Sinai Hospital of Baltimore Department of Surgery

1
Sinai Hospital of Baltimore Department of
Surgery

• Morbidity and Mortality Conference
• August 15, 2006

2
History of Present Illness

• 75 y/o Male presents with Gastric Adenocarcinoma
  diagnosed after work up for abdominal pain and
  melanotic stool
• Pt scheduled on 8/2/06 for Subtotal Gastrectomy

3
Past Medical History

• Ischemic Cardiomyopathy with EF of 30-35
• Hx of TIAs
• Atrial Fibrillation
• Hypertension
• Gout
• Alcohol Abuse
• Dyslipidemia

4
Medications

• Toprol
• Digoxin
• Cozaar
• Prevacid
• Norvasc
• Aldactone

5
Allergies

• Zestril
• HCTZ

6
Brief Operative Note

• PreOp Dx Gastric Adenocarcinoma
• PostOp Dx Same
• Procedure Partial Gastrectomy with Billroth II
  anastomosis
• AnesthesiaGET
• Complications None
• EBL 150 cc
• Pathology moderately well differentiated
  adenocarcinoma

7
Postoperative day 1

• Vitals stable
• H/H- 12.3/37/2 bmp-wnl
• Abdomen- Soft, Mild distension, no bowel sounds,
  incisional tenderness
• NGT 450cc/24hrs
• Urine Output 1.2 L/24 hrs
• A/P- await bowel fxn, check H/H

8
Postoperative Day 2

• Vitals- stable
• Wbc-20.9-gt20.6 h/h-11.4/34.6 bmp-wnl
• Abdomen- Soft, mild distension, no bowel sounds,
  incisional tenderness
• NGT 550cc/24hrs
• Urine Output-1.8L
• A/P- d/c A-line transfer to floor

9
Postoperative Day 4

• Vitals- stable
• Bloody drainage noticed from the NGT. H/H sent,
  which shows a drop to 8.9/27.4-gt transfused 2
  Units.
• WBC- 15
• Pt continues to be AAO x3
• NGT- 500cc/12hrs
• Positive for Flatus and BM

10
Postoperative Day 5

• Vitals- Afebrile, but HR increasing to 100 bpm,
  BP stable at 145/61, 100 on 2L
• WBC- increases to 17
• H/H responds to previous 2 Units- now at 11/33
• NGT- continues to have bloody drainage, now 1.2
  L/ 24hrs
• ABD- Soft, Mild distention, dressing intact, dry
  mild diffuse tendernes
• Clinically- patient has no new complaints
• A/P EGD to assess anastomotic bleeding and
  possible cauterization of bleeding serial H/H

11
Postoperative Day 5 (cont.)

• EGD-
• during procedure experienced one acute episode of
  hypotension (80/40) and desaturation into the low
  80s. Pt. responded to fluid resuscitaion and
  increased oxygen delivery
• EGD curtailed due to instability, but impression
  of procedure performed
• Evidence of Billroth II anastomosis and Partial
  gastrectomy in the stomach
• Erythematous, friable and hemorrhagic mucosa with
  erosions and active bleeding. Gastric pouch was
  filled with blood.
• Procedure was stopped due to hypotensive episode
• No isolation of bleeding
• Possible Erosive Gastritis vs Anastomotic Ulcer
• H/H post procedure was 8/24. Pt. given 2 more
  units of blood.
• CXR- caridomegaly, No infiltrates, No effusions
• RecommendationIV protonix, Vasopressin drip
  repeat EGD/Angio the next day if blleding
  persists
• Pt. transferred to the ICU for observation and
  serial H/Hs

12
Postoperative Day 6

• Vitals-stable- HR-72, BP-170/70, O2 sat-100 on 2
  L NC
• H/H after a total of 3 units 8/24-gt 11/33
• WBC 17, BMP-wnl
• ABD-Soft, ND, Bowel sounds decreased
• A/P- cont IV protonix stop Vsopressin in 24 hrs

13
Postoperative Day 7 8

• Vitals- Hypertensive, otherwise stable
• H/H maintaining at 10.8/32.3
• Vasopressin stopped, protonix continued
• Pt. begins to complain of bloating and nausea
• ABD-Soft, Distended, Mild diffuse tenderness, BS-
  hyperactive
• No flatus or BM in the past 24 hrs
• Reglan started for presumed gastroparesis

14
Postoperative Day 9

• Patient transferred to the floor
• C/o of recurrent emesis and denies flatus or BM
• Pt. made NPO
• No Active Bleeding
• UGI Series to evaluate patency of Anastomosis

15
Postoperative Day 9 (cont.)

• UGI series
• Obstruction of efferent loop
• NGT placed
• Plan
• Start TPN vs IVF
• EGD

16
Postoperative Day 12

• EGD-
• Nonerosive Gastritis
• Edema noted at the anastomosis