DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
A Continuing Advocacy
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Swallowed Santol Seeds (SS) Causing
Surgical Abdomen
Janix M. De Guzman, MD, FPCS, FPSGS
Glenn P. Villanueva, MD
Marienelle R. Maulion, MD
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
An Advocacy for Preventable Surgical
Abdomen and Premature Death
In 2001, the OMMC Department of Surgery
started the advocacy to educate the public and
other health professionals and later create
awareness on the potential public health
problem that swallowing of Santol seed impose.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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“The Case of the Deadly Santol Seeds”
by Dr. Rafael Castillo of the Philippine Daily Inquirer
published in 2001
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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According to Dr. Joson, “the
debilitation and deaths associated
with swallowing santol seeds have
reached such magnitude to
consider it a public health
problem”
The OMMC surgical
department has
started
disseminating
information about
the dangers of
swallowing santol
seeds.
Obstruction in the large
intestine with a hole or
perforation just before
the obstruction. Several
santol seeds were
found lodged in that
area.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Primary Prevention
• Creation of awareness of the danger of
swallowing the seeds
• Promote a habit not to swallow the seeds at all cost
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Secondary Prevention
• Prevent the morbidity and mortality
associated with swallowed santol seeds.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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“Please Don’t Swallow Santol Seeds, they could
be deadly” October 10, 2002
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Posted as a public health advisory in the OMMC
website in 2003
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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“Men Over Forty” Deadly Santol Seedsby Dr. Eduardo Gatchalian of the Manila Times
published in 2004
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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“Don’t Swallow Santol Seeds” by Dr. Willie T. Ong published in The Philippine Star,
July 20, 2010
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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“Enjoy the Fruit But Not the Seeds” by Dr. Eduardo Gonzales published in the Manila
Bulletin last 2013
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Ostomy News Notes
Vol.1 Issue2, page7
May-Aug 2012
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Review of Literature
- 6 journal articles = www
– Ramirez, Carlo G, Crisostomo A, Gutierrez, Romeo, Roxas A. Colonic Perforation Associated with “Santol” Seeds. Asian Journal of Surgery;Colorectal Surgery 1993;16 (3):232-5.
– Velayo B, DobleF, Delos Santos N, Talens E. Ten Cases of Intestinal Obstruction and/or Perforation Associated with Ingestion of Fruit Seeds. PJSS. 1998
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Review of Literature
- 6 journal articles = www
– Leyson O, Penserga E, Joson R. Swallowed “ Santol” Seeds As Cause of Surgical Abdomen – A Case Report. Unpublished. 2002
– Samboonpamya P. Sigmoid colon perforation by ingested Sandorica Seeds. J Med Assoc, Thai. 2001 Dec; 84(12):1751-3
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Review of Literature
- 6 journal articles = www
– Anan M, Boonchai N, Suphakarn T, Busaba S. Gastrointestinal Complications from Ingested Santol Seeds. The THAI Journal of SURGERY 2004; 25:91-112.
– Chaw S, Pranee S, Supaluk K. Non-traumatic Perforation of Colon: A 5-year Retrospective Study at Uthaithani Hospital. The THAI Journal of SURGERY 2009; 30:52-57.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OMMC Statistics
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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0
1
2
3
4
5
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Nu
mb
er
of
Cas
es
Number of Cases per Year
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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0
10
31-40 41-50 51-60 61-70 71-80
Age Distribution of Cases
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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0
5
10
Male
Female
Sex Distribution of Cases
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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0
10
Distribution per Month
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Anan, et al.
-Survey. Knowledge and Behaviour
-1601 General Surgeons of Thai Medical Council
-2880 Adults. Random Sample Population.
-Respondents:
-37.2% of 1601 GS
-29.9% had encountered cases of SSS
-34.2% of 2880 RSP
-56.6% did not know complication of SSS
-41.2% ingested santol seed
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Public Health Education:
• The public should be told what to do when
Santol seeds are unintentionally swallowed.
• They have to watch out for abdominal pain
and seek consult as soon as possible to
avoid late diagnosis of surgical abdomen due to intestinal perforation.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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• Death from swallowed santol seeds and
operations done in these patients should be
considered unnecessary because the
etiology is totally preventable and the death is considered premature.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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• Early diagnosis can be promoted by a
knowledge that surgical abdomen can be
caused by swallowed santol seeds as well as
by a high index of suspicion in patients who
have swallowed santol seeds and a surgical
abdomen occurring during the season
months of santol, from July to October in the Philippines.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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THANK YOU!
