Slide 1: M&M Conference
9/9/08
Slide 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
Slide 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
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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
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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
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Radiology
– Free intraperitoneal air c/w bowel perforation – SBO secondary to inflammatory process due to acute diverticulitis
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A/P
– – – – 78 y/o Female recurrent diverticulitis with localized tenderness no signs of diffuse abdominal tenderness Dehydration Aggressive fluid resuscitation NPO Serial abdominal exams Cipro, Flagyl
Plan
– – – –
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HD #1
– 6 am
– 12 pm
Pt feels well LLQ pain resolving, Minimal residual tenderness No N/V, +Flatus Plan-cont NPO, serial abdominal exams, cont abx
– – – – Mistakenly received CLD Lethargic, change in mental status Dyspnea, use of accessory muscle Abdomen Marked distention Increased tenderness in LLQ
Acute decompensation
Intubated at bedside To OR for Exploration
Slide 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
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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
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POD#5 POD#7
– Stabilized – Rate controlled – Transferred back to floor – Stable
Ostomy functioning well Remained afebrile ABX stopped POD#7
POD#9
– Discharged to Rehab facility – To follow Cardiology- anticoagulation
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Morbidity
– Recurrent Diverticulitis with free perforation – Delay in Operative Intervention
Slide 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?
Slide 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
Slide 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
Slide 17: Hinchey Classification
Stage I II III IV Description Pericolic or mesenteric abscess Walled off pelvic abscess Generalized purulent peritonitis Generalized fecal peritonitis
Slide 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.
Slide 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
Slide 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.
Slide 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
Slide 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
Slide 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
