Rural Surgery: Challenges and Solutions for the Rural Surgeon

Rural Surgery

 

Matthias W. Wichmann • David C. Borgstrom Nadine R. Caron • Guy Maddern (Editors)

Rural Surgery Challenges and Solutions for the Rural Surgeon

Editors Matthias W. Wichmann, FRACS Department of General Surgery Mount Gambier General Hospital and Flinders University Rural Medical School 276-300 Wehl Street North Mount Gambier, SA 5290 Australia [email protected] David C. Borgstrom, MD, FACS Department of Surgery Bassett Medical Center One Atwell Road Cooperstown, NY 13326 USA [email protected]

Nadine R. Caron, MD, MPH, FRCSC University of British Columbia-Northern Medical Program Prince George, BC Canada [email protected] Guy Maddern, MD Department of Surgery The Queen Elizabeth Hospital 28 Woodville Rd Woodville South, SA 5011 Australia [email protected]

The following figures are published with the kind permission of the respective owner Figures: 4.1, 4.3, 4.4, 4.5, 7.2, 7.3, 12.1, 12.3, 14.1, 14.2, 15.1, 15.2, 15.3, 30.1, 30.2, 30.3, 37.1, 37.2, 39.1, 39.2, 39.3, 39.4, 40.1, 40.2, 40.3, 40.4, 40.5, 53.1, 53.2, 53.3, 53.5, 61.1, 61.2, 61.4, 63.1, 63.2 Jauch K-W, Mutschler W, Wichmann MW (2007), Chirurgie Basisweiterbildung, Springer-Verlag, Berlin, Heidelberg

ISBN  978-3-540-78679-5     e-ISBN  978-3-540-78680-1 DOI  10.1007/978-3-540-78680-1 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2011923337 © Springer-Verlag Berlin Heidelberg 2011 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is ­concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant ­protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudioCalamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

To Juliane, Antoinette, Jakobus, and Evangelia – thank you for taking me “down under”! Matthias W. Wichmann To Donna, Catherine, and Samantha. Thank you for your love, confidence, and support. David C. Borgstrom To our fellow rural surgeons around the world. Guy Maddern To Gary F. Purdue† (1945–2010) – gifted surgeon, friend, humanitarian. David C. Borgstrom

 

Preface

We are very pleased to present our contribution to the developing field of rural surgery. Rural surgery requires the surgeon to always be prepared for a procedure or an intervention that he or she might not have done or seen either frequently or recently – this is the best definition of the challenge facing rural surgery. It does summarize well what the challenges of daily work for rural surgeons can be. These challenges become more complex due to the fact that expert support or advice and the technology requirements that often accompany them are frequently far away or not available. With this textbook on rural surgery we want to provide up-to-date information for senior as well as junior surgeons working in nonmetropolitan hospitals around the world. The book is a guide to get through the challenges of starting a surgical practice in a rural environment and can provide the scientific background for the routine work of the experienced rural surgeon. The book also aims to assist surgeons who provide locum services and may not always be used to working alone in a new environment. We hope that this book will become a valuable companion for surgeons working in the field of rural surgery around the world. The editors started to work on this project in 2007 when David Borgstrom came to present at the Annual Scientific Meeting of the Provincial Surgeons of Australia (PSA) in Whyalla (sp) (South Australia). Matthias Wichmann, Guy Maddern, and David Borgstrom agreed to edit a textbook on rural surgery based on the recent experience of one of the Australian editors (MW) who at that time was just beginning to adjust to the challenge and rewards of a rural surgical practice after moving to Australia from Germany. Nadine R. Caron soon joined the editorial team and we started to collect contributing authors around the world. We are very grateful to all the contributing authors for their input into this textbook. Their expertise and knowledge will help to make rural surgeons more comfortable with difficult situations and treatment decisions in our daily practice and serve as a resource for the future rural surgeons who will pursue this rewarding career. The editors would also like to express their gratitude to the team of the SpringerVerlag in Germany. From the start the publisher was very supportive of the idea to edit a book on rural surgery. We are especially thankful to Mrs. Stephanie Benko and Mrs. Rosemarie Unger and Mrs. Dakshinamoorthy Mahalakshmi for their help and assistance.



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Preface

We trust that you will enjoy this book and that it will be a valuable support for your work in rural surgery. Mount Gambier, SA, Australia

Matthias W. Wichmann, FRACS

Contents

Part I  Challenges of Rural Surgery   1 Rural Surgical Education: The Australian Approach . . . . . . . . . . . . . . Guy Maddern and Matthias W. Wichmann

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  2 Surgery for Rural America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David C. Borgstrom

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  3 Surgery in Rural Canada: Challenges and Possible Solutions . . . . . . . Nadine R. Caron and Stephen J. Pinney

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Part II  Pre- and Postoperative Care



  4 Fundamentals of Surgical Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hanno Niess, Karl-Walter Jauch, and Christiane J. Bruns

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  5 Palliative Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Matthias W. Wichmann

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  6 Fiber Optic Endoscopy: Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . Matthias W. Wichmann and Fritz W. Spelsberg

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  7 Fiber Optic Endoscopy: Gastroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . Matthias W. Wichmann and Fritz W. Spelsberg

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  8 Fiber Optic Endoscopy: Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . Matthias W. Wichmann and Fritz W. Spelsberg

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  9 Endoscopy for Rural Surgeons: ERCP . . . . . . . . . . . . . . . . . . . . . . . . . . Ian C. Roberts-Thomson

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10 Rigid Endoscopy: Cystoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mark Lloyd and John Miller

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Contents

11 Rural Surgical Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David A.K. Watters

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12 Acute Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Edmund A.M. Neugebauer, Astrid Althaus, and Christian Simanski

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13 Prophylaxis of Venous Thromboembolism . . . . . . . . . . . . . . . . . . . . . . . Robert A. Fitridge and Simon McRae

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14 Nutrition of the Surgical Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Florian Brackmann, Wolfgang H. Hartl, and Peter Rittler

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15 Surgical and Hospital-Acquired Infections . . . . . . . . . . . . . . . . . . . . . . Wolfgang Böcker and Wolf Mutschler

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16 Antimicrobial Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Christian P. Schneider and Beatrice Grabein 17 Preoperative Risk Assessment in Rural Surgery . . . . . . . . . . . . . . . . . . 133 Teresa Bueti, Munawar Rana, and Matthias W. Wichmann 18 Perioperative Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Peter Rittler and Wolfgang H. Hartl 19 Analgesia and Sedation in Intensive Care . . . . . . . . . . . . . . . . . . . . . . . 145 Christian Waydhas

Part III  Operative Care 20 Anti-reflux Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Glyn Jamieson 21 Gastric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Matthias W. Wichmann 22 Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting . . . . . . . . . . 169 Harsh A. Kanhere and Andrew D. Strickland 23 Liver Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Faud Alkhoury, Christine Vancott, and Randall Zuckerman 24 Pancreatic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Markus Trochsler, Thomas Satyadas, and Harsh A. Kanhere

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25 Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Martin Bruening 26 Surgery of the Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Matthias W. Wichmann 27 Complications After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 205 Brent White 28 Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Kerstin S. Schick and Johannes N. Hoffmann 29 Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Saukat T. Esufali 30 Diverticulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Matthias W. Wichmann and Karl-Walter Jauch 31 Therapy of Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Johannes N. Hoffmann 32 Bowel Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Peter Hewett and Cu Tai Lu 33 Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Peter Hewett 34 Stoma Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Nick Rieger 35 Acute Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Hajir Nabi 36 Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Friesen W. Randall 37 Mesenteric Ischaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Heinrich Stiegler, Florian Brackmann, and Laura Holzner 38 Management and Surgery of Inflammatory Bowel Diseases . . . . . . . . 281 William Roediger 39 Proctology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Alexander Herold and Laura Holzner 40 Abdominal Wall Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Reinhold A. Lang and Martin K. Angele

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41 Thyroid Surgery for the Community General Surgeon . . . . . . . . . . . . 309 Anthony J. Chambers and Janice L. Pasieka 42 Parathyroid Surgery in the Non-Tertiary Center . . . . . . . . . . . . . . . . . 315 Anthony J. Chambers and Janice L. Pasieka 43 Adrenal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Marlon A. Guerrero and Wen Shen 44 Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 David Walsh 45 Skin Cancer: Current Surgery for This Common Problem . . . . . . . . . 341 R. Gwyn Morgan 46 Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 Thao T. Marquez, Mara B. Antonoff, and Daniel A. Saltzman 47 Vascular Surgery: Acute Limb Ischaemia . . . . . . . . . . . . . . . . . . . . . . . 359 Mark Hamilton 48 Vascular Surgery: Management of the Diabetic Foot . . . . . . . . . . . . . . 369 Mark Hamilton 49 Minor Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Eric Mooney

Part IV  Relevant Orthopaedics for General Surgeons 50 Simple Orthopaedic Procedures and Common Diagnoses . . . . . . . . . . 389 David Wysocki and René Zellweger 51 Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 Hajir Nabi 52 Dupuytren’s Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 Barney McCusker 53 Hand Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415 Andreas Frick and Christiane G. Frick

Part V  Other Relevant Operative Specialities for General Surgeons 54 Rural Obstetrics and Gynaecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 Colin Weatherill

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55 Urological Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433 John Miller, Clair Whelan, and Kulendran Sivapragasam 56 Otolaryngologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 Cynthia Bonatucci Fisher

Part VI  Emergency Care 57 Airway Management: A Surgical Perspective . . . . . . . . . . . . . . . . . . . . 465 Adrian Anthony 58 Management of the Severely Injured . . . . . . . . . . . . . . . . . . . . . . . . . . . 483 Adrian Anthony 59 Rural Burn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501 Gary F. Purdue† and Brett D. Arnoldo 60 A Guide to Neurotrauma for the Rural Surgeon . . . . . . . . . . . . . . . . . . 507 David Omahen and Stephen J. Hentschel 61 Abdominal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529 Wolfgang E. Thasler 62 Trauma Surgery: Neck Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535 Harsh A. Kanhere and Robert A. Fitridge 63 Open Extremity Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541 Ekkehard Euler 64 Traumatic Injuries of the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547 Rudolf Beisse and Christoph Siepe 65 Trauma Surgery, Orthopaedic – Pelvic Fracture . . . . . . . . . . . . . . . . . . 555 Tim Pohlemann, Daniel Köhler, and Christopher Tzioupis 66 Trauma Surgery: Vascular Emergencies . . . . . . . . . . . . . . . . . . . . . . . . 563 Robert A. Fitridge and Mark Hamilton 67 Thoracic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571 Christian Müller Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577

 

Part Challenges of Rural Surgery

I

 

1

Rural Surgical Education: The Australian Approach Guy Maddern and Matthias W. Wichmann

1.1 Introduction Recruiting and maintaining a “critical mass” of the medical workforce within rural centers is a difficult challenge for the Australian society. Australia is one of the most urbanized societies on Earth, and the majority of the population (83%) lives in and around a small number of major cities that are mainly localized on the coastline. Until now, working in medicine in rural Australia appears to be attractive to only a few Australians and has been supported by a substantial number of healthcare providers who are educated and trained outside Australia. To address this significant and growing problem, all the major universities throughout Australia have established so-called Rural Medical Schools in order to expose students to rural medicine at a young age, hoping to retain a significant fraction of these students within the rural medical workforce. Various colleges of medical specialties have also introduced dedicated training programs that aim at recruiting and possibly retaining medical specialists in rural Australia. Whether or not these new concepts of medical teaching account for long-term success remains to be determined. Early

G. Maddern Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected] M.W. Wichmann (*) Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected]

results and the growing interest of students to participate in rural education, however, suggest a promising and encouraging beginning.

1.2 Rural Surgical Training in Australia Surgical training in Australia has been restructured and is now run within the Surgical Education and Training (SET) Program. Within the SET program, trainees are selected directly into one of the nine specialty training programs (cardiothoracic, general, neurosurgery, orthopedic, ENT, pediatric, plastic/reconstructive, urology, vascular). Length of training varies between 5 and 7  years depending on the specialty, and trainees can then present for fellowship examination. The earliest point at which an application can be made for the first year of training (SET1) is during Postgraduate Year 2 (PGY2). Trainees applying for general surgical training have the option to enroll into the Rural Surgical Training Program (RSTP), which has been introduced to enable early recruitment of trainees into the rural surgical workforce. The RSTP allows trainees to undertake a flexible program that includes regional, rural, and remote practice. Trainees within RSTP have access to a network of rural surgeons and mentor assistance, and receive additional financial assistance for conferences and training courses. Each trainee is allocated a mentor, who is responsible for helping the trainee develop a comprehensive training program, and who serves as a guide and counselor during the surgical training period. Rural trainees must complete the standard general surgical training program and can present for the fellowship exam in General Surgery at the completion of

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their 5-year program. Rural surgical education aims to equip the trainee for both metropolitan and rural surgical practice, but aims at trainees who have a rural background or have prior rural medical experience. The selection process for trainees who are interested in rural surgery and those who are not is the same. This selection involves a semi-structured interview, assessment of curriculum vitae, and evaluation of referee and supervisor reports. During recent years, Australia has relied on a large number of international medical graduates to maintain surgical services in rural and remote areas. In 2007, RSTP had produced 38 graduates since its commencement in 1998. In view of these figures, it is no surprise that foreign medical graduates currently represent a large fraction of the rural surgical workforce. Recent evidence suggests that a sustainable and safe service requires a minimum of three general ­surgeons within a rural surgical center. One model of addressing this workforce challenge is to bring rural surgeons into a network relationship with city institutions that allows for continuing professional development, access to locum cover, forum for quality assurance, and auditing as well as ongoing contact with students and trainees. Some centers are remote, but of insufficient size to support more than one general surgeon. If only serviced by one surgeon, they would need to be on call

G. Maddern and M.W. Wichmann

365 days a year. To deal with this problem, some towns have rotating surgeons from the city work in the town for 7 days and then return to the city to be replaced by another fresh surgeon for the following week. This model has been highly successful and well received by the patients of general practitioners. Provision of reliable locum support has also been successfully used to allow solo surgical practitioners to have respite and enable attendance at professional meetings. These efforts combined with major city hospitals offer a viable way forward. This combined with the joint efforts of universities, as well as the Australasian College of Surgeons, may result in a higher proportion of Australian graduates working in rural surgery in the years to come.

Recommended Reading Bruening, M.H., Maddern, G.J.: Surgical undergraduate education in rural Australia. Arch. Surg. 137, 794–798 (2002) Campbell, G.: Rural surgical training in Australia. ANZ J. Surg. 77, 922–923 (2007) Gough, I.: President’s perspective. Surgical News 10, 3–4 (2009) Green, A.: Maintaining surgical standards beyond the city in Australia. ANZ J. Surg. 73, 232–233 (2003) Maddern, G.J.: Rural general surgical placement: a necessity not an option. ANZ J. Surg. 73, 975 (2003)

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Surgery for Rural America David C. Borgstrom

It is estimated that 60 million Americans live in rural areas far removed from urban and suburban health care. Health care and surgical care for rural America is at a crisis. Rural Americans are, in general, older, sicker, poorer, and less educated than their urban and suburban counterparts. Infant mortality and injuryrelated mortality is greater, there is less insurance and fewer physicians per capita, and it is estimated that there is 20–30% less overall medical service for rural and remote Americans. As the economics of health care evolve, the constraints on rural America become even greater. Many rural hospitals are closing at a time when it is more and more clear that the general surgeon is the economic engine that drives the rural hospital and the rural hospital is quite often the economic engine of the rural community. To compound this problem, the number of surgeons per capita in rural America indicates this population is underserved and it is estimated there will continue to be a significant shortage of surgeons needed to practice in rural areas. Further, with the aging of the baby boomer population, the segment of America growing the fastest is those aged 65 and over. In this group of patients, it is estimated the general surgery workload is three times greater than in those of a younger age. As health care evolves, fewer and fewer surgeons in general surgery training programs are electing to remain in general surgery. Currently, only about 35–40% of residents completing US general surgery education

D.C. Borgstrom Department of Surgery, Bassett Medical Center, One Atwell Road, Cooperstown, NY 13326, USA e-mail: [email protected]

programs elect to go into practice where general ­surgery is part of their practice and of those, only 13% are electing to go into rural surgery locations. Student interest in these opportunities has declined, and there are fewer female students interested. General surgeons in rural America are by and large male, over 50 years of age; they are much more likely to be international medical graduates and are seeking earlier retirement than their urban/suburban counterparts. Where the estimated age of retirement used to be near 70, it is now around 62 years of age. Economic issues of lower reimbursement, technology advances, increased liability costs and culture diversity concerns of family make this a problem that is getting worse. The crisis is further compromised because of the fact that most Americans who live in rural America do not like the big city and would much prefer to get their health care away from urban areas. Fortunately, there is increasing recognition of this crisis, not only in the lay press, but also in organizations such as the Association of Program Directors in Surgery and the American College of Surgeons. There is now a recognized need to refocus efforts to not only train surgeons to feel qualified to care for this broad diversity of surgical need, but also to make it appealing both from an economic standpoint and an academic standpoint. The American Association for the Surgery Trauma has developed an acute care surgical fellowship in conjunction with a surgical critical care fellowship. While the intent of this at first glance is to develop mechanisms to care for the acute presentation of surgical disease in large academic medical centers, the diversity of experience is well designed for surgeons who are interested in providing surgical care for rural America.

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Finally, there are several institutions that have recognized the need to not only provide an experience in rural surgery practice, but also diversity training. The Oregon Health and Science University’s Department of Surgery has a program to introduce residents to a rural surgery practice as an alternative to spending time in a research lab. The University of North Dakota program also facilitates experiences for its residents to spend considerable time in a rural setting. Bassett Healthcare, in Cooperstown, New York, through the Mithoefer Center for Rural Surgery, provides fellowship opportunities for surgeons who have completed

D.C. Borgstrom

their traditional general surgery curriculum who have interest in additional training that will allow them ­better to care for rural America. Surgical care for rural America is at a crossroads. There is declining interest and increasing need. Fortunately, there are organizations that have recognized the critical nature of the concern and are attempting to develop programs that will not only make it appealing for newly trained surgeons, but to also provide them the training necessary to feel qualified to provide the broad array of surgical expertise necessary to care for rural America.

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Surgery in Rural Canada: Challenges and Possible Solutions Nadine R. Caron and Stephen J. Pinney

3.1 Introduction

3.2 How Do We Define “Rural Canada”?

The provision of timely and quality surgical services is a persistent challenge in rural Canada. As they work to provide rural surgical services, health-care providers, administrators, and policy makers confront considerable obstacles. With almost 10 million km2, Canada is the second-largest country in the world. However, its population density ranks in the lowest 5% of countries – 95% of the land in Canada is rural. Despite this, only about 20% of Canadians live in rural areas as defined by a community having a population of less than 10,000. These geographic factors alone produce inherent challenges, which are increased by the economic, socio-cultural, and political issues facing rural communities: rationalization of health-care resources to regional centers, relatively high poverty rates, plus issues in health status disparities, most of which are often associated with aboriginal populations. While these challenges are longstanding and difficult to overcome, the stress on the health-care system and the rural populations it serves creates an impetus for change. This chapter outlines the challenges in training for and providing rural surgery in Canada and suggests possibilities for creative solutions.

In the context of surgical practice, we define “rural” as communities whose small population and/or remote geographic location usually requires surgeons to maintain a broad practice with minimal clinical support and ­limited access to technical resources. In Canada, this most commonly refers to communities with one to two general surgeons and populations of less than 10–20,000 people.

N.R. Caron (*) University of British Columbia-Northern Medical Program Prince George, BC, Canada e-mail: [email protected] S.J. Pinney Department of Orthopaedics, St. Paul’s Hospital, 1081 Burrard St. Room C323, Vancouver, BC V6Z 1Y6, Canada e-mail: [email protected]

3.3 Challenges There are multiple challenges to providing highquality surgical services in rural Canada. These include (1) the limited number of practicing general surgeons; (2) the fact that skills needed for a rural surgical practice are increasingly de-emphasized in Canadian surgical training programs; (3) difficulties in recruiting and retaining surgeons to rural communities; (4) limited resources for establishing or maintaining surgical services and practices; and (5) poor integration and coordination of existing surgical services.

3.3.1 The Limited Number of Practicing General Surgeons Rural communities face a stark challenge: Few physicians choose careers in rural surgery. We will explore the causes for this shift in detail later, but let us begin with two key facts: Surgeons in rural locations are almost exclusively general surgeons, and the number

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of general surgeons in Canada is decreasing. Quite simply, more general surgeons have retired than have entered the Canadian work force over the past decade [1, 2]. With fewer graduates entering general surgery practice, it becomes difficult to find enough of them to meet the needs of rural Canadian communities.

3.3.2 Skills Needed for a Rural Surgical Practice Are Increasingly De-emphasized in Canadian Surgical Training Programs Another, more subtle shift has occurred as well: The culture of present-day surgical training in North America encourages subspecialization as opposed to the generalist training once well incorporated in standard General Surgery residencies [3]. Of those completing General Surgery training, a significant number now choose subspecialization, bypassing the option of rural surgery practice in favor of post-residency fellowships based on anatomic association, clinical etiology, technology utilized or age-related patient populations. It is estimated that up to 70% of graduates from Canadian general surgery residencies ­pursue postgraduate fellowships. This has limited the number of surgeons who can provide the wide range of surgical procedures required in rural Canada. A generation ago, a graduating ­general surgeon would feel comfortable performing a variety of common procedures in a range of disciplines such as caesarian sections, emergency craniotomy “burr holes”, skin grafting, draining peri-tonsillar abscesses, and stabilizing basic fractures. Today’s graduating general surgeons often have little hands-on experience performing these type of procedures and therefore many new surgeons do not feel comfortable performing the breadth of procedures that are needed in a rural community. One reason for this is program planning, the process whereby residency training programs structure observation, training, and hands-on learning. In many Canadian residency programs, general surgery residents no longer experience rotations in urology, obstetrics/ gynecology, plastic surgery, neurosurgery, and orthopedics. If they do, such rotations typically occur in the junior residency years when the focus of training is not on procedural competency but on understanding core

N.R. Caron and S. Pinney

surgical principles. Indeed, the only “off-service” rotation (not general surgery or one of its subspecialties) mandated by the Royal College of Physicians and Surgeons of Canada is Critical Care Medicine. General surgery residents spend their senior years focusing on subspecialty general surgery such as hepatobiliary, colorectal, or minimally invasive surgery, among a long list of others. They become comfortable and competent performing complex surgeries as part of a team at a tertiary center, but often have little experience performing a wide variety of the more basic surgical procedures in other disciplines on their own. Like most people, surgeons become comfortable with what they have been trained to do, in an environment they are familiar with and as a result, often distance themselves from the concept of rural practice. A further reason for this move toward subspecialization is role modeling, a factor that education specialists recognize as one of the most powerful teaching tools [3, 4]. Students model themselves on what they see, and surgery residents at major training programs in Canada tend to encounter subspecialists at greater frequency and significantly longer in duration than general surgeons due to their urban-based training. These individuals serve as role models for those training to be general surgeons; implicitly, this fosters the trend toward subspecialization that has made it so ­difficult to train generalists and recruit such surgeons to rural practices. Finally, we must consider that most training programs are situated in large urban centers. During the five or more years that it takes residents to train, they often become comfortable in this type of setting, developing friendships and/or partnerships, and building lives that make it difficult for them to move to a rural community when they finish their training.

3.3.3 Difficulties in Recruiting and Retaining Surgeons Rural Canadian communities face further challenges in recruiting and retaining surgeons, including (a) lower patient volumes to maintain subspecialty skills [3] and (b) the perception that rural surgical practices require demanding on-call schedules. First, as we have seen, surgeons increasingly choose to pursue subspecialization after their general training.

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3  Surgery in Rural Canada: Challenges and Possible Solutions

Having done so, they often wish to maintain a focused practice that does not extend significantly beyond their field of expertise. Such a scope of practice is neither predictable nor easily obtained in the rural environment, helping to explain why most subspecialty-trained surgeons do not move to rural locations. For rural general surgeons who have not pursued subspecialty training, their low case volume for subspecialty care creates increased pressure to transfer patients requiring elective care in subspecialty fields to regional or tertiary centers. This can limit the scope of rural elective general surgery and often adds to the stress of emergent surgical care [3]. Concerns regarding daunting emergency on-call responsibilities pose a further challenge. Surgeons in small rural communities simply do not have many local colleagues with whom to share on-call workload and this all too often correlates with increased frequency of formal and informal on-call schedules. While small populations may translate to less afterhours work when on-call, rural surgeons grapple with community expectations that they be available for urgent matters. As well, they face the considerable stress of caring for patients with challenging clinical presentations in the absence of colleague support, both medical and surgical. As a result, quality of life issues and professional burnout pose real concerns for surgeons practicing in rural areas [5].

3.3.4 Limited Resources for Establishing or Maintaining Surgical Services and Practices Ironically, government policies often discourage surgeons from pursuing rural surgery practices, as infrastructure funding for hospitals, labs, and imaging facilities tends to favor regionalization. From the ­government’s perspective, it makes sense to concentrate physical and human resources in larger centers. However, this means that surgeons wanting or needing to practice with access to these facilities and resources (especially subspecialists) will naturally be drawn to larger regional centers. For surgeons in rural communities, regionalization often means finding themselves (and their patients) hours away from well-equipped and well-staffed regional centers.

3.3.5 Poor Integration and Coordination of Existing Surgical Services Practical issues within the health-care delivery system further undermine the potential for a more widespread distribution of general surgeons. For example, many general surgeons would prefer not to practice as sole practitioners, preferring the freer lifestyle provided by a shared practice, but the catchment base in most rural communities is not large enough to keep more than one surgeon busy. In addition, many of the resources required to sustain a full surgical practice that meets clinical guidelines and public expectations such as CT scanners, MRIs, and laboratories are not available in rural centers.

3.3.6 Summary of Challenges A variety of forces are thus combining to undermine Canada’s ability to provide high-quality surgical care in rural areas. Fewer general surgeons are being trained and those who do graduate often are not prepared to provide the breadth of surgical procedures required in a rural community. In addition, trainees have limited exposure to rural surgery and few role models to encourage them to choose a rural surgery practice. The prospect of a demanding on-call schedule and professional isolation with the lack of colleagues may also act as additional deterrents. Combined with limited funding for infrastructure and the lack of an integrated system for providing surgical care, these factors have lessened the ability of rural communities to recruit and retain surgeons.

3.4 Possible Solutions To provide surgery in rural communities, you need both surgeons and the human and physical resources that support them: nursing, anesthesia, operating rooms, imaging equipment, and laboratory support. Despite the many problems associated with providing high-quality surgical care to rural populations in Canada – problems of surgical training, recruitment, workload, isolation, regionalization – there are practical strategies that would increase the number of surgeons

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willing to work in such communities and significantly improve the structures that support them there. These strategies include (1) using educational and program planning principles to encourage residents to pursue rural surgery practices; (2) optimizing the use of telemedicine as a means of providing clinical care and clinical teaching; (3) using a systems-based approach to improve integration between communities; (4) training some general practitioners to perform basic surgical procedures and provide initial trauma stabilization; and (5) utilizing physician extenders (PEs) to extend the range of surgeons in rural practices; and (6) increasing financial incentives for rural surgeons.

3.4.1 Invoking Educational and Program Planning Principles In order to train a new generation of surgeons ready to take up practice in rural Canada, medical programs will need to apply educational and program planning principles in a strategic fashion. Education principles that will facilitate this change include (a) role modeling; (b) outcome-based education; (c) utilizing the central role of evaluation; (d) target training to planned scope of practice and avoid “extraction education”; and (e) ensuring active learning. Program planning principles will also be essential to ensure that resources exist to support our current and future rural surgeons.

3.4.1.1 Role Modeling Role modeling is a critical educational tool that could be deployed to encourage more surgeons to consider rural practices. Surgical trainees – indeed, all trainees – are acutely influenced by role models [4]. In fact, what trainees observe teaches them far more than any lecture that they hear or paper that they read. If surgical trainees are not exposed to surgeons who have flourishing and enjoyable rural practices, very few graduates are likely to attempt this type of practice, especially given current trends toward regionalization. To encourage young ­surgeons to pursue rural careers, residency training ­programs must provide direct, sustained exposure to surgeons providing high-quality care in rural communities. Importantly, physicians chosen as role models should be ones who enjoy their work. Such role models would be most effectively used in conjunction with a student population that itself had

N.R. Caron and S. Pinney

roots in rural Canada. Although growing up in a rural community does not guarantee that individuals will stay in a rural community once they are trained, it does increase the likelihood of this happening. Medical schools and surgical residency programs should therefore actively encourage candidates who have grown up in rural communities and should try to match them with mentors who both model and speak about the attractions of rural surgical practice.

3.4.1.2 The Principle of Outcome-Based Education The principle of outcome-based education suggests that training for any profession should be dictated by what one actually needs to be able to do in practice [6]. This is the premise underlying the CanMEDS initiative that attempts to identify the knowledge, skills, and personal qualities that physicians graduating from Canadian medical schools should have [7]. This in turn demands that those in charge of the medical school curriculum create learning experiences so that their graduates will have the desired attributes. The same principle can be applied to training general surgeons for a rural surgery practice. For those destined to be general surgeons in rural practices, this means performing core surgical procedures in an appropriate spectrum of specialties without tertiary and quaternary resources. For medical schools interested in producing surgeons ready to practice in rural Canada, this means thinking carefully about what common clinical scenarios such physicians are likely to encounter and ­creating learning experiences that will allow them to provide these services within quality standards.

3.4.1.3 Appreciating Evaluation’s Central Role in Learning Appreciating evaluation’s central role in learning is critical during surgeons’ training and after they start practice. People tend to base their actions on how they are evaluated [8]. In this context, we are referring to “evaluation” in the broadest sense of the word. If a goal of residency training is to encourage more graduates into rural practices, then the content they are taught and upon which they are evaluated should reflect this. If medical school exams and assessments include content related to rural surgery, they will encourage mastery of such issues, regardless of students’ ultimate

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3  Surgery in Rural Canada: Challenges and Possible Solutions

practice type or location. Such content might involve patient transfers (the decision-making process and optimizing the transfer itself); telephone consultations; the spectrum of clinical approaches to the pathology; and clinical scenarios within the curriculum that will be based on resources available and how to differentiate such approaches. For trainees planning an urbanbased practice, the curriculum should generate an understanding of the challenges of rural surgical care and the responsibilities of referral centers to assist when human or technical resources are needed.

3.4.1.4 Over Education or “Extraction Education” Over education or “extraction education” is a negative principle that should be kept in mind by program planners as they promote the expansion of rural surgery. Essentially, as individuals become more highly trained, they usually gain more career opportunities. In the field of surgery, individuals with higher degrees of training (i.e., general surgeons with subspecialty training) commonly pursue non-rural positions. This suggests a potential benefit of training rural surgeons locally and at a level appropriate to what is needed for the rural practice. This will likely translate into less subspecialty rotations in fields least likely to be required in rural surgery such as hepatobiliary, complex pediatric surgery, or transplantation and more broad based training in preparation for the case loads expected in rural hospitals. This highlights the need for distributed training sites for surgical rotations in targeted or specific communities, where surgeons would master what they need for specific practices. Such targeted training has achieved a degree of success in General practitioner (GP) surgery training in Canada and other parts of the world. GP surgeons acquire the ability to perform a limited scope of identified surgical interventions with additional training dictated by a specific community needs such as skin grafts, hand ­procedures, tubal ligations, or others. A basic curriculum with additional procedures tailored to the community tends to enhance physician retention.

3.4.1.5 Active Learning Active learning refers to the principle that learning happens most effectively when learners are physically and/or intellectually engaged in the learning process [9]. It facilitates efficient learning and optimizes

retention of information and skills. Activities with a physical component, especially real or simulations of real events, can be very helpful to facilitate active learning. The “hands-on” approach to many aspects of surgical training is an example of active learning. It is a richer, more powerful mode of learning than the passive learning that, unfortunately, is the usual modality in continuing medical education (CME). To ensure maximum effect, education programs designed to ­foster skills essential to rural surgical practice should deploy active learning principles at every level, from residency to CME.

3.4.2 Telemedicine Telemedicine represents a unique opportunity to address some of the problems in providing surgical services to rural Canadian communities. For the purposes of this chapter, we define telemedicine as the use of live interactive video and audio feeds via the internet to facilitate either clinical care or health-care education from a distance. With recent advances in computing power, digital video, and internet technology, an increasing number of Canadian rural communities can now take advantage of this resource. There are three broad ways that telemedicine is used: (a) physicians diagnosing and in some instances treating patients from afar; (b) specialist physicians helping nonspecialist physicians manage complicated cases in their home community; and (c) providing interactive education to rural health-care providers. Each of these could dramatically improve surgical care in rural communities if the systems and culture are ­created to optimize how telemedicine is used.

3.4.2.1 Physicians Diagnosing and in Some Instances Treating Patients from Afar It is increasingly common in Canada for specialist surgeons to assess patients via telemedicine. This has expanded access to specialist physicians to a much broader segment of the population. Imagine a patient in British Columbia whose GP has identified a lung mass and begun a basic workup at the local hospital. Previously, such a patient was then required to travel 3  h or more each way to be seen by a specialist in

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thoracic surgery. This often required either a multiday trip or more likely, multiple day trips with associated expenses and thereby served to create a barrier to care. Often, patients are forced to avoid or delay these journeys for health-care access because of time, money, weather, or employment restrictions, among others. With telemedicine, patients can show up for an “appointment” at their local hospital and be assessed via telemedicine by a thoracic surgeon who is often hours away. These visits are often facilitated by a local nurse who collects all of the patient’s test results, reviews the patients’ history, and may even help carry out a basic physical exam under the direction of the consulting surgeon. In many instances, telemedicine either allows the patient to be managed locally or, if surgery is indicated, it can be done in one trip with the knowledge that the patient has been worked up prior to the procedure. Postoperative follow-up care can also benefit from this system. There are obvious limitations to this type of telemedicine as physicians cannot perform a hands-on examination. However, this type of telemedicine could serve to dramatically expand access to specialist care in a number of cases. Perhaps the biggest barrier to wide-scale implementation of this type of care is the traditional medical culture. Providing care via the internet may feel different to many surgeons and especially unnatural to more senior or less technologically savvy physicians. However, given the tremendous potential to extend care to a wide segment of the Canadian population that presently does not have access to specialist treatment, it is an approach that physicians and administrators should ­pursue vigorously.

3.4.2.2 Expert Physicians Helping Nonexpert Physicians Manage Complicated Cases in Their Home Community Telemedicine can also enable urban physicians and/or subspecialists to aid physicians in a rural area. Physi­ cians now commonly use video links to help rural ­colleagues manage a trauma patient, treat patients with acute coronary syndrome, or appropriately manage any patient with a complex problem. This use of telemedicine is likely to be more easily embraced as it represents an extension of traditional rural practice. For several generations of Canadian rural physicians, the telephone has served as a lifeline to expert

N.R. Caron and S. Pinney

consults. The ability to share images and live video feeds dramatically improves the accuracy and extent of care that can be provided via real-time physician-to­physician communications. This use of telemedicine can be done as easily as sending an x-ray image via a cell phone. However, for more involved interactions, a video linkup and a coordinated program for accessing expert physicians should be instituted. 3.4.2.3 Providing Interactive Education to Health-Care Providers Finally, telemedicine promises to make regular continuing medical education (CME) practical and economical for physicians practicing in rural communities. The ability to obtain and maintain core knowledge and skills and to learn about medical advances is particularly critical for rural physicians. However, attending a CME program requires extended travel time, cost, and time away from practices where few locums are available. Distance learning via telemedicine provides a potential solution to these problems. Interactive lecture presentations can now be easily presented online in the form of webinars. Even a coordinated curriculum providing a comprehensive review of a broad topic can now be provided online via distance learning complete with instructors, regular feedback, and examinations. These tools now make it much more manageable for rural physicians to keep knowledge and skills up-to-date.

3.4.3 Systems-Based Solutions Even if medical schools and their surgical residencies were to train a new generation of surgeons for rural Canada, many of the barriers to high-quality surgical care would still exist. These barriers stem from systemic or organizational issues. A trauma victim requiring a general surgeon, an orthopedic surgeon, and a CT scan may have to visit three different hospitals, each hours apart. These are problems that compromise care and the solutions to these issues require organizational or system changes that need to be instituted by the administrators of the overall health system. These are changes that require vision, creativity, and leadership and should be done without automatically defaulting to the regionalization approach where all resources are simply removed. However, as Canada

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3  Surgery in Rural Canada: Challenges and Possible Solutions

has a coordinated single-payer health system, these changes, while difficult, are not impossible.

3.4.4 Training General Practitioners (GPs) As Surgeons Training some general practitioners (GPs) to perform certain basic surgical procedures and provide initial trauma stabilization could prove to be a vital element of improved surgical care in rural communities. However, what procedures could be appropriately ­performed by GPs and how GPS should be trained and certified continue to be debated. Currently, there is only one formal GP surgery training site in Canada, which was initiated 2 years ago. Training rural GPs in Advance Trauma and Cardiac Life Support (ATLS and ACLS) is practical and indeed existing pathways for this training already exist. Extending this to training GPs to provide basic anesthesia and perform basic surgical procedures such as Caesarian sections, appendectomies, endoscopies, and applying external fixation to long-bone fractures would be a practical next step for GPs who are committed to learning, and maintaining these skills. As might be expected, there is some resistance from specialist surgeons to training GP surgeons. However, the benefits to rural communities are potentially profound and examples exist in Canada. For example, the ability for a mother to have a caesarian section (C/S) performed locally would have a dramatic effect on obstetrical care in a community. Indeed, obstetrical care in British Columbia, Canada is in crisis. As less obstetricians (specialist surgeons) set up practice in rural communities, there are more expectations that the local general surgeons provide C/S capacity. However, as stated previously, less general surgeons are going to rural communities and even less are trained in C/S skills. GP surgeons often fill this gap but the lack of training programs and opportunities limits new GP surgeons in filling these roles. Therefore, GPs who previously managed obstetrical patients are now relinquishing their privileges in this area due to lack of surgical backup that then adds to an already stressful practice pattern. For those GP’s that maintain obstetric care in the face of all limitations, they now have extensive call duties that has led to burnout and either moving to a center with surgical obstetrical backup or being forced to quit obstetrics

care. Ultimately, it is patient care that suffers. Many pregnant patients would be able to stay in their home communities and deliver their babies locally rather than travel away from their family and friends – and at their own expense – to await the birth of their child in a strange community. Similarly, early intervention in trauma and urgent cases such as appendicitis would improve outcomes and decrease cost. If standardized programs, real-time mentoring from specialists, and close monitoring of performance were established, such training could substantially expand surgical care in rural Canadian communities.

3.4.5 Utilizing Physician Extenders (PEs) to Extend the Range of Surgeons in Rural Practices The use of physician extenders (PEs) such as nurse practitioners (NPs) and physicians’ assistants (PAs) offers practicing surgeons the chance to increase the number of patients that receive their care. NPs are already used in many rural communities and physicians’ assistants now practice in some Canadian provinces. There are three general ways that PEs can improve access and care in rural communities. All are predicated on the PE being well-trained and working closely under guidance from physicians. One model involves the PE working directly with a surgeon to substantially increase the volume of patients that the surgeon can see without decreasing the quality of care. With appropriate training and division of labor, it is not uncommon for a competent well-trained PE to nearly double a surgeon’s clinic volume. This would be extremely beneficial when one of the limitations and stressors of clinical practice for rural surgeons is workload and expectations to meet it. For this to occur, the surgeon or physician overseeing the PE must spend the time, often 2–6 months, to adequately train the PE about his/her practice. In addition, often the practice itself needs to be modified so as to facilitate a greater flow of patients. Changes may include opening up a separate clinic schedule for the PE as well as training the individuals who schedule patients so that the ­delegation of patients between physician and PE is organized for optimal efficiency. Another model uses well-trained PEs to provide patient care in emergency rooms and urgent-care

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facilities under guidance from a physician. This type of PE work could allow surgeons in a rural community to avoid burnout knowing that they have someone to help manage on-call referrals. For communities trying to recruit and retain a surgeon or surgeons, a team of well-trained and proactive PEs can have a positive impact on a surgeon’s lifestyle. GP surgeons have also demonstrated this positive effect in a mixedmodel where they work in the same community with a specialist colleague. This in turn makes it more likely that surgeons will stay in the community in question. Finally, many communities use NPs to provide independent patient care. This allows many rural communities to provide basic medical care locally. This model can work very well provided the PE is well trained and is integrated into the wider medical system. The ability for the NP to have a network of physicians (including the most proximal rural surgeon) that they can call to help facilitate and expedite patient care is important. A coordinated program using PEs has the very real potential of extending meaningful health care to many rural Canadians who are presently not able to adequately access the health-care system.

3.4.6 Financial Incentives Finally, surgeons choosing a rural practice will need to be rewarded financially. Perhaps the most practical way to do this is to ensure that adequate operating time is available for rural surgeons. This does require an increased financial commitment from the government and therefore can be a challenge. However, if programs to increase the provision of surgical care are funded with appropriate incentives, they can serve as a tool to recruit and retain surgeons in rural areas and thereby improve surgical care.

3.5 Conclusion The challenge of providing surgical care in rural Canada is real. Factors undermining the provision of surgical care in rural Canada include: an overall shortage of general surgeons; residency training programs that have relatively few role models for promoting the

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virtues of a rural practice; persistent difficulties in recruiting and retaining surgeons in rural communities; and limited resources for establishing and maintaining a coordinated surgical service. However, with these ­challenges come opportunities to develop creative solutions and the Canadian health-care system in many ways is well positioned to enact many of these solutions. These solutions include better education and role modeling to promote rural surgery as a career choice; incorporation of telemedicine to expand and improve care in rural communities; making systematic organizational changes to improve the delivery of surgical care in rural areas; training GP surgeons to provide some basic surgical care; and utilizing physician extenders to expand the delivery of surgical care. Applying potential solutions will require innovative leadership and a vision that what is needed, is possible.

References   1. Pong, R.W., Lemire, F., Tepper, J.: Physician retirement in Canada: what is known and what needs to be done. Paper prepared for the 10th international medical workforce ­conference in Vancouver, British Columbia, Canada, http:// www.cranhr.ca/pdf/10_retCAN.pdf, March 2007   2. Scott, I.M., Matejcek, A.N., Gowans, M.C., Nut Diet, M., Wright, B.J., Brenneis, F.R.: Choosing a career in surgery: factors that influence Canadian Medical students’ interest in pursuing a surgical career. Can. J. Surg. 51(5), 371–377 (2008)   3. Rinker II, C.F.: Meeting the needs of rural general surgeons: the ACS subcommittee on rural surgery. Bull. Am. Coll. Surg. 90(8), 13–18 (2005)   4. Kenny, N., Mann, K., MacLeod, H.: Role modeling in physicians’ professional formation: reconsidering an essential but untapped educational strategy. Acad. Med. 78(12), 1203–1210 (2003)   5. Shanafelt, T.D., Balch, C.M., Bechamps, G.J., Russell, T., Dyrbye, L., Satele, D., Collicott, P., Novotny, P.J., Sloan, J., Freischlag, J.A.: Burnout and career satisfaction among American surgeons. Ann. Surg. 250(3), 463–471 (2009)   6. Frank, J.R., Danoff, D.: The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med. Teach. 29(7), 642–647 (2007)   7. Royal College of Physicians and Surgeons of Canada CanMEDS website: http://rcpsc.medical.org/canmeds/ index.php Accessed/edited date feb 4, 2011   8. Reznick, R.K., MacRae, H.: Teaching surgical skills – changes in the wind. N. Engl. J. Med. 355, 2664–2669 (2006)   9. Norman, G.R., Schmidt, H.G.: The psychological basis of problem-based learning: a review of the evidence. Acad. Med. 67, 557–565 (1992)

Part Pre- and Postoperative Care

II

 

4

Fundamentals of Surgical Oncology Hanno Niess, Karl-Walter Jauch, and Christiane J. Bruns

4.1 Introduction The proceedings in characterization of molecular changes in tumour cells have led to widespread acceptance of the hypothesis that on the cellular level cancer is a genetic disease. Rapid progressions in the field of molecular biology are increasingly suggesting that the transformation of a normal cell to a malignant cell is a multi-step process. This transformation of the cell could be a result of multiple gene mutations, gene amplifications, changes in transcriptional and translational activity and constant over-activation on protein level. The accumulation of gene mutations mostly takes place in genes that are crucial for normal cellular growth. Essentially, one distinguishes between two classes of genes that are important for the development of a tumour: protooncogenes/oncogenes, which positively influence tumour growth; and tumour ­suppressor genes, which negatively influence tumour growth. In sporadically occurring tumours, these mutations are acquired in somatic cells (somatic mutation) whereas in inheritable tumours, the gene mutations are passed on over the germline (germline mutation) and thus the mutations are existent in all cells of the body. Therefore, the fields of molecular genetics and tumour biology play an important role in the elucidation of malignant diseases, and are of increasing relevance in medical diagnostics, and in the near future, also in tumour therapy.

H. Niess, K.-W. Jauch, and C.J. Bruns (*) Department of Surgery, University Hospital Grosshadern, Marchioninistr. 15, 81377 Munich, Germany e-mail: [email protected]

4.2 Basic Molecular Genetics in the Context of Tumour Formation Most sporadically occurring colorectal carcinomas emerge from polyps within 5–10  years in the framework of the so-called adenoma–carcinoma sequence (Fig. 4.1) [1]. In the course of the adenoma–carcinoma sequence, mutations and losses of certain alleles, e.g. FAP, Ki-ras, DCC, p53, accumulate within a normal mucosal cell. Within 5–10 years, these damaged alleles can turn a mucosal cell into an adenoma and finally into an invasive carcinoma. In sporadically occurring ductal pancreatic carcinoma, one can retrace a form of sequence that is similar to the adenoma–carcinoma sequence. Through molecular triggers, normal ductal pancreatic tissue develops into intraductal papillary mucinous neoplasms (IPMNs), then into pancreatic intraepithelial neoplasms (PanIN), and finally into an invasive ductal pancreatic carcinoma [2]. The genetic cause for this sequence is, on the one hand, loss of chromosomes on which potential tumour suppressor genes are located, e.g. loss of 1p, 6q, 9p, 12q, 17p, 18q and 21q. On the other hand, genetic alterations of genes such as k-ras, p16, cyclin D1, p53, MTS1, BRCA2 or SMAD4 sustain the ­progression of the pancreatic cancer sequence. Familial adenomatous polyposis (FAP) is an example of an inheritable disease with a detectable genetic defect that predisposes for tumour development. One can identify a defect in the so-called APC gene. However, only 1% of the cases of colorectal carcinoma are based on the existence of FAP. FAP has an autosomal dominant inheritance with nearly complete penetrance. It is characterized by the early appearance of multiple colorectal polyps, which inevitably leads to the formation of colorectal carcinomas in the young adult.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_4, © Springer-Verlag Berlin Heidelberg 2011

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H. Niess et al.

Normal mucosa

Mutation/ allele loss FAP gene

Mutation Ki-ras Tubular adenoma

5–10 years

Loss of DCC Adenoma with severe atypia

Adenocarcinoma Mutation/ allele loss p53 gene

3–5 years

Fig. 4.1  Adenoma–carcinoma sequence in colorectal carcinoma

In 80% of the cases, there is a germline mutation of the APC gene, which leads to a functional inactivation of the gene product. Certain mutations of the APC gene result in an attenuated form of FAP in which patients develop fewer tumours at a later time point [3]. Hereditary nonpolyposis colorectal cancer (HNPCC) represents another inheritable tumour disease. It is characterized by colorectal adenocarcinomas in patients with less than ten polyps and an early manifestation age (less than 50 years). It is also characterized by the location of the carcinoma, usually proximal to the left colic flexure (about 70% of the cases), and frequent metachronal and synchronal occurrence of the colorectal carcinomas. HNPCC is inherited in an autosomal dominant manner with a penetrance of a colorectal carcinoma of about 85–90% up to the age of 70. Additionally, genetic carriers have an elevated risk of developing carcinoma of the endometrium, stomach, ovaries, breast, small bowel, hepatobiliary tract, urothelium and brain. In about 44–86% of HNPCC families, one can detect a germline mutation in a DNA-mismatch-repair (MMR-) gene such as hMLH1 or hMSH2, rarely also hMSH6, hPMS1 or hPMS2. MMR-genes encode for proteins that correct faults in DNA replication. Loss of function of the

MMR-genes by inactivating mutations leads to the accumulation of DNA errors, which can be detected as microsatellite instability (MSI) in 85–95% of HNPCCassociated tumours [4].

4.3 Goals of Surgical Oncology Depending on their objective, the principles of surgical oncology are distinguishable between curative and palliative procedures [5]. Surgery with curative intentions has the objective of healing the patient by means of tumour excision and prevention of a relapse. Occasionally, additional nonsurgical tumour-specific measures are applied preoperatively (neoadjuvant) or postoperatively (adjuvant). Surgery and non-operative measures performed with palliative intentions have the purpose of preventing or alleviating symptoms or, generally put, to improve the quality of life in incurable situations (see Chap. 5). Cytoreductive surgery has the purpose of removing the major part of tumour tissue (also called debulking) to improve the initial situation for additional tumourdestructive treatments.

4  Fundamentals of Surgical Oncology

To what extent even a tumour resection, which was started with primarily curative intentions, leads to healing or fulfills a palliative purpose, depends on the type, localization and stage of the tumour disease as well as the type of surgery performed and other ­factors. A crucial point within this scenario also is the biology of the tumour, which until now could be manipulated only to a limited degree.

4.4 Curative Surgical Oncology Bearing in mind the patient’s quality of life, the topmost objectives of surgical oncology in a multimodal setting are clearance of the tumour and low procedurerelated morbidity and mortality. The fundamentals in oncological surgery with curative intentions are: 1. Tumour excision within healthy tissue, including potentially afflicted neighbouring structures 2. The removal of the regional lymphatic drainage according to the anatomy 3. The avoidance of intraoperative tumour cell spread To ensure the tumour excision within healthy tissue in parenchymal organs, tumours of the soft tissue and tumours of the GI tract, one needs to remove a circumferential safety margin around the macroscopically viewable tumour. The size of the safety margin differs between the specific types of organ tumours and depends on its growth characteristics and respective tumour stage. In early tumour stages, maintaining the respective safety margin is easier than at later stages, and thus the rate of locoregional tumour recurrences increases with increasing tumour stages. In case of doubt, frozen sections performed during surgery may help to confirm clear safety margins. The existence of metastases does not necessarily exclude from performing a curative surgical intervention. However, the prerequisites for a curative procedure in metastatic disease are that the primary tumour and all metastases need to be removable, and that there would be no residual metastases after the surgery. Certainly all these requirements must be achieved with a justifiable operative risk. Resection of distant metastases is performed ­primarily for metastases of colorectal carcinoma and sarcomas of the soft tissue located in lung and liver. In individual cases, it appears to be justified to also

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consider resection of distant metastases of renal cell carcinoma and malignant melanoma. Anatomic structures are of great importance in the selection of the resection layer. The resection layer in the curative excision of rectal carcinoma serves as a classic example: the complete removal of the mesorectum is achieved by preparation inside the avascular layer between the parietal pelvic fascia and the visceral pelvic fascia (Waldeyer’s fascia in dorsal position and Denonvillier’s fascia in ventral position). This step is, besides maintaining a sufficient dorsal safety margin, crucial to obtaining a surgical clearance that is adequate to the spatial extent of the tumour [6]. Another example of an adequately radical tumour excision is the compartment resection for soft tissue tumours as the complete removal of a tumour-afflicted muscle group [7]. With increasing tumour expansion, the probability of lymph node involvement by the tumour increases as well. Generally, there is a constant, anatomically definable route of lymphatic drainage for each organ. Elective and prophylactic lymph node dissection within the framework of surgical oncology is performed because of the fact that lymph node metastases are often only detected during histopathological ­examination. Therefore, the tumour-dependent regional lymphatic drainage system is completely removed, and in most of the cases, this needs to be performed en bloc with the removal of the primary tumour itself. The elective lymph node dissection is carried out for diagnostic reasons to evaluate the tumour stage and to estimate the prognosis. In certain tumours (e.g. breast cancer, gastric cancer), the lymph node status is a decisive prognostic parameter [8]. Furthermore, the lymph node status serves as a criterion for adjuvant therapeutic measures (colorectal cancer, breast cancer) [9]. Concerning the extent of the lymph node dissection in a curative setting, removal of the first lymph node station of the respective tumour-afflicted organ is acceptable. Assuming that some patients might profit from an extended surgical removal of further lymph node stations, this is justified only in cases where it does not increase the operative risk. The concept of sentinel lymph node biopsy has evolved under the assumption of a constant lymphatic drainage. This means that the findings in the first draining lymph node (the sentinel lymph node) are representative for the whole regional lymph node section. In certain tumour entities, the decision of removing or leaving the regional lymph node section is based on the findings in the sentinel lymph node. Breast cancer

20

and malignant melanoma are the tumour entities where most experience with sentinel lymph node biopsies exists. Few reports do also exist about initial results for tumours of the gastrointestinal tract [10]. If lymph node infiltration is evident prior to surgery, the lymph node removal is called selective or therapeutic lymph node dissection. In patients with infiltration of the tumour into anatomically neighbouring structures, one should aim for their removal together with the primary tumour (multivisceral en bloc resection). This is because loosening possible adhesions between the tumour and its neighbouring structures might lead to opening of the tumour capsule and thus dissemination of tumour cells. The decision on the extent of the surgical procedure should be made individually based upon the quality of life, the operative risk, and the overall prognosis under consideration of the tumour biology. For example, colon cancer with infiltration of the neighbouring small intestine, bladder, adnexa or uterus is preferably removed via en bloc resection without loosening tumour adhesions or examining frozen sections [11]. In contrast to this stands the strategy of pretreatment of, e.g. rectal carcinoma in a neoadjuvant setting with radio-chemotherapy to minimize and devitalize the tumour. This leads to the possibility of a subsequent resection, which can be less extensive and thus less risky with regard to impaired quality of life (colostomy, neo-bladder, sexual dysfunction) [12]. In oncological standard procedures as for example in colorectal cancer, the surgeon not only removes the primary tumour with its respective safety margin and regional lymphatic tissue but also tries to ligate the draining veins as early as possible. This serves the purpose of preventing haematogenous tumour cell dissemination and is called the ‘no-touch-isolation-technique’. In laparoscopic oncological procedures, the prevention of tumour cell dissemination is achieved by covering the surgical incisions with foil when retrieving the tumour from the abdomen. Metastases implanted into the skin after removal of incidental gall bladder carcinoma have been described and these patients usually require additional surgery including excision of the port sites.

4.5 Palliative Surgical Oncology Despite curative objectives, only 50% of the patients with tumours of the gastrointestinal tract can be healed. In the other half of the patients with tumours of the GI

H. Niess et al.

tract, a surgical approach can only be considered as being palliative. The role of palliative surgical oncology is improvement of quality of life in patients with incurable disease by alleviating or abolishing tumour-related symptoms. In a broader sense, palliative surgical oncology has a prophylactic character by preventing the appearance of complications in advanced tumour disease and maintaining acceptable quality of life for the patients as long as possible. Palliative surgery includes the following procedures: removal of the primary tumour despite existence of distant metastases (e.g. colorectal carcinoma with distant metastases to prevent bowel obstruction or ­haemorrhage), small bowel anastomoses to bypass a tumour-induced bowel obstruction, colostomies, endoscopic procedures and procedures that prepare for ­supportive measures (e.g. port implantation). However, for gastric outlet stenosis produced by a locally advanced distal gastric carcinoma, the ­palliative distal gastric resection and thus removal of the tumour is superior to a gastro-enterostomy as bypass procedure, this of course only if the procedure comes with a justifiable perioperative risk for the patient. Further examples of palliative tumour resection include the lobectomy in abscessing advanced lung cancer or mastectomy in ulcerating metastasized breast cancer. Under certain circumstances, lifethreatening complications of a tumour disease may justify extended tumour resections in case the emergency situation can only be mastered by surgery, even if they involve a substantially increased risk (e.g. gastrectomy in massive bleedings from gastric cancer with distant metastases). Endocrinologically active non-resectable tumours justify procedures to downsize the tumour and thus alleviate symptoms and improve quality of life. However, in advanced tumours, often the only remaining option is to perform procedures that leave the tumour in situ. Besides surgery, other ­possible procedures are medicinal treatment, endoscopic or interventional radiology procedures, and radiotherapy. The selection of the correct procedure depends on the degree of impairment of quality of life by the tumour, the expected prognosis, the risk of the procedure and the patient’s wishes. Supportive measures are especially relevant in incurable situations. Among those are adequate pain therapy and nutritious support.

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4  Fundamentals of Surgical Oncology

4.6 Surgical Oncology as Part of a Multimodal Tumour Therapy Today surgical oncology usually is part of a multimodal interdisciplinary concept of tumour therapy. A multimodal approach includes classic procedures such as surgery, chemotherapy and radiotherapy. However, nowadays it also includes interventional radiology procedures such as chemoembolization, radiofrequency ablation, as well as systemic molecular biology approaches so-called targeted therapy. The respective multimodal treatment and the order of the different procedures should be discussed in an interdisciplinary tumour board and ascertained for each patient on an individual basis. Locally advanced rectal carcinoma (T3-4, N1) represents a typical example of a multimodal treatment approach. Before undergoing surgery (anterior rectosigmoid resection, low anterior resection, abdominoperineal resection), patients receive neoadjuvant radiochemotherapy, which is continued as systemic adjuvant chemotherapy after surgery. In doing so, the prognosis of these patients has been substantially improved and the risk of local recurrent tumour is significantly decreased [13]. Furthermore, the rate of sphincter-preserving surgery in tumours near the anal sphincter has been increased without impairment of the oncological radicality. To allow for local resectability in pancreatic cancer, similar approaches such as neoadjuvant radiochemotherapy are applied. Moreover, approaches from mole­ cular biology such as anti-angiogenic therapy (e.g. Bevacizumab in metastasized colorectal cancer) or thyrokinase inhibitors (e.g. Erlotinib in advanced ­pancreatic cancer) may be part of the multimodal treatment. The overall goal of multimodal oncological therapy is to improve the prognosis of each individual patient with the underlying tumour disease under consideration of the prognostic factors.

4.6.1 Established Prognostic Factors From many clinical trials the following prognostic factors relevant for therapy in oncology have evolved: • R-status (residual tumour status) • pTNM status

• Grading • Lymph node ratio (number of lymph nodes diseased/ number of lymph nodes removed) • Perioperative complications (nutritious status, total blood loss, need for blood transfusions, infections) • Tumour-specific experience of the treating centre (‘high volume hospitals’)

4.6.1.1 Residual Tumour Status (R-Status) The R0 status (no residual tumour) should relate to the primary tumour, its respective lymphatic drainage pathway and, if applicable, distant metastases. • Absolute R0 resection: All three dimensions of the primary tumour and the lymphatic drainage are free of tumour (lymph node ratio < 0.2) • Relative R0 resection: All three dimensions of the primary tumour and the lymphatic drainage are free of tumour but with an insufficient size of safety margins (lymph node ratio > 0.2) • R1 resection: Microscopic tumour residual • R2 resection: Macroscopic tumour residual

4.6.1.2 TNM Classification The TNM classification allows for an anatomic description of the tumour spread. T describes the extent of the primary tumour: • T0: No indications of a primary tumour (CUP: cancer of unknown primary) • Tis/Ta: The tumour has not infiltrated other tissue; these tumours usually go along with a good prognosis • T1, 2, 3 or 4: Increasing size of the tumour/infiltration of certain tissue layers in hollow organs/infiltration of adjacent organs • Tx: No statement about the primary tumour possible N describes the existence or absence of regional lymph node metastases: • N0: No evidence for lymph node infiltration • N1, 2 or 3: Increasing lymph node infiltration; classification into ipsilateral or contralateral affliction and mobility, as well as in relation to the primary tumour and number of positive lymph nodes • Nx: No statement on lymph node affliction possible

22

M describes the existence or absence of distant metastases: • M0: No evidence for distant metastases • M1: Distant metastases present • Mx: No statement on distant metastases possible

4.6.1.3 Grading/Histomorphologic Features Further addenda to describe the tumour are histomorphologic features such as Grading (G1–G4): Histomorphologic feature describing the state of differentiation of the tumour tissue • G1 = well differentiated; which means that the tumour tissue resembles the tissue of origin closely • G4 = undifferentiated; the tissue of origin is only detectable by ultrastructural or immunohistochemical analysis L0/L1: Invasion into lymph vessels or tumour cell emboli inside lymph vessels; contact to the lymph ­vessel wall is not necessary for the diagnosis V0/V1/V2: Invasion into veins (none/microscopic/ macroscopic) Sx/S0, 1, 2 or 3: Serum tumour markers; these are only registered in malignant testicular cancer (Sx: not available/examined; S0 = normal, S1–3 = at least one marker elevated) 4.6.1.4 Certainty of the Diagnostic Findings Adding the descriptor ‘C’ to the respective TNM category creates the possibility to denote certainty of the diagnostic findings. • C1: General examination methods such as physical examination or standard x-ray, etc. • C2: Special examination methods such as ERCP, CT, MRT, etc. • C3: Results of the surgical exploration, cytology or biopsy • C4: Insights from the surgical resection, the histopathologic examination; equivalent to the pTNM classification • C5: Insights from the autopsy including histopathologic results

H. Niess et al.

4.6.1.5 UICC-Staging In the framework of staging tumour diseases, several TNM categories are summarized into one UICC stage according to their prognosis. UICC stage

pTNM categories

Stage 0

TisN0M0

Stage I

T1, T2, N0, M0

Stage II

T3, T4, N0, M0

Stage III

Any T, N1, N2, M0

Stage IV

Any T, any N, M1

The UICC stages indicate that the size of the primary tumour is not the decisive factor for prognosis of the patients but the lymphatic and haematogenous dissemination (stage II vs. stage III). 4.6.1.6 Minimum Number of Lymph Nodes to Be Examined in Tumours of the GI Tract To be able to give an applicable statement on the lymph node status of the respective gastrointestinal tumour for the TNM classification, the examination of a minimum number of lymph nodes is required (Table 4.1). The lymph node ratio is calculated from the proportion of tumour-positive lymph nodes to the total number of lymph nodes removed.

Table 4.1  Required minimum numbers of lymph nodes to be removed Localization of the tumour

Minimum number of lymph nodes to be removed

Stomach

15

Colon, rectum

12

Pancreas

10

Liver, gall bladder, extrahepatic biliary tract

3

23

4  Fundamentals of Surgical Oncology

4.6.1.7 Perioperative Management One important factor that influences the outcome of oncological operations is the preoperative nutritional status of the patient [14]. Tumour cachexia is mostly accompanied by a poor protein synthesis by the liver and thus leads to immunosuppression. This status of impaired healing can then lead to infection and sepsis in the postoperative period. Immunosuppression on the one hand, and paracrine or endocrine effects of stress factors (IL-6, TNF-a, NFkB, etc.), growth factors (epidermal growth factor [EGF], vascular endothelial growth factor [VEGF], etc.) secreted by the remaining immune-competent cells on the other hand support angiogenesis and cell proliferation and thus lead to stimulation of tumour growth. Hence, performing surgery with a low rate of complications is also a factor relevant to prognosis (Fig. 4.2). A similar prognostic factor has been established in intraoperative blood loss and the amount of blood products given [15]. Apart from the early detection and correction of co-morbidities (cardiovascular and pulmonary risk factors, diabetes, renal failure, liver failure, preceding operations, etc.), the preparation of the tumour patient for surgery includes the optimization of his nutritional status. This is achieved by substituting calories, vitamins, trace elements, etc., depending on the extent of malnourishment. If necessary, total parenteral

nutrition with simultaneous application of oral immunonutrition is given over a period of 5–7 days before surgery.

4.7 Influence of Surgery on Metastasization Especially in colorectal cancer – but also in other tumours of the gastrointestinal tract – it has been discovered that the primary tumour possesses the ability to produce anti-angiogenic substances (e.g. angiostatin), which inhibit the outgrowth of micrometastases, for example in the liver, to macrometastases. These substances are secreted amongst others by the primary tumour and reach the liver by bloodstream. Thus, they act as endocrine substances. As long as the primary tumour remains in place micrometastases will form. However, they will also remain in their micrometastatic state because the decisive proangiogenic stimulus needed for a macroscopic outgrowth is suppressed amongst others by these substances secreted by the primary tumour [16]. This phenomenon of invisible, asymptomatic tumour cell spread is called ‘dormant disease’. As soon as the primary tumour has been surgically removed, the suppressing anti-angiogenic effect is absent and

Cell proliferation TNFa, NFkB IL-6

Immune cells VEGF, EGF, etc. Angiogenesis

Fig. 4.2  Influence of postoperative complications on tumour growth

For example, anastomotic insufficiency, peritonitis, sepsis

Immunosuppression

Tumour growth

24

H. Niess et al.

Fig . 4.3  ‘Tumour dormancy’ – antiangiogenic effects of the primary tumour on existing micrometastases Micrometastases

The primary tumour secretes antiangiogenic substances (endostatin, angiostatin)

Macrometastases

Discontinuation of antiangiogenic substances leads to growth of the metastases

Primary tumour

Before resection of the primary tumour

the micrometastases are able to generate an ‘angiogenic phenotype’. This leads to tumour cell proliferation and formation of visible, possibly symptomatic macrometastases (Fig. 4.3). Multimodal concepts of therapy, e.g. surgery with subsequent chemotherapy, are necessary to prevent such developments. Modern anti-angiogenic drugs and strategies might also be helpful to avoid the outgrowth of micrometastases.

4.8 Tumour Angiogenesis One decisive step for tumour growth as well as for the process of tumour cell spread is the creation of a sufficient vascular network inside the tumour and its surrounding tissue. Tumours that are smaller than 1 mm in diameter obtain their nutrients and oxygen by the process of diffusion. The larger the tumour becomes the more its growth is dependent on adequate formation of new vasculature. The transition of a microscopic tumour, which is not detectable by the established clinical examination methods into a macroscopic, clinically detectable mass is called the ‘angiogenic switch’ [17].

After resection of the primary tumour

The development of new vasculature in tumours is partially supported by the production and secretion of pro-angiogenic factors by the tumours itself, and partially by the production and secretion of ­pro-angiogenic factors in the surrounding tissue. Ultimately, the formation of new vasculature depends on the interaction between stimulating and inhibitory angiogenic factors produced by the tumour and its surrounding tissue. Presumably, the production of a multitude of pro-angiogenic factors is necessary to sustain vascular formation. The initiation of angiogenesis (Fig.  4.4) then leads to an exponential tumour growth. A very important pro-angiogenic factor is the ‘vascular endothelial growth factor’/‘vascular permeability factor’ (VEGF/VPF). The receptors for the growth factor VEGF are almost exclusively expressed on endothelial cells. After binding to their receptors, VEGF and others exert pro-angiogenic effects in terms of endothelial cell proliferation, degradation of extracellular matrix, endothelial cell migration, tube formation, and finally development of a tumour vessel system. Furthermore, in particular, VEGF acts as a survival factor for endothelial cells under hypoxia stress. A parameter used in many tumour systems to measure the influence of pro-angiogenic

25

4  Fundamentals of Surgical Oncology Tumour angiogenesis

Small localized tumour < 1 mm3

Tumour can now grow and spread

VEGF, bFGF, IL-8, HIF-1a, etc. molecule

Blood vessel

Fig. 4.4  Tumour angiogenesis

factors is the so-called microvessel density. To some extent, the microvessel density correlates with the degree and progression of the tumour disease and the general prognosis.

References   1. Schackert, H.K., Gebert, J., Ansorge, W., Herfarth, C.: Molecular principles of carcinogenesis. Significance of prevention and early detection of solid malignant tumors. Chirurg 64(9), 669–677 (1993)   2. Biankin, A.V., Kench, J.G., Dijkman, F.P., Biankin, S.A., Henshall, S.M.: Molecular pathogenesis of precursor lesions of pancreatic ductal adenocarcinoma. Pathology 35(1), 14–24 (2003)   3. Abdel-Rahman, W.M., Pletomaki, P.: Molecular basis and diagnostics of hereditary colorectal cancer. Ann. Med. 36(5), 379–388 (2004)   4. Chung, D.C., Rustgi, A.K.: The hereditary nonpolyposis colorectal cancer syndrome: genetics and clinical implications. Ann. Intern. Med. 138(7), 560–570 (2003)   5. Junginger, Th., Schlag, P.M.: Prinzipien der Chirurgischen Tumortherapie. Interdisziplinäre Leitlinie der Deutschen Krebsgesellschaft und der Chirurgischen Arbeitsgemein­ schaft Onkologie (CAO) der Deutschen Gesellschaft für Chirurgie. Kurzgefasste Interdisziplinäre Leitlinien 2002. 3. Auflage (2005)   6. Heald, R.J., Häsband, E.M., Ryall, R.D.: The mesorectum in rectal cancer surgery – the clue to pelvic recurrence? Br. J. Surg. 69, 613–616 (1982)

  7. Enneking, W.F., Spanier, S.S., Malawer, M.M.: The effect of the anatomic setting on the results of surgical procedures for soft parts sarcoma of the thigh. Cancer 47, 1005–1022 (1981)   8. Hölzel, D., Engel, J., Schmidt, M., Sauer, H.: Modell zur primären und sekundären Metastasierung beim Mammakarzinom und dessen klinische Bedeutung. Strahlenther. Onkol. 1, 10–23 (2001)   9. Junginger, Th, Hossfeld, D.K., Sauer, R.: Aktualisierter Konsensus der CAO, AIO und ARO zur adjuvanten Therapie bei Kolon- und Rektumkarzinom von 1.7.1998. Dtsch. Ärztebl. 96, 698–700 (1999) 10. Tsioulias, G.J., Wood, ThF, Morton, D.L., Bildnik, A.J.: Lymphatic mapping and focused analysis of sentinel lymph nodes upstage gastrointestinal neoplasms. Arch. Surg. 135, 926–932 (2000) 11. Hohenberger, W., Meyer, Th: Grundzüge der chirurgischen Onkologie. Zbl. Chir. 125, W39 (2000) 12. Budach, W., Hoffmann, W., Bamberg, M.: Stellenwert der Radiochemotherapie beim Rektumkarzinom. Verdauungsk­ rankh 16, 156–166 (1998) 13. Smith, D.E., Muff, N.S., Shetabi, H.: Combined preoperative neoadjuvant radiotherapy and chemotherapy for anal and rectal cancer. Am. J. Surg. 151(5), 577–580 (1986) 14. Klek, S., Kulig, J., Szczepanik, A.M., Jedrys, J., Kolodziejczyk, P.: The clinical value of parenteral immunonutrition in surgical patients. Acta Chir. Belg. 105(2), 175–179 (2005) 15. Takemura, M., Osugi, H., Higashino, M., Takada, N., Lee, S., Kinoshita, H.: Effect of substituting allogenic blood transfusion with autologous blood transfusion on outcomes after radical oesophagectomy for cancer. Ann. Thorac. Cardiovasc. Surg. 11(5), 293–300 (2005)

26 16. Hahnfeldt, P., Panigrahy, D., Folkman, J., Hlatky, L.: Tumor development under angiogenic signalling: a dynamical ­theory of tumor growth, treatment response, and postvascular dormancy. Cancer Res. 59(19), 4770–4775 (1999)

H. Niess et al. 17. Udagawa, T., Fernandez, A., Achilles, E.G., Folkman, J., D’Amato, R.J.: Persistence of microscopic human cancers in mice: alterations in the angiogenic balance accompanies loss of tumor dormancy. FASEB J. 16(11), 1361–1370 (2002)

5

Palliative Surgery Matthias W. Wichmann

5.1 Introduction Palliative surgery is an important part of surgical ­decision-making and should be carried out in agreement with a treatment decision based on the individual patient’s decision for his or her end-of-life treatment. The surgical team must try to identify the treatment goals together with the patient and the patient’s family – these may vary in patients with identical diagnosis and prognosis and it is important that the surgeon does not base the decision on what appears possible, but on what the patient has expressed as primary palliative treatment goals. It is also important to note and to explain, that palliative treatment does not aim to prolong life but to provide best possible symptom control (pain, nausea and vomiting, intestinal obstruction, ­dyspnoea). Obviously, palliative (surgical) care also does not aim to actively reduce the patient’s life expectancy. In the author’s view, palliative surgical care should be a team decision with the patient and his/her family in the center and a number of team members including (palliative care) nurses and allied health, social workers, psychologist, pain service, surgeons and palliative care physicians. In the rural setting, not all of these important contributors to palliative care may be available, which makes the role of the team leader (surgeon, if admitted under his/her care) even more important. For the rural surgeon, it is also important to consider that extensive surgery may require High Dependency Unit (HDU) or even Intensive Care Unit (ICU) admission which may M.W. Wichmann Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected]

not be available in the patient’s hometown, and therefore would require transfer away from the patient’s family. This is an important factor for most patients, and must be discussed prior to surgical intervention. It is also important to consider that operative morbidity is common (up to 40%) after palliative surgery and that a number of patients (10%) require additional surgery for the morbidity.

Palliative care is a team approach aiming at best ­possible symptom control during end-of-life treatment and focusing only on the patient’s/patient’s family decision regarding the priorities of treatment goals.

5.2 Surgical Palliative Procedures Malignant obstruction of the trachea or main bronchi: These lesions are usually suitable for bronchoscopic intervention including stent insertion, argon plasma beam coagulation, or laser ablation (see Chap. 6). Significant bleeding which cannot be controlled via bronchoscopy may require palliative resection of the affected lobe. Esophageal cancer: If a malignancy of the esophagus is not resectable due to advanced disease, most patients will receive palliative radio-chemotherapy under the care of medical and radiation oncology. In this setting surgical intervention may become necessary in terms of endoscopic stenting or endoscopic placement of a feeding gastrostomy (PEG) (see Chap. 7). Palliative resection of an advanced esophageal cancer is usually not recommended due to the significant morbidity and the range of endoscopic treatment options.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_5, © Springer-Verlag Berlin Heidelberg 2011

27

28

Gastric cancer: If the patient is fit for surgery, p­ alliative gastrectomy, or partial gastrectomy should always be considered first since these procedures offer best palliation and symptom control compared to endoscopic treatment or bypass surgery. If a resection is not possible, a gastro-jejunostomy (Roux-en-Y) as a palliative bypass should be constructed for malignant gastric outlet obstruction. Since the patient usually is less mobile and spends a lot of time in bed, an anastomosis at the posterior wall of the stomach should be preferred unless the underlying malignancy precludes sufficient mobilization of the stomach. Passage of a nasogastric tube through the anastomosis may improve the symptoms of postoperative paresis of the upper gastrointestinal tract. At the time of surgery, a feeding jejunostomy should also be considered. If a bypass cannot be constructed, a feeding jejunostomy plus a venting PEG are the author’s treatment of choice for malignant gastric ­outlet obstruction. Pancreatic cancer: Only 30% of all pancreatic ­cancers are resectable at the time of diagnosis. Surgical palliation therefore is an important part of pancreatic surgery. The decision for palliation very often must be made during explorative surgery when a pancreatic cancer which was considered resectable is shown to be non-resectable. The life expectancy in these patients is short (approximately 6 months) and surgical morbidity must be low. Biliary bypass surgery can be done using the gall bladder (cholecysto-jejunostomy) provided the gall bladder has flow into the common bile duct (can be probed via the cystic duct). If access to the common duct is good, a choledocho-jejunostomy or hepaticojejunostomy should be preferred. After removal of the gall bladder a cholangiogram can be done prior to construction of a side-to-side anastomosis between a Roux-en-Y jejunal limb and the common hepatic duct or the common bile duct. Duodenal obstruction may not be present at the time of initial surgery but frequently develops prior to the patient’s death from pancreatic cancer. We, therefore, suggest to also construct a side-to-side gastro-jejunostomy within the same surgery to avoid a repeat intervention at a later point in time when duodenal obstruction has developed. If preoperative staging indicates a non-resectable disease, palliative treatment may also be possible using endoscopic stents (metallic stents) which are introduced via ERCP (see Chap. 9). Gall bladder/bile duct cancer: Surgical palliation of non-resectable disease can be done using a

M.W. Wichmann

Roux-en-Y jejunal limb bypass or endoscopic stenting (usually metallic stents). There appears to be no survival advantages of either of the two approaches. In patients where endoscopic stent placement is not possible due to previous surgery or due to tumor growth, a percutaneous drainage is possible and even a percutaneous stent insertion can be attempted. We try to avoid ongoing percutaneous drainage wherever possible due to significant pain and discomfort resulting from a drain in the liver. Small bowel cancer: Non-resectable small bowel cancer can usually be treated using entero-enteric bypasses with side-to-side anastomosis between nonaffected parts of the small bowel. We prefer a two-layer running suture anastomosis with absorbable sutures. Colon cancer: Patients suffering from non-resectable large bowel cancer usually present with bowel obstruction. Non-resectability may result from the extent of tumor disease or the patient’s general health. Endoscopic stenting of the tumor stenosis has been shown to effectively treat the bowel obstruction and can be used as a bridging procedure prior to definite resection (after adequate resuscitation of the patient) or as a sole treatment if the patient is not considered/suitable for additional resection of the cancer. Stenting, however, does require a lumen which can be passed with the guide wire. If no rest-lumen can be identified, endoscopic stenting is not an option and palliative stoma (loop-colostomy) formation or bypass construction may be the only treatment options. Rectal cancer: Low rectal cancer may not be suitable for endoscopic stenting in view of the possibility to cause fecal incontinence and severe perineal pain. This has to be decided based on the exact position of the tumor and the length of the required stent. Good results can be obtained with stents within the rectosigmoid junction, although recent reports also suggest the option of pain-free stenting within 5 cm from anal verge. Obstructing lesions in the mid-rectum and lower third of the rectum usually require formation of a loopcolostomy for adequate palliation. Uncontrolled bleeding from rectal cancers can very often be managed endoscopically (injection, argon beam, laser, stent), or may require palliative resection even if complete clearance of the tumor cannot be achieved. Malignant ureteric obstruction: Retrograde stenting of the ureter is the treatment of choice, but may not be possible in all patients. If the retrograde approach fails, a percutaneous nephrostomy should be performed which may allow for antegrade stent placement.

29

5  Palliative Surgery

In view of the significant number of patients treated for non-resectable upper GI tract or large bowel cancer, the rural surgeon should be familiar with the technique of endoscopic stent application and a selection of endoscopic stents should be available in a rural center with an active endoscopy unit.

to sustain life and provide care regardless of whether the treatment is appropriate and compassionate given the condition of the patient. This makes palliative surgery a very challenging and interesting field of surgical decision-making.

Recommended Reading 5.3 Summary Palliative surgery is a very demanding part of our work and should ideally be part of a team approach to the patient’s end-of-life treatment. The patient’s wishes regarding this part of his or her life must guide any decision made by the treating team. With regard to this, it is of utmost importance to be aware of the fact that technological advancements have provided the means

Cady, B., Miner, T., Morgentaler, A.: Part 2: Surgical palliation of advanced illness: what’s new, what’s helpful. J. Am. Coll. Surg. 200, 281–290 (2005) Coustasse, A., Quiroz, T., Lurie, S.G.: To the bitter end: disparities in end-of-life care. J. Hosp. Mark. Public Relations 18, 167–185 (2008) Dunn, G.P.: Palliative surgery. In: Walsh, D. (ed.) Palliative Medicine, pp. 535–540. Elsevier Saunders, Philadelphia (2009) Tilney, H.S., Lovegrove, R.E., Purkayastha, S., et al.: Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg. Endosc. 21, 225–233 (2007)

 

6

Fiber Optic Endoscopy: Bronchoscopy Matthias W. Wichmann and Fritz W. Spelsberg

6.1 Introduction Practical knowledge and experience with bronchoscopy are of relevance not only for interventions within the trachea and the lung, but also for interventions within intensive care. With regard to this, bronchoscopy is not only a diagnostic but also a therapeutic tool. The anatomy of the bronchial system is illustrated in Fig. 6.1.

1

6.2 Instruments Flexible bronchoscopy, preferably with a video-­ bronchoscope, is the standard procedure with an instrument measuring approximately 5–6 mm in diameter. At the tip, the instrument can be flexed in two directions and it usually has one working channel (2.8–3.2 mm). Rigid bronchoscopy has few indications only, e.g., massive bleeding, foreign body removal.

M.W. Wichmann (*) Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected] F.W. Spelsberg Department of Surgery, University of Munich – Campus Grosshadern, Marchioninistr. 15, 81377 Munich, Germany

2 4

3

7

8 9

5 6

1 - trachea 2 - carina 3 - right main bronchus 4 - right superior lobe bronchus 5 - right middle lobe bronchus 6 - right inferior lobe bronchus 7 - left main bronchus 8 - left superior lobe bronchus 9 - left inferior lobe bronchus

Fig. 6.1  Diagram of the tracheo-bronchial system for documentation of bronchoscopic findings

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_6, © Springer-Verlag Berlin Heidelberg 2011

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M.W. Wichmann and F.W. Spelsberg

6.3 Patient Preparation Prior to the procedure, elective patients should be fasted for at least 6 h and anticoagulants should be stopped as indicated (7  days for aspirin, clopidogrel, warfarin, 24 h for low-molecular heparin). Atropine (0.5 mg sc) can be given as pre-medication, and following local anesthesia of the nasopharynx (spray, inhalation), i.v. sedation (midazolam 3–5  mg, propofol 2  mg/kg  bw) should be given. Intraoperative monitoring of oxygen saturation and liberal application of oxygen with a mask are mandatory. The bronchoscope can be introduced through the nose (or mouth) under vision. In ventilated patients, the bronchoscope is advanced through the endotracheal tube or laryngeal mask. Within the trachea, additional topical local anesthesia should be applied with a pump spray via the working channel.

6.4 Indications Common indications for bronchoscopy are summarized in Table 6.1.

6.5 Diagnosis and Treatment of Haemoptysis Any form of haemoptysis must be investigated with a bronchoscope. Preoperative investigations have to differentiate true haemoptysis from pseudo-­haemoptysis, which is caused by bleeding in the nasopharynx or the upper gastrointestinal tract. True haemoptysis usually Table 6.1  Indications for bronchoscopy Preoperative Intraoperative

has bright red foamy blood and the patient suffers from significant dyspnea and coughing. Mortality of this condition is as high as 80%, depending on the underlying cause. Table  6.2 summarizes the most common causes of haemoptysis. Around 90% of pulmonary bleedings originate from the bronchial arteries and 5% come from the pulmonary vessels, which means that the systemic arterial blood pressure is relevant for the severity of the bleeding. Patients with haemoptysis are initially managed with oxygen administration, chest elevation or positioning on the affected body side (if known). Blood, circulating volume, and coagulation factors should be substituted as needed. Patients who are not compromised with regard to blood pressure and oxygenation should first have a computed tomography (or chest X-ray if not available). Patients with compromised blood pressure despite substitution should be intubated early, and then require urgent bronchoscopy. Cave: Patients with pulmonary bleeding are ­primarily endangered due to hypoxia and not due to blood loss. In patients with massive bleeding, a rigid bronchoscopy may become necessary in order to directly occlude the bleeding bronchus. Following intubation, the bleeding source or at least the side of bleeding has to be established to allow for separate ventilation of the non-affected lung (intubation of

Postoperative

Intervention

Hoarseness

Intubation

Atelectasis

Aspiration

Persistent cough

Position control of ventilation tube

Anastomotic leakage

Foreign body

Dyspnea, stridor

Control of tracheal anastomosis

Bronchial stump leakage

Stenosis

Haemoptysis

Anastomotic stenosis

Tracheo-malacia

Histology needed

Follow-up

Lavage

Esophageal cancer

Fistula

Tracheal rupture

Palliation

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6  Fiber Optic Endoscopy: Bronchoscopy Table 6.2  Causes for haemoptysis Neoplastic Infectious

Cardiovascular

Traumatic

Others

Cancer

Tuberculosis

Embolus

Iatrogenic

Bronchiectasis

Metastasis

Pneumonia

Cardiac failure

Trauma

Endometriosis

Carcinoid

Abscess

Aneurysm

Sarcoidosis

Fungal

Wegener’s granulomatosis

Cystic fibrosis

Behcet’s syndrome Systemic lupus erythematosus

the main bronchus or usage of a double lumen tube). After securing the ventilation, a balloon can be used to selectively occlude the bleeding bronchus if this can be identified. Bronchoscopy also allows for ablation of malignant lesions and associated bleeding complications using laser therapy, argon-plasma coagulation, diathermy and cryosurgery. Furthermore, cold water and topical agents for vasoconstriction (adrenalin) can be used for bleeding control. In specialized centers, radiological embolization of the bleeding vessel may be possible using superselective catheters. If these interventions are not available or not successful, emergency surgery may be necessary.

6.6 Bronchoscopy-Assisted Intubation Conventional intubation may be impossible due to a number of causes (i.e., immobile cervical spine due to inflammatory processes/autoimmune disease, fractures of the cervical spine, enlarged thyroid, ENTcancer) and bronchoscopic assistance may be necessary. Usually, the ventilation tube is passed over the bronchoscope and this is then passed through the nose or the mouth into the trachea being subsequently used as a “guide-wire” for the passage of the ventilation tube. The correct position of the tube can then be visualized prior to withdrawal of the bronchoscope.

6.7 Percutaneous Puncture Tracheostomy Patient requiring long-term ventilation may require a tracheostomy, which can be constructed using a percutaneous dilatation tracheostomy kit. The bronchoscope

is placed into the trachea to confirm correct positioning of the guide wire following puncture of the trachea between the second and third cartilage and subsequent dilatation of the opening to fit a tracheal ventilation tube. It is important to note that percutaneous puncture tracheostomy carries significant risks of laceration of surrounding tissues and intraoperative complications and should not be performed by a novice without an assistant experienced in percutaneous puncture tracheostomy.

6.8 Bronchoscopic Treatment of Atelectasis Due to pain and inadequate mobilization, hypoventilation of one or several segments of the lung (atelectasis) can be observed after thoracic as well as abdominal surgery. This condition may require bronchoscopic intervention if patient positioning and physiotherapy do not resolve the problem. Bronchoscopy is much less traumatic than blind catheter aspiration of the lung, and allows for selective aspiration of the mucous as well as topical application of a mucolytic agent (acetylcysteine).

6.9 Treatment of Tracheo-Bronchial Stenosis Stenosed segments of the tracheo-bronchial system are a dangerous condition and cause significant discomfort for the patient due to dyspnea, retention pneumonia, bleeding, and coughing. Malignant, non-operable lesions require endoluminal therapy using laser or

34

argon-plasma coagulation as well as stenting or after loading therapy since systemic chemotherapy and radiation therapy usually do not have a sufficient local effect on the stenosis within the tracheo-bronchial system. Bronchoscopic re-canalization of the respiratory tract can be a life-saving palliative intervention in these situations. Stents may also be useful for the treatment of tracheo-malacia and for the closure of fistulas between the trachea and the esophagus (malignant or postoperative). A number of various stents are available for these indications.

6.10 Complications During bronchoscopy, hypoxia and hypercapnia can develop, especially in patients with compromised lung function. Furthermore, laryngeal or bronchial spasms and arrhythmias can be observed due to the intervention. Laceration of the trachea and/or bronchi can cause bleeding or perforation of these structures.

6.11 Rigid Laryngoscopy This procedure allows direct assessment of the ­oropharynx (base of tongue, vallecula, epiglottis), pharynx proper, larynx (vocal cords), and proximal

M.W. Wichmann and F.W. Spelsberg

trachea. The endoscope is inserted into the back of the mouth and delivers a magnified view of the laryngeal structures using an angled lens system. The procedure usually requires intubation and allows for detailed vision, biopsy and manipulation of all structures in the pharynx and larynx. Rigid laryngoscopy may be especially useful for removal of large foreign bodies, bleeding control and can also help to better visualize pathology within the upper third of the esophagus (i.e., endoscopic pouch repair). Rigid laryngoscopy carries a higher risk of soft tissue laceration, vocal cord edema and bleeding than flexible laryngoscopy and should not be carried out without proper training.

Recommended Reading Freitag, L.: Interventional endoscopic treatment. Lung Cancer 45, S235–S238 (2004) Rowe, L.D.: Otolaryngology – head and neck surgery. In: Doherty, G.M. (ed.) Current Surgical Diagnosis and Treatment, pp. 967–973. McGraw-Hill, New York (2006)

7

Fiber Optic Endoscopy: Gastroscopy Matthias W. Wichmann and Fritz W. Spelsberg

7.1 Introduction Flexible endoscopy is a significant part of the everyday workload of most general surgeons. The ongoing development of this technology has contributed to ­significant reduction of access trauma in most surgical specialties as well as in general surgery. Flexible endoscopy is part of preoperative assessment and treatment planning; it allows for intraoperative evaluation of the surgical site (i.e., anastomosis after resection, width of esophagus after fundoplication) and is part of the management of post-operative complications (i.e., stenting of fistulas, dilatation of stenoses, washout of anastomotic leakage). The endoscopic treatment of early stages of gastro-­intestinal cancers has been established, as well as the useful application of flexible endoscopy during so-called rendezvous procedures with minimal invasive surgery (i.e., resection of gastro-intestinal stroma tumors). Moreover, interventional endoscopy plays a major role in the palliative treatment of a number of advanced tumors within the ­gastro-intestinal tract and allows for ­maintenance of normal food passage and control of local complications such as blood loss or fistula formation.

M.W. Wichmann (*) Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected] F.W. Spelsberg Department of Surgery, University of Munich – Campus Grosshadern, Marchioninistr. 15, 81377 Munich, Germany

7.2 Upper Gastro-Intestinal Tract Endoscopy/Gastroscopy 7.2.1 Indications Flexible endoscopy of the upper gastro-intestinal tract is indicated when a known or suspected disease of the esophagus, stomach, or duodenum requires further investigation. Common indications for endoscopy of the upper gastro-intestinal tract are listed in Table 7.1.

7.2.2 Patient Preparation and Technique of Examination The patient needs to be informed about the risks and indication for the endoscopy and should be fasted for a minimum of 6 h. Anticoagulation therapy does not need to be stopped unless a more invasive intervention than biopsy is planned. The procedure is carried out with the patient lying on the left side. Usually, local anesthetics can be applied with a spray into the larynx (Xylocaine spray). Local anesthesia should not be applied in a not-fasted emergency patient since it increases the risk of aspiration. If the patient is sedated (Midazolam 3–5  mg i.v. or Disoprivan 50–70  mg bolus + maintenance boli of 10–30  mg i.v.), pulseoxymetry is mandatory for monitoring. The use of Disoprivan also requires the presence of a second ­physician during the investigation. The need of sedation for upper GI endoscopy can be discussed with the patient prior to surgery and should consider the

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_7, © Springer-Verlag Berlin Heidelberg 2011

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Table 7.1  Indications for upper gastro-intestinal endoscopy Preoperative Intraoperative

Post-operative

Intervention

Dysphagia

Localization (tumor, bleeding site)

Stenosis

Palliation

Reflux disease

Inspection of anastomosis/suture

Anastomotic leakage

Dilatation

Bleeding

Rendezvous

Postop. hemorrhage

Polypectomy

Suspected cancer

Ischemia

Feeding tube/PEG

Histology needed

Ulcer, gastritis

Foreign body removal

Staging

Follow-up

expected pathology, length of intervention, experience of the investigator, as well as the patient with similar previous interventions and the local infrastructure. The patient needs to have a bite guard introduced into the mouth to avoid damage of the gastroscope during the investigation. The endoscope is then advanced under vision, which allows for a detailed inspection of the esophagus, cardia (from above and in inversion), and stomach as well as parts I (bulbus duodeni) and II (pars descendens duodeni) of the duodenum. Biopsy forceps are used to collect specimens under vision from the upper GI tract for histopathological evaluation as well as Helicobacter pylori testing.

7.2.3 Bleeding Control Within the Upper Gastro-Intestinal Tract Endoscopic control of bleeding lesions within the upper GI tract is successful in more than 90% of all patients. A number of treatment options have been described, and their availability may vary in different locations. Most common causes of bleeding within the upper GI tract are ulcers of the stomach or the duodenum. Endoscopic treatment of these bleeding lesions is indicated for an actively bleeding ulceration (Forrest I), ulceration with a visible vessel (Forrest IIa) and ulceration with an adhering blood clot (Forrest IIb) (see Table 7.2 for the Forrest classification). With ongoing treatment of hemorrhagic shock, interventional endoscopy is the most important diagnostic and possibly therapeutic intervention and needs to be done as early as possible. To protect the patient from aspiration, an early intubation must be considered. Actively bleeding ulcers are treated with irrigation using ice-cold water and identification of the bleeding lesion. Subsequently, the ulcer is injected with a mixture of adrenaline (1 mg; 1:1,000) and normal saline (10 ml).

If available, fibrin glue depots should be injected into the base of the ulcer immediately adjacent to the bleeding vessel. If a vessel can be clearly identified, clipapplication should be considered as well. The risk of recurrent bleeding is highest (30%) during the first 72 h after treatment, and can be reduced to 5–15% with the endoscopic intervention and additional medical treatment (proton pump inhibitor therapy 40  mg i.v. three times/day or as continuous infusion). The usefulness of a routine control endoscopy at 24 h after the initial treatment is under constant debate. The authors are not in favor of this and prefer on-demand treatment. Approximately 10% of upper gastro-intestinal tract bleedings come from esophageal varices. The prognosis of this condition mainly depends on successful bleeding control. Endoscopic banding of esophageal varices is standard of care for this condition. Varicose veins of the gastric fundus should be injected with a mixture of histoacryl and lipiodol. Eighty percent to 90% of all bleeding variceses can be treated successfully with endoscopy. Failed treatment requires positioning of a SengstakenBlakemore or of a Linton-Nachlass tube into the esophagus. This tube has to be decompressed every 6–12 h to avoid pressure ulcers within the esophagus. Medical treatment can be done with Terlipressin or Somatostatin in cases of failed endoscopy, or in addition to endoscopic treatment. Table 7.2  Forrest classification of upper GI bleeding I: Active bleeding •

Ia: Spurting blood

•

Ib: Oozing blood

II: Signs of previous bleeding • IIa: Visible, non-bleeding vessel • IIb: Blood clot in ulcer • IIc: Blood-covered ulcer III: Ulcer without signs of previous bleeding

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7  Fiber Optic Endoscopy: Gastroscopy

Mallory–Weiss tears usually do not require endoscopic treatment and the bleeding stops without ­intervention. Dieulafoy lesions and gastric cancers are the underlying cause for upper GI bleedings in less than 5%. Diffuse bleeding may be difficult to treat and usage of Argon beam coagulation can be helpful (if available), otherwise cold water instillation into the stomach can also help to reduce the amount of blood loss. Figure 7.1 shows the endoscopic appearance of various lesions causing upper gastrointestinal bleedings.

stomach against the abdominal wall and avoids ­dislocation of the tube • Direct puncture of the stomach under vision, placement of two holding stitches to fix the stomach to the abdominal wall, placement of a feeding catheter into the stomach The most commonly used procedure is the pull-through technique with a thread and transoral introduction of the feeding tube.

7.3 Percutaneous Endoscopic Gastrostomy (PEG)

7.4 Endoscopic Treatment of Anastomotic Leakage or Stenosis

Endoscopic placement of an enteral feeding tube through the abdominal wall has become standard of care for a number of conditions causing dysphagia (i.e., neurological disorders, malignant disease). Two different techniques have been described:

Following esophageal resection up to 30% of the patients can suffer from anastomotic leakage. Endoscopy can be useful for diagnosis and treatment (debridement, fibrin glue application, stent insertion) of this dangerous condition.

• Puncture of the stomach under endoscopic view, introduction of a thread through the needle and pull-through of the thread with the gastroscope into the patient’s mouth, joining of the thread with the feeding tube and pull-through of the thread with the feeding tube into the stomach, an anvil places the

Endoscopic evaluation done by an experienced investigator is safe at any point in time after upper GI surgery, without resulting in an increased risk of perforation or anastomotic leakage

Fig. 7.1  Endoscopic appearance of lesion causing upper gastrointestinal bleeding. (a) Chronic ulcer of the anterior wall of the duodenal cap; (b) severe hemorrhagic gastritis without erosions; (c) bleeding from the apex of a stromal tumor (leiomyoma) in

the fundus of the stomach; (d) close-up view of a bleeding Dieulafoy lesion in the fundus of the stomach (Pictures courtesy of Professor Ian C. Roberts-Thomson, Queen Elizabeth Hospital, Adelaide)

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M.W. Wichmann and F.W. Spelsberg

Fig. 7.1  (continued)

Stenosis of the passage through the upper GI tract can be treated under vision with balloon dilatation (Through The Scope, TTS) or using Guillard-SavaryBougies with a guide wire placed through the working channel of the endoscope. A very short stenosed segment can also be treated with radial incisions (Truong technique). Usually any form of treatment requires more than one intervention to achieve long-lasting success.

a

Fig. 7.2  Inoperable esophageal cancer (a) prior to stent placement; (b) after stent placement of a partially covered metal stent

7.4.1 Palliative Tumor Treatment Inoperable stenosing cancers of the esophagus or cardia and the mediastinum, as well as recurrent disease after tumor resections within the upper GI tract, can be treated with a variety of stents (Figs. 7.2a, b). In some cases an anti-reflux stent can be applied to avoid reflux of gastric contents (Fig. 7.3a–c).

b

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7  Fiber Optic Endoscopy: Gastroscopy

a

b

Fig. 7.3  (a–c) Release of a self-expanding metal stent under image intensifier control

Recommended Reading Hung, W.K., Li, V.K., Chung, C.K., et  al.: Randomized trial comparing pantoprazole infusion, bolus and no treatment on gastric pH and recurrent bleeding in peptic ulcers. ANZ J. Surg. 77, 677–681 (2007)

c

 

8

Fiber Optic Endoscopy: Colonoscopy Matthias W. Wichmann and Fritz W. Spelsberg

8.1 Introduction Flexible endoscopy of the large bowel has significantly improved diagnosis and preoperative evaluation as well as post-operative care and palliation for almost all diseases of the large bowel and rectum. Colonoscopy, therefore, is part of pre-operative assessment and treatment planning, allows for intraoperative evaluation of the surgical site (i.e., anastomosis after resection, localization of pathology if not identified preoperatively) and is part of the management of post-operative complications (i.e., dilatation of stenoses, washout of anastomotic leakage). The endoscopic treatment of advanced polyps or early colon cancers (endoscopic mucosectomy) has been established, as well as the useful application of flexible endoscopy during so-called rendezvous procedures with minimal invasive surgery (i.e., laparoscopic resection of advanced polyps). Moreover, interventional endoscopy plays a major role in the palliative treatment of a number of advanced non-resectable tumors within the large bowel and allows for maintenance of normal food passage and control of local complications such as blood loss or fistula formation. As part of complete colonoscopy, an attempt should be made to also visualize the terminal ileum, although recent studies do not indicate that routine intubation of the ileum during surveillance colonoscopy offers any clinical advantage. The ileocaecal valve, as well as the

orifice of the appendix should, however, be clearly visualized and documented with a picture (Figs. 8.1 and 8.2). Withdrawal time after intubation of the caecum should be at least 7  min, with double passage of each colonic

Fig. 8.1  Endoscopic view of ileocaecal valve and appendiceal orifice

M.W. Wichmann (*) Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected] F.W. Spelsberg Department of Surgery,University of Munich – Campus Grosshadern, Marchioninistr. 15, 81377 Munich, Germany

Fig. 8.2  Endoscopic view of colon polyp

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_8, © Springer-Verlag Berlin Heidelberg 2011

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M.W. Wichmann and F.W. Spelsberg

Table 8.1  Indications for colonoscopy Preoperative Intraoperative

Post-operative

Intervention

Lower GI tract bleeding

Localization of lesion

Leakage

Polypectomy

Search for and localization of tumor

Control of suture

Stenosis

Dilatation

Inflammatory bowel disease

Rendezvous

Hemorrhage

Bleeding control

Histology needed

Decompression of pseudo-obstruction (Ogilvie syndrome)

Palliation

Unclear diarrhea

Ischemia

Invagination

Surveillance (>50 years)

Follow-up

Decompression

flexure during withdrawal of the colonoscope. Inversion in the ampulla of the rectum should also be documented with a picture, and allows for an orientation with regard to pathology of the anal canal. To complete the investigation of the anal canal, a proctologic examination (inspection, digital palpation, rigid proctoscopy) should be added. Indications for colonoscopy are listed in Table 8.1.

Table  8.2  Regimen for bowel preparation (Mount Gambier General Hospital) Laxative combination • GlycoPrep-C® (70 g) sachet: polyethylene glycol • 2 PicoPrep® (15.5 g) sachets: Na picosulfate Two days before examination • Stop eating brown bread, cereals, vegetables, and fruits

To clearly identify the exact localization of a pathologic finding within the rectum and distal sigmoid colon, a rigid rectoscopy is required. This procedure allows to exactly measure the distance from the dentate line, which is of relevance for preoperative planning, as well as discussion of neo-adjuvant treatment for rectal cancer (below the peritoneal flexion). Virtual colonoscopy (computed tomography colo­ no­scopy) is an attractive alternative for flexible colonoscopy in case of a failed or incomplete procedure. It, however, also requires a bowel preparation and significant air insufflation into the large bowel, and does not allow for a biopsy or polypectomy.

8.2 Patient Preparation and Technique of Examination A thorough bowel preparation is mandatory for adequate visualization of the entire large bowel. A number of various protocols have been established for this, and all of them require the patient to also follow a diet for at least 24  h prior to the investigation (an example for

• Do not eat anything with seeds in it • Do not eat any yellow cheese One day before examination • Drink at least one glass of clear fluid each hour • No solid foods and no milk products allowed, drink approved clear liquids (see below) only • Laxatives – First dose: 1 pm – add the entire contents of one sachet of PicoPrep in a glass of warm water and stir until dissolved; drink mixture slowly but completely – Second dose: 4 pm – make up sachet of GlykoPrep-C (70 g) with 1 L of water; drink the fluid within approximately 1 h – Third dose: 7 pm – add the entire contents of one sachet of PicoPrep in a glass of warm water and stir until dissolved; drink mixture slowly but completely Approved clear liquids (may not contain red or purple colorings): water, clear bullion, apple juice, grape juice, plain jelly, black tea/coffee, clear sports drinks, carbonated beverages, clear fruit cordials

bowel preparation is listed in Table  8.2). The major advantage of polyethylene-glycol-based iso-osmolar solutions (e.g., Golytely®, Klean-Prep®) when compared to saline solutions (Fleet®) is the option to also use them for patients with impaired cardiac or renal function.

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8  Fiber Optic Endoscopy: Colonoscopy

The procedure should be done using a fully flexible video-colonoscope with forward vision and a maximum viewing angle of 140°. Most colonoscopes have one to two working channels and are approximately 13 mm in diameter. The working length is 130 cm and the image gives a 1:20 enlargement of the visualized bowel. The use of so-called video-zoom colonoscopy with special lens systems allows for 1:100 enlargement, and the practicability of this is still under investigation. The use of special dyes and filters to visualize early neoplastic changes of the mucosa is also being investigated. The large-scale use of these techniques will most likely be limited due to the related costs and the additional time required for these procedures.

Cave: In high-risk patients (cardiac valve replacement, previous infectious endocarditis, leaking ­cardiac valves), antibiotic prophylaxis should be given to prevent bacterial endocarditis after the colonoscopy. Sedation of the patient (midazolal 3–5 mg i.v. and/or disoprivan 50–70 mg i.v. + maintenance boli 10–30 mg i.v.) with mandatory monitoring using pulse-oxymetry may be necessary. The investigation is started with the patient in left lateral position and the knees bent. During difficult investigations a repositioning (on the back or even on the front) of the patient or manual fixation of the bowel (pressure from the left lateral abdominal wall toward the center of the abdomen) by an assistant may be necessary. As mentioned above, the colonoscopy should clearly visualize the caecum and in specific cases (inflammatory bowel disease) the intubation of the terminal ileum is necessary. Figure 8.1 shows the ileocaecal valve as well as the appendiceal orifice as indicators of a complete colonoscopy. The learning curve for adequate completion of diagnostic colonoscopy has been established to be in the area of 150 procedures.

8.3 Polypectomy 8.3.1 Risk of Malignancy Adenomatous polyps of the large bowel are ­neoplasias which carry the potential to progress to a ­malignant ­disease (adenoma–carcinoma sequence). ­Approxi­mately

5% of large bowel polyps are thought to progress to large bowel cancers. High-grade dysplasia within a polyp is a risk factor for the development of colorectal cancer. Patient age, number, and size of the polyps as well as the fraction of villous adenomas are relevant for the risk of malignancy. Approximately 90% of all polyps in the large bowel are either tubular or tubulovillous in nature, and only 10% are pure villous adenomas. The risk of malignancy increases from 4% in tubulovillous adenomas <1  cm to 7% in adenomas measuring 1–2 cm and 46% in lesions larger than 2 cm. If a polyp is detected via rectoscopy, an additional colonoscopy must be carried out since additional polypoid lesions can be found in up to 40% of these patients.

8.3.2 Procedure Endoscopic excision of a large polyp (>1  cm) (Fig.  8.2) requires an adequate coagulation system (INR 1.4, PTT < 2× normal value, platelet count > 50,000/mm3), optimal bowel preparation, and risk-adjusted indication (risk of perforation and possible need for emergency surgery vs. elective bowel resection). Removal of the polyp is done using a diathermy snare, with the option of prior injection of adrenaline (1 mg, 1:1,000) mixed with normal saline (10  ml) to prevent bleeding, and to float the polyp off the mucosa (especially for flat and broad-based lesions). After polypectomy, clips may be applied for bleeding control and to close the mucosa to prevent secondary perforation of the bowel wall. Polyps smaller than 5 mm should be removed using a biopsy forceps, since diathermy would alter the tissue too much for adequate histological evaluation. Very large polyps may require removal in several pieces (piecemeal technique) or even with several procedures. Histological evaluation of these piecemeal specimens can be very difficult, and complete clearance of the advanced polyp cannot always be achieved. This must be considered when discussing the option of bowel resection after biopsy and tattooing of the advanced polyp. Figure 8.3 shows the polypectomy site of a large polyp before and after clip application for haemostasis and prevention of bowel perforation. Figure  8.4 shows a colon cancer as detected by colonoscopy. Figure 8.5 shows the endoscopic appearance of different colonic polyps.

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M.W. Wichmann and F.W. Spelsberg

a

b

Fig. 8.3  Endoscopic view of polypectomy site before (a) and after (b) clip application

8.3.3 Follow-up After complete removal of a polyp, follow-up should be done at 3–6 months, then at 3–5-year intervals. The author’s approach is slightly less aggressive with a repeat colonoscopy following polypectomy scheduled after 12  months (villous adenoma < 12  months). Surveillance colonoscopies are needed to be scheduled for:

Fig. 8.4  Endoscopic view of colon cancer

Aim of the procedure must be complete excision and complete retrieval of the polyp since up to 8% of all removed polyps contain parts of invasive carcinomas which may be missed if only ­partial excision is done, or part of the polyp is lost for histological examination.

• Familial hereditary non-polyposis colorectal cancer: every 1–2 years starting at age 20–30, annually after 40 years • First-degree relative with colon cancer/adenomatous polyp: start at age 40, then every 10 years • Personal history of polyps: every 3–5 years • Personal colon cancer history: 3–6  months after treatment, then every 3–5 years • Inflammatory bowel disease: every 1–2  years, beginning at any age • Family history of familial adenomatous polyposis (AFP): annual

8.3.4 Complications Destruction of the tumor using diathermy, laser, or argon-plasma coagulation should not be done because they do not allow for pathological evaluation. These techniques are of relevance, however, for palliation, and can restore normal fecal passage.

The complication rate of diagnostic colonoscopies is very low (<0.2%) and the associated mortality is <0.01%. The most common complications are cardiopulmonary problems (usually due to sedation) and bleeding episodes (<0.02%). Perforations usually occur

45

8  Fiber Optic Endoscopy: Colonoscopy Fig. 8.5  Endoscopic appearance of various colonic polyps. (a) Typical small polyp; (b) polyp on a large stalk; (c) typical flat polyp, 2 cm in diameter; (d) large polyp, 4 cm in diameter. Endoscopic resection of polyps (c) and (d) is often difficult and such patients may be best referred to specialized endoscopy centers (Pictures courtesy of Professor Ian C RobertsThomson, Queen Elizabeth Hospital, Adelaide)

within the recto-sigmoid junction or the sigmoid colon and have an incidence of less than 0.05%. Abdominal pain and discomfort is usually due to the insufflation of air – ongoing discomfort, however, requires exclusion of a perforation (abdominal X-ray, computed tomography). Therapeutic colonoscopies carry slightly higher complication rates with regard to bleeding (1–2%) and perforation (0.1–0.3%). The mortality rate is 0.05%.

(pain treatment ± antibiotic treatment) after radiological exclusion of a perforation. Should a ­perforation occur, it usually requires surgical intervention, although a conservative approach (nil per mouth, i.v. antibiotics) can be considered if the bowel ­preparation was very good, no cancerous lesion has been detected and the patient is not on regular corticosteroids.

8.4 Postpolypectomy Syndrome

8.5 Treatment of Anastomotic Leakage or Stenosis

Following polypectomy a transient episode of pain with local peritonism, fever, and raised white blood cell count can be observed without evidence of full thickness wall necrosis or perforation. This condition is believed to result from a localized peritonitic reaction to the polypectomy, and should be treated conservatively

After low anterior rectal resection, up to 30% of patients suffer from a leakage at the level of the anastomosis. In some cases, a wait-and-see policy with endoscopic washout and fibrin-glue application can be followed, whereas more severe cases may require endoscopic vacuum-assisted closure. This procedure uses the

46

principle of vacuum-assisted wound healing with a drainage connected to special foam which is being introduced through the area of leakage and drains into a suction bottle. This foam needs to be replaced endoscopically every 3–4 days and allows outpatient treatment of this severe complication of rectal surgery. The stenosis of an anastomosis within the colon or rectum can be treated using similar techniques as in the upper GI tract with balloon dilatation, Guillard-Savary, or Hegar bougies.

8.5.1 Palliative Treatment Patients with non-resectable large bowel cancer can benefit from endoscopic stent placement through the malignant stenosis. This can be done as a definitive procedure or as a bridging procedure allowing for ­adequate resuscitation prior to palliative or curative bowel resection.

