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Massive hemorrhage after colon interposition: Early and late
M assive Hemorrhage After Colon Interposition: Early and Late By Edward G. Stanley-Brown
D
U R I N G T H E 15-yr period from 1957 through 1972, we have performed
six colonic interposition operations for reconstruction of the esophagus. Five patients had atresia of the esophagus without tracheoesophageal fistula, and one child required esophageal reconstruction for stricture after lye ingestion. Two patients sustained massive gastrointestinal hemorrhage, one early and the other many months after colon interposition. This would appear to be a most u n c o m m o n complication. In a recent report, Postlethwait I did not list bleeding among the complications encountered in a collective review of 1024 patients who underwent colon interposition procedures. His report included adults as well as children. Gross 2 reported on 47 infants and children and he did n o t encounter hemorrhage as a complication. Malcolm 3 described ten adults with peptic ulceration in the transposed colon of whom four presented with hemorrhage as the earliest symptom. He did report one child of 6 yr who bled from a documented ulcer in the colon but he did not give details. Waterston, 4 in a personal communication, reported this complication on two occasions in an impressive series of 120 patients, infants and children only. In both of Waterston's patients duodenal obstruction in the form of a duodenal diaphragm in one and gastric duplication in the other explained the etiology. CASE REPORTS Case 1. M.F., No. 52-25-31, was born 3 / 1 / 6 5 with atresia of the e s o p h a g u s without tracheoesophageal fistula. At age 7 hr a S t a m m g a s t r o s t o m y was performed under local anesthesia. Barium injected into the g a s t r o s t o m y outlined a respectable lower segment of e s o p h a g u s which appeared to extend to the level o f the carina. This finding p r o m p t e d a retropleural thoracotomy. However, there was a gap of 7 cm between the two esophageal segments so the c h e s t was closed and a cervical e s o p h a g o s t o m y performed. T h e baby's m o t h e r learned the technique of gastrostomy feeding and the patient was allowed home on 3/31/65. O n 5/23/67, the right colon was brought up t h r o u g h a retrosternal tunnel and a satisfactory colon interposition c a r r i e d out. A pyloroplasty was done at the same time. Her postoperative course was marred by unexplained fever which subsided without specific treatment. The gast r o s t o m y tube was removed 3 days prior to discharge on 6/19/67, but the s t o m a failed to close spontaneously so this was accomplished surgically on 9/26/67. The patient was entirely well until 4 / 2 / 6 8 , when she vomited "coffee g r o u n d " material and was promptly admitted to our Hospital. She appeared pale and irritable and her hemoglobin, upon admission, was 13.2 g. After 24 fir she passed several dark bloody stools and went into clinical shock. A frantic search for a vein ensued, there having been " c u t - d o w n s " on all four extremities in the past. At last a plastic catheter was secured deep in the left antecubital fossa and a total
From the Department of Surgery (Pediatric), St. Luke's Hospital Center. New York, N. Y. Edward G. Stanley-Brown, M.D.: Attending Surgeon, St. Luke's Hospital Center, New York. N.Y. Address for reprint requests: Edward G. Stanley-Brown. M,D., St. Luke's Hospital Center, Amsterdam Ave. at l l4th St., New York, N~ Y. 10025. 9 1974 by Grune & Stratton, lnc~ Journal of Pediatric Surgery, Vol. 9, No. 2 (April). 1974
235
236
EDWARD G. STANLEY-BROWN
