sara0014
Contributor
Needing some assistants on all the CPT codes to pick up.
Thanks in advance!
PREOPERATIVE DIAGNOSIS: Colonic obstruction.
POSTOPERATIVE DIAGNOSIS: Benign colonic obstruction with megacolon secondary to smoldering chronic rectosigmoid diverticulitis.
PROCEDURE: Flexible sigmoidoscopy with laparotomy, Hartmann colostomy.
HISTORY OF GROSS FINDINGS: This farmer presented to the emergency department at 1 a.m. complaining of severe abdominal pain. No bowel movement for two weeks. No gas passage for almost two weeks. In the emergency room, plain x-rays were done which showed a megacolon with stool in the colon. There was some concern about just simple fecal impaction and obstipation and so the patient was given GoLYTELY and enemas. He had no output as a result of this treatment. Dr. X was asked to see him and she consulted and exam with him noted an extremely distended abdomen. He had a nasogastric tube placed in the emergency room. She ordered a CT scan and called me. While I was en route to the hospital, the CT scan was performed and when I arrived I reviewed the CT scan with Dr. Dolin. The patient has a megacolon with a rectosigmoid narrowing consistent with diverticular narrowing as opposed to carcinoma. Two years prior with Dr. Hughes, the patient had a rectosigmoid diverticulitis. Apparently he got better from that and I haven't seen him since. The patient is a farmer, self employed, without insurance. He had no regular visits to any physician. The patient was simply hoping he would feel better and never did. As a result of the mass distention of his colon, I did a rectal exam at the bedside. There was no fecal impaction. I tried passing a Foley catheter into the rectosigmoid junction to no avail. I performed a flexible sigmoidoscopy. The flexible sigmoidoscopy showed intense erythema of the rectosigmoid and I was able to get the scope into the more proximal colon and tried sucking out gas but the thick stool and the mass quantities kept obstructing the scope. The patient was massively distended already. I didn't want to risk perforated him with the colonoscopic gas pressure to just be able to see so I abandoned the procedure and recommended laparotomy a Hartmann diversion. During the diversion, the patient's colon was markedly distended containing immeasurable amounts of stool primarily liquid. Ultimately I divided the sigmoid just above the obstructive point and raised the colostomy trying to decompress as I will describe. There was minimal stool contamination in the abdomen.
After obtaining informed consent from the patient and his family for both the flexsig and the laparotomy with Hartmann colostomy, the patient was taken to surgery. The patient was prepped and draped in the supine position and a midline incision was created. He was preoperatively marked for a colostomy. Incision was created through the skin in subcutaneous fashion down to the rectus fascia which was incised. I immediately encountered the massively dilated sigmoid. I did an exploration with manual exploration. Colon was markedly dilated throughout. The small bowel was relatively decompressed. I palpated the deep pelvis. I could not feel any major phlegmon. I felt some degree of mass effect in the deep pelvis but nothing terribly impressive. I decided to attempt decompressing the colon from the exposed sigmoid loop. I purse-stringed it with 3-0 Vicryl suture. Once the purse string was complete, I created a puncture wound in the region at an area that I thought would ultimately be the colostomy. I then placed a Yankauer suction in and we sucked out about 300 mL of thick liquid stool and some gas but couldn't get the colon to decompressed. I placed a curved oyen clamp on the proximal sigmoid so that I could just simply decompressed the distal sigmoid enough to get a GIA across it. I was able to get it to decompress slightly but not completely. I pulled the Yankauer out and closed off the enterotomy with 3-0 Vicryl suture. I was then able to create a window through the mesentery adjacent to the sigmoid so that I could pass a GIA. I passed two GIA 16 mm loads and divided the colon. There was so much distention that the staple line leaked in the center between the two staple walls. I closed this off with two layers of 3-0 Vicryl suture on the distal end and on the proximal end. The colostomy was then fashioned by cutting a circular incision as marked with cautery. I then created the cruciate incision through the fascia about two-thirds lateral on the rectus muscle, opened the rectus muscle, opened the posterior rectus sheathe and peritoneum. I was able to pass the massively dilated colon through this opening and secure it to the fascia with 3-0 Vicryl sutures strategically.
Sponge, instrument, and needle counts were all found to be correct. The abdomen was irrigated with saline. The abdomen was closed with #1 Lu-PDS and surgical staples. The colostomy was mature by opening the colon. I then put a pull suction in trying to decompress. There was some propulsive output of stool initially and I matured the stoma circumferentially with 3-0 Vicryl sutures and we then placed a colostomy appliance over the region and transferred the patient to the recovery room.
I am ordering a c-difficile toxin on the patient just to be sure he is not a spontaneous c-difficile infection with megacolon and if so, if he doesn't progress well, he may need further surgery to do a colectomy. If not, then I am hopeful that he will continue to decompress spontaneously through the stoma. In the meantime I will keep him on both Zosyn and Flagyl in the event that he has c-difficile which I have a relatively low index of suspicion for but need to rule it out because of the severity of the megacolon. In the recovery room, he is having stool output. We are getting a specimen. We are having trouble keeping the colostomy device on his incision and this will probably be a problem for a few days, if not a few weeks, until staples are removed.
