Ms. N, a 64-year-old woman with CD and a history of coronary disease with circulatory failure, stroke, pulmonary emphysema, and psoriasis, was admitted to the authors’ surgery clinic in November 2016 due to an inflammatory tumor within the splenic flexure of the colon with accompanying intraperitoneal abscesses. A colonoscopy performed in 2010 had shown diverticula of the colon, and in January 2015, Ms. N underwent Hartmann’s sigmoidectomy with a terminal colostomy for critical stricture of the colon. Six (6) months later, a loop-transverse ostomy was performed due to stenosis of the previous terminal colostomy. Previously obtained histopathological results suggested colitis in the course of diverticulitis. Ms. N complained of bleeding through the stoma and weight loss after the primary operation. In addition, the loop ostomy had retracted and become strictured with concomitant peristomal fistulas. Another colonoscopy through the loop ostomy with biopsy performed in October 2015 showed CD contrary to the aforementioned postoperative histopathology assessment from January 2015. Following admission to the authors’ clinic on November 29, 2016, the remnant of the colon and ostomy were excised and a terminal ileostomy created.
Ms. N’s postoperative course was complicated; she experienced acute ischemia of the small bowel following extended resection of the diseased bowel loops and formation of a terminal jejunostomy on December 8. As a result, she developed SBS; a 60-cm length of the jejunum remained. Because stomal output on oral nutrition exceeded 1500 mL with resulting dehydration, malabsorption, and malnutrition (body mass index [BMI] 15.5), Ms. N was put on total parenteral nutrition. She also was treated using an open-abdominal (OA) technique, undergoing several laparotomies for recurrent intra-abdominal abscesses. In addition, the ischemic perforation of the stomach wall was oversown (see Figure 1); subsequently, an enterocutaneous fistula >20 cm developed over the jejunostomy (see Figure 2). Furthermore, Ms. N developed a recurrent walled-off perforation of the stomach, which together with the intestinal fistula provided up to 2000 mL of digestive content per day, resulting in a narrowing of jejunostomy (see Figure 3).
Ms. N’s general condition deteriorated, and she was admitted to the High Dependency Unit on December 30 in septic shock and multiorgan failure. Ventilator treatment, hemodialysis, and broad-spectrum antibiotics were provided. Pleural drainage was installed for increasing hydrothorax. Parenteral nutrition was modified with immune modulatory amino acids that included L-arginine and L-glutamine and medium chain triglycerides to address hypoalbuminemia and lymphopenia. Evaluation of Ms. N’s basal metabolic rate, including anthropometric grade and laboratory tests, yielded BMI of 15, albumin serum range 1.54 g/dL, and lymphocyte blood count 0.67 K/uL. Six (6) units of blood, 8 units of fresh frozen plasma, and 1100 mL of 20% albumin were transfused over a period of 6 weeks after the December 8 surgery.
The open wound with fistulas and strictured jejunostomy were treated with negative pressure wound therapy (NPWT) (VivanoMed Abdominal Kit; Paul Hartmann AG, Heidenheim, Germany), installed under general anesthesia due to massive adhesions within the peritoneal cavity. The bottom of the wound was covered with microperforated protective film filled with a regular polyurethane open-pored foam (VivanoMed Foam; Paul Hartmann AG, Heidenheim, Germany), and affixed to the adjacent skin with an adhesive hydrofilm. Next, an opening was created in the film, and a negative pressure port (VivanoTec Port; Paul Hartmann AG, Heidenheim, Germany) was installed. Another opening in the film, created for the jejunostomy, was sealed with stoma paste, and the stoma was protected with an ostomy bag (see Figure 4). Throughout the treatment, continuous negative pressure of -80 mm Hg was maintained to achieve a balance between appropriate conditions for proper wound healing and the risk of increasing the fistula output.
Analgesic treatment was provided using opioids and nonsteroidal anti-inflammatory drugs. Pain was monitored using a visual analog scale; pain did not exceed level 7 throughout the hospitalization period. In next 7 days, wound size decreased from 17 cm to 13 cm in the sagittal plane, and stoma elevation increased 2 cm. The NPWT dressing was changed twice during this time. In addition, the peritoneal cavity was supplied with 3 drains; discharge of the bowel and stomach content decreased from 1500 mL to 800 mL in 2 weeks. As a result, 2 of the 3 drains were removed. Extended NPWT treatment and mechanical dilatation of the jejunostomy resulted in steadily increasing output from the stoma, and the fistula healed within 6 additional weeks (see Figure 5). However, wound healing was unsuccessful due to protracted discharge of purulent exudate (100 to 150 mL) through the drain that remained in the wound.
Additionally, Ms. N developed dehiscence of the rectal stump with pathological communication between the stump, peritoneal cavity, and the wound (see Figure 6). Therefore, the endoluminal NPWT dressing was modified using a Foley catheter wrapped with the foam and covered with a protective paraffin cotton dressing; this was introduced into the canal after removal of an abdominal drain. Continuous negative pressure of -10 mm Hg was maintained (see Figure 7). This low negative pressure was introduced to achieve a balance between the effective evacuation of septic discharge and to decrease the risk of damage to the bowel. Subsequently, adequate drainage resulted in healing of the rectal stump in 8 weeks. Wound margins were finally closed with histoacryl glue (see Figure 8) by the end of April 2016.
Ms. N was released home in May 2016 in good general condition on parenteral nutrition after implantation of a Broviac catheter (Bard Limited, Crawley, UK). Oral nutrition was limited to 250 mL of fluids and 3 to 4 slices of rice or corn bread per day. Ms. N ultimately achieved metabolic balance (evidenced in a BMI of 17 and ostomy output under 1000 mL/ day). She has been in a good general condition for >24 months and is followed-up through the outpatient nutrition department.