A 67-year-old female with a 4-day history of a fever and cough was admitted to a local hospital for pneumonia. The diagnosis of COVID-19 was confirmed by a positive polymerase chain reaction (PCR) test result via a nasopharyngeal swab. Her respiratory condition gradually worsened after admission. Thus, she underwent intubation and was transferred to our hospital in need of intensive care 5 days after admission.
Her height and weight were 164.9 cm and 46 kg, respectively. She had comorbidities of diabetes mellitus, diabetic nephropathy requiring dialysis, angina, post-resection gastric cancer and postoperative spinal canal stenosis. She was taking several regular medications including an antiplatelet agent. On arrival, a physical examination revealed a body temperature (BT) of 34 °C, blood pressure (BP) of 110/65 mmHg, heart rate (HR) of 102 beats/min, and Glasgow Coma Scale of E1VtM1 with deep sedation. The arterial blood gas analysis showed pH 7.309, partial pressure of carbon dioxide (PaCO2) 41.5 mmHg, partial pressure of oxygen (PaO2) 78.2 mmHg with pressure control mechanical ventilation set as follows: positive end-expiratory pressure (PEEP) of 8 cmH2O, peak inspiratory pressure (PiP) of 25 cmH2O, fraction of inspired O2 (FiO2) of 0.5. The laboratory results were as follows: white blood cell counts (WBC) of 13,900/μl, C-reactive protein (CRP) of 13.1 mg/dL, D-dimmer of 7.25 µg/mL, activated partial thromboplastin time (APTT) of 170 s, and international normalized ratio (INR) of 1.35. Computed tomography (CT) revealed bilateral ground-glass opacity with lower-lung predominance. There were no evident abnormal findings in the abdominal region or thromboembolism; however, the intestine, including the transverse colon was edematous, and the abdominal vessels showed strong sclerotic changes (Fig. 1). Dexamethasone administration (6 mg/day), started at the previous hospital, was continued. Continuous renal replacement therapy was initiated for the chronic renal failure as well as appropriate body fluid management. On day 3 after admission, antibiotic therapy by cefepime was started for ventilator-associated pneumonia. The APTT decreased to 51.5 s, thus unfractionated heparin for prophylactic-dose anticoagulation was additionally administered to keep the APTT around 60 s.
On day 7 after admission, despite these treatments, her respiratory condition worsened as follows: pH 7.333, PaCO2 40.6 mmHg, PaO2 71.1 mmHg under the ventilator setting of PEEP of 10 cmH2O, PiP of 22 cmH2O, FiO2 of 0.8. Furthermore, hemodynamic deterioration also developed with a BP of 85/41 mmHg and HR of 108 beats/min under the noradrenaline administration (0.2 µg/kg/min). Laboratory tests revealed an increase in the inflammatory markers and derangements in the coagulative function as follows: WBC of 15,100 /µl, CRP of 32.14 mg/dL, D-dimmer of 26.51 µg/mL, APTT of 47.2 s, and PT-INR of 1.24. Therefore, follow-up CT was performed to re-evaluate the degree of lung injury and to detect other sources of infection. CT revealed massive ascites, free air, and wall defects of the transverse colon (Fig. 2). Emergency laparotomy as the source control of pan-peritonitis due to intestinal perforation was performed with the extracorporeal membrane oxygenation (ECMO) team on standby, as her respiratory condition was close to the limit of being able to be supported by a ventilator only. All surgical procedures were undertaken in the negative-pressure room of the intensive-care unit (ICU), considering the risks related to patient transfer such as further deterioration of the patient’s condition and pathogen exposure to the medical staff.
A midline skin incision was performed, and the abdomen was filled with contaminated ascites. Two perforation sites of 25 mm and 7 mm in diameter were identified at the right side of the transverse colon, and the tissue around the perforation sites changed necrotic (Fig. 3). PCR for the ascites showed a positive result and the number of copies of the virus was 42,056 (the number of copies of the virus in the sputum: 501,420). Abdominal lavage and partial resection of 17 cm of the transverse colon were performed. Considering the hemodynamic instability of the patient, open abdominal management with ABTHERA™ (KCI, now part of 3 M Company, San Antonio, TX, USA) and a planned relaparotomy strategy was selected. The secondary surgery was performed 2 days after the first operation. The abdomen was uncontaminated, and no remnant ischemic lesion was observed. Thus, colostomy was done, and the abdominal incision was closed with several drainage tubes into the abdomen. A histopathological examination revealed necrosis of the intestinal mucosa around the perforation sites and microcirculatory thrombosis in the mesentery veins, which was suspected of having been induced by COVID-19-related coagulopathy (Fig. 4).
Enteral feeding was re-started on postoperative day 2. All drains were removed on postoperative day 7. Abdominal complications, such as surgical site infection, remnant abscess and stump leakage, were not noted; however, the COVID-19 pneumonia ultimately progressed, and she died due of respiratory failure 24 days after admission (17 days after the initial surgery).
