Percutaneous Nephrolithotomy (PCNL) is a common urological procedure performed for complicated upper urinary tract stones. The advantages of PCNL include lower morbidity and mortality rates and quicker recovery compared to traditional open surgery. A number of complications have been reported which can be life threatening. Here we present a case of 71 years old lady, who developed subcutaneous emphysema following PCNL

Adamjee, Shabbir

Ali, Authar

Kassam, Nadeem

Mawalla, Isaac

Soomro, Hussam Uddin

English

eCommons@AKU

eCommons@AKU Faculty of Health Sciences, East Africa Faculty of Health Sciences, East Africa 8-17-2021 Postoperative subcutaneous emphysema following percutaneous nephrolithotomy: A rare complication Hussam Uddin Soomro Aga Khan Hospital, Tanzania Isaac Mawalla Aga Khan University, isaac.mawalla@aku.edu Shabbir Adamjee Aga Khan Hospital, Tanzania Nadeem Kassam Aga Khan Hospital, Tanzania Authar Ali Aga Khan University, athar.ali@aku.edu Follow this and additional works at: https://ecommons.aku.edu/eastafrica_fhs_fhs  Part of the Medical Education Commons Recommended Citation Soomro, H. U., Mawalla, I., Adamjee, S., Kassam, N., & Ali, A. (2021). Postoperative subcutaneous emphysema following percutaneous nephrolithotomy: A rare complication. International Journal of Surgery Case Reports, 106310. International Journal of Surgery Case Reports 86 (2021) 106310Available online 17 August 20212210-2612/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).Case report Postoperative subcutaneous emphysema following percutaneous nephrolithotomy: A rare complication Hussam Uddin Soomro a, Isaac Mawalla b, Shabbir Adamjee b, Nadeem Kassam c, Athar Ali b,* a Section of Urology, Department of Surgery, The Aga Khan University Medical College, East Africa (Dar) & Aga Khan Hospital, Dar-es-salaam, Tanzania b Department of Surgery, Aga Khan University Medical College, East Africa (Dar) & Aga Khan Hospital, Dar-es-salaam, Tanzania c Department of Internal Medicine, Aga Khan University Medical College, East Africa (Dar) & Aga Khan Hospital, Dar-es-salaam, Tanzania   A R T I C L E  I N F O   Keywords: Case report PCNL Subcutaneous emphysema Urological procedure A B S T R A C T   Percutaneous Nephrolithotomy (PCNL) is a common urological procedure performed for complicated upper urinary tract stones. The advantages of PCNL include lower morbidity and mortality rates and quicker recovery compared to traditional open surgery. A number of complications have been reported which can be life threatening. Here we present a case of 71 years old lady, who developed subcutaneous emphysema following PCNL.   1. Introduction Percutaneous Nephrolithotomy (PCNL) is considered gold standard for the management of large renal stones [1]. It provides maximal stone free rates and is considered to have a great influence in reducing morbidity and mortality rates [2,3]. Nevertheless, few complications have also been reported in literature. The commonly reported compli-cations include; significant bleeding, fever, thoracic complications including hydrothorax and pneumothorax, sepsis, bowel injury, uri-noma and most notably death [4]. Subcutaneous emphysema involving the chest wall along with pneumothorax or pneumomediastinum following PCNL is a rare complication but has been reported in a few case reports [5–7]. In this case report we describe a case of significant air in the retroperitoneal space and abdominal wall, following PCNL without related bowel injury. 2. Case report A 71 years old obese female, known case of hypertension, well controlled on medications, presented to the outpatient clinic with his-tory of on and off left flank pain for 6 months. Her condition was associated with on and off fever, occasional dark stained urine with increased frequency. Her preoperative investigations were unremark-able but her urine culture was positive for gram negative rods sensitive to ciprofloxacin, which was treated with oral ciprofloxacin according to the sensitivity pattern. Her Computed Tomography (CT) scan showed bilateral partialstag horn stones, measuring 3.4 × 1.8 mm on right side and 2.6 × 2.1 cm on left side (Fig. 1a & b). She was planned for elective PCNL on the left side. The procedure was performed in prone position by a specialist Urologist. A lower pole puncture was done under fluoroscopic guidance and the tract was dilated using serial metallic dilators up to 28 Fr. The puncture site was below the 12th rib and posterior to posterior axillary line. The stone was fragmented using pneumatic lithoclast and fragments were retrieved. A nephrostomy tube was placed at the end of procedure. Postoperatively the patient was vitally stable. The next day patient remained stable and was mobilized. Her urine output and nephrostomy output were clear, so both Foley's catheter and nephrostomy were eventually removed. Her postoperative laboratory work up that included a complete blood pic-ture and renal function were within normal limits and was eventually discharged