Case presentation

2002/10/28 By Liu Chih-Min

Patient’s Information

• Name: Lin G.G• Chart no: 4133516• Sex: Female• Age: 48 y/o• Admission date: 2002-10-17

• Chief complaint & Present illness:Colon cancer with liver metastasis which was diag

nosed at other hospitalBowel habit change since 4 months agoColonscopy showed tumor mass at sigmoid colon

and the pathology revealed adenocarcinomaAbdomonal sonogram was done and showed colon

cancer with liver metastasis, cancer peritonitis, and large amount of ascites

2002-10-21PM 3:40

1st time operation

• Clinical diagnosis: Colon cancer

• Operation proposed: Explorative laparotomy

• Operator: Dr. Liang

• Date of operation: 2002-10-21

Pre-operative evaluation

• Pre-operative data:BP: 130-90 mmHgHR: 82/min BW: 45.6 kg

• Past history:Allergy to unknown drug

• Laboratory data: Blood type: O+ WBC: 8610/mm3

RBC: 43100/mm3

Hb: 14.2 gm/dl PLT: 375000/mm3

PT: 12.2/11.6 PTT: 30.5/35.9

• Blood chemistry: A/G: 3.5/3.4 mg/dl Bilirubin T: 0.6 mg/dl GOT/GPT: 43/18 kU BUN: 5.5 mg/dl Creatinine: 0.5 mg/dl Na:132 mmol/l K: 2.8 mmol/l Ca: 2.16 mmol/l Sugar AC: 119 mg/dl

• ASA Class: 2• Terminal stage of colon cancer

OP note

• Post op diagnosis: Colon ca with liver and omentum metastasis

• Op method: Hartmann’s procedure Ileostomy + ometectomy + peritonectomy + bilateral salpin

go oothectomy

• Op findings: Colon mass: 8*5*6cm; LN (+) Multiple metastasis to colon, small intestine, liver, omentu

m and peritoneal Ascites, clear, 3800 c.c.

Anesthesia recordand

POR record

During op

Hb: 12.2 to 5.8 in 2 hours

Input: PRBC: 2U FFP: 2U HAES: 500 ml IVF: 3

200 ml

Output: Blood loss: 1700 ml Ascites: 3800 ml U/O: 1000 mll

During POR

• Input: PRBC: 10U WB: 2U FFP: 4U IVF: 1300 ml

Hb: 7.0 - 7.6 - 7.3 CVP: 5 mmHg SpO2: 100 > 97

• Output: Drain: 200 ml+ 25 ml U/O: 600 ml

BP: downhill HR: 90 > 130 /min

10/22 AM 1:00 Patient was transferred to 4C1

I/O

• 10/22 1:00~7:00AM Input:

WB: 4U, PRBC: 4U, PLT: 12U

Output: Chest tube: 1900 ml, Abdominal drainage:

340 ml Urine output: 200 ml

• 10/22 8:00~15:00 Input:

PRBC: 2U, PLT & FFP: 12U

IVF: 1300 ml

Output: Chest tube: 2400 ml Abdominal drainage:

170 ml Urine output: 400 ml

Summary during OP, POR & 4C1

(within 24 hours)

• Input: PRBC: 18U WB: 6U FFP:18U PLT: 24U IVF: 6300 ml

• Output: Blood loss: 2435 ml Chest tube: 4300 ml U/O: 2200 ml

• Hemodynamic: tachycardia, low BP

• Respiratory: Tachypnea: 40/min

• Chest X-ray: Left hemotheoax was noticed on 3AM

• Chest tube: initial drain1600 ml, bloody

• Average chest tube drainage: 300 ml/hour in 4C1

• F/U chest X-ray on 6AM: clear, no hemomediastinum was noted

• Drain function: Milking: minimal fresh blood

• Abdonimal sonogram: 2AM No specific finding, few blood clot

• Chest sonogram: 7-10AMNo fluid accumulation in plural space

• Abdominal sonogram: 10AMSeems large blood clots and small amount of fluid

accumulation, source?

• Intra-abdominal pressure: 10AM32 cmH2O

• CVS and chest consult: 12AMCheck bleeding source

2002/10/22PM 3:45

Emergent operation

I/O

• Input: PRBC: 28U WB: 8U FFP: 21U PLT: 24U Cry: 12U

• Output: Blood loss: 11000 ml U/O: 900 ml

OP findings

Profuse fresh blood and blood clot was noted in abdominal cavity

Diffuse oozing over rough surface of pelvic cavity, left side retroperitoneum, and right diaphragm

Diffuse tumor seeding over diaphragmA diaphragmatic tear over right posterior asp

ect, about 10 cm in lengthBlood loss: more then 13000ml

Post 2nd operation in 4C1

• 10/22 19:00~ 10/23 7:00 Input:

IVF: 1000mlPRBC: 3U

Output:Chest tube: minimalDrainge: right upper: 690ml, right lower: 350ml,

left side: 880ml (total: 1920ml)

Discussion

Unstable hemodynamic

• Hb down? BP down? Shock? Hypovolemic, septic, or cardiogenic?

• Not comparable input with output during POR?Where is the fluid?

• Internal bleeding? But there was not massive blood drained

• PE findings during POR & 4C1?Breathing sound, abdomen

Hemothorax?Hemopneumothorax?

Or other source?• Source?

Major vessel puncture in chest?Due to CVP?

Other source?What happened during operation?

• VATS; Angiography or any other internal bleeding?

Diagnosis of blunt rupture of the right hemidiaphragm by technetium scan.

May AK - Am Surg - 01-Aug-1999; 65(8): 761-5 University of Virginia Health Sciences Center, Charlottesville, USA.

• Rupture of the diaphragm, particularly of the right hemidiaphragm, may be occult and can be difficult to diagnose

• The majority of right-sided injuries are diagnosed during laparotomy performed for other injuries.

• Intraperitoneal injection of technetium sulfur colloid was used to establish the diagnosis of right diaphragm rupture, and an uncomplicated repair was undertaken.

Diagnosis and treatment of diaphragm ruptures

Abakumov MM - Khirurgiia (Mosk) - 01-Jan-2000; (7): 28-33

Russian

• Basic methods of diagnosis in this condition including X-ray, ultrasonic methods, computed tomography and thoracoscopy

• The differential diagnosis between right-sided coagulated hemothorax and diaphragm's right cupula ruptures was the most difficult

Should this operation be done?

Should we stop it?

Or take any other actions?