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336
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Fig. 63.1 CT scan showing
fl uid collection in whole
abdomen and
pneumoperitoneum
Fig. 63.2 CT scan showing
fl uid collection and
pneumoperitoneum. Drain
was left during operation
L. Gonzalez Sanchez
important pneumoperitoneum and moderate quantity of free fl uids in abdomen were
observed and it was decided to operate immediately. At laparotomy, peritonitis produced by perforation on anterior and posterior wall was found at 15 cm from ligament of Treitz. Perforations were one cm in size and the bowel was vital and nor
destroyed, and surgeon decided to close both lesions with interrupted suture. Bowel
was patent and vital and the pancreas was normal; abdomen was rinsed and closed
and a drain was left behind. The course of the fi rst two postoperative days was complicated by fever, but peristalsis recovered quickly. The patient only was frustrated
by the complications. After drainage of a small wound abscess, she recovered and
went home. Pathology of the uterus was uterus myoma.
63 Case on Inadvertent Small Bowel Lesion During Laparoscopic Operation
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Small bowel lesions during laparoscopy!
Illustration 63.1 To sum up, if we have a patient who has been operated by laparoscopic surgery, who develops postoperatively fever, tachycardia, abdominal pain, or any other sepsis or
peritonitis signs, then bowel damage must be excluded by a CT scan, followed by emergency
reintervention
Discussion
337
Currently, the laparoscopic approach is used more frequently; its advantages are
clear, but its use is not completely free of risks. Especially when gaining access
to the abdominal cavity by means of Veress needle, trocars, and such instruments, certain accidents are likely, such as inadvertent vascular lesions and hollow organ perforations, thereby putting patients at an important risk for their lives
(Illustration 63.1 ).
Schafer et al.—reporting on behalf of The Swiss Association for Laparoscopic
and Thoracoscopic Surgery (SALTS)—prospectively collected data on 14,243
patients undergoing various standard laparoscopic procedures between 1995 and
1997 [ 1 ]. The database contained 22 trocar and four needle injuries (incidence,
0.18 %). Nineteen lesions involved visceral organs; the remaining seven were ves-
sel injuries. The small bowel was the single most affected organ (six cases) followed by the large bowel and the liver. Nineteen trocar injuries were recognized
intraoperatively; diagnoses of two small bowel injuries and one bladder injury were
made postoperatively. Needle injuries were all diagnosed intraoperatively. Only fi ve
injuries could be repaired laparoscopically; the remaining lesions were repaired
openly. Four patients underwent an open reoperation, and another patient needed
fi ve reoperations. There was one death (4.0 %).
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L. Gonzalez Sanchez
Schafer et al. concluded that trocar and needle injuries constitute rare complica-
tions of laparoscopy. However, if unrecognized intraoperatively and not repaired
immediately, these induce increased morbidity and mortality. Both the open- and
closed establishment of the pneumoperitoneum are related to a potential danger of
perforating lesions. By inserting the fi rst trocar under direct vision, an early recognition and immediate repair of lesions may be possible.
In 1997, Bonjer et al. published a retrospective review of the literature and
authors’ experience, whereby they compared closed and open laparoscopy [ 2 ]. Data
were culled on closed laparoscopy in 489,335 patients and on open laparoscopy in
12,444 patients. Rates of visceral and vascular injury were respectively 0.083 % and
0.075 % after closed laparoscopy, and 0.048 % and 0 % after open laparoscopy.
Mortality rates after closed and open laparoscopy were respectively 0.003 % and
0 %. They found a statistically signifi cant difference in terms of visceral and vascular injury between closed and open laparoscopy, there being no such difference for
mortality rates. Their conclusion was that open establishment of pneumoperitoneum should be advocated in laparoscopic surgery, because it is safer than the
closed method.
Establishing the pneumoperitoneum and inserting the working ports remain the
most crucial steps in the laparoscopic approach. Fifty percent of laparoscopic complications are entry related. In order to mitigate laparoscopic entry mishaps and
improve patient safety, several international surgical corporations, including
European Association of Surgeons (EAES), have published clinical practice guidelines for laparoscopic entry practice [ 3 ].
Which of the two methods—the open or the closed using the Veress needle—
used for gaining access to the abdomen is safer remains a subject of controversy.
