Saturday, February 07, 2004
AN UNPLEASANT SURPRISE....THAT MAKES FOR A SAD CASE
Posting has been light, mainly because my day job has gotten in the way of my blogging. Anyway, I was on call Wednesday and accepted an elderly automobile collision victim from a referral facility that had no available neurosurgeon. The patient had a subdural and subarachnoid hemorrhage and a clavicle fracture. Their blood pressure was in the low 100's and improved with some adequate resuscitation. FAST exam showed a small amount of fluid so I obtained a CT scan of the abdomen and pelvis. The scan showed a large amount of fluid with no evidence of solid organ injury. Usually that means one of two things: a hollow viscus injury, or a mesenteric injury. Given the lack of free air on CT I doubted a bowel injury, and was leaning toward a mesenteric injury that had stopped bleeding. But off to the OR...
Encountered a large amount of old blood and a mesenteric injury that was no longer bleeding. A small splenic laceration was at the upper pole and did not respond to surgicel and other methods to achieve hemostasis. Out comes the spleen. While exploring the remainder of the abdomen I found, to my unpleasant surprise, a near-obstructing transverse colon cancer. Several large lymph nodes were seen in the mesentery. I resected it via expanded right hemicolectomy (terminal ileum, cecum, ascending colon and transverse colon). The question then becomes: Do I perform an anastomosis or construct stomas?
The current recommendations in the trauma literature are that colonic injuries may be treated with resection and anastomosis if the patient is not hypotensive, and soilage is minimal. Unfortunately this patient did not really meet the criteria for anastomosis. So in addition to the injuries described above the patient now owns a ileostomy and a mucus fistula. |
Posting has been light, mainly because my day job has gotten in the way of my blogging. Anyway, I was on call Wednesday and accepted an elderly automobile collision victim from a referral facility that had no available neurosurgeon. The patient had a subdural and subarachnoid hemorrhage and a clavicle fracture. Their blood pressure was in the low 100's and improved with some adequate resuscitation. FAST exam showed a small amount of fluid so I obtained a CT scan of the abdomen and pelvis. The scan showed a large amount of fluid with no evidence of solid organ injury. Usually that means one of two things: a hollow viscus injury, or a mesenteric injury. Given the lack of free air on CT I doubted a bowel injury, and was leaning toward a mesenteric injury that had stopped bleeding. But off to the OR...
Encountered a large amount of old blood and a mesenteric injury that was no longer bleeding. A small splenic laceration was at the upper pole and did not respond to surgicel and other methods to achieve hemostasis. Out comes the spleen. While exploring the remainder of the abdomen I found, to my unpleasant surprise, a near-obstructing transverse colon cancer. Several large lymph nodes were seen in the mesentery. I resected it via expanded right hemicolectomy (terminal ileum, cecum, ascending colon and transverse colon). The question then becomes: Do I perform an anastomosis or construct stomas?
The current recommendations in the trauma literature are that colonic injuries may be treated with resection and anastomosis if the patient is not hypotensive, and soilage is minimal. Unfortunately this patient did not really meet the criteria for anastomosis. So in addition to the injuries described above the patient now owns a ileostomy and a mucus fistula. |
