1. Case presentation 2002/10/28 By Liu Chih-Min

5. Patient ’ s Information Name: Lin G.G Chart no: 4133516 Sex: Female Age: 48 y/o Admission date: 2002-10-17

6. Chief complaint & Present illness: Colon cancer with liver metastasis which was diagnosed at other hospital Bowel habit change since 4 months ago Colonscopy showed tumor mass at sigmoid colon and the pathology revealed adenocarcinoma Abdomonal sonogram was done and showed colon cancer with liver metastasis, cancer peritonitis, and large amount of ascites

7. 2002-10-21 PM 3:40 1st time operation

8. Clinical diagnosis: Colon cancer Operation proposed: Explorative laparotomy Operator: Dr. Liang Date of operation: 2002-10-21

9. Pre-operative evaluation Pre-operative data: BP: 130-90 mmHg HR: 82/min BW: 45.6 kg Past history: Allergy to unknown drug

10. Laboratory data: Blood type: O+ WBC: 8610/mm 3 RBC: 43100/mm 3 Hb: 14.2 gm/dl PLT: 375000/mm 3 PT: 12.2/11.6 PTT: 30.5/35.9 Blood chemistry: A/G: 3.5/3.4 mg/dl Bilirubin T: 0.6 mg/dl GOT/GPT: 43/18 kU BUN: 5.5 mg/dl Creatinine: 0.5 mg/dl Na:132 mmol/l K: 2.8 mmol/l Ca: 2.16 mmol/l Sugar AC: 119 mg/dl

11. ASA Class: 2 Terminal stage of colon cancer

12. OP note Post op diagnosis: Colon ca with liver and omentum metastasis Op method: Hartmann ’ s procedure Ileostomy + ometectomy + peritonectomy + bilateral salpingo oothectomy Op findings: Colon mass: 8*5*6cm; LN (+) Multiple metastasis to colon, small intestine, liver, omentum and peritoneal Ascites, clear, 3800 c.c.

13. Anesthesia record and POR record

14. During op Hb: 12.2 to 5.8 in 2 hours Input: PRBC: 2U FFP: 2U HAES: 500 ml IVF: 3200 ml Output: Blood loss: 1700 ml Ascites: 3800 ml U/O: 1000 mll

15. During POR Input: PRBC: 10U WB: 2U FFP: 4U IVF: 1300 ml Hb: 7.0 - 7.6 - 7.3 CVP: 5 mmHg SpO2: 100 > 97 Output: Drain: 200 ml+ 25 ml U/O: 600 ml BP: downhill HR: 90 > 130 /min

16. 10/22 AM 1:00 Patient was transferred to 4C1

18. I/O 10/22 1:00~7:00AM Input: WB: 4U, PRBC: 4U, PLT: 12U Output: Chest tube: 1900 ml, Abdominal drainage: 340 ml Urine output: 200 ml 10/22 8:00~15:00 Input: PRBC: 2U, PLT & FFP: 12U IVF: 1300 ml Output: Chest tube: 2400 ml Abdominal drainage: 170 ml Urine output: 400 ml

19. Summary during OP, POR & 4C1 (within 24 hours) Input: PRBC: 18U WB: 6U FFP:18U PLT: 24U IVF: 6300 ml Output: Blood loss: 2435 ml Chest tube: 4300 ml U/O: 2200 ml

20. Hemodynamic: tachycardia, low BP Respiratory: Tachypnea: 40/min Chest X-ray: Left hemotheoax was noticed on 3AM Chest tube: initial drain1600 ml, bloody Average chest tube drainage: 300 ml/hour in 4C1 F/U chest X-ray on 6AM: clear, no hemomediastinum was noted

21. Drain function: Milking: minimal fresh blood Abdonimal sonogram: 2AM No specific finding, few blood clot Chest sonogram: 7-10AM No fluid accumulation in plural space Abdominal sonogram: 10AM Seems large blood clots and small amount of fluid accumulation, source?

22. Intra-abdominal pressure: 10AM 32 cmH 2 O CVS and chest consult: 12AM Check bleeding source

23. 2002/10/22 PM 3:45 Emergent operation

24. I/O Input: PRBC: 28U WB: 8U FFP: 21U PLT: 24U Cry: 12U Output: Blood loss: 11000 ml U/O: 900 ml

25. OP findings Profuse fresh blood and blood clot was noted in abdominal cavity Diffuse oozing over rough surface of pelvic cavity, left side retroperitoneum, and right diaphragm Diffuse tumor seeding over diaphragm A diaphragmatic tear over right posterior aspect, about 10 cm in length Blood loss: more then 13000ml

27. Post 2nd operation in 4C1 10/22 19:00~ 10/23 7:00 Input: IVF: 1000ml PRBC: 3U Output: Chest tube: minimal Drainge: right upper: 690ml, right lower: 350ml, left side: 880ml (total: 1920ml)

28. Discussion

29. Unstable hemodynamic Hb down? BP down? Shock? Hypovolemic, septic, or cardiogenic? Not comparable input with output during POR? Where is the fluid? Internal bleeding? But there was not massive blood drained PE findings during POR & 4C1? Breathing sound, abdomen

31. Hemothorax? Hemopneumothorax? Or other source? Source? Major vessel puncture in chest? Due to CVP? Other source? What happened during operation? VATS; Angiography or any other internal bleeding?

32. Diagnosis of blunt rupture of the right hemidiaphragm by technetium scan. May AK - Am Surg - 01-Aug-1999; 65(8): 761-5 University of Virginia Health Sciences Center, Charlottesville, USA. Rupture of the diaphragm, particularly of the right hemidiaphragm, may be occult and can be difficult to diagnose The majority of right-sided injuries are diagnosed during laparotomy performed for other injuries. Intraperitoneal injection of technetium sulfur colloid was used to establish the diagnosis of right diaphragm rupture, and an uncomplicated repair was undertaken.

33. Diagnosis and treatment of diaphragm ruptures Abakumov MM - Khirurgiia (Mosk) - 01-Jan-2000; (7): 28- 33 Russian Basic methods of diagnosis in this condition including X-ray, ultrasonic methods, computed tomography and thoracoscopy The differential diagnosis between right-sided coagulated hemothorax and diaphragm's right cupula ruptures was the most difficult

34. Should this operation be done? Should we stop it? Or take any other actions?