M.W. Wichmann and F.W. Spelsberg

Recommended Reading Iqbal, C.W., Cullinane, D.C., Schiller, H.J., et  al.: Surgical management and outcome of 165 colonoscopic perforations from a single institution. Arch. Surg. 143, 701–707 (2008) Lee, S.H., Chung, I.K., Kim, S.J., et al.: An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve. Gastrointest. Endosc. 67, 683–689 (2008) Tilney, H.S., Lovegrove, R.E., Purkayastha, S., et al.: Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg. Endosc. 21, 225–233 (2007) Weidenhagen, R., Gruetzner, K.U., Wiecken, T., et  al.: Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg. Endosc. 22, 1818–1825 (2008) Goldenberg, E.A., Khaitan, L., Huang, I.-P., Smith, C.D., Lin, E.: Surgeon-initiated screening colonoscopy program based on SAGES and ASCRC recommendations in a general surgery practice. Surg. Endosc. 20(6), 964–966 (2006)

9

Endoscopy for Rural Surgeons: ERCP Ian C. Roberts-Thomson

9.1 Introduction ERCP is an endoscopic procedure that involves cannulation of the ampulla of Vater and use of radiologic contrast to outline biliary and pancreatic ducts. The technique was first described from centers in the USA and Japan between 1968 and 1970, soon after the introduction of fiberoptic endoscopes. In 1974, a group from Germany described endoscopic sphincterotomy for bile duct stones and, in 1979, a different German group described the use of endoscopic stents for malignant bile duct obstruction. Despite these impressive developments, widespread adoption of the technique was relatively slow as the procedure was technically demanding and associated with significant complications. Even today, ERCP is performed by only a minority of gastroenterologists or surgeons and, in Australia, is largely restricted to major city hospitals.

9.2 Training Training in endoscopy has always been an issue for surgeons. In Australia and many other countries, surgical trainees have only had limited access to endoscopy training as the majority of training has been conducted in medical departments. Furthermore, for surgeons, training in endoscopy has only been a relatively small part of the total training experience. In contrast, the development of skills in endoscopy is a

I.C. Roberts-Thomson Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

major focus for advanced trainees in gastroenterology and hepatology. In relation to training for ERCP, particular issues are low case loads (even in some tertiary centers) and the possibility of lower success rates and higher frequencies of complications when procedures are solely or largely performed by trainees. In Australia, most of the training in ERCP is performed in medical departments in tertiary hospitals. A formal “recognition of training” certificate is provided by a national group after appropriate references and documentation of 200 procedures performed independently. In most tertiary centers, this will only be achieved after a minimum of 2 years of training.

9.3 Indications There have been major changes in the indications for ERCP over the last 30 years. For example, ERCP was widely used for the diagnosis of biliary and pancreatic disorders in the 1980’s but is now largely restricted to ­therapeutic procedures for bile duct stones, biliary and pancreatic cancer, and miscellaneous biliary disorders. The major reason for this change is the introduction of  various non-invasive procedures including upper abdominal ultrasound (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic US. Of these, only upper abdominal US and CT will be readily available to most rural surgeons. Current indications for ERCP are summarized in Table 9.1. At present, the majority of bile duct stones are treated by endoscopic biliary sphincterotomy and endoscopic extraction (Fig. 9.1). These stones may be diagnosed before cholecystectomy, by an intraoperative cholangiogram during cholecystectomy or because

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I.C. Roberts-Thomson

Table  9.1  Indications for endoscopic retrograde cholangio­ pancreatography Diagnostic

Confirm bile duct stones Confirm ampullary neoplasms Define post-operative biliary disorders Define pancreatic fistulae Confirm sclerosing cholangitis

Therapeutic

Biliary sphincterotomy for bile duct stones Biliary stents for malignant obstruction Biliary sphincterotomy for post-­ cholecystectomy pain Management of benign biliary strictures Management of post-operative biliary fistulae Pancreatic stents for pancreatic fistulae Endoscopic drainage of pancreatic pseudocysts Extraction of pancreatic duct stones

Fig. 9.1  Images of bile duct stones taken at ERCP. (a) Single small calculus; (b) multiple stones and one larger calculus; (c) multiple irregular stones and at least one large stone; (d) a single

of the development of early or late manifestations after cholecystectomy. Features of bile duct stones prior to cholecystectomy include abdominal pain and changes in liver enzymes, obstructive jaundice, cholangitis and changes in liver enzymes without pain. After surgery, bile duct stones should be suspected when there is persisting pain with changes in liver enzymes, the development of jaundice or the development of a biliary fistula, usually through the cystic duct stump. Patients diagnosed with bile duct stones months or years after cholecystectomy present in a similar way to those with bile duct stones prior to cholecystectomy. For biliary and pancreatic cancer, endoscopic procedures largely involve the insertion of biliary stents in patients with obstructive jaundice. However, ­diagnostic ERCP can have a role, particularly when US or CT images show obstruction close to the duodenal wall without an associated mass. Some of these patients have cancer of the ampulla of Vater while others have periampullary or duodenal cancer. Endoscopic US is also being increasingly used to assess the size and extent of spread of pancreatic and biliary neoplasms

huge calculus. Sphincterotomy and stone extraction is likely to be successful in (a) and (b) but (c) and (d) will be challenging, even for experts

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9  Endoscopy for Rural Surgeons: ERCP

and, if surgery seems unlikely, to obtain tissue for assessment by aspiration cytology. At present, tissue obtained by this technique has greater sensitivity and specificity for the diagnosis of cancer than diagnostic procedures at ERCP including brush cytology of ductal strictures and duct biopsy. Other miscellaneous indications for diagnostic and therapeutic ERCP include the diagnosis and endoscopic management of post-operative biliary strictures and sclerosing cholangitis. Diagnostic and therapeutic procedures have also been promoted for pancreatic pseudocysts, chronic pancreatitis, pancreatic trauma and pancreatic ascites, but endoscopic management should be restricted to experts. Another issue is that of biliary-type pain after cholecystectomy (without stones). If medical therapy fails, endoscopic sphincterotomy should be restricted to experts as selective cannulation of the bile duct is sometimes difficult and there is a higher than expected frequency of pancreatitis after the procedure.

9.4 Preparation and Sedation Patients should fast for at least 3 h prior to the ­procedure. Satisfactory sedation can usually be achieved with meperidine (pethidine) and midazolam but some practitioners routinely use propofol with help from anaesthetists or anaesthetic assistants. However, unconscious sedation does limit the use of positional changes that may facilitate the interpretation of ductal images. Theoretically, meperidine is preferable to fentanyl as the latter drug induces a greater degree of spasm in the sphincter of Oddi.

9.5 Endoscopic Stents for Malignant Biliary Obstruction Patients with malignant biliary obstruction can be treated with endoscopic stents, palliative bypass ­surgery or more radical surgery with the potential for cure. Ideally, management in individual patients should be discussed in a multi-disciplinary setting that includes surgeons and oncologist. Endoscopic stents

are likely to be the preferred form of therapy in patients with advanced disease and in those who are elderly (>85  years) or with significant comorbidities. Stents can be composed of either plastic or metal (nitinol or stainless steel). Conventional 10-French plastic stents are relatively cheap, remain patent for 3–4 months and can usually be readily replaced by repeat ERCP. In contrast, metal stents are more expensive and remain patent for a longer period. However, most metal stents are impossible to remove endoscopically and, in the event of stent occlusion, options include a second metal stent within the original stent or a plastic stent within the metal stent. In practice, plastic stents are often used in patients whose survival seems likely to be short while metal stents are used in those whose anticipated survival is > 4–6 months. An additional issue is the use of plastic stents to relieve jaundice prior to radical surgery. Advocates of this policy point to the avoidance of urgent procedures and a possible improvement in patient outcomes. Others who prefer to avoid pre-operative stents are concerned by stent-induced changes in ducts and a possible increase in post-operative infections. This issue has not been entirely resolved, although a recent randomized trial showed that pre-operative stents did not improve patient outcomes when the pre-operative serum bilirubin was < 250 mmol/l (14.6 mg/dl).

9.6 Complications The major complication of ERCP is the development of pancreatitis. This has been defined in a number of different ways but the clinical issue is pain after the procedure that is accompanied by a rise in the serum amylase to >300–500 U/l. The frequency of this complication ranges from 1% to almost 25% in unselected series but should be 7% or less. Several studies have shown higher risks for pancreatitis when procedures are performed by endoscopists with low case-loads. Other risk factors for pancreatitis include difficulties with cannulation, use of precut techniques, female gender and procedures on patients with recurrent ­pancreatitis or post-cholecystectomy pain. As various pharmacological agents have failed to reduce the risk of pancreatitis after ERCP, minimization of risk

50

continues to depend on appropriate case selection and a meticulous endoscopic technique. Less common complications after ERCP include duodenal bleeding after endoscopic sphincterotomy, cholangitis and duodenal perforation.

9.7 ERCP in a Rural Setting Competence at ERCP is largely determined by the quality and duration of training and by ongoing experience. The minimal case-load for maintenance of ERCP skills has not been defined but may be 50 cases/year. This is the approximate case-load that would be generated from a population of 50,000 people. Although ERCP in Australia is largely performed by gastroenterologists, there are some notable exceptions including rural surgeons. However, a significant issue for surgical trainees is access to ERCP training in large metropolitan hospitals.

Recommended Reading Coelho-Praghu, N., Baron, T.H.: Endoscopic retrograde cholangiopancreatography in the diagnosis and management of cholangiocarcinoma. Clin. Liver Dis. 14, 333–348 (2010)

I.C. Roberts-Thomson Davids, P.H., Groen, A.K., Rauws, E.A., Tytgat, G.N., Huibregtse, K.: Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet. 340, 1488–1492 (1992) de Groen, P.C., Gores, G.J., LaRusso, N.F., Gunderson, L.L., Nagorney, D.M.: Biliary tract cancers. N. Eng. J. Med. 341, 1368–1378 (1999) Freeman, M.L., Nelson, D.B., Sherman, S., et al.: Complications of endoscopic biliary sphincterotomy. N. Engl. J. Med. 335, 909–918 (1996) Moss, A.C., Morris, E., Leyden, J., MacMathuna, P.: Malignant distal biliary obstruction: a systematic review and metaanalysis of endoscopic and surgical bypass results. Cancer Treat. Rev. 33, 213–221 (2007) Roberts-Thomson, I.C.: Endoscopic sphincterotomy of the papilla of Vater: An analysis of 300 cases. Aust. N.Z. J. Med. 14, 611–617 (1984) Takagi, K., Ikeda, S., Nakagawa, Y., et al.: Retrograde pancreatography and cholangiography by fiber duodenoscope. Gastroenterology 59, 445–452 (1970) van den Gaag, N., Rauws, E.A.J., van Eijck, C.H.J., et  al.: Preoperative biliary drainage for cancer of the head of the pancreas. N. Engl. J. Med. 362, 129–137 (2010) Varadarajulu, S., Eloubeidi, M.A.: The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer. Surg. Clin. North Am. 90, 251–263 (2010)

Rigid Endoscopy: Cystoscopy

10

Mark Lloyd and John Miller

10.1 Introduction Cystoscopy is the endoscopic inspection of the lower urinary tract. Cystoscopy includes the endoscopic visualization of the urethra and bladder. Cystoscopy is a useful procedure for evaluation of urinary symptoms or signs including haema­turia, reduced urinary flow, urinary frequency and urgency. The male urethra is divided into penile, bulbar, membranous and prostatic urethra while the female urethra is quite short. The bladder includes base, dome, ureteric orifices and trigone. Cystoscopy may be achieved by use of the rigid cystoscope or the more recent flexible cystoscope. Rigid cystoscopy is usually performed under a general anaesthetic, particularly in the male, due to the discomfort associated with introducing the instrument. Rigid cystoscopy may be performed under local anaesthetic in the female owing to the short urethra. Flexible cystoscopy is performed under topical local anaesthetic gel. It provides a rapid and convenient assessment of the lower urinary tract. The advantage of rigid cystoscopy is the superior vision and the ability to introduce a biopsy forceps in order to biopsy any abnormal area. Any area of bleeding may be diathermied by use of the monopolar diathermy lead – which may also be used to stop bleeding from any site of bladder biopsy.

M. Lloyd (*) and J. Miller Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

10.2 Indications Cystoscopy is indicated for evaluation of lower urinary tract symptoms, haematuria, bladder lesions, stones and bladder outflow obstruction. A cystoscopy is recommended for evaluation of all cases of haematuria – particularly gross haematuria, and ongoing microscopic haematuria, particularly in those with significant microscopic haematuria, which is variously defined as over 5–10 red cells detected under light microscopy per high power field. All smokers with any degree of haematuria should undergo cystoscopy due to the high risk of transitional cell carcinoma. Other risk factors for neoplasia of the urothelium include exposure to petrochemical products, solvents and herbicides and pesticides. Recurrent urinary tract infection may also be investigated with a cystoscopy. Surveillance cystoscopy following treatment for transitional cell carcinoma of the bladder is mandatory and is initially repeated frequently to check for recurrences and following this annually.

10.3 Patient Preparation Prior to initial cystoscopy it is useful to obtain an ultrasound of the urinary tract and bladder and it is recommended to obtain a urine microscopy and culture to exclude infection and to quantify any haematuria. Urine cytology is particularly useful to check for any malignant cells in the urine, which is suggestive of transitional cell carcinoma. An active urinary infection is a contraindication to cystoscopy not only as the cloudy urine impedes vision but also due to the risk of sepsis particularly if the urothelium is breached.

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Antibiotic prophylaxis is at the clinician’s discretion but must be given if infection is suspected or if the patient is at risk in the event of bacteraemia (prosthetic heart valve especially).

10.4 Findings Transitional cell carcinoma appears as a papillary or solid mass in the bladder or urethra – this may be biopsied or referred primarily to an urologist for management. Cystitis appears as a diffuse inflammatory reaction of the bladder wall and is usually indicative of infection; however, the differential diagnosis includes carcinoma in situ (appearing as flat red areas in the bladder) and other forms of cystitis (interstitial cystitis, postradiotherapy and haemorrhagic cystitis). Bladder outflow obstruction is suggested by a benign prostatic hyperplasia (which may also be a common cause of haematuria if the cystoscopy is otherwise negative) or a tight bladder neck with muscular hypertrophy. Benign prostatic hyperplasia is indicated by a large prostate with lobes meeting and obstructing the prostatic urethra. Bladder outflow obstruction may be associated with bladder stones – which are easily seen with cystoscopy – small stones may be washed out – larger stones should be treated endoscopically at a tertiary centre. The ureteric orifices should be inspected and normally lie symmetrically opposite at the corners of the trigone – the ridge running transversely from one to the other aids identification and is termed the interureteric bar. The observation of a ureteric jet of urine is helpful for location and aids in excluding obstruction. Haematuria from a ureteric orifice is indicative of ­unilateral ureteric or renal pathology. Ureteric orifices may be cannulated with an openended ureteric catheter. A retrograde pyelogram may be obtained by the instillation of 10 ml of radio-opaque contrast to confirm the position. This may also be performed prior to difficult abdominal/pelvic surgery – a size 6 or 4 French catheter is used for this purpose. Cystoscopy may be performed intraoperatively to check for bladder or ureteric injury – this is suggested by the presence of blood on introduction of the ­cystoscope. A thorough evaluation of the bladder, ­presence or absence of ureteric jets should be done. Retrograde pyelogram or the instillation of methylene blue may also be performed.

M. Lloyd and J. Miller

During cystoscopy a urethral stricture may be detected – this may be impassable if dense but often is a flimsy stricture which can be dilated with the cystoscope. A stricture may be dilated with urethral sounds; however, the possibility of urethral injury and false passage should be borne in mind. Cystoscopy is not complete without a digital rectal examination as early prostate cancer sometimes presents with a prostatic nodule and is usually asymptomatic. It is also a useful way of assessing prostatic size.

10.5 Technique Cystoscopy is performed using a 21 or 23 French sheath and a 30° and 70° optical Hopkins rod telescope. The light source is usually halogen and the telescope is connected to a single or triple chip camera. Single chip cameras are perfectly suitable for cystoscopy. Cystoscopy can be combined with endoscopic ­surgery on the lower urinary tract. This requires the introduction of a resectoscope using a 26 or 28 French sheath. Usually this is a dual lumen sheath which features continuous flow to allow any blood to be washed away by fluids keeping the operative view clear with good light transmission. Using this sheath resection of a bladder tumour may be performed using an electrocautery resecting loop. Transurethral resection of the prostate may also be ­performed. Both procedures can be complicated by significant bleeding and hence the need for a continuous flow of irrigation fluid. Irrigation fluid may be saline, water or glycine; however, glycine must be used if diathermy is to be employed. Glycine is composed of amino-acetic acid and is used to allow transmission of an electrical current only through the instrument used and not through the fluid itself. Its osmolarity is greater than water but less than plasma. Saline does not allow diathermy to be used and water is hypotonic and can cause problems if absorbed in significant quantities. Glycine too can cause problems with excessive absorption usually occurring during TURP – this is termed TURP syndrome – it is characterized by dilutional hyponatraemia and expansion of the extracellular fluid space. The syndrome is commonly detected by a confusional state – if untreated it may lead to cerebral oedema, seizures and coma.

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10  Rigid Endoscopy: Cystoscopy

10.6 Complications Complications which can be observed after cystoscopy include: • False passage – without careful visualization the urethra may be perforated – this can occur at the level of the bulbar urethra. The management is placement of catheter into the true passage and into the bladder. • Bleeding from biopsy or resection sites – this is managed by diathermy and subsequent catheterization. • TURP (Trans Urethral Retrograde Prostatectomy) syndrome – managed by fluid restriction, diuretics and occasionally hypertonic saline intravenously. • Sepsis – managed by appropriate antibiotic therapy and catheter drainage. • Post-operative urinary retention or clot retention. Clearly, the best management is prevention by careful instrumentation of the sterile urinary tract together with antibiotic prophylaxis. Cystoscopy may be accompanied by prostatic biopsy if required – the indications for this are an ­elevated PSA or the presence of a suspicious prostatic nodule. Prostatic biopsy is performed by a trucut needle biopsy utilizing a spring-loaded biopsy device. The needle biopsy may be finger guided using great care

not to injure one’s finger! Most biopsies are now ­performed using a transrectal ultrasound probe which allows good visualization of the prostate and accurate needle placement for biopsy. Six to 12 biopsies are taken of the peripheral zone of the prostate where ­prostatic carcinoma is most likely to appear. This procedure may be accompanied by sepsis and therefore antibiotic prophylaxis for all patients is required together with an enema to empty the rectum before ultrasound is employed. Any anticoagulation must be ceased as for all surgery on the urinary tract. Endoscopy of the lower urinary tract is safe in terms of a diagnostic procedure. Operative endoscopy may be accompanied by ­complications for which the surgeon should be ready – bleeding, urinary retention and sepsis remain the most common.

Recommended Reading Hanno, P., Malkowicz, S.P., Wein, A.: Clinical Manual of Urology. McGraw-Hill, New York (2001) Tanagho, E.A., McAninch, J.W.: Smith’s General Urology Lange Clinical Medicine/McGraw-Hill, New York (2007) Wein, A.J., Kavoussi, L.R., Novick, A.C., Partin, A.W.: Campbell-Walsh Urology Review Manual, 9th edn. Saunders, Mosby (2007)

 

Rural Surgical Audit

11

David A.K. Watters

11.1 Definitions Surgical audit can be defined as ‘the systematic, ­critical analysis of the quality of surgical care that is reviewed by peers against explicit criteria or recognised standards, and then used to further inform and improve surgical practice’ [1, 2]. A briefer definition might be, ‘am I doing what I think I am doing?’ and ‘am I doing it as well as others?’ Surgical audit addresses the structure (access, efficiency), process (protocols, documentation and patient journey) and outcomes (mortality, morbidity, disability, improvement) of care. To be effective, surgical audit involves a feedback loop where issues identified by audit and peer review are reported, solutions are found, changes occur and the outcome of those changes are further monitored. Surgeons and their teams need to reflect on performance, and then engage the relevant stakeholders in devising and communicating improvements in care [2]. In recognition of the value of participating in surgical audit and peer review, many surgical colleges and hospitals have made such auditing a mandatory component of continuing professional development [3]. Mortality audits are specifically designed to learn from deaths, though there is a wide variability of mortality rates between specialties. The Royal Australasian College of Surgeons (RACS) regards participation in the Australia New Zealand Audit of Surgical Mortality (ANZASM) as an aspect of clinical governance,

a separate component from audit and peer review in maintaining professional standards [3]. Surgical audits may include one’s whole practice (all cases whether operated on or not), or focus on a specific procedure, presenting problem or outcome.

11.2 Performing a Surgical Audit in the Rural Context Rural surgeons tend to have a broader clinical practice than their metropolitan colleagues. Country towns often struggle to attract and retain a surgical workforce, so specialists are often isolated. Despite their isolation, such specialists still need to perform a regular surgical audit and obtain a review by peers. The models adopted for peer review vary according to ­circumstance and are discussed below. An audit must be complete (contain all cases for the particular condition or time frame), accurate and honest. The focus and period of the audit need to be defined. For example, all cases of colorectal surgery for years x–y; alternatively, all cases managed for time period z. Six monthly audits are commonly timed in training hospitals to coincide with registrar rotations. Yearly audits may be just as appropriate for the isolated rural surgeon or for an audit focused on one ­problem or group of procedures.

11.2.1 What Data to Collect? David A.K. Watters Department of Surgery, University of Melbourne and Barwon Health, Geelong Hospital, Geelong, VIC 3220, Australia e-mail: [email protected]

The data collected needs to identify what procedures were done on what sort of patients (risk, urgency, comorbidities) and the outcome of those procedures.

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D.A.K. Watters

Table 11.1  Minimum and expanded data sets advised for whole practice audit Minimum data set

Expanded data set

Name (or initials)

a

ID (or case record number)a

Admission type

Date of birth (age calculated) Sex

Presenting problem

Final diagnosis

Comorbidities

Admission date

Wound infection risk

Discharge date

ASA grading

Operation/procedure performed

Indication for operation

Operation date

Type of anaesthetic

Operation urgency

Operating magnitude

Complications and grade (Table 11.2)

Pathology information and diagnosis

Surgeon identifiera

Outcome/discharge type

Information that is private and not for release beyond the surgical unit responsible for care Source: RACS Surgical Audit and Peer Review Guide, 3rd edn.

a

The minimum and expanded datasets recommended by the Royal Australasian College of Surgeons (RACS) are shown in Table 11.1 [1, 2]. The expanded data set enables better risk stratification, which may facilitate ‘comparing with known standards’. The age of a patient, urgency of procedure, stage of disease and comorbidities are key aspects of stratifying the risk of morbidity and mortality. Some specialties have established scoring systems. Specialist data sets may also be appropriate for specific procedures. The recording of comorbidities is difficult to achieve retrospectively, and the American Society of Anaesthetists (ASA) status may be a reasonable alternative. In colorectal audits conducted by rural surgeons, a count of two or more comorbidities was associated with worse outcomes. Table 11.2 shows the comorbidities used by the Elixhauser [4] and Charlson [5] classifications, the latter list carrying a score. The third column shows complications (Clavien) [6] to provide useful drop-down menus to record comorbidities and grade complications. Risk stratification of the condition of the patient is essential to compare outcomes if like is to be compared with like. Trainee surgeons may also collect data about the supervision level and the learning impact of the case.

Trainee logbooks should prepare the trainee for a lifetime of surgical audit and not be simply a list of procedures without outcomes, learning or pathology data [7]. The Supervision Levels recommended for trainee logbooks are: S1: Surgeon Mentor Scrubbed S2: Surgeon Mentor in Theatre S3: Surgeon Mentor Available A1: Assisting Surgeon Mentor A2: Assisting Surgeon Registrar

11.2.2 How to Collect the Data for Audit The earliest and simplest surgical audits were conducted on paper. Paper-based audit require considerable discipline to consistently record the cases, often in a notebook. The more cases, the more challenging becomes the sorting and arranging of the information and its analysis. For these reasons, most surgeons ­prefer to record their data in an electronic format on a computer or personal digital assistant (PDA). The simplest software is to use a spreadsheet such as Excel (www.microsoft.com). Spreadsheets are limited in the number of columns that can be seen on the screen at any one time and are best for logbooks of activity with a limited number of characters in each cell. The best audit programs are based on a database that facilitates searching, summarising and calculations. Many examples of successful surgical audit have employed programs such as Filemaker Pro (www.filemaker.com), Microsoft Access (www.microsoft.com) or HanDbase (www.ddhsoftware.com). Google spreadsheets are another option. What is important is that a program is user friendly and, once the data is entered, the software can be used to generate useful reports without too much extra work. All of the available programs require a template for data entry to be created. Data entry is facilitated by a value list of common conditions such as is shown for the list of comorbidities and complications (Table 11.2). A free downloadable program using Filemaker Pro has been created by the author and is available from the RACS website, http://www.racs. edu.au/racs/fellows/cpd-recertification/cpd-resourcesand-tools/david-watters-surgical-audit-tool. The above hyperlink will lead you to a program that has been used by many rural surgeons but it is still only one

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11  Rural Surgical Audit Table 11.2  Useful comorbidities and complications for drop-down value lists Cardiovascular

Elixhauser

Charlson (score)

Clavien complications (grade)

Congestive heart failure

Congestive heart failure (1)

Atrial fibrillation

Arrhythmia

Metabolic

Valvular heart disease

Acute MI (1)

Hypertension

Cerebrovascular disease (1)

Peripheral vascular disease

Peripheral vascular disease (1)

Diabetes uncomplicated

Diabetes (1)

Diabetes complicated

Diabetes complications (2)

Tachyarrhythmia requiring B blocker (2) Bradyarrhythmia requiring pacemaker (3) Heart failure leading to low output syndrome (4) Cardiac insufficiency after myocardial infarction (4d)

Obesity Liver

Hepatic disease

Liver disease (1) Severe liver disease (3)

Renal

Renal failure

Pulmonary

Pulmonary circulatory disorders

Neurological

Renal disease (2)

Renal insufficiency requiring dialysis (4) Atelectasis requiring physiotherapy (1)

Chronic pulmonary disease

Pulmonary disease (1)

Pneumonia requiring antibiotics treated on ward (2)

Paralysis

Paraplegia (2)

TIA requiring anticoagulants (2)

Other neurological Cancer

Urinary tract infection requiring antibiotics (2) Reoperation for ureteric injury (3)

Postoperative stroke (4)

Solid tumour without metastasis

Cancer (2)

Metastatic cancer

Metastatic cancer (3)

Lymphoma Other general

AIDS Weight loss Drug abuse Alcohol abuse Psychosis Depression

HIV (6)

Anastomotic leak requiring surgery (3) Necrotising pancreatitis (4) Wound infection opened at bedside (1) Wound infection requiring antibiotic therapy (2) Wound dehiscence requiring OT closure (3) Transient confusion (1)

Rhematoid arthritis/collagen vascular diseases Fluid and electrolyte abnormality Coagulopathy Blood loss anaemia Deficiency anaemia In Australia and the UK, obesity is defined as BMI >25 (= overweight) and >30 (= high risk). Patients with dementia are given ‘other neurological disorder’ but it may be worth adding this. Acute myocardial infarction needs to be defined and I recommend this is within the preceding 30 days

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example to be considered. Verification should focus on what data are missing or inaccurate. Larger databases (clinical information systems) may be used to generate the data required for audit in individual hospitals (e.g. CORDis in Geelong/Victoria (AUS)).

D.A.K. Watters

centre and present the audit to the surgeons there. It is ideal if those who work in the referral centre, usually a city, have some appreciation of the context of rural practice. There may also be specific procedures, such as ERCP, that would be more appropriate to report through a focused audit and present to peers in a major centre to which the more complex cases would normally be referred [8, 9].

11.2.3 How to Prepare an Audit Surgical audit should review both the workload and the outcomes. The relevant outcomes vary according to procedure and specialty. A whole practice audit such as is often carried out by general surgeons in a rural hospital should include in its outcomes all major complications, unplanned reoperations, unplanned readmissions and mortalities. Most surgeons are assisted by a data and presentation checklist (Fig.  11.1). Problem cases should be presented with enough detail so that the peers have enough information on which to assess the clinical decision-making. For example, a single slide for each case that contains the age, sex, presentation, risk, procedure and the clinical course leading up to the adverse event. A PowerPoint template for surgical audit (Fair Dinkum Audit) can be downloaded from the RACS website, www.surgeons. org/media/16117/PSAauditpostertemplate.ppt.

11.3.1 Conduct of the Meeting A surgical audit meeting should generally not identify names of patients and be conducted in an open, honest but not aggressive way. The purpose of the meeting is to report, review and reflect, not to name and blame. The surgical peer review meeting should have a chairperson who is independent of the team presenting the audit. The chairperson should record the issues, effect on patient or hospital recommendations, action to be taken by whom and when (Fig. 11.3). It is a local decision whether only surgeons are present or whether anaesthetists, surgical ward/operating nurses and hospital managers are present. Certain technical issues arising may only require discussion within the craft group but other events will only be able to be addressed at a service or hospital-wide level. The Director of Surgery should normally be invited and will act as a means of communication between clinician and managers.

11.3 Peer Review An isolated rural surgeon may not have a local peer who practices in their specialty. Although there will be value in presenting one’s audits to other specialists, it is also important to present to at least two other surgeons in the same speciality. This can be achieved by teleconference, or by the peers agreeing to meet face to face every few months. Another alternative is for the audit to be presented at a conference where peers will be present. This method has been used by the Provincial Surgeons of Australia, using a standard poster template (Fig. 11.2) available from, www. surgeons.org/media/16117/PSAauditpostertemplate.ppt. A third model used by some centres in South Australia is for the rural surgeon to visit the referral

11.4 Reporting Surgical Outcomes Outcome reporting requires some degree of risk stratification as patients have individual risks of complications or mortality (Table 11.2). The simplest means is to use ASA [10], or a count of comorbidities from the list in Table 11.2. The use of POSSUM [11, 12] is complex, challenging and usually beyond the enthusiasm of general surgeons except in the research context [10]. The assessment and appropriate measurement of actual outcome varies from procedure to procedure though the principles are the same for all operations. The various specialties need to determine by consensus what the outcome indicators for operations within

11  Rural Surgical Audit Unit X, Surgeons A, B,C, Audit time period: date Y to date Z 1 Surgical caseload 1.1.Total Admissions 1.2 Total Operations 1.2.1 Sub-classified by emergency (1.2.1a), urgent 1.2.1b or elective (1.2) 1.2.2 Number of Complex, Major, Moderate and Minor operations Subclassified by emergency, urgent or elective where appropriate 1.3 Final diagnosis of non-operated admissions – table with numbers and a column that includes plan or outcomes 1.4 Types of Operation – table Tables Subclassified by specialty groups (e.g. endoscopies, breast, endocrine, colorectal, upper GI, etc.) 2 Morbidity and mortality (quality indicators) 2.1 Number of complications and classified by 2.1.1 Severity of complications into grades 1, 2, 3 according to their effect on the patient and the treatment required (see minimum dataset) 2.1.2 Type of complication 2.1.3 Rates for different procedures (see Table 3) Bile leak after cholecystectomy Recurrent laryngeal nerve palsy rate for thyroidectomy Colonoscopies should include completion rates and polypectomy rates Clinical Indicators may include unplanned overnight stay (for day case) as a quality of care indicator (The numerator is the number of complications or relevant performance indicator for each group. The Denominator is the total number of procedures.) 2.2 Number of unplanned readmissions 2.3 Number of unplanned re-operations 2.4 Number of unplanned ICU readmissions 2.5 Transfers to a higher level of care 2.6 Near misses 2.7 Incident reports 2.8 Complaints 2.9 Number of mortalities (= type 4 complication in minimum dataset) Sub-classify as avoidable, unavoidable and expected, unexpected 3 Case details Each readmission, re-operation, ICU readmission, transfer, mortality, type 3 complication and case of interest should be discussed with at least the following information (advise one slide per case): Age and sex Final diagnosis Reason for Readmission/re-operation/ICU readmission/transfer What was done (investigations, procedures etc) Complications, adverse events (with analysis) Outcome 4 What can be done differently? 4.1 Issues/events to report 4.2 Lessons learned 4.3 Recommendations for improvement

Fig. 11.1  Checklist of information, which might be included in a surgical audit presentation (Adapted from [2])

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60

Fig. 11.2  Fair Dinkum Audit template. Designed by David Watters and accessible from www.surgeons.org

D.A.K. Watters

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11  Rural Surgical Audit Fig. 11.3  Suggested format for a chairperson’s report of a surgical audit meeting [1, 2]. The report will normally have a row for each issue. The table above is taken from the RACS Surgical Audit and Peer Review Guide [3] and Watters et al. [2]

For Surgical Units OPQ Surgeon(s) ABC Dates Y to Z Chairman Mr H Issue

Effect on patient and hospital

their field are. Vascular surgeons may use limb salvage rates after femoropopliteal bypass rates or stroke rates after carotid endarterectomy. Cardiothoracic surgeons employ mortality, rebleeding and deep sternal infection rates to monitor outcomes. A colorectal surgeon will report outcomes based on mortality, anastomotic leak and unplanned reoperation rates. Death may occur so infrequently in some specialties (e.g. plastic surgery) that mortality rates bear no relationship to performance. Plastic surgeons often use take rates of a split skin graft, or adequacy of excision margins for skin cancers. Appropriate outcome indicators are shown in Table 11.3, which also lists some actual performance results achieved by rural surgeons. It is ideal if surgical outcomes can be classified as either a success or a failure. When this can be done, cumulative summation (CUSUM) analysis can be applied to give visual feedback on performance (Fig.  11.4). CUSUM involves a time plot of attempts against an agreed binary target. Cumulative failure means that each failure is recorded as an upstroke on a cumulative failure chart where the horizontal axis is number of attempts (procedures) and the vertical axis records failures; a success is recorded as a horizontal line. CUSUM and cumulative failure charts are visual and useful for feedback to surgeons, units and services on performance. They measure variation in small samples and allow for early detection of small aberrations, natural variations and procedural performance trends (Fig. 11.5) [13, 14].

11.4.1 Complications Complications should be graded according to their effect on the patient. Grade 1 complications are those that have little effect on the patient and do not significantly delay discharge from hospital. They include

Recommendation

Action by whom and when

Final outcome of report

wound erythema, postoperative retention that responds to catheterisation and trial of void, minor fluid and electrolyte derangements. Grade 2 complications are those that prolong postoperative stay or cause the patient ­significant suffering. Examples include a scrotal haematoma after inguinal herniorrhaphy, major wound infection, pneumonia and deep venous thrombosis. Grade 3 complications include those that require major intervention such as radiological drainage (for a collection), nutritional support (for prolonged ileus or intestinal fistula to be treated conservatively), and cardiac stenting. Unplanned reoperations, or ICU admission are other examples. Death is a Grade 4 complication. An alternative is the Clavien Classification of surgical complications, which has five grades (Table 11.2). Grade 1 complications are minor and include wound infections opened at the bedside. Blood transfusion and TPN are included under Grade 2 together with other complications requiring pharmacological treatment. Grade 3 requires surgical, endoscopic or radiological intervention. Grade 4 requires ICU care for a lifethreatening complication and single organ (4a) or multiorgan (4b) failure. Death is a Grade 5 complication.

11.4.2 Adverse Events and Incidents An adverse event is defined as unintentional harm (to the patient) arising from an episode of healthcare and not due to the disease process itself. Surgical adverse events include unplanned reoperation, unplanned readmission, medication errors and side effects, falls, pressure ulcers, hospital acquired infection and inadvertent injury during surgery. Adverse events occur in around 10% of general surgical cases. The rates vary between specialties. Adverse events need to be reported through both a hospital incident reporting system and through surgical audit. Each adverse event can be graded using

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D.A.K. Watters

Table 11.3  Key performance indicators for rural surgery Specific procedures Performance indicator

Expected result (derived from consensus or literature)

Actual results (reported by Rural craft Group Audit or SCARS)

Thyroid surgery

Recurrent laryngeal nerve palsy (requires pre- and postoperative cord visualisation)

<2% permanent, <5% temporary

Long-term results not available, temporary palsy = 1.5%

Total thyroidectomy

Hypoparathyroidism

Permanent < 5%

Long-term results not available

Temporary < 30%

Temporary = 17%

Elective laparoscopic cholecystectomy

Bile leak rate prolonging stay (>48 h)

<5%

1.2%

Elective lap cholecystectomy

Bile leak requiring intervention

<2%

1%

Elective lap cholecystectomy

Conversion after elective surgery

<5–10%

6.7%

Elective lap cholecystectomy

Unplanned ERCP after completing cholecystectomy laparoscopically

<2%

0.6%

Elect Lap Chole

Bile duct injury

<1%

0.4%

Colorectal resection

Anastomotic leak after elective resection

<3%

3/136 Anterior 1/135 Right

Colorectal resection

Mortality after elective surgery

<3%

1/136 Anterior SCARS: 2.8%

Colorectal resection

Mortality after emergency surgery

<10%

SCARS 8.3%

Breast cancer surgery

DCIS and no axillary surgery

>90%

Not reported

Breast cancer surgery

Invasive cancer with axillary staging surgery

>90%

Not reported

Breast cancer surgery

Referral for radiotherapy after breast conservation surgery for invasive cancer and DCIS

>85%

Not reported

Breast cancer surgery

Offering or prescribing hormonal treatment for oestrogen receptor positive tumours

>85%

Not reported

Breast cancer surgery

Clear margins for breast conserving surgery invasive cancers and DCIS

>95%

Not reported

Inguinal hernia repair

Postoperative pain >3/12 requiring referral to a pain clinic

<3%

Not reported

Inguinal hernia repair

Scrotal haematoma

<2%

0.6%

The SCARS project was a voluntary audit of 877 colorectal operations by 67 rural and regional surgeons. The Rural Craft Group Audit in Australia has amassed over 3,000 cases for inguinal hernia, thyroidectomy, cholecystectomy and colorectal and breast cancer surgery. The presence of more than two comorbidities raised the overall mortality (elective and emergency) from 4.6% to 16.4% [16]

a Severity Assessment Code (Fig. 11.6) on the basis of its effect on the patient or hospital service, and the likelihood of it recurring. Adverse events require honest and frank discussion with patient and/or their family. Patients who have suffered unintentional harm deserve to have their suffering

acknowledged with empathy, and apology should be offered without necessarily admitting any fault. Adverse events offer an opportunity to improve the system of healthcare if the response to their occurrence is positive. They require investigation in an atmosphere of ‘noblame’ with engagement of the major stakeholders.

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8

6 Cumulative Failure

Fig. 11.4  (a, b) CUSUM and cumulative failure chart for vocal cord palsy after thyroidectomy. On the top the cumulative failure chart (a) shows two permanent vocal cord palsies represented as steps but performance remains acceptable. The corresponding CUSUM chart on the below (b) shows acceptable performance travelling with the two failures represented by the saw teeth. The trend of the performance line is downwards from the horizontal

4

2 0

1

21

41

61 81 101 121 141 161 181 201 221 241 261 281 301 Case number

1

21 41 61 81 101 121 141 161 181 201 221 241 261 281 301 Case number

−2 −4 0.5 0 −0.5

CUSUM

−1 −1.5 −2 −2.5 −3 −3.5 −4

Limited Adverse Occurrence Screening of healthcare (LAOS) was introduced in a rural hospital to identify opportunities to improve the system. Alan Wolff and Jo Bourke [15] were able to demonstrate reduced adverse outcomes by reviewing and responding to unplanned readmissions, prolonged length of stay, mortalities and return to theatre. The technique could be replicated in any rural hospital. A sentinel event is defined as ‘a relatively infrequent, clear-cut event that occurs independently of a patient’s condition; it commonly reflects hospital systems and process deficiencies’. Sentinel events are catastrophic and include operating on the wrong site or side, retained swabs or instruments after ­surgery, ABO incompatibility and gas embolism. At hospital and department of health level, they require early reporting (within days), detailed investigation, often with root cause analysis, and verifiable system changes.

11.5 Rural Surgical Craft Group (Australia) The ability to provide evidence of performance has driven the rural and regional surgeons of Australia to establish their own database. Commonwealth of Australia funding was obtained to support surgical audits in a number of regional and remote centres. Over 3,000 operations and their outcomes were entered during the first two phases of the project and a third phase is ongoing. The findings have confirmed the ­earlier results of SCARS for colorectal surgery – that rural and remote surgeons have acceptable outcomes (Table  11.3). There will always be some cases that should be referred to a specialist centre, for example low rectal cancers. It is to be hoped that the performance of rural surgeons will be measurable (and so defendable) by being able to compare their results with the database and so compare with ‘known standards’.

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a

D.A.K. Watters

b

Cumulative failure graph

8

Cusum graph

10

5

4 2

Cusum

Cumulative failure

6

0

0

–2

–5

–4 –6

0

10 Attempt number

20

–10

0

10 Attempt number

20

Probably acceptable Definitely acceptable Probably unacceptable Definitely unacceptable

Fig. 11.5  (a, b) CUSUM and cumulative failure plots for anastomotic leak after the last 20 large bowel procedures. Cumulative failure graph (left) showing possibly unacceptable performance in colorectal surgery anastomotic leak rate. The corresponding

CUSUM graph on the right shows a tendency to rise rather than drop below the line. This particular surgeon reflected on their performance and subsequently had much fewer anastomotic leaks, indicative of the value of feedback on performance

Event classification Consequences/ISR Catastrophic (1)

Major (2)

Moderate (3)

Minor (4)

Almost certain

1

1

1

3

Likely

1

1

2

3

Occasional

1

2

3

4

Unlikely

2

2

3

4

Rare

3

3

3

4

Likelihood

Fig. 11.6  Classification of incidents and adverse events Reporting incidents into an incident reporting system such as RiskMan is assisted by grading the injury severity which is based on its effect and likelihood of recurrence. Hospital risk registers enable management to prioritise and formulate strategies to address the most important risks

ISR = Injury Severity Risk

11  Rural Surgical Audit

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11.6 Conclusion

Comorbidity Index predicted in-hospital mortality. J. Clin. Epidemiol. 57, 1288–1294 (2004)   6. Dindo, D., Demartines, N., Clavien, P.A.: Classification of surgical complications. Ann. Surg. 240, 205–213 (2004)   7. Watters, D., Green, A., van Rij, A.: Requirements for trainee logbooks. ANZ J. Surg. 76(3), 181–184 (2006)   8. Watters, D.A., Knight, R.E.: Isolated specialists: how many procedures do they need to carry out and how do we measure whether they are competent? ANZ J. Surg. 78(9), 731–732 (2008)   9. Dundee, P.E., Chin-Lenn, L., Syme, D.B., Thomas, P.R.: Outcomes of ERCP: prospective series from a rural centre. ANZ J. Surg. 77, 1013–1017 (2008) 10. Bowles, T.A., Sanders, K.M., Colson, M., Watters, D.A.: Simplified risk stratification in elective colorectal surgery. ANZ J. Surg. 78, 24–27 (2008) 11. Copeland, G.P.F.A.U., Jones, D.F.W., Walters, M.: POSSUM: a scoring system for surgical audit. Br. J. Surg. 78, 355–360 (1991) 12. Tekkis, P.P., et al.: Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br. J. Surg. 91, 1174–1182 (2004) 13. Bowles, T., Watters, D.: Time to CUSUM: simplified reporting of outcomes in colorectal surgery. ANZ J. Surg. 77(7), 587–591 (2007) 14. Yap, C., Colson, M., Watters, D.: Cumulative sum techniques for surgeons: a brief review. ANZ J. Surg. 77(7), 583–586 (2007) 15. Wolff, A.M., Bourke, J., Campbell, I.A., Leembrugen, D.W.: Detecting and reducing hospital adverse events. Med. J. Aust. 174, 621–625 (2001) 16. Birks, D.M., Gunn, I.F., Birks, R.G., Strasser, R.P.: Colorectal surgery in rural Australia: SCARS; a surgeonbased audit of workload and standards. ANZ J. Surg. 71, 154–158 (2001)

The principles of surgical audit are the same wherever a surgeon is based. The challenges of peer review can be overcome even by isolated practitioners. Rural Surgeons in Australia and New Zealand have demonstrated their willingness and ability to participate in craft group audit. The data so far accumulated suggests that rural performance is more than satisfactory. Userfriendly tools to assist with data collection and presentation have been developed.

References   1. Royal Australasian College of Surgeons.: Surgical audit and peer review guide, 3rd edn. Melbourne, Australia. Available from www.surgeons.org (2008)   2. Watters, D., Green, A., van Rij, A.: Guidelines for surgical audit in Australia and New Zealand. ANZ J. Surg. 76(1–2), 78–83 (2006). Review   3. Royal Australasian College of Surgeons.: Continuing ­professional development information manual 2007–2009, Melbourne, Australia. Available from www.surgeons.org (2006)   4. Elixhauser, A., Steiner, C., Harris, D.R., Coffey, R.M.: Comorbidity measures for use administrative data. Med. Care 36, 8–27 (1998)   5. Sundarajan, V., Henderson, T., Perry, C., Muggivan, A., Quan, H., Ghali, W.A.: New ICD-10 version of the Charlson

 

Acute Pain Management

12

Edmund A.M. Neugebauer, Astrid Althaus, and Christian Simanski

Pearls and Pitfalls

›› Pain management is an interdisciplinary task

›› Sufficient pain management is a prerequisite

›› ›› ›› ›› ›› ››

››

for enhanced patient recovery and for a ­reduction in postoperative morbidity and mortality. Pain assessment and documentation (‘fifth vital sign’) are fundamental prerequisites for adequate pain management. Opioids remain the fundamental group of analgesic drugs for the treatment of moderate-to-severe pain. Co-analgesics support the action of analgesics but are not sufficient alone for postoperative pain relief. Peripheral nerve blocks have the main advantage of not compromising patient alertness. Local analgesics are very effective in epidural analgesia. Epidural local anaesthetics lead to a decreased incidence of pulmonary infection and complications overall compared with opioids. Treatment of acute pain should be procedurespecific and treatment should be adapted to the measured pain intensity reported by the patient.

E.A.M. Neugebauer (*), A. Althaus, and C. Simanski Department of Medicine, University of Witten/Herdecke, Ostmerheimer Straße 200, 51109 Cologne, Germany e-mail: [email protected]

››

requiring close liaison with all personnel involved in the care of the patient. Use of evidence-based clinical practice guidelines are recommended and should be adapted locally.

Acute pain management is a basic human right (Professor M. I. Cousins, President, Australian and New Zealand College Anaesthetists)

Although major efforts have been taken to improve acute pain management in recent years, we are still far away in meeting this basic human right. In the USA and Europe, the results of studies dedicated specifically to both medical and postoperative patients in academic hospitals have shown unequivocally that pain remains undertreated. Insufficient pain management originates from organizational problems, time constraints in daily clinical routine, little motivation to change daily clinical routine, complexity of pain management, difficulties in assessing pain intensity, and insufficient knowledge of pain management. However, pain should not be an accompanying phenomenon of medical treatments. Adequate techniques (epidural analgesia, epidural catheter, patient-controlled analgesia, etc.) and effective analgesics exist and, in principle, the possibilities for adequate pain management are available to all. An adequate pain therapy is an important prerequisite for enhanced patient recovery, and will reduce the postoperative risk of morbidity and mortality. Moreover, a significant reduction in long-term morbidity can be achieved since moderate-to-severe

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_12, © Springer-Verlag Berlin Heidelberg 2011

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acute pain has been demonstrated as an independent predictor for chronic postoperative pain. Adequate pain therapy is cost-effective; it is associated with a decrease in both intensive care and overall hospital stay. Studies have shown that up to 70% of patients present to the hospital because of acute pain. Furthermore, they associate the success of medical treatment with the relief of pain and it is of significant value from the patients’ perspective. Pain is therefore considered an ideal parameter for the evaluation of the quality of in-hospital care.

12.1 Definitions Pain, as defined by the International Association for the Study of Pain, is ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. Pain is subjective and is an individual, multifactorial experience influenced by culture, previous pain events, mood, beliefs, and an ability to cope. Acute pain is defined as ‘pain of recent onset and probable limited duration’. It usually has an identifiable temporal and causal relationship to injury (trauma, operation) or disease (colic, peritonitis, etc.). Chronic pain persists commonly beyond the time of healing of an injury (>3–6 months) and frequently has no clear identifiable cause. Acute and chronic pain may represent a continuum.

E.A.M. Neugebauer et al.

Spinal cord level: Once transducted into electrical stimuli, conduction of neuronal action potentials into afferent input and dorsal horn outputs follows. This signal conduction is called transmission in the spinal cord. The processing of pain on its way from excitation to perception is subject to several transformations. Tissue damage such as that associated with infection, inflammation, or ischemia, produces an array of chemical mediators (algetic substances such as prostaglandins, histamine, etc.) which can sensitize nociceptors to increase pain perception. This increase in sensitivity is termed peripheral sensitization, which can also lead to central sensitization. In addition to the excitatory processes, inhibitory modulation occurs within the dorsal horn. Central projecting level: A peripheral pain signal which reaches the central nervous system after transduction, transmission, and transformation needs to be translated into pain perception. The areas of the brain involved are the limbic system, cortex (e.g., cingulate cortex, insula, prefrontal cortex), and thalamus. The perception and experience of pain is multifactorial and is further influenced by psychological and environmental factors of each individual. Figure 12.1 gives a schematic representation of the nociceptor pathway.

Pain perception and experience

Cortex thalamus

Transformation

12.2 Pathophysiological and Pharmacological Basics Pain development and transduction involves multiple interacting peripheral and central mechanisms. The understanding of principles is important for the choice of medical treatments, and will therefore be summarized briefly. The basis of each central nervous system function is the excitation–response relationship. Peripheral level: Acute pain starts by tissue injury caused by mechanical, thermal, or chemical excitation. The detection of noxious stimuli requires activation of peripheral sensory organs (nociceptors) and transduction of the energy into electrical signals for conduction to the central nervous system. Nociceptive afferents are distributed widely throughout the body (skin, muscle, joints, viscera, meninges).

Sympatic conduction and modulation

Spinal cord

Transformation Actions potentials Transmission Receptor potentials Transduction Mechanical, thermal, chemical stimuli

Fig. 12.1  Schematic representation of the nociceptor pathway

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12  Acute Pain Management

12.3 Analgesic Drugs For adequate pain management, it is necessary to be familiar with the main mechanisms of pain relief by the different analgesic drugs. Analgesic drugs can be subdivided into five major categories (Table 12.1).

12.3.1 Non-opioid Analgesics The basic action of most non-opioids (nonsteroidal anti-inflammatory drugs – NSAIDs) is the inhibition of the cyclooxygenase (COX) enzymes. Two subtypes of COX enzymes have been identified – the constitutive COX-1 and the ‘inducible’ COX-2, and now a COX-3 is being investigated. Many of the effects of NSAIDs can be explained by inhibition of prostaglandin synthesis in peripheral tissues, nerves, and the central nervous system. Prostaglandins have many physiological

functions including gastric mucosal protection, renal tubular function, intrarenal vasodilatation, bronchodilatation, and production of endothelial prostacyclin. Such physiological roles are mainly regulated by COX-1 and are the basis for many of the adverse effects associated with NSAID use. Tissue damage results in COX-2 ­production, leading to synthesis of prostaglandins that result in pain and inflammation. NSAIDs are nonselective COX inhibitors that inhibit both COX-1 and COX-2 with a wide spectrum of analgesic, anti-inflammatory, antipyretic effects. Aspirin acetylates inhibit COX irreversibly but NSAIDs are reversible inhibitors of enzymes. The COX-2 inhibitors (e.g., parecoxib) have been developed to inhibit selectively the inducible form. Arylacid derivatives (diclofenac) and aryl propionic derivates (ibuprofen) are nonselective COX-inhibitors. Para­cetamol (acetaminophen) and metamizol have additional central effects. A combination of paracetamol and NSAIDs has additive effects on postoperative analgesia. Figure 12.2 illustrates the nociceptive pathway and therapeutic options of pain relief.

Table 12.1  Categories of analgesic drugs

• Non-opioids • Opioids

12.3.2 Opioids

• Local anaesthetics

Opioids remain the central group of analgesic drugs for the treatment of moderate-to-severe acute pain and transmit their action via different types of receptors.

• Co-analgesics • Adjuvant drugs

Fig. 12.2  Nociceptive pathway and therapeutic options of pain relief

Hypothalamus/thalamus limbic system

Opioids/antidepressants (colitis, crohn, surgery of carcinoma)

Cortical translation

Opioids (thorax/esophageal/pancreas operations)

Spinal cord/brainstem

Non-opioids (in combination with COX-inhibitors in major operation, i.e., colon)

Afferent nerve conduction

Local anesthetics (inguinal hernia repair)

Nociceptor

COX-Inhibitors, NSAID’s (basic medication)

70

Opioids can be differentiated into pure m-agonists (morphine, oxycodone, fentanyl, tramadol), mixed agonists–antagonists (antagonistic at m-receptors and agonistic at k- and s-receptors, e.g., pentazocine, tilidine), partial agonists with high affinity and small intrinsic activity at m-receptors (buprenorphine), and pure antagonists (at m-, k-, and s-receptors) such as naloxone. The opioid receptors are located mostly at structures that are involved in transmission, transformation, and translation of afferent signals. A high density is found in the limbic system, the thalamus, the pons region, and the substancia gelatinosa in the dorsal horn. Clinically meaningful side effects are doserelated; once a threshold dose is reached, every 3–4 mg increase of morphine-equivalent dose per day is associated with one additional adverse event. The most significant adverse effects are sedation, pruritus, nausea, and vomiting. The risk can be reduced significantly by parallel application of NSAIDs and/or adjuvant drugs. In the management of acute pain, one opioid is not superior to others but some opioids appear more effective in some patients than others.

12.3.3 Local Anaesthetics Local anaesthetics exert their effects as analgesics by impeding neuronal excitation and/or conduction. Shortduration local anaesthetics (lignocaine, plasma half-life 90  min) have to be differentiated from long-duration local anaesthetics (bupivacaine, ropivacaine). The local anaesthetic effect primarily depends on the site of administration, the dose administered, and the presence or absence of vasoconstrictors. Local application of 20 ml 0.25% bupivacaine in the area of trocar incision sites in laparoscopic cholecystectomy or colectomy reduces significantly postoperative pain intensity. Local anaesthetics are very effective in epidural analgesia. The quality of pain relief from low-dose epidural infusion (bupivacaine 0.1%, ropivacaine 0.2%) is improved consistently from the addition of adjuvants such as ­opioids. The concept of fast-track recovery benefits most from the application of an epidural.

E.A.M. Neugebauer et al. Table 12.2  Co-analgesics and their main functions Antidepressant

Increase function of inhibitory transmitter (e.g., serotonin, noradrenalin, i.e., aminotryptiline)

Anticonvulsive

Supportive in neuropathic pain syndro­ mes (e.g., carbamacepine, gabapentin)

Muscle relaxant

Supportive in muscle pain and spasms (e.g., benzodiazepine)

Corticosteroid

Anti-inflammatory (e.g., dexamethasone)

Bisphosphonate

Supportive in bony pain syndromes after metastasis of tumours (e.g., clodronate, pamidronate)

However, they are extremely helpful in combination with opioids and NSAIDs, and can reduce postoperative analgesic requirements. Adjuvant drugs are mainly used to decrease side effects of analgesic drugs such as emesis, vomiting, and constipation. Co-analgesics can be classified as follows (Table 12.2): Antidepressants decrease the awareness of pain and enhance the functioning of inhibiting neurotransmitters (serotonin, noradrenalin). Beside their antidepressant effect, they also have analgesic properties. Anticonvulsants: Carbamazepine, clonazepam and gabapentin are the most common agents used in the treatment of neuropathic pain. Tonicity reducing medication (i.e., benzodiazepines) is used in the treatment of painful muscle tension and spasm. The mode of action of most substances remains unknown. Corticosteroids inhibit the formation of cytokine, leukotriene, prostaglandin and macrophage activating interferon-g, and suppress the formation of inflammatory processes. Bisphosphonates have a repressive effect on bone absorption and are particularly used in the therapy of bone pain and osteolytic bone metastasis. Adjuvants can be divided into antiemetics and lax­ atives and are used to manage anxiety and side eff­ects of analgesic therapy, i.e., nausea, vomiting, and constipation.

12.3.4 Co-analgesics and Adjuvant Drugs

12.3.5 General Pain Management

Co-analgesics support the action of analgesics but are not sufficient alone for postoperative pain management.

The surgeon has a special responsibility in the treatment of pain. Aside from pharmacological interventions,

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12  Acute Pain Management

consideration should be given to the possibility of intervention before, during, and after surgery to optimize pain management. All procedures should be performed under the philosophy of avoiding pain wherever possible (minimal invasive techniques, positioning, etc.). Drains should be avoided and wound closure should be performed preferably with absorbable sutures. Postoperatively, a whole array of preventive measures should be considered with respect to reducing pain and associated complications: early rehabilitation (fasttrack), wound management, physio­therapy, cold/heat, massage techniques, and removal of lines and drains as soon as possible.

but with adhesive tape. The patient’s position while being operated can also influence the emergence of postoperative pain; patients, who are operated in a dorsal position, i.e., abdominal operations, have less postoperative pain in the back if they have a pillow beneath their knees during the treatment. During prolonged operations, it is mandatory to put the patient in a position that avoids pressure on exposed body parts because this might lead to nerve damage or a compartment syndrome with additional pain (head of the fibula, sulcus ulnaris on the elbow, popliteal fossa during lithotomy position).

12.5 Intraoperative Interventions 12.4 Preoperative Interventions Preoperatively, the surgeon has to provide evidencebased information to the patient regarding the type of disease, available treatment options, and procedurerelated postoperative pain management. The information about possible upcoming pain should neither evoke unrealistic expectations nor fear. Adequate procedural information can reduce anxiety and has an advantageous influence on the patient’s pain assessment. The knowledge about the possibility to influence the pain sensation in a positive way enhances the pain tolerance and this in turn reduces the use of analgesics. By contrast, insecurity about the operation and possible upcoming pain can increase the fear of the operation. A high level of anxiety and unrealistic beliefs can in turn increase postoperative pain. The placebo-effect plays an important role, and should be used within the frame of positive and realistic information. Patient information and training regarding coping and relaxation strategies have been shown to reduce pain and distress. The patients should be convinced that their pain is of utmost importance to the treating team and that they can also contribute to the success of pain management (patient as partner/co-therapist). Information about the different possible pain therapies need to be adapted to the patient’s experiences. The patient needs to be informed about side effects and alternative pain treatments. Smaller interventions and wound care should be done using local anaesthetics. If children are treated, a sufficient wound adaptation can be achieved without a needle

Intraoperatively, the choice of the operative procedure and of the access is essential to reduce postoperative pain. Minimal invasive operative procedures have been established especially for operations of the appendix, gallbladder, groin hernia, and colon and constitute well-validated methods with significantly less post­ operative pain than the conventional procedures. Transversal incisions cause less pain than vertical ­incisions in laparotomies, and skin incisions via diathermy cause less pain than the conventional scalpel. Further ­pos­sibilities to reduce pain can be achieved by defining strict indications for the usage of drains and tubes. Usually, it  can be abstained from placing subcutaneous suction drains. Suture material can also influence postoperative pain. Absorbable sutures avoid painful removal.

12.6 Postoperative Interventions Surgeons can alleviate postoperative pain by using ­adequate bandages. Very tight or unneeded bandage have to be avoided. Tuberosities need sufficient cushioning when orthotics or orthopaedic casts are applied. The early mobilization of patients with the assistance of nursing staff or physiotherapists can help to avoid postoperative complications. By means of a stepwise augmentation of exposure and sufficient analgesia, excessive demands can be avoided. Newer ‘fast track concepts’ schedule the patient’s mobilization to a chair already 5 h after the operation. Physical treatment and adjuvant medications can be used in addition to alleviate pain.

72

If catheters, drains, and tubes are not needed anymore, they should be removed immediately. Analgesia can decrease physiologic reactions to surgical complications (fever, muscular defence). Thus, the surgeon has to be informed about increasing pain and use of analgesics.

12.7 Medical Interventions 12.7.1 Peripheral Nerve Blockade The main advantage of using peripheral nerve block techniques as compared to systemic drug therapy (see below) is that the use of local anaesthetics does not compromise patient alertness and allows pain-free mobilization. Peripheral nerve blocks may be used for diagnostic and therapeutic purposes. Important technical issues include the technique of nerve location, the type of catheter equipment, the amount of drug, and the duration of drug efficacy. Following localization of the nerve, a continuous block can be initiated. Local anaesthetics such as lidocaine, mepivacaine, or prilocaine are effective for 2  h whereas bupivacaine and ropivacaine can produce pain relief for up to 12  h. Adjuvant techniques may prolong the duration of action. For example, wound infiltration with a longacting local anaesthetic agent provides effective analgesia following inguinal hernia repair but not for open cholecystectomy or hysterectomy. Continuous femoral nerve blockade provides postoperative analgesia and functional recovery superior to intravenous morphine with fewer side effects and comparable to epidural analgesia following knee joint replacement surgery. Both single injection and continuous application carry the risk of neurological injury, intravascular injection, dislodgment, haematoma, and infection. The incidence of neurological injury following peripheral nerve blocks is 0.02–0.4%.

12.7.2 Epidural Analgesia Epidural analgesia (i.e., the provision of pain relief by continuous administration of pharmacological agents into the epidural space via an indwelling catheter) has

E.A.M. Neugebauer et al.

become a widely used technique for the management of acute pain after surgery and trauma. Regardless of the analgesic agent used, location of catheter, or the type of surgery, it provides better pain relief than parenteral opioid administration. Improved pain relief with epidural local anaesthetics leads to a decreased incidence of pulmonary infection and other pulmonary complications overall when compared with systemic opioids. The combination of a low concentration of local anaesthetic and opioid is superior to either of the drugs alone. The addition of small amounts of adrenaline (epinephrine) to such mixtures improves analgesia and reduces systemic opioid consumption. Administration of a local anaesthetic into the thoracic epidural space results in improved bowel recovery, while this benefit cannot be observed with lumbar drug administration. Adverse effects are uncommon but include permanent neurological damage, which is reported at 0.05–0.0005%, and epidural haematoma (0.0005%). Others include respiratory depression (1–15%) and hypotension (5–10%).

12.7.3 Systemic Analgesia Necessary prerequisites for patient-orientated systemic pain therapy are good knowledge and understanding of the cause of pain (inflammatory, spasm, type of operation or operative access, anxiety, or depression of the patient), the anatomy and pain transduction, and, based on this information, the necessary surgical, physical, psychological, or medical therapy. Whereas chronic pain treatment starts with non-pharmacological techniques (psychotherapy, TENS, etc.) followed by mild non-opioid analgesics, and, subsequently, strong opioids, the treatment of acute pain follows the reverse order (Fig. 12.3). Strong opioids combined with NSAIDs are used as first-line therapy to control pain when intensity is highest. Analgesic drugs given by the intravenous route have a more rapid onset of action compared with most other routes of administration. Titration of opioid therapy for severe acute pain is best achieved using intermittent intravenous bolus doses (2–3 mg of morphine at 5 min intervals until relief of pain). Relative or absolute overdosing (also rapid injection) may lead to complications and side effects independent of the opioid used. However, the risk of overdosing with resultant respiratory depression is not

73

12  Acute Pain Management “Reversed” WHO-pain ladder for acute pain therapy (Non-opioids always as basic medication) Strong opioids Moderate opioids Non-opioids

WHO pain ladder for chronic pain therapy Strong opioids Moderate opioids Non-opioids

Fig.  12.3  WHO pain ladder of acute and therapeutic pain therapy

an issue as long as the patient continues to experience pain. If it occurs, sufficient antagonists (naloxon 0.4 mg) should always be available and the sedation level should be assessed in parallel. Continuous infusion of opioids in the general ward setting is not recommended because of the increased risk of respiratory depression compared with other methods of parenteral opioid administration. Non-opioid analgesics have an antipyretic and antiinflammatory effect. They should be administered either solely (such as after minor operations) or in combination with opioids. Opioid and non-opioid drugs can be administered systemically by a number of different routes. The choice of route is determined by various factors including the overall condition of the patient but also by the ease of use, accessibility, speed of analgesic onset, duration of action, and patient acceptability. In general, the principle of individualization of dose and dosing intervals should apply to the administration of all analgesic drugs, whatever the route. Frequent assessment of the patient’s pain and their response to treatment rather than strict adherence to a given dosing regimen is required if adequate analgesia is to be obtained. Oral administration is straightforward, noninvasive, has good efficacy in most settings, and has a high patient acceptability. Other than in the treatment of severe

acute pain, it is the route of choice for most analgesic drugs provided that there is no contraindication to its use. After major operations or trauma, the aim should be to change to the oral route as quickly as possible. The analgesic efficacy varies from one pain model to another and the administration of analgesics should be procedure-specific. Although still used commonly, intramuscular injection of analgesic agents is no longer recommended because of the significant risk of abscess formation, nerve lesions, and necrosis. Subcutaneous injection shares the same problem as intramuscular administration that absorption may be impaired in situations of poor perfusion. This leads to inadequate early analgesia and late absorption of the drug depot when perfusion is reestablished. Rectal administration of drugs is useful when other routes are unavailable. Transdermal routes for opioid administration (fentanyl or buprenorphine patches) are not recommended for acute pain management due to safety concerns (respiratory depression) and the difficulties in short-term dose adjustments that may be required for titration. The general rule is that the patient should determine their analgesic requirement within given limitations for all routes of administration. Patient-controlled analgesia (PCA) refers to methods of pain relief that allow the patient to self-administer small doses of an analgesic agent as required. This is not necessarily associated only to the use of programmable infusion pumps. Adequate analgesia needs to be obtained prior to commencement of PCA. Initial instructions for bolus doses should take into account individual patient factors such as history of prior opioid use and patient age. Individual prescriptions may need to be adjusted and drug concentrations should be standardized within each institution to reduce programming errors. A background infusion is not recommended in acute pain management.

12.8 Non-medical Interventions Regarding severe postoperative pain pharmacological treatment is the first-line therapy. This can be complemented by nonmedical interventions including special nursing and physiotherapeutic techniques, psychological interventions, acupuncture, and contra-irritation techniques. All these procedures not only feature little or no side effects, but also provide the patient with attention and personal care.

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12.8.1 Nursing and Physiotherapy Within the postoperative therapy procedures such as general mobilization (exercises in bed, helping the patient to get up and walk around), demonstration of rather pain-free motion sequences, pain-free breathing and coughing techniques, tension-release techniques, active or passive motion exercises, techniques of massage, and special positioning of the patient should always be considered. Postoperative cooling therapy is advisable after orthopaedic surgical treatment. A recently conducted meta-analysis including six randomized studies revealed a significant analgesic effect in favour of patients who were treated with cooling after an arthroscopic cruciate ligament repair compared to the control group. In body areas with poor blood supply, for example, in vascular surgical patients, however, a cooling therapy is contraindicated.

12.8.2 Psychological Interventions Preoperatively, a combination of different cognitivebehavioural strategies has been proven to reduce pain and anxiety. Psychological interventions should also be integrated in the postoperative pain management; their efficacy is well-validated not only in the treatment of chronic pain but also in the therapy of acute pain. Cognitive-behavioural techniques as distraction, cognitive revaluation, and positive visualization have turned out to alleviate pain. Other strategies as imagination techniques, hypnosis, and relaxation exercises can reduce the degree of postoperative pain and the use of analgetics. Cognitive-behavioural techniques within the preoperative setting are not time-consuming and can be implemented promptly after the operation.

E.A.M. Neugebauer et al.

effects have been demonstrated after meniscus operations, thoracotomies, and shoulder joint operations.

12.8.4 Acupuncture Acupuncture has been proven to be effective and ­efficient in the treatment of certain chronic pain ­syndromes, whereas in postoperative pain high level evidence is still missing. In total hip replacement and arthroscopic shoulder joint surgery the use of analgetics was reduced by applying acupuncture. Regarding postoperative side effects (nausea, vomiting), a metaanalysis revealed a significant effect of P6 acupuncture compared to the application of fake acupuncture.

12.9 Assessment and Documentation of Acute Pain Pain assessment and documentation are fundamental prerequisites for adequate pain management. Regular assessment leads to improved pain management. Under routine clinical conditions, measurement of pain intensity is sufficient and should be performed by visual analogue or numerical rating scales. Self-reporting of pain should be used whenever appropriate as pain is by definition a subjective experience. In the pre- and postoperative setting scoring should include static (rest) and dynamic (pain on sitting, coughing) measurements at least two times a day and following treatment of pain to determine efficacy. The score should be documented in the patient’s charts as the ‘fifth vital sign’. Uncontrolled or unexpected pain requires reassessment of the diagnosis and consideration of alternative causes for pain.

12.8.3 Contra-Irritation Techniques

12.10 Organization of Acute Pain Management

The contra-irritation technique is based on the ­gate-control theory. After certain kinds of operations the additional application of a transcutaneous elec­trical nerve stimulation (TENS) with an intensity below the pain threshold (15  mA) can reduce the ­postoperative pain intensity as well as the need for analgetics. Positive

Pain management is an interdisciplinary undertaking. Successful management of acute pain requires close liaison with all personnel involved in the care of the patient and should include surgeons, anaesthesiologists, and nurses. Effective acute pain management will only result from appropriate education and organizational structures

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12  Acute Pain Management

for the delivery of pain relief. Clear-cut responsibilities between disciplines are mandatory and this may differ between countries or even hospitals. Effective organizational structures for the delivery of pain relief are often more important than the anal­gesic techniques themselves. In some institutions, acute pain services (APS) are responsible for managing more advanced methods of pain relief such as PCA and ­epidural analgesia. There is a wide diversity of APS structures (from low-cost nurse-based through to multidisciplinary services) with different responsibilities. A recent review of publications analyzing the effectiveness of APS concluded that its implementation is associated with a significant improvement of pain relief with a possible reduction of postoperative nausea and vomiting. Marked improvements in conventional methods of pain relief can be expected by the introduction of evidence-based clinical practice guidelines. However, it is the implementation of guidelines and not their development which remains the greatest obstacle to their use. Professional bodies in a number of countries have published guidelines for the management of acute pain. A procedure-specific approach is highly recommended such as the online PROSPECT group (www.postoppain.org). Resource availability, staff with pain management expertise, and the existence of formal quality assurance programmes to monitor pain management are positive predictors of compliance with guidelines. Official guidelines need to be adapted for individual hospital requirements and the ward nurses play the most significant role in local adaptation. With their support, and that of clinical management and directors of surgical departments, we have been successful in translating national guidelines on acute pain management into the ‘Initiative Pain Free Clinic’. The Cologne City Hospital Merheim was the first in Germany to receive board certification by an external organization. This initiative served as a role model for other hospitals in

improving the organization of acute pain management with resultant benefit to the patients and the hospital.

Recommended Reading American Society of Anesthesiologists: Practice guidelines for acute pain management in the perioperative setting. An updated report by the American Society of Anesthesiologists Task Force on acute pain management. Anesthesiology 100, 1573–1581 (2004) Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine: Acute pain management: scientific evidence, 2nd edn. National Health and Medial Research Council. http://www.nhmrc.gov.au/publications/subjects/clinical.htm (2005) Ballantyne, I.S., Carr, D.B., de Ferranti, S., et al.: The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anaesth. Analg. 86, 598–612 (1998) Kehlet, H.: Multimodal approaches to control postoperative pathophysiology and rehabilitation. Br. J. Anaesth. 78, 606– 617 (1997) Kehlet, H., Gray, A.W., Bonnett, F., et al.: A procedurespecific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy. Surg. Endosc. 19, 1396–1415 (2005) Neugebauer, E.: Initiative Schmerzfreie Klinik: (k)eine vision. Schmerz 19, 557 (2005) Laubental, H., Neugebauer, E., et al.: The German guidelines on the treatment of acute perioperative and posttraumatic pain. www.leitlinien.net-AWMF0041 Neugebauer, E., Hempl, K., Sauuerland, S.T., et al.: Situation der perioperativen Schmerztherapie in Deutschland: Ergebnisse einer reprasentativen, anonymen Umfrage von 1000 chirurgischen. Kliniken Chirurg 69, 461–466 (1998) Veterans Health Administration D.o.D.: Clinical practice guideline for management of postoperative pain. http://www.oqp. med.va.gov/cqg/PAIN/PAIN_base.htm (2002) Werner, M.U., Søholm, L., Rotbøll-Nielssen, P., et al.: Does an acute pain service improve postoperative outcome. Anaesth. Analg. 95, 1361–1372 (2002) Zhao, S.Z., Chung, F., Hanna, P., et al.: Dose-response relationship between opioids use and adverse effects after ambulatory surgery. J. Pain Symptom Manage. 28, 35–46 (2004)

 

Prophylaxis of Venous Thromboembolism

13

Robert A. Fitridge and Simon McRae

13.1 Prevention of VTE

13.1.2 Methods of Thromboprophylaxis

13.1.1 Incidence of VTE in Hospitalised Patients

Both mechanical and pharmacological methods of thrombo­prophylaxis have been clearly demonstrated in a number of studies to decrease the risk of DVT and pulmonary embolus (PE), including fatal events, as well as being cost effective. The choice of approach is predominantly determined by the absolute risk of VTE associated with a particular procedure. Generally, pharmacological prophylaxis has been shown to be more effective than mechanical methods alone, with the former reducing the risk of VTE by at least 60–70% in most patient groups.

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in our community, with an annual incidence of 1–2 per 1,000 individuals. ­App­roximately 50% of episodes of VTE are related to recent hospital admission, with an almost equal contribution from surgical and non-surgical patients. Without thromboprophylaxis, the incidence of DVT in hospitalised patients is significant (Table  13.1). As expected, variation is seen between different patient categories, with the incidence highest in patients undergoing major orthopaedic procedures and experiencing major trauma. The reported incidence of VTE is influenced by the method utilised to screen for events. Venography detects all events, including asymptomatic isolated distal DVT, and studies using this method give the highest reported rate. However, the incidence of  clinically significant symptomatic events in most ­studies has been shown to be directly proportional to the venographic incidence of VTE (approximately ­tenfold less).

R.A. Fitridge (*) and S. McRae Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected], [email protected]

13.1.2.1 Currently Available Methods of DVT Prophylaxis General Measures The importance of general measures such as adequate hydration of hospital inpatients, and early mobilisation while recovering from their illness or surgery should not be underestimated, although these measures have not been extensively studied. Mechanical Methods Mechanical methods include graduated compression stockings (GCS), intermittent pneumatic compression devices (IPC) and venous foot pump (VFP). The most obvious advantage of mechanical prophylaxis over pharmacological methods is that there is no increased risk of bleeding associated with the former. This is particularly important in patients who are at high risk of bleeding or procedures where post-operatively bleeding is particularly catastrophic, e.g. neurosurgery.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_13, © Springer-Verlag Berlin Heidelberg 2011

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78

R.A. Fitridge and S. McRae

Table 13.1  Risk of DVT without prophylaxis Condition Incidence (%) Major abdominal general surgery

15–30

Major trauma

40–80

Stroke

20–50

Patients in high dependency/ intensive care units

30–50

Table 13.2  Forms of DVT prophylaxis General

Early mobilisation Mechanical methods

Pharmacological Methods of Prophylaxis A number of pharmacological methods of VTE prophylaxis are now available. Unfractionated heparin (UFH) has been used for VTE prophylaxis for a number of decades, and is normally given at a dose of 5,000 units of sodium heparin twice or three times daily. Lowmolecular-weight heparin (LMWH) is a chemically or enzymatically modified form of UFH, which is generally given as a once-daily dose. LMWH has been shown to be more effective than UFH for a number of indications including prevention of DVT post major orthopaedic ­surgery, major trauma and ischaemic stroke, and current guidelines reflect these findings. Warfarin is still widely utilised for prophylaxis post major orthopaedic surgery in North America, and can also be used in other patient groups if extended prophylaxis is indicated (Table 13.2).

Graduated compression stockings (GCS) Intermittent pneumatic compression devices (IPC)

Pharmacological methods

The use of IPC devices alone has been shown to be effective in decreasing the risk of VTE in a number of surgical patient groups [1], and therefore, this approach should be utilised in moderate- or high-risk patients in whom anticoagulant therapy is contra-indicated. IPC is also often used as an adjunctive measure in addition to pharmacological methods in patients at particularly high risk of venous thromboembolism, an approach supported by the findings of a recent Cochrane review [2]. A recent systematic review suggested that use of graduated compression stockings results in up to a 50% reduction in all episodes of DVT; however, the data regarding the role of stockings in preventing the more clinically significant proximal DVT was inconclusive. There is ongoing debate about the effectiveness of knee-high GCS in comparison to full-length or thigh-high stockings, with the available data being inconclusive. However, frequent inappropriate application and poor patient compliance with full length stockings may limit their effectiveness in real life.

Adequate hydration

Unfractionated heparin Low-molecular-weight heparin Selective factor Xa inhibitor (Fondaparinux) Warfarin

A number of new antithrombotic agents that selectively inhibit specific activated clotting factors are presently or are soon to become available for use in patients requiring thromboprophylaxis. Fondaparinux is an injectable selective indirect inhibitor of factor Xa that has now been available for some years. Combined data from a number of trials has demonstrated that Fondaparinux is more effective in preventing VTE following major orthopaedic surgery than LMWH, at the expense of a slight increase in bleeding risk which has probably resulted in limited uptake of this agent. Renal clearance is the method of elimination of lowmolecular-weight heparin and Fondaparinux. In a setting of a creatinine clearance of <30 ml/min, a reduction in the calculated dose of low-molecular-weight heparin or Fondaparinux should be considered. Alternative agents should be considered in patients with more marked renal impairment. Due to the frequent age-related decrease in creatinine clearance, particular care should be taken when using these agents in very elderly. Significant interest has surrounded the development of a number of new oral agents likely to be used for both prevention and treatment of VTE. Rivaroxaban is an oral direct factor Xa inhibitor that has been shown to be more effective than the LMWH enoxaparin in preventing VTE following hip and knee arthroplasty, with similar bleeding rates. Dabigatran is an oral direct thrombin inhibitor that appears to be as effective as LMWH in preventing VTE following orthopaedic ­surgery. Both agents have been recently approved in a number of health jurisdictions for the above indications.

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13  Prophylaxis of Venous Thromboembolism

13.1.3 Inferior Vena Caval Filters There is ongoing debate regarding what constitutes appropriate use of inferior vena cava (IVC) filters. There is general agreement that IVC filter use is appropriate in patients with recent (within 1 month) symptomatic VTE requiring more than brief interruption of therapeutic anticoagulation. All other indications are open to debate, largely due to the lack of evidence for or against their use in other circumstances. Most controversial is the use of filters in trauma patients at high risk of VTE in whom anticoagulant therapy is contraindicated. The availability of temporary IVC filters able to be retrieved has no doubt contributed to the increase in filter use in recent years. However, it is not uncommon for these planned temporary devices to be unable to be retrieved, and clinicians should therefore consider that temporary IVC filters may in fact remain in-situ indefinitely, with their presence associated with a long-term increase in risk of DVT.

13.1.4 Risk Stratification for VTE As mentioned above, the risk of developing VTE can be stratified on the basis of both patient-related ­co-morbidities and procedure-related risks. Table 13.3 summarises these risk factors. Whilst it is possible to assess the risk for an individual patient, a more straightforward approach is to use simplified protocols, risk Table 13.3  Risk factors for venous thromboembolism [3] Patient related

Previous DVT or PE Cancer Immobility, e.g. CVA Oestrogen therapy (HRT or OCP)

stratifying patients primarily on the basis of their planned surgical procedure/or primary underlying medical condition and modify this only if a number of further risk factors are present. Figure  13.1 and Table 13.4 show contemporary protocols for prophylaxis based on risk developed by the ANZ Working Party on the Management and Prevention of Venous Thromboembolism and the American College of Chest Physicians. It is recommended that all health institutions adopt similar guidelines, with or without local modification as appropriate. Risk assessment should be performed in all patients at admission to hospital, if not already done so at surgical pre-assessment.

13.1.5 Current Compliance with VTE Prophylaxis Guidelines A number of studies have demonstrated inadequate adherence to guidelines for provision of VTE prophylaxis. Individuals can be risk stratified regarding their risk of developing DVT or PE on the basis of both patient-related co-morbidities and procedure-related risks. The ENDORSE trial [6] assessed over 68,000 surgical and medical inpatients in 32 countries of whom 45% were categorised as surgical. This study found that 64% of surgical and 42% of medical patients were considered to be at-risk of VTE. However, only 59% of surgical and 40% of medical individuals considered atrisk were receiving appropriate prophylaxis. A number of strategies have been demonstrated to improve the uptake of appropriate prophylaxis protocols, including the use of pre-printed order forms attached to admission bundles, computer reminders, and ongoing audit and feedback [7]. Adherence to VTE prophylaxis protocol guidelines is one appropriate measure for quality of care audit in contemporary surgical practice.

Thrombophilia Obesity Inflammatory conditions, e.g. inflammatory bowel disease Surgical procedure related

Hip, knee, lower limb orthopaedic surgery Laparoscopic surgery Cancer surgery

13.2 Diagnosis of Venous Thromboembolic Events Despite appropriate prophylaxis, there is still a small but definite risk of developing a VTE event during or soon after hospitalisation. Subjective diagnosis of both DVT and PE is often inaccurate, and therefore, an

STEP 1

†Additional VTE Risk Factors immobility, thrombophilia, oestrogen therapy, pregnancy or puerperium, active inflammation, strong family history of VTE and/or obesity.

*Major surgery: intra-abdominal surgery or any surgery > 45 minutes duration

• All other surgery

Fig. 13.1  Surgical VTE prophylaxis guide [4]

R I S K

L O W E R

R • Other surgery with prior VTE and/or active cancer I S K • Major surgery* age > 40 years

• Hip fracture surgery

H • Hip or knee arthroplasty I • Major trauma G H

Assess Patient Risk

Surgical VTE Prophylaxiss Guide

Prescribe: enoxaparin 40mg daily or dalteparin 5000U daily or for orthopaedic surgery fondaparinux 2.5mg daily (commence 6-8 hrs post-op) Duration 5-10 days EXCEPT 28-35 days for hip arthroplasty

Prescribe: enoxaparin 20mg daily or dalteparin 2500U daily or LCUH 5000 BD or TDS Duration 5-10 days

Consider LMWH or LDUH if addtional risk factors † Duration until hospital discharge

YES No anticoagulant

NO

YES No anticoagulant

NO

YES No anticoagulant

Duration 5-10 days EXCEPT 28-35 days for hip fracture surgery

or dalteparin 5000U daily or LCUH 5000 TDS or for hip fracture surgery fondaparinux 2.5mg daily (commerce 6-8 hrs post-op)

NO Prescribe: enoxaparin 40mg daily

YES No anticoagulant

NO

Renal impairment with LMWH - see manufacturer’s product information

Contraindication to anticoagulant prophylaxis Active bleeding / high risk of bleeding eg. haemophilia, thrombocytopenia (platelet count <50 × 10° /L), history of GI bleeding Severe hepatic disease (INR > 1.3) / adverse reaction to heparin On current anticoagulation Other eg. very high falls risk and palliative management.

Are there any contraindications to anticoagulant prophylaxis? (see below)

Are there any contraindications to anticoagulant prophylaxis? (see below)

Are there any contraindications to anticoagulant prophylaxis? (see below)

Are there any contraindications to anticoagulant prophylaxis? (see below)

Assess for Anticoagulant Prophylaxis

STEP 2

For ALL patients undergoing surgery or when surgery is imminent

Apply IPC and/or GCS

Apply GCS and/or IPC

Apply GCS and/or IPC

Consider GCS

YES Observe closely for VTE

NO

YES Observe closely for VTE

NO

YES Observe closely for VTE

NO

YES Observe closely for VTE

NO

LMWH - Low Molecular Weight Heparin LDUH - Low Dose Unfractionated Heparin GCS - Graduated Compression Stockings IPC - Intermittent Pneumatic Compression VTE - Venous Thromboembolism

Contraindication to Mechanical prophylaxis Severe peripheral arterial disease: Resent skin graft Severe peripheral neuropathy: Severe leg deformity

Are there any contraindication to mechanical prophylaxis? (see below)

Are there any contraindication to mechanical prophylaxis? (see below)

Are there any contraindication to mechanical prophylaxis? (see below)

Are there any contraindication to mechanical prophylaxis? (see below)

STEP 3

Assess Mechanical Prophylaxis

80 R.A. Fitridge and S. McRae

81

13  Prophylaxis of Venous Thromboembolism Table 13.4  Levels of thromboembolism risk and recommended thromboprophylaxis for patients in hospital [5] Levels of risk Approximate DVT risk Suggested thromboprophylaxis without thromboprophylaxis options (%)a Low risk

<10

Minor surgery in mobile patients

No specific thromboprophylaxis Early and “aggressive” ambulation

Medical patients who are fully mobile Moderate risk

10–40

Most general, open gynaecologic or urologic surgery patients

LMWH (at recommended doses), unfractionated heparin bd or tds, fondaparinux

Medical patients, bed rest or sick Moderate VTE risk plus high bleeding risk High risk

Mechanical thromboprophylaxisb 40–80

Hip or knee arthroplasty, hip fracture surgery Major trauma, spinal cord injury

LMWH (at recommended doses), fondaparinux, oral vitamin K antagonist (INR2-3)

Mechanical thromboprophylaxisb

High VTE risk plus high bleeding risk Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving thromboprophylaxis b Mechanical thromboprophylaxis includes IPC or VFP and/or GCS; consider switch to anticoagulant thromboprophylaxis when high bleeding risk decreases a

objective approach to diagnostic testing is required. Diagnostic algorithms combining non-invasive tests have largely replaced the previous invasive gold standards of venography and pulmonary angiography. Given the falling proportion of patients referred with suspected VTE that have the diagnosis objectively confirmed (as low as 10–15% in recent series), these algorithms have attempted to limit the need for diagnostic imaging while maintaining patient safety. The probability of individual patient’s having the diagnosis of VTE being confirmed can be stratified using clinical prediction rules, the most widely used of which are the DVT and PE Wells’ scores (Tables 13.5 and 13.6). In patients with a low pre-test probability (Wells score < 2, DVT unlikely), a negative sensitive D-dimer test, a product of the breakdown of crosslinked fibrin by plasmin, can be used to exclude DVT or PE without performing diagnostic imaging. Patients with either a high pre-test probability of VTE or a positive D-dimer test should proceed to diagnostic imaging, and as the majority of patients having undergone recent surgery will fall into one of these two categories, such algorithms are less useful in this patient population. Compression ultrasonography (CUS) is the commonly used diagnostic imaging test performed for suspected DVT. This technique is accurate for ruling in or

ruling out proximal DVT (popliteal and above). There is more debate regarding the accuracy (particularly the specificity) of CUS in the diagnosis of isolated calf vein or distal DVT, with diagnostic accuracy related to both the quality of the ultrasound machine as well as being operator dependent. While a negative complete compression ultrasound (examining proximal and distal vessels) has been shown to safely exclude DVT in most patients, where the clinician is highly suspicious of acute DVT but the initial study is negative, it is reasonable to repeat the imaging in 4–7 days to detect an initial small thrombus that may have subsequently propagated. Current imaging techniques for PE include ventilation/perfusion (V/Q) scanning, and increasingly spiral computerised tomographic pulmonary angiography (CTPA). A V/Q scan is reported on the presence or absence of mismatched perfusion defects. A high probability scan (the presence of a segmental sized or larger mismatched perfusion defect) is diagnostic of PE and justifies initiation of treatment, while a normal perfusion scan safely excludes PE. All other test results should be considered non-diagnostic, and further investigation is required. A non-diagnostic scan is more likely in patients with pre-existing lung pathology, and therefore, CTPA should be the investigation

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R.A. Fitridge and S. McRae

Table 13.5  Diagnostic algorithm for patients with episode of suspected first deep vein thrombosis Patient with suspected DVT

Assess Pre-test Probability using the Well’s Prediction Rule (see below)

“DVT unlikely” (score < 2)

“DVT likely” (score ? 2)

Proceed directly to diagnostic imaging in these patients.

D-dimer test

Negative D-dimer

Compression Ultrasonography (CUS)

Positive D-dimer

NEGATIVE

POSITIVE

DVT confirmed Proceed to treatment algorithm

DVT excluded

Table 13.6  Wells et al. [8] score for the diagnosis of DVT Clinical characteristic Score Active cancer (ongoing or Rx within 6 months)

1

Paralysis, paresis or recent plaster immobilisation

1

Recently bedridden for >3 days or surgery within 12 weeks (requiring general anaesthetic)

1

Previously documented DVT or PE

1

Localised tenderness along the distribution of the deep venous system

1

Entire leg swelling

1

Calf swelling at least 3 cm larger than the asymptomatic leg (measured 10 cm below the tibial tuberosity)

1

Pitting oedema confined to the symptomatic leg

1

Alternative diagnosis as least as likely as DVT

−2

Interpretation: Score < 2 = DVT unlikely; score ³ 2 = DVT likely

*Do not perform D-Dimer if (a) Anticoagulation for > 24 h (b) Symptoms lasting > 14 days (c) Patient is pregnant

of choice in this group. A filling defect in a segmental level or more proximal pulmonary artery on spiral CTPA is diagnostic of PE and justifies treatment. A number of recent studies have shown that it is safe to withhold anticoagulation in patients with a normal CTPA. CTPA has the additional advantage of having the potential to detect alternative causes of chest pain in patients with suspected PE.

13.3 Management of Venous Thromboembolic Events 13.3.1 Calf Vein Thrombosis The majority of post-surgical DVTs will be isolated to the calf veins below the level of the politeal vessel (isolated distal DVT). These may often be asymptomatic, but can on occasion result in significant discomfort

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13  Prophylaxis of Venous Thromboembolism

and swelling. Left untreated, approximately 10–25% of isolated distal DVTs will extend into the proximal veins, increasing the risk of PE. Calf vein thrombosis that is going to extend proximally normally does so within 1 week. There are no clear consensus guidelines at present for management of calf vein DVT. Based on the above natural history, a number of potential therapeutic approaches are reasonable. These include: (a) Symptomatic treatment alone with the performance of repeat ultrasonography at 1 week to detect those thrombi that have extended proximally and therefore require therapeutic anticoagulation. (b) Therapeutic anticoagulation for a 6–12  week period. This approach is likely to be appropriate in patients with ongoing risk factors (e.g. malignancy) or with more extensive thrombi. (c) Although not widely studied, many clinicians may utilise a shorter period of anticoagulation such as 2 weeks of LMWH, reassessing for progression at the end of this period with a repeat ultrasound.

13.3.2 Proximal DVT Traditionally, individuals have been formally anticoagulated with intravenous heparin and Warfarin. This approach required a period of in-hospital stay until the INR has been stabilised. Currently, patients who are judged to be reliable who do not have marked obstructive symptoms, and who do not have marked iliofemoral thrombus, can be managed as an outpatient utilising once-daily subcutaneous LMWH until they are therapeutically anticoagulated with Warfarin. This approach requires adequate community nursing support so that regular INRs can be taken and also lowmolecular-weight heparin can be injected where the patient is unable to do so. A recent Cochrane review found that there is a lower risk of bleeding associated with the use of LMWH than intravenous UFH, and that the risk of recurrent thrombotic events was also lower. Based on the protocols used in the initial clinical trials establishing their efficacy, both LMWH or UFH should be given for a minimum of 5 days, with the requirement that the INR is ³2 on two occasions 24  h apart prior to parenteral anticoagulation being ceased.

13.3.3 Duration of Anticoagulation The duration of anticoagulation is a balance between the risk of recurrent VTE once anticoagulation is ceased, and the risk of major bleeding whilst on warfarin (which is 2–3% per year in most series). The best predictor of recurrence risk is the presence or absence of a provoking risk factor at the time of the initial event. Isolated distal DVT is also associated with a lower risk of recurrent thrombosis. Based on these facts, the following broad recommendations can be made on duration of treatment: (a) Isolated distal DVT – 6–12 weeks (annual risk of recurrence < 3%) (b) Proximal DVT or PE associated with a major provoking risk factor (i.e. major surgery or trauma) – 3–6 months (annual recurrence risk ~ 3%) (c) Proximal DVT or PE with minor provoking risk factor (medical illness, oral contraceptive pill usage, travel) – 6 months (annual recurrence risk ~ 3–5%) (d) Unprovoked proximal DVT or PE – minimum of 6  months treatment, consideration of long-term therapy (annual recurrence risk ~ 10%) Repeat imaging should be performed at the cessation of anticoagulation to obtain a new baseline that can be used for comparison with future sc0ans. Patients with unprovoked events or with events at a young age, or with a strong family history should be considered for thrombophilia testing, as some conditions (protein C and protein S deficiencies, antithrombin deficiency and anti-phospholipid antibody syndrome) may require long-term anticoagulation due to a significant increase in risk of recurrent events. The role of new predictors of recurrence such as D-dimer testing and the presence of residual changes on imaging are still being evaluated.

References   1. MacLellan, D.G., Fletcher, J.P.: Mechanical compression in the prophylaxis of venous thromboembolism. ANZ J. Surg. 77, 418–423 (2007)   2. Kakkos, S.K., Caprini, J.A., Geroulakos, G., et al.: Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients (review). Cochrane Database Syst. Rev. 8(4), CD005258 (2008)

84   3. McRae, S.J., Ginsberg, J.S.: In the diagnosis of deep-vein thrombosis and pulmonary embolism. Curr. Opin. Anaesthesiol. 19(1), 44–51 (2006)   4. Australia and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism: Prevention of venous thromboembolism: best practice guidelines for Australia and New Zealand, 4th edn. Health Education and Management Innovations, Sydney (2007)   5. Geerts, W.H., Bergqvist, D., Pineo, G.F., et al.: Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edn.). Chest 133, 381–453 (2008)

R.A. Fitridge and S. McRae   6. Cohen, A.T., Tapson, V.F., Bergmann, J.F., et  al.: Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-­ sectional study. Lancet 371(9610), 387–394 (2008)   7. Tooher, R., Middleton, P., Pham, C., et  al.: A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann. Surg. 241(3), 397–415 (2005)   8. Wells, P.S., Anderson, D.R., Rodger, M., et al.: Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N. Engl. J. Med. 349(13), 1227–1235 (2003)

Nutrition of the Surgical Patient

14

Florian Brackmann, Wolfgang H. Hartl, and Peter Rittler

14.1 Changes of the Substrate Metabolism After Surgical Disturbance of Homeostasis 14.1.1 Basic Principles The hormonal changes after surgical trauma represent the essential basis for the adjustment of the substrate metabolism during this period. Catabolism, i.e. breakdown of all existing substrate depots in the body, is the main process. Initially, this represents a reasonable physiological reaction to provide the organism with elements for energy production and composition of important functional proteins. Thus, enhanced lipolysis in the adipose tissue leads to increased release of free fatty acids, which can, on the one hand, be used as an alternative substrate for the non-obligatory carbohydrate-dependent tissues (skeletal muscles), and represent, on the other hand, energy sources for the accelerated metabolism in the liver. Parallel to the restricted carbohydrate utilization in the skeletal muscles, a pronounced protein breakdown takes place here as well. By that, released amino acids fulfil mainly two purposes: on one side, the gluco­ neogenetic amino acids can be drawn on for the accelerated production of glucose in the liver; on the other side, the nitrogen carriers released from the skeletal muscles

F. Brackmann Department of General Surgery, Mount Gambier General Hospital, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia W.H. Hartl, and P. Rittler (*)  Department of Surgery, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany e-mail: [email protected]; [email protected]

are essential for wound healing. In this context, the supply of the gastrointestinal tract with certain amino acids (glutamine) is worth mentioning. Glutamine-dependent repair mechanisms are said to limit the extent of integrity disturbance within the g­ astrointestinal tract. The main site of metabolic changes after trauma or surgery is the liver. Here carbohydrates from gluconeogenesis and glycolysis are released into the blood. The accelerated hepatic production of glucose together with the peripheral insulin resistance lead to hyperglycaemia, which helps to optimize the glucose supply and by that the glucose intake and energy metabolism in the obligatory glucose-dependent tissues (immunocompetent cells, fibroblasts) (Figs. 14.1 and 14.2). Utilization of endogenously released amino acids for glyconeogenesis leads to irrevocable loss of nitrogen in the form of urea from the body. This loss of nitrogen equates to a loss of body proteins and is the biochemical correlate of the decrease of muscle mass. After elective surgical procedures, and with uncomplicated postoperative recovery, the maximum of ­metabolic changes occurring in the course of the ­post-aggression syndrome will be seen within the first 2  weeks after surgical disturbance of homeostasis. The insulin resistance with concomitant hyperglycaemia reaches its peak within the first 48  h, while the decrease in body proteins will have its maximum after 2 weeks. Accordingly, the protein metabolism recovers only very slowly.

Replenishment of body protein supply can only be expected 3–6 months after extensive surgical procedure without complications or trauma. The body weight does not reach the initial level before a similar period of time either.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_14, © Springer-Verlag Berlin Heidelberg 2011

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Lipolyse

Free fatty acids Keytone bodies Glucose Glycogenesis Lactate, Pyruvate Alanine, Glutamine

Urea

Proteolysis

Urea Balance Fig. 14.1  Substrate flow in the post-aggression metabolism

Glycerol 30g

114g

Glycogen Glucose 320g

3C

8g

76g

Blood cells 130g Wound

104g Lactate

Urea in the urine

Alanine, Lactate Gluamine

80g Amino acids

Fig. 14.2  Glucose ­regeneration during stress

14.2 Metabolic Particularities of the Intensive Care Patient With persistent Systemic Inflammatory Response Syn­ drome (SIRS) or severe sepsis, the severe disturbance of the carbohydrate metabolism with hyperglycaemia and insulin resistance remains because of the ongoing hormonal activation. Under such conditions very high

carbohydrate concentrations might -if untreated- have negative consequences for the patient’s prognosis due to immunosuppressive effects. Furthermore, there is a striking protein catabolism. Mainly four mechanisms seem to be initially responsible for this prolonged massive loss of proteins: • Immobilization of the patient • Release of catabolic hormones

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• Regularly seen hypercatabolism with increased metabolic rate • Activation of certain cytokines In long-term courses, another important mechanism to trigger and maintain the prolonged protein catabolism is the pathological change in the peripheral and central nervous system. This so-called septic neuropathy (in 70–90% of all intensive care patients) is associated with peripheral neuropathy and signs of axonal degeneration. Subsequently, functional denervation develops, which leads to drastic increase of protein breakdown. More than 90% of the critically ill patients show atrophy of the skeletal muscles (necrosis of muscle, intracellular lipid deposits). Another central finding with almost all intensive care patients is the increasing fatty degeneration of the liver caused by imbalance between fatty acid intake, fatty acid oxidation and fatty acid administration through VLDL-triglycerides. Protein catabolism leads to defective VLDL-triglyceride synthesis or secretion as well.

14.3 Nutritional Status and Caloric Demand Nutritional therapeutic measures are essential to ­minimise complications and achieve the best possible quality of life in the preoperative, intraoperative and postoperative period including the rehabilitation phase. For all measures, appropriate consideration of nutritional supply and status is required.

14.4 Assessment of Nutritional Status Today, reliable assessment of the nutritional status has to be regarded as a necessary component and prerequisite of any efficient nutritional therapy. Particularly severely malnourished patients are affected by increased perioperative morbidity and therefore benefit most from adequate nutritional therapy. Basic details regarding nutritional status are body height and weight to calculate the BMI (Body-Mass

Index), and inquiring about weight loss. The BMI is mainly established to classify overnutrition (moderate > 25, definite > 30, massive > 40). To assess under-/ malnourishment, it is only valid for chronic severe under-/malnourishment (BMI < 18.5), but not to detect short-term under-/malnourishment in acute conditions like malignancies, etc., and in cases of previously existing overnutrition. From a clinical point of view it has been proven as useful to classify patients as normally nourished, moderately undernourished or severely undernourished: • Considered as moderately undernourished are those patients that have lost 10–15% of their body weight preoperatively and concurrently have hypoalbuminaemia or disturbances in other body systems. • Severe undernourishment equals weight loss of 15% or more. In practice, assessment of the nutritional status based on the so-called Subjective Global Assessment (SGA) or the Nutritional Risk Screening 2002 (NRS 2002) has become widely accepted. This method mainly consists of taking accurate medical history, physical examination and estimation of the current energy demand of the individual patient. SGA allows making rough nutritional classifications of individual patients by discriminating between • Well nourished • Moderately undernourished • Severely undernourished The variables for the SGA are listed in Fig.  14.3. Special attention is paid to changes in body weight, alterations in nutritional intake, gastrointestinal disorders, physical activity and the underlying disease with its relation to nutritional demand. Furthermore, in the physical examination, loss of subcutaneous fat and clinically evident muscular atrophy are recorded. Additionally, ankle and flank oedema as well as ascites are to be noted. No defined numeric algorithm is used to get an appropriate SGA classification. Rather, a categorization on a basis of subjective evaluation is performed. In spite of this subjectivity, a clear correlation between SGA and prognosis of the surgical patient is found. This only applies for preoperative assessment, though; there is still no precise method for postoperative surveillance or intensive care patients available.

88 Fig. 14.3  Variables of the “Subjective global Assessment” (SGA)

F. Brackmann et al. A. History 1. Weight change Overall loss in past 6 months: – amount = # ___________ kg; – % loss = # ____________ Change in past 2 weeks: – ___________________ increase, – ___________________ no change, – ___________________ decrease. 2. Dietary intake change (relative to normal) ___________ No change, ___________ Change ___________ duration = # ___________ weeks type: – ___________ suboptimal liquid diet, – ___________ full liquid diet – ___________ hypocaloric liquids, – ___________ starvation. 3. Gastrointestinal symptoms (that persisted for >2 weeks) ___________ none, ___________ nausea, ___________ vomiting, ___________ diarrhea, ___________ anorexia. 4. Functional capacity ___________ No dysfunction (e.g., full capacity), ___________ Dysfunction ___________ duration = # ___________ weeks. type: __________________ working suboptimally, __________________ ambulatory, __________________ bedridden. 5. Disease and its relation to nutritional requirements Primary diagnosis (specify) ___________________________________________ Metabolic demand (stress) : – ____________ no stress, – ____________ low stress, – ____________ moderate stress, – ____________ high stress. B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe). # ______________________________ loss of subcutaneous fat (triceps, chest) # ______________________________ muscle wasting (quadriceps, deltoids) # ______________________________ ankle edema # ______________________________ sacral edema # ______________________________ ascites C. SGA rating (select one) __________________ A = Well nourished __________________ B = Moderately (or suspected of being) malnourished __________________ C = Severely malnourished Select appropriate category with a checkmark, or enter numerical value where indicated by “#”

Besides those general diagnostics that should always be done in specific situations as in chronic diseases (e.g. liver cirrhosis, chronic pancreatitis, immunosuppression), or severe undernourishment (tumours, Crohn’s disease), problem-oriented diagnostic investigations

(serum albumin level, short-lived functional proteins, 24  h urine-creatinine excretion, bioelectrical impedance analysis [BIA]) can be carried out to detect and distinguish protein deficiency or specific nutritional deficiencies.

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14.5 Estimating the Perioperative Caloric Demand Postoperatively, fluid and electrolyte supply has to be aligned to calorie and substrate supply. For that, it is necessary to determine the patient’s energy demand first. You start with the basic energy metabolic rate, that can be calculated approximately according to Harris and Benedikt for the healthy person based on body weight, age, gender and height. In clinical routine, the basic metabolic rate can be calculated by Stein and Levine’s rule of thumb (basic energy metabolism [kcal]/day = 24 × kg bodyweight). Generally, it can be assumed that caloric demand immediately after elective procedures is equivalent to the metabolic rate at rest. After mobilizing the patient the rate increases about 10%. Hence, only fluids and electrolytes are given on the day of surgery. Administration of vitamins and trace elements during this period is not necessary. From the first day on calories should be administered preferably orally or enterally via a tube. If this is not possible, glucose and amino acids can be administered parenterally for a few days. Parenteral nutrition is only required for patients who cannot be fed orally or enterally after 1 week.

Note:  Caloric deficiency always leads in the medium term to under-/malnourishment and increases the risk for complications or delayed rehabilitation. Therefore, especially after resolving the acute phase sufficient nutrition and, where required, additional energy- and protein-rich drinking supplements should be administered.

14.6.1 Oral Nutrition Usually, products for oral nutrition are supplied by the hospital kitchen. Apart from mainly liquid diet (tea, soup, biscuits, oral drinking supplements with high calorieand protein concentration), there are more preparations with different consistencies and fibre ­concentrations (filtered diet, light diet, full diet). Oral food intake should be the rule. Drinking ­supplements can be used as additive measures in case of inadequate oral food intake especially for severe under-/malnourishment and during the postoperative period. Studies established the merit of such measures for old patients after hip fractures or after gastrectomy.

14.6.2 Enteral Nutrition Substrates are administered enterally in case of dysphagia or malfunctioning of the upper gastrointestinal tract (stomach/oesophagus). For enteral nutrition, fabricated balanced diets are used that meet all the patient’s needs regarding nutrients, trace elements, electrolytes and vitamins. Most of them are suitable as full nutrition but are more expensive than normal hospital diet. Nutrient defined diets (NDD) have to be distinguished from chemically defined diets (CDD) (Table 14.1). For catabolic patients NDDs with higher caloric density and higher protein content are available to provide protein rich nutrition (1.3–1.5 g/kg bodyweight/day). For uncomplicated long-term feeding and in case of unrestricted gastrointestinal functioning, NDDs containing fibre can be used. Here diets containing insoluble fibre (cellulose) and diets with soluble fibre (prebiotics: pectin, agar, mucilage, oligofructose) can be distinguished.

14.6.3  Diets Adapted to Metabolism 14.6 Substrates for Perioperative Nutrition Perioperative feeding can be done orally, enterally or parenterally. Accordingly, there are commercial products for all three modalities.

So-called diets adapted to metabolism are designed for patients with specific organic diseases and in­­ sufficiencies as well as for situations with metabolic peculiarities: • Diabetes diet • Diets with immunomodulatory effects

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Table 14.1  Nutrient defined and chemically defined diets Nutrient defined diets (NDD) Composition

Chemically defined diets (CDD)

Carbohydrates in form of oligo- and polysaccharides (50–60%)

Amino acids, tripeptides or oligopeptides

Intact protein from milk, soy, egg albumin and meat protein (15–20%) Lipids from vegetable oil

Low in lipids

Essential fatty acids Saturated fatty acids (short-chain, medium-chain and long-chain fatty acids) Low in fibre

Free of fibre

Properties

High molecular

Low molecular slightly hyperosmolar because of osmotically active protein hydrolysate

Location of resorption

Entire GI tract

Jejunum and Ileum

Application

For normal digestion and resorption performance

For global impairments of the intraluminal hydrolyse capacity and resorption (e.g. exclusive jejunal feeding)

• Liver-adapted tube diets • Kidney-adapted diets

14.6.4 Parenteral Nutrition

Diabetes diets contain reduced amounts of carbohydrates and an increased fraction of unsaturated fatty acids and help to control glycaemia and reduce insulin demand. Immunomodulating diets contain substrates like Glutamine, Arginine, Omega-3-fatty acids and nucleotides that have been shown to have certain immunomodulatory effects. In general, the aim is to dampen the hyperinflammatory processes which occur within SIRS and sepsis, and to strengthen the specific immune system on the other side. Glutamine is supposed to have further positive effects on gastrointestinal tract function. Liver-adapted tube diets contain specific amino acid patterns. The goal of this modification is to restore normal plasma aminograms in patients with liver failure, especially patients with hepatic encephalopathy, who have increased plasmatic levels of aromatic amino acids and methionine, but decreased levels of branched chain amino acids. Therefore, diets enhanced with branched chain amino acids can help to improve this amino acid imbalance. Patients with marginally impaired kidney function can benefit from kidney-adapted diets with a reduced proportion of nitrogen and a high proportion of essential amino acids or adapted electrolyte compositions.

In case of malfunction of the lower GI tract (small bowel/large bowel) feeding has to be parenteral. It should be hypocaloric for the first week after surgical trauma and normo (iso-) caloric in the second week. For both, the early (day 1–3) and the late (day 4–6) postoperative phase, commercialised infusion solutions are available which take the specific ­metabolic demands of each phase into account (Table 14.2). If electrolyte- or water imbalances occur in the late postoperative period, it is necessary to combine single solutions of amino acids and sugar according to the above principles instead of using the amino acid carbohydrate solutions. The concentrations of sugar solutions range between 10% and 40% and allow isocaloric nutrition for patients with such dysfunctions. Of course, the amounts of carbohydrates administered in such manner have to be adjusted to the extent of the post-aggression metabolism. Additionally, it is necessary to combine this with separate amino acid solutions that usually contain 10% synthetic crystalline amino acids. Those solutions are generally composed of 40–50% essential amino acids, the rest being non-essential amino acids.

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14  Nutrition of the Surgical Patient Table 14.2  Infusion solution for the different phases of parenteral postoperative nutrition Hypocaloric nutrition in the early postoperative phase

Hypocaloric nutrition in the late postoperative phase

Complete isocaloric parenteral nutrition

Timing

Day 1–3 after surgery

Day 4–6 after surgery

From day 7 after surgery

Composition and properties

Slightly hypertonic (700–800 mosm/l)

High osmolarity (1,300 mosm/l)

High osmolarity (>1,300 mosm/l)

Low caloric density (0.3–0.4  kcal/ml)

High caloric density (0.6–0.7 kcal/ml)

High caloric density (1–1.2 kcal/ml)

5% glucose, 3.5% amino acids and electrolyte proportioned to the maintenance dose

Carbohydrates, amino acids, trace elements, electrolytes, proportioned to the increased protein- (1–1.2 g/kg body weight/ day) and carbohydrate demand (4 g/kg body weight/day)

Amino acid-carbohydratelipid-combination solutions or amino acid-carbohydratesolutions with lipids separate

Amount of infusion

40 ml/kg bodyweight/day

25–30 ml/kg bodyweight/day

Way of application

Peripheral venous line

Central venous line

14.6.5  Parenteral Application of Lipids For complete isocaloric parenteral nutrition hyperosmolaric amino acid/carbohydrate/lipid combination solutions are available. Lipids, however, can also be administered as a separate part of parenteral nutrition. Because of its high caloric density (2  kcal/ml), only small amounts of lipids are sufficient to administer adequate amounts of calories. At present, there are five different infusion solutions for the application of lipids with different compositions. As a general rule these solutions contain 20% of lipids in 250 ml: • Lipid emulsions based on soy bean oil (20  g fat/100 ml with 52% linoleic acid) • MCT/LCT-solutions: soy bean or coconut oil (so-called medium chain triglycerides); 10  g soy bean oil/100  ml with 10  g coconut oil/100  ml in physical mixture • Structured lipids: same composition as MCT/LCTsolutions, not physically but biochemically mixed • Lipid emulsions based on soy bean and olive oil with 4 g soy bean oil/100 ml (equal to 18% linoleic acid) and 16 g olive oil/100 ml • Preparations with higher fractions of omega-3 fatty acids (fish oil) Linoleic acid plays an important role as it is the precursor substance of arachidonic acid, which many

Central venous line

inflammatory mediators (prostaglandins, leucotrienes) with immunosuppressive functions are made from. To reduce these effects, new solutions contain considerably smaller amounts of linoleic acids (higher proportions of MCT or olive oil). Furthermore, infusion solutions with higher fractions of omega-3 fatty acid might have positive immunologic effects due to the decreased synthesis of immunosuppressive prostanoids.

