trauma-list Digest, Vol 56, Issue 4

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--- You wrote:
1.  Resect enbloc and temporary closure
2.  Second look, resect more if necessary, third look if necessary then create end ostomies
3.  TPN
4.  Multivisceral transplant when stable.

We have had a successful outcome using that algorithm with just the patient you described.  
--- end of quote ---

I am surprised no one has mentioned anything about re vascularization or what presumably caused this small bowel catastrophe in the first place. I am assuming nothing can be done to fix or alter that piece of the puzzle.

I have been impressed with how hard it is to truly recognize dead bowel ( unless it is totally black and flaccid) and would agree that very conservative resection , no anastomosis, is the way to proceed acutely and then consider a second look if one is to press on.

However, in this particular case, with his vascular co morbidities and hx of heart disease, this man's 5 year survival is close to zero anyway even if he hadn't had this complication. I doubt very seriously if any transplant program would consider multivisceral transplant in THIS scenario for this particular patient and thus in the long run, doing nothing and providing palliative care to me seems to be the most reasonable decision.

John E. Sutton, Jr., M.D. , F.A.C.S
Professor of Surgery,  Dartmouth Medical School
Division Chief, Trauma and Acute Surgical Care
phone: 603-650-8022
fax :     603-650-8030

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