A 52-year-old man undergoes emergency laparotomy for peritonitis after he was stabbed in the abdomen during a robbery. During the operation, minor spillage of enteric contents is discovered, and a small bowel injury is found and repaired. When the rest of the intraabdominal organs are examined for injury, an approximately 10 cm gastric mass is found that appears most consistent with a gastrointestinal stromal tumor. Resection of the mass would require partial gastrectomy. Which of the following is the most appropriate next step?

Question

A 52-year-old man undergoes emergency laparotomy for peritonitis after he was stabbed in the abdomen during a robbery.  During the operation, minor spillage of enteric contents is discovered, and a small bowel injury is found and repaired.  When the rest of the intraabdominal organs are examined for injury, an approximately 10 cm gastric mass is found that appears most consistent with a gastrointestinal stromal tumor.  Resection of the mass would require partial gastrectomy.  Which of the following is the most appropriate next step?

Quizplus · Accepted Answer

Explanation: Informed consent is the process by which a physician provides a patient with the information necessary to make an educated health care decision. Informed consent is typically required prior to performing a procedure on a patient, although important exceptions exist: Informed consent A life-saving procedure may be performed in an emergency where obtaining consent is not possible. Extension of a procedure is acceptable if an unexpected complication arises that requires immediate treatment (eg, unexpected ostomy creation is necessary because profound enteric spillage makes bowel repair unsafe). The additional procedure is typically related to the initial indication (eg, peritonitis) for treatment. This patient is undergoing emergency laparotomy because of peritonitis after penetrating trauma. Following appropriate treatment (ie, repair of injured small bowel), a large gastric mass is incidentally discovered. In this case, the mass's removal is not related to the original indication for surgery, its presence is not imminently life-threatening, and its resection would cause additional risks to the patient. Therefore, the mass should not be removed without the patient's further consent. Advantages of deferring resection of the gastric mass include avoiding the increased risk of infection (eg, from enteric spillage) and limiting operative time in the setting of trauma (Choices A and C). Advantages to performing a simultaneous resection include avoiding another operation in the setting of adhesions and decreasing total medical costs and patient recovery time (Choices E and F). However, none of these advantages (for either deferred or simultaneous resection) override the necessity of obtaining the patient's informed consent before performing the additional procedure. (Choice D) A gastric mass of this size (ie, 10 cm) has a high likelihood of malignancy, and resection is likely to be recommended after complete workup (eg, imaging to rule out lymph node involvement or metastases). However, it is the patient's (not the surgeon's) right to choose (or refuse) resection, even if the mass is malignant. Educational objective: An exception to the requirement of informed consent is extension of an authorized procedure if an unexpected complication arises that demands immediate treatment. However, this exception does not cover procedures for unrelated issues that are not imminently life-threatening. References: From informed consent to informed dissent in health care: historical evolution in the twentieth century. (http://www.ncbi.nlm.nih.gov/pubmed/28845838) Informed consent-it's more than a signature on a piece of paper. (http://www.ncbi.nlm.nih.gov/pubmed/28974311)

A 52-Year-Old Man Undergoes Emergency Laparotomy for Peritonitis After He