Cervical and Mediastinal Emphysema as the First Manifestation of Colonic Laceration Following Cesarean Section

Introduction

Cesarean section is a major surgical procedure that can be associated with short- and long-term complications. ¹ Understanding the long-term and short-term effects of cesarean section for women is subject to constraints. These limitations can include study design, the inadequacy of a study, and inappropriate selection of the groups to be compared.^2–4 Bleeding, pelvic adhesions, and surgical injuries to the bowels and pelvic viscous are among the most-common complications of cesarean sections.^3,5

Mediastinal and subcutaneous emphysema is the presence of inappropriate and outward air in mediastina, subcutaneous, or interstitial tissue. ⁶ Subcutaneous emphysema is a pathologic condition that can be secondary to many events. In general, iatrogenic, traumatic, infectious, or spontaneous injuries can play roles in the formation of cervical, subcutaneous, and mediastinal emphysema. ⁷ Intubation, mechanical ventilation, vaginal delivery, dental surgeries, surgical procedures, and colon perforation are also reported causes of mediastinal emphysema.^7–10

The occurrence of extensive cervical and mediastinal emphysema as the presenting sign following colon perforation is very rare. ¹¹ This report presents a rare case of cervical and mediastinal emphysema as the first clinical manifestation following colon perforation caused by a cesarean section.

Case

A 27-year-old woman underwent cesarean-section surgery. She was discharged 48 hours after the surgery and,12 hours later, she came back to the emergency room due to crepitus palpation. On physical examination, her vital signs were as follows: pulse rate, 110 beats per minute; temperature, 37.5°C; blood pressure, 110/60 mm Hg; and respiratory rate (RR), 22.

A physical examination revealed that she had “snowball” crepitation in her neck and upper chest that suggested subcutaneous emphysema in these areas. Other examinations including the abdomen and incision line yielded normal results. An electrocardiogram only showed sinus tachycardia, but a chest-X ray revealed mediastinal emphysema.

This patient was referred to the thoracic surgery department for an investigation to see if she had mediastinal emphysema and to rule out esophageal perforation. Three hours after admission to the ward, she was febrile (temperature: 39°C), with a prothrombin ratio of 120/minute and an RR of 25/minute. She was conscious but seemed to be ill and complained of having difficulty breathing and swallowing.

Her surgical history, included the fact that she had had a previous cesarean section. Yet, she did not have any complaints regarding her abdomen. Her incision line was normal without any discharge or edema, and her bowel sounds were also normal.

There were two questions: (1) Was the main pathology in the chest due to any esophageal or tracheal perforations? Or (2) was it in the abdomen? To rule out esophageal perforation, an esophagogram was performed with gastrographin and barium. Computed tomography (CT) and the chest and abdomen was also performed. The esophagogram yielded normal results, but the CT scan showed that she had mediastinal emphysema (Fig. 1). There were chest-wall emphysema and air in the abdominal-wall muscles without any gases in the intra-abdominal space (Figs. 2 and 3). During these investigations, erythema, edema and other signs of cellulitis appeared on the patient's the left flank. Accordingly, the diagnostic dilemma was resolved with the appearance of this left-flank cellulitis and with the CT results.

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FIG. 1.

Chest computed tomography in the axial plane (at the level of the apex of the lungs) showing mediastinal and cervical emphysema (arrows).

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FIG. 2.

Abdominal computed tomography scan in the axial plane showing abdominal-wall subcutaneous emphysema in the left flank (arrow).

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FIG. 3.

Chest computed tomography scan in the axial plane showing chest-wall subcutaneous emphysema (arrows).

Results

Granulation tissue gradually appeared at the incision line over the intestine and lateral wound. At this point, the skin in the upper and lower parts of the midline incision were approximated, and a lateral wound was left open for spontaneous closure. A few days after the surgery, the subcutaneous and mediastinal emphysema disappeared.

