Daniela Arias Rodriguez
Surgery H&P#1 10/21/20
Identifying Data:
Name: Mr. M
Date of Birth: 57 yrs old
Date & Time: October 20, 2020
Location: Woodhull Hospital
Source of Information: Self and medical chart
Chief complaint:Dysphagia to solid and liquids x 4 months.
HPI:Mr. M is a 57 y/o Hispanic male with PMHx of gastric carcinoma T3N0M0 (diagnosed 4/21/2017, s/p 3 cycles of chemotherapy), DM, HTN, HLD, GERD, CVA, carotid aneurysm, depression and bipolar affective disorder who was admitted to Woodhull on 10/6/20 due to progressive dysphagia to solid and liquids x 4 months as well as c/o of weight loss, nausea and vomiting. Pt was initially seen by medicine for this complaint on 7/30/20. At that time, a fluoroscopy esophagram showed penetration of the laryngeal vestibule. Pt was referred to GI/ENT specialist and CT of neck for which results were not found. On 10/5/2020, pt presented to Woodhull ED with worsening dysphagia and 12 Lb weight loss in a period of 15 days. During the hospital course, FL esophagram was repeated which showed a stricture in the distal esophagus and EGD w/biopsy showed a fungating mass in the cardia indicating cancer progression. Biopsy was positive for adenocarcinoma with signet ring cell features. After refusing surgery and treatment in the last years, pt agreed to surgical intervention. He was taken for a total gastrectomy with possible distal esophagectomy on 10/19/20. Total gastrectomy with esophagectomy couldn’t be performed due to metastasis. Pt underwent exploratory laparotomy with biopsy of mesenteric lymph nodules, which was positive for metastatic adenocarcinoma.
After surgery, pt recovered in PACU and was transferred to PCU for 3 days and later to the medical floor until discharge. At bedside on POD# 2, pt looks comfortable and without apparent distress. Pt reported a sharp mild abdominal pain 4/10 in severity at the incision site and nausea. Pt admits passing gas, but denies having bowel movement since the surgery. Pt reports tolerating clear liquid diet and urinating without any difficulty on urinal bottle. Pt denied wound discharge, vomiting, diarrhea, fever, chills, chest pain, SOB, dysuria, hematuria or dizziness.
Past Medical History:
Present illnesses – Gastric cancer T3N0M0 (4/21/2017) s/p 3 cycles of chemotherapy and then discontinued treatment (refused chemo 5/2018 and surgery 10/2018), DM2, HTN, HLD, GERD, CVA, carotid aneurysm, depression and bipolar affective disorder.
Hospitalized – (see PSHx).
Immunizations -unknown.
Past Surgical History:
No pertinent surgery
Medications:
Amlodipine-benazepril 5-40mg 1 capsule daily
Atorvastatin 40 MG 1 tablet daily
Metoprolol succinate 50 MG 1 tablet daily
Insulin aspart 100 unit/ml, inject 0.06 ml tib before meals
Insulin glargine 100 unit/ml, inject 0.48 ml nightly
Famotidine 20 MG 1 tablet 2 times a day
Paroxetine 10 MG 1 tablet every morning
Paroxetine 40 MG 1 tablet every morning
Baclofen 10 MG 1 tablet daily
Gabapentin 300 MG 1 capsule nightly
Acetaminophen 325 mg bid every 6 hrs prn for pain
Ciplopirox 8% solution topically nightly
Ergocalciferol 50,000 units by mouth once weekly
Psyllium 30.9% powder, 3.4 g tib by mouth.
Allergies: No allergies
Family History: Liver and gallbladder diseases
Social History:Denies use of alcohol, illegal drugs or smoking. Pt lives with his wife and children.
ROS:
Gen –Admits decreased appetite due to difficulty eating solid food, and 12 Lbs weight loss. Denies fever, chills, fatigue or night sweats.
Skin, hair, nails—Denies hair loss, excessive sweating, dryness, or skin change texture.
