NMS. Casos Clínicos

254

Part II ♦ Specific Disorders

Q: What is the next step? A: Surgery to remove the cancer is necessary. The patient should undergo a careful medical evaluation to assess operative risk and should also receive supplemental iron preoperatively. Q: What would you tell the patient about his operative risk and potential complications? A: The operative risk for a routine colectomy is no different from that of most abdominal procedures. Postoperative complications include the following: ◆ ◆ Wound infection, which occurs in approximately 5%–10% of cases. The risk is higher than with a clean operation. ◆ ◆ A risk of an anastomotic leak. ◆ ◆ The need for a colostomy if an unforeseen operative problem occurs. ◆ ◆ Involvement by tumor or injury to the ureter. This possibility warrants discussion. ◆ ◆ Biopsy or removal of any suspicious lesions for metastasis, particularly in the liver. ◆ ◆ Recurrence. The patient agrees to the surgery. Q: What procedures are appropriate? A: A mechanical bowel “prep” and oral antibiotic “prep” used to be standard procedure for colectomy, but evidence shows that it might not be necessary or helpful. Surgeons who still elect to use a mechanical and/or antibiotic bowel prep typically use polyethylene glycol, magnesium citrate, or another potent laxative. Oral, nonabsorbed antibiotics are often given to decrease colonic bacterial levels with or without a mechanical prep, along with a single preoperative dose of a second-generation cephalosporin to diminish wound infection. A laparoscopic or open approach can be used. The initial step is a careful assess- ment of the primary tumor followed by a careful assessment for metastasis . Surgeons should specifically seek metastasis in the small bowel mesentery, the peritoneal surface, the diaphragm, the liver, and other locations. Even if another tumor is present, resection is still appropriate to prevent obstruction and bleeding, even though the procedure is not curative. Figure 8-25 illustrates various segmental colonic resections. A partial colectomy, typically a hemicolectomy , is warranted in this case. In addition to removing the tu- mor-bearing colon, it is necessary to remove the mesenteric tissue, including the regional lymph nodes . Reanastomosis of the bowel involves connecting the terminal ileum to the transverse colon, a so-called ileotransverse colostomy. Closure of the rents in the mesentery prevents internal herniation and obstruction of the small bowel. Closure of the abdomen is the final step. You have performed a right colectomy and excision of mesenteric lymph nodes. The remainder of the abdomen, including the liver, is normal. Q: What postoperative management is appropriate? A: The patient should remain NPO on IV fluids until bowel function returns. Once the patient can tolerate food, the patient can be discharged. On postoperative day 2, the patient’s pathology result returns; it reports moderately differentiated adenocarcinoma of the cecum, with tumor penetration through serosa. Nodes are negative. SAMPLE