General Surgery DnC

Sundeep Guliani

HS

• 53 yo male screening colonoscopy -> endoscopically unresectable 2.5 cm ascending colon polyp

• PMH/PSH: Unremarkable

• Laparoscopic Right hemicolectomy– Stapled side-to-side anastamosis– EBL: 30 cc

Cont

• POD 0-2 – Hgb 14->10-> 8, HD stable, Abd distention, No blood requirement

• POD 6-7– Temp 102-103 -> CT: Ileus, blood around spleen, liver, no fluid

collections or free air

• POD 8– Resp distress, ICU tx -> PE CT neg– eventual intubation, hypotension– Bld cx: GNR, unremarkable urinalysis/cxr

Cont

• Re-exploration– No leak or abscess– Anastamosis intact– 2 L blood removed

• Cx: Ecoli in blod, psuedomonas from intra-op cx

• Path: Tubulovillous adenoma with focal intramucosal adenocarcinoma (Tis)

• Currently on general diet, home today or tomorrow

• Retrospective study sought to define the accuracy of CT scan to diagnose early postoperative LGI leaks in patients who were reoperated within 30 days for clinical and/or radiologic evidence of a leak and in whom a leak was confirmed during re-operation

Cont

• 70 pts over 8 years with leaks– 41 pts who had CT scans

within 72 hrs of re-operation but were explored on grounds of subsequent clinical detioration were analyzed

– 29 were re-operated on based on clinical grounds alone

Colon surgery most common

• 32 CT scans were performed within 24 hours of re-operation

• Leak, high prob, low prob, no leak

• Preoperative CT findings showed leak or high probability of leak 47%

• No real difference in small bowel VS large bowel

Cont

• While all patients receiving CTs were symptomatic, the mean interval until reoperation was 7.3±4.4 days in patients who underwent CT studies compared to 4.5± 2.4 days in patients who were reoperated without CTs (p=0.003).

• Study cautioned CT scans being used as justification for the absence of a leak

Teaching points/Issues

• Re-exploration

• CT okay doesn’t mean patient is okay