The family decided to have her surgery done at Mumbai in J hospital. On 19th June 2010, I was requested to have a meeting with the currently treating surgeon and psychiatrist. The plan was chalked out for surgery of reducing the trans-mesocolic internal herniation of jejunum (which I had surmised studying the past 2-3 Ba meal FTs), dismantling the D2-J anastomosis and on table enteroscopy.
On 26th June 2010, instead of J the surgery was done at B hospital. A laparotomy was done through the scar for D-J. About 1.5 to 2 feet of jejunum was found in the supracolic compartment and it had found its way through the mesocolic window in medial para anastomotic location. It was adherent to the gall bladder and the mesocolic window. This was reduced successfully.
The operating surgeon then made an enterotomy on Kocherised duodeno-jejunostomy for 1/3 circumference on the (R) lateral surface Please see the line drawing beneath.
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| A line diagram to show the anatomy of operated area and the duodeno-jejunal incision marked on D2 |
He then pushed his finger into the D3 to feel for SMA compression. He felt that there indeed is SMA compression to the D3. On his request, I too assessed the area, but I did not get the same feel. But he was thoroughly convinced about the SMA compression of D3. Therefore, I suggested that we MUST do an on-table enteroscopy of anastomosis and retro-SMA area of D3 and proceed to dismantle the D2-J and do the standard infra-colic D3-J or convert the current situation to Roux-en-Y. But he refused to do that, claiming that he has always been doing D2-J s (just as the one done for Miss V K) and they all function very well. Also, he was feeling that if she really has an SMA syndrome, restoring anatomy could cause a duodenal blow-out! Therefore, he closed the duodenotomy and placing the para-duodenal drain, closed the belly. Pt came back home on 8th post-op day.
Post op period was marked by abdominal pain that was hardly less than before surgery. She also kept having episodic vomiting the frequency of which was same as before. I did another Ba meal FT during similar bad abdominal pain episode. It again showed a massively dilated loop with narrowing at the anastomotic site.
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| The dilated small bowel is 5.5 CM across. |
Excellent progress for the patient. Shows why basics and fundamentals are the foundations of science. The page numbers with each heading will help locate pages more easily.
ReplyDeleteHats off to the patience shown in handling the patient.