
==== Front
Clin Case Rep
Clin Case Rep
10.1002/(ISSN)2050-0904
CCR3
Clinical Case Reports
2050-0904
John Wiley and Sons Inc. Hoboken

10.1002/ccr3.9397
CCR39397
CCR3-2023-12-2941
Anesthesia
Case Report
Case Report
Rhabdomyolysis following colorectal endoscopic submucosal dissection: A case report
Chen et al.
Chen Ying 1
Zhang Wenxuan 1
Cai Junqiang 1
Zhong Min https://orcid.org/0000-0002-8759-7983
1 304637372@qq.com

1 Department of Anesthesiology Guangdong Provincial Hospital of Traditional Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine) Guangzhou China
* Correspondence
Min Zhong, Department of Anaesthesiology, Guangdong Provincial Hospital of Traditional Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), No. 111 Dade Road, Guangzhou, Guangdong 510000, China.
Email: 304637372@qq.com

11 9 2024
9 2024
12 9 10.1002/ccr3.v12.9 e939724 12 2023
15 8 2024
© 2024 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Key Clinical Message

The occurrences of rhabdomyolysis after endoscopic submucosal dissection surgery were rarely reported. This is a case involving rhabdomyolysis affecting the muscles of the left buttocks and left hip following a prolonged endoscopic submucosal surgery.

case report
endoscopic submucosal dissection
endoscopy
rhabdomyolysis
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:11.09.2024
Chen Y , Zhang W , Cai J , Zhong M . Rhabdomyolysis following colorectal endoscopic submucosal dissection: A case report. Clin Case Rep. 2024;12 :e9397. doi:10.1002/ccr3.9397

Ying Chen and Wenxuan Zhang contributed equally to the work and should be considered co‐first authors.
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pmc1 INTRODUCTION

Rhabdomyolysis (RML) is a medical condition characterized by the release of myoglobin and other intracellular proteins from damaged muscle tissue into the circulatory system. 1 , 2 This process gives rise to a generalized clinical syndrome, which may encompass electrolyte imbalances, hypovolemia, metabolic acidosis, coagulation abnormalities, and acute kidney injury. 2 , 3 , 4 The hallmark of RML is a significant elevation in serum creatine kinase (CK) activity, typically exceeding five times the upper limit of normal, followed by a rapid decline. 1 , 5 , 6

The most prevalent acquired causes of RML are attributed to various factors, with substance abuse (34%), medication use (11%), trauma (9%), and epileptic seizures (7%) ranking among the top contributors. 7 Less frequent causative factors encompass metabolic disturbances, infections, muscle ischemia, extended periods of immobilization, strenuous exercise, and excessive heat exposure. 8 , 9 Notably, in most cases (approximately 60%), two or more contributing variables are identified. 8 Several risk factors have been established, including prolonged surgical procedures (lasting over 7 h) without adequate repositioning, patient positioning (commonly in lithotomy or lateral decubitus positions), extended tourniquet application (lasting more than 1 h), a body mass index (BMI) exceeding 40 kg·m−2, as well as co‐existing conditions such as diabetes, hypertension, and peripheral vascular disease. 10

Colonoscopy has become an essential tool in both the diagnosis and treatment of various colorectal diseases. 11 Endoscopic submucosal dissection (ESD) is recognized as an effective therapeutic approach, particularly for addressing laterally spreading tumors and early‐stage colorectal cancer. 12 , 13 However, it is worth noting that ESD presents greater technical complexity compared to conventional endoscopic mucosal resection (EMR) when it comes to treating colorectal lesions, carrying a heightened risk of adverse events. 14 The expanding prevalence of endoscopic surgeries has the potential to increase the proportion of cases involving prolonged ESD procedures. Nevertheless, the reports of RML associated with ESD surgery remain exceptionally rare. 13

This case report describes a patient diagnosed with laterally spreading carcinoma in situ of the rectum who developed RML following an extended ESD surgery performed in the left lateral decubitus position.

2 CASE PRESENTATION

A 63‐year‐old woman with a history of chronic gastritis, duodenal ulcer, and reflux esophagitis underwent scheduled ESD surgery due to a giant laterally spreading tumor in situ of the rectum occupying more than seven‐eighths of the colonic circumference (LST‐G‐NM) diagnosed by colonoscopy during hospitalization (Figure 1). The patient underwent an interventional surgery for hepatic lobe hemangioma 16 years ago and a modified radical mastectomy for left breast cancer 8 years ago. She had a body mass index of 24.4 kg·m−2 (height: 1.67 m, weight: 68.5 kg) and showed no clinical abnormalities upon general physical examination. The patient denied relevant family history. Preoperative laboratory tests revealed a hemoglobin level of 142 g·L−1 and a serum creatinine (Cre) level of 81 μmol·L−1. A preoperative chest X‐ray showed no evident cardiopulmonary abnormalities, and a transthoracic echocardiogram indicated an ejection fraction of 76%.

