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Oral Board Review: Colorectal Surgery Mock Orals (Podcast)
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Oral Board Review: Colorectal Surgery Mock Orals (Podcast)
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>> Behind the Knife, the surgery podcast where we take a behind-the-scenes, intimate look at surgery from leaders in the field. [ Music ] >> Welcome to another episode of Behind the Knife. We're continuing our mock oral series with a focus on colorectal today. Doctor Sean Langenfeld, assistant professor of surgery and associate program director for the general surgery residency program at the University of Nebraska Medical Center, will lead our two guest residents through some common board scenarios.
Joining us are Jonathon Abelson, a fifth-year resident from the New York Hospital Weill Cornell medicine program, and Paul Johnson, another fifth-year from the Rutgers New Jersey Medical School program. Both are pursuing colorectal fellowships. Thank you for volunteering, and good luck. >> Just a couple of things to remind you about as we get started. I don't think anybody's trying to trick you or intimidate you. It's actually counter-productive to intimidate people during this process, because it keeps me from being able to extract whether you know what you're doing or not.
But your first patient is a 52-year-old male. He presents to your office complaining of a three-month history of rectal bleeding. Upon further questioning, he states that there's no pain associated with it. The blood is mixed with the stool, and his stools are otherwise normal. He doesn't have any past medical or surgical history, he doesn't take any medications, and he's adopted, so he doesn't know his family history. >> Okay, great. So that's all the history that I need. So I'd proceed to a physical exam, focusing on the abdomen and doing an anorectal exam.
>> Okay. You do a head-to-toe physical exam, which is -- the abdominal exam portion is normal. On digital exam, you can palpate a circumferential mass about four centimeters above the anal verge. It appears partially obstructing, but you can pass your finger through it. Otherwise, the exam is normal. >> Okay. So at this point, I'm concerned for rectal cancer. So I'd want to proceed with getting a diagnosis, so I need to obtain a biopsy, and so I would like to know if the patient has had a colonoscopy in the past or recent biopsy.
>> No, he's not had any colon or other any other biopsies. >> Okay. So then my next step would be to arrange for a colonoscopy with biopsy to obtain a diagnosis. >> Okay. You do that, and you're able to pass a scope through the lesion and get to the cecum. You don't have any other abnormal findings, but you find a large fungating mass in the distal rectum, biopsies of which reveal adenocarcinoma.
>> Okay. So now that I have a diagnosis, I want to stage the patient. So as part of that, I want to get blood work, including LFTs and a CEA as well as a CT chest down to the pelvis with Po90 contrast followed by an MRI of the rectum. >> Okay. So the CEA is ten. The rest of his labs are normal. The CT of the chest, abdomen, pelvis is also normal, except they can also appreciate the distal mass and possibly an enlarged nymph node.
The pelvic MRI shows that the mass invades through the muscularis with several one-centimeter lymph nodes suspicious for malignancy in the presacral space. >> Okay. So at this point, clinical stage of stage three, so this patient needs to be referred for neoadjuvant chemoradiation therapy, depending on his response, hopefully followed by potentially surgery. >> Tell me what you mean by chemoradiation therapy. What does that consist of? >> The patient is going to undergo 5-FU.
It's leucovorin as well as radiation therapy targeting the pelvis over a four- to six-week period. >> Okay, and what surgery are you planning to perform once that's completed? >> So once he's -- once that's completed, then I'd want to repeat my history and physical in the office and confirm my location of my mass as it pertains to the anal sphincters, and that would determine my operative approach.
>> The mass is -- you know, it's above the levators. It's mobile. Grossly, it appears to have shrunk quite a bit with radiation therapy. You're examining him, I guess, two weeks after therapy completes. The rest of the exam is the same. >> Okay. So in that case, I would have an extensive discussion with the patient regarding the risks of benefits of both low anterior resection as well as an abdominal perineal resection. Given the fact that I think that I can obtain at least a one-centimeter margin, I would offer the patient a low anterior resection with a diverting loop ileostomy, but counseling the patient that should I not be able to obtain that margin, then the patient would ultimately need an abdominal perineal resection, and also counsel the patient for the high risk of anastomotic leak given the low position of the tumor.
>> Okay. When do you want to do the surgery? >> So I'm going to wait about four to six weeks after he's finished his chemoradiation. >> Okay. So you do the operation. Are you going to do it open or laparoscopic or robotic? You're going to do taTME? >> So the patient ultimately needs the best cancer operation they can, with a TME resection or TME procedure. So I'll start with a laparoscopic approach, and so I'd start my dissection medial to lateral.
Adequate length on my proximal cone that I'm going to be anastomosing into my rectum. >> Okay. So you do that, and the patient does well. Goes home in four days. Final pathology reveals a T2, N1 cancer. He's back in your office, and he goes, "What next?" >> Okay. So this patient's going to need adjuvant chemotherapy. As I mentioned before, I would have given the patient a diverting loop ileostomy, and so I'm going to defer reversal of the ileostomy until chemotherapy is finished, and then at that point, the patient would be seen again in my office for possible ileostomy reversal.
>> Okay. So you do all those things. He does well with chemo. He does well with your ileostomy reversal. And how do you plan to follow this patient in the long term, after you've done this surgery with curative intent? >> So I'd need then to see the patient in clinic for follow-up, three to six months for the first two years. Then I would need to get a repeat colonoscopy within a year. Oh, and the patient also with CEAs, roughly every six months.
