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65 Case on Complications of Intestinal Malrotation
https://t.me/med1917
Fig. 65.2 Plain abdominal
X-ray. 2011. Distended colon
347
Postoperative Course: Identifi cation and Treatment
of Complication
Patient was readmitted 6 months later due to the same clinical picture of intestinal
obstruction and abdominal pain. On a CT scan, the image of a volvulus of the colon
was observed and patient was reoperated. During the operation, the colon was
attached to the left abdominal wall by stitches, permitting the small bowel to remain
free at the right side of the abdomen.
A long period of 2 years followed with intermittent abdominal pain, the patient
in the meantime having delivered a child.
One year later, a period followed of intense abdominal pain and obstruction; on
the CT scan an important colon distension of 13 cm was seen (Fig. 65.2 ). At relapa-
rotomy a bride crossed over the colon at the place where the colopexy was performed 2 years previously. The bride was taken down and the colon recovered after
decompression. The patient recovered and is nowadays stable (Fig. 65.3 ).
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Fig. 65.3 MRI showing
stable situation. Midgut
malrotation
M.A. Cuesta
Discussion
Lesson of this case is how diffi cult is to manage and operate an adult patient with
malrotation.
First described by Ladd in 1932 involving children [ 1 ], Pickhardt et al. have
described extensively the radiology diagnosis of the midgut malrotation in adults.
Midgut malrotation has been estimated to occur in approximately one in 500 live
births [ 2 – 4 ]. Reportedly, 64–80 % of patients present the symptoms within the
fi rst month of life. In older children and adults, malrotation is rarely suspected on
clinical grounds and is generally fi rst visible on imaging studies or at laparotomy.
Conventional radiography is neither sensitive nor specifi c for malrotation. The
upper gastrointestinal barium series remains accurate for detection; the duodenojejunal junction fails to cross the midline and lies below the level of the duodenal bulb. The enema fi ndings are also nonspecifi c because cecal location can be
variable without malrotation. Enhanced CT scan with oral contrast serves best to
diagnose this condition. Obstruction at duodenojejunal junction produced by the
65 Case on Complications of Intestinal Malrotation
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Divisisum
of Ladd’s bands
Ladd’s
bands
Appendicectomy
Illustration 65.1 Malrotation in adults is a rare condition, but if an acute abdomen occurred it is
important to know the embryological principles of its cause and what to do ?. Gastric dilatation
caused by Ladd’s bands, midgut malrotation, and internal hernias are the three most important
clinical situations
349
Ladd’s bands, small bowel displaced to the right abdomen, the colon to the left
and inverted relationship between superior mesenteric artery, and superior mesenteric vein are important fi ndings to establish the diagnosis of midgut malrotation
(Illustration 65.1 ).
Midgut volvulus is a complication of malrotation in which clockwise twisting of
the bowel around the SMA axis occurs because of the narrowed mesenteric attachment This life-threatening condition is a clear indication for emergency surgery.
The clinical diagnosis of midgut volvulus in adolescents and adults is diffi cult
because the presentation is usually nonspecifi c and malrotation is rarely considered.
Recurrent episodes of colicky abdominal pain with vomiting over a period of
months or years are typical and may eventually lead to imaging [
2 – 4 ].
Fortunately, the CT fi ndings of malrotation with midgut volvulus are character-
istic. The CT whirl or whirlpool sign describes the swirling appearance of bowel
and mesentery twisted around the SMA axis. Additional CT fi ndings include duodenal obstruction, congestion of the mesenteric vasculature, and evidence of underlying malrotation The presence of intestinal ischemia or necrosis is an ominous sign.
Surgical treatment should be performed if volvulus, duodenal obstruction
(division of Ladd’s bands), and internal hernia (Illustration 65.1 ) are factors.
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M.A. Cuesta
References
1. Ladd WE. Congenital obstruction of the duodenum in children. N Eng J Med.
1932;206:277–83.
2. Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescent and adults. Spectrum of clinical and
imaging features. Am J Roentgenol. 2002;179:1429–35.
3. Maxson RT, Franklin PA, Wagner CW. Malrotation in the older child: surgical management,
treatment and outcome. Am Surg. 1995;61:135–8.
4. Bernstein SM, Russ PD. Midgut volvulus: a rare cause of acute abdomen in an adult patient.
Am J Roentgenol. 1998;171:639–41.
Chapter 66
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Case on Leakage After Right Hemicolectomy
Nike M. Hanneman
Keywords Colon cancer • Laparoscopic hemicolectomy • Leakage anastomosis •
Peritonitis
First Patient
Diagnosis and Indication for Surgery
A 61-year-old man with anemia was sent to a gastroenterologist, who diagnosed a
disc-shaped anomaly at the Bauhin’s valve. Biopsy showed a tubulovillous
adenoma with severe dysplasia—most likely an intestinal adenocarcinoma. The
additional CT scan showed no evidence for metastatic disease.
Operation
A laparoscopic right hemicolectomy was performed with a side-to-side stapled
anastomosis.
N. M. Hanneman , M.D.
Department of Surgery ,
Medisch Centrum , Alkmaar , The Netherlands
e-mail: n.hanneman@mca.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_66,
© Springer International Publishing Switzerland 2014
351
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N.M. Hanneman
Postoperative Course: Identifi cation of Complication
Two days postoperative, the patient developed fever with tachycardia and abdominal tenderness. The CT scan showed a leakage of the blind ileum loop. A laparotomy showed a local purulent peritonitis, so it was decided to resect the anastomosis
and perform a new side-to-side anastomosis. The pathology showed a T2N0M0.
The patient left the hospital 12 days after his last operation.