FIGURE 1 Preoperative endoscopic examination was performed for the laterally spreading tumor in situ of the rectum, which occupied more than seven‐eighths of the colonic circumference.

Upon entering the operating room, patient's baseline vital signs included a heart rate of 105 beats per minute and a blood pressure reading of 121/78 mmHg. The surgery was conducted under general anesthesia with tracheal intubation, closely monitored in accordance with the American Society of Anesthesiologists (ASA) guidelines.

The anesthesia induction consisted of sufentanil (15 μg), propofol (200 mg), and cisatracurium (15 mg). Mechanical ventilation was administered using volume‐controlled ventilation with a tidal volume of 500 mL, a respiratory rate of 12 breaths per minute, and a positive end‐expiratory pressure of 5 cm H₂O. General anesthesia was maintained with sevoflurane, cisatracurium, dexmedetomidine (20 μg), and sufentanil (15 μg).

The patient remained in the left lateral position with a gel pad under her left arm for about 10 h and 25 min although she was repositioned to a supine position three times during the operation. Hemodynamic stability was maintained throughout the operation with mean arterial pressures (MAP) consistently in the range of 60–65 mmHg.

The surgical procedure extended to approximately 11 h and 40 min, primarily due to the presence of a sizable lesion. Notably, no observable bleeding occurred at the surgical site, and any local muscular propria injury was addressed using a titanium clamp to mitigate the risk of delayed perforation. The conclusion of the operation was achieved with minimal blood loss, measured at 15 mL, facilitated by the local application of hemostatic material to preempt delayed bleeding (Figure 2). Throughout the procedure, the patient received 2600 mL of crystalloids, and her urine output, clear in appearance, totaled 750 mL. Following the surgery, the patient's trachea was successfully extubated, maintaining pulse oxygen levels above 94% while breathing air. Subsequently, the patient reported experiencing severe acute‐onset myalgia in the muscles of her left buttock and hip, along with temporary weakness in both lower limbs. Notably, she presented with skin lesions and ecchymosis, measuring approximately 8 × 7 cm, on her left buttock and thigh muscles. These skin abnormalities corresponded to the areas that had been in contact with the operating table during the procedure. Upon returning to her ward, the patient displayed signs of drowsiness, accompanied by a drop in blood pressure and decreased arterial oxygen saturation levels. Consequently, a decision was made to transfer the patient to the intensive care unit (ICU).

FIGURE 2 Postoperative endoscopic examination of the rectal lesion and the surgical specimen.

3 INVESTIGATIONS

A comprehensive set of laboratory tests was conducted, and the following were recorded: Postoperative day (POD) 1: CK 2976 U/L (normal range: 40–200); N‐terminal pro‐brain natriuretic peptide (NT‐Pro BNP) 178 ng/L (normal range: 0–125); Troponin T (TNT) 0.032 μg/L (normal range: 0–0.014); Cre 80 μmol/L (normal range: 41–81). POD 2: CK 3582 U/L (normal range: 40–200); NT‐Pro BNP 3962 ng/L (normal range: 0–125); myoglobin (MYO) 213 μg/L (normal range: 25–58).

Both CK and MYO levels began to decline on POD 3 (Figure 3), with MYO returning to normal on POD 5, and CK levels normalizing on POD 7. Throughout this period, potassium levels remained consistently within the normal range.

FIGURE 3 The serum levels of muscle enzymes, including creatine kinase (CK) and myoglobin (MYO), were assessed postoperatively.

The diagnosis of RML due to intraoperative compression from prolonged fixed positioning was supported by a serum CK level of 2976 U/L, complaints of myalgia in the left buttock and hip muscles, as well as temporary muscle weakness in both lower limbs.

4 TREATMENT

The patient was admitted to ICU and provided with oxygen through high‐flow oxygen therapy. Hypoxia was attributed to lung injury and infection due to prolonged mechanical ventilation. Empiric antibiotics were administered to address the pulmonary infection. Aggressive fluid resuscitation was initiated using 0.9% NaCl to safeguard renal function and counteract the risk of acute renal failure. Mannitol and bicarbonate therapy were introduced to facilitate the removal of myoglobin and correct metabolic acidosis. Continuous monitoring of urine volume and arterial blood gas parameters was carried out.

Following the administration of intensive treatment measures, the patient's blood creatinine levels exhibited a slight increase on the day after surgery but subsequently normalized. Furthermore, there were no instances of electrolyte imbalances or hyperkalemia. Unfortunately, due to the excessive fluid load, acute heart failure manifested the day after surgery, leading to an elevation in NT‐Pro BNP levels to 3962 ng/L. Subsequent treatment with diuretics and positive vasoactive agents resulted in a notable improvement in the patient's condition.

