The Case

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. After admission, the patient was found to have extraperitoneal perforation of the anterior rectum. He was treated with antibiotics and bowel rest and discharged three days later with a plan to follow up with a colorectal surgeon in two weeks. However, the earliest available appointment with the identified surgeon was over four weeks later.

Four days before the scheduled surgical appointment, the patient presented to the Emergency Department (ED) for continued rectal bleeding and pain, now complicated by urine leaking from the rectum. He was not admitted but was told to keep his surgical appointment 4 days later. Surgical options were discussed at this colorectal surgery visit; the patient was “urgently” referred to a urologist for consideration of urinary diversion for presumed rectovesical fistula. One week later, he was seen by the urologist and was found to be tachycardic and febrile, with acute kidney injury and severe pelvic pain. Urine output could not be assessed due to the rectovesical fistula. He was directed to the ED and was admitted immediately to the Hospital Medicine service for treatment of sepsis.

Computed tomography (CT) imaging showed persistent anterior rectal perforation with increased collection of feculent material and air extending to the symphysis pubis and dissecting into the right abductor musculature. With consultation from the colorectal surgeon, an interventional radiologist aspirated the thigh abscess and placed a drain to the skin. He was discharged after one week of intravenous antibiotics and drainage, with instructions to return to the hospital 5 days later for elective cystoscopy and diverting colostomy.

The Commentary

by Lucy Shi, MD and Erik Noren MD, MS

This case describes a patient who developed the potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. Rectal perforation is an uncommon process, most often related to traumatic injury or associated with underlying diseases such as malignancy.¹ Radiation therapy to the pelvis including the prostate, as with this patient, can result in chronic radiation injury and proctitis. In severe cases, this can lead to spontaneous rectal perforation and fistula formation. Radiation proctitis is associated with chronic microvascular obliteration resulting in ischemic tissue atrophy and fibrosis. The affected tissue demonstrates markedly compromised integrity and impaired wound healing, which dramatically increases the risk for complications including leak, inadvertent injury, and failure of surgical repair.¹ Collaborative multidisciplinary approaches are often required for management of these complex disease processes.

Historically, cases of rectal perforation were managed with fecal diversion (e.g., ileostomy or colostomy), often combined with primary repair and presacral drainage. While this approach remains the standard, there is evidence that an initial nonoperative approach may be non-inferior for selected patients with traumatic or iatrogenic injury,² thereby avoiding the morbidity and recovery time associated with surgery. Many patients prefer a trial of nonoperative management when it is an option, but these patients must be managed expectantly to promptly identify those who have treatment failure and require definitive surgical intervention. This approach requires multidisciplinary care coordination and close follow-up monitoring for the development of sepsis or worsening clinical symptoms. Individualized management decisions require careful consideration of the etiology and severity of the injury, as well as patient factors such as medical comorbidities, fitness, and health literacy and engagement.

In this case, the likelihood of treatment failure with conservative management was significantly elevated due to the patient’s history of radiation therapy. The elevated risk increased the importance of adherence to his follow up care. When surgical intervention is delayed, progressive infection and septic complications may worsen and lead to increased patient morbidity and mortality. This patient was unfortunately unable to follow up for more than 4 weeks after discharge, and a full two weeks after completion of his antibiotic course. While the exact circumstances contributing to the delay in this case are unknown, such delays are not uncommon, resulting from individual and systems-based factors. By the time this patient ultimately underwent surgical reassessment, his symptoms had worsened and he manifested significant complications due to disease progression. Close follow-up and early recognition of treatment failure may have led to prompt fecal diversion. It is impossible to know whether earlier diversion would have prevented the rectovesical fistula, but earlier intervention likely would have prevented the subsequent septic complications.

Errors in Clinical Judgement

Clinical decision making is a complex process which depends on the ability to gather accurate information and to integrate and interpret clinical data to draw accurate diagnostic conclusions. This case highlights multiple potential diagnostic errors and cognitive biases which may have contributed to both the failure to identify the patient’s clinical decline as well as the delay in getting the patient to surgery. The patient presented to the Emergency Department (ED) four days before his surgical appointment, which should have prompted a reassessment of the plan for nonoperative management.  There were clear signs that the initial course was potentially unsuccessful, including persistent or worsening pain and passage of urine per rectum.  Interval imaging at this point would have been appropriate and would likely have demonstrated progression of the pelvic abscess in addition to the rectal fistula.  While the patient’s clinical evaluation did not necessitate admission or emergency surgery at this point, recognition that the trial of nonoperative management had failed would have indicated the need for an expedited plan for surgery rather than the routine follow-up that was planned. It is additionally unfortunate that the patient’s distressing symptoms related to passage of urine per rectum were not addressed at this time, and instead required navigating the disjointed process of specialist-to-specialist outpatient referrals a week later. 

The patient in this case ultimately developed septic complications and was admitted to the hospital for treatment. Interval imaging demonstrated extensive progression of the pelvic abscess, indicating an urgent need for fecal diversion. Initial percutaneous drain placement for source control is appropriate in some cases, including in the presence of hemodynamic instability, when the expertise to perform the procedure is readily available.  However, once the patient was stable for enough to safely undergo surgery, it is unclear what benefit was achieved by further delaying fecal diversion.  In fact, it is likely that the continued stream of fecal contamination prolonged the time to resolution of the infection. 

