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