14.6.6 Special Preparations for Patients with Organ Dysfunctions Similarly to enteral nutrition, there are also specific preparations of parenteral nutrition to compensate for organ dysfunctions. The so-called kidney solutions contain only essential and few semi-essential amino acids. Since increasingly damaging effects of urea concentrations above 100 mg/ dl can be expected, administration of daily proteins has to be cut down to one-third of the calculated daily intake if haemofiltration/dialysis is meant to be postponed. With this nutritional regime, production of urea is lower than with carbohydrate supply only. Yet in case of longer-lasting renal failure, resumption of isocaloric nutrition with full amino acid supply is preferable. For patients with hepatic encephalopathy and ammoniac concentrations of more than 100  mg/dl,

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special liver solutions exist for parenteral administration that contain higher fractions of branched chained amino acids (see above).

14.6.7. Supply of Glutamine, Vitamins and Trace Elements Nowadays, special amino acid solutions which include glutamine in the form of dipeptides (in combinations or single solutions) are available. So far, amino acid solutions did not contain glutamine, because glutamine is instable in solution. Linking glutamine to alanine or glycine makes parenteral supply possible as well. Especially intensive care patients (see below) show a distinct glutamine deficiency both in their plasma and in their muscle tissue. Postoperative application of vitamins and trace elements is only required in cases of long-term parenteral nutrition. Preparations that contain the most important trace elements (chrome, copper, iron, manganese, fluorine, molybdenum, selenium and zinc) exist and are usually administered daily. Water-soluble vitamins can be given additionally (thiamine, riboflavin, pyridoxine, pantothenic acid, ascorbic acid, biotin, folic acid, cyanocobalamine). The administration of lipophilic vitamins (vitamin A, D2, K and E) can be done parenterally as well, if the patient receives lipids intravenously in the context of nutritional therapy. If the patient does not receive lipids intravenously, the same vitamins can alternatively be administered in specially processed normal saline.

14.7 Preoperative Nutritional Therapy 14.7.1 Indication Indication for preoperative nutritional therapy is moderate-to-severe malnourishment for all patients with elective procedures. It has been shown that pre-existing, relevant undernourishment leads to a perioperative shift of fluids into the “third space”, is associated with muscle weakness, significantly interferes with wound healing and leads to pronounced immunodeficiency. All of these phenomenons significantly increase postoperative morbidity and mortality. By enforcing

F. Brackmann et al.

aggressive preoperative nutritional therapy over a period of at least 1 week, postoperative complications can be reduced by 20–35%. A further indication for preoperative nutrition is given in tumour patients prior to big visceral operations, even if no relevant undernourishment is present. Drinking supplements with immunomodulatory substances are used for this purpose during a period of 5–7 days before surgery. This kind of nutritional therapy is usually carried out up to the evening before surgery, and decreases the perioperative morbidity by reducing infectious complications.

14.7.2 Calorie Supply Tumour patients who are not undernourished preoperatively receive additive immunomodulatory supplements with 500–1,000 cal. The amount of administered calories for undernourished patients is not based on the expected current metabolic rate but should be hypercaloric. Here 30–40 kcal/kg body weight/day non-protein calories should be administered with one-third given in the form of lipids. Proteins should be given in the amount of 1–1.5 g/kg body weight/day. Ideally, this calorie intake can be achieved with oral supplements high in protein. Only in cases of dysphagia or high risk of aspiration, enteral nutrition (nutrient defined diet) is used. Only if oral/enteral nutrition is impossible or insufficient, it becomes reasonable to use complete parenteral nutrition with balancing of vitamin- and trace element deficiencies over the period of one week. The efficiency of these measures is shown by an increase of short-lived functional proteins (prealbumin, retinol binding protein) in the circulation.

14.8 Postoperative Nutritional Therapy 14.8.1 Indication Postoperative oral food intake should be started as soon as possible and gradually increased according to the conditions of post-aggression metabolism. In case

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of insufficient swallowing and/or gastrointestinal functioning artificial alimentation has to be considered. Indication for artificial feeding (enteral/parenteral) is given • for all patients who are undernourished preoper­ atively • for patients who have no signs of undernourishment but are expected not to receive oral food intake for more than 7 days or only food intake not covering their full demand In these patients alimentation should be started after surgery without delay. Parenteral nutrition is indicated only in cases with absolute contra-indications for enteral nutrition. Possible indications are: • Bowel obstruction with relevant impairment of passage • Persistent intestinal leakage • Paralytic ileus • Severe shock with circulatory instability In all other cases it is recommended to at least try to use enteral nutrition (gastric/jejunal). If the intestinal passage is only partly restricted, enteral nutrition should be combined with parenteral nutrition to cover caloric demands. Even for patients with gastrointestinal anastomosis, generally a discontinuation of oral/enteral food intake is not necessary. The gradual build-up of diet should be adapted to the patient’s tolerance. After anastomosis of the small bowel, colon and rectum, oral/enteral food intake can be started on the first day post op. For anastomosis of the upper gastrointestinal tract (oesophagus resection, gastrectomy), enteral food intake through a tube inserted distal to the anastomosis or specific catheter jejunostomy during the first days is recommended. Even a small fraction of caloric intake is beneficial. Small bowel mucosa enterocytes need glutamine from an enteral source.

Early enteral diet build-up decreases the risk of infection and at the same time shortens the length of hospital stay.

14.8.2 Oral/Enteral Calorie Intake Basic requirement for any kind of oral/enteral therapy is a sufficient passage and resorption of the administered substrates. In addition, the following has to be considered: • Capacity of passage in the GI tract • Type of surgical procedure After all thoracic and orthopaedic procedures, light diet can be started immediately after operation provided the GI tract is intact. After abdominal surgery, without harming the integrity of the intestinal tract, oral build-up of diet can be started on the first postoperative day as well. After feeding mainly liquids for a short period, diet can be switched over to light, low-fibre food already on the second postoperative day. Here the supplied amount of calories has to be adapted to the characteristics of the post-aggression metabolism – as it is done in parenteral nutrition. After surgery in the lower GI tract, diet build-up is slightly held up and then started with liquid nutrition in the first 2 days followed by the normal diet build-up as described.

The actual intake of the supplied calories has to be monitored carefully to avoid unexpected calorie deficiency.

After procedures in the upper GI tract, especially ­gastric or oesophageal resections, feeding is done by ­special, intraoperatively placed tubes (catheter jejunostomy). Special enteral nutritional solutions (see above) are administered, starting with 250  ml continuously for 24 h on the first day post op. If oral feeding cannot be achieved sufficiently, infusions are carefully increased over the next days by 250  ml/24  h every 1–2 days until the caloric demand of 24 kcal/kg bodyweight is reached. If patients after thoracic, vascular or orthopaedic surgery or extraintestinal abdominal procedures are not capable of taking food orally, enteral feeding via nasogastric tube is started early. Here, too, diet buildup is done gradually, starting at 500  ml on the first

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postoperative day. The intake is increased by 500 ml/ day until the caloric optimum is reached. There is strong evidence that especially patients after big visceral tumour surgeries or severe polytrauma, benefit from postoperative enteral feeding. If there is a need for long-term enteral feeding (>4  weeks), changing to a transcutanous tube (e.g. PEG) is recommended. A further specific feature applies for oncologic patients. It is suggested to continue feeding of the ­preoperative immunomodulatory tube nutrition postoperatively. In case of uncomplicated progress, a period of 5–7 days is sufficient for that.

14.8.3 Parenteral Calorie Intake Following the immediate postoperative period, and after estimating the calorie- and water demand, it is also important to assess the fraction of protein- and non-protein calories in the total calorie intake. The healthy adult needs approximately 0.8  g protein/kg body weight/day. Patients after big ­surgical interventions need between 1 and 1.2  g protein/kg body weight/day depending on the extent of their disease.

The main focus of postoperative nutritional therapy has to be on sufficient supply of proteins. Based on a demand of 1 g/kg body weight/day an amount of 4 kcal/kg body weight/day should be administered in form of amino acids during the entire postoperative period.

The additional amount of carbohydrates and lipids depends on the calculated energy demand and the expected metabolic impairment. Therefore, only 50–60% of the estimated calorie demand is administered between the first and third postoperative day, i.e. 12  kcal/kg body weight/day (according to Stein and Levine). Deducting the administered amount of protein calories from that (4  kcal/kg body weight/day) results in a daily amount of carbohydrates of about

8 kcal/kg body weight/day (equal to 2 g carbohydrates/ kg body weight/day). Remission of the post-aggression syndrome and increase in substrate metabolism can be expected between day 4 and 6 post operation, if no complications occur. During that period about three-fourths of the amount of calories calculated as basic metabolic rate is administered, i.e. about 18  kcal/kg body weight/day. Deduction of the protein calories results in an amount of carbohydrates of about 13 kcal/kg body weight/day. Beginning with the seventh postoperative day, it is possible to use complete isocaloric nutrition with amino acids/proteins (1.5  g/kg body weight/day), carbohydrates (4  g/kg body weight/day) and lipids, usually increasing the amount of lipid calories from 0.5 to 1 g (= 5 respectively 10 kal/kg/day). The dosage is approached to the calculated calorie demand while careful attention is given to the level of blood glucose and triglycerides. If long-term parenteral feeding is to be expected, the daily maintenance dose of vitamins and trace elements should be administered from the first day after surgery.

14.8.4 Complications of Early Oral/ Enteral Nutrition Early oral/enteral nutrition is not generally without risks, and if complications occur morbidity is significantly increased (Table 14.3). Nonetheless, taking all positive and negative effects into account, there is still an advantage for patients to be fed orally/enterally early during the postoperative course. However, in certain clinical situations considerable variations of the usual gastrointestinal tract motility occur (mainly gastric emptying). Repeat high residual volumes of the stomach when aspirating through the nasogastric tube are the best indicators of functional failure of gastric emptying. The reason for this is ­multifactorial: sepsis, acute hyperglycaemia, autonomous neuropathy, catecholamines, beta2-mimetics and analgosedation. In this case, motility enhancing drugs (metroclopramid, erythromycin) should be used. Another unintentional effect is the increase of the gastric pH. This leads to weakening of the gastric acid barrier (especially due to antacid therapy) and therefore to ascension of bacteria and colonisation of the

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14  Nutrition of the Surgical Patient Table 14.3  Complications and concomitant symptoms of early postoperative oral/enteral feeding Complications

Possible causes and risk factors

Functional impairment of gastric emptying

Mostly extra-gastric, primary or concomitant disease •  Severe systemic disease •  Acute hyperglycaemia •  Autonomous neuropathy •  Drug effects

Hospital acquired pneumonia

Ascension of bacteria and fungi as a consequence of elevation of the gastric pH

Diarrhoea

Intestinal primary or concomitant disease, often multifactorial •  Infections of the GI tract • Motility-, resorption- or passage impairments

Passage impairments in small- or large bowel

Intestinal or extraintestinal primary or concomitant disease • Decrease of blood circulation in the abdomen •  Infection of the GI tract •  Drug effects

oesophagus and pharynx. Micro-aspirations can develop which increases the risk of hospital-acquired pneumonia. Stopping the feeding during the night allows the gastric pH to fall and restores the acid barrier. The most common complication of enteral feeding is diarrhoea. The cause of diarrhoea is multifactorial and the composition of the feeding solution only rarely is the reason for this problem. Critical pathomechanisms are infectious diseases of the intestinal tract and impairment of motility, resorption or blood supply. The antibiotic-induced pseudomembranous colitis has to be considered as a differential diagnosis as well. The diarrhoea can be treated by reducing the flow, changing the nutritional regime or modality or by changing the antibiotics. In severe cases (haemorrhagic colitis) a total feeding pause might be indicated. Apart from impairment of motility in the upper GI tract, passage failures in the small and large bowel are relevant. The combined small-/large-bowel ileus has to be differentiated from the isolated large-bowel ileus (Ogilvie-syndrome, pseudo obstruction of the colon). If this condition cannot be fixed with mechanical means (enema, endoscopic aspiration) or

by administration of prokinetics, oral/enteral therapy must be changed to a total parenteral regime.

14.8.5 Practice of Enteral Nutrition To commence enteral feeding some kind of access to the GI tract has to be established, usually using transnasal tubes. For nasogastric feeding tubes with the largest tolerated lumen (12–14 charriere) should be used, this also allows for decompression of the stomach. If the upper GI tract will not work for a foreseeable period of time, a catheter jejunostomy should be performed during surgery. Alternatively, it can be considered to place nasojejunal tubes endoscopically. This offers simple and secure access to the upper small bowel and can also be used to bypass an insufficient anastomosis after gastrectomy/oeso­ phagectomy. In principal, two different modalities of application are available: continuous administration, or bolus feeding of 50–300 ml. In general, continuous administration is better tolerated leading to a higher energy- and substrate supply, since the rate of treatment limiting diarrhoea and aspirations is smaller. On the other hand, acute blockage can be missed which could lead to a life-threatening aspiration.

In case of uncertain tube function, bolus feeding is preferable since the nursing staff can check the amount of residual volume in the stomach before every application and reduce the amount of feeding if necessary.

14.9 Particularities of Nutrition in Critically Ill Patients 14.9.1 Substrates Immunomodulatory tube nutrition for patients with surgical sepsis is not indicated at present regardless of the severity of the disease. Especially pro- and

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anti-inflammatory reactions to nutrition play a role here, although this impact has not been clearly specified. In patients with total parenteral feeding, glutamine in form of dipeptides (20 g/day) should be added. This prevents common glutamine deficiencies and the ­associated immunodeficiency. On a long-term basis, a decrease in mortality has been reported. The main focus of nutritional therapy in the intensive care patient is to prevent protein catabolism. Patients with severe SIRS or sepsis lose between 1.2 and 1.4  kg of protein in a period of about 3  weeks (mainly skeletal muscles), which is approximately 13% of the baseline. The amount of calorie intake in relation to the total metabolic rate hardly influences protein catabolism. Even large amounts of protein intake, can only reduce protein catabolism, but not fully prevent it. The optimal daily intake of proteins is about 1.5 g protein/kg body weight/day. Larger amounts do not have positive effects on protein metabolism. The different feeding modalities certainly play a role in reducing protein loss. Enteral feeding, for example, can almost halve the protein loss of intensive care patients within 10 days compared to isocaloric parenteral feeding.

14.9.2 Caloric Demand The vast majority of intensive care patients is supplied sufficiently with a conservative calorie administration of 21–25 kcal/kg body weight/day (depending on the amount of physical activity and analgosedation). Calorie administration at this level is a trade-off between trying to compensate losses as far as possible and reducing toxic side effects on the other hand.

14.9.3 Additive Pharmacotherapy Because of the well-known adverse effects of ­hyperglycaemia to the immune system, rigid control of the blood glucose level is mandatory. Plasma glucose

levels in intensive care patients should not exceed 150 mg/ dl. Hyperglycaemia needs to be treated with insulin therapy, possibly with continuous insulin infusion via a perfusor and close monitoring.

14.9.4 Metabolic Monitoring At present, a reliable and easy-to-use method to clinically estimate the protein demand of the individual surgical patient does not exist. It is possible to minimise the daily protein loss for most of the elective surgical patients by administration of 1–1.2  g/kg body weight/day protein. This can be increased to 1.5 g/kg body weight/day in intensive care patients. Creatinine or urea concentrations are only very limited indicators for an increasing protein catabolism. However, measuring those serum concentrations is necessary to early detect toxic levels of these metabolites in acute renal failure and to initiate adequate therapeutic measures if needed. After overcoming sepsis, protein intake can be increased up to an amount where urea levels are within the upper normal range. To monitor lipid utilization, it is necessary to measure plasma triglyceride concentrations in regular intervals. This helps to detect impairments of lipid metabolism at an early stage. Malfunctioning of the carbohydrate metabolism can be diagnosed by measurements of blood glucose levels several times per day (blood glucose profile). The electrolyte demand of the patient is usually determined by measurements of their serum concentrations. To detect real deficiencies of the so-called micronutrients (trace elements, vitamins) indirect functional tests would be required which are complicated and cannot be performed in practice. Therefore, patients at risk are usually administered appropriate vitamins and trace elements prophylactically in regular intervals.

Recommended Reading Alberda, C., Gramlich, L., Jones, N., Jeejeebhoy, K., Day, A.G., Dhaliwal, R., Heyland, D.K.: The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 35(10), 1728–1737 (2009)

14  Nutrition of the Surgical Patient Braga, M., Gianotti, L., Nespoli, L., Radaelli, G., Di Carlo, V.: Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch. Surg. 137, 174–180 (2002a) Braga, M., Gianotti, L., Vignali, A., Carlo, V.D.: Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery 132, 805–814 (2002b) Griesdale, D.E., de Souza, R.J., van Dam, R.M., Heyland, D.K., Cook, D.J., Malhotra, A., Dhaliwal, R., Henderson, W.R., Chittock, D.R., Finfer, S., Talmor, D.: Intensive insulin ­therapy and mortality among critically ill patients: a meta-­analysis including NICE-SUGAR study data. CMAJ 180, 821–827 (2009)

97 Jones, N.E., Heyland, D.K.: Implementing nutrition guidelines in the critical care setting: a worthwhile and achievable goal? JAMA 300, 2798–2799 (2008) Kondrup, J., Rasmussen, H.H., Hamberg, O., Stanga, Z., Ad Hoc ESPEN Working Group: Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin. Nutr. 22, 321–336 (2003) Sorensen, J., Kondrup, J., Prokopowicz, J., Schiesser, M., Krähenbühl, L., Meier, R., Liberda, M., EuroOOPS study group: EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin. Nutr. 27, 340–349 (2008)

 

Surgical and Hospital-Acquired Infections

15

Wolfgang Böcker and Wolf Mutschler

15.1 Background 15.1.1 Basic Concepts

3. Non-abscessing infections (e.g., fasciitis, peritonitis) 4. Posttraumatic infections (e.g., osteomyelitis following open fracture) 5. Postoperative surgical site infections (e.g., wound infection, abdominal wall abscess)

15.1.1.1 Infection, Infectious Disease, and Inflammation An infection is defined by the invasion and reproduction of bacteria, viruses, fungi, parasites, prions, or viroids within the human body. Whether the invading pathogen leads to a clinical manifestation of an infectious disease depends on the number and virulence of the pathogen as well as on the resistance of the patient. The host responds to the infection with an inflammation.

15.1.1.2 Surgical Infections Surgical infections have to be either treated by an operation or have been caused by a surgical intervention. Surgical infection can be divided into five different groups: 1. Primary abscessing infections (e.g., furuncle, carbuncle) 2. Secondary abscessing infections (e.g., liver abscess)

W. Böcker University of Munich, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected] W. Mutschler (*) Hospital of University of Munich, Ludwigs-MaximiliansUniversity, Nussbaumstrasse 20, 80336 Munich, Germany e-mail: [email protected]

15.1.1.3 Diagnosis of Surgical Infections Surgical infections primarily present with clinical symptoms. The clinical presentation on the body surface is one or more cardinal symptoms of inflammation: 1. Rubor (= redness) 2. Calor (= heat) 3. Tumor (= swelling) 4. Dolor (= pain) 5. Functio laesa (= impaired function) Infections of deep sites (e.g., abdominal abscess, implants) can initially have a complete lack of local symptoms and are sometimes difficult to diagnose. Systemic symptoms such as chills and fever may be present. Leukocytosis and elevated erythrocyte sedimentation rate (ESR) may be the only signs. Deep infections often need additional diagnostic tools such as CT scan, MRI, or PET scan. Scintigram may be helpful to diagnose infections of artificial joints and osteosynthesis materials. Sometimes needle aspiration with cells count and microbiology culture may give the final clue.

15.1.1.4 Infection Defense The goal of the body’s immune system is the elimination or inactivation of the invading organism. There are

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_15, © Springer-Verlag Berlin Heidelberg 2011

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several physiological protective mechanisms which prevent the invasion of pathogens: 1. Intact body surface 2. Adequate tissue perfusion 3. Physiological bacterial colonization The human body responds to infection with a congenital unspecific and an acquired specific immune system. Several factors can lead to a failure or dysfunction of the immune system. Apart from congenital immune defects, acquired immune defects can impair the immune response: 1. Accompanying disease (e.g., diabetes, HIV, malignoma, hematological disease) 2. Medication (e.g., steroids, immunosuppressants) 3. Nicotine use 4. Older age 5. Bad general condition and malnutrition Several local factors favor an infection: 1. Opening of body surface (traumatic or operative) 2. Limited blood perfusion 3. Unfavorable wound conditions (necrosis, compromised blood perfusion) 4. Inadequate wound care (late wound closure, hematoma, long surgery time) 5. Implantation of foreign bodies (i.v. access, peritoneal dialysis catheter, long stay of drains, osteosynthesis material, endoprostesis, valves) Studies have also shown a coincidence of surgical site infections with remote site infections. Therefore, prior to elective surgery (e.g., joint replacement), these infections should be treated first.

15.1.1.5 Principles of Therapy The surgical therapy of infections consists of: 1. Operative treatment 2. Correction of the acquired immune defect (if possible) 3. Systemic antimicrobial therapy First-line treatment is early surgery with incision, removal of necrosis, and placement of a drain. This is particularly true for abscesses (Ubi pus ibi evacua!). One exception is an intra-abdominal abscess, which may be successfully treated by drainage alone. For

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local antimicrobial therapy, antiseptics can be used. Local application of antibiotics should be avoided because of the generation of resistance. Cooling by alcohol packing may suppress the inflammation. Systemic antimicrobial therapy is indicated (see Chap. 16): 1. With generalized infection (fever, chills) 2. With particular dangerous infections (e.g., gas ­gangrene, mediastinitis, pneumonia, sepsis) 3. As prophylactic perioperative measure (inserting implants and prosthesis; procedures, which are accompanied by an increased risk of infection: e.g., gastrointestinal tract surgery; operations on neck, eye, and breast) Systemic antibiotic therapy alone for abscessing infection is not recommended, since the pathogens cannot be reached by the drugs. Moreover, the treatment with antimicrobial drugs alone would prolong the course of infection.

15.1.2 Prevention of Surgical Infections 15.1.2.1 Hygiene The goal of hygienic measures is the prevention of ­surgical and nosocomial infections. With hygiene ­measures on patients, infection rates can be reduced. Mupirocin ointment is effective as a topical agent for eradicating S. aureus from the nares of colonized patients. Preoperative shaving of the surgical site the night before an operation is associated with a significantly higher risk of surgical site infections. Therefore, shaving immediately before the operation is recommended. Several antiseptic agents are available for preoperative preparation of skin at the incision site. Alcohol-containing products, iodophores (e.g., povidone-iodine), and chlorhexidine gluconate are the most commonly used agents. Hygiene measures with patient contact using masks, gloves, and gowns protect the patient as well as the surgical team. To prevent wound infections with dressing changes, aseptic measure should be used. Hygiene measures in the operating room which have been shown to be effective are the use of ventilation, routine cleaning of surfaces, the usage of drapes, and sterilization of surgical instruments. Positive

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pressure prevents airflow to enter from less clean areas into the operating room.

15.1.2.2 Asepsis and Antisepsis In general, septic and aseptic surgeries can be discriminated. If possible, patients with and without wound infections should be separated on the ward and in the operating room. In aseptic surgeries, no pathogens are released. The postoperative risk of infection is significantly below 5%. Rigorous adherence to the principles of asepsis by all scrubbed personnel is the foundation of surgical site infection prevention. During septic procedures, a massive release of pathogens can be observed. Antisepsis describes the use of antiseptic agents in order to reduce the numbers of pathogens. Members of the surgical team who have direct contact with the sterile operating field or sterile instruments used in the field wash their hands and forearms by performing a traditional procedure known as scrubbing. This happens immediately before donning sterile gowns and gloves. Alcohol or povidone-iodine is considered the gold standard for surgical hand preparation. Surgical hand disinfection is a two step process: 1. Thorough cleaning underneath fingernails (usually with a brush) 2. Scrubbing at least for 3–5 min After performing the surgical scrub, hands should be kept up and away from the body (elbows in flexed position) so that antiseptic agent runs from the tips of the fingers toward the elbows. Jewelries and artificial nails have to be removed before scrubbing.

15.1.2.4 Antimicrobial Prophylaxis Surgical antimicrobial prophylaxis is used as a single i.v. administration of an antimicrobial agent just before the start of an (elective) procedure (within 30  min prior to  skin incision). Contaminated wounds often require longer duration of prophylaxis. Antimicrobial agents are used as intravenous infusions to reduce the microbial burden of intraoperative contamination to a level that cannot overwhelm host defenses. Serum and tissue levels should be maintained during the whole procedure. Antimicrobial prophylaxis is an evidence-based measure to reduce postoperative infections in a number of ­procedures (e.g., joint replacement, gastrointestinal surgery). The choice of the antimicrobial agent depends on the most likely pathogens (e.g., joint replacement: S. aureus, coagulase-negative Staphylococci, gram-negative bacilli; appendectomy: gram-negative bacilli, anaerobes). 15.1.2.5 Hospital-Acquired Infections Nosocomial infections are acquired in medical institutions and affect 4–10% of all inpatients and 25% of intensive care patients. Most common infections are pneumonia, upper respiratory tract, urinary tract, and wound infections as well as sepsis. Typical pathogens are Enterococcus spp., Staphylococcus aureus, coagulase-negative staphylococci, Escherichia coli, Pseudomonas aeroginosa, and fungi. A major problem with hospital-acquired infection is the prevalence of resistance against many different antimicrobial agents (multiple drug resistance), which has to be addressed with the choice of the antimicrobial agent. 15.1.2.6 Surveillance of Nosocomial Infections

15.1.2.3 Surgical Technique Excellent surgical technique is widely believed to reduce the risk of surgical site infections. Such techniques include gentle tissue handling, removing devitalized tissues, eradicating dead space, preserving adequate blood supply, preventing hypothermia, avoiding inadvertent entries into a hollow viscus, and appropriately managing the postoperative incision. All foreign bodies including suture material, prosthesis, and drains promote infections. Drains are effective in evacuating ­postoperative hematoma or seroma, which – if present – increases the risk for surgical site infection.

Many countries have implemented regulations that require hospitals to conduct surveillance of particular nosocomial infections. These measures are not only meant to identify outbreaks with pathogens that have multiple drug resistance, but also to identify an increa­sed incidence of surgical site infection of certain surgical procedures. MRSA is the most common pathogen with multiple drug resistance and most frequently observed in intensive care, trauma surgery, and vascular surgery wards. If there is an increased incidence of nosocomial infection, certain measures (screening, education, changes in hygiene procedures) have to be followed. A routine screening of all patients and personnel has not been recommended.

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15.1.2.7 Management of MRSA (MethicillinResistant Staphylococcus aureus) Methicillin-resistant Staphylococcus aureus is a feared pathogen in nosocomial infections. These are asso­ciated with higher morbidity and mortality. The prevalence has increased significantly over the last few years. Patients at risk for MRSA (positive history, transfer from an institution with high prevalence, contact with MRSA carrier, chronically ill patient) have to be isolated until negative screening results are available. Colonized or infected patients have to be isolated. Personnel have to disinfect hands and wear gloves, mask, and gowns, which all remain in the room before leaving. All instruments (e.g., stethoscope, ECG, ultrasound) have to be disinfected. Daily cleaning of surfaces in the patient’s room is required. Patient’s blankets and pillows are washed daily. Elective surgeries should be avoided, and small procedures should be conducted in the patient’s room. Major surgeries should be performed in the septic operating room, and at the end of the daily operating program. Treatment of MRSA is done according to the sensitivity testing (e.g., vancomycin). The nares of colonized patients are treated effectively with Mupirocin ointment (3× daily, at least for 3 days). For eradication of skin colonization, whole body washings with antiseptic agents are performed. Also colonized personnel have to be eradicated and should not have patient contact before. Isolation of MRSA-colonized patients can be lifted, when 3  days after completion of treatment three consecutive smears are negative.

15.2 Surgical Infections 15.2.1 Bacterial Infections 15.2.1.1 Introduction Bacterial infection can be discriminated by different criteria: 1. Anatomically (skin: furuncle, fascia: necrotizing fasciitis) 2. Pathogen (Staphylococcus ssp., Streptococcus ssp., etc.) 3. Urgency of surgical intervention (urgent: furuncle; emergency: necrotizing fasciitis) 4. Extent of infection (local: abscess; diffuse: fasciitis)

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5. Degrees (uncomplicated infection; complicated infection: larger surgical intervention necessary, extension in deep soft tissues or severe comor­bidity) 6. Growing condition (aerobe, anaerobe) 7. Pus generation In clinical practice, infections are separated into aerobic and anaerobic infections.

15.2.2 Aerobic Infections 15.2.2.1 Abscess Definition: A collection of pus which accumulated in a tissue cavity formed on the basis of an infectious process. Abscesses can develop in any kind of solid tissue, but are most frequently localized on the body surface (e.g., needle abscess). More rarely abscesses are found within inner organs (brain, tonsils, teeth, liver). Typical pathogens are Staphylococcus, E.coli, and mixed infection. Symptoms: Cardinal symptoms of inflammation. Sometimes fluctuation can be observed near the body surface. A pulsating pain is typical. Therapy: Surgical drainage of the abscess is usually indicated once the abscess has developed from a harder serous inflammation to a softer pus stage. This is expressed in the Latin medical aphorism: Ubi pus, ibi evacua (“where there is pus, evacuate it”). Curettage, flushing, and local antiseptic agents clean the cavity. In addition, drains are frequently placed. With smaller localized abscesses, antimicrobial agents are not required. Needle aspiration of the abscess as only treatment is the exception, e.g., with placement of pigtail-catheter in intra-abdominal abscesses.

15.2.2.2 Empyema Definition: Infection in a preformed cavity with a missing initial necrosis. Localization: pericardium, gallbladder, pleura, and joints. Pathogens: Staphylococcus ssp., Streptococcus ssp., N. gonorrhoeae, E. coli, Proteus, anaerobic organisms, frequently mixed flora. Symptoms: Depend on localization. Shortness of breath and thoracic pain are seen with pleural- and pericardial empyema. Abdominal pain with gallbladder empyema. Swelling and redness with joint empyema. Fever and chills. Therapy: Incision, flushing, removal (where possible, e.g., gallbladder), drainage, and systemic

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antimicrobial therapy are the major steps of adequate surgical intervention.

extensive necrosis. Therapy: Excision of necrosis. All abscesses have to be drained. Frequently antimicrobial therapy is necessary. Consider underlying undiagnosed immune suppression.

15.2.2.3 Furuncle Definition: Skin infection starting from hair follicles with localized accumulation of pus (Fig.  15.1). Localization: All hairy body surfaces. Pathogen: Staphylococcus ssp. Symptoms: Classical symptoms of inflammation. Can be very painful. Therapy: Most furuncles run their course within 1 week. Soaking the furuncle with warm water can help to alleviate the pain and hasten draining the pus. Incision is rarely necessary and only performed with local pus accumulation. Antimicrobial agents are only necessary in severe cases and with generalized spread (furunculosis). Always consider underlying immune suppression (e.g., undiagnosed diabetes, malnutrition with vitamin deficiency).

Definition: Acute Streptococcus infection of the skin and subcutaneous tissue (Fig. 15.2). Localization: Most frequently face and extremities. Pathogen: Streptococcus pyogenes. Symptoms: Patients typically develop symptoms including high fevers, chills, and general illness within 48 h of the initial infection. Characteristically, the erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge (Fig. 15.3). Therapy: Antimicrobial therapy, immobilization, cold dressing. Search for skin ulcerations (e.g., between toes) and consider immune suppression.

15.2.2.4 Carbuncle

15.2.2.6 Phlegmon

Definition: Confluent skin infection originating from several furuncles. Localization: Preferably neck, back, and buttocks. Pathogen: Staphylococcus ssp. Symptoms: Pain with pressure and redness of skin, sometimes with

Definition: Diffuse and infiltrating infection. Due to special enzymes (hyaluronidase, streptokinase), pathogens spread in the interstitial soft tissue (Fig.  15.2). Loca­lization: Skin, intermuscular

Folliculitis

Boil

15.2.2.5 Erysipelas

Carbuncle

Fig. 15.1  Folliculitis, furuncle and carbuncle are distinguished by the extent of infection. These skin infections are most frequently caused by Staphylococcus ssp. infection

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Epidermis

Dermis

Subcutaneous tissue Fascia Muscle

Erysiplas

Phlegmon

Necrotizing fasciitis

Fig.  15.2  Erysipelas are infection of the dermis. Phlegmon extents with special enzymes into the soft tissue of the subcutis. Necrotizing infections are even more aggressive and invade the through fascia into the muscle

15.2.2.7 Gangrene

Fig. 15.3  Typical clinical presentation of erysipelas. This acute Staphylococcus pyogenes infection characteristically enlarges rapidly and has a sharply demarcated raised edge

and intramuscular, mediastinal, and retroperitoneal. Pathogens: Strepto­coccus ssp., Staphylococcus ssp., Proteus, anaerobes (Bacterioides), enterobacteria, sometimes mixed flora. Symptoms: Depend on type of pathogen and localization. Frequently diffuse redness and swelling is found. Fever and leukocytosis. Therapy: Antimicrobial therapy is mandatory. In severe cases, immediate surgical intervention is necessary. Eradicate the source.

Definition: Complication of necrosis caused by infection and/or ischemia. A necrosis without inflammation is called mummification. Localization: Most frequently lower extremities. Less frequent other soft tissues: Fournier’s gangrene (severe spontaneous gangrene of scrotum with high morbidity and mortality). Pathogens: Anaerobes, saprogenic microorganisms, frequently mixed flora. Symptoms: Extended necrosis with black to gray-green discoloration, fecal smell, often without pain. The toxic products formed by bacteria are absorbed and can cause systemic manifestation of septicemia as well as death. Therapy: Removal of all necrotic tissue. Amputation of extremities is often necessary. Improvement of vascular perfusion is essential.

15.2.2.8 Necrotizing Infection Definition: Live-threatening and fast progressing infection with necrosis of fascias and muscle (Fig.  15.2). Pathogens: Streptococcus (Streptococcus gangrene, necrotizing fasciitis, Streptococcus myositis), Staphylococcus (necrotizing fasciitis), Clostridium (myositis, cellulitis), sometimes mixed flora. Localization: Infections extend along subcutis, fascia, and muscle septums. Symptoms:

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Severe pain and characteristic livid red discoloration of the skin. With progression development of necrosis. Fast development of a septic picture with multiple organ failure. Therapy: Immediate surgical intervention with extended debridement is essential. With delayed surgical intervention, mortality exceeds 50%. Intensive care treatment is usually needed. Systemic antimicrobial therapy with broad-spectrum antibiotics. Hyperbaric oxygen therapy (HOT) has significantly reduced fatality rates. After debridement, wounds are left open and closure may be attempted after second look operation. Vacuum-assisted closure can be considered after complete surgical removal of all necrotic tissues.

15.2.2.9 Panaris and Paronychia Definition: Infection of the nail fold or wall. Symptoms: Initially redness and severe pressure pain. Later development of an abscess. Therapy: In early stages, finger bath and local anti-inflammatory treatment with immobilization. Abscesses must be drained.

15.2.2.10 Bursitis Definition: Acute or chronic inflammation of a bursa. Commonly caused by repeated movement and excessive pressure. Carries a high risk of infection with open injuries. Localization: Typically in exposed positions (elbow and knee). Pathogens: In open injuries, Streptococcus and Staphylococcus. Symptoms: Pain, redness, swelling, and fluctuation. Therapy: Surgical excision of the bursa in case of purulent bursitis and in open injuries. Immobilization.

15.2.3 Anaerobic Infections 15.2.3.1 Tetanus Definition: Wound infection caused by bacteria which secrete a neurotoxin (tetanospasmin). As the infection progresses, the released neurotoxin causes characteristic muscle spasms. In some countries, the disease is notifiable. Localization: Any contaminated wound. Pathogen: Clostridium tetani. Symptoms: After an

incubation time of 3–60  days (typically 1–2  weeks) initial unspecific general symptoms. Thereafter, a characteristic sequence of symptoms: muscle spasm in the jaw (trismus or lockjaw), facial spasm (risus sardonicus), followed by difficulty to swallow and rigidity of calf and pectoral muscle. Spasms shape the body into a characteristic hyperlordosis called opisthotonus. Symptoms may last for several weeks, if left untreated. Therapy: Until now, only symptomatic treatment is available. Therefore, tetanus prophylaxis is very important. In addition to adequate wound care to avoid anaerobe wound condition, prophylaxis by immunization is essential. With existing pre-immunization, refreshment is ­necessary with tetanus toxoid every 5  years. With no  pre-immunization, a simultaneous immunization with tetanus toxoid and passive immunization with human anti-tetanospasmin immunoglobulin or tetanus immunoglobulin is crucial.

15.2.3.2 Gas Gangrene Definition: Bacterial tissue infection with gas-producing pathogens. Rapidly progressing and lifethreatening infection. Typically, the environmental bacteria enter through contaminated wounds and expand in anaerobic environments. The organism not only produces gas, but also secretes powerful exotoxins. Localization: Soft tissues. Pathogens: Clostridium perfringens (90%) and other Clostridium species. Symptoms: Extremely painful, rapidly progressing wound infection. Charac­teristically crepitation on palpation. Drainage of black-blood-stained fluid, foamy, sweet-rotten smelling secretion. The affected muscles appear gray-red. Sometimes, on X-ray, the gas can be seen. The general condition of the patient rapidly deteriorates with sepsis and multiple organ failure. Therapy: Must start immediately with clinical suspicion. Leaving this condition untreated always ends with the patient’s death. Surgical interventions with extended debridement have to counteract anaerobe wound conditions. If necessary, affected extremities have to be amputated. Antimicrobial therapy has to start with suspicion. Even with surgery and antimicrobial therapy, mortality still is up to 40%. With hyperbaric oxygen therapy (HOT), mortality rates can be decreased to 20–25% and amputation rates can be decreased by 70%.

 

Antimicrobial Therapy

16

Christian P. Schneider and Beatrice Grabein

16.1 Introduction Antimicrobial agents are widely used pharmaceuticals in hospital and outpatient care. They are causal therapeutic agents and their rational use can decrease antibiotic resistance, and therefore, hospital stay and treatment costs. However, due to increased quality standards and cost pressure for public health services, these requirements can only be achieved if up-to-date infectious disease management strategies have been implemented. Although guidelines and recommendations from several associations and institutions were included in this chapter, it is important to note that rational empiric antibiotic therapy underlies continuous alterations. Therefore, therapeutic recommendations can only capture basic principles. Often various therapeutic options are available, and the therapeutic spectrum is not always comparable in different countries or institutions. Various treatment options help to avoid allergic reactions and allow to choose antibiotic agents according to the individual patient’s risk profile.

C.P. Schneider (*) Department of Surgery, University Hospital Munich, Ludwig-Maximilians University Munich, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany e-mail: [email protected] B. Grabein Max von Pettenkofer-Institute for Hygiene and Clinical Microbiology, Ludwig-Maximilans University Munich, Campus Großhadern, Marchioninistr. 15, 81377 Munich, Germany e-mail: [email protected]

16.2 Basic Principles of Antimicrobial Therapy Characterization of antibiotics, pharmacokinetics, efficacy, antibiotic resistance, and side effects (Table 16.1). The antibiotic agents described were selected with specific consideration of their importance in the surgical field.

16.3 Penicillins The classification of penicillins is based on their chemical structure. Different chemical constitutions imply varying effects against pathogens and their beta-­ lactamases. Penicillins are bactericidal due to blockade of bacterial transpeptidases which are important for the peptidoglycan synthesis in the bacterial cell wall. Benzylpenicillins, aminopenicillins, and isoxazolylpenicillins are available in parenteral and enteral pharmaceutical forms, whereas acylaminopenicillins can only be administered intravenously. Penicillins are approved for treatment of systemic and local infections with various gram-positive and gram-negative pathogens. A wider range of pathogens can be treated via combination of penicillins with a beta-lactamase inhibitor.

16.3.1 Pharmacokinetics Penicillins generally exhibit a medium to high plasma concentration while their half-life is in the low to middle range (0–10 h). They reside mostly in the extracellular space with a low relative distribution volume of 0–0.4 L/kg. The rate of metabolization is low,

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_16, © Springer-Verlag Berlin Heidelberg 2011

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Table 16.1  Antimicrobial agents for parenteral application Groups Subgroups Drugs Penicillins

Maximum dosage

Benzylpenicillin

Benzylpenicillin

10 million units q4–6 h

Aminopenicillin

Ampicillin

2 g q8h

Aminopenicillin/BLI

Amoxicillin/clavulanate

2.2 g q8h

Ampicillin/sulbactam

3 g q8h

Carboxypenicillin/BLI

Ticarcillin/clavulanate

3.1 g q4–6 h

Acylaminopenicillins

Piperacillin

4 g q8h

Mezlocillin

4–5 g q8h or 10 g q12h

Acylaminopenicillin/BLI

Piperacillin/tazobactum

4.5 g q8h

Isoxazolylpenicillins

Flucloxacillin

2 g q4–6 h

Oxacillin

4–8 g q4–6 h

First generation

Cephazolin

2 g q8h

Second generation

Cefuroxime

1.5 g q8h

Cefotiam

2 g q8h

Cefotaxime

2 g q8h

Ceftriaxone

2 g q12h

Third generation with anti-pseudomonal activity

Ceftazidime

2 g q8h

Fourth generation

Cefepime

2 g q8–12 h

Fifth generation

Cefoxitine

2 g q8h

Group 1

Imipenem

1 g q8h

Group 2

Meropenem

1 g q8h

Ertapenem

1 g q24h

Doripenem

500 mg q8h

Aztreonam

2 g q6–8 h

Ofloxacin

400 mg q12h

Ciprofloxacin

400 mg q8h

Group 3

Levofloxacin

500 mg q12h

Group 4

Moxifloxacin

400 mg once daily

Erythromycin

1 g q6h

Clarithromycin

500 mg q12h

Azithromycin

500 mg once daily

Vancomycin

15–20 mg/kg BW q12h

Teicoplanin

400 mg q12h on day 1,and than 400 mg once daily

Lipopeptide

Daptomycin

4 mg/kg BW once daily

Aminoglycoside

Amikacin

15 mg/kg BW once daily

Gentamicin

5–7 mg/kg BW once daily

Netilmicin

5–7 mg/kg BW once daily

Tobramycin

5–7 mg/kg BW once daily

Cephalosporins

Third generation

Carbapenems

Ungrouped Monobactams Fluroquinolones

Macrolide

Glycopeptide

Group 2

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16  Antimicrobial Therapy Table 16.1  (continued) Groups Subgroups

Drugs

Maximum dosage

Oxazolidinone

Linezolid

600 mg q12h

Lincosamide

Clindamycin

600 mg q8h

Streptogramin

Quinupristin/dalfopristin

7.5 mg/kg BW q8h

Tetracycline

Doxycyclin

200 mg q24h on day 1, and than 100 mg once daily

Glycylcycline

Tigecycline

100 mg q24h on day 1, and than 50 mg once daily

Ansamycins

Rifampicin

10 mg/kg BW once daily, (maximum 900 mg/day)

Nitroimidazole

Metronidazole

500 mg q8h

Fosfomycine

Fosfomycin

4–8 g q8h

Sulfonamide/ Benzylpyrimidine

Co-trimoxazol

960 mg q12h

q every, h hours, kg kilogram, g gram, mg milligram, BW body weight, BLI beta-lactamase inhibitor

and penicillins are mainly eliminated via the kidneys through tubular secretion. Isoxazolylpenicillins have a high plasma protein–binding capacity and low tissue distribution compared to the other penicillins. The best time-dependent efficacy kinetics can be reached if drug concentrations at the site of infection are above the minimum inhibitory concentration and therefore short treatment intervals are necessary.

16.3.2 Efficacy and Indication The efficacy of penicillins is dependent on their chemical structure. It ranges from small spectrum (Penicillin G) and extends to broad-spectrum efficacy if combined with beta-lactamase inhibitors (Piperacillin-Tazobactam). Application of Penicillin G is limited to Strep­ tococcus species (spp.), Pneumococci, Meningococci, and some anaerobic pathogens (Clostridium spp., Actinomyces spp.) and should not be given as a single agent if a serious infection is present. Nevertheless, Penicillin G is still the first choice for erysipelas and treatment of infections with Streptococcus and Pneumococcus if cultures do not reveal mixed pathogens. Aminopenicillins have a broad-spectrum efficacy. They are very effective against Enterococcus and some gram-negative pathogens. Aminopenicillins are approved for treatment of endocarditis and meningitis. In combination with beta-lactamase inhibitors, their spectrum is extended to infections with several other gram-positive

and gram-negative pathogens, including infections of the upper respiratory tract, urinary tract, abdomen, genitals, skin, and soft tissue. Isoxazolylpenicillins have a narrow spectrum only and are useful against Staphylococcus including those strains producing penicillinase. Possible indications are endocarditis, arthritis, infection of the skin and soft tissue as long as the Staphylococcus strain is not resistant against methicillin. Acylaminopenicillins are broad-spectrum antibiotics and include gram-positive and gram-negative aerobic and anaerobic pathogens. Piperacillin also covers infections with Pseudomonas aeruginosa. In combination with beta-lactamase inhibitors, they are also effective against various beta-lactamase-producing pathogens. Indications are infections of nearly all organ systems. Piperacillin-Tazobactum can be used as rational empiric antibiotic therapy for serious infections.

16.3.3 Antibiotic Resistance Resistance of Streptococcus and Pneumococcus against penicillin is still low at approximately 2% of the isolates, but can reach up to 30% in some countries. The resistance rate of Escherichia coli against aminopenicillins increased within the last years to more than 50%. The efficacy of piperacillin-tazobactam against Pseudomonas aeruginosa is still sufficient. The fraction of oxacillin-resistant Staphylococcus aureus (MRSA) is continuously increasing. It ranges

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from approximately 15% of Staphylococcus aureus isolates from hospital patients in some European countries to more than 60% in the United States. The antibiotic resistance rate for Staphylococcus epidermidis and coagulase-negative Staphylococcus is commonly more than 70%.

16.3.4 Side Effects (Table 16.2) Allergic reactions can be observed in 0.7–10% of all patients treated with penicillins and occur particularly after repeated applications. These hypersensitive reactions are characterized by nausea, vomitus, bronchospasm, and hypotonia. Delayed allergic reactions can appear 7–10  days after administration of penicillins with fever, urticaria, lymph node swelling, and hemolytic anemia, defined as Type III hypersensitivity reactions (Arthus type). Neurotoxicity can arise only after application of high dosage of penicillins (80–100  Mio. IU/day). Additionally, pseudoallergic skin reactions may occur after treatment with aminopenicillins if a concomitant viral infection is present (mononucleosis). Antibiotic therapy with isoxazolylpenicillins can increase liver enzymes.

16.4 Cephalosporins Cephalosporins are grouped into basic and broadspectrum cephalosporins. They are generally classified into five groups. Cephalosporins are bactericidal, and their pharmacokinetic characteristics are comparable to penicillins. Agents of groups 1 and 2 are effective against Staphylococci which decreases in groups 3–5. In contrast, substances of groups 2–5 have increasing efficacy against gram-negative pathogens. Additionally, cephalosporins possess a good efficacy against pathogens producing beta-lactamase based on their stability against various kinds of bacterial beta-lactamases.

16.4.1 Pharmacokinetics Most cephalosporins are eliminated unmodified via the kidneys, and their mean half-life is 2 h in patients with normal renal function. Their distribution in the different body compartments is also similar to those of penicillins. Only ceftriaxone (group 3a) reveals an extended half-life of 8 h, and therefore, a single daily application is sufficient. Moreover, approximately 50% of ceftriaxone is excreted via the biliary system.

Table 16.2  Side effects of penicillin treatment and alternative treatment options Cross-reactivity between beta-lactam antibiotics Penicillins

® First-generation cephalosporins

1.7–5.6%

® Second-generation cephalosporins ® Third-generation cephalosporins Penicillins

® Carbapenems

~50%

Penicillins, cephalosporins

® Aztreonam

Rarely

Cephalosporins

® Carbapenems

Lowly

Ceftazidime

® Aztreonam

Commonly

Staphylococcus spp.

Clindamycin, doxycyclin, glycopeptide, linezolid, macrolide, rifampicin

Alternative antimicrobial substances Gram-positive bacteria

Streptococcus spp. Pneumococcus Gram-negative bacteria

Escherichia coli Enterobacteriaceae

Aminoglycoside, aztreonam, fluoroquinolones, doxycycline

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16.4.2 Efficacy and Indication

16.4.4 Side Effects

In general, all cephalosporins are ineffective against Enterococci and methicillin-resistant Staph­ylococci. Substances of the first generation ­(cephazolin) have a good efficacy against methicillin-sensible Staphy­ lococci and Streptococci, but are weak against gramnegative pathogens. Cepha­losporins of the second generation (cefuroxime, cefotiam) have an extended spectrum against gram-negative bacteria and con­ tinuing activity against gram-positive pathogens. ­Third-generation cephalosporines (cefotaxime, ceftriaxone) have a broad-spectrum with excellent activity against gram-negative bacteria but decreasing effects against Staphylococci. In addition, ceftazidime (third generation with anti-pseudomal activity) and cefepime (fourth generation) exhibit anti-pseudomonal activity. Cefepime also has good efficacy against Staphylococci, Streptococci and beta-lactamase-producing bacteria compared to ceftazidime. Furthermore, cephalosporins of the fifth generation (cefoxitine) are effective against anaerobic pathogens. Cephalosporins are approved for treatment of various kinds of infections, including infections of the respiratory and urinary tracts, bones and joints, genitals, skin and soft tissue. Cefotiam and cephalosporins of the third to fifth generation are also approved for infections of the biliary tract and abdomen. In addition, cephalosporins of the first, second, third, and fifth generation are used as prophylactic antibiotics during the perioperative phase.

Possible side effects are comparable to those of penicillins, but allergic reactions are fewer. Increased liver enzymes and gastrointestinal discomfort occur in 5–10% of all treated patients. Augmented risk of bleeding may appear if anticoagulants are given simultaneously with cefoxitin. Therapeutic administration of ceftriaxone can rarely lead to shadows in the ultrasound of the gall bladder which is called transitory ­biliary pseudolithiasis.

16.4.3 Antibiotic Resistance High rates of antibiotic resistance for second-generation cephalosporins can be detected in Enterobacter spp., Citrobacter, and indol-positive strains of the Proteus group. Since several years, increasing antibiotic resistance rates up to 28% can be observed in Escherichia coli isolated from ICU patients. Isolates of Klebsiella pneumoniae and Escherichia coli producing extendedspectrum-beta-lactamases (ESBL) cause antibiotic resistance against third- and fourth-generation cephalosporins ranging from 4–8% up to 55% (South America) in hospitalized patients.

16.5 Carbapenems Carbapenems are also beta-lactam antibiotics with bactericidal efficacy due to inhibition of the bacterial cell wall synthesis. They are divided into two groups with group 1 consisting of imipenem and group 2 of meropenem and ertapenem. Carbapenems, especially those of group 1, are broad-spectrum antibiotics approved for the treatment of serious life-threatening infections and empiric therapy in patients receiving immunosuppressive medication.

16.5.1 Pharmacokinetics The distribution volume of carbapenems is small and mainly extracellular. Protein-binding capacity is more than 90% for ertapenem, while imipenem and meropenem have much lower capacities with 20% and 2%, respectively. In part, carbapenems are metabolized and predominately eliminated via the kidneys. Ertapenem has a longer plasma half-life of 4 h compared to the other carbapenems.

16.5.2 Efficacy and Indications Carbapenems are broad-spectrum antibiotics, and their efficacy includes almost all bacteria including anaerobic pathogens, except for Enterococcus facium, methicillin-resistant Staph­ylococci, and Stenotropho­ monas maltophilia. Doripenem is very effective against

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Pseudomonas aeruginosa, Enterobacteriaceae, and Acinetobacter spp. which are resistant against other antimicrobial drugs. The efficacy of ertapenem is different with no effects against Pseudomonas aeruginosa, Acinetobacter spp., and Enterococci. Carbabenems are approved for the treatment of serious pneumonia, intra-abdominal infections, sepsis, and infections of the skin and soft ­tissue and for empiric therapy in neutropenic patients.

16.6.1 Pharmacokinetics

16.5.3 Antibiotic Resistance

16.6.2 Efficacy and Indication

Currently, antibiotic resistances including Entero­ bacteriaceae are rare. It has been shown that some Klebsiella species are resistant against carbapenems due to release of carbapenem-hydrolyzing metallobeta-lactamases. Although the efficacy of carbapenems is still good, infections with Pseudomonas aeruginosa, Burkholderia cepacia, or other non-­fermenting bacteria in hospitalized and/or immunosuppressed patients demonstrate increased rates of resistance.

Aztreonam has strong activity against susceptible gram-negative bacteria, including Pseudomonas aerug­ inosa. It is approved for treatment of pneumonia, skin and soft tissue infections, complicated and uncomplicated urinary tract infections, gynecologic infections, and intra-abdominal infections and septicemia caused by gram-negative bacteria in combination with anaerobic coverage.

16.5.4 Side Effects

The distribution volume of aztreonam is low, but sufficient levels can be reached in urine; bile; and pleural, pericardial, and synovial fluids. Approximately 56% is bound to plasma proteins and the plasma half-life is 2 h. Aztreonam is not metabolized and is mainly excreted via glomerular filtration and tubular secretion as unchanged drug.

16.6.3 Antibiotic Resistance

Mild gastrointestinal symptoms can be observed in 5–10% of all treated patients. Allergic reactions occur rarely with less than 3%.

Anaerobic bacteria, Acinetobacter spp., Burkholderia cepacia-complex, Stenotrophomonas maltophilia, and gram-positive pathogens are generally resistant against aztreonam.

16.6 Monobactams

16.6.4 Side Effects

The only available monobactam is aztreonam. The mechanism of action is similar to beta-lactams. It is stable against some beta-lactamases. Aztreonam is bactericidal through inhibition of mucopeptide synthesis in the bacterial cell wall, and thereby blocking peptidoglycan crosslinking. It is only active against gram-negative bacteria. Aztreonam displays good efficacy against Entero­bacteri­ aceae and non-lactose fermenters including Pseudomonas aeruginosa. There is limited cross-reactivity between aztreonam and other beta-lactam antibiotics, and it is generally considered safe to administer aztreonam to patients with hypersensitivity to penicillins.

Side effects include injection site reactions, rash, ­gastrointestinal disorder, and rarely toxic epidermal necrolysis. There may be drug-induced eosinophilia.

16.7 Fluroquinolones Fluoroquinolones are divided into four groups. Group one has no clinical relevance and clinical relevant agents are ciprofloxacin, ofloxacin and norfloxacin (group 2), levofloxacin (group 3), and moxifloxacin

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(group 4). They can be administrated parenterally as well as orally due to their excellent acid stability. Fluroquinolones are bactericidal through inhibition of bacterial DNA-gyrases which are important for the nucleotide acid synthesis.

strains. Escherichia coli has resistance rates from 7% up to 20% of all isolates, Staphylococcus aureus from 15% up to 60% (mostly MRSA isolates) and Pseudomonas aeruginosa from 10% up to 30% against ciprofloxacin.

16.7.1 Pharmacokinetics

16.7.4 Side Effects

The relative distribution volume of all fluoroquinolones is large with 2 up to 41  L/kg and they penetrate excellently into various tissues. Their plasma protein– binding capacities add up to <40%. The half-life varies between 3 and 4 h for ciprofloxacin and norfloxacin, 7–8 h for ofloxacin and levofloxacin, and >10 h for moxifloxacin. Therefore, their intervals of administration differ. Levofloxacin and ofloxacin are eliminated via renal secretion while ciprofloxacin and norfloxacin also are eliminated via the liver and intestines. Moxifloxacin is almost completely eliminated via ­conjugation reactions.

Side effects after treatment with fluoroquinilones are present in 4–10% of all patients. Common symptoms are gastrointestinal irritation, affection of the CNS with sleep disturbances and obnubilation. Reactions of the skin are rare, but UV exposure should be avoided due to the phototoxic effects of all fluoroquinolones. Caution is needed in patients with tendon degeneration, since tendon ruptures have been described after administration of fluoroquinolones. Additionally, prolongation of the QTc-interval has been observed after therapy with fluroquinolones.

16.7.2 Efficacy and Indications Fluoroquinolones are approved for the treatment of infections of the urinary tract, ENT and respiratory tract, abdomen, genitals, bones, skin and soft tissues as well as for serious systemic infections (i.e., sepsis). Ciprofloxacin, ofloxacin, and norfloxacin (group 2) have a good efficacy against gram-negative bacteria (Enterobacteriaciae, Hemophilus influencae, Pseudomonas aeruginosa) and a considerably lower effectiveness in the gram-positive field (Staphylococci, Pneumococci, and Enterococci). Levofloxacin (group 3) has better and moxifloxacin (group 4) much better effects against gram-positive and atypical pathogens. Moxifloxacin has a poor effectivity against Pseudomonas aeruginosa but the antibiotic spectrum of moxifloxacin also includes anaerobic bacteria.

16.7.3 Antibiotic Resistance In recent years, antibiotic resistance rates against fluroquinolones are on the rise in all relevant bacterial

16.8 Macrolides The most commonly used macrolides are erythromycin, clarithromycin, and azithromycin which can be applied parenterally, while roxithromycin can only be given enterally. The mechanism of action of macrolides is inhibition of bacterial protein biosynthesis by binding reversibly to the subunit 50S of the bacterial ribosome, thereby inhibiting translocation of peptidyl-tRNA. This action is mainly bacteriostatic, but can be bactericidal in high concentrations. Macrolides tend to accumulate within leukocytes, and therefore, they become transported to the site of infection. Presently, their use in the surgical field is limited.

16.8.1 Pharmacokinetics The half-life of macrolides ranges from 2.5 h for erythromycin, 2–5 h for clarithromycin, 12 h for roxithromycin, and >14 h for azithromycin. The distribution volume varies considerably from 0.7 L/kg BW for erythromycin up to 25 L/kg BW for azithromycin. Erythromycin is predominantly metabolized by demethylation in the

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liver. The main elimination route of macrolides is via the biliary tract, and a small fraction via the urine (<4.5%).

16.8.2 Efficacy and Indications Macrolides are approved for the treatment of infections of the upper airways, ENT field and the urinary tract caused by Streptococci, Pneumococci, Chlamydia, Legionella, Mycoplasma, and Ureaplasma. Entero­ bacteriaceae and Pseudomonas spp. are generally resistant against macrolides. Macrolides represent an alternative treatment option for infections with Strep­ tococci (scarlet fever, erysipelas) in patients with an allergy to penicillins.

16.8.3 Antibiotic Resistance

C.P. Schneider and B. Grabein

the addition of new units to the peptidoglycan. Glycopeptides are only effective against gram-positive bacteria. They are considered as reserve option for the treatment of infections with multi-resistant gram-positive pathogens, as their efficacy in beta-lactam-susceptible pathogens is worse than that of the beta-lactams.

16.9.1 Pharmacokinetics Glycopeptides have a time-dependent therapeutic effect and are distributed only within the extracellular space. Therefore, their distribution volume is very small. In addition, their ability to penetrate into tissue is limited. The half-life of vancomycin ranges from 6 to 8 h and for teicoplanin from 70 to 100 h. Teicoplanin has a much higher protein-binding capacity with 90% compared to vancomycin with 55%. Glycopeptides are eliminated via renal secretion. Therapeutic drug monitoring is mandatory during treatment with glycopeptides because pharmacokinetics vary largely between individuals.

Antibiotic resistance rates of Pneumococci against macrolides range at approximately 20%.

16.9.2 Efficacy and Indication 16.8.4 Side Effects Macrolides, mainly erythromycin and clarithromycin, have a class effect of QT prolongation which can lead to torsade de pointes. Macrolides exhibit enterohepatic recycling which can lead to recurrence of the product in the system, causing nausea, gastrointestinal disorder, and increase in liver enzymes. Local reactions at the site of application (phlebitis) are frequent. Furthermore, treatment with macrolides can cause vertigo.

16.9 Glycopeptides The glycopeptides vancomycin and teicoplanin are only available for parenteral application because they are not absorbed after oral intake. This class of drugs inhibits the synthesis of cell walls in susceptible microbes by inhibiting peptidoglycan synthesis. They bind to the amino acids within the cell wall preventing

Glycopeptides are very effective against various infections with gram-positive pathogens (Staphylococci, Streptococci, and Enterococci), such as endocarditis, pneumonia, bone infection, infection of the kidneys, and serious systemic infections (sepsis). Importantly, glycopeptides are the first-line antimicrobial agent for infections with multi-resistant Staphylococci (MRSA and MRCNS) and Enterococci.

16.9.3 Antibiotic Resistance Antibiotic resistance of methicillin-resistant Staphy­ lococcus aureus and Enterococcus faecalis against glycopeptides is still very rare but can be occasionally observed for Staphylococcus epidermidis. In contrast, antibiotic resistance of Enterococcus faecium against glycopeptides can be seen frequently with varying profiles of resistance against both vancomycin and teicoplanin. The resistance rates can reach up to 30% which usually occurs in intensive care patients.

16  Antimicrobial Therapy

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16.9.4 Side Effects

(including glycopeptide-resistant Enterococci (GRE)), Staphylococci (including methicillin-resistant Staphy­ lococcus aureus), Streptococci, and corynebacteria. Daptomycin is approved for skin and skin structure infections caused by gram-positive infections, Staphy­ lococcus aureus bacteremia, and right-sided S. aureus endocarditis. In lung tissue, daptomycin becomes ­rapidly inactivated by surfactant, and ­therefore, daptomycin is ineffective in pneumonia treatment.

Glycopeptides are usually given as an infusion and can cause tissue necrosis and phlebitis at the injection site if administered too rapidly. Indeed pain at the site of injection is a common adverse event. One of the side effects is called “Red man syndrome,” an idiosyncratic reaction to bolus administration, caused by histamine release. Some other side effects of vancomycin are nephrotoxicity including renal failure and interstitial nephritis, blood disorders including neutropenia, deafness, and gastrointestinal disorder (reversible after termination of treatment).

16.10 Lipopeptides Daptomycin represents the first antibiotic agent of this new antibiotics class. Daptomycin has a distinct mechanism of action, disrupting multiple aspects of bacterial cell membrane function dependant on calcium integration into cytoplasmic cell membrane. It appears to bind to the membrane and cause rapid depolarization, resulting in a loss of membrane potential leading to inhibition of protein, DNA, and RNA syntheses, which results in bacterial cell death.

16.10.3 Antibiotic Resistance Antibiotic resistance against daptomycin has been observed only in few cases.

16.10.4 Side Effects Side effects commonly seen after administration of daptomycin are elevation of creatinine kinase, gastrointestinal disorders (constipation, nausea, diarrhea, vomiting, dyspepsia, abdominal pain, decreased appetite, stomatitis, and flatulence), pain at the site of administration, headache, and insomnia.

16.10.1 Pharmacokinetics 16.11 Aminoglycosides Half-life of daptomycin is 7–9 h and more than 90% binds to plasma proteins. Elimination takes place in 78% via renal secretion and 5% are egested via feces. Adjustment of dosage in older patients and patients with mild-to-moderate liver dysfunction (Child-Pugh classes A and B) is not necessary but administration intervals extend up to 48 h in patients with renal failure (creatinine clearance <30 mL/min, hemodialysis, and peritoneal dialysis).

16.10.2 Efficacy and Indications Daptomycin is active against gram-positive bacteria only. It has proven in vitro activity against Enterococci

The most important substances of this antibiotic class are amikacin, gentamicin, netilmicin, and tobramycin all of which can be administrated parenterally only. Tobramycin may be given in a nebulized form as well. Aminoglycosides demonstrate rapid bactericidal effects through irreversibly binding to the bacterial 30S ribosomal subunit (amikacin works by binding to the 50S subunit), inhibiting the translocation of the peptidyl-tRNA from the A-site to the P-site, and also causing misreading of mRNA, leaving the bacterium unable to synthesize proteins vital to its growth. Indications are serious infections with gram-negative bacteria and also in combination with beta-lactam antibiotics therapy of endocarditis caused by gram-positive cocci (Enterococci and Streptococci) due to synergistic

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effects. However, the decision to use aminoglycosides must be made carefully due to their poor tissue distribution and high nephrotoxicity.

16.11.1 Pharmacokinetics Aminoglycosides are almost exclusively distributed within the extracellular space. Therefore, their distribution volume is low with a short half-life of approximately 2 h in patients with normal kidney function. Since the therapeutic ratio of aminoglycosides is low, drug monitoring is mandatory particularly if renal function is impaired. A daily single application time point of the total dosage has been established for all aminoglycosides because of comparable antimicrobial activity and reduced nephrotoxicity compared to administration in three smaller dosages.

C.P. Schneider and B. Grabein

16.11.4 Side Effects Aminoglycosides have potential nephrotoxic and ­ototoxic side effects which are cumulatively and dose dependant. They also interfere with neuromuscular signaling, and therefore, they should not be given if patients suffer from Myasthenia gravis. Allergic reactions, blood disorders, and impaired liver function are side effects which can occasionally be observed after treatment with aminoglycosides.

16.12 Oxazolidinone Linezolid is the only agent of this new antibiotic class and can be given orally as well as i.v. Oxazolidinones are protein synthesis inhibitors and stop growth and reproduction of bacteria by disrupting translation of messenger RNA (mRNA) into proteins in the ribosome. Linezolid is considered bacteriostatic against most organisms, but has some bactericidal activity against Streptococci.

16.11.2 Efficacy and Indications Aminoglycosides are primarily used for treatment of infections involving aerobic, gram-negative bacteria, such as Pseudomonas, Acinetobacter, and Enterobacter as well as Staphylococci. In general, they should be given in combination with other antimicrobial substances, preferably with beta-lactam antibiotics due to synergistic effects. The therapeutic administration of aminoglycosides is approved for the treatment of serious infections (sepsis), fever in neutropenic patients, Pseudomonas infections in patients with cystic fibrosis (also for inhalation), and endocarditis. Amikacin is also effective against gram-negative pathogens with resistance against gentamicin and tobramycin.

16.11.3 Antibiotic Resistance Antibiotic resistance develops fast because of decreased accumulation of the substances in bacteria and loss of binding affinity. Additionally, inactivation of aminoglycosides takes place through enzyme induction via acetylation, adenylation, and phosphorylation of the drugs.

16.12.1 Pharmacokinetics Linezolid has a high bioavailability which is independent of the application route (orally or intravenously). Linezolid has low plasma protein–binding capacity (approximately 31%, but highly variable) and a volume of distribution at steady state of around 40–50  L. The tissue distribution is generally good and half-life averages around 5–7 h. Linezolid is metabolized in the liver, by oxidation of the morpholine ring, without involvement of the cytochrome P450 system, and is eliminated mainly via renal secretion (85%).

16.12.2 Efficacy and Indications Linezolid is effective against all clinically important gram-positive bacteria, notably Enterococcus faecium and Enterococcus faecalis (including vancomycin-­ resistant Enterococci), Staphylococcus aureus (including

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16  Antimicrobial Therapy

methicillin-resistant Staphylococcus aureus, MRSA), Streptococcus agalacticae, Streptococcus pneumoniae, Streptococcus pyogenes, the viridans group Streptococci, and Listeria monocytogenes. It is also highly active in vitro against several mycobacteriae.

The elimination half-life is 1–5 h. Clindamycin is ­primarily eliminated by hepatic metabolism (80%) and the metabolites are excreted via the urine.

16.13.2 Efficacy and Indications 16.12.3 Antibiotic Resistance Resistance rates have remained stable and extremely low, less than 0.5% of isolates in general, and less than 0.1% of S. aureus samples.

16.12.4 Side Effects Common side effects of linezolid include diarrhea, headache, nausea, vomiting, rashes, constipation, altered taste perception, and discoloration of the tongue. In particular, a decrease in leukocyte and platelet counts can be observed after long-term use of linezolid, and therefore, in these patients, repeated blood counts are mandatory.

16.13 Lincosamides Clindamycin can be given parenterally and orally. It has a bacteriostatic effect and interferes with bacterial protein synthesis (in a similar way to erythromycin, azithromycin, and chloramphenicol), by binding preferentially to the 50S subunit of the bacterial ribosome. Clindamycin is usually used to treat infections with gram-positive anaerobic bacteria.

16.13.1 Pharmacokinetics Approximately 90% of an oral dose of clindamycin is absorbed from the gastrointestinal tract and it is widely distributed throughout the body, excluding the central nervous system. Adequate therapeutic concentrations can be achieved in bone. There is also active uptake into white blood cells, most importantly neutrophils.

Clindamycin has good efficacy against Staphylococci, Streptococci, gram-positive anaerobic bacteria, Bacter­ oides spp., and Mycoplasma pneumoniae. Clindamycin is used primarily to treat infections caused by susceptible anaerobic bacteria, including infections of the respiratory tract, skin and soft tissue infections, as well as peritonitis. It is also used to treat bone and joint infections, particularly those caused by Staphylococcus aureus.

16.13.3 Antibiotic Resistance Resistance rates for clindamycin range at 10% for blood isolates of Staphylococcus aureus, 30% for coagulasenegative Staphylococcus, and 10–20% for Bacteroides spp. Additionally, resistance rates of MRSA and MRSE continue to rise.

16.13.4 Side Effects Common side effects associated with clindamycin therapy, which can be observed in more than 1% of patients include diarrhea, pseudomembranous colitis, nausea, vomiting, abdominal pain or cramps, increased liver enzyme, rash, and/or itch. High doses (both ­intravenous and oral) may cause a metallic taste, and topical application can cause contact dermatitis.

16.14 Streptogramins Streptogramins are cyclic peptides and are available as a fixed combination of dalfopristin (70%) and quinupristin (30%). Both agents have bacteriostatic effects and have bactericidal effects in combination with a ­distinct post-antibiotic effect. The combination of

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quinupristin/dalfopristin is only available for parenteral application. Quinupristin binds to the 50S ribosomal subunit and prevents elongation of the polypeptide. Dalfopristin binds to a nearby site, changes the conformation of the 50S ribosomal subunit, and enhances the binding of quinupristin by a factor of about 100. Quinupristin/dalfopristin is effective against all clinically relevant gram-positive bacteria, notably multi-resistant staphylococci (MRSA) and glycopeptide-resistant Enterococcus faecium. The use of quinupristin/dalfopristin should be limited to infections with gram-positive bacteria where no other antibiotics are effective.

16.14.1 Pharmacokinetics Quinupristin/dalfopristin has a medium distribution ­volume, and their half-lives range from 1 to 3 h. They are mainly metabolized in the liver and eliminated via the biliary tract. The protein-binding capacity varies from 55–78% for quinupristin to 11–26% for dalfopristin.

C.P. Schneider and B. Grabein

recommended. Other frequent side effects include arthralgia and myalgia, gastrointestinal disorder (nausea, diarrhea, or vomiting), headache, and increased liver enzymes. Quinupristin/dalfopristin also interferes with the cytochrome P450 enzyme system in the liver.

16.15 Tetracyclines Tetracyclines are a group of broad-spectrum antibiotics which have lost their general usefulness due to the development of bacterial resistance. Despite this, they remain the treatment of choice for some specific indications. The clinically most relevant agent of this antibiotic group is doxycycline which can be administered parenterally and orally. Tetracyclines generally have bacteriostatic effects through inhibition of protein synthesis by binding to the 30S ribosomal subunit in the mRNA translation complex. The treatment spectrum covers gram-positive and gram-negative bacteria.

16.14.2 Efficacy and Indications The use of Quinupristin/dalfopristin is limited to infections with gram-positive cocci, including multi-resistant Staph­ylococci (MRSA) and glycopeptide-resistant Enterococcus faecium (VRE). The drug combination should not be used against Enterococcus faecalis. Quinupristin/dalfopristin is approved for the treatment of infections of the lung, skin, and soft tissues and all infections caused by glycopeptide-resistant Enterococ­ cus faecium.

16.14.3 Antibiotic Resistance Enterococcus faecalis, anaerobic and aerobic gramnegative bacteria are resistant against streptogramins.

16.14.4 Side Effects Allergic reaction at the application site is common and administration via a central venous catheter is

16.15.1 Pharmacokinetics The distribution of doxycycline is mainly intracellular, and it penetrates well into all tissues. The halflife ranges from 10 to 20 h. Doxycycline is partly metabolized in the liver and eliminated via feces and urine.

16.15.2 Efficacy and Indications Nowadays, the use of doxycycline is limited to few indications. It is frequently used to treat infections caused by Chlamydia (trachoma, psittacosis, salpingitis, urethritis and L. venereum infection), Mycoplasma, Rickettsia (typhus, Rocky Mountain spotted fever), brucellosis, and spirochetal infections (borreliosis, syphilis, and Lyme disease). In general, approved indications for the use of doxycycline are infections of the upper and lower respiratory tracts, the bile tract, and pelvic inflammatory disease.

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16  Antimicrobial Therapy

16.15.3 Antibiotic Resistance The local resistance rates differ significantly, and there is a lack of published data. Resistance rates range from 10% to 20% for gram-positive bacteria and are higher in the gram-negative field.

16.15.4 Side Effects Treatment with doxycycline can cause stomach or bowel upsets. Of particular note is a possible photosensitive allergic reaction which increases the risk of sunburn. Allergic reactions and hepatotoxicity are rarely seen.

resistant strains of Acinetobacter baumannii, and isolates of Klebsiella pneumoniae and Escherichia coli producing AmpC-beta-lactamases or extended-spectrumbeta-lactamases (ESBL). Currently, the drug is licensed for the treatment of skin and soft tissue infections as well as intra-abdominal infections.

16.16.3 Antibiotic Resistance In general, tigecycline has no activity against Pseudomonas spp., Proteus spp., and Burkholderia cepacia. Antibiotic resistance against usually susceptible bacteria has been observed only in few cases so far.

16.16.4 Side Effects 16.16 Glycylcyclines Tigecycline is the first clinically available drug in a new class of antibiotics called the glycylcyclines and has a similar structure as the tetracyclines. Tigecycline has a bacteriostatic effect and is a protein synthesis inhibitor by binding to the 30S ribosomal subunit of bacteria.

16.16.1 Pharmacokinetics Tigecycline has a long half-life of 25–42 h, and it has a large distribution volume. It is eliminated via kidneys (33%) and liver (60%) without modification. No dose adjustment is needed for patients with impaired kidney or liver function (Child-Pugh-Stadium A and B). Tigecycline does not interact with the cytochrome P450 enzyme system in the liver.

16.16.2 Efficacy and Indications Tigecycline is active against many gram-positive bac­ teria, gram-negative bacteria, anaerobes, mycoplasma and chlamydiae. It is also active against methicillinresistant Staphylococcus aureus (MRSA), multi-drug

The most common side effects of tigecycline are ­gastrointestinal disorders (diarrhea, nausea, and vomiting). Increased serum bilirubin can also be rarely observed.

16.17 Ansamycins Rifampicin can be administered intravenously as well as orally. It has bacteriostatic and bactericidal effects on proliferating cells which depend on the administered dose as well as the activity of the bacteria. Rifampicin inhibits DNA-dependent RNA polymerase in bacterial cells by binding to its beta-subunit, thus preventing transcription to RNA and subsequent translation into proteins. It has a good efficacy against tuberculosis as well as in combination with other antibiotics against multi-resistant gram-positive bacteria.

16.17.1 Pharmacokinetics Rifampicin has a high distribution throughout the body, and reaches effective concentrations in many organs and body fluids, including the cerebrospinal fluid. About 60–90% of the drug is bound to plasma proteins. The half-life of rifampicin ranges from 6 to 7 h

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and depends on the duration of therapy because selfinduction by the agent causes increased metabolization rate. Approximately 7% of the administered drug is excreted unchanged through the urine; urinary elimination, however, accounts for 30% while 60–65% of the administered dosage is excreted via the feces.

C.P. Schneider and B. Grabein

as well as orally. It has a high bactericidal activity against anaerobic bacteria because it is taken up by diffusion and then inhibits protein synthesis via binding to DNA.

16.18.1 Pharmacokinetics 16.17.2 Efficacy and Indications Apart from the “typical use” for the treatment of myco­ bacterium infections, including tuberculosis and ­leprosy, rifampicin has a role in combination with glycopeptides or other antibiotics for the treatment of infections with Staphylococci (including methicillinresistant strains), Streptococci, and Enterococci if ­susceptibility is confirmed.

16.17.3 Antibiotic Resistance Rifampicin resistance develops quickly during monotherapy. Primary resistances against Mycobacterium tuberculosis and meningococci are rare.

Metronidazole has a medium distribution volume, and its half-life ranges from 6 to 8 h. The agent is partially bound to plasma proteins (10–20%), and after metabolization, it is eliminated mainly via renal excretion (60–80%).

16.18.2 Efficacy and Indications Metronidazole is approved for treatment of infections caused by anaerobic bacteria (including meningitis and brain abscess). It is used in combination for perioperative prophylaxis. Metronidazole is further indicated for the treatment of protozoal infections due to Entamoeba histolytica, Giardia lamblia (Giardiasis), and Tricho­ monas vaginalis. Metronidazole has also been proven to be effective for the treatment of pseudomembranous colitis caused by Clostridium difficile.

16.17.4 Side Effects The more common unwanted effects include hepatotoxicity, gastrointestinal disorder, and altered blood counts. Rifampicin is an effective liver enzymeinducer, promoting the upregulation of hepatic cytochrome P450 enzymes, and therefore, increasing the rate of metabolism of many other drugs that are cleared by the liver through these enzymes.

16.18.3 Antibiotic Resistance Primary resistance among anaerobic bacteria is rarely seen. Some strains of Helicobacter pylori have developed resistance against metronidazole.

16.18.4 Side Effects 16.18 Nitroimidazoles Metronidazole is the most important nitroimidazole and it is used mainly in the treatment of infections caused by susceptible organisms, particularly anaerobic bacteria and protozoa. Metronidazole has an excellent bioavailability and can be administered parenterally

Common side effects include nausea, diarrhea, and a metallic taste in the mouth. Therapy with metronidazole can be associated with leucopenia, neutropenia, and increased risk of peripheral neuropathy. Consump­ tion of alcohol should be avoided while using metronidazole because a significant alcohol intolerance can develop.

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16.19 Fosfomycin

16.20 Co-trimoxazole

Fosfomycin can be given parenterally and orally, but the enteral form (Fosfomycin-Trometamol) is only approved for the treatment of urinary tract infections. Fosfomycin is an antimetabolite of phosphoenolpyruvate in the enzymatic synthesis of bacterial cell wall components and has bactericidal activity. Fosfomycin is active against gram-positive and gram-negative bacteria, including Pseudomonas aeruginosa, but resistance develops rapidly under monotherapy.

Co-trimoxazole is a sulfonamide antibacterial combination of trimethoprim and sulfamethoxazole and is used for the treatment of a variety of gram-positive and gram-negative bacterial infections. Trimethoprim and sulfamethoxazole inhibit successive steps in the folate synthesis pathway. Each component alone exhibits bacteriostatic effects, but together they have bactericidal effects.

16.20.1 Pharmacokinetics 16.19.1 Pharmacokinetics Fosfomycin is distributed selectively in the extracellular space, and therefore, its distribution volume is small. Fosfomycin does not bind to plasma proteins and is eliminated unmodified via the urinary tract.

Co-trimoxazole is distributed in the intra- and extracellular spaces, and its tissue distribution volume is low for sulfamethoxazole and medium for trimethoprim. Seventy percent of sulfamethoxazole and 45% of trimethoprim are bound to plasma proteins, and their half-lives range from 10 to 12 h. Co-trimoxazole is partly metabolized and then excreted via the urine.

16.19.2 Efficacy and Indications 16.20.2 Efficacy and Indications Fosfomycin is effective against Staphylococci, grampositive and gram-negative bacteria. Its use is approved for infections in different locations (particularly bone and meninges) as long as susceptibility of the pathogen has been proven.

16.19.3 Antibiotic Resistance Resistance rapidly develops under monotherapy due to spontaneous mutations.

16.19.4 Side Effects Gastrointestinal disorder and pain at the application site are often seen during fosfomycin therapy. Attention must be paid to the high sodium chloride content of the solution.

Co-trimoxazole is effective against gram-positive and gram-negative bacteria and is predominantly used for the treatment of infections with Stenotr­ ophomonas maltophilia, Pneumocystis jiroveci (formerly Pneumocystis carinii) and in combination with other drugs for infections with methicillin-resistant Staphylococcus aureus. It can be effective in a variety of upper and lower respiratory tract infections, renal and urinary tract infections (UTI), and can be used for long-term prophylaxis of UTI in patients at risk.

16.20.3 Antibiotic Resistance Escherichia coli, Salmonella, Shigella, and other Enterobacteriacae have developed increased resistance rates during recent years.

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C.P. Schneider and B. Grabein

16.20.4 Side Effects Administration of high dosages of co-trimoxazole can be associated with gastrointestinal disorders, crystalluria (formation of crystals and excretion in the urine), and acute renal failure. Serious adverse effects including Stevens–Johnson syndrome, myelosuppression, mydriasis, agranulocytosis, and hepatitis are rarely seen.

16.21 Characterization of Antifungals (Table 16.3), Pharmacokinetics, Efficacy, Resistance, and Side Effects (Table 16.4)

fungal infection is often difficulty. Verification of fungi in primarily sterile material or histological detection of invasiveness in bioptic material may represent distinct markers of invasive fungal infections. Local and systemic fungal infections are often seen in patients with diminished immunological competence, for example after organ transplantation. Additionally, biological selection of fungi occurs after long-term antibiotic therapy, and therefore, critical ill patients are at increased risk of IFI. If fungal infections are assumed or established, in particular with molds (e.g., Asper­ gillus spp.), antifungal therapy must be given for ­significantly longer periods of time compared to antibacterial therapy. Efficacies of important antifungal drugs in the clinical setting are summarized in Table 16.4.

16.21.1 Introduction

16.22 Polyenes

Invasive fungal infections (IFI) only play a minor role in the surgical field. Microbiological detection of fungi (e.g., Candida spp.) is common but is usually due to colonization of the host. Under these circumstances, antifungal treatment is usually not indicated. Nonethe­ less, differentiation between colonization and invasive

Amphotericin B is available for parenteral application as well as an oral preparation. It may also be given in a nebulized form and for topical application, for example intra-abdominal irrigation. A liposomal formulation of amphotericin B for injection has been developed which exhibits fewer side effects (particularly nephrotoxicity)

Table 16.3  Systemic antifungal agents for parenteral and oral applications Group Drugs Maximum dosage Intravenously

Orally

Polyene

Amphotericin B Amphotericin B liposomal

1–1.5 mg/kg BW once daily 3–5 mg/kg BW once daily

n/a n/a

Azole

Fluconazole

10 mg/kg BW once daily

10 mg/kg BW once daily

Itraconazole

200 mg q12–24 h

200 mg q12–24 h

Voriconazole

6 mg/kg BW q12h on day 1, and then 3–4 mg/kg BW q12h

400 mg q12h on day 1, and then 200 mg q12h

n/a

400 mg q12h

Posaconazole Fluorinated pyrimidine

Flucytosine

25–37.5 mg/kg BW q6h

n/a

Echinocandins

Caspofungin

70 mg once daily on day 1, and then 50 mg once daily

n/a

Anidulafungin

200 mg once daily on day 1, and then 100 mg once daily

n/a

Micafungin

150 mg once daily

n/a

n/a non-applicable to reach therapeutic systemic levels, q every, h hours, BW body weight

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16  Antimicrobial Therapy Table 16.4  Antifungals’ efficacy

Pseudallescheria

Zygomycetes

?

Dermatophyte

Aspergillus flavus

?

Cryptococcus neoformans

Aspergillus fumigatus

Amphotericin B

Candida krusei

Polyene

Candida glabrata

Drugs

Candida tropicalis

Candida albicans

Group

Amphotericin B liposomal Azole

Fluconazol

R

Itraconazol

R

R

Voriconazol Posaconazol Fluorinated

Flucytosin

pyrimidine Echinocandins

Caspofungin Anidulafungin Micafungin

No efficacy

Effective

R = potentially resistant ? = efficacy unclear

while having similar efficacy. Nystatin is only available as oral preparation. Amphotericin B antagonizes the sterol synthesis, the main component of fungal cell membranes, forming a transmembrane channel that leads to potassium leakage and fungal cell death. Polyene antifungal agents have a broad-spectrum efficacy which covers Candida and Aspergillus spp., except Scedosporium (Pseudallescheria) spp.

16.22.1 Pharmacokinetics Amphotericin B and Nystatin are not absorbed after oral intake. After parenteral application, amphotericin B binds up to 90% to plasma proteins and its half-life ranges to about 20 h. The highest tissue concentration

can be reached in the liver while its concentration is lower in the lungs and kidneys, but can increase up to 65% of plasma concentration in pleural, peritoneal, and synovial fluids if infection is present. The distribution into the cerebrospinal fluid is marginal. Amphotericin B is slowly eliminated via the kidneys over several days, and it cannot be removed via dialysis.

16.22.2 Efficacy and Indications Amphotericin B is approved for the treatment of serious systemic fungal infections including peritonitis, sepsis, meningitis, and endocarditis. The oral preparation can be used for intestinal decontamination and therapy of thrush or other topical forms of candidiasis.

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16.22.3 Resistance Development of resistance under amphotericin B therapy is uncommon, and only individual reports have been published indicating primary resistance of some Candida strains.

16.22.4 Side Effects Nephrotoxicity is a frequently reported side effect, and it is much milder when the liposomal formulated amphotericin B is used. Frequently, a serious acute reaction after infusion (1–3 h later) can be noted consisting of high fever, shaking chills, hypotension, anorexia, nausea, vomiting, headache, dyspnea, and tachypnea. Other possible side effects include thrombophlebitis at the application site, several forms of anemia and other hematological problems as well as backache.

16.23 Azoles Systemic applicable antifungal agents of this group are fluconazole, itraconazole, voriconazole, and posaconazole, which are chemically different azole derivates with imidazole or triazole structure. Inhibition of the fungal enzyme 14a-demethylase which produces ergosterol (an important component of the fungal plasma membrane) is the common mode of action. All azole derivates also inhibit cytochrome P450 enzyme system and parts of the human steroid synthesis. Therefore, careful patient evaluation must look for possible interactions with other medications. Fluconazole, itraconazole, and voriconazole can be given parenterally and orally, while posaconazole is only available for oral administration. The effectiveness varies significantly among the azole derivates. Fluconazole is highly effective against several Candida species, but shows poor activity against Candida glabrata and no effect against Candida krusei and molds. Itraconazole has similar efficacy across Candida spp. and is additionally active against Aspergillus spp. Voriconazole also covers Candida glabrata, Candida krusei, Fusarium

C.P. Schneider and B. Grabein

spp., and Scedosporium spp. Posaconazole, the most recent azole derivate, also has good efficacy against Zygomycetes.

16.23.1 Pharmacokinetics Fluconazole is well absorbed after oral intake, and its half-life reaches up to 25 h. Plasma protein–binding capacity of fluconazole is low with approximately 12%. It penetrates well into various tissues and reaches high concentrations in urine, saliva, sputum, and cerebrospinal fluids. Most of the administered fluconazole (60–80%) is eliminated unmodified via the kidneys. Itraconazole is also well absorbed after oral intake, particularly if taken together with alimentation. However, the bioavailability varies individually, and therefore, drug monitoring is necessary to modify the dosage and reach therapeutic levels. Intraconazole has a half-life of 24 h and is nearly 99% bound to plasma proteins. It does not penetrate into the cerebrospinal fluid and neither renal failure nor dialysis has an impact on intraconazole serum levels. Voriconazole is almost completely absorbed after oral intake. Its half-life ranges from 6 up to 12 h and approximately 60% is bound to plasma proteins. The cerebrospinal fluid level of this drug can reach nearly 50% of plasma levels. Most of the drug (95%) is metabolized in the liver, 80% is then excreted via the urine (2% unmodified), and 20% via the feces. Posaconazole is slowly absorbed after oral intake which depends on the fat content of the nutrition. Posaconazole has a high distribution volume and a medium half-life of 35 h. Almost 98% of the drug is bound to plasma proteins and the major proportion is eliminated via the feces, while 15% is removed via the urine.

16.23.2 Efficacy and Indications Fluconazole is widely used for the treatment of fungal infections caused by Candida albicans and tropicalis while itraconazole is approved for therapy and prophylaxis of various kinds of mycosis in immunocompromised patients. Voriconazole has approval for the treatment of invasive Aspergillus infection and serious

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16  Antimicrobial Therapy

candidiasis, which are resistant to fluconazole, as well as fungal infections caused by Fusarium spp. and Scedosporium spp. Posaconazole is approved for ­therapy of refractory Aspergillus infections, Fusarium infection, and Zygomycosis.

proteins, and its half-life ranges from 3 to 4 h. Flucytosine penetrates well into cerebrospinal and peritoneal fluids. The drug is excreted mainly unchanged via the urine (90%), and only traces are metabolized and excreted with the feces.

16.23.3 Resistance

16.24.2 Efficacy and Indications

A fraction (5–10%) of Candida spp. develop secondary resistance under fluconazole therapy. Primary resistance exists in Candida glabrata and krusei, molds and dermatophytes. In HIV-positive patients, secondary resistant Candida spp. are rarely observed under itraconazole therapy. Resistances against voriconazole and posaconazole are rarely seen.

The range of efficacy includes Candida spp., Cryptococcus spp., and some Aspergillus spp. The combination of flucytosine and amphotericin B may exhibit synergistic effects in vitro, particularly for the treatment of life-threatening fungal infections (e.g., cryptococcal meningitis), but may also increase the toxicity of amphotericin B and vice versa.

16.23.4 Side Effects The most common side effects associated with azole antifungal agents are gastrointestinal disorders, rash, adverse effects on the central nervous system, elevated liver enzymes and bilirubin, peripheral edema, and respiratory disorders. Adrenal insufficiency can occur under itraconazole therapy, and visual disturbances (blurred vision, increased light sensitivity) are unique to voriconazole.

16.24 Fluorinated Pyrimidine Flucytosine, or 5-fluorocytosine, a fluorinated pyrimidine analogue, is a synthetic antimycotic drug which is available in oral and (in some countries) also in injectable form. Flucytosine represents an antimetabolite and inhibits fungal DNA synthesis.

16.24.3 Resistance Secondary resistance is quite commonly seen under monotherapy, and therefore, flucytosine should be combined with other antifungal agents. Resistance in Candida spp. has been noted to occur in 10–50% and in 2–20% of Cryptococcus neoformans isolates.

16.24.4 Side Effects Bone marrow depression (anemia, leucopenia, pancytopenia, or even rarely agranulocytosis) may reversibly occur in 10% of the patients. Elevations of liver enzymes and bilirubin, gastrointestinal disorder, and adverse central nervous system effects are rarely observed during flucytocine therapy.

16.25 Echinocandins 16.24.1 Pharmacokinetics Flucytosine is well absorbed (75–90%) from the gastrointestinal tract. Small amounts are bound to plasma

Caspofungin is an antifungal drug, the first of a new class termed the echinocandins, which was introduced in 2001. Further derivatives, anidulafungin and micafungin, were approved by the Food and Drug Administration in 2005 and 2006, as well as in

126

Europe in 2007 and 2008. Echinocandins inhibit the enzyme b(1,3)-d-Glucan synthase and disturb the integrity of the fungal cell wall. These agents exhibit fungicidal efficacy and cover almost all Aspergillus and Candida spp.

16.25.1 Pharmacokinetics All echinocandins are administered intravenously and 84–99% is bound to plasma proteins. Their half-lives range from 9 to 11 h for caspofungin, 11–17 h for micafungin, and 40–50 h for anidulafungin. All echinocandins are slowly metabolized and egested via feces and urine. Neither mild to medium hepatic nor renal dysfunction has an impact on drug serum levels. None of the echinocandines can be removed by dialysis.

16.25.2 Efficacy and Indications These drugs are approved for the treatment of general invasive candidiasis (acute disseminated candidiasis, candida peritonitis, abscesses and esophageal candidiasis), invasive Aspergillus infection, and empiric therapy in neutropenic patients with fever. Micafungin is also approved for the prophylaxis of candida infections in patients undergoing hematopoietic stem cell transplantation.

16.25.3 Resistance Resistance in Candida albicans has been described for caspofungin, but is currently still rare. Cryptococcus spp. and Mucoraceae are primarily resistant against echinocandins.

16.25.4 Side Effects Fever, phlebitis, gastrointestinal disorder, adverse central nervous system effects, increased liver enzymes, altered blood count, rash, proteinuria and erythrocyturia may occur under antifungal therapy

C.P. Schneider and B. Grabein

with echinocandins. Hypersensitivity reaction with rash, facial edema, and pruritus can be observed rarely.

16.26 General and Specific Aspects of Antimicrobial Therapy (Table 16.5) Antimicrobial therapy is defined as the monocausal use of drugs which selectively and directly affect specific pathogens. Therefore, location and kind of infection, particularly in surgical patients, has to be evaluated and adequate antimicrobial substances have to be selected before antimicrobial therapy is introduced. The option of surgical intervention must always be considered. The rational use of antimicrobial agents for directed therapy can only occur on the basis of sufficient microbiological diagnostics. For this purpose, a close cooperation between attending physician and the microbiologist is of importance.

Note: Fever alone is no indication for antimicrobial therapy!

16.26.1 General Principles of Antimicrobial Therapy • Microbiological diagnostics should always be done prior to initiating antimicrobial therapy. Therefore, correct sampling of suitable material and transportation in the correct medium (e.g., transport medium for detection of anaerobic pathogens or specific blood culture media) must be ensured. • Selection of the agent for calculated antimicrobial therapy should be directed by the location of the assumed infection and by the associated microbiological spectrum, as well as the local pathogen and resistance situation. Additionally, patient-specific issues have to be considered before selecting a certain substance (length of hospitalization, prior surgical interventions, underlying disease, specific risk factors, and previous antibiotic therapy).

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16  Antimicrobial Therapy Table 16.5  Selection of antimicrobial agents for different indications

A A A A

Cefotaxime/ Ceftriaxone

A

A

Ceftazidime

A

Cefepime

A

Sepsis

R

Flucloxacillin Oxacillin A

Pyelonephritis

A

Piperacillin/Tazobactam

Cephazolin Cefuroxime/ Cefotiam

Pneumonia

Phlegmon

Peritonitis

Pancreatitis

Osteomyelitis

Meningitis

A

Gastroenteritis

A

Gangrene

Endocarditis

A

Impurity infection

Diverticulitis

A

Erysipelas

Cholangitis

Ampicillin Amoxicillin/clavulanate Piperacillin Mezlocillin

Arthritis

Abscesses

Antimicrobial drugs Benzylpenicillin

A

A

A A A

A

A

A

A

A

A

A

A

A A

Cefoxitine Imipenem

A

A A

A R R

Meropenem Ertapenem Doripenem Aztreonam

R

R

R

R

A

R

Ofloxacin/ Ciprofloxacin

A

A

A

A

A

A

A

A

A

Levofloxacin

A

A

A

A

A

A

A

A

A

Moxifloxacin Erythromycin

R

R

R

R

R

R

R

R

R

R

R

A

Clarithromycin

R

A

Azithromycin

R

A

Vancomycin/ Teicoplanin R Daptomycin R Amikacin

R R

A

A

A

A

A

Gentamicin

R

A

A

A

A

A

Netilmicin

R

A

A

A

A

A

A

A

A

A

Tobramycin Linezolid

R

R/A R

R

R

Clindamycin

R

A

Fosfomycin

A

R/A A A

Co-trimoxazol

R

R

R

R

R

R

R

R

R

R

R/A R/A

R/A

R/A R

A

A

R/A

A

A

A

R/A R/A R

R R/A

A

R A

A

Antibiotic reserve for specific indications A = Adjunction

A

R

A A

R/A

R/A

A A

R

R/A R

A R

R/A

Metronidazole

= Indication

R

R

A

Quinupristin/ Dalfopristin R Tigecycline R Rifampicin

R

R = Therapeutic reserve

Note: Indication does not always equate approved specific treatment recommendations (off-label-use)

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• Calculated antimicrobial therapy for treatment of serious infections (e.g., pneumonia, peritonitis, ­sepsis), especially during the postoperative course, should always be given parenterally to reach effective tissue levels rapidly. • The antimicrobial agent should always be given at the highest recommended dosage and the treatment period should be maintained as short as possible. After receiving microbiological results, the selected antibiotic substance should be adjusted according to the antibiogram. Oral administration of the antimicrobial substances should be considered if a medium severe infection is present and uncomplicated enteral resorption of the drug is assumed. Mild infections (e.g., soft tissue or urinary tract infections) can be treated with orally available antibiotics. • If clinical symptoms do not improve within 3 days of antimicrobial therapy, the assumed site of infection must be reevaluated and treatment with a different antibiotic should be initiated.

16.26.2 Causes for Failure of Antimicrobial Treatment and Primary/Secondary Resistance Contradicting results of microbial sensitivity testing and clinical effects of specific antimicrobial therapy can occur for a number of reasons. The following issues must always be considered: • Tissue concentration does not reach therapeutic drug levels due to application of an insufficient ­dosage or impaired tissue diffusion. • Discrepancy between in vivo and in vitro activities of the antimicrobial substance, testing of nonrelevant pathogens, change of the underlying pathogen, and/or development of secondary resistance during therapy. • Patient-specific causes (preexisting disease, imm­ unodeficiency). • Incorrect application of the antimicrobial drug (inactivation due to interaction with other drugs), antagonism of antimicrobial drug combinations, absence of bactericidal activity of the used agent.

C.P. Schneider and B. Grabein

16.26.3 Antibiotic Resistance Currently plays an increasing role and is due to unfocused application of antimicrobial agents. Several mechanisms contribute to the development of anti­ biotic resistance of pathogens. These include pro­ duction of enzymes which inactivate antimicrobial substances, altered target molecules, and impaired permeability (reduced cell penetration). The encoding genes for antibiotic resistance can be located within the bacterial chromosome or in plasmids which allows for a rapid horizontal spread. The development of antibiotic resistance in bacteria relies on genetic variability and selection of resistant mutants. Development of antibiotic resistance can be influenced by the following measures: • Antibiotic therapy should be patient specific. • The use of treatment regimes combining different antibiotics should be preferred. • The same diagnosis does not always require the same antibiotic regimen. • Indications for antibiotic prophylaxis and topical application should always be considered critically. • Statistical evaluation of local pathogen environment and resistance rates should be documented continuously and critically reviewed. • Staff members must be continuously educated in close collaboration with the clinical microbio­ logists.

Note: We are only guests on the planet of the bacteria!

16.27 Antimicrobial Prophylaxis in Surgical Procedures 16.27.1 Definition Antimicrobial prophylaxis for surgical procedures is a short-term (usually single shot) administration of antimicrobial agents, just before the start of (or latest during) surgical procedures. The prophylaxis aims to

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minimize the rate of surgical site infections which are caused by displaced or resident bacteria within the operating field.

Cave Antimicrobial prophylaxis in surgical procedures: • Cannot compensate for insufficient basic hygiene and aseptic technique or suboptimal surgical technique • Cannot “sterilize” the tissue and prevent all potential infections Generally accepted indications for antimicrobial prophylaxis in surgical procedures (modified surgical site classification according to Cruse [1]) are: • Surgical procedures with high rates of surgical site infections: “clean-contaminated” (e.g., appendectomy, cholecystectomy) or “contaminated” operations (gross spillage from the ­gastrointestinal tract or incisions into acute nonpurulent inflammation) • “Clean” surgical procedures with low rates of surgical site infection, but serious consequences if an infection occurs (prosthetic material, mesh) • “Clean” surgical procedures with specific risk factors (Table 16.6) “Evidence-based” principles of antimicrobial prophylaxis in surgical procedures are: −− Antimicrobial prophylaxis should only be given with clear indication. −− Antibiotics should be selected considering the local microbiological environment as well as local patterns of antibiotic resistance. −− The initial dosage should always be given intravenously. −− Bactericidal serum and tissue levels should be warranted at the time of incision. −− Therapeutic serum and tissue levels of the antimicrobial agent should be maintained throughout the operation and for several hours afterward.

Table 16.6  Risk factors of surgical site infections (Ref. 2) Patient-specific risk factors Age Diabetes mellitus Immunological incompetence Reduced general condition Obesity Malnutrition ASA > III MRSA carrier Fever/shivering within 1 week before surgery Female gender, e.g., colon surgery Male gender, e.g., trauma or vascular surgery Dialysis patient Hepatitis Substance addiction Infections on other localizations Arterial mal perfusion Neuropathy Preoperative Emergency surgery Extended hospital stay before surgery Ineffective antibiotic prophylaxis Antibiotics was applied 2 h too late or too early Surgical wound classification “contaminated” Post-radiation High-risk surgery Recurrent surgery Choledocholithiasis Increased C-reactive protein Impurity implantation Hair removal not just before the operation Intraoperative Quality of the surgeon Time of surgery > 2 h Infected surgical field Surgical site contamination Blood transfusion Prolonged anesthesia More than one surgical intervention Use of diathermia Systemic oxygen drop Hypothermia Unforeseen complications Postoperative Presence of wound drains for more than 3 days Respiratory tract infection Hypothermia Invasive techniques: urine catheter, chest drain, nasogastric tube, central venous catheter Evidence of Enterococcus spp., Enterobacteriaceae, or Bacteroides fragilis in the surgical wound

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16.27.2 Selection Criteria for Antimicrobial Agents and Antimicrobial Prophylaxis for Surgical Procedures (Table 16.7) Antimicrobial prophylaxis must be selected based on  the expected microbiological spectrum, the local ­resistance epidemiology of the institution, and ­pharmacokinetics of the substance (e.g., half-life,

concentration within the target tissue). Furthermore, toxicity and compatibility of the antimicrobial agent must be taken into account. Controlled randomized studies (where available) should be the basis for selection of a certain agent. Antibiotic prophylaxis in surgical practice should adhere to the following principles: • Single-shot application of the maximum dosage. • Administration less than 2 h before surgery to ensure optimal plasma and tissue levels.

Table 16.7  Recommendation for antimicrobial prophylaxis in surgical procedures Type of surgery Expected pathogens First choice antibiotics

Alternative antibiotic drugs (Beta-lactam allergy)

Second-generation cephalosporins (e.g., cefuroxime 1.5 g) + metronidazole 500 mg

Amoxicillin/clavulanate 2.2 g Beta-lactam allergy:

Risk patients:

Clindamycin 600 mg +

Third-generation cephalosporins (e.g., ceftriaxone 2 g) + metronidazole 500 mg

Gentamicin 1.5 mg/kg KG

Enterobacteriaceae, Streptococcus spp., anaerobic bacteria from the upper respiratory tract (Peptostreptococcus spp.)

Second-generation cephalosporins (e.g., cefuroxime 1.5 g)

Amoxicillin/clavulanate 2.2 g

Risk patients vide supra

Vascular and implant surgery

Staphylococcus aureus, Coagulase-negative Staphylococcus

Second-generation cephalosporins (e.g., cefuroxime 1.5 g)

Beta-lactam allergy vide supra Beta-lactam allergy: Vancomycina 1 g

Thoracic surgery

Staphylococcus aureus, Coagulase-negative Staphylococcus, Pneumococcus, Enterobacteriaceae

Second-generation cephalosporins (e.g., cefuroxime 1.5 g)

Beta-lactam allergy: Vancomycina 1 g

Orthopedic surgery

Staphylococcus aureus, ­coagulase-negative Staphylococci, gram-negative bacteria

Second-generation cephalosporins (e.g., cefuroxime 1.5 g)

Amoxicillin/clavulanate 2.2 g

(+ metronidazol 500 mg)

Beta-lactam allergy:

Colon and rectum surgery, appendectomy, liver resection, pancreas resection, emergency surgery (ileus, acute unclear abdomen)

Enterococcus spp., Enterobacteriaceae, anaerobic bacteria

Esophagus, stomach and bile duct surgery

Clindamycin 600 mg + gentamicin 1.5 mg/kg KG Plastic and hand surgery

Staphylococcus aureus, coagulase-negative Staphylococci

Second-generation cephalosporins (e.g., cefuroxime 1.5 g)

Amoxicillin/clavulanate 2.2 g

Minimal invasive surgery According to the specific non-minimal invasive surgical procedures! ® No antimicrobial prophylaxis in surgical procedures

CAVE: RISK FACTORS!

– Laparoscopic cholecystectomy/cyst surgery – Hernia repair without mash – Thyroid surgery – Breast surgery – Soft tissue tumors (without hollow organ involvement) – Proctological surgical procedures Recommendations have to be modified according to patient-specific risk factors, the expected local microbiological environment as well as resistance epidemiology of the institution! a Should be administered at least 2 h before the surgical procedure!

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• If the surgical procedure does not exceed 3 h, singledose administration is sufficient. • Second shot administration should be considered if the surgical procedure takes longer than 3 h or blood loss exceeds 1 L. • Antimicrobial prophylaxis for more than 24 h after surgery is not reasonable. • Intravenous application of the antibiotic agent is beneficial. • Patients who will need postoperative antimicrobial therapy should receive these antibiotics also as ­prophylactic agents.

Classen, D.C., Evans, R.S., Pestotnik, S.L., Horn, S.D., Menlove, R.L., Burke, J.P.: The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N. Engl. J. Med. 326, 281–286 (1992) Dellinger, E.P., Gross, P.A., Barrett, T.L., Krause, P.J., Martone, W.J., McGowan Jr., J.E., Sweet, R.L., Wenzel, R.P.: Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America. Clin. Infect. Dis. 18, 422–427 (1994) Wacha, H., Hau, T., Dittmer, R., Ohmann, C.: Risk factors associated with intraabdominal infections: a prospective multicenter study. Peritonitis Study Group. Langenbecks Arch. Surg. 384, 24–32 (1999)

Reference

http://www.fda.gov/ http://www.cdc.gov/ http://www.health.gov.au/ http://www.nhmrc.gov.au/ http://www.emea.europa.eu/ http://www.earss.com/

1. Cruse, P.J.: Feedback technique reduce surgical infections. Hosp. Infect. Control 5, 113–114 (1978)

Recommended Reading Beilman, G.J., Dunn, D.L.: Chapter 5: Surgical infections. In: Brunicardi, F.C., Andersen, D.K., Billiar, T.R., Dunn, D.L., Hunter, J.G., Matthews, J.B., Pollock, R.E., Schwartz, S.I. (eds.) Schwartz’s Principles of Surgery, 8th edn. The McGraw-Hill Companies, New York (2005)

Online resources

 

Preoperative Risk Assessment in Rural Surgery

17

Teresa Bueti, Munawar Rana, and Matthias W. Wichmann

17.1 Introduction Preoperative risk assessment aims to identify patients with a higher risk of peri- and postoperative complications early during the preparation for elective surgery. In patients who are not properly prepared for surgery, higher rates of cancellations and delays as well as a longer postoperative length of stay must be expected. Cancellations which occur on the day of surgery are a significant waste of resources, are expensive for the hospital and also produce a significant psychological and financial burden for the patient. Careful early assessment of the patient for possible surgical and anaesthetic perioperative complications can help to avoid these late cancellations.

17.2 Organization of the Preadmission Clinic To improve preoperative assessment and preparation of the patient a nurse-led outpatient preadmission

T. Bueti Outpatients Department, Mount Gambier General Hospital, 276-300 North Wehl Street, Mount Gambier, SA 5290, Australia M. Rana Department of Anaesthesia, Mount Gambier General Hospital, 276-300 North Wehl Street, Mount Gambier, SA 5290, Australia M.W. Wichmann (*) Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected]

clinic can streamline the elective surgical process and help to reduce length of stay and allow for a co-ordinated approach to each patient’s elective surgical admission. In this role the preadmission nurse provides a link between the surgeon’s assessment and hospital admission. After the surgeon’s review, the preadmission nurse carries out the initial screening of patients referred for surgery. The ageing patient population presents with a diverse range of healthcare needs and co-morbidities which requires a comprehensive and efficient preoperative assessment for a good outcome. The preadmission nurse also provides educational and practical advice for the patient with regard to the peri- and postoperative course and can help to organize community support and can provide information about pain management options. It is the preadmission nurse’s obligation to ensure the patient is at his/her best possible health at the time of surgery to reduce the risk of postoperative complications and/or exacerbation of pre-existing medical conditions.