Moreover, the outcome of injuries is strongly related to the type of anatomical
structure damaged (bladder, bowel, vessels, etc.), its immediate recognition, and
meticulous repair, which usually necessitates a conversion to a laparotomy [ 4 ].
Inadvertent small bowel perforation in laparoscopic surgery seems underre-
ported [ 4 – 6 ]. There is no evidence of the infl uence of the type, size, or shape of
trocars [ 4 ]. However, there are several conditions that can increase the risk of bowel
lesions, such as:
– Obesity (for needing to exert more pressure when inserting working ports)
– Extreme thinness (caused by the short distance between the skin and anatomical
structures)
– Dilated bowel loops (e.g., in case of intestinal obstruction)
– Previous history of abdominal or pelvic surgery
That last issue is the most important factor. In fact, the probability of bowel
injury is ten times greater if patient has had three previous laparotomies or more [ 6 ].
Inadvertent small bowel perforation is potentially a lethal complication of lapa-
roscopic surgery; the mortality rate for bowel injuries being between 3 and 4 %
[ 4 – 6 ].
63 Case on Inadvertent Small Bowel Lesion During Laparoscopic Operation
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339
To sum up, if we have a patient who has been operated by laparoscopic surgery,
who postoperatively develops fever, tachycardia, abdominal pain, or any other sepsis or peritonitis signs, then bowel damage must be excluded by a CT scan, followed
by emergency reintervention [ 4 ]. Nevertheless, we should not forget that some-
times—as in the case of our patient above—clinical symptoms are poorly visible
and that patients should maintain an acceptable general situation. Because of that,
diagnosis can be very complicated and should certainly involve recognizing that this
complication may be diagnosed several days after the fi rst procedure.
References
1. Schafer M, Lauper M, Krahenbuhl L. Trocar and Veress needle injuries during laparoscopy.
Surg Endosc. 2001;15:275–80.
2. Bonjer HJ, Hazenbroek EJ, Kazemier G, et al. Open versus closed establishment of
pneumoperitoneum in laparoscopic surgery. Br J Surg. 1997;84:599–602.
3. Neudecker J, Sauerland S, et al. The European Association for Surgery. Clinical practice guideline on the pneumoperitoneum for laparoscopic Surgery. Surg Endosc. 2002;16:1121–43.
4. Steven J, Binenbaum MD, Michael A, Goldfarb MD. Inadvertent enterotomy in minimally
invasive abdominal surgery. JSLS. 2006;10:336–40.
5. Tinelli A, et al. Laparoscopy entry in patients with previous abdominal and pelvic surgery. Surg
Innov. 2011;18:201–5.
6. Orlando R, Lirussi F. Delayed recognition of inadvertent gut injury during laparoscopy. Surg
Endosc. 2000;14:1188–9.
Chapter 64
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Case on Small Bowel Ischemia During
Neoadjuvant Chemotherapy for
Gastroesophageal Junction Cancer
Miguel A. Cuesta and Donald L. van der Peet
Keywords Hernia • Duodenum • Colon • Necrosis • Complication • Paraesophageal
hernia • Esophageal cancer • Neoadjuvant chemotherapy • Intestinal ischemia
Diagnosis and Identifi cation of Complication
A 60-year-old man was referred to us because of progressive dysphagia complaints.
Three years before he had been operated on twice because of paraoesophageal hernia and postoperative dysphagia. Finally, a Nissen fundoplication was created with
no further swallowing complaints until now. By endoscopy, a gastroesophageal
junction adenocarcinoma was found with no signs of metastases on the CT scan of
thorax and abdomen (Fig. 64.1 ). An endoscopic ultrasonography had staged the
tumor as T3N1. Patient was proposed for neoadjuvant chemotherapy, the MAGIC
study. After the third cycle, patient was admitted to the Department of Oncology
because of progressive sickness with bone marrow depression and abdominal pain.
On the CT scan, an image of distended small bowel was observed with pneumatosis
intestinalis (Fig. 64.2a, b ).
Treatment of Complication
Patient was proposed for an exploratory laparotomy, but oncologists accentuated
the risks for laparotomy because of bone marrow depression and the possibility of
spontaneous recovery with antibiotics and a wait-and-see policy.
