Gastrojejunostomy: a potential hazard to the surgeon

Abstract

This case report highlights the potential hazard of emergency operating of an obstructed hollow viscus in the era of World Health Organization checklists.

This article describes the first case of burn injury to the hand of a surgeon during an open gastrojejunostomy for a subacute gastric outlet obstruction. The most commonly described injuries in surgical practice are needlestick injuries and those related to exposure to blood and blood borne products.¹ Adverse events in the operating theatre related to fire or explosions, however, are rare. In the operating theatre environment a number of hazards exist that could potentially contribute to an adverse event. Numerous departmental protocols including the World Health Organization checklist are employed, as far as possible, to minimise any risk to the patient or theatre staff.² Unfortunately, these checklists failed to identify this particular risk to the surgeon.

Flammable gases in the gastrointestinal tract have been reported to cause explosions in the operating theatre.³ Advisory recommendations have therefore been made to avoid the use of diathermy in cases where free gas may be expected in the peritoneal cavity.⁴ Produced from anaerobic degradation of organic products in the gastrointestinal tract, methane has an explosive range of 5–15% and is the most common gas present in the stomach and colon.

In this case, an open gastrojejunostomy was performed for a gastric outlet obstruction secondary to chronic pancreatitis causing a duodenal stricture (Fig 1). Following laparotomy, at anterior gastrotomy (performed using diathermy), an audible explosion occurred causing burns to the surgeon’s hand (Fig 2). It is known that fuel, heat and oxygen are the three ingredients of fire formation. This occurred dramatically when, along with oxygen, contact was made via diathermy with the contents of the obstructed gastric cavity containing methane gas. Most operating theatre explosive incidents described are of those related to colonic explosions during laparotomy.⁵ However, a dilated obstructed stomach is potentially a greater hazard as the gastric cavity contains a higher percentage of oxygen (10%) than the colon (5%).⁴ The above burns were sustained despite the surgeon using a double gloved technique.

Figure 1.

Pre-operative computed tomography showing the dilated gastric loop

Figure 2.

Blistering sustained secondary to burns over the third and fourth digits of the surgeon

Pre-operative decompression of the stomach using a nasogastric tube is routine practice. Not only does it decompress the stomach to alleviate symptoms and reduce the risk of aspiration but it also minimises bowel gas. In this instance, however, the reduction in bowel gas had been suboptimal.

In this case, no further injuries were sustained and the procedure was completed successfully with the patient making an uneventful recovery. We therefore recommend that the operating surgeon should be mindful of the potential for such an adverse event. The surgical checklist for such procedures should indicate aspiration of the nasogastric tube by the anaesthetist prior to gastrotomy performed with a non-thermal device.