I, assisted by Dr V S (consultant pediatric surgeon in Goa Med College), did the 5th abdominal surgery for this girl. Our findings on table were quite remarkable.
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| While studying the duodenotomy scar done on 28th June at Mumbai, we felt that it was a blessing in disguise for the patient that the earlier surgeon stopped at that level of enterotomy. The direction of joint between duodenum & jejunum was completely missed and the enterotomy was reaching IVC and posterior aspect of pancreatic head. |
• Dilated D1 and D2 with very capacious stomach
• Immobile anastomotic area with dense adhesions between the upper extent of anastomosis with gall bladder and hepatic flexure.
• On defining the medial circumference of the D2-J (that was constructed on 13 May 2003), a very short afferent segment was seen. The afferent segment was stretched across the vertebral column and it was pulling the D2-J medially. Thus there was an explanation for the slit like appearance of native distal D2 on the OGD done in March 2010. In other words, the most lateral wall of D2 was being pulled medially and it was tending to assume the anterior position, causing pinching and twisting of the lumen of the D2 segment. (Try following the violet coloured anti-mesenteric border of the D2 in line diagram above.)
• The efferent loop showed a thickened segment almost 15 cms. long. The dilatation was starting a few cms. from the D2-J. At the place where the dilatation was no more, a few flimsy adhesions were seen in its mesentery.
• Rest of the small bowel was normal.
• The IC-Jn was normal.
• We then did dismantling of the D2-J remaining on the jejunal side of anastomosis all through-out the circumference.
• Testing the patency of whole intestine:
- We did an on table enteroscopy of the D2-D3 and D4 area and found no compression anywhere along its length.
- Then through the distal jejunotomy, we passed about 750 ml warmed saline and squeezed it through the whole extent of the small bowel noting normal peristalsis of the gut in its whole length.
-Then I inserted a glass marble into the enterotomy and milked it quite easily through the length of the bowel upto the IC-Jn and retrieved it again by milking it in reverse direction.
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| The glass marble was passed through this enterotomy to IC-Jn and retrieved from the same opening. |
• We then resected the dilated piece of the efferent loop to include a couple of cms. of undilated segment.
• We restored bowel continuity after a lot of deliberation. We did a Roux-en-Y reconstruction.
• We kept a Ryle's tube in stomach, a drain in (R) paracolic gutter and closed the abdomen in single layer en-masse.
Post -operative period
• Pt was maintained in ICU for 2 post-op days in which her vitals were stable. She had bloody RT Aspirate, which became dark and on 2nd post-op day was dark greenish.
• She started demanding food on 3rd post-op day and the RT Aspirate was less than 300 mls / day. She was shifted to the ward. She passed some melena.
• 4th Post-op day: I gave her oral clear liquids keeping RT clamped. Despite an intake of about 600 mls of oral liquids, her RT Aspiration was hardly 250 mls.
• Her Hb on 5th Post-op day was 8.7 gm % and a unit of PCV was given to her. She was stable and was having liquids orally. She was craving for bread and some vegetables. And she stealthily did eat thick rice about a bowl-full of it, and had some abdominal pain, which made her uneasy and worried and she began thinking if this current surgery is going to help her at all or is she going to be in square one? All this made her mentally unstable and she began throwing tantrums. She disconnected her central line, locked herself in the toilet, then on coaxing she came out after about 30 mins and then refused to lie on her bed and squatted on the floor. By night she went ballistic complaining of tingling of head, cramps in the legs and breathlessness and began beating her back on the bed. She was so violent that I had to tie her with bed-sheets to the bed posts.
• Her 6th post-op day was no different to the 5th. Clinically she was fine with normal temp, hemodynamic stability, abdomen that was soft with normal peristaltic sounds, good I/O balance and normal biochemistry.
• On 7th Post-op day I did a gastrografin meal and FT to assess the newly constructed junctions, which showed undilated bowels and stomach to IC-Jn time of 1 hr 30 mins (for the first time since 2002 - 2009 in which time all her timings were 7 to 18 hrs for the same points along GI tract). By evening the same disturbed behavioral pattern started showing up and she did the same restless body activities going ballistic in the bed.
• On 8th Post op day I repeated her Hb as she reported of having had 2 bouts of melena at night, and it showed Hb of 6.8 gm%. Also she had a spike of 104 F temp. We removed her CVP line and sent the tip for C&S as also blood and urine. CVP tip C & S came back as growth of Campylobacter Boumanii.
• 9th Post op day: She had passage of better formed stools with black color still persisting and only one such episode. She is taking soups, tea, coffee, buttermilk and water orally. Temp is down to 100 F.
• 10th Post-op day was uneventful and after repeated explanations about what has been done at surgery and how the anastomotic edema will take gradual course to subside over next few weeks, she is more docile.
• 11th Post-op day: went very well with some restlessness on account of post prandial abd discomfort in the night. Never-the-less, she had had plenty of solid oral intake quite contrary to the advice of having liquid diet.
• 12th Post-op day is quite all right with better intake and less degree of pain. She passed better formed stools which were blackish. There was no drop in HB. Hb is at 10.5 gm%
• About 20 days post op: Patient is doing much better. Patient is having better oral intake and passing motions almost every day. She has not had any repeated vomiting.
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