Head—Admits lightheadedness. Denies headache or recent head trauma.
Eyes—Denies blurring vision, dryness, lacrimation or fatigue.
Ears— Denies pain, discharge, hearing difficulty or tinnitus.
Nose/sinuses—Denies nose bleed, discharge or obstruction.
Mouth/throat—Denies sore throat, bleeding gums, mouth ulcers or changes in voice.
Neck—Denies swelling, lumps or decreased range of motion
Pulmonary – Denies SOB, cough, hemoptysis or wheezing.
CV—Denies chest pain, peripheral edema, palpitation or known heart murmur.
GI— Reports 4/10 abdominal pain at the incision site and nausea. Denies vomiting or diarrhea.
GU—Denies hematuria, frequency, urgency, or dysuria.
Nervous— AOx3. Denies headache, numbness, tingling or hx of seizures.
Musculoskeletal—Denies swelling, muscle/joint pain or weakness.
Hematological— Denies easy bruising, anemia, hx of blood transfusion or DVT/PE.
Endocrine—Denies polyuria, diaphoresis, polydipsia, heat or cold intolerance
Psychiatric— Patient admits hx of depression and currently on paroxetine. Denies suicidal ideations or thoughts.
10/21/20
VS:T: 98.2 F, HR 75 bpm, BP 161/85, RR , SpO2 95% room air, BMI: 24.4
Physical Exam:
Gen– AOx3, NAD, sitting comfortably, average build, and appears his stated age
Skin: Warm, non-icteric and non-diaphoretic. Noted catheter in right chest and wound dressing in mid-abdomen.
Nails: No signs of clubbing, lesions, paronychia, capillary refill <2 second.
Hair: Evenly distributed with no signs of erythema or dryness in the scalp.
Head:Normocephalic, atraumatic with no tenderness to palpation.
Eyes:Non-icteric and pink conjunctiva bilaterally. PERRLA, full visual fields and intact EOM with no nystagmus.
Mouth: Pink and moist mucosa with no masses or tonsil exudate. Uvula middle line. Trachea/thyroid:midline and non-tender to palpation. Non-palpable nodule or lymphadenopathy.
Lungs: Clear to auscultation bilaterally. No rales, rhonchi or wheezing on auscultation. Unlabored breathing.
Cardiac:Normal S1/S2 and RRR. No murmur, JVD or carotid bruits.
Abdomen:Soft and nondistended. Intact 10cm mid-abdomen incision without discharge. Bowel sound present in all 4 quadrants. Mild tenderness to palpation. No guarding or rebound tenderness.
GU:Denied
Rectal: Denied
Extremities: Full passive and active ROM in upper and lower extremities bilaterally. 2+ pulses in upper and lower extremities. No sign of edema.
Neurology: AOx3. No focal deficits.
DDX
- Progression of gastric carcinoma
- Esophageal carcinoma
- Achalasia
- Peptic stricture
- Esophageal spasm
Labs 10/21/20
CMP
Anion gap: 9 BUN: 19 Phosphorus: 3.3
Na+: 135 Creatinine: 1.11 eGFR >60.00
K+: 3.8 Glucose: 95
Chloride: 101 Calcium: 8.2
CO2: 25 Mg: 1.8
CBC
Hgb 8.2 MCV 88.7 MCHC 33.6 WBC 6.39 Platelet 193 Monocyte 8.9
Hct 24.4 MCH 29.8 RBC 2.75 Neutrophil % 72.3 lymphocytes 15.5
Eosinophil 2.5 Basophil 0.3
POC glucose 10/21/20
12:19 | 17:50| 21:05
122 201 137
COVID 10/6/20 Negative
Imaging
10/21/20 CT head w/c contrast: No evidence of acute infarction or intracranial hemorrhage.
10/13/20 US thyroid:Within physiologic limits
10/7/20 CT abdomen/pelvis: dense contrast material noted in the fundus of the stomach and within the ascending colon in the RLQ causing a streak artifact.
