Case Report Reconstructive Obstruction of Vena Cava and Collateral Flow after Abdominal Reconstruction for Gastroschisis Wenceslao M. Calonge, MD* Manuel R. Ramos, MD† Paulo Coelho, MD‡ Júlio R. Alves, MD* António Ochoa de Castro, MD†
Summary: The upper limit of intra-abdominal pressure after closure of gastroschisis has been suggested around 20 mm Hg. An acute abdominal compartmental syndrome may produce intestinal ischemia with perforation and hepatic or renal failure. We present a case of a baby born with gastroschisis and ileal atresias 2 decades ago. The closure of the defect entailed a borderline abdominal compartmental syndrome with caval occlusion and development of collateral venous circulation. This was evidenced by a phlebographic study at the age of 8. At the age of 19, the patient continued to show a superficial, varicose net and some aesthetic concerns. This minor condition seems not previously reported. The authors intend to raise awareness about current methods for indirect assessment of intra-abdominal pressure when performing abdominal reconstruction for a gastroschisis defect. (Plast Reconstr Surg Glob Open 2015;3:e304; doi: 10.1097/ GOX.0000000000000276; Published online 18 February 2015.)
A
male newborn was delivered at 36 weeks by Cesarean section after an ultrasound examination that showed images of gastroschisis. His mother was a 17-year-old primigesta. Birth weight was of 2860 g, and Apgar scores were 9/10/10. A duodenal perforation and multiple ileal atresias were visible at the operation theater, as well as several accessory spleens. As the conglomerate of atretic segments seemed swollen and extremely difficult to individualize, the surgeon of the time decided to perform a second procedure some days later. Duodenostomy and primary abdominal closure were performed as a first operation. According to the operatory report of our former colleague, “bowel loops were easily reintegrated without much pressure into the abdomen.” The report does not offer full details about the technique for primary From the *Department of Plastic Surgery, Pediatric Hospital Coimbra, Coimbra, Portugal; †Department of Oncologic Surgery, Pediatric Hospital Coimbra, Coimbra, Portugal; and ‡Department of Radiology, Pediatric Hospital Coimbra, Coimbra, Portugal. Received for publication November 4, 2014; accepted January 5, 2015. Copyright © 2015 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. DOI: 10.1097/GOX.0000000000000276
abdominal closure, but current inspection of the vertical skin scar suggests a direct approach of peritoneum, muscle, and skin in separate layers and probe-coated, transverse retention sutures. Parenteral nutrition was onset, and a second procedure was performed at 37 days for multiple anastomosis and resection of atretic, perforated segments. The remaining small intestine was about 70-cm long. The surgeon followed the scar line of the first operation by resecting its borders and reapproaching them in the same vertical fashion. Attempts of oral feeding were burdened by sepsis (Staphylococcus epidermidis) and by several occlusion and diarrhea episodes. The central line had to be changed 2 times (neither of them through the femoral vessels). The last substitution was performed through left saphenous vein and, according to the surgeon’s notes, the intraoperatory C-arm radioscopy showed how the catheter followed anomalous ways around the vena cava. Ultrasound showed what seemed an infraumbilical hypoplastic inferior cava and azygos vein dilatation. Finally, the baby could be discharged on oral feeding at the age of 4 months. The patient had a new episode of bowel obstruction at the age of 8. Moreover, he had developed a notorious development of superficial infraumbilical veins. After usual management (nihil per os, nasogastric probe), a phlebographic examination showed an
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
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Fig. 1. Phlebographic study through right inguinal and brachial access showed an abnormal drainage. Suprahepatic cava was permeable though azygos vein appeared slightly wider than usual. A dilated, venous net showed foci of established varicosity.
established occlusion of infrahepatic vena cava and a parallel net with several varicosities (Fig. 1). Fortunately, he developed without any major occlusive episodes during the following years. He has worn adapted, compressive girdle and pants that he tolerates in everyday living. However, he feels bothered and avoids bathing in public places (Fig. 2).
DISCUSSION
Thrombotic complications derived from central line insertion may occur far from the catheter tip,1 but it is difficult to figure out how such a massive thrombosis could skip cardiac, pulmonary, and systemic passage.
Fig. 2. Superficial venous flow at the age of 19.
