|Home | About | Journals | Submit | Contact Us | Français|
Dr Biswas and colleagues (February 2001 JRSM, pp. 88-89) indicate that the main message of their case report is that traumatic diaphragmatic hernia can be associated with serious intrathoracic complications, particularly if the colon is ruptured. However, I venture to suggest that this particular case report has a much more important message relating to the failure to follow cumulated experience on how to manage intestinal fistulation following breakdown of intestinal anastomotic repair. It is noteworthy that the previously fit 45-year-old man had two further colonic resections after his initial resection had broken down and formed a fistula. At his second operation, resection was undertaken after failure of attempts at percutaneous drainage and parenteral nutrition to close the fistula. Anastomosis was carried out, despite the fact that there were abscess cavities in the subphrenic space. To those experienced in fistula surgery it would come as no surprise that this second anastomosis, performed in an adverse environment, also broke down and formed a fistula. Despite this, at the third laparotomy yet another anastomosis was carried out although it was considered prudent to ‘protect’ it by a defunctioning loop ileostomy.
Although biochemical details are not given, it is almost certain that this patient would have been hypoalbuminaemic at the time of his second and third operations, a finding known to be predictive of anastomotic failure and other complications. However, even if the albumin was in the normal range it has long been recognized by those units with considerable experience of dealing with recurrent fistulation following an anastomotic leakage that anastomoses placed in a septic environment almost invariably lead to further leakage. Exteriorization of both ends of the colon should have been the preferred option at the first operation, but certainly no later than the second operation. Though the management pathway for recurrent fistulation given above has been known for many years1, the message concerning exteriorization still fails to get through.
The problem with any short case report is that only points relevant to the issue being raised can be highlighted and many of the other factors, important as they are, cannot fully be addressed. Clearly as Sir Miles realizes the intention of the presentation was to point out the serious intrathoracic complication.
By the time the patient was referred to St Mark's Hospital the sepsis was very localized in the left subphrenic/supraphrenic area and was rather akin to a localized abscess in association with, for example, an area of Crohn's disease. The serum albumin was normal. Contrary to Sir Miles' assertion—a misunderstanding due to the brevity of the report—the anastomosis was not ‘placed in a septic environment’. It was nowhere near the localized sepsis in the left upper quadrant but was in a clean uncontaminated abdomen.
There was no anastomotic failure after the repeat operation, in which the bowel was defunctioned. Death was unrelated to the abdomen, but was found at post mortem to be due to respiratory failure. ‘Pace, Sir Miles’.