That would be my initial approach. >> Okay. Let's change scenario. Let's say that when this patient initially presented to you, instead of having a tumor that invade through the muscularis with suspicious lymph nodes, the tumor was confined to the sub mucosa and had no suspicious lymph nodes. >> Okay, and what's the size of the lesion, and what circumference of the bowel wall does it incorporate?
>> Well, actually, I said sub mucosa. It's my own fault for [inaudible] that whole question. It goes two to 70 coats into the muscularis. It's a circular lesion, same one as before. >> Okay. So the difference in this case being I don't have concern for positive lymph nodes? >> Yeah. >> And so instead of a, you know, T3, T4 lesion, I'm concerned more of T2 lesion, and so in this case, I could offer the patient some up-front surgery as opposed to subjecting them to neoadjuvant chemoradiation therapy.
>> Okay. Now, what would you do if instead of all this -- go back in time -- presents to your office. He has a circumferential nonobstructing lesion, and he also presents with widespread bilobar liver metastasis. How do you treat that patient? >> Okay. So, you know, this patient, by definition, has stage four disease, and so is going to need systemic chemotherapy. The concern that I would have in this case is whether this patient is going to obstruct and therefore not be able to proceed with chemotherapy due to obstruction.
So, you know, based on my colonoscopy, I'd want to see how close I feel he is to obstructing. If I feel that he is close to obstructing, then I would offer the patient diverting stoma so that they can complete -- successfully complete chemotherapy. >> What sort of diverting stoma do you mean? >> I would do a diverting colostomy. >> An end colostomy, a loop colostomy?
>> I would do a diverting loop colostomy. >> Okay. Last scene on the scenario. I probably -- I ran it long intentionally just to help you sweat a little bit. I think you did a really good job overall. Overall assessment is that that's a passing exam, if that makes sense. There's three categories -- pass, fail, and in the middle is equivocal -- and to me, that's a clear pass. I was pretty happy with your performance. Just some tips.
You were very linear. No problems there. Your speed was good. You didn't dwell on the history and physical, which I appreciate. They won't let you dwell, either, on the actual exam. People typically don't wait four to six weeks. That's a pretty short interval after chemoradiation. A more common interval, as in the old days, was six to eight weeks, and now in more modern days, it's more like eight to 12 weeks, with the exception of if you had, for instance, a threat margin where you might go a little bit longer than 12 weeks, even up to 16.
You described the operation. I didn't actually ask you to do that, so that might count as volunteering information. You did mention that you'd do a high ligation to the IMB. That's correct, and it's good to have good reach down to the pelvis, but from an oncologic perspective, the pre-mesenteric artery ligation is what needs to be high in order to be an oncologically sound operation. The surveillance that you recommended is fine -- every three to six months. I would look at whichever guidelines you subscribe to and have a little tighter response on that.
An example would be physical exam with CDA every three months for the first two years, then every six months for the next three. colonoscopy is once -- on your one-year anniversary, and then three years after that, and then every five years, and then CAT is once a year. The other thing to keep in mind for people that have had lower anterior resection is they need a local exam once every six months to assess for local recurrence. That may eventually go away, as I think a lot of those recommendations came up, so people were doing good mesorectal excisions, but that being said, that's still the recommendation.
Wouldn't say you could do X, Y, Z. I would just say what you were going to do, and if they're obstructing, I think a loop colostomy is the best way to go. Palliative pelvic surgery, where you go down and actually remove the tumor, is very rarely a good idea, and so diversion is better. Did use a loop ileostomy, and they have a competent ileocecal valve, hypothetically, they could still get a large bowel obstruction, and then if you do an N colostomy instead of a loop, you get a large bowel obstruction, a closed loop obstruction above the tumor.
So anyway, I think you did a good job. This is the next patient. You have an 83-year-old male who prevents to the ER from the nursing home with severe abdominal distention. You're called down to the ER to evaluation. When you get there, you find that the patient has a past medical history of heart disease, hypertension, atrial fibrillation, and diabetes. The only surgical history is bilateral inguinal hernia repair. Medications include aspirin, warfarin, metformin, and metoprolol, and that's all the information you'll able to get.
Family history and social history are sort of non-contributory. >> Okay. So I got pretty much all the history that I need as well, so I would first see how his vitals are. Is he currently stable? >> Yes, he is stable. Pulse is 70, blood pressure is 130 over. Respiratory range is 22, and pulse ox. is 99% air. >> Great. So at this time, I would send off a full set of labs, CMP, CBC, as well as including a lactate as well.
>> Okay. So you do that, and the lactate is normal, CMP is normal, CBC's normal. The white blood cell count is ten. >> Okay, great. So at this point, I'm concerned for possibly an embolic event due to his history of AFib, so I would send him down for a CT angio, abdomen. >> Just the angiogram. Okay. So you do that, and when you get down there, what you find is that there's no embolic event.
The patient has a large distended colon with swelling in the mesentery consistent with sigmoid volvulus. >> Okay. So at that time, I would talk to the patient, sigmoid using endoscopy means, and then I would tell -- also counsel him that if this was unsuccessful, he would need an operation. >> Okay. Try to describe for me in detail how you'd go about endoscopically detorsing the sigmoid.
>> Okay. So I would advance the scope through the rectum and attempt to insufflate, oh, a regular colonoscope -- >> Okay. >> -- width, and then as I was insufflating, I would see if the mucosa would start to detorse through gentle insufflation. >> Okay, and if you're successful in detorsing it? >> If I was successful while I was detorsing, I would leave a rectal tube and then have that in place for at least two days and watch for a return of bowel function or any worsening abdominal exam.
