M&M Conference 9/9/08
M&M Conference <ul><li>MM </li></ul><ul><li>78 y/o F presented with a 5 day hx of left lower quadrant pain and  abdominal ...
M&M Conference <ul><li>PMHx- Recurrent diverticulitis, DM, HTN, Hyperlipidemia,  </li></ul><ul><li>PSHx-Mastoidectomy, App...
M&M Conference <ul><li>Vitals </li></ul><ul><ul><li>Tmax 36.4  P-87  BP-110/64  O2 sat-98 % RA </li></ul></ul><ul><li>GEN-...
M&M Conference <ul><li>Labs </li></ul><ul><ul><li>Na 134 K 4.9 Cl 95 CO2 24 BUN 70 Crea 3.0 </li></ul></ul><ul><ul><li>Glu...
M&M Conference <ul><li>Radiology </li></ul><ul><ul><li>Free intraperitoneal air c/w bowel perforation </li></ul></ul><ul><...
 
M&M Conference <ul><li>A/P </li></ul><ul><ul><li>78 y/o Female  </li></ul></ul><ul><ul><li>recurrent diverticulitis with l...
M&M Conference <ul><li>HD #1 </li></ul><ul><ul><li>6 am </li></ul></ul><ul><ul><ul><li>Pt feels well </li></ul></ul></ul><...
M&M Conference <ul><li>Post Op Dx- Acute Diverticulitis with free perforation </li></ul><ul><li>Procedure- Exploratory Lap...
M&M Conference <ul><li>Post Operative Course </li></ul><ul><ul><li>POD#1 </li></ul></ul><ul><ul><ul><li>Increase Cardiac e...
M&M Conference <ul><li>POD#5 </li></ul><ul><ul><li>Stabilized  </li></ul></ul><ul><ul><li>Rate controlled </li></ul></ul><...
M&M Conference <ul><li>Morbidity </li></ul><ul><ul><li>Recurrent Diverticulitis with free perforation </li></ul></ul><ul><...
Diverticulitis <ul><li>Many controversies lie within the topic of diverticulitis </li></ul><ul><ul><li>Conservative vs Ope...
Diverticulitis <ul><li>Clinical presentations of diverticular disease range from asymptomatic diverticulosis, diverticulos...
Diverticulitis <ul><li>1) European Association for Endoscopic Surgeons developed a classification scheme based upon the se...
Hinchey Classification Generalized fecal peritonitis IV Generalized purulent peritonitis III Walled off pelvic abscess II ...
Diverticulitis <ul><li>Operations are mainly reserved for cases of complicated diverticulitis </li></ul><ul><ul><li>i.e., ...
Diverticulitis <ul><li>Operation is clearly indicated when the patient presents with perforation and diffuse peritonitis, ...
Diverticulitis <ul><li>Hartmann’s resection has proven to be a safe and effective approach, and is based upon the idea tha...
Diverticulitis <ul><li>simple washout with drainage </li></ul><ul><ul><li>paucity of data to support a minimalist, simple ...
Diverticulitis <ul><li>Hartmann’s procedure vs Primary anastomosis with or without ostomy </li></ul><ul><ul><li>Systematic...
Diverticulitis <ul><li>Overall </li></ul><ul><ul><li>There is intriguing data about the surgical management of acute diver...
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  1. 1. M&M Conference 9/9/08
  2. 2. M&M Conference <ul><li>MM </li></ul><ul><li>78 y/o F presented with a 5 day hx of left lower quadrant pain and abdominal distention. </li></ul><ul><li>Pt admittledly has chronic constipation, but noticed a recent increase in difficulty to defecate </li></ul><ul><li>The patient did have a large bowel movement a day before presentation to the er </li></ul><ul><li>After that BM she began to experience LLQ pain, at times “intense” </li></ul><ul><li>Also, during the last 5 day she claimed to have lost her appetite </li></ul><ul><li>Denied Nausea/Vomiting. Denied dysuria </li></ul>
  3. 3. M&M Conference <ul><li>PMHx- Recurrent diverticulitis, DM, HTN, Hyperlipidemia, </li></ul><ul><li>PSHx-Mastoidectomy, Appendectomy </li></ul><ul><li>Meds- Atenolol, Metformin </li></ul><ul><li>SHx-lives with daughter; denies alcohol, smoking, drugs </li></ul><ul><li>FHx- HTN, DM </li></ul><ul><li>Allergies-NKDA </li></ul>
  4. 4. M&M Conference <ul><li>Vitals </li></ul><ul><ul><li>Tmax 36.4 P-87 BP-110/64 O2 sat-98 % RA </li></ul></ul><ul><li>GEN-AAOx3, No acute distress </li></ul><ul><li>Skin- Poor skin turgor </li></ul><ul><li>HEENT-PERRL , No Lymphadenopathy </li></ul><ul><li>CVS-RRR </li></ul><ul><li>Lung-CTAB, no rales, no rhonchi </li></ul><ul><li>Abd- Soft, ND, LLQ tenderness, +BS </li></ul><ul><ul><li>No rebound tenderness , No mass, minimal LLQ guarding </li></ul></ul><ul><li>Ext- L UE congenital deformity </li></ul><ul><li>Rectal- Good tone, No stool, No blood </li></ul>
  5. 5. M&M Conference <ul><li>Labs </li></ul><ul><ul><li>Na 134 K 4.9 Cl 95 CO2 24 BUN 70 Crea 3.0 </li></ul></ul><ul><ul><li>Glu 157 AST 30 ALT 16 ALP 37 </li></ul></ul><ul><ul><li>WBC 4.8 Hgb 10.4 Hct 31.1 Plt-302 </li></ul></ul>
