The M+M Matrix for July 31, 2008
The Matrix Conference
Department of Surgery
Patient Safety Curriculum
Los Angeles, California
During which we analyzed the complications of excision of cystic retroperitoneal masses, peri-partum surgical emergencies, the complications of jejunostomy and the management of post-dilatation esophageal perforations.
Representative Moderator-Resident colloquy follows the Matrix outline.
1. Complications of Excision of Retroperitoneal Masses
A. Differential Diagnosis of Retroperitoneal cystic masses
B. Structures most susceptible to injury
C. Laparoscopic or open approach
D. Diagnostic workup: risks of aspiration
2. Per-Partum Surgical Emergencies
A. Diaphragmatic injuries
B. Influence of prior peri-diaphragmatic surgeries
C. Pulmonary peripartum complications; aspiration, pneumothorax
D. Also consider: appendicitis, acute cholecystitis, breast mass, management of breast cancer in the gravid patient
3. Complications of Jejunostomy
A. Clinical indicia of a leak
B. Types of jejunostomy
C. Competitive risks of TPN vs enteric feedings
D. Indications for re-operation
E. Indications for jejunostomy closure
F. Clinical signs of necrotizing fasciitis
4. Management of the Post Endoscopic Perforated Esophagus
A. Incidence of esophageal stricture following repair of TEF
B. Clinical indications of an esophageal perforation
C. Treatment: tube thoracostomy; thoracotomy
D. Indications for esophageal diversion
E. Indications for colon interposition
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Resident-Moderator Colloquy Based on the
Matrix Conference of July 31, 2008
From Resident #1:
Case 1: This case was interesting in that it reinforces the surgical approach to cystic lesions. If a cystic lesion is encountered, it is undetermined whether the lesion is benign or malignant. A laparoscopic approach for a malignant lesion can potentially disrupt the lesion and cause dissemination/seeding of the peritoneum. Therefore, it is important to have an open approach for removal of the lesion without spillage. Another interesting teaching point is the pathology in this case, benign cystic lymphangioma, which is a rare benign cyst that arises from lymphatic tissue, with an unclear etiology, perhaps from the developmental failure of the lymphatic system.
What are the most likely structures subject to injury during excision of such masses?
What else could this cystic lesion be?
Did you notice that this asthenic female had had two prior ER visits?
Case 2: There are a few important teaching points in this case. Recognition and early management of necrotizing fasciitis is extremely important. It is a life threatening soft tissue infection involving the superficial fascia. There are several findings that can be encountered in the operating room: grayish necrotic fascia, lack of resistance during dissection, lack of bleeding, and foul smelling “dish water” pus. In this case, the fasciitis was secondary to J tube dislodgement and feeding into soft tissue. Therefore, it is important to recognize J tube complications: dislodgement and abscess formation.
Would TPN have been a better alternative in a patient with an already diseased GI tract?
Case 3: It is important to recognize and treat diaphragmatic rupture which can occur as a complication following delivery. Failure to diagnose diaphragmatic rupture can be fatal. In addition, diaphragmatic defects encountered during surgery should be addressed in order to prevent potential complications.
Always consider the prior operation when a patient presents urgently.
Case 4: TEF repair can present with multiple complications in the future, including strictures. This patient had a TEF repair as an infant with multiple complications and presents with a large hot dog lodged in the esophagus. The foreign object was removed and the patient underwent balloon dilation. Another management approach could have been to remove the foreign object and perform dilation a few days later rather than immediately.
{Key point – one step at a time]
What else could cause a long esophageal stricture in a child?
From Resident #2:
Case 1 - Complications of excision of retroperitoneal tumors
Don't rupture the wall of an unknown cystic lesion! Could spread malignant material all over peritoneal cavity. Therefore you should get tissue first if at all possible to rule out malignancy. Injuries that can occur include various (Veress) needle injuring the bowel upon entering the abdominal cavity, enteric injury, injury to major vascular structures. Other complications include lymphatic leak and reoccurrence. If you are doing an abdominal surgery and incidentally find a mass originating from a part of the body you are not qualified to perform surgery on (i.e. general surgeon investigating a ovarian mass) do not biopsy the mass! Call appropriate surgical team for consult.
I would also add the differential diagnosis of cystic retroperitoneal masses: lymphangiosarcoma, pancreatic cysts, etc.
Case 2 - A 70 y/o male with necrotizing Fasciitis following placement of a jejunostomy tube
Always be alert during closure of the fascia and skin. This may be the last part of the operation and it is easy to become complacent, however closure is just as important as primary objective of surgery. The question is should the enterotomy been closed once the patient was determined to have fascitis.
I believe it should have been closed because it is a potential source of infection. However the tissue is most likely inflamed and friable, therefore closure may not have been in option. A longitudinal Witzel was used for j-tube placement which has the lowest rate of complications.
What are the relative benefits/drawbacks of TPN versus enteric feedings in this case?
Case 3 - An Acute Diaphragmatic Herniation in a 37 y/o Female Following Delivery
Always close hole in diaphragm after splenectomy or an other surgery causing injury intentional or unintentional to the diaphragm.
Be aware of other emergencies in the gravid patient: trauma; acute appendicitis, cholecystitis, etc.
Case 4 - A perforated Esophagus Following extraction of a foreign body in a 4 y/o male
It is possible to wait after foreign body removal, then perform dilatation. Although at Cedars standard procedure is to remove foreign body and dilate during the same procedure; In this case i believe the dilatation was done too early.
Leo A. Gordon. MD,FACS
Associate Director
Surgical Education
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