This preoperative operation almost detonated the patient's intestines

This article is written by Dr. Yu

Whenever I think about it, I still have palpitations.

I was on day duty when one of my patients suddenly rushed into the office.

"Doctor, I'm going to have surgery on intestinal polyps today, I've already drunk a lot of laxatives, my stomach doesn't react, and I'm nauseated and want to vomit." What should I do?"

This is a patient 2 years after colon cancer surgery, multiple colon polyps were found during a re-colonoscopy, and today's endoscopic colon polypotomy was scheduled. I also prepared his intestines according to the usual method, considering that the patient was prone to constipation after colectomy, and I also prescribed him an additional box of laxatives.

I comforted him, "Don't worry too much, you drink slowly, walk more, rub your stomach more, and go down with the laxative."

There are not a few patients like him who have discomfort, and we will let patients who are preparing for the intestines drink a lot of water (about 2 to 3 L), and when they drink too quickly, they are prone to nausea and vomiting.

He went back to the ward in disbelief.

01.

After another 1 hour, he hurried in again.

Doctor, I did as you said, but I still can't do it, and I haven't solved a little. Why don't you give me an enema?" Enemas are routine procedures in our gastroenterology department, enema medications can stimulate intestinal motility, and patients with constipation and intestinal obstruction can be treated with enemas. It has few side effects and is quite good.

Seeing that he was uncomfortable, I promised to clean the enema with "normal saline + Kelsai dew".

Prepare the liquid in the enema bag, adjust the temperature of the enema liquid to 40 ° C, hang the enema bag on the infusion rack, paraffin oil lubricate the canal, gently insert the canal into the anus for 8 cm, fix, put the liquid.

Waiting after an enema is a torturous thing. The fluid in the intestine presses against the anus, and the gradual increase in stool will stretch 10 times every 1 second. I instruct the patient to take a deep breath and try to retain the enema fluid for as long as possible.

A thin layer of sweat appeared on his forehead, and he was obviously very hard to endure. After 2 minutes, he finally unpacked the yellow stool. I breathed a sigh of relief and told him, "You must wait until the stool is like water before you can have polyps surgery, otherwise there will be feces in the intestines, and the doctors will not be able to see the polyps."

The patient looked at me and nodded his head very sincerely, indicating that he understood... I learned later that he didn't listen to me at all.

In general, patients need to decontaminate more than 10 bowel movements to complete bowel preparation. This patient may have had an unsmooth bowel due to postoperative adhesions and poor bowel movements, so he went directly to the endoscopy room after only 5 stools.

02.

Endoscopic operating room.

The patient's postoperative adhesions are very strong, the lens is very difficult, we spent a lot of effort to achieve the ileum; and the patient's polyps are large and large, some are more broad-based, and it is quite troublesome to deal with.

My superior doctor usually cut the polyps with ease, but it was difficult to face this patient. She called for the deputy director on duty in the endoscopy room.

As soon as the deputy director came in, he frowned when he saw the intestinal situation. Your gut preparation is so poor, your gut is full of, you can't do it.

When the patient heard that he couldn't do it, he immediately panicked: "Don't be a doctor, my intestines are very hard to prepare, and I just had a special enema, what can you do if you don't do me?"

The deputy director frowned even tighter, did not explain anything, and waved his hand to let the patient return to the ward first.

The operation was not completed, and I did not think much about it, thinking that it was only because the patient's intestinal preparation was not in place, and when it was time to leave work, I would go home as usual.

Without taking two steps, I was stopped by the deputy director.

"Did you know that today you almost caused a catastrophe?"

"Huh?"

03.

"Did you give an enema to a patient today?"

I nodded confusedly: Is the director so angry because the patient's intestines are not well prepared?

"Fortunately, today it was me, and I was stopped in the endoscopy room." Otherwise, once the patient has surgery, the intestine may explode! Then this will be a medical accident, and none of us will be able to escape!"

