trauma-list Digest, Vol 56, Issue 5

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I agree entirely.  This patient should be offered a multivisceral  
transplant, provided he is medically suitable.  In the meantime,  
provide reliable central venous access for TPN.


Sent from my iPhone

On Feb 4, 2008, at 6:00, trauma-list-request at trauma.org wrote:

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> Today's Topics:
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>   1. Re: trauma-list Digest, Vol 56, Issue 4 (John E. Sutton Jr.)
>   2. Ref:Re: total small bowel infarction (josemaya01)
>   3. Re: trauma-list Digest, Vol 56, Issue 4 (caesar ursic)
>   4. (no subject) ( luis felipe de los rios pe?a )
>
>
> ----------------------------------------------------------------------
>
> Message: 1
> Date: 03 Feb 2008 10:30:44 -0500
> From: John.E.Sutton.Jr at Hitchcock.ORG (John E. Sutton Jr.)
> Subject: Re: trauma-list Digest, Vol 56, Issue 4
> To: trauma-list at trauma.org
> Message-ID: <30846922 at mailbox3.Hitchcock.ORG>
> Content-Type: text/plain; charset=iso-8859-1
>
> --- 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
>
>
> ------------------------------
>
> Message: 2
> Date: Sun,  3 Feb 2008 11:21:11 -0600
> From: "josemaya01" <josemaya01 at prodigy.net.mx>
> Subject: Ref:Re: total small bowel infarction
> To: "trauma-list" <trauma-list at trauma.org>
> Message-ID: <JVOAVC$2BD639CFF9E7AF7EDC5747F5537AD1F9 at prodigy.net.mx>
> Content-Type: text/plain; charset=iso-8859-1
>
> Sounds easy, unfortunately most facilities don´t have that much avai 
> lability of resources.
> José Mayagoitia M.D., FACS
> Hospital General de Mexicali, México
>
>
> De : "Ben Reynolds" aneurysm_42 at yahoo.com
> Para : "Trauma &amp; Critical Care mailing list" trauma- 
> list at trauma.org
> Copia :
> Fecha : Sat, 2 Feb 2008 11:53:52 -0800 (PST)
> Asunto : Re: total small bowel infarction
>
>
>> When reading below understand that my approach is predicated on the  
>> availability of particular premium resource at my institution  
>> (namely Kareem Abu-Elmagd).
>>
>> 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.
>>
>> Ben Reynolds, PA-C
>> Pittsburgh, PA
>>
>> ----- Original Message ----
>> From: caesar ursic
>> To: "Trauma &, Critical Care mailing list"
>> Sent: Friday, February 1, 2008 7:30:03 PM
>> Subject: total small bowel infarction
>>
>> 60 y.o male vasculopath (multiple prior myocardial infarctions,  
>> peripheral
>> vascular reconstructions, etc) s/p blunt abdominal trauma and  
>> repair of mid
>> small bowel blow-out injury (seatbelt injury). Did well post-op,  
>> discharged
>> home. Re-presents three weeks later with sudden onset abdominal pain.
>> Re-explored. Entire small intestine infarcted, from ligament of  
>> Treitz to
>> ileocecal valve.
>>
>> Therapeutic options? Close abdomen, morphine drip, game over
>> or....resect, drain, support, hope he can be nourished parenterally  
>> if he
>> makes it to ICU.
>>
>> What's the survival rate for total loss of small bowel in this age  
>> group?
>>
>> Cordially, etc.
>>
>> CM Ursic, MD
>> Santa Fe, USA
>> --
>> trauma-list : TRAUMA.ORG
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>
>
> ------------------------------
>
> Message: 3
> Date: Sun, 3 Feb 2008 10:50:26 -0700
> From: "caesar ursic" <cmursic at gmail.com>
> Subject: Re: trauma-list Digest, Vol 56, Issue 4
> To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
> Message-ID:
>    <7d3839570802030950x38a01757q3370f90c78c9918c at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
>
> Thanks for all of the suggestions and ideas.  Here's the current  
> situation:
>
> We resected all dead (and it was dead) small bowel, which left him  
> with a
> staple line at the ligament of treitz and another staple line at the
> ileocecal valve (about 2 cm of terminal ileum remain).  Also a  
> gastrostomy
> tube and a tube duodenostomy.  Second look laparotomy 24 hours later
> (yesterday) showed no progression of ischemia - i.e. colon looked  
> great, as
> does the duodenum.  Abdomen 'closed' with wound-vac.  Will need formal
> closure in the next few days.
>
> This morning (two hours ago) he was extubated.  Kidneys working fine
> (creatinine slightly up at 1.5 but stable) as are (obviously) his  
> lungs, and
> his liver.  Blood pH is normal, serum lactic acid normal.
>
> He says he wants to live.  We are starting TPN.  Family asking about  
> small
> intestinal transplant.
>
> CM Ursic
> Santa Fe, USA
>
>
> ------------------------------
>
> Message: 4
> Date: Sun, 3 Feb 2008 14:53:24 -0400
> From: " luis felipe de los rios pe?a " <luisfr28 at gmail.com>
> Subject: (no subject)
> To: trauma-list at trauma.org
> Message-ID:
>    <ae39e6b60802031053h66c809b4he3a90daf3b6a6304 at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
>
>
>
>
> ------------------------------
>
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> End of trauma-list Digest, Vol 56, Issue 5
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