錢家陞、康智雄¹

雲林長庚紀念醫院 外科部 泌尿科；¹高雄長庚紀念醫院 外科部 泌尿科

Chia-Shen Chien, Chih-Hsiung Kang¹

Divisions of Urology, Department of Surgery, Yunlin Chang Gung Memorial Hospital, Taiwan; ¹Divisions of Urology, Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan

 

The use of mechanical stapling devices in bowel re-anastomosis has become a common practice in modern surgery. Postoperative ileus is significantly reduced in stapler way than in hand-sewn method. Here we represent a rare case of small bowel obstruction caused by retained staples after ileal ureter replacement surgery.

 

A 54-year-old male has history of bladder cancer post transurethral resection. He underwent retroperitoneoscopic radical ureterectomy and ileal ureter replacement for left ureteral urothelial carcinoma. Two linear cutting staplers were utilized for small bowel continuity restoration in side-to-side anastomosis. The patient was discharged without complications. However, he presented to the emergency room for abdominal pain and distention for 3 days after two months. The abdominal plain film showed disproportional dilatation of small intestine, indicating intestinal obstruction (Panel A). No air accumulation in large intestine with abrupt termination of gas in right lower quadrant. Non-enhanced computed tomography(CT) scan disclosed transition area over stapled anastomotic site in terminal ileum(Panel B). Lab data showed no hyperchloremic metabolic acidosis or electrolytes imbalance, but slightly elevated serum creatinine. He was treated conservatively with 3-day fasting and nasogastric tube placement for intraluminal gas/fluid drainage, as well as intravenous fluid replacement. Gradual oral intake with liquid diet for 7 days, and he was discharged in the following day. At follow-up 9 months after treatment, he had no evidence of any complications, including bowel obstruction, local or distal disease recurrence. Followed-up 3D CT urography showed no urinary or bowel obstruction(Panel C).

 

The advantages of ileal ureter replacement for upper tract urothelial carcinoma are adequate preservation of renal function with low risk of anastomotic stricture and metabolic acidosis, though transient paralytic ileus is its weakness. Surgical staples related small bowel obstruction is rare. By reviewing articles, most cases were related to fibrotic bands arising from retained staples or internal hernia caused by unformed staples hooked on adjacent structures, and they all prompted early diagnostic laparoscopy. However, conservative treatment still worked successfully in our case. Urologists should be mindful of staples related complications and clearly investigate any retained staples or unformed staples during operation. Conservative treatment might be a choice, but re-exploration is still needed if any warning signs showed.