Subcutaneous Emphysema, Pneumoretroperitoneum, and Pneumomediastinum Following Rectal Surgery" R e p o r t of a Case a n d R e v i e w of the L i t e r a t u r e * R E N A T O A . BONARDI,
M.D., t
J O H N D . ROSIN,
M.D.,+
t~RWIN W I T K I N ,
M.D.w
From the Greater Baltimore Medical Center, Baltimore, Maryland
urinalysis were w i t h i n n o r m a l limits, coagulation history negative, S.T.S. negative, s e r u m electrolytes normal; the a l b u m i n / g l o b u l i n ratio was slightly elevated, 2.56 (normal range for this hospital 1.02.50). Chest x-ray disclosed no abnormality. T h e p a t i e n t was given a clear-liquid diet, laxatives a n d enemas, for three days, to clean the colon for the surgical repair. K a n a m y c i n , 1 g every h o u r for four hours, t h e n 1 g every six hours, by m o u t h , was added to t h e r e g i m e n over the same period. Satisfactory results were obtained with this preparation. T h e operative procedure, done J u l y 25, 1975, consisted of repair of the severed anal sphincters a n d rectovaginal s e p t u m with rectoplasty. T h e levator ani muscles as well as the severed anal sphincters were dissected free a n d closed in the m i d l i n e witho u t tension. T h e rectal a n d vaginal mucosae were a p p r o x i m a t e d individually. T h e p r o c e d u r e was well tolerated. Postoperatively the p a t i e n t c o n t i n u e d to receive a clear-liquid diet p l u s an elemental diet (Ensure@) as desired, medication for p a i n as required, a stool softener, a n d no antibiotic. T h e postoperative period was u n e v e n t f u l u n t i l J u l y 27, 1975, w h e n the p a t i e n t c o m p l a i n e d of low back p a i n as well as p a i n in the left flank, s h a r p a n d particularly exacerbated d u r i n g passage of flatus. O n physical e x a m i n a t i o n , vital signs were stable. T h e t e m p e r a t u r e was 99.8F, orally. T h e w o u n d a n d the labia were very edematous, w i t h m o d e r a t e serosanguineous drainage. Painless, subcutaneous crepitus e x t e n d e d f r o m the perineal area to the buttocks, left flank, a n d back. T r e a t m e n t with i n t r a v e n o u s fluids, penicillin, 20 million u n i t s every six h o u r s intravenously, a n d gentamicin, 80 m g i n t r a m u s c u l a r l y every eight h o u r s was started, a n d one shot of tetanus toxoid given immediately. Plain r o e n t g e n o g r a m s of the pelvis, a b d o m e n , a n d chest showed air dissecting a r o u n d the r e c t u m to the left peritoneal area, a r o u n d both kidneys, the liver, a n d the spleen, above the d i a p h r a g m , a n d a r o u n d the m e d i a s t i n u m , o u t l i n i n g the pericard i u m . T h e r e was also a considerable a m o u n t of s u b c u t a n e o u s e m p h y s e m a on the a b d o m i n a l wall,
A CASe of subcutaneous emphysema, pneumoretroperitoneum and pneumomediastinum that arose as a complication following repair of a cloaca and a rectovaginal fistula is presented. The complication differs from the more common complications related to rectal surgery. Report
of a
Case
A 44-year-old m a r r i e d white woman, para 4-0-13-3, was a d m i t t e d to the Greater Baltimore Medical Center because of a cloacal a n d rectovaginal fistula of 20 years' duration, w h i c h h a d developed after delivery of h e r second child. Physical e x a m i n a t i o n on admission revealed that the p a t i e n t was well-developed a n d well-nourished, a n d in no acute distress. E x a m i n a t i o n of external genitalia showed absence of the perineal body with a complete a p p r o x i m a t i o n of the vaginal m u c o s a with the anterior rectal wall. B i m a n u a l e x a m i n a tion vaginally showed the u t e r u s to be n o r m a l , urinary b l a d d e r well supported, a n d lateral areas clear. Rectal e x a m i n a t i o n revealed a scarred anterior rectal wall, no perineal body, a n d w h a t seemed to be, on b o t h vaginal a n d rectal e x a m i n a t i o n , a small fistulous tract to the left of the midline. T h e r e was an incomplete cloaca formation, a n d no mass was palpable. T h e r e m a i n d e r of the physical e x a m i n a t i o n disclosed no o t h e r abnormality. Laboratory studies showed h e m o g l o b i n 13.2 g/ 100 ml, h e m a t o c r i t 39 per cent, a n d leukocyte c o u n t 7,500, with a n o r m a l differential. Results of * Received for p u b l i c a t i o n M a r c h 15, 1976. J-Resident, Colon a n d Rectal Surgery. + Chief, Colon a n d Rectal Surgery. w D e p a r t m e n t of Gynecology. Address r e p r i n t requests to Dr. Rosin: Departm e n t of Colon a n d Rectal Surgery, Greater Baltimore Medical Center, 6701 N o r t h Charles Street, Baltimore, M a r y l a n d 21204.