10/7/20 CT of chest: unremarkable CT scan. No pulmonary metastases or adenopathy. No evidence of lytic or blastic lesions
10/7/20 FL esophagram: Findings concerning for a stricture in the distal esophagus.
10/6/20 Chest x ray:Right port-a-cath system. Hyperaerated lungs fields without pulmonary infiltrates, consolidations, hilar lymphadenopathy or masses.
8/4/20 FL esophagram: penetration of laryngeal vestibule.
Assessment/plan:Mr. M is a 57 y/o Hispanic male s/p exploratory laparotomy with biopsy and PMHx of gastric carcinoma T3N0M0 (diagnosed 4/21/2017, s/p 3 cycles of chemotherapy), DM, HTN, HLD, GERD, CVA, carotid aneurysm, depression and bipolar affective disorder currently on POD# 2 and a new diagnosis metastatic adenocarcinoma.
#Metastatic gastric carcinoma
-oncology referral
#Abdominal pain
-Dilaudid 0.5 mg IV for pain
-continue regular wound care
# Nausea
-4mg IV Ondansetron one dose
-Clear diet as tolerated
#DM
-Continue Insulin aspart 100 unit/ml, inject 0.06 ml tib before meals and Insulin glargine 100 unit/ml, inject 0.48 ml nightly
#HTN
-continue Amlodipine-benazepril 5-40mg 1 capsule daily and Metoprolol succinate 50 MG 1 tablet daily
-consult cardiology for possible readjustment of metoprolol and amlodipine. BP: 161/85
#HLD
–Continue atorvastatin 40 MG 1 tablet daily
#Bipolar affective and depression
–Continue paroxetine 10 MG 1 tablet every morning and paroxetine 40 MG 1 tablet every morning.
# continue DVT prophylaxis
Article summary
Systematic review of single-incision versus conventional multiport laparoscopic surgery for sigmoid colon and rectal cancer. Liu X, Li JB, Shi G, Guo R, Zhang R. World J Surg Oncol. 2018 Nov 10;16(1):220. doi: 10.1186/s12957-018-1521-4. PMID: 30414613 Free PMC article.
- This is a systematic review of nine clinical controlled trials published in 2018. Its journal is currently indexed by Medline.
- It compares the benefits and outcomes of single-incision (SILS) versus conventional multiport laparoscopic surgery (CLS) for the treatment of colon and rectal cancer.
- Of the nine studies, two were randomized clinical trials while seven were non-randomized clinical trials. This study has a total sample size of 829 patients of which 299 underwent single incision surgery and 539 patients had conventional multiport laparoscopic surgery. Seven studies were English and two were Chinese.
- Two studies assessed sigmoid colon cancer, five rectal cancer, one rectosigmoid junction cancer and one study evaluated sigmoid and rectal cancer
- Sigmoid and rectal cancer were confirmed by pathologists in all patients.
Results:
- This systematic-review found that SILS has smaller incision length as compared to CLS (SMD− 2.46, 95% CI − 4.02 to − 0.90). More lymph nodes are able to be resectedwith SILS as compared to CLS (SMD − 0.25, 95% CI − 0.50 to − 0.002, P = 0). Operative time, quantity of bleeding, conversion rate and distal surgical edge were similar in both procedures.
- Post-surgery, SILS was found to have less complications, and noticeable benefits in terms of defecation time, exhaust time, pain score and hospitalization duration as compared to CLS. No noticeable difference was found in the anastomotic fistula rate between the two groups.
- In terms of cancer type, rectal cancer had fewer complication rates with SILS as compared to CLS. For sigmoid colon cancer, SILS also had shorter operative time, incision length, and shorter hospital course than with CLS.
Conclusion: Single incision laparoscopic surgery has few advantages over conventional multiport laparoscopic surgery such as shorter hospital duration, smaller incision, faster recovery of bowel movements, fewer complication rates and better pain score. However, both of the procedures have similar results in terms of blood loss, conversion rate, anastomotic fistula rate, readmission, recurrence and distal metastasis.
