M

1
M M

• Aug 7, 2007

2
HS 11309437

• 72 y. o. retired pathologist
• Upper GI bleed s/p endoscopy at GBMC
• h/o Hep C, GERD, BPH
• smoking

• Hypotensive, tachycardic, NG tube aspirate was
  bright red
• Transfused, resuscitated
• GI ? endoscopy, bleeding vessel injected,
  fulgurated, endoclipped

3
Labs
10.9
12
83
37
144
122
42
139
3.8
16
2
7.7
3.6
1.8
53
45
2.0
37
4
Assessment

• Hypovolemic shock
• Acute renal failure
• Hepatic dysfunction
• Mixed Gap acidosis

5
Hosp. course

• Day 1 Rebleed, takeback to OR by GI
• Re-injection and banding of bleeding
  vessel, octreotide
• Day 2 Rebleed, 9 units PRBC, Surgical
  consult, taken emergently to OR
• OP findings 5 x 5 cm epiphrenic esophageal
  diverticulum, no active bleeding vessel.
  Resection of diverticulum, gastrostomy, Chest
  tube.
• 5 units PRBC, 2 FFP, 1 6-pack platelets

6
Post-op course
Slow return of bowel function POD 5
gastrograffin swallow ? no leak Tube feeds
started POD 7 Failed void trial (BPH) Chest
Tube high CT output initially, air leak. Left
Superficial femoral venous thrombosis
7
Post-op course

• Progressive deconditioning
• (transferrin 83, prealbumin 4.3)
• Azotemia pre-renal as well as renal
• Leucocytosis
• Increasing ascites, oliguria, elevated liver
  enzymes, hepatorenal syndrome
• POD 14 transferred to ICU hypotensiion,
  mixed metabolic and respiratory, oliguria, renal
  failure.

8
ICU course

• Progressive renal failure requiring RRT
• Respiratory failure, Rt UL segmental PE
• Klebsiella, Candida pneumonia
• Progressive metabolic acidosis
• Sepsis
• Refractory to pressors.

9
DM 10932963

• 72 yo 385 lb, caucasian male
• DM, HTN, CAD, GERD
• Acute cholecystitis.
• Gangrenous, tense GB, omental adhesions
• Open conversion for intra-op hemorrhage
• 1.5 l blood loss, 2 units PRBC
• Side rent in accessory / replaced Rt hepatic
  artery, controlled with 5-0 prolene
• Uneventful post-op, d/c d home POD 3

10
Table 1. Anatomy Classification of Right Hepatic
Artery
One arterial orifice Type IA MHA from LHA Type
IB MHA from LHA Type IC Replaced RHA from
SMA Type ID Replaced RHA and MHA from SMA Type
IE Entire CHA from SMA
Transpl Proc. March 2007 Klein et al
11
Anatomic variations of cystic artery
12
And more