I realized that things weren't that simple.

The deputy director looked at me and explained in a serious tone: "The composition of kaiserin is glycerin, which belongs to the alcohol class, and the alcohol will be decomposed by bacteria in the intestine to produce methane and hydrogen." Electrocution is required during surgery, and then an explosion will be induced."

When he was reminded of this, I suddenly remembered that Ouyang Qin's "Digestive System Disease Rounds and Doubts" did mention that "do not use mannitol and sorbitol for intestinal preparation, otherwise there will be an explosion during electrocoagulation treatment."

The deputy director sighed and told me to be careful in the future. I nodded, and the roots of my ears were hot.

When I got home, I immediately went through the materials and found that there were indeed case reports of deaths due to an explosion while electrocuting polyps using mannitol for intestinal preparation [1]. The guidelines also mention that do not prepare the intestines with mannitol, otherwise an intestinal explosion will occur when the polyps are cut electrically [2].

Some scholars have deliberately conducted relevant studies and made suggestions: before colonoscopic treatment, do not use enemas for intestinal preparation; do not use mannitol or sorbitol or any drug that may produce flammable gases; and use carbon dioxide when inflating the intestine.

04.

There is no excuse in the face of medical safety, and although it is true that patients are unable to operate because of inadequate bowel preparation, this is still my omission.

Clinical medicine is a discipline full of unknowns and risks, and today my unintentional "routine operation" almost pushed patients to death, and almost pushed my career and my colleagues into the abyss.

I also take this opportunity to remind my colleagues that clinical work must be careful and careful, learn more from the words and lessons of the predecessors, and continue to grow, so as to minimize the occurrence of "accidents".

Acknowledgements: This article was professionally reviewed by Wu Hanping, deputy chief physician of the Department of Gastroenterology, Mingzhou Hospital, Zhejiang University, and Ding Qingyu, Digestive Group of the Special Needs Medical Service Center of Zhujiang Hospital of Southern Medical University

【Note】

Southern Medical University Zhujiang Hospital Special Needs Medical Service Center Digestive Group Ding Qingyu Audit Opinion:

There are two kinds of commonly used kaiser, one is the main ingredient is glycerin and the other is sorbitol. According to the "Guidelines for Intestinal Preparation Related to The Diagnosis and Treatment of Digestive Endoscopy in China", it is not recommended that therapeutic colonoscopy use mannitol and sorbitol for intestinal preparation, which can produce flammable gases after being fermented by bacteria in the intestine, and there is a risk of explosion in high-frequency electrocoagulation and electrocuted polyps at this time.

Ordinary colonoscopy will not cause intestinal explosion, only if there is an appropriate amount of flammable gas in the intestinal cavity, an appropriate amount of oxygen, at this time electrocoagulation or electrocution and then appear electric spark, the possibility of explosion will appear. But for patients, even a 1 in 10 million probability can have serious consequences, and we need to prevent it before it happens.

Studies have shown that enemas are more likely to produce flammable gases in the intestinal lumen than oral laxatives. Therefore, for the safety and adequate intestinal preparation of patients, we recommend that the appropriate oral laxatives be preferentially selected for intestinal preparation according to the patient's situation, and try to avoid the use of Kaiserol enemas before colonoscopic treatment, as well as the use of carbon dioxide inflation during colonoscopy, through these methods to avoid the occurrence of intestinal explosions.

Curator: Ground Cat, Leu.

Executive Producer: Gyouza

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Resources:

1. Yu Zhongjian. Fatal colonic explosion during colonoscopic polypectomy[J]. Foreign Medicine (Internal Medicine Fascicle), 1981(2).

2. Chinese Medical Association Digestive Endoscopy Branch. Guidelines for intestinal preparation related to digestive endoscopic diagnosis and treatment in China (draft)[J]. Chinese Journal of Digestion, 2013, 19(9):354-356.