Typhon Report
Rotation Reflection
End of Rotation Self-reflection: Surgery
- Exposure to new techniques or treatment strategies – how did that go?
During this rotation, I have the opportunity to learn and practice wound care in post-op patients and in patients with leg ulcers caused by peripheral vascular deficiencies. One treatment strategy that I learned in the vascular clinic for leg ulcers is Unna boot. It consists of a cast-like material that provides leg compression to help with blood circulation. Before applying the Unna boot, the ulcer should be cleaned with saline water and measured to monitor improvement. Depending on the severity of the ulcer, Xeroform can be applied which is a petroleum-based gauze with bismuth tribromophenate to help with healing. During the five weeks rotation, I got to perform between 9-12 Unna boots and to witness myself the improvement in ulcer healing in these patients. Majority of the patients went to the vascular clinic weekly for Unna boot change and ulcer monitoring.
Xeroform Unna boot
- What was a memorable patient or experience that I’ll carry with me? During this rotation, I met a Hispanic male diagnosed with metastatic gastric carcinoma who initially presented with progressive dysphagia to solid first and then to liquid. This patient was diagnosed with gastric cancer 3 years ago and received 3 cycles of chemotherapy; however, he refused to continue treatment and was lost in follow-up. After the patient agreed to surgical treatment in this admission, surgery couldn’t be performed due to metastasis. After explaining the diagnosis, the patient was in complete denial and had a mental breakdown. This case will be very memorable to me, because it shows the importance of reinforcing treatment compliance in patients (of course patients can deny treatment), but most importantly explaining the seriousness of the disease and the consequences of not receiving treatment. It is crucial that we make sure that patients understand the severity of their disease and the outcomes of refusing intervention.
- How could the knowledge I’ve gained here be applicable in other rotations/disciplines? As I have mentioned in previous reflections, I am very interested in emergency medicine or internal medicine. During this rotation, I had the opportunity to practice suturing skills in a few surgeries. This is a skill that I am pretty sure I will be practicing in emergency medicine as well as assessing trauma patients and providing initial treatment SBO, abscess, acute cholecystitis, appendicitis etc. I also had the opportunity to perform wound care such as changing wound dressing in post-op patients and in patients with pressure and diabetic ulcers and rectal and breast abscess. These skills can serve me well when taking care of elderly patients in internal medicine.
Evaluation Reflection
For my first site evaluation, I presented a 57 y/o Hispanic male with PMHx of gastric carcinoma (refused treatment after 3 chemotherapy cycles), DM, HTN, HLD, GERD, CVA, carotid aneurysm, depression and bipolar affective disorder who was admitted to Woodhull due to progressive dysphagia to solid and liquids x 4 months as well as c/o of weight loss, nausea and vomiting. Pt was taken for gastrectomy, but couldn’t be performed due to metastasis. In our discussion, Prof. Rachwalski advised me to clarify no treatment adherent in more detail in the HPI. We also had a good discussion on the importance of palliative care for patients with poor survival prognosis.
For the second site evaluation, I presented a 48 y/o African American female without significant PMHx who was scheduled for laparoscopic sigmoidectomy due to a partially obstructing large mass in the recto-sigmoid colon on colonoscopy and CEA of 38.9. Pt initially presented to the ED of Woodhull hospital with complaints of bloody stool with clots per bowel movement x 1 month. For this case, we discussed possible complications after colon resection and familial syndromes related to colon cancer. Related to this case, I found a systematic review that found that single incision laparoscopic surgery has few advantages over conventional multiport laparoscopic surgery including shorter hospital duration, smaller incision, faster recovery of bowel movements, fewer complication rates and better pain score. However, both of the procedures have similar results in terms of blood loss, conversion rate, anastomotic fistula rate, readmission, recurrence and distal metastasis.