>> Okay. So describe for me what you mean by a rectal tube. Where is this tube going to lie, and what would you use? >> So I would pass it during my colonoscopy. I would lay the tube in the descending colon and under direct visualization while doing it. >> Okay. So you do that, and in the process, the patient's colon decompresses. The patient is doing well, is resuscitated.
You reverse the INOR. It's been a couple days. Now what do you want to do with this patient? >> If he's currently doing well, I would be able -- and he's tolerating diet and everything's well, his abdominal exam was fine, and I would confirm that the colon is successfully detorsed through radiographic imaging. If all those things are in place, I would have him back electively for a sigmoidectomy.
>> So you send him out, and about 48 hours later, he presents with the same symptoms. His [inaudible] doing the same thing. You detorse him again. Now, he's resuscitated again, and you're afraid to send him back home because you're afraid the same thing's going to happen again. >> All right. So I would counsel the patient that I think the risk reverses the benefits are now weighing in the favor of taking him directly to the operating room, and then I would tell him he should still be reversed based on their -- and if not, he would -- his INR would have to be again reversed.
He would be optimized as best possible, seeing that he's temporized with the detorsion and a rectal tube again. Make sure that he's medically optimized, and once that's concluded, I would take him for a lap. sigmoid. >> Lap. sigmoid? Okay. Are you going to do an anastomosis? >> Based on his -- I would have to base it on his current status, so if his albumin is appropriate and he's been otherwise healthy, I would attempt a primary anastomosis for that.
>> Okay. Well, he is, and you do it. Let's change the scenario for a minute, and let's pretend that instead of presenting with sort of benign findings initially, he comes in with a rigid abdomen. White blood cell count is 17. He's going to diffuse tenderness. >> Well, if he has a rigid abdomen, I would take him directly to the OR and bypass the detorsion. I would also make sure that, of course, he was reversed and quickly reversed and then hanging FRP, probably, on the way to the OR.
Other than that, I would -- for him, since it's more critical, I think might be on pressors plus or minus, I would consider it a proximal diversion. >> Okay. Just while we're changing scenarios, let's pretend that this patient, same patient, same medical problems, but presents to the emergency room with a cecal volvulus, and the INR this time is normal. What do you do for somebody with a cecal volvulus?
>> So a cecal volvulus is a little different. It's not as easy to detorse. So for him, he would go for a right hemi. >> And do you do anastomosis neck condition? >> If he -- again, if he was stable, like in the lap. case, I would probably do a primary anastomosis as well, as long as -- depending on how distended the bowel is as well. >> Okay. So that's the end of that scenario. I think you did a good job overall.
You fund of knowledge is there. You have everything, I think, that you need to pass this scenario. I think you're somewhere between a pass and an equivocal. You skipped the physical exam during the initial work-up. You know, keep in mind, though, that, you know, for the most part, they're trying to give you all that and get you to management, so I don't think they're going to try to catch you up in that, but that's a concern, skipping that. Did not check an INR initially. I would probably be a little more specific with your decisions about what to do and use formal language, and so what I mean by that is to say "I'd probably take him to -- for endoscopy for detorsion," that would do -- you say, "I would colonoscopy with endoscopic detorsion and placement of the rectal tube." Or instead of saying, "I'd do a lap.
sigmoid, I'd say, "I'd do a laparoscopic sigmoid colectomy." Instead of saying right hemi, I'd say right hemicolectomy -- things like that, just so you come off appropriately formal for the environment. Now, some judgment things. I would say that most of these patients, if you send them home, they're going to retorse. A matter of fact, the retorsion rate in the short term can be as high as 50%, and so most of the time, the patient's not going to go home and come back for their colectomy, and so often they will kind of say okay, you sent him home because [inaudible] if anything happened.
After you decompressed the patient, when you talk about medical optimization, some things that that might specifically entail -- I was making sure he's fit for pelvic or fit for abdominal operation. Make sure he's had a recent colonoscopy and doesn't need an colonoscopy prior to surgery to make sure you don't have like whatever. You know, it's an 83-year-old guy. He could have a cecal cancer for all you know that's incidentally found, and then when you are in extremis, you said you'd bypass the torsion. I think you should be more specific that you had actually excised the torsion rather than -- you know, when you say bypassed the torsion, it's insinuating that you're almost leaving the dead sigmoid in there.
Otherwise, that was a good job. Pretty common scenario. I will tell you that historically, that's a common question that's asked, and so it's good to get to know it. Cecal volvulus less often, but, you know, that's just fine. Jonathon, are you ready for a round? >> Yeah. >> Okay, great. You have a patient who's 58-year-old female who presents to your office complaining of fever, nausea, and abdominal pain.
She says the pain started about two days ago. It's been gradual onset. It's localized to her left side. It's constant. She's nauseated. No emesis. Last bowel movement was a couple days ago, which is normal. Past medical history is negative. She has a history of a hysterectomy, surgically.
Family history is negative for anything significant. She doesn't take anything medications. >> So I would start with my physical exam, obtaining vital signs in my office and then doing an abdominal exam and an anorectal exam. >> Okay. So you do that, and she's got localized pain in the left lower quadrant as well as some suprapubic tenderness. There's some guarding just in those areas, but there's no guarding elsewhere, and there's no rebound. >> Okay, and for my vital signs, is she tachycardic or hypotensive?
>> Heart rate's about 100. Blood pressure's normal. Other vital signs are normal. >> Okay, and then for my rectal exam, any obstruction or gram-positive? >> Rectal exam is normal. >> Okay. So at this point, I'm concerned that the patient has an episode of diverticulitis, and so I'd want to see blood work as well as a CAT scan, C10 imposed with Po90 contrast. The blood work I could likely send off in my office, but the CAT scan I'd want to have on a more urgent basis, and so in order to obtain that, I'd likely send the patient to the emergency department for that.