710 Dis. Col. & Rect. Nov.-Dec. 1976
Volume 19 Number 8
Volume 19 Number 8
E M P H Y S E M A FOLLO~,VING R E C T A L S U R G E R Y
711
Fro. 1. Pelvic x-ray, showing s u b c u t a n e o u s emphysema.
below the u r i n a r y bladder, lateral to the left labia, a n d e x t e n d i n g toward the medial aspect of the thigh. T h e r e was also the suggestion of air surr o u n d i n g the intestinal tract as p n e u m a t o s i s intestinalis. T h e s e radiologic findings were speculated to represent c o m m u n i c a t e d air ratber t h a n gas from gas-forming organisms (Figs. 1-3). Cultures of material from the vagina and r e c t u m yielded m o d e r a t e growth of Proteus wzlgaris, no growth of anaerobic organisms, a n d no growth of enteric pathogens. H e m o g l o b i n was 12.2 g/100 ml, h e m a t o c r i t 36.5 per cent, a n d leukocyte c o u n t showed an elevation to the range of 11,000. T h e patient's condition r e m a i n e d stable, h e r t e m p e r a t u r e subsided the same day, a n d she cont i n u e d afebrile d u r i n g the following five days of close observation. She was never toxic or septic. T h e s u b c u t a n e o u s e m p h y s e m a resolved satisfactorily over that period. T h e antibiotics were disc o n t i n u e d at the end of the five days a n d h e r i m p r o v e m e n t was satisfactory except for developm e n t of n u m e r o u s small perineal abscesses t h a t necessitated local drainage. H e r hospital course r e m a i n e d u n r e m a r k a b l e u n t i l discharge on the e i g h t e e n t h postoperative day.
FIG. 2. Retroperitoneal e m p h y s e m a with evident delineation oC p o r t a h e p a t i s a n d both kidneys.
Discussion
Air may enter the retroperitoneal or mediastinal space after trauma or during operative procedures. Mediastinal emphysema can also occur spontaneously from rupture of pulmonary alveoli, 1 but this is a benign complication and infection is ahuost never carried along with the gas infiltrating
FIG. 3. Chest x-ray, d e m o n s t r a t i n g mediastinal e m p h y s e m a with gas dissecting between p l e u r a a n d pericardium.
7 12
BONARDI, ET AL.
the tissue planes. 4 T h i s may be true of intestinal gas passing to the retroperitoneal space also. T h e surgical procedure required 9to repair the cloaca a n d rectovaginal fistula in our patient established a communication of the rectum with the pelvirectal space bv dissection of the sphincter muscles which, even after reconstruction, allowed passage of gas from the rectum into the retroperitoneal space.Z, s, 6 T h e intestinal gas rapidly dissected the subcntaneous and retroperitoneal spaces in the ~pelvis and abdomen, then passed to the mediastinum, as demonstrated by x-ray studies (Figs. I - 3 ) . T h e five gases quantitatively i m p o r t a n t in the gut, nitrogen, oxygen, hydrogen, methane, and carbon dioxide, were assumed to be present in this complication. Nitrogen, usually the p r e d o m i n a n t gas in the bowel, is c o m m o n l y derived from swallowed air; however, diffusion from the bfood should also be given consideration. T h e r e is practically no oxygen within the intestinal tract. Presumably the oxygen that enters the bowel via swallowing of air or diffusion is rapidly utilized by the intestinal bacteria, rendering the bowel essentially anaerobic. T h e three nonatmospheric gases, hydrogen, methane, and carbon dioxide, are present in variable concentrations. M e t h a n e produced in the intestinal lumen is absorbed into the portal blood and carried to the lungs, where it is excreted on the breath. Carbon dioxide can be liberated by bacteria, like hydrogen and methane, but probably a more important but seldom recognized source of carbon dioxide in the intestine is the reaction of bicarbonate and acid.a O u r patient was treated with penicillin and gentamicin, and her condition remained
Dis. Col. & Rect. Nov.-Dee. 1976
stable during the period that air in the subcutaneous space could be detected clinically. T h i s can explain ttle fact that the gas passed from the rectum did not carry any infection or gas-forming organism. T h e considerations a b o u t the intestinal gases mentioned above can explain the rapid diffusion and resolution of the retroperitoneal, mediastinal and subcutaneous emphysema.
