0:00

Okay, so our patient went off to surgery.

0:02

Indeed, they did have a perforated cecum.

0:05

That was completely correct.

0:06

There's the free air.

0:07

There was a need for the patient.

0:09

But let's take a little closer look at this case.

0:11

So here again, we see the free air, and as we

0:14

come down we're going to see the dilated colon

0:16

with a little dots of air all around the cecum.

0:18

Okay?

0:18

Perforated, which is cool.

0:21

But as we follow the descending colon down

0:24

deep into the pelvis, and don't get me wrong.

0:27

This person has bilateral hip replacements,

0:29

which is there just to mess you up

0:30

and make it very difficult to see.

0:32

You're going to see an abrupt caliber change

0:34

of that sigmoid colon, and this ended up

0:38

being a sigmoid colon obstructing tumor.

0:41

So this is a patient who actually had a large

0:44

bowel obstruction related to colon cancer.

0:47

So let's talk about this.

0:49

Why.

0:50

Did the cecum perforate?

0:51

Okay, but this is going to take you back to

0:53

high school physics, back to Laplace's Law.

0:55

I'm sure you're still having

0:56

anxiety dreams about this, but.

0:58

Come to now, come to reality.

0:59

We're going to still talk about the same

1:01

principles that you've known forever and

1:03

how they apply to a bowel obstruction.

1:05

So Laplace's Law will tell you that in the

1:08

location of the greatest radius under a closed

1:12

system, and we're talking about a closed loop,

1:14

we talked about how the small bowels of closed

1:16

loop obstruction, we talked about how that large

1:18

bowel obstruction was a closed loop obstruction.

1:20

That's the physiology is a closed system.

1:23

In a closed system, the location with the largest

1:26

radius will undergo the largest wall tension.

1:29

So what does that mean to us?

1:30

In the GI tract, following our 3 6 9 rule of the bowel,

1:35

knowing that the greatest diameter of the small bowel

1:37

should be up to three centimeters, the colon up to six

1:40

centimeters, the cecum is then the nine centimeters.

1:43

Right?

1:43

So the greatest radius is naturally within

1:46

the cecum because that's the location where we

1:49

know that the cecum can go to nine centimeters.

1:52

That is the location with greatest wall tension.

1:55

So what we're going to remember is that if

1:58

you see a cecal perforation, yes, that's

2:01

where the colon is going to perforate.

2:03

But your job isn't necessarily just

2:05

to find the location of perforation.

2:07

You need to find the cause for perforation, and

2:09

that's this apple-core lesion deep in the pelvis.

2:12

This colon cancer, unfortunately this patient went

2:15

to surgery, got a right hemicolectomy, and just.

2:18

Continued to have trouble, and it took

2:21

a while until they found that this was

2:23

the cancer that was causing the problem.

2:25

So always remember that cecal perforations frequently

2:28

can be caused by a distal obstructing lesion

2:31

because indeed that is a closed-loop obstruction.

2:33

And in a closed system, the location with

2:36

the greatest R, the greatest radius, is gonna

2:38

have the highest amount of tension, and that

2:40

will be the location that will perforate.

2:43

Our first patient here with the large bowel

2:46

obstruction was lucky in that that was identified

2:48

as an emergent large bowel obstruction, and our

2:51

hospital, our endoscopists will come in and very

2:54

gently try to thread a wire through these high-grade

2:58

obstructions and are able to put in a stent.

3:01

These stents allow the colon to then drain out,

3:03

decreasing the pressure of this closed-loop.

3:07

We'll allow them to clean out the colon so that

3:09

they can do a one staged resection in the patient,

3:12

which means that they are able to do a anastomosis

3:15

at the time of surgery, and that really saves

3:17

the patient an ostomy, which is really something

3:20

that most patients really much appreciate.

3:21

So you need to recognize high-grade

3:25

colonic obstructions as indeed closed-loop.

3:28

Emergent, so that they can be treated emergently

3:31

before they perforate because the perforation

3:35

is a dreaded outcome of this process.