>> Okay. She goes to the emergency room at the same facility where you have your office, and there, the white blood cell count is 17. Every other lab is normal. CT abdomen, pelvis does show sigmoid diverticulitis. There's a small amount of pericolonic free air. Then she has a five-centimeter pelvic abscess. >> Okay. So I would again assess the patient after she'd gotten the CAT scan and, with some resuscitation, do a repeat abdominal exam.
>> It's the same. >> Okay. So at this phase -- point, I would counsel the patient on the findings and discuss the options, which would be either taking the patient for an operation or performing a percutaneous drainage of the abscess. Given the fact that she does have an element of air associated with that, I would take the patient ot the operating room. >> Okay. Let's say there wasn't those few specks, the free air, on the perforated colon.
Then what would you do? >> In that case, I would feel a little bit more comfortable with consulting interventional radiology colleagues and asking them to drain the abscess and monitoring her from there. >> Okay. So you do that. They drain the abscess. It has purulent discharge. Patient recovers well. You bring her to the hospital for a few days.
She goes home. Four days later, now she's back in your office. She's still got the drain in, and she wants of know what you want to do next. >> Okay. So this patients's going to need a colonoscopy about six weeks after this episode, assuming that she continues to feel well. I would want to obtain a repeat CAT scan prior to performing that colonoscopy to ensure that inflammation has decreased, and then with respect to the drain, once the drain output is minimal, less than 20 ccs per day, and it's cleared up, then I would feel comfortable with removing the drain.
I didn't mention this before, but I would also have had the patient on antibiotics -- >> Okay. >> -- to cover the -- cover her abscess. >> Okay. So you do that. The drain comes out. Th colonoscopy shows diverticulosis throughout the entire colon, including the right side of the transverse colon. It's otherwise normal. There's no masses or other findings.
>> Okay. So in that case, I would counsel the patient that she did have an episode of complicated diverticulitis, and so, you know, given that, I think she'd be at a high rate of recurrence, and so I'd offer her an elective sigmoidectomy. >> Okay. Is that something that you perform open or laparoscopically? >> So, in my hands, I would perform an open sigmoidectomy. >> Okay. Does the patient get an anastomosis?
>> Depending on the level of inflammation at this point, my intention would be to do it under less acute setting, and so if the tissue appears healthy, then I would perform a primary anastomosis. >> So you're doing your operation open, and despite your best efforts, you transect the ureter on the left side at the level of the pelvic brim. It's done with cautery. You identify it right away.
What do you want to do now? >> So I would place the intraoperative consult to the urology service for assistance, but my overall plan would be to free the edges of the ureter and attempts reimplantation into the bladder if I'm able to obtain sufficient length. >> Okay. Let's just back up and change the scenario to a patient, and instead of having localized tiredness and an abscess, you have a patient that comes in with diffuse abdominal pain and peritonitis.
You take that patient to the operating room, and you find, you know, perforated diverticulitis with feculent peritonitis. What operation would you do for that patient? >> So this patient, if I can resect the diseased bowel, then I would perform a resection and then a Hartmann's pouch. >> Okay. All right. We're done with that scenario.
I think you did a good job. I would give you a clear pass. The diverticulitis questions come up a lot, and I think that the examiners can often change it to whatever they want it to be, whether it's a stable patient or a septic patient, whether they got peritonitis or localized tenderness, and so you have to be able to sort of respond to what they give you. I think what I was giving you there was a very stable patient with stable vitals, and I wouldn't be too deterred by the pericolonic free air.
That is something that does not require a sigmoid colectomy acutely. You know, you're treating the patient. If they got a reliable exam, localized tenderness, they don't need the operation. When you go in there acutely, very frequent, the patient does require a Hartmann's, but as you guys know, it's a very morbid operation. It's very hard to reverse later. A lot of people end up with a permanent bad as opposed to if you're able to coll them and drain the pus and will exclude malignancy, you can come back later and do an elective laparoscopic operation with a primary anastomosis.
>> I agree with you calling urology into the room. I think in the old days, people would always say something like, "oh, you can't ask for help," but realistically, you know, how many reimplantation have you done, and then at that level -- I mean, I guess that side of the [inaudible] I had done it to you, but at that level, at the pelvic brim, you're absolutely right -- reimplantation, the bladder's good. >> You can see Hartmann's procedure. It's a, well, kind of accepted eponym, but I think that the -- probably saying I'd do a resection with end colostomy is a little more specific.
So, otherwise, good job. If we had more time, we could talk about, you know, how many uncomplicated cases for our elective resection, et cetera, but I don't think it fits the scenario very well. What questions do you have? >> So yeah, in that case, you know, you would have offered the sigmoidectomy after she recovered from her perforation. >> I would. I think that over time, we're finding that complicated diverticulitis is a very mixed bag.
People that have ongoing symptoms like fistula or obstruction or something along that lines, it's a little easier to make the decision to operate. When they had a pelvic abscess and it's drained and it gets better, certainly those patients are at increased risk of having subsequent complicated attacks, but the risk of progressing to like uncontrolled sepsis in a Hartmann's procedure or emergency surgery is lower than we thought. So doing surgery with the intent of preventing some sort of future hypothetical emergency -- probably not necessary, but in general, I recommend that they undergo a colectomy.
