Author: Ian Whiteley RN BN STN Grad Cert (Health Science, Nursing Education) Cert IV Workplace Assessment and Training – CNC Concord Repatriation and General Hospital, Concord, NSW.
The patient is a 36 year old male with previously undiagnosed Buerger’s disease. His past medical history includes; the treatment of a spontaneous left calf deep vein thrombosis (DVT) in 1998 and in 2003 a cholecystectomy was performed. It was speculated that the DVT developed as a result of a long road trip and the hospitilisation for the cholecystectomy was uneventful. Following these events the patient continued to smoke 20 cigarettes per day.
The patient was transferred from another health care facility following a 48 hour admission investigating a two week history of abdominal pain, worsening over the past 72 hours and associated with diarrhea. During this two week period the patient had experienced a weight loss of approximately 12kg. A CT scan (computerised tomography) revealed superior mesenteric artery, superior mesenteric vein and left renal vein thrombosis.
Following the patient’s surgery, which is outlined in the subsequent section, the histopathology report described thrombosis involving the mesenteric arteries and veins with complete occlusion of many of the vessels. This represented unusual pathology as there was no evidence of small vessel disease in the extremities. Despite the absence of small vessel disease, the vascular changes present were consistent with Buerger’s disease.
Buerger’s disease has an unknown etiology, however it results in a non-atherosclerotic inflammatory process that mostly affects the small to medium sized arteries, veins and nerves in the upper and lower extremities. The disease results in occlusive thrombosis causing ischemic ulcers or gangrene to the distal extremities1,2. Involvement of large arteries and veins is uncommon and does not normally occur in the absence of small vessel disease (Ref. 2). This is a rare disease with a reported incidence in the USA of 4-11.6 per 100,000 people and most commonly occurs in males before the age of 40. Tobacco use is associated with all known cases1. Although the disease is linked to the use of tobacco, other factors may include a genetic predisposition, immunological dysfunction and coagulation anomalies (Ref. 1)
The surgery and outcome
The patient underwent an emergency laparotomy which included a right hemicolectomy and small bowel resection. There was ischemic bowel from the proximal jejunum to the mid-ascending colon. An end to end amastomosis was performed, joining the remaining 95cm of viable small bowel to the ascending colon.
The following day the decision was made to re-operate and the preoperative stoma siting was complicated due to significant abdominal distention. The patient was alert but intubated, making the usual preoperative siting routine impossible.
During the second laparotomy a further small bowel resection was performed, preserving 80cm of viable small bowel which was bought out as a loop jejunostomy. The distal end of the loop stoma was stapled and the end of the ascending colon was bought up to just below the surface of the skin in the midline wound as a mucous fistula.
This unusual surgical technique creating a loop jejunostomy rather than an end stoma was done with the aim of achieving a better spout on the stoma as it could be supported with a rod until the mucocutaneous junction healed. This also decreased the risk of retraction of the stoma.
The rod remained insitu for 10 days to ensure adequate healing. We maintain a database of patients who undergo surgery resulting in the creation of a stoma. This database currently contains 518 patients with stomas, 41% of these patients’ stomas were created using a rod. Of the stomas created using a rod, the majority (64%) had the rod removed after 3 days. Leaving the rod insitu for this extended period resulted in an area of mucocutaneous separation at 3 o’clock and ulceration at 9 o’clock due to the pressure created by the rod (Figure 1). Once the rod was removed the stoma was relatively flush with the abdominal plane.
Fig 1 which shows:
- Mucocutaneous separation at 3 o’clock following rod removal
- Ulceration at 9 o’clock due to pressure from the rod
- Denuded peristomal skin due to leakage
Managing the challenges
The output from the jejunostomy has remained high and has varied between 1800-3900mls/day. High output has been defined as being greater than 1.5 litres in 24 hours3. It has been documented that most patients with less that one metre of small bowel will require ongoing parenteral nutrition support (ref 4) due to malabsorption and fluid losses. During a trial cessation of total parenteral therapy (TPN) the patient’s weight continued to decrease and his electrolytes and renal function were unstable.
Therefore, despite being on a high calorie ‘stoma’ diet the patient has been recommenced on TPN and will require ongoing TPN support.
In an attempt to slow the output from the jejunostomy and to aid fluid and nutritional absorption we used a combination of medications which have previously been trialled and their effectiveness documented4. These medications included; Loperomide (6mg eight times per day), Codeine Phosphate (60mg four times per day) and Pantoprozole (40mg twice per day). Octreotide has not been introduced as it may decrease nutritional absorption.
Initially the high output was managed using a flat Dansac Nova1® Fold-up Maxi Pouch, which holds 900mls. Due to a decrease in abdominal distention and continued weight loss the patient developed indentations on either side of his stoma which resulted in leakage and the high enzymatic content of the jejunostomy effluent caused painful and denuded peristomal skin (Figure 1). An Eakin Cohesive® seal was introduced, however the leakage problems persisted.
The area of denuded peristomal skin, ulceration and mucocutaneous separation needed to be protected from the jejunostomy effluent in order to heal. The Eakin® Cohesive Slim seal achieved these goals by moulding into the peristomal skin indentations, providing protection to the areas of ulceration, denuded skin and mucocutaneous separation which aided in healing (Figure 2). The Omnigon Almarys® Twin Plus high output two piece appliance with a flat base was used over the Eakin® seal and was successfully trialled.
Fig 2 which shows:
- Eakin Cohesive® Slim Seal
- Additional strips of Eakin Cohesive® Slim Seal used to fill the indentations.
Figure 4Figure 3
The Eakin® seal was used as an alternative to convexity as I am reluctant to use convex appliances on stomas with mucocutaneous separation or ulceration as the increased pressure may contribute to capillary compression and delayed wound healing. The flat Omnigon Almarys® Twin Plus which was bordered with Hydroframe® flange extensions and a belt to provide additional security and wear time (Figures 3 & 4).
A photographic stoma care chart was created and placed in the patient’s bedside chart to assist the patient and nursing staff with the set-up of the appliances and care of the stoma. The denuded peristomal skin and ulceration has healed and the mucocutaneous separation is improving (Figure 5). The patient is gaining confidence and is now independent with his stoma care. The patient changes his base early in the morning as we have found that the stoma is less likely to be overly active. The base of the appliance requires changing every third day.
Unfortunately, the patient remains in hospital due to ongoing complications.Figure 5
Fig 5 which shows:
- Denuded peristomal skin healed
- Healed ulcer at 9 o’clock
- Mucocutaneous separation improving at 3 o’clock
1. Olin, J.W. & Shih, A. (2006) Thromboangiitis obliterans (Buerger’s disease). Current Opinion in Rheumatology, 18(1), pp. 18-24.
2. Cooper, L.T., Tse, T.S., Mikhail, M.A., McBane, R.D., Stanson, A.W., & Ballman, K.V. (2004). Long-term survival and amputation risk in thromboangiitis obliterans (Buerger’s disease). Journal of the American College of Cardiology, 44, pp. 2410-2411.
3. Brown, J., Folkedahl, B., & Smith, D. (2003). Case Study of a patient with a distal jejunostomy. The Journal of Wound, Ostomy and Continence Nursing, 30(5), pp.272-277.
4. Carlsson, E., Berglund, B., & Nordgren, S. (2001). Living with an ostomy and short bowel syndrome: Practical aspects and impact on daily life. The Journal of Wound, Ostomy and Continence Nursing, 28(2), pp.96-105.