Gastrointestinal injuries during gynaecologic operations at a university teaching hospital in Thailand: a 10-year review

The objective of this study was to investigate the incidence of gastrointestinal injuries during gynaecologic operations, the management of such injuries and associated risk factors. This case-control study (1:4) examined patients who received gynaecologic operations from 2007 to 2016 in Ramathibodi Hospital. The study cases comprised patients who had gastrointestinal injuries, while the control cases comprised patients who had gynaecologic surgeries in the same period with matching the types of procedures. The 10-year incidence was 0.38% (104 cases of gastrointestinal injuries among a total of 27,520 cases). The most common injury site was the small bowel (43.3%). There were 102 cases (98%) of gastrointestinal injuries which were diagnosed intraoperatively and which were immediately repaired with successful outcomes. Logistic regression indicated that a pelvic adhesion, previous pelvic surgery and previous abdominal surgery were predictive risk factors associated with the injuries (odds ratios: 9.45, 3.20 and 11.84, respectively). An immediate consultation with a surgeon and surgical repair of the injury resulted in excellent outcomes. Impact statement What is already known about this subject? Gastrointestinal injury is a rare, but fatal complication of gynaecologic operations. The previous small study identified some risk factors such as surgical approach and pelvic surgery associated with the injury. What do the results of this study contribute? Our study identified the associated risk factors for gastrointestinal injury, including previous abdominal injury, pelvic adhesion and previous pelvic surgery. A previous abdominal surgery was the most associated risk factor. Patients with the history of abdominal surgery had an almost 4-fold higher odds ratio than the ones with previous pelvic surgery. Other factors, including endometriosis, ovarian cancer and subsequent oncological procedures, and surgical staging were less related to the gastrointestinal injury. What are the implications of these findings for clinical practice and/or further research? The knowledge is useful for pre-operative evaluation and preparation. Bowel preparation and consultation with surgeon are necessary for patients with these risk factors prior to their surgeries. Moreover, an immediate intra-operative surgical correction of the injury results in excellent outcomes.

A Comparison of Thermal Plasma Energy Versus Argon Beam Coagulator-Induced Intestinal Injury After Vaporization in a Porcine Model

OBJECTIVES

Complete cytoreduction of ovarian cancer often requires excision or ablation of bowel serosa implants. Both argon beam coagulator (ABC) and thermal plasma energy (TPE) (PlasmaJet; PlasmaSurgical, Roswell, Ga) have been used to ablate bowel serosa implants. Our objective was to identify comparable power settings as well as determine the rate of bowel perforation, depth of thermal injury, and extent of inflammatory response with ABC versus TPE in a porcine model.

MATERIALS AND METHODS

Nine pigs underwent vaporization of small bowel and colon serosa according to assigned treatment group (TPE vs ABC) and settings (ABC: 30, 50, and 70 W; TPE: Cut 10U, 20U, and 30U and Coagulation 10U, 20U, and 30U). Animals underwent necropsy with blinded histomorphologic evaluation on days 0, 3, and 10 postprocedure to assess for presence of bowel perforation, depth of thermal injury, and extent of inflammatory response.

RESULTS

At necropsy, bowel perforation was not identified in any animals. Depth of treatment with ABC in the porcine colon was variable and unrelated to power settings whereas TPE was associated with a consistent treatment depth of 1.0 mm regardless of location or power. Treatment with ABC resulted in greater tissue coagulation and desiccation as well as increased rates of mucosal necrosis, especially at higher settings (>50 W). Treatment with TPE primarily resulted in tissue ablation and minimal mucosal necrosis at low settings (Coag 10U-20U). The inflammatory response associated with TPE treatments was interpreted as biologically benign, and less than that observed with the ABC regardless of treatment settings.

CONCLUSIONS

Both ABC and TPE effectively ablate bowel serosa in a porcine model. The TPE seems to result in a more predictable tissue effect with less inflammatory response, especially when used at low power settings such as Coag 10U or 20U. These characteristics are appealing for ablation of bowel serosa implants during ovarian cancer surgery and warrant further investigation.

Delayed Manifestations of Laparoscopic Bowel Injury

Bowel injury (BI) is a complication of open and laparoscopic abdominal surgery associated with increased morbidity and mortality. If BI is missed at the time it occurs, it can have devastating consequences. Electrosurgery is used extensively in laparoscopic surgery and can cause thermal injuries that are harder to detect than mechanical injuries and may evolve over time. The medical literature of the past 10 years was searched for large series and compilation studies reporting overall incidence of and mortality from BI in laparoscopy, and the results of seven relevant articles, which included over 300,000 procedures, were analyzed and tabulated. The literature was then reviewed for additional information about the specific incidence and outcome of missed BI and the role of electrosurgical thermal sources in causing BI. BI is underreported, frequently missed at surgery, and results in significant morbidity and mortality that can be ground for malpractice claims against the surgeon. Thermal injury from electrosurgical instruments may be involved in a number of injuries in laparoscopic surgery. Nearly undetectable partial-thickness thermal injury may play a role in the atypical and delayed presentation of some cases of BI.

[Intraoperative complications of the lower gastrointestinal tract : Prevention, recognition and therapy]

Every surgical intervention is associated with the risk of intraoperative complications. These occur in approximately 2-12% of patients but significantly influence the postoperative outcome, overall complication and mortality rates. This article presents the treatment of typical intraoperative complications during surgery of the lower gastrointestinal tract with a focus on the prevention and identification of risk factors. Especially changes in the regular anatomy caused by previous surgery, inflammation, tumors and emergency situations carry the risk of iatrogenic injuries to the bowels, spleen, ureter and blood vessels. These risk factors must be considered when choosing a surgical procedure, a surgical approach or an appropriate surgeon. The early detection of complications with a definitive restoration is the essential step for a successful treatment without long-term sequelae. Every delay in therapy is associated with an increased morbidity and mortality and should be avoided.