17.3 Nursing Requirements To fulfil the important tasks as outlined above, the preadmission nurse must be an experienced nurse with advanced skills, sound knowledge and understanding of the patient’s medical and psychosocial factors, the planned surgical procedure as well as associated anaesthesiological requirement. This nurse must have the capacity to refer patients to other health care providers for treatment options. To minimize postoperative risks the preadmission nurse categorizes patients into those

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_17, © Springer-Verlag Berlin Heidelberg 2011

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• Patients who will require an anaesthetic assessment prior to the day of surgery • Patients who will only need to see the preadmission nurse • Patients who will require intensive discharge planning • Patients who require additional information from other hospitals or other health care providers involved in their care All results of routine preoperative testing are reviewed

by the preadmission nurse and relevant abnormalities are discussed with the surgeon and anaesthetist. Minor illnesses (respiratory tract infection, urinary tract infection), unstable hypertension, or other conditions requiring preoperative intervention will be referred back to the patient’s general practitioner for treatment. Surgery may then need to be rescheduled. During preadmission assessment (Fig.  17.1) the nurse plans all required investigations (blood tests, ECG, anticoagulant therapy, etc.), evaluates the risk of possible intraoperative problems (positioning, latex

Preadmission Nurse - patient assessment & referral

Decision to perform elective procedure. Surgeon obtains informed consent

Patient considered high risk

Preoperative Assessment Medical History · Allergies and intolerances · Known medical problems · Surgical history · Trauma · Current medications (including non prescription) ·

Referred to preadmission clinic for assessment

Refer to anaesthetist/other health practitioners for further evaluation/treatment or surgery delayed

Focused review of issues relevant to the scheduled surgery

Physical Examination · Vital signs · Height and weight · Cardiopulmonary exam · Other pertinent exam · Previous anaesthetic history Electrocardiogram (ECG) · Recommended for all patients over 50 ·

Other relevant investigations

Patient education · Procedure specific All assessments, test results etc. filed in patient’s medical record. Communicate results to site where patient admitted prior to scheduled surgery

Immediate pre-procedure assessment at hospital admission

Fig. 17.1  Preoperative assessment by preadmission nurse

Out of guideline

·

Hospital orientation

Discharge planning · Expected length of stay · Support at home/discharge instructions · · · · · ·

Rehabilitation/physiotherapy Equipment required & ordered Sick leave Transport Meals on wheels Respite

Community nurse

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17  Preoperative Risk Assessment in Rural Surgery

allergy, etc.) and discusses possible issues with postoperative care (in-hospital as well as after discharge).

17.4 Benefits of Preoperative Assessment Thorough preoperative assessment provides an integrated, efficient and streamlined approach to each patient’s elective surgical admission. The assessment helps to generate an individual plan for patients with complex needs as well as standardized care for patients without specific findings in their assessment. The preadmission nurse discusses the type and complexity of surgery, the anaesthesiological requirements, the patient-specific needs and fitness for surgery. Evaluation of the need for perioperative DVT prophylaxis and testing of patients at risk for MRSA infection is also part of the preadmission assessment. The nurse, furthermore, coordinates all required investigations as well as referrals to other health professionals. The preadmission clinic aims to • • • • • •

Optimize the patient’s health prior to surgery Educate patient and family Prepare discharge Optimize operating room scheduling Promote day of surgery admission Optimize resource utilization

To achieve these goals, a comprehensive patient questionnaire is used (Fig.  17.2). In elderly patients perioperative morbidity and mortality are increased. Co-morbidity therefore must be carefully evaluated. This may be difficult due to language barriers, cultural barriers, intellectual disability, or impaired vision and hearing. In these patients additional risk assessment includes falls, mobility and skin integrity.

17.5 Healthcare Initiatives The preadmission appointment provides a perfect opportunity for introducing healthy lifestyle strategies (available programs for patients who want to give up smoking, diabetes education, cardiac rehabilitation, etc.) to the individual patient and his family. The

preadmission nurse, therefore, needs to have extensive knowledge about available services and programs within the local environment as well as within the metropolitan area.

17.6 Anaesthetic Risk Assessment Anaesthetic risks can be minimized by understanding the patient’s physiological limitations and the anaesthetic issues. These include preoperative, intraoperative and postoperative issues.

17.6.1 Patient Issues It is important to know that surgery puts stress on the cardiopulmonary systems which may be comparable to that of professional athletic competition. Optimi­ zation of the individual patient’s physiological reserves therefore is pivotal. Oral medications may need to be stopped or continued by weighing the risk and benefits. Generally, most medicines can be taken with sips of water even on the day of surgery while fasting. The need for blood thinners and diabetic medications may need assessment by a multidisciplinary team and/or physician with regard to timing and alternative treatment options. Fasting requirements usually are 2 h for clear fluids and 6 h for solid foods. Cessation of smoking needs to be encouraged as it increases airway irritability and can result in perioperative airway complications. A common cold, flu symptoms, or pneumonia during a 4–6 weeks period prior to surgery increases the airway risks in the perioperative period. The extent of surgery (minor, intermediate or major) and the patient’s physiological reserves as assessed from the patient’s ability to do daily activities (distance the patient can walk, ability to climb a flight of stairs) are good indicators of the risk for perioperative complications (see guidelines of the American Heart Association for details). It is important to note the association of obesity with difficult airway management and reduced pulmonary reserve. In these patients difficult IV access, special bed requirements, more advanced perioperative

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T. Bueti et al. Affix patient identification label in this box U.R. No.

PRE ADMISSION QUESTIONNAIRE

Surname Given Names D.O.B.

Your anaesthetist requires the following to be completed Is this patient a child or young person under the guardianship of the Minister? (i.e. 18 years or less) Have you had a general anaesthetic in the past? Have you had any problems with or during previous anaesthetics? Do you have a family history of problems with anaesthetics? Do you have any problems with your heart? (e.g. angina, heart attacks, palpitations, rheumatic fever etc) Have you ever been treated for high blood pressure?

Sex

YES

NO

Do you get severe shortness of breath or any chest pain after exercise or climbing stairs? Have you had treatment for or taken medicine for breathing problems? (e.g. asthma, bronchitis, sleep apnoea or any other lung disease) Do you smoke?

COMMENTS If yes refer to CHSA Rapid Response protocol and checklist

How many / day.............

Have you suffered a chest infection, head cold or sore throat in the last month? Have you ever been treated for epilepsy, convulsions, fits, ‘strokes’ or blackouts? Do you suffer from arthritis or muscular disease? Have you ever been treated for anaemia or any other blood disorder? Have you ever had a blood clot? Have you recently been treated with any of the following drugs: Steroids, Aspirin, Warfarin, Antibiotics or Anti Depressants? Have you ever used recreational or street drugs? e.g. heroin, LSD, marijuana, ecstasy, cocaine Do you have loose teeth, caps or dentures? Do you drink alcohol?

How much.............................

Have you had jaundice, hepatitis or liver disease Do you have any kidney disease? Is there ANY possibility you may have any infectious diseases? Have you ever been an inpatient in another Hospital in the last 3 months? Is there ANY possibility that you may have MRSA and if so have you been swabbed? Is there ANY possibility that you may be pregnant What operations have you had?

Are you allergic to anything? e.g. drugs, food, elastoplast etc Alert Sheet completed? Are you a Diabetic? If YES please indicate last BSL If YES to above please tick if you are: Insulin OR Are you currently taking any tablets, medications or herbal preparations?

Date / Time: Tablet

OR

BSL:

Diet Controlled

Your Weight in kilograms

Fig.  17.2  Example of Preadmission Questionnaire for preoperative identification of patients at risk of peri- or postoperative complications

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17  Preoperative Risk Assessment in Rural Surgery

monitoring and postoperative ventilation requirements need to be kept in mind.

17.6.2 Anaesthetic Issues It is important to be aware of a number of simple indicators of a difficult airway. These include previous difficulty of airway establishment, mouth opening less than three fingers, overbite, inability to see uvula and posterior tonsillar pillars, thyromental distance less than 6  cm, decreased neck extension, neck circumference more than 42 cm. Any of these findings or a combination of several result in increased risks of airway difficulties. Any of these markers may require specialist anaesthetist assessment in a high-risk anaesthetic clinic. Special issues like MRSA/VRE patients, Latex allergy, dialysis patients and IDDM patients require more detailed planning by theatre and anaesthetic staff for the required surgery. Anticipated prolonged surgery, major intraoperative fluid shifts and elderly patients with poor physiological reserves also require more detailed planning for prevention of perioperative complications. A simple and reliable classification of physical fitness and the associated perioperative risks for patients undergoing surgery is the ASA score (Table  17.1). This score should be routinely applied and can also be used to identify patients suitable for day surgery (ASA classes I and II). Table  17.1  American Society of Anaesthesiologists (ASA) classification of physical fitness Class I

Fit patient

Class II

Mid-to-moderate systemic disease, no functional limitation controlled hypertension, mild diabetes, mild asthma

Class III

Severe systemic disease with some functional limitation plus diabetes with complications, severe asthma, myocardial infarction >6 months

Class IV

Severe systemic disease that is a constant threat to life plus unstable angina, severe cardiac, pulmonary, renal, hepatic or endocrine insufficiency

Class V

Moribund patient not expected so survive 24 h (with or without surgery)

17.7 High-Risk Anaesthetic Clinic This clinic receives referral of patients who are considered to be at increased surgical and/or anaesthesiological risks and should be seen prior to surgery by an experienced anaesthetist. Referral usually occurs after review of the preoperative health assessment but may also be done directly by the responsible surgeon. High risk particularly refers to the risk of cardiac or airway complications. Due to time restriction not all patients can be seen prior to surgery. To avoid unnecessary referrals to this specialist clinic a number of recommendations have been made. The following conditions are considered to be relevant for preoperative assessment by the anaesthetist: • Any patient where the surgeon or the preadmission nurse have concerns and feel assessment by an anaesthetist is necessary • Obese patients with body weight >120 kg (males) or >100 kg (females) • Cardiac co-morbidity: angina, congestive heart failure, significant arrhythmias, valvular disease, congenital heart disease (unless symptom free for more then 6  months); coronary stents on blood thinners • Hypertension • Dialysis and renal transplant patients • Insulin-dependent diabetes mellitus (IDDM) • Poorly controlled non-insulin-dependent diabetes mellitus (NIDDM) • Respiratory co-morbidity: asthma, chronic obstructive airway disease, sleep apnoea, poor exercise tolerance (patient can only walk <200  m due to shortness of breath) • Epilepsy • Lack of physiological reserve (patient can only walk <100 m or less than one flight of stairs) During high-risk clinic assessment the anaesthetist will determine the patient’s fitness for anaesthesia and document the findings in the patient’s case notes. During this assessment relevant drugs will be ordered and the consent for anaesthesia will be signed by the patient as well as the anaesthetist. If additional tests appear to be needed, these will be organized by the anaesthetist and a plan for peri- and postoperative pain management will be developed.

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17.8 Summary Preadmission assessment by dedicated nursing staff as well as medical specialists has successfully reduced the risk of surgical intervention in rural surgical practice. This clinic has contributed to a significant reduction of delays on operating lists as well as late cancellations due to unforeseen health problems of elective surgical patients. Patients, relatives and all caregivers are aware of possible risks and these can be addressed ahead of time. A dedicated preadmission clinic is an integral part of elective surgery and should be established in all (rural) hospitals

T. Bueti et al.

performing medium and major surgery on an elective basis.

Recommended Reading American Society of Anesthesiology: ASA Classification of Surgical Patients. American Society of Anesthesiology, Chicago (1991) Fleisher, L.A., et al.: ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary. Circulation 116, 1971–1996 (2007) Institute for Clinical Systems Improvement (ICSI): Preo­ perative evaluation. National guideline clearinghouse. www.guideline.gov

Perioperative Fluid Management

18

Peter Rittler and Wolfgang H. Hartl

18.1 Management of Postoperative Fluid Imbalances and Electrolyte Disorders Because of the pathophysiological changes in microcirculation, the post-operative patient has to be considered hypovolaemic with a need for fluid substitution. Usually, the common clinical signs for a fluid deficit, i.e. the signs of dehydration, are limited significantly due to redistribution processes such as capillary leakage. Fluid monitoring and management of the postoperative patient require close control of arterial blood pressure, heart rate and urinary output. The most important signs of post-operative intravascular hypovolaemia are tachycardia with simultaneously decreased blood pressure and decreasing renal output (<1 ml/kg/ body weight/h). The measurement of central venous pressure is only a limited monitoring tool. Especially in abdominal surgical patients, central venous pressures (CVP) may be falsely high due to an increased post-operative intra-abdominal pressure. Inaccurate CVP values may prevent detection of an intravascular fluid deficit, and a normal post-operative CVP value does not exclude a possible need for extra fluids. Only very low CVP values combined with oliguria can be taken as a sign of a significant intravascular fluid deficit. Another definite sign of an intravascular fluid deficit is a temporary rise of blood pressure when the patient is brought into a Trendelenburg (head-down) position.

P. Rittler and W.H. Hartl (*) Department of Surgery, Campus Grosshadern LMU Munich, Marchioninistr. 15, D-81377 Munich, Germany e-mail: [email protected]

The pathophysiological changes during the acute post-operative phase (i.e. the first 3–4 post-operative days) usually lead to an increased fluid and potassium requirement and to a decreased requirement for sodium. Demands vary with the magnitude of the surgical trauma and with the extent of the consecutive systemic inflammatory response syndrome (SIRS). After uncomplicated operation, fluid requirements will be maximal during the first 12–16  h after surgery. The exact amount of post-operative fluids, which are necessary to correct intravascular deficits during that time, depends on several variables such as length of the operation, type of operation, magnitude of intraoperative fluid substitution, and – above all – on perioperative complications (haemorrhagic shock, ischaemia-reperfusion injury, release of inflammatory mediators from an infectious site). The administration of fluids and electrolytes in the immediate post-operative period has to be guided by haemodynamic parameters and laboratory findings. The approximate baseline fluid requirement of an adult patient during that phase is usually in the range of 1–1.5 ml/kg/ h, but may be significantly higher in severe sepsis or SIRS. If monitoring indicates a lack of intravascular fluids despite baseline fluid administration, fluid intake has to be increased until welldefined haemodynamic goals have been reached. Specific haemodynamic goals to be reached or maintained during the immediate post-operative phase are shown in Table 18.1. After major operations (possibly associated with complications) increased fluid and potassium requirements may persist until the third post-operative day. During this time, 1 ml/kg/ h will usually be sufficient to account for those delayed deficits. Fluids are usually given intravenously. However, oral or enteral administration is also possible provided the gastrointestinal

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Table  18.1  Haemodynamic goals for post-operative fluid management Mixed-venous oxygen saturation

>65%

Central venous oxygen saturation

>70%

Arterial lactate concentration

<2 mmol/l

Mean arterial blood pressure

>70 mmHg

Heart rate

70–110 beats/ min

Central venous pressure (values may be falsely high after abdominal surgery or in abdominal hypertension)

<15 mmHg

Urine production

>0.5 ml/kg/ h

tract is functioning normally. Potassium requirements have been put at 1–1.2  mval/kg/ day and sodium requirements at 2  mval/kg/ day. If a post-operative patient shows persisting or new signs of circulatory failure despite adequate fluid intake, it will be essential to evaluate this patient thoroughly with respect to haemorrhage, infection or a cardiac complication. If an infectious complication or bleeding can be ruled out, circulatory failure will most likely be caused by a primary myocardial pathology (ischaemia, infarction, pulmonary embolism). It is important to adjust the post-operative fluid and electrolyte intake to pre-existing diseases such as severe renal failure or congestive heart disease. In such conditions, an uncontrolled fluid therapy may eventually result in volume overload. In such high-risk patients, tight haemodynamic monitoring is indispensable. A subtle clinical examination of the patient is also essential to identify an impending volume overload. Visible and palpable oedemas of the hands, legs and flanks are valuable signs suggesting excess fluids. In case of a significant organ dysfunction (impaired pulmonary gas exchange), a therapeutic intervention is mandatory (water restriction and forced diuresis). Simultaneously, fluid management of such patients should include a precise recording of total body fluid intakes and outputs (urine, drainages) allowing an exact calculation of daily losses or gains. A key parameter for post-operative fluid management is urine production. In case of a post-operative oliguria, it is essential to differentiate between different causes. Oliguria may result from an intravascular volume deficit (prerenal failure), from a post-operative impairment of renal function (intrarenal failure) or

may be related to problems eventually arising from the Foley catheter (postrenal failure). Management of oliguria has to consider these differentials. It is usually not sufficient to evaluate plasmatic renal function parameters (urea- and creatinine concentration). Corresponding concentrations may be abnormal with all three differentials. As a first step, it is crucial to exclude an intravascular volume deficit using the target values mentioned above (Table 18.1). If an intravascular volume deficit has been excluded, and if there are even clinical signs indicating a fluid overload, the post-operative oliguria is most likely due to renal failure caused by SIRS or sepsis. The therapeutic consequences have to follow the underlying pathology. In patients with oliguria due to an intrarenal failure, diuretics (furosemide, maximum dosage of 10 mg/h) may be given to normalize diuresis. In patients with oliguria secondary to hypovolaemia, additional fluids should be given to correct the deficit. Since, after a certain time, prerenal renal failure may cause secondary intrarenal failure, it is recommended to administer small doses of diuretics in combination with extra fluids to achieve a positive fluid balance. Post-operative SIRS, which represents a physiological response to surgical trauma, is known to always impair renal function to a certain degree even in otherwise healthy individuals. However, in case of a very strong SIRS (e.g. severe surgical trauma in association with a prolonged haemorrhagic shock) severe intrarenal failure may develop rapidly. Misinterpretation of this pathophysiologic mechanism, in combination with an ongoing high fluid intake (to correct the erroneously assumed persisting fluid deficit), will result in fluid overload. The latter may remain without consequences for circulatory function in patients who do not suffer from additional cardio-pulmonary pathologies. However, other unwanted detrimental side effects of fluid overload are known (such as intestinal wall oedema, intestinal atony, severe ileus or even anastomotic leakage). Therefore, fluid overloading during the post-operative period should be avoided. A strategy of restricted fluid intake is also a central component of the fast-track concept. Until now, the best way to control post-operative fluid intake has not yet been defined. This uncertainty results from contradicting study results and a lack of evidence regarding the optimal constitution and amount of post-operative fluid intake. Furthermore, it is likely that the clinical

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effects of a certain amount of fluid differs according to the magnitude of the operation, of the subsequent postoperative SIRS, and, consequently, of the capillary leak and its associated fluid sequestration into the third space. There is evidence that even an excess fluid intake (>10  L/day) may not increase post-operative morbidity, if this amount of fluid is needed due to the extent of the capillary leak, and if fluid therapy is strictly guided by established haemodynamic goals.

18.2 Solutions Available for Perioperative Fluid Replacement 18.2.1 Crystalloids Crystalloid solutions are defined as solutions containing electrolytes or low molecular carbohydrates. They differ in osmolarity (plasma-isotonic, -hypertonic, -hypotonic) and in their electrolyte composition (full strength, one-third- and two-thirds electrolyte solutions). Crystalloid solutions can diffuse through the capillary membranes. Therefore, only one-third of their volume remains in the intravascular compartment. Crystalloid solutions are an essential component of the immediate post-operative fluid therapy in order to cover basic requirements. The post-operative fluid deficit (intravascular or interstitial) should be corrected by using full strength crystalloid electrolyte solutions. This concept is sufficient for most surgical procedures with minor blood loss. It is important to consider the distribution space of crystalloid solutions. The plasmatic space (4% of the body weight) amounts to only one-fourth of the interstitial space (16% of the body weight). Therefore, compared to colloidal solutions, four times as much crystalloids will be needed if the same intravascular volume effect is required.

adjust fluid therapy to the particular requirements of the post-operative period. These full strength electrolyte solutions can be also used to rapidly replace minor blood or plasma losses, and are also the hallmark of fluid therapy in situations with an extraordinary high fluid demand (e.g. septic shock).

18.2.1.2 Isotonic Sodium Chloride Solutions Isotonic sodium chloride solutions are isotonic with respect to plasma osmolarity, but they do not reflect the plasma electrolyte content. Compared to plasma, isotonic sodium chloride solutions contain more sodium (154 mval/l) and chloride (154 mval/l). Isotonic sodium chloride solutions are used to correct extracellular fluid deficits, which are combined with hyponatraemia, hypochloraemia and also with hyperpotassaemia. If large amounts of isotonic sodium chloride solutions are given during over a short period of time, sodium concentrations will rise rapidly, resulting in hypernatraemia or hyperchloraemia. It is essential that the daily increase of plasma sodium concentration is less than 10 mmol/l. A faster rise will cause central pontine myelinolysis. Usually, such fast changes of sodium concentration will not occur, if less than 1.5 ml/kg/ h of an isotonic sodium chloride solution is administered. To identify unwanted concentration changes, sodium concentrations should be measured at least four times per day. To avoid a rapid increase of sodium concentration in situations which require administration of large amounts of fluids (e.g. septic shock in combination with hyperpotassaemia), one may either use half strength sodium chloride solutions, or one may administer isotonic sodium chloride solutions in combination with 5% glucose solutions on a 1:1 basis.

18.2.1.3 Glucose 5% Solutions 18.2.1.1 Full Strength Electrolyte Solutions Full strength electrolyte solutions contain the most important electrolytes, and their overall ­concentration corresponds to the osmolarity of the plasma. Full strength solutions are plasma isotonic, and various products are commercially available which vary ­according to their individual electrolyte content. Thereby, it is possible to

Glucose 5% solutions contain 50 g glucose in 1 l water. The solution is hypotonic and acidotic (pH-value 4.5) with a glucose concentration of 253 mol/l. The amount of glucose which is contained in 1  l corresponds to 200  kcal. After glucose has been metabolized in the body, the solution no longer contains any osmotic active substances and becomes free water. Because of this quality, this solution is predominantly appropriate

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to correct fluid deficits in combination with hypernatraemia. However, also a rapid decline of sodium concentration may also be detrimental, and should not exceed 10 mmol/l/day. To avoid such rapid concentration changes, glucose 5% infusion rate should not surmount 1.5  ml/kg/ h. If more fluid needs to be given, glucose 5% solutions should be combined with standard full strength electrolyte solutions on a 1:1 basis. Because of the low calorie content, glucose 5% solution is not suited for parenteral nutrition. To provide an appropriate amount of carbohydrate calories, unacceptably large volumes of glucose 5% would have to be infused.

18.2.2 Colloidal Solutions Colloidal solutions are characterized by a high molecular weight. Therefore, they leave the intravascular space very slowly through the capillary wall. Colloids increase the intravascular colloid osmotic pressure and subsequently reduce the efflux of other fluids from the intravascular space into the interstitial space. During an acute fluid loss (e.g. haemorrhagic shock) colloids allow a faster and more efficient correction of deficits than crystalloid solutions. Haemodynamic effects and plasma half-life of colloids are determined by their molecular weight, their dispersion, their viscosity, and – last but not least – by their metabolism and rate constants. Several types of colloidal solutions are commercially available. However, all products suffer from distinct disadvantages such as impaired coagulation,

pruritus, accumulation in plasma or various tissues, or variable haemodynamic effects. Synthetic colloids which can be used to expand the plasmatic volume are gelatine compounds, dextrans and hydroxyethyl starches. Albumin is produced by the body and is a natural colloid with ideal characteristics. However, albumin can only be obtained from blood donations, and its high costs and potential, albeit very rare, infectious side effects prevent its use for routine fluid replacement. Only severely burned patients, who demonstrate extraordinarily high albumin losses through their skin wounds, may profit from a large-scale albumin replacement. Artificial colloids are characterized by their concentration, mean molecular weight, and degree of cross-linking and of molecular substitution (hydroxyethyl starch). In contrast to albumin, supply of these colloids is unlimited, and they are stable and can be stored for a long period of time. Furthermore, they do not carry the risk of blood-borne infections and are inexpensive. Because of their rapid intravascular action, artificial colloids are the solutions of choice for correction of acute post-operative fluid deficits. However, none of the colloidal solutions, which are available for post-operative fluid therapy, have proved superior to crystalloid solutions with respect to patient outcome (Table 18.2).

18.2.2.1 Gelatin Solutions Gelatin solutions contain bovine collagen. For production, collagen is depolymerized; subsequently, the extracted polypeptide fragments are cross-linked

Table  18.2  Association of different, non-crystalloid solutions with patient outcome (mortality) when compared to crystalloid solutions (According to Perel and Roberts [1] Outcome No. of studies No. of participants Statistical method Effect size Mortality

Risk ratio (M-H, fixed, 95% CI)

Subtotals only

Albumin

23

7,754

Risk ratio (M-H, fixed, 95% CI)

1.01 [0.92, 1.10]

Hydroxyethyl starch

16

637

Risk ratio (M-H, fixed, 95% CI)

1.05 [0.63, 1.75]

Modified gelatin

11

506

Risk ratio (M-H, fixed, 95% CI)

0.91 [0.49, 1.72]

Dextran

9

834

Risk ratio (M-H, fixed, 95% CI)

1.24 [0.94, 1.65]

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again. There are different compounds available, e.g. oxypolygelatin, succinylated gelatin and polymerized urea gelatin, which all possess different molecular weights. Before renal elimination, gelatin is metabolized completely and does not accumulate in the body. In normovolaemic healthy subjects, 50% of the infused gelatin may eventually leave the intravascular space by crossing the capillary wall. Because of their low molecular weight, the intravascular half-life of these compounds is short (0.5–1 h). In comparison to dextrans and hydroxyethyl starch solutions, the incidence of anaphylactic reactions is higher with use of gelatin and amounts to about 0.8%. The advantage of gelatin solutions is that they do not compromise renal function or the coagulation system. Therefore, these compounds may be used in patients with renal diseases or coagulation disorders. However, when compared to crystalloid solutions, benefits are only minor because of the short intravascular half-life, and  crystalloids are today favoured over gelatin solutions.

18.2.2.2 Dextran Solutions Dextrans are glycosidically linked glucopolysaccharids (junction between C1 and C6). Dextrans are produced at a molecular weight of 40 and 60 kD and represent hyperoncotic solutions. Thereby, the effect on intravascular volume is stronger than could be expected by the actually infused volume. Per gram Dextran, 20–25 ml of water can be bound in the intravascular space and could eventually also be mobilized from the interstitial space. Dextrans are metabolized and eliminated via the kidneys; they may remain in the intravascular space for 2–6  h depending on the individual molecular weight and half-life. The most important side effect of dextrans concerns blood coagulation, where thrombocyte adhesion may become impaired. Furthermore, anaphylactic and ­anaphylactoid reactions have been described with a frequency of approximately 1%. Implementation of Hapten-prophylaxis with Promit® has reduced the severity of anaphylactic reactions. Because of coagulatory side effects, dextrans have not been used for fluid replacement in the past. On the other hand, today there is a certain role for Dextran 60, which is used for thromboprophylaxis, and for Dextran 40, which has been shown to improve rheology and microcirculatory

function. Dextrans are always given together with electrolyte solutions to prevent a dehydration of the extracellular space and an impairment of renal function.

18.2.2.3 Hydroxyethyl Starch Hydroxyethyl starch (HAES) is a non-ionic starch derivative, which is made from corn or potato, and which describes an acid-hydrolyzed and hydroxy­ ethylized high-branched chain amylopectin starch. After infusion, HAES is enzymatically degraded and is removed from the intravascular space either by metabolization or via the reticulo-endothelial system. HAES solutions are characterized by three different criteria: (1) molecular weight (solutions vary between 70 and 200 kD), (2) grade of substitution (ratio of glucose units, which are substituted with hydroxyethyl groups, to the overall number of glucose units; e.g. 0.5 or 0.7), (3) position in the glucose molecule where the hydroxyethyl group has been substituted (C2 or C6; described as the C2/C6 hydroxyethylization ratio). The higher the ratio, the more glucose molecules are hydroxyethylized in position C2 compared to C6. In  general, length of intravascular stay and plasma half-life will increase if molecular weight, C2/C6 ratio and substitution grade rise. The haemodynamic effect of HAES solutions correlates with the average molecular weight and with the concentration of the solution (3%, 6% and 10%). HAES fragments with a molecular weight of less than 60 kD are eliminated via glomerular filtration. Larger molecules are split by serum amylase and are taken up by the hepatic reticulo-endothelial system. There, HAES split products may be stored for days to weeks. Surprisingly, no data are available which describe the precise duration of storage, or the potential effects which stored HAES fragments may have on the organism. In critically ill patients with SIRS or  sepsis, detrimental effects have been discussed (immune-dysfunction due to a partial blockade of the RES). In addition, disorders of the tubulus system have been described following application of HAES in critically ill patients. HAES derivatives with a higher molecular weight (200 kD) have been demonstrated to have increased rates of acute renal failure, and need for renal replacement therapy and to decrease long-term survival when used alone in

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cases of severe sepsis compared with electrolyte or gelatine solutions [2, 3]. These studies specifically used 10% HAES with 0.45–0.55 substitution grade and molecular weight of 200 kD. The same effects have not been observed with HAES 130 kD/0.4. (Voluven®) or HAES 70 kD/0.5 (Expafusin®), which are lower substituted novel hydroxyethyl starches. The occurrence of anaphylactic reactions caused by HAES is less than in gelatin compounds and is currently quoted at 0.1%. A few days after HAES infusion patients may experience protracted itching, which, however, should be largely limited to products with a molecular weight of 200 kD or more. Similar to Dextrans, the major side effects of HAES comprise a coating effect with a subsequent impairment of thrombocyte adhesive capacity and with an alteration of plasmatic and cellular blood coagulation. Such side effects will be less pronounced, if molecular weight, grade of substitution, and C2/C6 ratio are lower. These side effects will be also significantly less frequent or even absent, if low molecular HAES is used with a low grade of substitution (e.g. HAES 130/0.4 or HAES 70/0.5). Such lower substituted novel hydroxyethyl starches are mainly eliminated via the kidneys, and only minimal storage in the reticulo-endothelial system is observed. However, compared to middle molecular or high molecular hydroxyethyl starches, low molecular compounds are less efficient in terms of their haemodynamic effects because of their significantly shorter intravascular half-life (2–3  h). Nonetheless, due to their superior side-effect profile, low molecular hydroxyethyl starches are favoured today for the rapid correction of minor fluid deficits, and they are first-line solutions to treat new and acute fluid deficits. However, treatment should not go beyond a maximum dose of 20 ml/kg/ day. At higher doses, the extent of plasma dilution will affect plasmatic coagulation.

P. Rittler and W.H. Hartl

References 1. Perel, P., Roberts, I.: Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst. Rev. 17(4), CD000567 (2007) 2. Brunkhorst, F.M., Engel, C., Bloos, F., Meier-Hellmann, A., Ragaller, M., Weiler, N., Moerer, O., Gruendling, M., Oppert, M., Grond, S., Olthoff, D., Jaschinski, U., John, S., Rossaint, R., Welte, T., Schaefer, M., Kern, P., Kuhnt, E., Kiehntopf, M., Hartog, C., Natanson, C., Loeffler, M., Reinhart, K., German Competence Network Sepsis (SepNet): Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N. Engl. J. Med. 358(2), 125–139 (2008) 3. Schortgen, F., Lacherade, J.C., Bruneel, F., Cattaneo, I., Hermery, F., Lemaire, F., Brochard, L.: Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet 357, 911–916 (2001)

Recommended Reading Bunn, F., Trivedi, D., Ashraf, S.: Colloid solutions for fluid resuscitation. Cochrane Database Syst. Rev. 23(1), CD001319 (2008) Chappell, D., Jacob, M., Hofmann-Kiefer, K., Conzen, P., Rehm, M.: A rational approach to perioperative fluid management. Anesthesiology 109(4), 723–740 (2008) Holte, K., Kehlet, H.: Fluid therapy and surgical outcomes in  elective surgery: a need for reassessment in fast-track ­surgery. J. Am. Coll. Surg. 202(6), 971–989 (2006) Kleespies, A., Thiel, M., Jauch, K.W., Hartl, W.H.: Perioperative fluid retention and clinical outcome in elective, high risk ­colorectal surgery. Int. J. Colorectal Dis. 6, 699–709 (2009) Lenz, A., Franklin, G.A., Cheadle, W.G.: Systemic inflammation after trauma. Injury 38(12), 1336–1345 (2007) Powel-Tuck, J., Gosling, P., Lobo, D.N., Allison, S.P., Carlson, G.L., Gore, M., Lewington, A.J., Pearse, R.M., Mythen, M.G.: British consensus guidelines on intravenous fluid therapy for adult surgical patients GIFTASUP http://www. renal.org/pages/media/Guidelines/GIFTASUP%20 FINAL_31-10-08.pdf (2009) Treib, J., Baron, J.F., Grauer, M.T., Strauss, R.G.: An international view of hydroxyethyl starches. Intensive Care Med. 25, 258–268 (1999) Yeager, M.P., Spence, B.C.: Perioperative fluid management: current consensus and controversies. Semin. Dial. 19(6), 472–479 (2006)

Analgesia and Sedation in Intensive Care

19

Christian Waydhas

19.1 Introduction To soothe suffering is one of the major tasks of a ­physician. There are few fields in medicine where more distress for patients and their relatives can be found than during intensive care treatment. Despite a broad application of sedative and analgesic medication still more than 70% of critically ill patients complain about moderate or severe pain (e.g., during procedures such as endotracheal suctioning, positioning, change of dressing, bedside intervention). Up to 90% of intensive care patients suffer from anxiety and agitation and a large proportion of these patients experience periods of delirium. This indicates that the attention of the medical personal has to concentrate not only on cure and lifesustaining therapy but also has to focus on palliation of pain and other causes of suffering. In addition to the medical knowledge about the drugs which can be used to relieve discomfort, the ethical attitude of the medical team and all care providers is of major importance.

19.2 Basic Concepts Pain, anxiety, delirium, and states of withdrawal have to be differentiated. Although they may interact and there are many overlaps between these entities the differentiation of the patient’s complaints and symptoms is a prerequisite

C. Waydhas Trauma Intensive Care Unit, Department of Trauma Surgery, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany e-mail: [email protected]

for a rational therapy, since single substances predominantly affect only one of the entities. Therefore, fixeddose combinations of sedative and analgesic drugs should not be used but titrated separately to the individual requirements of a patient. The registration of complaints and symptoms poses no significant problem in the alert and communicable patient. Many critically ill subjects, however, cannot talk or are comatose for reasons of tracheal intubation and mechanical ventilation, drug actions, brain dysfunction due to the underlying disease or others. In these circumstances members of the medical team have to substitute. This poses several problems since their observations are subjective. Many symptoms (e.g., tachycardia, tachypnoea, restlessness, agitation, sweating) that might indicate pain, anxiety or discomfort are unspecific or ambiguous. The assessment by a second person may be subject to his or her personality or mood. Furthermore, it has been shown that judgment varies between physicians, nurses, or relatives. It has been shown that pain and anxiety may be underestimated by medical personal in more than 50% of cases. On the other hand, there also is a significant rate of overestimation. Validated scales and scores appear to be valuable tools to assess pain, anxiety, and delirium more objectively and independently from the observer (see below). It has been shown that the routine use of such tools improves therapy and reduces length of stay. These scores should be applied to all critically ill patients at least every 6–8 h, particularly if they are not communicable. Before analgesic or sedative medication is given, other reasons that might have caused the symptoms should be ruled out. Furthermore, general pain relieving and comforting measures should be taken. Fever, dyspnea, hypoxia, hypotension, sepsis, problems with the ventilator (insufficient settings, malfunction), or airway obstruction are among the major

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_19, © Springer-Verlag Berlin Heidelberg 2011

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reasons of agitation. Pain may be caused by pressure during positioning or from immobilizing splints or by a deterioration of the underlying condition. If sedation and pain medication is increased without considering and treating these conditions, serious complications may be masked and may delay diagnosis and treatment. Sleep deprivation is another problem as well as sensory overload from interruption of the circadian rhythm, artificial illumination, noises from alarms, telephones, loud conversation, mechanical devices, interventions or nursing procedures during night hours. In such situations, other measures than giving sedatives or analgesics may be more appropriate or necessary. General measures to reduce sensory overload include single-bed rooms, keeping doors closed, individualized setting of alarm limits and sounds, and the consideration of the circadian rhythm with respect to illumination and routine work with the patient. An empathetic attitude toward the patient even when sedated and suspected not to perceive the environment is important. Patients should be addressed before nursing or medical interventions are started. Discussions about the medical condition, loud conversations, and conversations about private topics (of the personnel) should be avoided. To create a familiar atmosphere (pictures, photographs, or music) may help to calm a patient and to save on medication. The analgo-sedation should aim at a patient that is calm, has no significant pain, and tolerates well mechanical ventilation, endotracheal suctioning, the reduced option for communication, and other interventions but remains awake or arousable. The keystone study from Kress and colleagues (2000) who demonstrated that a daily interruption of sedation resulted in earlier extubation and a reduction of days spent on the intensive care unit, initiated a change of paradigm: It is no longer believed that patients have to be sedated because they need artificial ventilation, they rather have to be ventilated because they are sedated. Less sedation means shorter ventilation and reduced requirements of catecholamines. This link between sedation and ventilation has resulted in the general aim of having patients as awake as possible – they should tolerate their treatment but at the same time be calm and arousable to obey commands and give answers. However, there are several conditions

C. Waydhas

in which the patients may require deep sedation to achieve adequate ventilation and oxygenation such as acute circulatory or cardiac failure, severe ARDS, or severe traumatic brain injury. There are presently no clear-cut criteria to determine when the shift from deep sedation to arousing the patient is appropriate. Deep sedation for a prolonged period of time increases the risk of drug-overdose or unnecessary extended coma.

In order to achieve adequate analgo-sedation the following principles should applied: • Monitor pain and depth of sedation using validated scores and tools • Define a goal for depth of sedation • Apply SOPs about which substances are to be used and how their dosage should be readjusted in case of over- or under-sedation

It has been shown that under most circumstances written algorithms, standard operating procedures or protocols improve the quality of analgo-sedation and the adherence to given standards of care. They work well in many different organizational models all around the world and result in lesser days on ventilation, days in the intensive care unit, undesired side effects, and costs. The preference of substances used for pain control and sedation leaves some space for decision since there is no high grade evidence to indicate the superiority of one commonly used drug over another. Therefore, no specific recommendation which substances are to be used can be made. The choice may depend on the (estimated) duration of analgo-sedation, possible drug interactions, comorbidities, acute organ dysfunctions, costs, and other factors. Renal and hepatic disease (acute or chronic) need to be addressed specifically, since most drugs are degraded or eliminated via one of these organs. Furthermore, there are distinct preferences in different countries. Regional differences in the approval have to be accounted for as well. A common problem for most drugs used for analgosedation is their potential for addiction. Already after a few days with a high dosage patients may develop dependency and present with signs of withdrawal when the drug is discontinued. After long-term application (e.g., longer than 1 week) a gradual dose reduction is preferred. One suggested possibility is a decrease by

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10–25% from the initial dose per day. It is not recommended to antagonize the drugs used for analogsedation to accelerate the waking-up process.

19.3 Pain Management Pain control is indicated not only for humane reasons. There are virtually no contraindications to giving adequate pain medication. Particularly, the concern of concealing symptoms of a disease or the fear of depressing ventilation efforts may preclude the use of analgesics. The choice of a substance as well as the dose and route of application must be adjusted to the individual patient’s circumstances. The dose required depends on the actual effects and the dosage recommendations provided here should be considered as a rough guide only. In individual patients, lower (elderly people, subjects with renal or hepatic dysfunction) or higher (patients with enzyme induction, i.v. drug users) doses may be appropriate.

19.3.1 Monitoring Pain is highly subjective and may be markedly influenced (in addition to objective triggers) by the patient’s personality, anxiety, fear, and many other factors. Therefore, only the patient is able to indicate whether he or she has pain and how intense it is. Grading pain is usually no major problem as long as the patient can communicate. However, it may be difficult to describe pain intensity in a reliable and reproducible way based on verbal communication alone. It is recommended to use a Visual Analog Scale (VAS) or a Numeric Rating Scale (NRS). While both offer a spectrum between “no pain” and “maximum possible pain,” the patient has to indicate the severity of pain intensity on a continuous scale (VAS) or a graded numeric grading scale between zero and 10 (NRS). The NRS appears to be better accepted by elderly patients. A pain intensity of 3 or less is the aim for the patient in rest. During smaller interventions and nursing procedures, it is aimed to score 5 or less. Evaluation of pain intensity is much more difficult in patients who cannot communicate. Commonly used signs of pain are tachycardia, hypertension, tachypnea, lacrimation, sweating, facial movements, restlessness, agitation, and defense. These are unspecific, however,

and some uncertainty about their cause always remains. Application of a probatory dose of an analgesic may help to elucidate the cause of such symptoms. Recently, the Behavioral Pain Scale has been suggested and validated to describe pain intensity in the noncommunicative patient. It remains to be shown whether its use results in better patient satisfaction and improved outcome. Monitoring and documenting pain intensity on a regular basis (e.g., at least once per shift) with one of the tools described above is recommended.

19.3.2 Pain Medication 19.3.2.1 Route of Application Oral application is possible in all patients with reliable enteral absorption. It is usually not sufficient to control acute pain (e.g., during change of dressing, positioning, other painful interventions) since its onset and magnitude of effect is usually not fast or strong enough. Most critically ill patients require intravenous or regional/local application. Many postoperative patients have regional pain catheters in place. They should be used and may lead to significant sparing of systemic analgesic drugs with a reduced rate of side effects. Regional pain catheters may also be inserted in the intensive care unit and the list of indications, contraindications, dosage recommendations, and precautions is comparable to the elective situation. However, the prevalence of coagulation disorders, application of anticoagulants, or the presence of sepsis often precludes their use. Regional catheters are excellent to control pain after lower extremity and abdominal surgery and after serial rib fractures. Patients who are awake and cooperative may benefit from a patient-controlled analgesia also in the intensive care setting. The analgesic regime requires a basic medication supplemented with extra analgesia during procedures. Basic analgesia is guided by monitoring pain (see above) and adjusting the dosage to reach the predefined level (e.g., VAS of 3 or less). It may be given continuously or by intermittent doses. While the latter

148

is usually preferred in the extubated patient, continuous application via a pump is favored during invasive ventilation. There are no clear-cut scientific data to prefer one over the other and the management best suited to the local circumstances can be chosen.

Intravenous application is not recommended on an “as required” basis, since this may lead to delayed and often insufficient pain medication.

19.3.2.2 Fentanyl Fentanyl is one of the most frequently used opioids in intensive care. Like all others opioids its action is mediated via different opioid-receptors. The stimulation of the m-receptor results in analgesia, euphoria, bradycardia, constipation, and depression of breathing effort; the k-receptors mediate sedation and miosis, while the s-receptors are responsible for dysphoria, delirium, and hallucinations. Due to its lipophilic ­property fentanyl has a faster onset of action (about 1–2 min), is easier to titrate, and has a 100-fold stronger effect than morphine. Typical doses vary between 0.05 and 2  mg/h for ­continuous infusion and from 0.05 to 0.2 mg for bolus application. It is usually started by a bolus infusion. Due to the short duration of action, this is followed by continuous administration using a pump. For shortterm analgesia during interventions, bolus application is appropriate. Patient-controlled analgesia requires specific dosing regimes. Several adverse effects are relevant: Respiratory depression: The analgesic and respiration-depressant action is mediated by the same receptor. Therefore, the two effects are coupled to a certain degree. Elderly patients and subjects with sleep-apnea syndrome may react particularly sensitive. The side effect can be amplified by simultaneous application of benzodiazepines and careful titration is required. On the other hand the respiratory-depressant effects may not be predominant as long as the pain is persisting and patients should not be left in pain due to the fear of overdosing. Decrease of gastrointestinal motility and ileus: A decrease in gastrointestinal motility may lead to

C. Waydhas

persistent obstruction and paralytic ileus that are refractory to usual treatment. Oral naloxone might reverse the effects on the gastrointestinal tract without attenuating the analgesic action. Hypotension: During hypovolemia and conditions of vasodilation, fentanyl might aggravate low blood pressure (and bradycardia) which may require treatment with fluid administration or vasopressors, particularly if fentanyl is given fast. Withdrawal syndrome: Withdrawal syndrome might present with yawning, rhinorhea, piloerection, sweating, lacrimation, mydriasis, restlessness, anxiety, vomiting, tremor, abdominal cramps, and others. Further important adverse effects include itching, hallucinations, and overt delirium. Like most other opioids, fentanyl is metabolized in the liver and its metabolites are excreted via the kidney. However, there are no general recommendations available how to reduce the drug in patients with hepatic or renal dysfunction. Doses should be adjusted to the desired effect and care should be given that underdosing as well as major overdosing are avoided by close monitoring. 19.3.2.3 Sufentanil In some countries, sufentanil is used as often as fentanyl in critically ill patients. It differs in a somewhat stronger analgesic action and a shorter half time which makes it better controllable. The sedative effect is stronger than that of many other opioids. Using sufentanil might spare sedative medication. Accumulation during long-term use is less pronounced than with fentanyl. Typical dosages are 25–100 mg/h (0.15–1.0 mg/kg/h). In the low dose range, sufentanil can be used during weaning from ventilation and in the spontaneously breathing patient. Adverse effects are similar to those of fentanyl. 19.3.2.4 Morphine Morphine has a delayed onset (10–20 min) and a prolonged duration of action (approx. 4  h) compared to fentanyl. Intermittent boluses of 2–10 mg i.v. or a continuous infusion of 1 to 5 mg/h are recommended for most patients. Some data indicate that it may have a stronger depressing effect on gastrointestinal motility and releases more histamine than other opioids. Particularly, the histamine release might be unwanted

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in hemodynamically compromised patients. There are, however, no clinical studies that have clearly shown the unequivocal clinical superiority of one opioid over another. Care should be used in subjects with renal insufficiency because active metabolites may accumulate and may lead to an overdose. The use of hydromorphone may be an alternative in such patients.

19.3.2.5 Other Opioids Priritramid is widely used in some European countries where it is the predominant opioid for discontinuous application in the postoperative period. Typical dosages are 3.75–7.5 mg given as bolus injection or short infusion. A careful application is required in the elderly patient. Pethidin is degraded into a metabolite that is highly nephrotoxic and may induce delirium, hallucinations, psychosis, and seizures. It is eliminated via the kidney at a slow rate and quickly accumulates with repeated doses or in patients with renal dysfunction.

19.3.2.6 Peridural Analgesia Peridural analgesia appears to be superior to intravenous opioids for postoperative pain control and a reduction of postoperative pulmonary complications such as atelectasis and pneumonia. Typical regimes for regional catheters use bupivacain 0.125–0.25% with an infusion rate of 6–10 ml/h. A similar concentration of bupivacain is used for lumbar or thoracic peridural catheters with infusion rates of 6–10 and 4–6  ml/h, respectively. An initial bolus (e.g., 5 ml) is used to start analgesia. Peridural (but not regional) catheters can be supplemented by morphine, 2  mg tid, fentanyl, or ­clonidine. A urinary catheter for bladder drainage is needed, because urinary retention develops in 15–90% of patients with peridural analgesia.

19.3.2.7 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)and Other Analgesic Agents NSAIDs can be used as single agents or in combination with other drugs for pain therapy in critically ill subjects. Their use may help to reduce the need for opioid treatment. They may be of specific value after restoration of

body homeostasis, when the patient is ready for transfer to intermediate care or the normal ward. However, the effects of these substances are not well studied in this group of patients. Their influence on inflammation and anti-inflammation, coagulation, and organ function in the different phases of critical illness is not clear. Therefore, these substances should be used with care. Nonacidic antipyretics such as metamizol and paracetamol or coxibes may be used. When they are administered one has to bear in mind that they reduce fever and thus render this indicator of inflammation and sepsis unreliable. Whether the lowering of fever has undesired effects on the course of an infection is not known. Some side effects have to be accounted for, which appear to be specifically relevant in critically ill patients. Coxibes are known for their renal and cardiac toxicity, disturbance of coagulation, and the induction of gastric ulcers. Particularly elderly patients and subjects with hypovolemia, hypotension, and preexisting renal disease are at an increased risk for acute renal ­failure. Metamizol may lead to hypotension, particularly with intravenous application and is not available in a number of countries. Paracetamol should not be used in patients with liver disease or impaired liver function.

In hemodynamically compromised patients continuous infusion of fentanyl or sufentanil appears to be the preferred analgesic regime because these drugs are easier to control and have a lower potential for histamine release with consecutive vasodilation and hypotension than morphine. Morphine should be used with care in patients with renal insufficiency. Patients with less severe organ dysfunction and those who can be transferred to a lower level of care may receive nonsteroidal analgesics (with specific focus on the profile of side effects). If additional analgesia is required, bolus application of piritramid or morphine may be used.

19.4 Anxiety and Agitation Anxiety is a universal problem in critically ill patients. Anxiety in combination with increased motor activity may be called agitation. It has to be differentiated from

150

delirium. The aim of giving sedative medication is to enable the patient to calmly tolerate the medical treatment and especially the endotracheal tube without suffering. In the ideal situation the patient would be calmly awake or easily arousable and cooperative. Unnecessary over-sedation should be avoided as well as agitated states with the risk of self-inflicted harm. A lower level of sedation results in fewer days on the ventilator and reduced requirements for vasopressors and inotropes. Pain has to be controlled before sedation is intensified.

19.4.1 Monitoring Sedation therapy requires monitoring patients with reliable tools. It may be difficult to differentiate between pain and anxiety, particularly in subjects who cannot communicate. The subjective character of clinical signs as well as different care providers who evaluate and observe the patient are further impediments for correct evaluation of the level of sedation. The use of different validated sedation scores has led to a significant reduction in the use of sedative medication and a decrease in duration of ventilation and length of ICUstay. The Motor Activity Assessment Scale (MAAS), the Sedation Agitation Scale (SAS), the Vancouver Interaction and Calmness Scale (VICS) and the Richmond Agitation Scale (RASS, see Table 19.1) are among the validated scores that are recommended, while one of the best-known scores, the Ramsey Sedation Scale has never been validated for critically ill patients. The use of any of these scores is strongly recommended. During goal-directed sedation, a score range is defined to preset the desired depth of sedation. Sedative medication is then continuously adjusted to achieve this goal. For most situations, a low level of sedation (easily arousable or calmly awake) is desired. In deeply sedated patients with and without muscle paralysis in whom scoring systems or clinical judgment are of limited value, the use of neurophysiological measurements such as EEG, acoustic evoked potentials, or bispectral index are discussed. None of these methods has gained wide acceptance in the critical care setting, partly because they are restricted to special situations or have not been shown to be of outcome relevance.

C. Waydhas Table 19.1  Richmond Agitation–Sedation Scale (RASS) +4

Combative

Combative, violent, immediate danger to staff

+3

Very agitated

Pulls or removes tube(s) or catheter(s); aggressive

+2

Agitated

Frequent nonpurposeful movement, fights ventilator

+1

Restless

Anxious, apprehensive but movements are not aggressive or vigorous

0

Alert and calm

−1

Drowsy

Not fully alert, but has sustained awakening to voice (eye opening & contact > 10 s)

−2

Light sedation

Briefly awakens to voice (eye opening &contact < 10 s)

−3

Moderate sedation

Movement or eye opening to voice (but no eye contact)

−4

Deep sedation

No response to voice, but movement or eye opening to physical stimulation

−5

Unarousable

No response to voice or physical stimulation

19.4.2 Drugs 19.4.2.1 Midazolam and Other Benzodiazepines Midazolam is one of the most frequently used sedative drugs in critical care medicine. It is characterized by a high degree of lipophilia which results in a fast onset of action within 1–5 min. Midazolam (like all other benzodiazepines) is metabolized in the liver and excreted via the urine. The elimination half-life is relatively short (about 2 h) compared to other benzodiazepines. However, the time interval between cessation of drug administration and awakening is highly variable and may not be much shorter than with substances like diazepam or lorazepam. Particularly elderly persons and those with heart or liver insufficiency are susceptible to a prolonged sedative effect. Depression of respiratory drive can be a problem in elderly patients, in patients with chronic hypercapnia, and during simultaneous application of opioids. Typical doses of bolus application vary between 2.5 and 10  mg (0.025–0.1  mg/kg). The continuous administration (2–10  mg/h; 0.01–0.18  mg/kg/h) has

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19  Analgesia and Sedation in Intensive Care

the imminent risk of over-sedation and is not recommended by some experts. Despite its short elimination half-life, midazolam may accumulate during prolonged administration and may result in delays between stop of medication and awakening of several days. Pro­ longed action may also be encountered in  obese patients. The concept of daily interruption of sedative medication counteracts these undesired effects. Apart from prolonged time of action one of the most prominent undesired effects are drug withdrawal symptoms. The total dose of midazolam (more than 60 mg/kg) is a more important risk factor than the duration of administration itself. Drug withdrawal is more pro­minent after an abrupt cessation of ­admi­nistration. Therefore, a stepwise reduction is recommended. Midazolam exhibits drug interactions that may lead to prolonged or shortened duration of action. Particularly erythromycin and theophylline should not be administered during midazolam treatment. Diazepam encompasses several shortcomings that include a high potential for accumulation after repeated doses, low solubility, incompatibility with many infusion solutions, venous irritation and has lost wide acceptance as a sedative drug in the critically ill patient. Lorazepam has a delayed onset of action (5–15 min) and a long half-life of 10–20 h. It is used, particularly in North America for long-term sedation of stable patients. Due to the solvants polyethylglycole and ­propylglycole that are used for the intravenous preparation, there is a potential for lactate acidosis and acute tubular necroses when high doses or prolonged administration are used. 19.4.2.2 Propofol Propofol is a lipophilic fast-acting sedative drug (onset of action within 1–2  min) with a short half-life. Most patients wake up within 5–15  min after cessation of drug administration and the risk of accumulation is greatly reduced in comparison with other sedatives. The drug is easily controllable and may even be used in nonintubated patients. It may be used for short-term as well as for long-term sedation (maximum approved duration of application has to be attended to). Propofol is metabolized in the liver. It has no inherent analgesic effects!

Typical doses to induce narcosis vary between 25 and 100  mg (0.25–1  mg/kg), the maintenance doses range from 50 to 300 mg/h. A dose of 4 mg/kg/h should be exceeded only for short periods. For dose calculation the actual (not the ideal) body weight, especially with obese patients, should be used. One of the most relevant side effects is vasodilation with consecutive hypotension, particularly in hypovolemic or hemodynamically unstable patients that may require the use of vasopressors. In such situations other sedative agents may be more appropriate. A rare but life-threatening complication is the propofol syndrome which presents with severe metabolic and lactic acidosis, rhabdomyolisis, acute renal failure, heart failure, and bradycardic cardiac arrest. Since the frequency of the propofol syndrome seems to be dose-dependent, the upper dosage limits given above have to be adhered to. Since the propofol syndrome is more predominant in children, it must not be used for long-term sedation in children below 16 years of age. One major technical difficulty is the incompatibility of propofol with virtually all other substances; propofol has to be administered via a separate lumen. A central venous line is required if propofol is administered in the 2% preparation. Propofol is supplied in a fatty emulsion and its infusion results in a considerable administration of triglycerides (1.1  kcal/ml). The amount of trigly­ cerides given with the propofol solution has to be included in the calculation of (parenteral) nutrition requirements. 19.4.2.3 a2-Adrenoceptoragonists Clonidin is a central a2-adrenoceptoragonist that quickly enters the central nervous system due to its lipophilia and exerts a sympatholytic effect via stimulation of a2-adrenoceptors. It is widely used as an adjuvant to other sedative or analgesic substances and may result in a sparing of opioids and benzodiazepines. Clonidin may be used alone or in combination in agitated patients with tachycardia and hypertension, for prophylaxis or therapy of withdrawal syndromes after long-term sedation or alcohol withdrawal syndromes. Therapy is usually started with a bolus infusion of 0.075 mg, followed by a continuous infusion of 0.03– 0.15 mg/h. Oral application is an option. Typical side effects include hypotension and bradycardia and restrict

152

its use in patients on vasopressors and with bradycardic arrhythmias. Constipation and even ileus is of concern, particularly if it is coadministered with an opioid. Dexmedetomidin, a newer a2-adrenoceptoragonist appears to have a better profile of desired and ­undesired effects but may not be available in all countries.

19.4.2.4 Other Sedatives Ketamine is used in many intensive care units as an adjuvant substance during long-term sedation. It should be combined with low-dose benzodiazepines because if used alone it may lead to hallucinations and nightmares. The increased rate of salivation may require the application of vagolytic agents. Ketamine has a strong broncholytic effect and may be helpful in patients with concomitant bronchospasm. In contrast to most other sedatives and analgesics, Ketamine does not lead to hypotension and may be used in situations with low blood pressure of non-cardiac origin. Ketamine is contraindicated during increased intracranial pressure, cardiac shock, and acute myocardial infarction. A typical starting dose is 5 mg/kg/min. Barbiturates are reserved for specific neurological or neurosurgical indications to reduce brain metabolism. These drugs should not be used to sedate critically ill patients. For short-term sedation (e.g., postoperative) many users prefer propofol. Its use during weaning also appears favorable. For expected sedation periods of less than 7 days propofol may be given preference over benzodiazepines due to the shorter awakening time. However, in several randomized trials there was no consistent advantage of propofol. Propofol must not be used for sedation in children under 16 years (acceptable only during surgery and short interventions). For long-term sedation, propofol is not appropriate because of the increased risk of the propofol syndrome and, therefore, is not approved for use of more than 7 days. Midazolam is the benzodiazepine of choice in many intensive care units. It may be switched to longer acting substances (e.g., lorazepam) during withdrawal syndromes after prolonged administration of midazolam.

C. Waydhas

19.5 Delirium Delirium is an acute, reversible, organic psychosis that is characterized by disturbances of vigilance, attention deficit disorder and disorientation, (optical) hallucinations, affective disturbances (anxiety, irritability, restlessness) and affection of the sympathetic system (tachycardia, sweating), interruption of circadian rhythms, tremor, and agitation. It has to be differentiated from withdrawal syndromes, pain, and insufficient compliance with the ventilator. A search for treatable causes of delirium such as sepsis, fever, hypoxia, and metabolic disorders should be initiated. The Confusion Assessment Method for Intensive Care Units (CAM-ICU) may be a valuable tool to make a diagnosis and to monitor severity. The CAM-ICU can be applied by nurses. Haloperidol is the most widely used drug to treat delirium and hallucinations. It is a strong neuroleptic substance with additional sedative and antiemetic effects. The onset of action is within 20 min. It is usually started by intravenous bolus injection of 2.5–5 mg. If the initial effect is not satisfactory, the dose may be doubled every 20  min up to a maximum bolus of 20  mg. If still no adequate delirium control can be achieved another neuroleptic substance should be tried and an additional application of a benzodiazepine may be helpful. The usual maintenance dose of haloperidol is 5  mg every 4–6  h. In the further course, the dose should be tapered gradually. Depression of breathing efforts and hypotension are rarely encountered. Extrapyramidal symptoms seem to be rare in critically ill patients (below 5%); dysphoria, however, may be a problem more often. A rare but lifethreatening complication (independent from dosage and duration) is the neuroleptic-induced malignant hyperthermia with a sharp rise in body temperature to more than 41°C, muscle rigidity, rhabdomyolysis, and acute renal failure. Early recognition and immediate treatment with dantrolene are of utmost importance. Another potential problem of haloperidol is the prolonged QT interval. The concomitant administration of other QTprolon­ging substances (e.g., chinolones, amiodarone sotalol, erythromycin) to haloperidol should be avoided, if possible.

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An alternative to haloperidol may be olanzapine. In a randomized study, an enteral daily dose of 5 mg olanzapine showed a comparable anti-delirant effect as 2.5–5  mg haloperidol qid with less extrapyramidal symptoms. Levomepromazine and promethazine are weak neuroleptic substances with a stronger sedative effect. During intravenous bolus injection, the development of hypotension is a well-known complication and they should be used with caution in elderly and hypovolemic patients.

bronchial secretions, pressure sores, critical illness polyneuro- and myopathy, difficult weaning from the respirator, over- or under-sedation, insufficient pain control. If, despite these disadvantages, they are used for more than a single dose, monitoring with peripheral muscle stimulation (TOF, train of four) and bispectral index are strongly recommended. A clear recommendation for a single substance cannot be made. Pancuronium, however, has a strong histaminic effect and succinylcholine should be avoided in polytraumatized patients.

19.6 Withdrawal Syndromes

Recommended Reading

Withdrawal syndromes are a common problem after high-dose or long-term sedation. Symptoms and differential diagnosis are outlined above in this chapter. If motor activity and agitation prevail, long-acting benzodiazepines (e.g., lorazepame) may be used. Sympathetic hyperacitivity may be controlled with clonidine or other a2-adrenoreceptoragomists or b-blockers. During productive-psychotic states, haloperidol is recommended.

Devlin, J.W., et al.: Motor activity assessment scale: a valid and reliable sedation scale for use with mechanically ventilated patients in adult intensive care. Crit. Care Med. 27, 1271–1275 (1999) Ely, E.W. et  al.: Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA 289, 2983–2991 (2003) Gommers, D., Bakker, J.: Medications for analgesia and sedation in the intensive care unit: an overview. Crit. Care 12(Suppl 3), S4 (2008) Hayden, W.R.: Life and near-death in the intensive care unit. Crit. Care Clin. 10, 651–657 (1994) Jacobi, J., Fraser, G.L., Coursin, D.B., et  al.: Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit. Care Med. 30, 119–141 (2002) Kress, J.P., Pohlman, A.S., ÓConnor, M.F., Hall, J.B.: Daily interruption of sedative infusions in critically ill patients undergoing mechanical intervention. N. Engl. J. Med. 342, 1471–1477 (2000) Payen, J.F., Bru, O., Bosson, J.L., Lagrasta, A., Novel, E., Deschaux, I., Lavagne, P., Jaquot, C.: Assessing pain in critically ill sedated patients by using a behavioural pain scale. Crit. Care Med. 29, 2258–2263 (2001) Sessler, C.N. et  al.: The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am. J. Respir. Crit. Care Med. 166, 1338–1344 (2002) Vender, J.S., Szokol, J.W., Murphy, G.S., Nitsun, M.: Sedation, analgesia, and neuromuscular blockade in sepsis: an evidence-based review. Crit. Care Med. 32(Suppl), S554–S561 (2004)

19.7 Muscle Relaxants Muscle relaxation is only indicated during acute procedures and interventions that require a complete avoidance of muscle activity such as some types of surgery, tracheotomy, intubation, bronchoscopy, or acute ventilation problems that are referred to muscle rigidity. A more than single dose is only required in rare exceptions. Adequate deep analgesia and sedation are a prerequisite. A positive effect of muscle relaxation in increased intracranial pressure has not been shown. Some undesired effects comprise a suppression of coughing with inadequate clearance of

 

Part Operative Care

III

 

Anti-reflux Procedures

20

Glyn Jamieson

20.1 Fundoplication in Rural Surgery Since anti-reflux surgery is essentially elective and ­discretionary surgery, the indication for performing it, whilst agreed upon to a certain degree, nevertheless depends also on a patient’s wishes. It can rarely be necessary to undertake such surgery in a rural setting in the absence of expertise to carry out such surgery.

20.2 Investigations Prior to Surgery The essential principle, on which the indication for any anti-reflux surgery is based, is to establish that a patient has abnormal gastro-oesophageal reflux. To establish this can be quite straightforward. For example, a patient who complains of heartburn, which is abolished either temporarily by antacids, or in a more ­prolonged way with proton pump inhibitors, and who has ulcerative oesophagitis on endoscopy, really needs no further investigation to establish the diagnosis. Similarly, patients who regurgitate fluid into their mouth when bending over, or who have aspiration symptoms from regurgitated fluid at night, are highly likely to have gastro-oesophageal reflux disease which can be cured by surgery. Therefore, a careful history and an endoscopy are all that are usually required in a rural setting before a patient should be considered for anti-reflux surgery. But there

G. Jamieson Department of Surgery, The Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia e-mail: [email protected]

are pitfalls. Symptoms which differ from heartburn and regurgitation such as burning pain in the epigastrium, chest pain or discomfort, acid taste in the mouth, bloating and fullness after eating and cough, all can be associated with, and/or caused by, gastro-oesophageal reflux but all can have causes which are not reflux related. Therefore, in centres of excellence oesophageal manometry and sometimes 24  h pH monitoring is added routinely in the workup for surgery. Oesophageal manometry excludes achalasia and other motility disorders such as an adynamic oesophagus, and 24 h pH monitoring can not only establish the fact that abnormal reflux is occurring but also establish a temporal relationship between symptoms and reflux events.

20.3 Indications for Surgery Most patients who have the straightforward and commonest symptom of reflux, that is, retrosternal burning (heartburn), would also obtain relief of their symptoms with a proton pump inhibitor. When then is anti-reflux surgery indicated? 1. When symptoms supervene in spite of proton pump inhibitors. Some patients initially will obtain excellent relief of heartburn with a proton pump inhibitor but after some years on the therapy they find that their symptoms start to recur. These symptoms are often called ‘breakthrough’ symptoms. This problem may occur as a result of parietal cell hyperplasia which can occur in patients on long-term proton pump inhibitor therapy. The therapy is then increased but some time later the scenario repeats itself. Patients who develop breakthrough symptoms are candidates for anti-reflux surgery. In these

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_20, © Springer-Verlag Berlin Heidelberg 2011

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158

days of widespread use of proton pump inhibitor therapy for reflux, this is probably the commonest indication for anti-reflux surgery. 2. In spite of the fact that proton pump inhibitors are extremely safe and well tolerated, there is a small group of patients who are intolerant of the therapy because of side effects. Obviously these patients are candidates for anti-reflux surgery. 3. There is also a group of patients who do not wish to be reliant on taking tablets for the rest of their life who elect to have anti-reflux surgery. 4. Complicated reflux disease, such as patients with stricture formation, may be an indication if stricturing remains a problem in spite of dilatation and proton pump inhibitor therapy. Whether Barrett’s oesophagus, as a complication of reflux disease, is an indication for anti-reflux surgery is somewhat controversial. In the absence of symptoms of reflux, at the present time there is no compelling evidence that anti-reflux surgery is indicated in these circumstances. 5. Lastly, and very importantly, is volume reflux. This is the argot for excessive regurgitation and when this causes aspiration symptoms (usually awakening the patient from sleep) it is a very strong indication for anti-reflux surgery. More controversial is when regurgitation or reflux is thought to be associated with supra-oesophageal symptoms such as chronic cough, huskiness of voice, acid taste in the mouth, dental problems, etc. Most often, and even when abnormal reflux has been demonstrated, antireflux surgery does not cure these problems. In the absence of abnormal reflux these sorts of symptoms should almost never be seen as an indication for anti-reflux surgery.

20.4 The Principles Underlying Anti-reflux Surgery The principal objective in anti-reflux surgery is to restore the anatomy of the hiatal region to normal and to do so in such a way that this will be maintained. This is done using three manoeuvres. First, to restore a portion of about 2–3 cm of the oesophagus into the abdominal cavity. Second, to narrow the hiatal opening to accommodate the oesophagus only. Third, to construct a one-way valve at the gastro-oesophageal junction.

G. Jamieson

20.4.1 Intra-abdominal Oesophagus Most patients who come to anti-reflux surgery have a hiatus hernia and so the oesophagus and proximal stomach are required to be mobilised in order to reduce the hernia and bring 2–3 cm of oesophagus back into the positive pressure environment of the abdominal cavity.

20.4.2 Narrowing of the Hiatus This can be carried out either in front of, or behind, the oesophagus. Most surgeons favour using posterior sutures as it seems more anatomical and tends to leave a normal racquet-shaped hiatus. Because the hiatal aperture is oblique, a posterior narrowing allows more of the oesophagus to lie intra-abdominally than an anterior narrowing. Also, anterior sutures have a ­tendency to turn the hiatal opening into a vertical slit rather than its usual racquet-shaped appearance. The narrowing is usually achieved using one or two non-absorbable sutures. It is very important not to narrow the hiatus to a degree which impinges on the oesophagus and it seems sensible to place a 52 French bougie in the oesophagus so the surgeon can be certain the closure is not too tight.

20.4.3 Construction of a One-Way Valve Whilst not exactly controversial, there are many ways of achieving the construction of a one-way valve. All methods produce an acute angle of entry of the oesophagus into the stomach. Probably by far the most popular and simplest operation is a total fundoplication – often called a Nissen fundoplication – even though the operation performed differs substantially from the operation which Rudolf Nissen described. In this procedure, the fundus of the stomach is taken behind the oesophagus and then sewn to the stomach in front of the oesophagus with two or three sutures. Some surgeons, perhaps a majority of surgeons, mobilise the fundus by dividing all its attachments such as the short gastric and posterior gastric vessels. Others use the anterior wall of the stomach for the wrap, a technique first described by Rudolf Nissen as an alternative to the technique which he initially

159

20  Anti-reflux Procedures Fig. 20.1  (a) Anterior 180° fundoplication, a partial anterior fundal wrap; (b) posterior 270° fundoplication, a partial posterior fundal wrap; (c) Nissen 360° fundoplication, a loose 2 cm long fundal wrap constructed over a 52Fr intraoesophageal bougie, without division of the short gastric vessels

a

described. Once again a 52 French (or larger) bougie is placed in the oesophagus to try and prevent constriction of the oesophagus by the wrap. However, it should be noted that the presence of a bougie in the oesophagus is not a guarantee of a loose fundoplication. Some surgeons prefer a partial fundoplication. Such procedures fall into two classes, either anterior or ­posterior. Varying degrees of wrap have been described with 270°, 180° and 90°, all having been reported. The degrees refer to the amount of the circumference of the oesophagus which is covered by the wrap (Fig. 20.1). There are many other variations described such as attaching the stomach to the diaphragm (crown sutures), attaching stomach to the hiatal pillars (gastropexy) and attaching stomach to the oesophageal wall. My preferred technique for the procedure is described in the following.

20.5 Operative Technique In giving a description of this operation it is assumed that the surgeon has expertise in laparoscopic abdominal surgery in general but not necessarily in surgery around the oesophageal hiatus. The patient is positioned on the operating table in the lithotomy position with the table tilted 30° head up and the surgeon sits between the patient’s legs. Insufflation of the abdomen is undertaken to a pressure of approximately 12  mm of mercury. Five ports are placed. I place the camera port about midway between the xiphisternum and the umbilicus and about 2–3 cm to the left of the midline. With the port placed in this position it is usually comfortable to use a 0° laparoscope. Other surgeons who prefer to use a 30° or 45°

b

c

laparoscope place the port in the region of the ­umbilicus in the midline. A five millimetre port is placed in the mid-clavicular line just below the right costal margin and it is important that this port is well lateral to assist in passing an instrument behind the oesophagus. Two further 5  mm ports are placed, one just below the xiphisternum in the midline and one in the left flank below the left costal margin in about the anterior ­axillary line. The right-hand working port is placed in the mid-clavicular line, 3–4  cm below the left costal margin (this is a 10 mm port). After a laparoscopic inspection of the upper abdominal contents, a non-traumatic grasper is used by the assistant through the left-most port to grasp the stomach just below the gastro-oesophageal junction and to pull the oesophagus downwards and slightly to the left. I believe the next step is very important in always ­orientating the surgeon. This is to go to the lesser-­ omentum in front of the caudate lobe of the liver and to the left of the inferior vena cava and above the branches of the vagus nerve to the hilum of the liver. This is an area where it is safe to open the lesser omentum, using diathermy. This opening can be enlarged by placing blunt graspers through it and using a distracting force to separate the graspers. This takes the surgeon directly down onto the right pillar of the hiatus. Some form of liver retraction is used through the 5 mm epigastric port and we find the Nathanson hook a most useful retractor in this regard. Next, a blunt instrument is placed to the immediate left of the right pillar and gently pushed inwards. This creates a groove between the oesophagus and the right pillar which I call the oesophago-hiatal groove. Gentle distracting movements with two forceps in a vertical direction in the depth of this groove opens into the mediastinum to the right of the oesophagus. Once

160

opened the area into the mediastinum is enlarged further, again by gentle distraction using the two forceps in opposing directions in a vertical plane. The peritoneum and the retro-peritoneal tissues along the edge of the right pillar and down towards the gastro-oesophageal junction are then divided using diathermy. This division is continued distally until a thick fatty bundle of tissue is reached. This bundle of tissue contains the hepatic branch of the vagus nerve and the left gastric artery. Attention is now turned to the left pillar of the hiatus. The assistant pulls the gastro-oesophageal junction downwards and in the direction of the patient’s right iliac fossa and once again using a blunt grasper, the left oesophago-hiatal groove is created and the peritoneum is divided over the edge of the left pillar of the hiatus distally until the region of the fundus of the stomach is reached. If the operation is undertaken without a mentor present then it helps enormously to have an endoscope in position in the lower oesophagus with a light on to show the surgeon exactly where the oesophagus sits. Without such an aid, exact identification of the oesophagus is not quite as simple as the surgeon might expect from experience of the procedure in the open setting. The manoeuvre which many surgeons find the most difficult to learn, in the technique of laparoscopic fundoplication, is to mobilise posterior to the oesophagus to create a window behind it. I find this best done using the surgeon’s left-hand instrument passing with the blunt tip behind the oesophagus and holding the oesophagus forward. Dissection of the meso-­oesophagus can then take place. The surgeon must remember that the only major structure posterior to the oesophagus here is the aorta. Once the instrument has passed behind the oesophagus it can usually be seen protruding from within the chest into the diaphragm, to the left of the left pillar. It can then be ‘walked down’ the inside of the diaphragm until it appears in front of the left pillar. Once this point has been reached, a tape or small catheter such as an infant gavage tube is inserted through the 10 mm left port and brought behind the oesophagus and then out through the port again. During the dissection behind the oesophagus, the vagus nerve is usually seen and often it moves with the oesophagus. It can be either included with the oesophagus or dissected away from the oesophagus. If a total fundoplication is to be performed then the window behind the oesophagus should be of the order of 3–5  cm in diameter. The assistant’s forcep now picks up the tape encircling

G. Jamieson

the oesophagus and can hold it in various directions to facilitate further dissection of the window behind the oesophagus. At this juncture the oesophageal-hiatus is narrowed. I have used both anterior and posterior sutures in the hiatus for this narrowing. I prefer posterior sutures as they tend to reconstruct the hiatus more anatomically. Nevertheless, anterior sutures can be used and these tend to make the oesophageal-hiatus more of a slit than a round opening. If a total fundoplication is to be performed, the surgeon’s left-hand grasper is passed behind the oesophagus and the right-hand grasper takes the anterior wall of the stomach lateral to the oesophagogastric junction and passes it up to the grasper behind the oesophagus. The surgeon then gently eases the anterior wall of the stomach behind the oesophagus until it can be grasped by the right-hand grasper and held in position. At this point I usually pick up different points of the stomach to the right of the oesophagus to find out which part lies behind with least tension. When a ‘square’ of stomach of about 3 cm × 2–3 cm has been produced, the assistant’s grasper is placed across the base of the square of stomach to hold it in position for the construction of the fundoplication. At this point a large bougie is placed in the oesophagus and it should be observed as it is passed into the stomach. Non-absorbable sutures are used for the fundoplication. Three interrupted sutures are used. I use 2.0 Prolene for the sutures as they are less likely to cut either gastric or oesophageal tissue. These can be tied either intracorporeally or extracorporeally. I usually take a superficial bite through the wall of the oesophagus with the first suture which is placed about 3 cm up the oesophagus. The sutures are approximately 1 cm apart so that these three sutures construct a fundoplication of about 2 cm in length. It must be realised that even though a bougie is in position this does not stop the formation of a tight wrap. Nevertheless, with a bougie in position, if the wrap appears loose and instruments can be passed through it, it is unlikely that long-lasting dysphagia will occur.

20.6 Variations to This Technique There are many variations that have been described, most of them relating to lesser degrees of fundoplication. The other thing which still provokes discussion

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20  Anti-reflux Procedures

is whether the fundus of the stomach should be fully mobilised for the construction of the total fundoplication. There are several randomised controlled studies in the literature to suggest that this is not necessary and so the technique will not be ­discussed here.

20.7 Post-operative Management Patients are placed on a liquid diet from the first day and are usually discharged on day 2 or day 3. Nearly all patients will experience dysphagia for solids for some weeks. Patients are discharged on day 2 or day 3 when they are managing to take a soft and moist diet and they are told to stay on this diet until they can appreciate that their difficulty in swallowing lessens, usually in the second or third week after surgery. Patients are given 2 weeks off from their work but are also told that heavy lifting should be avoided for 12 weeks. I also undertake a contrast swallow on the first post-operative day as a routine. This is to check that the wrap is in a good position, that there are no leaks and no acute para-oesophageal hernias which sometimes occur even in the absence of symptoms. It is important to detect any problems early since a return to the operating theatre in the first 2 or 3 days is usually straightforward and does not delay a patient’s discharge from hospital by more than 2 or 3  days. However, even if left until the end of the first postoperative week, re-operation can suddenly become extremely difficult, with the tissues being woody in consistency and difficult to work with. It is for that reason that the routine contrast study is undertaken at an early time post-operatively. There are several things which might alert the ­surgeon to a problem in the post-operative period. The first is undue pain. Patients should not have pain requiring narcotics, and if this is the case, then there should be a high index of suspicion that something is amiss. Second, sometimes there is an obvious problem such as a patient who is unable to swallow even their saliva. Often they sit in the ward with a bowl in front of them spitting out their saliva. Under these circumstances

I usually go straight to an endoscopy. If the endoscope passes easily through the wrap then it is likely that the problem will resolve. If there is any degree of difficulty in passing the endoscope then the patient is returned to the operating theatre. If the patient develops a leak either from the oesophagus or the stomach, in my experience placing a drain to the area and undertaking a feeding jejunostomy is the preferred way of dealing with this.

20.8 Results There is now ample evidence in the literature that if patients are selected carefully and the operation is undertaken in a standardised fashion then almost all patients will have their reflux cured in the short term. Unfortunately there is a recurrent reflux rate which tends to occur most in the first 3 years and affects about 10% of patients. There is a very small group of patients (probably less than 1%) who have troublesome dysphagia to the point that a further operation is required at some later stage. Revisional anti-reflux surgery should be undertaken in a centre specialising in laparoscopic surgery of the upper gastro-intestinal tract.

Recommended Reading Catarci, M., Gentileschi, P., Papi, C., Carrara, A., Marrese, R., Gaspari, A.L., Grassi, G.B.: Evidence based appraisal of anti-reflux fundoplication. Ann. Surg. 239(3), 325–337 (2004) Salminen, P.: The laparoscopic Nissen fundoplication – a better operation? Surgeon 7(4), 224–227 (2009) Varin, O., Velstra, B., DeSutter, S., Ceelend, W.: Total versus partial fundoplication and the treatment of gastro-oesophageal reflux disease: a meta- analysis. Arch. Surg. 144(3), 273–278 (2009) Watson, D.I., Jamieson, G.G.: Treatment of gastro-oesophageal reflux disease. In: Griffin, S.M., Raimes, S.A. (eds.) Oesophago-Gastric surgery, 3rd edn. Elsevier Saunders, Philadelphia, 279–304 (2006)

 

21

Gastric Surgery Matthias W. Wichmann

21.1 Introduction 9

Surgery of the stomach can be a challenge in the rural setting due to the potential lack of necessary infrastructure for the management and diagnosis of peri- and postoperative complications. Nonetheless, treatment of both benign and malignant conditions of the stomach in the emergency and elective setting is an important part of rural general surgery. Especially for elective surgery, it is the surgeon’s responsibility to evaluate whether the caseload as well as the available infrastructure and experience (level of peri- and posto­ perative care, diagnostic/interventional radiology and endoscopy, experience of nursing staff) are sufficient to provide safe gastric surgery.

21.2 Relevant Anatomy The stomach is divided into fundus (superior to the gastroesophageal junction), body and antrum and there are two important physiologic divisions: the fundic gland (parietal cell; acid production) and the pyloric gland (antral cell; mucous production, gastrin and somatostatin secretion) areas. The blood supply to the stomach is maintained by six major vessels (right and left gastric artery, right and left gastroepiploic artery, splenic artery (vasa brevia), gastroduodenal artery) (see Fig. 21.1).

M.W. Wichmann Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected]

1 5

4

3

8

2

6 7

Fig. 21.1  Blood supply to the stomach. 1 celiac axis, 2 splenic artery, 3 left gastric artery, 4 common hepatic artery, 5 right gastric artery, 6 gastroduodenal artery, 7 right gastro-epiploic artery, 8 left gastro-epiploic artery, 9 short gastric vessels

21.3 Indications Most common indications for gastric surgery are ­cancer, ulcer disease, and associated hemorrhage as well as feeding access.

21.3.1 Surgery for Gastric Cancer As opposed to other gastrointestinal malignancies, ­the incidence of gastric cancer has been significantly decreasing during recent years. Although improvements in nutrition, occupational hazards, and socioeconomic conditions have been discussed, the reasons for the decline in the incidence of gastric cancer remain unclear. It appears that mass screening (as done in

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Japan) and eradication therapy for Helicobacter pylori also have contributed to this positive development. The lymphatic drainage of the stomach is difficult to predict and the submucosal extent of the adenocarcinoma can be bigger than may be appreciated by macroscopic inspection. For these reasons, the ideal security margin for gastric cancers has been considered to be 6 cm proximal and distal to the tumor. If preoperative histology reveals cancer of the so-called intestinal type, one should aim for an oral security margin of 8 cm. For carcinoma of the mid and lower body and antrum of the stomach, radical subtotal gastrectomy has been accepted as standard of care. This procedure includes: • 75–90% distal gastrectomy with the aboral resection margin 3 cm postpyloric, • Division of right and left gastric artery and right gastroepiploic artery at their origin and clearance of all associated lymphoid tissue, • Removal of the lesser and greater omentum. Lymph node dissection should include the infra- and supraduodenal areas, the retropancreatic region, the hepatic pedicle, the mesenteric root, and the common hepatic and celiac arteries (D1 lymphadenectomy: ­cardia nodes, lesser curve nodes, greater curve nodes, short gastric artery nodes, left and right gastroepiploic nodes, nodes proximal and distal of the pylorus). Lymph node dissection is usually done en bloc with removal of the stomach. With regard to the discussion of how extensive the lymph node sampling should be carried out, it is of interest that a recent study comparing D2 lymphadenectomy with more extensive para-aortic nodal ­dissection in more than 500 patients could not show significant differences in 5-year survival rates (69 vs 70%) between both patient groups. In patients with early nodal involvement, D2 lymphadenectomy is of prognostic importance and should be performed resulting in at least 25 lymph nodes available for pathological evaluation. D2 lymphadenectomy involves lymph node sampling from the following areas: left gastric artery nodes, common hepatic artery nodes, celiac trunk nodes, nodes of the splenic hilus, splenic artery nodes, nodes of the hepatoduodenal ligament. Total gastrectomy has been accepted as the treatment of choice for upper and middle gastric cancer.

M.W. Wichmann

It is the only surgical option for linitis plastica-type lesions that involve most of the stomach. In addition to the steps outlined above, the entire stomach is being resected, and the gastrosplenic ligament as well as crural lymphatic tissue needs to be removed. For lesions of the gastroesophageal junction, the upper resection margin includes the distal esophagus. Ongoing debate involves the role of palliative gastrectomy in stage IV gastric cancer, the role of splenectomy for completion of D2 lymph node dissection, and  the role of lymph node dissection for long-term survival (D1 vs D2/D3 dissection). A Cochrane review that examined extended versus limited lymph node dissection for adenocarcinoma of the stomach showed comparable survival in both study groups, with a higher postoperative mortality in the group of patients undergoing extended note dissection. Splenectomy should only be performed if the spleen is directly involved with the malignant lesion or grossly enlarged lymph nodes in the splenic hilum are being detected. During recent years, the role of palliative gastric surgery has evolved and it has been shown that resectional surgery – although it carries a high rate of morbidity and mortality (up to 40% and 10%, respectively) – offers better survival and quality of life than bypass procedures or best supportive care only. Staging laparoscopy prior to curative surgery or neoadjuvant radio-chemotherapy has gained acceptance during recent years in view of significantly improved survival rates with preoperative chemoradiation if disseminated peritoneal disease was diagnosed using minimal invasive surgery.

21.3.1.1 Reconstruction Reconstruction of intestinal continuity is usually done by a Roux-en-Y esophago-jejunostomy. The anastomosis can be hand-sutured in two layers or a ­circular mechanical stapler (25  mm diameter) can be used. We cover the stapled anastomosis with interrupted absorbable stitches. The entero-entero-anstomosis of the Roux-en-Y limb is constructed as a side-to-side anastomosis 40–60 cm distal to the esophago-jejunostomy. This effectively prevents reflux of duodenal juices (Fig. 21.2).

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c­ arries the risk of significant morbidity (leakage, mechanical obstruction, bleeding, wound infection). Drains should be placed to cover potential leaks at the level of the esophago-jejunostomy (or gastrojejunostomy in patients with subtotal gastrectomy) as well as of the duodenal stump.

21.3.1.2 Additional treatment options for gastric malignancy

40–60cm

During recent years, a number of promising oncological treatment options (e.g., MAGIC trial) have been developed for gastric malignancies and the potential benefits of either preoperative neoadjuvant, postoperative adjuvant, or palliative (radio-) chemotherapy should be discussed within the setting of a multidisciplinary tumor board.

21.3.1.3 Complications

Fig.  21.2  Reconstruction after total gastrectomy with pouch and Roux-en-Y esophago-jejunostomy

There is no evidence available which favors main­ tenance of duodenal passage after gastrectomy. It appears, however, that pouch construction improves eating and weight maintenance in patients after gastrectomy within the first year after surgery. The pouch is formed by constructing a side-to-side anastomosis between the ascending and descending parts of the first jejunal loop prior to the esophago-jejunostomy (HuntRodino-Pouch). Depending on the nutritional status of the patient and the surgeon’s evaluation of the risk of postoperative ileus or leakage, the need for a feeding jejunostomy must be discussed. We favor the liberal use of this device since it allows for an early start of enteral nutrition. However, it is important to note that a feeding jejunostomy also

After gastric resection and anastomosis, any suture line may leak and has the potential to create a fatal situation. Increasing postoperative pain, fever, abdominal distension, and rising inflammatory markers must prompt further investigations. Most importantly, a CT scan should be done urgently which can also allow for radiological placement of a drain. If this is not possible, a reoperation with irrigation and drainage of the infected peritoneum must be done. The leaking segment must be decompressed and a feeding jejunostomy should be placed (if not already done during the initial surgery). A number of postgastrectomy syndromes have been described. These include: • Dumping syndrome (early – treatment with saline infusion, late – treatment with sugar); • Diarrhea (truncal vagotomy); • Gallstone disease (vagal denervation); • Metabolic disorders: weight loss, anemia (iron absorption, vitamin B12 and folate deficiency), fat malabsorption, osteoporosis (disturbed calcium and vitamin D metabolism). It is important to monitor patients closely during the  immediate postoperative phase as well as in the

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l­ong-term, to detect early complications and to reduce ­associated morbidity and mortality.

21.3.2 Surgery for Ulcer Disease The introduction of very effective acid suppressive drugs (proton pump inhibitors) and the detection of the relevance of Helicobacter pylori for the pathogenesis of gastric ulcer disease have resulted in a “sudden death” of elective surgery for gastric and duodenal ulcers. Nowadays, we are dealing with the acute complications of peptic ulcer disease: bleeding, perforation (and obstruction). Initial bleeding control should always be attempted using gastroscopy after the patient was stabilized with adequate blood and fluid transfusions. With the decision to perform an emergency endoscopy, the patient should receive 10–20-mg metoclopramide i.v. to promote gastric emptying and clearance of old blood. Early intubation is recommended to avoid aspiration pneumonia and for good airway control during the (often lengthy) procedure. We recommend usage of ice water for initial washout and occasionally it can be worthwhile to use a colonoscope with a wider suction canal for removal of clotted blood from the upper GI tract. If a bleeding lesion can be identified, it should be injected and clipped (see Chap. 7 for more details). If endoscopy does not achieve bleeding control or an early recurrent bleed develops, surgical intervention may be necessary. The following findings favor the need for definite surgical intervention: • Total blood loss > 2,000 ml, • Hypotension due to ongoing blood loss, • Need to transfuse > 1,000 ml blood/24 h to maintain patient’s blood pressure. Definite surgical treatment can be done as distal gastrectomy (2/3) with Billroth I or II reconstruction or as gastrostomy/duodenotomy with oversewing of the ulcer, vagotomy, and pyloroplasty depending on the performance status of the patient.

M.W. Wichmann

In patients with perforated ulcer disease, a laparoscopic or open omental patch closure of the perforation site should be done after washout and drainage of the peritoneal contamination. We perform the Graham patch technique, which places omentum over the ­perforation site and fixes the omentum in place with three interrupted stitches. All patients are started on H. pylori eradication immediately after surgery, followed by long-term proton pump inhibitor therapy. After initial successful treatment, all patients require an endoscopy within 4–6 weeks after surgery to control for complete ulcer healing and to exclude malignancy (for gastric ulcers).

21.3.3 Surgery for Feeding Access Usually, feeding access to the stomach should be gained using an endoscopic technique (see Chap. 7 for details). In patients with known esophageal or proximal gastric malignancies (who are not suitable for resection), a regular endoscopic surveillance must be performed to not miss the development of complete obstruction. Prior to complete obstruction, either a stent or an endoscopic percutaneous feeding gastrostomy must be inserted. If the passage into the stomach via the esophagus is impossible due to proximal obstruction, a laparoscopic or open gastrostomy can be performed. Two different procedures have been described: the Stamm (tube) gastrostomy as well as the Janeway gastrostomy. For the tube gastrostomy, a stab incision into the stomach close to the greater curve is made and secured with a purse-string suture. A balloon catheter is introduced through the abdominal wall and inserted into the stomach. After closure of the purse-string suture, the stomach is sutured to the abdominal wall with four interrupted sutures. The balloon catheter can be removed if access to the stomach is not needed anymore. The Janeway gastrostomy (see Fig. 21.3) does not require a long-term tube insertion and consists of a gastric “nipple” created with a linear stapling device

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a

on the anterior gastric wall. The stapler is fired from the lesser curve into the direction of the greater curve across the anterior gastric wall, which is elevated using Babcock clamps. This procedure creates a tunnel of gastric mucosa (“nipple”) which is used to form a stoma after suturing the stomach to the abdominal wall with interrupted sutures. A catheter is only required in this stoma until it has completed healed.

Recommended Reading b

Fig.  21.3  Janeway gastrostomy: fashioning of the gastric ‘nipple’

Brennan, M.F.: Current status of surgery for gastric cancer: a review. Gastric Cancer 8, 64–70 (2005) Grabowski, M.W., Dempsey, D.T.: Stomach and duodenum. In: Scott-Conner, C.E.H. (ed.) Chassin’s Operative Strategy in General Surgery, pp. 223–322. Springer, New York (2002) McCulloch, P., Nita, M., Kazi, H., et al.: Extended versus limited lymph node dissection technique for adenocarcinoma of the stomach. Cochrane Database Syst. Rev. (4):CD001964 (2004) Pacelli, F., Papa, V., Rosa, F., et al.: Four hundred consecutive total gastrectomies for gastric cancer. Arch. Surg. 143, ­769–775 (2008) Sasako, M., Sano, T., Yamamoto, S., et  al.: D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. N. Engl. J. Med. 359, 453–462 (2008) Thompson, J.C.: The stomach and duodenum. In: Sabiston, D.C. (ed.) Textbook of Surgery, pp. 756–813. W.B. Saunders, Philadelphia (1991)

 

Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting

22

Harsh A. Kanhere and Andrew D. Strickland

22.1 Introduction Laparoscopic cholecystectomy (LC) is the current gold standard treatment of gallstone–associated biliary disease. This is a procedure performed by most general surgeons worldwide. With improved imaging techniques, better awareness of gallstone-associated symptoms and increased availability of laparoscopic training, LCs are set to become even more commonplace. This is borne out by the fact that LCs are being ­performed at rural, regional and remote centres with increasing confidence, especially in the developed world. While this is a welcome development as it decreases the workload of the frequently overburdened referral centres, the onus falls entirely on the rural surgeon to perform the procedure safely. As such, not only do the rural surgeons need to be technically adept, but also be well aware of the limitations of the system that they are working in, especially in the areas of ­personnel and logistics. For a successful LC, the availability of appropriately trained personnel, including assistants and nurses, is critical. Unfortunately, assistants well versed in laparoscopic procedures, and operating room personnel as well as ward nurses acquainted with postoperative care can be difficult to recruit and retain in the rural setting. Additionally, patients with complex medical comorbidities require multidisciplinary input, which can be difficult to obtain in a rural setting. Rural surgeons

H.A. Kanhere (*) and A.D. Strickland Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected], [email protected]

therefore have to either shoulder the responsibility of  managing these problems or consider transferring these patients to a tertiary referral centre. It is dealing with limitations like these, and many more that can make rural surgery, in general, and ­laparoscopic surgery, in particular, a daunting prospect. Beyond mastering these limitations, there are several essential requirements for a successful LC. These are considered in further detail below.

22.2 Laparoscopic Cholecystectomy: Essential Requirements To successfully undertake procedures like LC, certain elements are essential. These include competent surgical staff, the availability of necessary infrastructure and appropriate ancillary services. These are explored in further detail below:

22.2.1 Competent Surgical Staff It is stating the obvious that a competent surgeon is ­crucial to any surgical procedure, and LCs are no exception: The surgeon performing a LC has to be well trained and possess the essential skill set for performing laparoscopic procedures. Structured supervised training is required to gain expertise in laparoscopy, and currently, this is provided by most surgical training programmes worldwide. However, it is important to note that every laparoscopic procedure has an individual learning curve, and evidence suggests that complication rates steadily reduce, then plateau after approximately 200 individually performed LCs. Surgeons should ensure their proficiency in performing a LC before

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attempting to undertake the procedure within an isolated rural hospital, and certainly those still in their learning curve would be ill advised to carry out the surgery when expert supervision is unavailable. If the surgeon is inexperienced with regard to LCs, it is essential that additional training be arranged in performing LCs to gain proficiency in performing the procedure. However, technical competence is only one aspect of competency. Among other things, a thorough knowledge of normal anatomy and awareness of anatomical variations is vitally important. Further, the ability to recognise complications such as injury to the bile duct and managing these expediently is essential. It is also important to understand that some complications are difficult to manage in the rural centre and close ties with region wide tertiary referral centres are essential to ensure appropriate management of these patients. Close collaboration with the tertiary centres provides means to a readily available specialist opinion if required. Also, should the need arise, a rapid pathway for patient transfer and management is available.

22.2.1.1 Assistants Although some rural and regional surgeons may be ­privileged to have a surgical trainee attachment, most would find recruiting assistants difficult in rural centres. Assistants adept in assisting laparoscopic procedures are invaluable but unfortunately not readily available in the rural setting. Local General Practitioners (GPs) can help address this problem. This can be achieved via a structured training programme organised with the help of hospital administration for GPs interested in assisting during surgery. Upon completion of the programme, they can then be included in the surgical team regularly as assistants.

22.2.1.2 Nursing Staff As with surgical assistants, nursing staff trained in laparoscopic surgery is at a premium in rural hospitals. Age-old problems of social and professional isolation make it difficult to attract experienced nursing staff to the rural setting. Nurses assisting laparoscopic procedures need to be well versed with the functioning

H.A. Kanhere and A.D. Strickland

of laparoscopic trolleys, adept in assembly of laparoscopic instruments, and experienced at assisting these surgeries.

22.2.2 Patient Selection One should never forget the principle “Choose well, cut well, get well”. Optimal preoperative assessment by the surgeon, anaesthetist and nursing staff is vital and will have a direct impact on patient outcome. Therefore, preadmission clinics should be organised for all patients with a review by the consultant anaesthetist and ­nursing staff after the surgical decision is made. Complex medical comorbidities requiring multi­ disciplinary management mostly preclude surgery in regional setting. Any patient perceived to be a postoperative ICU candidate due to such comorbidities should be appropriately investigated and referred to a tertiary centre. When surgery is deemed technically difficult, such as in patients with previous upper GI/hepatobiliary surgeries, morbid obesity, and/or Mirizzi syndrome, the surgeon should make the decision regarding eligibility based on their own surgical expertise.

22.2.3 Appropriate Infrastructure and Facilities Appropriate infrastructure to support a surgical service is essential to perform any procedure safely. This includes the availability of well-equipped operating rooms, appropriate instruments, facilities to perform an intraoperative radiological examination, a well-equipped and staffed recovery ward and finally good surgical wards. Surgeons should be well versed with the available instruments and ensure that good quality instruments in optimal working order are available. Every surgeon has personal preferences regarding instruments and operating room setup, and they should take steps to ensure that these requirements are met with. Figure 22.1 depicts most commonly used laparoscopic instruments.

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Fig. 22.1  Instrument tray

Summary

›› The surgeon undertaking the procedure should

››

›› ›› ››

be proficient in performing laparoscopic surgery, be well aware of complications and be able to deal with them. Good communication and rapport with a tertiary referral centre is important for specialist advice so that transfer is facilitated in a timely and smooth manner in case of complications. Patient eligibility should be assessed thoroughly preoperatively. Good lines of communication between anaesthetist, surgeon and nursing staff are essential. Appropriate infrastructure and facilities are mandatory.

22.3 Operative Technique

Fig. 22.2  Typical laparoscopic trolley

Appropriate laparoscopic setup includes good three chip cameras, 0° and 30° telescopes, a good light source and a gas insufflator. The surgeon should be acquainted with the working of all of these instruments. At least two such laparoscopic instruments trolleys should be available. Figure 22.2 shows a typical laparoscopic trolley.

This section covers some pertinent ergonomic issues with LC’s and is not intended as a detailed description of the procedure (such a description can be found in an operative surgery textbook). These simple steps help in avoiding irritating technical difficulties during surgery. The ‘open technique to create pneumoperitoneum’ is recommended by most surgical colleges. Laparoscopes should be placed in a warmer prior to use to avoid ‘fogging’ of the lens. Fogging necessitates frequent withdrawal of the scope to clean the lens, thereby causing repeated interruptions in the smooth flow of the surgery.

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Patient position: Patient is positioned supine with the operating table manoeuvred into position with elevation of the right side to obtain proper exposure. Patient position should be carefully adjusted to obtain clear views of the operative site by using gravity to lower the hepatic flexure of the colon and duodenum away from the operative field. Port positioning and direction: Standard port positions include 10–12 mm umbilical and epigastric ports and two 5  mm ports in the right upper quadrant (Fig. 22.3). It is common practice to insert the ‘camera port’ in close proximity of the umbilical scar. Obese patients and those in whom the umbilicus and the xiphisternum are spaced widely apart (more than ¾ the  length of the telescope) may pose a problem with this approach as the length of the telescope falls short of the operative site with this distance being ­further widened after pneumoperitoneum and cranial traction on the gall bladder compound the problem. This will lead to suboptimal visualisation of the operative site increasing risk of heuristic perception errors. A supraumbilical incision (2–3 cm cranial to the umbilicus) should be considered in this situation. This ensures adequate reach of the laparoscope to the operative site despite this distance being increased further with pneumoperitoneum and cranial retraction of the gallbladder. The 10  mm epigastric port should be inserted as close to the xiphisternum as possible initially directed straight into the peritoneal cavity and then cranially toward the patient’s right shoulder. This ensures optimal ergonomic position of the wrist with good triangulation of instruments after the gallbladder is retracted a

Fig. 22.3  Port positions

H.A. Kanhere and A.D. Strickland

cranially and to the patient’s right. An inferiorly directed/placed port makes it difficult to perform finer manoeuvres that are essential in dissection of Calot’s triangle. It is usual practice to place two 5 mm ports in the right upper quadrant, one in the proximity of the midclavicular line and the second close to the anterior axillary line. Both ports should be directed cranially. The medial port should be inserted after visualising the fundus of the gallbladder. This ensures proper positioning in relation to the gallbladder fundus. Optimal port positioning is also essential to facilitate performing a cholangiogram. This port should therefore be no more than 4 cm inferior to the costal margin. Correct port positioning allows the cholangiogram catheter and the cystic duct to be parallel and not at an angle as would be the case if this port is inserted inferiorly (Fig. 22.4a, b).

Summary

›› Use an Open technique of pneumoperitoneum ›› ››

b

– consider supraumbilical if umbilicus and ­xiphisternum are widely spaced. Optimal port positioning and direction epigastric port – close to xiphisternum, direct straight inwards and then to right shoulder. Medial 5 mm port – after visualising the gallbladder fundus, inserted subcostally, directed cranially.

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a

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b

Fig. 22.4  (a) Cholangiograsper, catheter and cystic duct in straight line by virtue of proper port placement. (b) Cholangiograsper and catheter at 90° angle to the cystic duct due to inferiorly placed port

22.4 Calots Triangle and the Critical View of Safety 22.4.1 How to Dissect Dissection of the Calots triangle is the most critical manoeuvre in a LC. This is the area bounded by the inferior surface of the liver, the common hepatic duct and the cystic duct, and is traversed by the cystic artery. The cystic artery and the duct have to be clearly defined to obtain the ‘critical view of safety’. These structures are exposed by careful dissection of the fibrofatty tissue within the Calot’s triangle. Good lateral traction on the Hartman’s pouch with gentle teasing and blunt dissection along with judicious use of diathermy will ensure good exposure. The Maryland forceps or an equivalent instrument is useful in this manoeuvre. Diathermy should be used in short sharp bursts if at all as it can cause inadvertent thermal injury to the bile duct. Division of the peritoneal attachment of the neck of the gallbladder to the liver will enhance the angle and facilitate this manoeuvre.

base of the liver bed is exposed by detaching the lowest part of the gallbladder from the liver. It is not necessary to see the common bile duct (CBD). This is the critical view of safety and once this is obtained, the cystic duct and artery can be safely clipped (Fig. 22.5). Strasberg and colleagues were the first proponents of the critical view of safety. Failure to achieve this critical view of safety is essentially a failure to delineate the anatomy satisfactorily which may be due to severe

22.4.2 Critical View of Safety Once the fibrofatty tissue is cleared, the cystic artery and the cystic duct are conclusively identified as the only two structures passing into the gallbladder and the

Fig. 22.5  Critical view of safety: Visualisation of the liver behind the cystic artery (a) and between the cystic artery and the cystic duct (b) by dissection of Calot’s triangle and detachment of the peritoneal attachment of the gallbladder base to the liver (c)

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inflammation, aberrant anatomy or troublesome bleeding, all of which are independent risk factors for bile duct injury. An open conversion should be therefore considered if this critical view is not obtained. Overzealous attempts to complete the procedure laparoscopically are fraught with a high risk of bile duct injury, and thus, an open conversion is a prudent decision.

Summary

›› Critical view of safety is vital. ›› Conclusive identification of cystic

duct and

cystic artery is essential.

›› The CBD need not be visualised. ›› Conversion to an open surgery is advocated if the critical view of safety is not achieved.

22.5 Dissection of the ‘Difficult Gallbladder’ The wall of the gallbladder cannot be grasped easily in presence of significant inflammation and this problem is compounded if the gallbladder is distended. A simple solution is to puncture the gallbladder and drain the contents, as emptying the gallbladder collapses its wall and makes it much easier to grasp and manipulate. Drainage can be achieved by inserting a large bore needle (in particular, the outer sheath of a Veress needle) into the fundus and connecting the suction tubing to the hub of the needle. Another alternative is to use the trocar of the 5 mm port to puncture the fundus and insert the suction into the gallbladder directly especially if the contents are very thick. Utmost care should be taken during these manoeuvres to prevent counterpuncture of the opposite wall of the gallbladder and disastrous liver or bile duct injury. It is advisable to divide all the adhesions between the liver and the omentum at the outset. This makes the liver more compliant, and it can be easily pushed cranially without the fear of capsular tears and bleeding from shearing of these adhesions. Severe inflammation around the Calots triangle sometimes makes antegrade dissection of the gallbladder very difficult. Judicious blunt dissection with graspers alternating with irrigation and suction is at

times the best way to progress. The suction cannula is a very functional instrument in this regard and can be used to bluntly dissect the adherent tissue, irrigate with saline under pressure and suck out the fluids. If satisfactory progress is not achieved, retrograde dissection and a subtotal cholecystectomy should be considered. The gallbladder is dissected off the liver beginning at the fundus. This dissection is carried towards the neck of the GB. Once the majority of the fundus has been mobilised, the GB can be opened and the stones extracted. A cholangiogram can be performed through the gallbladder to delineate the anatomy of the biliary tree. A subtotal cholecystectomy can then be performed. The stump of the gallbladder can be closed with endoloops or sutured laparoscopically provided such expertise is available. Large bore drain should be placed next to the gallbladder remnant, as the bile leak rates are high. Open conversion is always safe, and even then, a subtotal cholecystectomy may be the only option to deal with the problem.

22.6 Intraoperative Cholangiography Intraoperative cholangiography (IOC) has been traditionally performed to diagnose CBD stones/pathology. However, two recent publications have emphasised the role of routine intraoperative cholangiography in avoiding bile duct injury. Debate continues on the use of routine versus selective cholangiography, but it is essential that all the surgeons planning to undertake a  laparoscopic cholecystectomy are experienced in performing a cholangiogram. Various techniques are used to perform a cholangiogram. Every surgeon should select the technique that they are most familiar with. The simplest technique is to use a cholangiogram catheter passed through a cholangiogram grasper. The opening in the cystic duct is made with scissors held in the left hand of the surgeon and passed through the medial 5 mm port in the right upper quadrant. This ensures that the flap of duct wall does not obstruct the passage of the catheter into the cystic duct. Performing routine cholangiography will ensure that the technical skills are maintained, and the procedure is performed in optimal time as the necessary

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setup and support staff is ready and prepared to undertake the procedure. Several publications, however, challenge the routine use of intraoperative cholangiography. Additional costs and time needed for this procedure as well as the risk of false positive findings must be balanced against the potential benefits.

22.6.1 Interpretation of Results Every experienced surgeon advises that performing a  cholangiogram is of no use if it is not interpreted properly by the operating surgeon.

22.6.1.1 What Should Be Seen? A complete anatomy of the biliary tree has to be visualised. This includes the right and left hepatic ducts and the  common hepatic and bile ducts. Opacification of the segmental ducts should be sought as well. Attention should also be paid to delineating any filling defects within any portion of the bile duct. Flow of contrast into the duodenum should also be visualised (Fig. 22.6). Non opacification of the supracystic portion of the bile duct should NEVER be accepted and persistent attempts should be made to achieve a complete picture of the biliary tree. Non visualisation of any portion of the biliary tree despite manoeuvres like the Trendelenberg position to opacify proximal ducts is a failure to define the anatomy clearly and therefore an absolute indication to convert to open surgery (Fig. 22.7).

Fig. 22.6  Intraoperative cholangiogram

Summary

›› Evidence suggests that routine use of cholang›› ››

iography reduces the risk of bile duct injury. Surgeons should use techniques that they are comfortable with and standardise them. All attempts should be made to achieve a ‘complete’ cholangiogram when one is performed – an incomplete cholangiogram is a definite indication for open conversion. Fig.  22.7  Non-opacification of the supracystic portion of the biliary tree – absolute indication for open conversion

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22.7 Other Strategies to Avoid Bile Duct Injury A. All surgeons undertaking the procedure should be aware of the risk factors for bile duct injury such as acute cholecystitis, repeated attacks of pain, gall stone pancreatitis, Mirizzi syndrome, and post ERCP. Surgeons should ensure adequate assistance and take extra care to perform a methodical dissection in these situations. A low threshold for open conversion is advisable in the presence of these predictive factors and this should not be viewed as a complication but rather as a means to avoid a serious complication. B. Awareness of various anatomical variations of the biliary tree and the hepatic vasculature is vital. These aberrations are present in about 10% of patients. Most commonly, an aberrant/accessory right posterior sectoral duct joins the common hepatic duct. This can easily be mistaken for the cystic duct and divided if due care is not taken. Incorrect heuristic perceptions are responsible for a fair proportion of bile duct injuries and a second opinion should be sought in case of any doubts regarding the anatomy, although this is not always possible in the rural setting. A cholangiogram through direct puncture of the gallbladder can be valuable in delineating the anatomy and should be considered before any further dissection is performed. A liberal view towards open conversion is justified in these circumstances. C. Diathermy injuries are not uncommon and judicious use of diathermy in dissection of the Calot’s triangle is advocated. Coagulation of small volumes of tissues in short bursts is important. The cystic duct should not be dissected/divided with diathermy. This causes thermal necrosis deep to the cut surface of the duct and will lead to a biliary leak. D. Tenting of the CBD due to excessive traction on the gallbladder can lead to bile duct injury, especially when there is an inflamed gallbladder with a short cystic duct. Awareness of this possibility is essential and if injury is detected, attempts should be made to establish the critical view of safety. Excessive force and traction in retraction of the gallbladder should be avoided.

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E. Traction to the Hartman’s pouch should be applied laterally and outwards carrying the gallbladder away from the liver. This opens up the angle between the cystic duct and the CBD and helps in achieving the critical view of safety. A cranial retraction of the Hartman’s pouch should be avoided as it closes this angle and aligns the CBD and the cystic duct in a straight line, thus appearing as a single structure and potentially leading to misidentification injuries. F. Intraoperative Cholangiogram – as discussed above, two large population-based studies have inferred that routine intraoperative cholangiography reduces the risk of bile duct injury. This is by virtue of defining the anatomy before any structure is divided. Once Calot’s triangle is dissected and a normal cholangiogram is obtained, the cystic artery and duct are clipped and divided. The gallbladder is then dissected off the liver using diathermy and ‘flagging’ it to divide the peritoneum anteriorly and posteriorly. This plane is generally avascular. Drains – There is no evidence to support or refute the routine use of drains in laparoscopic cholecystectomy, and so this practice is generally driven by the surgeon’s personal preference. While operating in a regional centre, however, a somewhat liberal use of drains may be justifiable. Drains do not prevent complications like bile leaks or bleeding, but their presence may alert the surgeon/nursing staff to these complications earlier in the postoperative period. This essentially helps to deal with these complications much earlier and quicker transfer to a tertiary centre will be facilitated.

Summary

›› Awareness

›› ›› ››

of the risk factors for bile duct injury is vital. Extra care and meticulous ­dissection is required in these situations. Early decision for open conversion can avoid a potentially serious complication. Awareness of aberrations of biliary anatomy. Judicious use of diathermy and traction in the dissection of Calot’s triangle. Routine cholangiography.

22  Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting

22.8 Postoperative Care Surgeons have to ensure proper postoperative care by undertaking postoperative ward rounds and documenting detailed instructions regarding patient care as well as being aware of the capabilities of nursing and support teams within this context. This is critically important in the rural setting where resident surgical staff is often not readily available. Clear instructions should be provided to the nursing staff regarding recording vital signs and observations. A low threshold should be maintained in alerting the surgeon to any possible complication(s). It is vitally important to detect problems as early as possible and therefore one of the strategies may be to use drains to diagnose bile leak/bleeding as alluded to earlier. Good clinical examination and close monitoring however are indispensable.

22.9 Complications: Detection and Management Protocol Complications of LC include bleeding, biliary leak and bile duct injuries.

