final update goloran

7/22/2019 Final Update Goloran

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Pre-Operative

Case

PresentationUpdateGS II (DR. BRAVO/TEMONIO/DONAYRE/NOVENO)Department of Surgery

Davao Regional Hospital, Tagum City


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General Data

J. G.

19 years old

Male

Single

Filipino Roman Catholic

Patin-ay, Prosperidad, Agusan del Sur


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Diagnostics

Chest X-Ray PA Negative Chest

Abdomen U/S

Nothing significant in the abdomen

Pelvis AP

No significant abnormality is noted


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UPRIGHT VIEW VIEW


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R FEMUR


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INTERNAL MEDECINE RODs IMPRESSION:

Anemia sec to UGIB (resolved) probably sec. to Liver

Schistosomiasis;

Palpable LLQ mass.


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Salient Points

History

(+) history of vehicular crash

(+) mass LLQ area, enlarging,tender

(+) icterisia

(+) melena

(+) fever

(+) SCHISTOSOMIASIS 4 yrsPTA treatment given as

claimed

(+) Lives in an area infested to

Schistosoma parasite

Physical Examination

Temperature: 37OC

(+) jaundice Icteric sclera, pale palpebral

conjunctiva

Liver edge 5cms

palpable mass at the LLQ

(approximately 10cm X 4cm), non-tender, fixed, no skin discoloration

above the mass

(+) Deformity R thigh


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IMPRESSION

1. ANEMIA SEC PROB SEC TO BPUD PROB SEC TOBLEEDING PEPTIC ULCER DISEASE

2. OBSTRUCTIVE JAUNDICE SEC TO CHOLELITHIASIS ANDCHOLEDOCHOLITHIASIS NOT IN CHOLANGITIS

3. PANCREATIC TAIL MASS, T/C PSEUDOCYST

4. LEFT LOWER QUADRANT MASS PROBABLY COLONIC INORIGIN

5. NEGLECTED CLOSED FEMORAL FRACTURE, M3RD,RIGHT SEC TO VA


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PREVIOUS

PLANS


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PLAN A

OPTIMIZED PATIENTS STATUS:

NUTRITIONALLY,

PHYSICALLY, PSYCHOLOGICALLY


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PLAN B

Treatment of UGIB:

For UGI Endoscopy


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PLAN C

For Treatment of Obstuctive Jaundice sec to Choledocholithiais

and Cholelithiasis:

ERCP OPEN CHOLECYSTECTECTOMY WITH CBDE, IOC, TUBE

CHOLEDOCHOSTOMY


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PLAN D

IF (+) Pancreatic tail mass (PSEUDOCYST): CA19-9 DETERMINATION

CT SCAN OF THE CHEST, ABDOMEN, PELVIS (TRIPLE CONTAST)

DRAINAGE:

(EXTERNAL) Percutaneous catheter drainage- high chance of persistent

pancreatic fistula (ultrasound or CT scan guided)

(INTERNAL) Endoscopic drainage- less invasive, becoming more popular,

techically demanding

Cyst gastrostomy

Cyst doudenostomy

Cyst jejnunostomy

Segmental resection and Roux-n-Y reconstruction

DISTAL PANCREACTECTOMY

necessary in complicated pseudocysts, failed nonsurgical, and multiplepseudocysts


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PLAN E

For the LLQ mass t/c Colonic in origin:

Colonoscopy w/ biopsy

CT SCAN OF THE CHEST, ABDOMEN, PELVIS

(TRIPLE CONTAST)

Baseline CEA


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PLAN F

For treatment of Schistosomiasis:

Stool examination Rectal biopsy - DONE


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PLAN F

Treatment of Neglected Femoral Fracture:

Refer to Ortho Consultant

For ORIF, Intramedullary Nailing, Right Femur


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LATEST DIAGMOSITICS


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CT Scan of the whole abdomen

done w/c revealed:


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IMPRESSIONS:

INTRAHEPATIC AND EXTRAHEPATIC BILIARYDILATATION DUE TO AN OBSTRUCTING CALCULUSOR MASS IN THE PANCREATIC PORTION OF THE CBD.

