NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Case Variation 8.23.4. A 1-cm lesion palpable on the surface of the liver at surgery ◆ ◆ A small lesion on the liver, particularly at the edge of the liver, usually can be wedged out as a total excision. If the lesion were contiguous with vital structures such as a hepatic vein, then a biopsy of the lesion would be appropriate, with no further therapy during that operation. Case Variation 8.23.5. An 8-cm lesion palpable on the surface of the liver at surgery ◆ ◆ Larger lesions should not be resected when discovered at the time of surgery. A major liver resection increases both the intraoperative risk of bleeding and the overall complexity and duration of the operation. Many general surgeons also are not experienced hepatic sur- geons. Postoperative complications such as infection and bile leakage are possible; none of these have usually been discussed with the patient preoperatively. Most surgeons would complete the colectomy, biopsy the liver lesion, and plan possible resection at a later date after further evaluation. Case Variation 8.23.6. A poorly differentiated tumor histology obtained preoperatively from the primary tumor ◆ ◆ The operative procedure is unchanged. Factors associated with a worsened prognosis in- clude poorly differentiated tumors, especially mucin-producing and “signet cell” tumors, tumors with venous or perineural invasion, and tumors presenting with perforation. Case Variation 8.23.7. A 2-cm nodule apparent on CXR ◆ ◆ The nodule warrants evaluation by chest CT and biopsy by percutaneous needle biopsy if suspicious for cancer. Many surgeons would include an abdominal CT to gain further in- formation for operative planning. Ametastatic lung nodule makes a curative operation very unlikely. However, it is still necessary to perform a colectomy to remove the primary tumor to manage it locally and prevent further blood loss or bowel obstruction.

Case 8.24 Complications of Postoperative Colectomy ◆ ◆ This scenario suggests that the patient’s GI tract is not functional, which could be secondary to a persistent, postoperative ileus, mechanical obstruction, or a leak. Feculent vomiting results from bacterial overgrowth in the stomach and proximal small bowel due to failure to propel food and secretions distally. NPO feeding and IV fluids are appropriate, along with insertion of an NG tube. Evaluation of the abdomen with a physical exam and an obstructive series is necessary. The concerns are two in number: (1) Leakage from the anastomosis has occurred, causing a persistent ileus, or (2) a mechanical obstruction SAMPLE Most patients who undergo an elective colectomy have an uneventful recovery in the postoperative period. Q: How would you manage the following situations? Case Variation 8.24.1. The patient becomes distended and vomits feculent material on the third postoperative day