Colorectal anastomosis, “Minor leak-major outcomes”

Complications like anastomotic leakage (AL) after colorectal procedures are associated with significant morbidity. Subclinical AL can be misleading due to clinical behaviour and hence poses a diagnostic dilemma. Sometimes Radiological investigations are adjunct but may be detouring in diagnostic progression. We present a case of subclinical AL where near-miss in diagnosis led to unfavourable outcomes. In susceptible patients, diagnostic results need to be interpreted with caution in background of clinical scenario. Surgeons and radiologists need to be well familiarised of different presentations of postoperative complications after lower gastrointestinal surgery and their manifestations on imaging. Introduction Colo-rectal procedures comprise a major part in general surgery. In spite of all the advancements and precise surgical technique, complications, including anastomotic leak (AL), cause significant morbidity and mortality [1]. A local or confined leakage presents without alarming symptoms hence called subclinical anastomotic leak [2,3]. Computed tomography (CT) of abdomen has become the method of choice when assessing postsurgical complications. While its superiority in such cases is beyond proven, human errors in reporting leading to substandard outcome are not uncommon. Reliance on imaging as a diagnostic tool to replace clinical judgement (due to medico-legal impact), has become an issue of concern. Case presentation An 82-year-old male admitted to the medical unit for unusual lethargy. He had a Laparoscopic assisted anterior resection with a covering ileostomy for a mid rectal adenocarcinoma six weeks back. Anastomosis was performed with a 30 mm circular stapler. During current presentation, he complained of increased stoma output and unusual tiredness. The physical examination was unremarkable. Routine haematological tests showed high urea/creatinine ratio and electrolytes abnormalities. Management for volume and electrolytes’ abnormalities was initiated. Subsequently output from stoma gradually diminished and patient started to complain of abdominal pain and vomiting. Surgical team was involved at this point of care. Abdominal radiographs demonstrated dilated loops of small bowel and multiple air fluid levels. CT abdomen showed dilated small bowel loops. Colorectal anastomosis was reported intact with no evidence of leakage. Differential diagnosis was either adhesive bowel obstruction or ileus secondary to electrolyte abnormalities. Nasogastric decompression and fluid resuscitation commenced. Anticipating a delayed recovery in the background of adhesions and previous surgery, parenteral nutrition was commenced. Initially Obstructive features improved after 48hours with return of stoma function. However on reintroducing clear oral fluids, patient developed recurrent pain and bilious vomiting. Water-soluble contrast was given through Nasogastric tube (NGT) to achieve diagnostic and therapeutic results. Study reported small bowel obstruction proximal to site of ileostomy and a contrast administration through ileostomy was advised by the radiologist for confirmation. A Foley’s catheter was inserted through stoma and patient was sent to imaging department for a repeat scan. Unexpectedly report suggested extravasations of contrast in peritoneal cavity and pneumoperitoneum. A perforation at ileostomy site, perhaps due to catheter, was suggested as a possible cause. Considering ileostomy perforation, decision was made for an emergency laparotomy. As it was sixth week since primary procedure, water soluble-contrast enema was performed to check for anastomotic integrity prior to possible ileostomy resection or reversal if needed. It was reported as intact colorectal anastomosis with good rectal distension. Pooling of free contrast in the pelvis was assumed as spillage from ileostomy perforation at previous instance (Figure 1 arrow). A re-look midline laparotomy was performed. Surprisingly no macroscopic perforation was visualized. Findings included moderate amount of haemoserous fluids with few fibrinous adhesions without any obstructive bands. Normal calibre, adherent small bowel loops were noticed down in the pelvis. These were not disturbed by the operating surgeon (no anastomotic leak on imaging). Adhesiolysis of remaining small bowel was done and ileostomy was reversed. Patient was transferred to high dependency unit and was closely observed. He remained stable until fifth postoperative day when became delirious and developed rapid atrial fibrillation. Laparotomy Correspondence to: Zainab Naseem, Caboolture Hospital, Caboolture.PO: 4510, Queensland, Austrlalia, Tel: 61421864975; E-mail: [email protected]