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
N. G.
39-year-old Male
Malate, Manila
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
ABDOMINAL PAIN
RIGHT LOWER QUADRANT
AREA
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Chief Complaint
One Day PTC
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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History of Present IllnessAbdominal pain, RLQ
Area, Colicky in
character, 6/10 in
severity
(+)anorexia
(+)fever(T 38.0˚C)
(+)post-prandial
vomiting, 3 episodes
No consult done
No medications taken
On the day of
consult
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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History of Present IllnessIncrease in severity of
pain to 10/10
Prompted consult at
our institution
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Review of Systems
No headache, tinnitus, no blurring of vision, no
sore throat
No cough, no difficulty of breathing, no
shortness of breath
No easy fatigability, no palpitations, no chest
pain
No frequency, no urgency, no hematuria, (+)
dysuria
No polyuria, no polyphagia, no polydipsia
No weakness, no seizures, no loss of
consciousness
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Past Medical History
(+) Benign Prostatic Hypertrophy, recently
diagnosed maintained in Tamsulosin
200mg/tab ODHS
(+) S/P Herniorrhaphy, Right
(ManilaMed, Medical Center Manila, 1998 )
No Hypertension, Bronchial Asthma
No Diabetes Mellitus, Pulmonary Tuberculosis,
No Allergies to food and medications
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Family History
No Hypertension, Bronchial Asthma,
Diabetes Mellitus, Pulmonary Tuberculosis,
Cerebrovascular Disease, Cancer
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Personal / Social History
Smoker, 5 pack years
Alcoholic beverage drinker (2-3 bottles of beer,
2 drinking session per week)
Methamphetamine drug use
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
Vital Signs:
General:
SHEENT:
BP: 120/90 HR: 95 RR: 23 T: 38.0
O2Sat: 99%
Awake, coherent, not in
cardiorespiratory distress
Good skin turgor, anicteric sclerae,
pink palpebral conjunctivae, no
nasoaural discharge, no cervical
lymphadenopathy, flat neck veins
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
Chest and
Lungs:
Heart:
Abdomen:
Symmetric chest expansion, no
retractions, clear breath sounds
Adynamic precordium, normal rate,
regular rhythm, no murmurs
Flabby, Non-distended,
Normoactive bowel sounds,
(+) Direct tenderness on right lower
quadrant more than the
hypogastric area
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
Abdomen:
Flabby, Non-distended,
Normoactive bowel
sounds,
(+) Direct tenderness
on right lower
quadrant more than
the hypogastric area
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
DRE:
Extremities:
No anal tags or fissures, No
hemorrhoids, good sphincteric
tone, non-collapsed rectal vault,
no mass or tenderness, (+) fecal
material on examining finger
Grossly normal, no edema, no
cyanosis, full pulses
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Pre-treatment Diagnosis
Acute Surgical Abdomen probably
secondary to Ruptured Appendicitis
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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120/90
95
23
38.0
NPO
IVF: D5LRS 1L to run at 125 cc/hr
Therapeutics:
• Cefuroxime 1.5gm TIV
• Metronidazole 500mg TIV q8
• Ranitidine 50mg TIV q8
• Paracetamol 300mg TIV now
Book to OR for “E” Appendectomy
Emergency Room
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Emergency Room
CBC
WBC 23.7
Neutrophil 87.7
Lymphocyte 3.3
Monophil 8.6
Eosinophil 0.2
Basophil 0.2
RBC 4.51
Hemoglobin 15.2
Hematocrit 43.3
MCV 96
MCH 33.6
MCHC 35
Platelet 369
URINALYSIS
Color Amber
Transparency Turbid
Epithelial cell Occasional
Mucus thread Few
Amorphous
urates
Many
Amorphous
phosphates
None
WBC 10-15
RBC Many
Albumin None
Sugar None
SG -
pH -
Bacteria Moderate
Yeast cells None
Waxy casts None
Coarse Granular
Cast
None
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
Intra-operative FindingsTransverse Right
Lower Quadrant
Incision
• Grossly normal
appendix
• Fecal seepage
coming from the
pelvic area
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
Intra-operative FindingsFull midline Ex-Lap
Incision
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
Intra-operative Findings
• Sigmoid colon
perforation with
noted
• Localized fecal
peritonitis