Ask me again in ten years, though, and I might give you a different answer. >> Okay. >> We'll do the next case. You have a 73-year-old woman who presents to the emergency room with severe left-sided abdominal pain and hematachezia. She reports a three-day history of worsening abdominal pain. Started having bloody diarrhea this morning. She's never had anything like this before. She does have a history of heart disease as well as peripheral arterial disease and atrial fibrillation.
She has a left lower extremity arterial stent. No other surgical history. Medications include aspirin, warfarin, metoprolol, and atorvastatin. >> Okay. So thank you for her history. I would begin by doing a physical examination and also getting vital signs. >> So vitals are completely normal. Heart rate is 90. Blood pressure 130 over 90. Respiratory rate is 15.
On exam, she has a regular heart rate. Regular, not irregular. She has localized left lower quadrant pain with some guarding there. She has had a lot of pain there, but there's no rebound. >> Any blood on my glove hand? >> Yes. You -- if you do a digital exam, you do find some bright red blood. >> Okay. So I would start with resuscitation, make sure she has two large 4RBs, and then I would start giving her with -- give her a liter of LR.
In the meantime, I would send off some labs, make sure she has a CBC, CRP, lactate, -- >> Okay. >> -- OX, an EKG, and then a type and cross?. >> Okay. So you do that, and the white blood cell count is 14. Hemoglobin is 11. INR, 2.2. Basic metabolic panel is normal with the exception that BON's 30 and the creatinine is 1.5. EKG shows a sinus rhythm, and you said anything else?
Lactate's normal. >> Okay, and then I would also send out like stool cultures and a C diff just to make sure there's no infectious colitis. >> Those are pending. She's sitting the ER, but did you say you wanted to get a CT of the abdomen and pelvis? >> Yes. >> Okay. Yeah. So you get that, and that showed thickening of this splenic flexure and descending colon as well as possibly some pneumatosis in the descending colon wall.
There's no free -- no air. There's no other abnormalities. >> Okay. At this time, I'm concerned for possible ischemic colitis. I would also reverse her -- at this point, I would reverse her INR to make sure to decrease her bleeding risk, and then I would continue conservative care with hydration, antibiotics as well to cover gut flora and just supportive management.
>> Okay. So you do that, and she's better. The pain goes away. The white blood cell count goes own. The hematachezia resolves. When are you going to feed her? >> So as soon as her -- she really had a white count, but as soon as her abdominal pain is subsided and she starts having a return of bowel function, I would start diet. >> Okay, and after she's kind of recovered from this episode, she's back in your office.
She feels better. She says, "What next?" >> At this point, I would really try and ascertain the reasons that she might be having this episode of ischemic colitis. I would also counsel her to see if she's ever had a colonoscopy. She would need one now that the acute phase has passed. >> What are some reasons that people get ischemic colitis? >> So risk include like AIDS, being female. Heart disease is a main one.
Times -- a lot of patients we see have like if they're on pressors, and -- >> Okay. >> What are some other causes besides ischemic colitis of left-sided colitis like this, localized to the splenic flexure and descending colon? >> It's a watershed area, so it's a lot of times dehydration is also cause. >> That's the end of that scenario. You know, things we could do if we wanted to. Could change scenario to have a patient that's perforated, but I think we know that you will resect and possibly do a colostomy with that.
I would call that a clear pass. I think you passed that scenario. Resuscitation was good. The reversing the INR was good, the presentation. You stayed linear, did not skip the physical exam this time. Something to keep in mind on these patients is they've got a lot of red herrings at baseline because, you know, she's got a lot of medical problems, and so talking about AFib and peripheral arterial disease are kind of red herrings, you know, that probably be a bigger risk for mesenteric ischemia, which is an eruption of the small bowel blood supply.
It often requires surgery and it's a completely different entity compared to ischemic colitis, which is kind of a microvascular problem that happens in watershed. So I think you managed that well. I agree with giving the patient IV fluids, antibiotics, and bowel rest, and so all of those you did very well on. Something to keep in mind Colonoscopy, I agree. The main reason for colonoscopy, in addition to just if she needs one anyways, is to make sure you have the correct diagnosis, you know, ischemic colitis is a reversible thing, but if the patient has another form of colitis, we're just trying to get you walking on that road of things like IBD, diverticulitis, infection, et cetera.
You know, then that would be something you could identify with a colonoscopy. They very rarely require an operation. I wouldn't be deterred by pneumatosis in the wall. They frequently do have pneumatosis. As far as causes, I agree with you 100%. I think a lot of times, it's the body being smart. You know, you have a stress somewhere else in the body, and maybe they're dehydrated as well, and lysosome is shown to all the attention to the liver and the brain, and the colon gets left out, and so people that are dehydrated, marathon runners and so forth, and women can get it.
You know, little old ladies can get it even just from a urinary tract infection or something like that as well, so. We'll switch over to Jonathon. Jonathon, you ready? >> Yeah. >> Your patient is a 72-year-old man. He presents to the emergency room with new onset hematachezia. He was in a normal state of health until this morning, when he experienced four loose, bloody bowel movements.
Doesn't have any abdominal pain. Doesn't have any recent changes in routine. His activity is somewhat limited. He's got bilateral knee and shoulder pain. He takes a lot of Aleve for that. He occasionally has blood on the toilet paper. Otherwise he had nothing like this before. Last colonsc [phonetic] was eight years ago, which showed a single benign polyp, and he also had sigmoid diverticulosis.
