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Pre-Operative
Case
PresentationUpdateGS II (DR. BRAVO/TEMONIO/DONAYRE/NOVENO)Department of Surgery
Davao Regional Hospital, Tagum City
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General Data
J. G.
19 years old
Male
Single
Filipino Roman Catholic
Patin-ay, Prosperidad, Agusan del Sur
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Diagnostics
Chest X-Ray PA Negative Chest
Abdomen U/S
Nothing significant in the abdomen
Pelvis AP
No significant abnormality is noted
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UPRIGHT VIEW VIEW
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R FEMUR
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INTERNAL MEDECINE RODs IMPRESSION:
Anemia sec to UGIB (resolved) probably sec. to Liver
Schistosomiasis;
Palpable LLQ mass.
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Salient Points
History
(+) history of vehicular crash
(+) mass LLQ area, enlarging,tender
(+) icterisia
(+) melena
(+) fever
(+) SCHISTOSOMIASIS 4 yrsPTA treatment given as
claimed
(+) Lives in an area infested to
Schistosoma parasite
Physical Examination
Temperature: 37OC
(+) jaundice Icteric sclera, pale palpebral
conjunctiva
Liver edge 5cms
palpable mass at the LLQ
(approximately 10cm X 4cm), non-tender, fixed, no skin discoloration
above the mass
(+) Deformity R thigh
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IMPRESSION
1. ANEMIA SEC PROB SEC TO BPUD PROB SEC TOBLEEDING PEPTIC ULCER DISEASE
2. OBSTRUCTIVE JAUNDICE SEC TO CHOLELITHIASIS ANDCHOLEDOCHOLITHIASIS NOT IN CHOLANGITIS
3. PANCREATIC TAIL MASS, T/C PSEUDOCYST
4. LEFT LOWER QUADRANT MASS PROBABLY COLONIC INORIGIN
5. NEGLECTED CLOSED FEMORAL FRACTURE, M3RD,RIGHT SEC TO VA
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PREVIOUS
PLANS
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PLAN A
OPTIMIZED PATIENTS STATUS:
NUTRITIONALLY,
PHYSICALLY, PSYCHOLOGICALLY
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PLAN B
Treatment of UGIB:
For UGI Endoscopy
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PLAN C
For Treatment of Obstuctive Jaundice sec to Choledocholithiais
and Cholelithiasis:
ERCP OPEN CHOLECYSTECTECTOMY WITH CBDE, IOC, TUBE
CHOLEDOCHOSTOMY
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PLAN D
IF (+) Pancreatic tail mass (PSEUDOCYST): CA19-9 DETERMINATION
CT SCAN OF THE CHEST, ABDOMEN, PELVIS (TRIPLE CONTAST)
DRAINAGE:
(EXTERNAL) Percutaneous catheter drainage- high chance of persistent
pancreatic fistula (ultrasound or CT scan guided)
(INTERNAL) Endoscopic drainage- less invasive, becoming more popular,
techically demanding
Cyst gastrostomy
Cyst doudenostomy
Cyst jejnunostomy
Segmental resection and Roux-n-Y reconstruction
DISTAL PANCREACTECTOMY
necessary in complicated pseudocysts, failed nonsurgical, and multiplepseudocysts
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PLAN E
For the LLQ mass t/c Colonic in origin:
Colonoscopy w/ biopsy
CT SCAN OF THE CHEST, ABDOMEN, PELVIS
(TRIPLE CONTAST)
Baseline CEA
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PLAN F
For treatment of Schistosomiasis:
Stool examination Rectal biopsy - DONE
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PLAN F
Treatment of Neglected Femoral Fracture:
Refer to Ortho Consultant
For ORIF, Intramedullary Nailing, Right Femur
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LATEST DIAGMOSITICS
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CT Scan of the whole abdomen
done w/c revealed:
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IMPRESSIONS:
INTRAHEPATIC AND EXTRAHEPATIC BILIARYDILATATION DUE TO AN OBSTRUCTING CALCULUSOR MASS IN THE PANCREATIC PORTION OF THE CBD.