Summary A case of retroperitoneal, mediastinal, a n d subcutaneous emphysema following rectal surgery is described. T h i s complication has not been reported in medical literature. T r e a t m e n t was based on the fear of a more extensive and irreversible situation, because on the basis of the single case, it could not be demonstrated that the intestinal gas was not associated with infection. References 1. Artz CP, Hardy JD (eds): Emphysema. I n : Management of Surgical Complications, Third edition. Philadelphia, ~,g. B. Saunders, 1975, pp 103-04; 222; 283-84; 319; 320 2. Goligher JC, Duthie HL, Nixon HH: The fascial relations of the rectum. I n : Surgery of the Anus, Rectum and Colon. Second edition. Springfield, II1., Charles C Thomas, 1967, pp 6-8 3. Levitt MD: Studies on intestinal gas. I n : Najarian JS, Delaney J (eds): Surgery of the Gastrointestinal Tract. New York, Intercontinental Medical Book Corporation, 1974, pp 283-91 4. Nora PF (ed): Mediastinal emphysema, treatment of. I n : Operative Surgery; Principles and Techniques. Philadelphia, Lea and Febiger, 1972, p 284 5. Warwick R, Williams PL: Horizontal disposition of the peritoneum. I n : Gray's Anatomy. 35th edition. Philadelphia, W. B. Saunders, 1973, p 1259 6. Warwick R, Williams PL: The rectum. I n : Gray's Anatomy. 35th edition. Philadelphia, W. B. Saunders, 1973, pp 1290-91
M.D., t
J O H N D . ROSIN,
M.D.,+
t~RWIN W I T K I N ,
M.D.w
From the Greater Baltimore Medical Center, Baltimore, Maryland
urinalysis were w i t h i n n o r m a l limits, coagulation history negative, S.T.S. negative, s e r u m electrolytes normal; the a l b u m i n / g l o b u l i n ratio was slightly elevated, 2.56 (normal range for this hospital 1.02.50). Chest x-ray disclosed no abnormality. T h e p a t i e n t was given a clear-liquid diet, laxatives a n d enemas, for three days, to clean the colon for the surgical repair. K a n a m y c i n , 1 g every h o u r for four hours, t h e n 1 g every six hours, by m o u t h , was added to t h e r e g i m e n over the same period. Satisfactory results were obtained with this preparation. T h e operative procedure, done J u l y 25, 1975, consisted of repair of the severed anal sphincters a n d rectovaginal s e p t u m with rectoplasty. T h e levator ani muscles as well as the severed anal sphincters were dissected free a n d closed in the m i d l i n e witho u t tension. T h e rectal a n d vaginal mucosae were a p p r o x i m a t e d individually. T h e p r o c e d u r e was well tolerated. Postoperatively the p a t i e n t c o n t i n u e d to receive a clear-liquid diet p l u s an elemental diet (Ensure@) as desired, medication for p a i n as required, a stool softener, a n d no antibiotic. T h e postoperative period was u n e v e n t f u l u n t i l J u l y 27, 1975, w h e n the p a t i e n t c o m p l a i n e d of low back p a i n as well as p a i n in the left flank, s h a r p a n d particularly exacerbated d u r i n g passage of flatus. O n physical e x a m i n a t i o n , vital signs were stable. T h e t e m p e r a t u r e was 99.8F, orally. T h e w o u n d a n d the labia were very edematous, w i t h m o d e r a t e serosanguineous drainage. Painless, subcutaneous crepitus e x t e n d e d f r o m the perineal area to the buttocks, left flank, a n d back. T r e a t m e n t with i n t r a v e n o u s fluids, penicillin, 20 million u n i t s every six h o u r s intravenously, a n d gentamicin, 80 m g i n t r a m u s c u l a r l y every eight h o u r s was started, a n d one shot of tetanus toxoid given immediately. Plain r o e n t g e n o g r a m s of the pelvis, a b d o m e n , a n d chest showed air dissecting a r o u n d the r e c t u m to the left peritoneal area, a r o u n d both kidneys, the liver, a n d the spleen, above the d i a p h r a g m , a n d a r o u n d the m e d i a s t i n u m , o u t l i n i n g the pericard i u m . T h e r e was also a considerable a m o u n t of s u b c u t a n e o u s e m p h y s e m a on the a b d o m i n a l wall,
