Morbidity and Mortality Conference

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Morbidity and Mortality Conference

• 9/20/2006

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CC/HPI

• CC
• abdominal distention with Nausea and Vomiting
• HPI
• FB is a 66-year old African American Male
• Presents with 5 day history of increasing
  abdominal distention and vague lower abdominal
  pain
• obstipation, Nausea/Vomiting
• denied fever/chills, SOB
• Recently had colonoscopy at another facility
  (8/24)- showed nearly obstructing circumferential
  lesion in the distal transverse colon

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PMHx

• PMHx
• HTN
• NIDDM
• Hypercholesterolemia
• PSHx
• Left hip replacement (10 yrs ago)
• Right Knee surgery (6 yrs ago)

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Meds/Allergy

• Medications
• Metformin
• Lisinopril
• Zocor
• HCTZ
• Allergies
• NKDA

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Physical Exam

• Vital signs-
• T 36.7 P-120 BP- 96/70 RR-18 9
• General - AAO x3 mild distress
• HEENT- No lymphadenopathy, nonicteric
• CVS- S1 S2 No murmurs
• Lung- CTAB
• ABD- Soft, marked distention, lower abdominal
  tenderness, bowel sounds-hypoactive, No Masses,
  No scars, - rebound
• Ext- palpable pulses all 4 ext.

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Lab Values

• Na-134 K-3.7
• Cl-90 CO2-25 BUN-41 Crea-2.94
• Ast-22 Alt-44 Alp-154 T.Bili-0.6
• WBC-14.6 Hgb-15.1 Hct-44.5 Plts-363
• PT-9.8 INR- 1.3 PTT-25.5

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Imaging

• Abdominal x-ray-
• Probable Ileus. Diffuse Small Bowel distention
  with multiple fluid air levels. Air seen to the
  distal transverse colon
• CT-scan-
• Considerable dilatation of colon traced down to
  the level of the sigmoid with small bowel
  dilatation

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Imaging
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Imaging
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Imaging
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Imaging
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Assessment/Plan

• Assessment
• 66 y/o AA male in acute renal failure with a
  pancolonic dilatation maximum at the cecum (close
  to 10 cm)
• Plan
• Consult GI for attempted passage of obstructing
  lesion and placement of a stent for colonic
  decompression

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Colonoscopy

• Colonoscopy-
• advanced to 50 to 55 cm from the anal verge
• Suspicious looking mass mixed with stool at this
  point causing obstruction
• Could not negotiate past this point
• Procedure then aborted
• Due to failure of colonic decompression and
  passage of obstruction, patient then taken to the
  OR to relieve apparent Closed Loop Obstruction

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Operation

• Upon entry into abdomen- entire Small Bowel wall
  is found to be distended and edematous
• Right transverse and descending colon found to be
  distended with air and liquid stool
• Overall, both small and large bowel are dilated
  and difficult to mobilize
• No pathologic lesions found in the small bowel
• Distal transverse colon down and descending colon
  mobilized and transected

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Operation

• Specimen examined and found to have no lesions
  present
• Right colon was decompressed by opening
  transverse colon and suctioning colon contents
• Cecum then properly evaluated, which showed
  serosal tears that were repaired
• Cecum gently retracted to allow for inspection of
  sigmoid
• Dense adhesions were noted in the small of the
  pelvis. Also, dense adhesions from omentum to
  sigmoid consistent with previous episodes of
  diverticulitis

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Operation

• Once adhesions were freed, sigmoid inspection
  reveals a tumor from distal 1/3 of sigmoid to
  peritoneal reflection
• Tumor is circumferential with high grade to
  complete obstruction. No obvious invasion of
  pelvic side wall, retroperitoneum or mesentery.
• Sigmoid resection performed
• Transverse colostomy created

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Post Operative Course

• Extubated POD 1
• Currently, awaiting return of bowel function
• Vitals stable
• Acute Renal failure resolved

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Complication

• Performed Left hemicolectomy versus sigmoidectomy
• 1st instinct was to perform procedure according
  to CT-scan results
• Judgment skewed by two colonoscopy reports
  identifying lesion in distal transverse colon or
  proximal descending colon
• Procedure made more complicated by short
  mesentery of small bowel and overall marked
  dilatation of bowel which made mobilization
  difficult