GALLBLADDER CALCULUS WITH INFLAMMATORY

CHANGES IN THE GALLBLADDER WALL. CONSIDERALSO A ROUNDWORM (ASCARIS) OR ITS CARCASSWITHIN THE CBD AND GALLBLADDER

HEPATOMEGALY AND SPLENOMEGALY

ILIOPSOAS AND INGUINAL ABSCESS, LEFT


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Diagnostics

CBC Nov. 14, 2013 Nov. 16, 2013 Normal Values

Hemoglobin

97(L) 90(L) 140170 g/LHematocrit

0.29(L) 0.26(L) 0.400.50

WBC

16.4(H) 14.2(H) 5.010.0 X 109/L

Neutrophils

0.84(H) 0.84(H) 0.550.65%Lymphocytes

0.11(L) 0.10(L) 0.250.35%

Monocytes0.05 0.06(H) 0.020.05%

Platelets

660(H) 565(H) 150500 X 109/L


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Diagnostics

Reticulocyte Count: 37 (H) 1.12.7%

MCV: 77 (L) 8298fL

MCH: 28.3 2833pg

Amylase 48.80 28100U/L


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Diagnostics

Prothrombin

TimeNovember

14, 2013

Normal

ValuesPT - %

Activity 82%

PTControl13.1 15.0sec

PTINR 1.13

PT - Patient

14.4 1117sec

Blood No ember 14 N b 16


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Diagnostics

Blood

Chemistry

November 14,

2013

November 16,

2013Normal Values

Sodium137.10 141.30

135

148mmol/L

Potassium4.40 4.10 3.55.5mmol/L

Calcium 1.25 1.20 1.11.4mmol/L

Chloride 111.90 105.20 97110mmol/L

Creatinine53.50 60.50

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115.0umol/LTotal Bilirubin

----- -----2.0

21.0mmol/L

Direct Bilirubin ----- ----- 0.13.4mmol/L

Indirect

Bilirubin ----- ----- 014.50mmol/L

Alkaline

Phosphatase----- ----- 35130U/L

Albumin 21.97(L) ----- 3550g/L

SGOT/AST ----- ----- 042U/L

SGPT/ALT ----- ----- 041U/L


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Total

Bilirubin329.05 (H) ----- -----

2.0

21.0mmol/L

Direct

Bilirubin 232.62 (H) ----- -----0.1

3.4mmol/L

Indirect

Bilirubin96.43 (H) ----- -----

0

14.50mmol/L

Alkaline

Phosphatase672.20 (H) ----- ----- 35130U/L

Albumin ----- ----- 3550g/L

SGOT/AST 140.20 (H) ----- ----- 042U/L

SGPT/ALT 76.6 (H) ----- ----- 041U/L


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Diagnostics

Arterial

Blood Gas October30, 2013October30, 2013

November1, 2013

NormalValues

pH 7.122 (L) 7.359 7.403 7.357.45

pCO2 25.0 (L) 22.3 (L) 26.5 (L) 3545

HCO3 10.4 (L) 16.1 (L) 19.1 (L) 2226O2Sat 93.6% 93.6% 98.1% 80100


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LATEST ABG


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Diagnostics

Stool Exam November 13,

2013

Normal

Values

Color Yellowish

brown7.357.45

Consistency Soft 3545

Ova/ParasitesNone seen 80100


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Diagnostics

Urinalysis November 11,

2013

Normal

Values

Color Yellowish

brown-----

TransparencySoft -----

pH7.0 -----

Specific

Gravity1.015 -----

AlbuminTrace -----

Pus Cells02 -----

RBC01 -----

Epithelial

Cells

Occasional -----


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Peripheral blood smear:


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Rectal Biopsy done:


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CHILDS PUGHCLASSIFICTION

Factor 1 point 2 points 3 points

Total bilirubin

(mol/L)

50

Serum albumin(g/L)

>35 28-35


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CHILDS PUGHCLASSIFICTION

Class A Class B Class C

Total points 5-6 7-9 10-15

1-year survival 100% 80% 45%2-year survival 85% 60% 35%


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FINAL DIAGNOSIS

1. ILIOPSOAS AND INGUINAL ABSCESS, LEFT

2. OBSTRUCTIVE JAUNDICE SEC TOCHOLEDOCHOLITHIASIS VS CARCASS, CHOLELITHIASIS,

NOT IN CHOLANGITIS

3. ANEMIA PROB SEC TO BLEEDING ESOPHAGEAL VARICES

PROB SEC TO PORTAL HYPERTENSION PROB SEC TOLIVER SCHISTOSOMIASIS

4. NEGLECTED CLOSED FEMORAL FRACTURE, M3RD,

RIGHT SEC TO VA


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Functional Status


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PRESENT

PLANS


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PLAN A

1. OPTIMIZED PATIENTS STATUS:

NUTRITIONALLY,

PHYSICALLY,

PSYCHOLOGICALLY,

EMOTIONALLY


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PLAN B

1. For Treatment of Iliopsoas and Inguinal Abscess,

Left:

