Discontinuity of Gastrointestinal Tract

THE NEW YORK HOSPITAL MEDICAL CENTER of QUEENS
OPERATIVE REPORT

NAME: KO, KANG WEI
MRN: 3197633
SURGEON: STEPHEN MEROLA, MD
DATE: 04/18/2012
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ASSISTANTS: ROSENSTOCK. MD; OMAVRICK, MD

ANESTHESIOLOGIST: FELER, MD; HWANG, MD; HU, MD

PREOPERATIVE DIAGNOSIS: Massive gastrointestinal bleed from gastric pouch, from gastric bypass.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION: Exploratory laparotomy, takedown of gastrojejunostomy and resection of small bowel, resection of gastric remnant, fundus and resection of gastric pouch along with placement of ABThera device.

ANESTHESIA: General endotracheal.

SPECIMEN: A piece of fundus and small bowel and gastric pouch.
DRAINS: None.
COUNTS: Needle, sponge and instrument counts correct.
PATIENT CONDITION: The patient left the operating room in critical condition.

FINDINGS: The patient [was] explored and on opening had extremely distended bowel full of blood, almost all the small bowel, the colon and even the gastric remnant were all filled with blood. A bariatric Omni was placed and bowel decompressed just below the gastrojejunostomy to allow for a better manipulation, then ultimately divisions were done of the Roux limb of the gastric remnant to exclude the fundus, that was adherent to the gastric pouch and ** the gastric remnant.  Of note, endoscopy was performed by GI, that showed no bubbling, no evidence of any anastomotic of staple line leak.

Once this was completed. Due to instability and inability to close his abdomen, a ABThera was placed with plans to stabilize the patient, to likely change the ABThera in 2-3 days and the 2-3 days after that discuss closure and possible re-anastomosis in the same admission.

INDICATIONS: The patient is a 35-year-old male, who underwent a gastric bypass at Cornell University one month ago by Dr. Francesco Rubino.  The patient had two, if not three episodes of GI bleeding in the months since surgery, that were treated nonoperatively, without reoperation, but simply with EGD and injection. However, after a recent discharge, he now presented with syncope and dark stools and a hemoglobin of 7 and was found to have an additional GI bleed.

He was brought to the emergency room at NYCQ with plans to transfer to Cornell.  Ultimately, this transfer did not occur for reasons unclear. Although possibly due to discussion that the patient was unstable and the patient was admitted to the Critical Care Unit at New York Hospital Medical Center of Queens.  I was made aware of this patient at approximately 9:30, 10:30 AM on 04/18. I received a call from Dr. Alfonse Pomp telling me that the patient was in the hospital who has a massive GI bleed and was being intubated and bleeding to death.  He asked that I evaluate the patient.

I evaluated the patient in the Critical Care Unit with the Surgical ICU Team and felt the patient was hemodynamically stable at the time, was undergoing endoscopy with Dr. San Kim.  He placed a number of clips and epinephrine. In the end there still was some oozing, but no brisk bleeding.  The hematocrit at 10:30 in the morning was about 23, in the afternoon, about 1:30, it was the same and he was admitted to SICU for stabilization and possible transfer.

Discussion were made about possible transfer here if he remained stable and he received two additional units of blood and his hematocrit went to 26.5 up less than 4% with 2 units of blood.  I discussed with Dr. Pomp about transferring and he felt that he did not want the patient transferred while being transfused, although I did state the transfusion had been completed.  He was also unclear whether there were any Intensive Care Unit beds.  We talked to Surgical ICU at Cornell and there were two beds available.  However, by 6:30, 7:00 o'clock the patient had vomited blood and had become oliguric and at this point appeared to be going into shock and it was felt that this patient was now not stable [to] transfer.

I discussed with the family in detail. I felt that at this point the only option would be to operate on him, as he was having significant GI bleed and we could not simply try and stabilize him overnight with the hope to transfer.  There was no guarantee he would be transferred and he needed surgical treatment for his bleeding that included resection.

We discussed options including resecting the anastomosis and not putting it back together again possibly putting in a gastrostomy tube.  The possibility of needing reconstruction at a later date, either in days or months, possibly through the left chest.  Multiple risks related to procedure including the high likelihood of death, approaching at least a one-in-three change that he will ultimately die, if not necessarily the day of surgery, but in the recovery period from this big operation.

They deemed understanding and they gave written and verbal consent for this surgical procedure.