A CASe of subcutaneous emphysema, pneumoretroperitoneum and pneumomediastinum that arose as a complication following repair of a cloaca and a rectovaginal fistula is presented. The complication differs from the more common complications related to rectal surgery. Report
of a
Case
A 44-year-old m a r r i e d white woman, para 4-0-13-3, was a d m i t t e d to the Greater Baltimore Medical Center because of a cloacal a n d rectovaginal fistula of 20 years' duration, w h i c h h a d developed after delivery of h e r second child. Physical e x a m i n a t i o n on admission revealed that the p a t i e n t was well-developed a n d well-nourished, a n d in no acute distress. E x a m i n a t i o n of external genitalia showed absence of the perineal body with a complete a p p r o x i m a t i o n of the vaginal m u c o s a with the anterior rectal wall. B i m a n u a l e x a m i n a tion vaginally showed the u t e r u s to be n o r m a l , urinary b l a d d e r well supported, a n d lateral areas clear. Rectal e x a m i n a t i o n revealed a scarred anterior rectal wall, no perineal body, a n d w h a t seemed to be, on b o t h vaginal a n d rectal e x a m i n a t i o n , a small fistulous tract to the left of the midline. T h e r e was an incomplete cloaca formation, a n d no mass was palpable. T h e r e m a i n d e r of the physical e x a m i n a t i o n disclosed no o t h e r abnormality. Laboratory studies showed h e m o g l o b i n 13.2 g/ 100 ml, h e m a t o c r i t 39 per cent, a n d leukocyte c o u n t 7,500, with a n o r m a l differential. Results of * Received for p u b l i c a t i o n M a r c h 15, 1976. J-Resident, Colon a n d Rectal Surgery. + Chief, Colon a n d Rectal Surgery. w D e p a r t m e n t of Gynecology. Address r e p r i n t requests to Dr. Rosin: Departm e n t of Colon a n d Rectal Surgery, Greater Baltimore Medical Center, 6701 N o r t h Charles Street, Baltimore, M a r y l a n d 21204.
710 Dis. Col. & Rect. Nov.-Dec. 1976
Volume 19 Number 8
Volume 19 Number 8
E M P H Y S E M A FOLLO~,VING R E C T A L S U R G E R Y
711
Fro. 1. Pelvic x-ray, showing s u b c u t a n e o u s emphysema.
below the u r i n a r y bladder, lateral to the left labia, a n d e x t e n d i n g toward the medial aspect of the thigh. T h e r e was also the suggestion of air surr o u n d i n g the intestinal tract as p n e u m a t o s i s intestinalis. T h e s e radiologic findings were speculated to represent c o m m u n i c a t e d air ratber t h a n gas from gas-forming organisms (Figs. 1-3). Cultures of material from the vagina and r e c t u m yielded m o d e r a t e growth of Proteus wzlgaris, no growth of anaerobic organisms, a n d no growth of enteric pathogens. H e m o g l o b i n was 12.2 g/100 ml, h e m a t o c r i t 36.5 per cent, a n d leukocyte c o u n t showed an elevation to the range of 11,000. T h e patient's condition r e m a i n e d stable, h e r t e m p e r a t u r e subsided the same day, a n d she cont i n u e d afebrile d u r i n g the following five days of close observation. She was never toxic or septic. T h e s u b c u t a n e o u s e m p h y s e m a resolved satisfactorily over that period. T h e antibiotics were disc o n t i n u e d at the end of the five days a n d h e r i m p r o v e m e n t was satisfactory except for developm e n t of n u m e r o u s small perineal abscesses t h a t necessitated local drainage. H e r hospital course r e m a i n e d u n r e m a r k a b l e u n t i l discharge on the e i g h t e e n t h postoperative day.
