Written informed consent for participation in this case series and any accompanying images was obtained from patient’s next of kin (due to death of patient) for patients 1, 2, and 3 and directly from patient 4.
Patient 1. Ms. H, 60 years old, presented with 1 to 2 days of worsening abdominal pain. She had a history of stage IV lung adenocarcinoma diagnosed 1 year prior and treated recently with 6 rounds of chemotherapy (carboplatin and pemetrexed). She was hemodynamically stable but in acute distress, with an abdominal exam concerning for peritonitis. Serum complete blood count was significant for chemo-induced neutropenia and thrombocytopenia. A computed tomography scan of the abdomen revealed gas and fluid collection adjacent to the sigmoid colon with fat stranding and free intraperitoneal air, suggesting perforated diverticulitis. She underwent an emergency exploratory laparotomy, resection of the affected sigmoid colon, and creation of a descending end colostomy and Hartmann’s pouch. Postoperatively, she recovered in the surgical intensive care unit. The ostomy was immediately productive of formed stool but began to appear dusky on postoperative day (POD) 4. Serial test tube examination using a hand-held flashlight showed a pale color flash, but these results were equivocal and her clinical condition remained critical along with persistent stoma discoloration. On POD 7, a VATTT was done, which showed ischemic discoloration, mucosal hemorrhage, and necrosis down to the level of the fascia (see Figure 2a,b). She underwent operative revision of the stoma. Intraoperative assessment and pathology reports confirmed transmural necrosis of the resected segment. A postrevision VATTT was done in the operating suite, which demonstrated pink viable mucosa (see Figure 2c,d). Due to her metastatic lung cancer and severe immunosuppression, Ms. H’s prognosis was poor. She died several weeks later upon withdrawal of care by family due to overwhelming sepsis refractory to medical therapy.
Patient 2. Mr. M, 49 years old with a history of Tetralogy of Fallot status postrepair in 1969, presented with pulmonary valve regurgitation and underwent a pulmonary valve replacement by cardiac surgery. The postoperative course was complicated by severe bleeding, right heart failure, and respiratory failure, requiring venoarterial extracorporeal membrane oxygenation. He developed melena and underwent a nuclear scan that localized radioactively tagged red blood cells to the small bowel, identifying it as the source of the gastrointestinal bleeding. After multiple failed attempts by Interventional Radiology to embolize the source, an emergency exploratory laparotomy was performed. A carcinoid mass was found, leading to a small bowel resection, creation of an end ileostomy, and mucus fistula with temporary abdominal closure due to hemodynamic lability. Despite further resuscitation, serial washouts, and eventual abdominal closure, Mr. M clinically deteriorated and developed septic shock of unclear etiology. The congested but productive ostomy was assessed with a VATTT after a test tube test did not show clearly whether ischemia extended deeper than the surface. The mucosa was pink and viable throughout the ostomy, suggesting it was not the source of his instability, thus preventing further relaparotomy. The patient ultimately developed severe acute respiratory distress syndrome and expired after withdrawal of care.
Patient 3. Mr. P, a 66-year-old man with severe left heart failure, developed septic shock and hyperlactinemia after placement of a left ventricular assist device. After an emergency exploratory laparotomy and resection of gangrenous ileocecal segment, an end ileostomy and mucus fistula were created. Mr. P had intermittent hemodynamic instability and increasing vasoactive pressor requirements over the next 2 weeks. On POD 15, ostomy congestion and duskiness had not resolved, and after a test tube test did not clearly show distinct depth of ischemia, a VATTT was done, which showed viable pink mucosa of the proximal bowel. Four (4) days later, Mr. P developed abdominal distension and elevated peak airway pressures. A decompressive laparotomy was done at the bedside, yielding several liters of simple ascites. The ileostomy was assessed at this time, and it appeared healthy. An ileoscopy also was performed to diagnose and control a new onset gastrointestinal bleed, and the mucosa was noted to again be viable for 15 cm, although no bleeding source was identified. The patient eventually developed severe coagulopathy, intractable gastrointestinal hemorrhage, and due to futility of further intervention, he expired after the family withdrew care.
Patient 4. A 72-year-old man with distal pancreatic cancer, Mr. Q underwent a distal pancreatectomy and splenectomy. On POD 4, he developed peritonitis with fecal drainage noted in the Jackson-Pratt drain. He underwent an emergency exploratory laparotomy, which revealed a perforated transverse colon. The diseased area was resected and an end transverse colostomy was created. By POD 3, the colostomy remained congested and discolored. The standard test tube test was equivocal with respect to the color of the mucosa deeper in the stoma. A VATTT showed pink viable mucosa. The ostomy was observed with no further surgical intervention. The patient recovered and was discharged home within 1 week. Pertinent patient information is summarized in Table 1.