He has a past medical history of heart disease, hypertension, atrial fibrillation, and osteoarthritis. Medical history includes -- or his medications include metoprolol, aspirin, warfarin, naproxen, and then socially, he drinks about four to six beers a day that he'll admit to you, smokes a half pack a day, and otherwise family history is noncontributory. >> Okay. So I would start with a physical exam, and as I'm doing that, I would ensure that the patient has two large bore IVs and is resuscitation.
So my physical exam focus on the vital signs, my abdominal exam, and then a rectal exam. >> Okay. So temperature, 98. Blood pressure is 90 over 60. Pulse is 120. Respiratory rate is 18. Pulse ox. is 98% of room air. The abdominal exam is normal. On digital rectal exam, you don't identify any masses or anything, but he does have some bright red blood that you can appreciate.
>> Okay. On my external exam, do I see any hemorrhoids? >> No. >> Okay. So I would make sure that my resuscitation is ongoing, I'd place a Foley catheter, and I would want to drop an NG tube and assess the return and make sure it's bilious, not bloody. >> Okay, and it's not bloody. You do see bile. >> Okay, and so as I'm doing my work-up, I'm going to -- I know that I'm going to want to send this patient to the ICU, so I'm going to be in touch with my critical care colleagues to facilitate that as I'm proceeding.
My work-up at this point is going to proceed with resuscitation and see his response to that, and as I'm doing that, I'm going to get a full set of labs, including coags for his warfarin use and type and cross. >> Okay. So white blood cell count is normal. Hemoglobin is 7.2. Platelet, 250. The INR is 6.2. The comprehensive metabolic panel and lipase are normal. >> Okay. So this patient needs to have his warfarin reversed, so I'm going to give the patient FFP as well as transfuse the patient, one unit packed red blood cells for his hemoglobin of 7.2, and assess his response in terms of his vital signs after I initiate that resuscitation.
>> You do that and he seems to be responsive to the blood. You recheck his hemoglobin and it's 7.2 again, so you -- what do you want to do then? >> So this patient needs scope. So the patient needs upper endoscopy as well as a colonoscopy. So I would start my prep if he'll tolerate that and not develop unstable vital signs.
>> Well, unfortunately, he is kind of getting a little bit unstable. He'll transiently respond when you give him blood, and you do get his INR down to 1.3. However, he continues to have bright red bloody bowel movements. Now he's received eight units of blood. His tachycardia persists. Blood pressure is probably 80 over 40. >> Okay. So unfortunately, I don't want to send an unstable patient for diagnostic imaging, and he's already received [inaudible] four units of packed red blood cells over a 24-hour period, so I'm concerned that this patient needs an emergent operation.
So I would talk with the patient extensively regarding the risks and benefits of forming a colectomy, especially considering I haven't been able to localize the source of his bleeding. >> So you want to take him to the operating room? Describe for me briefly what operation you want to do for this patient. >> So given his history, I'm concerned that he has a diverticular bleed, which would be more common on the left side. However, I don't know its exact location, so in this case, he'd need to have a subtotal colectomy.
I would need to assess the small bowel and see if there's any evidence of blood in the small bowel prior to going straight to a subtotal colectomy. >> Okay. So the colon is full of blood in the operating room, but there's no blood in the small bowel. You do your subtotal -- what does a subtotal colectomy mean? What's the distilled extent of that resection? >> So I'm going to go to the peritoneal reflection and do an ileorectal.
Basically the rectum, as it's at the peritoneal reflection. >> And do then do an ileorectal anastomosis, you said? >> So yeah, I guess depending on the patient's vital signs at this point in the operation, it he hypertensive and on pressors? >> Yes. >> Okay. So in that case, I would not -- I would not anastomose, and I would do a proximal diversion. >> Okay. So let's change the scenario a little bit. Let's make the patient start out the same, but this time, you're able to give him a couple units of blood and stabilize him out.
You reverse his INR. Hemoglobin is hanging out around 9, 10, but then he continues to have intermittent kind of ongoing hematachezia and transfusion requirements. He's no longer in the ICU, but you have, over the course of a couple days, given him, you know, six, seven units of blood. >> Okay. So in this case, if the patient's stable, then I would want to be able to localize the source of bleeding, so I'd want to obtain a colonoscopy if I can obtain a prep.
>> Okay. So you do the prep. He is fine with that. You do the colonoscopy, and you see a little bit of blood scattered through the colon, but otherwise not able to identify a source. >> Okay. >> The next day, he bleeds a little bit more, requires another unit of blood. >> Okay. So if the patient continues to be stable, I would arrange for a tagged red blood cell scan to try and localize the source of bleeding. >> Okay, and let's say that you find that he is -- tagged red blood cell scan localizes it to the right colon -- >> Okay.
>> -- [inaudible] wall. >> Okay. So in that case, I would try and arrange for angiography to try and localize the bleeding vessel and see if this can be further characterized in terms of whether or not this represents an AVM or something that could be amenable to interventional radiology approach. >> Okay. All right, that's the end of the scenario. I would say that you passed this scenario.
The important things here that you touched upon but can't be overlooked is that if you have a patient that's bleeding significantly, he's in the, you know, emergency room, and he is hypotensive, then you start with the ABCs, just like you did, and then you make sure he's in the right scenario or in the right location for your ongoing evaluation, which would the be intensive care unit. I like that you started resuscitation and that you reversed his INR, because that's the most important thing, and then whenever somebody has a lower GI bleed, the first step is always to exclude an upper GI bleed, and you did a good job with that.
