December 17, 2010
Mrs. Gupta all of 63years came with complaints of post menopausal heavy bleeding. A histopathology report of hyperplasia on hysteroscopy and hemoglobin of 8gm% despite two units of transfusion she was advised a laparoscopic hysterectomy with bilateral salpingo-ophorectomy.
A little on the heavier side she weighed almost 105 kilos.
A technically extremely difficult and challenging Hysterectomy was done on 17/12/2010, two units of blood were given preoperatively and two intra-operatively, and she was discharged on the 19th morning with a hemoglobin of 10.4gm%.
She came back on 5th day of surgery with discharge from port site which was thought to be a sub cutaneous seroma and dressed and was sent back.
Stitch removal was done on the 8th day (26th) and discharge continued though was less and dressings were done thereafter regularly.
On the 10th day she complained of leaking from the vagina and was taken up for a cysto-urethro-ureterogram which was normal and she was sent home.
Abdominal dressings (large binders to stop seroma drainage) continued.
On the 12th day she complained telephonically of even more vaginal leakage in the evening and was asked to come in the next morning. Abdominal wound continued to discharge.
When she came in she was toxic looking and dehydrated. Abdominal port sites continued to discharge though not much leaking was seen vaginally.
She had stopped eating and drinking and on biochemical tests showed a very high blood urea (105) and creatinine (3.3). Her leukocyte counts were 28000/cumm.
Ultrasound was done and showed gross ascietes with septations and the sonologist gave a provisional differential of tuberculosis which fit in with still not healing and discharging port sites. An ascietic tap was done and the fluid was examined for tuberculosis tests and did not show any evidence of this.
Retrospectively on her laparoscopy her liver appeared pockmarked and cirrhotic and with a preoperative mildly deranged prothrombin time a provisional diagnosis of under lying liver disease was made, her bilirubin now being 2.4gm%.
Hence now a complete diagnosis of Septicemia with acute renal failure with decompensated liver disease with ascietes was made.
She was admitted to the ICU and aggressive management with antibiotics (Meropenem, targocid) was done along with other supportive treatment like proteins (she was severely hypo-proteinemic) was done.
She responded very well and all her parameters returned to preoperative normal levels and ascietes decreased to minimal levels. This also led to the port site wounds healing and the vaginal leaking abating.
She was discharged on the 15th day after admission to the ICU into the long term care of an extremely competent gastroenterologist who was a part of the managing team in the ICU.
Discussion
Surgery in a patient with liver disease, especially end-stage liver disease with cirrhosis and portal hypertension, poses a formidable challenge for all physicians involved. Targeted interventions before surgery may help to prevent complications and improve outcomes.
The cornerstones of perioperative management are medical treatment of the complications of liver disease, including coagulopathy, ascietes, encephalopathy, and malnutrition. Attention must also be paid to risk factors for infection and renal dysfunction after surgery. Sepsis, coagulopathy, and emergency surgery are most strongly correlated with postoperative mortality. Therefore, a multidisciplinary approach to postoperative care is imperative and should include input from anesthesiologists, surgeons, internists and gastroenterologists.
Laparoscopy port sites may take longer to heal and these generally occur if
- they get infected (some infected non healing discharging tracts may need surgical removal)
- obese patients may form discharging seroma and tracts (strapping and regular dressings along with serial wound culture sensitivity swabs to choose antibiotics is the way to manage and they generally do well with patience)
- tuberculosis (anti tuberculosis treatment works well )
- This latest case showed us an unusual situation where due to ascietic fluid in the peritoneal cavity the wound kept weeping with ascietic fluid. These will never heal till the underlying cause for ascietic fluid is not removed which will decrease the ascietes and fluid coming out hence giving rest to the wound and a chance to heal.
The number of patients with cirrhosis who require surgery is on the rise. Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are gaining more attention, especially in association with metabolic syndrome and obesity. At the same time, the amount of medications and treatments aimed at improving survival among patients with cirrhosis has been increasing. Therefore, it can be expected that a growing number of patients with liver disease, both known and as yet undiagnosed and asymptomatic, will undergo surgery.