Second Patient
Diagnosis and Description of Operation
A 76-year-old lady, known with auricular fi brillation and taking coumarin, underwent a laparoscopic extended right hemicolectomy because of an adenocarcinoma
located proximal of the hepatic fl exure. Course of operation was uncomplicated,
dissection was adequate, blood loss 100 cc, and after retrieval of the specimen
through a transumbilical incision, anastomosis was performed extra-corporeally
manually in side-to-side fashion. Stage of tumor was T3N0.
Postoperative Course: Identifi cation of Complication
Initially, she was treated postoperatively according to fast track principles, but the
third day postoperative a paralytic ileus developed and treatment was changed in
nasogastric tube and Total Parenteral Nutrition. Vicissitudes followed in this situation up to the eighth day postoperative when she developed fever and abdominal
pain. CRP values were 270 and she had a leukocytosis of 18,000. Patient was sick,
and the whole abdomen showed signs of peritonitis. Blood pressure was normal,
auricular fi brillation of 124 bpm and oliguria of 25 cc/h. Patient was admitted to the
Medium Care ward and a CT scan performed. The CT scan showed free air and fl uid
collections on the right more than left abdomen and a leakage of contrast through
the anastomosis (Fig. 66.1 ). Emergency laparotomy followed; important purulent
peritonitis was found with leakage of 2 cm at the ileum side of anastomosis. Patient
was unstable during operation, and we decided to disconnect the anastomosis and
create an ileostomy in the right lower abdomen, the transverse colon being closed
by staplers. Patient was admitted to the Intensive Care Unit, was mechanically
66 Case on Leakage After Right Hemicolectomy
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Fig. 66.1 CT scan showing
intraabdominal fl uids,
leakage of contrast, and
pneumoperitoneum
ventilated, and was noradrenaline dependent. Digoxin was given to control the
fi brillation and on the 1st postoperative day, cardioversion became necessary to control the atrial fi brillation. After 3 days, her situation improved and gradually she
could be weaned off the mechanical ventilator. Initially, ileostomy production was
high, 2,300 cc necessitating fl uids reposition and NaCl. Patient was dismissed after
30 days. Six months later through a laparotomy ileostomy was reversed by a new
ileotrasversostomy. Patient is doing well and cancer control is good.
353
Discussion
Right-sided or proximal colon cancers are increasing; as of today, 34–44 % of all
colon cancers are proximal to the splenic fl exure. The incidence in the Netherlands
is about 50 cases per 100,000 inhabitants per year. The most dreaded complication
of operation is anastomotic leakage. The percentage of occurrence of anastomotic
leakage for the colon holding for the Netherlands in the year 2010 has been 7 %.
There are many risk factors categorized as patient specifi c and intraoperative.
Surgical treatment includes resection of the anastomosis or fecal diversion via ileostomy (Illustration 66.1 ). With a small degree of contamination the right-sided
colonic leaks can often be reanastomosed and drained. With more extensive contamination, resection with ileostomy should be performed. There is no place for
simple local repair [ 1 ].
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N.M. Hanneman
Illustration 66.1 In the case of anastomosis leakage after right hemicolectomy, surgical treatment
includes resection of the anastomosis or fecal diversion via ileostomy. With a small degree of
contamination, the right-sided colonic leaks can often be reanastomosed and drained. With more
extensive contamination, resection with ileostomy should be performed. There is no place for
simple local repair
Reference
1. Snijders HS, Wouters MW, van Leersum NJ et al. Meta-analysis of the risk for anastomotic
leakage, the postoperative mortality caused by leakage in relation to the overall postoperative
mortality. Eur J Surg Oncol. 2012;38:1013–9.
Chapter 67
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Case on Anastomotic Rotation After
Laparoscopic Right Hemicolectomy
for Colonic Cancer
Bastiaan R. Klarenbeek
Keywords Cecal cancer • Intestinal obstruction • Laparoscopic right hemicolec-
tomy • Torsion anastomosis
Diagnosis and Indication for Surgery
An otherwise healthy 69-year-old male patient without a medical history was
referred to the outpatient clinic of Internal Medicine because of fatigue and energyloss based on a microcytic anemia. A colonoscopy during the study revealed an
ulcerative cecal carcinoma. A thoracic X-ray and a four-phase intravenous contrast
abdominal CT scan showed no distant metastases. Patient was scheduled for a laparoscopic right hemicolectomy.
Operation
Operation coursed without incidents; blood loss was less than 50 cc and through a
well-protected trans umbilical incision, specimen was retrieved without division of
ileum and transverse colon, division followed outside. After division by means of
staplers, anastomosis was performed in a side-to-side fashion using a hand-sewn
one-layer running suture technique. The defect in the mesentery was closed by an
absorbable suture and the bowel was repositioned in the abdomen.
B.R. Klarenbeek
Department of Surgery , MC Leeuwarden , Leeuwarden , The Netherlands
e-mail: bas.klarenbeek@znb.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_67,
© Springer International Publishing Switzerland 2014
355
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B.R. Klarenbeek
Postoperative Course: Identifi cation and Treatment
of Complication
Postoperatively, the patient developed at once an ileus, which did not resolve with
conservative measures during the fi rst 10 days (Fig. 67.1 ). Clinically, he was not
sick, no fever, abdomen distended yet not painful, light leukocytosis, and a stable
CRP of 120. An abdominal CT scan showed no signs of anastomotic leakage, but an
obstructive ileus with a transition zone at the anastomotic site (Fig. 67.2 ). Pathology
study showed a T3N0M0 cecal carcinoma.
Because of the clinical and CT scan fi ndings, a laparotomy was performed at
day 11.
Fig. 67.1 X ray of abdomen
showing postoperative small
bowel obstruction
Fig. 67.2 CT scan with
small bowel obstruction at
the level of the anastomosis
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