Farooq. V, a 38-year-old native hailing from Ponnani, Malappuram is an exceptional survivor of a disease that has an otherwise very high death rate, said Dr. Prakash K, Senior Consultant Gastro Surgery, Aster Medcity, Kochi. It is known that Covid-19 affects the lungs, kidneys and various other organs. Blockage of blood vessels to the intestine and massive bowel gangrene is a fatal but less known complication with a very high mortality rate. There were recent case series from Rajasthan and from western countries with equally high mortality rates.
“Here is a patient who had several complications of Covid-19, including massive bowel gangrene, multiple surgeries, and sepsis, and yet with the persistent collective approach of the critical care team and surgeons, the patient was successfully saved”, added, Dr. Prakash.
The patient is a 38-year-old daily wage worker and was diagnosed with Covid-19 in mid-June and later on was admitted in a Government Medical College with severe abdominal pain and weakness. Doctors recognize that Covid-19 infection precipitates blood clotting and can affect the lungs, kidneys, brain, and sometimes intestines. When blood vessels to the intestine are blocked due to massive thrombosis a good length of the intestine could turn non-viable and becomes gangrenous. Usually, massive bowel gangrenes is a fatal condition as it results in severe sepsis in a few hours’ time unless an emergency surgical intervention is done. During surgery, if a patient has nonviable bowel for a considerable length, the only option is to remove the dead intestine and it might result in a shortage of length of available healthy intestine for long term survival which is termed as ‘” short bowel syndrome” in medical terms.
The patient also had bowel gangrene and to save his life a good proportion of the small intestine had to be removed surgically. As the ends of the bowels were not healthy for re-joining, the surgeons at the Medical College brought the ends of the bowel as a stoma. However, as it was difficult to maintain the patient with high output stoma, the early reversal was performed. The ends of the intestine were joined together, but unfortunately, Farooq had leakage from the bowel anastomosis and he became septic, and hence was referred to Aster Medcity Kochi.
At the time of admission, he was on a ventilator, partly due to a resolving Covid-19 infection and partly due to the ongoing sepsis, his BP and urine output were low and he was in florid sepsis. A medical team comprising Anaesthesia & Critical Care Head Dr. Suresh G Nair, Consultant Dr. Jobin, and Gastro surgeons Dr. Prakash K, Dr. Kamalesh, Dr. Vipin, and Dr. Sidharth succeeded in careful round the clock supervision, thus stabilizing the patient within 6 days and he was subsequently removed off ventilator support. The next challenges were leaking intestines, respiratory distress, and difficulty sustaining him with nutritional support. Yet, he was not fit for another surgery to correct his leaking intestine.
After 3 weeks, post critical care evaluation and treatment, his general condition improved, and he was more or less ready for corrective surgery. The challenges during the surgery to correct his intestinal fistula were multi-fold. Dense adhesions due to sepsis, a short length of intestine leaving no room for additional resection of bowel, suboptimal blood supply to the bowel due to previous blood clots, and a mentally and nutritionally compromised patient were the major concerns. As expected, it was a difficult surgery lasting 6 hours. With careful and painstaking dissection, the gastro surgery team could identify the fistula, repair it, and join the bowel together without further length loss. His postoperative course was also stormy, but over the next 10 days, he made a slow and steady improvement and was discharged uneventfully.
The management at Aster Medcity has also pitched in to support the patient’s family to arrange for financial help and has provided necessary concessions.