I just have to mention for listeners that once you pass an NG tube, you're looking to make sure that's bile and no blood. If somebody has brisk upper GI bleed, they'll have hematachezia, and they'll bleed to death while you're getting your whatever, colonoscopy prep done or something like that. And so if you put an NG in and you don't get back bile or blood, then the patient still needs an EGD, because if they have a large duodenal ulcer that can cause spasm of the pylorus, and you could be bleeding profusely and really not have any return from the stomach, and so that's why he mentioned the bile and no blood.
Once you have a patient and you're starting to resuscitate him and you're giving him the blood, the threshold for the operating room is sort of arbitrary. You mentioned four units. I don't know. I wouldn't take anybody to the operating room with four units, personally. I think that how many units to give is arbitrary, right? You gave one. Somebody else might give four right up front, you know, and so how do you know what there's no magic number.
I would say that probably giving one unit initially in this scenario is under-resuscitating the patient. If there's an ongoing bleed, I probably would given a little bit more, but when you -- when you're forced to the operating room without a localized area of bleeding, you did the absolute right thing, which is a total colectomy. If you say that you would take the colon down to the peritoneal reflection, you know, the peritoneal reflection is deep in the pelvis, about anywhere between four and eight centimeters above the anal verge, depending on the patient, so that's pretty low.
I'm sure you probably meant the sacral promontory, but you're not alone in saying that that's what people did. That'd be a total colectomy, total abdominal colectomy. I would do an ileorectal anastomosis in the background of ongoing bleeding with unlocalized bleeding, because you have a patient that is most likely very unstable in that environment. If you didn't do a good job of excluding an upper GI bleed, sometimes the examiner will take you down that road, let you make your ileostomy, and they'll say that the next day, the patient's bleeding profusely out of the ileostomy.
So, not for you. You did okay with that. Now, on the other hand, if you have kind of a slower bleed, depending on who you ask and which textbook you read or which practice parameters you read, the order of events is different for everybody, but as far as whether the patient should have an immediate colonoscopy or an immediate tagged scan or probably more likely these days a CT angiogram, because they're getting so good, it depends on who you ask. There are still some people who believe colonoscopy should be first.
Personally, I don't think you can find a whole lot with that up front. They say blood's a cathartic, and so it's going to clean out the colon, but in general, if you don't prep the patient, you can't see much of anything with the colonoscopy, and if you do prep them, a lot of times, if it's a slow enough bleed, we won't catch it. But if you do receive the angiogram or prep scan, you're absolutely right that angioembolization is a wonderful tool. When I was training, it was very frowned upon. They thought you'd kill the colon, but the colon's pretty resilient, and it doesn't from angioembolization almost ever, so.
Good job. What questions do you have on that scenario? >> So yes, you know, I didn't do an anastomosis. I guess the other option is to do the anastomosis but still divert proximally. Does either one of those answers sound, you know, better in this scenario? >> No. I think you did the right thing. I wouldn't do -- in a patient that's -- you know, has ongoing hemorrhage and has a blood pressure 80 over 40, you're taking him to the OR, got a colon full of blood, the safest thing to do is to get rid of the source and get him back to the ICU for further resuscitation, and messing around with an anastomosis a loop ileostomy upstream from there is probably not the best answer.
>> Okay. >> We're on to the final scenario. This patient is a 63-year-old male who is undergoing a laparoscopic sigmoid colectomy on your service for colon cancer. On postoperative day number three, while you're covering for you partner who did the operation, the nurse calls you and reports fever of 102 Fahrenheit as well as new onset tachycardia. >> Okay. So I'll go assess the patient, and I'll need a -- I'll perform a physical exam and also get baseline vitals.
>> So you get baseline vitals, and temp. is 102, pulse is 120, respiratory rate's 25. He's got a pulse oximetry of 94% room air. Your physical exam head to toe outside of the abdomen is normal, but the abdomen is distended. He's got diffuse tenderness, and he's got guarding in his left lower quadrant. >> Okay. So I'm going to send off a full set of labs -- well, CMP, CRB, coags, and then also lactate.
>> Okay. Lactate is normal, coagulation factors are normal, CMP is normal. The white blood cell count is 16. It was 12 yesterday. The remainder of their lab's normal. >> You haven't said -- can you repeat when his -- >> Surgery was three days ago. >> Three days ago? Okay. I would make sure that he has IV access and start resuscitating him and also give him some -- make him NPO and then possibly -- and send him down for a CT of the abdomen and pelvis concerning for early leak.
>> So you do a CT. What sort of contrast do you want with that? >> I will do Po90. >> Okay. So CT is done, and it does show some free air, and there's some free fluid in the pelvis as well, with a couple of those free air there. >> Is there any free air around the anastomose or any localized air around the anastomosis or any signs concerning extravasation of oral contrast?
>> There's no extravasation of oral contrast. It does not reach the anastomosis, but there is a little bit of free air around the anastomosis as well. It's mostly in the anterior abdomen. >> At this point, I would start the patient on antibiotics, and I'm concerned for early leak, and with those findings, I would talk to the patient about just going back and examining the anastomosis to make sure there's no free -- no leak.
>> How do you want to examine the anastomosis? >> So I would -- can you repeat the method of which he did the surgery? It was a lap? >> It was an laparoscopic sigmoid colectomy. They did a stapled colorectal anastomosis with an EEA 29 millimeter stapler. >> Okay. So I would go back into the abdomen laparoscopically and just inspect the anastomosis to make sure that there's no signs of leak, and -- >> Okay.
>> -- what do I find, then? >> So you explore the patient laparoscopically. You find some purulence in the pelvis, and when you inspect the anastomosis, you find that there's a greater than 50% disruption of the anastomosis with a little bit of stool leaking into the abdomen as well. >> Okay. At that point, I would convert to open, and I would resect the anastomosis and then do a proximal diversion.
