CECUM
PERFORATION IN PERCUTANEOUS RENAL SURGERY
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HELIO BEGLIOMINI, DEMERVAL MATTOS JR.
Division of Urology, Hospital do Servidor Público do Estado de São Paulo, SP, Brazil
ABSTRACT
Introduction:
We report a case of cecum lesion during percutaneous nephrolithotripsy
not diagnosed during surgery.
Case Report: A 48-year-old woman was submitted
to a right percutaneous nephrolithotomy due to a 2-cm renal pelvis calculus.
The puncture was performed in the right lumbar region, 0.5 cm medial to
the posterior axillary line and around 2 cm below the 12th rib extremity.
In the 2nd post-operative day, fecaloid liquid and gas elimination was
present around the nephrostomy opening. An exploratory laparotomy showed
feces in the peritoneal cavity and the nephrostomy catheter that transfixed
the cecum. The nephrostomy was removed, the cecum openings were revived
and sutured in two plans. The nephrostomy was replaced with right flank
exteriorization. The peritoneal cavity was washed, and early maturation
loop ileostomy was performed.
Comments: The case reported here presents
the particularity of having the whole percutaneous procedure performed
through the cecum, despite not identified intraoperatively. Taking into
consideration that the puncture was not foreseen, and that there were
two cecum openings, it is inferred that the cecum could be abnormally
distended and dislocated upwards and backwards, conditions which would
justify the complication.
Key words:
kidney; nephrolithotomy; percutaneous; complications; cecum perforation
Braz J Urol, 28: 132-134, 2002
INTRODUCTION
Percutaneous nephrolithotomy was described over 30 years ago, and since the eighties it has been considered an effective procedure for urinary lithiasis treatment in the urological practice. Because a small cutaneous incision of approximately 2-cm is used, it presents a good post-operative recovery and fast return to normal activities. A case of involuntary transcecum approach, not diagnosed during the surgery, is reported. Any report of cecum perforation in this type of surgery was found in the literature.
CASE REPORT
A
48-year-old woman was submitted to a right percutaneous nephrolithotomy
due to a 2-cm renal pelvis calculus which did not fragmented after two
attempts of extracorporeal shock wave lithotripsy (ESWL) (Figure-1). The
puncture was performed in the right lumbar region, 0.5 cm medial to the
posterior axillary line and around 2-cm below the 12th rib extremity.
A pneumatic lithotriptor was used and there were no abnormalities during
the procedure (Figure-2). Postoperatively, the patient presented flank
and right lumbar region pain. In the second postoperative day (PO) she
presented fecaloid liquid and gas elimination around the nephrostomy opening.
In the third PO day, the patient was submitted to median laparothomy under
the suspicion of acute abdomen intestinal perforation, due to severe right
flank pain, painful abdominal decompression, general state fall and fecaloid
liquid elimination around the nephrostomy. During the procedure, feces
in the peritoneal cavity and the nephrostomy catheter which transfixed
the cecum were identified. The nephrostomy was removed, the cecum openings
were revived and sutured in two plans. The nephrostomy was replaced with
right flank exteriorization. The peritoneal cavity was exhaustively washed
with saline. Early maturation loop ileostomy was performed. The peritoneal
cavity was drained with a rubber drain. The nephrostomy was removed in
the 7th PO day. The patient improved slowly and was discharged from hospital
in the 22nd PO day. Ileostomy closing was scheduled after 3 months.
COMMENTS
Among
the percutaneous renal surgery complications, there are the immediate,
such as hemorrhage, hematuria, pneumohydrothorax, pathway loss, gastrointestinal
and gallbladder perforation, ureteropyelic junction rupture, impaction
of the calculus extractive probe in the ureter, guiding string rupture,
iodine contrast allergic reactions, bacterial infection and hydro-electrolitic
metabolic dysfunction. Among the latest, there are urinary infections,
residual lithiase and ureteropyelic junction obstruction (1).
The percutaneous renal access is a relatively
safe procedure, with complication rates varying from 5 to 8%. Adjacent
organs lesions are not common; however, isolated cases of gastrointestinal
lesions have been reported. The majority of these accidents involves the
colon and, more rarely, the duodenum and gallbladder, which can lead to
peritonitis and fistulas (1).
In some cases, the colon can be in a posterior
position in the retrorenal space, which favors this kind of accident.
The incidence of colon lesions in percutaneous renal procedures is low,
of around 0.6% (2). In slim patients, there are more chances of the colon
be located posteriorly, because they have less retroperitoneal fat. The
abdomen computed tomography is the best procedure to evaluate this suspicion,
although its use in the preoperative of all patients to be submitted to
percutaneous renal surgeries is not feasible (2).
When the diagnosis is made during the surgery
by organ contrasting, a conservative approach may be adopted if a small
and punctiform lesion is evident. In these cases, fasting, nasogastric
probe for 10 to 14 days and parenteral food is indicated. There are authors
who take advantage of the Amplatz sheath to place a Malecot or Foley catheter
inside the colon or duodenum, to control the debt and avoid peritonitis.In
these cases, urinary drainage through a double J ureteral catheter may
also be useful (3). If the lesion is larger or in case of doubt, open
surgery should be indicated.
The case reported here presents the particularity
of having the whole percutaneous procedure performed through the cecum,
despite not identified intraoperatively. Taking into consideration that
the puncture was not foreseen, and that there were two cecum openings,
it is inferred that the cecum could be abnormally distended and dislocated
upwards and backwards, conditions which would justify the complication.
REFERENCES
- Lopes Neto AC, Machado MT, Juliano RV, Lipay MA, Borrelli M, Wroclawski ER: Duodenal damage complicating percutaneous access to kidney. São Paulo Med J, 118: 116-117, 2000.
- Maillet PJ, Dulac JP, Barth X, Pelle-Francoz D, Peix JL, Bobin JY: Colonic perforations during interventional urinary radiology. J Radiol, 67: 225-229, 1986.
- Ahmed M, Reeve R: Iatrogenic duodeno-cutaneous fistula at percutaneous nepholithotomy managed conservatively. Br J Urol, 75: 416-418, 1995.
______________________
Received:
October 9, 2001
Accepted after revision: February 8, 2002
_______________________
Correspondence address:
Dr. Helio Begliomini
Rua Bias, 234
São Paulo, SP, 02371-020, Brazil
Fax: + + (55) (11) 6982-5573