FIG. 2. Retroperitoneal e m p h y s e m a with evident delineation oC p o r t a h e p a t i s a n d both kidneys.
Discussion
Air may enter the retroperitoneal or mediastinal space after trauma or during operative procedures. Mediastinal emphysema can also occur spontaneously from rupture of pulmonary alveoli, 1 but this is a benign complication and infection is ahuost never carried along with the gas infiltrating
FIG. 3. Chest x-ray, d e m o n s t r a t i n g mediastinal e m p h y s e m a with gas dissecting between p l e u r a a n d pericardium.
7 12
BONARDI, ET AL.
the tissue planes. 4 T h i s may be true of intestinal gas passing to the retroperitoneal space also. T h e surgical procedure required 9to repair the cloaca a n d rectovaginal fistula in our patient established a communication of the rectum with the pelvirectal space bv dissection of the sphincter muscles which, even after reconstruction, allowed passage of gas from the rectum into the retroperitoneal space.Z, s, 6 T h e intestinal gas rapidly dissected the subcntaneous and retroperitoneal spaces in the ~pelvis and abdomen, then passed to the mediastinum, as demonstrated by x-ray studies (Figs. I - 3 ) . T h e five gases quantitatively i m p o r t a n t in the gut, nitrogen, oxygen, hydrogen, methane, and carbon dioxide, were assumed to be present in this complication. Nitrogen, usually the p r e d o m i n a n t gas in the bowel, is c o m m o n l y derived from swallowed air; however, diffusion from the bfood should also be given consideration. T h e r e is practically no oxygen within the intestinal tract. Presumably the oxygen that enters the bowel via swallowing of air or diffusion is rapidly utilized by the intestinal bacteria, rendering the bowel essentially anaerobic. T h e three nonatmospheric gases, hydrogen, methane, and carbon dioxide, are present in variable concentrations. M e t h a n e produced in the intestinal lumen is absorbed into the portal blood and carried to the lungs, where it is excreted on the breath. Carbon dioxide can be liberated by bacteria, like hydrogen and methane, but probably a more important but seldom recognized source of carbon dioxide in the intestine is the reaction of bicarbonate and acid.a O u r patient was treated with penicillin and gentamicin, and her condition remained
Dis. Col. & Rect. Nov.-Dee. 1976
stable during the period that air in the subcutaneous space could be detected clinically. T h i s can explain ttle fact that the gas passed from the rectum did not carry any infection or gas-forming organism. T h e considerations a b o u t the intestinal gases mentioned above can explain the rapid diffusion and resolution of the retroperitoneal, mediastinal and subcutaneous emphysema.
Summary A case of retroperitoneal, mediastinal, a n d subcutaneous emphysema following rectal surgery is described. T h i s complication has not been reported in medical literature. T r e a t m e n t was based on the fear of a more extensive and irreversible situation, because on the basis of the single case, it could not be demonstrated that the intestinal gas was not associated with infection. References 1. Artz CP, Hardy JD (eds): Emphysema. I n : Management of Surgical Complications, Third edition. Philadelphia, ~,g. B. Saunders, 1975, pp 103-04; 222; 283-84; 319; 320 2. Goligher JC, Duthie HL, Nixon HH: The fascial relations of the rectum. I n : Surgery of the Anus, Rectum and Colon. Second edition. Springfield, II1., Charles C Thomas, 1967, pp 6-8 3. Levitt MD: Studies on intestinal gas. I n : Najarian JS, Delaney J (eds): Surgery of the Gastrointestinal Tract. New York, Intercontinental Medical Book Corporation, 1974, pp 283-91 4. Nora PF (ed): Mediastinal emphysema, treatment of. I n : Operative Surgery; Principles and Techniques. Philadelphia, Lea and Febiger, 1972, p 284 5. Warwick R, Williams PL: Horizontal disposition of the peritoneum. I n : Gray's Anatomy. 35th edition. Philadelphia, W. B. Saunders, 1973, p 1259 6. Warwick R, Williams PL: The rectum. I n : Gray's Anatomy. 35th edition. Philadelphia, W. B. Saunders, 1973, pp 1290-91
