Did delayed recognition and management of a missed enterotomy and intra-abdominal infection deviate from the standard of care in a patient with small bowel obstruction (SBO)?

Management of Missed Enterotomy and Intra-abdominal Infection in SBO Patient

The delayed recognition and management of a missed enterotomy with resulting intra-abdominal infection for 10 days clearly deviated from the standard of care, leading to significant morbidity that could have been prevented with earlier intervention and appropriate antimicrobial therapy. 1

Standard of Care for Intra-abdominal Infections

Early Recognition and Intervention

• Intra-abdominal infections are common surgical emergencies with significant morbidity (59%) and mortality (21%) rates, requiring early diagnosis, appropriate surgical intervention, and adequate antimicrobial therapy 1
• The cornerstones of effective treatment of intra-abdominal infections are early recognition, adequate source control, and appropriate antimicrobial therapy 1
• Delayed or inappropriate antimicrobial treatment can lead to increased risk of death, necessity of re-operation, or prolonged hospitalization 1

Management Timeline

• For patients with signs of peritonitis, emergency surgical procedures should be performed as soon as possible 1
• Even for hemodynamically stable patients without acute organ failure, intervention should not be delayed for more than 24 hours if appropriate antimicrobial therapy is given 1
• Progressive clinical deterioration with fever, increasing pain, and inability to ambulate should prompt immediate investigation and intervention 1

Specific Deviations from Standard of Care

Missed Diagnosis

• The missed enterotomy during laparoscopic exploration should have been recognized intraoperatively or immediately post-operatively when the patient showed signs of clinical deterioration 2
• Inadvertent enterotomy is a known complication of laparoscopic surgery with an overall incidence of 0.58%, but is especially dangerous if unrecognized during the primary operation 2

Delayed Intervention

• The 10-day observation period without antibiotics or intervention despite clear signs of intra-abdominal infection (fever, pain, inability to ambulate, large intra-abdominal fluid collection) was inappropriate 1
• When a patient appears clinically toxic after laparoscopic surgery, prompt investigation is mandatory 2
• Patients with signs of peritonitis, sepsis, or increased abdominal pain after laparoscopic surgery must be promptly investigated 2

Inadequate Antimicrobial Therapy

• Early administration of adequate empirical broad-spectrum antimicrobial therapy influences the rates of patient morbidity and mortality 1
• For intra-abdominal infections, antimicrobial therapy should be initiated once such an infection is considered likely 1
• Appropriate agents for intra-abdominal infections include broad-spectrum antibiotics such as piperacillin-tazobactam, meropenem, or imipenem-cilastatin 3

Consequences of Delayed Management

Increased Morbidity

• The delayed management resulted in extensive resection (12.5 cm of jejunum, 45 cm of ileum, and 15 cm of cecum) and prolonged hospitalization (additional three weeks) 4
• Inadequate source control and delayed antimicrobial therapy led to progression from a localized infection to abscess/phlegmon formation with chronic inflammation 4, 5

Causality

• There is a direct causal relationship between the delayed recognition and management of the missed enterotomy and the adverse outcome 1, 4
• A prospective cohort study established a statistically significant relationship between inadequate antimicrobial treatment of infections and hospital mortality 1

Medicolegal and Ethical Implications

Documentation Issues

• Accurate documentation of operative findings is essential for appropriate post-operative management 6
• The discrepancy between the operative report (documenting serosal injuries) and the actual missed enterotomy raises concerns about documentation accuracy 6

Decision-Making

• The decision to observe without antibiotics or intervention for 10 days despite clinical deterioration was not consistent with standard practice 1, 4
• Ignoring patient requests for further imaging and intervention until clinical deterioration became severe represents a failure to provide appropriate care 6

Preventive Measures

Operative Considerations

• Only surgeons trained in advanced laparoscopy should attempt complicated cases and must always be vigilant for possible bowel injury 2
• For patients with a history of prior abdominal surgeries, there should be heightened awareness of the increased risk of enterotomy 2
• When enterotomy is recognized or suspected, a staged approach with repair of enterotomy and delayed definitive procedure may be appropriate 7

Post-operative Vigilance

• Any patient with signs of peritonitis, sepsis, or increased abdominal pain after laparoscopic surgery must be promptly investigated with appropriate imaging and laboratory tests 2
• Persistent fever, pain, and inability to ambulate should trigger immediate evaluation for possible missed enterotomy or intra-abdominal infection 1, 2

In conclusion, the 10-day delay in recognizing and managing a missed enterotomy with resulting intra-abdominal infection clearly deviated from the standard of care, leading to significant and preventable morbidity for this patient.