Follow-up Limitations

In the past decade, surgical patients have grown increasingly complex,³ and there is growing pressure to shift care from the inpatient to the outpatient setting. Patients are often discharged with ongoing care needs but may receive suboptimal care when there is poor communication and coordination among care team members. A focus on safe and effective transitions of care from the inpatient to outpatient setting is vital to prevent delays in care and to identify complications early, thereby avoiding morbidity and reducing health care costs by preventing unnecessary readmissions. Multiple studies suggest that patients who are seen in follow-up after discharge are less likely to be readmitted, although the optimal timing of follow up care is uncertain,^4-6 and may vary across patients, depending on social factors and underlying disease processes.

Arranging post-discharge follow-up can be challenging for both patients and providers. A significant portion of specialty medical and surgical care is provided through a patchwork of unconnected providers and group practices.  Even integrated health systems may have variation in their clinic scheduling processes, and clinic constraints often limit urgent appointment availability. Follow up care can be further fragmented when there is a need to navigate insurance authorizations, which may limit options for follow up and delay scheduling. It is often desirable for complex surgical patients to follow up with the provider who saw them in the hospital to improve the transition between inpatient and outpatient care and to limit handovers in care. However, as clinic schedules have been increasingly busy with long referral wait times, it can be difficult to balance continuity of patient care with the need for time-sensitive follow-up. Complex patients are also frequently under the care of multiple providers in different specialties. There can be a large gap in care coordination when patients are readmitted, particularly if patients are admitted to a different provider, different service or even a different facility entirely.

System Change Needed

Hospitals and patients benefit from dedicating resources to develop a robust post-discharge follow-up program that supports the transition from inpatient to outpatient care in a systematic fashion. Multiple interventions have been studied to improve transitions of care, with bundled care changes likely working better than single interventions.⁷ Such a program might start in the hospital prior to discharge with a pharmacist facilitating medication reconciliation, enhancing patient education efforts, and scheduling follow-up appointments before discharge. Care coordinators should be hired by hospital systems to partner with inpatient teams to better coordinate discharge needs, such as establishing a primary care provider and setting up outpatient appointments in an appropriate time frame. Post-discharge interventions may include follow up telephone calls to identify patients with worsening symptoms early in their clinical course, home visits, and timely follow-up appointments. Existing transitions-of-care programs appear to vary in the interventions adopted. However, dedicated transitions-of-care staff, patient-centered education, and telephone follow-up appear to be components that may lead to lower readmission rates,⁷ better provider communication and patient satisfaction, and ultimately better patient outcomes.

In this case, it is unclear if the inpatient team scheduled the patient for his follow up appointment prior to discharge. The common practice of simply including clinic referral and contact information for follow-up in the discharge packet is poorly suited for high-risk patients. Gaps in care coordination, as illustrated in this case, as well as insurance pre-authorization requirements, can result in significant delays or loss to follow-up. If the initial inpatient team had discovered that the next available appointment was four weeks later, the team could have chosen an augmented follow up plan involving other care providers and detailed patient instructions. If the surgical specialist had participated directly in coordinating the recommended follow-up, an earlier “add-on” appointment might have been approved by the clinic “gatekeeper.” Even with a relatively late surgical follow up appointment, a care coordinator could have scheduled an earlier outpatient appointment with the patient’s primary care physician to ensure that he was seen within two weeks of discharge. In addition, a follow up telephone call might have identified subtle signs of disease progression before the ED visit.

For patients with complex medical conditions and ongoing surgical needs, joint ownership of the care plan by all team members can lead to a culture of better communication, greater engagement, and improved patient outcomes. In fact, a common theme of successful surgical and medical co-management models is the involvement of multidisciplinary care teams.⁸ Traditional consultation models have limitations when patient complexity rises, increasing the risk of misunderstanding between consultants and the primary care team. Close working relationships between services, derived from rounding together in the hospital on mutual patients or establishing collaborative-care programs, can improve the coordination of care for shared patients.⁹ When patients are admitted with both acute medical and surgical needs, multiple care team members should have shared input and responsibility to optimize the likelihood of a successful outcome.

Take Home Points

• Pelvic radiation therapy increases the risk for adjacent tissue injury and can be associated with rectal perforation and fistula formation.
• Nonoperative management requires close follow up to enable prompt recognition of treatment failure. Timely delivery of definitive surgical intervention is necessary to avoid preventable patient morbidity in cases where conservative management fails.
• Follow up care after discharge is an important component in reducing unnecessary readmissions.
• Successful post-discharge follow-up programs require bundled care changes that span the inpatient and outpatient transition period.
• Direct communication during transitions of care and between services is vital to improve care coordination.

Lucy Shi, MD
Associate Physician Diplomate
Department of Internal Medicine
Division of Hospital Medicine
UC Davis Health
Lzshi@ucdavis.edu

Erik Noren, MD, MS
Assistant Clinical Professor
Department of Surgery
Division of Colorectal Surgery
UC Davis Health
ernoren@ucdavis.edu

References

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