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468
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J. de Bruin
Fig. 85.1 CT scan, juxtarenal abdominal aorta aneurysm
loss was 800 cc. Postoperatively, the patient was transferred to the intensive care
unit.
Postoperative Course: Identifi cation and Treatment
of Complication
During the fi rst 24 h, the patient developed acute renal insuffi ciency and remained
dependent on noradrenalin. After 48 h, the patient’s condition worsened and he developed lactic acidosis with bowel distension. A colonoscopy was performed, under
suspicion of sigmoid ischemia, showing ulcerative colitis with ischemia in the sigmoid (Fig. 85.2 ). Patient was transferred to the operating room and a laparotomy was
performed; during the operation, ischemic changes of the sigmoid and left descending colon were seen. A left-sided colectomy was performed, rectal stump closed, and
a colostomy was made (Illustration 85.1 ). The abdomen could not be closed without
tension; therefore, a double Vicryl mesh ® was used. After the second operation, the
patient received two additional interventions to remove contaminated fl uids in the
pelvic space. Moreover, he had myocardial infarction due to a coronary stenosis;
therefore, an angioplasty with coronary stenting was done. Three months after initial
surgery, a split skin graft was performed to cover the large abdominal wound.
85 Ischemia–Necrosis of the Sigmoid After Repair of a Ruptured Juxtarenal Aneurysm
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Fig. 85.2 Colonoscopy:
ischemia of the sigmoid
469
Illustration 85.1 Ischemia of the sigmoid is a serious complication after repair of an acute rupture of an abdominal aorta aneurysm. If suspicion, because of sepsis, a colonoscopy will establish
the diagnosis. A sigmoid resection and Hartmann procedure should be done
Hartmann
procedure
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J. de Bruin
Discussion
Several risk factors leading to colonic ischemia (CI) after abdominal aortic aneurysm repair have been identifi ed: aneurysm rupture, long duration of operation, and
prior renal disease [ 1 ]. The incidence of CI has not changed with the introduction of
endovascular aortic aneurysm repair [ 1 , 2 ]. After elective open abdominal aortic
aneurysm repair, the rate of incidences vary between 1 and 3 % [ 2 , 3 ]. However,
after ruptured aneurysm, the incidence of clinically signifi cant CI reaches 10 %.
Routine postoperative colonoscopy shows higher incidences of ischemic colitis
after both elective and ruptured aneurysm repair [ 4 ]. A defi nitive diagnosis is best
made by colonoscopy. Diagnosis of CI is strongly associated with poor survival—
especially after ruptured abdominal aortic aneurysm repair [ 5 ]. In the case of isch-
emia by colonoscopy and a hemodynamic unstable patient or having high lactate,
ischemia should be considered transmural and a laparotomy should be performed.
During laparotomy the ischemic part of the left colon or sigmoid has to be resected
followed by creation of a left abdomen colostomy (Hartmann procedure).
References
1. Becquemin JP, Majewski M, Fermani N, et al. Colon ischemia following abdominal aortic
aneurysm repair in the era of endovascular abdominal aortic repair. J Vasc Surg.
2008;47:258–63.
2. Dadian N, Ohki T, Veith FJ, et al. Overt colon ischemia after endovascular aneurysm repair: the
importance of microembolization as an etiology. J Vasc Surg. 2001;34:986–96.
3. Van Damme H, Creemers E, Limet R. Ischaemic colitis following aortoiliac surgery. Acta Chir
Belg. 2000;100:21–7.
4. Schiedler MG, Cutler BS, Fiddian-Green RG. Sigmoid intramural pH for prediction of isch-
emic colitis during aortic surgery. A comparison with risk factors and inferior mesenteric artery
stump pressures. Arch Surg. 1987;122:881–6.
5. Acosta S, Lindblad B, Zdanowski Z. Predictors for outcome after open and endovascular repair
of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2007;33:277–84.