Thanks in advance!
PREOPERATIVE DIAGNOSIS: Colonic obstruction.
POSTOPERATIVE DIAGNOSIS: Benign colonic obstruction with megacolon secondary to smoldering chronic rectosigmoid diverticulitis.
PROCEDURE: Flexible sigmoidoscopy with laparotomy, Hartmann colostomy.
HISTORY OF GROSS FINDINGS: This farmer presented to the emergency department at 1 a.m. complaining of severe abdominal pain. No bowel movement for two weeks. No gas passage for almost two weeks. In the emergency room, plain x-rays were done which showed a megacolon with stool in the colon. There was some concern about just simple fecal impaction and obstipation and so the patient was given GoLYTELY and enemas. He had no output as a result of this treatment. Dr. X was asked to see him and she consulted and exam with him noted an extremely distended abdomen. He had a nasogastric tube placed in the emergency room. She ordered a CT scan and called me. While I was en route to the hospital, the CT scan was performed and when I arrived I reviewed the CT scan with Dr. Dolin. The patient has a megacolon with a rectosigmoid narrowing consistent with diverticular narrowing as opposed to carcinoma. Two years prior with Dr. Hughes, the patient had a rectosigmoid diverticulitis. Apparently he got better from that and I haven't seen him since. The patient is a farmer, self employed, without insurance. He had no regular visits to any physician. The patient was simply hoping he would feel better and never did. As a result of the mass distention of his colon, I did a rectal exam at the bedside. There was no fecal impaction. I tried passing a Foley catheter into the rectosigmoid junction to no avail. I performed a flexible sigmoidoscopy. The flexible sigmoidoscopy showed intense erythema of the rectosigmoid and I was able to get the scope into the more proximal colon and tried sucking out gas but the thick stool and the mass quantities kept obstructing the scope. The patient was massively distended already. I didn't want to risk perforated him with the colonoscopic gas pressure to just be able to see so I abandoned the procedure and recommended laparotomy a Hartmann diversion. During the diversion, the patient's colon was markedly distended containing immeasurable amounts of stool primarily liquid. Ultimately I divided the sigmoid just above the obstructive point and raised the colostomy trying to decompress as I will describe. There was minimal stool contamination in the abdomen.
After obtaining informed consent from the patient and his family for both the flexsig and the laparotomy with Hartmann colostomy, the patient was taken to surgery. The patient was prepped and draped in the supine position and a midline incision was created. He was preoperatively marked for a colostomy. Incision was created through the skin in subcutaneous fashion down to the rectus fascia which was incised. I immediately encountered the massively dilated sigmoid. I did an exploration with manual exploration. Colon was markedly dilated throughout. The small bowel was relatively decompressed. I palpated the deep pelvis. I could not feel any major phlegmon. I felt some degree of mass effect in the deep pelvis but nothing terribly impressive. I decided to attempt decompressing the colon from the exposed sigmoid loop. I purse-stringed it with 3-0 Vicryl suture. Once the purse string was complete, I created a puncture wound in the region at an area that I thought would ultimately be the colostomy. I then placed a Yankauer suction in and we sucked out about 300 mL of thick liquid stool and some gas but couldn't get the colon to decompressed. I placed a curved oyen clamp on the proximal sigmoid so that I could just simply decompressed the distal sigmoid enough to get a GIA across it. I was able to get it to decompress slightly but not completely. I pulled the Yankauer out and closed off the enterotomy with 3-0 Vicryl suture. I was then able to create a window through the mesentery adjacent to the sigmoid so that I could pass a GIA. I passed two GIA 16 mm loads and divided the colon. There was so much distention that the staple line leaked in the center between the two staple walls. I closed this off with two layers of 3-0 Vicryl suture on the distal end and on the proximal end. The colostomy was then fashioned by cutting a circular incision as marked with cautery. I then created the cruciate incision through the fascia about two-thirds lateral on the rectus muscle, opened the rectus muscle, opened the posterior rectus sheathe and peritoneum. I was able to pass the massively dilated colon through this opening and secure it to the fascia with 3-0 Vicryl sutures strategically.
Sponge, instrument, and needle counts were all found to be correct. The abdomen was irrigated with saline. The abdomen was closed with #1 Lu-PDS and surgical staples. The colostomy was mature by opening the colon. I then put a pull suction in trying to decompress. There was some propulsive output of stool initially and I matured the stoma circumferentially with 3-0 Vicryl sutures and we then placed a colostomy appliance over the region and transferred the patient to the recovery room.
I am ordering a c-difficile toxin on the patient just to be sure he is not a spontaneous c-difficile infection with megacolon and if so, if he doesn't progress well, he may need further surgery to do a colectomy. If not, then I am hopeful that he will continue to decompress spontaneously through the stoma. In the meantime I will keep him on both Zosyn and Flagyl in the event that he has c-difficile which I have a relatively low index of suspicion for but need to rule it out because of the severity of the megacolon. In the recovery room, he is having stool output. We are getting a specimen. We are having trouble keeping the colostomy device on his incision and this will probably be a problem for a few days, if not a few weeks, until staples are removed.