervention is crucial to achieve patient’s full recovery.

ACKNOWLEDGEMENTS

The authors thank all the participants and investigators for their efforts and are grateful for the support provided by the Hefei First People’s Hospital.