22.9.1 Bleeding Care should be taken during surgery to ensure a secure application of the clips by closing the jaws of the applicator firmly after the clip has completely occluded the artery. Postoperative bleeding may necessitate urgent intervention which may be in the form of a laparoscopy or open exploration. Every attempt should be made to resuscitate the patient with IV fluids, oxygen, and regular monitoring. Blood transfusion should be organised if warranted. Haemodynamically unstable patients should be ­re-explored with the approach guided by the surgeon’s expertise. A bleeding cystic artery stump can often be controlled with laparoscopic exploration, washout and re clipping or applying endoloops. An open approach is always safe should the surgeon feel that laparoscopy

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would be logistically difficult to organise in the emergency setting as is often the case in the rural centres. As discussed in the preceding sections, a well-defined pathway for transfer to a tertiary care centre should be in place in case the need arises.

22.9.2 Bile Duct Injuries Bile duct injuries should never be dealt with surgically or otherwise at regional centres unless hepatobiliary expertise is available. Repair by a specialist hepatobiliary surgeon other than the one performing the LC is advocated. There is a high rate of vascular injuries associated with CBD injury and consequently a high stricture rate if a hepaticojejunostomy is performed with the distal bile duct. Multidisciplinary input is invaluable in decision making and complex surgery (proximal Hepaticojejunostomy/lateral hepaticojejunostomy with the segment III duct) will often be required. If a bile duct injury is suspected, a specialist hepatobiliary surgical opinion should be immediately sought before proceeding to perform any further manoeuvres like T tube insertions. Use of T tubes in a nondilated duct with an associated element of vascular injury will predispose to stricture formation in the long term. A primary repair (lateral hepaticojejunostomy to a segment III duct) may be preferable in such situations. Large bore drains should be placed to prevent biliary contamination of the peritoneum. Arrangements for an urgent transfer to a hepatobiliary centre should be made. Adequate information should be provided to the patient. Early repairs of bile duct injuries can be carried out if the patient is transferred within 24 h of the surgery and generally have good results. As is many times the case, bile duct injuries are not diagnosed intraoperatively and a high index of suspicion of bile leak should be maintained in anyone who ‘appears unwell’ on the first postoperative day.

22.10 Management of CBD Stones CBD stones can pose a therapeutic dilemma in the rural setting.

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A diagnosis of CBD stones is made on the basis of clinical, biochemical and radiological grounds. A detailed history and clinical examination are indispensable. A history of recent episode of jaundice, high coloured urine and pale stools will alert the surgeon to this possibility. Every patient should have liver function tests carried out prior to surgery. CBD stones may not always be seen on an ultrasound examination, but a dilated CBD in combination with elevated liver function tests should always be regarded as suspicious. CBD stones should therefore be presumed to be present in patients with clinical evidence/history of jaundice, raised liver function tests and a dilated CBD in presence of gall stones. Further investigations (CT scan/MRCP) can be carried out if clinically warranted and facilities are available. The various options available for management of CBD stones include A. Preoperative ERCP followed by cholecystectomy B. Laparoscopic transcystic bile duct exploration with removal of stones and cholecystectomy C. Laparoscopic choledocotomy and extraction of stones with choledocoscopy and cholecystectomy D. Open bile duct exploration Most institutes have protocols for management of CBD stones depending on the resources available. A. Preoperative ERCP is an effective option of removing stones from the CBD. ERCP has a success rate of almost 90% in stone extraction. It does have the potential short-term side effects of bleeding and pancreatitis and the theoretical risk of long-term sequelae from a sphincterotomy. False negative results are also known. If facilities are not available to perform an ERCP, a transfer to a tertiary centre should be undertaken preoperatively. Postoperative ERCP should not generally be relied upon if CBD stones are diagnosed preoperatively. B. Where technical skills and equipment are available, laparoscopic transcystic bile duct exploration and stone extraction is an excellent option. The obvious advantage is a single stage treatment as well as reduction in the number of unnecessary ERCPs with the attendant risks. This is a cost-effective, safe and efficacious procedure if performed by experienced surgeons.

H.A. Kanhere and A.D. Strickland

The basic principle of a laparoscopic transcystic bile duct exploration is to pass a balloon trawling catheter/basket into the CBD through the cystic duct. A cholangiogram is performed to confirm the presence of bile duct stones. The cholangiogram catheter is then withdrawn, and the balloon catheter/basket is passed down into the bile duct through the cholangiograspers. The catheter is negotiated beyond the stones, the balloon is inflated and the stones are trawled out. A transcystic exploration is certainly possible in the rural setting and does not require many specialised instruments. Large and impacted stones however are difficult to extract by this technique. C. Laparoscopic choledocotomy and formal CBD exploration is a relatively specialised procedure. It requires expertise in specialised laparoscopic skills on the part of the surgeon. Not only is surgical skill important but the assistant needs to be well trained in using specialised equipment like a choledochoscope. However, if all these prerequisites are met, it is feasible to perform this procedure in the rural and regional centres. An Australian study performed on 1,567 consecutive patients undergoing laparoscopic cholecystectomy in rural hospitals found 82 (5.2%) cases with choledocholithiasis at intraoperative cholangiography. A total of 86 laparoscopic CBD explorations were undertaken in these patients with 37 (43%) via a transcystic approach and 49 (57%) via a laparoscopic choledochotomy. All CBD calculi were successfully removed in 78 cases, representing an overall duct clearance rate of 90.7%. Complications were noted in seven patients which represents a morbidity rate of 8.5%. Median operative time for the procedure over the study period was 173 min. Median hospital stay was 6  days for all patients. The authors conclude that laparoscopic CBD exploration can be successfully undertaken in a rural setting by general surgeons who have appropriate laparoscopic experience, and should be the procedure of choice for the management of choledocholithiasis in these patients. It should not be restricted to specialised surgical departments in major referral centres. Authors like Vecchio and others though advise caution as the technique requires proficiency in advanced laparoscopic skills including suturing,

22  Gallbladder Surgery: Laparoscopic Cholecystectomy and Management of Bile Duct Stones in the Rural Setting

and knot tying, as well as using equipment such as a choledochoscope, guidewire, dilators and balloon stone extractors. Although laparoscopic CBD exploration appears to be the most cost-effective method to treat CBD stones, it should be emphasised that this procedure is very challenging and thus should be performed by well-trained laparoscopic surgeons with experience in biliary surgery. Note: Any instrumentation of the CBD should be carried out with a longitudinal incision on the anterior wall of the CBD to avoid injury to the blood supply of the duct. D. An open bile duct exploration with cholecystectomy with or without T tube placement depending on the size of the common duct is a safe option. The rural surgeon has to possess skills to perform this procedure as it is the only option available in case logistical ration is the most reliable option if the stones are large and/or impacted. Kochers manoeuvre is essential to obtain good exposure and access to the bile duct. Stoproblems precluding any of the other management pathways. Open bile duct explones can be cleared with the use of a choledocoscope if one is available. Other options include the use of a fogarty catheter to trawl the stones, or a stone extraction forceps (Desjardins). Careful postoperative care is essential. A T tube is usually used to drain the bile duct and a subhepatic drain is advocated. Logistical limitations and lack of trained personnel can preclude ERCP and laparoscopic bile duct exploration in the rural setting. Thus, even if the surgeon is skilled in performing these procedures, careful consideration must be given to these aspects of the surgery. Preoperative diagnosis of CBD stones may therefore require transfer to a facility where these procedures are regularly performed. E. Postoperative ERCP should be undertaken if stones are diagnosed at the time of intraoperative cholangiography and the technical expertise to perform a bile duct exploration is not available. These technical and logistical problems are expectedly high in the rural setting and consequently a higher rate of postoperative ERCP is expected. The use of a drain and endoloops to secure the cystic duct stump in this situation is somewhat of a surgical dogma. Although no clear evidence

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exists to support it, this appears to be a logical practice to prevent cystic duct stump leaks from raised intraductal pressure (obstruction due to stones and ERCP). This approach does run the risk of a third procedure being required if ERCP fails.

22.11 Summary Laparoscopic cholecystectomy can be performed safely and efficiently in rural and regional centres where trained staff and expertise is available along with all the necessary equipment. Criteria for patient selection and protocols for management of complications should be clearly defined beforehand. Support from a specialised hepatobiliary unit should always be available should the need arise.

Recommended Reading Avgerinos, C., Kelgiorgi, D., Touloumis, Z., et al.: One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. J. Gastrointest. Surg. 13(3), 498–503 (2009) Fletcher, D.R., Hobbs, M.S., et al.: Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann. Surg. 229(4), 449–457 (1999) Flum, D.R., Dellinger, E.P., Cheadle, A., et  al.: Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289(13), 1639–1644 (2003) Hemli, J.M., Arnot, R.S., Ashworth, J.J., et  al.: Feasibility of laparoscopic bile duct exploration in a rural centre. ANZ J. Surg. 74(11), 979–982 (2004) Pierce, R.A., Jonnalagadda, S., Spitler, J.A., et al.: Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP. Surg. Endosc. 22(11), 2365–2372 (2008) Strasberg, S.M.: Avoidance of bile duct injuries during laparoscopic cholecystectomy. J. Hepatobiliary Pancreat. Surg. 9(5), 543–547 (2002) Strasberg, J.M.: Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J. Hepatobiliary Pancreat. Surg. 15(3), 284–292 (2008) Thomson, B.N., Parks, R.W., Madhavan, K.K., et  al.: Early ­specialist repair of biliary injury. Br. J. Surg. 93(2), 216–220 (2006) Vecchio, R., MacFadyen, B.V.: Laparoscopic common bile duct exploration. Langenbecks Arch. Surg. 387(1), 45–54 (2002)

 

23

Liver Surgery Faud Alkhoury, Christine Vancott, and Randall Zuckerman

23.1 Anatomical Considerations The anatomy of the liver is defined by the underlying vascular and biliary anatomy inside of the liver rather than on surface features. At the first level, the liver is divided into two hemilivers (right and left). At the second level, it is divided into four sections (right posterior, right anterior, left medial, and left lateral). At the third level, it is divided into eight segments, each of which is a discrete anatomic unit that possesses its own nutrient blood supply and venous and biliary drainage. The right hemiliver consists of segments 5 through 8 and is nourished by the right hepatic artery and the right portal vein; the left hemiliver consists of segments 2 through 4 and is nourished by the left hepatic artery and the left portal vein. The caudate lobe, a portion of the liver that is separate from the two hemilivers, consists of segment 1. The anatomic division between the right hemiliver and the left is not at the falciform ligament (the most readily apparent visual landmark on the anterior liver), but follows a line projected through a plane (the principal plane, or Cantlie’s line) that runs posterosuperiorly from the medial margin of the gallbladder to the left side of the vena cava. The venous drainage of the liver consists of ­multiple small veins draining directly from the back

F. Alkhoury and C. Vancott Department of Surgery, Hospital of St. Raphael, 1450 Chapel St. New Haven, CT 06511, USA R. Zuckerman (*) North Country Hospital, 189 Prouty Drive, Newport, VT 05855, USA e-mail: [email protected]

of the right hemiliver and the caudate lobe to the vena cava, along with three major hepatic veins. These major hepatic veins occupy three planes, known as portal scissurae. The three scissurae divide the liver into the four sections, each of which is supplied by a portal pedicle; further branching of the pedicles subdivides the sections into their constituent segments. The right hepatic vein passes between the right anterior section (segments 5 and 8) and the right posterior section (segments 6 and 7) in the right scissura. This vein empties directly into the vena cava near the atriocaval junction. The middle hepatic vein passes between the right anterior section and the left medial section (segment 4, sometimes subdivided into segments 4a and 4b) in the central, or principal, scissura, which represents the division between the right hemiliver and the left. The left hepatic vein runs in the left scissura between segments 2 and 3 (which together make up the left lateral section). In most persons, the left and middle hepatic veins join to form a common trunk before entering the vena cava. Occasionally, a large inferior right hepatic vein is present, which may provide adequate drainage of the right hemiliver after resection of the left even when all three major hepatic veins are ligated [1]. The portal vein and the hepatic artery divide into left and right branches below the hilum of the liver. Unlike the major hepatic veins, which run between segments, the portal venous and hepatic arterial branches, along with the hepatic ducts, typically run centrally within segments. On the right side, the hepatic artery and the portal vein enter the liver substance almost immediately after branching. The short course of the right-side extrahepatic vessels and the variable anatomy of the biliary tree make these

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_23, © Springer-Verlag Berlin Heidelberg 2011

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vessels vulnerable to damage during dissection [2]. In ­contrast, the left branch of the portal vein and the left hepatic duct take a long extrahepatic course after branching beneath segment 4. When these vessels reach the base of the umbilical fissure, they are joined by the left hepatic artery to form a triad, which then enters the substance of the left hemiliver at this point. It must be emphasized that proximal to the base of the umbilical fissure, the left-side structures are not a triad. A consequence of the long extrahepatic course of the left-side structures is that for tumors that involve the hilum (e.g., Klatskin tumors), when a choice exists between an extended right hepatectomy and an extended left hepatectomy, most surgeons choose the former because the greater ease of dissection on the left side facilitates preservation of the leftside structures.

23.2 Primary Cancers 23.2.1 Hepatocellular Cancer Hepatocellular cancer (HCC), or hepatoma, is the fifth most common cancer in the world. The most common cause is viral hepatitis. In the United States, some 3 million people are infected with hepatitis C virus (HCV), and more than one million people have liver disease associated with hepatitis B virus (HBV). HCV infection is more likely to lead to HCC than HBV infection is.

23.2.1.1 Clinical Evaluation The usual presentation of sporadic HCC consists of pain, mass, and systemic symptoms of cancer, though the disease may also be discovered incidentally. HCC is often manifested first as a deterioration of liver function with the onset of jaundice, ascites, or encephalopathy.

23.2.1.2 Investigative Studies Screening programs are employed in high-risk populations. These programs, which use a-fetoprotein

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(AFP) levels and ultrasonographic examination of the liver to detect early HCC, may detect asymptomatic tumors. The diagnosis of sporadic HCC is based on elevation of AFP levels (an indicator with 50–60% sensitivity) and the presence of a hepatic mass on axial images. HCCs typically demonstrate hypervascularity, pseudocapsule is often visualized, and multifocality is also common in HCC, and this finding often serves to differentiate it from other hepatic neoplasms. Routine biopsy is not indicated in patients with a characteristic mass, those who have a mass and an elevated AFP level, or those who are symptomatic and require treatment for pain. Biopsy is associated with a small risk of bleeding or tumor seeding.

23.2.1.3 Surgical Staging Staging of sporadic HCC requires axial imaging of the abdomen and imaging of the chest. FDG-PET scanning is only marginally useful: HCCs are typically well differentiated, and as a result, only 50% of the tumors are visualized. Staging laparoscopy is helpful: additional tumors are found in about 15% of patients [3]. The Child-Pugh classification is used to determine operability. With few exceptions, resection is limited to Child class A patients with near normal bilirubin levels (<1.5  mg/dl), a normal or marginally raised prothrombin time (PT), and no or minimal portal hypertension. The extent of resection must be tailored to the severity of the liver disease. In Japan and China, indocyanine green (ICG) clearance is used in Child class A patients to determine the possible extent of resection. Partial liver resection is the procedure of choice for sporadic HCC in patients with normal livers. In Child class B or C patients with chronic liver disease, liver resection can be hazardous, and orthotopic liver transplantation (OLT) is the procedure of choice. OLT is restricted to patients with a single tumor less than 5 cm in diameter or to patients with as many as three tumors, none of which are more than 3  cm in diameter (the Milan criteria). These criteria have been shown to be associated with OLT outcomes comparable to those for benign conditions [4].

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In Child class A patients with liver disease, hepatic resection and OLT are options if the Milan criteria are met. Currently, it would seem that the best strategy in patients who meet the criteria for OLT is to perform primary OLT for HCV-associated disease [5] and to perform resection and salvage OLT for HBV-associated disease [6] and other HCCs of non-HCV origin. In patients who do not meet the OLT criteria, resection would be performed even if the tumor is of HCV ­origin. At present, there is a trend toward liberalizing the OLT criteria to include single tumors 6 or 7  cm in diameter, especially if the source of the organ is a living donor. When OLT is to be performed, it is important that the waiting time be short; these tumors progress over a timescale of a few months, and when viewed on an intention-to-treat basis, the results of OLT deteriorate significantly if the waiting time is long [7]. In the United States, this concern has been dealt with by the introduction of the Model for End-stage Liver Disease scoring system, which gives priority to recipients with HCC. It is common in the United States – and usual in countries with longer waiting times – to inhibit the growth of the HCC with various bridgingto-transplantation strategies during the waiting period for OLT. Such strategies include systemic chemotherapy, local treatments (e.g., radiofrequency [RF] ablation and alcohol injection), transarterial chemoembolization, and even resection of the HCC (so-called bridge resection). As much as 70% of the liver may be safely excised when normal liver function is present. The size of the future hepatic remnant may be determined by means of imaging. Portal Venous Embolization (PVE) of the side of the liver to be resected may be performed preoperatively to increase the size of the future remnant. It may also be used for this purpose in patients with liver disease. In these patients, PVE functions as a test of the liver’s ability to regenerate. Failure to respond to PVE is itself a contraindication to surgery in patients with chronic liver disease. As a rule, liver resections for HCC should be anatomic. Recurrence rates are higher with nonanatomic resections because HCCs grow along portal veins and metastasize locally within segments, sections, or hemiliver, depending on how far they reach back along the portal veins. When HCC reaches the main portal vein, resection is generally contraindicated; the results are very poor in this situation.

23.2.2 Intrahepatic Cholangiocarcinoma 23.2.2.1 Clinical Evaluation Intrahepatic Cholangiocarcinomas arise from intrahepatic bile ducts. There are three types: a mass-forming type (MF), a periductal infiltrating type (PI), and a type that grows as an intraductal papillary tumor (IG). The MF type is by far the most common. Intrahepatic CCA tumor usually occurs in normal livers. The presentation is similar to that of sporadic HCC. 23.2.2.2 Investigative Studies On diagnostic imaging, the appearance of intrahepatic CCA is suggestive of a secondary tumor. Diagnosis of intrahepatic CCA usually requires a biopsy, and special stains may be helpful in differentiating this tumor from a true secondary malignancy, but the differentiation is rarely certain. An elevated CA 19–9 concentration is strongly suggestive of this diagnosis if it is higher than 100 U/ml. To make the diagnosis of intrahepatic CCA, primary tumors in other sites must be excluded by means of axial imaging of the chest, the abdomen, and the pelvis; upper and lower GI endoscopy; and mammography. FDG-PET scanning is another means by which an extrahepatic primary may be identified, but it has not been fully evaluated in this setting. 23.2.2.3 Surgical Staging FDG-PET scanning appears to be a promising staging tool for identifying portal lymph node and distant metastases when the primary is actually an intrahepatic CCA. Portal lymph node metastases are a contraindication to resection in patients with MF tumors; the results of resection in this situation are very poor. Leftside tumors may metastasize to lymph nodes at the cardia of the stomach and along the lesser curvature.

23.2.2.4 Management The considerations related to resection for intrahepatic CCA are similar to those for sporadic HCC (see above). Liver transplantation generally is not performed for this tumor, because of the typically poor results.

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23.3 Secondary Cancers 23.3.1 Colorectal Metastases 23.3.1.1 Clinical Evaluation and Investigative Studies About 50% of the 150,000 patients who are diagnosed with colorectal cancer annually in the United States either have or will have liver metastases. About 20% of patients with these colorectal metastases (CRMs) are eligible for liver resection. CRMs may be diagnosed either at the time of treatment of the primary colorectal cancer (synchronous tumors) or at a later stage (metachronous tumors). Synchronous tumors are diagnosed by means of either, preoperative CT scanning, intraoperative palpation, or intraoperative ultrasound. LFTs may show elevations (especially of the serum alkaline phosphatase level), but these results are not specific. CEA levels are not helpful as long as the primary tumor is in place. Metachronous tumors are most often diagnosed in the course of a postcolectomy surveillance program, either by imaging the liver with CT scans or FDG-PET scans or by detecting a rise in the CEA level. When synchronous metastases are discovered preoperatively, a FDG-PET scan should be done to complete the staging.

23.3.1.2 Surgical Staging In about 25% of patients, FDG-PET scanning changes management by detecting unsuspected extrahepatic or intrahepatic disease. Sometimes, it demonstrates that apparent metastases are actually benign lesions. Second primaries are not uncommon in patients with metachronous lesions; accordingly, such patients should also be staged by means of colonoscopy, if this procedure was not done in the preceding 6 months, as well as FDG-PET scanning. Staging laparoscopy adds little to staging if an FDG-PET scan has been done. Intraoperative ultrasound of the liver may also detect unsuspected lesions, though this is less likely if the patient has already been staged by means of FDG-PET. The main value of FDG-PET in this setting is its ability to discover unsuspected extrahepatic disease. In so doing, it helps eliminate futile hepatic resections.

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If a patient with extrahepatic disease is treated with hepatic resection, a “recurrence” is inevitable. Elimination of pointless resections has a positive effect on survival: The overall 5-year survival rate after FDG-PET was about 60%, compared with 40% after conventional imaging [8]. Furthermore, the study showed that after FDG-PET scanning, the classic prognostic factors of the secondary tumor (e.g., tumor number and tumor size) were no longer significant; rather, the most important prognostic factor was the grade of the primary tumor. FDG-PET scanned patients with poorly differentiated primary tumors did very poorly in terms of overall survival after hepatic resection [8]. Currently, standard PET scanners are rapidly being replaced with CT-PET scanners, which fuse the images and provide superior ­diagnosis and staging. However, the level of detail provided by high-quality, contrast-enhanced CT or MRI is also required. The criteria that determine eligibility for resection are (1) that the primary tumor has been or can be completely resected, (2) that (with uncommon exceptions) there is no extrahepatic tumor (other than the primary), and (3) that it is possible to resect all tumors in the liver while leaving enough of a hepatic remnant to ensure that hepatic failure does not develop postoperatively. The considerations governing the extent of the resection and the use of PVE are similar to those for sporadic HCC. Treatment of multiple tumors is more common with CRMs than with HCC. However, non-anatomic resections are as effective as anatomic resections as long as the resection margin is microscopically clear. Synchronous resection of the primary tumor and the liver metastases has proved to be safe [10] and is desired by many patients. The decision to proceed with hepatic resection should not be made until resection of the primary tumor has been completed and it has been determined that the margins are clear and the patient is stable.

23.3.1.3 Ablation of Colorectal Metastases In situ destruction of tumors with cryotherapy, radio­ frequency (RF), or microwave ablation may expand the surgeon’s ability to eradicate CRMs localized to the liver [11]. RF ablation has largely supplanted cryotherapy in this context as a result of its lower incidence of complications and greater ease of use.

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Ablation may be used either as an adjunct to operative management or as the sole treatment when there are many metastases (but usually < 10). The efficacy of RF ablation as an adjunct to surgery remains to be determined. It is doubtful, however, that using this modality alone to eradicate multiple lesions will improve overall survival significantly, because the tumor biology in such cases is likely to be that of an aggressive tumor. FDG-PET scans should be performed in all such patients; the likelihood of discovering extrahepatic tumors increases as the number of hepatic tumors increases [8]. RF ablation is not recommended for treatment of resectable metastases: it is not approved for this purpose, and using it in this way would mean substituting an unproven therapy of unknown efficacy for a proven therapy of known value.

23.3.2 Neuroendocrine Metastases Neuroendocrine metastases are characteristically slow growing. Some are functional, especially if they arise from the ileum; metastatic liver disease from this source may produce carcinoid syndrome. OctreoScan provides staging information comparable to that provided by FDG-PET in patients with CRMs. The aims of surgical treatment are (1) to eradicate the cancer and (2) to reduce hormonal symptoms. Resection should be performed if all cancer can be removed and no extrahepatic cancer is detectable. In highly symptomatic patients in whom conservative therapy with octreotide has failed, debulking the tumor by means of either chemoembolization or surgery may provide relief. The former is more suitable for patients with multiple small, diffuse metastases, whereas the latter is preferred for patients with large localized tumors.

23.3.3 Noncolorectal, Nonneuroendocrine Metastases Occasionally, liver metastases from other primary sites behave like CRMs, in that they are localized to part of the liver in the absence of extrahepatic disease. Such

patients can be managed according to the same approach employed for CRMs, though the outcome is somewhat less satisfactory. Tumors that have been treated in this way with acceptable results include breast cancers, renal cell cancers, gastric cancers, acinar cell cancers of the pancreas, and ovarian cancers, and sarcoma. Liver resection for more aggressive malignancies (e.g., metastases from gallbladder cancer and pancreatic ductal adenocarcinomas) can be expected to yield very poor results.

23.4 Incidentally Discovered Asymptomatic Hepatic Mass Now that transaxial imaging of the abdomen is commonly performed for a variety of complaints, the ­problem of the incidentally discovered asymptomatic hepatic mass is being encountered with increased frequency. Generally, cysts are easily distinguished from solid tumors; the main diagnostic issue is differentiation of the various solid lesions. The differential diagnosis of the benign solid hepatic mass includes hepatic adenoma, focal nodular hyperplasia (FNH), focal fatty infiltration, cavernous hemangioma, and other rare neoplasms (e.g., mesenchymal hamartoma and teratoma) – all of which must be distinguished not only from one another but also from malignant tumors. In the past, several diagnostic tests (e.g., ultrasonography, CT, sulfur colloid scanning, and angiography) were used to differentiate these neoplasms. Currently, many perform MRI with gadolinium contrast enhancement, which generally allows accurate differentiation among benign tumors with a single test. Cavernous hemangiomas are usually easy to distinguish because they have a characteristic appearance on MRI (hypointense on T1-weighted images, very intense on T2-weighted images, and filling in from the periphery with gadolinium injection); if they are asymptomatic, they need not be resected. It is important to distinguish asymptomatic FNHs from hepatic adenomas: whereas resection is recommended for adenomas, because of their potential for hemorrhage or malignant degeneration, asymptomatic FNHs can safely be observed. An FNH is nearly isointense on T1- and T2-weighted images; it shows slightly more

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enhancement than normal liver parenchyma in the early phase after contrast injection, and then becomes isointense. A central scar is often, but not always, seen. Conversely, a hepatic adenoma exhibits strong early phase enhancement with contrast administration, and it tends to be hyperintense on T1-weighted images. Given that a symptomatic hepatic mass is usually treated with resection, preoperative biopsy for tissue diagnosis is rarely necessary or desirable. Modern noninvasive radiologic tests, in conjunction with a careful patient history, are often quite accurate in predicting histologic diagnosis. As a rule, biopsies should be performed when definitive surgical intervention is not planned and when pathologic confirmation is necessary for institution of nonsurgical therapy.

23.4.1 Techniques/When to Refer There has been advancement in the technology available for liver resection. Crush and clamp techniques are still widely used and effective. Energy devices such as ultrasonic shears and ligasure are very effective for transecting the first few centimeters of liver in a bloodless fashion. RF devices are very expensive but useful as well [9]. Endo-GIA staplers are becoming routine for parenchymal transection and are very good for controlling large vessels and bile ducts. For peripheral lesions and non-anatomic resections, if experienced and comfortable, a surgeon could approach these in a rural center. For resections involving more than two segments or in diseased liver, referral to a specialist surgeon is advisable.

F. Alkhoury et al.

References   1. Baer, H.U., Dennison, A.R., Maddern, G.J., et al.: Subtotal hepatectomy: a new procedure based on the inferior right hepatic vein. Br. J. Surg. 78, 1221 (1991)   2. Smadja, C., Blumgart, L.H.: The biliary tract and the anatomy of biliary exposure. In: Blumgart, L.H. (ed.) Surgery of the Liver and Biliary Tract, 2nd edn. Churchill Livingstone, London (1994)   3. Lo, C.M., Lai, E.C., Liu, C.L., et al.: Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma. Ann. Surg. 227, 527 (1998)   4. Mazzaferro, V., Regalia, E., Doci, R., et al.: Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N. Engl. J. Med. 334, 693 (1996)   5. Adam, R., Azoulay, D., Castaing, D., et al.: Liver resection as a bridge to transplantation for hepatocellular carcinoma on cirrhosis: a reasonable strategy? Ann. Surg. 238, 508 (2003)   6. Poon, R.T., Fan, S.T., Lo, C.M., et al.: Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation. Ann. Surg. 235, 373 (2002)   7. Llovet, J.M., Fuster, J., Bruix, J.: Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. Hepatology 30, 1434 (1999)   8. Fernandez, F.G., Drebin, J.A., Linehan, D.C., et al.: Fiveyear survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET). Ann. Surg. 240, 438 (2004)   9. Topp, S.A., McClurken, M., Lipson, D., et al.: Salinelinked surface radiofrequency ablation: factors affecting steam popping and depth of injury in the pig liver. Ann. Surg. 239, 518 (2004) 10. de Santibanes, E., Lassalle, F.B., McCormack, L., et  al.: Simultaneous colorectal and hepatic resections for colorectal cancer: postoperative and longterm outcomes. J. Am. Coll. Surg. 195, 196 (2002) 11. Strasberg, S.M., Linehan, D.: Radiofrequency ablation of liver tumors. Curr. Probl. Surg. 40, 459 (2003)

Pancreatic Surgery

24

Markus Trochsler, Thomas Satyadas, and Harsh A. Kanhere

24.1 Introduction The pancreas is a unique organ with complex anatomy and physiology. It is difficult to access because of its deep retroperitoneal location. The gland itself is very vascular and often very soft and friable. It has a very close relationship with major blood vessels and the common bile duct. Performing surgery on the pancreas can thus be very challenging. In the modern era, most pancreatic pathologies are referred to tertiary-level metropolitan hospitals due to these reasons. Interestingly though, pancreatic surgery seems to have its roots in rural Germany. Friedrich Wilhelm Wandesleben (1800–1868), a small-town German physician, performed the first reported surgical ­procedure on the human pancreas. In November 1841, he surgically drained a traumatic pancreatic pseudocyst. Pancreatic cancer was first surgically tackled by pancreaticoduodenectomy, performed by Walter Kausch in 1912 and further modified by A.O. Whipple in 1934. Most common surgical conditions of the pancreas include acute and chronic pancreatitis, trauma and neoplasms. The inflammatory conditions often require conservative treatment and the neoplasms are best managed in tertiary referral centres with multidisciplinary teams. Nevertheless, some pancreatic pathologies can be successfully managed in a rural surgical

M. Trochsler (*), T. Satyadas, and H.A. Kanhere Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected], [email protected], [email protected]

setting. These include necrosectomy in the context of acute necrotizing pancreatitis, management of pseudocysts and initial management of pancreatic trauma. This chapter focuses mainly on these procedures. A brief outline of surgical management of pancreatic neoplasms will be provided for the interested reader.

24.2 Relevant Surgical Anatomy The pancreas is a deep-seated retroperitoneal organ that is difficult to access. It lies across the spinal ­column at the level of the 1st to 3rd lumbar vertebrae extending from the C-loop of the duodenum to the hilus of the spleen. The splenic artery and vein run along its cranial–dorsal border. The superior mesenteric artery originates dorsal to the body of the pancreas. The superior mesenteric vein runs upwards and to the left, to join the splenic vein behind the neck of pancreas and forms the portal vein. The common bile duct descends posterior to the head of the pancreas and enters the duodenum with the pancreatic duct. The pancreas shares its blood supply with the duodenum from the common hepatic and superior mesenteric artery. It is drained by the superior mesenteric and the splenic vein. A plethora of peripancreatic lymph nodes primarily drain the organ and further drain – from right to left – into subpyloric, portal, mesenteric, mesocolic and aortocaval nodes. The close anatomic relationship of the friable pancreas with these major intestinal blood vessels makes bleeding a major concern in pancreatic surgery and trauma. Furthermore, the relative rigid fixation of the head of the pancreas in the C-loop of the duodenum

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allows only minimal movement of the organ, and therefore, makes it vulnerable to blunt trauma, especially over the spinal column.

24.3 Surgical Access to the Pancreas The pancreas is best approached transperitoneally. Various incisions can be used to provide good access to the pancreas. The choice of incision depends on the patient’s body habitus, the type of pathology and the region of the pancreas to be accessed. A midline laparotomy provides good access to the pancreas and furthermore enables the surgeon to adapt to the intra-abdominal findings, especially in case of emergent surgery in trauma or acute pancreatitis. Tumours and pathologies in the body and tail of the pancreas can be best accessed by a left subcostal incision with a right-sided extension if required. A right subcostal incision with a left-sided extension (roof top incision) provides excellent access to the head of the pancreas and the portal triad, making this a preferable approach in pancreaticoduodenectomies. The organ itself is accessible at its retroperitoneal location using a combination of three manoeuvres. The division of the gastrocolic ligament will provide access to the lesser sac to expose the body and tail of the pancreas. The view may be limited if a generous opening is not performed. The access to the head of the pancreas is further gained by performing a liberal Kocher’s manoeuvre. Incising the peritoneum lateral to the duodenum and blunt dissection in an avascular plane between the inferior vena cava and the C-loop of the duodenum will provide access to the dorsal surface of the pancreatic head. This may be combined with the division of the ligament of Treitz to expand the view to the dorsal aspect of the pancreas. The opening of the gastrocolic omentum by dividing it along the colonic wall to enter the lesser sac will exhibit the ventral pancreatic surface in its entire extent. The initial opening should be made towards the left lateral aspect where the two layers of the omentum are separate and easy access to the lesser sac can be gained. This technique opens the lesser sac completely and will allow the assessment of the whole organ. The third approach combined with the Kocher manoeuvre will allow the most comprehensive access to the pancreas without devascularisation of the pancreas.

M. Trochsler et al.

24.4 Necrotising Pancreatitis 24.4.1 Nonsurgical Management Acute pancreatitis is managed conservatively whenever possible. This may require immediate transfer of the patient to a tertiary care facility with a fully equipped intensive care unit (ICU) and the possibility of invasive monitoring (central venous or Swan-Ganz monitoring catheter). The role of surgical intervention in management of sterile pancreatic or peripancreatic necrosis is controversial. In a controlled and stable clinical situation, nonoperative treatment is favoured. There is, however, a general consensus that some form of intervention is required in patients with infected necrosis – indicated by clinical suspicion, extraintestinal gas bubbles or positive cultures on fine needle ­aspiration. These may include in selected patients antibiotics alone, or antibiotics with endoscopic drainage or antibiotics with CT-guided percutaneous drainage. One has to remember that the paste-like necrotic pancreas tissue is difficult to drain completely by smalldiameter drainage catheters.

24.4.2 Indication for Surgery Rapid clinical deterioration with the onset of or manifest multiorgan failure despite maximal supportive therapy demands for immediate surgical intervention. This may be indicated by worsening of known pancreatitis scores, rising C-reactive protein in the presence of necrotic and infected pancreatic tissue. The timing of the initial surgical intervention seems to be closely related to the outcome. Delaying the operative intervention, if possible, may lead to better demarcation of the necrosis, and therefore, may help to distinguish between necrotic and viable pancreatic tissue. The timing has to be ultimately dictated by the patient’s clinical condition.

24.4.3 Surgical Management The goal of the intervention is to remove as much as possible of the infected necrotic tissue and provide sufficient drainage for the remaining viable pancreatic

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tissue. The best approach is a midline or subcostal laparotomy. Division of the gastrocolic ligament will allow good access to the pancreas. Necrosis of the pancreatic tissue may not be distinguishable from necrotic peripancreatic tissue. First step is to obtain a swab for microbiological analysis. The fibrous capsule of the pancreas is divided. Necrotic tissue is carefully excised. Often blunt finger dissection will be the best technique to achieve this goal. Vital pancreatic tissue with good capillary bleeding should be spared. Necrosis may extend not only in the retroperitoneal and retrocolic space but also caudally along the base of the ­mesentery. The superior mesenteric and splenic veins are identified and very carefully safeguarded to prevent troublesome bleeding, which is difficult to control. Diffuse bleeding may make open packing necessary. After debriding necrotic tissue and achieving hemostasis, closed local irrigation with 6–8  L/day physiological saline through an indwelling double-lumen catheter should be commenced. This is continued until no discharge of necrotic tissue is observed. This technique will normally allow abdominal wall closure. In certain circumstances like abdominal compartment syndrome, the retroperitoneal space and the lesser sac should be packed following necrosectomy. Open drainage is achieved by laparostomy and the procedure will need to be repeated every 2–3 days until abdominal wall closure can be achieved. At the time of final debridement, drains and a feeding jejunostomy are placed. High-level care is essential for appropriate postoperative care as sepsis and shock very commonly accompany this scenario and measures should be undertaken to transfer patients to institutes where such facilities are available.

24.5 Pseudocysts 24.5.1 Nonsurgical Management The presence of a pancreatic pseudocyst in itself is not an absolute indication for intervention. Recent reports have shown that many pseudocysts eventually resolve without complications. Large pseudocysts (>6 cm in diameter), however, are less likely to resolve spontaneously. Indications for intervention include pseudocysts that give rise to abdominal symptoms (e.g. pain, ­gastric

outlet obstruction), increase in size or are associated with complications (i.e. bleeding, infection). Various options are available for drainage and the choice depends primarily on location of the pseudocyst as well as the locally available expertise. (a) Percutaneous drainage may be considered in poor surgical risk patients and in the absence of endoscopic expertise. The major drawback is the risk of catheter-induced infection and development of an external pancreatic fistula. (b) Internal drainage can be accomplished endoscopically. Depending on the anatomic location of the pseudocyst, drainage may be achieved endoscopically by transpapillary drainage, cystogastrostomy or cystoduodenostomy. This approach requires advanced endoscopic expertise in endoscopic ultrasound, which may not be available locally. (c) Surgical indications include enlarging, symptomatic and complicated pancreatic pseudocysts. Timing of surgery is determined by the maturity of the cyst wall. As the tissues holding the sutures must be firm, it is desirable to avoid surgery within the first 6–10  weeks after the onset of an acute ­pancreatitis. Ultrasonography and CT is of great value to monitor the ‘maturity’ of the pseudocyst.

24.5.2 Surgical Management Surgical internal drainage of pseudocysts is usually accomplished by Roux-en-Y cystojejunostomy, a sideto-side cystogastrostomy, or as side-to-side cystoduodenostomy. The close anatomic relation of pseudocysts to the stomach and the duodenum allows easy internal drainage into these organs. A cystgastrostomy is the simplest of these procedures and can be accomplished in the rural setting without great difficulty. A midline laparotomy is generally preferred but a left or right subcostal incision will provide good access as well. After the abdomen is explored for the presence of collections, an anterior gastrotomy is performed. The posterior wall of the stomach is opened on the dome of the cyst preferably with a diathermy. The cyst wall and the posterior wall of the stomach are fused together in a fully mature cyst. Thus, opening the posterior wall of the stomach provides direct access to the contents of the cyst. The

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cyst is evacuated with suction and biopsies from the cyst wall should be taken. The opening is extended for about 5 cm and the cystgastrostomy is completed with absorbable monofilament sutures. Care should be taken to confirm hemostasis and wide-bore drains can be placed in the region if deemed necessary. Roux-en-Y cystojejunostomy can be considered as a universal surgical approach for pancreatic pseudocysts. Access is gained through a subcostal incision, ideally located over the palpable pseudocyst. Division of the gastrocolic ligament will allow good access to the pancreas dorsal of the lesser sac. Confirm the location of the pseudocyst by palpation and by aspiration with an 18-gauge needle. Palpate the pseudocyst to make sure that that there is no pseudo aneurysm. Should this be the case, angiography and embolisation of the aneurysm should be performed preferably preoperatively. Resection of the pseudocyst can be a complex procedure and hence good preoperative imaging is of utmost importance. Palpation can confirm the maturity of the pseudocyst and confidence of obtaining a firm tissue base for the anastomosis. The pseudocyst is widely incised (>5 cm), the cystic fluid aspirated and hemostasis of the cystic wall confirmed. The pseudocystic content is inspected and eventual necrotic tissue is carefully removed. A full thickness biopsy specimen of the wall is obtained. A Roux-en-Y loop of jejunum is constructed, and the Roux limb is preferably placed ­retrocolic to the left of the middle colic artery, where the transverse mesocolon is essentially avascular. A wide two-layer anastomosis between the pseudocyst and the blind end of the Roux loop is constructed using interrupted sutures for the inner and outer layer. This anastomosis as any pancreatic anastomosis must be constructed with meticulous care to prevent leakage of aggressive pancreatic juice. We recommend to drain the procedure site using a large-diameter silicon drain.

24.6 Pancreatic Trauma 24.6.1 Nonsurgical Management Due to its protected location, trauma to the pancreas is rare. Nevertheless, 3–12% of patients with severe abdominal trauma (blunt or penetrating) have pancreatic injury. Mechanism of trauma and progressive rising

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of serum amylase activity may indicate pancreatic injury. Contrast-enhanced CT is the most useful noninvasive diagnostic tool to detect pancreatic injury. The management of pancreatic injuries depends on the presence of pancreatic duct injury or major peripancreatic vascular bleeding. Minor contusions or lacerations of the pancreas without duct injury may be treated by observation only. If locally available and under stable clinical conditions, peripancreatic vascular injuries may be treated with angiography and embolisation.

24.6.2 Indications for Surgery Major contusion without duct injury, pancreatic duct injuries, pancreatic transsections, massive disruptions and vascular injury necessitate immediate exploratory laparotomy. Clinical deterioration of patients with minor pancreatic injuries require surgical intervention.

24.6.3 Surgical Management Midline laparotomy is the access of choice in patient with pancreatic trauma. Division of the gastrocolic ligament and a Kocher manoeuvre will allow optimal assessment of the pancreas. Packing of the lesser sac may help to control haemorrhage and facilitate evaluation of the extent of damage. Major lacerations of the pancreas without duct injury are traditionally treated by debridement of necrotic tissue, adequate haemostasis, and placement of thick diameter silicon drains. Some authors advocate covering the disrupted capsule of the pancreas using an omental patch. Injuries involving the body, neck and the tail of the pancreas, and those with high suspicion or evidence of pancreatic duct injury, are treated best with distal pancreatectomy left of the injured duct. Spleen preserving procedures are advocated but depending on clinical situation, ­presence of other injuries and surgical expertise, the procedure may include a splenectomy. Injuries to the head of the pancreas are most challenging, because they often involve the duodenum, major intestinal blood vessels and the papilla of Vater. In a damage control approach, the goal in these multiply injured patients is to obtain hemostasis, minimize

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contamination and repair associated injuries. Along with this, simple external drainage even in the presence of a pancreatic duct disruption as a first approach is ­recommended. A small-diameter percutaneous silicon tube inserted into the pancreatic duct may be very useful to temporally prevent intra-abdominal pancreatic juice leakage. In the presence of concomitant duodenal injury, pyloric exclusion with gastrojejunostomy should be considered. A feeding jejunostomy should be performed whenever feasible. A definitive repair may be postponed until the patient’s condition has improved, and should preferably be carried out at a tertiary hospital.

24.7 Pancreatic Neoplasms 24.7.1 Introduction Pancreatic resection is the only modality of treatment that can provide reasonable survival and in a proportion of cases, a potential for cure in cases of pancreatic cancer. Pancreatic surgery is very challenging and technically demanding. Availability of expertise in multiple specialties is essential to achieve good outcomes. Over the last few decades, there has been a reduction in the mortality associated with this operation from more than 40% to less than 5% and indeed in specialized institutions, the mortality rate is close to 1%. This is a reflection of increasing specialization not just among surgeons, but the other personnel involved in the care of the patient, the gastroenterohepatologists, intensive care physicians, anaesthetist, interventional radiologists, dietetic services and the physiotherapists. Modern medicine dictates that all patients with suspicious periampullary or pancreatic malignancy are discussed in a multidisciplinary team (MDT) setting, which involves all these specialties. The rural surgeon will mostly be involved with the preoperative workup in such scenarios. This involves assessment of resectability and fitness for the procedure. Old age in itself is not a contraindication to ­pancreatic resection and there is increasing body of evidence suggesting good post-operative outcomes even in octogenarians. It is mandatory that these patients with lesions in the pancreas are discussed in the MDT

with up to date multislice, double-contrast CT scans. Endoscopic ultrasound has shown promise in improving local staging and obtaining tissue for diagnosis. A percutaneous biopsy or aspiration cytology should NOT be performed if the disease is localized. Assessment of fitness will invariably include an echocardiography and pulmonary function tests.

24.7.2 Resection Only a brief outline of the operative procedure will be provided as this surgery should ideally not be performed in the rural setting. The following description is primarily intended to outline the importance of ­preoperative assessment of resectibility. Laparotomy is done by a midline, upper abdominal transverse/rooftop or a reverse L incision. We prefer a transverse/rooftop incision. A thorough assessment is done to exclude any peritoneal or liver metastasis. The next step is to assess resectibility. An extended Kocher’s manoeuvre is performed and the hepatic ­flexure of the colon is mobilized – the so called CattellBraasch manoeuvre. The lesser sac is opened widely by dividing the gastrocolic omentum to inspect and assess the ventral surface of the pancreas. The superior mesenteric vein (SMV) can be identified at this stage and this will also allow the assessment of the stage of the disease and the potential for resection. Dissecting the superior mesenteric artery (SMA) has the advantage of thorough staging with the use of frozen section and also allows one to be in total control of SMA whilst resecting the uncinate process off the retroperitoneal tissue. The next step is to define the retropancreatic tunnel anterior to the SMV and portal vein (PV). The retropanreatic tunnel is carefully dissected with right-angled forceps with a blunt tip. If the tumour is free from the PV, this dissection is straightforward. However, it requires a lot of patience and gentle handling of ­tissues. The hepatoduodenal ligament is dissected and a cholecystectomy is performed. The common bile duct is isolated and lymph nodes in this area are dissected. The common hepatic artery is identified to the left of the common bile duct and is traced backwards to identify the origin of the gastroduodenal artery (GDA). The suprapancreatic portion of the PV lies immediately posterior to the GDA and is identified easily once this

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vessel is isolated. The retropancreatic tunnel is now completed from the cranial end. It is essential to apply a vascular clamp on the GDA prior to division and ligation to ascertain good hepatic arterial flow. Once resectability is established in this manner, the bile duct can be transected along with the distal stomach. The gastric division is carried out with a ­linear stapling device. The ligament of Treitz is dissected to the left of the root of the mesentry and the proximal jejunum is mobilized. The jejunum is divided with a linear stapling device about 10 cm distal to the duodenojejunal flexure. The harmonic shears are very useful in this dissection. The transected jejunum is delivered to the right from behind the superior mesenteric vessels. The pancreas is then divided at the neck after placing hemostatic sutures at the superior and inferior borders. Bleeding from the cut surface of the pancreas should be attended to at this stage. Finally, the uncinate process is separated from the PV with careful identification and division of venous tributaries entering the portal vein. The specimen is removed and all bleeding is attended to.

24.7.3 Reconstruction We prefer a Roux-en-Y configuration for reconstruction. The roux limb is usually 70–80 cm in length. A pancreaticojejunostomy is our method of choice for pancreatic reconstruction. This is accomplished as a duct to mucosa anastomosis in two layers. The outer layers are sutured with monofilament non-absorbable material usually 4–0 prolene. The ductal mucosa is anastomosed directly with the small bowel mucosa with absorbable material such as 5–0 maxon/PDS. The number of sutures placed varies with the diameter of the duct. The choledocho/hepaticojejunostomy is constructed as a single layer anastomosis with absorbable monofilament sutures usually 4–0 maxon/PDS. This anastomosis is made easier by using the Blumgart technique. The gastrojejunostomy is performed on the other limb of the bowel. This is a standard double-layered anastomosis with absorbable sutures. Two wide-bore drains are placed – one on the right next to the pancreatic and biliary anastomosis and one

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in the lesser sac posterior to the stomach and anterior to the pancreas. Thorough inspection is done to confirm complete hemostasis.

24.7.4 Post Operative Management All patients should be transferred to ICU post-operatively. The post-operative care is specialized and needs thorough knowledge of critical care physiology and post-operative surgical anatomy. Imaging and interventional radiology services are frequently required. Gastroenterology support is mandatory. It is for these reasons that the procedure needs to be performed in specialized institutions with the ability to provide such services. These patients are frequently transferred to the rural hospital for rehabilitation and recuperation. In these situations, the rural surgeon may come across delayed complications from this procedure. These include delayed gastric emptying or biliary anastomotic strictures, pancreatic insufficiency, delayed pancreatic anastomotic leaks, etc. Close liaison with the operating surgeon and the hospital where the surgery was performed is of paramount importance. Pancreatic anastomotic leak is the most dreaded complication and all such patients should be preferably transferred back to the care of the tertiary centre where the surgery was performed. In some situations where the patient is clinically stable and a pancreatic fistula is established through the drain site, it can be managed in the rural setting with appropriate fluid and electrolyte replacements, and close monitoring of the patient’s condition by an experienced surgeon. In conclusion, the pancreas is a unique organ in all respects and hence patients with pancreatic pathologies require specialized care in tertiary referral centres in most situations. The rural surgeon requires sound knowledge of the anatomy, physiology and surgical approaches to the organ as, emergency life saving ­procedures may need to be performed in the vicinity of the pancreas in the rural setting e.g. in trauma. The primary role of the rural surgeon in the elective setting is to undertake appropriate investigations and initiate appropriate pathways for expedient and expert management of these conditions.

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Recommended Reading Cannon, J.W., Callery, M.P., Vollmer Jr., C.M.: Diagnosis and management of pancreatic pseudocysts: what is the ­evidence? J. Am. Coll. Surg. 209(3), 385–393 (2009) Hidalgo, M.: Pancreatic cancer. N. Engl. J. Med. 362(17), ­1605–1617 (2010) Isaji, S., et  al.: JPN guidelines for the management of acute ­pancreatitis: surgical management. J. Hepatobiliary. Pancreat. Surg. 13(1), 48–55 (2006) Keith, R.G.: Definition and classification of chronic pancreatitis. World J. Surg. 27(11), 1172–1174 (2003) Michalski, C.W., Weitz, J., Buchler, M.W.: Surgery insight: ­surgical management of pancreatic cancer. Nat. Clin. Pract. Oncol. 4(9), 526–535 (2007)

193 Schnelldorfer, T.: The birth of pancreatic surgery: a tribute to Friedrich Wilhelm Wandesleben. World J. Surg. 34(1), 190–193 (2010) Stawicki, S.P., Schwab, C.W.: Pancreatic trauma: demographics, diagnosis, and management. Am. Surg. 74(12), 1133–1145 (2008) Vege, S.S., Baron, T.H.: Management of pancreatic necrosis in severe acute pancreatitis. Clin. Gastroenterol. Hepatol. 3(2), 192–196 (2005) Whipple, A.O., Parsons, W.B., Mullins, C.R.: Treatment of carcinoma of the ampulla of vater. Ann. Surg. 102(4), 763–779 (1935)

 

25

Pancreatitis Martin Bruening

25.1 Definition Pancreatitis can represent a challenging problem for the rural surgeon. There are many possible presentations of pancreatitis, ranging from acute and severe to chronic and recurrent. The definition of acute pancreatitis, as derived by the 1992 Atlanta conference, is an acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems. Chronic pancreatitis is a condition characterised by recurrent episodes of inflammation leading to fibrosis and the loss of exocrine and endocrine function. The inflammatory process is thought to represent autodigestion, with the activation of pancreatic enzymes leading to damage with a local and systemic inflammatory response mediated by cytokines. The causes of pancreatitis are many and varied, but essentially, in the civilised world, the two main aetiological causes are gallstones and alcohol. Other less common causes are shown in Table 25.1.

25.2 Symptoms and Signs The most overwhelming symptom that patients present in acute pancreatitis is severe abdominal pain. This pain is usually upper abdominal in nature and often radiates through to the back. The onset of the pain can be relatively sudden. Nausea and vomiting are common features. On examination, the patient looks unwell

M. Bruening Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA 5011, Australia e-mail: [email protected]

and demonstrates signs of hypovolaemia. Abdominal palpation may reveal rigidity, or on occasion, a soft abdomen. Periumbilical bruising, known as Cullen’s sign and flank bruising, known as Grey-Turner sign indicates a severe form of pancreatitis known as haemorrhagic necrotizing pancreatitis. Evidence of jaundice with associated pyrexia may indicate gallstone aetiology for the pancreatitis.

25.3 Diagnosis The diagnosis of acute pancreatitis is made by history, examination and investigation. Traditionally, an elevation of the serum amylase level more than three times the upper limit of normal has been the hallmark of the pancreatitis diagnosis. In recent years, lipase levels have become the preferred diagnostic serum investigation. The pancreas is the only source of lipase and this enzyme has superior sensitivity and specificity than amylase. In addition to lipase, a full blood count, ­electrolytes, liver function tests, calcium, albumin, C-reactive protein, coagulation profile and an arterial blood gas are performed. Radiological investigations include CT scans, which in the early stages of presentation may help rule out other differentials for an acute abdomen. Early CT, however, has provoked much debate as to the potential for causing deterioration in pancreatic necrosis and renal failure and current guidelines would suggest that CT scans have the most benefit in cases of severe pancreatitis towards the end of the first week of admission. Pancreatic necrosis may take up to 72  h to become ­evident on CT scanning, and therefore, an early CT immediately on admission may underestimate the severity of the attack. A CT grading system for acute

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Table 25.1  Acute pancreatitis: aetiological factors

and a repeat scan at a later date is required. The role of magnetic resonance imaging (MRI) may be helpful in demonstrating bile duct stones (MRCP) or a pancreas divisum, but at this point in time, the routine use of MRI is not indicated. Armed with the results from the blood investigations and radiology, a diagnosis of acute pancreatitis should be secure. The next step is to determine the severity of the condition. In addition to the aforementioned radiological index, a number of scoring criteria have developed over the years and include the Glasgow/ Imrie (Table 25.3) and Ranson (Table 25.4) criteria. These clinico–biochemical scoring systems measure various parameters over a 48 h period to predict the severity of an attack. If three or more indicators are present at 48 h, the pancreatitis is deemed severe. In recent times the acute physiology and chronic health enquiry (APACHE) score, which quantifies the degree of abnormality of multiple physiological parameters, has been used as a prognostic assessment tool, enabling a prediction of severity of acute pancreatitis at admission rather than at 48 h. An APACHE score of greater

Cholelithiasis Alcohol Infection (mumps, cytomegalovirus) Trauma Iatrogenic (ERCP) Hyperlipidaemia Hypercalcaemia Pancreas divisum Drugs (azathioprine, 6-mercaptopurine) Hereditary Idiopathic Neoplasms (ampullary, pancreatic) Sphincter of Oddi dysfunction Scorpion bite Cardiopulmonary bypass Vasculitis

Table 25.2  Balthazar CT index Balthazar CT index

Score

A

Normal pancreas

0

B

Oedematous pancreatitis

1

C

Peripancreatic inflammation

2

D

Single peripancreatic fluid collection

3

E

Extensive fluid collections or peripancreatic gas

4

Necrosis

None

0

Necrosis

<30%

2

Necrosis

30–50%

4

Necrosis

>50%

6

Table 25.3  Modified Glasgow/Imrie score Age > 55 years WBC count > 15 × 109/l Blood glucose > 10 mmol/l Blood urea > 16 mmol/l Arterial oxygen partial pressure < 8.0kPa Serum albumin <32 g/l Serum calcium <2.0 mmol/l

CT grade + necrosis score = CT severity index Source: Balthazar et al. [1]

Lactate dehydrogenase >600 IU/l Source: Blamey et al. [2]

Table 25.4  Ranson criteria On admission Age >55 years

Calcium < 2 mmol/l

WBC count > 16 × 10 /l

Urea > 1.8 mmol/l increase

Blood glucose > 11.1 mmol/l

Haematocrit decrease > 10%

Lactate dehydrogenase > 350 IU/l

Base deficit > 4 mmol/l

Aspartate transaminase > 250 IU/l

Fluid sequestration > 6 l

9

pancreatitis, known as the Balthazar CT Index (Table 25.2), has been developed and may prove useful in determining morbidity and mortality risks. Ultrasound is a mandatory investigation to establish whether gallstones are the aetiological factor in the presentation, although it is often found that excessive bowel gas obscures a clear picture of the biliary tree

After 48 h

Arterial pO2 < 60 mmHg Source: Ranson et al. [3]

25  Pancreatitis

than 8 upon initial assessment denotes severe acute pancreatitis. The overall mortality rate for pancreatitis is upwards of 10%; however, should the degree of pancreatitis be classifies as severe, the risk of multiorgan failure increases significantly and the mortality rate approaches upwards of 40%.

25.4 Management The initial management of acute pancreatitis is supportive and revolves around fluid resuscitation. Administration of intravenous fluids and oxygen are critical in the early treatment phase and should be instituted for all degrees of pancreatitis upon admission. If the pancreatitis has been assessed as severe, insertion of an indwelling urinary catheter and transfer into a high dependency unit with strict fluid balance monitoring is mandatory. Analgesia should also be prescribed with a patient controlled analgesia, a suitable option in selected cases. Nasogastric tube placement may benefit those cases with severe vomiting and prolonged paralytic ileus. Respiratory compromise may necessitate the transfer to an intensive care unit (ICU) and possible intubation and ventilation. If multisystem failure becomes established, inotropic support is also needed. Unfortunately, to date, there have been no studies to conclusively prove that medications such as octreotide, gabexate or lexipafant are effective. The use of prophylactic antibiotics is equally as controversial and the role of antibiotics such as miripenem and ciprofloxacin is a work in progress. A policy of prophylactic antibiotics only in cases of pancreatic necrosis of more than 30% has been advocated. Nutritional support in severe acute pancreatitis can be delivered by either the parenteral or enteral routes. The complications of parenteral feeding have been well documented, and it would seem preferable for the eneteral mode of nutrition if feasible. However, as ­paralytic ileus often accompanies a severe attack of pancreatitis, enteral delivery may be ineffective, thereby necessitating the use of total parenteral nutrition (TPN).

25.5 Surgical Treatment Where the aetiology of pancreatitis has been proven to be related to cholelithiasis, several treatment options are available. In a severe attack, where there is evidence

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of choledocholithiasis, an early endoscopic retrograde cholangiopancreatography (ERCP) performed within the first 72 h has been shown to decrease morbidity. An endoscopic sphincterotomy should also be carried out to allow adequate biliary drainage. In any form of pancreatitis due to gallstones, a cholecystectomy should be performed following resolution of the initial attack and prior to discharge from hospital. If a laparotomy has been performed for an acute abdomen and pancreatitis is discovered, a cholecystectomy and operative cholangiogram should be performed. Surgery on the pancreas itself is limited to cases of severe pancreatic necrosis where the patient’s symptoms are persisting and a FNA (CT-guided) has documented a positive bacterial culture. The usual time frame for this sequence of events to evolve is in the order of 7–14  days. Radiological intervention in the form of a percutaneous drain may be of benefit in cases of pancreatic abscess formation, but necrosectomy and debridement form the basis of treatment in severe pancreatitis with necrosis. Pancreatic necrosectomy involves the removal of the necrotic tissue via a blunt finger technique. This can then be combined with a continuous lavage of the retroperitoneum with a series of drains or alternately planned staged relaparotomies with repeated lavage. While radiological interventional techniques in the form of simple percutaneous drainage have proven largely unsuccessful due to blockage of the tube with necrotic material, recent developments have seen the combined use of CT-guided catheters, dilation of the tract and either a nephroscope or laparoscope to remove the necrotic material under direct vision. This percutaneous pancreatic necrosectomy is classified as a minimally invasive procedure and may benefit those patients who are critically unwell or elderly. Surgery of any form, whether open or laparoscopic, in these situations is prone to complications and post-operative mortality rates in the range of 30–40% are often quoted. Pancreatic fistula, haemorrhage and incisional hernia represent the most frequent types of morbidity, while long-term complications may include diabetes mellitus and exocrine pancreatic insufficiency. The management of these patients post-operatively, apart from analgesia and fluid balance, requires close attention to glucose levels and insulin infusions may be necessary. The more likely scenario following acute pancreatitis in which surgery may be required is that of a developing pseudocyst. If a pseudocyst persists for longer

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than 6 weeks after the onset of the acute attack or is larger than 6 cm in size, the likelihood of spontaneous resolution is unlikely and surgical drainage will be required. Traditionally, this has involved fashioning either a cystgastrostomy or a cystenterostomy, and in recent years, this has been performed laparoscopically. Radiological drainage has not been as successful in preventing reaccumulation of pseudocyst fluid. More success in long-term treatment has been achieved with the use of endoscopic ultrasound to locate the pseudocyst and insert a drainage catheter. This minimally invasive approach has been shown to be effective with minimal mortality and morbidity. A rare and often lethal complication from a pseudocyst is haemorrhage into the cyst from a pseudoaneurysm rupture. Pseudoaneurysms can form after both acute and chronic pancreatitis and if detected can be treated ­successfully using endovascular techniques.

25.6 Chronic Pancreatitis Chronic pancreatitis, while less of an immediate life threatening condition, can represent a difficult problem to treat. Alcohol remains the most common aetiological agent, although there is a hereditary group in which a large proportion of those with the autosomal dominant inheritance will experience pancreatitis before the age of 20. Other causes of chronic pancreatitis are listed in Table 25.5, and are also often the same aetiological factors responsible for the onset of acute pancreatitis. The predominant symptom of chronic pancreatitis is pain. As the gland becomes increasingly fibrotic and exocrine and endocrine function falter, symptoms Table 25.5  Chronic pancreatitis: aetiological factors Alcohol Idiopathic Hyperlipidaemia Hyperparathyroidism Tropical Infection Autoimmune disease Choledochal cyst

M. Bruening

consistent with pancreatic insufficiency and diabetes appear. In terms of investigations, the usual serum blood tests are performed with the addition of a glycated haemoglobin level. Faecal elastase can be used to determine the degree of exocrine pancreatic dysfunction. Ultrasound may detect pancreatic stones, calcification within the gland and pancreatic duct dilatation. CT scan remains the radiological investigation of choice and MRCP is proving to be of increasing benefit for delineation of the pancreatic and biliary ducts. With the advent of MRCP, the role of ERCP in chronic pancreatitis is limited to treatment rather than investigation. There are few indications for surgical intervention in chronic pancreatitis and the treatment is limited largely to symptom management including pain ­control, diet modification, enzyme replacement and ­abstinence from alcohol. Where there is documented pancreatic duct dilatation, a drainage procedure, in the form of a pancreaticojejunostomy, may be of some value in those individuals with chronic intractable pain. There may be cases where radiological investigations have demonstrated features of a pancreatic mass and it can be difficult to distinguish whether the mass represents a chronic inflammatory or neoplastic ­phenomenon. In these rare situations, resection of the pancreatic head may be an option.

25.7 The Role of the Rural Surgeon The management of pancreatitis in the rural setting is dependent on the facilities available within the regional hospital. Most cases of pancreatitis are not severe and can be ably dealt with by the rural surgeon. It is widely acknowledged, however, that for the treatment of acute severe pancreatitis, tertiary hospital facilities are required. Few regional hospitals in Australia have the necessary intensive care facilities and support services required. While there may be individual rural surgeons with the necessary surgical skill and expertise to perform the often complicated and high-risk surgery on the small group of patients requiring intervention, there are many other links in the chain, which would necessitate a large teaching hospital environment. The availability of experienced surgical and anaesthetic colleagues, resident medical staff, 24-h laboratory and radiology facilities, ERCP

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availability, pharmacy for TPN and ICU facilities are the basic requirements before considering whether to launch into a surgical procedure of the magnitude as described. The other factor to consider is that of small volume versus large volume experience, and all recommendations would suggest that in the case of a patient with severe pancreatitis, early referral to a specialist hepatobiliary unit within a tertiary hospital setting occurs as soon as practicable. The importance of good links between the rural and tertiary hospital cannot be understated and clear communication pathways from rural surgeons to their city colleagues are invaluable.

References   1. Balthazar, E.J., Freeny, P.C., van Sonnenberg, E.: Imaging and intervention in acute pancreatitis. Radiology 193, 297–306 (1994)   2. Blamey, S., Imrie, C., O’Neill, J., et al.: Prognostic factors in acute pancreatitis. Gut 25, 1340–1346 (1984)

  3. Ranson, J.H., Rifkind, K.M., Roses, D.F., et al.: Prognostic signs and the role of operative management in acute ­pancreatitis. Surg. Gynecol. Obstet. 139, 69–81 (1974)

Recommended Reading Barreto, S.G., Rodrigues, J.: Comparison of APACHE II and Imrie Scoring Systems in predicting the severity of acute pancreatitis. World J. Emerg. Surg. 2, 33 (2007) Bradley III, E.L.: A clinically based classification system for acute pancreatitis”. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch. Surg. 128, 586–590 (1993) Connor, S., et al.: Early and late complications after pancreatic necrosectomy. Surgery 137, 499–505 (2005) Lopes, C.V., et  al.: Endoscopic-ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts and abscesses. Scand. J. Gastroenterol. 42, 524–529 (2007) Slavin, J.: Acute pancreatitis. Surg. Int. 59, 227–230 (2002) Taylor, Sl, et  al.: A comparison of the Ranson, Glasgow, and APACHE II scoring systems to a multiple organ score in ­predicting patient outcome in pancreatitis. Am. J. Surg. 189, 219–222 (2005) UK Working Party on Acute Pancreatitis: UK guidelines for the management of acute pancreatitis. Gut 54(Suppl 111), iii1–iii9 (2005)

 

Surgery of the Spleen

26

Matthias W. Wichmann

26.1 Introduction

26.2 Relevant Anatomy

Surgery of the spleen is generally done for ­hematological disease or trauma. For elective procedures – as for other less common indications in the rural setting – it is the surgeon’s responsibility to evaluate whether the caseload as well as the available infrastructure and experience is sufficient to provide safe surgery of the spleen. The spleen is especially suitable for laparoscopic surgery, but the patient must be fit for open surgery as well since a very low conversion threshold should be adopted to avoid postoperative morbidity and mortality. Open splenectomy, however, is also associated with morbidity rates of up to 25% and mortality rates of up to 6%. Laparoscopic splenectomy offers significant advantages with regard to wound-related morbidity, length of hospital stay, postoperative pulmonary complications.     In elective splenectomy, preoperative vaccination with pneumococcal, meningococcal, and Haemophilus vaccine should occur approximately 2 weeks prior to surgery. In patients after emergency splenectomy, this vaccination needs to be done as soon as an adequate immune response can be expected (usually within 1 week after surgery). This vaccination is necessary to prevent the so-called OPSI-syndrome (overwhelming post splenectomy infection mainly due to Pneumococci or Haemophilus influenzae infection) which occurs in up to 5% of adults after splenectomy and has a mortality rate of up to 50%.

The arterial blood supply (approximately 7% of minute stroke volume) to the spleen comes from the celiac axis via the splenic artery and the short gastric vessels. The splenic vein and artery run along the dorsal surface of the pancreas. The spleen is fixed in the left upper quadrant below the costal arch by the splenophrenic, ­splenorenal, and gastrosplenic (short gastric vessels) ligaments.

M.W. Wichmann Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected]

26.3 Indications 26.3.1 Splenectomy for Hematological Disease Splenectomy (unfortunately) is considered the last resort of treatment for patients suffering from hemolytic or thrombocytopenic disorders such as idiopathic thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), autoimmune anemia, hereditary spherocytosis, or elliptocytosis. The indication for surgery usually results from a failure of medical treatment or the patient’s refusal of further medical treatment (i.e., side effects of steroid treatment) and it is the author’s opinion that surgeons are not involved early enough with decision making in these patients. For discussion of surgical indications, it is important to note that (open) splenectomy is known to result in long-term hematologic success in 70–90% of all patients. In patients undergoing elective splenectomy for disease, it is most important to localize and remove

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accessory splenic tissue, which can be found in 15–30% of all patients with the accessory spleen usually localized close to the main organ. The accessory spleen, however, can be localized anywhere on the patient’s left side of the abdomen including the scrotum. Preoperative localization can be done by ultrasound.

26.4 Surgery of the Spleen for Trauma The easiest decision for a surgeon regarding splenic surgery is a trauma patient with an injured spleen who is unable to maintain hemodynamic stability despite adequate fluid resuscitation – here the injured spleen must be removed without hesitation (“Should be in the bucket in less than 2 minutes!”). Nowadays, however, the majority of splenic injuries can be managed conservatively without surgical intervention. This situation requires good radiological imaging (best done using computed tomography), ongoing close monitoring of the trauma patients (at least using a High Dependency Unit) with blood pressure, pulse and O2 saturation measuring, as well as 24-h availability of a surgeon and theater staff to perform emergency surgery whenever nonoperative treatment fails and splenectomy must be carried out. At least four units of blood and two units of fresh frozen plasma should be available at any given point during the observation period of approximately 1  week after trauma. Computed tomography allows for a grading of the splenic injury (Table 26.1) which is a good indicator of whether or not conservative treatment will be successful. Table  26.1  Computed tomography–based classification of splenic injury [1] % Pat. requiring surgery Grade 1

Capsular avulsion, superficial laceration, or subcapsular hematoma <1 cm

0

Grade 2

Laceration 1–3 cm deep, central/ subcapsular hematoma <3 cm

17

Grade 3

Laceration >3 cm deep, central/ subcapsular hematoma >3 cm

67

Grade 4

Fragmentation of ³3 sections, devascularized spleen

55

If a patient requires surgery due to ongoing blood loss without being hemodynamically unstable and a splenic injury is found, a number of techniques have been described that may be useful for splenic salvage. These procedures include splenorrhaphy, partial splenectomy, usage of haemostatic agents, and argon beam coagulation. The potential immunological and hematological benefits of not losing the spleen have to be weighed against the risks of a repeat emergency surgery for failure of this approach and the operating time needed for the acrobatic surgical maneuvers of splenic conservation. This is of special importance in the rural setting, where constant monitoring of the patient and 24-h availability of an emergency theater may not be given. Here a reduced threshold to perform splenectomy appears to be justified in the author’s view.

26.5 Surgical Techniques Elective open splenectomy: A midline or Kehr subcostal incision can be used to provide adequate exposure. The splenic artery should be identified by opening the gastrocolic omentum and palpation along the upper border of the pancreas. After identification, the artery is tied off and transected. The short gastric vessels can be ligated in the gastrosplenic ligament during the exposure of the splenic artery as well. The spleen is then pulled toward the center of the abdomen allowing for dissection of the splenophrenic, splenorenal, and finally the splenocolic ligaments. Now the spleen can be elevated out of the abdominal cavity with the pancreatic tail still attached to the hilus of the spleen. After dissection of the pancreatic tail away from the posterior aspects of the spleen, the splenic artery and vein can be identified, tied, and transected. Emergency splenectomy: After confirming the splenic injury, the splenorenal, splenophrenic, and splenocolic ligaments are dissected to allow delivery of the spleen to the center of the abdomen. Bleeding control can be achieved by compression of the splenic artery during this procedure. Expose the posterior aspect of the splenic hilus and identify, ligate, and transect the splenic vessels and remove the spleen. Confirm sufficient bleeding control and continue the trauma laparotomy.

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Laparoscopic splenectomy: This procedure is done using the “hanging spleen technique” with the patient in right lateral position and the spleen suspended by its peritoneal attachments. Usually four ports are needed (paraumbilical camera port, left hypochondrium, below the xiphoid and in the midline between xiphoid and umbilicus) and the splenocolic ligament is dissected first. Then, the short gastric vessels are divided, and splenic artery and vein are dissected (using vascular endoscopic staplers) in the hilum of the spleen. The splenic attachments to the diaphragm and the capsule of the kidney are divided, and the spleen is removed using a retrieval bag. Prior to removal from the abdominal cavity, the spleen must be morcellated in the bag. After any form of surgery of the spleen, a drain should be placed into the left subphrenic space to avoid hematoma and abscess formation.

26.6 Complications Common postoperative complications include bleeding, subphrenic abscess formation, pancreatitis, and pancreatic fistula formation. Pulmonary complications include atelectasis and pleural effusion which are more common after open splenectomy.

Reference 1. Mirvis, S.E., Whitley, N.O., Gens, D.R.: Blunt splenic trauma in adults: CT-based classification and correlation with prognosis and treatment. Radiology 171, 33–39 (1989)

Recommended Reading McCray, V.W., Davis, J.W., Lemaster, D., et al.: Observation for nonoperative management of the spleen: how long is long enough? J. Trauma 65, 1354–1358 (2008) Melman, L., Matthews, B.D.: Current trends in laparoscopic solid organ surgery: spleen, adrenal, pancreas, and liver. Surg. Clin. North Am. 88, 1033–1046 (2008). vii Nathens, A.B.: Blunt abdominal trauma. In: Schein, M., Rogers, P.N. (eds.) Schein’s Common Sense Emer­­gen­­cy Abdominal Surgery, pp. 305–319. Springer, Berlin/Heidelberg (2005) Pachter, H.L., Edye, M., Guth, A.A.: Concepts in splenic surgery. In: Scott-Conner, C.E.H. (ed.) Chassin’s Operative Strategy in General Surgery, pp. 727–731. Springer, New York/Berlin/Heidelberg (2002)

 

Complications After Bariatric Surgery

27

Brent White

27.1 Introduction

27.2 Roux-en-Y Gastric Bypass

Throughout the USA and much of the industrialized world, rates of morbid obesity have risen rapidly over the past several decades to nearly 5% of the US population [1]. Surgical procedures have been developed that can potentially cure or mitigate morbid obesity and its attendant comorbid conditions. Numerous studies have demonstrated the reduction in death and disability associated with obesity surgery [2]. With the advent of minimally invasive surgical techniques, such surgeries are now being performed more commonly than ever before. Rates of bariatric procedures reached a rate of 140,000 operations in the USA alone in 2004 [3]. Though clearly offering benefits to the morbidly obese, these surgeries also have significant rates of complications, as high as 32.8% [4]. Clearly a morbid obesity operation is associated with the kind of complications that can arise after any abdominal surgery under general anesthesia (e.g., pneumonia, DVT, wound infection). In fact due to associated comorbid conditions such as diabetes, obstructive sleep apnea, gastroesophageal reflux disease, and hypertension, these are more common than in most other patient populations. In addition to these general complications, however, obesity operations are associated with unique problems that can arise as a ­consequence of the nature of the operations themselves. This chapter will focus on the diagnosis and treatment of these unique bariatric complications arising from the  two morbid obesity operations most commonly ­performed in the USA and the western world.

The Roux-en-Y gastric bypass (RYGBP) procedure consists of a 75–150 cm Roux-en-Y limb anastomosed either antecolic or retrocolic to a 50 cc proximal ­gastric pouch (Fig. 27.1). The operation is principally restrictive in its mechanism for weight loss but there is also a component of malabsorption. This procedure is now frequently performed laparoscopically in both the USA as well as much of the industrialized world. This

B. White Bassett Healthcare, One Atwell Road, Cooperstown, NY 13326, USA e-mail: [email protected]

Roux-en-Y Gastric Bypass

Esophagus

Bypassed portion of stomach

Proximal pouch of stomach “Short” intestinal roux limb Pylorus

Duodenum

Fig. 27.1  Diagram of a Roux-en-Y gastric bypass (From http:// www.genesishealth.com/services/bariatric_surgery/rouxeny_ illustration.aspx)

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operation is associated with an average loss of 61.6% excess body weight [4].

27.2.1 Anastomotic Leak The development of an anastomotic leak, which occurs in 1–2% of cases, is both an early complication after surgery as well as a potentially life-threatening one [5]. Leaks generally manifest within the first 10 days of the operation. Patients often have excessive abdominal pain after surgery and also occasionally have vague feelings of “impending doom.” While the diagnosis of a leak can be made with either an upper gastrointestinal fluoroscopic study or with a CT scan, the sensitivity of these studies is only approximately 40% [6]. Instead of imaging studies, physical examination and the presence of tachycardia (especially >120) and/ or hypotension provide the surgeon with the most ­sensitive indicator of an anastomotic leak in the early postoperative period. Should a leak be suspected, prompt surgical intervention is warranted. The original surgical approach and the operating surgeon’s confidence with advanced laparoscopic techniques should determine the operative approach to repairing such a leak. Regardless of the approach chosen, there are three principle objectives when operating on an acute leak after bypass. The first objective is to identify and repair the source of staple-line failure. Leaks can occur at any of the staple lines created at the time of the operation (Fig. 27.2). While this can be readily identified in some cases (Fig.  27.3), finding the precise source of leak can occasionally be challenging. An endoscope or NGT carefully passed into the gastric pouch can be used to insufflate air while the bowel is submerged under saline – bubbles can then guide the surgeon to the area of leak. Once the defect is oversewn, wide drainage of the area with closed-suction drains is the second objective, anticipating possible breakdown of the repair. Finally, wherever possible, we place a feeding tube within the gastric remnant. This allows enteral drainage in the early postoperative course and enteral access later for nutrition while allowing the gastrojejunal anastomotic repair to heal. Immediate postoperative care in this setting is best achieved within an intensive care unit with parenteral nutrition provided.

Fig.  27.2  Potential sites for staple-line failure: (1) gastrojejunostomy, (2) gastric remnant, (3) closure of the stomach through which the anvil of the circular stapler was introduced, and (4) jejunojejunostomy (From Rosenthal and Jones [7], p. 366, Fig. 1)

Fig. 27.3  View of gastrojejunostomy leak at laparoscopic reexploration. The black arrow marks the site of free flow of enteric fluid from the leak (Courtesy of Edward Lin, Emory University School of Medicine)

27  Complications After Bariatric Surgery

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27.2.2 Anastomotic Stricture

Miller), through-the-scope balloon dila­tation is perhaps the most common method of treating these strictures (Fig. 27.5). In our practice, we generally utilize no more than three different sizes of balloon in a given setting (e.g., 6–8 mm, 8–12 mm, 12–15 mm). We believe this reduces the chance of inadvertent perforation. Should the dilatation prove effective but insufficient to alleviate all the patient’s symptoms, further dilatations can be performed over time. In one recently reported series, 38 patients with anastomotic stricture after bypass underwent an average of 2.1 dilatations with a 95% success rate and a 3% complication rate using this endoscopic balloon dilatation technique [8].

Anastomotic strictures occur at the site of the gastrojejunal anastomosis in 0.5–6.8% of cases [8]. Such a diagnosis should be suspected when a patient presents 3–6  months after surgery complaining of difficulty swallowing and/or frequent nausea/vomiting. A gastrografin or barium swallow study can confirm the diagnosis (Fig.  27.4), demonstrating gastric pouch dilatation with narrowing and/or impeded flow of contrast into the roux limb. Once diagnosed, most gastrojejunal strictures can be treated endoscopically. The chief goals in endoscopic evaluation are to: (1) document the presence of any marginal ulceration, (2) sample the gastric pouch for presence of urease to determine if Helicobacter pylori is present, and (3) perform dilatations as appropriate. If marginal ulceration is present, treatment must include the use of proton-pump inhibitor medication with repeat endoscopic evaluation in 4–6 weeks to ensure healing of these ulcerative lesions. If pouch biopsies are positive for the presence of urease, then a therapeutic regimen should be prescribed to eradicate these bacteria, which can predispose to marginal ulceration in the bypass patient. Endoscopic dilatation can be accomplished with a number of different dilatation techniques. While fluoroscopic dilatation techniques can be utilized (e.g., Savary-

Fig. 27.4  Upper GI series images in a woman 5 weeks after a Roux-en-Y Gastric bypass with multiple episodes of nausea and emesis. The asterisk and arrow demonstrate a tight anastomosis

27.2.3 Internal Hernia Formation Internal hernias can occur at any of several different sites after a gastric bypass in up to 5% of cases (Fig. 27.6) [7]. Perhaps because of the paucity of scar tissue formed, it has been observed that this complication occurs more frequently after laparoscopic gastric bypass surgery than after its open counterpart. This complication typically manifests around 6–24 months after surgery. Patients can present with a wide range of symptoms and signs – nonspecific mild abdominal pain, nausea and vomiting with signs of intestinal

that doesn’t change or distend with swallowing of contrast (From Merkle et al. [9], p. 680, Fig. 9)

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Fig. 27.5  A through-thescope (TTS) balloon photographed fully dilated (left) as well as within the distal esophagus viewed from the endoscope at time of deployment

Fig. 27.7  CT scan image of internal hernia through Peterson’s space with dilated jejunum (J) and an associated swirl sign (arrow) (From Carucci et al. [10], pp. 247–260, Fig. 16b) Fig.  27.6  An internal hernia can potentially occur through either two or three defects, depending on whether a retrocolic or antecolic technique is used for the Roux limb (From Rosenthal and Jones [7], p. 380, Fig. 1)

obstruction, or even fulminant sepsis and bowel necrosis if the hernia has compromised bowel blood supply. When clinically suspecting an internal hernia, an abdominal and pelvis CT scan is the most sensitive imaging study. While some cases with associated obstruction can be readily appreciated (Fig.  27.7), in subtler cases the “swirl” sign can be the best indication of an internal hernia. Looking almost like a satellite image of a hurricane, the “swirl” sign appears when the internally herniated bowel is associated with twisting

of its mesenteric blood supply (Fig. 27.8). One recent study found that the “swirl” sign has a sensitivity of 78–100% and specificity of 80–90% for detecting the presence of an internal hernia [11]. Because no test has perfect sensitivity for this complication, surgical exploration to rule out an internal hernia is justifiable in the absence of an explanation for a patient’s symptoms – even in the absence of clear radiologic evidence. Efforts to repair an internal hernia require familiarity with the potential places these hernias can occur (Fig.  27.6). When using a laparoscopic approach, placement of a 12 mm port in the peri-umbilical area with 5 mm trocars on either side of the abdomen allows the surgeon to “walk” the bowel its entire length. The

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27  Complications After Bariatric Surgery

a

Fig. 27.8  The positive swirl (seen within box) led to exploration in this patient with the discovery of an internal hernia through the jejunojejunostomy defect (a). The arrow demonstrates the

b

swirl at the SMA – a herniation though Peterson’s space was found at time of operation (b) (From Rosenthal and Jones [7], pp. 382–383, Figs. 2 (left) and 3 (left))

Fig. 27.9  Laparoscopic images at exploration for a hernia through Peterson’s space. Careful but thorough running of the small bowel is generally required to understand the nature of the hernia (Courtesy of Edward Lin, Emory University School of Medicine)

bowel must be examined from the gastrojejunal anastomosis distally to the ligament of Treitz (Fig. 27.9). While doing this, it is imperative to identify both the areas behind the Roux limb known as Peterson’s space as well as the mesenteric junction of the jejunojejunostomy. If either of these potential spaces is open then it must be sutured closed after first reducing any herniated bowel contents. In a retrocolic Roux-en-Y, the

opening through the colonic mesentery must similarly be inspected and repaired. In instances where the anatomy is confusing or the degree of herniation makes proximal to distal examination of bowel difficult, we recommend starting distally at the ligament of Treitz and proceeding proximally – this will often assist in  establishing proper orientation and conducting a successful operation.

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27.3 Laparoscopic Adjustable Gastric Band The laparoscopic gastric band is an operation that places a silastic ring around the proximal portion of the stomach (Fig.  27.10). The band is held in place via naturally occurring posterior gastrophrenic attachments and imbricated gastric tissue sutured into place over the anterolateral aspect of the band. Within this band there is a soft, inner adjustable balloon that can be filled with a variable amount of sterile saline via a subcutaneous port connected to the band via silastic tubing. The lap band is purely restrictive as a means of achieving weight loss. It is associated with an average loss of 47.5% excess body weight [4]. Though not performed as commonly as the gastric bypass, annual numbers of these cases have increased rapidly in recent years.

27.3.1 Band Erosion The erosion of the band through the full thickness of the gastric wall occurs in approximately 1% of cases [12]. This complication usually occurs after 6 months or more

Fig.  27.10  Diagram of laparoscopic gastric band (From http:// www.davidgalloway.co.uk/Images/Surgery/LAGB%20diagram.jpg)

B. White

after surgery. Patients will frequently present with complaints of vague new onset abdominal discomfort or the sudden loss of dietary restriction. Additionally, any infectious complication at the site of the subcutaneous port occurring outside of the perioperative period should be considered indicative of possible band erosion. This complication is almost never associated with free abdominal perforation or clinical findings of peritonitis. When suspected, carefully conducted upper endoscopy in the retroflexed orientation is the most effective means of establishing the diagnosis. The endoscopic appearance of a normal band with healthy overlying mucosa (Fig.  27.11) needs to be kept in mind. Any silastic band material visible on endoscopy, no matter how small, represents band erosion (Fig. 27.12). Once band erosion is diagnosed, current standard of care requires removal of the gastric band. This can often be accomplished laparoscopically. In case of a small band erosion, the band can be cut where apparent on the serosal surface of the proximal stomach. Any visible defect can be sutured closed primarily with viable omentum sutured over as a patch. Abdominal drains should be placed at the discretion of the operating surgeon as well as a postoperative nasogastric tube. In instances where the majority of the band has eroded into the stomach (Fig. 27.12), a gastrotomy can be created on the mid to distal portion of the stomach and the band can then be cut out from within the lumen of the stomach before closing the gastrotomy. There is seldom any safe means of replacing a gastric band at time of removal for erosion.

Fig. 27.11  Endoscopic retroflex view of the gastroesophageal junction. The arrow points out the bulge indicating the presence of the band with healthy overlying mucosa

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a

b

Fig. 27.12  Endoscopic retroflex views of the gastroesophageal junction demonstrating 180° erosion of band (asterisk) into gastric lumen (a) and 270° erosion of band (asterisk) into gastric

lumen (b) (Courtesy of Edward Lin, Emory University School of Medicine)

27.3.2 Band Slippage

complication can occur any time after surgery and occurs in approximately 4–5% of cases [12]. Hiatal hernias that are not corrected at time of band placement may be associated with an increased risk of ­slippage. Patients typically present with symptoms of nausea, vomiting, dysphagia, or abdominal discomfort. Many of these symptoms are very similar to a band that has been adjusted too tightly. The first diagnostic step if the patient presents with significant symptoms is to empty or partially empty the band, especially if it has been recently adjusted. This can be accomplished by sterilely accessing the port with a long Huber needle. Such a needle is generally selected because it is non-coring and unlikely to injury the ­diaphragm of the port (Fig. 27.14).

Band slippage occurs when distal stomach tissue manages to herniate through the band or there is migration of the band along the stomach (Fig.  27.13). This

Fig. 27.13  Diagram of gastric band demonstrating how stomach can herniate (arrow) up through the band, thus creating ­conditions that can, in worst case scenarios, give rise to potential gastric ischemia and necrosis (From Tanner and Allen [6], pp. 103–112)

Fig.  27.14  Photograph demonstrating appearance of Huber needle. Such a needle profile can be used to access the diaphragm of the band port repeatedly without compromising the integrity of the diaphragm’s seal (From http://www.victor-g. com/huber%20needle%20non%20coring%20for%20rfid.jpg)

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a

may be at risk for ischemia and damage. The band can usually be cut at its buckle and thereby released without need for extensive adhesiolysis or dissection along the gastric tunnel (Fig.  27.17). While a band can conceivably be replaced at time of removal for slippage, only experienced bariatric surgeons should attempt this.

27.3.3 Concentric Pouch Dilatation

b

Fig. 27.15  Appropriate positioning of the band on upper gastrointestinal series. (a) Demonstrates the band aligned so that an open ring is not evident and the band sits at an approximate 45° angle. (b) The gastric pouch (P) is small and the stoma (S) has ready flow of contrast into the gastric fundus (F) (From Carucci et al. [10], pp. 261–274, Fig. 3)

If symptoms are not completely resolved with this maneuver, an upper GI contrast study is the most sensitive imaging study to determine if the band has slipped. An ideally positioned band sits below the diaphragm at a 30–45° angle from an imaginary horizontal or axial line. Contrast passing through a normal band should demonstrate a small pouch centered over the band with passage occurring into the remainder of a normally appearing stomach (Fig. 27.15). If the band loses this normal 30–45° angle or if the pouch is exceedingly dilated and eccentric in appearance over the band then this generally indicates slippage (Fig.  27.16). Any ­previous plain films or upper gastrointestinal contrast studies should be used as a comparison. Once the diagnosis is made of slippage, the band must be removed expeditiously as herniated stomach

Concentric or symmetrical pouch dilatation is believed to occur when increased pressure develops in the gastric pouch proximal to the band, due to either quick, high volume eating or over tightening of the band device. The incidence of this complication is thought to be relatively low (approximately 4%) [13]. Regard­ less of etiology, patients present with symptoms often quite similar to band slippage, e.g., vomiting and abdo­ minal discomfort. The first diagnostic step, as in pouch slippage, is completely emptying the band. This can be accomplished as previously detailed in the section on slippage. As in cases of slippage, an upper GI contrast study is the most sensitive imaging study for determining whether pouch dilatation has occurred. However, radiographically distinguishing slippage versus dilatation can occasionally be difficult. If emptying the band completely resolves symptoms, then further intervention or evaluation can be made in an elective setting with the patient’s bariatric surgeon. If severe symptoms persist and the UGI is equivocal for pouch dilatation versus true slippage, then emergent surgical evaluation may be indicated as discussed in the previous section.

27.3.4 Port and Tubing Problems The subcutaneous port used to access and adjust the band is sutured to the anterior aspect of the abdominal wall at time of surgical implantation. If the sutures break or are inadequately secured to fascia, the port can detach from the abdominal wall, allowing it to flip or move subcutaneously. Additionally, the tubing ­connecting the port to the band can conceivably kink

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27  Complications After Bariatric Surgery

Fig. 27.16  Progressive slippage of band. (a) Initial postoperative film demonstrates normal band positioning. (b) A supine fluoroscopic series demonstrates normal small pouch (P) with flow through the band (arrow) and into the gastric fundus (F). (c) A film performed in the same patient nearly a year later demonstrates a change in the band positioning, with the band located lower and more horizontal (arrowhead). (d) An UGI at

that same time in the upright position demonstrates the pouch (P) is dilated and displaced over the band with a much narrowed stoma (arrow). (e) Another UGI image from a follow-up a month later demonstrating further eccentric dilatation of the pouch (P) with displacement of the band inferior (arrowheads). The arrow demonstrates the stoma (From Carucci et  al. [10], pp. 261–274, Fig. 11)

or crack. Both of these problems can make reliable access to the port and therefore adjustment of the band difficult or impossible. These problems can occur in up to 6% of cases. Most problems with tubing only become apparent to the adjusting bariatric physician or provider. However, if the port becomes loose the patient may complain of feeling the port move and sometimes discomfort at the site. The diagnosis of a flipped port can typically be made on physical examination, though fluoroscopy can be used to confirm the diagnosis in difficult cases (Fig.  27.18). Such a condition is not an emergency under most circumstances. A repair of this problem typically requires operative repair of the port and or distal tubing using a replacement kit provided by the

manufacturer of the specific band device. Under most conditions, the replacement port and tubing are simply attached to the existing tubing and the port is resecured to the fascia. The surgery is conducted at the subcutaneous and fascial level and intra-abdominal exploration is usually not necessary.

27.4 Bariatric Programs Even as rates of bariatric surgery have increased explosively over the last 10 years, so has the accreditation and development of bariatric surgical centers of excellence. These programs are accredited in the USA by either the

214 Fig. 27.17  Laparoscopic photograph of a dilated pouch (asterisk) proximal to a slipped band (a). Laparoscopic photograph of a slipped band with obvious distal stomach herniated through the band – simply cutting the buckle of the band (asterisk) releases the band and allows it to be removed (b) (Courtesy of Edward Lin, Emory University School of Medicine)

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a

b

American Society for Metabolic and Bariatric Surgery or the American College of Surgeons. These accreditations are rigorous and mandate round-the-clock coverage for bariatric emergencies by a bariatric surgeon as well as long-term follow-up of postoperative bariatric patients. With over 479 such programs in the USA, community surgeons not practicing bariatric surgery should become familiar with neighboring programs. In most cases, patients having undergone surgery at one of these programs should be transferred back there to receive any

and all definitive surgical care for postoperative complications. These programs can and should also be contacted for advice in the evaluation and management of bariatric patients, even where transfers are unlikely or not feasible, e.g., unstable patients and medical tourists. Bariatric surgery rates have increased substantively and, as a natural consequence, so have the numbers of bariatric surgical emergencies and complications that are occurring each year both here in the USA and in much of the western world. Increasing

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References

Fig.  27.18  A fluoroscopic image from an attempted band adjustment demonstrates the port is inverted, making needle access impossible (From Carucci et  al. [10], pp. 261–274, Fig. 13)

numbers of bariatric centers of excellence may reduce the need for community surgeons to take care of these bariatric complications in the future. For now, the community surgeon must maintain a clear understanding of the common bariatric procedures performed as well as their associated complications. In this way, bariatric patients can be assured they will be provided expeditious evaluation and quality surgical care no matter where they are when problems arise.

  1. Hensrud, D.D., Klein, S.: Extreme obesity: a new medical crisis in the United States. Mayo Clin. Proc. 81(10 Suppl), S5–S10 (2006)   2. Buchwald, H., Avidor, Y., Braunwald, E., et  al.: Bariatric surgery: a systematic review and meta-analysis. JAMA 292, 1724–1737 (2004)   3. Nguyen, N.T., Root, J., Zainabadi, K., et  al.: Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch. Surg. 140, 1198–1202 (2005)   4. Encinosa, W.E., Bernard, D.M., Du, D., Steiner, C.A.: Recent improvements in bariatric surgery outcomes. Med. Care 47(5), 531–535 (2009)   5. Podnos, Y.D., Jimenez, J.C., Wilson, S.E., et  al.: Complications after laparoscopic gastric bypass: a review of 3,464 cases. Arch. Surg. 138, 957–961 (2003)   6. Tanner, B.D., Allen, J.W.: Complications of bariatric surgery: implications for the covering physician. Am. Surg. 75, 103–112 (2009)   7. Rosenthal, R.J., Jones, D.B.: Weight Loss Surgery: A multidisciplinary Approach, pp. 379–385. Matrix Medical Communications, Edgemont (2008)   8. Go, M.R., Muscarella, P., Needleman, B.J., et al.: Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass. Surg. Endosc. 18(1), 56–59 (2004)   9. Merkle, et al.: Roux-en-Y Gastric Bypass for Clinically Severe Obesity: Normal Appearance and Spectrum of Complications at Imaging. Radiology 234(3), 674–683 (2005) 10. Carucci, et  al.: Imaging Evaluation Following Roux-en-Y Gastric Bypass Surgery for Morbid Obesity. Radiol. Clin. N. Am. 45(2), 247–260 (2007) 11. Iannuccilli, J.D., Grand, D., Murphy, B.L., et al.: Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y ­gastric bypass surgery. Clin. Radiol. 64(4), 373–380 (2009) 12. O’Brien, P.E., Dixon, J.B.: Weight loss and early and late complications – the international experience. Am. J. Surg. 184, 42S–45S (2002) 13. Brown, W.A., Burton, P.R., Anderson, M., et al.: Symmetrical pouch dilatation after laparoscopic adjustable gastric banding: incidence and management. Obes. Surg. 18(9), 1104–1108 (2008)

 

28

Appendicitis Kerstin S. Schick and Johannes N. Hoffmann

28.1 Epidemiology Appendicitis is the most common cause of acute abdo­ minal pain, with a peak between the ages of 10–30 years (110–200/100,000 patients per year). Diagnosis of appendicitis is often delayed in children, elderly people, and a significant number of patients (10–20%) present with perforated appendicitis. In 25% the diagnosis appendicitis is missed initially, and about 25% of the patients undergoing surgery for acute appendicitis do not suffer from appendicitis.

28.2 Etiology and Pathogenesis Acute appendicitis is an enterogenous rather than a hematogenous infection. It is thought to be facilitated by congestion, narrowing of the intestinal lumen, deviation, scar strands, or fecal stones. Contributing factors are general and intestinal infections (local inflammatory edema of the mucosa). Histologically, appendicitis is characterized by migration of neutrophils into the surrounding lymphoid follicles, and by superficial erosion of the mucosa with fibrin coating. A distinction is made between the reversible catarrhal stage with congestion and swelling, and the seropurulent stage, which indicates progression to infection. Through this progress, a destruction of the intestinal wall occurs with increasing permeability for bacteria. This periappendicitis may progress to a perforation. Perforated appendicitis is K.S. Schick and J.N. Hoffmann (*) Department of Surgery, University of Munich – Großhadern, Marchioninistr. 15, 81377 Munich, Germany e-mail: [email protected]

observed in 10–20% of patients, and is more common with increasing age, reaching an incidence of up to 45% in elderly patients.

28.3 Symptoms and Diagnosis 28.3.1 History Acute appendicitis is characterized by an acute onset of abdominal pain. Initially, the pain is localized in the upper and central abdomen (visceral pain fibers), it gradually moves (within hours) into the right lower quadrant and is described as a sharp pain (peritoneal pain fibers). Usually the abdominal pain has been present for less than 24 h – pain lasting longer than 24 h without development of generalized peritonism is unlikely to be caused by acute appendicitis.

28.3.2 Symptoms Patients may present with loss of appetite, nausea, vomiting, ileus or diarrhea, and fever. With disease progression signs of generalized peritonitis (acute abdomen) develop, and may progress to sepsis if left untreated. Usually pain develops prior to the onset of  other symptoms. In elderly patients, however, the clinical picture may not be as typical and a delay in diagnosis is more likely. It is important to note that an acute exacerbation of Crohn’s disease can mimic symptoms of acute appendicitis

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On physical examination, some clinical signs of acute appendicitis may be found in typical localizations (the names of these signs appear to be more important for some examiners rather than have clinical relevance). Clinical signs of acute appendicitis • Tenderness and guarding in the right lower abdominal quadrant is due to peritoneal irritation through local release of fibrin within the area of the inflamed appendix resulting in spasm of the abdominal wall muscles. • McBurney’s point: pain half way between the umbilicus and the anterior superior iliac processus. • Lanz point: pain in a point located one third of the distance between the left and right anterior superior iliac processus. • Blumberg sign: contralateral rebound tenderness due to peritoneal irritation. • Rovsing sign: pain due to an attempt to apply retrograde pressure on the large bowel content resulting in irritation of the inflamed area in the right iliac fossa (this is painful in healthy individuals as well). • Unspecific sign: Painful rectal examination when pressure is applied to the Douglas Pouch. • Psoas sign: painful flexion of the extended right leg against resistance. A positive psoas sign has the highest specificity for acute appendicitis and indicates retrocecal position of the appendix. The appendix is usually located anterior to the cecum in the right lower abdomen. A retro cecal position is found in approximately 25% of the patients and tends to make the diagnosis of acute appendicitis more difficult. In addition, the para cecal location, a very low location in the pelvis or a raised appendix, as well as a situs inversus can change the clinical picture. In children, maneuvers to distract their attention (sticking the tongue out, squeezing the examiner’s hand) may be helpful, to identify “true” guarding. The diagnosis or suspicion of appendicitis is usually made through history taking and clinical examination. It is mainly a clinical diagnosis! Once the diagnosis is made or appears to be very likely an urgent operation must be performed. The use of a standardized investigation sheet for documentation of a complete physical examination is recommended.

K.S. Schick and J.N. Hoffmann

Diagnostic steps for patients with suspected appendicitis are: • History of presenting condition • Clinical examination • Blood tests including inflammatory markers, urine testing, pregnancy test for female patients of childbearing age • Abdominal ultrasound Additional tests/investigations should be arranged if needed (CT scan), depending on the former results. The implementation of a diagnostic and therapeutic algorithm is highly recommended.

It is important to remember that a single negative diagnostic parameter cannot exclude the diagnosis of acute appendicitis!

When in doubt, keeping the patient under observation for reevaluation with repeat examinations and blood tests is recommended.

28.3.3 Diagnostic Scores A number of different diagnostic scores for acute appendicitis have been developed. These scores aim to facilitate the diagnosis by combining a number of different clinical parameters. The Ohmann score has been introduced to routine daily use in a number of institutions. With a point value of >12, the diagno­ sis  appendicitis is most likely, with a value <6 it is unlikely. Symptoms and signs

Point value

Rebound tenderness

4.5

Blumberg’s rebound tenderness

2.5

Missing dysuria

2.0

Continuous pain

2.0

Leukocytes >10 G/l

1.5

Age >50 years

1.0

Migration of pain from epigastrium to right iliac fossa

1.0

Pain in the right iliac fossa

1.0

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28.3.3.1 Laboratory Data Leukocytosis of 10,000–15,000 leukocytes and increased CRP are very common.

28.3.3.2 Imaging Studies Abdominal ultrasound is often recommended for the diagnosis of acute appendicitis. However, the ­sensitivity of ultrasound at German university clinics varies between 30% and 80%. Ultrasound is dependent on the examiner and the lack of its reproducibility is a wellknown problem. Ultrasound can detect the so-called target sign (thickened/inflamed intestinal wall), free fluid in the lower abdomen, or an abscess. Negative ultrasound results have no diagnostic value. In USA and Great Britain, computed tomography of the abdomen with i.v. contrast is used more and more often to investigate appendicitis. One study suggested substantial cost saving using this approach because it resulted in a reduction of hospital stay. Due to the significant radiation, computed tomography of the abdomen is currently not routinely used in most European countries for the evaluation of right lower quadrant a­ bdominal pain.

28.3.3.3 Differential Diagnosis It is important to consider pain duration and localization as well as pain characteristics for the differential diagnosis of acute appendicitis: • Inflammatory bowel disease: Crohn’s disease, ulcerative colitis • Meckel diverticulitis • Gynecological disorders: menarche, endometriosis, persistence of ovarian follicles, salpingo-oophoritis, ectopic pregnancy, ovarian cyst • Urological disorders: cystitis, pyelonephritis, urolithiasis • Infectious diseases: gastroenteritis, viral infections, enteral yersiniosis • Other less common causes: iliac aneurysms, myocardial infarction, irritable bowel, bowel cancer, typhus and paratyphus, porphyria, intoxication, foreign body, constipation Laboratory tests can be misleading! Up to 30% of the patients with acute appendicitis have pathological urine findings with leukocyturia and bacteriuria resulting from inflammatory involvement of the ureter.

28.4 Management After acute appendicitis has been diagnosed, an urgent operation must be scheduled because surgery is the only effective therapy. A recent randomized clinical trial, however, reports that antibiotic treatment (cefotaxime 1 g bd i.v. and metronidazole 1.5 g od i.v. for a minimum of 24  h) also is a safe first-line therapy in unselected patients with acute appendicitis without peritonitis [1]. Even when in doubt, an operation may be performed to avoid serious complications, especially in elderly patients and children because in these patients, development of fever, pathological laboratory tests, and abdominal pain may be limited or delayed.

28.5 Informed Consent The patient’s operation information should include the main possible surgical complications such as intraoperative and postoperative bleeding, surgical site infection, superficial wound infection, and impaired wound healing, injury of surrounding organs (bowel, ureter) and should also mention the possible need for a bowel resection. Technical complications like bowel or ureter injuries must be mentioned independent of their rare incidence. The patient should be involved in the discussion of what to do with an “innocent” appendix. At this point, there is no evidence favoring routine appendectomy or diagnostic laparoscopy only. The patient should be included into the decision process (leave it or cut it) before the operation, because it is possible to diagnose appendicitis in 95% of the cases with laparoscopy in a correct way and in these cases surgery could be ended as a diagnostic laparoscopic procedure. If an open appendectomy was planned, the appendix should be removed regardless of whether or not it is inflamed. Two surgical procedures are commonly used: open or laparoscopic appendectomy.

28.5.1 Open Appendectomy The most popular approach for open appendectomy is an incision in the right lower quadrant. In cases suspected to have an advanced inflammation, a pararectal

220

incision would be more advantageous because it can be extended cranially and caudally. This incision also allows for more extended procedures, like an ileocecal resection. In unclear cases when surgery is exploratory, a low midline laparotomy is advocated, because it allows a wider exploration.

28.5.2 Laparoscopic Appendectomy Three trocars are used, one close to the umbilicus, one in the midline above the pubic bone, and the third in the right or left lower abdomen. The mesoappendix is cut using a laparoscopic stapler or bipolar coagulation and the base of the appendix is then closed with an endoscopic Roeder’s loop or a second endoscopic linear stapler. The appendix is removed by using a recovery-bag to avoid subcutaneous wound infection. There is also some experience with single part techniques showing promising results. A single i.v. dose of a second-generation cephalosporin or an aminopenicillin is recommended to reduce the incidence of postoperative wound infections. Continuation of antibiotic therapy is only indicated if peritonitis is found at the time of surgery.

28.5.3 Laparoscopic Versus Open Appendectomy While laparoscopic cholecystectomy has been established as the standard technique for cholecystectomy, laparoscopic appendectomy remains controversial. A recently published double-blind randomized study comparing laparoscopic and open appendectomy did not show a clear advantage for the laparoscopic approach with regard to postoperative recovery and quality of life, but reported slightly higher complication rates. Furthermore, there appears to be a clear advantage of shorter operating times and reduced costs for open appendectomy. Laparoscopic appendectomy causes significantly less wound healing problems and allows for a faster return to activities of daily living. Laparoscopy allows for a better diagnostic view than conventional appendectomy. Minimal invasive surgery, furthermore, is of

K.S. Schick and J.N. Hoffmann

advantage in obese patients and in women of childbearing age. With regard to training in laparoscopy, it is important to consider laparoscopic appendectomy in uncomplicated cases as an important training procedure. However, in patients with a perforated appendix, the rate of postoperative abscess formation appears to be higher when compared with conventional appendectomy. The authors’ institution has experience with more than 1,000 laparoscopic appendectomies and when compared to the open procedure, there is a reduced length of postoperative stay with a low complication rate [2].

28.5.4 Histology All removed specimens should be examined by a pathologist to confirm the diagnosis and to detect other rare conditions such as carcinoid or mucinous adenocarcinoma. Histology identifies the following stages of acute appendicitis: Duration of symptoms (h) 6

Stage Vascular injected appendix (congested vessels in the serosa)

12

Phlegmonous appendicitis (fibrinous purulent coated serosa)

24

Ulcero-phlegmonous appendicitis (flat ulcers and defects of the mucosa)

48

Suppurate appendicitis (necrosis of walls with defects, macroscopically the appendix appears gray to green)

28.6 Results Surgical mortality for non-perforated appendicitis is about 0.06%, which equals the mortality risk of ­general anesthesia. With perforation, the mortality increases approximately 30 times. In older patients it can even reach 5–10%. Morbidity for not-perforated appendicitis is low (3%). Perforated appendicitis carries a higher morbidity (wound healing problems, abscess formation, leakage from the appendiceal stump).

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Late complications include incisional hernias, adhesions with resulting mechanical obstructions, and stump appendicitis. Whether or not long-term complications occur less often after laparoscopic appendectomy remains to be determined.

Patients are usually discharged on the first or second day after laparoscopic appendectomy and may require a slightly longer stay after open appendectomy.

Reference 28.6.1 Complicated Appendicitis When the correct diagnosis is not made early during the disease process, complications are more likely to occur. Perforation leads to localized peritonitis with abscess formation or generalized peritonitis. Therapy of free perforation with peritonitis follows the guidelines treatment for peritonitis. Perityphlitic abscess formation can be treated ­following two different strategies, which have been established: • Ultrasound or CT-guided abscess drainage or laparoscopic drainage followed by eventually appendectomy in the inflammation-free interval. • Ileocecal resection at the time of diagnosis, which avoids interval appendectomy. If the postoperative course is uncomplicated feeding can be started with tea and soup on the day of surgery. Normal feeding can start on day one after surgery.

  1. Hansson, J., Körner, U., Khorram-Manesch, A., Solberg, A., Lundholm, K.: Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br. J. Surg. 96, 473–481 (2009)   2. Schick, K.S., Huettl, T.P., Fertmann, J.M., Hornung, H.M., Jauch, K.W., Hoffmann, J.N.: A critical analysis of laparoscopic appendectomy: how experience with 1,400 appendectomies allowed innovative treatment to become standard in a university hospital. World J. Surg. 32, 1406–1413 (2008)

Recommended Reading Becker, K., Höfler, H.: Pathologie der Appendicitis. Chirurg 73, 777–781 (2002) Katkhouda, N., Mason, R.J., Towfigh, S., Gevorgyan, A., Essani, R.: Laparoscopic versus open appendectomy a prospective ­randomized double blind study. Ann. Surg. 242, 439–450 (2005) Kraemer, M., Ohmann, C., Leppert, R., Yang, Q.: Macroscopic assessment of the appendix at diagnostic laparoscopy is ­reliable. Surg. Endosc. 14, 625–633 (2000)

 

Bowel Obstruction

29

Saukat T. Esufali

Patients with bowel obstruction may present challenging problems of management. Decision-making has to take account of many factors and circumstances. When discussing treatment of bowel obstruction within rural settings with rural surgeons, there are different points of view that have to be factored in, along with other issues coming into play apart from surgical decision-making processes (Bruening and Maddern, 2009). Most surgeons practising in rural settings have trained in urban centres and teaching hospitals. As such, it may be inappropriate to label ‘rural surgery’ as a specialty which has major differences in practice. The management of patients with defined surgical problems would follow the same practice as urban centres, and there would be criticism if there were major changes in approach. While the lack of services such as ICU can limit the scope of surgery, this should not change the type of surgery for defined problems. Rural hospitals with surgical facilities can vary considerably. Mount Gambier District Hospital (MGDH) is in a developed country, Australia, in a rural centre. The Limestone Coast region is home to 65,402 people. Mount Gambier, the largest city in the region, has a population of around 25,000 people and is the regions’s (including far western Victoria) commercial centre. http://www.infrastructure.sa.gov.au/_data/assets/

S.T. Esufali Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia and School of Medicine, Melbourne University of Notre Dame, Australia and Department of Surgery, Werribee Mercy Hospital, 300 Princess Highway Werribee, Victoria 3030, Australia e-mail: [email protected]

pdf_file/0014/53114/ROLimestoneCoast.pdf Sep 2010. There are in addition to MGDH small hospitals run by family doctors, some of whom have minor operating theatres. The flying doctor service may be relied on to transfer a patient from MGDH to a major urban centre within 4 h of being contacted. In contrast, rural centres in poorer countries such as Sri Lanka have no sophisticated transfer facilities, and patients may face an arduous ambulance journey by road that can take 8–10 h with little paramedic or medical input. In these settings, the scope and type of surgery carried out would be markedly different and the ­surgeon has to have a much wider repertoire of surgeries under his/her belt. In attempting to put matters into greater perspective, the management of bowel obstruction in a rural setting would need to take into account the following factors: • Surgeon training and experience: In most rural ­settings, surgeons would have adequate training and experience to tackle bowel obstruction. They would have the necessary skills and awareness of the different surgical options at their disposal. With the availability of the internet and interactive learning tools, surgeons in most rural settings are able to keep themselves abreast of the latest opinions based on studies from academic institutes. Surgeons in rural settings often work alone. They have the capacity to discuss a case with a colleague by phone, but a hands-on second opinion or team approach – taken for granted in urban centres- is sadly lacking and this can be an impediment to optimal management of medical problems. There has been some debate recently regarding the merits of major surgery and procedures being performed by specialists in rural centres. The minimum number of specific procedures/surgeries

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per surgeon per year for maintaining standards has yet to be decided and will no doubt be a matter for debate (Dundee et al. 2007). • Available facilities, technical support and manpower: The problems that rural-based surgeons often encounter go far beyond their technical abilities to perform the necessary surgical procedures. The available radiological and laboratory backup, especially after hours, may be inadequate. Invariably, the most challenging problems are encountered after hours, which can tax even the most experienced surgeons. Theatre nurses are on call and need to be called in; and first assistants are usually theatre nursing staff, non-surgical trainee medical staff or non-surgical trainee junior doctors. Despite their best efforts and mental motivation, they still might not be able to provide as much technical support as colleagues or trainee surgeons. Anaesthetic staffing shortage problems are often experienced in rural settings in Australia. General practitioner anaesthetists play a major role in covering the shortfall of specialists. This may become an issue when a patient with bowel obstruction has metabolic, hypovolemic, nutritional or septic complications. ICU facilities are rarely available in rural hospitals. Some patients may require ventilation, nutritional support, second-look laparotomy or other intervention. In this situation, the surgeon faces the issue of transferring a patient before surgery or immediately after surgery or later if problems arise. Ideally, from the receiving staff point of view, early transfer is optimal prior to organ failure states. • Community expectations: There is a difficult and imperceptible line when it comes to estimations of the capability of performing surgery in a rural setting. On the one hand, one can refer all complex surgical problems to urban centres and avoid having problems with regard to morbidity and mortality. On the other hand, one can be overenthusiastic, strain the system and subsequently encounter postoperative problems with poor outcomes. This can lead to a negative mindset amongst medical and nursing colleagues. Both ways obviously have cost implications, and ramifications for the future viability of the hospital. An issue that recently created much public debate with ongoing legal implications surrounded a surgeon and complications at Bundaberg Hospital in rural Queensland, Australia. The surgeon concerned was found to have carried out surgery beyond his capability

S.T. Esufali

and also the facilities available locally, compounded with a reluctance to transfer the patients prior to and also after surgery. This led to media frenzy and may have altered the practice of surgery in rural settings. Properly promoting appropriate surgery in a rural setting can ultimately be beneficial for the community, as well as saving many patients and their families the additional difficulties posed by travel, treatment in unfamiliar environs and cost. At present there is awareness about the complexities of rural surgical practice. Most urban surgeons and specialists are cooperative and understanding when approached for support. Many surgical trainees spend part of their training in rural settings, and are generally very positive about their experiences. Mount Gambier Hospital surgeons have a close link with the urban academic surgical centre in Adelaide and have weekly video-link with case conferences, as well as regular audit and academic exchanges. This support is extremely valuable in enhancing skills and confidence in ruralbased surgeons in a modern developed-world setting.