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Full midline Ex-Lap Incision
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
Procedure
Transverse Right
Lower Quadrant
Incision converted to
Exploratory
Laparotomy,
Hartmann’s Procedure
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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130/80
104
22
36.5
(-) Colostomy
output
Soft
Abdomen,
Tender only in
the operative
site
1st Post-op Day
NPO
IVF: D5LRS 1L to run at 125 cc/hr
Therapeutics:
• Shift to Pip-Tazo 4.5gm TIV q8
• Metronidazole 500mg TIV q8
• Ranitidine 50mg TIV q8
• Ketorolac 30mg TIV q8 PRN
• Paracetamol 300mg TIV PRN
IFC
Course in the wards
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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120/80
90
19
36.9
(-) Colostomy
output
Soft abdomen
Tender only
on post-
operative site
2nd Post-op Day
Soft Diet
IVF: D5LRS 1L to run at 125 cc/hr
Therapeutics:
• Pip-Tazo 4.5gm TIV q8
• Metronidazole 500mg TIV q8
• Ranitidine 50mg TIV q8
• Ketorolac 30mg TIV q8 PRN
• Paracetamol 300mg TIV PRN
Remove IFC
Course in the wards
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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120/80
72
17
36.8
(+) Colostomy
output
Soft abdomen
Tender only
on post-
operative site
3rd Post-op Day
Soft Diet to DAT
IVF to consume
Therapeutics:
• Cefuroxime 500mg/cap TID
• Metronidazole 500mg/cap TID
• Mefenamic Acid 500mg/cap q8
PRN
Course in the wards
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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120/90
84
18
36.5
(+) Colostomy
output
Soft abdomen
Tender only
on post-
operative site
4th Post-op Day
DAT
Therapeutics:
• Cefuroxime 500mg/cap TID
• Metronidazole 500mg/cap TID
• Mefenamic Acid 500mg/cap q8
PRN
May ambulate
Course in the wards
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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130/90
84
20
36.5
(+) Colostomy
output
Soft abdomen
Tender only
on post-
operative site
5th Post-op Day
DAT
May go home
Therapeutics:
• Cefuroxime 500mg/cap TID
• Metronidazole 500mg/cap TID
• Mefenamic Acid 500mg/cap q8
PRN
Course in the wards
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”FINAL DIAGNOSIS
Gangrenous colitis, ruptured, sigmoid
colon
Planes of resection, viable
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Histopathologic Diagnosis
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”FINAL DIAGNOSIS
Acute Surgical Abdomen secondary to
Localized Fecal Peritonitis secondary to
Sigmoid Perforation secondary to
Santol Seed Ingestion
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Final Diagnosis
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
J.E.
53-year-old Female
Tondo, Manila
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
GENERALIZED ABDOMINAL
PAIN
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Chief Complaint
Five Days PTC
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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History of Present IllnessAbdominal pain,
Crampy, Generalized
8/10 in severity
(+) Fever (T 38.6˚C)
No consult done
No medications taken
One Day PTC
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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History of Present IllnessIncrease in severity of
pain to 10/10
Prompted consult at
our institution
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Review of Systems
No headache, tinnitus, no blurring of vision, no
sore throat
No cough, no difficulty of breathing, no
shortness of breath
No easy fatigability, no palpitations, no chest
pain
No frequency, no urgency, no hematuria, no
dysuria, no polyuria, no polyphagia, no
polydipsia
No weakness, no seizures, no loss of
consciousness
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Past Medical History
No Hypertension, Bronchial Asthma
No Diabetes Mellitus, Pulmonary Tuberculosis,
No Allergies to food and medications
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Family History
No Hypertension, Bronchial Asthma,
Diabetes Mellitus, Pulmonary Tuberculosis,
Cerebrovascular Disease, Cancer
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Personal / Social History
Smoker, 10 pack years
Non-alcoholic beverage drinker
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
Vital Signs:
General:
SHEENT:
BP: 140/80 HR: 85 RR: 22 T: 36.5
O2Sat: 99%
Awake, coherent, not in
cardiorespiratory distress