Chapter 86
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Case on Complications and Approach
in Post-radiation Enteritis
Suzanne S. Gisbertz
Keywords Cervix cancer • Radiotherapy • Radiation enteritis • Parenteral nutrition
• Laparotomy
First Patient
Diagnosis and Indication for Chemoradiotherapy
A 36-year-old supermarket employee was diagnosed of having a cervix carcinoma
stage IIB (Fig. 86.1 ). The patient was proposed to treat the tumor by chemo-
radiotherapy, in this case, the external radiotherapy of 23 × 2 Grays in combination
with weekly iv. Cisplatin ® was given, and between the fourth and sixth week, HDR
brachytherapy (2 × 8.5 Grays ) at the place of point A of cervix was administered
through the Fletcher applications system (Fig. 86.2 and Illustration 86.1a ).
Postoperative Course: Identifi cation and Treatment
of Complication
The tumor responded optimally to the treatment, but the patient started experiencing
abdominal cramps, diarrhea, and weight loss. Suspicion arose of radiation enteritis
and this was confi rmed by the CT scan. After a period of 3 months, the patient’s
appetite was decreasing and she had started vomiting. Her abdomen was found distended and in spite of extra nutrition advice, she ended up with a weight of 40 kg.
So, she was admitted to the department of gynecology for treatment. Total
S. S. Gisbertz , M.D.
Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
e-mail: s.gisbertz@antoniusziekenhuis.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_86,
© Springer International Publishing Switzerland 2014
471
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Fig. 86.1 MRI, cervix
carcinoma stage 2B
S.S. Gisbertz
Fig. 86.2 Brachytherapy
treatment
86 Case on Complications and Approach in Post-radiation Enteritis
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Fig. 86.3 MRI, 9 months
later radiation enteritis
parenteral nutrition was started and surgeons were consulted. Exploring the patient
and seeing the CT scan, we observed a malnourished young patient having a strong
abdominal distension as caused by small bowel and having colonic ileus as caused
by stenosis of the sigmoid. Moreover, radiation enteritis of the distal loops of small
bowel was observed (Figs. 86.3 and 86.4a, b ). The stomach was also dilated.
Treatment was started with the TPN, nasogastric tube, and metabolic correction of
electrolytes. This situation was considered chronic and in talks with patient and
family we advised her to take at least 6–8 weeks of time for improving her general
condition and weight before a laparotomy could be planned. Despite her acute disappointment, she accepted this proposal. After the period of 6 weeks her weight now
was 47 kg with still abdominal distention and intestinal obstruction. A laparotomy
was performed; loops of ileum were covering a proximal rectal perforation of 10 cm
at the anterior side. Small bowel was thick but patent. Rectum was dissected distal
of perforation and at normal aspect (7 cm from anal verge) was divided by means of
stapler device. We decided do not perform a primary anastomosis and an end-colostomy was created outside of the radiation fi eld at the left upper abdomen (Illustration
86.1b ). Her postoperative period was uncomplicated, and the patient could be dis-
charged after 10 days without TPN. At gynecological examination, a complete
regression of the tumor in the cervix was observed. After a period of 6 months, she
suggested taking down the colostomy. Rectal enema was considered normal and the
intervention was performed after mobilizing the splenic fl exure and transverse colon
conveniently (Illustration 86.1b ). Small bowel loops were still thick but patent. She
recovered very quickly and could be discharged after a week. She is under control
of gynecology and surgery. On MRI scan, no rest of the tumor is seen.