29.1  Clinical Decision Making There are many algorithms for managing bowel obstruction. Management-based decision-making is preferable to a diagnosis-based approach (Table 29.1). Patients with bowel obstruction usually present acutely with abdominal pain, vomiting, distension and constipation. These symptoms vary depending on the level of obstruction within the GI tract. Other diagnoses could be acute appendicitis, acute pancreatitis, gastroenteritis. To confirm that the GI tract is obstructed, clinical factors and investigations are needed. The mainstay of specific investigations are radiological. Plain X-rays were and continue to be the investigation most used. The main features on X-rays are dilated bowel loops, central location, paucity of gas in the rectum/ colon and recognition of haustral patterns. Now CT scan has proved to be a valuable adjunct in establishing a diagnosis and also helpful in assessing for a closed loop bowel obstruction. Distal small bowel obstruction and high proximal obstruction can be difficult to diagnose due to the paucity of vomiting in the former and late constipation in the latter (Cappell, Batke 2008). Later on in the presentation of mechanical obstruction, an ileus sets in and classical colicky

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29  Bowel Obstruction Table 29.1  Algorithm for Clinical Decision Making in Bowel Obstruction

Possible bowel obstruction X-rays, contrast studies, CT Scan

Definite bowel obstruction CT Scan, Clinical assessment

Mechanical

Paralytic ileus/adynamic

Simple mechanical

Strangulation

Early/emergency Surgery

Endoscopic Treatment

Non-operative Investigate

Surgery

Generalised

Non-operative Measures

Surgery for Causes Eg. Appendicitis

Endoscopic decompression

Settles

pain may not be a feature. Plain X-rays have been the mainstay of radiological diagnosis, but more recently CT scans with oral and intravenous contrast can be more definitive helping to highlight the level and extent of obstruction. CT scans are especially helpful in the challenging situation of discerning between a mechanical obstruction and a paralytic ­(adynamic) obstruction (Rhodes et al. 2001). Blood tests need to be carried out for complete blood count (CBC), urea, creatinine and electrolytes (U and Es), liver function tests (LFT), C-reactive ­protein (CRP), blood group, lactate and acid studies. Patients can have profound fluid and electrolyte shifts with bowel stasis, especially distal obstruction states. These need correction prior to surgical intervention. Initial management of bowel obstruction rests with fluid and electrolyte resuscitation, nasogastric aspiration, analgesia and further regular assessments. Monitoring the amount of urine production is a valuable indicator of adequate volume resuscitation. Some

Segmental

Surgery/colostomy

elderly patients with cardiac disease may be easier to manage with central venous monitoring as far as fluid input is concerned. Once the patient is stabilized, the next question to address is whether the patient has a mechanical or ­paralytic obstruction. The two may coexist, especially in the later stages of a mechanical obstruction. When the ileus is localized due to an inflammatory focus such as appendicitis, then the clinical signs of localized peritonitis should prevail and warrant surgery, depending on the degree of peritonitis. The differentiation between ileus and mechanical obstruction depends on the clinical presentation and radiological findings (Table 29.2). Colicky pain usually indicates a mechanical problem. Abdominal distension disproportionate to the pain/discomfort would point to an ileus rather than a mechanical component. Visible or palpable waves of peristalsis across the abdominal wall ­usually indicate a mechanical problem. Radiology can be most helpful with plain films, CT scans and

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Table 29.2  Clinical and radiological findings to distinguish between mechanical obstruction and Ileus Mechanical Ileus obstruction Clinical signs

•  Colicky pain •  Visible peristalsis

• Localized peritonitis (if due to an inflammatory focus) • Abdominal distension disproportionate to pain/ discomfort

Radiological investigations

• Collapsed loops distal to the dilated loops (CT)

• Air/gas seen in colon/rectum

contrast studies contributing to diagnosis. The presence of air/gas in the colon and ­rectum is the most reliable sign of an ileus. Collapsed loops distal to the dilated loops on CT are indicative of a mechanical problem. Patients with an ileus need medical attention and observation until the problems settle. The causes may be due to metabolic or local problems in the peritoneum; such as ascites or haemoperitoneum (e.g. after hip or lumbar trauma as well as post abdominal surgery). Postoperative ileus also occurs due to fibrinous, flimsy adhesions. The ileus usually settles within a few days after surgery, but if it persists or recurs, then a postoperative event such as an anastomotic leak or collection should be suspected. An ileus that persists despite time and general measures, warrants continued attention and possibly surgery. Medical agents such as dopamine antagonists (metoclopramide) and sympathetic blockers (neostigmine) may be of benefit. Nonetheless, we do not recommend ongoing use since the prevailing ileus may be masked, a perforation may occur or an underlying cause for the ileus may be missed. An ileus may be segmental as in colonic ileus (also labelled as pseudo-obstruction) or Ogilvie’s syndrome. Endoscopic deflation may be useful until the initiating/ prevailing cause settles. Endoscopic views of the colon or contrast studies can also check for an obstructing problem or a volvulus in the colon, which may occur in the elderly. Rarely would a colostomy or ileostomy be required, to prevent the prospect of perforation. Even for the most experienced clinicians differentiation between a mechanical and non-mechanical obstruction may be difficult. CT scans are helpful but not always

accurate. Water-soluble contrast follow-through studies via a nasogastric tube or jejunal tube can be most useful, and on occasions, ­therapeutic. Contrast should be present in the caecum/colon within 2–3  h. If the flow is delayed and the small bowel loops continue to distend with the contrast, this is strongly suggestive to a mechanical obstruction. Radiologists have mixed views about the use of water-soluble contrast studies when the plain films show dilated bowel loops, because the mucosal delineation is lost. It remains a subjective preference, but can be a useful adjunct in the differentiation between a mechanical and non-mechanical problem. Patients with a mechanical obstruction generally require intervention, either as an open surgical procedure, or laparoscopic intervention if facilities exist. The timing of surgery would depend on the risk of the mechanical obstruction being compounded by strangulation. This is particularly so with a closed loop obstruction. The venous congestion and subsequent vascular inflow occlusion due to the mesenteric pressure lead to a rapidly deteriorating clinical state. The combination of congestion and obstruction has the effect of ischemia in association with bacterial multiplication and ensuing bacteraemia. Patients are often more unwell than expected for the clinical presentation and duration of symptoms. They appear septic and toxic with tachycardia despite adequate filling, tachypnea (due to acidosis), low-grade pyrexia and peritonism (albeit a late sign indicating perforation). The blood parameters may show a leukocytosis, elevated inflammatory markers, lactic acidosis amongst others. If there is doubt as to the nature of the obstruction, early surgery is advised. Delay in the management of strangulating obstruction leads to increased morbidity and mortality, and further adhesions. Strangulated obstruction is classically caused by adhesions, volvulus, intussusception or obstructing inguinal/femoral herniae. Patients with sigmoid volvulus and intussusception can be managed without laparotomy if they are clinically stable and do not show signs of strangulation. Sigmoidoscopy using a flexible instrument may untwist the volvulus and decompress the dilated redundant sigmoid loop. If successful and no further episodes of volvulus occur, then surgery can be avoided or delayed. In children intussusception is often successfully managed by hydrostatic decompression under radiological control (Rohrschneider et al. 1995). Mechanical bowel obstruction without strangulation can be initially managed with decompression and

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29  Bowel Obstruction Table 29.3  Common causes of bowel obstruction Age group Intraluminal causes Intramural causes

Extramural causes (extrinsic compression)

Neonates and infants <24 months

Meconium ileus, obstruction, foreign bodies

Congenital atresias, stenoses and webs; duplication cysts; intussusception

Congenital inguinal/diaphragmatic hernia, congenial bands, midgut volvulus, postoperative adhesions

Children and young adults

Foreign bodies, worms

Crohn’s disease, benign neoplasms, primary and secondary malignant neoplasms

Inguinal hernia, congenital and postoperative adhesions, midgut volvulus, intussusception, complications of appendicitis

Elderly persons

Foreign bodies, gallstones

Crohn’s disease, tuberculosis, primary and secondary neoplasia, radiation strictures, complications of surgical anastomosis

Postoperative adhesions; femoral, inguinal, umbilical or incisional hernia; colonic and ovarian neoplasia; adhesion to an ­inflammatory process (e.g. appendicitis or diverticulitis)

fluid/electrolyte maintenance. This would give time for further investigations to delineate the level and extent of obstruction. With time, and simple non-surgical measures, some patients with adhesion obstruction may settle spontaneously. If they do not settle, then radiological contrast studies and endoscopic means are available to ascertain the level of obstruction and often the cause. Patients with colonic obstruction can be stented endoscopically, either as a bridging procedure with surgical resection after stabilization or as a definite palliative intervention. Bowel obstruction accounts for almost 15% of emergency admissions for general surgeons, and the majority of these patients generally require surgery, with adhesions/band obstruction being a major causative factor (Table 29.3). Adhesions can be challenging technically with iatrogenic injury, risk of leaks and fistulae being a sequel (Menzies 1992). Thankfully, this happens rarely, but most ­surgeons unfortunately have had such a case and will remember that patient indefinitely! Figures 29.1 to 29.5 show examples of bowel obstruction seen and treated in rural surgery. At operation for mechanical bowel obstruction, there are dilated loops proximal to the obstruction and collapsed loops distally. The aim of surgery is to restore continuity. With adhesions from previous operations, there is often a single dense fibrous band causing the closed loop obstruction and this requires division. Small bowel viability has to be confirmed, and if there is doubt then a resection is needed and continuity should be restored with a primary anastomosis. Prevention of adhesions has been the subject of much debate (Menzies 1992). Gentle handling, sound surgical technique and avoiding areas of ischaemia are

Fig.  29.1  Plain X-rays of patient presenting with abdominal pain, distension and vomiting 3 months after laparoscopic cholecystectomy. CT scan shown below Fig. 29.2 (Source: Benson’s radiology, Adelaide/Mount Gambier, Australia)

still sound principles. Limiting the use of foreign material/sutures has also has been shown to reduce adhesion formation. Lavage has not shown to offer any advantages but is still a tradition with many surgeons. Dealing with large bowel obstruction may be more  challenging for technical reasons and patient factors. Colonic primary anastomosis ideally requires a clean bowel (although this has been challenged by a number of studies which do not support the notion that a clean bowel carries a reduced risk of anastomotic leakage when compared to unprepared bowel), tension-free colon

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Fig. 29.2  CT scan findings in a patient (Fig. 29.1) with large bowel obstruction due to adhesions after previous laparoscopic cholecystectomy for biliary pancreatitis (Insert images  1, 2; Source: Bensons Radiology, Adelaide/Mount Gambier, Australia). There was a dense band of adhesions causing a mechanical obstruction at the mid transverse colon level. Right hemicolectomy required

Fig. 29.4  Supine abdominal X-rays of patient as shown Fig. 29.3 (Source: Benson’s radiology Adelaide/Mt Gambier, Australia)

Fig. 29.3  Erect X-rays of patient presenting with Vomiting, colicky abdominal pain and constipation. There is gross dilatation of small bowel. There is some air in the transverse colon and splenic flexure. There was a past history of gynecologic surgery. See Fig 29.4 and 29.5. (Source: Benson’s radiology Adelaide/ Mt Gambier, Australia)

Fig. 29.5  Plain film and CT scan findings in a patient with small bowel obstruction due to an ischaemic segment of small bowel (Insert images 3–5; Source: Bensons Radiology, Adelaide/Mount Gambier, Australia). Laparotmy revealed an ischaemic segment of small bowel due to a band adhesion from previous surgery

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and good blood supply for healing. Due to the obstruction, patients are unwell and have adverse physiology scores. At surgery for colonic bowel obstruction, the colon may be loaded. On table lavage, is an option to achieve a clean colon (Seow-Choen et al. 1993). However, exteriorisation of the ends or decompression stoma is often used in the acute setting. With regard to stomas following surgical resection of an obstructed segment of colon, it is also important to consider that reversal of the colostomy may not be easy because of adhesion formation and other patient-related health factors. A number of patients after surgery live for a long time with a temporary stoma, not requesting reversal or being advised against surgery due to the high risk of surgery for the reversal. In conclusion, management of patients with bowel obstruction in a rural setting can be a challenging and rewarding experience. The options for management vary depending on the clinical presentation. Often surgery is required, and the procedure has to be carefully tailored to the circumstances and facilities available for post-operative care. Surgery may vary from a decompression stoma (and transfer of patient to a tertiary care centre) to a major bowel resection, using on-table bowel lavage techniques prior to a primary anastomosis. In my experience, regular collaboration and dialogue with urban based surgeons and peers, has made working in a rural setting most satisfying and rewarding.

Summary

›› Bowel obstruction is frequently seen in rural

surgical practice and often requires expedite management often involving major surgery. The outcome for patients has improved with early resuscitation, early surgery in those ­reco­gnized to be at risk of strangulation and a combined operative and non-operative

››

management of those with simple mechanical obstruction. In rural settings, the operative technique adheres to accepted principles. The limiting factors relate to the availability of postoperative facilities such as an ICU. Adhesions causing bowel obstruction will continue to be a frequent surgical problem, but with minimally invasive techniques replacing open surgery, it remains to be seen whether or not there is a reduction in the incidence of adhesions causing band obstruction.

Recommended Reading Bruening, M.H., Maddern, G.J.: Rural Surgery: The Australian experience. Surg. Clin. North Am. 89(6), 1325–1333 (2009) Cappell, M.S., Batke, M.: Mechanical obstruction of the small bowel and colon. Med. Clin. North Am. 92(3), 575–597 (2008) Dundee, P.E., Chin-Lenn, L., Syme, D.B., Thomas, P.R.: Outcomes of ERCP: prospective series from a rural centre. ANZ J. Surg. 77(11), 1013 (2007) Menzies, D.: Peritoneal adhesions: incidence, cause, and prevention. Surg. Ann. 24, 27–45 (1992) Rhodes, A.I., Shorvon, P.J.: Recent advances in small-bowel imaging: a review. Curr. Opin. Gastroenterol. 17(2), 132–139 (2001) Rohrschneider, W.K., Troger, J.: Hydrostatic reduction of ­intussusception under US guidance. Pediatr. Radiol. 25(7), 530–534 (1995) Seow-Choen, F., Eu, K.W.: Intra-operative irrigation for acute distal colonic obstruction caused by carcinoma. Br. J. Surg. 80, 516 (1993)

 

30

Diverticulitis Matthias W. Wichmann and Karl-Walter Jauch

30.1 Epidemiology

30.2 Localization

Diverticulosis is a very common finding in most western societies, which affects approximately 12% of the population and has an increasing incidence with age. While only 5% of the population at age 40 present with diverticulosis, approximately two-thirds of the population at age 65 have this condition. An estimated 10–25% of patients with diverticulosis develop symptomatic diverticular disease. Only 5% of patients with diverticulosis require surgical treatment for the disease. A number of risk factors for the development of diverticulitis have been established:

Diverticulosis mainly affects the sigmoid and descending colon. In patients with diverticular disease of the entire large bowel, most inflammatory changes are still observed in the left colon, whereas most bleeding complications develop in the ascending colon. The underlying causes for these differences in localization  of complications of diverticular disease are not known.

• • • • • • •

30.3 Etiology and Pathogenesis

Caucasian race Male gender Obesity Advanced age Low-fiber diet Lack of exercise Immune suppression

M.W. Wichmann (*) Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia e-mail: [email protected] K.-W. Jauch Department of Surgery, University Hospital Grosshadern, Marchioninistr. 15, 81377 Munich, Germany

Diverticula of the large bowel are usually so-called pseudo-diverticula, which only consist of mucosa and submucosa (Fig. 30.1). These pseudo-diverticula penetrate the circular muscles of the large bowel at the site of entrance of submucosal vessels. As possible causes for the development of diverticulosis, the following patho-mechanisms have been discussed: • Chronically increased intraluminal pressure • Defect of intestinal innervation with subsequent muscular hypertrophy • Changes of collagen synthesis and structure • Changes of bowel motility with subsequent socalled hypersegmentation (increased pressure zones through large portions of the large bowel not limited to the space between two haustri)

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_30, © Springer-Verlag Berlin Heidelberg 2011

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Fig. 30.2  Computed tomography: acute complicated diverticulitis with free perforation and abscess formation in the pelvis (Source: K. Herrman, Department of Radiology, University of Munich, Munich, Germany) Fig. 30.1  Colonoscopy finding: diverticulosis

30.4 Clinical Symptoms and Diagnosis 30.4.1 Clinical Examination The leading symptoms of patients with diverticulitis are pain in the left iliac fossa as well as a varying degree of peritonitis (guarding, rebound tenderness). Occasionally, a large mass can be palpated in the left iliac fossa. Approximately 5% of all patients presenting with symptoms of acute abdominal pain suffer from diverticulitis.

30.4.2 Additional Diagnostic Options

tests, urea, creatinine, lipase, C-reactive protein, and urine dipstick. The following imaging studies are available: • Computed tomography of the abdomen with i.v., oral and rectal contrast (300 ml of water) (Fig. 30.2) • (Editorial comment: rectal contrast is not considered a diagnostic standard in some countries (i.e., the USA)) • Abdominal ultrasound • Colonoscopy • Contrast enema with water-soluble contrast Computed tomography allows for a reliable diagnosis in almost all cases of diverticulitis and is the imaging technique of first choice for these patients.

Additional diagnostic measures aim to • • • •

Confirm the clinical diagnosis Establish the severity of disease Allow for grading of the disease process Detect/exclude other potential causes for left iliac fossa pain (colon cancer, gynecological/urological causes, volvulus, inflammatory bowel disease, incarcerated hernia)

The following laboratory tests should be ordered in patients with suspected diverticulitis: full blood cell count, electrolytes, coagulation studies, liver function

Major advantage of computed tomography (CT) is that complications such as fistula formation, stenosis, perforation, and abscess can be diagnosed and treated at the same time (drainage of perforation and abscess). Moreover, the CT allows to determine the extent of inflammatory changes as well as the risk of recurrent disease. Abdominal ultrasound can be considered a ­com­plimentary examination which may be helpful to investigate other causes of acute abdominal pain (cholecystitis, adnexitis, stones within the renal tract).

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Colonoscopy is used as an elective tool after complete clearance of the acute inflammation and should be carried out 4–6 weeks after hospital discharge following successful conservative treatment. There is, however, a trend to perform colonoscopy earlier (1–2 weeks) after acute diverticulitis. This procedure allows to exclude large bowel cancer and is necessary to evaluate the severity of diverticular disease and the possible need for elective surgical intervention. A ­contrast enema of the large bowel can also be used at this stage as an additional imaging tool but provides only limited additional information to the CT with rectal contrast. Cave The colonoscopy should not be carried out during acute inflammation due to the extremely high risk of large bowel perforation.

30.5 Classification of Diverticulitis Two important classifications of diverticulitis exist – the Hinchey classification (1978) and the Hansen and Stock classification. While the Hinchey classification (Table 30.1) is based on the intraoperative findings of perforated diverticulitis, the classification of Hansen and Stock (Table  30.2) considers the findings of

clinical evaluation, colonoscopy, contrast enema, and CT. This classification, therefore, includes all stages of the disease and does not require surgical intervention to be applied.

30.6 Therapeutic Strategy Uncomplicated diverticulitis without signs of systemic disease can be treated without hospital admission using oral antibiotics (amoxicillin + b-lactamase inhibitor or ciprofloxacin + metronidazole) and fluid/light diet for 3–5  days. Signs of peritonitis and/or systemic infection require hospital admission, intravenous antibiotics (second generation cephalosporin or ciprofloxacin plus metronidazole), and liquid/low residue diet only. The diagnosis should be established urgently (emergency CT). Clinical findings and the results of CT will allow the surgeon to decide whether emergency surgery is necessary (free perforation), or a conservative approach can be chosen. The flowchart in (Fig.  30.3) indicates the recommended diagnostic and therapeutic steps for patients with suspected diverticulitis.

30.7 Conservative Therapy Table 30.1  Hinchey classification of perforated diverticulitis I. Pericolic abscess formation II. Covered abscess in lower abdomen, retroperitoneum or pelvis III. Free perforation with putrid peritonitis IV. Free perforation with fecal peritonitis

Table  30.2  Hansen and stock classification of diverticular disease 0. Asymptomatic diverticulosis I. Uncomplicated diverticulitis II. Complicated diverticulitis   (a) Inflammation and phlegm of the pericolic fatty tissue   (b) Abscess formation   (c) Free perforation III. Chronic recurrent diverticulitis

If uncomplicated diverticulitis is diagnosed with the help of CT (Stage I of the Hansen and Stock classification), there is no indication for surgical intervention. Treatment usually consists of the following: • Reduction of oral food intake reduced to liquids or nil per mouth • Intravenous fluid therapy and supplementation of electrolytes, in severely sick patients parenteral nutrition can be considered • Intravenous antibiotics Clinical assessment and blood tests (body temperature, white blood cell count, C-reactive protein) should show a significant improvement within 72  h after initiation of treatment. Should no improvement or worsening of symptoms be detected, a repeat CT should be done to exclude a secondary perforation.

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After 1st episode of uncomplicated diverticulitis: plan colonoscopy 3–6 weeks after inflammation has settled. After 2nd episode of uncomplicated diverticulitis: plan early-elective or elective resection. Following emergency surgery: plan stoma reversal 3–6 months after discharge.

Admission diagnosis: Acute abdominal pain

Clinical impression: Acute diverticulitis

Laboratory diagnostics Full blood cell count, electrolytes, coagulation studies, liver function tests, urea, creatinine, urea, C-reactive protein

CT contrast with rectal filling

Uncomplicated diverticulitis

Conservative therapy: • Admission • Clear fluid diet • IV antibiotics

Complicated diverticulitis: without free perforation

Emergency intervention: • CT/US-guided drainage Emergency operation • Hartmann procedure • If possible primary anastomosis ± covering stoma Early-elective surgery after successful drainage

Complicated diverticulitis: with free perforation

Emergency operation: • Hartmann procedure • If possible primary anastomosis ± covering stoma

Fig. 30.3  Flow-chart: diagnostic and treatment of acute diverticulitis

If the conservative treatment is successful, oral food intake can be restarted and antibiotics should be given for a total of 3–5 days. Prior to discharge, the patient should be informed about the need for high fiber diet, weight reduction, and regular exercise to avoid recurrent diverticulitis. 4–6 weeks after clinical normalization, the large bowel needs to be investigated with colonoscopy or virtual colonoscopy (possibly contrast enema as well).

30.8 Surgical Therapy 30.8.1 Timing of Surgery Surgery can be done as an emergency, early elective (3–7 days after onset of symptoms and initial resuscitation) or elective (> 3 weeks after conservative treatment of acute diverticulitis) procedure.

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30.8.2 Indication for Surgical Treatment (a) Uncomplicated acute diverticulitis (stage I) Following successful conservative treatment, almost all patients will remain free of recurrent problems and will not require additional treatment. There is no indication for emergency surgery, and elective surgery should only be discussed in immunocompromised patients. (b)  Acute complicated diverticulitis −− Phlegm of the pericolic fatty tissue (stage IIa): successful conservative treatment does not require additional elective surgery; failure of conservative treatment or early recurrent symptoms justify early elective surgery −− Pericolic abscess formation or covered perforation (stage IIb) usually requires surgical intervention, which can be done after initial stabilization, antibiotic treatment, and interventional abscess drainage; if the clinical situation does not improve within 72 h or interventional drainage is not available, emergency surgery is needed; it is important to note that interventional drainage is only possible in approximately 10% of the patients and has a complication rate of up to 5%; usually surgery can be carried out safely as an early elective procedure within 4–5 days after initial stabilization, which saves a second hospital admission −− Free perforation (stage IIc) with diffuse peritonitis always requires emergency surgery (c)  Chronic recurrent diverticulitis (stage III) Chronic pain following multiple episodes of acute diverticulitis usually requires surgical intervention, although it has been reported that a significant number of patients will not remain free of symptoms after surgery. Recent studies, furthermore, do not support mandatory surgery with recurrent diverticulitis since most complications appear to develop with the first episode, and not with later episodes of diverticulitis.

recurrent disease. Non-inflamed diverticula do not need to be removed; care should be taken, however, not to include a diverticulum into the anastomosis. The distal extent of resection is of major importance to avoid recurrent disease. The anastomosis needs to be formed distal to the RSJ within the mid-rectum to remove the recto-sigmoid highpressure zone. Surgical consent must mention the major complications: covering ileostomy or loop-/end-colostomy, laceration of the urether, anastomotic leakage, and sepsis. (a) Primary anastomosis has only recently been included into the guidelines for treatment of perforated diverticulitis. Resection of the sigmoid colon and RSJ with primary anastomosis can safely be done in most patients even when free perforation has occurred. Formation of a covering loop ileostomy should be considered during surgery and may be useful to avoid secondary sepsis from anastomotic failure. (b) Hartmann procedure with resection of the sigmoid colon and formation of an end colostomy without anastomosis. This procedure can be very difficult to reverse and subsequently up to 45% of these patients have a permanent end colostomy. Primary anastomosis should not be attempted if the patient suffers from significant comorbidity (need of intensive care at the time of surgery, immune dysfunction, liver cirrhosis, renal failure) at the time of surgery. Surgery can be carried out via conventional midline laparotomy, Hockey-stick incision in the left lower abdomen or as a laparoscopic procedure. Peri- and postoperative care should include ongoing antibiotic treatment for 3–5 days, low-molecular-weight heparin and early start of enteral nutrition. In patients with severe sepsis, a delay of enteral feeding may be necessary and some of these patients may require parenteral nutrition.

30.8.3 Surgical Procedures

30.9 Complications of Diverticulitis

Aim of surgical treatment is the complete removal of the inflamed/perforated segment of the large bowel including the recto-sigmoid junction (RSJ) to avoid

• Fistula formation: 10% of in-hospital treatment of patients with diverticular disease; two-thirds colovesicular fistula; indication for elective surgery

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• Impaired colonic passage: irreversible fibrous stenosis of the large bowel; indication for elective surgery • Bleeding: most common cause of lower gastrointestinal bleeding (40%); 15% of patients with diverticulosis; high risk of recurrent bleeding (40%); bleeding source usually in the ascending colon (>50%); emergency surgery may be necessary; selective abdominal angiogram should be carried out for localization and possible embolization

30.10 Prognosis The first episode of acute diverticulitis can usually be managed with conservative treatment and 75% of these patients do not suffer from recurrent disease and only 10% require surgical intervention at a later point in life. Following surgical treatment, recurrent disease has been observed in up to 11% of the patients and reoperation is necessary in 3%. Recurrent disease

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mainly results from a too high anastomosis above the RSJ. If the inflamed large bowel is removed completely during the primary intervention, the more proximal diverticular do not influence the risk of recurrent disease.

Recommended Reading Chapman, J., Davies, M., Wolff, B.: Complicated diverticulitis: is it time to rethink the rules? Ann. Surg. 242, 576–581 (2005) Constantinides, V.A., Tekkis, P.P., Athanasiou, T.: Primary resection with anastomosis vs. Hartmann’s procedure in nonselective surgery for acute colonic diverticulitis: a systemic review. Dis. Colon Rectum 49, 966–981 (2006) Platell, C.: Critical evaluation: surgery for uncomplicated diverticulitis. ANZ J. Surg. 78, 96–98 (2008) Rafferty, J., Shellito, P., Hyman, N.H., et al.: Practice parameters for sigmoid diverticulitis. Dis. Colon Rectum 49, 939–944 (2006) Zorcolo, L., Covotta, L., Carlomagno, N., et al.: Toward lowering morbidity, mortality and stoma formation in emergency colorectal surgery: the role of specialisation. Dis. Colon Rectum 46, 1461–1467 (2003)

Therapy of Sepsis

31

Johannes N. Hoffmann

31.1 Definition

defined, which allowed the diagnosis of SIRS, if two or more of following symptoms are fulfilled:

With the initiation of the first large sepsis trials, the necessity of a common definition of sepsis was generally accepted. In contrast to the historical definitions, which implicated bacteraemia (Schottmüller 1918), sepsis was for the first time defined as the systemic reaction of the organism to infection (formally sepsis syndrome as introduced by Bone) based on clinical criteria of sepsis. The change in sepsis definition was necessary since only 20–40% of patients with sepsis show bacteraemia.

• • • • •

Sepsis does not necessarily implicate the diagnosis of bacteraemia. Thus, in 60–80% of patients with sepsis microbiology is negative despite clear clinical signs of infection. A consensus definition of sepsis was published in 1992 by the American College of Chest Physicians, the Society of Critical Care Medicine and other important societies. This definition is currently accepted also in terms of clinical studies.

Body temperature > 38.0°C or < 36.0°C Heart rate > 90/min Respiratory rate > 20/min PaCO2 < 30 mmHG Leukocytes > 12  G/l or < 4  G/l or less than 10% unripe leukocytes.

31.3 Sepsis Sepsis is defined as an inflammatory reaction of the organism to an infection. The diagnosis of sepsis implicates occurrence of at least two criteria of SIRS in combination with suspected or manifest infection. Infection is diagnosed if microorganisms are detected in normally sterile tissues or body cavities, or if there is a strong clinical suspicion of infection. This implicates that the infectious agents do not have to be identified when the diagnosis of sepsis is made.

31.4 Severe Sepsis 31.2 Systemic Inflammatory Response Syndrome Systemic inflammatory response syndrome (SIRS) describes the inflammatory reaction of the organism as a part of inflammation. Several clinical criteria were

Severe sepsis is defined as sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Hypo­per­ fusion or perfusion abnormalities can occur as lactate acidosis, oliguria, or changes in mental status.

31.5 Septic Shock J.N. Hoffmann Department of Surgery, University of Munich – Großhadern, Marchioninistr. 15, 81377 Munich, Germany e-mail: [email protected]

Septic shock is defined as hypotension despite adequate volume administration or catecholamine therapy with concomitant changes in microperfusion. Changes

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Table 31.1  Organ support in severe sepsis Organ Treatment

Remarks

Lung

Controlled ventilation with reduced volumes (4–6 ml/kg bodyweight) combined with PEEP (independent from FiO2)

Recommendation according to multiple prospective randomized trials (ARDS network study)

Circulatory failure

Volume application (300–500 ml/30 min.) as initial treatment for haemodynamic stabilization, followed by higher amounts until stabilization

Recommendation according to Rivers, who described initial hemodynamic stabilization in pts. with severe sepsis in an emergency unit

Central venous saturation >70%, volume application, erythrocyte concentrates to correct Hb >8, dobutamin Kidney

Haemofiltration- or haemodialysis therapy Intermittent or continuous treatment

Coagulation

Therapy of disseminated intravascular coagulation

in organ perfusion can manifest as lactate acidosis, oliguria, or acute central nervous dysfunction.

In acute renal failure, early high-volume haemofiltration is justified. High amounts of daily ultrafiltration rates (>2 L/day) correlate with low survival rates Antithrombin is recommended in DIC based on phase-II-studies. Expert opinions differ substantially

have to be treated, the incidence of sepsis is currently increasing all over the world.

31.6.1.1 Risks for the Development of Sepsis

31.6 Multiorgan Dysfunction Syndrome Multiorgan dysfunction syndrome (MODS) is defined as an acute change in organ function in critically ill patients. To preserve haemostasis, intervention is necessary. The four stages of sepsis directly correlate with mortality: Mortality of SIRS reaches 10%, sepsis has a mortality of approximately 20%, severe sepsis of about 40%, and septic shock leads to death in about 80%.

31.6.1 Epidemiology Severe sepsis (sepsis with associated organ dysfunction) and multiorgan failure are the leading cause of death of critically ill patients from non-cardiology intensive care units. In Germany, about 60,000 patients per year die from severe sepsis or septic shock. Therefore, sepsis is the third common reason of death in Germany. More than 50% of patients develop septic shock, which is related to a mortality of 60–80%. Since increasing numbers of older patients with complicated illnesses or other concomitant risk factors for sepsis

• Immunosuppression (diabetes, alcoholism, chronic renal failure) • Tumor • Higher age • Invasive procedures • High BMI

31.6.2 Pathophysiology In patients with sepsis, the primary protective processes of local defense of inflammation convert to detrimental actions against the host, and can lead to “whole body inflammation.” Primarily, inflammation is triggered by toxins or other components of the bacterial cellular wall, which are released from microorganisms (e.g., endotoxin of gram-negative bacteria or exotoxins from gram-positive bacteria). Also, fungal and viral infective agents can invade the circulation via disrupted mucosal layers. Pro- and anti-inflammatory mediator systems may enhance release of these toxins.

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In addition, inflammatory mediators can activate different humoral cascade systems, such as the coagulation system, the fibrinolytic system, and the kallikreinekinine system. The underlying pathomechanisms have been well characterized for gram-negative sepsis. Endotoxin of gram-negative bacteria (Lipopolysaccaride) binds to LPS-binding protein (LBP), an acute phase protein, which is produced by the liver. Thereby, the complex from LPS and LBP activates the monocyte/macrophage receptor (CD14), which presents endotoxin to the TLR-4-receptor. Via a complex signal transduction cascade, an activation of transcription factors within the nucleus is induced (e.g., nuclear factor kappa beta, NFkB). This central transcription factor initiates gene expression of multiple proinflammatory cytokines such as Interleukin 1 (IL-1), IL-6, and tumor necrosis factor alpha (TNF-a). The organism mutates to an active player in the inflammation processes, which induces the changes in regulation and cascade systems. Over the last decade, the important role of coagulation in sepsis has been defined. Tissue factor release and increased thrombin production were recognized as main mechanisms of septic coagulopathy. Simulta­ neously, natural inhibitors of coagulation (antithrombin, Protein C, tissue factor pathway inhibitor, protein S, protein Z) are consumed. The degree of inhibitor consumption correlates with a poor prognosis in sepsis. Thus, antithrombin activities < 40% are correlated with 50% mortality in septic patients. Changes in endothelial function are mediated by the activation of monocytes and macrophages and other inflammatory cells, which result in an additional release of tissue factor. The normally anticoagulant endothelial cell surface is changed to procoagulatory. This change in surface characteristics induces an interaction of leukocytes with endothelial cells, and, thereby, acute “microcirculatory failure” in the organs, which is manifesting as secondary multiple organ dysfunction syndrome. Microcirculatory failure also has been defined as the motor of sepsis. A loss of endothelial integrity induces changes in the endothelial barrier allowing bacterial toxins and bacteria to evade. Thus, it has been shown that endotoxin can translocate from the bowel to the portal vein and the liver, thereby inducing systemic inflammation. For the development of therapeutic strategies, the phase of inflammatory response plays a key role. It is

Table 31.2  Common sources of sepsis Focus of sepsis Lung

50%

Abdomen/pelvis

20%

Urosepsis and soft-tissue infection

10–15%

Catheter infection

<10%

Unclear focus

~10%

critical to discriminate between the hyperinflammatory status and the status of immunoparalysis/immunosuppression. This clinical important discrimination is nowadays possible by using systemic Interleukin-6 (IL-6) and procalcitonin measurements as well as HLA-DR-expression on monocytes. Several studies show that early interventions in sepsis can improve prognosis. Thus, causative or supportive therapy is related to a lower mortality. In addition, it is highly important to discriminate between the different stages of sepsis (SIRS, sepsis, severe sepsis, MODS). In severe sepsis, it is crucial to introduce early goal-directed volume therapy to stabilize the circulation. Also, the early use of antibiotics has been related to better survival in critically ill patients. To allow an adequate diagnosis of sepsis, it is important to know about typical localizations of the septic focus. Table 31.2 shows the distribution of different sepsis focuses in critically ill patients. In surgical patients with sepsis, more than 20% have an abdominal focus. Patients suffering from sepsis with unclear focus have an extremely poor prognosis because causative therapy is not possible (mortality reaches 100%). Every effort must, therefore, be made to establish the cause of sepsis and to allow for adequate treatment.

31.6.3 Past Medical History History taking includes the documentation of important risks for the development of sepsis. To allow the correct diagnosis, history of operations (wound infection, anastomotic leakage) or interventions (puncture, catheters, endoscopy, radiofrequency ablation) has to be documented.

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31.6.4 Clinical Symptoms The clinical picture of patients with sepsis can show great variation. Typical symptoms of patients with sepsis are • Unclear change of the mental status as a sign of septic encephalopathy • Fever or hypothermia, shivering • Exsiccosis • Hypotension, tachycardia

In postoperative patients with or without fever, who show a change of their mental status, which cannot be explained, sepsis must be considered as a potential cause.

31.6.5 Diagnostic Procedures in Patients with Suspected Sepsis After collecting the patient’s history and clinical examination, the following steps should be considered: • Removal of central venous catheters and other catheters and microbiologic testing of the catheter tips • Before application of antibiotics: appropriate blood sampling taken from different sites to allow blood cultures • Sampling of urine, pleural fluids, wounds, drainages, and gram staining as well as appropriate cultures • At least two blood cultures (aerobic an anaerobic) from venous puncture, or alternatively from central venous catheters • Laboratory tests (white blood count, IL-6, procalcitonin, partial thromboplastin time, thromboplastin time, antithrombin, pO2, pCO2, pH lactate, bicarbonate, creatinine, bilirubin) • Radiological imaging (chest x-ray, CT scan, ultrasound) If catheter-associated infection is suspected, the catheter has to be removed. Changes via guide wire should not be performed in this situation. Changes of catheters as a part of the clinical routine, however, cannot minimize

J.N. Hoffmann

the risk of catheter infection. Blood cultures have to be taken after adequate disinfection via peripheral venous puncture. Probes should be filled with at least 10 ml of blood and 2–3 cultures should be performed (aerobic and anaerobic). If a ventilator-associated pneumonia is diagnosed, endotracheal aspirates or a protected specimen brush sampling can be used. Quantitative measurements appear to yield a more secure diagnosis of pneumonia. If a wound infection is diagnosed, microbiological specimens should be taken. Parameters of infection should be measured as well as indicators of organ dysfunction. Since disseminated intravascular coagulation implies a two times higher mortality in patients with severe sepsis, coagulatory studies should be done. X-rays are to be performed depending on the clinical picture and the severity of sepsis.

31.6.6 Interventions in Postoperative Patients Standardized protocols should be used when dealing with postoperative patients who are believed to suffer from sepsis. Initially, central venous catheters have to be removed. This measure often reduces the need for further diagnostic steps and may be all the therapy needed.

31.6.6.1 The Postoperative Patient • History: When has the patient been operated? Implantation of foreign material? Transfusions? Septic wounds/operations? • Clinical evaluation (septic focus?) • Inspection of wounds. Removal of all bandages and thorough clinical evaluation (fluctuation, redness?) • Signs of pulmonary infection? • Abdominal pain? Paralysis? Guarding? Quality of drainage secretion, bilirubin (leakage?), or creatinine determination in drainage fluid specimens • Analysis of pleural effusions, ascites, fluids in operation wounds

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31.6.7 Therapy

31.7 Necrotizing Soft Tissue Infections

Sepsis therapy can be categorized in three steps:

Necrotizing infections/necrotizing fasciitis are lifethreatening illnesses. Potential microbiologic agents are Streptococci, Staphylococci, Clostridia, and sometimes Candida.

• Clearance of the septic focus (operation, intervention, drainage, antibiotics) • Support of organ dysfunction (mechanical ventilation, haemofiltration, catecholamine, and volume therapy) • Adjunctive sepsis therapy

31.6.8 Clearance of the Septic Focus The septic focus has to be cleared as fast as possible.

Clearance of the septic focus represents the main basis for successful treatment of severe sepsis and septic shock.

A number of retrospective analyses clearly indicate that failure of surgical clearance of the septic focus is associated with a significant increase in mortality, which reaches almost 100%. In peritonitis, the time lost until effective clearance of the septic focus is achieved correlates with an increase of mortality.

31.6.8.1 Interventions to Clear the Septic Focus Abscess

Incision and drainage

Necrotizing fasciitis

Resection, vacuseal treatment

Subphrenic abscess

CT or ultrasound-guided abscess drainage, operation

Septic gangrene

Amputation

Peritonitis

Revision surgery, wash-out, drainage

Abdominal compartment

Laparotomy, open abdomen

Pancreatitis

Surgical/radiological drainage, removal of necrosis

31.8 Damage Control Damage control can be achieved by removal of necrotic tissue during the initial operation, but also during ­second- or third-look operations. Especially in necrotizing soft-tissue infections, effective initial resection is crucial. A gram preparation should be performed. Histology confirms the diagnosis. Second-look operations after 24 h depending from the clinical status are re­commended. Earlier reoperations have to be ­performed in case of deteriorating organ function. High-dosed Penicillin G (4 × 10  M) combined with carbap­enems are recommended.

31.9 Peritonitis Exploration of all four abdominal quadrants is mandatory. Surgical clearance of the focus may be supported by antimicrobial therapy. The primary antibiotic therapy is empiric respecting the most probable bacterial load. After receiving microbiology, calculated antibiotic therapy is performed.

31.10 Anti-infectious Treatment in Sepsis Anti-infectious therapy is early performed with antibiotics and antimycotic substances. Also, antiviral drugs can be used. Current guidelines recommend antibiotic treatment during the first hours after initiating the diagnosis. Bacterial cultures should be taken before antibiotic therapy starts. In sepsis of unknown origin, a therapy with cephalosporins group 3, acyl-aminopenicillin plus betalactamase inhibitors or carbapenems is recommended. In suspected pulmonary infection third-generation cephalosporins, acyl-aminopenicilline plus inhibitors of betalactamase or carbapenems are indicated.

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J.N. Hoffmann

For abdominal infections, acyl-aminopenicillins or third-generation cephalosporins plus metronidazol or carbapenems are recommended. The antibiotic regimen is to be tested in terms of efficacy every 72  h. Therapeutic escalation should be performed if necessary. If resistant bacteria are diagnosed, antibiotics should be changed. Duration of antibiotic therapy should not exceed 5–7 days. In Pseudomonas infections, a Pseudomonas active substance should be used (ureidopenicillins or third/ fourth generation cephalosporin or carbapenem). In multiresistant staph. aureus (MRSA)-infection glycopeptides (e.g., Vancomycin) or oxazolidon (Zyvoxid) should be used. Zyvoxid is also recommended in pulmonary infections. A prophylactic antimycotic therapy is not indicated with the exception of immunocompromised patients with severe sepsis. In transplantations and neutropenic patients, antimycotic therapy should be introduced earlier.

31.11 Support of Organ Function in Sepsis All efforts must be made to improve microperfusion in critically ill patients. Thereby, development of multisystem organ failure may be prevented.

With regard to circulatory failure, early goaldirected therapy includes volume administration at 300–500  ml during the first 30  min for circulatory support followed by larger amounts until stabilization. Central venous oxygen saturation is maintained above 70% and blood transfusions are given to correct the hemoglobin above 8. If needed, inotropes (dobutamin) are used to maintain blood pressure.

31.12 Adjunctive Therapy Adjunctive therapy of sepsis has to be combined with standard therapy (clearance of septic focus). In the last decade, multiple concepts investigating specific sepsis therapies antibodies against endotoxin and exotoxins or sepsis mediators, e.g., anti-TNF, anti-IL-1, anti-PAF, were investigated; all studies were negative. However, promising results from phase-III-trials with coagulatory inhibitors have been published. One phase-III-trial with activated protein-C showed a significant reduction in mortality. Confirmatory trials have been started. Antithrombin has been effective in septic patients without receiving concomitant heparin (Table 31.3).

Table 31.3  Adjunctive therapy in sepsis (examples) Medication Implementation/indication/doses Low-dose/high-dose Corticoids

200–300 mg/d continuously over 24 h n pts. with septic shock that does not response to vasopressors

Remarks High-dose cortisone is not recommended Randomized trial negative for low-dose corticoids (CORTICUS trial. Sprung et al.) Cardiocirculatory stabilization

Recombinant activated protein C

24 mg/kg KG/over 96 h during 24 h after diagnosis of sepsis in pts with APACHE II >25 or >2 organ failures respecting contraindications No indication in children

Not generally accepted, one positive randomized controlled trial. Confirmatory trial (PROWESS Shock) actually conducted

No indication in 1-organ-failure, especially after surgical treatment Antithrombin

6,000 IE/24 h over 4 d (AT did not result in reduction of 28-d-mortality being combined with heparin. If heparin administration is omitted, there was a clear reduction in mortality in a subgroup of pts with DIC

Mortality reduction only if heparin is omitted (Hoffmann et al.), not recommended by guidelines

Immunoglobulines

i.v. IgGMA application reduced mortality in multiple phase-II-trials. A recent meta-analysis showed positive effects for IGMAs, not for IGG Expert opinions differ substantially

Not generally recommended

31  Therapy of Sepsis

31.13 Summary Sepsis remains a challenging problem in intensive care medicine and is associated with significant mortality. Despite a number of clinically relevant phase III treatment trials, mortality has not substantially improved during the last decades. Clearance of the septic focus and initiation of relevant diagnostic interventions must be done immediately if sepsis is suspected. Antibiotic and specific surgical therapy is to be performed as soon as possible after taking blood cultures. It has been demonstrated that anti-inflammatory strategies targeting specific cytokines or other inflammatory mediators cannot reduce mortality. Therefore, pleiotropic acting agents are nowadays tested in phase III trials.

Recommended Reading Abraham, E., Laterre, P.F., Garg, R., Levy, H., Talwar, D., Trzaskoma, B.L., François, B., Guy, J.S., Brückmann, M., Rea-Neto, A., Rossaint, R., Perrotin, D., Sablotzki, A., Arkins, N., Utterback, B.G., Macias, W.L., Administration of Drotrecogin Alfa (Activated) in Early Stage Severe Sepsis (ADDRESS) Study Group: Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N. Engl. J. Med. 353(13), 1332–1341 (2005) Dellinger, R.P., Levy, M.M., Carlet, J.M., Bion, J., Parker, M.M., Jaeschke, R., Reinhart, K., Angus, D.C., BrunBuisson, C., Beale, R., Calandra, T., Dhainaut, J.F., Gerlach, H., Harvey, M., Marini, J.J., Marshall, J., Ranieri, M., Ramsay, G., Sevransky, J., Thompson, B.T., Townsend, S., Vender, J.S., Zimmerman, J.L., Vincent, J.L., International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses, American College of Chest Physicians, American College of Emergency Physicians, Canadian Critical Care Society, European Society of Clinical Microbiology and Infectious Diseases, European Society of Intensive Care Medicine, European Respiratory Society, International Sepsis Forum, Japanese Association for Acute Medicine, Japanese Society of Intensive Care Medicine, Society of Critical

243 Care Medicine, Society of Hospital Medicine, Surgical Infection Society, World Federation of Societies of Intensive and Critical Care Medicine: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit. Care Med. 36(1), 296–327 (2008). Erratum in: Crit Care Med. 2008 Apr;36(4):1394-1396 Hoffmann, J.N., Mühlbayer, D., Jochum, M., Inthorn, D.: Effect of long-term and high-dose antithrombin supplementation on coagulation and fibrinolysis in patients with severe sepsis. Crit. Care Med. 32(9), 1851–1859 (2004) Hoffmann, J.N., Wiedermann, C.J., Juers, M., Ostermann, H., Kienast, J., Briegel, J., Strauss, R., Warren, B.L., Opal, S.M., KyberSept investigators: Benefit/risk profile of high-dose antithrombin in patients with severe sepsis treated with and without concomitant heparin. Thromb. Haemost. 95(5), 850–856 (2006) Lever, A., Mackenzie, I.: Sepsis: definition, epidemiology, and diagnosis (Review). BMJ 335(7625), 879–883 (2007) Martí-Carvajal, A., Salanti, G.: Cardona, A.F., Human recombinant activated protein C for severe sepsis. Cochrane. Database. Syst. Rev. 2008 23;(1):CD004388. Review Rivers, E.P., Coba, V., Whitmill, M.: Early goal-directed therapy in severe sepsis and septic shock: a contemporary review of the literature (Review). Curr. Opin. Anaesthesiol. 21(2), 128–140 (2008) Russel, J.A.: The current management of septic shock (Review). Minerva Med. 99(5), 431–458 (2008) Russell, J.A.: Management of sepsis (Review). N. Engl. J. Med. 355(16), 1699–1713 (2006) Sprung, C.L., Annane, D., Keh, D., Moreno, R., Singer, M., Freivogel, K., Weiss, Y.G., Benbenishty, J., Kalenka, A., Forst, H., Laterre, P.F., Reinhart, K., Cuthbertson, B.H., Payen, D., Briegel, J., CORTICUS Study Group: Hydrocortisone therapy for patients with septic shock. N. Engl. J. Med. 358(2), 111–124 (2008) Storck, M., Hartl, W.H., Zimmerer, E., Inthorn, D.: Comparison of pump-driven and spontaneous continuous haemofiltration in postoperative acute renal failure. Lancet 337(8739), 452–455 (1991) Warren, B.L., Eid, A., Singer, P., Pillay, S.S., Carl, P., Novak, I., Chalupa, P., Atherstone, A., Pénzes, I., Kübler, A., Knaub, S., Keinecke, H.O., Heinrichs, H., Schindel, F., Juers, M., Bone, R.C., Opal, S.M., KyberSept Trial Study Group: Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial. JAMA 286(15), 1869–1878 (2001). Erratum in: JAMA 2002 Jan 9; 287(2):192

 

32

Bowel Cancer Peter Hewett and Cu Tai Lu

32.1 Introduction

32.2 Diagnosis

In most developed nations, there has been a steady increase in the incidence of colon cancer over the last 20–30 years. In South Australia, this has been driven largely by an increase in the incidence of colon cancer in males. However, colon cancer mortality rates have shown a steady decline in the 1977–2006 periods. This decline has been in the female population, whose ­mortality rate has dropped from over 20/100,000 in the 1970s to 11.2/100,000 [1]. As there is an increasing uptake of Faecal Occult Blood Test, screening for bowel cancer is beginning to show a pattern of increasing incidence and decreasing mortality that is similar to that of breast cancer. The reported improvements in bowel cancer survival are promising. There is evidence that more cancers are being diagnosed in the proximal sections of the large bowel, which may reflect better diagnostic techniques. This trend may continue as bowel cancer screening becomes more widely adopted. Australians of northern and western European extraction continue to have the highest rates of bowel cancer incidence and mortality in South Australia.

Adequate history taking and physical examination including digital rectal examination remain vitally important for proper diagnosis of colorectal cancer. Digital rectal examination and rigid or flexible sigmoidoscopy after preparation with an enema helps diagnose rectal cancer. At least 50% of cancers in the lower gastrointestinal tract are within reach of a flexible ­sigmoidoscope. Of all bowel cancer sites, rectum and sigmoid colon account for 49.3% of all male bowel cancers and 42.9% of all female cancers for the 10-year period 1997–2006 [1]. Endoscopic examination of the rectum and colon remains the definitive diagnostic modality. If this is not possible due to technical difficulties or patient comorbidity, barium enema should be performed, or if available, CT virtual colonoscopy is a viable alternative.

P. Hewett (*) and C.T. Lu Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

32.3 Familial Large Bowel Cancer Familial colorectal cancer accounts for about 2–4% of  all colorectal cancer. Hereditary non-polyposis ­colorectal cancer (HNPCC)) and familial adenomatous polyposis (FAP) are the two most common hereditary forms of colorectal cancer. HNPCC is an autosomal dominant condition distinguished from FAP by the absence of multiple colorectal adenomas. The lifetime risk of colorectal cancer in HNPCC is 80%. The associated cancers include that of the endometrium, ovary, stomach, small bowel, renal pelvis, and ureter. Mutations in the mismatch repair genes (MMR) give rise to HNPCC. The product of MMR genes repair incorrect base pair matching during DNA replication in cell division. The defect in MMR

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_32, © Springer-Verlag Berlin Heidelberg 2011

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genes results in the accumulation of more mutations, leading to instability in the length of microsatellite sequences in the DNA, also known as microsatellite instability (MSI) [2]. HNPCC is characterized by the early onset of colorectal cancer, in particularly proximal colonic cancer. Other features include poorly differentiated mucinous adenocarcinoma, synchronous or metachronous tumours, and marked infiltration of lymphocytes and lymphoid aggregation at tumour margins. Cancer registries and familial cancer clinics are involved in counseling and undertaking germ line genetic testing to identify affected families and affected members. Revised Bethesda guideline can be used as an adjunct to determine whether tumour tissue should be tested for MSI as the first line of investigation for HNPCC [3]. 1. Colorectal cancer diagnosed in a patient who is less than 50 years of age 2. Presence of synchronous, metachronous colorectal cancer, or other HNPCC-associated tumours regardless of age 3. Colorectal cancer with the MSI-H histology diagnosed in a patient who is less than 60 years of age 4. Colorectal cancer diagnosed in one or more firstdegree relatives with an HNPCC-related tumour, with one of the cancers being diagnosed under age 50 years 5. Colorectal cancer diagnosed in two or more first- or second-degree relatives with HNPCC-related tumours, regardless of age MSI testing is now readily available and should be performed on tumours from patients that fulfil any of the Bethesda criteria. Referral to a familial cancer clinic is necessary if there is a suspicion that there is a familial predisposition to formation of colorectal cancer. Upon consultation and counseling the affected individuals, germ line genetic testing may be performed.

P. Hewett and C.T. Lu

age 25 years or 5 years younger than the index case is recommended [5]. Surveillance for HNPCC-related tumours should be considered as routine. Prophylactic surgery in HNPCC remains controversial. Colectomy for adenoma or cancer should be either total colectomy and ileorectal anastomosis or formal hemicolectomy. FAP accounts for less than 1% of total colorectal cancer; it is less frequent than HNPCC. FAP is also an  autosomal dominant condition. A mutation of the adenamatous polyposis coli (APC) gene, a tumour suppressor gene, located on chromosomes 5q21, is responsible for the early development of hundreds of colorectal adenomas in early teen and eventually develops into colorectal cancer by the age of 50 years.

32.3.2 Prophylactic Surgery Evidence suggests prophylactic surgery reduces the risk of colorectal cancer, but long-term survival depends on the recognition of extracolonic tumours [6]. Total colectomy and ileo-rectal anastomosis is recommended as early as 15 years of age. Subsequent close surveillance of the rectum with flexible sigmoidoscopy is then required. The quality of life improves with less bowel frequency and allows the establishment of family prior to pelvic dissection in restorative proctocolectomy. Desmoid tumours, in particular, intra-abdominal desmoid tumours, are the second commonest cause of death in FAP. Duodenal cancer is the third most common cause of death in FAP [7]. By 70 years of age, over 90% of FAP would develop duodenal adenomas and the median age at diagnosis is 38. Surveillance for extra-colonic tumours such as duodenal cancer is mandatory.

32.4 Surgery for Colon Cancer 32.3.1 Surveillance and Surgery in HNPCC Colorectal cancer surveillance is paramount. Regular surveillance colonoscopy reduces the risk of colorectal cancer in HNPCC [4]. In a case of confirmed HNPCC, colonoscopy at 12 monthly intervals is recommended [5]. In those at risk, colonoscopy every 2 years from

32.4.1 Preoperative Preparation Careful preoperative preparation of the patient to reduce the incidence of postoperative morbidity is an essential but often overlooked part of surgery for ­colorectal cancer. This is particularly so in the elderly patient. Careful assessment and preoperative ­maximization of cardiac, respiratory and renal function, correction of

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preoperative anaemia, and nutritional assessment are all measures that will assist the patient in the post­ operative period. It may be necessary to delay surgery for a period of weeks to achieve these outcomes.

32.4.2 Mechanical Bowel Preparation Traditional surgical dogma holds that mechanical bowel preparation is essential for any colectomy. RCT has shown mechanical bowel preparation is not necessary for intra-abdominal colectomy [8]. However, an RCT by Platell et al. 2006, of high-risk rectal anastomoses demonstrated more anastomotic leaks requiring reoperation in the group treated with a phosphate enema compared to the group treated with polyethylene glycol bowel preparation [9]. In patients who will require an anastomosis with a defunctioning proximal stoma, bowel preparation should be given preoperatively.

32.5 Prophylactic Antibiotics Prophylactic antibiotics in colorectal surgery have become standard practice. Ample evidence exists to suggest a single dose of antibiotics at or after induction of anaesthesia reduces the risk of sepsis from colorectal resection. Antibiotics selected for prophylaxis in colorectal surgery should be active against both aerobic and anaerobic bacteria. Administration should be timed to make sure that the tissue concentration of antibiotics around the wound area is sufficiently high when bacterial contamination occurs [10]. Triple antibiotic regime (ampicillin, metronidazole, and gentamicin) is as effective as third-generation cephalosporin plus metronidazole, and results in a decreased incidence of pseudomembranous colitis.

32.6 Thromboembolism Prophylaxis The risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in colorectal cancer resection is significant. Low-molecular-weight heparin (LMWH) or unfractionated heparin are both effective in reducing the risk of thromboembolism. DVT prophylaxis protocols should be common in all institutions.

Administration of LMWH 2 h prior or at induction of anaesthesia resulted in a slightly increased risk of ­haemorrhage and this risk can be significant in pelvic dissection. The risk between postoperative bleeding and the risk of thromboembolism is balanced by administrating unfractionated heparin or LMWH 6  hours postoperatively. Other adjunct therapies in thromboembolism prophylaxis include intermittent sequential calf compression devices and graduated compression stockings. Recently, continuation of prophylaxis after hospital discharge has been advocated for high-risk patients to reduce the risk of late onset thromboem­bolic events.

32.7 Operative Surgery The art of colectomy is well described in operative texts. Key points of the operation are adequate tumourfree margins, adequate and appropriate lympho­vas­ cular  clearance, and well-vascularised, tension-free anastomoses. The site of colonic cancer influences the operative approach. Right hemicolectomy and extended right hemicolectomy are indicated for proximal colonic cancers, whereas left hemicolectomy, subtotal colectomy, and high anterior resection are for left-sided colonic cancers. Complete oncological resection includes a minimal 5 cm longitudinal resection margin at both ends of the specimen, a clear circumferential margin, high ligation of the appropriate arterial blood supply to adequately remove the lymphatic drainage of the colon.

32.8 Laparoscopic Colectomy for Cancer Should colectomy for cancer be done using a laparoscopic-assisted approach? The evidence in regard to advantages of operative technique can be taken from four published randomized controlled trials COST, COLOR, CLASSIC & ALCCaS. These trials have shown that laparoscopic colectomy is not inferior to open colectomy in regard to short-term morbidity but does take about 30% more time in the operating theatre and reduces in-hospital stay by 1–2  days. Operating room costs are increased. Most importantly is the

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question of whether laparoscopic-assisted colectomy influences long-term disease-free survival. A metaanalysis of four studies has shown no difference between colectomy by laparotomy and laparoscopicassisted colectomy in regard to disease-free survival and overall survival 3 years post operation [11]. Given this situation, surgeons not trained in laparoscopic colectomy can continue to offer open colectomy knowing that no difference exists in survival and that ­clinical benefits of laparoscopic surgery are not overwhelming. Conversely, surgeons trained in laparoscopic-assisted surgery can continue to offer laparoscopic surgery to their patients while awaiting the 5 year survival figures from randomized controlled trials (RCTs). Conversion from laparoscopic-assisted colectomy to laparotomy has been associated with increased morbidity, in-hospital length of stay, and cost. Careful preoperative assessment combined with a decision to convert to laparotomy early in the operation if difficulty is encountered will decrease the frequency of conversion and its clinical impact. Laparoscopic-assisted colectomy requires adequate training in open colectomy technique followed by sufficient mentored experience in laparoscopic-assisted colectomy cases to become skilled in the technique. A common figure quoted for this is 20 cases and this has been used as entry criteria for the previously mentioned RCTs. In reality, the figure is between 50 and 60 cases before the learning curve effects level out. A ­surgeon trained in open colectomy, who wishes to embark on training in laparoscopic surgery, must have a ­sufficient case load to develop and maintain skills, a dedicated theatre team, a supportive operating room, administration and colleagues who are able and willing to assist and train the surgeon.

32.9 Stapled vs. Hand-Sewn Anastomoses Hand-sewn intestinal anastomoses form one of the basic skills to master in general surgery and in particular, colorectal surgery. There are many variations in suturing techniques. The common technique adopted by many colorectal surgeons is end-to-end anastomoses by single interrupted suture technique using absorbable monofilament suture material. The requirements of this technique are avoiding excessive

P. Hewett and C.T. Lu

suture tension, evenly spacing each suture, and ensuring serosa is included in each suture. The alternate technique of stapled anastomoses has been shown to have a similar anastomotic success rate. This technique can be used to advantage when anastomosing bowel of disparate diameter. Disposable linear and circular stapling devices are available. They are available in different lengths, diameters, and different height of the staples. 3.5 mm staples are normally used in ileo-colic anastomoses and 4.8 mm staples are for colorectal anastomoses, as the contracted rectal wall is thicker than colonic wall. Cost of the procedure is increased by use of stapling devices. There is no evidence to suggest either hand-sewn or stapled anastomoses is superior to one another. There is no statistical significant difference in anastomotic dehiscence rate between the two techniques. Inverting the staple line at the time of performing the anasto­ moses does not reduce the risk of bleeding; however, under-running the staple line with a continuous over and over suture might reduce the risk of haemorr­ hage but has no influence on the rate of anastomotic dehiscence.

32.10 Complications 32.10.1 Anastomotic Dehiscence The anastomotic dehiscence rate ranges from 2% to 4%. Multiple factors contribute to anastomotic failure, including technical failure, patient factors, and postoperative factors. Early detection and prompt surgical management will lead to decreased mortality and morbidity. A high index of suspicion is required. Failure of the patient to clinically progress, a low grade or swinging high temperature, persistent tachycardia, respiratory failure, unexplained arrhythmia, and leucocytosis are all signs consistent with anastomotic dehiscence. The investigation of choice to detect anastomotic dehiscence in right hemicolectomy is contrast CT scan but having said that, the findings can be difficult to determine and any doubt should result in laparotomy. A gastrograffin enema with conventional X-ray or preferably CT scan is the investigation of choice for detection of a leak after anterior resection. The operation of choice is to take apart the anastomosis, perform a thorough lavage, place drains to dependent areas, and

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form an end stoma. Early identification of anastomotic dehiscence before significant soiling or inflammation may allow repair or revision of the anastomosis with a covering stoma. However, the proximal colon should be cleared of stool.

complications. Balloon dilatation of the ­malignant stricture with the stent in situ should not be performed as it predisposes to tumour perforation. Generally, permanent colonic stenting should be reserved for those whose survival is unlikely beyond 12 months [13].

32.11 Emergency Colonic Resection

32.12 Palliative Resection

Up to 20% of colonic cancers present on an emergency basis. The majority presents with obstructing cancers and less frequently perforation. An obstructing colonic cancer positioned from the caecum around to the splenic flexure can be managed with either right or extended right hemicolectomy. There are two options for managing an obstructed left-sided colonic cancer, they are Hartmann’s procedure or on-table colonic lavage with primary anastomosis with or without defunctioning loop ileostomy. Hartmann’s procedure remains the operation of choice in many centres because it allows excision of pathology and control of sepsis in situation where there may be lack of equipment and senior assistants, especially after hours when many resections are performed. Minimal mobilisation of the upper rectum would ­permit easier reversal of the Hartmann’s procedure. The insertion of two nonabsorbable stay sutures to the rectal stump allows identification if and when reanastomosis is performed. On-table colonic lavage was first described by Dudley et al. 1980 [12]. Complete mobilisation of the whole colon will facilitate the lavage more efficiently. The irrigation continues until the effluent is clear, usually requires about 3–4 L of warm irrigation fluid. Defunctioning loop ileostomy should be considered if the colon is markedly dilated or the patient’s clinical condition is compromised as the anastomotic leak rate is increased in this situation. Primary anastomosis in the presence of gross faecal peritonitis in perforated colonic cancer is not recommended again due to concern of a high rate of anastomotic failure. The treatment of an obstructing left-sided tumour by endoscopic stent can be used as a bridging measure to formal resection. This technique can be useful in patients who have widespread metastatic disease as a definitive treatment. Stenting of obstructing transverse and right colon cancer is technically challenging to perform. Stent migration and tumour perforation are known

Recent development and availability of novel chemotherapeutic agents has extended survival in patients presenting with disseminated colonic malignancy. Trials are proposed to see if immediate colonic resection in patient’s presenting with disseminated disease is advantageous compared to no surgical intervention and immediate chemotherapy.

32.13 Distant Metastases Liver metastases were once considered to be terminal event and survival following attempted resection was poor. Recent advances in adjuvant chemotherapy and improvements in the technical aspects of a liver resection have improved survival. 20–40% of patients presenting with liver metastases will be suitable for resection of the disease. The survival rate is 38% at 5  years for those with resectable liver metastases. In those with recurrence of resectable liver metastases, the second resection with clear margin has similar ­survival outcomes as those of the first resection. The mortality rate in major hepatobiliary units in Australia is less than 2% [14].

32.14 Rural Issues of Treatment Planning for Patients with Advanced Disease Access to trials and other advanced treatment options as well as diagnostic tools can be very difficult for rural patients. A close link between rural surgeons and a regional or metropolitan multidisciplinary cancer treatment team should be established to help with planning and coordination of treatment for patients with disseminated disease.

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References   1. South Australian Cancer Registry, Epidemiology Branch: Cancer in South Australia 2006 with projections to 2009. A report on the incidence and mortality patterns of cancer Cancer Series Number 29 October 2008   2. Jacob, S., Praz, F.: DNA mismatch repair defects: role in colorectal carcinogenesis. Biochemie 84(1), 27–47 (2002)   3. Umar, A., Boland, C.R., Terdiman, J.P., Syngal, S., de la Chapelle, A., Rüschoff, J., et al.: Revised Bethesda guidelines for hereditary nonpolyposis colorectal cancer (Lynch syndrome) and microsatellite instability. J. Natl Cancer Inst. 96(4), 261–268 (2004)   4. Winawer, S., Fletcher, R., Rex, D., et  al.: Colorectal cancer screening and surveillance: clinical guidelines and rationale – update based on new evidence. Gastroenterology 124(2), 544–560 (2003)   5. Church, J., Simmang, C.: Practice parameters for the treatment of patients with dominantly inherited colorectal cancer (familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer). Dis. Colon Rectum 46(8), 1001–1012 (2003)   6. Bulow, S.: Results of national registration of familial adenomatous polyposis. Gut 52(5), 742–746 (2003)   7. Arvanitis, M.L., Jagelman, D.G., Fazio, V., et al.: Mortality in patients with familial adenomatous polyposis. Dis. Colon Rectum 33(8), 639–642 (1990)

P. Hewett and C.T. Lu   8. Ram, E., Sherman, Y., Weil, R., Vishne, T., Kravarusic, D., Dreznik, Z.: Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch. Surg. 140(3), 285–288 (2005)   9. Platell, C., Barwood, N., Makin, G.: Randomized clinical trial of bowel preparation with a single phosphate enema or polyethylene glycol before elective colorectal surgery. Br. J. Surg. 93(4), 427–433 (2006) 10. Song, F., Glenny, A.M.: Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. Br. J. Surg. 85(9), 1232–1241 (1998) 11. Bonjer, H.J., Hop, W.C., Nelson, H., Sargernt, D.J., Lacy, A.M., Castells, A., et al.: Laparoscopically assisted vs open colectomy for colon cancer: a meta analysis. Arch. Surg. 142(3), 298–303 (2007) 12. Dudley, H.A.F., Radcliffe, A.G., MeGeehan, D.: Intraoperative irrigation of the colon to permit primary anastamosis. Br. J. Surg. 67(2), 80–81 (1980) 13. Watt, A.M., Faragher, I.G., Griffin, T.T., Rieger, N.A., Maddern, G.J.: Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann. Surg. 246(1), 24–30 (2007) 14. Scheisser, M., Chen, J.W.C., Maddern, G.J., Padbury, R.T.A.: Perioperative morbidity affects long-term survival in patients following liver resection for colorectal metastases. J. Gastrointest. Surg. 12(6), 1054–1060 (2008)

33

Rectal Cancer Peter Hewett

33.1 Incidence

33.3 Imaging

Cancers of the rectum increased in incidence through to the 1990s, beyond which time, incidence has levelled out. Mortality rates also reached a peak in the 1990s in both sexes, and have declined slightly since. Rectal cancer accounts for 23% of colorectal cancer in females and 27% in males in South Australia [1].

When diagnosis has been confirmed, imaging is required to accurately stage the patient. Chest X-ray and ultrasound of the abdomen or CT scan of the chest and abdomen will reveal pulmonary and hepatic metastases. PET scanning can be used if available to determine the status of a lesion when it is unclear on routine imaging. Staging of the rectal cancer by imaging is by endorectal ultrasound or MRI. Both modalities require considerable expertise by their operators. Both methods are limited because peritumoral inflammation cannot be precisely distinguished from infiltration by the tumour. Correct lymph node staging is hampered in advanced disease using trans-rectal ultrasound (TRUS) [2].

33.2 Symptoms and Signs Symptoms such as rectal bleeding, passage of mucous per rectum, alteration in bowel habit or tenesmus, need to be investigated to exclude rectal cancer. Rectal ­cancer can be diagnosed by digital rectal examination (DRE) and rigid or flexible sigmoidoscopy after preparation with an enema. DRE gives important information about distance of the tumour from the anal verge and degree of tumour fixation. Rigid sigmoidoscopy gives an accurate distance measurement of the tumour from the anal verge, which is important in treatment planning. Full colonoscopy is mandatory to exclude synchronous lesions. It is essential that a biopsy confirms adenocarcinoma before treatment occurs as benign conditions such as solitary rectal ulcer syndrome can at times mimic rectal cancer.

P. Hewett Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

33.4 Multidisciplinary Committee Meetings Combined meetings involving surgeons, oncologists, radiotherapists, pathologists, stoma therapists and nursing staff to discuss treatment options for patients with rectal cancer have become established in many institutions. The advantage of such panels is to help standardise management to best practice, allow patients entry to clinical trials and assess outcomes. With the advent of video and internet conferencing, the ability to participate in these conferences has become easier and possible even in more rural or remote settings where general surgeons treating rectal cancer are located.

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33.5 Preoperative Chemoradiotherapy The role of preoperative chemoradiotherapy (CRT) is described in an article by Ciccocioppo et al. [3]. If clinical examination and/or staging of the tumour reveals fixation to adjacent structures, penetration of the mesorectum by the tumour or involved lymph node status (T3 or T4 status), preoperative CRT can be considered. Preoperative neoadjuvant CRT has a role in the management of rectal cancer. It may improve survival and decrease local recurrence rates. Improved survival was shown in the Swedish rectal cancer trial after preoperative short-course radiotherapy (RT) (25  Gy delivered in five fractions)  [4]. The Dutch colorectal cancer group reported that preoperative short-course RT reduced local recurrence rates but did not improve shortterm overall survival [5]. Conventional fractionated preoperative RT with chemotherapy will also reduce the risk of local recurrence and may be associated with reduced toxicity compared with post-operative CRT [6]. Prior to these trials, a meta-analysis was undertaken to look at the efficacy of preoperative RT [7]. Fourteen randomised controlled trials (RCTs) were analysed that compared preoperative rRT plus surgery with surgery alone. These only included patients with resectable, histologically proven rectal adenocarcinoma without metastatic disease. Preoperative RT significantly reduced the 5-year overall mortality rate, cancer-related mortality rate and local recurrence rate. However, the margin of benefit was small and the authors concluded that ‘criteria are needed to identify patients most likely to benefit from adjuvant RT’ [7]. Complete pathological response is seen in 15–25% of patients treated. While there is some speculation that such patients can be treated by observation to assess further tumour growth, this is largely anecdotal and the planned operative and post-operative treatments should be carried out. It should be noted that the effect of RT is to halve the local recurrence rate. Diminishing returns exist for this therapy as a practitioner’s known local recurrence rate decreases. For example, local recurrence rates vary between 2.6% and 32%. Clearly, a greater number of patients will benefit if the surgeons local recurrence rate is known to be high [8].

P. Hewett

33.6 Short-Course Radiotherapy Versus Long-Course Chemoradiotherapy Preoperative long-course CRT has been used to downstage disease and help obtain R0 status when imaging has indicated that the mesorectal envelope has been breached by tumour. Surgery is scheduled for around 6 weeks following completion of RT. Short-course RT will not down-stage tumours but has been found to be as effective in terms of survival, recurrence, perioperative complications, sphincter preservation and toxicity. Short-course RT gives the tumour field 50 Gray over 5 days. Operation normally is performed within 1 week following completion of RT. Some Scandinavian centres are trialling delay in surgery for 5–6  weeks to assess efficacy and post-operative morbidity. The ability for the patient to attend RT clinics away from home may influence the treatment regime offered. RCTs are underway to compare these modalities.

33.7 Preoperative Versus Post-operative Radiotherapy The CR07 trial compared short-course preoperative RT versus initial surgery with selective post-operative CRT. The primary outcome measure was local recurrence. It found a reduction of 61% in the relative risk of local recurrence for patients receiving preoperative RT and an absolute difference at 3 years of 6.2% (95% CI 5.3–7.1) (4.4% preoperative RT vs 10.6% selective post-operative CRT). The study recorded a relative improvement in disease-free survival of 24% for patients receiving preoperative RT. QOL in the preoperative short-course group was worse in respect to male sexual function and faecal incontinence [9]. Optimal treatment of rectal cancer is a special challenge that calls for the best possible clearance of the tumour in association with preservation of the anal sphincter mechanism and avoidance of injury to the pelvic autonomic nerves. There are at least 22 studies of colorectal cancer patients correlating outcome and volume (hospital/surgeon or both) since 1984, which show clear difference in quality of life indicators such as permanent stoma rates between low-volume and high-volume surgeons [10].

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33  Rectal Cancer

Preoperative CRT does not take the place of e­ xcellent surgical technique nor should it alter the operative strategy initially decided. The principle of Total Mesorectal Excision (TME) as described by Heald involves removing the rectum with an intact mesorectal fascial envelope [11]. It is a technique that must be learnt from an experienced practitioner and requires a sufficient case load to gain and maintain proficiency. The decision as to whether a restorative resection should be performed is based on the ability to obtain safe oncological margins (2 cm distal margin) and leave the anal canal intact. A history of previous incontinence will also influence this decision. In patients who are planned for restorative procedures with an anastomosis localized within 2 cm of the anal verge 5 cm, long colonic reservoirs are recommended to improve post-operative bowel function. The advantage of these reservoirs is of clinical relevance during the first 2 years after resection. Laparoscopic resection of rectal cancer is currently being studied in a number of prospective randomised trials.

33.8 Abdominoperineal Resection Routine abdominoperineal resection (APR) has the patient in the lithotomy position and involved two ­surgeons operating from the abdominal and perineal aspect to remove the anus and rectum. A recent development “Cylindrical APR” is similar to the original Miles procedure [12]. This procedure involves the mobilisation of the rectum via the abdominal approach as far as the origins of the levator muscle. Once the abdomen has been closed and the stoma formed, the patient is moved into the prone position and the perineal dissection is commenced. This dissection will include the removal of the coccyx with the specimen to allow better exposure. The levator muscles are divided and the proximal rectum can be delivered and retracted inferiorly to place the anterior dissection plane on tension. If the anterior margin is involved, a portion of vagina or prostate can be excised under direct vision. This may produce a large perineal defect and a gluteus maximus rotation flap has been described for closure.

Advantages of this technique are that Cylindrical APR performed in the prone position for low rectal cancer removes more tissue around the tumour, which leads to a reduction in circumferential resection margin involvement and intraoperative perforations, which should reduce local disease recurrence [13].

33.9 Local Excision Local excision or transanal endoscopic excision of ­rectal cancer should be restricted to T1 rectal cancers in selected patients according to the following guidelines: • Mobile tumour <3 cm • T1 on endorectal ultrasound or MRI • Not poorly differentiated on histology (biopsy) Local recurrence rates of about 25% have been reported after 5  years of follow up. Half of the patients with local recurrence can be salvaged by additional resectional surgery. As these results are worse than treatment by resection, this modality should be restricted to patients with considerable risk of severe post-operative morbidity or mortality.

33.10 Complications The major intraoperative complication of bleeding can be avoided by close adherence to anatomical planes. If presacral vessels are breached, control can be difficult. Compression by a “thumbtack” device can be literally lifesaving as it plugs the sacral foramina that the ­vessels retract into. Urinary and sexual dysfunction in males following surgery for rectal cancer is between 30% and 70% due to damage to sympathetic and parasympathetic nerves at the pelvic brim and around the prostate gland. Care in identifying the nerves at this point is mandatory. Anastomotic dehiscence will occur in ultralow anterior resection with an increased incidence after preoperative RT. Defunctioning the anastomosis with a covering stoma should be performed in this situation.

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33.11 Extended Resections In patients who present with involvement of adjacent structures or who present with local recurrence following resection, extended radical resection is a possibility. These procedures are performed in dedicated centres with a team of surgeons of differing specialties including colorectal, urological, gynaecological, orthopaedic and neurosurgeons. The aim is to clear tumour by resection through extrafascial planes to obtain negative resection margins. Up to 40% cancer-specific 5  year survival has been achieved with this technique [14].

33.12 Chemotherapy Post-operative chemotherapy should be considered when patients have nodal involvement or poor tumour prognostic factors and who are well enough to undergo chemotherapy. Referral to an oncologist and/or multidisciplinary tumour board to discuss the relative merits of post-operative chemotherapy is usual.

33.13 Post-operative Surveillance As in colon cancer, the aim of surveillance is to detect local and distant recurrence and metachronous tumours. Direct viewing of the anastomosis should occur every 6 months for 3 years. Recommendations with regard to surveillance colonoscopy vary and the author performs this routinely every 3  years. CT scan to detect liver metastases should be included in the surveillance plan.

References   1. South Australian Cancer Registry, Epidemiology Branch. Cancer in South Australia: a report on the incidence and mortality patterns of cancer. Cancer Series Number 29, October 2008

P. Hewett   2. Dinter, D.J., Hofheinz, R.D., Hartel, M., Kaehler, G.F., Neff, W., Diehl, S.J.: Preoperative staging of rectal tumors: comparison of endorectal ultrasound, hydro-CT, and high-resolution endorectal MRI. Onkologie 31(5), 230–235 (2008)   3. Ciccocioppo, A., Stephens, J.H., Hewett, P.J., Rieger, N.A.: Complete pathologic response after preoperative rectal ­cancer chemoradiotherapy. ANZ J. Surg. 79(6), 481–484 (2009)   4. Swedish Rectal Cancer Trial: Improved survival with ­preoperative radiotherapy in resectable rectal cancer. N. Engl. J. Med. 336(14), 980–987 (1997)   5. Kapiteijn, E., Marijnen, C.A., Nagtegaal, I.D., et  al.: Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N. Engl. J. Med. 345(9), 638–646 (2001)   6. Sauer, R., Becker, H., Hohenberger, W., et al.: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N. Engl. J. Med. 351(17), 1731–1740 (2004)   7. Camma, C., Giunta, M., Fiorica, F., Pagliaro, L., Craxi, A., Cottone, M.: Preoperative radiotherapy for resectable rectal cancer: a meta-analysis. JAMA 284(8), 1008–1015 (2000)   8. Heald, R.J., Husband, E.M., Ryall, R.D.: The mesorectum in rectal cancer surgery-the clue to pelvic recurrence? Br. J. Surg. 69(10), 613–616 (1982)   9. Sebag-Montefiore, D., Stephens, R.J., Steele, R., Monson, J., Grieve, R., Khanna, S., Quirke, P., Couture, J., de Metz, C., Myint, A.S., Bessell, E., Griffiths, G., Thompson, L.C., Parmar, M.: Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet 373(9666), 811–820 (2009) 10. RE Hodgson, D.C., Zhang, W., Zaslavsky, A.M., Fuchs, C.S., Wright, W.E., Ayanian, J.Z.: Relation of hospital volume to colostomy rates and survival for patients with rectal cancer. J. Natl Cancer Inst. 95, 708–716 (2003) 11. Heald, R.J., Ryall, R.D.: Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1(8496), 1479– 1482 (1986) 12. Holm, T., Ljung, A., Haggmark, T., Jurell, G., Lagergren, J.: Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br. J. Surg. 94(2), 232–238 (2007) 13. West, N.P., Finan, P.J., Anderin, C., Lindholm, J., Holm, T., Quirke, P.: Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J. Clin. Oncol. 26(21), 3517–3522 (2008) 14. Heriot, A.G., Byrne, C.M., Lee, P., Dobbs, B., Tilney, H., Solomon, M.J., Mackay, J., Frizelle, F.: Extended radical resection: the choice for locally recurrent rectal cancer. Dis. Colon Rectum 51(3), 284–291 (2008)

34

Stoma Surgery Nick Rieger

34.1 Introduction Intestinal stomas may be required in both elective and emergency abdominal surgery. A stoma may be temporary or permanent. The creation of a stoma has major implications to the physical and psychological wellbeing of a patient, and hence, must be created with due consideration and care. Education, counselling and rehabilitation of a patient requiring a stoma, in collaboration with a stomal therapy service, are essential and ideally should be commenced preoperatively. The sighting of a stoma must take into account the build, type of clothes worn (should the stoma be above or below the belt line) and the potential skin creases of the patient in differing postures (sitting and standing). When siting a stoma, it should be placed away from the umbilicus, bony prominences and old scars so that the base of the stoma appliance plate fits easily to the skin. Siting a stoma usually places it below the level of the umbilicus, on the left or right lower quadrant, on the upper surface of the lower abdominal fat mound and through the rectus sheath [1]. A stoma may be created with an open laparotomy incision or with the aid of laparoscopy. Consideration of the primary pathology is important when placing skin incisions. Paramedian or transverse incisions may compromise potential stoma sites in conditions such as Crohn’s disease or malignancy. A midline incision skirting the umbilicus to the side away from a potential stoma site is usually satisfactory. In emergency surgery,

N. Rieger Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

mark the stoma site before making the abdominal incision, as the incision will distort the abdomen and impact on the best stoma site. With laparoscopy, the site should be marked with the abdomen deflated for the same reasons. When considering whether to perform stoma surgery, there are no easy algorithms or hard rules. In ­rectal resection, should an anastomosis be covered by a proximal loop stoma? For emergency surgery (obstruct­ ing cancer, diverticulitis), should the patient have a Hartmann’s resection or an anastomosis? Decisions are based on the experience of the surgeon, the pathology, the condition of the patient, the technical ease of the operation and the perceived risk of the anastomosis compared to that of a stoma and its eventual closure. It is well recognised that reversible stomas such as a Hartmann’s end colostomy may never be reversed even though technically feasible [2]. The attending surgeon, when considering the surgical options for a particular clinical presentation, must also be aware of options that may avoid a stoma. A colonic stent may be applicable for obstructing lesions to the colon. These can be a bridge to later resection. A stent may also be used as definitive treatment of a colonic carcinoma when there are inoperable metastases [3]. Another common dilemma applies to the acute presentation of a left-sided carcinoma with obstruction. The surgical options include proximal stoma and no resection, resection and stoma (Hartmann’s procedure), resection and primary anastomosis (with and without on table washout and with or without a covering loop stoma) and subtotal or total colectomy and anastomosis. All of these procedures are acceptable in certain circumstances although may not always be in the surgeon’s armamentarium. Seeking advice or referral to a specialist centre may assist in the care of the patient in these complex circumstances.

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34.2 The Stoma Trephine Having chosen the ideal site for the stoma, a skin disc is excised. The underlying subcutaneous fat is excised as a core with the skin disc or split to the anterior rectus sheath. The anterior sheath is exposed with retractors and incised vertically and transversely (cruciate). The underlying rectus muscle is split vertically in line with its fibres. Care must be taken to avoid the inferior epigastric vessels. The posterior sheath and peritoneum is divided vertically. A soft grasping instrument such as a Babcock clamp can be introduced into the stoma trephine to deliver the bowel. The bowel should have been adequately mobilised so that there is no tension to avoid later retraction and the stoma trephine should be of adequate diameter to deliver the bowel easily (usually admitting two ­fingers). With a fat mesentery, the posterior sheath incision may need to be enlarged. After the stoma is matured, a clear appliance bag should be used to ­permit easy inspection of the stoma in the subsequent postoperative days.

34.3 End Stomas 34.3.1 End Colostomy This is usually placed in the left iliac fossa. Ideally, it is budded and projects 3–5 mm above the skin level

Fig. 34.1  End ileostomy

N. Rieger

to enable easy appliance placement. The sutures are placed circumferentially picking up the bowel edge and nearby serosa. The bowel should be sutured to the dermis only and not the epidermis of the skin to avoid peristomal granulomas. With distended bowel (e.g., obstruction) only a portion of the staple line should be opened to create the stoma. The residual staple or suture line can remain subcutaneous.

34.3.2 End Ileostomy This is usually placed in the right iliac fossa. An ileostomy may have an initial high output (>2 l per day). High output may necessitate intravenous therapy and monitoring of electrolytes until this reduces and the bowel adapts. Bryan Brooke devised the evaginated ileostomy in 1952 [4]. An ideal length is 2–3 cm. This is achieved with sutures placed through the full thickness of the cut bowel end, seromuscular to the bowel at the level of the skin and to the dermis of the skin (Fig. 34.1).

34.4 Loop Stomas A bridge is used to hold the bowel in position for 3–5 days until the stoma is adherent to the abdominal wall. This prevents retraction. It may be left longer in the obese, where there has been difficulty with mobilising the bowel and where poor healing is anticipated.

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34  Stoma Surgery Fig. 34.2  Loop colostomy

34.4.1 Loop Colostomy This usually utilises the sigmoid or transverse colon. The mobilised colon is incised longitudinally (along the taenia) and matured over a bridge (Fig. 34.2).

34.4.2 Loop Ileostomy This is the author’s preferred method for faecal diversion. It is easier to manage compared to loop colostomy. It is also easier to close with less associated morbidity [5]. The exteriorised loop of bowel is incised eccentrically at the level of the skin on the distal (non-functional) end. The proximal end can then be folded over and evaginated over the skin bridge to produce a spout of 2–3 cm. Sutures through the cut end of bowel also incorporate the seromuscular layer at the skin level and the dermis of the skin (Fig. 34.3).

Fig. 34.3  Loop ileostomy

34.4.3 End Loop Stoma

34.5 Closure of Loop Stomas

This stoma may be utilised particularly in obese patients or where there is a short mesentery that does not easily permit the bowel to be mobilised, without tension,

Closure of a temporary loop stoma is associated with its own morbidity. This includes wound infection, anastomotic dehiscence, obstruction and late incisional

through the abdominal wall. The distal end is oversewn or stapled and left subcutaneously or intraperitoneally and the proximal end fashioned as for an end stoma. Another variation is where an end stoma cannot be fashioned because of the proportions of the patient. The actual distal end is oversewn. More proximally, the bowel is brought out as a loop stoma.

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hernia. The stoma is mobilised via a circumstomal incision into the peritoneal cavity. For a loop transverse stoma, it is closed transversely with sutures to avoid narrowing the bowel lumen. For closure of a loop ileostomy, my preferred method is a side-to-side (functional end-to-end) anastomosis with a linear stapler. This gives a good-sized lumen and is easy to perform especially when there is discrepancy with the size of the bowel lumens. Alternatively, a loop ileostomy can be closed end to end with interrupted sutures having excised the bowel ends. This is the preferred method if the bowel is difficult to mobilise because of adhesions.

34.6 Stoma Complications Stoma ischaemia, retraction and stenosis are usually due to inadequate mobilisation of the bowel or poor attention to its vascularity. A revision of the stoma is

N. Rieger

usually required. Late complications such as prolapse and peristomal hernia may also require revisional surgery.

References   1. Corman, M.L. (ed.): Colon and Rectal Surgery, 4th edn. Lippincott-Raven, Philadelphia (1998). Chapter 32 Enterostomal therapy   2. Nunes, G.C., Robnett, A.H., Kremer, R.M., et  al.: The Hartmann procedure for complications of diverticulitis. Arch. Surg. 114, 425–429 (1979)   3. Watt, A.M., Faragher, I.G., Griffin, T.T., Rieger, N.A., et al.: Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann. Surg. 246(1), 24–30 (2007)   4. Brooke, B.N.: The management of an ileostomy including its creation. Lancet 2, 102–104 (1952)   5. Kaiser, A.M., Israelit, S., Klaistenfeld, D., et al.: Morbidity of ostomy takedown. J. Gastrointest Surg. 12, 437–441 (2008)

Acute Abdominal Pain

35

Hajir Nabi

35.1 Preface Abdominal pain is to the general surgeon as flour is to the baker. They are the foundation of our practice. The importance of clinical acumen in differentiating between its numerous causes cannot be overemphasised. The clues a surgeon gains from a well-taken history and carefully executed examination aid in diagnosis and importantly determine the urgency with which future management needs to be implemented. Needless investigations, which can potentially act to delay life-saving management, can often be obviated by astute clinical judgements.

35.2 Presentation A well-taken history is a key element in assessing undifferentiated abdominal pain. A keen history taker needs to be aware of their available resources. Collateral information obtained from case notes, ambulance officers, nursing and allied health staff as well as relatives and carers can be invaluable (especially when patients are unable to communicate). Some of the salient factors that can help differentiate causes of abdominal pain are outlined in Table 35.1. In addition to enquiring about pertinent surgical history, one should also seek to clarify relevant past medical

H. Nabi Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

history, medications, allergies, social (cigarettes, illicit drugs, alcohol) and family history. An understanding of the abdominal anatomy is important in differentiating causes based on the location of pain (Table 35.2). When assessing patients, always remember the ­priorities in assessment and management are: 1. Airway patency (while ensuring the cervical spine is protected) 2. Breathing (oxygen saturations) 3. Circulation (blood pressure) 4. Disability (a drop in Glasgow coma scale score may indicate an immediate need to secure airway patency- Table 35.3). The examination begins as soon as we enter the patient’s space. The patient’s conscious level, general appearance, body habitus, discoloration from jaundice/ icterus, cyanosis and pallor, restlessness, presence of vomit bowls and odours (such as melena) all give valuable insights.

35.2.1 Vital Signs Vital signs – and their trends – need to be carefully assessed. Keep in mind that those who were previously well will be able to maintain their blood pressure until very late in the course of shock. If we wait for a fall in blood pressure before instituting management, we will have often already missed the opportunity to save life. Tachycardia is often one of the first signs of shock – whether hypovolemic, septic, cardiogenic or spinal. A normal temperature does not exclude an infective cause – especially in the elderly.

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Table 35.1  Factors to be extracted during history taking Factors Examples Timing of onset

Left upper quadrant

Splenic infarction

Acute

Splenic laceration

Subacute

Pancreatitis

Chronic

Left lower lobe pneumonia

Acute on chronic Nature

Associated features

Radiation

Preceding events

Pulmonary embolus

Sharp Colicky Fever

Gastritis

Myocardial infarction/ischaemia Right lower quadrant

Appendicitis

Changes in bowel motions

Inguinal/femoral hernia incarceration

Dysuria

Renal calculus

Haematuria

Ovarian cyst torsion/rupture

Vaginal discharge

Endometriosis

Back

Salpingitis

Groin

Mittelschmerz pain

Trauma

Pyelonephritis

Recent surgery

Ectopic pregnancy

Relationship to meals

Meckel’s diverticulitis

Timing in menstrual cycle

Inflammatory bowel disease Psoas abscess

Table 35.2  Location of pain and likely differentials Location Differentials Right upper quadrant

Suprapubic

Cystitis

Cholecystitis

Pelvic inflammatory disease

Cholelithiasis

Ectopic pregnancy

Hepatitis

Endometriosis

Duodenal ulcer Pancreatitis Right lower lobe pneumonia

Epigastric

Sigmoid diverticular disease

Left lower quadrant

Sigmoid diverticular disease (diverticulitis, perforation, abscess) Colon malignancy

Pulmonary embolus

Inguinal/femoral hernia incarceration

Subphrenic abscess

Renal calculus

Hepatic abscess

Ovarian cyst torsion/rupture

Peptic ulcer

Endometriosis

Pancreatitis

Salpingitis

Gastritis

Mittelschmerz pain

Reflux oesophagitis

Pyelonephritis

Peptic ulcer

Ectopic pregnancy

Myocardial infarction/ischaemia

Inflammatory bowel disease

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35  Acute Abdominal Pain Table 35.2  (continued) Location Differentials Generalised/central

Colitis (ischemic, inflammatory, infective) Abdominal aortic aneurysm Bowel obstruction Gastroenteritis Spontaneous bacterial peritonitis Perforated abdominal viscus

Table 35.3  Glasgow coma scale (GCS) A. Eye opening   4. Spontaneous   3. To voice   2. To pain

Palpation needs to be systematic with all quadrants palpated looking for tenderness, masses, evidence of peritonism (guarding/rigidity, rebound and percussion tenderness) as well as presence and reducibility of hernias (inguinal, femoral, umbilical, epigastric and incisional). One needs to keep underlying anatomy in mind while palpating. Organs such as liver, spleen and kidneys need to be palpated, to document organomegaly and organ tenderness. A pulsatile mass is suggestive of an abdominal aortic aneurysm – and its dimensions should be ascertained. Percussion for shifting dullness will confirm the presence of ascites. Presence or absence of bowel sounds may be valuable, as may auscultation for bruits. The only contra-indications to a digital rectal examination are the absence of the patient’s rectum, or the absence of the examiner’s digit. Although unpleasant, vaginal examination can often also aid in diagnosis.

  1. Nil B. Vocalising

35.3 Investigations

  5. Orientated   4. Confused sentences

35.3.1 Blood Tests

  3. Inappropriate words   2. Incomprehensible sounds   1. Nil C. Movements   6. Obeys orders   5. Localises to pain   4. Normal flexion to pain   3. Abnormal flexion to pain   2. Extension to pain   1. Nil Total score of 3–15 is added across three fields

35.2.2 Abdominal Examination Inspection may reveal many things. Scars will disclose a great deal about past surgical history. Abdominal ­distension has many causes (fat, flatus, faeces, foetus, filthy big tumour and phantom pregnancy). Pulsations, abnormal peristaltic waves, distended veins, masses, evidence of trauma, bruising, insulin injection sites and obvious hernias should all be sought.

(a) White cell count – When elevated, can be a useful marker of acute inflammation – predominantly neutrophils. However, WCC response is altered in certain patient groups – for example, immunosuppressed and elderly. It is important to remember that inflammatory markers are not uncommonly normal in inflammatory conditions like acute appendicitis and that management decisions should be based on clinical decisions. The same applies to other inflammatory markers like C-reactive protein and erythrocyte sedimentation rate. (b) Haemoglobin – Values are concentrations and not absolute levels. Consequently, haemoglobin levels take time to drop in the setting of acute haemorrhage. (c) Troponin (T or I), Creatinine Kinase (MB), Lactate dehydrogenase – cardiac enzymes which are elevated after myocardial muscle death (remember that it may take several hours before levels are elevated in serum). (d)  D Dimer – A sensitive but non-specific test for pulmonary embolus. (e)  Amylase/Lipase – Markers of acute pancreatitis (non-specific).

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(f) Electrolytes, Urea and Creatinine – Important in determining fluid management and for the administration of renally cleared medications. (g) Liver function tests – Aid in the diagnosis of hepatitis, important for administration of hepatically cleared medications and in the setting of biliary obstruction (total bilirubin, alkaline phosphatase and gamma glutamyl transpeptidase will be elevated – often caused by gallstones in common bile duct). (h) Arterial blood gas analysis – Gives an objective measure of blood oxygenation, and blood pH. (i) Serum Lactate – Important marker for ischaemic bowel.

35.3.2 Urine Dipstick Urine dipstick testing is quick, cheap and readily available. Urinary tract infection is suggested by positive nitrites and leucocytes. One should send a formal midstream urine specimen for microscopy, culture and sensitivity prior to commencement of empirical antibiotics. Renal colic is strongly associated with haematuria. All women of childbearing age should be considered pregnant until proven otherwise by urine beta human chorionic gonadotropin (hCG) testing.

35.3.3 Electrocardiogram (ECG) An ECG can aid in differentiating myocardial ischaemia/infarction from intra-abdominal pathology.

H. Nabi

Please note CT (without i.v. contrast) is the investigation of choice in investigating possible renal calculi given the possibility of radiolucent stones or projection over bony structures [1].

35.3.5 Abdominal Ultrasound (US) Abdominal ultrasound is particularly good at assessing the biliary tract (visualisation of gallstones, gallbladder wall thickness and diameter of common bile duct). They are also useful at assessing abdominal aortic aneurysms, the spleen, pancreas, hernias, urinary tract, ovaries, fallopian tubes and the uterus. Ultrasound has limited capabilities when assessing gas-filled structures, such as the bowel. This imaging modality has several advantages over CT – it is cheaper, involves no exposure to radiation and can be done at the patient’s bedside.

35.3.6 Computer Tomography (CT) Where available, CT often proves a superior imaging modality with reference to detection of organ damage post-trauma (such as splenic lacerations), abdominal aortic aneurysms, acute pancreatitis, diverticular disease, intra-abdominal abscess, bowel obstruction, appendicitis, liver pathology, splenic infarction, pyelonephritis, renal colic and viscus perforation [2]. CT has the disadvantages of expense, radiation and contrast exposure; patient needs to be transported to radiology department when potentially unstable and it may delay life-saving management.

35.3.4 Plain Film X-Ray Chest X-rays are important in the identification of lower lobe pneumonia. Free air under the hemidiaphragms can be an indicator of bowel perforation. Abdominal X-rays have a very limited role in the assessment of the acute abdominal pain. Plain X-rays are indicated when considering: • Bowel perforation (free air) • Bowel obstruction (loops of dilated bowel with multiple associated air-fluid levels)

35.3.7 Diagnostic Peritoneal Lavage (DPL) The presence of blood, intestinal contents or pus on DPL indicates the need for laparotomy. However, no cause or site can be ascertained form this investigation [3]. The author does not advocate the widespread use of DPL given its invasive nature and the lack of specificity in its findings. Its use has been largely replaced by CT and ultrasounds where available.

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35  Acute Abdominal Pain

35.3.8 Endoscopy Upper GI endoscopy and colonoscopy can be useful investigatory tools in the acute setting. They may be able to localise and control bleeding in gastrointestinal haemorrhage. In the acute setting of diverticulitis or peptic ulcer perforation, they can exacerbate problems by blowing air through perforation sites into the peritoneal cavity.

35.3.9 Diagnostic Laparoscopy Laparoscopy is a diagnostic tool that can also act as a therapeutic tool. Through laparoscopy, various conditions can be effectively managed: appendicectomy, cholecystectomy, drainage of intra-abdominal abscess, adhesion division and even oversewing of perorated peptic ulcer [4].

35.3.10 Exploratory Laparotomy Signs of diffuse peritonism often warrant immediate laparotomy – which will be diagnostic and therapeutic. An example of an exception to this is peritonism from acute pancreatitis – which can be made worse by laparotomy. However, in unstable patients for whom the cause of acute abdominal pain is uncertain, an exploratory laparotomy may be life-saving. This is especially true in the setting of trauma. This should not be delayed while awaiting investigations, which will not alter management.

35.4 Differentials and Management The various causes of abdominal pain appear to be ­seasonal and are population dependant. However, some studies looking at mainly Western populations provide some insight on what to expect as common causes for acute abdominal pain (Table 35.4) [5]. It is beyond the scope of this chapter to give a thorough description of all possible causes of acute abdominal pain; we will highlight some important disease processes to aid with clinical assessment of common causes of acute abdominal pain.

Table  35.4  Causes of presentation to hospital with acute abdominal pain in the Western world [5] Cause Overall percentage of cases Non-specific abdominal pain

34

Acute appendicitis

28

Acute cholecystitis

10

Small-bowel obstruction

4

Gynaecological disease

4

Acute pancreatitis

3

Renal colic

3

Perforated peptic ulcer

2

Cancer

2

Diverticular disease

1

Miscellaneous

9

35.4.1 Acute Appendicitis Classically presents with a history of vague generalised abdominal pain (visceral pain fibres) which then becomes sharp and localised to right iliac fossa (parietal pain fibres) (see Chap. 28). Can be associated with fever, nausea, vomiting, diarrhoea and occasionally microscopic haematuria from inflammation of adjacent ureter if appendix retrocaecal. Location of pain over McBurney’s point (third of way from anterior superior iliac spine to umbilicus) is variable because of the unpredictable position of the appendix. This is a diagnosis that should be made clinically – serum inflammatory markers are often normal early, ultrasound scans are notoriously poor at visualising the appendix and clinical decisions should be made without waiting for CT scans. Complications stemming from perforation include the formation of a peri-appendiceal abscess or diffuse peritonism. This can be life-threatening as patients can develop septic shock. Definitive management is with laparoscopic or open appendicectomy. The appendiceal abscess is sometimes best managed with drainage of the collection and staged appendicectomy. Likewise, some argue that the appendiceal mass (inflamed appendix surrounded by omentum) can sometimes be managed conservatively with intravenous antibiotics and staged appendicectomy [6].

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35.4.2 Acute Cholecystitis/Cholelithiasis Pain from cholelithiasis is commonly described as sharp constant pain in the right upper quadrant, which follows large or particularly fatty meals, and tends to resolve in several hours without intervention (see Chap. 22). These patients often do not need hospital admission and can be managed with staged elective cholecystectomy. Cholecystitis, on the other hand, implies a prevailing inflammatory process (often chemical inflammation). There is often an associated elevation in serum inflammatory markers. Patients are clinically more likely to be febrile and on examination be Murphy’s test positive (inspiration is held as inflamed gallbladder hits examining hand held along right costal margin). Elderly patients may however be afebrile with normal inflammatory markers. Ultrasound scans performed on these patients will often reveal gallbladder wall thickening and pericholecystic fluid. Most centres now advocate cholecystectomy during current admission to manage acute cholecystitis. A subcategory of patients who present with symptoms suggestive of common bile duct obstruction (jaundice/icterus, pale stools, dark urine), biochemical derangements (elevated bilirubin, GGT, ALP), dilation of common bile duct on ultrasound or pancreatitis may need an endoscopic retrograde cholangiopancreatography (ERCP) to retrieve any common bile duct stones prior to cholecystectomy.

35.4.3 Small Bowel Obstruction Common causes of small bowel obstruction include internal herniation (related to adhesions, often from previous operations), external hernias (inguinal, femoral, umbilical, epigastric or incisional), intussusception (common in children and associated with malignant lesions in adults) and volvulus (see Chap. 29). Patients commonly present with central colicky pain, often associated with abdominal distension, ­nausea, vomiting and constipation. On examination, hernias need to be sought. Bowel sounds are often described as tinkling. Abdominal X-rays reveal loops of dilated bowel with multiple air-fluid levels. Contrast imaging such as gastrograffin follow-through and more commonly CT will allow for identification of cause.

H. Nabi

Not all patients with bowel obstruction need (immediate) surgery. Bowel obstructions caused by adhesions often resolve with conservative measures – bowel rest, intravenous therapy, nasogastric tube proximal drainage. Urgent operations may be necessary if an obstructed hernia (bowel lumen occluded within the hernia) or strangulated hernia (impairment of the blood supply to the bowel, giving rise to signs of peritonism) is detected.

35.4.4 Acute Gynaecological Problems Several gynaecological conditions can produce acute abdominal pain (see Chap. 54). Even normal ovarian follicle rupture at the time of ovulation can be associated with pain (Mittelschmerz). Ovarian cysts can present with pain in either iliac fossa if they are torted or rupture. Salpingitis – frequently related to intrauterine contraceptive devices – can produce lower abdominal pain, fevers and vaginal discharge. Pregnancy – whether intrauterine or ectopic – should be considered in all females of childbearing age. Where appropriate, a vaginal examination can provide valuable information. Likewise, urine pregnancy testing, pelvic ultrasounds and even diagnostic laparoscopy can be particularly helpful diagnostic tools in females presenting with lower abdominal pain.

35.4.5 Acute Pancreatitis Patients suffering from acute pancreatitis frequently present with epigastric pain, which may be associated with nausea, vomiting and fevers (see Chap. 25). There is often evidence of peritonism on abdominal examination. In the developed world, acute pancreatitis is most commonly caused by gallstones and alcohol. Less common causes can be remembered by using the GET SMASHED pneumonic (Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Hyperlipidaemia/ Hypercalcaemia, ERCP, Drugs – such as thiazide diuretics and azathioprine). Scoring criterion, such as the modified Glasgow criteria, can be used to grade severity of episodes on

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35  Acute Abdominal Pain Table 35.5  Modified Glasgow criteria for grading severity of acute pancreatitis on admission Criteria can be remembered with the pneumonic PANCREAS P – PO2 <60 mmHg A – age >55 years

CT scans are the investigation of choice, as a small portion of stones is radiolucent, and others may be positioned over bony structures. Stones 5-mm diameter or less often pass spontaneously. Larger stones and those leading to hydronephrosis may require intervention by urologists.

N – neutrophils (WCC >15 × 109/L) C – serum calcium (Ca2+ <2 mmol/L) R – serum urea >16 mmol/L

35.4.7 Perforated Peptic Ulcer

E – enzymes (AST >200 iu/L, LDH >600 iu/L) A – serum albumin <32 g/L S – sugar (blood glucose >10 mmol/L) Mild

0 criteria

Moderate

1 criterion

Severe

2 or more criterion

admission (Table 35.5). Severe episodes require early imaging (i.e. CT scan) and are more likely to require transfer to intensive care facilities [7]. One needs to be aware of the numerous complications of acute pancreatitis and manage them actively. These complications include pancreatic abscess formation, hypocalcaemia, disseminated intravascular coagulation, septic shock, pancreatic pseudocyst formation, development of chronic pancreatitis (steat­orrhoea, malabsorbtion and diabetes mellitus), acute res­piratory distress syndrome and multiorgan failure. Initial management involves supportive measures. Intensive care referral should be made early, as patients can deteriorate rapidly. Intubation may be required. Intravenous therapy is required to compensate for third space fluid losses. Alcohol withdrawal needs to be managed. Early ERCP may be required early (if there is evidence of cholangitis) [8]. Percutaneous drainage of collections and even pancreatic necrosectomy may be required later.

35.4.6 Renal Colic Renal Colic commonly presents with colicky flank pain which radiates to the groin (see Chap. 55). This may be associated with haematuria. Patients will often be very restless as they struggle to find a position that alleviates the pain.

Patients with perforated peptic ulcers commonly ­present with epigastric or diffuse abdominal pain (see Chap. 21). On examination, diffuse peritonism is common. Signs may be localised if the perforation has sealed itself off. Free gas is seen under the hemidiaphragms on plain CXR. In selective cases, sealed-off perforations can be  managed conservatively. Laparoscopic repair of perforations is possible. Most surgeons would prefer omental patch repair.

35.4.8 Acute Diverticular Disease Diverticular disease is most often limited to the sigmoid colon (see Chap. 30). Complications of diverticular disease include diverticulitis, perforation, abscess or stenosing stricture formation, haemorrhage and fistula formation (enterocutaneous, enterovesical, etc.). Diverticulitis commonly presents with constant left iliac fossa pain, often associated with fevers. If a redundant loop of ­sigmoid colon exists on the right side, right iliac fossa pain may be the presenting symptom. Diagnostic tool of choice is the CT scan with i.v. and oral contrast. Most cases of diverticulitis can be managed conservatively with antibiotics – oral antibiotics in the community if mild, or inpatient intravenous antibiotics if severe. Perforations can be managed with radiologically guided percutaneous drains if sealed off. Others may require laparotomy and sigmoid colectomy (often Hartman’s procedure necessary). Colonoscopy in the acute setting is ill-advised. To document the extent of diverticular disease, patients can be brought back and colonoscopy can be performed in the outpatient setting once the inflammation has subsided.

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H. Nabi

35.4.9 Urinary Tract Infections

References

Urinary tract infections range from mild cystitis to severe pyelonephritis (see Chap. 55). Dysuria and fevers accompanying lower abdominal pain is suggestive of cystits. When associated with flank pain, imaging to exclude pyelonephritis should be performed. Urinary dipstick testing provides a quick indicator of urinary infection – ­positive nitrites and leucocytes are suggestive. One should ensure midstream specimens are taken for M,C&S prior to the initiation of empirical treatment.

