Transcript Document

Low Anterior Resection of a
Recto Sigmoid Carcinoma
Case presentation by Jeffrey
Buterbaugh PA-S
History
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Cc: 59 y/o male complaining of
intermitant rectal bleeding and
constipation over the last few
months.
Is this normal?
• Hemorrhoids?
• Diet high in fiber?
HPI
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59 y/o white male states rectal bleeding is a moderate amount
and is a bright red color. He states this occurs during times of
constipation. His bowel movements alternate between normal
and constipated. Pt denies any other GI or abdominal symptoms
such as change in appetite, nausea, vomiting, painful bowel
movements, or abnormal pain. Pt has a positive history of
hemorrhoids. He uses stool softeners regularly. He was first
scheduled for a colonoscopy in February 2007, but it was limited
due to formed stool in the colon. A repeat colonoscopy was
completed on 5/3/07 with exaggerated bowel prep. A tumor in
the recto sigmoid was identified and a biopsy was taken at 20 cm.
The clinical appearance was of a large carcinoma of the sigmoid.
The pathology showed atypical colonic epithelium. The pt is
scheduled for a low anterior resection of the recto sigmoid on
6/12/07.
In January 2004 the pt had an attempted colonoscopy which also
had to be repeated a short time later. The colonoscopy found a
small sessile polyp which was removed at the 30 cm level and it
was benign. The pt’s older brother was found and treated for
colon cancer in the past year.
Pertinent PMH, SH, and FH
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PMH/Surgery: Pt had an angioplasty on 2
separate occasions for CAD. Pt had two right
inguinal hernia repairs in the past. Pt is a Type
II, non-insulin dependent diabetic. Pt also has
degenerative disc disease of his back.
Social/Family: Pt has not smoked for six years.
Positive family history of colorectal cancer in pt’s
older brother. Pt has support system to help him
rehabilitate after surgery. Extensive family
history not taken at this time because he was
referred to the surgical clinic concerning rectal
bleeding and now to treat his likely recto-sigmoid
cancer. Other family history is unhelpful in this
situation.
Medications and Allergies
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Meds:
• Metformin 500 mg twice a day PO (Last Metformin on 6/9/07)
• Plavix and Aspirin daily PO (Last Aspirin and Plavix taken on
6/1/07)
• Isosorbide 30 mg daily PO
• Metoprolol 50 mg daily PO
• Cyclobenzaprine 10 mg at bedtime PO
• Ranitidine 150 mg twice per day PO
• Oxycodone APAP 7.5/325 once every 6 hrs PO prn back pain
• Morphine Sulfate 50 mg twice daily PO prn back pain
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Allergies:
• Procardia, Darvocet, and Inderal. Pt could not state how the
allergies presented just that he was “allergic” to them.
ROS
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General: Pt states he feels strong and healthy, denies change in
weight.
Skin: Pt denies any rashes, pruritis, dryness, or easy bruising.
Head: Pt denies h/o fainting, blackouts, pain, or head injury
Eyes: Pt does not wear glasses or contact lenses. Denied change
of vision, diplopia, halos, flashes, excess tearing, pain,
photophobia, redness, discharge, infections. Denied h/o
glaucoma, cataracts
Ears: Denied hearing impairment or use of hearing aid. Denied
pain, discharge, vertigo, ringing or infections
Nose: Pt denies rhinorrhea, nasal congestion, nose bleeds, injury,
sinus infection, itching or changes in smell
Mouth/Throat: Denied bleeding gums, sores, hoarseness, voice
changes, sore tongue, or change in taste.
Neck: Denied swollen glands, pain with movement, thyroid
problems
Cardiovascular: No history of rheumatic fever, murmurs, or MI.
Pt denies chest pain or dyspnea. Positive history for CAD with
angioplasty on 2 occasions. Last EKG before colonoscopy on
5/3/07.
ROS cont’d
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Respiratory: Denies cough, sputum production, hemoptysis, shortness
of breath, SOB on exertion, or pain with respiration. Pt states he has good
exercise tolerance. Denied h/o TB, pneumonia, asthma, pleurisy, or
bronchitis.
GI: See HPI. Pt denies change in appetite, nausea, vomiting, painful
bowel movements, or abnormal pain. Pt has positive history of
hemorrhoids, blood in stool, change in stool color, and constipation.
GU: Pt denied hematuria, urgency, stones, lesions, discharge, or flank
pain, denied incontinence or nocturia.
Lymph: Denied tenderness or enlargement of lymph nodes, no h/o lymph
problems
Endocrine: Denied heat or cold intolerance, excessive sweating, hair loss,
nervousness. No h/o hypo or hyperthyroidism.
MS: Pt states he has degenerative disk disease and lower back pain,
denies gout or muscle weakness.
Neuro: Pt denied LOC, fainting, blackouts, burning, loss of memory,
speech disorder, hallucinations, or seizures
Psych: Pt states he is doing well and has a good support system.
PE
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General: Well developed, well nourished male with no signs of distress.
