Delayed Bowel Perforation Intervention Causes Patient Kidney Injury

This case involves a 69-year-old male patient with a complicated medical history who underwent a colonoscopy. He was noted to have a diverticular stricture and the surgeon suspected perforation. The structure was marked with an ink spot, and a chest radiograph and an abdominal film were done. An abnormal presence of air was discovered in the peritoneal cavity. The patient underwent an exploratory laparotomy converted to open sigmoidectomy with colocolic anastomosis. Initially, he did okay. However, a subsequent CTAP without contrast showed a gas and fluid collection. A reread showed free air throughout the abdomen and pelvis. The patient was started on antibiotics. The CT was repeated later, again without contrast showing air. The patient was then intubated. He was taken back to the operating room and found to have a small bowel perforation which was resected and primarily anastomosed. He developed acute kidney injury and bladder pressures were attempted. His ICU course continued with a wound infection positive for Klebsiella and enterococcus. A CTAP without contrast was subsequently done while the patient was still intubated but was unremarkable. The patient was then extubated, however, he regressed. His ICU course continued with pulmonary reintubation and cardiac complications.

Question(s) For Expert Witness

1. How often do you treat patients with sigmoid perforation?

2. What should the antibiotic regimen be after a sigmoidectomy and a colocolonic anastomosis?

3. What CT findings might warrant a patient's return to the operating room?

Expert Witness Response E-074309

The answer to this question varies depending on the clinical scenario. For a straight forward sigmoid colectomy, only a single dose of pre-operative antibiotics are indicated. If there is an acute perforation with contamination, the post-operative regimen can vary. In a case such as this, the patient was undergoing a colonoscopy and must have had a bowel prep prior to the procedure which would minimize the contamination associated with an iatrogenic perforation making a post-op regimen unnecessary. Post-operative free air on CT can be difficult to interpret as one is trying to evaluate the degree of free air seen and compare to that expected. A large amount of free air seen on any imaging study 4 days post operation in the setting of clinical deterioration should have been a strong indicator that the free air was not simply related to the previous ex-lap. An additional 2-day delay in repeat ex-lap is concerning. I have reviewed previous cases which involve a delay in diagnosis. Each of these cases surrounds the issue of immediate identification of a clinical problem which requires urgent or emergent surgical exploration the surgeon's delay in intervention which resulted in additional post-operative complications and one which resulted in death.