PERCUTANEOUS DRAINAGE OF Iliopsoas and Inguinal

Abscess, Left, JP DRAIN

OR EXLAP, Evacuation of Iliopsoas and Inguinal Abscess,

Drain


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PLAN C

1. For Treatment of Obstructive Jaundice sec to

Choledocholithiasis vs Carcass, Cholelithiasis, not in

Cholangitis:

OPEN CHOLECYSTECTECTOMY WITH CBDE, IOC, TUBE

CHOLEDOCHOSTOMY


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PLAN D

1. Anemia prob sec to Bleeding Esophageal Varices prob sec to

portal hypertension sec to Liver Schistosomiasis:

CORRECT ANEMIA WITH BLOOD TRASFUSION

UGI ENDOSCOPY

IF POSITIVE WITH BEV:

SCLEROTHERAPHY OF THE ESOPHAGEAL VARICES

HASSABSS PROCEDURE

is a satisfactory approach to controlling varices

Steps:

1. Splenectomy

2. Devascularization of the distal 7 cm of the esophagaus

3. Devascularization of the proximal part of the stomach

4. Vagotomyand pyeloroplasty
http://en.wikipedia.org/wiki/Splenectomyhttp://en.wikipedia.org/wiki/Vagotomyhttp://en.wikipedia.org/wiki/Vagotomyhttp://en.wikipedia.org/wiki/Splenectomy


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TREATMENT OF SCHISTOSOMIASIS:


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PLAN E

Treatment of Neglected Femoral Fracture:

For ORIF, Intramedullary Nailing, Right Femur


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DISCUSSION


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Non-shunt procedures in

management of variceal

bleeding


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Most episodes of variceal haemorrhage will besuccessfully treated by resuscitation and injection

sclerotherapy, and indeed the efficacy of this approachhas now been confirmed by several well-controlled trials.

Nevertheless, in a significant minority either acutebleeding will persist, or rebleeding will occur in the nearor long term.

In this situation there is little doubt that some form ofportal hypertension systemic decompression is the mostsuccessful treatment for bleeding.


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In the vast majority of centres, the currently favoured

non-shunting procedures are:

simple stapled esophageal transection,

esophagogastric devascularization

combination of the two


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Portoazygous

Disconnection


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Hassab procedure

Consists of devascularization of the upper half of the stomachand oesophagus

The first step is usually splenic artery ligation followed bycareful mobilization of the spleen. This mobilization as in alldissections in portal hypertension, requires patient ligation andcoagulation of multiple collaterals within the peritonealreflections, and after individual ligation and division of theshort gastric vessels, the spleen is removed

The whole proximal stomach is then devascularized from theterminal two branches of the left gastric artery at the incisura

angularis upwards by ligation and division of the lesser andgreater omentum, and of the posterior gastric adhesions.


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Hassab procedure

After division of the oesophagogastric reflection of peritoneum andmobilization of the vagi, the distal 7 to 8 cm of oesophagus is

mobilized and all feeding vessels are ligated and divided. Exposurein this part of the procedure is much facilitated by the use of costalmargin retractors

The distal 3 cm of oesophagus and proximal 5 cm of stomach maythen be opened longitudinally thus displaying the varices and

allowing obliteration of each variceal column by undersewing fromas high as possible within the oesophagus with an absorbable suture

After positioning of a nasogastric tube the oesophagogastrotomy iscarefully closed by suturing or stapling. Some authors recommend

closure by swinging a flap of stomach wall into the oesophagealdefect, thus minimizing oesophageal stricturing.


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Sugiura procedure

is a much more radical development of the above

method, classically performed in two staged procedures

At the first operation, via a left thoracotomy, the distal

intrathoracic oesophagus is devascularized and an

oesophageal transection performed. Six weeks later, via

an upper abdominal midline incision, the intra-abdominal

oesophagus and proximal stomach are devascularized by

lesser and greater curve division and splenectomy


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Sugiura procedure

Vagotomy and pyloroplasty are then performed.

This massive procedure has been modified into a one-

stage operation using a transabdominal approach

facilitated by the use of costal margin and sternal

retractors.

After division of the crura of the diaphragm, 10 cm of

oesophagus can be devascularized, a staple transection

performed via a gastrotomy and the rest of the abdominal

part of the operation completed.


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final update goloran

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