Good skin turgor, anicteric sclerae,
pink palpebral conjunctivae, no
nasoaural discharge, no cervical
lymphadenopathy, flat neck veins
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
Chest and
Lungs:
Heart:
Abdomen:
Symmetric chest expansion, no
retractions, clear breath sounds
Adynamic precordium, normal rate,
regular rhythm, no murmurs
Slightly distended, hypoactive
bowel sounds,
(+) Direct tenderness on left upper
and lower quadrant with
involuntary muscle guarding
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
Abdomen:
Slightly distended,
hypoactive bowel
sounds,
(+) Direct tenderness
on left upper and
lower quadrant
with involuntary
muscle guarding
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Physical Examination
DRE:
Extremities:
No anal tags or fissures, No
hemorrhoids, good sphincteric
tone, non-collapsed rectal vault,
no mass or tenderness, (+) fecal
material on examining finger
Grossly normal, no edema, no
cyanosis, full pulses
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Pre-treatment Diagnosis
Acute Surgical Abdomen secondary to
Perforated Viscus
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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150/80
94
20
36.9
NPO
NGT inserted and kept open
IVF: PNSS 1L to run at 125 cc/hr
Therapeutics:
• Ceftriaxone 1gm TIV q8
• Metronidazole 500mg TIV q8
• Ranitidine 50mg TIV q8
• Paracetamol 300mg TIV now
IFC
Book to OR for Ex-Lap
Emergency Room
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Emergency Room
CXR PA Upright:
• Pneumoperitoneum
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Emergency Room
PFA Upright:
• Ileus
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Emergency Room
CBC
WBC 17.9
Neutrophil 88.4
Lymphocyet 5.9
Monocyte 2.7
Eosinophil 2.1
Basophil 0.9
RBC 4.81
Hemoglobin 12.1
Hematocrit 37.9
MCV 78.9
MCH 25.1
MCHC 31.8
Platelet 439
Urinalysis
Color Dark Yellow
Transparency Clear
Epithelial cell Few
Mucus thread Occasional
Amorphous
Urates
Occasional
Amorphous
Phosphates
None
WBC 2-4
RBC 0-2
Albumin +2
Sugar Negative
SG 1.020
pH 5.0
Bacteria Moderate
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Emergency Room
Clin Chem
BUN 9.9
Crea 0.61
Na 136
K 4.2
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
Procedure
Full midline
Exploratory Laparotomy
Incision
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
Intra-operative Findings
• Perforated
diverticula on the
Sigmoid colon with
noted Santol seed
on the diverticulum
• Several Santol
seeds were also
noted on the
Sigmoid
• Generalized fecal
peritonitis
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
Procedure
Hartmann’s Procedure
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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100/60
77
18
36.5
(-) Colostomy
Output
Soft abdomen
Tender only
on post-
operative site
1st Post-op Day
NPO
IVF: D5LRS 1L to run at 150 cc/hr
Therapeutics:
• Shift to Pip-Tazo 4.5gm TIV q8
• Metronidazole 500mg TIV q8
• Ranitidine 50mg TIV q8
• Ketorolac 30mg TIV q8 PRN
• Paracetamol 300mg TIV PRN
IFC
Course in the wards
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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120/80
90
19
36.9
(-) Colostomy
Output
Soft abdomen
Tender only
on post-
operative site
2nd Post-op Day
NPO
IVF: D5LRS 1L to run at 125 cc/hr
Therapeutics:
• Pip-Tazo 4.5gm TIV q8
• Metronidazole 500mg TIV q8
• Ranitidine 50mg TIV q8
• Ketorolac 30mg TIV q8 PRN
• Paracetamol 300mg TIV PRN
Remove IFC
Course in the wards
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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120/80
72
17
36.8
(+) Colostomy
output
Soft abdomen
Tender only
on post-
operative site
3rd Post-op Day
Soft Diet
IVF: D5NM 1L to run at 100ccc/hr
Therapeutics:
• Cefuroxime 500mg/cap TID
• Metronidazole 500mg/cap TID
• Celecoxib 200mg/cap q12 PRN
for Pain
Course in the wards
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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120/90
84
18
36.5
(+) Colostomy
output
Soft abdomen
Tender only
on post-
operative site
4th Post-op Day
DAT
IVF to consume
Therapeutics:
• Cefuroxime 500mg/cap TID
• Metronidazole 500mg/cap TID
• Celecoxib 200mg/cap q12 PRN
for Pain
May ambulate
Course in the wards
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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130/90
84
20
36.5
(+) Colostomy
output
Soft abdomen
Tender only
on post-
operative site
