Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 1: Emergency Surgery in a High-Risk Patient
Clinical Image
Source: Wikimedia Commons - Bowel Obstruction CT - CC BY-SA 4.0
Case Presentation
An 85-year-old woman with dementia, heart failure (EF 25%), and COPD presents with 2 days of abdominal pain, distension, and vomiting. She lives in a nursing home and is non-verbal at baseline but now appears more distressed than usual. CT shows a complete small bowel obstruction with a transition point in the right lower quadrant and a closed-loop configuration concerning for volvulus. There is no free air, but there is bowel wall thickening at the transition point suggesting ischemia. The surgical team calculates her ACS NSQIP risk: estimated mortality 22%, serious morbidity 45%. Her frailty index is high. The attending surgeon meets with the patient's daughter (healthcare proxy) for a shared decision-making discussion. She explains: "Your mother has a bowel blockage that appears to be twisting on itself. Without surgery, the bowel will die and she will not survive. With surgery, her chances of surviving are about 75-80%, but she faces significant risks of complications and may not return to her previous baseline." The daughter asks what her mother would have wanted. The team reviews her prior statements and advance directive, which states she would not want "heroic measures" but does not address surgery. After discussion, the daughter decides to proceed with surgery with the understanding that if intraoperative findings are worse than expected, the surgeons will limit the operation rather than pursue extensive resection. The patient undergoes exploratory laparotomy, and a band causing closed-loop obstruction is lysed with viable bowel. She recovers slowly but returns to her nursing home baseline in 3 weeks.
Key Learning Points
- Surgical decision-making in frail, elderly patients requires explicit risk-benefit analysis using validated tools (ACS NSQIP, frailty indices) and honest communication with surrogates
- Emergency surgical indications (perforation, ischemia, strangulation, hemorrhage) generally favor operative intervention even in high-risk patients, though goals-of-care discussions should occur
- Shared decision-making explores patient values and what the patient would have wanted, not just what family members want
- Damage control principles may apply: limit the operation to what is necessary if the patient is unstable or findings are dire