AGS Block 12

Jeffrey Stromberg

Complication Summary

• Staff – Dr. Goldberg• Resident – Dr. Stromberg• Date – 4/10• Diagnosis – Colovesicular Fistula• Surgery – Open sigmoidectomy• Complication – Missed ureter injury• Outcome – prolonged hospitalization,

additional procedures

HPI

• 67 year old F with > 3 episodes of diverticulitis since 2012. Last normal colonoscopy 2011.

• Diagnosed with chronic diverticulitis 2013 and had to rule out mass due to persistent colonic thickening. Then lost to follow up.

• In past year, developed frequent UTIs, pneumaturia and eventual feculuria. Initially sent to Urologist who then referred back to AGS clinic for presumed colovesicular fistula.

• In preparation for surgery, referred to cardiology for clearance and had cardiac cath with BMS placement. Once off Plavix, returned to clinic for preop H&P.

HPI

• PHMx– Obesity, CHF, CAD s/p MI and BMS 2012/2014, mild to severe

MR, HTN, asthma, home O2• PSHx– Hysterectomy

• Social Hx– Neg x3

• Family Hx – No GI malignancy• Meds– Albuterol, ASA, Lasix, Lisinopril, metoprolol, nitroglycerin PRN,

oxybutynin

Operation• Put in lithotomy. Midline incision created. • Immediately noted a large inflammatory mass in distal sigmoid colon densely

adherent to abdominal wall, omentum, and 2 loops of small bowel• When mobilizing the sigmoid colon, dissection performed laterally while

hugging the colon as much as possible since did not know location of ureters or iliacs. This is also why cautery not used.

• 2 densely adherent loops of small bowel that were adherent to the mass were separated and the ensuing enterotomy was primarily repaired

• Colon transected at earliest disease free portions• Mesentery taken with suture ligation while hugging colon• EEA end-side anastomosis• Full thickness bladder defect never visualized. • Omental pedicle placed between colon and bladder to cover anastomosis and

serve as barrier.• Ureter never visualized. Discussion about using methylene blue but comfortable

with dissection based on where ureter should be.• Closed

Hospital Course• POD1

– Oliguric, mildly hypotensive, tachycardic, with mild increase in creatinine. Clinical diagnosis of hypovolemia. Resuscitated with 3 1L boluses and epidural held.

• POD2 – Hgb down to 7, given 2 units PRBC– Rapid response midway through 2nd transfusion for persistent tachycardia up to

160s, mild hypoxemia, PaO2 66 on 4L NC, fever 38.4.– Transferred to ICU due to clouded picture

• Transfusion reaction ? (Elevated haptoglobin and LDH, no antibodies)• Worsening AKI (Cr 1.76 from 1.0 preop), fever, tachycardia -> sepsis from UTI? • PE due to tachycardia and hypoxia?• Hypoxia from hypervolemia?

– CXR with vascular engorgement, bilateral atelectasis, small bilateral effusions, mild pulm edema• Signs hypovolemia resolved.

• POD5 abd US performed for mild hyperbilirubinemia– Pertinent findings include small volume complex ascites around paracolic

gutters, no hydronephrosis, no biliary pathology• Transferred out of unit POD5. Remained tachycardic to 130s and

intermittently oliguric. • WBC 14. Given tachycardia, planned for abdominal CT in addition to

planned CT cysto. • POD7 CT PE, abd/pelv, CT cysto

– PE added due to second rapid response

Hospital course cont.

• Urology consulted. Recommended perc nephrostomy with attempted ureteral wire placement for possible stent (unsuccessful) in addition to perc drain of urinary ascites

• Perc drain culture eventually grew rare E coli and candida albicans.

• POD10 developed midline wound drainage of urinary ascites• For remainder of hospital course: UTI from perc nephrostomy

treated, midline urinary drainage nearly closed. Discharged to SNF after 4 week hospital stay

• Readmitted 1 week later for N/V. – Nephrostomy tube replaced– New PE

Retrospectivescope• Preop

– Longstanding significant inflammation -> should have preoperatively placed ureteral stents

• Intra-op– Degree of inflammation and nonvisualization of ureter should have

prompted investigation• Methylene blue

• Postop– Her AKI, if present, quickly resolved. Never confirmed with FENa– Persistent SIRS likely due to peritonitis from urine leak– Should have prompted earlier investigation before POD7