5th Post-op Day
DAT
May go home
Therapeutics:
• Cefuroxime 500mg/cap TID
• Metronidazole 500mg/cap TID
• Mefenamic Acid 500mg/cap q8
PRN
Course in the wards
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”FINAL DIAGNOSIS
Acute on chronic peridiverticulitis,
Congestion and Hemorrhage with
rupture, Sigmoid Colon
Planes of resection, viable tissues
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Histopathologic Diagnosis
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”FINAL DIAGNOSIS
Acute Surgical Abdomen secondary to
Generalized Fecal Peritonitis secondary
to Perforated Diverticulitis secondary
to Santol Seed Ingestion
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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Final Diagnosis
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”FINAL DIAGNOSIS
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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CASE 1 CASE 2
AGE 39 53
SEX MALE FEMALE
PRESENTING
SYMPTOMS
• Abdominal Pain
• Sudden
• Abdominal Pain
• Gradual
Comparison of the 2 Cases
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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CASE 1 CASE 2
ABDOMINAL
FINDINGS
• Flabby, Non-
distended,
Normoactive bowel
sounds,
• (+) Direct
tenderness on right
lower quadrant
more than the
hypogastric area
Flabby, Non-
distended,
Normoactive bowel
sounds,
(+) Direct tenderness
on left upper and
lower quadrant with
involuntary muscle
guarding
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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CASE 1 CASE 2
INTRA-OP
FINDINGS
• Sigmoid colon
perforation with
noted Santol seeds
• Localized fecal
peritonitis
• Perforated
diverticula on the
Sigmoid colon with
lodged Santol seed
• Generalized fecal
peritonitis
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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CASE 1 CASE 2
HISTO-
PATHOLO
GIC
• Gangrenous
colitis, ruptured,
Sigmoid Colon
• Planes of
resection, viable
• Acute on chronic
peridiverticulitis,
Congestion and
Hemorrhage with
rupture, Sigmoid
Colon
• Planes of resection,
viable
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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FACTS FROM PREVIOUS STUDIES
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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“The presence of hard stool or a foreign body
like santol seeds can cause pressure necrosis
ulceration and perforation of the bowels.”
Ramirez, Carlo G, Crisostomo Armando, Gutierrez, Romeo, Roxas Alberto. Colonic
Perforation Associated with “Santol” Seeds. Asian Journal of Surgery;Colorectal
Surgery 1993;16 (3):232-5.
DEPARTMENT OF SURGERY
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• Distal colon have relatively poor blood supply
• Fecal content become dehydrated in the
distal colon
• Sigmoid and the rectosigmoid can generate high intraluminal pressure
Ramirez, Carlo G, Crisostomo Armando, Gutierrez, Romeo, Roxas Alberto. Colonic
Perforation Associated with “Santol” Seeds. Asian Journal of Surgery;Colorectal
Surgery 1993;16 (3):232-5.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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“Bangkok Santol seeds, which are bigger and
have sharper ends, the most common adverse
event seems to be primary perforation even in the absence of structural defect in the colon.”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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What is the pathophysiology?
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OBSTRUCTION CAUSED BY SANTOL SEEDS
THEORY 1: DIVERTICULUM
LODGE OF THE SANTOL SEED ON A
DIVERTICULUM
PUNCTURE OF THE DIVERTICULAR WALL BY THE
SHARP END OF THE SEED
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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THEORY 1: DIVERTICULUM
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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OBSTRUCTION CAUSED BY SANTOL SEEDS
THEORY 2: NORMAL BOWEL
DILATATION OF THE COLON
PRESSURE NECROSIS AND PUNCTURE OF THE
BOWEL WALL BY THE SHARP END OF THE SEED
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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THEORY 2: NORMAL BOWEL
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER“Towards Patient Safety in Surgery”
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THANK YOU!