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 in Small Bowel Obstruction

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) represents a significant deviation from the standard of care, which requires early recognition, prompt intervention, and appropriate antimicrobial therapy for suspected intra-abdominal infections. 1

Standard of Care for Intra-abdominal Infections

• Intra-abdominal infections are serious 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 include early recognition, adequate source control, and appropriate antimicrobial therapy - all of which were delayed in this case. 1

• Progressive clinical deterioration with fever, increasing pain, and inability to ambulate should prompt immediate investigation and intervention, not prolonged observation. 1

Specific Deviations from Standard of Care

Delayed Recognition and Intervention

• For patients with signs of peritonitis or intra-abdominal infection, emergency surgical procedures should be performed as soon as possible, with intervention not delayed beyond 24 hours even in hemodynamically stable patients. 1

• The 10-day observation period without antibiotics or intervention despite clear signs of intra-abdominal infection was inappropriate and inconsistent with standard practice. 1

• The biggest challenge with complicated intra-abdominal infections is early recognition - a challenge that was not met in this case despite multiple clinical indicators. 2

Inadequate Antimicrobial Therapy

• Early administration of adequate empirical broad-spectrum antimicrobial therapy significantly influences patient morbidity and mortality rates. 1

• For intra-abdominal infections, antimicrobial therapy should be initiated once such an infection is considered likely, not delayed for 10 days. 1

• Inappropriate empiric antimicrobial therapy is associated with delayed clinical resolution, increased length of hospital stay, and increased risk of mortality. 3

Causal Relationship to Adverse Outcome

• There is a direct causal relationship between the delayed recognition and management of the missed enterotomy and the adverse outcome experienced by this patient. 1

• The extensive surgical resection required (12.5 cm of jejunum, 45 cm of ileum, and 15 cm of cecum) and the three-week hospitalization are direct consequences of the untreated infection that was allowed to progress. 1

• Missed enterotomies are particularly dangerous complications with significant morbidity if not recognized and addressed promptly. 4

Risk Factors and Recognition of Enterotomy

• Enterotomy occurs in approximately 2.6% of patients undergoing laparoscopic procedures and is missed 21.8% of the time, highlighting the importance of vigilance. 5

• Patients with prior abdominal surgeries (as in this case) are at significantly increased risk of enterotomy during subsequent operations. 4

• Any patient with signs of peritonitis, sepsis, or increased abdominal pain after laparoscopic surgery must be promptly investigated, not observed. 4

Proper Management Timeline

• For suspected intra-abdominal infections, antimicrobial therapy should be initiated immediately and continued for 5-7 days. 2

• If sepsis persists after one week of appropriate treatment, a diagnostic workup should be performed and surgical reintervention considered - not delayed for 10 days as in this case. 2

• The mortality rate for serious intra-abdominal infections can exceed 20%, emphasizing the critical importance of timely intervention. 6

Medicolegal and Ethical Implications

• The decision to observe without antibiotics or intervention for 10 days despite clinical deterioration represents a clear deviation from standard practice. 1

• The fact that imaging and further intervention were only pursued after repeated patient requests raises significant ethical concerns about patient advocacy and appropriate response to clinical deterioration. 1

• Documentation should reflect appropriate clinical decision-making based on patient presentation and standard of care guidelines, which appears to have been lacking in this case. 1