M

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M M Conference

• Yassar Youssef
• May 20th, 2008

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Case 1

• 61 year-old female patient
• Elective sigmoidectomy for diverticular disease
• CAD, DM, breast cancer, S/P cholecystectomy and
  umbilical hernia repair with mesh
• Ureteral stents
• Laparotomy

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OR

• Exp Lap
• Excision of mesh
• Sigmoidectomy with primary anastomosis
• Splenectomy
• Lt salpingectomy
• Hct38 to 21. Transfused 2 units

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Pathology

• Sigmoid Diverticulosis coli with
  peridiverticular abscess formation and serosal
  fibrosis
• (There are also multiple abscess cavities
  filled with pink to green necrotic material, the
  largest of which measures 2.5 cm. in maximum
  dimension)
• Spleen Capsular tear

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Review

• Iatrogenic splenic injuries
• Timing for sigmoidectomy after acute
  diverticulitis
• OPSI and vaccinations

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Splenic injury

• 40 of all splenectomies are performed 2nd to
  iatrogenic injuries
• Of these, 60 from colon surgery
• Mobilization of splenic flexure

Iatrogenic splenic injury. Am J Surg. 1990
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Splenic injury

• Laparoscopy may decrease that incidence Better
  exposure and less aggressive traction
• Established in open vs lap Nissen and gastric
  bypass

Laparoscopic vs conventional Nissen
fundoplication. Surg Endosc. 1997 Complications
after laparoscopic gastric bypass a review of
3463 cases. Arch Surg. 2003
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Comparison of Iatrogenic Splenectomy During Open
and Laparoscopic Colon ResectionSurg Laparosc
Endosc Percutan Tech. 2007 Oct17(5)385-7

• Mount Sinai
• Retrospective- 11 year period
• Laparoscopy 1911 Open 5477
• Splenic injuries 0/1911 vs 13/5477

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Timing

• Early vs. delayed elective laparoscopic-assisted
  colectomy in sigmoid diverticulitis timing of
  surgery in relation to the acute attack
• Dis Colon Rectum. 2007
  Nov50(11)1911-7
• Early (1 week) vs late (6 weeks)

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Timing

• What is the optimal time of surgical intervention
  after an acute attack of sigmoid diverticulitis
  early or late elective laparoscopic resection?
• Dis Colon Rectum. 2006
  Dec49(12)1842-8
• early (5-8 days after initial antibiotic
  treatment) vs. late (4-6 weeks after initial
  hospitalization)

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Timing

• Laparoscopic sigmoid colectomy after acute
  diverticulitis when to operate?
• Surgery.
  2004 Oct136(4)725-30
• Less than 30 days
• Between 1 and 2 months
• More than 2 months

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OPSI Risk

• Age Younger patients
• Underlying disease
  underlying immunodeficiency gt thalassemia gt
  sickle cell anemia gt traumatic splenectomy
• Time since splenectomy Recent splenectomy

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OPSI Pathogens

• Encapsulated bacteria S. pneumoniae
  (most common) H. influenza, N.
  meningitidis
• S. aureus
• Numerous gram negatives including E. coli, K.
  pneumoniae, Salmonella sp. and Capnotcytophagia
  sp. (the latter usually acquired from a dog bite)
• Malaria
• Babesia (acquired from ticks in the
  Eastern seaboard particularly Cape Cod, Marthas
  Vineyard, Nantucket, Block Island)

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Vaccination

• Pneumococcal vaccine, H. influenza and
  quadrivalent meningococcal vaccine if possible up
  to three weeks prior to removal of the spleen to
  optimize the immune response
• emergency splenectomy as soon as possible after
  the patients recuperation

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Vaccination And Abx

• A booster PPV23 should be given approximately 5
  years after the initial vaccine/series
• Antibiotics Controversial
• The only regimen which has been studied is
  penicillin prophylaxis for patients with
  functional asplenia from sickle cell anemia

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Vaccination And Abx

• Resistance to penicillin (and other antibiotics)
  is a growing concern, so its efficacy is
  currently presumed to be lower
• Compliance
• May be given for children but not adults

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N.B.

• Be sure that patients understand the need for
  prompt medical evaluation for all febrile
  illnesses
• Patients who do not have rapid access to medical
  care should be advised to develop resources for
  the local availability of appropriate
  antibiotics.
• Patients need to be aware of the increased risk
  posed by dog bites, and tick and mosquito bites
  in areas endemic for babesia and malaria
  respectively.

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Case 2

• 61 year-old female CAD, HTN, Dyslipi.
• Obstructive jaundice and weight loss
• ERCP ampullary tumor with biopsy showing Adeno
  Ca
• CT scan and EUS
• OR Pylorus-preserving Whipple

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Pathology

• Ampullary carcinoma 1.3 cm
• Poorly differentiated
• Margins negative
• LN 3 out of 7 were positive

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Post-op

• OR on 05 / 08
• Drain amylase on 05 / 13
• Serum 48 Drain 47 900
• NPO, TPN and Octreotide

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Pancreatic fistula

• Hallmark of complications
• No clear definition Incidence?
• ISGPF (International Study Group on Pancreatic
  Fistula) The presence of any measurable, amylase
  rich (3 times the normal serum level) fluid
  output on or after postoperative day 3