of 1000 cc of whole blood, were infused over the ensuing 12 hr. Her shock state was quickly reversed and the active bleeding ceased on 4/4/68. Five days later upper gastrointestinal x-rays were obtained which revealed no evidence of ulceration. The interposed colon looked perfectly normal as did the stomach and those anastomoses which were visualized. She left the Hospital on 4/11/68 and has been perfectly well since that time. For about a year after this massive hemorrhage she was given antacids and between-meal feedings, especially at bed time. In as much as there was hematemesis as well as melena, it seems proper to theorize that this child had peptic ulceration in the interposed segment of colon. Case 2. A.P., No. 65-20-63, was born on 3/5/70 with atresia of the esophagus without tracheoesophageal fistula at 5 lb 10 oz, and with dextrocardia noted on x-ray. At 20 hr, a Stamm gastrostomy was carried out under local anesthesia. Gastrostomy feedings were well tolerated and the blind upper pouch was decompressed with constant intermittent suction. By 5/6/70 the patient weighed 7 lb 13 oz, and a left cervical esophagostomy was carried out. By 5/12/70 the mother had fed, bathed, and cared for her baby to the satisfaction of our nurses and he was allowed home. On 11/1/71, the patient was readmitted for colon interposition. He was 17 me old and weighed 24 lb. On 11/3/71, the right colon was interposed between proximal esophagus and stomach having been brought through a retrosternal tunnel. A pyloroplasty was pertbrmed at the same time. The operation went smoothly, but a cervical leak developed along with daily spiking fevers to 103 ~ 104~ On the 5th postoperative day he passed a large tarry stool and then proceeded to bleed massively for four consecutive days during which time he received 1050 cc of whole blood and 250 cc of fresh-frozen plasma. Seven days after colonic interposition the gastrointestinal bleeding continued unabated as did the spiking fevers and a new complication developed, that of swelling in the neck. With a tentative diagnosis of necrosis of the interposed colon, he was returned to the operating room. Both cervical and abdominal incisions were reopened. There was thin, purulent material in the subcutaneous tissues in both incisions but no frank peritonitis. All anastomoses were patent and intact, and there was no blood within the GI tract, Externally the colon and stomach appeared perfectly normal. Both abdominal and cervical incisions were closed in a single layer, as for a dehisence, and the subcutaneous tissues were drained. Escherichia coli was grown from the cultures taken at the time of reexploration indicating contamination during the initial operative procedure. The cervical leak slowed, finally stopped, and both incisions healed promptly. There was no further gastrointestinal bleeding. An upper gastrointestinal x-ray on 12/1/71 revealed widely patent anastomoses and no evidence of ulceration in either colon or stomach. He went home the next day and has remained entively well with continuing normal growth and development. While we did not open this child's stomach at reexploration, it would seem likely that he had stress ulcers. This child never really left his mother's arms for the first 17 me of his life save when he was asleep. She carried him everywhere she went and permitted none but herself to care for him. After esophageal reconstruction he had intravenous lines, was in an oxygen tent for humidity, and all four extremities were restrained most of the time. He cried piteously for his mother despite the fact that she was right beside the bed almost all the time. This experience could have scarcely been more stressful, particularly since no English was spoken in the patient's home. DISCUSSION
We have presented two patients with massive gastrointestinal hemorrhage after c o l o n i n t e r p o s i t i o n . In o n e p a t i e n t b l e e d i n g o c c u r r e d d u r i n g t h e i m m e d i ate postoperative period and was presumably due to "stress ulceration" of the stomach although we have no definite proof of this. The other patient sustained a life-threatening hemorrhage many months after esophageal reconstruction. B l e e d i n g in t h a t p a t i e n t w a s o f s u d d e n p a i n l e s s o n s e t a n d s e e m e d in all likelih o o d d u e t o p e p t i c u l c e r a t i o n in t h e t r a n s p o s e d c o l o n . A g a i n , u n f o r t u n a t e l y , w e could not document the precise source of bleeding. These two patients are presented simply because of the rarity of this complication.