1. Forster, T.H., Bonkat, G., Wyler, S., Ruszat, R., Ebinger, N., Gasser, T.C., Bachmann, A.: Diagnosis and therapy of acute  ureteral colic. Wien. Klin. Wochenschr. 120(11–12), 325–334 (2008) 2. Urban, B.A., Fishman, E.K.: Targeted helical CT of the acute abdomen: appendicitis, diverticulitis, and small bowel obstruction. Semin. Ultrasound CT MR 21(1), 20–39 (2000) 3. Whitehouse, J.S., Weigelt, J.A.: Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand. J. Trauma Resusc. Emerg. Med. 17, 13 (2009) 4. Perri, S.G., Altilia, F., Pietrangeli, F., Dalla Torre, A., Gabbrielli, F., Amendolara, M., Nicita, A., Nardi Jr., M., Lotti, R., Citone, G.: Laparoscopy in abdominal emergencies. Indications and limitations. Chir. Ital. 54(2), 165–178 (2002) 5. de Dombal, F.T.: Diagnosis of Acute Abdominal Pain [A  Compilation of Scientific Studies of Abdominal Pain Completed over 20 years.], 2nd edn. Churchill Livingstone, Edinburgh (1991) 6. Meshikhes, A.W.: Management of appendiceal mass: ­controversial issues revisited. J. Gastrointest. Surg. 12(4), 767–775 (2008) 7. Nathens, A.B., Curtis, J.R., Beale, R.J., Cook, D.J., Moreno, R.P., Romand, J.A., Skerrett, S.J., Stapleton, R.D., Ware, L.B., Waldmann, C.S.: Management of the critically ill patient with severe acute pancreatitis. Crit. Care Med. 32(12), 2524–2536 (2004) 8. Gupta, R., Toh, S.K., Johnson, C.D.: Early ERCP is an essential part of the management of all cases of acute ­pancreatitis. Ann. R. Coll. Surg. Engl. 81(1), 46–50 (1999)

35.5 Summary Acute abdominal pain is a common reason for referral to the rural general surgeon. Its causes range from the relatively trivial to the life-threatening. In view of their proportionately limited resources, rural surgeons have to place great emphasis on their clinical judgement in managing these patients. By adopting a systematic approach to one’s assessment and management, the intimidating task of differentiating between potential causes is made much easier.

Gastrointestinal Bleeding

36

Friesen W. Randall

Gastrointestinal bleeding, or hemorrhage, is a common presentation to physicians everywhere. While its severity may vary, it often provokes concern and anxiety in both patient and doctor. The rural surgeon requires skills in rapid assessment and intervention, and in addition, must often address questions of triage and transport. This chapter will discuss the following: 1. Definitions 2. Diagnosis 3. Management a. Supportive b. Specific i. Pharmacological ii. Hematological iii. Procedural c. Patients on anticoagulants 4. Rural issues a. Triage b. Transport

36.1 Definitions 36.1.1 Upper Versus Lower Gastrointestinal Hemorrhage Gastrointestinal hemorrhage, generally referred to as “GI Bleed,” is commonly divided geographically into “upper” and “lower” cases. The ligament of Treitz

F.W. Randall Department of Surgery, Victoria Hospital, 1200 - 24th Street West, Prince Albert, SK S6V 5T4, Canada e-mail: [email protected]

(i.e., the duodenojejunal ligament) marks the point at which the origin of a bleed is designated as one or the other. For practical purposes, bleeding episodes are usually classified based on clinical presentation. Upper bleeds manifest as hematemesis (vomiting of frank blood, clots, and/or “coffee-ground emesis,” and ­melena stools). Lower bleeds may present with frank hematochezia, varying in severity from traces of blood on ­toilet paper, to passage of large amounts of frank blood and/ or clots.

36.1.2 Acute Versus Chronic Blood loss may be catastrophic, leading to shock and even death (e.g., aorto-enteric fistula). It may also be very chronic, occurring so slowly that its occurrence may not be noticed until symptoms of anemia set in, or a fecal occult blood test becomes positive (e.g., colon cancer). This variability in acuity necessarily leads to a variable algorithm, and thus early and accurate evaluation of acuity takes priority in assessment.

36.2 Diagnosis 36.2.1 Upper Versus Lower Distinguishing between an upper and a lower origin of bleeding may be simple, as when frank hematemesis occurs. Retrograde flow of blood from below the ligament of Treitz almost never occurs, so such bleeds are always considered “upper.” Change in stool color

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_36, © Springer-Verlag Berlin Heidelberg 2011

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(in the face of bleeding) is affected by factors such as gut transit time, rapidity of blood loss, dietary and drug intake. One can be misled by the presence of melena, diagnosing an upper GI bleed when the actual source is the right colon.

36.2.1.1 History However, frank hematemesis or hematochezia can originate from a wide variety of pathological conditions. Common causes of upper bleeds include esophageal varices, gastritis, and/or gastric ulceration (often associated with anti-inflammatory drug use), and ­duodenal ulceration. Lower causes include colonic diverticulosis or angiodysplasia. Thus, obtaining an accurate history is paramount. Information from the patient, the family physician, family members, friends, co-workers, ambulance staff, nurses, pharmacists, and other caregivers can usually establish a working diagnosis without resorting to emergency diagnostic procedures. Data from previous investigations must be rigorously sought after, whether from local clinical charts, from other physicians, or even from remote institutions. A history of retching or vomiting prior to onset of hematemesis should raise the suspicion of a traumatic mucosal tear (so-called Mallory-Weiss tear). Detection of underlying diseases is also very helpful. For example, if signs of chronic liver disease are detected, portal hypertension becomes a more likely etiologic factor for bleeding. Likewise, consumption of anti-inflammatory drugs (even small doses such as ASA 81 mg) must be vigorously pursued in taking a history. Many patients do not consider these over-thecounter medications to be significant, and omit them unless specifically questioned. Similarly, consumption of ethanol and other chemical irritants must be documented, both short and long term. Acute gastritis after a weekend binge may manifest much like an acute variceal bleed, but their treatments are quite different. Note that household members are often more objective in their quantification of ­ethanol intake than the patient. Determining the actual amount of blood lost in an acute setting can be very difficult, and is typically overestimated by patients and observers. Referring to objective measures when asking questions helps avoid vague descriptions such as “there was blood everywhere,” or “the toilet bowl was full of blood.”

F.W. Randall

The most vital history seeks for symptoms of hypovolemia. Aside from patients with known esophageal varices or coagulopathy, most patients without symptoms can be initially assessed outside of a hospital. All aspects of history take on significance. The ­family history may reveal bleeding tendencies, liver disease, or peptic ulcers. The psychosocial history might reveal the use of street drugs or ethanol abuse.

36.2.1.2 Physical Examination The vital signs comprise the most “vital” part of physical evaluation. These must be interpreted in light of the patient’s age and their usual parameters. Vital signs are the primary method for triaging cases, both in an office setting, and in a hospital emergency department. In the absence of equipment to assess blood pressure, palpation of peripheral pulses gives the most basic assessment of vascular perfusion. Severe pallor, dyspnea, diaphoresis, peripheral vasoconstriction, and orthostatic dizziness/syncope are also valuable clues. These signs must take into account the effect of drugs; e.g., beta-blockers prevent tachycardia and peripheral vasoconstriction, thus concealing evidence of shock. While the presence of pallor must always remain subjective, experienced clinicians still assess for it generally, and in anatomic locations where skin pigmentation is absent (e.g., oral mucosa, conjunctiva). Stigmata of chronic hepatic dysfunction include clubbing, asterixis, spider nevi, ascites, dependant edema, and gynecomastia. Unless previously done by an experienced and trusted practitioner, rectal examination should be done by the surgeon. If the source of bleeding is uncertain, gastric lavage may help to confirm a proximal source. This should however only be considered if an urgent or semi-urgent (depending on the amount of blood loss) upper gastrointestinal tract endoscopy cannot be done. “Blind” insertion of a nasogastric tube can lead to disruption of a clot or may cause bleeding from varices. Furthermore, bleeding from below the pylorus cannot be excluded with a nasogastric tube alone since it is usually positioned proximal to the pylorus and may not detect blood distal to a competent pylorus.

36.2.1.3 Laboratory Tests While hematological parameters are not necessary for primary triage and the diagnosis of shock or severe

36  Gastrointestinal Bleeding

blood loss, they are very helpful in guiding treatment. Either the hemoglobin or the hematocrit will provide an approximate idea of the extent of blood loss, but in very rapid loss, will underestimate the actual loss, because both of these values reflect ratio of red blood cells, or hemoglobin, to blood volume – as opposed to the total circulating volume of RBC’s or hemoglobin. Assessment of platelet numbers must also be performed, even though adequate numbers do not guarantee adequate function (see below). The lab values must always be interpreted in light of the clinical presentation; isolated values alone cannot provide certainty about degree of urgency or exact nature of any treatment plan. For example, a young fit person may withstand a hemoglobin level as low as 40 g/L (4 g/dL) with only mild cardiovascular stress, while an elderly person with cardiac dysfunction might be at risk of serious complication with a hemoglobin level of 90 g/L (9 g/dL). Whether bleeding is acute or chronic, coagulation should always be assessed. Prothrombin time (PT) and the associated international normalized ratio (INR) need to be measured, usually in conjunction with activated partial thromboplastin time (APTT). Antiplatelet drugs will affect clot formation, but tests of platelet function are not as functionally useful, and are not always readily available. In all cases of significant blood loss, as evidenced by cardiovascular compromise or by very low hemoglobin levels, determination of blood group (ABO) and type (Rh status) must be done. Screening tests for circulating antibodies are often done at the same time (i.e., “group and screen” test), so that if cross-matching is requested, it can be done expeditiously. Fecal occult blood testing (FOBT) has only an occasional role to play; the low specificity and sensitivity render these tests of little utility in most cases. If utilized, a fecal immunochemical test (FIT) should be preferred over other older types (i.e., guaiac-based) since it is specific for human blood.

36.2.1.4 Imaging The advent of flexible GI endoscopy has brought opportunity for rapid and precise diagnosis of the anatomic location and pathological cause of most bleeds. The equipment and skills for esophagogastroduodenoscopy (EGD), in particular, can and should be readily available in most hospitals where bleeds commonly present (Figure 36.1). Barium studies are best avoided, as they interfere with other imaging studies.

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The timing of EGD depends on the acuity of the presentation. Ideally, all patients with suspected upper GI hemorrhage should undergo endoscopy within 24–48 h. If bleeding is suspected to come from esophageal varices, a higher degree of urgency for both diagnostic and therapeutic endoscopy is indicated. Those patients with significant ongoing bleeding need more rapid testing, so that treatment can be directed at the anatomic site and underlying pathology (see below). If a patient remains unstable despite adequate blood and fluid administration, an emergency endoscopy must be performed. During this procedure, ice-water irrigation of the stomach/bleeding lesion can help to identify the blood source and may contribute to a reduction of blood loss. Care should be taken not to make a bleed worse with these interventions. For lower GI bleeding, assessment is hampered by the presence of stool. Bowel cleansing for an acute bleed should be done cautiously, to avoid aggravating bleeding or inducing hypovolemia. A brisk bleed will itself act as a cathartic, and enemas can cleanse the lower colon and rectum efficiently and safely. Unlike EGD, lower endoscopy offers little in the way of therapeutics, as most cases of bleeding settle without treatment, and many causes are not amenable to endoscopic intervention, anyway (e.g., diverticulosis). Other endoscopic techniques such as enteroscopy and capsule endoscopy are typically available only in large referral centers, and are rarely helpful in the acute setting. Where radionuclide imaging is available, a “tagged” RBC scan will help. One must select cases in which the bleeding is brisk enough to show up, but not so brisk as to place the patient at risk because of the time required to perform such testing. There is no therapeutic benefit with this modality, but it can be repeated (within 24-48 hours, without another radionuclide injection)... in the event of intermittent symptomatology. In brisk bleeding, angiography becomes useful for localization; immediate treatment by embolization may cure the patient, or at least slow down bleeding temporarily. Occasionally, imaging modalities such as CT scanning, MR imaging, and similar modalities may help in diagnosis; CT angiography may hold promise for localization of bleeding. Rarely, operative intervention may be required. Laparoscopy may show either a general site (as evidenced by proximal extent of blood in the gut), or a specific anatomic pathology (e.g., leiomyoma of small bowel). Laparotomy may be required for severe bleeding as a lifesaving measure; one might only be able to estimate the general area of bleeding, and then resect a segment of gut “blindly.”

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F.W. Randall

Fig. 36.1  Endoscopic appearance of lesions causing upper gastrointestinal bleeding. (a) Chronic ulcer on the anterior wall of the duodenal cap. (b) Severe hemorrhagic gastritis without erosions. (c) Bleeding from the apex of a stromal tumor (leiomyoma) in the fundus of the stomach. (d) Close-up view of a bleeding Dieulafoy lesion in the fundus of the stomach. (Source: Prof. Ian Roberts-Thomson, Adelaide)

36.3 Management 36.3.1 Supportive For acute hemorrhage, oxygen and intravenous isotonic fluids through a large-bore catheter constitute essential interventions. Central venous access may be useful, but large-bore peripheral venous catheters are the first choice because of availability, efficiency, and efficacy. Transfusion of red blood cells should be considered whenever bleeding is catastrophic or response to isotonic fluids fails to meet expectations. Non-cross matched RBC’s should be given only if bleeding is immediately life-threatening. The older algorithms tended to rely on laboratory parameters as indicators

for RBC use. There is much evidence to indicate that the safer, although more complex, route is to use physiological parameters such as organ perfusion and global function (e.g., urine output, vital signs, ability to do normal activities without difficulty) to determine when and how much to transfuse. Basic homeostasis must be sought after; thus, core temperature must be normalized, using warm fluids whenever possible. Urine output should be carefully monitored via a urinary catheter in any unstable patient. Monitoring of central venous pressure may be useful, especially if significant underlying cardiac dysfunction exists. Iced saline lavage has been used, but without convincing evidence of effectiveness. Nasogastric suction tubes have not been shown to be helpful, and certainly do carry some morbidity and discomfort.

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36  Gastrointestinal Bleeding

Placement of intraluminal balloons (e.g., SengstakenBlakemore tube) to tamponade variceal bleeding might provide temporary control, but in the long term does not make a significant difference in outcomes.

36.3.2 Specific 36.3.2.1 Pharmacologic Most upper GI bleeding will stop within 24 h on proton pump inhibitor (PPI) therapy alone. Typical protocols require an intravenous bolus, followed by an ongoing infusion. For less acute bleeds, oral therapy may replace the infusion; the initial treatment for an acute bleed should always be intravenous. Histamine (H2) blockers do not have a detectable effect on bleeding, nor do oral antacids. There is no recognized role for vasopressors. Measures to control portal venous pressure (e.g., somatostatin analogues, beta-blockers) do help control bleeding and to decrease transfusion requirements in variceal bleeding. In the acute setting, beta-blockers should be avoided to allow for a physiological response to blood loss. Vitamin K (orally or parenterally) will help patients with demonstrated or suspected coagulopathy (e.g., patients on warfarin, those with impaired fat absorption, etc.). Do not forget to withhold offending agents (e.g., anti-inflammatory drugs, antiplatelet drugs, etc.). Re-introduction of such drugs should be done only after weighing the pros and cons (e.g., giving clopidogrel to a patient who has had TIA’s or recent placement of coronary artery stents).

36.3.2.2 Hematologic If no coagulopathy exists, and bleeding is not massive (a universal definition of “massive” is lacking), routine use of blood products is not recommended. These products are generally, but not universally safe. They have limited availability and are expensive. Traditionally, infusing coagulation factors was done only when coagulopathy was proven. More recently,

use of such products has been advocated in all cases where bleeding is brisk, and where transfusion requirements exceed two units of RBC’s. Some experts recommend “routine” use of fresh frozen plasma (FFP); they suggest a ratio of RBC to FFP units of between two and four. Whether this should apply to all cases of bleeding, or a specific population of patients, is not clear. Consider FFP use when the traditional standard for massive bleeding (i.e., need for six units of RBC’s in 24 h) is met. If laboratory findings on coagulation are abnormal, correction of these parameters is almost always required. FFP is often readily available and is easily administered. Cryoprecipitate may be useful if disseminated intravascular coagulation (DIC)/consumption coagulopathy is present. For specific cases, administration of Factor VIII concentrate should also be considered, especially if a family history of bleeding is manifest. If brisk bleeding occurs in a patient taking antiplatelet medication (e.g., clopidogrel), platelet transfusion should be considered earlier rather than later. Aspirin, on the other hand, rarely calls for such measures. Thrombocytopenia requires attention; if consumption or platelet destruction (e.g., hypersplenism) is ongoing, repeated transfusion may be needed. Do not wait for laboratory results (e.g., bleeding time) before ordering platelets (see above for rationale).

36.3.2.3 Procedural Procedures to control bleeding can be done through endoscopic, vascular, or surgical means. Clinical judgment must be exercised in all cases, based on one’s knowledge of each technique, one’s skill in applying the technique, and the availability of other options. An inexperienced endoscopist can get into trouble with precipitating worse bleeding, perforation, and pulmonary aspiration of blood. Fiber-optic GI endoscopy has revolutionized the management of upper GI hemorrhage. Forces can be brought to bear on the exact location of the bleeding source. This force may be mechanical (e.g., application of a clip to a spurting or visible vessel, or of an elastic band to an esophageal varix). It may be thermal (e.g., YAG laser, heater probe, bipolar cautery, etc.).

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It may be a combined effect, as in injection treatment (e.g., saline, adrenalin, glues, etc.). These techniques are best done with video equipment, an experienced endoscopist, and a skilled endoscopy assistant. Two working channels allow for simultaneous suctioning and application of therapeutic devices. Lower GI bleeds are more problematic, as visualization is typically poor. Although unproven, the belief that bowel cleansing exacerbates such bleeding seems intuitive. Thus, both diagnosis and intervention can be safely delayed in the stable patient. Fortunately, the vast majority of cases (most commonly diverticular disease and angiodysplasia) do not require specific intervention, as their natural history is one of spontaneous cessation. Controlling blood loss through vascular means requires angiography facilities (Figure 36.2). The creation of a transvenous intrahepatic porto-systemic shunt (“TIPS”) will decrease portal venous pressure and associated bleeding. Embolization of arteries is mentioned above. Operative techniques are seldom required when the above measures are skillfully applied. However, laparoscopic and open procedures may be both diagnostic and curative. The most common traditional indication for surgery was duodenal ulcer; endoscopic measures now almost always suffice. Emergency open portosystemic shunts are rarely justifiable. Given the rarity of surgery for bleeding, such operations should be undertaken only when clearly necessary, and with skilled assistance. Blood and blood products must be readily available. Localization of bleeding may be achieved laparoscopically, especially if the source is in the small bowel (e.g., leiomyoma, neuro-endocrine tumor, Meckel’s diverticulum, etc.).

Intraoperative endoscopy may help, (e.g., after intraoperative “on table” colonic lavage). Massive gastric hemorrhage from diffuse gastritis may require extensive gastric resection; morbidity will be high. When the location is the bowels, careful segmentation of the lumen with non-crushing clamps (or fingers!) may reveal the area of bleeding, thus allowing isolation to tamponade and/or resect of that segment.

36.3.3 Patients on Anticoagulants Patients on anticoagulant drugs require special attention. They are more likely to bleed from pathology that would not ordinarily result in bleeding. They are more likely to be elderly, frail, and compromised in terms of cardiovascular function. They may require extensive and expensive drugs and/or blood products to normalize coagulation, and their definitive investigations and interventions are thus often delayed. For patients on warfarin, if Vitamin K and FFP do not restore normal clotting parameters quickly enough to allow for such tests and treatments, prothrombin complex concentrate (PCC) (where available) should be considered. It is safe and rapidly effective. Protamine sulfate can be used to reverse the effects of heparin. Its utility in patients on low molecular weight (LMW) heparins varies, depending on exactly which type of heparin is in use; consult manufacturer’s documentation and online sources for up-to-date data. Always bear in mind that the effects of protamine are almost always of a shorter duration than that of LMW heparin, thus necessitating repeated doses of the former until the latter has “worn off.”

Triage

Factors to be Accounted for

Patient factors

Hemodynamic stability

Etiology of bleeding

Comorbidities

Patient preferences

Transport mode

Helicopter

Fixed-wing aircraft

Ambulance

Other

Transport security

Weather

Terrain

Distance

Military issues

Hospital support

Blood bank

Endoscopy

Nursing personnel

Staff to go with patient

Transport personnel

Availability

Number

Training

Experience

36  Gastrointestinal Bleeding

273

Fig. 36.2  Bleeding large bowel lesion on angiography with ­successful bleeding control using embolization. (Pictures courtesy of Department of Radiology, Flinders Medical Centre, Adelaide)

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36.4 Rural Issues 36.4.1 Triage When resources are limited, as is inevitably the case in rural settings, the question of transfer to another location becomes crucial. Is it safe to send a very ill patient? If not, should attempts be made to make it safe, or should resources be directed at arranging definitive care at the local facility? What is the expected duration of the trip? Will weather conditions permit travel, and if so, will they influence the timing or the duration of the trip? Is the receiving facility ready and willing to accept the case? What are the patient’s (or the family’s) wishes? Is qualified staff available to care for the patient en route? If blood transfusion is required during transport, proper infusion devices and clerical processes must be place to ensure safety. Skills and medications must also be in place to deal with transfusion reactions. Sometimes the best treatment modality is not available at a rural facility. However, the risk of the patient coming to harm because of delays related to transport, must be weighed against the risk of the patient coming to harm because of suboptimal treatment. This kind of risk assessment requires experience and judgment; often, a discussion with a physician at the receiving facility prior to transport helps.

36.4.2 Transport Once a decision has been reached to send a patient elsewhere for care, the physician must try to anticipate events during the trip, and to thus plan for them. Vital resuscitation equipment, oxygen, intravenous fluids, vital signs monitoring devices, suction tubing, and good temperature regulation are all essential. Having said this, experience shows that such preparation consumes time, and delays often lead to worsened outcomes.

F.W. Randall

Ambulance personnel vary widely in their qualifications; ancillary hospital staff (e.g., respiratory technician, nurse) may need to accompany the patient. If the patient is grossly unstable, a physician may be required. In facilities with very limited personnel, sending staff out may render that facility unable to provide essential services; thus, such decisions must be made carefully. In summary, triage decisions are complex and must take into account a wide range of non-medical data, as well as knowledge of local resource issues, to allow for best outcomes for rural patients.

Recommended Reading Adler, D.G., Leighton, J.A., Davila, R.E., Hirota, W.K., Jacobson, B.C., Qureshi, W.A., Rajan, E., Zuckerman, M.J., Fanelli, R.D., Hambrick, R.D., Baron, T., Faigel, D.O., ASGE: ASGE guideline: the role of endoscopy in acute nonvariceal upper-GI hemorrhage. Gastrointest. Endosc. 60(4), 497–504 (2004) Barkun, A., Bardou, M., Marshall, J.K., Nonvariceal Upper GI Bleeding Consensus Conference Group: Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann. Intern. Med. 139(10), 843–857 (2003) Davila, R.E., Rajan, E., Adler, D.G., Egan, J., Hirota, W.K., Leighton, J.A., Qureshi, W., Zuckerman, M.J., Fanelli, R., Wheeler-Harbaugh, J., Baron, T.H., Faigel, D.O., Standards of Practice Committee: ASGE guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest. Endosc. 62(5), 656–660 (2005) Murray, M., Bullard, M., Grafstein, E.: for the CTAS and CEDIS National Working Groups: revisions to the Canadian emergency department triage and acuity scale implementation guidelines. CJEM 6(6), 421 Oops. Nov, 2004 NSW Health (Sydney, Aust.). Triage and management of patients in NSW rural and remote EDs where there are no On-site doctors. SHPN: 040128; ISBN: 0734736878 (http:// www.health.nsw.gov.au/pubs/2004/pdf/triage_rural_remote. pdf) (01 Aug 2004) accessed 20 Feb, 2011 Thompson, J.M., Irvine, H., Von Hollen, B., Peters, M.: Triage system for rural hospital emergency services. Can. Fam. Phys. 37, 1252–1266 (1991)

Mesenteric Ischaemia

37

Heinrich Stiegler, Florian Brackmann, and Laura Holzner

37.1 Epidemiology The incidence of acute mesenteric ischaemia (AMI) is about 1/100,000 per year. In 0.4–1.0% of all patients with unclear abdominal pain, it is the underlying cause. The risk increases with age and reaches 3.8% in the population over 80  years. Venous occlusion is less ­frequent; it differs in pathogenesis and therapy from ischaemia due to arterial occlusion and will therefore be discussed separately.

37.2 Localisation Mesenteric ischaemia usually involves the area supplied by the superior mesenteric artery, i.e. ischaemia usually occurs about 5–7  cm distal of the ligament of Treitz (blood supply by the celiac trunk to this point) down to the left colonic flexure, where the blood supply via the inferior mesenteric artery starts. Depending on the extent of arterial obstruction, smaller and simultaneously sequential ischaemic areas are possible. H. Stiegler (*) Department of General-, Visceral- and Vascular Surgery, Klinikum Kaufbeuren-Ostallgäu, Dr. Gutermannstr. 2, 87600 Kaufbeuren, Germany e-mail: [email protected] F. Brackmann Department of General Surgery, Mount Gambier General Hospital, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia L. Holzner Department of General Surgery, Mount Gambier General Hospital and Flinders University Rural Medical School, 276-300 Wehl Street North, Mount Gambier, SA 5290, Australia

37.3 Aetiology and Pathogenesis Sixty percent of AMI cases are caused by impairment of arterial perfusion, 25% are of non-occlusive origin (NOMI), 15% of mesenteric ischaemias are due to venous occlusion. Irrespective of the cause but based on a common final pathway, it always leads to necrosis of the mucosa (possibly only in the form of damage to the internal layer) and subsequent disintegration of intestinal barrier function, finally advancing to necrosis of musculature and possibly resulting in perforation and peritonitis (Table 37.1).

37.4 Clinical Symptoms and Diagnostics The following triad is characteristic: • Acute onset of abdominal pain • History of cardiac problems • Lactate acidosis. Prior to the introduction of Angio-CT, these signs were indication for emergency laparoscopy or laparotomy. As differential diagnosis for acute abdominal pain, the following causes have to be kept in mind: • • • • • • •

Myocardial infarction Basal pneumonia Pleurisy Biliary colic Pancreatitis Perforation of an ulcer Ruptured/sealed rupture of aortic aneurysm

The clinical course can be divided into three typical phases (Table 37.2).

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_37, © Springer-Verlag Berlin Heidelberg 2011

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Table 37.1  Causes of mesenteric ischaemia

37.5 Further Investigations

Arterial occlusion − Embolism of the superior mesenteric artery (cardiac origin in case of hypokinetic disorder, atrial fibrillation, valve defects) − Thrombosis of the superior mesenteric artery due to arteriosclerosis − Aortic dissection − Vasculitis/arteritis − Direct trauma (e.g. mesenteric tear, ligation of the inferior mesenteric artery) NOMI − Hypotension − Cardiac insufficiency − Septic shock − Hypoperfusion due to medication (catecholamines, calcium antagonists, nitrates, diuretics, beta blocker, ACE inhibitors) Venous occlusion   Primary − Hereditary thrombophilia (deficiency of protein C, S, AT III, APC-resistance, antiphospholipid syndrome, homocysteinaemia)   Secondary − Pancreatitis − Inflammatory bowel disease − Appendicitis

In previous times, angiography, duplex sonography or occasionally explorative laparotomy was most prevalent; presently, angio-CT is the diagnostic method of choice. This tool allows the superior mesenteric artery to be visualized with all its branches, e.g. the ileocolic artery. In addition, the angio-CT provides important information regarding differential diagnosis. Traces of free air can be detected with the CT rather than with an x-ray, signs of peritonitis, thickening of the intestinal wall or gas trapping in the intestinal wall (Pneumatosis intestinalis) can be seen as well. For differential diagnostic considerations, the following investigations are needed: −− Chest x-ray in two planes −− ECG and cardiac enzymes −− Lipase Sensitivity for the AMI in the angio-CT is 80%. NOMI is more difficult to detect which means that in case of doubt, angiography or laparoscopy has to be done. Especially for peripheral thrombosis or embolisms in the mesenteric artery, angiography has some diagnostic advantages and local lysis therapy as well as other drugs (e.g. Papaverin) can be administered through the catheter in place. Figure  37.1 shows the diagnostic and therapeutic algorithms if AMI is suspected.

− Portal hypertension − Paraneoplastic syndrome

37.6 Therapeutic Strategy Table 37.2  Time flow of acute mesenteric ischaemia (h) 0:00

Acute abdominal pain, cardiac history, lactate acidosis (depending on the extent of ischaemia)

3:00

Changing of pain symptoms, hyperperistalsis, ‘silent interval’

6:00

Increased guarding, translocation peritonitis

Severe abdominal pain with sudden onset in the beginning, followed by varying abdominal pain which is less severe than during the acute period at the start of ischaemia and can conceal the true extent of the condition. This contrast to the overall impression of a severely ill patient indicates the need for an aggressive workup. Anamnestic evidence of prior embolisms (arm, leg, apoplexy) can add to the suspicion.

The main problems of this disease are its low incidence, its initially diffuse character, and the short period of time in which therapy has to be started to reduce the high mortality rate (50–85%). Within 3 h, severe wall damage occurs, which may be reversible if vascular reconstruction is done. Six hours after complete occlusion of the superior mesenteric artery, the bowel usually cannot be rescued in spite of successful embolectomy. The urgency of immediate measures makes alertness for this condition eminently important; it has to be ‘on your mind’ to promptly initiate ­angio-CT and if confirmed conduct laparotomy.

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37  Mesenteric Ischaemia Fig. 37.1  Algorithm for the clinical approach if acute mesenteric ischaemia is suspected

Clinical suspicion for AMI

Angio-CT

Unclear findings

AMI

Angiography

Doubtful prognosis

Possibly local lysis Intra-arterial therapy

Laparoscopy Explorative laparotomy

Embolectomy Resection Second look where applicable

Palliative/best supportive care

During laparotomy, the superior mesenteric artery is exposed at the lower pancreatic margin, a preparation which can be very difficult in obese patients because of the jejunal veins. After looping the artery and systemic administration of heparin, the embolectomy is performed; the mesenteric insertion is compressed digitally to mobilize potential small thrombi retrogradely. The transverse arteriotomy is closed with a monofilament non-resorbable suture (6–0, 7–0). If the reconstruction of the vessel is complicated due to calcification, a venous patch can be formed using the Saphenous vein. Therefore, this area has to be kept in mind when draping the patient. The bowel is packed in warm towels and reperfusion is awaited. The parts of the bowel which do not show recovery have to be resected, although slightly damaged inner wall can be left if the embolectomy went well. Bowel parts in doubt will be left for a ‘­second look operation’ 24  h later, possibly even a ‘third look operation’ as well.

Life-long anticoagulation

Further therapeutic measures are: • • • • •

Injection of papaverin where appropriate Systemic administration of heparin, PTT-controlled Diet build-up according to peristaltic movement Antibiotic coverage PPI administration

In cases of central ischaemia of the superior mesenteric artery and irreversible damage to the bowel, extensive resection with high jejunocecostomy can be performed in the young patient even after embolectomy. Depending on the age of the patient, small bowel transplantation or enteral ‘home nutrition’ has to be considered later. If the patient is very old and has numerous comorbidities, an individual decision with respect to the patient’s will has to be made; possibly the laparotomy or laparoscopy has to be stopped and considered explo­ rative, and best supportive care started. It is reasonable to leave the patient analgosedated under ventilation at ambient air; death can be expected within 1–2 days.

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In cases of peripheral embolism of the superior mesenteric artery, angiography with an interventionalist on standby can be sensible. Lysis is done with rtPA (e.g. 10  mg in 100-ml NaCl, inoculation of the clot with 5-ml bolus each, usually less than 10-mg rtPA are sufficient). The selectively placed catheter can be left; it allows further administration of Papaverine and secondary angiography. After successful revascularisation (and resection if needed), heparin treatment has to be changed to Warfarin after a sufficient amount of time to allow for mucosal healing. Changeover to Warfarin should not happen too early to prevent complicated Warfarin-related bleeding if inner wall damage exists.

37.7 Complications • Secondary bleeding under Warfarin: As a preventive measure, doubling of the PTT should only be approached after 24 h. • Anastomotic leakage: This requires immediate re-laparatomy. • Short-bowel-syndrome: Due to the damage of the mucosa, exudative exacerbation can occur and may require parenteral feeding.

37.8 Prognosis Despite medical and surgical progress, the prognosis of acute mesenteric ischaemia is still poor with mortality ranging from 50% to 93%. If intervention starts within 12 h, mortality ranges from 17% to 40%. The worst outcome has to be expected in mesenteric ischaemia resulting from disseminated arteriosclerosis in the context of NOMI.

37.9 Acute Thrombosis of the Portal Vein/Superior Mesenteric Artery Mesenteric ischaemia resulting from venous obstruction is not as common, and pain is less severe than in AMI.

H. Stiegler et al.

In these patients, recanalisation due to endogenous lysis often starts parallel to the development of the thro­ mbosis. Therefore, a quick diagnosis with efficient ­anti­coagulation is required to optimize the effect of endogenous lysis.

37.10 Aetiology The causes of venous occlusion are listed in the scheme above (Table 37.1). If hereditary thrombophilia is homozygous, occlusions can already occur in adolescents. In this case, a broad thrombophiliascreening is needed. Secondary causes of venous occlusion occur within paraneoplastic syndromes, sometimes favoured by local infiltration of the vein, e.g. in pancreatic cancer. Regarding inflammatory diseases, not only Crohn’s disease and ulcerate colitis have to be considered, but also protracted appendicitis can cause a venous occlusion of the superior mesenteric vein in terms of an ascending thrombophlebitis.

37.11 Therapy Figure 37.2 shows a therapeutical algorithm. In cases of acute abdominal pain, laparatomy/laparoscopy is inevitable. The extent of bowel resection depends on the extent of the venous gangrene. A venous thrombectomy is reserved for very rare indications (due to the low-flow-system, the danger of rethrombosis is extraordinarily high). If symptoms are less severe, an explorative laparoscopy can precede a laparotomy; otherwise, clinical control under sufficient heparinisation with subsequent parallel changeover to Warfarin is usually adequate.

37.12 Prognosis The prognosis of the disease is usually determined by  its cause. The slower and more gradual the thro­ mbosis develops, the more likely is recovery under anticoagulation.

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37  Mesenteric Ischaemia Fig. 37.2  Algorithm for the approach to acute thrombosis of the portal vein or superior mesenteric vein

Clinical suspicion Subtle symptoms

Angio-CT

Acute abdomen

Laparotomy

Venous bowel gangrene

Resection

Questionable acute abdomen

Laparoscopy

Questionable finding

Second look operation where applicable

Life-long anticoagulation

Subclinical findings

Clinical control

 

Management and Surgery of Inflammatory Bowel Diseases

38

William Roediger

38.1 Introduction Inflammatory bowel diseases comprise ulcerative colitis, Crohn’s disease, and more recently, indeterminate colitis and pouchitis [1, 2], which remain distinct from colitis related to Clostridium difficile, Mycobacteria, Cytomegalovirus, Salmonella, Shigella and enterotoxic E.coli.

38.2 Diagnosis of Inflammatory Bowel Disease A combination of specific clinical criteria often described as a “phenotype,” in conjunction with ­precise histological features, are essential to separate ulcerative colitis from Crohn’s colitis and indeterminate colitis [3].

38.3 Ulcerative Colitis 38.3.1 Clinical Symptoms and Diagnosis The cardinal symptom of ulcerative colitis is rectal bleeding with loosening of bowel motions, usually in younger patients (aged 16–38) while manifestation in

W. Roediger Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA 5011, Australia e-mail: [email protected]

older patients is the same with the added concern of colonic neoplasia. Typically, ulcerative colitis manifests in attacks, which descriptively are graded into mild, moderate or severe (Table 38.1). Confirmation of disease is made on complete colonoscopy to the caecum with disease manifestation seen in those areas of the colon where prolonged microbial contact occurs; that is, the distal colon and rectum or appendiceal lumen. Mucosal appearances on colonoscopy comprise (1) loss of mucosal light reflex, (2) redness with loss of definition of blood vessels, (3) friability of the mucosa, (4) diffuse granularity and micro-ulceration or (5) gross ulcers and pseudo polyp formation. The extent and exact length of the disease along the rectum or colon must be recorded and whether “sparing of the rectum” has occurred. A colitis involving the whole colon is now rarely found unless symptoms have been neglected for a long time. Histological changes on biopsy are increased numbers and variety of inflammatory cells in the lamina propria and epithelial cell changes of increased crypt branching, increased apoptosis, diminished mucus ­production and diminished surface microvilli. Crypt abscess formation hallmark ulcerative colitis before obvious ulcers, epithelial cell atrophy and inflammatory pseudo polyps manifest. As ulcerative colitis is a “pre-neoplastic” disease a statement on the degree of dysplasia should be included in all histological reports. To clinch a diagnosis of ulcerative colitis, exclusion of other disease conditions needs to be made by, for example, stool culture, stool toxin analysis and antibody detection of Yersinia and amoebiasis. In elderly patients, two conditions may mimic ulcerative colitis: (1) ischaemic colitis when there is vascular compromise of the superior and inferior mesenteric arteries; and (2) the presence of diverticular colitis secondary to active diverticulitis.

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W. Roediger

Table 38.1  Clinical grading of “attacks” of ulcerative colitis Mild Moderate Severe Frequency of bowel actions

3–4

4–6

6–10

Stool consistency

Solid to semi solid

Semi solid

Mushy

Mucus production

+/−

–

–

Blood in stool

Occult

+ to +++

++++

Systemic involvement

−

+/−

++

38.3.2 Aetiological Considerations in the Medical and Surgical Management of Ulcerative Colitis A broad generalization of the aetiology of ulcerative colitis is [1, 2] “the presence of an overactive immune system responding in a specific genetic setting to unknown environmental factors, mainly an altered microbial population in the colon.” Frequent reference of a “dysbiosis” leading to ulcerative colitis has been made and one newer proposal of a dysbiosis is exaggerated bacterial denitrification in the colon, which leads to harmful levels of nitric oxide being produced [4]. An excess production of sulphide in the colon has also been proposed to cause colitis. Many other hypotheses for the production of ulcerative colitis have been put forward [1, 2].

38.3.3 Medical and Surgical Treatment of Ulcerative Colitis Ideally, this constitutes input from three sources: selfdirected treatment by the patient, overview of treatment by a gastroenterological physician and the standby of a gastroenterological surgeon. Treatment emphasis is on controlling an acute attack of colitis followed by maintenance therapy to prevent remission of disease. Surgery is employed to eliminate colitic mucosa but entails the loss of the colon. In principal, therapy is directed at (1) colonic microbial popu­lations, (2) restoration of epithelial integrity and (3) suppression of immune cell activity and cytokine production.

Patients should be made aware of the treatment goals, the necessity of their cooperation and the fact that benefits of treatment may only accrue after 6–8 weeks of therapy.

38.3.4 Medical Management (a) Microbes: Dietary change to diminish an excess of sulphur amino acids reaching the colon, thereby changing provision of substrates for bacterial fermentation with decrease in sulphide formation. Probiotics, living bacteria such as Bifidobacteria, E.coli Nissle, prebiotics such psyllium husks or plantago and synbiotics, which are a combination of prebiotics and probiotics have proven value in  both acute and maintenance therapy of ulcerative coltis [5]. Non-absorbable oral antibiotics (Tobramycin) may be useful. Salazopyrin or the active ingredient 5-aminosalicylic acid diminishes colonic sulphide formation. (b) Epithelium: Providing probiotics, which promote n-butyrate formation, the chief metabolic substrate for colonic epithelial cells, may be of value. Addition of folic acid (5 mg/day) may boost epithelial cell function and ability to detoxify nitric oxide. (c) Immune or cytokine suppression: Prednisolone (maximum of 60  mg/day), azathioprine (up to 150  mg/day), methotrexate and monoclonal antibodies against TNF-a provide options to diminish immune cell activity [6] that damages the colonic epithelium. The use of azathioprine, methotrexate, cyclosporin and biologicals are preferably dealt with by a gastroenterological physician interested in inflammatory bowel disease.

38.3.5 Surgical Management The need for surgical treatment of ulcerative colitis can be divided into absolute, strong or relative, highlighting that medical therapy may not control all contingencies of ulcerative colitis. Failure of medical therapy may occur in the acute or chronic phases of the disease.

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38  Management and Surgery of Inflammatory Bowel Diseases

38.3.6 Indications for Surgical Treatment Severe acute colitis Absolute

− Perforation − Life-threatening haemorrhage

Strong

Relative

− Dilatation of the colon with an irregular mucosal line on the plain x-ray of the abdomen. This appearance usually indicates that there is deep mucosal ulceration, which has penetrated to involve the external muscle coats of the colon. The situation is potentially reversible in its early stages by medical treatment but persistent or increasing dilatation is a danger sign − Failure to respond to potent medical treatment usually Prednisolone 60 mg daily by intravenous infusion over several days

Chronic colitis Absolute

− Carcinoma

Strong

− Growth failure/sexual retardation Macroscopic lesion(s) (elevated, villous or polypoid area) associated with dysplastic epithelium, or high-grade dysplasia confirmed by sequential biopsy in flat mucosa

Relative

− Physical disability social disability – especially urgency and frequency of defaecation. Statistical carcinoma risk – extensive colitis, history greater than 10 years (associated disorders, e.g. liver disease)

Quiescent colitis Absolute

− Carcinoma

Strong

− Macroscopic or high-grade dysplasia (as above)

Relative

− Recurrent severe acute attacks. Statistical carcinoma risk (as above)

38.3.7 Emergency Surgery Cases with perforation, “toxic” megacolon (an indicator of deep penetrating ulcers) or fulminant colitis resistant to all medical therapy requires a prompt operation. The prime operation is a colectomy with ileostomy and either preservation of the rectum that is closed off or bringing out the rectosigmoid as mucous fistula. Of

these two options, a rectal stump and Brooke type everting ileostomy after colectomy is preferable. The rectal stump may be prone to continuing inflammation as “diversion colitis” though this is treatable with fibre suppositories and rectal steroid administration. A mucous fistula often presents more problems (wound infection, slow healing), then any potential advantages of such a procedure and is now rarely performed. Whatever distal colon or rectum is left, it should have sufficient length to enable an elective ileorectal or ileoanal pouch anastomosis.

38.3.8 Elective Surgery The choice for an elective operation, based on the criteria given above, is a proctocolectomy, either with (1) Brooke type everting end ileostomy, (2) ileorectal anastomosis or (3) a restorative pouch with ileoanal anastomosis. The last option can be done with a mucosectomy and hand-sewn anastomosis or by a circular stapling technique, which leaves a cuff of 1–2 cm of anal mucosa. Of all these options, a restorative ileal J  pouch of 15–20  cm length with a stapled ileoanal anastomosis is currently the most favoured procedure. The nature of ileal pouch, either a J, S or W pouch, rests on which pouch leads to least frequency of bowel actions and the best continence at night. The debate as to who should or should not be given a pouch continues: elderly patients and cases of Crohn’s colitis should be steered away from a pouch towards an end ileostomy. The risks of pouchitis in ulcerative colitis cases resistant to all forms of medical therapy before surgery may be an unconvincing reason for not offering pouch surgery. Laparoscopic appendicectomy has recently been advocated to diminish the severity of ulcerative colitis in the colon. Controlled trials so far have produced conflicting results and the utility of appendicectomy in the treatment of ulcerative colitis remains an open question. The technical aspects of surgery are excellently described by Keighley and Williams [7].

38.4 Crohn’s Disease Crohn’s disease of the ileum and colon was first clinically described by Dalziel almost 100 years ago (1913). The disease was named after Burril Crohn whose own

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observations, listed as “regional ileitis,” were described in 1932. The disease comprises, in its early phases, apthous ulceration from oral cavity to anal canal and genitalia. In decreasing frequency, it involves the ileum, colon, perianal region, rectum, jejunum, oral cavity, stomach, duodenum and oesophagus. Over the last five decades, the disease has been more frequently reported in the developed countries, compared to the developing world [8, 9], and the disease expression of severe stenosis and transmural fissuring has given way to manifestations of early inflammation. Clinical awareness of Crohn’s disease and development of endoscopes may have led to such a change.

38.4.1 Clinical Symptoms and Investigations Symptoms of the initial presentation can be grouped according to the point in the gastrointestinal tract at which disease prevails. Symptoms of chronic, established Crohn’s disease may however differ from the initial presentation. (a) Abdominal pain may either be in the mid or lower abdomen and be intermittent or colicky, yet severe enough for the patient to seek medical advice. A time/duration record of the pain is useful and especially the frequency of pain per day or week. Occasionally, overt bowel obstruction may occur but this is more usual in chronic disease. (b) Perianal abscess or inflammation of a fissure or haemorrhoid, particularly in young patients (<35 years), may be an initial presentation. Perianal or even genital ulceration may more rarely be the initial presentation. (c) Diarrhoea, loose bowel actions and rectal bleeding, usually intermittent can present in Crohn’s disease and mimic ulcerative colitis. (d) Malaise, weight loss, low-grade fever and tiredness may accompany the above symptoms. The diagnosis of active Crohn’s disease is sometimes only made 6–12 months after the initial onset of symptoms. Abdominal findings on examination are variable ranging from mild tenderness to frank peritonitis. A palpable mass may reflect chronic abscess formation. Perianal plum discolouration or ulcers, fissures and fistulation may be visible.

W. Roediger

Diagnostic confirmation of inflammation by C Reactive Protein (CRP) and less convincingly erythrocyte sedimentation rate (ESR) or by technetiumlabelled white cell scan or PET scan may pinpoint the level and extent of inflammation. These investigations are helpful in monitoring disease or the detection of recurrent active disease. Colonoscopy, preferably to the caecum and including the ileum may show the hallmark features of Crohn’s disease: discrete apthous ulcers, which are superficial, course patchy linear ulceration, inflammatory polyps, with reddened mucosa or those features observed in ulcerative colitis may be a part of Crohn’s colitis. Biopsies are helpful in leading to a diagnosis but at best only 60% of cases show chronic granulomata, the hallmark of Crohn’s disease. Other features of epithelial cell destruction, increased inflammatory cells, fibrosis and fissuring of tissue are also diagnostic of Crohn’s disease. Barium meal with a follow-through study, CT and MRI scanning are a good means to assess the small bowel. Thickening of the bowel wall, mucosal ulceration, narrowing and stricturing are typically features of Crohn’s disease. MRI scanning is needed to assess perianal disease, particularly fistula in the perineum.

38.4.2 Grading of Crohn’s Disease There are a number of clinical diseases activity indices (Crohn’s disease activity index [CDAI] HarveyBradshaw and Van Hees indices), based on numerical scores assigned to symptoms, signs and blood investigations. These indices are good for clinical trials and assessment of drug treatment but are not used in routine clinical practice. Regular CRP estimation is the best means to assess progress, whether improvement or deterioration, of active Crohn’s disease.

38.4.3 Aetiological Clues in the Management of Crohn’s Disease The antigens leading to the inflammation in Crohn’s disease are unknown and make treatment of the disease empirical. Crohn’s disease is most likely an infective process, a conclusion derived from two primary

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observations. Firstly, luminal diversion of small bowel improves existing Crohn’s disease or prevents recurrent disease after primary resection [10]. Secondly, antibiotics often have a remarkable curative effect in many cases of acute Crohn’s disease. Three microbial agents have attained “candidate status” as being potentially causative of Crohn’s disease. 1. Atypical mycobacteria (MAP) cause enteritis in cattle, sheep, goats, deer and alpacas, though in these animals no mucosal ulceration or luminal stenosis is apparent. Acid fast bacilli so far have not been found in Crohn’s disease in humans, though found with cases of MAP in animals. A large body of work both for and against MAP in human Crohn’s disease exists. The final verdict of MAP being causative of Crohn’s disease remains undecided and the debate continues. 2. Adherent invasive E.coli (AIEC) has been promulgated as causative of Crohn’s disease. These specific E.coli have yet to reach diagnostic value in the disease process as well as in management or therapies. 3. Entero-epithelial mycoplasma, particularly Myco­ plasma fermentans, have been detected by polymerase chain reaction (PCR) in acute Crohn’s disease. A large number of clinical correlates bet­ ween mycoplasma infection and the spectrum of Crohn’s disease [11] have given mycoplasma a strong consideration in the disease process of ongoing Crohn’s manifestation. Certainly, antibiotics aimed at mycoplasma (clarithromycin) have been found effective in the treatment of a number of cases of acute Crohn’s disease. If Crohn’s disease is an infective disease, then early treatment with antibiotics appears mandatory but ­convincing support for this view has yet to be developed.

to 60  mg daily for 12  weeks is permissible. Prolonged use of steroids causes osteoporosis, bone fragility or fractures. • Elemental diets, preferably low in fat, have been shown to improve acute Crohn’s disease. • The use of Salazopyrin or 5-aminosalicylic acid do not have a statistically proven benefit in management, nevertheless are widely used for active Crohn’s disease. • The use of macrolide antibiotics in acute Crohn’s disease may produce dramatic improvement (Clarithromycin 500 mg tds for 6 weeks). The aim is to suppress MAP or mycoplasma. • Metronidazole (200 mg tds × 14 days) as a suppressant of anaerobic bacteria has been found of modest benefit in acute Crohn’s disease. • Administration of more powerful immunosuppression with cyclosporin, methotrexate, azathioprine or monoclonal antibodies against TNF-a is preferably supervised by a gastroenterological physician.

38.4.5 Surgical Management The principles of surgical management are given in Table 38.2. The extent of surgical excision has over the last 50 years moved from radical excision to a limited local excision [12] with strong emphasis on post-­ operative medical management to prevent recurrences [13] (see below). The former operation of “bypass surgery” for active disease is no longer practised and is generally ineffective. Defunctioning of chronic disease by ileostomy is also no longer practised unless to ­protect an anastomosis of the colon.

38.5 Regional Surgical Management 38.4.4 Medical Management 38.5.1 Perineal Disease • Cessation of smoking is essential as response to medical therapy is thereby improved and also ­disease progress is diminished. • Steroid therapy may improve mural oedema and suppress inflammatory cell activity. Intravenous hydrocortisone progressing to oral Prednisolone up

Perineal abscesses need prompt drainage. Established fistulae are preferably treated by Seton to avoid abscess collection. Fistulectomy in one procedure or staged procedure should be done in a quiescent phase and ­following optimal immunosuppression.

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Table 38.2  Principles of surgical management Obstruction

Inflammatory

Steroids and diet

Fibrosis

Resection Strictureplasty

Heineke-Mikulicz Finney

Fistula

− Can be left for long time − Bowel to bowel – excision in “burn out phase” if possible − Bowel to elsewhere – excision +/− colostomy

Abscesses

– Drain

Bleeding

– Control by resection

Carcinoma

– Resection

38.5.2 The Crohn’s Appendix The histological finding of Crohn’s disease after appendicectomy is an occasional finding. Evaluation of the small bowel (Barium meal with follow through or capsule endoscopy) and large bowel by ileocolonoscopy is warranted. If apthous ulceration is found, such cases would benefit from a course of macrolide antibiotics.

38.5.3 Ileitis Found at Appendicectomy Acute ileitis due to Yersinia or campylobacter may be responsible for the finding of an inflamed ileum. Diagnostic workup and antibiotic management may be warranted. Removal of the appendix makes histological assessment possible.

quiescent phase of the disease may only achieve a 50% success rate.

38.5.6 Bowel Stricturing Strictures and chronic Crohn’s disease may occur in the distal small bowel or colon. Two surgical possibilities exist: (1) local excision with careful anastomosis under antibiotic cover is one option, or (2) if multiple strictures are found, the procedure of strictureplasty (analogous to the principles of pyloroplasty) can be undertaken provided no acute Crohn’s inflammation is detectable. Either a Finney type or Heineke-Mickulicz type strictureplasty have been used and both of these procedures preserve bowel length as no resection is involved.

38.5.7 Bleeding and Carcinoma 38.5.4 Abdominal Mass and Fistulisation Chronic palpable masses with fistulisation from small bowel to small bowel or small bowel to colon may not necessarily require operation. Depending on systemic responses, drainage of abscesses and limited resection of the involved bowel may be worthwhile.

38.5.5 Bowel to Other Organ Fistulisation Fistulisation to bladder or vagina are a problem of long-term management. Surgical correction during a

These should be treated along standard surgical principles. The incidence of carcinoma in longstanding chronic Crohn’s colitis is higher than in the general population.

38.6 Post-operative Treatment of Crohn’s Disease All cases of Crohn’s disease operated on need postoperative surveillance and further treatment for 3–5 years or up to a point where a burn-out state has

38  Management and Surgery of Inflammatory Bowel Diseases

been achieved. From 5% to 50% of ileocolonic resections will develop a recurrence just proximal to the anastomosis. Prophylactic treatment with metronidazole [13] or clarithromycin, has been shown of value. Continuing immunosuppression may also be of use. A  number of clinical trials are currently being conducted in this area.

References   1. Sartor, R.B., Sandborn, W.J.: Kirsner’s Inflammatory Bowel Diseases, 6th edn. Saunders, Edinburgh (2004)   2. Jewell, D.P., Mortensen, N.J., Steinhart, A.H., Pemberton, J.H., Warren, B.F. (eds.): Challenges in Inflammatory Bowel Disease, 2nd edn. Blackwell Publishers, Oxford (2006)   3. Geboes, K., Van Eyken, P.: Inflammatory bowel disease unclassified and indeterminate colitis: the role of the pathologist. J. Clin. Pathol. 62, 201–205 (2009)   4. Roediger, W.E.W.: Nitric oxide from dysbiotic bacterial ­respiration of nitrate in the pathogenesis and as target for therapy of ulcerative colitis. Aliment. Pharmacol. Ther. 27, 531–541 (2008)

287   5. Fujimori, S., Gudis, K., Mitsui, K., et  al.: A randomized controlled trial on the efficacy of synbiotic versus probiotic or prebiotic treatment to improve the quality of life in patients with ulcerative colitis. Nutrition 25, 520–525 (2009)   6. Rutgeerts, P., Vermeire, S., Van Assche, G.: Biological ­therapies for inflammatory bowel diseases. Gastroenterology 136, 1182–1197 (2009)   7. Keighley, M.R.B., Williams, N. (eds.): Surgery of the Anus, Rectum and Colon, 2nd edn. Saunders, London (1999)   8. Russel, M.: Changes in the incidence of inflammatory bowel disease: what does it mean? Eur. J. Intern. Med. 11, 191–196 (2000)   9. Das, K., Ghoskal, U.C., Dhali, K., et al.: Crohn’s disease in India: a multicenter study from a country where tuberculosis is endemic. Dig. Dis. Sci. 54, 1099–1107 (2009) 10. Rutgeerts, P., Geboes, K., Peeters, M., et al.: Effect of faecal stream diversion on recurrence of Crohn’s disease in the neoterminal ileum. Lancet 338, 771–774 (1991) 11. Roediger, W.E.W.: Intestinal mycoplasma in Crohn’s disease. Novartis Found. Symp. 263, 85–98 (2004) 12. Andersson, P., Olaison, G., Hallbook, O., Sjodahl, R.: Segmental resection or subtotal colectomy in Crohn’s colitis? Dis. Colon Rectum 45, 47–55 (2002) 13. Ng, S.C., Kamm, M.A.: Management of postoperative Crohn’s disease. Am. J. Gastroenterol. 103, 1029–1035 (2008)

 

39

Proctology Alexander Herold and Laura Holzner

39.1 Haemorrhoids Above the dentate line below the rectal mucosa, there is a circular arteriovenous conglomerate, the corpus cavernosum recti. A hyperplasia of these vascular structures is called haemorrhoids; if the hyperplasia additionally causes pain, it is considered as haemorrhoidal disease. These arteriovenous cavernous bodies, which predominantly occur in three, seven and 11 o’clock with the patient in the lithotomy position are of great importance for the anal fine continence. Arterial blood supply to the haemorrhoids comes from the superior rectal artery.

39.1.1 Symptoms The complaints resulting from haemorrhoids are nonspecific and occur in many other proctological diseases as well. They do not correlate with the size of the haemorrhoids. Bleeding is the most common symptom. It usually occurs during or after defecation and varies in intensity. Typically are alternating phases: bleeding that appears daily with each defecation and stops after weeks or months without special treatment. Very often, the faecal continence is impaired. This might lead to weeping, smearing, and quite frequently, stool-stained

A. Herold () End- und Dickdarmzentrum Mannheim, Bismarckplatz 1, 68165 Mannheim, Germany e-mail: [email protected] L. Holzner Department of Surgery, Mount Gambier & Districts Health Service, Wehl Street North, Mount Gambier SA 5290, Australia e-mail: [email protected]

underwear. Anal eczemas with pruritus are a direct consequence of enlarged haemorrhoids. Haemorrhoids usually do not cause pain. Some patients, however, might complain about occasional anal pressure unrelated to defecation or a foreign body sensation in the anus. Pain often results from a coexistent small fissure (with grade II haemorrhoids in up to 70%). However, severe pain does occur with a thrombosed and incarcerated prolapse of the haemorrhoids.

39.1.2 Diagnostics Non-prolapsing haemorrhoids (grade I haemorrhoids) are only visible with a proctoscope. Prolapsing haemorrhoids clearly show after defecation or while pressing during the medical examination. Grade II haemorrhoids reduce spontaneously, grade III haemorrhoids have to be reduced digitally. Haemorrhoids that are not reducible at all (grade IV haemorrhoids) can be easily assessed on inspection. There is no need for further examination for haemorrhoids. However, to exclude other colorectal pathology further examinations (e.g. rectoscopy, colonoscopy, function tests amongst others) are required.

39.1.3 Differential Diagnosis Very often, perianal skin tags are mistaken as haemorrhoids. Haemorrhoids frequently appear in combination with mariscas or anodermal prolapse. Even the perianal thrombosis (though confusingly commonly termed ‘external haemorrhoid’) is not an actual haemorrhoid but a small blood clot in the perianal subcutaneous veins. It is only its nodular appearance that makes it resemble haemorrhoids.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_39, © Springer-Verlag Berlin Heidelberg 2011

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39.1.4 Therapy Every causal treatment aims to reconstruct the anal canal, restore the physiology and ease the complaints but not to radically eradicate the haemorrhoidal plexus. Bowel regulation should be the basic therapy before starting any further treatment. Local treatment with creams, suppositories or anal tamponades will not cure the complaints that solely ascribe to the haemorrhoids (e.g. bleeding), but can help to relief attendant inflammatory or oedematous changes.

39.1.5 Sclerotherapy Sclerosing of the haemorrhoids can be done as described by Blond or Blanchard. Both methods are the treatment of choice in grade I haemorrhoids. Blond method. The sclerosant (e.g. Polidocanol, Thesit, Chinin, Calcium zinc chloride) is circularly injected in the submucosa above the dentate line through a proctoscope with lateral fenestration (Bond proctoscope). For this treatment, 0.5–1 mL sclerosant should be sufficient. Blanchard method. One milliliter to 3 mL phenol in almond or peanut oil is injected into the supplying haemorrhoidal arteries at 3, 7 and 11 o’clock with the patient in the lithotomy position. Often, three to four sessions at 2-weekly intervals are required to ease the complaints occurring in grade I haemorrhoids. The therapeutical effect results from a fixation and scarring contraction of the haemorrhoidal convolutes above the dentate line. Complications. Complications occur in less than 5% of the cases. The most common complication is bleeding, which in rare cases, mostly 8–14 days after treatment, can reach drastic intensity. Sometimes, unpleasant pressure or foreign body sensation can occur after treatment. Sclerosants containing Chinin cause allergic reactions in about 3–4% of the cases. In isolated cases, rectal necrosis and septic complications resulting in death were reported. Bleeding can be ­successfully treated in over 80%. There is a high long-term ­recurrence rate of 70% after 3 years.

A. Herold and L. Holzner

39.1.6 Rubber Band Ligation Procedure. Nodular haemorrhoids can be treated and removed quite elegantly with small elastic bands (Barron-Ligature). With a special applicator and a proctoscope with a distal opening, the nodular haemorrhoids are ligated proximal of the dentate line. The bands cause ischemic necrosis of the haemorrhoids, which slough off in a few days. By this, the haemorrhoid convolute can be prevented from prolapsing without being completely destroyed. Continence problems as a consequence of this treatment are not to be expected, even though some patients show a weaker anal sphincter after the procedure. Due to possible complications, multiple ligatures should preferably not be done at one session. Usually, three to four single bands are placed at intervals of 3–4 weeks. Complications. Besides pain (in 14% of the cases), significant bleeding can occur. Furthermore, in isolated cases, urinary retention, fever, abscesses, thrombosis and fistulas may develop. Very rare cases of clostridial infections after rubber band ligation resulting in death have been reported. Results. The therapeutic success of rubber band ligation of grade II haemorrhoids is around 70–80% after 3–5 years. The recurrence rate of 25% is significantly lower than in sclerotherapy.

39.1.7 Doppler-Guided Haemorrhoidal Artery Ligation The therapeutic option to reduce grade II and III haemorrhoids with Doppler-guided haemorrhoidal artery ligation (HAL) was originally described by Morinaga and modified by Meintjes. This method allows one to find the supplying haemorrhoidal arteries using a special proctoscope with attached Doppler transducer. This method allows one to ligate very precisely, which quickly leads to a contraction of the haemorrhoidal convolutes. Not only should this remove the haemorrhoidal prolapse but also the associated pain. There is no prospective and randomised study evaluation on this method of treatment at this point. A final evaluation of both indication and efficiency is not possible yet.

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39.1.8 Operative Therapy Grade III haemorrhoids that prolapse during defecation and do not reduce spontaneously but have to be reduced manually are only in rare cases successfully treated with conservative measures. Usually these haemorrhoids require surgery. Haemorrhoidectomy can be performed in the following techniques:

Fig. 39.1  (a–d) Milligan–Morgan haemorrhoidectomy. Each of the affected segments is excised ovally and between the excisions a 1.5  cm broad anodermal bridge is left. The supplying

• • • • • •

Open Milligan–Morgan haemorrhoidectomy Closed Ferguson haemorrhoidectomy Subanodermal Parks haemorrhoidectomy Reconstructive Fansler–Arnold haemorrhoidectomy Supraanodermal Whitehead haemorrhoidectomy Stapled supraanodermal mucosectomy

The Milligan–Morgan and Ferguson method (Fig. 39.1) are especially recommended in segmental

arteries are ligated proximally. All excisions remain open to heal by secondary intention (From Herold 2005)

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haemorrhoidal prolapse. The enlarged haemorrhoidal nodules are resected in segments leaving an adequate anodermal bridge to prevent stenosis or incontinence. In the Milligan–Morgan operation, the anodermal wounds are left open to heal by secondary intention while the Ferguson technique leaves slightly more of the anoderm to allow for suture of the wound. The complication rate is usually below 10%. The reoccurrence rate is quoted between 3% and 26%, depending on the definition of ‘reoccurrence’ and the period of follow-up. Another possibility for subanodermal/submucosal resection of the haemorrhoids is the operation technique according to Parks. It includes a reposition of the displaced anoderm and is therefore preferred in higher grade findings. Only in recent years, the stapled-haemorrhoidopexy has been established in the treatment of circular grade III haemorrhoids (Fig. 39.2). Using a staple gun (that has been used in visceral surgery for more than 20 years) and a special introducer, the prolapsed haemorrhoids are reduced and the proximal mucosal tissue is circularly resected. Thus the prolapsing anoderm and haemorrhoidal tissue is fixed in its physiological intraanal position and in the further course reduced to normal size due to secondary alteration. Since there is no wound in the sensitive anoderm, this technique has become an effective alternative with higher comfort for the patient. The main advantage is less postoperative pain. The complication rate is lower than in conventional haemorrhoidectomy; length of stay in hospital and invalidity are shorter. Non-reducible haemorrhoidal prolapse is considered as grade IV haemorrhoids. For chronic, fibrosed and fixed findings, mostly with concomitant circular anoderm prolapse, the plasticreconstructive Fansler–Arnold procedure can be useful. This method, which is much more complex regarding technique and time (operation time 30–60  min), achieves resection of the haemorrhoidal tissue and circular or semi-circular complete reconstruction of the anal canal with a sliding flap. This technique has a high postoperative complication rate of up to 20%. In cases of acute thrombosis or incarceration, conservative treatment with antiphlogistics, analgesics and local treatment is preferable. Experienced surgeons might also operate immediately. In this case, particularly, the danger of postoperative stenosis due to excessive resection in the oedematous state has to be considered.

A. Herold and L. Holzner

Results. With all techniques, over 90% of the patients are free of symptoms after 2 years. The number of relapses increases over the years, but most of them can be treated conservatively. The reoperation rate lies below 5%. Incontinence as the patient’s most feared complication occurs in up to 30% immediately after the operation, long-term dysfunction is seen in up to 5% while a permanent incontinence even for solid faeces only appears in very few isolated cases.

39.2 Anal Fissure 39.2.1 Pathogenesis The anal fissure is an elongated ulcer-like defect in the highly sensitive anoderm. A chronic course of the disease over years is common. The development of anal fissures is multifactorial. Faecal consistence seems to be of great importance since both hard and loose stool can promote the development of anal fissures. Haemorrhoids seem to play an important part too. It appears that even the physiological pressure during defecation can lead to tears in the anoderm, which tend to heal poorly. The progression of the disease is promoted by severe pain, causing reactive muscular spasm with ischemia of the tissue and consecutive healing deficiency. This vicious circle is also influenced by an elevated internal anal sphincter tonus, which offers an option for treatment of this condition.

39.2.2 Symptoms The characteristic symptom is sharp burning pain that starts during defecation and can last for hours. This often leads to reflexive spasm of the internal sphincter. The anodermal defect is constantly eroded by the stools, which often show streaks of blood. As chronicity advances, the constant secretion leads to weeping and development of a secondary anal eczema. Anal fissures occur in 80% of the cases in the midline posteriorly, in 10–15% in the midline anteriorly and in few cases in the lateral sectors. Acute anal

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Fig. 39.2  (a–d) Stapled-haemorrhoidopexy. In contrast to conventional techniques, the haemorrhoids are reduced and moved into the stapler by means of a circular purse-string suture. This

device resects and closes the resulting lesion with titanium clips in a single step (From Herold 2005)

fissures are elongated defects of the anoderm. In the beginning, the bottom of the wound is blood stained and coated with smudge. The edges are well defined and mostly reddened by local inflammation. Chronic anal fissures show typical secondary changes: solid ulcer, exposed internal sphincter, inflamed indurated margins, anal fibroma on the proximal edge and a sentinel pile (an inflamed, oedematous marisca) on the

distal edge. As the inflammation progresses and reaches deeper regions, fistulas in the subanoderm and in between the sphincters may follow. These fistulas usually start proximally and are often incomplete, so they run pouch-like below the anoderm. In English ­literature, the chronicity is usually determined by time: If the symptoms last for more than 6  weeks, it is ­considered a chronic fissure.

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39.2.3 Diagnostics As the fissures usually lie in the distal anoderm, they are easy to see during inspection by gently parting the margins of the anus. Because of the intense pain caused by it, this examination should be done under local anaesthetics. Fissure-like defects in Crohn’s disease and anal carcinoma have to be considered as differential diagnosis.

39.2.4 Conservative Treatment Stool regulation for smooth stool, which ensures physiological, constant extension of the anal canal, is both causal and preventive treatment. Conservative measures like injection of local anaesthetics beneath the ground of the fissure will usually relief the pain. This enables many patients to do a daily dilatation of the anal sphincter by passing an anal-­ dilator supplied with an anaesthetic lubricant. In less painful anal fissures, this initial treatment can be done without local anaesthetics. Up until recent years, this was the only conservative option for treatment. Nowadays, newly developed ointments are used as primary treatment: Glyceryl trinitrate ointment (GTN) relaxes the internal sphincter when locally applied in a concentration of 0.1–0.4%. This improves the subanodermal perfusion and allows the fissure to heal. For chronic fissures, prospective randomised studies show significant short-term pain relief in 50–70% and healing of the fissure after 8–12 weeks. Alternatively and with analogue effect, 2% ointments mixed with calcium antagonists can be used. The treatment with Botulinum toxin aims in a similar direction. Applied intramuscularly, it causes a 3-month paralysis of the muscles and a reduction of the muscle tone by blocking the distribution of acetylcholine. A transient impairment of continence has to be expected in 2–3% of the cases. The therapeutical outcome is comparable to GTN.

39.2.5 Anal Fissure Occasionally, conservative management for anal fissure fails. Once stool softeners, fiber bulk agents, and correction of dysfunctional bowel habits have been

A. Herold and L. Holzner

tried and are unsuccessful, there are two other modalities that have been tried with a great deal of success by the author. The first option is a medical therapy for the hypertrophic spasm of the internal anal sphincter. Nifedipine paste has been used with a great deal of success. The patient is instructed to take a pea-sized dollop of the ointment and place it up into the anal canal as far and comfortably as they can twice daily. Clearly, those who have significant pain early on may not be able to make considerable strides very quickly, but eventually, patients are able to get this paste to the anal canal. The smooth muscle blocking effects of the Nifedipine paste help to get the patient over the most difficult time of spasm of the anal sphincter, breaking this vicious cycle of spasm, loss of relaxation and further trauma. It is the author’s experience that this is almost always successful and since the use of this has begun, the author has had to resort to surgical intervention only very rarely. • Nifedipine powder, surgilube and propylene glycol are used. 0.2  g of powder is wet with propylene ­glycol to make a paste. Surgilube is levigated with the paste to bring total weight of 100 g. This amount lasts about 1 month. The entire amount should be used, even when symptoms improve. On those rare occasions when the above medical therapies are unsuccessful, then surgical intervention is warranted. The preferred approach is a lateral internal sphincterotomy (LIS). The key issues to performing this are: first, to assure that there is minimal risk of incontinence related to cutting too much of the sphincter mechanism, and second to determine if the patient can have this done as an outpatient under local anaesthesia or will require regional or general anaesthetic. In the office, if the patient can tolerate a digital ­rectal examination in the setting of an anal fissure, then LIS can be performed in the clinic with the patient in the dorsal lithotomy position. The area may be topically controlled with some Lidocaine gel, but ultimately, either 3 or 9:00 position of the ano–rectal verge is infiltrated with 0.25% Lidocaine solution with Epinephrine. Gentle digital examination is then performed. With the patient comfortable, the surgeon then delivers an #11 blade scalpel through the skin just distal to the dentate line parallel to the skin fold. With a finger in the anal canal, the hypertrophic anal sphincter can easily be identified. The knife is slid up along side

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of the finger in a subcutaneous plane. Then the blade, of course, is turned out away from the finger within the anal canal. With a gentle push of the anal canal finger against the backside of the blade; the surgeon can feel the fibers of the internal sphincter being cut slightly. The scalpel is then gently removed. Typically, it takes very little surgical intervention to get the patient to the point where they can break the cycle of spasm and loss of relaxation with bowel function. This also minimizes the risk of incontinence. It is better to have to repeat the procedure once than to leave the patient with incontinence. Finally, as an alternative, if the patient is too tender from the fissure to allow digital rectal examination in the clinic, the procedure can be performed in the operating room with either regional or general anaesthesia. This is a very safe, effective method to allow final recovery of those occasional refractory patients with an anal fissure.

39.3 Abscess and Fistula 39.3.1 Pathogenesis Abscess is the acute, fistula the chronic form, of the same inflammatory process. Periproctal abscesses are mostly based on an infection of the rudimentary proctodeal glands. These cryptoglandulary structures occur in the majority of the cases in the area of the midline posteriorly. If the inflammation cuts its way along ­predefined gaps in the submucosa, subanoderm, in between or across the sphincters, this leads to abscesses. Without treatment, they can perforate into the rectum, the anal canal or outwards, depending on the location of the abscess. In most of the cases, the permanent contamination and insufficient drainage lead to a persisting fistula; only 20–40% recover completely. A dysfunction of the continence organ is an inevitable consequence.

39.2.6 Surgical Therapy An operation is indicated if conservative treatment did not show any success or if healing cannot be expected due to secondary changes as a hypertrophic anal papilla with deep crypts or undermined sentinel piles but also fistulas in the subanoderm and in between the sphincters at the base of the fissure. There are two methods for operative treatment of anal fissures: the lateral sphincterotomy and the tangential fissurectomy. Lateral sphincterotomy. The aim is to reduce the sphincter tone through an incision of the distal margin of the internal sphincter and by that promotion of the healing process. However, if the spincterotomy is done too extensively, continence dysfunction must be expected in up to 30% of the cases. In Anglo–American countries, this technique is the standard operation for fissures. Tangential fissurectomy. During fissurectomy, the fissure is excised including its scarred margins, the sentinel pile and hypertrophic anal fibromas. Results. These techniques accomplish a long-term cure of the fissure in 90–98% of the patients.

39.3.2 Classification Classification is made according to the relation to the sphincter, which also defines the subsequent therapy (Fig. 39.3).

39.3.3 Symptoms The main symptoms of the abscess are pain and swelling; the fistula mostly causes secretion and pruritus. The complaints caused by the abscess range from inconvenient pressure or foreign body sensation to severe pain with fever or chills. In contrast to abscesses, the clinical symptoms of perianal fistulas are less dramatic. Purulent serous secretion can lead to irritation of the perianal skin or distinct anal eczema. Superficial epithelisation of the external opening of the fistula might temporary restrain the secretion without actually healing it. The collection of secretion will in most cases perforate the thin epithelial skin layer again within a few days. If the secretion remains in the ­fistula, an acute abscess might develop again.

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Fig. 39.3  Schematic classification of abscesses and fistulas (From Herold 2005) Pelvic rectal abscess

Extrasphincteric fistula

M.levator ani

suprasphincteric fistula

M.sphincter ani internus Ischioectal abscess Intersphincter abscess

Transsphincteric fistula

Subcutaenous, subanodermal abscess

Intersphincteric fistula Subanodermal fistula

39.3.4 Diagnostics An abscess can be diagnosed solely by inspection and palpation based on the typical anamnesis. Superficial abscesses show the typical painful reddening and swelling. The rare deep pararectal abscesses are invisible from the outside, but in most cases, may be detected by palpation. The diagnosis needs to be confirmed by further examination. Fistulas show an outwards aperture with more or less pronounced induration of the surrounding skin or towards the inner aperture. With some experience, the path of the fistula can be easily followed using a button probe. If the fistula cannot be displayed with this simple clinical measure, an examination under general anaesthesia is the next step. The fistula can not only be illustrated here but treated at the same time. Only in special, often complicated, cases diagnostic imaging is necessary: Retained secretion, scarred lesions and fistula pathways can be displayed using endosonography, computed tomography

or MRI. Using an x-ray (fistulography) is unnecessary for it does not give any further information.

39.3.5 Differential Diagnosis In case of inflammations in the anal region, Crohn’s disease always needs to be considered. Ten per cent to 30% of the Crohn’s patients show their first symptoms in the anal area. As in the typical fistula, these inflammatory processes can be based on an infection of the proctodeal glands. The typical Crohn’s fistula, however, does not stick to predefined structures but penetrates destructively into any surrounding tissue. Anal fistulas have to be distinguished from inflammatory lesions caused by inverse acne. Those multiple confluent abscesses with numerous apertures typically show blue-livide surroundings. The fistulas are not connected to the anal canal or the rectum. In very few

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cases, perianal fistulas associated with tuberculosis have been reported.

39.3.6 Therapy of the Abscess

An anorectal abscess is generally opened immediately after diagnosis.

There must not be any delay in starting the therapy for there is always danger of progressive infection up to generalised sepsis. Therapy consists in a broad, funnelshaped opening of the skin with subsequent secondary healing. When opening an abscess, the latitude of the excision should always be bigger than the profundity of the wound to make sure healing starts from the ground and not only the skin is closing, which would bear the risk of a relapse.

Note: Working close to the anus (1–2  cm), it is important to particularly mind the sphincter! To avoid huge wounds in very big ischio- or pelvirectal abscess cavities (e.g. a horseshoe-fistula), a small incision with counter-incision might allow sufficient drainage. Special drainage catheters are normally restricted to few special cases (e.g. peritoneal expansion). An exclusive or additional treatment with antibiotics is only useful in very few cases, e.g. with immunosuppression, accompanying soft tissue phlegmone or severe concurrent sepsis. During every operation of an anorectal abscess, the experienced surgeon should try to find the cause at the same time. If the connection between fistula and anal canal can be found, the fistula may be primarily repaired or it can be drained with a thread for some weeks and later taken care of surgically. If the fistula cannot be found during the revision, the surgeon should abstain from further manipulation to avoid the danger of causing a via falsa. Further assessment should follow after remission of the acute inflammation.

39.3.7 Therapy of the Fistula The aim of every operative repair of a fistula is rehabilitation without loss of continence and without relapse. Which operative technique is chosen depends on the fistula pathway and its relation to the sphincter. Fistulas in the subanoderm, submucosa, in between or distal (deep) across the sphincters. Those fistulas only embrace a small part of the sphincter muscles and can be split completely without having an impact on anal continence. The recurrence rate is below 10%, the continence dysfunction depends on the extent to which the sphincter is involved. While in previous years, up to two thirds of the sphincter was cut, nowadays a more careful approach is chosen. There are no general specifications on how much of the sphincter can be cut without causing continence problems, because continence depends on many other factors (e.g. age, sex or stool consistency) and is influenced by the patient’s individual conditions (e.g. previous operations, recurrent fistulas or localisation of the fistula) that have to be considered when opening the abscess. The reported range of postoperative incontinence, therefore, varies from 5% to 40%. Fistulas proximal (high) across, above or outside the sphincters. Fistula pathways that embrace substantial parts of the muscles are primarily drained with a thread and at the next session in the non-inflamed stage extirpated and plastically occluded. After completely extirpating the fistula pathway, especially in the cryptoglandulary region, the sphincter muscles are directly joint and the closure is secured with a transposed flap consisting of mucosa or mucosa/submucosa/internal sphincter to close the inner aperture of the fistula (Fig.  39.4). An immediate suture insufficiency appears in 10–25%, the recurrence rate is between 5% and 30%. Apart from the methods above, other techniques can be used in certain cases: • Direct complete splitting and reconstruction of the musculature in one or two steps • Interposition of muscles, e.g. gracilis muscle or rectus abdominis muscle, long-term drainage with a thread and joining with fibrin • Drainage with a thread according to Hippokrates aiming at a slow dissection of the sphincter muscles

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is contraindicated because of the high incontinence rate and the severe pain it causes. Recto- and anovaginal fistulas. Diagnosis and treatment of this special form of fistulas are analogues to the principles above. However, due to their location, plastic surgery is necessary in most of the cases. Due to the lack of connective tissue and muscle tissue of the rectovaginal septum in that area, the success rate is lower than in other anal fistulas. Anorectal Crohn’s fistulas. Anal Crohn’s fistulas are as other fistulas in 75% of cryptoglandulary origin and follow the pathways mentioned above. However, 25% do not follow anatomical structures and penetrate the surrounding tissue destructively. Treatment is done according to the strategies described above. It is especially important to mind the sphincter as the high recurrence rate of the primary disease often requires repeated surgery. Prior to any fistula reconstruction, the systemic disease must be under control and no local inflammation should be present. In complex fistulas with recurrent exacerbation, the long-term drainage with a thread for months or years is a good method that 39.4  is usually veryofwell to avoid or at least Fig.  (a–d) tolerated Plastic closure a fistula (flap-technique). A funnel-shaped extirpation the peripheral part of the fistula delay the application of aofstoma. (outside the musculature) is done, the part penetrating the muscles is excided or curetted. After that, the muscular defect is

closed with few sutures. After mobilising a muscularis-mucosaflap with a proximal pedicle, it is pulled over the muscle suture with a second suture row and fixed distally (From Herold 2005)

Abdominal Wall Hernias

40

Reinhold A. Lang and Martin K. Angele

40.1 Definition and Classification Hernias are defined as a protrusion of the peritoneum through acquired or congenital gaps (hernial orifice). A hernia consists of the hernia orifice and the hernia sac. The hernia orifice represents the defect within the abdominal wall, the hernia sac is an outpouch of the peritoneum and may contain abdominal organs (bowel, large omentum, etc.) (Fig.  40.1). A hernia is considered external if the sac protrudes through the abdominal wall, internal if the sac is within the visceral cavity. If the hernia content can be returned into the abdominal cavity, the hernia is reducible, otherwise it is not reducible.

alba, the semilunar line of Spieghel, the diaphragm. Muscle atrophy or surgery may result in additional predisposing areas within the abdominal wall for the development of hernias. Predisposing factors for hernia development are: • Chronic increase in abdominal pressure due to: –– Obesity –– Recurrent –– Respiratory disease –– Chronic constipation –– Recurrent vomiting –– Ascites –– Prostate hypertrophy –– Pregnancy –– Tumors • Diminished collagen synthesis and traumatic damage of the abdominal wall.

40.2 Epidemiology and Etiology The estimated incidence of hernias is 2–4% with a preponderance of the male gender. With increasing patient age, the incidence of hernias as well as the need for hospitalization go up. Ninety-five percent of hernias are external, 75% of these are inguinal hernias. Hernias develop where aponeurosis or fascia are not supported by striated muscle. Physiologically, many such sites are present, e.g., in the groin, the umbilicus, the linea

R.A. Lang and M.K. Angele (*) Department of Surgery, University of Munich, Campus Großhadern, Marchioninistr. 15, D-81366 München, Germany e-mail: [email protected]

40.3 Symptoms Many hernias are asymptomatic and only a lump may be palpable. Hernia symptoms usually are unspecific and due to the content of the sac and the pressure by the sac on adjacent tissue. The discomfort is increased during the day and symptoms are relived at night when the patient reclines. In particular, with small hernias, incarceration of small bowel and greater omentum may occur. An incarceration is defined as an irreducible mass within the hernia sac. In rapid succession, incarceration can be followed by mechanical ileus and bacterial transmigration. Regional pain, swelling, and cellulitis are continuously increasing.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_40, © Springer-Verlag Berlin Heidelberg 2011

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300 Fig. 40.1  Therapeutic algorithm for the treatment of hernias (Adapted from Chirurgie Basisweiterbildung, Springer, Hrsg. Jauch, Mutschler, Wichmann)

R.A. Lang and M.K. Angele Hernia

No Incarceration

Recent Incarceration, currently reduced

Outpatient care

Admission observation

Elective

Early Elective

Incarceration, reduction not possible

Emergency

Surgery

40.4 Diagnosis External hernias can be diagnosed by physical examination. Physical examination consists of inspection and palpation of the tissue and the hernia orifice. Typically, a hernia sac with its contents enlarges and transmits a palpable impulse when the patients strains or coughs. In particular, adipose patients may require ultrasound or CT scan for an adequate diagnosis.

40.5 Complications The most serious complication of hernias is strangulation resulting in compromised vascularity of the protruded viscus. In these cases, venous congestion leads to edema, which ultimately causes arterial perfusion deficits. Necrosis of the affected tissue may result. In addition, strangulation may cause perforation with subsequent bacterial peritonitis and sepsis. Some patients present with signs of a mechanical ileus due to incarcerated bowel. Reduction of

a strangulated hernia is contraindicated if there is sepsis or if the contents of the sac are thought to be gangrenous. Lactate measurements or radiological imaging may help with diagnosis of complications due to incarceration.

40.6 Different Forms of Incarceration Fecal incarceration: Gas distension induces increased bowel volume within the prolapsed loop. Elastic incarceration: Despite decreased intraabdominal pressure, the hernia sac does not reduce. Retrograde incarceration (Maydl hernia): Herniation of mesentery or small bowel leads to necrosis of intraabdominal bowel loops. Richter–Littré-hernia: As opposed to regular hernias, only part of the circumference of the bowel wall is involved. Delayed diagnosis after perforation and peritonitis may result. Omental incarceration: Portions of incarcerated greater omentum usually only cause localized inguinal pressure pain.

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40.7 Therapeutic Strategies

Morbidly obese patients may need a laparoscopic umbilical hernia repair using a composite mesh.

The following principles apply to all types of hernias: • Only surgical management allows for persistent therapeutic success. • Incarceration requires emergency surgery. • Forceful reposition maneuvers should be omitted. To avoid complications during reposition, adequate analgesia must be provided. For the reposition maneuver, the hernia sac is pushed into the abdominal cavity with two hands. During the maneuver, there is a risk of reposition of gangrenous bowel, perforation of the bowel, or reposition en bloc (despite “successful” reposition, the bowel remains within the neck of the hernia). Due to these potential complications following reposition, the following approach is recommended: • Early surgical repair is required following successful reposition. The patient should stay in the hospital until definite treatment is provided. • When the reposition maneuver fails, emergency surgery is indicated.

40.8 Umbilical Hernia The umbilicus represents one of the weak areas within the abdominal wall. In particular, incomplete fusion of the periumbilical fascia at the base of the umbilical cord may contribute to the development of an hernia. The infantile umbilical hernia closes without surgery. If they appear in adult patients, umbilical hernias are generally treated surgically. In cases of major comorbidity (e.g., ascites caused by liver cirrhosis), surgical treatment should only be considered in selected patients. Female adults are affected more often than males. Obesity, pregnancy, and ascites predispose for umbilical hernias. Umbilical swelling and pain are typical symptoms in these patients. After the resection of the sac, nonabsorbable sutures are used for primary repair of the fascia defect. In patients with large defects, prosthetic mesh reinforcement may be needed (mesh plug, inlay mesh).

40.9 Epigastric (Ventral) Hernia An epigastric hernia is located within the linea alba between the xiphoid process and the umbilicus. This potentially multilocular hernia occurs without previous surgery. In most cases, preperitoneal fat is herniated into the sac. Nonspecific epigastric discomfort is variable due to posture and abdominal tension. Affections of organs in the upper abdomen (e.g., stomach, duodenum, pancreas, bile duct) have to be considered as differential diagnosis. Indication for surgery is based on clinical symptoms.

40.10 Diastasis of the Rectus Muscle Diastasis recti is defined as a separation of the rectus abdominis muscle into right and left fractions, which normally are joined at the linea alba at the midline. Diastasis of this muscle occurs in newborns and pregnant women. The protrusion down the midline to the umbilicus becomes prominent with muscular strain and usually resolves with muscular relaxation. Most patients do not require any treatment but may benefit from physiotherapy. Selected cases of diastasis recti may require a surgical approach using direct suture of the rectus sheath. Surgical repair has a high recurrence rate and the application of alloplastic mesh grafts is more and more common.

40.11 Incisional Hernia Incisional hernia formation is a very common postoperative complication after abdominal surgery. An incidence of up to 29% within 5 years after laparotomy has been reported. Secondary hemorrhage, wound infection, type of incision formation, and obesity contribute to the

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development of incisional hernias as well as coughing, ­constipation, straining, hypoproteinemia, factor XIII deficiency, anemia, nerve injury, and medications (e.g., steroids).

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a

40.11.1 Therapy The objective of incisional hernioplasty is anatomic reconstruction of the abdominal wall. Because of a reduction of intraabdominal adhesions and completion of the wound healing process, hernia repair should be avoided within the first 6  months after primary surgery. Primary repair by approximating the edges of the aponeurosis with sutures is associated with recurrence rates as high as 50%. Due to this unacceptable high recurrence rate, tension-free repair approaches using mesh material have been introduced and should be considered the standard procedure. Alloplastic mesh grafts (e.g., Polypropylene, Gore-Tex, etc.) can be placed ventral to the anterior fascia (onlay technique) (Fig.  40.5a), posterior to it (inlay technique) or posterior to the posterior fascia (sublay technique) (Fig.  40.5b). Taking into account that the fascia defect represents the beginning of a complex incisional hernia, complete coverage of the whole primary incision line is required. The mesh has to overlap the fascia edge by at least 5 cm. The onlay or sublay technique is combined with an adaptation of the fascia edges. In an attempt to realize a tension-free hernia repair, a laparoscopic approach has been introduced. With this technique, the fascia defect is covered by a mesh without adapting the fascia edges. Thus, a visible swelling and palpable fascia defect persist despite adequate repair. Furthermore, excessive preparation within the abdominal wall muscle layers can be avoided, as alloplastic material special grafts (composite mesh) with an anti-adhesive surface facing toward the intestines to avoid adhesions and fistula formation are needed. Although several studies have been conducted, there is no evidence favoring conventional vs. laparoscopic surgery, onlay vs. sublay mesh position, location and fixation of mesh grafts as well as the best material for mesh grafts. To avoid hernia recurrence, patients are advised not to lift weights of more than 5  kg for 8  weeks after surgery.

b

c

Fig. 40.2  Preparation of the inguinal area during anterior hernia repair. (a) Identification of the spermatic cord. (b) Elevation of the spermatic cord. (c) Plication of transversalis fascia. (Adapted from Chirurgie Basisweiterbildung, Springer, Hrsg. Jauch, Mutschler, Wichmann)

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40.12 Less Common Abdominal Hernias 40.12.1 Spigelian (Lateral Ventral) Hernia A defect at the spigelian fascia occurs between the internal oblique muscle, semilunar line, and the lateral rectus sheath. The peritoneal sac can contain preperitoneal fat, omentum, or intestine. Patients’ complaints may be nonspecific abdominal pain, palpable resistance in the anterior abdominal wall, and intestinal obstruction. If the hernia extends intramurally under the external oblique muscle, palpation will be difficult, especially in obese patients. Additional investigation, i.e., ultrasound or CT-scan may be indicated to obtain a reliable diagnosis. Incarceration may be the first symptom of these hernias and has been reported to occur in 20% of cases. For hernia repair, a transverse or oblique skin incision is useful, the hernia sac can be excised or inverted. In most cases, the hernia is treated by primary repair. Very large defects with diminished fascia may be closed with alloplastic mesh graft. For better identification of the defect, a laparoscopy can be necessary, which can also be used for hernia repair using a composite mesh.

40.12.2 Obturator Hernia These hernias occur within the obturator foramen anterior or medial to the neuromuscular bundle following the obturator vessels and the obturator nerve. It occurs below the pectineal muscle and is only in one-fourth of patients palpable inside the thigh. Obturator hernias appear in elderly females suffering from increasing atrophy of the pelvic floor. After previous attacks of nausea, abdominal pain, and constipation, a mechanical ileus may result. Irritation of the obturator nerve causes pain in half of the patients, which intensifies during flexion of the thigh with adduction of the leg. Surgical treatment is done by primary suture repair ventrally underneath the pubic bone.

40.12.3 Sciatic Hernia Sciatic hernia leave the sciatic foramen either above or  below the piriform muscle (Supra-/Infrapiriform

h­ ernia) or in front of the sacrotuberal ligament (Spinotuberal hernia). The hernia sac usually contains omentum or intestine, sometimes ovary or parts of the ureter. The hernia may even cause urinary obstruction.

40.12.4 Perineal Hernia Perineal hernias occur before or behind the deep transverse perineal muscle, they penetrate the pelvic floor or the levator ani muscle (ischiorectal hernia). Perineal hernias represent a rare form and are mostly iatrogenic. Abscesses, cysts, or tumors like lipoma have to be ­considered as differential diagnosis.

40.12.5 Internal Hernia Congenital internal hernias are very rare. The following intraperitoneal openings are physiological weak spots through which peritoneal contents may protrude: omental bursa, duodenal flexure, Treitz hernia, mesocolon, caecum, sigmoid. The hernia sac is formed by or via duplications of the peritoneum. Nausea, vomiting, abdominal obstruction culminating in ileus, and small bowel gangrene can be observed. In most cases, internal hernias are confirmed surgically. Most internal hernias, however, are acquired following previous surgeries caused by insufficient or defaulted closure of the mesenteric gap.

40.13 Inguinal Hernia The clinically most relevant hernia is the inguinal hernia (approximately 75%). Inguinal hernias arise above the abdominocrural crease as opposed to femoral hernias that occur below. Indirect inguinal hernias (mostly congenital, not completely obliterated processus vaginalis, origin lateral to the epigastric vessels, passes the inguinal canal, 60–70% of all inguinal hernias) and direct hernias (always acquired, origin medial to epigastric vessels, passes medial to the spermatic cord) have to be distinguished. Both sexes develop inguinal hernias although men are 25 times more often affected. Indirect inguinal hernias are twice as often on the right

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as on the left side. This is due to a delay in the atrophy of the processus vaginalis that follows the normally slower descent of the right testicle. It is important to examine both groins since bilateral hernias are present in 15% of the patients.

40.13.1 Indication Symptomatic inguinal hernias clearly require surgical repair. The need for surgery in completely asymptomatic hernias is still under debate and requires an individualized decision. Elective surgery is recommended for inguinal hernias with a narrow neck and for non­ reducible hernias, and if the patient has pain during activities of daily life. If a strangulation is detected, the patient should undergo emergency surgery without delay. Higher age and/or comorbidity usually do not justify conservative therapy because inguinal hernias can be treated using local anesthesia only. Inguinal hernias carry a high risk of strangulation independent of age and comorbidity and strangulation is most likely within the first 3  months after hernia development. Small hernia orifices bear a higher risk of incarceration but big orifices are affected as well.

The goal of groin hernioplasty is to augment the dorsal wall of the inguinal canal. This strengthening can be done using synthetic mesh implants or by placation of tissue. Two competing surgical procedures are available, open and a minimal invasive surgery.

40.13.2 Therapy 40.13.2.1 Open Approach: Suture Techniques Without (e.g., Shouldice) and With (e.g., Lichtenstein) Alloplastic Mesh Graft A ventral, extraperitoneal access is used for open suture techniques. Most procedures can be done under local anesthesia. The most commonly used technique for hernia repair without alloplastic material is the Shouldice

Fig. 40.3  Mesh placement during hernia repair in Lichtenstein technique (Adapted from Chirurgie Basisweiterbildung, Springer, Hrsg. Jauch, Mutschler, Wichmann)

technique (Fig.  40.2 a–c). In brief, the hernia sac is excised and divided of the cremaster muscle through an opening of the transversalis aponeurosis. For reconstruction of the posterior wall, the transverse fascia must be duplicated by a separate suture line. In a second layer, the internal oblique muscle and the transversalis muscle are fixed to the inguinal ligament. The Lichtenstein technique includes reconstruction of the posterior wall using a mesh graft. A 15 × 10 cm polypropylene mesh is covering the pubic tubercle along the inguinal ligament (Fig.  40.3). A slit in the lateral part of the mesh graft contains the spermatic cord. Main advantages of the Lichtenstein technique are the technical convenience as well as a low recurrence rate of approximately 5%.

40  Abdominal Wall Hernias

305

Fig. 40.4  Laparoscopic hernia repair. Main surgical landmarks for the TAPP technique (Adapted from Chirurgie Basisweiterbildung, Springer, Hrsg. Jauch, Mutschler, Wichmann)

A number of additional techniques for open inguinal hernia repair have been described (e.g., Bassini, McVay, Lotheissen, etc.).

40.13.2.2 Endoscopic Techniques (TAPP:TEP) For the endoscopic technique, a transabdominal preperitoneal (TAPP) as well as a total extraperitoneal (TEP) are available. Using the TAPP technique, the left and right site can be explored for the existence of hernias. TAPP: First the peritoneum is opened (Fig. 40.4a), the hernia exposed and the inguinal hernia sac repositioned into the abdominal cavity. The epigastric

vessels, dividing indirect (lateral) and direct (medial) hernias and the spermatic cord can be identified (Fig. 40.4b). For hernia closure, a polypropylene mesh is inserted (Fig.  40.4c). Finally, the peritoneum is readapted to cover the mesh (Fig. 40.4d). There is a risk of intraabdominal complications, which have to be considered. TAPP and TEP require the placement of a 11 × 15  cm polypropylene mesh graft covering all possible hernia orifices with an adequate overlap. For these procedures, general or spinal anesthesia is necessary. Inguinal hernias in children are treated with the Halsted–Ferguson procedure. The hernial sac is excised without suturing of the posterior wall of the inguinal canal.

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• Nerve injuries (ilioinguinal and iliohypogastric nerves) • Injury of femoral vessels • Wound infection • Chronic inguinal pain • Recurrence

40.14 Femoral Hernia

Fig.  40.5  Illustration of mesh placement for hernia repair with onlay (a) and sublay (b) technique (Adapted from Chirurgie Basisweiterbildung, Springer, Hrsg. Jauch, Mutschler, Wichmann)

40.13.2.3 Complications The most common early complications are temporary urinary retention and scrotal hematoma. Wound infections have been observed in less than 2% and are usually treated locally. Mesh infection requiring removal of the alloplastic material occurs in only few cases. Late complications like testicular atrophy due to ischemic orchitis, infertility, and dysejaculation syndrome are reported in a small number of patients. In particular, nerval irritations are bothering for patients and difficult to treat. Postoperative pain is a significant long-term complication after inguinal hernia repair and has been observed in up to 10% of patients independent of the selected surgical repair technique.

40.13.2.4 Recurrences Within the first 6 months, a recurrence must be considered to be technical failure. Recurrence rates do not vary significantly between the different tension-free procedures and have been reported in up to 10% of all patients. • Injury of vas deferens • Injury of testicular vessels and testicular atrophy • Scrotal hematoma

Whereas inguinal hernias are located above the inguinal ligament, femoral hernia occur below it and pass through the lacuna musculorum or through lacuna vasorum of the femoral canal. In this canal, the femoral vein can expand for increased venous return. Femoral hernias are more common in females (f:m/3:1) and usually occur in patients over 50 years. The incidence of strangulation in femoral hernias is high and small bowel obstruction may be caused by a femoral hernia. The diagnosis is often difficult and femoral hernias can be rarely palpated. Until incarceration occurs, they are inconspicuous. In some cases, dys- and haematuria are caused by involvement of the bladder.

40.14.1 Therapy Due to the high risk of incarceration, femoral hernias should be treated promptly. The surgical approach can  be performed inguinal (Lockwood’s infra-inguinal approach, Lotheissen’s trans-inguinal approach, Mc Evedy’s high approach), as well as femoral. Infra-inguinal approach is preferred for elective repair. After resection of the hernia sac, the inguinal ligament is sutured to the pectineal ligament. In any approach, injury to the urinary bladder, which is often a part of the medial part of the hernial sac, and constriction of the femoral vein should be avoided. Complications are similar to inguinal hernia repair.

Recommended Reading Kehlet, H., Kingsnorth, A.: Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br. J. Surg. 90, 1479–1492 (2003)

40  Abdominal Wall Hernias Müller-Riemenschneider, F., Roll, S., Friedrich, M., Zieren, J., Reinhold, T., von der Schulenburg, J.M., Greiner, W., Willich, S.N.: Medical effectiveness and safety of conventional compared to laparoscopic incisional hernia repair: a systematic review. Surg. Endosc. 21(12), 2127–2136 (2007) Pham, C.T., Perera, C.L., Watkin, D.S., Maddern, G.J.: Laparoscopic ventral hernia repair: a systematic review. Surg. Endosc. 23, 4–15 (2009)

307 Schumpelick, V., Klinge, U., Junge, K., Stumpf, M.: Incisional abdominal hernia: the open mesh repair. Langenbecks Arch. Surg. 389(1), 1–5 (2004) Stickel, M., Rentsch, M., Clevert, D.A., Hernandez-Richter, T., Jauch, K.W., Löhe, F., Angele, M.K.: Laparoscopic mesh repair of incisional hernia: an alternative to the conventional open repair? Hernia 11(3), 217–222 (2007)

 

Thyroid Surgery for the Community General Surgeon

41

Anthony J. Chambers and Janice L. Pasieka

41.1 Introduction Disorders of the thyroid gland occur commonly in the general population, and as a result are a common form of presentation to surgeons in community practice. As many as 4–8% of the population may develop nodular lesions of the , which become clinically palpable, and high-resolution ultrasound can detect nodules in 50% of those 50 years of age or older. The overwhelming majority of such lesions are benign each, yet must be differentiated from those due to malignancy. Surgeons in community practice play an important role in the evaluation and management of benign and malignant thyroid disorders, and in many cases, may act as the first point of referral for patients with these conditions. The following chapter aims to provide a framework for the evaluation of benign and malignant lesions of the thyroid, and their surgical management.

41.2 Clinical Evaluation of Thyroid Disorders Presenting to the Community Surgeon Discovery of a nodule or a mass arising from the thyroid gland is a common presentation to surgeons in community practice. The evaluation of such patients involves careful history, physical examination, and appropriate use of investigations. The thyroid mass may be noted by the patient, or more commonly discovered on routine physical examination in an ­otherwise asymptomatic

A.J. Chambers and J.L. Pasieka (*) Department of Surgery, The University of Calgary, 1403-29th Street NW, Calgary, Alberta, T2N 2T9, Canada e-mail: [email protected]

patient. Symptoms of compression of the airway or esophagus should be sought. Patients should also be evaluated for symptoms ­suggestive of hyperthyroidism. Symptoms of voice change and hoarseness can occur as a result of involvement of the recurrent laryngeal nerve (RLN) with malignancy, and should be further investigated by direct laryngoscopy to examine vocal cord movement. The patient should be questioned carefully regarding prior exposure to ionizing radiation, particularly radiation treatment during childhood for benign or malignant conditions, and occupational radiation exposure. Patients living in the Ukraine and surrounding regions at the time of the Chernobyl nuclear accident in 1986 are also at risk of thyroid cancer secondary to environmental radiation exposure. Previous ionizing radiation exposure is a life-long risk factor for thyroid cancer, increasing the risk of this by 50 times, and as many as 50% of thyroid nodules developing in this context are malignant [1]. A family history of thyroid malignancy may be present in patients with familial medullary thyroid cancer (MTC) or multiple endocrine neoplasia (MEN) syndromes types 2A or 2B. In addition to MTC, a family history or prior history of ­pheochromocytoma, extra-adrenal paraganglioma, or hyperparathyroidism may be present in patients with MEN 2A or 2B. Familiar papillary thyroid cancer (PTC) is becoming more prevalent. Although the genetic cause is yet unknown, a history of first degree relatives with PTC increases the risk of the nodule being cancer. On physical examination, the number, size, and location of palpable nodules within the thyroid gland should be determined. Mass lesions that are hard to palpation or with fixation to surrounding neck structures are features suggestive of malignancy. Enlarge­ment of cervical lymph nodes may indicate regional spread of thyroid malignancy. Cervical ultrasound is now commonly used to assess the thyroid and regional lymph nodes.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_41, © Springer-Verlag Berlin Heidelberg 2011

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41.3 Investigation An algorithm outlining the diagnostic work-up and management of the patient with a thyroid nodule is shown in Fig. 41.1. Thyroid function should be assessed by measurement of serum thyroid stimulating hormone (TSH). Suppression of TSH indicates overproduction of thyroid hormone due to autonomous secretion by toxic follicular adenoma or nodule(s) within a multinodular goiter (Plummer’s disease). Further assessment of patients with suppressed TSH using Iodine-123 (I123) scanning should be performed to identify the hyperfunctioning lesions, seen as “hot”nodules. In contrast, hyperthyroidism due to Grave’s disease shows diffusely increased uptake of I123 within the thyroid. Hot autonomous nodules within the thyroid are usually benign follicular adenomas, and therefore fine needle aspiration biopsy (FNAB) is not indicated. The natural history of hot autonomous nodules within the thyroid is that in one-third of cases, it will increase in size;

-No Family history -No compression -No radiation

Family history of MTC

Compressive symptoms

TSH

-urine metanephrines -serum Calcium & PTH -CEA & Calcitonin levels

-Direct laryngoscopy -CT neck & thorax -pulmonary function tests

suppressed

- Medical control: antithyroid drugs -surgery or I-131 ablation

Radiation exposure

normal

Ultrasound

Radioactive lodine scan

-Aspirate x3 -surgery if recurrent

o­ ne-third of cases will stabilize; and in the remaining one-third, will reduce in size during follow-up. Surgical resection is indicated for hot nodules greater than 3 cm in size, and where hyperthyroidism fails to respond to radioactive iodine ablation with Iodine-131. Radioactive thyroid scans for patients with thyroid nodular disease where the TSH level is normal is rarely useful and is not recommended. In patients with a family history of MTC or where MEN 2A or 2B are suspected, raised serum levels of calcitonin, or carcinoembryonic antigen (CEA) may indicate the presence of MTC. High-resolution ultrasonography is the imaging modality of choice for the evaluation of thyroid lesions. The size and number of nodules within the gland can be accurately determined, particularly the presence of bilateral or multinodular disease. Ultrasonographic features of nodules, which have been associated with an increased likelihood of malignancy, include hypoechoic or heterogeneous internal echotexture, lesions with irregular borders,

Simple cyst

Solid nodule Benign features

Solid nodule Malignant features

FNA

Inadequate

Benign

Follicular/ Hürthle cell neoplasm

Malignant

-Repeat FNA U/S guided x1 -then diagnostic lobectomy

Clinical observation

Diagnostic lobectomy & isthmusectomy

Total thyroidectomy

Completion thyroidectomy if malignant

Fig. 41.1  Algorithm summarizing the diagnostic work-up and management of patients presenting with a thyroid nodule or mass. TSH serum thyroid stimulating hormone, U/S ultrasonography

41  Thyroid Surgery for the Community General Surgeon

hypervascularity, and internal microcalcifications [2]. Ultrasound can also differentiate simple cysts from other thyroid lesions, which can be safely aspirated. Where a solid component is present, or a complex cystic mass seen, a cystic malignancy of the thyroid should be suspected. Cervical lymph nodes in the central and lateral compartments can also be evaluated by ultrasound. Enlargement in size, loss of the fatty hilum, and distortion of normal lymph node architecture on ultrasound are indicators of nodal involvement with malignancy. Where local invasion of surrounding structures by thyroid malignancy is suspected on clinical grounds, cross-sectional imaging with computed tomography (CT) or magnetic resonance (MR) should be performed to evaluate the presence and extent of locally advanced disease. CT of the neck and thorax is also indicated where retrosternal or intrathoracic extension of thyroid enlargement is suspected, to evaluate the extent of this extension and the relationship to mediastinal structures. FNAB of thyroid lesions is perhaps the most important investigation in the evaluation of the thyroid lesion, and the correct interpretation of FNA results is critical in the further management of these lesions. FNA can be performed as an office procedure at the time of initial evaluation of palpable lesions, or can be performed under ultrasound guidance. Where multiple lesions are present in the thyroid, FNA of the largest lesions or those with features suspicious of malignancy on ultrasound or clinical evaluation should be undertaken [12]. The cytological results can be grouped into one of the following four categories: 1. Insufficient sample 2. Consistent with benign lesion 3. Consistent with follicular or Hürthle cell lesion either neoplastic or non-neoplastic 4. Consistent with malignant lesion [3] The cytological features associated with these four ­categories and the differential diagnoses for each are shown in Table 41.1. Simple thyroid cysts where a solid component is not seen on ultrasound and FNA does not show any malignant cells can be safely managed by aspiration alone. Recurrence of simple cystic lesions after three or more aspirations may indicate an underlying malignancy, and is an indication for surgical resection. Solid components of complex cystic lesions should always be biopsied directly under ultrasound guidance. Thyroid lesions other

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than simple cysts where the results of FNA are inadequate should have the FNA repeated, preferably under ultrasound guidance to reduce any sampling error. Where FNA is consistent with a benign lesion, it is important that this be placed into the context of the patient’s clinical evaluation. If there are clinical features suggestive of malignancy on history or physical examination, a history of previous radiation exposure or ultrasonographic features of malignancy, then surgical resection is still indicated regardless of the results of FNA in order to rule out malignancy. Where none of these features are present and the lesion is clinically consistent with a benign diagnosis, the patient can be reassured. Follow up with regular physical examination can be undertaken, and ultrasound and FNA repeated if features suspicious for malignancy are found. Repeat ultrasound at 6 months for nodules with benign cytology on FNA has been recommended ­previously, looking for an increase in size of the index lesion that may be associated with malignancy. However, as many as 23% of benign nodules may increase in size on long-term follow-up, and malignant lesions can be indolent and slow-growing, and for this reason, changes in lesion size are a poor indicator of the risk of underlying malignancy [4]. For lesions with FNA cytology consistent with a ­follicular or Hürthle cell lesion can be either neoplastic or non-neoplastic. The non-neoplastic lesions in the appropriate clinical text can be followed similar to the benign lesions. It is not possible to differentiate benign neoplasms (follicular or Hürthle cell adenoma) from malignant lesions (follicular or Hürthle cell carcinoma) based on the FNA cytology findings [5]. Due to the benign appearance of the malignant cells that comprise well-differentiated follicular or Hürthle cell carcinomas, the diagnosis of malignancy for such lesions relies on demonstrating capsular or vascular invasion on final histopathology. Underlying malignancy is encountered in 24% of lesions with FNA cytology consistent with a follicular or Hürthle cell neoplasm on final histopathology [6]. Due to this risk of malignancy, surgical resection is recommended for definitive diagnosis and is best achieved by diagnostic lobectomy and isthmusectomy. Intraoperative frozen section examination of the nodule at the time of diagnostic lobectomy is not reliable in the diagnosis of malignancy as capsular and vascular invasion cannot be accurately determined using this technique, and this is therefore not recommended [7]. Where permanent section histopathology shows vascular or capsular invasion, which are the defining features

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Table 41.1  Fine-needle aspiration biopsy results for lesions of the thyroid and their differential diagnosis Cytology Cytological appearance Differential diagnosis category Inadequate

Acellular or hypocellular

Sampling error

<6 cells clusters per slide

Thyroid cyst Necrotic or cystic malignancy

Benign features

Scattered clumps of normal appearing follicular cells

Hyperplastic nodule

Abundant colloid

Colloid nodule

Macrofollicles

Adenomatous nodule

Occasional Hürthle cells

Nodular Hashimoto’s

Occasional macrophages, lymphocytes Follicular or Hürthle cell lesions

Sheets of normal appearing follicular or Hürthle cells

Hyperplastic nodule/Colloid nodule Non-neoplastic

Large clusters of cells

Follicular adenoma Neoplastic

Scant or absent colloid

Hürthle cell adenoma Neoplastic

Hypercellular

Follicular carcinoma Neoplastic

Microfollicles

Hürthle cell carcinoma Neoplastic Follicular variant of PTC Neoplastic

Malignant

Nuclear changes of PTC (enlarged, atypical, optically clear nuclei nuclear crowding, overlapping or folding, pseudoinclusions, prominent nucleoli)

PTC

Neuroendocrine cells

Medullary thyroid cancer

Amyloid deposition Stains positively for calcitonin Anaplastic, pleomorphic, or spindle cells

Anaplastic thyroid cancer

Monoclonal lymphocyte proliferation

Lymphoma

PTC papillary thyroid cancer

of a follicular or Hürthle cell carcinoma, completion thyroidectomy to remove the remaining thyroid lobe will then be required. Frozen section can however be helpful in confirming a malignant diagnosis in the setting of suspicious lymph nodes. Where FNA cytology is consistent with a malignant lesion, this is highly specific and more than 98% of such lesions will be confirmed as malignant on final histopathology [3]. Further management is dependent on the type of malignancy identified. Papillary thyroid cancer (PTC) accounts for more than 80% of malignant lesions, and FNA cytology shows nuclear changes including grooving, crowding, and overlapping of nuclei with prominent nucleoli and pseudo-inclusions. Total thyroidectomy is recommended for patients with PTC due to the increased risk of multifocal disease involving both thyroid lobes (demonstrated in 40% of cases), to enable the administration of radioactive

iodine (RIA) as an adjuvant therapy, and to allow biochemical surveillance for recurrent disease using serum thyroglobulin measurements during follow-up [8]. As many as 60–80% of patients with PTC harbor metastatic disease within regional cervical lymph nodes, with the central nodal compartment (level VI nodes) most commonly affected. The central compartment is defined as that region of the central neck bounded laterally by the common carotid arteries, inferiorly by the suprasternal notch and superiorly by the hyoid bone. This compartment contains pretracheal (“Delphian”), paratracheal, and peri-thyroidal lymph nodes, as well as the parathyroid glands and the RLN bilaterally. Nodal recurrence in the central compartment accounts for 60% of disease recurrence in patients with PTC during long-term follow-up, even following adjuvant treatment with RAI. Recurrence of PTC is being increasingly diagnosed with the use of regular

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41  Thyroid Surgery for the Community General Surgeon

serum thyroglobulin assays and high-resolution ultrasound scanning. Reoperative surgery for recurrence in this anatomic region is technically challenging and places the parathyroid glands and RLN at risk, and for this reason, routine ipsilateral dissection of the central compartment at the time of total thyroidectomy for patients with PTC is being increasingly recommended [9]. Systematic removal of all lymph node-bearing tissue in the central compartment with identification and preservation of the parathyroid glands and their blood supply and RLN is critical in performing central nodal dissection, and this should only be performed by ­surgeons trained in this technique. Medullary thyroid cancer (MTC) is a malignancy of parafollicular C-cells and accounts for 7% of thyroid cancers. MTC is diagnosed on FNA cytology by the characteristic appearance of oval or spindle-shaped neuroendocrine cells staining positively for calcitonin on immunohistochemistry. Patients with MTC regardless of whether a family history is present should be investigated for the coexistence of other tumors related to the MEN 2A and 2B syndromes, namely hyper­ parathyroidism and pheochromocytoma. Pheochro­ mocytoma should be ruled out by measurement of urinary or serum metanephrines, particularly prior to  operation as this can precipitate life-threatening hypertensive crisis in such patients. All patients with MTC should also be referred to a clinical genetics service for testing to identify the presence of RET protooncogene mutations associated with familial MTC, MEN 2A and MEN 2B. Identification of RET gene mutations in index cases has important implications for the assessment of other family members, and should be carried out in conjunction with appropriate genetic counseling. For patients with confirmed MTC, the surgical management of this disease is critical as no effective adjuvant therapy exists, unlike the use of RAI for carcinoma of follicular cell origin. Lymph node metastases occur commonly in MTC, with central and ipsilateral cervical chain metastases seen in 50–60% of cases, and contralateral cervical chain involvement in 20–30%. For these reasons, the initial surgical management of MTC involves total thyroidectomy in conjunction with formal central compartment lymph node dissection and plus or minus modified selective neck dissection of lateral nodal compart­ments  [10, 11]. Due to the complexity of the initial operative management and subsequent followup of patients with MTC, referral to an appropriately specialized institution is recommended.

