VAC Change & Abdomen Exploration

THE NEW YORK HOSPITAL MEDICAL CENTER of QUEENS
OPERATIVE REPORT

NAME: KO, KANG WEI
MRN: 3197633
SURGEON: ADAM ROSENSTOCK, MD
DATE: 04/23/2012
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ASSISTANT: Ambujakshan Dildeep, MD

PREOPERATIVE DIAGNOSIS: Open abdomen status post exploratory laparotomy.

POSTOPERATIVE DIAGNOSIS: Open Abdomen.

OPERATION: Abdominal exploration and changing of ABThera wound VAC.

ANESTHESIA: General Endotracheal.
COMPLICATIONS: None.
SPONGE, NEEDLE, AND INSTRUMENT COUNTS: Correct at the end of the case.
DISPOSITION: Stable, intubated to the surgical intensive care unit.

INDICATIONS: The patient is a 35-year-old male who was previously operated on five days ago for upper GI bleed status post Roux-en-Y gastric bypass. The patient was left in discontinuity due to his hemodynamic instability and an open abdomen via ABThera VAC was placed. Two days prior, the ABThera was changed in the operating room and this morning the small bowel appeared to be protruding around the inner portion of the ABThera VAC. Since there was a concern that the small bowel was in direct contact with the outer foam of the VAC machine, the decision was made to take the patient to the operation room for an exploration and change of this VAC.

PROCEDURE: The patient was taken to the operating room and the procedure was performed on his surgical ICU bed. He was placed supine. Venodyne stockings were in place and cardiopulmonary monitoring was applied by anesthesia. The patient was already intubated and a Foley catheter was in place. Anesthesia was induced and the abdomen was prepped and draped in the usual sterile fashion.  An appropriate time out procedure was performed.

The ABThera seal was removed and the abdomen was again fully prepped with Betadine at this time.  Once the VAC was removed, the small bowel was inspected and no injuries were noted.  All four quadrants of the abdomen were inspected.  There was no blood, minimal fluid, and no pus. There were a small amount of adhesions to the left lateral trocar site and these were left in place.

An ABThera VAC was then reapplied being sure to ensure that the small bowel was completely covered in both the right and left gutters as well as in the pelvis.  The VAC was hooked up to the vacuum canister and suction was applied.  Suction was excellent at 125mmHg.

Sponge, needle, and instrument counts were correct at the end of the case. The patient was taken intubated in stable condition back to the surgical ICU.

ADAM ROSENSTOCK, MD

DICT: AR 04/25/2012
TRANS: ST/DLA 04/25/2012
JOB: 891423
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Digitally signed on 4/25/2012 at 2:11:17 PM by Adam Rosenstock.

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.

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.