45 Anastomotic leakage and peritonitis secondary to cocaine consumption after elective colorectal surgery

Abstract Introduction Many well-known factors contribute to the success or failure of an intestinal anastomosis. Cocaine is a sympathomimetic drug, with an important effect on the cardiovascular system, more precisely a peripheral vasoconstriction. In patients who have recently undergone surgery with an intestinal anastomosis, the vascular supply of that union is a crucial aspect to bear in mind, and any situation favouring vasoconstriction can have an effect on adequate healing. Case report We present the case of a 54-year-old male, with medical history of a gastrointestinal bleeding due to a gastric ulcer. He was admitted to our tertiary care university hospital for an acute decompensation of heart failure with severe aortic insufficiency, caused by bacterial endocarditis, which ended up needing cardiac surgery and implantation of a prosthetic biological valve. During the work-up study of the endocarditis, an abdominal CT-scan incidentally diagnosed a tumour in the right colon. Colonoscopy was performed and the biopsy confirmed an adenocarcinoma, without metastasis. The patient underwent an elective intervention: laparoscopic right colectomy, with a hand-sewn ileo-colic anastomosis, uneventful. There were no complications during the immediate postoperative period. The patient was able to eat orally within 3 days, the stool was normal in consistency, and the lab-results were normal in the second and fourth day including WBC and C-reactive protein. The patient was discharged on the 6th postoperative day. Six days after (twelve after the surgery) the patient came to the Emergency Department (ED) referring intense abdominal pain, with increasing tenderness in a time-lapse of 12 hours approximately. New lab tests showed elevated WBC, and CRP of 250 mg/l. A CT scan was performed showing pneumoperitoneum in the proximity of the anastomosis, free fluid inside the abdominal cavity and signs of low perfusion in the small bowel. He was taken to the OR and a mid-line laparotomy was performed. A localized peritonitis was found, due to anastomotic leakage with ischemia of the terminal ileum. A resection of the affected colon was performed, and it was decided to make a new ileo-colic anastomosis. The postoperative period was, again, uneventful and the patient completed antibiotic treatment and was discharged after 12 days. That same day, before going home, he confessed to the medical team that since the first day he arrived home after surgery, he consumed ‘excessive amounts’ of cocaine. So he had been consuming cocaine daily for 6 days until he returned to the ED with the leak. Conclusions The patient described had many cardiovascular risk factors, which could have affected the blood supply of the primary anastomosis like the aortic valve endocarditis, or the cardiac surgery just 2 months before. However, he had surgery with those conditions and everything went well without complications. The only new variable in those 6 days while the patient was at home was the consumption of cocaine. The importance of this clinical case is that as General Surgeons, we should know the factors that affect the success or not of an intestinal anastomosis: good technique, tension-free segments and an adequate blood supply. In this last aspect, cocaine consumption is not usually mentioned by patients when taking their medical history, but it can have an important impact, generating peripheral vasoconstriction with ischemia and resulting in anastomotic leakage and peritonitis.