Complications in Acute Care Surgery by Jose J. Diaz & David T. Efron

Author:Jose J. Diaz & David T. Efron
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Additional Considerations

Selection and duration of antibiotics is beyond the scope of this chapter, but it is worth noting that antibiotics should be initiated as soon as a leak is suspected and continued at least until source control is achieved.

Prolonged or recurrent pelvic sepsis delays eventual ostomy reversal and can ultimately impair future neorectum function. For this reason, use of the endo-sponge, an endoluminal vacuum device, has been proposed to help expedite healing of pelvic abscess cavities. This has been investigated in patients who develop anastomotic leaks after low anterior resection for malignancy or restorative proctocolectomy for ulcerative colitis with some positive results [13, 14]. This arguably may also have applications in patients with extraperitoneal rectal stump leaks or low pelvic stump leaks not amenable to intraoperative closure.

Long Hartmann or rectal stump dehiscence after surgery for malignancy carries an additional risk of increased locoregional recurrence and decreased survival, presumably due to spread of micrometastatic disease [11, 15]. Though this does not necessarily affect immediate management approaches to stump blowout, it may compel the surgeon to mature a mucus fistula when possible to facilitate earlier initiation of chemotherapy, and of course the patient should be counseled accordingly.

Clinical Scenario

“Patient is a 60 yo female on whom you have done a R colectomy, ileostomy, and long Hartmann for cecal perforation 1 week ago. She had cecal pneumatosis for Ogilvie’s after R hip replacement secondary to R femoral head necrosis due to prolonged steroid use. She develops fever and increased abdominal pain 5 days postcolectomy. CT scan of her abdomen is obtained as part of her workup, which demonstrated free air and ascites. At laparotomy, she has a blowout of her Hartmann stump. No distal obstruction is identified.”

This patient brings multiple risk factors for stump blowout to the table: (1) potentially ongoing colonic pseudo-obstruction (Ogilvie’s) which would put undue mechanical strain on the stump staple line, (2) prolonged steroid use, which impairs wound healing and potentially delays recognition of a leak by hindering the initial inflammatory response, and (3) the unstated reason for her steroid use, which may be a contributor to her poor wound healing capacity. Her nutritional status is also unclear. Given that she has a long Hartmann stump, we have the luxury of resecting the unhealthy portion and presumably still having a substantial length of colon preserved. The main question is whether to mature a mucus fistula or leave her stump intraperitoneal, and this may be determined by whether the stump appears to have blown out due to mechanical forces (Ogilvie’s) or poor wound healing. Given that Ogilvie’s is not a true obstruction, stump closure and decompression via transanal drainage catheter would be preferable to mucus fistula, as the mucus fistula creates an additional wound to manage. However, if the blowout appears to be due to poor wound healing rather than excessive distention, then a mucus fistula would be the safest option, as none of her wound healing risk factors will be altered. In either case, transabdominal drain placement would be prudent.

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