Recurrent hemoperitoneum after esophago-gastrectomy

Ten days ago I helped my close colleague and friend do an Ivor Lewis (two- stage) procedure on a 65 year old male (also a close friend) for an adenocarcinoma of the lower end of the esophagus. The procedure was tidy an d straightforward, though unfortunately there were several small mets in the liver. Post-op he was on a ventilator overnight, as he was subject to recurrent bronchitis, but otherwise recovered well.

Two days later he developed tachycardia and later abdominal pain and distension. I helped at the second operation which showed 3 litres of blood , recurrent hemoperitoneum mainly in left upper quadrant. The left gastric pedicle was quite secure, a small graze on the spleen at the original procedure didn’t look like the site of any bleeding, and there was no other cause evident for this heavy bleed. He put in a large-bore Redivac drain, which only collected a small quantity of blood and then serous fluid.

He recovered well from this second procedure, without needing ventilation, and a gastrograffin swallow on day 5 showed a nicely patent stoma with no leak. He complained of colicky abdominal pain after a couple of days later, which was partly relieved by passage of flatus.

Last night his lower abdominal pain increased and this morning he had further abdominal distension. Abdominal films were not helpful, his haemoglobin had dropped from 12 to 11 grams/litre overnight, and the only abnormality on other tests was a platelet count of 700k.

My colleague carried out a third laparotomy during the day, which I wasn’t there to help with. Once again there was some old clot with about 1500ml of fresher blood, with fibrinous adhesions along the small intestine and round the spleen, but no bleeder despite another careful search. He carried out a splenectomy and passed a Baker’s tube through to the ileocaecal junction, and closed the abdomen with a fine redivac to the splenic bed.

I’m writing this report from home, without the notes by me, but after chatting i detail by phone with my colleague this evening, when we went over the case without coming up with any new diagnosis. The patient has been on subcutaneous heparin, 5000 u twice daily, on TPN, and antibiotics at different stages. After the first operation, when for a while it seemed his tachycardia was cardiac in origin while his CVP?was normal, he was on a low dopamine infusion when in retrospect it was hypovolaemia, but otherwise there wasn’t anything out of the ordinary in the surgical care.

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