The patient was discharged with instructions to take a daily bath and was also given instructions for dressing the lateral surgical wound. After 4 weeks, the lateral surgical wound had closed.

Discussion

Neck emphysema and pneumomediastinum emphysema are complications that occur for various reasons, including head-and-neck surgery and trauma. ⁸ In particular, subcutaneous and mediastinal emphysema can be a very rare symptom of colonic perforation. In this condition, despite the presence of colonic perforation, diagnosis and treatment can be delayed due to the absence of peritoneal inflammation and typical complaints.^12,13

Cesarean sections are among the most-common surgical procedures increasingly performed around the world. Occurrences of adhesion bands in repeat cesarean sections and intestinal injuries have been seen, although an optimal technique for cesarean sections still exists. ³

Intestinal perforation, a sufficient pressure gradient between the intestinal duct and the subcutaneous space, and the anatomical location of the perforation are among the most important factors leading to subcutaneous emphysema with diffusion from the gastrointestinal (GI) tract.^7,14 In the current case, the patient's sigmoid colon was attached to the incision site by an adhesion band and, due to reincision, a laceration was created at the point where the colon was attached to the old incision site, and the sigmoid colon was also still connected to the abdominal wall. After closure of the Pfannenstiel incision, formation of a dead space in Camper's fascia along with tissue movement in the wound area leads to an increased pressure gradient and development of emphysema.

Yet, it seems that the association between the endothoracic fascia and Camper's fascia in the abdomen can be considered as a transmitter of emphysema from the subcutaneous to mediastinum spaces. More importantly, the presence of free communication of the neck with the retropharyngeal, carotid, and visceral spaces—as well as with the mediastinal space can be considered as a causative agent of pneumomediastinum. ¹⁵

In a case report and review study by Oetting et al., ¹⁴ although the exact cause of perforation was different, intestinal perforation in different parts of the intestine was considered as a causative agent of emphysema. The most-common causes of emphysema with GI origin among the cases reviewed by Oetting et al. ¹⁴ and Muronoi et al. ¹² were gastric ulcer and diverticulitis, respectively. Other reported factors included intestinal traumatic perforations, appendicitis, carcinoma, ulcerative colitis, stercoroma, and gastric and rectal cancer. Similar to the case described here, in that review study, the most commonly reported perforation site was the sigmoid colon.

Several case reports were reviewed by Muronoi et al. ¹² In these cases, retroperitoneal emphysema was also reported, while, in the current case, unlike previous reported cases, no gas was seen in the retro- or intraperitoneal spaces. It seems that because the fistula created between the intestine and the abdominal wall had no leakage to the abdominal space, no retro- or intraperitoneal emphysema occurred.

None of the cases reviewed by Oetting et al. ¹⁴ and Muronoi et al. ¹² showed signs of infection and generalized peritonitis before the onset of the occurrence of emphysema. Similar to previous case reports, in the present case, there was no evidence of infection and generalized peritonitis during preoperative examinations.

Similar to a case reported by Lee et al., ¹⁵ in the present case, respiratory distress along with difficulty in swallowing, was noted, which could be related to the cervical and mediastinal emphysema.

For managing mediastinal emphysema, in numerous cases reviewed by Muronoi et al., ¹² only a chest drain was placed. In the current case, the pneumomediastinum emphysema was managed by drainage through a collar incision.

Conclusions

Adhesion bands are among the complications of various surgical procedures, including cesarean section. Considering the high probability of delivery through cesarean section in patients who have had previous cesarean sections, this can increase the possibility of damage to the intestines in the presence of adhesion bands—especially in cases when cesarean section is of an emergency nature—that might be missed and involve severe consequences to the patient. In this situation, if subcutaneous emphysema occurs, given that it might not be associated with peritonitis and other symptoms, the damage may be misdiagnosed. Therefore, in these cases, in the event of cervical subcutaneous and mediastinal emphysema following various surgical procedures, the possibility of perforation and emphysema with an intestinal origin should be considered.