PROCEDURE: The patient was brought to the operating room, placed supine on the operating table. Cardiopulmonary monitoring was applied. IV was inserted. He was already intubated previously and after anesthesia was obtained, the abdomen was prepped and draped with ChrolaPrep. A time-out was performed and the skin was incised from the xiphoid to just below the umbilicus with a 10 blade scalpel.  Once the abdomen was entered, the bowel was quite distended and it was impossible to work due to the large distention.  Clearly the patent was not a candidate for laparoscopy, given this large distention.

I, therefore, ultimately opted to open the small bowel just distal to the gastrojejunostomy to decompress all the blood out of the small bowel.  Once this was done, I opted to divide the small bowel just below the anastomosis and then take the mesentery with the harmonic scalpel and staplers and this allowed the Roux limb to fall down to lower abdomen with antecolic anastomosis. I then evaluated the anastomosis by cutting back the small bowel and looking within the anastomosis. The clips could be palpated and seen through the anastomosis on the stomach side, and that was where they were placed.  Of note, the stomach was densely adherent to the gastric remnant and the gastric remnant was also quite distended.

I opened this up and found dark blood in the gastric remnant and what appeared to be a possible fistulation.  This could represent a leak from the previous anastomosis had eroded into the gastric remnant.  Given this finding, and the likely possibility of a small leak or small fistula in to the remnant, I opted to resect the upper part of the stomach.  I, therefore, cut the short gastrics with harmonic scalpel and resected the upper stomach with staplers and left the gastric remnant. This was quite mobile and it would be easy to place a gastrostomy tube, that he will need at some point.  At this point with the gastric remnant divided and removed, the Roux limb divided and attention was given to the anastomosis.

The anastomosis was evaluated and I opted to divide the pouch.  His stomach was quite small only about 2cm from the hiatus.  The bleeding was at least 1cm above that, leaving only about 1cm of stomach below the GE junction.  A stapler was applied and I had GI, Dr. Nussbaum, do intraoperative endoscopy.  It appeared that the way the staples sat there was no bleeding at that level.  In addition, blood had been emanating up his esophagus, sitting at the GE junction, just about 1cm distal to staple line and sitting up at the GE junction with no further bleeding coming up from the pouch, as the pouch was not filling up with blood, and again, the staple line was inspected with no significant bleeding.

I, therefore, at this point, fired the stapler, cut the end off and then I did note some bleeding from the staple line.  To [ensure] that this would not continue to bleed, I over-sewed this with 2-0 Prolene. In the end, it was felt that there was no significant bleeding in the pouch.

At this point with no bleeding in the pouch or esophagus, no bleeding in the jejunum, no bleeding in the gastric remnant, it appeared that his bleeding source was under control.  At this point, he had some bleeding in the upper abdomen, that was controlled with a combination of suturing and Evicel. In the end, there is no bleeding noted in the abdomen and, again, the bleeding point that caused him to have a massive bleed was stopped.

At this point, he had oliguria with low blood pressure and another 6-10 units of packed red blood cells were given.  Given the large volume of transfusion, at this point, 4-5 hours into the procedure, I felt that an attempt to do anastomosis in this large man with diabetes, hypertension and obstructive sleep apnea and atrial fibrillation just below his GE junction would be difficult and would be at risk of a leak, that clearly he would not survive.  I, therefore, placed an ABThera device, a vacuum dressing to his abdomen.  I did not feel the need to bring up the gastrostomy tube at this point, as he would have to come back for permanent closure and he will be transferred to the SICU for resuscitation. I would like to have the ABThera changed in 2-3 days and after diuresis and bowel decompression of all the blood that has been passed, his abdomen might likely be closed.  I will also stress the possibility of recreating the gastrojejunal anastomosis or possibly esophagojejunal anastomosis, possibly in the abdomen and if not possible in the abdomen, possible in the chest versus putting in a gastrostomy tube, closing his abdomen and planning for re-operation in a month or so when he is more stable and this will all be determined over the coming days.

I will touch base with the physicians at Cornell regarding their patient with a massive GI bleed, who underwent life-saving resection of the bleeding gastrojejunostomy.  I discussed the outcome with the patient's family outside the operating room at approximately 3:30 in the morning on 04/19.

STEPHEN MEROLA, MD

DICT: STEPHEN MEROLA, M.D. 04/19/2012
TRANS: ST/CJA 04/19/2012
JOB: 888573
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Digitally signed on 4/21/2012 at 4:46:47 PM by Stephen Merola.