BOWEL
PERFORATION DURING PERCUTANEOUS RENAL SURGERY
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HELIO BEGLIOMINI, DEMERVAL MATTOS JUNIOR
Division of Urology, Hospital do Servidor Público do Estado de São Paulo, SP, Brazil
ABSTRACT
Introduction:
We report the case of a 74 years old patient presenting bowel lesion in
a percutaneous renal surgery to extract a 2.5cm diameter stone.
Case Report: The access to percutaneous
nephrostolithotomy was performed between the 11th and 12th left ribs at
the posterior axillary line. An abdominal transversal pad was placed and
a guide was passed down the ureter with no difficulty. Surgical time was
of approximately 40 minutes. Antegrade pielography performed at the end
of the procedure was normal. In the first post-operative day, the patient
presented severe pain and abdominal defense. An additional descendent
pielography was performed gently pulling the nephrostomy catheter, thus
contrasting the bowel. The patient underwent an exploratory laparotomy
where lacerations in left colon external wall and a bowel transfixing
lesion were found. Non-absorbable sutures in two layers were performed.
The patient presented a good progress with no occurrences during post-operative
period, and was discharged in one week.
Key words:
kidney; nephrostomy, percutaneous; intraoperative complications; intestinal
perforation
Int Braz J Urol. 2002; 28: 533-6
INTRODUCTION
Percutaneous
renal surgery is an efficient and safe procedure for treating several
urologic conditions. Complications are infrequent and consist of bleeding
and sepsis. Intra- or extra-abdominal visceral lesions are rare, although
lesions in lung, colon, duodenum, spleen, liver, and gallbladder have
been described (1-3).
The aim of this work is to report a rare
case of bowel lesion during a percutaneous renal surgery for pelvic stone
extraction.
CASE REPORT
A.C.
74 years old, male, white, had a 2.5cm stone in left renal pelvis. He
underwent 2 ESWL with double-J catheter, with no results (Figure-1). He
was submitted to a left percutaneous nephrostolithotomy, with puncture
between 11th and 12th ribs at the posterior axillary line. The patient
was brevilineous and, in spite of the placement of an abdominal transversal
pad, there was not much working space left between the 12th rib and the
superior border of the iliac bone. The surgery was performed with no adverse
events in approximately 40 minutes. A guide was passed down the ureter
without any difficulty. Descendent pielography at the end of the procedure
was normal, contrasting only the excretory system (Figure-2). In the first
post-operative day, the patient presented severe abdominal pain in the
left upper quadrant and at physical exam the abdomen presented defense.
The patient was submitted to a computed tomography, and the result was
normal. Under fluoroscopic control, the balloon of the Foley catheter
was emptied and, at the same time that contrast was injected, the catheter
was pulled. An intestinal loop was thus contrasted (Figure-3). At the
same day (1st PO day), the patient underwent an exploratory laparotomy
with identification of an extramucosal abrasion in the descendent colon
and transfixation of the Foley catheter in jejunal portion of the small
bowel, with omental blockade. In colon abrasion, 2 extramucosal prolene
3-0 U-shaped sutures were applied; in the small bowel loop, the borders
were revitalized and a 2 layers prolene 3-0 continuous suture was performed
(total and extramucosal). The nephrostomy was replaced in the left parietocolic
gutter and the abdominal cavity was washed with saline until there was
no trace of intestinal residue. A Penrose drain was left through previous
nephrostomy. The patient progressed well, being discharged in the 7th
PO day of exploratory laparotomy.
COMMENTS
The
incidence of colonic lesion during percutaneous renal procedures is approximately
0.6% (2,3). In this review, we found only 2 works in the literature about
small bowel lesion during percutaneous renal surgery, excepting the duodenal
portion (1,2).
The patient in this case was brevilineous,
presenting about 2cm between iliac crest and the border of 12th rib after
the placement of a transversal pad in the superior part of the abdomen
with ventral flexion of the table. The surgery was performed in prone
position. In addition, the stone projected itself over the 12th rib at
fluoroscopy. These circumstances determined the puncture between the 12th
and the 11th ribs at the posterior axillary line.
The use of ventral and axillary pads (to
improve ventilation), in addition to ventral flexion of the surgical table
to increase working space, are procedures that we adopt in these cases.
However, in this specific case, we assumed that the pad, together with
the high and lateralized puncture, contributed to transfix the ileal loop.
Descendent pielography at the end of the
surgery did not diagnose the lesion in the small intestine, probably due
to the loop transfixation, and because the balloon of the Foley catheter
was located in renal pelvis.
Injuries to duodenum and colon in percutaneous
renal surgery may be conservatively treated as long as there is no alteration
in general condition of the patient, and that clinical evolution is favorable.
In the case reported, it would not be possible due to the presence of
2 openings in the small bowel loop by the catheter, as observed during
exploratory laparotomy.
Perhaps this complication could be avoided
through punctures not lateralized, which is not always anatomically feasible
in percutaneous renal surgery.
REFERENCES
- Santiago L, Bellman GC, Murphy J, Tan L: Small bowel and splenic injury during percutaneous renal surgery. J Urol. 1998; 159: 2071-3.
- Viville C, Garbit JL, Firmin F, Bonnaud P: Les perforations digestives dans la chirurgie percutanée du rein. Ann Urol (Paris). 1995; 29: 11-4.
- Begliomini H, Mattos Jr. D: Cecum perforation in percutaneous renal surgery. Braz J Urol. 2002; 28: 132-4.
____________________
Received: July 24, 2002
Accepted after revision: November 11, 2002
_______________________
Correspondence address:
Dr. Hélio Begliomini
Rua Bias, 234 – Tremembé
São Paulo, SP, 02371-020, Brazil
Despite
the considerations about the patient’s brevilineous biotype, the
possibility of retrorenal peritoneal reflexion, that may exceptionally
occur, allowing colon or small bowel interposition, between the posterior
aspect of the kidney and lumbar region wall is more common in thin and
longilineous patients (1).
Apparently the surgery had no adverse events.
It was not explained in the paper whether the injury to the bowel happened
before renal puncture or through transfixing the kidney. In the first
case, the complication seemed unpredictable and inevitable. Perhaps the
anatomical variation could be known through a computed tomography, study
usually not necessary before a percutaneous surgery. In the second case,
if the injury of the loop occurred after transfixing the kidney, it would
be a technical defect.
In supra-costal punctures, the most frequent
complications are pleural.
Didactically there are 3 types of renal
punctures in percutaneous surgery: posterior (vertical) puncture, oblique
puncture (at the posterior axillary line) with patient in prone position,
and Valdivia-Úria lateral, also at the posterior axillary line,
however the patient is in supine position, slightly obliquely. I agree
with the authors that the posterior vertical puncture is the one which
offers less risk, however this complication is so infrequent that it does
not warrant warning against one or other access. Another advantage of
the posterior puncture is that it offers better tri-dimensional notion.
Generally, in oblique and lateral puncture, we work with the fluoroscope
only in anteroposterior position (bi-dimensional image), making difficult
depth evaluation.
Reference
1. Barata, HS, Carvalhal EF: Cuidados Pós-operatórios e Complicações. In: Mitre AI, Chambô JL, Arap S (eds). Manual Prático de Endourologia, São Paulo, Sarvier, 2001, p.212.
Dr. Anuar Ibrahim Mitre
Associate Professor of Urology
State University of São Paulo
São Paulo, SP, Brazil