Vital signs: Weight 253 lbs, blood pressure 142/84 (right arm), pulse
66, and respiratory rate 14.
Skin: Negative for rashes, lesions, cyanosis, jaundice or bruising.
Positive for psoriasis. Skin warm and dry. No clubbing of nails.
Head: Head is normocephalic. Normal facial muscles of expression.
Muscles of mastication intact and symmetric. TMJ palpable, full ROM,
negative for pain or crepitus.
Ears: Auricles negative for lesion or deformity, non-tender to
manipulation. No mastoid tenderness. External canals patent, TM’s pearly
gray. Good light reflex AU, landmarks well visualized.
Eyes: Eyelids and lacrimal apparatus clear s redness, swelling, discharge,
or lesions. Conjunctiva pink, noninjected, moist. Sclera white. No ptosis.
Nose: Nares patent bilaterally, mucosa pink, septum midline. No
discharge present. Maxillary and frontal sinuses non-tender to percussion.
Neck: Trachea midline without visible masses or pulsations. No JVD. No
tenderness, No palpable lymphadenopathy within anterior posterior
cervical chains. Thyroid palpable without enlargement, tenderness or
masses noted. No carotid bruits noted.
PE cont’d
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Thorax: Symmetrical A/P-Lateral ratio 1:2. No rashes, deformities, intercostal
retractions, or accessory muscle use noted. Palpation without tenderness or masses
noted. Respiratory excursion full. Tactile fremitus symmetrical throughout all areas.
Percussion resonant throughout thorax. Diaphragmatic excursion 4 cm bilaterally.
Lung sounds- clear without any wheezes, rhonchi, or rales.
Cardiac: Without visible lifts or heaves. Palpation without tenderness, lifts, heaves,
or thrills noted. PMI palpable at L 5th ICS MCL. Regular Rate & Rhythm without
murmurs, rubs, S3 or S4 noted. S1>S2 at base.
Abdomen: Active bowel sounds heard throughout all regions. No abdominal/femoral
bruits noted. Percussion reveals normal tympani. Light & deep palpations reveal no
masses, tenderness or organomegaly. No rebound tenderness. Negative Murphy’s
sign. Scars reflect past history of two right inguinal hernia repairs.
Rectal: Not done at this time since he has a known recto sigmoid carcinoma. See
HPI.
Vascular: Carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis
pedis pulses 2+ and symmetrical. No varicose veins noted.
Lymph: No occipital, pre/post auricular, submental, submaxillary, superficial or
posterior cervical, supraclavicular, axillary, epitrochlear, poplitearl, femoral, or
inguinal adenopathy.
Neuro: no obvious defects, able to communicate and comprehend what needs to be
done.
MS: negative for deficiencies except for use of cane during ambulation. Pt had
discomfort when sitting up on the examination table. Negative for strength
deficiency.
Assessment and Plan
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Assessment:
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Large neoplasm of recto sigmoid, most likely a carcinoma.
CAD
HTN
Type 2 Diabetes, non-insulin dependent
Degenerative disc disease of back
Plan:
• Pt is scheduled for a low anterior resection of recto sigmoid on
6/12/07.
• Pt was educated on the surgery and the possible side effects,
and then informed consent was obtained.
• Pt instructed on bowel prep to be completed before the
surgery.
• Pt prescribed neomycin and erythromycin to take as instructed
for the two days prior to the surgery. Possible side effects are
nausea and vomiting.
Pathophisiology
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Second leading cause of cancer related
deaths for both men and woman.
Stage of Cancer depends on metathesis:
• Stage 0: just mucosa
• Stage 1: mucosa and partly into muscle wall
• Stage 2: through wall of colon but not into
lymph nodes
• Stage 3: invaded nearby lymph nodes
• Stage 4: cancer has spread to distant sites
Treatment Options
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Primarily: Pt needs surgery to
remove the cancerous section and
this will allow staging of the cancer.
• Low anterior resection of the recto
sigmoid colon using an EEA through the
anus.
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Pt will be referred to oncologist to
decide about further treatment such
as chemotherapy or radiation.
Pathology
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Tissue Removed:
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Left pelvic peritoneal nodule
Distal donut
Proximal donut
Recto sigmoid
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Fragment of fibroadipose tissue with necrotic fat. No
malignancy identified.
Segment of unremarkable colon.
Segment of unremarkable colon.
Infiltrating moderately differentiated adenocarcinoma
of colon. Infiltrates entire muscularis. (Stage II)
Margins of colon appear free of tumor. Lymph nodes
(24), negative for tumor.
Diagnosis:
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4.
What’s Next
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The patient tolerated the procedure
very well and was discharged from
the hospital after a five day stay.
Pt’s bowel habits should be near to
normal now.
Pt will meet with oncologist to
discuss if it is advantageous for any
further treatment.
References
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http://galeon.hispavista.com/drmari
n/laplar.htm
http://www.valleylab.com/product/v
essel%5Fseal/
http://www.jnjgateway.com/home.jh
tml