Detailed Treatment Process
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Male, 77 years old The following is the discharge summary Department: Gastrointestinal Surgery Date of admission: February 23 Date of discharge: April 2 Outpatient diagnosis: Malignant tumor of the colon, hypertension, post-cerebral infarction Admission diagnosis: Malignant tumor of the colon, hypertension, post-cerebral infarction Discharge diagnosis: Malignant tumor of the colon, hypertension, post-cerebral infarction; status post radical resection of right-sided colon cancer, status post small bowel necrosis resection and ostomy, pulmonary infection, respiratory failure, hepatic insufficiency, renal insufficiency, pancytopenia, sepsis, multiple organ dysfunction Admission status Chief complaint: Hematochezia for over one month. Physical examination: The patient was alert and oriented with satisfactory mental status. No jaundice of the skin or sclera. No supraclavicular lymphadenopathy. The abdomen was soft and flat without muscle guarding, tenderness, or rebound tenderness. No palpable masses. Murphy sign was negative. The liver and spleen were not palpable. No hepatic or renal percussion tenderness. No shifting dullness. Bowel sounds were normal. No lower limb edema. Digital rectal examination was negative. Key laboratory results February 24 Complete blood count (CBC): White blood cell count 6.81×10⁹/L, hemoglobin 101 g/L, platelet count 238×10⁹/L. Blood type: ABO group A, Rh(D) positive. Renal function + eGFR + cystatin C + liver function (new 2) + electrolytes + glucose: Albumin 36.6 g/L, alanine aminotransferase (ALT) 29 U/L, aspartate aminotransferase (AST) 26 U/L, direct bilirubin 2.0 μmol/L, total bilirubin 6.0 μmol/L, urea nitrogen 5.50 mmol/L, creatinine 83.0 μmol/L, fasting blood glucose 4.94 mmol/L, sodium 137.2 mmol/L, potassium 3.6 mmol/L, chloride 105.1 mmol/L. Thromboelastography (standard test): Fibrinogen level 2.10 min, fibrinogen angle 67.60 deg, platelet function 65.40 mm; TEG coagulation factor activity normal, TEG fibrinogen level normal, TEG platelet function normal, TEG fibrinolytic system normal. DD/FDP (urgent): Fibrin degradation products 2.70 μg/ml, D-dimer 0.48 DDU μg/ml. April 1 B-type natriuretic peptide (BNP): 160.0 pg/mL (H). April 2 Procalcitonin: 2.01 ng/ml. Complete blood count (CBC): White blood cell count 3.59×10⁹/L, red blood cell count 2.31×10¹²/L, hemoglobin 64 g/L, platelet count 4×10⁹/L (SL). Renal function + cystatin C + liver function (new 2) + total calcium + phosphorus + magnesium: Albumin 30.2 g/L, ALT 50 U/L, AST 42 U/L, direct bilirubin 162.9 μmol/L (H), total bilirubin 255.4 μmol/L (H), urea nitrogen 27.20 mmol/L (H), creatinine 120.0 μmol/L (H). DIC coagulation profile: Fibrin degradation products 6.83 μg/ml (H), thrombin time 31.40 s (H), antithrombin AT-III 29.00% (L), prothrombin time 11.80 s, fibrinogen 1.71 g/L (L), activated partial thromboplastin time 81.1 s (H), INR 1.07, D-dimer 0.96 DDU μg/ml (H). (1,3)-β-D-glucan: 61.5 pg/ml. Special examinations and important consultations March 1 Pathology (18-04901): Terminal ileum + right hemicolectomy specimen: “Ileocecal” tubular adenocarcinoma grade II (infiltrative type, 4.5×4×2 cm), invading the serosa, with cancer emboli in vessels. Lymph nodes at tumor level (3/18) positive for metastasis. Proximal and distal margins, appendix, and “4bD group lymph nodes” (0/3) negative. Immunohistochemistry: “Ileocecal” tubular adenocarcinoma (E). Tumor cells CK20(+), p53(+), Ki-67 90% positive, HER-2(0), MLH1(+), PMS2(+), MSH2(+), MSH6(+). March 7 Pathology (18-05524): “Right hemicolon anastomosis and terminal ileum”: Extensive congestion and hemorrhage of the intestinal wall with necrosis and heavy infiltration by acute inflammatory cells. March 16 Pathology (18-06536): Small bowel: Focal ulceration of the intestinal wall with acute inflammatory cell infiltration (most prominent in the serosal layer) and granulation tissue formation. March 26 CT scan of the head, chest, and upper and lower abdomen (plain): Multiple lacunar infarcts in the bilateral basal ganglia, periventricular areas, and centrum semiovale, some appearing relatively old. Age-related brain changes. Multiple exudative and consolidative opacities in both lungs (more marked in the right lower lobe), progressed compared with previous scan (March 9); small bilateral pleural