  6. 6. M&M Conference <ul><li>Radiology </li></ul><ul><ul><li>Free intraperitoneal air c/w bowel perforation </li></ul></ul><ul><ul><li>SBO secondary to inflammatory process due to acute diverticulitis </li></ul></ul>
  7. 8. M&M Conference <ul><li>A/P </li></ul><ul><ul><li>78 y/o Female </li></ul></ul><ul><ul><li>recurrent diverticulitis with localized tenderness </li></ul></ul><ul><ul><li>no signs of diffuse abdominal tenderness </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><li>Plan </li></ul><ul><ul><li>Aggressive fluid resuscitation </li></ul></ul><ul><ul><li>NPO </li></ul></ul><ul><ul><li>Serial abdominal exams </li></ul></ul><ul><ul><li>Cipro, Flagyl </li></ul></ul>
  8. 9. M&M Conference <ul><li>HD #1 </li></ul><ul><ul><li>6 am </li></ul></ul><ul><ul><ul><li>Pt feels well </li></ul></ul></ul><ul><ul><ul><li>LLQ pain resolving, Minimal residual tenderness </li></ul></ul></ul><ul><ul><ul><li>No N/V, +Flatus </li></ul></ul></ul><ul><ul><ul><li>Plan-cont NPO, serial abdominal exams, cont abx </li></ul></ul></ul><ul><ul><li>12 pm </li></ul></ul><ul><ul><ul><li>Acute decompensation </li></ul></ul></ul><ul><ul><ul><ul><li>Mistakenly received CLD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lethargic, change in mental status </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dyspnea, use of accessory muscle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Abdomen </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Marked distention </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increased tenderness in LLQ </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Intubated at bedside </li></ul></ul></ul><ul><ul><ul><li>To OR for Exploration </li></ul></ul></ul>
  9. 10. M&M Conference <ul><li>Post Op Dx- Acute Diverticulitis with free perforation </li></ul><ul><li>Procedure- Exploratory Laparotomy/ Moblization of Splenic flexure/ Hartmann’s Procedure </li></ul><ul><li>Details of Procedure </li></ul><ul><ul><li>Feculant material found surrounding sigmoid colon </li></ul></ul><ul><ul><li>Perforation noted at center of sigmoid colon </li></ul></ul><ul><li>Specimen- Descending and Sigmoid Colon </li></ul><ul><li>EBL-100cc </li></ul><ul><li>Complication- none </li></ul>
  10. 11. M&M Conference <ul><li>Post Operative Course </li></ul><ul><ul><li>POD#1 </li></ul></ul><ul><ul><ul><li>Increase Cardiac enzyme </li></ul></ul></ul><ul><ul><ul><ul><li>Cardiology consulted </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>No urgent intervention- more related to overall condition and renal insufficiency opposed to obstructive disease </li></ul></ul></ul></ul></ul><ul><ul><li>POD#4 </li></ul></ul><ul><ul><ul><li>Extubated progressing well </li></ul></ul></ul><ul><ul><ul><li>Transferred out of ICU </li></ul></ul></ul><ul><ul><ul><li>Later that evening </li></ul></ul></ul><ul><ul><ul><ul><li>Atrial Fibrillation </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rate controlled started on Amiodarone, diltiazem </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Transferred back to ICU </li></ul></ul></ul></ul></ul>
  11. 12. M&M Conference <ul><li>POD#5 </li></ul><ul><ul><li>Stabilized </li></ul></ul><ul><ul><li>Rate controlled </li></ul></ul><ul><li>POD#7 </li></ul><ul><ul><li>Transferred back to floor </li></ul></ul><ul><ul><li>Stable </li></ul></ul><ul><ul><ul><li>Ostomy functioning well </li></ul></ul></ul><ul><ul><ul><li>Remained afebrile </li></ul></ul></ul><ul><ul><ul><li>ABX stopped POD#7 </li></ul></ul></ul><ul><li>POD#9 </li></ul><ul><ul><li>Discharged to Rehab facility </li></ul></ul><ul><ul><li>To follow Cardiology- anticoagulation </li></ul></ul>
  12. 13. M&M Conference <ul><li>Morbidity </li></ul><ul><ul><li>Recurrent Diverticulitis with free perforation </li></ul></ul><ul><ul><li>Delay in Operative Intervention </li></ul></ul>
  13. 14. Diverticulitis <ul><li>Many controversies lie within the topic of diverticulitis </li></ul><ul><ul><li>Conservative vs Operative </li></ul></ul><ul><ul><li>Operative intervention in acute setting vs. elective </li></ul></ul><ul><ul><li>When to Operate in younger pts </li></ul></ul><ul><ul><li>When or if to operate in older pts </li></ul></ul><ul><ul><li>Focus </li></ul></ul><ul><ul><ul><li>What type of operative intervention does the literature support? </li></ul></ul></ul>
