NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

there is no intestinal anastomosis, there is no risk of anastomotic breakdown. Patients may also benefit from intraoperative or postoperative mesenteric angiography to allow assessment of the vasculature. Case Variation 8.7.15. Ischemia but no necrosis of the intestines and acute occlusion of the origin of the superior mesenteric artery ◆ ◆ In this situation, it is desirable to revascularize the bowel. The superior mesenteric artery should be exposed and the occlusion either removed or bypassed. The bowel can then be inspected for viability and managed accordingly. In addition, these patients are ideal sub- jects for preoperative mesenteric angiography. Case Variation 8.7.16. Ischemia of the intestines with multiple small punctate areas of necrosis throughout the jejunum and ileum in a patient with a pulse in the superior mesenteric artery and mild chronic congestive heart failure ◆ ◆ This presentation suggests either multiple small emboli or a low-flow state. Obviously, necrotic areas warrant resection. Postoperative optimization of hemodynamics and a “second-look” operation are a reasonable management scheme, although the outlook is poor. Angiography may demonstrate a low mesenteric flow rate. Case Variation 8.7.17. Viable but ischemic intestines in a patient with a pulse in the superior mesenteric artery but evidence of a low-flow state ◆ ◆ The hemodynamic status of this patient should be optimized. Preoperative angiography and recognition of the low-flow state would be better treated by optimizing vascular perfu- sion than with surgery. This would avoid an unnecessary operation.

INFLAMMATORY BOWEL DISEASE Critical Surgical Associations If You Hear/See Think Crohn colitis

Chronic disease, operate on complications SAMPLE Ulcerative colitis Ulcerative colitis Cured with colectomy Increased risk of cancer over time Colon polyps Rectal cancer Anal cancer Pneumaturia May progress to cancer Neoadjuvant therapy Definitive medical treatment (not surgery) Fistula to bladder from diverticulitis Diverticular bleeding Typically stops spontaneously

Splenic flexure

Watershed area, avoid anastomosis

Melena

Right colon bleeding

Hematochezia

Left colon bleeding (but can be fooled!)