2
So, although a congenital vascular malformation or even a distant venous thrombosis could be a possible explanation, this case probably illustrates long-term outcomes of a borderline abdominal compartment syndrome. The upper limit of intra-abdominal pressure for abdominal reconstruction in gastroschisis has been suggested around 20 mm Hg (27.2 cm H2O).2 Abdominal compartmental syndrome, a well-known complication of primary closure,3,4 may produce intestinal ischemia with perforation and hepatic or renal failure. More than 30 years ago, the fingers of surgeons on abdominal great vessels, the size of the defect, intraoperative respiratory and cardiac rates, and perfusion of lower limbs were the
Calonge et al. • Obstruction of Vena Cava and Collateral Flow only available guides. Some indirect methods for assessment have appeared in the last decades, including nasogastric probes,5 bladder catheters,6 end-tidal carbon dioxide,7 and airway pressure.8 Most anesthesiologists, who were instructed to manually ventilate during reconstruction for gastroschisis in former years, seem to prefer this last method. On the other hand, many pediatric intensive care units rely on measurement of bladder pressures for postoperative monitoring.9,10
Conclusion
As for all accounts that involve some kind of iatrogeny, this case report should be taken as a warning and a remembrance of the times when indirect measurement of intra-abdominal pressure was not so easily available as nowadays. Wenceslao M. Calonge, MD Department of Plastic Surgery Pediatric Hospital Coimbra Coimbra, Portugal E-mail: [email protected]
REFERENCES
1. Askegard-Giesmann JR, Caniano DA, Kenney BD. Rare but serious complications of central line insertion. Semin Pediatr Surg. 2009;18:73–83.
2. Olesevich M, Alexander F, Khan M, et al. Gastroschisis revisited: role of intraoperative measurement of abdominal pressure. J Pediatr Surg. 2005;40:789–792. 3. Yaster M, Buck JR, Dudgeon DL, et al. Hemodynamic effects of primary closure of omphalocele/gastroschisis in human newborns. Anesthesiology 1988;69:84–88. 4. Ein SH, Superina R, Bagwell C, et al. Ischemic bowel after primary closure for gastroschisis. J Pediatr Surg. 1988;23:728–730. 5. Wesley JR, Drongowski R, Coran AG. Intragastric pressure measurement: a guide for reduction and closure of the silastic chimney in omphalocele and gastroschisis. J Pediatr Surg. 1981;16:264–270. 6. Nakayama M, Horikawa D, Nagai H, et al. [Utility of intra-bladder pressure monitoring during closure of abdominal wall defects in newborn infants]. Masui 1992;41:1647–1650. 7. Puffinbarger NK, Taylor DV, Tuggle DW, et al. End-tidal carbon dioxide for monitoring primary closure of gastroschisis. J Pediatr Surg. 1996;31:280–282. 8. Banieghbal B, Gouws M, Davies MR. Respiratory pressure monitoring as an indirect method of intra-abdominal pressure measurement in gastroschisis closure. Eur J Pediatr Surg. 2006;16:79–83. 9. Michaud D, Abbas M, Gélinas C, et al. Intra-abdominal pressure monitoring for critically ill patients. Dynamics 2003;14:15–19. 10. Lacey SR, Carris LA, Beyer AJ III, et al. Bladder pressure monitoring significantly enhances care of infants with abdominal wall defects: a prospective clinical study. J Pediatr Surg. 1993;28:1370–1374; discussion 1374–1375.
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Summary: The upper limit of intra-abdominal pressure after closure of gastroschisis has been suggested around 20 mm Hg. An acute abdominal compartmental syndrome may produce intestinal ischemia with perforation and hepatic or renal failure. We present a case of a baby born with gastroschisis and ileal atresias 2 decades ago. The closure of the defect entailed a borderline abdominal compartmental syndrome with caval occlusion and development of collateral venous circulation. This was evidenced by a phlebographic study at the age of 8. At the age of 19, the patient continued to show a superficial, varicose net and some aesthetic concerns. This minor condition seems not previously reported. The authors intend to raise awareness about current methods for indirect assessment of intra-abdominal pressure when performing abdominal reconstruction for a gastroschisis defect. (Plast Reconstr Surg Glob Open 2015;3:e304; doi: 10.1097/ GOX.0000000000000276; Published online 18 February 2015.)
A
male newborn was delivered at 36 weeks by Cesarean section after an ultrasound examination that showed images of gastroschisis. His mother was a 17-year-old primigesta. Birth weight was of 2860 g, and Apgar scores were 9/10/10. A duodenal perforation and multiple ileal atresias were visible at the operation theater, as well as several accessory spleens. As the conglomerate of atretic segments seemed swollen and extremely difficult to individualize, the surgeon of the time decided to perform a second procedure some days later. Duodenostomy and primary abdominal closure were performed as a first operation. According to the operatory report of our former colleague, “bowel loops were easily reintegrated without much pressure into the abdomen.” The report does not offer full details about the technique for primary From the *Department of Plastic Surgery, Pediatric Hospital Coimbra, Coimbra, Portugal; †Department of Oncologic Surgery, Pediatric Hospital Coimbra, Coimbra, Portugal; and ‡Department of Radiology, Pediatric Hospital Coimbra, Coimbra, Portugal. Received for publication November 4, 2014; accepted January 5, 2015. Copyright © 2015 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. DOI: 10.1097/GOX.0000000000000276
abdominal closure, but current inspection of the vertical skin scar suggests a direct approach of peritoneum, muscle, and skin in separate layers and probe-coated, transverse retention sutures. Parenteral nutrition was onset, and a second procedure was performed at 37 days for multiple anastomosis and resection of atretic, perforated segments. The remaining small intestine was about 70-cm long. The surgeon followed the scar line of the first operation by resecting its borders and reapproaching them in the same vertical fashion. Attempts of oral feeding were burdened by sepsis (Staphylococcus epidermidis) and by several occlusion and diarrhea episodes. The central line had to be changed 2 times (neither of them through the femoral vessels). The last substitution was performed through left saphenous vein and, according to the surgeon’s notes, the intraoperatory C-arm radioscopy showed how the catheter followed anomalous ways around the vena cava. Ultrasound showed what seemed an infraumbilical hypoplastic inferior cava and azygos vein dilatation. Finally, the baby could be discharged on oral feeding at the age of 4 months. The patient had a new episode of bowel obstruction at the age of 8. Moreover, he had developed a notorious development of superficial infraumbilical veins. After usual management (nihil per os, nasogastric probe), a phlebographic examination showed an
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
www.PRSGlobalOpen.com
1
PRS Global Open • 2015
Fig. 1. Phlebographic study through right inguinal and brachial access showed an abnormal drainage. Suprahepatic cava was permeable though azygos vein appeared slightly wider than usual. A dilated, venous net showed foci of established varicosity.
