wound healing

On 7th June '10 I had some fairly serious abdominal surgery. It has now been 110 days and I still have a "sinus" in the incision line. It is about the size of a belly button and is described as having a "pit". The surgeon is "not worried" as non diabetics also have the same problem. My GP is a little more concerned and cites the diabetes as an exacerbating influence. I have had diabetes for 32 years and would like to know if the problem healing relates to general health (and complications) from being a long term diabetic or does it reflect the current BGs. Advice from both the surgeon and GP is to keep the levels as low as possible (as if I don't). I have had no prior surgery (except wisdom teeth extraction about 5 years ago).
Treatment is currently removing "proud" flesh and packing with a gel that promotes epithelialization. Prior to this it was simply bathing in saline and keeping it dry. Any advice?

Helen

Helen, Do you see anyone at a Hospital for your Diabetes or just your GP. The issue for me is GP's are NOT Diabetes experts and generally seem to think any issue that could be diabetes related IS diabetes related. I had another condition 2 years ago that has re-occured since. The GP's reaction was its caused by your Diabetes, my Diabetes consulant and the consultant I see for the condtion both say, it had nothing to do
with your Diabetes. Since both of these are experts rather than 'General Practioners' I tend to go with their opinions. I have absolutely no
issues with GP's doing what they normally do, its just I don't trust mine to manage my Diabetes.
As a non medical person, I would say that generally if your diabetes is reasonably well controlled it should have no impact on the healing process. You should heal just like a non-diabetic. Hopefully a HCP on the site can confirm this or give some guidance as to why this is not the
case.

Thanks, Marke,
I don't see anyone at the hospital but I do have a private endocrinologist. When the surgery was scheduled I was between endocrinologists (the old one...I had had him for thirty two years, retired!) I have seen the new one since the surgery and he (Dafne supporter) was happy to leave "the pit" to the surgeon. I understand that the absolute last resort is a surgical repair but according to the surgeon (saw him a week ago and am scheduled to see him in another 3 weeks) says we are a long way from that. He said that what the GP was doing was what he would do!

I really like my GP. He is a bit rattled by Dafne and my propensity to fiddle with doses but other than that he asks appropriate questions and seems happy to leave it to me and the endocrinologist. The GP has not suggested I go back to the endocrinologist for advice over the "pit". (Do you detect my absolute frustration?)

My need for insulin seems to vary quite a bit. Two weeks after surgery (eating as usual) my TDD was 85-88 currently it is over 105! I have about 10CPs a day. I was relieved and confident. I trust it will drop back to somewhere around 90 in the not too distant future.

The GP is supportive of the Dafne protocols and I suspect he has done his homework since taking me on. Currently I am attending his surgery twice a week and under his supervision/direction it (the pit) is being attended to by a nurse. I can't do it at home...not enough hands. His assessment is that it is not getting any better but it is also not getting worse. It is not infected. Any advice I get from here I will discuss with the GP.

Emotionally this is throwing me. The surgery was for cancer (no radiation/no chemotherapy) and the diagnosis was followed a week later by the surgery. It is probably more complicated than just "the pit". This situation is also probably not helping my BGs.

I have just reread this and it looks a bit like a dog's breakfast but I hope it is all there.

Thanks for the psychotherapy!

Helen

Helen, i would say your altered insulin requirement is almost certainly do to what you are going through. The stress both emotionally and physically is bound to be having an effect. Its good to hear you GP is supportive but it would be good to hear a Diabetes Consultants take on all of this. There are a lot of factors involved here and its an area where someone with a deep understanding of Diabetes and the effects of things like surgery etc could provide valuable input. They could also probably give you an idea how long the effects on your insulin requirements might last. Perhaps your DAFNE Educator can help with some information ?
I can only wish you well with your recovery and ask that you keep us posted on your progress.

Hi Helen
I am no surgeon but Marke is right. Longstanding diabetes doesn't affect healing unless your blood glucose control is uneven with lots of high glucose values. The cells which fight infection (and those leading to healing and the formation of scar tissue), unsurprisingly work most effectively at a glucose of 5-8 mmol/l. I guess a poor blood supply might also increase the chances of infection but not in the site you mention. If you had impaired kidney function from diabetes that might also add to susceptibility but I guess that isn't an issue there. the low grade infection could be adding to your insulin requirements as well as a bit of emotional stress but as you say insulin doses should fall as things resolve, indeed, this might be the first sign that the infection is improving. I think you are doing all the right things. ATB Simon

Thanks Simon,

In spite of my best efforts the BGs are not as good as they have been and I am currently having multiple (up to 8-10) injections a day (the pump you have when you don't have a pump). I have largely kept myself out of trouble (a few hypos in the early mornings) but living this way is no fun. The higher readings are also having an effect on my confidence to manage the diabetes. The reason I am doing the multiple injections (and multiple tests) is that there simply is no pattern to base increases on. I have also modified my eating in that I do not eat anything that I do not have a carb label to dictate the insulin.

The pit/sinus is not infected. So I am really only dealing with the lack of healing (I think).

Thanks for the encouragement. I will keep you all posted.
Helen

Hi Simon and Marke!

Well in spite of a months serious attention by the GP the "wound" is no better (and no worse) and in the opinion of both the GP and surgeon still not infected! This morning the GP suggested I ring the surgeon who requested I see him in an hour! His assessment is that I have three options; do what I am doing and it will eventually heal; he can excise it and re-stitch but he is fearful that in 6 weeks time we could be in exactly the same situation, or; see a plastic surgeon. He thinks the problem is largely one of location. I asked what he would do and he nominated the plastic surgeon.

So where am I now? Seeing the endocrinologist next Tuesday to see what I can do to reduce the HbA1c (7.8 before surgery and now 8.5!) and cleaning with saline until I see the plastic surgeon on 11/11/10. If he decides to do some "knitting" then that will be done before Christmas.
I will keep you in the loop.
Helen

Sorry to show my ignorance here, but what is an endocrinologist?

My rough understanding of what an endocrinologist is, is this, they deal with the endocrine system, that is the system that deals with the release of hormones - such as insulin - in effect your diabetic consultant. Of course I may be wildly off the mark, in which case please, anyone, please feel free to give a much better reply.

Here in Australia most diabetics (certainly Type 1s) have a specialist who looks after their diabetes. Some see a physician but most see an endocrinologist (or in the vernacular..the endo!). As Simon says they deal with the endocrine system which includes the pancreas. They also deal with growth hormones in kids, some fertility issues etc etc. I believe that a significant part of their work, however, is with diabetics (is that me being egocentric?). Some endocrinologists develop a reputation for being excellent with children and some have reputations for being Dafne friendly. You basically find one you like and the GP refers you to them and off you go. I picked up my original one in intensive care after the coma that gave me the diabetic diagnosis and I kept seeing him for 32 years (until his retirement) through all the ups and downs. I tried a second but was very unhappy with the assessment letter she wrote to my GP who knows me well and was prepared to share the info, so I searched and asked fellow diabetics and have come up with a third. This one is a Dafne supporter and quite laid back. So far so good.

Some GPs believe that diabetics don't need a specialist and would rather see "the patient" monthly at their surgery. I am less convinced and am happier seeing the endo 2-3 times a year and my GP for everything else. My GP sometimes writes my prescriptions for insulin etc and asks appropriate questions when I do see him but he is happier with the relationship I have with the endocrinologist regarding the diabetes. I also return periodically to the Dafne Forum at the hospital where I did my Dafne course. I also have this site. So, all in all, have all bases covered.

Helen