M. A. Cuesta , M.D. () • D.L. van der Peet
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_64,
© Springer International Publishing Switzerland 2014
341
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Fig. 64.1 CT scan
showing the tumor at the
gastroesophageal junction
with the Nissen
fundoplication
M.A. Cuesta and D.L. van der Peet
At laparotomy, an extensive ischemia/necrosis of the entire small bowel was
found (Fig. 64.3 ). The superior mesenteric artery was patent with pulsations up to
the bowel. No resection was considered but to await some demarcation of the necrosis. Decision was taken to perform a second look after 24 h.
Patient seemed stabilized and the next day at laparotomy, the necrosis was found
patchy, including the duodenum and ascending colon. Considering the situation, no
further aggressive treatment was provided.
Discussion
Lesson of this case is that currently the neoadjuvant therapy has an important role
in the treatment of many gastrointestinal cancers such as esophageal and gastric.
The expected response to neoadjuvant therapy and reasonably good prognosis after
surgery never should exclude the possibility that these may cause as such high toxicity resulting in morbidity and even mortality, as took place in the present case.
Toxicity and morbidity are clearly reported, but mortality rate exclusively due to the
neoadjuvant therapy is not clearly reported.
In the MAGIC trial, they randomly assigned patients with resectable adenocarci-
noma of the stomach, esophagogastric junction, or lower esophagus to either perioperative chemotherapy and surgery (250 patients) or surgery alone (253 patients)
[ 1 ]. Chemotherapy consisted of three preoperative and three postoperative cycles of
intravenous epirubicin and cisplatin, and a continuous intravenous infusion of fl uorouracil. The primary end point was overall survival.
ECF-related adverse effects were similar to those previously reported among
patients with advanced gastric cancer. Rates of postoperative complications were
similar in the perioperative-chemotherapy group and the surgery group (46 % and
45 %, respectively), as were the numbers of deaths within 30 days after surgery.
They reported that with a median follow-up of 4 years, 149 patients in the
64 Case on Small Bowel Ischemia During Neoadjuvant Chemotherapy
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Fig. 64.2 ( a , b ) Intestinal
dilatation with pneumatosis
intestinalis
a
b
343
Fig. 64.3 Operative picture.
Extensive patchy ischemia of
the small bowel
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M.A. Cuesta and D.L. van der Peet
perioperative- chemotherapy group and 170 in the surgery group had died. As compared with the surgery group, the perioperative-chemotherapy group had a higher
likelihood of overall 5-year survival rate and of progression-free survival. In conclusion there are enough arguments to use the neoadjuvant therapy without forgetting
that it will be the cause of such a complication.
Reference
1. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery
alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355:11–20.
Chapter 65
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Case on Complications of Intestinal
Malrotation
Miguel A. Cuesta
Keywords Intestinal obstruction • Colopexy • Midgut malrotation • Adult
malrotation
Diagnosis and Indication for Surgery
A 29-year-old nurse was referred to us from a regional hospital because of intestinal
obstruction. She had never been operated on before and the physical examination
revealed no inguinal or femoral hernias. Three years before this patient did have an
episode of some hours of intense pain in her abdomen, explained then by the GP as
a colic condition.
On the X-ray of her abdomen and on the CT scan, a gastric dilatation was seen
and also that the distended small bowel was displaced to the right side of the abdomen and the right colon to the left hemiabdomen, suggesting the existence of a
midgut malrotation in an adult patient (Figs. 65.1 and 65.2a–c ).
Operation
After initial conservative treatment by nasogastric tube and parenteral feeding, she
was operated on laparoscopically in order to take down the Ladd’s bands. The bands
were not clearly found by laparoscopy and operation was converted to upper
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_65,
© Springer International Publishing Switzerland 2014
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M.A. Cuesta
a
b
c
Fig. 65.1 ( a ) CT scan, midgut malrotation showing small bowel to the right , colon left , and gastric
dilatation probably due to Ladd’s bands. ( b ) Contrast through tube introduced in small bowel
showing the bowels on the right side . ( c ) Small bowel right , duodenojejunal junction on the right ,
and colon left
laparotomy because of a diffi cult anatomy. After exploring the abdomen, the Ladd’s
bands were found and divided, small bowel volvulus derotated, and an appendectomy performed.
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