Management of a Septic Open Abdomen Patient with Spontaneous Jejunal Perforation after Emergent C/S with Confounding Factor of Mild Acute Pancreatitis

15.05.2016 18:19


Introduction. We report the management of a septic Open Abdomen (OA) patient by the help of negative pressure therapy (NPT) and abdominal reapproximation anchor (ABRA) system in pregnant woman with spontaneous jejunal perforation after emergent cesarean section (C/S) with confounding factor of mild acute pancreatitis (AP). Presentation of Case. A 29-year-old and 34-week pregnant woman with AP underwent C/S. She was arrested after anesthesia induction and responded to cardiopulmonary resuscitation (CPR). There were only ash-colored serosanguinous fluid within abdomen during C/S. After C/S, she was transferred to intensive care unit (ICU) with vasopressor support. On postoperative 1st day, she underwent reoperation due to fecal fluid coming near the drainage. Leakage point could not be identified exactly and operation had to be deliberately abbreviated due to hemodynamic instability. NPT was applied. Two days later source control was provided by conversion of enteroatmospheric fistula (EAF) to jejunostomy. ABRA was added and OA was closed. No hernia developed at 10-month follow-up period. Conclusion. NPT application in septic OA patient may gain time to patient until adequate source control could be achieved. Using ABRA in conjunction with NPT increases the fascial closure rate in infected OA patient.

1. Introduction

Acute pancreatitis (AP) is a rare event in pregnancy (3/10 000) including a wide range of situations ranging from mild pancreatitis to serious one. Rate of AP is correlated directly with advancing gestational age. Older reviews of AP in pregnancy reported maternal and fetal mortality rates as high as 20 and 50%, respectively [1]. Contrary to this, Hernandez et al. reported 34 cases of AP with no maternal deaths and a fetal loss of only 4.7% [2].

The incidence of bowel injuries is 0.08% in cesarean section (C/S). Patients with a history of abdominal surgery scar are at high risk for intestinal injuries [3]. After C/S there was very rare spontaneous cecal perforation but there was no spontaneous small bowel perforation in the literature [4].

Enterocutaneous fistulas (ECF) are one of the most devastating abdominal complications in intra-abdominal surgery. A newly defined complication is called enteroatmospheric fistula (EAF) which is an enteric fistula in the middle of an Open Abdomen (OA) [5]. The OA is defined in World Society of Abdominal Compartment Syndrome guideline as one that requires a temporary abdominal closure due to the skin and fascia not being closed after laparotomy [6]. OA management is a life-saving and challenging strategy in situations such as the abdominal compartment syndrome (ACS) and damage-control surgery in severe generalized peritonitis [7, 8]. Mortality rates up to 50% were reported and even higher in the infected OA [9, 10].

We would like to report the management of a septic OA patient by the help of dynamic abdominal closure systems in a 34-week pregnant woman with spontaneous jejunal perforation developing after emergent C/S with her confounding factor of mild acute pancreatitis.

2. Presentation of Case

A 29-year-old and 34-week pregnant woman was admitted to emergency department with the complaint of abdominal pain, nausea, and vomiting for three days. Epigastric pain radiating to back was present. In her past history, she had been operated on for perforated appendicitis and C/S 10 and 5 years ago, respectively. Her vital parameters were as fallows: blood pressure (BP): 100/50 mmHg, heart rate (HR): 94, and fever: 36.7°C. On her abdominal examination, badly healed midline incision scar from xiphoid to pubis and C/S scar were present. Peritoneal signs and rebound tenderness were positive at epigastric region. In biochemical analysis, LDH: 277 U/L, lipase: 256 U/L, Amylase: 288 U/L, AST: 81 U/L, ALT: 101 U/L, CRP: 7 mg/dL, and in total blood count WBC: 12,000 K/μL. Multiple small calculi in different sizes were seen and pancreas was evaluated as edematous suboptimally in abdominal US. The patient was admitted to service to observe and treat for mild AP. The patient underwent C/S emergently for fetal distress 3 days after hospitalization. The patient had a cardiac arrest just after anesthesia induction. She responded to cardiopulmonary resuscitation (CPR) performed approximately for 15 minutes. Fetus was dead on delivery and did not respond to neonatal resuscitation. After C/S, on abdominal exploration, it seemed that there was ash-colored serosanguinous fluid and excessive visceral adhesions. After C/S, the patient was transferred to ICU with vasopressor support. The patient was consulted to us for fecal fluid at the drainage site on postoperative 1st day. At that time her vital parameters under high dose of vasopressor treatment were as follows: BP: 80/45 mmHg, HR: 154 F: 37.9, and RR: 34; her laboratory values were as follows: LDH: 729 U/L, creatinine: 1.6 mg/dL, Alb: 1.61 g/dL, WBC: 2.400 K/uL, CRP: 36.8 mg/dL (0–0.8), procalcitonin: 62.1 ng/mL (<0.5), INR: 1.4, and D-dimer > 1000 ng/mL. In arterial blood gas analysis, pH was 7.24, pCO2 was 34, pO2 was 159, HCO3 was 14, BE was −12, and lac was 9.6. The patient was in septic-shock and metabolic acidosis. The increases in CRP, lactate, and procalcitonin values were shown in Figure 1; increases in creatinine and INR values were shown in Figure 2. SOFA score at that time was 12 (Figure 3) and expected mortality was 45% accordingly.