A fairly thorough
COLON INTERPOSITION
237
search of the English literature revealed one report of hemorrhage n o t e d by M a l c o l m .
in t h e c h i l d
REFERENCES 1. Postlethwait RW, Sealy WC, Dillon ML, et al: Colon interposition for esophageal substitution. Ann Thorac Surg 12:89, 1971 2. Gross RE, Firestone FN: Colonic reconstruction of the esophagus in infants and children. Surgery 61:955, 1967
3. Malcolm JA: Occurrence of peptic ulcer in colon used for esophageal replacement. J Thorac Cardiovasc Surg 55:763, 1968 4. Waterston, D J: Personal Communication. 2/9/73
D
U R I N G T H E 15-yr period from 1957 through 1972, we have performed
six colonic interposition operations for reconstruction of the esophagus. Five patients had atresia of the esophagus without tracheoesophageal fistula, and one child required esophageal reconstruction for stricture after lye ingestion. Two patients sustained massive gastrointestinal hemorrhage, one early and the other many months after colon interposition. This would appear to be a most u n c o m m o n complication. In a recent report, Postlethwait I did not list bleeding among the complications encountered in a collective review of 1024 patients who underwent colon interposition procedures. His report included adults as well as children. Gross 2 reported on 47 infants and children and he did n o t encounter hemorrhage as a complication. Malcolm 3 described ten adults with peptic ulceration in the transposed colon of whom four presented with hemorrhage as the earliest symptom. He did report one child of 6 yr who bled from a documented ulcer in the colon but he did not give details. Waterston, 4 in a personal communication, reported this complication on two occasions in an impressive series of 120 patients, infants and children only. In both of Waterston's patients duodenal obstruction in the form of a duodenal diaphragm in one and gastric duplication in the other explained the etiology. CASE REPORTS Case 1. M.F., No. 52-25-31, was born 3 / 1 / 6 5 with atresia of the e s o p h a g u s without tracheoesophageal fistula. At age 7 hr a S t a m m g a s t r o s t o m y was performed under local anesthesia. Barium injected into the g a s t r o s t o m y outlined a respectable lower segment of e s o p h a g u s which appeared to extend to the level o f the carina. This finding p r o m p t e d a retropleural thoracotomy. However, there was a gap of 7 cm between the two esophageal segments so the c h e s t was closed and a cervical e s o p h a g o s t o m y performed. T h e baby's m o t h e r learned the technique of gastrostomy feeding and the patient was allowed home on 3/31/65. O n 5/23/67, the right colon was brought up t h r o u g h a retrosternal tunnel and a satisfactory colon interposition c a r r i e d out. A pyloroplasty was done at the same time. Her postoperative course was marred by unexplained fever which subsided without specific treatment. The gast r o s t o m y tube was removed 3 days prior to discharge on 6/19/67, but the s t o m a failed to close spontaneously so this was accomplished surgically on 9/26/67. The patient was entirely well until 4 / 2 / 6 8 , when she vomited "coffee g r o u n d " material and was promptly admitted to our Hospital. She appeared pale and irritable and her hemoglobin, upon admission, was 13.2 g. After 24 fir she passed several dark bloody stools and went into clinical shock. A frantic search for a vein ensued, there having been " c u t - d o w n s " on all four extremities in the past. At last a plastic catheter was secured deep in the left antecubital fossa and a total
From the Department of Surgery (Pediatric), St. Luke's Hospital Center. New York, N. Y. Edward G. Stanley-Brown, M.D.: Attending Surgeon, St. Luke's Hospital Center, New York. N.Y. Address for reprint requests: Edward G. Stanley-Brown. M,D., St. Luke's Hospital Center, Amsterdam Ave. at l l4th St., New York, N~ Y. 10025. 9 1974 by Grune & Stratton, lnc~ Journal of Pediatric Surgery, Vol. 9, No. 2 (April). 1974
235
236
EDWARD G. STANLEY-BROWN
