Abdominal Visceral Injury, a Devastating Consequence of Abdominal Liposuction: A Case Report and Literature Review

Abdominal liposuction is a commonly performed cosmetic procedure. However, as with any procedure, it can be associated with complications. One of the life-threatening complications of this procedure is visceral injury and bowel perforation. This complication is very rare, nevertheless general, and acute care surgeons must be aware of its possibility, its management, and its possible sequelae. We report a case of a 37-year-old female who underwent abdominal liposuction which was complicated by bowel perforation and was transferred to our facility for further care. She underwent an exploratory laparotomy in which multiple perforations were repaired. The patient then underwent multiple surgeries including stoma creation and had a long postoperative course. A literature review reveals the devastating sequelae of reported similar visceral and bowel injuries. The patient eventually did well and her stoma was reversed. This patient population will require close intensive care unit observation and a low threshold of suspicion for missed injuries during initial exploration. Further down the line, they will need psychosocial support and the mental health implications of this outcome must be cared for. The long-term aesthetic outcome is yet to be addressed.


Introduction
Abdominal liposuction is one of the most common and routinely performed cosmetic procedures, however, it can have complications. The procedure can be performed in the outpatient setting making it appealing to the public and possibly downplays the potentially deadly complications that may occur. Complication rates are reported between 0% to 10% compared to mortality rates reported at <1% at the hands of experienced plastic surgeons. Bowel and visceral perforation during liposuction are rare complications with a reported incidence of <0.1 [1,2]. In 1989, an initial report of peritoneal perforation during liposuction was published, where two patients were explored due to this complication [3]. Major complications resulting in mortality after liposuction include pulmonary emboli followed by bowel perforation [2]. Some reports have documented the detrimental effect of this complication leading to death in several reported cases [4]. Many of these patients present with peritonitis, shock, and extensive necrotizing fasciitis, and despite best efforts, cannot be saved [5,6]. We present a patient referred to our hospital two days after liposuction resulting in small bowel injury with a complicated post-operative course. We aim to shed light on a potentially devastating complication of a routine procedure and how it was managed.

Case Presentation
A 37-year-old female with no past medical history and a past surgical history of abdominoplasty and umbilical hernia repair, with a body mass index of 28, was transferred from an outside hospital to our emergency department two days after undergoing abdominal liposuction. She had developed generalized abdominal pain after the procedure, which was worsening in severity, and unresponsive to analgesics.
On arrival at our institution, the patient was in evident distress and pain, she had a heart rate of 160 beats per minute, a respiratory rate of 43 breaths per minute, blood pressure of 105/68 mm/Hg. Abdominal examination revealed distension with generalized tenderness, guarding all over the abdomen, and visible well-healed scars from her prior abdominoplasty. Labs were significant for a white blood cell count of 12.5 x 103/uL, hemoglobin of 15.4 gm/dL, urea of 7.8 mmol/L, creatinine of 82 umol/L, and a lactate of 4.2 mmol/L.
A CT scan had already been done at the referring facility. We were able to review the images at the time which showed free air in the peritoneal cavity and a significant amount of free fluid. She was diagnosed with perforated viscous post-abdominal liposuction. The patient was stabilized with intravenous fluids and antibiotics and prepared for emergency surgery. The patient was taken for an emergency exploratory laparotomy which revealed four enterotomies (Figure 1), mesenteric laceration (Figure 2), and five seromuscular injuries in the small bowel. All bowel injuries were repaired primarily, and the abdomen was closed. Her condition did not improve in the following days, and a repeat CT scan showed mesenteric fat stranding, dilated bowel loops and no evidence of contrast leak ( Figure 3).  She had rising inflammatory markers, interval development of bacteremia, pleural effusion, and a persistent fever. The patient was re-explored on postoperative day 5, where two further enterotomies ( Figure 4) were identified including one on the mesenteric border of the small bowel in addition to persistent leak from prior repair sites. The affected segment with the persistent leak was resected and bowel continuity was restored, the abdomen was kept open.

FIGURE 4: One of the newly discovered enterotomies on re-exploration
A relook surgery on postoperative day 8 revealed persistent intestinal content leak from the previously repaired perforations and additional mesenteric border perforation was identified, and the patient underwent further bowel resection. During the surgery, the patient was hemodynamically unstable with an increasing requirement for vasopressor support. We opted not to anastomose at the time and she was left with an open abdomen for planned re-exploration. On postoperative day 10, she was taken back for relook surgery where a peri splenic abscess was drained and additional perforation was identified and resected, with the creation of a double barrel ileostomy and application of vacuum-assisted closure (VAC) device for her midline wound. Her abdominal wound was eventually partially approximated with the aid of a bridging mesh on postoperative day 13.
She had a turbulent postoperative course with ongoing bacteremia, candidemia, and altered mental status requiring reintubation. She was supported with total parenteral nutrition and transitioned to nasogastric feeds until she tolerated the oral diet. She eventually recovered with the aid of physical and speech therapy. She was discharged two months after admission.
The patient was referred to the plastic surgery service. She underwent partial thickness skin grafting of her abdominal wound with a favorable outcome. In the interim, she has had multiple visits to the emergency with fatigue, vague abdominal symptoms, and signs of dehydration requiring fluid resuscitation due to high stoma output. She eventually underwent a successful reversal of her stoma and the repair of an incisional hernia.

Discussion
Liposuction is a common procedure and its popularity is on the rise [7,8]. Our case report highlights a potentially fatal complication of a routinely performed procedure. Emergency medicine, plastic, and acute care surgeons must be aware of the potential complications associated with this seemingly safe, straightforward procedure. The commonly encountered complications after liposuction are usually mild and can be managed conservatively. However, some life-threatening complications must be kept in mind [9][10][11].
A review of the literature on similar cases identified 45 cases where patients had undergone abdominal liposuction complicated by visceral injury.   [5]. Table 2 shows the imaging modality and findings, management, and outcomes. Unfortunately, of the reported cases, seven deaths (16%) were reported. A review of the outcomes shows intensive care unit stays, prolonged hospital stays, and the need for multiple surgeries. Another associated problem is necrotizing fasciitis requiring extensive debridement. Some patients present within a day others presented after a week. Injuries may involve the liver, gall bladder, spleen, and small and large bowel.    [28]. As evident from our review, these patients present in a critical state with active sepsis and shock and require emergency surgery. With our patient, she had multiple missed perforations which declared themselves on re-exploration. Given our experience with this patient, we would recommend planned relooks after initial exploration and meticulous examination of the bowel including the mesenteric border as well for any suspicious areas of perforation. It is also worth noting that the perforations repaired primarily failed to heal most likely due to the poor underlying condition of sepsis, bacteremia, and hostile abdomen with peritonitis. Further attention must be paid to nutritionally supporting this patient population from the moment they present in anticipation of future surgery.

Conclusions
Abdominal liposuction is a well-established and safe procedure; however, we must be aware of its potentially life-threatening complications and how to deal with them. Our case report outlines our experience with a patient who recently underwent abdominal liposuction and her prolonged postoperative course in and out of the hospital setting. In this case, we had a favorable outcome despite her instability in presentation and complicated postoperative course. However, there is a mental health and psychosocial implication on the patient that has not been studied in this case.
Patients who undergo liposuction complicated by perforation require a multidisciplinary approach of emergency medical care, intensivists, surgeons, psychologists, and therapists to aid their recovery.