M&M CONFERENCE VICTOR H BARNICA 4/7/2016

LM 76 YO F who has recently underwent a laparoscopic peritoneal lavage with diverting loop descending colostomy for perforated diverticulitis at an OSH. She was subsequently referred to us for definitive surgical management. PMH: Afib on Coumadin, arthritis, depression, diverticulitis PSH: Laparoscopic lavage with loop colostomy, cataract surgery.

On 3/15/16 she underwent an open colostomy take down, sigmoid resection with low coloproctostomy and DLI. Operative findings: Large sigmoid colon phlegmon involving the proximal rectum, hence the decision to do a low coloproctostomy with proximal diversion, and pelvic drain placement. Op time: 3hrs 45 min EBL approx. 200ml

She recovered well postoperatively Anticoagulation was started 2 days prior to discharge and she was finally discharged on 3/22 (POD 7) after pelvic drain removal. On 3/26 she presented to an OSH c/o blood per rectum, lower abdominal/pelvic pain. She was accepted on transfer to MMC once w/u was completed. HD stable Labs: WBC 14+ Hgb 7.8 < 9.0 INR 2.2 Broad spectrum abx started, FFP, 2 PRBCs

Hgb peaked up to 8.7 after transfusion and slowly drifted down to 8.0 and remained there. 72 hrs after admission a repeat CT scan was obtained, showing increase in pelvic collection size.

Flexible sigmoidoscopy demonstrated an ecchymotic but patent and intact anastomosis. A percutaneous drain was placed by IR and serosanguinois fluid drained, (negative microbiology). The patient had near complete resolution of symptoms and was discharged home on 4/4/16 with a drain in place and plan to postpone anticoagulation for a few days.

SUMMARY 76yo F readmitted with a pelvic hematoma after a sigmoid colectomy for complicated diverticulitis. Clasification IIIa, Patient disease

PERIOPERATIVE BRIDGING ANTICOAGULATION To eliminate effect of antithrombotic therapy before surgery, treatment should be stopped before surgery (~5 days for warfarin, 7-10 days for antiplatelet drug) to minimizing bleeding risk Giving bridging after surgery increases risk for bleeding; this risk depends on anticoagulant dose (therapeutic-dose > low-dose) and proximity to surgery (higher risk if given closer to surgery) Delaying resumption of therapeutic-dose bridging (for h after surgery), decreasing the dose or avoiding its use after surgery can mitigate the risk for bleeding

PERIOPERATIVE BRIDGING ANTICOAGULATION If antithrombotic therapy is interrupted before surgery, is “bridging Anticoagulation” needed? The need for bridging is driven by patients' estimated risk for thromboembolism (TE): In high-risk patients, the need to prevent TE will dominate management irrespective of bleeding risk; the potential consequences of TE may justify bridging In moderate-risk patients, management will depend on individual patient risk assessment In low-risk patients, the need to prevent TE will be less dominant and bridging may be avoided In all patients, judicious use of postoperative bridging is needed to minimizing bleeding that would have the undesired effect of delaying resumption of antithrombotic therapy after surgery

TP 56 yo F admitted to MMC on 3/9/16 with c/o Nausea, vomiting, abdominal distention and pain. Recently treated as OP for acute diverticulitis. PMH cervical cancer treated with radiation (last 2/25/16), diverticulitis, anxiety, depression, GERD, HLD. PSH: Colonoscopy in 2015, Hysterectomy and tubal ligation. SH: Smoker ½ to 1 PPD, no etoh or illicit drugs FH: breast and colon cancer Exam: Distented and tipanic but minimally tender.

She was treated with broad spectrum abx and bowel rest. Over the course of the next 5 days her symptoms were waxing and waning w/o consistent improvement. A gastrografin enema showed a sigmoid colon stricture w/o complete obstruction

She was taken to the OR on 3/18, Colonoscopy, exploratory laparotomy, Sigmoid colectomy with en block small bowel resection and end colostomy. Operative time over 4 hr EBL approx. 200

POD 1 c/o numbness of the lateral aspect of the left leg and dorsum of the foot with marked weakness on dorsiflexion. PT consultation obtained and foot drop exercises and split started showing significant improvement with a residual dorsiflexion weakness. She recovered well from the surgical standpoint and was discharged to rehab on the 3/25 and spent there 6 days.

SUMMARY 56 yo F with diverticular stricture requiring sigmoid with en block small bowel resection and end colostomy. Complicated with foot drop postop. Classification IId (Disability) Technical error

PERONEAL NERVE

LITHOTOMY POSITION: NERVE INJURY In a study which looked retrospectively at 198,461 patients undergoing surgery in the lithotomy position). Etiology: 2/2 compression. Most Commmon: common peroneal (78%) Etiology: compression of the nerve between the lateral head of the fibula and the bar holding the legs Risk Factors: low BMI, smoking, prolonged surgery Manifestation: common peroneal is L4-S2, responsible for foot dorsiflextion and toe extension (thus leads to foot drop) M A Warner, J T Martin, D R Schroeder, K P Offord, C G Chute Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position. Anesthesiology: 1994, 81(1);6-12 M A Warner, D O Warner, C M Harper, D R Schroeder, P M Maxson Lower extremity neuropathies associated with lithotomy positions. Anesthesiology: 2000, 93(4);938-42