of 1000 cc of whole blood, were infused over the ensuing 12 hr. Her shock state was quickly reversed and the active bleeding ceased on 4/4/68. Five days later upper gastrointestinal x-rays were obtained which revealed no evidence of ulceration. The interposed colon looked perfectly normal as did the stomach and those anastomoses which were visualized. She left the Hospital on 4/11/68 and has been perfectly well since that time. For about a year after this massive hemorrhage she was given antacids and between-meal feedings, especially at bed time. In as much as there was hematemesis as well as melena, it seems proper to theorize that this child had peptic ulceration in the interposed segment of colon. Case 2. A.P., No. 65-20-63, was born on 3/5/70 with atresia of the esophagus without tracheoesophageal fistula at 5 lb 10 oz, and with dextrocardia noted on x-ray. At 20 hr, a Stamm gastrostomy was carried out under local anesthesia. Gastrostomy feedings were well tolerated and the blind upper pouch was decompressed with constant intermittent suction. By 5/6/70 the patient weighed 7 lb 13 oz, and a left cervical esophagostomy was carried out. By 5/12/70 the mother had fed, bathed, and cared for her baby to the satisfaction of our nurses and he was allowed home. On 11/1/71, the patient was readmitted for colon interposition. He was 17 me old and weighed 24 lb. On 11/3/71, the right colon was interposed between proximal esophagus and stomach having been brought through a retrosternal tunnel. A pyloroplasty was pertbrmed at the same time. The operation went smoothly, but a cervical leak developed along with daily spiking fevers to 103 ~ 104~ On the 5th postoperative day he passed a large tarry stool and then proceeded to bleed massively for four consecutive days during which time he received 1050 cc of whole blood and 250 cc of fresh-frozen plasma. Seven days after colonic interposition the gastrointestinal bleeding continued unabated as did the spiking fevers and a new complication developed, that of swelling in the neck. With a tentative diagnosis of necrosis of the interposed colon, he was returned to the operating room. Both cervical and abdominal incisions were reopened. There was thin, purulent material in the subcutaneous tissues in both incisions but no frank peritonitis. All anastomoses were patent and intact, and there was no blood within the GI tract, Externally the colon and stomach appeared perfectly normal. Both abdominal and cervical incisions were closed in a single layer, as for a dehisence, and the subcutaneous tissues were drained. Escherichia coli was grown from the cultures taken at the time of reexploration indicating contamination during the initial operative procedure. The cervical leak slowed, finally stopped, and both incisions healed promptly. There was no further gastrointestinal bleeding. An upper gastrointestinal x-ray on 12/1/71 revealed widely patent anastomoses and no evidence of ulceration in either colon or stomach. He went home the next day and has remained entively well with continuing normal growth and development. While we did not open this child's stomach at reexploration, it would seem likely that he had stress ulcers. This child never really left his mother's arms for the first 17 me of his life save when he was asleep. She carried him everywhere she went and permitted none but herself to care for him. After esophageal reconstruction he had intravenous lines, was in an oxygen tent for humidity, and all four extremities were restrained most of the time. He cried piteously for his mother despite the fact that she was right beside the bed almost all the time. This experience could have scarcely been more stressful, particularly since no English was spoken in the patient's home. DISCUSSION
We have presented two patients with massive gastrointestinal hemorrhage after c o l o n i n t e r p o s i t i o n . In o n e p a t i e n t b l e e d i n g o c c u r r e d d u r i n g t h e i m m e d i ate postoperative period and was presumably due to "stress ulceration" of the stomach although we have no definite proof of this. The other patient sustained a life-threatening hemorrhage many months after esophageal reconstruction. B l e e d i n g in t h a t p a t i e n t w a s o f s u d d e n p a i n l e s s o n s e t a n d s e e m e d in all likelih o o d d u e t o p e p t i c u l c e r a t i o n in t h e t r a n s p o s e d c o l o n . A g a i n , u n f o r t u n a t e l y , w e could not document the precise source of bleeding. These two patients are presented simply because of the rarity of this complication.
A fairly thorough
COLON INTERPOSITION
237
search of the English literature revealed one report of hemorrhage n o t e d by M a l c o l m .
in t h e c h i l d
REFERENCES 1. Postlethwait RW, Sealy WC, Dillon ML, et al: Colon interposition for esophageal substitution. Ann Thorac Surg 12:89, 1971 2. Gross RE, Firestone FN: Colonic reconstruction of the esophagus in infants and children. Surgery 61:955, 1967
3. Malcolm JA: Occurrence of peptic ulcer in colon used for esophageal replacement. J Thorac Cardiovasc Surg 55:763, 1968 4. Waterston, D J: Personal Communication. 2/9/73