GALLBLADDER CALCULUS WITH INFLAMMATORY
CHANGES IN THE GALLBLADDER WALL. CONSIDERALSO A ROUNDWORM (ASCARIS) OR ITS CARCASSWITHIN THE CBD AND GALLBLADDER
HEPATOMEGALY AND SPLENOMEGALY
ILIOPSOAS AND INGUINAL ABSCESS, LEFT
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Diagnostics
CBC Nov. 14, 2013 Nov. 16, 2013 Normal Values
Hemoglobin
97(L) 90(L) 140170 g/LHematocrit
0.29(L) 0.26(L) 0.400.50
WBC
16.4(H) 14.2(H) 5.010.0 X 109/L
Neutrophils
0.84(H) 0.84(H) 0.550.65%Lymphocytes
0.11(L) 0.10(L) 0.250.35%
Monocytes0.05 0.06(H) 0.020.05%
Platelets
660(H) 565(H) 150500 X 109/L
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Diagnostics
Reticulocyte Count: 37 (H) 1.12.7%
MCV: 77 (L) 8298fL
MCH: 28.3 2833pg
Amylase 48.80 28100U/L
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Diagnostics
Prothrombin
TimeNovember
14, 2013
Normal
ValuesPT - %
Activity 82%
PTControl13.1 15.0sec
PTINR 1.13
PT - Patient
14.4 1117sec
Blood No ember 14 N b 16
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Diagnostics
Blood
Chemistry
November 14,
2013
November 16,
2013Normal Values
Sodium137.10 141.30
135
148mmol/L
Potassium4.40 4.10 3.55.5mmol/L
Calcium 1.25 1.20 1.11.4mmol/L
Chloride 111.90 105.20 97110mmol/L
Creatinine53.50 60.50
53
115.0umol/LTotal Bilirubin
----- -----2.0
21.0mmol/L
Direct Bilirubin ----- ----- 0.13.4mmol/L
Indirect
Bilirubin ----- ----- 014.50mmol/L
Alkaline
Phosphatase----- ----- 35130U/L
Albumin 21.97(L) ----- 3550g/L
SGOT/AST ----- ----- 042U/L
SGPT/ALT ----- ----- 041U/L
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Total
Bilirubin329.05 (H) ----- -----
2.0
21.0mmol/L
Direct
Bilirubin 232.62 (H) ----- -----0.1
3.4mmol/L
Indirect
Bilirubin96.43 (H) ----- -----
0
14.50mmol/L
Alkaline
Phosphatase672.20 (H) ----- ----- 35130U/L
Albumin ----- ----- 3550g/L
SGOT/AST 140.20 (H) ----- ----- 042U/L
SGPT/ALT 76.6 (H) ----- ----- 041U/L
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Diagnostics
Arterial
Blood Gas October30, 2013October30, 2013
November1, 2013
NormalValues
pH 7.122 (L) 7.359 7.403 7.357.45
pCO2 25.0 (L) 22.3 (L) 26.5 (L) 3545
HCO3 10.4 (L) 16.1 (L) 19.1 (L) 2226O2Sat 93.6% 93.6% 98.1% 80100
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LATEST ABG
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Diagnostics
Stool Exam November 13,
2013
Normal
Values
Color Yellowish
brown7.357.45
Consistency Soft 3545
Ova/ParasitesNone seen 80100
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Diagnostics
Urinalysis November 11,
2013
Normal
Values
Color Yellowish
brown-----
TransparencySoft -----
pH7.0 -----
Specific
Gravity1.015 -----
AlbuminTrace -----
Pus Cells02 -----
RBC01 -----
Epithelial
Cells
Occasional -----
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Peripheral blood smear:
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Rectal Biopsy done:
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CHILDS PUGHCLASSIFICTION
Factor 1 point 2 points 3 points
Total bilirubin
(mol/L)
50
Serum albumin(g/L)
>35 28-35
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CHILDS PUGHCLASSIFICTION
Class A Class B Class C
Total points 5-6 7-9 10-15
1-year survival 100% 80% 45%2-year survival 85% 60% 35%
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FINAL DIAGNOSIS
1. ILIOPSOAS AND INGUINAL ABSCESS, LEFT
2. OBSTRUCTIVE JAUNDICE SEC TOCHOLEDOCHOLITHIASIS VS CARCASS, CHOLELITHIASIS,
NOT IN CHOLANGITIS
3. ANEMIA PROB SEC TO BLEEDING ESOPHAGEAL VARICES
PROB SEC TO PORTAL HYPERTENSION PROB SEC TOLIVER SCHISTOSOMIASIS
4. NEGLECTED CLOSED FEMORAL FRACTURE, M3RD,
RIGHT SEC TO VA
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Functional Status
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PRESENT
PLANS
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PLAN A
1. OPTIMIZED PATIENTS STATUS:
NUTRITIONALLY,
PHYSICALLY,
PSYCHOLOGICALLY,
EMOTIONALLY
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PLAN B
1. For Treatment of Iliopsoas and Inguinal Abscess,
Left:
PERCUTANEOUS DRAINAGE OF Iliopsoas and Inguinal
Abscess, Left, JP DRAIN
OR EXLAP, Evacuation of Iliopsoas and Inguinal Abscess,
Drain
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PLAN C
1. For Treatment of Obstructive Jaundice sec to
Choledocholithiasis vs Carcass, Cholelithiasis, not in
Cholangitis:
OPEN CHOLECYSTECTECTOMY WITH CBDE, IOC, TUBE
CHOLEDOCHOSTOMY
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PLAN D
1. Anemia prob sec to Bleeding Esophageal Varices prob sec to
