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Sinai Hospital of Baltimore Department of Surgery

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75 y/o Male presents with Gastric Adenocarcinoma diagnosed ... Obstruction of efferent loop. NGT placed. Plan. Start TPN vs IVF. EGD. Postoperative Day #12 ... – PowerPoint PPT presentation

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Title: 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
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