Morbidity and Mortality Conference Section of Trauma January 2017 Angelica Aliado, MD Myra Alexandra Firaza, MD General Surgery Resident

R.M., 33/M Admitting Diagnosis Post-operative Diagnosis #1 Wound dehiscence, t/c intraabdominal abscess; ruptured appendicitis with localized peritonitis, s/p appendectomy (1/2/17, JRRMMC) Post-operative Diagnosis #1 Wound dehiscence secondary to intraabdominal abscess secondary to blown-up stump; ruptured appendicitis with localized peritonitis; s/p appendectomy (1/2/17, JRRMMC) Procedure #1 Done Exploratory laparotomy, adhesiolysis, evacuation of abscess, cecorraphy, repair of serosal tear, JP drain (1/11/17, JRRMMC) Adverse Outcome Blown-up stump

R.M., 33/M Pre-operative Diagnosis Post-operative Diagnosis #2 t/c Repair leak; s/p exploratory laparatomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain (1/11/17); s/p appendectomy (1/2/17) Post-operative Diagnosis #2 Intraabdominal abscess secondary to repair leak, cecum; s/p exploratory laparatomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain (1/11/17); s/p appendectomy (1/2/17) Procedure Done #2 Exploratory lapatomy, adhesiolysis, evacuation of abscess, R hemicolectomy (1/15/17, JRRMMC) Adverse Outcome Repair leak

Background History of Present Illness Past Medical History Case of acute appendicitis, s/p appendectomy (1/2/17) Six days prior to admission (+) purulent discharge per wound site, accompanied by fever and abdominal pain, no BM since post appendectomy Past Medical History No HTN, DM Family History: Unremarkable Personal and Social History Unremarkable

Background Physical Examination Awake, not in cardiorespiratory distress VS BP 120/80, HR 84, RR 20, T 36.7, O2 sat 99% BMI 22 Pink palpebral conjunctivae, anicteric sclerae Clear breath sounds, no crackles Soft abdomen, (+) dehiscence at incision site, (+) tenderness, (+) foul-smelling, fecaloid, purulent discharge DRE: Unremarkable

Background Ancillaries (before 1st reop) CBC: Hgb 13.3, Hct 38.2, WBC 13.1, Plt 703 Creatinine: 63 umol/L, Sodium 135.5, Potassium 4.12 PT: 13.1 (13.0) INR 1.01, 98% activity PTT: 32.5 (30.0) CT 5’00” BT 3’00” Chest X-ray Inadequate lung expansion secondary to poor inspiratory effort Magnified heart vs true cardiomegaly

Chest xray

Background Intraoperative Findings (1st re-op) Localized intra-abdominal abscess at the right lower quadrant Adhesions (non-obstructing) on ileum and cecum Small and large bowels non-dilated Blown-out stump Other structures normal

Background Surgical Procedure #1 Post-operative Diagnosis Exploratory laparotomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain Firaza/ De Guzman/ Aliado OR Time: 2:30 hours EBL: Minimal Post-operative Diagnosis Wound dehiscence secondary to intraabdominal abscess secondary to blown-up stump; s/p appendectomy (1/2/17, JRRMMC)

Operative pictures

D1 Post Re-Op (+) Febrile episodes (Tmax 38.1) VS BP 120/80, HR 84, RR 20, T 36.5 Abdomen was soft with tenderness on the post-op site JP 65 cc x 12h, serosanguinous output NGT: 50 cc, brown-colored output UO: 0.83 ckh, clear Still on NPO. IV Cefoxitin was continued. Pain medications (Tramadol drip, Ketorolac IV, Morphine IV) started. TPN started

D2 Post Re-Op No hypotension, (+) febrile episodes (Tmax 38.1) No vomiting, no DOB No flatus yet (+) post-op site pain VS BP 120/70, HR 94, RR 20, T 37.8 Slightly distended abdomen, well-coapted wound, with moderately soaked dressing UO 0.5ckh x 24h JP 60 cc x 24h NGT 230 cc, 24h Septic work-up done (blood c/s, urine g/s, c/s, wound g/s, c/s) Shifted Cefoxitin to Piperacilllin-Tazobactam, Metronidazole, analgesics and TPN continued

Ancillaries (before 2nd reop) CBC: Hgb 11.9, Hct 34.8, WBC 20.87, Plt 519 Creatinine: 72 umol/L, Sodium 134, Potassium 3.81 Chest X-ray: no significant chest findings Plain abdomen: Dilated bowel loops with multiple air-fluid levels, presacral gas present, interserosal spaces not thickened t/c intestinal obstruction

Plain abdomen xray

D3 Post Re-Op No febrile episodes/vomiting (+) flatus, (-) BM VS BP 110/80, HR 92, RR 20, T 36.8 Slightly distended abdomen, (+) seropurulent discharge on wound site, (+) tenderness Shifted Piperacillin-Tazobactam to Ciprofloxacin (culture-guided), Metronidazole, analgesics and TPN continued A: Repair leak P: ‘D’ Exlap

Background Intraoperative Findings (2nd re-op) Localized right lower quadrant abscess collection Repair leak at cecum Multiple dense adhesions Dilated small bowels

Background Surgical Procedure #2 Post-operative Diagnosis Exploratory laparotomy, adhesiolysis, evacuation of abscess, right hemicolectomy, JP drain Firaza/ De Guzman/ Aliado OR Time: 5:15 hours EBL: 700 cc Post-operative Diagnosis Intra-abdominal abscess secondary to repair leak, cecum; s/p exploratory laparatomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain (1/11/17)

Operative pictures

D1-3 Post 2nd Re-Op No hypotensive episodes, no febrile episodes BP 130/80, HR 70, 21, T 36.8 Clear breath sounds Soft, non-distended abdomen Wound well-coapted with no purulent discharge NPO IV antibiotics continued NGT, JP, IFC maintained

D4 Post 2nd Re-Op No febrile episodes/vomiting No DOB (+) flatus, (-) BM Minimal post-op site pain BP 120/80 HR 72 RR 20 T 37.0 Clear breath sounds Soft abdomen with well-coapted wound with no purulent discharge Diet progressed (CLGL) NGT, IFC removed (D4)

D5 Post 2nd Re-Op No febrile episodes, no vomiting (+) BM Normotensive, normal heart rate Diet progressed (Soft diet)

D6 Post 2nd Re-Op No febrile episodes, no vomiting (+) BM Normotensive, normal heart rate Soft abdomen, well-coapted wound with moderately soaked dressing, serosanguinous JP: 39 cc serous, removed Diet progressed (DAT with SAP) Shifted all medications to oral (Ciprofloxacin, Metronidazole and Celecoxib)

D7 Post 2nd Re-Op Afebrile (+) BM, flatus Soft non-distended abdomen May go home