home. On follow up, 4th Postoperative day as an outpatient she reported abdominal pain, more on left flank associated with anorexia, con-stipation, nausea, non-projectile vomiting and low grade fever. On ex-amination she was noted to be febrile (37.8 ◦C) and tachycardic (110b/ min), there was mild erythema around the puncture site as well as sig-nificant subcutaneous emphysema on the left flank extending anteriorly towards epigastrium and left iliac fossa was noted. On expression, foul smelling purulent discharge was seen from the puncture site. Ausculta-tion of the bowel had decreased bowel sounds Abdominal X-ray was done which showed air in the left iliac fossa (Fig. 2a & b). She was admitted and her septic work up was done and a CT scan was * Corresponding author. E-mail address: athar.ali@akhst.org (A. Ali).  Contents lists available at ScienceDirect International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr https://doi.org/10.1016/j.ijscr.2021.106310 Received 2 July 2021; Received in revised form 7 August 2021; Accepted 7 August 2021   Downloaded for Anonymous User (n/a) at The Aga Khan University Hospital Nairobi from ClinicalKey.com by Elsevier on November 17, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.International Journal of Surgery Case Reports 86 (2021) 1063102ordered which showed significant air in left retroperitoneal space (Fig. 3a & b). There was no evidence of any bowel perforation, lung or pleural injury. She underwent daily dressing and was started empirically on Intravenous antibiotics. Her Repeat Urine culture showed Klebsiella oxytoca and Pus Culture showed E. coli, which were treated with Injec-tion Meropenem. She improved clinically after initiation of antibiotics and inflammatory markers subsequently settled. Subcutaneous emphy-sema reduced spontaneously with time and was discharged home with daily dressing. She was followed up 4 weeks post operatively, her wound had completely healed and subcutaneous emphysema resolved completely. 3. Discussion Subcutaneous emphysema is characterized by swelling of the tissues due to accumulation and spreading of air along tissue planes. More often it suggests a communication between the subcutaneous tissue and an organ containing air (such as airway or viscera). However, it can be due to infection of subcutaneous tissue. Although it is usually benign and self-limited, it may be associated with a life-threatening situation [8]. Subcutaneous emphysema is a rare but known manifestation of intra- abdominal pathology. There are several reports of abdominal and thoracic subcutaneous emphysema following iatrogenic perforation of the colon (by colonoscopy) or due to perforated diverticulitis [9,10]. Among urological procedures, subcutaneous emphysema has been re-ported following retroperitoneoscopic surgery for renal problems, iat-rogenic bowel injury following retroperitoneal surgery or percutaneous nephrolithotomy. Wang et al. reported a case of pneumomediastinum caused by the collection of retroperitoneal air, produced by bacteria in a case of emphysematous pyelonephritis [11]. Chang et al., reported an unusual case of pneumomediastinum following PCNL, who suggested iatrogenic introduction of air into the collecting system and retroperi-toneal space through the irrigation system as a possible cause [5]. Chubak et al., reported an unusual presentation of colon perforation after PCNL, characterized by sore throat, pneumomediastinum, and neck and shoulder crepitus [6]. Dwivedi et al., reported a case of pneumomediastinum and bilateral pneumothorax following PCNL [7]. They also suggested iatrogenic introduction of air into the retro-peritoneum via the irrigating system. In our case, we found significant emphysema along with septic presentation of the patient a) b)Fig. 1. a & b; showing bilateral renal staghorn calculi (white arrows).  a) b)Fig. 2. a & b; Abdominal X-ray erect and supine, depicting subcutaneous emphysema (air in the left iliac fossa).  H.U. Soomro et al.                                                                                                                                                                                                                              Downloaded for Anonymous User (n/a) at The Aga Khan University Hospital Nairobi from ClinicalKey.com by Elsevier on November 17, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.International Journal of Surgery Case Reports 86 (2021) 1063103postoperatively. As the preoperative culture performed was positive and the stone itself may be a possible source of infection.We could attribute the emphysema to be caused by two possible reasons, one being infec-tion caused by air producing organisms and also to erroneously intro-duced air via irrigating system. In light of these findings we propose that, an air tight irrigation tubes should be used, air removed before con-necting the tubing to the nephrostomy sheath and irrigation fluid replaced timely before air enters the tubing.We also looked for devel-opment of pneumomediastinum or pneumothorax which was not seen in our case and the patient was managed conservatively with intravenous antibiotics after which she responded well and recovered completely. The case report has been formulated as per SCARE guidelines [12]. 