Saturday, July 19, 2008

Prasad

I had a chance last night to revisit an old technique I had learned in residency; the Prasad colostomy. This was an ancient lady who had had an major operation on just about every significant blood carrying artery in her body over the past ten years, who presented acutely in the ER with abdominal pain. Vasculopaths like this who present with a chief complaint of acute abdominal pain ought to set off internal alarms in the heads of any decent general surgeon. Mesenteric ischemia goes right to the top of the list of the differential diagnoses.

Basically, she had peritonitis on exam, thereby obviating a bunch of hemming and hawing on whether or not to get an angiogram so I booked her for the OR. I opened and found a hemorrhagic infarct of the sigmoid colon. Ten minutes later about a foot of bowel was in a dish on the back table. Although pink and grossly well vascularized, I was worried about doing a primary anastomosis in a case of mesenteric ischemia, especially when I wasn't sure about her remaining vascular anatomy (history of aorta-bifemoral bypass in the distant past). And maybe I was a little bit of a wuss. Whatever. So I mobilized the descending colon and the rectosigmoid distal stump and brought them both through the same stoma aperture in the left lower quadrant, sort of a like a double barrel colostomy. The variation of the Prasad is that you only mature a corner of the distal stump, tacking it to the proximal stump which is fully matured in the standard fashion. The benefit is that it is much easier to re-establish intestinal continuity down the road compared to a standard Hartman's colostomy. Often you just have to make a small incision around the colostomy, staple the ends together, and pop it back into the abdomen. Also, the Prasad gives you easy access to both limbs of large bowel; useful if the patient doesn't do well and you want to inspect the mucosa for progressive ischemic disease.....

3 comments:

make mine trauma said...

Cool, I've never seen or heard of that before. Hope she does well for you.

Anonymous said...

NICE!! Never heard of it before either, but probably will find a situation where I can use it in the future.

s

Orac said...

Actually, I trained briefly under Dr. Prasad when he was at Mt. Sinai. :-)