VAC Change & Abdomen Exploration

THE NEW YORK HOSPITAL MEDICAL CENTER of QUEENS
OPERATIVE REPORT

NAME: KO, KANG WEI
MRN: 3197633
SURGEON: STEPHEN MEROLA, MD
DATE: 04/21/2012
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PREOPERATIVE DIAGNOSIS: Abdominal swelling, recent severe hemorrhage.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION: Reopening of recent laparotomy wound and exchange of ABThera dressing and re-exploration of the abdomen.

SPECIMEN: None.
DRAINS: None.
NEEDLE, SPONGE, AND INSTRUMENT COUNTS: Correct.
PATIENT CONDITION: The patient [left] the operating room intubated, in stable condition with a new ABThera device in place.

INDICATIONS: The patient is a 35-year-old male who I met on the morning of 04/18 when I was called by Dr. [Alphonse Pomp] at Cornell University being told that a patient from Cornell University had gastric bypass one month ago, suffering from a severe gastrointestinal bleed, and was likely to die. He asked that I evaluate the patient. Of note, the patient had gastric bypass one month ago and two episodes of severe bright red blood bleeding with hematemesis that was controlled endoscopically at Cornell. This was at least his third episode of red blood.

I evaluated him and he underwent EGD that morning by Dr. Sang Kim that slowed, but may have not completely stopped the bleeding, however, his hematocrit remained stable and he remained hemodynamically stable throughout the day. However, in the late afternoon I made a call to Cornell to transfer given his stability, but they though there were no beds. We then checked despite being told by the surgeons that there were no beds and the ICU attending did note that there were two beds available. However, it was late in the evening and the plan was to transfer the patient the following day.

However, that night, he vomited 100mL of red blood, became oliguric, dropped his blood pressure and clearly did not appear that he could wait for the morning for further intervention.  An attempt to endoscopic control was already made, so it was felt at this point, since that failed, that his best approach would be operative intervention as a life-saving [measure].

On the night of 04/18 until the early morning of 04/19, he underwent exploratory laparotomy with transection of his Roux limb and dissection of the Roux limb at the gastrojejunal anastomosis as well as excision of the upper half of his gastric remnant.  It appeared that he may have had a fistula from leakage from his gastrojejunal anastomosis with bleeding and then ultimately I stapled across his stomach passage above the anastomosis and I confirmed that there was no bleeding with the endoscopy. In all, ends were all stapled out.

At this point given his massive transfusion requirements and his instability, it was clearly unsafe to perform an anastomosis in this setting. It would have been difficult as he [had] about 1cm of stomach remaining just at the hiatus and his bowels were quite distended.  All his bowel was full of blood. His abdomen could not even be closed. We then felt that this anastomosis was extremely high risk in a patient whose abdomen could not be closed and was requiring a large amount of volume. I therefor opted to leave the stapled end with a gastric tube just above the GE junction and stapled Roux limb, stapled remnant that was now mobile enough actually for a gastrostomy tube when needed, and then I closed the abdomen with ABThera. This was discussed with the family afterwards in detail including the plan for change of his ABThera on 04/21 and then definitive planning after speaking with the surgeons at Cornell when they return from their trip earlier in the coming week.

Of note, at this time his hematocrit was stable at 23% and he received a total of 22 units of blood, a large amount of crystalloid and other blood products. Of note, he tolerated period of extubation a day prior, but was reintubated earlier that day for planned surgery, but clearly he is strong enough to be extubated and his vital signs are stable. We discussed with the family that we needed to change the ABThera every two to three days, although some people leave it longer, change it today and make definitely plans for closure and feeding access and question of whether to reconstruct or not reconstruct early in the week.

I discussed the risks, benefits, and alternatives with them and they agreed to the change in the ABThera.

PROCEDURE: The patient was left on the ICU bed and brought to the operating room as the operating room table was removed. The table was flattened and the patient received sedation paralysis by anesthesiology, Dr. Balakumar. The abdomen was then prepped widely with Betadine and prepped and draped in the usual sterile surgical fashion.  He received Ancef 2g for skin flora since the only possibility would be contamination with skin flora. Again, Betadine was applied and sterilely draped. A time out was performed. At this point the previous Tegaderm was removed as well as the sponge.

At this point, I looked in the abdomen. It was still quite edematous and although his bowel was less distended, he still had a fair amount of blood in his intestines that was giving him significant distention.  The omentum adhered down to the end of the mesentery and stapled off Roux limb.  The Roux limb was tethered down in a way that it would be difficult without significant mobilization to reach the upper abdomen or possibly running it retrocolic retrogastric. There was no significant bleeding noted. At this point clearly he was in no position, due to severe abdominal edema, to even consider an anastomosis and that clearly was not the plan. Of note, you can grasp the fascia with Kocher clamps and clearly could not come together due to the abdominal distention and likely edema again from the over 22 units of blood since his arrival to the hospital on 04/18.

I therefore replaced the ABThera sponge in the abdomen as well as the overlying sponge and then covered it with the Tegaderm and placed the ABThera suction sponge in the middle after cutting a quarter size opening and then placed it back on suction 125 pressure.  The sponge sucked down well without any leaks.

He tolerated the procedure well and at the end actually his heart rate was 87. Previously it had been in the 130s to 140s when I operated on him. Blood pressure was 110/70, saturating 100%. So stable, he no longer required an arterial line and again he was strong enough for extubation the day prior.

Of note, his nasogastric tube that had been secured to his nose with nylon appeared to be too tight and it was therefore secured to his nose with a very loose silk suture, once again leaving it in the same location just above the GE junction. There was no blood emanating from it, so clearly it appears that his gastrointestinal bleed had been controlled by surgery three days earlier.

At this point, with no further gastrointestinal bleeding, continued diuresis, complete good hemodynamic stability, I told the family after the operating room that the plan would be to discuss with Dr. [Rubino] his surgeon at New York [Presbyterian] Hospital who returns on 04/22 and will be in I suspect on the morning of 04/23, I would discuss with him the next step in management. I feel that at this point he would be fairly high risk for anastomosis, however, delayed anastomosis would be difficult to do later on, although he would be edematous, he would be thinner as we could control his calories through gastric feeding and attempt at anastomosis could be performed with he is skinnier.  The only issue would be management of the saliva whether that would be a nasogastric tube for three to six months or if he would best be served by a spit fistula. Regardless, I discussed with the family that I would speak to the surgeons at Cornell on Monday and see if they wished to transfer and if the family is in agreement, he will be transferred back to Cornell for further management of the leak and bleed after the gastric bypass of one month ago.  Clearly they feel he should be reconstructed and although I think this would be high risk, I advised the family that he should go to Cornell for this reconstruction. They may agree and feel reconstruction at this time is a bad idea and suggest that we simply close his abdomen and place a gastrostomy tube that I am willing to do, get him back to health, and then down the road, again in three to six months, he would be a candidate for reconstruction.

STEPHEN MEROLA, MD

DICT: SM 04/21/2012
TRANS: ST/DLA 04/22/2012
JOB: 889832
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Digitally signed on 5/1/2012 at 7:28:17 AM by Stephen Merola.