ABSTRACT
Pulmonary embolism (PE) is a common cause of death in hospitalized patients. These emboli are usually related to deep venous thrombosis, but other etiologic factors may be the cause. A 60-year-old male was diagnosed with rectal adenocarcinoma and treated by surgical rectal resection. After surgery, he presented with a decreased level of consciousness and hypoxia with no signs of bleeding. PE was ruled out by pulmonary angiography. Given the hemodynamic instability, contrast-enhanced CT was performed, showing a discrete leak related to the rectal anastomosis, which required urgent surgery. The patient suffered cardiorespiratory arrest prior to surgery, and once resolved, the surgical procedure was limited to disconnecting the intestinal anastomosis, leaving the colon and rectal stumps free in the abdomen and keeping the abdominal cavity open with negative-pressure therapy. The patient suffered from another cardiorespiratory arrest after surgery, with abdominal distension and serous-hemorrhagic material discharge through the negative-pressure device. On a new surgical revision, no bleeding was identified, so the symptoms were attributed to coagulopathy. The patient died and autopsy was performed. The autopsy revealed no surgery-related complications. The lungs were increased in weight and showed a normal macroscopic appearance; in contrast, the histological study revealed multiple and bilateral thrombo-embolisms affecting small distal arteries. Those thrombi were composed of intestinal contents, including vegetal particles, mucinous and biliary material, fibrin, and bacterial structures. Fecal PE is an extremely infrequent event. Isolated cases have been described in association with communications between the digestive tract lumen and the systemic circulation, with a generally fatal prognosis.
ABSTRACT
BACKGROUND: The closure technique of the abdominal wall is a key factor in the development of incisional hernia. Our aim was to implement a protocol for closure of median laparotomy, to evaluate the grade of implementation, as well as to assess the results and safety of the technique. METHODS: A series of formative activities to implement the small bites technique for closure of median laparotomy in elective operations were designed. After 1 year, a survey was conducted on knowledge and use of the technique. Prospective compilation of data of all median laparotomy in elective operations and their follow-up was done for 1 year. The incidence of incisional hernia depending on the fulfilment of the protocol was compared. RESULTS: A total of 74 surgeons participated in the activities. All the participants accomplished the technique perceiving low difficulty (1.9/10). After 1 year, 44 surgeons answered the survey; 95% stated that they knew the small bites technique and used it always or almost always, but only 52% performed the calculation of the suture length and the incision length ratio. A total of 114 median laparotomy in elective operations were analyzed; among them, 30.7% were closed with small bites presenting a lower frequency of incisional hernia and burst abdomen (small bites 3.6% vs large bites 12.1%; odds ratio 1.30; confidence interval, 0.992--1.711; P = .20). CONCLUSION: The measures were effective for learning, but education alone was not enough to implement the technique in the real scenario. Small bites technique is reproducible, has no risks, and provides low incidence of incisional hernia. More incentives and actions are needed to improve laparotomy closure.