5 OUTCOME AND FOLLOW‐UP

The episode of RML exhibited a good prognosis in this patient. By POD 3, her condition showed marked improvement, accompanied by notable reductions in CK and MYO levels. On POD 5, her condition remained stable, and she had regained strength in both lower limbs. Consequently, she was transferred back to the regular ward on POD 5 and subsequently discharged home on POD 8. Clinical follow‐up 1 month after hospital discharge revealed that she had no recurrence of myalgia in the muscles and weakness in both lower limbs.

6 DISCUSSION

This case exemplifies the manifestation and therapeutic considerations of RML, primarily affecting the muscles of the gluteal region in a patient undergoing an extended left lateral position ESD surgery. The anticipated complexity of the procedure led to a noteworthy extension of the surgical duration. Prolonged surgical interventions, especially when coupled with the immobilization inherent in the lateral decubitus posture, emerge as substantial risk factors contributing to the occurrence of RML.

Kikuno et al. proposed that the duration of an operation exceeding 5 h represents the most substantial risk factor for RML and subsequent acute renal failure (ARF). 15 Targa et al. demonstrated that RML exhibited a direct correlation with the duration of surgery. Remarkably, instances of ARF were absent when the mean surgical duration was 3.5 h. 16 Following these findings, we assert that prioritizing the reduction of surgical time is imperative in the proactive prevention of RML.

Giant‐sized lesions (>30 mm in diameter) that occupy more than one‐third of the colonic circumference pose the greatest complexity and difficulty, presenting a technical challenge with an elevated risk of complications in ESD surgery. 17 , 18 Despite ESD being deemed a minimally invasive endoscopic technique, its application can be time‐consuming, extending to several hours, thereby diminishing its attractiveness. 17 , 19 , 20 When contemplating ESD surgery with prolonged duration and a heightened risk of complications, the decision to pursue endoscopic therapy should be approached with careful consideration, prioritizing patient welfare.

The primary mechanism of RML undergoing prolonged immobilization‐induced RML is the reperfusion of damaged tissue following a period of ischemia. This process is accompanied by the release of necrotic muscle material including CK and MYO into the circulation upon the alleviation of pressure. 9 , 15 , 16 The elevation of CK levels serves as the most sensitive diagnostic indicator of muscle injury, rendering it the predominant marker in clinical practice for guiding both the diagnosis and treatment of RML. 1 , 5 , 6 The commonly utilized criteria for defining RML involve an arbitrary CK level range of 500–1000 IU/L or 5–10 times the upper limit of normal, with higher CK levels correlating with a more extensive degree of muscle injury. 21

During extended surgical procedures, the incidence of RML can be attenuated through various strategic measures. These measures encompass expediting the procedural time, utilizing gel or foam pads on pressure points, periodic intraoperative repositioning, implementing aggressive fluid replacement, and promoting early ambulation. 22 It is important to underscore that the longer a patient remains immobilized, the greater the risk of RML. Even when patients are appropriately positioned and padded, a risk persists if the surgical duration is prolonged. To manage the risk effectively, Regan et al. have advocated for the segmentation of complex and time‐consuming procedures into two stages to reduce operative time. 23

Early recognition and prompt management are imperative in preventing complications resulting from untreated RML. Treatment strategies aim to halt further skeletal muscle damage, prevent ARF, and swiftly identify potentially life‐threatening complications. Prior studies have indicated that an initial CK level exceeding 40,000 U/L is associated with an elevated risk of ARF and in‐hospital mortality. 24 , 25 It may be advisable to routinely monitor blood urea nitrogen (BUN), Cre, and CK levels to assess renal function and promptly identify RML following any prolonged procedures. For the prevention and management of ARF linked to RML, a comprehensive approach is required. This includes aggressive intravenous hydration, urine alkalization, and vigilant monitoring of urine output and blood creatinine levels. It is crucial to note that, in this case, the patient experienced acute heart failure as a result of rapid and substantial fluid infusion.

7 CONCLUSIONS

RML constitutes a severe medical emergency that requires early diagnosis, and immediate treatment. We present a case where RML developed following an extended left lateral decubitus position ESD surgery. Paramount in the prevention of RML is the reduction of surgery time. Additional preventive measures encompass meticulous padding, frequent repositioning, early diagnosis by monitoring CK levels, and vigorous fluid replacement.

AUTHOR CONTRIBUTIONS

Ying Chen: Conceptualization; data curation; investigation; methodology; project administration; resources; writing – original draft. Wenxuan Zhang: Conceptualization; data curation; project administration; resources; supervision. Junqiang Cai: Conceptualization; data curation; resources. Min Zhong: Conceptualization; data curation; methodology; project administration; resources; supervision.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to declare.

ETHICS STATEMENT

The case report meets ethical guidelines and adheres to the local legal requirements.

CONSENT

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

ACKNOWLEDGMENTS

The authors would like to thank the patient for approving the publication of her case details.

DATA AVAILABILITY STATEMENT

The case report's pertinent data are available from the corresponding author upon reasonable request.
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