473
Second Patient
Diagnosis and Indication for Surgery
A 44-year-old female patient was diagnosed with rectal cancer. She had been
referred by her general practitioner to a local hospital with rectal blood loss. Physical
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Fig. 86.4 ( a ) CT scan,
obstruction at the level of the
sigmoid and small bowel
ileus. ( b ) CT scan showing
intestinal obstruction
S.S. Gisbertz
a
b
86 Case on Complications and Approach in Post-radiation Enteritis
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475
a
External
radiotherapy
Brachytherapy
b
Radiation
enteritis
Cervix
cancer
Illustration 86.1 ( a , b ) A minority of cases with radiation enterocolitis is managed by a surgical
intervention. Most patients can be treated with supportive care such as fl uid replenishment and
nutritional support. Indications for surgery usually comprise of gastrointestinal obstruction, perforation, or severe proctitis
Rectal
perforation
Colostomy
Anastomosis
Hartmann procedure
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Fig. 86.5 CT scan showing
thickened walls of the small
intestine, distended colon,
infi ltration of the mesentery,
and free fl uid
Fig. 86.6 CT scan showing a
thickened rectosigmoid loop
S.S. Gisbertz
examination, including rectal examination, was normal. A colonoscopy revealed a
tumor at 10 cm from the anal verge. Biopsies showed a moderately differentiated
adenocarcinoma. Endoscopic ultrasound and pelvic MRI staged the tumor as T2N2.
CT scanning of thorax and abdomen did not show any signs of metastases. She was
treated with neoadjuvant chemoradiation consisting of daily administration of
Capecitabine and 5 days per week radiation fractions of 2 Gray to a total amount of
50 Gray in 5 weeks. However, after 18 fractions and in a little more than 3 weeks
later she developed severe toxicity, consisting of grade III diarrhea, nausea, vomiting, neutropenic fever, and with a distended, painful abdomen on physical examination. CT scanning showed thickened walls of the small intestine and rectosigmoid
loop, distended colon, infi ltration of the mesentery, and free fl uid (Figs. 86.5 and
86.6 ). She was transferred to an academic hospital for further treatment. There she
was treated with supportive therapy consisting of intravenous fl uids, total parenteral
nutrition, pain medication, and antibiotics. Seven weeks after the discontinuation of
the neoadjuvant therapy, her clinical condition improved in such extent that she
could be operated on. She, however, retained low weight (weight 48 kg, length
1.73 m, BMI 16).
86 Case on Complications and Approach in Post-radiation Enteritis
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477
Operation Description
A laparoscopic low anterior resection was performed. The rectosigmoidal junction
had an infl amed aspect with a thick wall and vascular injection. We therefore chose not
to perform an anastomosis; instead a colostomy in the descending colon was created.
Oncologic Stage
The pathological–anatomical investigation revealed a radically removed tumor
without lymph node involvement, therefore classifi ed as T1N0M0. Additionally,
extensive chemoradiation therapy effects were shown.
Postoperative Course: Identifi cation and Treatment
of Complication
The postoperative course of this patient was uneventful; no complications occurred.
One year postoperatively, a colonoscopy of the distal rectum and of the colon via
the colostomy was performed, as well as a MRI enteroclysis for visualization of the
small intestine, without any signs of radiation enteritis. Mild diversion colitis was
seen in the distal rectum. Dissemination investigations did not show signs of metastasis or recurrent disease. Additionally, she gained weight, and her performance
status improved to normal levels. On basis of these fi ndings, the continuity was
restored with a laparoscopic procedure. This operation was uncomplicated as well.
Discussion
Symptoms of radiation enteritis include nausea, vomiting, colic pain, diarrhea,
fever, and additional weight loss; all observed in these two cases [ 1 ]. A minority of
cases is managed by a surgical intervention. Most patients can be treated with supportive care such as fl uid replenishment and nutritional support. Indications for surgery usually comprise gastrointestinal obstruction, perforation, or severe proctitis
[ 4 ]. It is noteworthy that radiation enteritis and the need for salvage surgery can still
be observed until some years after radiation therapy (early versus later radiation
enteritis) [ 1 , 2 ]. Considering the fi rst case with obstruction at the level of the recto-
sigmoid junction, after getting the patient in a better general and nutritional condition, a resection was made of the proximal rectum with creation of a colostomy.
Almost a year later, the colostomy was reversed with success.
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