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

Management of Missed Enterotomy and Delayed Treatment in Small Bowel Obstruction

The delayed recognition and treatment of a missed enterotomy with subsequent intra-abdominal infection in this case represents a clear deviation from the standard of care, as immediate intervention was warranted given the patient's progressive clinical deterioration.

Standard of Care for Intra-abdominal Infections

• The cornerstones of effective management of intra-abdominal infections are early recognition, adequate source control, and appropriate antimicrobial therapy 1, 2
• For patients with signs of peritonitis or clinical deterioration, emergency surgical procedures should be performed as soon as possible, even if ongoing measures to restore physiologic stability need to be continued 1
• Antimicrobial therapy should be initiated once an intra-abdominal infection is diagnosed or strongly suspected 1

Deviations from Standard of Care in This Case

Delayed Recognition and 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 and inconsistent with standard practice 2
• 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 and careful clinical monitoring is provided 1
• Progressive clinical deterioration with fever, increasing pain, and inability to ambulate should have prompted immediate investigation and intervention 2

Inadequate Antimicrobial Management

• Antimicrobial therapy should have been initiated once intra-abdominal infection was suspected 1
• For intra-abdominal infections, antibiotics should be administered within 8 hours after presentation in patients without hemodynamic compromise 1
• Delaying antimicrobial therapy has been associated with poorer outcomes in patients with intra-abdominal infections 1

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 in this case 2
• The extensive resection required (12.5 cm of jejunum, 45 cm of ileum, and 15 cm of cecum) was likely a consequence of prolonged infection and inflammation 2
• The extended hospitalization (additional three weeks) was a direct result of the complications from delayed intervention 2

Appropriate Management That Should Have Been Provided

Immediate Post-Operative Period

• Any serosal injury during laparoscopic surgery should be carefully evaluated to rule out full-thickness enterotomy 3
• When enterotomy is suspected during laparoscopic surgery, a staged approach with repair of enterotomy and delayed definitive surgery may be considered 3

Upon Clinical Deterioration

• An appropriate source control procedure to drain infected foci and control ongoing peritoneal contamination should have been performed promptly 1
• Antimicrobial therapy should have been initiated as soon as intra-abdominal infection was suspected 1
• Imaging studies should have been obtained earlier when the patient showed signs of clinical deterioration 2

Fluid Collection Management

• Percutaneous drainage of abscesses and well-localized fluid collections should have been considered as an initial approach 1
• If percutaneous drainage was not feasible or effective, surgical intervention should have been performed 1

Medicolegal and Ethical Implications

• The decision to observe without antibiotics or intervention for 10 days despite clinical deterioration represents a significant deviation from standard practice 2
• The delay in obtaining imaging and pursuing further intervention until after repeated patient requests raises concerns about appropriate clinical decision-making 2
• Proper documentation of the rationale for management decisions is essential, particularly when deviating from standard practice 2

Prevention of Similar Outcomes

• Post-operative vigilance for signs of missed enterotomy is crucial, including monitoring for fever, increasing pain, and inability to ambulate 2
• Early imaging should be obtained when there is suspicion of post-operative complications 2
• Antimicrobial therapy should be initiated promptly when intra-abdominal infection is suspected 1
• Timely source control is essential for optimal outcomes in intra-abdominal infections 4

In conclusion, the management in this case deviated significantly from the standard of care, with delayed recognition and treatment of a missed enterotomy leading to preventable complications and extended hospitalization.