Postradical cystectomy bowel perforation caused by a drainage tube: a case report
© Chatzidarellis et al; licensee BioMed Central Ltd. 2008
Received: 28 May 2008
Accepted: 25 November 2008
Published: 25 November 2008
Open drains are frequently placed in the abdominal cavity to prevent the collection of fluid or blood following major surgery.
We describe a case of perforation of the large bowel caused by the drain tube placed in a 74-year-old patient who had undergone radical cystectomy for invasive bladder cancer.
Perforation of the large bowel secondary to pressure necrosis caused by open drainage tubes is an extremely rare complication following major intra-abdominal surgery. Currently only twelve cases been reported in the literature, all in general surgery operations [1–7]. We describe a similar case in a patient who underwent radical cystectomy for muscle-invasive bladder cancer. We also discuss possible predisposing and precipitating factors.
A 74-year-old patient with a past medical history of diabetes, cerebral vascular disease and a moderate degree of cardiac insufficiency underwent radical cystectomy for an extensive T2G3N0M0 bladder tumor. Prior to surgery there was no evidence of preexisting bowel disease, while the patient had never been operated intraabdominally or undergone a preoperative colonoscopy. A left crossed renal ectopia was found, during the urologic evaluation which included an excretory urogram (IVU) and an abdominal computed tomography scan.
The patient was classified as ASA score III and his operation was considered of increased surgical difficulty because of the presence of the fused left renal ectopia abutting the bladder and iliac vessels. As a consequence a fully informed consent was signed preoperatively. The patient underwent an uneventful 4-hour radical cystectomy and an ileal conduit with bilateral end to side uretero-enteric anastomoses was created. The stoma was fashioned at the pre-selected site at the right lower abdominal quadrant.
Bowel perforation caused by drainage tubes following abdominal surgery is a rare complication, with only twelve cases thus far reported in literature [1–7]. All cases occurred in general surgical procedures, while this rare complication has never been reported following Urological surgery. The underlying mechanism responsible for this complication differs depending on the type of the drains used. Bowel wall can be drawn into the side holes of a suction drain due to the creation of high negative pressure which can reach the level of -180 mmHg . Open drains may cause perforation due to pressure necrosis by the tip of the tube. In addition, "stripping" of silicon surgical drains may increase the negative pressure to a level of -80 mmHg. We retrospectively tried to identify predisposing or precipitating factors for this complication. Radical cystectomy in patients with fused pelvic "lump" kidneys has rarely been reported [9–11]. Three previous reports indicated a higher difficulty compared to formal cystectomies, mainly due to the alternate vascularization and to the shortness of the left ureter. However, in our case there was no difficulty in identifying the left ureter, while its length was adequate for re-implantation. The possibility of an iatrogenic injury of the bowel with the use of cautery, cannot be excluded but is considered highly unlikely, since ligation of vessels close to the bowel was only performed by sutures. Dissecting the sigmoid colon away was easy without any obvious serosal tears or injury of its arterial supply. Ischemic arterial disease was the main predisposing factor in our case as was indicated by the patient's medical history and according to the pathology report. The complication was precipitated by the late withdrawal of the drainage tube. This was mainly due to the delayed bowel function restoration in our patient. In order to avoid this complication, soft-type drains should be placed carefully without suction and removed or mobilized early after the drain fluid has decreased, especially when patients with vascular insufficiency are being operated on.
Written informed consent was obtained from the patient's sons for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
American Society of Anesthesiologists
The authors gratefully acknowledge the advice and assistance of Konstantinos Delamarinis, MD (Radiologist)
- Hee RV: Complication of drainage. Acta Chir Belg. 1983, 83: 340-344.PubMedGoogle Scholar
- Benjamin PJ: Faeculent peritonitis: a complication of vacuum drainage. Br J Surg. 1980, 67: 453-454. 10.1002/bjs.1800670627.View ArticlePubMedGoogle Scholar
- Gray AJ, Copeland GP: Small bowel perforation following vacuum suction drainage. J R Coll Surg Edinb. 1985, 30: 324-325.PubMedGoogle Scholar
- Reed MW, Wyaman A, Thomas WE, Zeiderman MR: Perforation of the bowel by suction drains. Br J Surg. 1992, 79: 679-10.1002/bjs.1800790729.View ArticlePubMedGoogle Scholar
- Grunewald B, Kato G: Intestinal perforation by suction drains. N Z Med J. 1997, 110 (1036): 19.PubMedGoogle Scholar
- Nomura T, Shirai Y, Okamoto H, Hatakeyama K: Bowel perforation caused by silicone drains: A report of two cases. Surg Today Jpn J Surg. 1998, 28: 940-942. 10.1007/s005950050257.View ArticleGoogle Scholar
- Wang JY, Hsieh JS, Chen FM, Lee LW, Hou MF, Huang YS, Huang TJ: Rectal perforation secondary to surgical drains after low anterior resection: a report of two cases and review of the literature. Kaohsiung J Med Sci. 2002, 18 (3): 146-148.PubMedGoogle Scholar
- Graham D, Coit D, Brennan MF: Perforation of the bowel by suction drains. Br J Surg. 1993, 80: 128-129.PubMedGoogle Scholar
- Vaughn W, Hickey D, Milam HW, Soloway M: Radical Cystectomy in presence of fused "cake" kidney. Urology. 1987, 29: 552-554. 10.1016/0090-4295(87)90050-1.View ArticlePubMedGoogle Scholar
- Quek ML, Basrawala Z, McClung C, Flanigan RC: Radical cystectomy with extended lymphadenectomy in the presence of a pelvic kidney. Urology. 2006, 68: 672.e21-672.e22. 10.1016/j.urology.2006.03.048.View ArticleGoogle Scholar
- Iritiani Y, Yoshimoto M, Yamaguchi T, Maekawa M: A case of fused pelvic kidney (lump kidney) with invasive bladder tumor. Hinyokika Kiyo. 1989, 35 (6): 1041-1045.Google Scholar
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