• Outcome– Earlier recognition would have decreased morbidity by allowing for intra-op

identification and immediate correction or allowing for early re-laparotomy with corrective procedure rather than perc nephrostomy

Iatrogenic Ureter Injuries• Most common in gynecologic surgeries• APR, LAR, sigmoidectomies most common general surgical surgeries

(<2% incidence)– Any colectomy, Kocher maneuver, intra-abdominal vascular operation are

not immune• Predilection for above injuries due to anatomical relationship with

associated vasculature and organs• 50-70% injuries are missed leading to delay in diagnosis• Missed injuries increase morbidity, mortality, hospital stay

– Sepsis, pain, wound problems with fistulas or dehiscence, additional procedures or surgeries

• Prevention is the best treatment• If it occurs, early recognition is paramount to limit above.

Ureter Anatomy• Retroperitoneal structure• Courses along anterior edge of psoas adjacent to colon.

– Preferentially adheres to the peritoneum rather than the underlying psoas• Passes over iliac vessels approximately around area of iliac bifurcation• Intimately associated with major vessels

– Left• IMA or left colic pass ventral to ureter• Sigmoid mesentery

– Right• Right colic, ileocolic vessels

• Cephalad to iliacs – blood supply is medial; caudal to iliacs – blood supply enters laterally– Blood supply via adventitia which must be preserved– Injury can lead to delayed perforation or ischemic stricture

Intra-op Recognition• Understand anatomical relationships and respect that normalcy goes out the door with

inflammation• Preop stent placement

– Can feel stent– Can better identify a transection– Stenting in colorectal fairly well studied

• Placement does not prevent injury but does increase sensitivity of intraoperative recognition of injury– New lighted stents not well studied and might change this

• Increases operative time only 10-20 min

• IV injection of methylene blue or indigo carmine– See blue fluid enter operative field– Not highly sensitive

• Ureter may be spasmed and temporarily prevent leakage• Unlikely to identify blunt, ischemic, or thermal injuries.

• On table IVP– 2 cc/kg IV contrast with KUB 10 minutes later

• On table cysto with retrograde injection of ureters with above medium is most sensitive test– Technically difficult

Postoperative Signs

• Fever, flank pain, nausea, vomiting • Peritonitis, abscess, sepsis• Hydronephrosis• Urinoma• Ureteral fistula to incision (skin, vagina, etc)• Rising creatinine

– Can be due to obstructive nephropathy or peritoneal absorption of urine

• Hematuria not reliable indicator– Gross hematuria present in < 50%, microscopic in 38% of

injuries

Repair

• Whenever feasible, get urology involved– Complications of repair include leaks or stricture

• In a rural setting or on your boards when Urology never available, therefore need to know the following:– Tension free repair– Absorbable suture to prevent stone formation– Always stent the ureter regardless of repair technique– Always place drains

• In the event of leak, can prevent urinoma and check creatinine for diagnosis

Ureterouereterostomy

• For proximal 1/3 injuries or middle third injuries proximal to iliacs

• < 3cm gaps• Mobilize kidney to

allow for 4cm gaps• Always spatulate

Psoas Hitch• For longer defects in middle third• Mobilize bladder in space of Retzius• Ligate the contralateral superior bladder pedicle for

mobilization– Avoid contralateral ureter injury when performing this maneuver

• Secure the detrusor muscle to psoas muscle with monofilament suture in longitudinal placement– Assists in avoiding genitofemoral nerve and femoral nerve deep in

muscle. • Reimplant the ureter on anterior or posterior aspect (not

lateral) of bladder to prevent kinking• Tunnel in bladder wall to prevent reflux (not required but

recommended) using a separate cystotomy.

• For proximal and middle injuries

• When primary reanastomsis or ureteroneocystostomy precluded (major vascular injury, rectal injury, bladder injury)

• Mobilize donor ureter only to preserve blood supply to anastomosis

• Last resort procedure

Sources

• Burks FN, Santucci RA. Management of iatrogenic ureteral injury. Ther Adv Urol. 2014 6(3);115-124

• Delacroix SE, Winters JC. Urinary Tract Injuries: Recognition and management. Clin Colon Rectal Surg 2010;23:104-112

• Elliott SP, McAninch JW. Ureteral injuries: External and iatrogenic. Urol Clin N Am 33(2006);55-66

• Halabi WJ et al. Ureteral injuries in colorectal surgery: An analysis of trends, outcomes, and risk factors over a 10 year period in the united states. Dis Colon Rectum 2014;57:179-186