Morbidity & Mortality

Resident Conference

Steven S. Godelman, MD, PGY-3

Aventura Hospital Medical Center
Kendall Regional Medical Center
Department of Surgery
February 22, 2016

86M w/ vague abdominal

discomfort, constipation and
tenesmus

86M w/ vague abdominal discomfort,

constipation and tenesmus

PMHx: DM2 (diet controlled), Glaucoma

PSHx: None
Home Rx: Zantac
SHx: neg x3; lives w family, independent,
good support
FHx: Noncontributory; no known h/o
malignancy
ROS: abd pain, GERD, constipation,
tenesmus, decreased appetite

 Vitals:
T:36.2 HR:66 BP: 138/72 RR:16 SaO2:98% RA

Exam:
A&Ox3, age appropriate
RRR, no m/r/g
CTAB, no w/r/r
Abd S/ND/NT, +BSx4, no HSM, no
palpable masses
+FOBT

 CBC: 9.4, 9.3/28.6, 63

BMP: 136 103 25
3.1 26 1.8

LFTs: 0.5, 18/22, 109

 Studies
CXR: unremarkable
CT IV/PO: cholelithiasis, no gross abnormalities,
contrast in colon, non-specific mildly prominent
RP LNs
Spleen US: unremarkable

Hospital Course
2/7: Admission; GS, GI, HO consulted
2/8: upper endoscopy, mild gastritis, no
bleeding, H Pylori neg
2/9: prep for c-scope
2/10: c-scope and polypectomy
Multiple polyps
Cecum x3
Desc Colon/Rectum x3; 50cm, 40cm, 30cm

Pathology
A. BIOPSY FROM CECAL POLYP:
- INVASIVE MODERATELY DIFFERENTIATED ADENOCARCINOMA
B. BIOPSY OF COLON MASS AT 50 CM:
- SUPERFICIAL FRAGMENTS OF ADENOCARCINOMA WITH ULCERATION
C. BIOPSY OF COLON POLYP AT 40 CM:
- TUBULAR ADENOMA
D. BIOPSY OF COLON MASS AT 30 CM:
- SUPERFICIAL FRAGMENTS OF ADENOCARCINOMA
E. BIOPSY FROM RECTAL POLYP:
- TUBULOVILLOUS ADENOMA.
- SEPARATE PORTION OF BLOOD CLOT W MICROSCOPIC FRAGMENT OF
ADENOCARCINOMA

Hospital Course
2/11: flex sig w/ polypectomy
Pathology: acute/chronic inflam changes,
no malig

Preop Planning

H/H stable
PLTs 84
Colon prep
T&S
LE Duplex

Appropriate Resection?

Surgery
2/15
Procedure:
exploratory laparotomy
lysis of adhesions
mobilization of splenic flexure
subtotal colectomy
ileo-sigmoid colon anastamosis
Side-to-side, functional end-to-end
GIA 75mm stapler
Intra-op Path: Confirmation of all polyps
removed
EBL: 100cc

Postoperative Course
2/15:
Extubated in PACU
Admitted to SICU

2/17:
Bowel fx
HD stable, no bleeding

2/18:
Started on CLD
Transferred to floor

Postoperative Course
2/17:

Bleeding subsided
Weaned off pressors
Repeat ABG BE -1
H/H, PLTs stable

2/15-2/16:

Bleeding per rectum, bright red w/ dark clots

HD stable
8.2/25/79, 1.54/16.8/31, PFTs 239; + PLT ABs
Given 2 pRBC, Neo per primary

2/16:
Episodes of bleeding
4 pRBC/PLT/FFP, 30 DDAVP
Fac VII

 Anastomotic Bleeding:
More common after stapled anastomoses
Prevention:
-Inspect staple line
-Use antimesentericborder of bowel

Most cases are mild and self-limited

-Stabilize, correct coagulopathy, hold meds that
may exacerbate bleeding

More serious bleeding

-Retention enemas (saline and epinephrine)
-Endoscopy
-Return to OR