portal hypertension sec to Liver Schistosomiasis:
CORRECT ANEMIA WITH BLOOD TRASFUSION
UGI ENDOSCOPY
IF POSITIVE WITH BEV:
SCLEROTHERAPHY OF THE ESOPHAGEAL VARICES
HASSABSS PROCEDURE
is a satisfactory approach to controlling varices
Steps:
1. Splenectomy
2. Devascularization of the distal 7 cm of the esophagaus
3. Devascularization of the proximal part of the stomach
4. Vagotomyand pyeloroplasty
http://en.wikipedia.org/wiki/Splenectomyhttp://en.wikipedia.org/wiki/Vagotomyhttp://en.wikipedia.org/wiki/Vagotomyhttp://en.wikipedia.org/wiki/Splenectomy7/22/2019 Final Update Goloran
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TREATMENT OF SCHISTOSOMIASIS:
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PLAN E
Treatment of Neglected Femoral Fracture:
For ORIF, Intramedullary Nailing, Right Femur
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DISCUSSION
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Non-shunt procedures in
management of variceal
bleeding
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Most episodes of variceal haemorrhage will besuccessfully treated by resuscitation and injection
sclerotherapy, and indeed the efficacy of this approachhas now been confirmed by several well-controlled trials.
Nevertheless, in a significant minority either acutebleeding will persist, or rebleeding will occur in the nearor long term.
In this situation there is little doubt that some form ofportal hypertension systemic decompression is the mostsuccessful treatment for bleeding.
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In the vast majority of centres, the currently favoured
non-shunting procedures are:
simple stapled esophageal transection,
esophagogastric devascularization
combination of the two
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Portoazygous
Disconnection
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Hassab procedure
Consists of devascularization of the upper half of the stomachand oesophagus
The first step is usually splenic artery ligation followed bycareful mobilization of the spleen. This mobilization as in alldissections in portal hypertension, requires patient ligation andcoagulation of multiple collaterals within the peritonealreflections, and after individual ligation and division of theshort gastric vessels, the spleen is removed
The whole proximal stomach is then devascularized from theterminal two branches of the left gastric artery at the incisura
angularis upwards by ligation and division of the lesser andgreater omentum, and of the posterior gastric adhesions.
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Hassab procedure
After division of the oesophagogastric reflection of peritoneum andmobilization of the vagi, the distal 7 to 8 cm of oesophagus is
mobilized and all feeding vessels are ligated and divided. Exposurein this part of the procedure is much facilitated by the use of costalmargin retractors
The distal 3 cm of oesophagus and proximal 5 cm of stomach maythen be opened longitudinally thus displaying the varices and
allowing obliteration of each variceal column by undersewing fromas high as possible within the oesophagus with an absorbable suture
After positioning of a nasogastric tube the oesophagogastrotomy iscarefully closed by suturing or stapling. Some authors recommend
closure by swinging a flap of stomach wall into the oesophagealdefect, thus minimizing oesophageal stricturing.
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Sugiura procedure
is a much more radical development of the above
method, classically performed in two staged procedures
At the first operation, via a left thoracotomy, the distal
intrathoracic oesophagus is devascularized and an
oesophageal transection performed. Six weeks later, via
an upper abdominal midline incision, the intra-abdominal
oesophagus and proximal stomach are devascularized by
lesser and greater curve division and splenectomy
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Sugiura procedure
Vagotomy and pyloroplasty are then performed.
This massive procedure has been modified into a one-
stage operation using a transabdominal approach
facilitated by the use of costal margin and sternal
retractors.
After division of the crura of the diaphragm, 10 cm of
oesophagus can be devascularized, a staple transection
performed via a gastrotomy and the rest of the abdominal
part of the operation completed.
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THANK YOU!!!!