effusions. Please correlate with clinical findings and follow up after treatment. Multiple small mediastinal lymph nodes; calcifications in the mediastinum and bilateral hila. Enlarged cardiac silhouette with small pericardial effusion. Atherosclerosis of the aorta and coronary arteries. Status post radical resection of right-sided colon cancer. Abdominal and pelvic fluid collections similar to previous scan (March 9), with right lower abdominal stoma. Mild fatty liver. Gallbladder distension. Possible multiple small renal cysts. Intravesical gas with indwelling urinary catheter. Treatment course After admission, the patient completed the necessary preoperative investigations. On February 27, he underwent radical resection of right-sided colon cancer under general anesthesia. Intraoperatively, the tumor was located in the cecum, measuring approximately 5 cm in diameter, with an ulcerative-infiltrative appearance, firm consistency, and extension beyond the serosa. Enlarged lymph nodes were palpable at the root of the mesentery. Exploration of the liver, stomach, and pelvis was negative. Postoperatively, the patient received anti-infective therapy, fluid support, and symptomatic treatment. On March 5, drainage from the tube showed fecal-like fluid accompanied by fever. Anastomotic leak was suspected, and emergency exploratory laparotomy was performed. Intraoperatively, edema was noted at the original right hemicolon anastomosis with a 1.0 cm leak, surrounded by heavy purulent exudate. Ischemic necrosis of the small bowel was observed within 90 cm of the anastomosis. Approximately 200 ml of fecal-purulent fluid was present in the peritoneal cavity. The remainder of the small bowel and colon appeared grossly normal. Partial small bowel resection with ostomy was performed (distal end closed, proximal end brought out as stoma). The patient was transferred to the SICU for monitoring and received imipenem-cilastatin for infection control, albumin support, and other symptomatic measures. Due to pulmonary infection, imipenem-cilastatin + vancomycin + fluconazole were administered. On March 12, the pulmonary infection worsened with respiratory failure, requiring endotracheal intubation and mechanical ventilation along with supportive care. On March 14, turbid fecal-like fluid drained from the tube and similar fluid exuded from the wound. Necrosis was noted at the small bowel stoma surface. Suspecting recurrent small bowel necrosis or further leak, emergency exploratory laparotomy was performed under general anesthesia. Intraoperatively, necrosis of the small bowel was found within 50 cm of the stoma, with a 0.5 cm central perforation covered by purulent exudate. The peritoneal tissues were edematous and adherent, with approximately 50 ml of turbid fluid. The remaining bowel showed no obvious vascular compromise. Partial small bowel resection with new ostomy was performed. The patient returned to the SICU for monitoring, blood transfusion, anti-infective therapy, and supportive care. Given the severe pulmonary infection and poor general condition, the antibiotic regimen was adjusted after consultation with the institute of antimicrobial research. From March 16, piperacillin-tazobactam 4.5 g every 8 hours + levofloxacin 0.5 g daily + amikacin 0.4 g daily were used. On March 19, this was changed to tigecycline 100 mg every 12 hours + piperacillin-tazobactam 4.5 g every 8 hours. Due to hepatic insufficiency, tigecycline was halved on March 26 and cefoperazone-sulbactam 3.0 g every 8 hours was added. Tigecycline was discontinued on March 31 because of progressively rising bilirubin. Despite treatment, the patient’s condition continued to deteriorate, with hepatic insufficiency, renal insufficiency, pancytopenia, and sepsis. The family requested transfer to a local hospital, and the patient was discharged. Complications: See discharge diagnosis Condition at discharge: The patient remained intubated on mechanical ventilation. Heart rate 86 beats/min, blood pressure 143/69 mmHg, respiratory rate 32 breaths/min, SpO₂ 100%. Coarse breath sounds in both lungs. Abdomen soft and nontender. Minimal purulent drainage from the original right abdominal drain site. Wound dry with good approximation; tension sutures in place. Ileostomy producing stool. The above constitutes the content of the discharge summary. The patient died several days after discharge.