4. Conclusion PCNL is a commonly performed procedure for complex renal stones with lower morbidity and mortality. Still it can be associated with sig-nificant postoperative complications. Special vigilance is required to recognize rare and potentially life threatening complications. Preoper-ative planning of puncture for access, perioperative antimicrobial coverage and an air free irrigation system are obligatory to avoid such complications. Declaration of patient consent Written informed consent was obtained from the patient for publi-cation of this report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Financial support and sponsorship None. Provenance and peer review Not commissioned, externally peer-reviewed. Ethical approval The Case report was approved by the institutional research com-mittee, patient gave her consent for publication. Consent No details of the patient were given. Author contribution All authors contributed equally, drafted the manual script, looked for appropriate literature and sent for publication. Registration of research studies Not applicable. Guarantor Dr. Athar Ali (head of the General Surgery). Declaration of competing interest There are no conflicts of interest. References [1] G.M. Preminger, D.G. Assimos, J.E. Lingeman, S.Y. Nakada, M.S. Pearle, J.S. Wolf, Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations, J. Urol. 173 (6) (2005) 1991–2000. [2] A. Skolarikos, Alivizatos G. de la Rosette JJMCH, Percutaneous nephrolithotomy and its legacy, in: 47, Eur. Urol., 2005, 22-8. [3] P. Alken, G. Hutschenreiter, R. Günther, Percutaneous kidney stone removal, Eur. Urol. 8 (1982), 304-11. [4] Jdl Rosette, D. Assimos, M. Desai, J. Gutierrez, J. Lingeman, R. Scarpa, The clinical research office of the endourological society percutaneous nephrolithotomy global study: indications, complications, and outcomes in 5803 patients, J. Endourol. 25 (1) (2011), 11-7. [5] C.-H. Chang, Y.-C. Jou, C.-H. Wu, C.-W. Hsieh, Pneumomediastinum: an unusual complication after percutaneous nephrolithotomy, Tzu-Chi Med. J. 29 (2) (2017) 118. [6] B. Chubak, J.M. Stern, An unusual presentation of colon perforation following percutaneous nephrolithotomy, Can. Urol. Assoc. J. 8 (11–12) (2014), E862. [7] D. Dwivedi, S. Sud, S. Singh, M. Kumar, Postoperative pneumomediastinum with bilateral pneumothorax following percutaneous nephrolithotomy, Indian J. Respir. Care 9 (1) (2020) 113. [8] A.F. Carvalho, C. Branco, P. Leão, C. Antunes, Extensive Subcutaneous emphysema as a presentation of ischemic colitis, Case Rep. Surg. 2015 (2015), 587508 (2 pages). [9] S. Fosi, V. Giuricin, V. Girardi, E. Di Caprera, E. Costanzo, R. Di Trapano, Subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and pneumoscrotum: unusual complications of acute perforated diverticulitis, Case Rep. Radiol. 2014 (2014), 431563 (5 pages). a) b)Fig. 3. a & b; white arrows, showing free air in the retroperitoneal space.  H.U. Soomro et al.                                                                                                                                                                                                                              Downloaded for Anonymous User (n/a) at The Aga Khan University Hospital Nairobi from ClinicalKey.com by Elsevier on November 17, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.International Journal of Surgery Case Reports 86 (2021) 1063104[10] 1190-2 R. Kassir, K. Abboud, J. Dubois, S. Baccot, T. Debs, J.-P. Favre, et al., Perforated diverticulitis of the sigmoid colon causing a subcutaneous emphysema, Int. J. Surg. Case Rep. 5 (12) (2014). [11] 909-11 Y.C. Wang, J.M. Wang, Y.C. Chow, A.W. Chiu, S. Yang, Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis, Int. J. Urol. 11 (10) (2004). [12] for the SCARE Group, R.A. Agha, Franchi, C. Sohrabi, G. Mathew, The SCARE 2020 guidelines: updating consensus Surgical CAse REport (SCARE) guidelines, Int. J. Surg. 84 (2020) 226–230. H.U. Soomro et al.                                                                                                                                                                                                                              Downloaded for Anonymous User (n/a) at The Aga Khan University Hospital Nairobi from ClinicalKey.com by Elsevier on November 17, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. 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Postoperative subcutaneous emphysema following percutaneous nephrolithotomy: A rare complication

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Postoperative subcutaneous emphysema following percutaneous nephrolithotomy: A rare complication

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