established occlusion of infrahepatic vena cava and a parallel net with several varicosities (Fig. 1). Fortunately, he developed without any major occlusive episodes during the following years. He has worn adapted, compressive girdle and pants that he tolerates in everyday living. However, he feels bothered and avoids bathing in public places (Fig. 2).
DISCUSSION
Thrombotic complications derived from central line insertion may occur far from the catheter tip,1 but it is difficult to figure out how such a massive thrombosis could skip cardiac, pulmonary, and systemic passage.
Fig. 2. Superficial venous flow at the age of 19.
2
So, although a congenital vascular malformation or even a distant venous thrombosis could be a possible explanation, this case probably illustrates long-term outcomes of a borderline abdominal compartment syndrome. The upper limit of intra-abdominal pressure for abdominal reconstruction in gastroschisis has been suggested around 20 mm Hg (27.2 cm H2O).2 Abdominal compartmental syndrome, a well-known complication of primary closure,3,4 may produce intestinal ischemia with perforation and hepatic or renal failure. More than 30 years ago, the fingers of surgeons on abdominal great vessels, the size of the defect, intraoperative respiratory and cardiac rates, and perfusion of lower limbs were the
Calonge et al. • Obstruction of Vena Cava and Collateral Flow only available guides. Some indirect methods for assessment have appeared in the last decades, including nasogastric probes,5 bladder catheters,6 end-tidal carbon dioxide,7 and airway pressure.8 Most anesthesiologists, who were instructed to manually ventilate during reconstruction for gastroschisis in former years, seem to prefer this last method. On the other hand, many pediatric intensive care units rely on measurement of bladder pressures for postoperative monitoring.9,10
Conclusion
As for all accounts that involve some kind of iatrogeny, this case report should be taken as a warning and a remembrance of the times when indirect measurement of intra-abdominal pressure was not so easily available as nowadays. Wenceslao M. Calonge, MD Department of Plastic Surgery Pediatric Hospital Coimbra Coimbra, Portugal E-mail: [email protected]
REFERENCES
1. Askegard-Giesmann JR, Caniano DA, Kenney BD. Rare but serious complications of central line insertion. Semin Pediatr Surg. 2009;18:73–83.
2. Olesevich M, Alexander F, Khan M, et al. Gastroschisis revisited: role of intraoperative measurement of abdominal pressure. J Pediatr Surg. 2005;40:789–792. 3. Yaster M, Buck JR, Dudgeon DL, et al. Hemodynamic effects of primary closure of omphalocele/gastroschisis in human newborns. Anesthesiology 1988;69:84–88. 4. Ein SH, Superina R, Bagwell C, et al. Ischemic bowel after primary closure for gastroschisis. J Pediatr Surg. 1988;23:728–730. 5. Wesley JR, Drongowski R, Coran AG. Intragastric pressure measurement: a guide for reduction and closure of the silastic chimney in omphalocele and gastroschisis. J Pediatr Surg. 1981;16:264–270. 6. Nakayama M, Horikawa D, Nagai H, et al. [Utility of intra-bladder pressure monitoring during closure of abdominal wall defects in newborn infants]. Masui 1992;41:1647–1650. 7. Puffinbarger NK, Taylor DV, Tuggle DW, et al. End-tidal carbon dioxide for monitoring primary closure of gastroschisis. J Pediatr Surg. 1996;31:280–282. 8. Banieghbal B, Gouws M, Davies MR. Respiratory pressure monitoring as an indirect method of intra-abdominal pressure measurement in gastroschisis closure. Eur J Pediatr Surg. 2006;16:79–83. 9. Michaud D, Abbas M, Gélinas C, et al. Intra-abdominal pressure monitoring for critically ill patients. Dynamics 2003;14:15–19. 10. Lacey SR, Carris LA, Beyer AJ III, et al. Bladder pressure monitoring significantly enhances care of infants with abdominal wall defects: a prospective clinical study. J Pediatr Surg. 1993;28:1370–1374; discussion 1374–1375.
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