>> What do you mean by proximal diversion? >> I would give him a transverse, end transverse, colostomy. >> And so what do you -- so if you do an end transverse colostomy, what are you going to do with the descending colon that was previously anastomosed? >> Oh, I resect the anastomosis that's stapled, and so the distal one is a blind pouch, almost like a heart. >> Okay. So that patient gets better.
Let's change the scenario, and this time, instead of having all these problems in the first days after the operation, it's more like seven days out. He's having fevers and localized tenderness. White count goes up to 16. You do a CT scan on him, and there's no free air, but there's a five-centimeter -- an abscess at the level of the anastomosis, and you can see a little bit of air in the abscess.
What would you do for that patient? >> And you said -- can you repeat his vitals? >> Vitals are stable. Temperature 102. >> And an examination was -- >> Pulse is 120. Abdomen shows guarding in left lower quadrant with localized tenderness. >> Okay, and this patient, if it's a smoldering leak, it can be managed non-operatively, and you can do an IR drainage of the pericolonic abscess with a bile rest, hopefully, that it will seal over.
>> Okay. >> Then I would also, yeah, [multiple speakers]. >> How long is this patient bile rest? >> I would do approximately five days and then repeat the oral -- I would repeat the oral contrast and allow it time to transit to that area. If there's any concern about extravasation of contrast at that time, I would take him to the OR. >> Okay. So this is post-op day seven when you kind of initiate -- you kind of first saw him, and so you place that IR drain.
You waited your five days, so now it's postoperative day number 12, and you repeat the scan, and there's a little bit of contrast extravasation into the drain, and the abscess is more like one centimeter now. The white count is 11. Exam is unchanged, but there is contrast extravasation, which take -- that patient has to go to the operating room, you're saying? >> I would take him to the operating room.
>> Okay. Okay. So that scenario is done. You got to go the OR, which I know you're excited to do in these scenarios. This is kind of, in my opinion -- I try to throw in one case that I consider to be more of kind of a perioperative care question related to colorectal surgery. You're more likely to get that in your trauma critical care room as opposed to the room that typically is colorectal questions. Some things that you did a good job on You -- very linear. You went to the bedside.
You evaluated the patient, assessed whether they were toxic or not. Something style points-wise I probably would have said up-front is I would review his past medical and surgical history as well as his operative report, because [inaudible] patient and you weren't there. That'll help you identify other contributors to the problem. Post-op day three, a CT scan might help you, might not. I don't know if I would have done that. I would base it more on exam. I [inaudible] he got an x-ray to see if he's got a bunch of free air or not.
As far as observation versus exploration up front, I think it really does depend on the patient's exam. If their diffusely tender and they've got what seems to be progressive sepsis on the third post-operative day and they've got free air that's prevalent, then exploration's a very safe answer, especially on a board exam. If you have a patient with a more equivocal exam, it's okay to just basically observe them and see which route they choose over some sort of arbitrary amount of time.
You can certainly re-explore these people laparoscopically. I think that's fine as long as you kind of respond to the problem appropriately, which you did. If you find a leak in the acute postoperative period that's large, like what you described or what I described, 15% -- 50% or more disruption, then that has to come down. Now, if it's a perfect scenario and the patient doesn't have much contamination and there's not a whole lot of associated surrounding inflammation, there are some patients we can do a reanastomosis and a loop ileostomy, but in general, you're probably going to bring up an end colostomy.
What you described, then transverse colostomy, blind pouch, I just would -- I'd just get a little cleaner with that. You know, what you're doing is you're bring up an end colostomy, an end descending colostomy, because you're taking down your anastomosis. You're not bringing up some sort of random diversion above the anastomosis. The alternative is you may go in there and find the patient has more of a pinpoint leak or definitive leak that you can see and repair. In that situation, it's very reasonable to repair the anastomosis for smaller leaks and then bring up a diverting loop ileostomy proximal to that.
Don't be surprised if that patient goes on to develop and stricture at their anastomosis. If that happens, a lot of times, you can do balloon dilation or something like endoscopically to treat it. As far as management of the more kind of insidiously leak, the one that presents later on with an abscess, I think it's very important that you know that the longer you go without doing an operation, the harder it gets, and so having some decision to go in five days later if there's contrast extravasation, you're going to be met with a very hostile abdomen with the risk that you're going to cause a problem trying to fix a problem, you know, making a neurotomy, not be able to get down to the anastomosis itself, deep in the pelvis, and so I think that in that scenario, you know, I honestly don't care if there's a leak or not as long as it's controlled with a drain.
You know, the contrast extravasation doesn't surprise me, you know, but if it's controlled and it goes out the drain and there's not a big, progressive abscess and the patient has controlled sepsis, there's no evidence of ongoing infection, then I would not explore a patient just because there's a communication between the anastomosis and the drain. So I don't know. I probably wouldn't have chosen that answer, but I think I kind of pushed it in that direction a little bit, too, so. So I'll give you an equivocal in that scenario, depending on -- you know, if you changed a couple of things, it could've been a clear pass, and I have nothing to add other than practice makes perfect.
The more often you guys do these exercises, the better you're going to be when the real time comes. Thank you. >> Great job to both of you, and thanks to all three of you for joining us today. Hopefully the audience will be well-prepared to dominate the colorectal questions on board. So good luck to everyone, and all of our three participants today, their Twitter handles will be in our show notes, so you can reach out to them if you would like to. >> Until next time, dominate the day.
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