  14. 15. Diverticulitis <ul><li>Clinical presentations of diverticular disease range from asymptomatic diverticulosis, diverticulosis with periodic spasmodic abdominal pain and bloating, diverticulosis with hemorrhage, and finally, diverticulitis. </li></ul><ul><li>Two commonly utilized classifications of diverticulitis </li></ul>
  15. 16. Diverticulitis <ul><li>1) European Association for Endoscopic Surgeons developed a classification scheme based upon the severity of its clinical presentation </li></ul><ul><ul><li>diverticulitis is divided into symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease </li></ul></ul><ul><li>2) Hinchey </li></ul><ul><ul><li>In 1978, Hinchey and colleagues devised a staging system for grading the degree of perforation in diverticulitis </li></ul></ul><ul><ul><ul><li>Use of radiologicand intra-operative findings </li></ul></ul></ul>
  16. 17. Hinchey Classification Generalized fecal peritonitis IV Generalized purulent peritonitis III Walled off pelvic abscess II Pericolic or mesenteric abscess I Description Stage
  17. 18. Diverticulitis <ul><li>Operations are mainly reserved for cases of complicated diverticulitis </li></ul><ul><ul><li>i.e., patients with perforation and peritonitis, abscess formation, fistula, or obstruction. </li></ul></ul><ul><li>Although this may seem clear-cut, decisions regarding if and when to operate patients with diverticulitis remain a topic of significant debate. </li></ul>
  18. 19. Diverticulitis <ul><li>Operation is clearly indicated when the patient presents with perforation and diffuse peritonitis, whether it is purulent or feculent (Hinchey stages III and IV). </li></ul><ul><ul><li>However, the ideal surgical procedure in such cases of perforation remains a matter of debate. </li></ul></ul><ul><ul><ul><li>simple washout of the abdomen with drainage </li></ul></ul></ul><ul><ul><ul><li>resection with a Hartmann pouch </li></ul></ul></ul><ul><ul><ul><li>primary resection with anastomosis with diverting ileostomy </li></ul></ul></ul><ul><ul><ul><li>primary resection with anastomosis and no temporary stoma </li></ul></ul></ul>
  19. 20. Diverticulitis <ul><li>Hartmann’s resection has proven to be a safe and effective approach, and is based upon the idea that an anastomosis in the setting of acute infection/inflammation is dangerous and associated with a high rate of suture line breakdown. </li></ul>
  20. 21. Diverticulitis <ul><li>simple washout with drainage </li></ul><ul><ul><li>paucity of data to support a minimalist, simple washout approach </li></ul></ul><ul><ul><ul><li>there are only 18 case reports in the literature describing the technique and its results </li></ul></ul></ul><ul><ul><ul><ul><li>Moderate success </li></ul></ul></ul></ul><ul><li>Primary Anastomosis with and without diversion </li></ul><ul><ul><li>Some evidence of low leak rate with primary anastomosis w/o ostomy </li></ul></ul><ul><ul><ul><li>Questionable studies where patient status not evenly evaluated </li></ul></ul></ul><ul><ul><ul><ul><li>Pt’s comorbidities not compared </li></ul></ul></ul></ul>
  21. 22. Diverticulitis <ul><li>Hartmann’s procedure vs Primary anastomosis with or without ostomy </li></ul><ul><ul><li>Systematic literature review of 50 studies comparing a Hartmann’s procedure to a primary resection with anastomosis for perforated diverticulitis found 569 reported cases of primary anastomoses </li></ul></ul><ul><ul><ul><li>mortality and morbidity in the patients with an anastomosis was the same as in the patients who underwent the Hartmann’s procedure </li></ul></ul></ul><ul><ul><ul><ul><li>patient condition </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Comorbidites </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Not evenly facotred </li></ul></ul></ul></ul>
  22. 23. Diverticulitis <ul><li>Overall </li></ul><ul><ul><li>There is intriguing data about the surgical management of acute diverticulitis, </li></ul></ul><ul><ul><ul><li>But it must be viewed with caution, </li></ul></ul></ul><ul><ul><ul><ul><li>especially in the case of toxic patients with multiorgan system failure and/or shock </li></ul></ul></ul></ul><ul><ul><li>Safest method </li></ul></ul><ul><ul><ul><li>Perform a Hartmann’s procedure in the face of an acute perforated diverticulitis with perotionits </li></ul></ul></ul><ul><ul><li>There is a viable argument to perform a primary ananstomosis even in the face of feculant contamination, especially in relatively healthy patients </li></ul></ul>

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