Anaplastic and poorly differentiated thyroid cancers are malignancies of follicular cell origin that lack the well-differentiated character usually associated with thyroid cancer, and are associated with rapid growth, local invasion into surrounding structures, a high incidence of disseminated metastatic disease and a poor prognosis. Extrathyroidal invasion into the RLN, trachea or larynx, esophagus or vascular structures is seen in 60% of cases at presentation and is best assessed by cross-sectional imaging with CT or MRIz [11]. FNA cytology shows loosely arranged, poorly differentiated giant or spindle-shaped cells, with pleomorphism and irregular nuclear forms. The management of patients with anaplastic or poorly differentiated thyroid cancer involves multimodality therapy. Patients with locally invasive disease that is not surgically resectable are best managed initially with combination radiotherapy and chemotherapy, with surgical resection reserved for patients responding to this treatment where the disease becomes resectable [12]. All patients with anaplastic and poorly differentiated thyroid cancer should be referred to specialized institutions where a multidisciplinary approach to management can be instituted.

41.4 Operative Technique: Diagnostic Lobectomy and Isthmusectomy Diagnostic lobectomy involves removal of the ipsilateral thyroid lobe with the entire thyroid isthmus and pyramidal lobe. A curvilinear incision is made in the skin of the lower neck, and deepened to incise the platysma muscle. Superior and inferior skin flaps are raised deep to platysma to the level of the hyoid bone and suprasternal notch. The strap muscles are then divided in the midline, and on the side to be removed are dissected separately. Prior to dissecting in the plane between the strap muscles and the thyroid lobe, palpation through the sternothyroid muscle of the underlying thyroid nodule is performed to identify invasive disease. If invasion of the thyroid lesion into the strap muscles is suspected, the muscle should be resected en-bloc with the thyroid lesion and not dissected free. If invasive disease is not present, then the strap muscles are dissected off the thyroid lobe and reflected laterally. The strap muscles of the contralateral side are not disturbed to facilitate completion thyroidectomy if this is ultimately required. As an early maneuver, the

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pyramidal lobe (if identified arising from the thyroid isthmus) is removed with its suspensory ligament and thyroglossal duct remnant to the level of its insertion into the body of the hyoid bone. Removal of the pyramidal lobe during diagnostic lobectomy is important in the event that malignancy is diagnosed and completion thyroidectomy is required, as this is more difficult to achieve in the reoperative surgical field. Dissection of the thyroid lobe is then carried out, identifying the external branch of the superior laryngeal nerve (EBSLN) in proximity to the superior lobe vessels, the RLN in the tracheo–esophageal groove, and both the superior and inferior parathyroid glands. The preservation of all of these structures and their vascular supply is of paramount importance, particularly in the event that reoperation is required, and their status at the end of the procedure should be carefully documented in the operative report. Parathyroid glands that are devascularized during dissection of the thyroid lobe are set aside, finely minced and transplanted into the ipsilateral sternocleidomastoid muscle at the end of the procedure. A frozen section of the suspected parathyroid gland should be performed to confirm correct histology and avoid implant of a lymph node into the sternocleidomastoid muscle. Once the thyroid lobe has been fully mobilized, this is removed with the entire thyroid isthmus up to its junction with the contralateral lobe, and this is again important in facili­tating completion thyroidectomy. As stated above, where diagnostic lobectomy is performed for follicular or Hürthle cell neoplasms, frozen section examination of the resected lesion is not reliable in the diagnosis of malignancy and is not recommended. Where malignancy is clinically apparent at the time of initial surgery, as indicated by the presence of local invasion into strap muscles or surrounding structures, or where abnormal or enlarged lymph nodes are found and confirmed to be malignant on frozen section examination, then total thyroidectomy should be performed.

41.5 Summary Nodules and mass lesions within the thyroid gland are a common presentation to surgeons in community practice, the majority of which will be benign in etiology. Clinical evaluation of the patient, ultrasound

A.J. Chambers and J.L. Pasieka

imaging and the results of FNA cytology provide the basis for diagnosis and guide further management [13]. Surgical resection in the form of diagnostic lobectomy and isthmusectomy plays an important role in both the diagnosis and definitive treatment of thyroid nodules where FNA is consistent with a follicular neoplasm. Where FNA is consistent with thyroid malignancy, further surgical management of the primary tumor and regional lymph node compartments is dependent upon the type of malignancy encountered, and referral to specialized centers for definitive management of such cases is recommended.

References   1. Tucker, M.A., Morris-Jones, P.H., Boice, J.D., et  al.: Therapeutic radiation at a young age is linked to secondary thyroid cancer. Cancer Res. 51, 2885 (1991)   2. Frates, M.C., Benson, C.B., Charboneau, J.W., et  al.: Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 237, 794 (2005)   3. Yang, J., Schnadig, V., Logrono, R., et  al.: Fine-needle ­aspiration of thyroid nodules: a study of 4703 patients with histologic and clinical correlations. Cancer 111, 306 (2007)   4. Kuma, K., Matsuzuka, F., Yokozawa, T., et  al.: Fate of untreated benign thyroid nodules: results of long-term ­follow-up. World J. Surg. 18, 495 (1994)   5. Baloch, Z.W., LiVolsi, V.A.: Our approach to follicular-­ patterned lesions of the thyroid. J. Clin. Pathol. 60, 244 (2007)   6. McHenry, C.R., Huh, E.S., Machekano, R.N.: Is nodule size an independent predictor of thyroid malignancy? Surgery 144, 1062 (2008)   7. Udelsman, R., Westra, W.H., Donovan, P.I., et  al.: Randomized prospective evaluation of frozen-section analysis for follicular neoplasms of the thyroid. Ann. Surg. 233, 716 (2001)   8. Dackiw, A.P., Zeiger, M.: Extent of surgery for differentiated thyroid cancer. Surg. Clin. North Am. 84, 817 (2004)   9. White, M.L., Gauger, P.G., Doherty, G.M.: Central lymph node dissection in differentiated thyroid cancer. World J. Surg. 31, 895 (2007) 10. Scollo, C., Baudin, E., Travagli, J.P., et  al.: Rationale for central and bilateral lymph node dissection in sporadic and hereditary medullary thyroid cancer. J. Clin. Endocrinol. Metab. 88, 2070 (2003) 11. Kross, R.T., et al.: Medullary Thyroid cancer management guidelines of the ATA. Thyroid 19, 565 (2009) 12. Pasieka, J.L.: Anaplastic thyroid cancer. Curr. Opin. Oncol. 15, 78 (2003) 13. Cooper, D.S.: Revised ATA management guidelines for patients with thyroid nodules and differentiated thyroid ­cancer. Thyroid 19, 1167 (2009)

Parathyroid Surgery in the Non-Tertiary Center

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Anthony J. Chambers and Janice L. Pasieka

42.1 Introduction Hyperparathyroidism is a group of disorders associated with excessive production of parathyroid hormone (PTH). PTH is produced by the parathyroid glands in response to low serum levels of calcium, and acts to increase calcium resorption from bone by osteoclasts, and increases renal calcium resorption, thereby reducing calcium excretion. Hyperparathyroidism is categorized into primary, secondary, and tertiary forms. Primary hyperparathyroidism (PHPT) is due to autonomous secretion of PTH by abnormal gland or glands in the absence of a secondary stimulus. PHPT is the commonest cause of hyperparathyroidism, occurring with an incidence of 0.1–0.4% of the population. Secondary hyperparathyroidism occurs where parathyroid hyperfunction is driven by a secondary stimulus, and is most commonly seen in association with chronic renal failure due to reduced renal production of 1,25 dihydroxy vitamin D, reduced phosphate ­excretion/phosphate retention, and resistance of bone to higher PTH levels. Tertiary hyperparathyroidism is seen in patients with chronic renal failure after successful renal transplantation, where autonomous parathyroid hyperfunction occurs despite normalization of renal function, and autonomous parathyroid secretion in patients on long-term dialysis with prolonged secondary hyperparathyroidism. As PHPT is being increasingly detected in otherwise asymptomatic patients, and parathyroidectomy

A.J. Chambers and J.L. Pasieka (*) Department of Surgery, The University of Calgary, 1403-29th Street NW, Calgary, Alberta, T2N 2T9, Canada e-mail: [email protected]

offers the only effective treatment for this condition, surgeons will be increasingly involved in the management of this condition. It is important that surgeons involved in the management of patients with PHPT should have an understanding of the biochemical work-up required to confirm the diagnosis of this condition, the indications for surgical intervention, the role of localizing imaging studies to identify hyperfunctioning glands and the options for operative management.

42.2 Primary Hyperparathyroidism PHPT can present with symptoms related to hypercalcemia, loss of bone mineralization, and renal calculus disease, and is also being increasingly diagnosed as an incidental finding on routine biochemical investigations in patients who are either asymptomatic or with minimal symptoms. PHPT is due to a single parathyroid adenoma in approximately 80% of cases, due to two or more parathyroid adenomas in 5%, and due to hyperplasia of all four glands in 10% of cases [1]. Parathyroid carcinoma is a rare cause of PHPT, accounting for less than 1% of cases. PHPT occurs in both sporadic and familiar forms. Sporadic PHPT occurs most commonly in older age groups (mean age 60  years), and effects females four-times more commonly than males. Familial PHPT occurs in association with multiple endocrine neoplasia (MEN) syndrome type 1 due to mutation of the MENIN gene (in association with pituitary adenomas, pancreatic and duodenal neuroendocrine tumors, bronchial and thymic “carcinoid” neuroendocrine tumors, adrenal adenomas, lipomas, and cutaneous and mucosal angiomas), as part of the MEN 2A syndrome due to

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_42, © Springer-Verlag Berlin Heidelberg 2011

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mutation on the RET proto-oncogene (in association with pheochromocytoma and medullary thyroid carcinoma), and as part of the hyperparathyroidism-jaw tumor syndrome due to mutation of the HRPT2 gene (associated with parathyroid carcinoma, fibro-osseous tumors of the mandible and maxilla, renal stromal tumors, and renal cysts). The age of onset of familial forms of PHPT is earlier than for sporadic forms of the disease, and is more likely to be due to multiple adenomas or four-gland hyperplasia. Where a family history of PHPT or its clinical manifestations (particularly renal calculi), or of tumors associated with the MEN 1, MEN 2A, or hyperparathyroidism-jaw tumor syndrome are present, patients should be referred to a clinical genetics service for genetic testing and counseling. The management of familial causes of PHPT is highly specialized, and where this is suspected, referral to a specialist institution or endocrine surgical ­service is recommended. The elevation of serum calcium levels in PHPT leads to an increase in renal calcium excretion, predisposing to the formation of renal calculi, which is seen in 15–20% of patients. In the longer term, prolonged renal exposure to high calcium loads can also lead to a deterioration of renal function. Activation of osteoclast function in PHPT causes bone demineralization, which over time leads to osteopenia and an increased risk of fractures. In severe cases, now uncommonly seen in clinical practice due to the earlier diagnosis of the condition, the classic features of osteitis fibrosa cystica occur with bone cysts (seen on skull radiographs as a “pepper-pot” appearance), reabsorption of subperiosteal bone (best seen at the radial aspects of the middle and distal phalanges of the hand), fibrous tissue replacement of bone and “brown tumor” formation, osteopenia, and pathological fracture. Patients with severe hypercalcemia from PHPT can present with complications of hypercalcemic crisis, with dehydration, polyuria and polydipsia, confusion and reduced levels of consciousness, acute pancreatitis, and acute renal failure. Such patients require urgent resuscitation and lowering of serum calcium levels. It is being increasingly recognized that patients with PHPT also manifest a range of less acute symptoms that are frequently overlooked or attributed to other conditions, including fatigue, ­muscle weakness, joint and bone pain, depressed mood, irritability, memory disturbance, and poor work-­performance [2].

A.J. Chambers and J.L. Pasieka

42.3 Diagnosis and Clinical Evaluation The diagnosis of PHPT is made on biochemical criteria, demonstrating hypercalcemia in the presence of elevated PTH levels, after ruling out causes of secondary hyperparathyroidism. Serum calcium, phosphate, and PTH levels are measured. An elevated serum ­calcium in conjunction with an elevated PTH level confirms the diagnosis of hyperparathyroidism and differentiates this from other causes of hypercalcemia, including metastatic malignancy, multiple myeloma, Paget’s disease, tuberculosis, and sarcoidosis. In these conditions, PTH levels will be secondarily suppressed or within the normal range. Serum phosphate levels are typically low or within the low-normal range in PHPT. Serum creatinine is measured to rule out chronic renal insufficiency as a cause of secondary hyperparathyroidism. Twenty-four hour urinary collection of calcium and creatinine should be performed in all patients to rule out benign familial hypocalciuric hypercalcemia (BFHH). In this familial syndrome, heterozygous mutation of the gene encoding the PTHreceptor causes hypercalcemia, inappropriate elevation of PTH, and reduced urinary excretion of calcium. This condition is differentiated from PHPT based on urinary calcium excretion, which is reduced in BFHH and elevated in PHPT. This is most accurately performed by calculation of the calcium excretion fraction, derived from serum and urinary calcium and creatinine levels as shown in (Fig.  42.1). A calcium excretion fraction of less than 1% is consistent with the diagnosis of BFHH. Patients with BFHH are not candidates for parathyroidectomy, and for this reason, it is critical to exclude this condition in all patients with suspected PHPT. Serum levels of 25-hydroxy ­vitamin D, the storage form of this vitamin that best reflects total body stores, should also be performed to rule out vitamin D deficiency as a cause of secondary elevation of PTH levels. Where vitamin D deficiency is found, oral supplementation should be commenced and biochemical testing for PHPT repeated after 6 weeks of replacement.

Urinary calcium Serum creatinine x Serum calcium Urinary creatinine

Fig. 42.1  Formula for the calculation of the calcium excretion fraction for the diagnosis of benign familial hypocalciuric hypercalcemia

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42  Parathyroid Surgery in the Non-Tertiary Center

Where PHPT is confirmed on biochemical criteria, the only effective treatment for the condition is parathyroidectomy. In patients with complications of PHPT such as renal calculi and osteopenia, the rationale of surgical intervention is to reduce the formation of new renal calculi and to reduce the rate of further bone demineralization driven by high PTH levels. Where complications of PHPT are present, namely renal calculi, renal impairment, bone disease or pathological fracture, or hypercalcemic crisis, there is a clear indication for surgery for this condition. As a large proportion of patients with PHPT are diagnosed on routine biochemical testing and are otherwise asymptomatic or complain of vague nonspecific symptoms only, guidelines have been formulated to assist in the selection of patients for parathyroidectomy. It is being increasingly recognized that patients with nonspecific symptoms related to PHPT, even where the above criteria for parathyroidectomy are not met, may still obtain measurable improvement in symptoms and quality of life measures after surgery [3, 4]. A consensus development conference held at the National Institutes of Health in 1990 formulated guidelines for the management of asymptomatic patients with PHPT, and these were revised in 2002 (Table 42.1) [5]. A recent revision of these guidelines published in 2009 recommends that all patients with biochemically proven PHPT should be referred to an experienced parathyroid surgeon for assessment regarding the risks and benefits of surgery for this condition, regardless of the presence or absence of symptoms [6]. When surgery is not undertaken, it is recommended that patients undergo annual biochemical surveillance of serum calcium and creatinine levels, and annual bone mineral densitometry, for the early identification of progressive disease.

42.4 Localizing Imaging Studies Prior to parathyroidectomy for PHPT, imaging studies can assist in the localization of hyperfunctional parathyroid glands and thereby assist the surgeon in identifying these at the time of surgery. Localizing imaging studies have no role in the diagnosis of PHPT, and are only employed after biochemically confirming this condition. High-resolution ultrasound and nuclear scanning with radiolabeled sestamibi are the two most commonly employed imaging modalities for the localization of hyperfunctioning glands [7]. High-resolution ultrasound of the neck aims to identify enlargement of parathyroid glands. Advantages of this technique include its noninvasive nature and relatively low cost. However, this technique is operator dependent, and is limited by a relative lack of specificity, where thyroid nodules and cervical lymph nodes may be misinterpreted as parathyroid enlargement. Enlarged parathyroid glands in a retro-esophageal or retro-tracheal location, glands located inferiorly in the root of the neck or in a retrosternal location may also be poorly imaged due to their anatomical position. The sensitivity of high-resolution ultrasound for the detection of enlarged parathyroids varies between 72% and 89%, and false positive results are reported in as many as 15–20% of studies [7]. Nuclear medicine scanning using technetium-99 radiolabeled sestamibi can be used to detect enlar­ ged or hypersecreting parathyroid glands (Fig. 42.2).

Table 42.1  National Institutes of Health consensus development conference guidelines for parathyroidectomy in asymptomatic primary hyperparathyroidism (2002) 1.  Serum calcium > 0.25 mMol (1 mg/dL) above normal range 2.  Total 24-h urine calcium excretion > 10 mMol (400 mg) 3. Creatinine clearance reduced > 30% (compared to age-matched controls) 4. Bone mineral density of spine, hip, or distal radius reduced more than 2.5 standard deviations below peak bone mass, i.e., T-score <−2.5 at any of these sites 5.  Age younger than 50 years 6.  Patients not suitable for regular medical surveillance

Fig. 42.2  Techniecium-99 radiolabeled sestamibi scan showing increased uptake in a left superior parathyroid adenoma in a patient with primary hyperparathyroidism (arrow)

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Sestamibi is taken up by mitochondria, and the high mitochondrial content of abnormal parathyroid tissue forms the basis for its identification using this technique. Scanning of the thyroid gland with radiolabeled pertechnetate is typically performed initially to enable comparison with the later sestamibi scan images. Parathyroid enlargement is seen as areas of increased sestamibi uptake, and may be more prominent on delayed images. Cross-sectional imaging using single photon emission computed tomography (SPECT) can assist in the three-dimensional localization of enlarged parathyroid glands, particularly in locating superior parathyroid glands in a posterior or retro-esophageal location. The wide field of scanning is useful in the detection of abnormal parathyroid glands located outside the neck, particularly inferior parathyroid glands in a mediastinal or high-cervical location. Falsepositive results can occur due to uptake of sestamibi within thyroid nodules and neoplasms, particularly mitochondria-rich Hürthle cell adenoma and carcinomas. The sensitivity of sestamibi scanning for the detection of abnormal parathyroid glands varies from 68% to 88% [7]. Sestamibi scanning is limited in its ability to identify multiply enlarged parathyroid glands, as occurring in four-gland parathyroid hyperplasia or multiple parathyroid adenomas. In only 30–40% of such patients will two or more abnormal glands be identified; in the remaining patients only a single abnormal gland will be demonstrated (30%) or no abnormal glands are seen (30%) [7].

42.5 Surgery for Primary Hyperparathyroidism The aim of surgery for PHPT is the identification of all hyperfunctioning parathyroid glands and their surgical excision. Historically, bilateral neck exploration with inspection of all four parathyroid glands has been the operative approach of choice for PHPT. Successful cure of PHPT is reported in more than 95% of cases after fourgland exploration in most large series. With the introduction of localizing imaging studies in recent years, less invasive operative strategies have evolved. Where a single abnormal parathyroid gland is identified on preoperative imaging, a unilateral neck exploration to identify the two parathyroid glands on the side of detected abnormality

A.J. Chambers and J.L. Pasieka

can be performed, or image-directed parathyroidectomy of the enlarged gland via small incision or video-endoscopy assisted techniques [8]. Rapid measurement of PTH levels intraoperatively has been developed with the aim of improving the success rates associated with these lessinvasive approaches [9]. Documenting a fall in intraoperative PTH levels after removal of the enlarged gland or glands enables the surgeon to confirm removal of all hyperfunctioning parathyroid glands without inspection of all four glands. In patients with PHPT where preoperative sestamibi scanning and/or ultrasonography fail to localize an abnormal parathyroid gland, four-gland exploration is required. It can be argued that for surgeons who do not perform a high volume of parathyroid procedures, or where intraoperative PTH measurement is not available, that four-gland parathyroid exploration remains the procedure of choice regardless of imaging ­localization, and is associated with the highest rate of successful cure of the disease [10]. A leading cause of persistent hyperparathyroidism after parathyroidectomy is failure to identify multi-gland disease (secondary to four-gland hyperplasia or dual adenomas) at the  time of initial surgery, which occurs in 15–20% of  cases, and routine four-gland exploration aims to ­minimize the risk of this occurrence [11].

42.6 Operative Technique of FourGland Parathyroid Exploration Four-gland parathyroid exploration requires general anaesthesia, and a curvilinear incision centered over the midline of the lower neck is made. The underlying platysma muscle is divided, and superior and inferior skin flaps raised deep to this layer. The strap muscles are incised in the midline and reflected laterally, dissecting them free from the underlying thyroid lobes. The inferior thyroid artery is identified as a landmark. The superior parathyroid gland is typically encountered on the posterolateral surface of the thyroid lobe just above the level of the inferior thyroid artery, and this region should be inspected to look for fat-pads that may be associated with parathyroid tissue, or an enlarged gland itself [12]. The posterior location of the superior gland means that it may be located in a retroesophageal position, and may enlarge in an inferior

42  Parathyroid Surgery in the Non-Tertiary Center

direction here toward the posterior mediastinum. Blunt dissection to the prevertebral fascia and behind the pharynx and esophagus is performed to allow palpation with the index finger in this space. Palpation behind the esophagus, sweeping the index finger in a cranio-caudal direction to feel the posterior aspect of the thyroid lobe, may identify an enlarged superior gland here. Sweeping this finger laterally, below the inferior thyroid artery, and performing bimanual palpation with the index finger of the other hand in this region may also identify an enlarged gland in this location, which can be “balloted” between the fingers. Finally, the thyroid lobe is retracted medially to allow palpation at the edge of the thyroid above the entry of the inferior thyroid artery. The inferior parathyroid gland is typically located at the inferior aspect of the thyroid lobe in the region of the thyrothymic tongue. The appearance of fat-pads in this region associated with the parathyroids may assist in their identification. A tongue of thymic tissue extending superiorly toward the inferior pole of the thyroid is often seen “pointing” to the inferior parathyroid gland. Abnormal parathyroid glands are identified based on their increase in size (greater than 7 mm in largest dimension). All four glands should be identified and inspected prior to removal of any abnormal glands. Experience is required to recognize the appearance of abnormal and normal parathyroid glands, and to accurately differentiate these. Where the surgeon is uncertain regarding whether a structure is parathyroid tissue, a small biopsy of the distal part of the gland may be taken using fine “iris” scissors and submitted for frozen section histology for confirmation. Routine biopsy of all normal appearing parathyroid tissue is not recommended due to the risk of devascularizing the remnant glands. All resected glands should be submitted for frozen section histology to confirm parathyroid tissue, as lymph nodes and fatty tissue may closely resemble parathyroid glands macroscopically. Where a single enlarged parathyroid gland is encountered, and the remaining glands are confirmed to be normal in size, the abnormal gland can be safely resected. Where two enlarged parathyroid glands are seen, extra care should be taken to inspect the remaining two glands and confirm that they are indeed normal, and that four-gland hyperplasia is not present. If double adenomas are confirmed, the two abnormal glands are removed and submitted to frozen section confirmation. Where four-gland

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hyperplasia is encountered, subtotal parathyroidectomy is performed [11]. This involves identification of the smallest or least abnormal appearing parathyroid gland, which is partially dissected, taking care to preserve its blood supply to the hilum of the gland. A metal clip is placed across the gland, leaving a 50  mg remnant of gland proximally, and the distal part of the gland is removed and sent for frozen section to confirm parathyroid etiology. If the gland remnant remains vascularized and viable, removal of the remaining three parathyroids glands is then performed. If the single gland remnant is not considered viable, this is instead removed and the next smallest parathyroid gland selected as the remnant gland, using the previously described technique. Ideally, an inferior parathyroid gland is preferred as the remnant gland, pulled away from the recurrent laryngeal nerve in case reoperation for recurrent hyperparathyroidism is required. Where an abnormal parathyroid gland cannot be located at the time of time of neck exploration, it is important that the surgeon reconfirms the status of all the parathyroid glands identified up to that point. As the majority of parathyroids will be in symmetrical positions bilaterally, this should be used to guide the surgeon if the corresponding contralateral gland is identified. In the event that an abnormal parathyroid gland cannot be found despite detailed search of likely locations, the strategy for further exploration is dependent on whether the unidentified gland is likely superior or inferior in origin. Superior parathyroid not identified. Where an abnormal parathyroid gland has not been identified and is thought to be superior in origin, thorough ­inspection of the posterior aspect of the thyroid lobe and into the retro-esophageal space should be performed. Dissection in this space inferiorly toward the posterior mediastinum may reveal a gland in this location. Thorough inspection of the surface of the thyroid lobe should also be performed, looking for any suggestion of an intrathyroidal parathyroid, which may be visible beneath the capsule of the gland (1% of parathyroids occur in an intrathyroidal location). Inferior parathyroid not identified. Due to its embryo­ logical descent as part of the third branchial pouch, the inferior parathyroid gland has a more variable location than its superior counterpart. Detailed inspection of the inferior aspect of the thyroid lobe and tissues within the thyrothymic ligament should be ­performed. The ipsilateral thymus should be gently dissected upward from the

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anterior mediastinum and removed, taking care to preserve the recurrent laryngeal nerve. Failure to identify the missing gland within the thymus should lead to the exploration of locations along the embryological decent of the gland. The carotid sheath should be opened and inspected as this is rarely the site of an inferior gland. Superior sites adjacent to the superior thyroid pole and along the superior pole vessels should also be inspected to look for an inferior gland that failed to descend. Inspection of the thyroid lobe for evidence of intrathyroidal parathyroid tissue should also be performed. Where an abnormal parathyroid gland cannot be found despite thorough and systematic exploration of possible locations, the intraoperative opinion and assistance of a second or more experienced surgeon should always be sought if available. Thyroid lobectomy of the side of the missing parathyroid should be considered in case of an intrathyroidal parathyroid. A possible explanation for the failure to identify an abnormal gland ­during bilateral neck exploration is the presence of a parathyroid adenoma in an ectopic or mediastinal location, and this explains the 5% failure rate of neck exploration reported even by specialized centers. When an abnormal parathyroid gland cannot be found despite a thorough bilateral exploration, the location of all identified normal parathyroids should be carefully documented and the procedure terminated. Parathyroid glands with a normal size and appearance should not be removed. The patient should be referred to an appropriately specialized institution for further management. Reconfirmation of the diagnosis of PHPT and further localization studies with radiolabeled sestamibi scanning, cross-sectional imaging of the neck, and mediastinum with computed tomography or magnetic resonance and/or selective venous sampling will be required.

42.7 Unilateral Versus Image-Directed Parathyroidectomy When preoperative sestamibi scanning and/or ultrasound localizes a single abnormal parathyroid gland, a unilateral exploration of the parathyroid glands on the side of the imaging abnormality can be undertaken [8]. The unilateral approach minimizes the extent of operative dissection, and the risk of injury to contralateral parathyroid glands and the recurrent laryngeal nerve. In

A.J. Chambers and J.L. Pasieka

this approach, exploration is commenced on the side of the imaging abnormality, and both parathyroid glands on this side are identified and inspected. Identification of an abnormal gland corresponding to the imaging abnormality in association with a parathyroid gland of normal appearance on this side rules out the presence of four-gland hyperplasia, and exploration of the contralateral parathyroid glands is not required. In the event that an abnormal gland cannot be identified on the index side, the contralateral side must be explored to identify the hyperfunctioning gland. In the event that normal parathyroid gland is not identified in association with the abnormal gland, the contralateral neck must be explored to rule out parathyroid hyperplasia/multi-gland disease. The unilateral approach will not detect the rare occurrence of a double adenoma occurring in the contralateral side. Persistent elevation of calcium and PTH is seen after a unilateral exploration and parathyroidectomy, that multi-gland disease was present, and exploration of the contralateral side is indicated. Patients such as this with persistent or recurrent PHPT after parathyroidectomy should be referred to specialized centers for further investigation and management. Image-directed parathyroidectomies can be done; however, the need for intra-operative PTH to confirm all parathyroid tissue has been removed makes this technique rare in the community hospital setting. Focused image-directed parathyroidectomy requires a great deal of experience as exposure is ­limited and the risk to the RLN can be increased. Therefore, it is our opinion that the unilateral approach to is a much safer operation for the community surgeon to undertake.

42.8 Conclusion PHPT is being increasingly diagnosed in asymptomatic or minimally symptomatic patients in the com­ munity setting. The diagnosis of PHPT is made on bio­chemical criteria after ruling out causes of secondary elevation of PTH. The only effective treatment for this condition is parathyroidectomy, with four-gland parathyroid exploration considered the “gold-­standard” operative approach for this condition, associated with the lowest risk of persistent or recurrent hyperparathyroidism. This approach is recommended for surgeons not performing a high volume of parathyroid procedures, and for those working in the community setting.

42  Parathyroid Surgery in the Non-Tertiary Center

Unilateral exploration is an acceptable alternative to four-gland exploration in patients where sestamibi scanning or ultrasonography can localize an abnormal parathyroid preoperatively. Focused image-directed parathyroidectomies should be limited to centers where intra-operative PTH is available.

References   1. DeLellis, R.A., Mazzaglia, P., Mangray, S.: Primary hyperparathyroidism: a current perspective. Arch. Pathol. Lab. Med. 132, 1251–1262 (2008)   2. Pasieka, J.L., Parsons, L.L., Demeure, M.J., et  al.: Patientbased surgical outcome tool demonstrating alleviation of symptoms following parathyroidectomy in patients with ­primary hyperparathyroidism. World J. Surg. 26(8), 942–949 (2002)   3. Caillard, C., Sebag, F., Mathonnet, M., et  al.: Prospective evaluation of quality of life (SF-36v2) and nonspecific symptoms before and after cure of primary hyperpa­rathyroidism (1-year follow-up). Surg. 141, 153–159 (2007)   4. Mack, L.A., Pasieka, J.L.: Asymptomatic primary hyperparathyroidism: a surgical perspective. Surg. Clin. North Am. 84(3), 803–816 (2004)

321   5. Bilezikian, J.P., Potts Jr., J.T., Fuleihan Gel, H., et  al.: Summary statement from a workshop on asymptomatic ­primary hyperparathyroidism: a perspective for the 21st century. J. Bone Miner. Res. 17(Suppl 2), N2–11 (2002)   6. Udelsman, R., Pasieka, J.L., Sturgeon, C., et al.: Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J. Clin. Endocrinol. Metab. 94(2), 366–372 (2009)   7. Johnson, N.A., Tublin, M.E., Ogilvie, J.B.: Parathyroid imaging: technique and role in the preoperative evaluation of primary hyperparathyroidism. AJR Am. J. Roentgenol. 188(6), 1706–1715 (2007)   8. Russell, C.: Unilateral neck exploration for primary hyperparathyroidism. Surg. Clin. North Am. 84, 705–716 (2004)   9. Chen, H., Pruhs, Z., Starling, J.R., et al.: Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy. Surg. 138, 583–587 (2005) 10. Beyer, T.D., Solorzano, C.C., Starr, F., et  al.: Parathy­ roidectomy outcomes according to operative approach. Am. J. Surg. 193, 368–372 (2007) 11. Rose, D.M., Wood, T.F., Van Herle, A.J., et al.: Long-term management and outcome of parathyroidectomy for ­sporadic primary multiple-gland disease. Arch. Surg. 136, 621–626 (2001) 12. Doherty, G.M., Moley, J.F.: Conventional exploration for hyperparathyroidism. Operative Techniques in General Surgery 1, 4 (1999)

 

43

Adrenal Surgery Marlon A. Guerrero and Wen Shen

43.1 Introduction Tumors of the adrenal gland are rare. Their retroperitoneal location and inconsistent biochemical activity results in a variable clinical presentation and can pose a diagnostic dilemma. Surgical resection is the preferred treatment modality for tumors that are hormonally functional, malignant, or have features suspicious of malignancy. The proper work-up of adrenal tumors entails a comprehensive biochemical and radiographic evaluation. Both open and laparoscopic techniques are utilized for surgical resection. Though laparoscopic adrenalectomy has become the gold standard for benign tumors, the appropriate approach is dependent on tumor size, malignant potential, and patient anatomy. Regardless on the approach utilized, meticulous dissection and careful vascular control is imperative.

43.2 Clinical Presentation The presentation of a patient with an adrenal tumor is usually nonspecific and ranges from an incidentally discovered mass to hormonal hyperactivity producing a clinical syndrome. The most important process in the evaluation of a patient with an adrenal tumor is to determine its biochemical activity. Hypersecretion of one or more adrenal hormones may result in the

M.A. Guerrero (*) and W. Shen Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected], [email protected]

manifestation of a clinical syndrome. Though there are no specific symptoms diagnostic of an adrenal tumor, the astute clinician must be aware of the symptoms associated with these syndromes (Table 43.1). Advances in modern imaging technology have improved the diagnostic capability of clinicians for a myriad of diseases. These improvements, however, have led to an overuse of imaging in the diagnostic process. As such, the prevalence of finding an incidental adrenal tumor has increased from 0.5–2% to 4% [8]. Although the majority of adrenal incidentalomas are non-functioning, it is important to perform a comprehensive hormonal evaluation of these tumors. Note: It cannot be overstressed that fine needle aspiration biopsy of an adrenal mass has no role in the work-up of an adrenal mass. The only exception is in patients with an adrenal tumor and a known history of malignancy and only after a pheochromocytoma has been biochemically excluded.

43.3 Biochemical Evaluation 43.3.1 Pheochromocytoma The incidence of pheochromocytomas is two to eight per million [1], but pheochromocytomas comprise 5–11% of adrenal incidentalomas [8]. Screening entails obtaining a 24-h urine collection of metanephrines and fractionated catecholamines or plasma-free metanephrines has a high sensitivity of 99% and specificity of

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_43, © Springer-Verlag Berlin Heidelberg 2011

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Table  43.1  Hormonal syndromes associated with adrenal tumors Tumor Symptoms Pheochromocytoma

Headache, chest palpitation, hypertension, vision changes, anxiety, sweating

Cushing’s syndrome

Weight gain, central obesity, peripheral muscle wasting, posterior neck fat pad, hypertension, acne, hirsutism, diabetes

Conn’s syndrome

Hypokalemia, hypertension

89% and is therefore recommended as the diagnostic test of choice by the NIH [2]. This test is especially useful in testing patients genetically predisposed to develop a pheochromocytoma (Table 43.2). However, it has a high false-positive rate of 10%, so caution must be used if using it for a screening test [1]. Though 80–90% of pheochromocytomas are sporadic [1], their frequent association with other diseases should prompt a complete genetic evaluation.

43.3.2 Cushing’s Syndrome Screening for Cushing’s syndrome involves an overnight dexamethasone (1  mg) suppression test. A

cortisol level <5 mg/dL excludes Cushing’s syndrome. An elevated cortisol necessitates confirmation with either a 24-h urinary free cortisol, midnight salivary cortisol test, or a high dose (8 mg) dexamethasone suppression test. Plasma adrenocorticotropic hormone level should also be obtained [3, 4].

43.3.3 Aldosteronoma Primary aldosteronomas account for 1.5–3.3% of adrenal incidentalomas [8]. Primary hyperaldosteronism is suggested in patients with concurrent hypertension and hypokalemia. A normotensive patient with normal serum potassium excludes aldosteronism. However, in hypertensive patients, a plasma aldosterone to renin activity ratio should be calculated. A ratio >20 and a plasma aldosterone level >15 ng/dL confirms the presence of an aldosteronoma [2].

43.3.4 Virilizing/Feminizing Tumors Most patients with adrenal incidentaloma do not require testing for virilizing or feminizing tumors; testing for these tumors is generally reserved for

Table 43.2  Inherited syndromes with pheochromocytoma Syndrome Associated diseases

Genetic defect

MEN 2A

Pheochromocytoma, medullary thyroid cancer, primary hyperparathyroidism

RET gene on chromosome 10q11.2

MEN 2B

Pheochromocytoma, medullary thyroid cancer, mucocutaenous neuromas, muscular hypotonia, marfanoid habitus

RET gene on chromosome 10q11.2

Von Hippel-Lindau

Pheochromocytoma, retinal hemangiomatosis, cerebellar hemangioblastoma, renal tumors, pancreatic tumors

Chromosome 3p26-p25

Neurofibromatosis type I (Von Recklinghausen’s disease)

Pheochromocytoma, neurofibroma, schwannomas, café au lait spots, glial tumors, skeletal manifestations

Chromosome 17

Sturge-Weber

Port-wine stain, seizures, mental retardation, glaucoma, leptomeningeal angioma

Tuberous sclerosis

Hamartomas, seizures, developmental delay, renal angiomyolipomas, renal cell carcinoma, lung cysts, cardiac rhabdomyomas, retinal lesions

Carney’s

Paraganglioma, gastric leiomyosarcoma, pulmonary chondroma

MEN multiple endocrine neoplasia, VHL von Hippel-Lindau

TSC1 on chromosome 9 q34 and TSC2 on chromosome 16 p13.3

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43  Adrenal Surgery

patients with clinical evidence of androgen or estrogen excess. Evaluation of virilizing or feminizing tumors involves checking for all the sexual steroids and their precursors. Serum levels of testosterone, dehydroepiandrosterone sulfate (DHEA-S), androstenedione, 17-hydroxy-progesterone, and 17-b-estradiol should be tested. It is important to note that an elevated level of DHEA-S is highly suggestive of an adrenocortical carcinoma (ACC). Even ACC that are not hormonally active are found to have high levels of androstenedione or 17-hydroxy-progesterone [4].

43.4 Imaging Patients found to have an adrenal mass should undergo dedicated imaging to evaluate for size, extent of tumor involvement, and distant metastasis. Feat­ ures suggestive of malignancy include irregular borders, heterogeneity, stippled calcifications, necrosis, local tissue invasion, lymphadenopathy, or distant metastasis.

43.4.1 CT The preferred imaging modality is a high-resolution computed tomography (CT) scan of the abdomen. The lipid content on the adrenal mass measured by Hounsfield units (HU) and the timing of contrast washout help distinguish the adrenal mass. Adrenal adenomas have a density of £10 HU on unenhanced CT and <30 HU on contrast-enhanced CT with rapid washout of contrast ³50% at 10 min. Adrenocortical carcinomas are typically vascular, with slow washout (<50%) and >10 HU on unenhanced CT [5].

43.4.2 MRI Magnetic resonance imaging (MRI) of the abdomen, though more expensive than a CT scan, is also utilized to evaluate adrenal tumors. Features on MRI that suggest malignancy include heterogeneous signal

intensity on T1 and T2-weighted imaging, peripheral nodular enhancement, and central hypoperfusion on contrast MRI [6].

43.5 Open Adrenalectomy In the era of minimally invasive surgery, laparoscopic adrenalectomy has now become the standard approach for most adrenal tumors. Clear indications for open surgery remain and the surgeon must be well versed with this technique. The absolute and relative indications for an open adrenalectomy include: Absolute 1. Known or suspected adrenocortical carcinoma 2. Complications (bleeding, bowel injury) during a laparoscopic adrenalectomy Relative 1. Reoperation for recurrent adrenal tumors 2. Large tumor size (>10 cm) 3. Local or vascular invasion 4. Extensive lymphadenopathy 5. Virilizing tumors in women or feminizing tumors in men because up to 80% of these tumors are adrenocortical carcinomas

43.5.1 Anterior Approach The anterior approach is the most common open procedure performed. The advantages of utilizing this approach are the surgeon’s familiarity with the anatomy, feasibility of performing a complete abdominal exploration, and accessibility to the contralateral gland without needing to reposition the patient. These benefits must be outweighed by the increased morbidity associated with the open approach; for example, wound complications in obese Cushing’s patients. The incision should be tailored to the surgeon’s familiarity and includes a midline, bilateral subcostal, or unilateral subcostal incision. Upon entering the peritoneal cavity, a thorough abdominal exploration is performed.

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43.5.1.1 Right-Sided Tumor Right-side dissection is begun by obtaining adequate exposure. The triangular ligament of the liver is dissected and the liver is retracted superomedially. If the tumor is large or has a retrohepatic extension, the coronary ligament may be divided to completely mobilize the right lobe of the liver. The hepatic flexure of the colon is taken down and the colon is retracted caudad. A Kocher maneuver may be performed to mobilize the duodenum medially. These maneuvers provide wide exposure to the adrenal gland and inferior vena cava (IVC). Meticulous dissection should proceed along the medial border of the gland, from superior to inferior, to identify the right adrenal vein. The right adrenal vein courses a short distance to enter the IVC posteriorly. The vein is carefully doubly ligated and divided. Several small arteries supply the adrenal gland and should be divided. Accessory adrenal veins may also be present; these should be divided after assuring that they do not correspond to the renal vascular pedicle. Dissection ensues along the inferior border of the adrenal gland laterally. The Harmonic scalpel or Ligasure can be used to expeditiously divide the inferior and lateral attachments of the adrenal gland.

43.5.1.2 Left-Sided Tumor The key to resecting left-sided adrenal tumors is also exposure. First, the splenic flexure is mobilized by dissecting the lateral aspect of the gastrocolic ligament and the superior lateral attachments of the descending colon. Further exposure is obtained by dividing the lateral attachment of the spleen and pancreas to reflect both organs anteromedially. As with right-sided tumors, dissection proceeds along the medial border of the adrenal gland. The inferior phrenic vein has a superolateral to inferior course and is usually encountered first. This vein should be ligated and divided. The left adrenal vein is longer than the right and drains into the left renal vein rather than the IVC. It should be doubly ligated and divided along its course in the inferior-medial aspect of the adrenal gland. The rest of the dissection proceeds in a similar fashion as right-sided tumors.

43.5.2 Posterior Approach The posterior approach was initially described by Young in 1936 [7]. The advantage of this approach is

M.A. Guerrero and W. Shen

that it is extraperitoneal and avoids a large abdominal wound and its associated complications. It also offers a more direct route to the adrenal glands compared to the other open approaches. The disadvantage is that only one gland can be resected per incision. It is also limited by the exposure for large tumors, so the limit of resection is up to 5 cm [9]. Also, vascular exposure and control is more challenging with this approach. As with any other surgical procedure, positioning and exposure is the key to a successful operation. The patient is placed in prone jack-knife position with the bend of the table at the level of the 12th rib. A transverse incision that follows the course of the 12th rib or a hockey stick incision is performed through the subcutaneous tissues. The latissimus dorsi muscle and sacros­ pinalis muscle are transected. The costal attachment of the sacrospinalis muscle is transected. The lumbodorsal fascia is then incised and the posterior subcostal ligament is divided to release the pleura. The 12th rib is divided after the periosteum is elevated. The 11th rib and pleura are then retracted upward. After this exposure, dissection begins through perinephric fat to expose Gerota’s fascia. The kidney is retracted caudally and the adrenal gland is dissected from superior to inferior direction. Vessels entering the adrenal gland are carefully divided. The adrenal vein is then doubly liga­ted and divided. Dissection continues circumferentially to freely mobilize the adrenal gland [9].

43.6 Laparoscopic Adrenalectomy The first transabdominal laparoscopic adrenalectomy was performed by Gagner et  al. in 1992 [10]. Since then, it has become the gold standard approach for benign adrenal tumors. The advantages of the laparoscopic approach is the shorter hospital stay, improved recovery time, decreased pain, and reduced blood loss compared to the open approach [11]. In 1995, Mercan et  al. described the posterior laparoscopic adrenalectomy [12]. Though many surgeons prefer the transabdominal approach because of familiarity with the anatomy, the use of the posterior approach has become more prevalent [13, 14]. This approach allows direct access to the adrenal gland and vasculature without needing to mobilize any abdominal organs. This is especially advantageous in patients with prior abdominal surgery. Both laparoscopic approaches are described below.

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43.6.1 Transabdominal Lateral Approach 43.6.1.1 Right-Sided Tumor The patient is positioned in the left lateral decubitus position (right-side up). A 1 cm transverse incision is made in the midclavicular line. A Veress needle is inserted to establish pneumoperitoneum to 15 mmHg with CO2. A 10 mm trocar is inserted for a 30-degree camera. Under direct visualization, a 10  mm port is placed laterally at the anterior axillary line. Two more 10  mm ports are placed, splitting the difference between the previously inserted ports. All ports should be placed 1–2  cm below the costal margin. A liver retractor is inserted through the most medial port for anteromedial retraction. The angled camera is used through the adjacent port. The remaining two lateral ports are the surgeons working ports. The surgeon stands on the left side of the table with the assistant standing adjacent and cephlad to the surgeon. The key to a successful and bloodless operation is adequate exposure by first mobilizing the liver. The lateral hepatic attachment is divided utilizing hook electrocautery and the dissection is continued to the triangular ligament. The liver fan-retractor is used to retract the liver anteromedial. The dissection is then continued in a cephlad to caudad direction creating a “V” in the plane between the IVC and medial border of the periadrenal tissue. We prefer hook electrocautery for this part of the procedure because it allows for optimal visualization. Cautious dissection should continue inferiorly as the adrenal vein is approached. The adrenal vein has a short course as it exits the medial border of the adrenal gland. A blunt grasper is then used to carefully dissect the adrenal vein free. The vein is divided after placing two clips medially and one laterally. Dissection is continued along the inferomedial aspect of the adrenal gland with the adrenal gland retracted superolaterally. This allows for clear visualization of the kidney and avoids potential injury to the hilar vessels. Once the superior pole of the kidney is visualized, the Harmonic scalpel is used to finish the dissection laterally. The adrenal tumor is removed in a specimen bag through the lateral port. Tumor morselization allows for effortless removal without needing to extend the port incision. The ports are then removed under direct visualization after confirming adequate hemostasis. The incisions are closed in standard fashion.

43.6.1.2 Left-Sided Tumor The patient is placed in the right-lateral decubitus position with the left side up. The surgeon and assistant stand on the right side of the table in the positions outlined above. The abdominal cavity is accessed as described for right-sided tumors except that three 10 mm ports are used. The first port is situated 2 cm below the costal margin at the midclavicular line. The lateral port is placed under direct visualization at anterior axillary line. The remaining port is placed between these two ports. The two lateral ports are the working ports. A fourth port may be inserted for additional retraction if visualization is inadequate. The splenic flexure is first mobilized to expose the splenorenal ligament. The splenorenal ligament is divided in a cephlad direction until the stomach and short gastric vessels are visualized. This allows for medial mobilization of the spleen and tail of the pancreas. As described for right-sided tumors, the hook electrocautery is used to dissect in a cephlad to caudad direction creating a “V” between the aorta medially and periadrenal tissue laterally. The inferior phrenic artery is often encountered along its superolateral course from the aorta and may be divided with impunity. Caution should be used along the inferior border of the adrenal gland as the adrenal vein exits along the inferomedial margin of the gland. Once the vein is bluntly dissected free, it is transected between clips. The adrenal gland is retracted in a superolateral direction and the Harmonic scalpel is used to continue the dissection laterally. It is important to visualize the superior pole of the kidney before proceeding with the lateral dissection to assure that the renal vessels are free from the tumor. The specimen is removed in a specimen bag. Hemostasis is confirmed prior to removing the ports and the incisions are closed in the standard manner.

43.6.2 Posterior Approach General endotracheal anesthesia is performed in the supine position. The patient is then placed in the prone position. The pressure points are protected with padding and the thorax is secured laterally with bolters. Once the patient is secured, the table is placed in the jackknife position. A transcuteneous ultrasound can be

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used to map the kidney and adrenal tumor on the skin [13]. The technique used is modified by that described by Walz et al. [14, 15]. A 1.5 cm transverse incision is made 2  cm inferior and parallel to the 12th rib. The retroperitoneum is accessed using an open technique. An index finger is then used to create a space within the retroperitoneum. A 10 mm port is placed medially using the index finger to guide its entry. The same technique is used to place a lateral 10 mm port. A 10 cm spherical dissecting balloon may also be used to create a space within Gerota’s fascia under direct visualization [13]. After all three ports are placed, pneumoretroperitoneum is achieved to 20–24 mmHg with CO2. A 30° videoscope is placed into the middle port. Blunt dissection is used to create a space within the retroperitoneum. Gerota’s fascia is entered and the superior pole of the kidney is identified. The adrenal gland is dissected along its inferior margin by bluntly retracting the periadrenal tissue cephlad and kidney caudad. Dissection proceeds medially until the adrenal vein is identified. The vein is then clipped and tran­ sected. Using a Harmonic scalpel, the adrenal gland is dissected laterally and superiorly. Leaving the superior attachments of the adrenal gland optimizes visualization of the adrenal vein. Another technique is to approach the adrenal gland along the superior margin to separate it from the diaphragm. The harmonic scalpel is used and dissection continues laterally. The inferior border is then dissected off the superior pole of the kidney. The medial border is dissected last and the adrenal vein is carefully transected after clips are applied. The adrenal gland is removed using an endobag and the incisions are closed in the usual manner after assuring that hemostasis is achieved.

43.7 Complications The risks of adrenalectomy should be discussed with the patient in detail prior to proceeding with surgery. It is also important to set accurate patient expectation. Open procedures are associated with increased morbidity compared to the laparoscopic approach. The open approach may result in more pneumonia, unplan­ ned intubation, unsuccessful ventilator wean, systemic sepsis, cardiac arrest, renal insufficiency, and wound infections [6]. The patient should also be aware that the laparoscopic approach is associated with a 0–4.5%

M.A. Guerrero and W. Shen

conversion rate [3]. Studies comparing open versus laparoscopic adrenalectomy have shown that the open approach results in increased operative times (3.9 ± 1.8 h versus 2.9 ± 1.3 h, p < 0.0001), transfusion requirements (0.7 ± 1.8 U versus 0.1 ± 0.5 U, p < 0.0001), length of stay (9.4 ± 11.0  days versus 4.1 ± 4.7  days, p < 0.0001) and 30-day morbidity rates (17.4% versus 3.6%, p < 0.0001) [16].

43.8 Summary Although rare, the medical and surgical implications of adrenal lesions are clinically significant. Identi­ fication of symptoms and syndromes may be the more common presentation in rural populations with less access to advanced radiologic imaging. Regardless of presentation, the discussed biochemical work-up and radiologic evaluation is vital. Laparoscopic approach has well-documented benefits when indications are appropriate. Consideration for referral is based on surgical and anesthesiology expertise and should be strongly considered in rural environments with limited medical and critical care support.

References   1. Allolio, B., Fassnacht, M.: Clinical review: adrenocortical carcinoma: clinical update. J. Clin. Endocrinol. Metab. 91, 2027–2037 (2006)   2. Caoli, E.M., Korobkin, M., Francis, I.R., Cohan, R.H., Platt, J.F., Dunnick, N.R., Raghupathi, K.I.: Adrenal masses: characterization with combined unenhanced and delayed enhanced CT. Radiology 222, 629–633 (2002)   3. Gagner, M., Lacroix, A., Bolte, E.: Laparoscopic adrenalectom in cushing syndrome and pheochromocytoma. N. Engl. J. Med. 327, 1003–1006 (1992)   4. Grant, C.S.: Pheochromocytoma. In: Clark, O.H., Duh, Q.Y., Kebebew, E. (eds.) Textbook of Endocrine Surgery, 2nd edn, pp. 621–633. Elsevier, Philadelphia (2005)   5. Kebebew, I., Siperstein, A.E., Duh, Q.Y.: Laparoscopic adrenalectomy: the optimal surgical approach. J. Laparo­ endosc. Adv. Surg. Tech. 11, 409–413 (2001)   6. Lee, J., El-Tamer, M., Schifftner, T., Turrentine, F.E., Henderson, W.G., Khuri, S., Hanks, J.B., Inabnet III, W.B.: Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program. J. Am. Coll. Surg. 206(5), 953–959 (2008)   7. Mercan, S., Seven, R., Ozarmagan, S., Tezelman, S.: Endoscopic retroperitoneal adrenalectomy. Surgery 118, 1071–1076 (1995)

43  Adrenal Surgery   8. NIH: NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”). NIH Consens State Sci. Statements 19(2), 1–25 (2002)   9. Perrier, N.D., Kennamer, D.L., Bao, R., Jimenez, C., Grubbs, E.G., Lee, J.E., Evans, D.B.: Posterior retroperitoneoscopic adrenalectomy: preferred technique for removal of benign tumors and isolated metastases. Ann. Surg. 248(4), 666–674 (2008) 10. Quiros, R.M., Wilhelm, S.M., Prinz, R.A.: Open operative approaches to the adrenal gland. In: Clark, O.H., Duh, Q.Y., Kebebew, E. (eds.) Textbook of Endocrine Surgery, 2nd edn, pp. 641–646. Elsevier, Philadelphia (2005) 11. Schteingart, D.E., Doherty, G.M., Gauger, P.G., Giordano, T.J., Hammer, G.D., Korobkin, M., Worden, F.P.: Management of  patients with adrenal cancer: recommendations of an

329 i­nternational consensus conference. Endocr. Relat. Cancer 12(3), 667–680 (2005) 12. Singh, P.K., Buch, H.N.: Adrenal incidentaloma: evaluation and management. J. Clin. Pathol. 61, 1168–1173 (2008) 13. Siperstein, A.E., Berber, E., Engle, K.L., Duh, Q.Y., Clark, O.H.: Laparoscopic posterior adrenalectomy. Arch. Surg. 135, 967–971 (2000) 14. Walz, M.K., Peitgen, K., Hoermann, R., Giebler, R.M., Mann, K., Eigler, F.W.: Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: results of 30 adrenalectomies in 27 patients. World J. Surg. 20, 769–774 (1996) 15. Young, H.H.: A Technique for simultaneous exposure and operation on the adrenals. Surgery 63, 119 (1936) 16. Young, W.F.: The incidentally discovered adrenal mass. N. Engl. J. Med. 356, 601–910 (2007)

 

44

Breast Surgery David Walsh

44.1 Introduction Surgical procedures on the breast divide logically into those performed for benign disorders (including diagnostic procedures) and surgical interventions for malig­ nant disease. For benign conditions, cosmesis is a key consideration, whilst for malignant disease the focus is clearly oncological control. This chapter will address the following operative procedures for both benign and malignant diseases. Benign disorders • • • •

Breast abscess Mammary fistula Incisional breast biopsy Excisional breast biopsy −− Palpation −− Guided • Microdochectomy • Central duct excision Malignant disease • Wide local excision −− Palpation −− Guided

• Mastectomy • Sentinel lymph node biopsy −− Axillary −− Internal mammary • Axillary clearance

44.2 Benign Disorders 44.2.1  Breast Abscess Breast abscesses have traditionally been considered to be a lactation-related phenomenon. Recently, early post-natal care employing breast emptying techniques, antibiotics and lactation suppression, have reduced the need for surgical drainage of breast abscesses in this situation. In current surgical practice, most abscesses requiring operative drainage are seen in peri-­menopausal women, usually secondary to infections arising in areas of duct ectasia. In general, infected localised collections in the breast can often be successfully managed by antibiotic cover for gram-positive and anaerobic organisms, and repeated needle aspiration, either by palpation or more commonly targeted by ultrasound. However, if a patient is systemically unwell, has an abscess >5 cm, fails to respond to repeated aspiration or there are features where the possibility of malignancy is present, then open surgical intervention is indicated. 44.2.1.1 Technique

D. Walsh Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

• General anaesthesia is preferred. • The incision should be placed over a central area of the abscess. If possible, a circumareolar incision will be most cosmetic in the long term.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_44, © Springer-Verlag Berlin Heidelberg 2011

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• The incision is deepened towards the liquefied ­centre of the abscess, which may only be a small component of the entire inflammatory mass. If the pus within the mass is difficult to identify, it can be helpful to probe the area with an artery forceps. • Once the abscess cavity is identified, a swab for culture is taken and any loculations are broken down to create a single space, the incision is enlarged to give adequate access for post-operative dressings. • A full thickness biopsy of the abscess wall should be sent for histological assessment in all cases. • After lavaging the cavity with saline and establishing haemostasis, the cavity is packed lightly with a  dressing, with an alginate dressing being most ­comfortable for the patient post-operatively.

• After establishing haemostasis, the cavity is packed lightly with a dressing, with an alginate dressing being most comfortable for the patient postoperatively.

44.2.1.2 Rural Issues

44.2.3 Incisional Breast Biopsy

• Antibiotics are generally not needed after 48 h. • Nursing care will consist of daily dressings for a week and then two to three dressings weekly for around 6 weeks (often easier to organise in the rural setting than the city). • Breastfeeding patients will almost always need phar­maceutical suppression of lactation, DOSTINEX (Cabergoline) 1 mg stat orally works within 24 h.

Incisional biopsies are performed where there is a large breast lesion that cannot be excised for technical reasons (e.g. malignancy fixed to chest wall) or cosmetic reasons where the area is likely to be a benign process. Increasingly, locally advanced stage III breast cancers are being offered neo-adjuvant therapy prior to resectional surgery; in these cases, a core or incisional biopsy is generally undertaken before treatment begins.

44.2.2 Mammary Fistula

44.2.3.1 Technique

Most women with mammary fistulae have underlying duct ectasia. In cases of recurrent disease, the procedure of central duct excision may be more appropriate than just laying open the fistula surgically.

• General or local anaesthesia are suitable. • The key issues are the placement of the incision and securing haemostasis. • Incisions must be placed within the skin envelope that would subsequently be excised in a resectional procedure, such as a mastectomy. • The tissues removed should include viable tumour (necrotic material alone is unhelpful) and skin if dermal involvement is present. • If the pathological process could be benign, judgement is needed in removing enough tissue for a diagnosis, without needlessly distorting the breast. • Bleeding, wound breakdowns and infections delay treatments and distress patients. • Tissue should be formalin fixed, oestrogen, progesterone and Her2 receptor assays are routinely requested.

44.2.2.1 Technique • General anaesthesia is generally preferred, and a single dose of prophylactic antibiotics given. • The fistula opening on the areolar margin in carefully entered with a medium lacrimal probe and the fistula into the nipple is defined. • The fistula is laid open onto the probe. • The epithelialised lining and any granulation tissue is curetted away. Tissue should be sent for biopsy and culture.

44.2.2.2 Rural Issues • Nursing care will consist of daily dressings for a week and then two to three dressings weekly for around 6 weeks (often easier to organise in the rural setting than the city). • A key risk factor for mammary fistulae is nicotine usage and if possible this should be addressed before surgical intervention.

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44.2.3.2 Rural Issues

44.2.4.2 Rural Issues

• Incisional biopsies are virtually always performed on palpable lesions, so localization issues are rare. • This procedure is an important early step in breast cancer management and is readily achieved in the rural setting. • Usually multi-disciplinary consultation is undertaken prior to an incisional biopsy for breast cancer. • Frozen section assessments have almost nothing to add in this procedure.

• This is an ideal procedure for the rural settings. • The technique can be used for palpable and imagedetected lesions. For image-detected lesions, localization using a hook wire or carbon technique can be used. (see Wide Local Excision). • Ultrasound is used for mass imaging lesions and a  hook wire employed for areas of more subtle ­mammographic distortion or calcification. • Localised biopsies can be undertaken in rural centres, but will depend on the timely availability of radiological services. • Frozen section assessments have almost nothing to add in this procedure. • Pathology in the removed specimen must be correlated with the pre-op expectations, biopsies and imaging. Often, follow-up with imaging 3 months after the biopsy is prudent, to ensure that a missed lesion is not still present.

44.2.4 Excisional Biopsy Removal of an entire breast lesion is performed for therapy in benign masses and for diagnostic purposes in indeterminate cases. Unlike excisions in cases of proven malignancy, cosmetic considerations are forefront, and the lesion is removed intact but with a ­minimal margin.

44.2.4.1 Technique • A palpable mass must be marked with the patient awake and involved, if there is any doubt around identification (often an initial biopsy haematoma resolves)….stop, re-think, localise. • General or local anaesthesia are suitable. • The key issues are the placement of the incision and securing haemostasis. • Incisions must be placed within the skin envelope that will subsequently be excised in a resection ­procedure, such as a mastectomy. Skin is usually not removed for an excision biopsy. • A surgical margin of a few millimetres is adequate. • Avoid the temptation to diagnose a malignant process with your fingers and change to an unplanned more radical procedure. Await formal histology. • Closure is an important issue. The author prefers to avoid closing the deep breast cavity. This allows a controlled seroma to form, which gradually resorbs leaving minimal cosmetic distortion in the long term. • Drains are generally not required.

44.2.5 Microdochectomy Microdochectomy is the removal of a specific breast duct in isolation, as compared to central duct excision, which removes the entire retro-areolar duct complex. This procedure allows the diagnosis and treatment of pathological nipple discharges, whilst preserving the ability to subsequently breastfeed. It is the procedure of choice for nipple discharge in the setting of younger women (who wish to breastfeed), a single duct discharge and bloody nipple discharge (where a localised, intraduct papilloma is likely).

44.2.5.1 Technique • General anaesthesia is usually preferred. If local anaesthesia is employed, adrenaline and vasospastic agents must be used with caution around the nipple. • The pathological duct is identified by expressing fluid (avoid attempting to express any discharge fluid for several days prior to the procedure) and then cannulated with a lacrimal probe. • A radial incision is performed over the line of the probe from the duct orifice towards the areolar

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•

•

• • •

­ argin. It is not necessary to go beyond this marm gin, and incisions within the nipple aeolar complex will heal virtually imperceptibly. With the lacrimal probe in place, fine scissors are used to develop the plane adjacent to the pathological duct. Surrounding ducts are left intact. Dissection of the duct extends radially outwards until retromammary fat or non-pathological breast parenchyma is identified. The specimen is orientated and sent for histology. Haemostasis is secured and the cavity is closed in layers with absorbable sutures. No drain is required.

44.2.5.2 Rural Issues • Pre-op imaging with mammography and ultrasound is essential. • If the pathology being dealt with is likely to be mammary duct ectasia, then microdochectomy has a significant rate of discharge recurrence. Central duct excision may be more appropriate. • If the pathological duct cannot be identified, it may be prudent to abandon the procedure and await events.

44.2.6 Central Duct Excision This procedure involves the complete removal of the retroareolar breast ducts. It is the procedure of choice for women with multiple discharging ducts in the setting of mammary duct ectasia or recurrent mammary fistulae. This procedure precludes subsequent breastfeeding and so must be used selectively in younger women. It is both therapeutic and diagnostic and can be used for recurrent discharges after microdochectomy.

44.2.6.1 Technique • A single dose of prophylactic antibiotics with gram positive and anaerobic cover should be considered. • General anaesthesia is usually preferred. If local anaesthesia is employed, adrenaline and vasospastic agents must be used with caution around the nipple.

D. Walsh

• A circumareolar incision is used along the inferior line of the nipple complex. This avoids compromising the blood supply to the nipple, which enters via subcutaneous vessels at 2 and 10 o’clock. • A plane under the areola is developed, avoiding ­buttonholing or compromising the viability of the nipple or areola, until the breast ducts under the nipple are identified. • Blunt dissection with an artery forceps is used to encircle the duct system and then to clip the bunched ducts. • The ducts are amputated just below the nipple and the clip on the duct stumps is used for retraction whilst the duct system is sharply dissected as a disc of tissue down to the retro mammary fat. • The specimen is orientated and sent for histology. • Haemostasis is secured and the cavity is closed in layers with absorbable sutures. The cylindrical space is best closed with a series to deep purse string sutures. • A suction drain is used very selectively.

44.2.6.2 Rural Issues • Pre-op imaging with mammography and ultrasound is essential. • If a woman is still premenopausal, then a microdochectomy, which preserves the potential for breastfeeding, may be more appropriate.

44.3 Malignant Disease 44.3.1  Wide Local Excision (WLE) This procedure is used to locally resect proven breast malignancies. Unlike an excisional biopsy, there is a deliberate attempt to remove the known breast lesion with a macroscopic margin of normal surrounding breast parenchyma. A correctly performed WLE with pathologically proven clear margins and post-­operative radiotherapy is equivalent to performing a mas­ tectomy for the management of breast cancer. The decision to perform a WLE excision involves an important balance between adequate tumour control and final cosmesis of the breast. The introduction of

44  Breast Surgery

mammographic screening of asymptomatic women, with detection of smaller invasive breast cancers and higher rates of in situ malignancy, means that WLE is now the commonest procedure for breast cancer. Nearly all patients with breast cancer should have an overall management plan formulated before proceeding to a definitive procedure such as WLE. For invasive cancers, concurrent axillary lymph node staging is generally performed.

44.3.1.1 Technique • General anaesthesia is used in all but exceptional circumstances. • If there have been recent breast procedures (e.g. hook wire placement, SLNB studies), antibiotic cover is given. • Incisions must be placed within the skin envelope that would subsequently be excised in a resectional procedure, such as a mastectomy. • A key difference in the procedure occurs depending on whether the tumour is palpable or not. (a)  Palpable masses −− Carefully mark the tumour and establish the likely boundaries of the excision before making the incision. Prior biopsy sites are included if at all possible. −− Aim to excise an ellipse of skin over the tumour and sharply divide the breast parenchyma 2 cm for the tumour edge. This is most easily done on the side away form the nipple where the breast disc is less dense and the tumour margin more readily palpated. A 2-cm surgical margin will generally translate into an acceptable pathological margin of around 1 cm. −− Realise that final cosmesis relates closely to the extent of skin removed and less directly to the volume of tissue removed. −− The tissue removed is always excised from skin to chest wall, meaning that when subsequent pathology reports are considered, only the lateral margins of excision are relevant, re-excision or mastectomy will not improve superficial or deep margins if this approach is employed. −− Once the chest wall is identified, the tumour is mobilised and is more easily palpable, which assists in obtaining a clear margin on the central breast disc side.

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−− The specimen is orientated and sent for histology. Typical orientation uses different length sutures (short = superficial, medium = medial, long = lateral). −− After excision, the tumour cavity is carefully palpated to check for additional masses and the specimen is checked to ensure that there are adequate margins as far as can be discerned macroscopically. Many surgeons routinely re-excise or biopsy the narrowest margin. −− Tissue should be formalin fixed, oestrogen, progesterone and Her2 receptor assays are routinely requested. −− Careful haemostasis is secured. Bleeding, wound breakdowns and infections delay treatments and distress patients. −− Metallic clips are placed in the edges to facilitate subsequent radiotherapy planning and follow-up breast imaging. −− Closure is an important issue. The author prefers to avoid closing the deep breast cavity. This allows a controlled seroma to form, which gradually resorbs leaving minimal cosmetic distortion in the long term. −− Drains are generally not required. −− Tissue should be formalin fixed, oestrogen, progesterone and Her2 receptor assays are routinely requested. (b)  Non-palpable masses −− The tumour should be localised. Blind excisions are not acceptable. Ultrasound or stereotactic mammography can be used. Ultrasound is used for mass lesions and a stereotaxis employed for areas of more subtle mammographic distortion or calcification. −− Either a hook wire or a carbon track can be used for localization, but the surgeon must be aware of the details of the localization (site and direction). All relevant imaging must be available at the time of the procedure. −− All of the principles of WLE for palpable tumours apply to localised procedures. −− Whilst hook wires can be intercepted via a skin incision away from the insertion site in exceptional circumstances, for carbon tracks and most hook wires insertion sites are generally excised in the skin ellipse excised with the tumour. −− The principle is to follow the wire or track to the breast lesion. The hook wire is excised with a

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D. Walsh

pre-determined margin around the tip based on the tumour size. Masses are often palpable as they are approached. Using carbon, then the area to be removed is excised without interrupting (seeing) the carbon track. Remember, hook wires can be pulled out and diathermy lesions can look like carbon. The excised tissue is then sent for specimen mammography. Metallic clips on the specimen (1 = superior, 2 = medial, 3 = lateral) can allow orientation and interpretation of the specimen X-ray.

44.3.1.2 Rural Issues • WLE for palpable tumours is easily undertaken in the rural setting. • Issues of concurrent axillary surgery (SLNB), radiotherapy and systemic treatments for breast cancer are more complex. • Localised WLE can be undertaken in rural centres, but will depend on the timely availability of radiological services. • Hook wires can be placed 24 h ahead of the procedure, and carbon tracks can be undertaken well ahead of schedule. • The key rural issue is often the issue of specimen imaging during the intra-operative phase. • Specimen imaging and expert interpretation is a key requirement for localised WLE. • For mass lesions, surgeon-performed intra-op ultrasound can be a solution in the rural setting.

44.3.2 Mastectomy Whilst the majority of breast malignancies are now treated with breast conservation, there remains an important role for mastectomy that is unlikely to change. Current indications include: Extensive disease (large tumour, small breast, 4 cm is a watershed) Multi-centric/multi-quadrant disease (not necessarily just multi-focal)

Failed attempted breast conservation Desire for a single procedure in a marginally fit patient Extensive in situ malignancy Contraindication/desire to avoid radiotherapy Local recurrence after prior breast conservation and radiotherapy Prophylactic surgery Patient Preference Male breast cancer If mastectomy is contemplated, then a multi-­ disciplinary team opinion is recommended prior to surgery. Women facing a mastectomy need careful counselling and the involvement of an experienced breast care nurse. Locally advanced tumours (T3, 4) are best offered pre-op systemic neo-­a djuvant ­therapy, rather than attempting a heroic salvage mastectomy.

44.3.2.1 Technique • General anaesthesia is required. • Simple, total mastectomy is employed. No pectoral muscle resection is required unless there is unanticipated chest wall involvement. • Marking of skin flaps is important. Prior incisions and biopsy sites are excised whilst retaining sufficient skin for a tension-free closure. Care with tension and flap viability is especially important in the elderly and diabetics. • If immediate breast reconstruction is planned, then skin preserving flaps can be planned. • Skin flaps are dissected at the level of subcutaneous fat using scissor or cutting diathermy. • Breast tissue is excised from clavicle, to inframammary fold, leaving bare pectoral muscle. • Concurrent axillary surgery can be undertaken, or if mastectomy only is being undertaken, the dissection of the axillary tail ceases as soon as the clavipectoral fascia is reached. • The mastectomy specimen is orientated with a suture placed at 12 o’clock. Tissue should be formalin fixed, oestrogen, progesterone and Her2 receptor assays are routinely requested. • Haemostasis is secured and suction drains placed under the skin flaps and axilla if dissected.

44  Breast Surgery

• Drains under the mastectomy flaps can be removed at 48  h, and a temporary breast prosthesis can be used from this point. • Chest wall seromas can be drained by simple aspiration, but only if they are symptomatic. Patience is often needed if seromas are persistent, they will settle.

44.3.2.2 Rural Issues • Mastectomy, especially with axillary clearance, is well suited to a rural setting, but a rural setting alone does not justify treating a breast cancer with mastectomy. • Local rural supports are a great asset for women facing mastectomy, a breast care nurse is worth their weight in gold.

44.3.3 Sentinel Lymph Node Biopsy (SLNB) Essentially, SLNB has two advantages for women with invasive breast cancer. First, it offers reduced axillary/ arm morbidity compared to formal axillary clearance. Second, the combination of focused pathology and immunohistochemical studies performed on SLN offers better tumour staging. SLNB is most accurate when performed using a combination of radio lymphoscintigraphy and patent blue dye. This poses issues for performing the procedure in the rural practice. Successful SLNB requires co-ordination of expert radiology, nuclear medicine specialists and theatre staff. Surgeons performing SLNB need specific training in the procedure. Current evidence suggests that SLNB is indicated for all invasive breast cancers. It should not be for used for DCIS unless a mastectomy is being performed. Obviously involved LNs are contraindication to SLNB and these cases should proceed to formal axillary dissection.

44.3.3.1 Technique • General anaesthesia is usual, but the technique is easily adapted to local anaesthesia. • A limited incision of 2–3 cm is employed, usually transversely just below the hairbearing region of the

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axilla. If the SLNB has been marked at the time of lymphoscintography, this can be used to modify the incision placement. • The incision is deepened to divide the clavipectoral fascia at the edge of pectoralis minor, and the axilla is entered. • Here blue dye may be seen in lymphatic channels and these can be traced up to the SLN. • If no blue dye can be seen, then palpation and the gamma probe are used to identify the SLN. • All blue, all hot and all palpable lymph nodes are considered SLN. They should be carefully removed, preserving all axillary neurovascular structures. • If radio lymphoscintography is used, the initial gamma probe axillary counts should be reduced by at least 90% after hot SLN removal. Care needs to be taken to reduce shine through artefact counts from the primary tumour injection site. • Generally, four SLNs is the limit removed, but removing multiple SLNs does increase the accuracy of the procedure. • All SLNs are sent for histological examination, which should include serial slicing and routine ­epithelial IHC studies. • After obtaining haemostasis, the wound is closed in layers. No drain is used. • If a surgeon cannot identify an SLN confidently, they and the patient should be prepared to perform a level II axillary clearance to ensure accurate axillary staging (an axillary LN replaced with tumour may not take isotope or blue dye). • Patients with SLNs involved by tumour (including micrometastases) should be offered a completion Level II axillary clearance. • Intra-operative pathological assessment of SLNs is practised in some centres. It is however, not ­routine and generally not practical for rural surgeons. (a)  Radio Lymphoscintography • This procedure requires close co-ordination with an experienced nuclear medicine service. • The isotope injection can occur up to 24 h prior to the SLNB, the dose being adjusted to fit the timing of surgery. • Isotope injection technique varies. In Australia, it is common to inject each quadrant peritumourally, and if no SLN is seen after 90  min. to perform a  periareolar injection. In the USA, periareolar ­injection is done initially.

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• SLNs seen on lymphoscintography have their locations carefully marked on the skin pre-op. A positive SLN on lymphoscintography correlates closely with successful identification at surgery. • Non-palpable tumours may need image-guided injections. • A hand-held gamma probe must available in theatre. • Radiation exposures are minimal to all involved with standard techniques. (b)  Blue dye • Patent Blue V (Isosulafan Blue in the USA) is used. In the author’s experience, Methylene blue does not work, but different opinions about this exist with good results when used via periareolar injection. • Two millilitre of dye is diluted in 2 ml saline and injected as above, after the induction of anaesthesia, and the breast is massaged for 5 min. • Split dye can permanently tattoo the skin. • Impalpable tumours are usually dealt with by a quadrant localised injection. • The dye can interfere with pulse oximetry readings and cause blue urine. • Allergic reactions are uncommon (<1%), but potentially catastrophic. (c)  Extra-axillary SLNs • These occur in approximately 1–5% of cases. • They will only be identified if radio lymphoscintography is used. • They are controversial; the author’s practice is to resect such LNs only when no axillary SLN can be identified. • LNs in regions such as the supraclavicular fossa can be resected as per axillary SLNs. • Internal mammary SLNs are a particular challenge, as they are usually small, behind the costal cartilages and adjacent to the internal mammary vessels, lung and heart. • Additional scarring, haemorrhage, pericardial injury and pneumothorax are potential compli­cations. • The prognostic significance of extra-axillary SLNs is not clear.

44.3.3.2 Rural Issues • The ability to perform SLNB is one of the major challenges to breast cancer surgery in the rural setting.

D. Walsh

• Timely access to local nuclear medicine facilities and intra-op gamma probes make radio-guided SLN localization difficult for many rural surgeons. • Blue dye alone techniques are possible, but require formal training and usually a learning period using radioisotope techniques. • Case volume will often determine how practical it is to offer SLNB in a rural setting.

44.3.4 Axillary Clearance Prior to SLNB, axillary clearance was the benchmark for axillary staging in breast cancer. Indeed most studies in breast cancer have based patient prognosis on information obtained from this procedure. Its primary role has now been replaced by SLNB and this has been a challenge for rural breast surgery. Much of the feared surgical morbidity of breast cancer surgery (e.g. lymphoedema) relate to this procedure. Currently LN involvements rates are only 20–30% in breast cancer at diagnosis, and so for most women this procedure can be avoided. Bulky, fixed axillary LNs are best treated with pre-op systemic neo-adjuvant therapy, rather than attempting heroic procedures.

44.3.4.1 Technique • General anaesthesia is required. • A curved skin incision is made just below the border of the axillary hairbearing area. • The incision is deepened into the subcutaneous fat and superior and inferior skin flaps are raised over 3–4 cm to improve access to the axilla. The incision is considerably more cosmetic if it remains behind the anterior axillary skin fold. • The pectoralis muscle lateral border is defined and the clavipectoral fascia is opened. • Once the inferior border of the axillary vein is encountered, this forms the upper margin of dissection. Inferior tributaries of the axillary vein are then divided to begin mobilising the pyramid of fat and lymph nodes to be removed in the clearance.

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• It is generally accepted that an acceptable axillary clearance involves removal of level I and II nodes. This means nodes behind pectoralis minor, but not above, are removed. A typical yield would be 12–15 nodes. • Dissection above pectoralis minor medially and the axillary vein laterally, increases the risk of subsequent lymphoedema without oncological benefit. • In general, the axillary contents are removed in a complete fascial envelope, down to the axillary tail. • Removal of the lymph nodes involves a somewhat mystical combination of sharp and blunt dissection, diathermy, sutures, surgical clips and judgement. • The thoracodorsal nerve, long thoracic nerve and medial pectoral nerve should be identified and protected. The issue of preserving the sensory intercostobrachial nerves is more controversial, especially after a prior SLNB. • The removed specimen is orientated with an apical suture. Many surgeons submit the apical one or two nodes as a separate specimen. • A suction drain is placed and the wound closed in layers with absorbable sutures. • The drain is removed if it becomes non-functional, drains <40 ml in 24 h, or after 1 week.

• Axillary seromas can be drained by simple aspiration, but only if they are symptomatic. Patience is often needed if seromas are persistent, they will settle. • Early and full shoulder movements are encouraged immediately.

44.3.4.2 Rural Issues • Axillary clearance is a procedure well suited to rural practice. • Management of issues such as care for drains and dealing with post-op seromas is often easier using local rural supports, than it can be achieved in urban surgical practice.

Recommended Reading NHMRC Clinical practice guidelines management of early breast cancer. www.nbocc.org.au/bestpractice/resources/ CPG124_clinicalpracticeguid.pdf. Published 2001, accessed Jan 2010 NHMRC Recommendations for use of sentinel node biopsy in early (operable) breast cancer. www.nbocc.org.au/bestpractice/resources/SNBG_recommendationsforus.pdf. Published 2008, accessed Jan 2010

 

Skin Cancer: Current Surgery for This Common Problem

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R. Gwyn Morgan

45.1 Skin Malignancies Australia has the highest skin malignancy rate in the world. This is almost certainly due to the preponderance of fair-skinned individuals in our population and the high ambient solar ultraviolet radiation. Australians living in rural communities have the highest incidence of skin malignancies because of their occupations which subject them to high levels of radiation.

45.1.1 Basal Cell Carcinoma Basal cell carcinomas (BCCs) are the most common skin malignancies seen in Australia, the incidence being inversely related to latitude. Overall, males show a greater frequency than females. The highest incidence is in the areas exposed to the sun with the face being the commonest site. The paler skins of people of Northern European origins have the highest incidence. Basal cell carcinomas are clinically of three types, the nodular lesion, superficial spreading and the morphoeic type of tumour (Fig. 45.1a–c). The nodular BCCs and the morphoeic ones tend to occur more frequently on the head and neck whilst the superficial spreading BCCs occur more commonly on the trunk and limbs. The differing clinical types of BCCs are quite distinctive, the nodular lesions typically presenting as a translucent or pearly papule

R.G. Morgan  Department of Plastic Surgery, The Flinders Medical Centre, Bedford Park, SA 5042, Australia e-mail: [email protected]

nodule, which with time often shows a central area of necrosis and crusting formation. The superficial spreading BCCs present as erythematous plaques or macular lesions whilst the morphoeic tumours have more the appearance of an old scar and may have what appears to be skip lesions.

45.1.2 Squamous Cell Carcinoma Squamous cell carcinomas (SCCs) of the skin have only about one-third the incidence of BCCs. But like BCCs the incidence increases with decreasing latitude. The highest incidence again is on the face with the dorsum of the hands and forearms being the next most affected areas. Bowen’s disease is a variant of squamous cell ­carcinoma in that it is a squamous cell carcinoma in situ. Bowen’s disease is more commonly found on the limbs. Bowen’s disease tends to be reasonably well defined round or oval hyper keratotic plaques and they are usually quite erythematous. These lesions are usually long standing and grow only slowly (Fig. 45.2). SCCs initially have the appearance of an erythematous nodule and may be surrounded by areas of hyper keratosis. With the passage of time they become increasingly more tender. Ulceration and bleeding are common in these lesions (Fig. 45.3). Another lesion that may be confused with the squamous cell carcinoma is the keratoacanthoma. It is thought by some to be a well-differentiated form of squamous cell tumour; however, these spontaneously regress after growing very rapidly initially. Their distribution is similar to that of squamous cell carcinomas. The distinguishing feature of a keratoacanthoma is  the rapid growth with a dome shape that rapidly

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c

b

Fig. 45.1  (a) Nodular basal cell carcinoma. (b) Superficial spreading basal cell carcinoma. (c) Morphoeic basal cell carcinoma

Fig. 45.2  Bowen’s disease

Fig. 45.3  Squamous cell carcinoma

develops a central keratin plug. These can grow to quite a large size and are very often extremely tender. If one follows these, the keratin plug falls out and the lesion resolves, usually leaving a pale scar. However

the appearance of these tumours can be mimicked by a rapidly growing SCC. If one is suspicious of these, then total excisions of the lesion and histological analy­sis are mandatory (Fig. 45.4).

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45  Skin Cancer: Current Surgery for This Common Problem

SCC metastasis occurs more frequently with tumours on the hand and face. The factors influencing metastasis include tumour size (greater than 2  cm), depth of invasion (greater than 4 mm), the presence of perineural invasion and the degree of differentiation. Poorer differentiated lesions are more likely to metastasise. Patients who are immune suppressed are also more likely to show metastasis.

45.1.4 Merkel Cell Tumours

Fig. 45.4  Keratoacanthoma

45.1.3 Prognosis of Basal Cell and Squamous Cell Carcinomas The prognosis of BCCs depends very much on the site and the size and the depth of invasion of the lesion. The recurrence of basal cell carcinomas has been observed to be greater around the facial areas particularly lesions on the nose, eyes and ears. This may well reflect more conservative excisions in these particular regions. Once cartilage or bone is invaded, control of the disease may be more difficult because of one’s inability to accurately define the margins of the tumour. Perineural spread particularly from the nose and eyelid area also carries a graver prognosis as the tumour can track along the nerves to the brain. With SCC the prediction of the prognostic outcome will be aided by using the TNM classification where T is the size of the lesion, N is the presence or absence of involved regional nodes and M is the presence of distant metastases. This latter factor if present indicates a grave prognosis. The T classification extends from T1 to T4, T1 the tumour size less than 2  cm, T2 greater than 2–5  cm, T3 greater than 5  cm and T4 involving deep extra dermal structures such as cartilage, skeletal muscle or bone. The presence of nodal metastases significantly reduces the overall 5-year survival. Perineural spread is relatively rare in squamous cell tumours, the majority involving the facial cranial nerves and will necessitate a much wider excision of the primary lesion.

Merkel cell tumours are an extremely rare and aggressive form of skin cancer that are believed to arise in the neuroendocrine cells called Merkel cells. Like the pigment cells, they migrate from the neural crest to the skin. Their incidence is about 60 times less than that of melanomas. These tumours are rare in people under the age of 50 and like all of the other skin cancers are more common in the pale-skinned Northern European patients. The aetiology is unknown but it does appear to be linked to sun exposure and again the smaller the latitude the greater the incidence. These tumours present as pink or reddish nodule tumours that grow very rapidly over a few weeks or months, rather like keratoacanthomas. More than 50% of these tumours occur on the head and neck, especially around the eye and the eyelid. The next common areas of occurrence are on the sun-exposed parts of the arms and legs. These tumours are not usually painful and biopsy is usually required to differentiate them from the other skin malignancies (Fig. 45.5).

Fig. 45.5  Merkel cell tumour

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45.2 Melanoma Melanoma, if one excludes non-melanoma skin cancer, is the third most common cancer in Australia. Because in many cases diagnosis is delayed mortality is higher than it need be. A high index of suspicion should be maintained with all pigmented lesions if there has been any change in its appearance (Table 45.1 and Fig. 45.6). People with dysplastic naevi syndrome or firstdegree relatives with melanoma have a significantly higher risk of developing melanoma. Melanoma danger signs are listed in Table 45.1. Diagnosis can often be difficult and pigmented lesions need to be differentiated from pigmented melanoma (Table 45.2). Table 45.1  Melanoma danger signs 1. Change in size 2. Change in colour 3. Change in surface characteristics 4. Change in consistency 5. Change in shape or outline

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A useful guide for establishing the diagnosis of a melanoma is the ABCDE guide (Table 45.3). The differential diagnosis of the amelanotic melanoma is listed in (Table 45.4 and Fig. 45.7).

Table 45.2  Differential diagnosis of pigmented melanoma Dysplastic naevus Spitz naevus Pigmented basal cell carcinoma Blue naevus Haemangioma Pigmented seborrhoeic keratosis

Table 45.3  ABCDE guide for melanoma diagnosis A = Asymmetry B = Border C = Colour D = Diameter E = Elevation

6. Change in surrounding skin 7. Change in sensation 8. Sudden appearance of a new pigmented spot in an area that used to be normal

Table 45.4  Differential diagnosis of amelanotic melanoma Dermatofibroma Desmoplastic melanoma Pigmented basal cell carcinoma Spindle cell tumour

Fig. 45.6  Malignant melanoma

Fig. 45.7  Amelanotic malignant melanoma

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45  Skin Cancer: Current Surgery for This Common Problem Table 45.5  Prognostic factors for malignant melanoma Tumour thickness Clark level Mitosis rate Anatomical local of the tumour Ulceration Satellitosis

For a small pigmented lesion, i.e. 5 mm in diameter or less, excision biopsy is the preferred option (Fig. 45.8). The tumour should be marked out with the aid of magnification and then the proposed excision marked out above this. On the face, the orientation of excision should be along the lines of expression (Fig. 45.9).

Lymphatic invasion

Table  45.6  Ten-year survival of malignant melanoma related to tumour thickness Ptis – melanoma in situ

100%

PT1 – melanoma < 0.75-mm thick

99%

PT2 – melanoma < 0.75–1.5-cm thick

90%

PT3 – melanoma < 1.5–3-cm thick

75%

PT4 – melanoma < 3.0-cm thick

55%

45.2.1 Prognosis of Malignant Melanoma Fig. 45.8  Excision biopsy

In stages I and II of melanoma, where the disease is localised to the primary lesion site, the tumour thickness is a more objective indicator of prognosis than the Clark level. Microscopic satellitosis or lymphatic invasions are indicators of a high possibility of occult regional node metastasis. The higher the mitosis rate the worse the prognosis as is with the presence of ulceration. Tumour sites where a delay in diagnosis occurs frequently, such as subungual, sole of the foot and palm of the hand, scalp and ear, also have a worse diagnosis (Table 45.5). The 10-year survival rate for primary melanoma is closely related to the tumour thickness (Table 45.6).

45.3 General Principles for Excision of Skin Malignancy If unsure of the diagnosis a biopsy should be obtained. For larger tumours, a punch biopsy of at least 3 mm is usually adequate.

Fig. 45.9  Lines of expression

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Table  45.7  Recommended excision margins for malignant melanoma Ptis melanoma in situ

5 mm

PT1 or PT2 melanoma 0–1.5 cm

10 mm

PT3 melanoma 1.5–4 cm

10–20 mm

PT4 melanoma >4 cm

20–30 mm

(Excision depth should equal the minimal excision margin)

The margins of clearance depend on the nature of the tumour. With BCCs a 3 mm clearance is perfectly adequate. With SCCs the recommended margin is 4  mm. This also applies to keratoacanthomas, as the diagnosis may not be possible until the lesion has been excised. Merkel cell tumours, being so highly aggressive malignant tumours that metastasise early, should be  given a clearance of at least 3 and 5  cm if possible. Melanoma in situ requires a 5-mm margin, it should be pointed out, however, that the margins of in situ melanomas are often very indistinct and it is better to err on a slightly larger clearance. Melanoma, 0–1.5-mm thick, a 10-mm clearance is regarded as adequate. Melanomas thicker than 1.5 mm should have a margin of at least 2 cm. For lesions greater than 4  mm, the recommended margin is 3 cm around the lesion. The depth of the excision should equal the minimal excision margin where possible (Table 45.7). It is imperative that a marker suture for orientation for reporting by the pathologist is placed in every specimen. This enables the pathologist, if an incomplete excision has been carried out, to supply a diagram to show where the tumour extends to the margin.

older patients. Often the margins are quite indistinct and careful marking out of the lesion with magnification is recommended (Fig. 45.10). Many basal cell and squamous cell carcinomas can be excised and the defect closed primarily. On special areas such as the nose, eyelids and ears skin grafts or skin flaps may be necessary for closure. Full thickness skin grafts are to be preferred in these areas as they do not contract and will give a better aesthetic result. It is possible to place dermis grafts beneath these grafts later to fill in contour defects (Fig. 45.11a, b). Melanoma excision may be followed by direct closure, graft or flap repair depending on the site and adequacy of excision (Fig. 45.12a, b). Prophylactic node dissection is not recommended in the absence of confirmed lymph node involvement. Confirmation should be obtained by needle biopsy in the first instance or if the surgeon is trained in the technique then sentinel node biopsy is an alternative.

45.3.1 Lentigo Maligna Lentigo maligna (Hutchinson’s Freckle) is an in situ melanoma. These lesions are often seen on the face of

Fig. 45.10  Lentigo maligna

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a

b

Fig. 45.11  (a) Skin lesion prior to excision. (b) Skin lesion after full thickness skin graft

Subungual melanomas on fingers or toes should be treated by ray amputation (Fig. 45.13a–c). In the case of the thumb, disarticulation at the inter-phalangeal joint along with skin to just proximal to the metacarpo-phalangeal joint will give

adequate clearance. This can then be reconstructed with a flap such as a groin flap along with a ­n eurovascular island flap from the ring finger to ­p rovide sensation to the new pulp and tip (Fig. 45.14a–c).

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Fig. 45.12  (a) Rotation skin flap for melanoma excision prior to surgery. (b) Complete healing after melanoma excision and closure with skin flap

Fig. 45.13  (a) Malignant melanoma on fourth toe. (b) Outline of fourth ray amputation. (c) Surgical result after ray amputation

45  Skin Cancer: Current Surgery for This Common Problem

a

b

c

Fig.  45.14  (a) Malignant melanoma of the thumb. (b) Intraoperative finding after resection of the tumour. (c) Result after r­ econstruction or the thumb

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Pediatric Surgery

46

Thao T. Marquez, Mara B. Antonoff, and Daniel A. Saltzman

46.1 Introduction Children can be a unique challenge to the general surgeon. They may present with a special set of surgical problems related to congenital anomalies or specific to pediatric pathophysiology. Surgical diagnoses that are common to adults and children require additional consideration of the age-specific physiology of the child.

ranges (Table 46.1). A child’s cardiopulmonary reserve is large; therefore, hypotension will be a late manifestation of an uncompensated shock state. Infants and young children are at high risk for hypothermia and significant hypovolemia from insensible losses; therefore, close attention should be paid to maintaining normothermia, with radiant heaters, and replacing fluids aggressively with warmed solutions.

46.2.2 Fluid Resuscitation 46.2 Pediatric Physiology and Resuscitation 46.2.1 Age-Specific Physiology When evaluating a pediatric patient, especially in the newborn period, important physiologic differences must be noted. Their smaller size, volume capacities, and immature organ systems make them physiologically distinct from adults. When evaluating vital signs in a child, one must consider age-specific normal

T.T. Marquez and M.B. Antonoff Senior Resident in Surgery, Department of Surgery, University of Minnesota, 195 MMC 420 Delaware Street SE, Minneapolis, Minnesota 55455, USA D.A. Saltzman (*) Associate Professor of Surgery and Pediatrics Chief, Division of Pediatric Surgery, University of Minnesota Medical School, Surgeon-in-Chief, University of Minnesota Amplatz Children’s Hospital, 195 MMC 420 Delaware Street SE, Minneapolis, Minnesota 55455, USA e-mail: [email protected]

When assessing a child’s fluid replacement needs, one must assess the child’s preexisting fluid deficits, ongoing metabolic demands, and ongoing fluid losses. Volume depletion should be categorized as mild (5%), moderate (10%), or severe (>15%). Signs and symptoms of volume depletion in a child include weight loss, mental status changes (hyperirritable to lethargy), elevated heart rate, delayed capillary refill time (>2 s), dry mucous membranes, dry or sunken eyes, absence of tears, and a sunken fontanel. For mild volume deficit, and if able, one should consider oral replacement fluids. Moderate or severe volume depletion should promptly be replaced intravenously. An initial 20 ml/ kg fluid bolus of isotonic fluid (normal saline or Lactated Ringers) should be administered. Repeat the crystalloid bolus once as needed. Additional hypovolemia due to blood loss should be replaced with packed red blood cells at 10 ml/kg, repeated as needed once. Goals of fluid resuscitation include correction of water deficits, electrolyte abnormalities, and metabolic acidosis. Following initial fluid resuscitation, the child should be placed on age and weight appropriate IV maintenance fluids.

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Table 46.1  Normal pediatric vital signs Age Heart Blood rate pressure

Respiratory rate

Premature

120–170

55–75/35–45

40–70

0–3 months

100–150

65–85/45–55

35–55

3–6 months

90–120

70–90/50–65

30–45

6–12 months

80–120

80–100/55–65

25–40

1–3 years

70–110

90–105/55–70

20–30

3–6 years

65–110

95–110/60–75

20–25

6–12 years

60–95

100–120/60–75

14–22

12+ years

55–85

110–135/65–85

12–18

46.2.3 Vascular Access Vascular access in the child and infant can be challenging. Vascular access procedures are one of the most commonly performed procedures by pediatric surgeons. Peripheral access sites are initially attempted. These include the superficial dorsal veins of the hands and feet. In infants, scalp vein including the superficial temporal, supratrochlear, and posterior auricular veins are options. If peripheral IV access cannot be accomplished, and dependent on the urgency of the clinical scenario, other vascular options exist such as interosseous access, peripheral vein cut-down, or central venous access. Interosseous access can provide rapid access to the venous system in the acute emergency setting. This allows for fluid resuscitation, blood sampling for laboratory data, and the administration of drugs. The proximal tibia is the ideal site for interosseous access. A 15–18 gauge, half long bone marrow aspirate needle is inserted approximately 2 cm below the tibial tuberosity at a 45–60° angle inferiorly, away from the growth plate. Other less common sites for interosseous access are the distal tibia and fibula, sternum, and iliac crest. Contraindications include fracture or infection near the proposed insertion site, osteoporosis, and osteogenesis imperfecta. Peripheral vein cut-downs (via greater saphenous, median basilic, or cephalic veins) can be attempted given each surgeon’s comfort level/discretion. Central venous access in children is often referred to a pediatric surgeon.

46.3 Abdominal Pathology 46.3.1 Evaluation of the Pediatric Acute Abdomen History taking is complex in the ill child and often the parent must relay symptoms for their child, a difficult task. One should obtain as best as possible the time frame and duration of abdominal symptoms. Oral intake, to include their most recent meal, as well as symptoms of nausea and vomiting should be assessed. The character (e.g., bilious, projectile), frequency, and amount of emesis should be noted. Evidence of bowel inflammation should be documented (blood/mucous in stools) as well as any diarrhea, constipation, and change in stooling pattern should be noted. Subjective increase in abdominal girth, fevers, and sick contacts should also be queried. An important initial component of the physical exam is observation. Does the child appear sick? Is it lethargic? Abnormal vital signs should be noted and reassessed frequently. Anxiety, fear, and crying can make the abdominal exam challenging. Increased crying/fussing with abdominal exams could indicate tenderness. Evaluate for focal tenderness, with diffuse peritonitis often resulting in involuntary guarding or rebound tenderness. The abdomen should be inspected for distension and percussed. The inguinal areas as well as a rectal exam should always be performed in a child with abdominal pain.

46.3.2 Adjunct Studies in the Pediatric Patient Laboratory tests often supplement the clinical history and physical exam. A complete blood count, chemistry panel, and inflammatory markers Erythrocyte Sedi­ mentation Rate and C-Reactive Protein are often obtained. Urinalysis should also be performed. Abdo­ minal radiographs are commonly helpful to evaluate obstruction, constipation, and the evaluation for free air in the setting of an acute abdomen. Evaluation with CT imaging can be utilized, with care to minimize

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unnecessary ionizing radiation for children. Adjunct studies such as contrast enemas and abdominal ultrasounds often aid in the diagnosis.

performed. Each surgeon should weigh the risks and benefits of contralateral exploration based on their personal experience and expertise.

46.3.2.1 Specific Disease Processes

Abdominal Wall Defects

Appendicitis

Umbilical hernias are common reasons for children to present to a surgeon (incidence 10–25%). A majority of umbilical hernias close spontaneously by age 4. Evidence of incarceration or strangulation (rare) prompts emergent repair. Operative repair is recommended after age 4 or if the defect is larger than 1.5–2  cm. The fascial defect should be repaired primarily with running suture. Other abdominal wall defects include gastroschesis and omphalocele. For these conditions, referral for definitive care of these children to a pediatric surgeon and dedicated children’s hospital is recommended. As neonates with either gastroschesis or omphalocele can have a significant risk of evaporative fluid losses due to exposed abdominal contents/hernia sac, it is paramount to keep these newborns warm. Place the child in a sterile bowel bag to the axillae. An NG tube should also be placed for decompression of the gastrointestinal tract, early IV access must be established, and the child requires fluid resuscitation prior to transfer.

Pediatric appendicitis occurs at a mean age of 10–12 years and is rare in those <5 years old. Perforation occurs commonly between 12 and 24 h after onset of symptoms with a perforation rate approaching 35–45% in the pediatric population, with perforation rates as high as 65% in those under 5 years of age. History and clinical exam by a surgeon can accurately diagnose appendicitis in up to 80% of cases. Presenting symptoms commonly include abdominal pain, nausea +/− vomiting, anorexia, and fevers. Local tenderness often can be elicited over McBurney’s point or there may be evidence of diffuse peritonitis following appendiceal perforation. Evaluation with ultrasound or CT imaging can further confirm the diagnosis of appendicitis, however, should be reserved only for cases where the diagnosis of appendicitis is unclear. A palpable abdominal mass should be further evaluated with imaging. Treatment of appendicitis includes IV resuscitation, IV antibiotics and appendectomy for early acute appendicitis without complications such as a phlegmon or abscess. Open versus laparoscopic appendectomy approach should be based upon surgeon experience and skill.

Hernias The incidence of inguinal hernias in children ranges from 0.8% to 4%, with a higher incidence in premature infants (16–25%). Hernias most commonly occur on the right with a 3–10:1 male to female ratio. A patent processus vaginalis results in a congenital inguinal hernia. It is recommended that all hernias in children be repaired due to the risk of incarceration. Evidence of incarceration or ovarian contents at any age should be repaired emergently. High ligation of the hernia sac at the level of the internal inguinal ring should be

46.3.2.2 Obstructive Processes Pyloric Stenosis Hypertrophic pyloric stenosis (HPS) is a common surgical condition of infancy, presenting in 3/1,000 live births. The precise etiology remains unknown despite many theories (e.g., abnormal endocrine signals, work hypertrophy, neurologic immaturity, or degeneration, etc.). HPS commonly presents as non-bilious, projectile vomiting in a child 3–6 weeks of age. An epigastric mass or “olive” can typically be palpated. These children are often hypovolemic with a metabolic alkalosis. The study of choice to confirm the diagnosis is an abdominal ultrasound. HPS will often have US findings of a pyloric channel length greater than 15  mm and pyloric muscle thickness >4  mm. If the

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ultrasound is inconclusive or there is concern for gastroesophageal reflux or malrotation, an upper GI endoscopy should be performed. Following adequate resuscitation to correct any electrolyte abnormalities, the child should be taken to the operating room for an extramucosal pyloromyotomy. Surgeon preference and expertise should dictate operative approach (opensubcostal or periumbilical incision vs. laparoscopic). Postoperative recovery is typically rapid with ability to feed 6 h postoperatively if there was no concern for mucosal disruption.

Intussusception Intussusception refers to the prolapse of one segment of bowel (the intussusceptum) into the lumen of an adjoining segment (the intussuscipiens). In the ­pediatric population, intussusception most frequently involves the distal ileum invaginating into the coecum. The natural course of intussusception includes bowel obstruction and progressive bowel ischemia. Infants and toddlers represent the most commonly affected age group. An identifiable anatomic leadpoint for intussuception is uncommonly found in children. Most cases are idiopathic, and thought to be the result of hypertrophic Peyer’s patches in the face of viral gastrointestinal illness. Presentation frequently includes severe, intermittent abdominal pain, accompanied by vomiting and the passage of bloody mucous (red currant jelly) per rectum. A “sausageshaped” mass has been described in the right abdomen. For infants with suspected instussusception, barium (or air-contrast) enema is recognized as the gold standard for diagnosis, and additionally may provide therapeutic reduction, as well. This should be performed with a surgeon present, with the column of barium no greater than 3 ft high (app. 1 m), and with no greater than three attempts made. Indications for surgery include failure of enema reduction as well as initial presentation with peritonitis, sepsis, or suspicion of bowel necrosis. Access is gained through a right-lower quadrant incision. Appli­cation of retrograde pressure by squeezing the intussusceptum proximally within the intussuscipiens should be attempted. Resection should be performed if the intussusception cannot be reduced, if the reduced

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bowel appears nonviable, or if an anatomic lead-point is identified.

Bowel Atresia Duodenal atresia is felt to be due to a failure of recanalization of the lumen in utero. Its presentation resembles that of other sources of proximal obstruction, with bilious vomiting on the first day of life and a “double bubble” sign seen on abdominal plain film. Annular pancreas and duodenal web will present similarly. Surgical treatment is nearly always indicated, and the operation of choice is a duodenoduodenostomy. This is usually performed with a proximal transverse duodenotomy and a longitudinal distal duodenotomy, followed by anastamosis. In contrast to more proximal atresias, jejunal and ileal atretic segments result from in utero vascular accidents. The affected bowel subsequently becomes fibrotic or is entirely absorbed. Infants may present bilious vomiting in the first week of life, abdominal distention, and failure to pass meconium. Abdominal films will reveal dilated loops of bowel with air/fluid levels, and barium enema will show a small unused colon. Following appropriate resuscitation, the infant should be explored surgically. After identifying the area of atresia, the distal bowel should be opened and examined to rule out distal atresias. Prior to performing primary anastomosis, the dilated proximal segment should be tapered. The bowel should be run to exclude any synchronous lesions.

Malrotation Normal midgut anatomy results from in utero events including 270° of counterclockwise rotation and fixation of the cecum in the right iliac fossa and the duodenojejunal junction at the ligament of Treitz. Insufficient rotation (180°) or nonrotation may occur, followed by inappropriate fixation via adhesions known as Ladd’s bands. This can result in a narrow-based mesentery, leaving the bowel vulnerable to volvulus, ischemia, and loss of bowel supplied by the superior mesenteric artery. Patients with malrotation and midgut vovulus may present with abdominal pain, bilious emesis, and

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radiologic suggestion of small bowel on the right side of the abdomen, with the colon and coecum residing on the left. With suspicion of volvulus, urgent laparotomy is indicated in order to prevent loss of viable bowel. Operative repair includes resection of any compromised bowel, followed by a Ladd’s procedure: (1) detorsion of the midgut, (2) division of abnormal peritoneal attachments (Ladd’s bands), (3) broadening of the mesenteric vascular pedicle, and (4) incidental appendectomy to prevent future confusion due to unusual anatomy. If time permits referral for definitive care of these children to a pediatric surgeon and dedicated children’s hospital may be necessary.

46.3.2.3 Complex Abdominal Pathology Stabilization Children may present with a variety of complex abdominal pathologies, including, among other diagnoses, Hirschsprung’s Disease, necrotizing enterocolitis, imperforate anus, small left colon syndrome, and intestinal duplication. Regardless of the diagnosis, it is the role of the general rural surgeon to achieve stabilization followed by timely transfer to definitive care.

Resuscitation Children with obstructive processes, perforation, or abdominal sources of sepsis should have adequate vascular access, resuscitation to euvolemia (as assessed by age-appropriate urine output), initiation of nutritional supplementation, nasogastric decompression if obstructed, and appropriate antimicrobial therapy for bowel perforation or infectious etiologies.

Diversion/Decompression Patients with atresias and other anatomic causes of obstruction may need to be temporarily diverted prior to definitive management. Depending on the circumstances of transfer to definitive care, including distance, availability of transportation, and availability of receiving pediatric surgeon, diversion of enteric stream may be appropriate prior to transfer. Depending on the

child’s specific anatomy, this may be accomplished by diverting loop ileostomy.

When to Transfer All patients with complex abdominal pathology should be transferred to centers with pediatric surgeons and the availability of a pediatric critical care unit. Patients should be stabilized prior to transfer; however, transfer should not be delayed for diagnostic studies.

46.4 Genitourinary Pathology 46.4.1 Circumcision Circumcision is a common procedure performed by a variety of practitioners (surgeons, pediatricians, obstetricians, family practitioners). A general anesthetic is advised for boys greater than 6 weeks of age with local anesthesia in the form of a penile block for adolescents. Operative approaches include the dorsal slit circumcision, adjunctive devices such as the Gomco clamp or Plastibell®, or free hand sleeve circumcision. The circumcision suture line is covered with antibiotic ointment, which should be continued twice daily for 7–10 days.

46.4.2 Torsion Testicular torsion presents as acute, unrelenting scrotal pain with swelling. It may have associated nausea and vomiting. Physical exam should attempt to rule out other etiologies of scrotal pain such as inguinal hernia, epididymitis (non-tender testes with posterior tenderness at the site of the epididymis), or torsion of the appendix testis (upper pole testicular tenderness with blue nodular discoloration – “blue dot sign”). Diagnosis is confirmed with a doppler flow ultrasound. Attempt at manual detorsion should be made to preserve testicular viability. Emergent exploration should always be performed for suspected torsion, even with successful manual detorsion. Exploration is through a midline

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raphe incision. If the involved testicle is viable, bilateral orchidopexy should be performed by suture fixation of the tunica to the dependent scrotum. If obvious necrosis is present, the testicle should be removed.

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support. Nutrition should be provided enterally or parenterally, as appropriate.

46.5.3 Transfer to Definitive Care 46.4.3 Hydrocele A hydrocele in a child is the result of a patent or delayed closure of the processus vaginalis. It is a cystic mass, which transilluminates, and is non-tender. Simple hydroceles should be observed as most resolve by age 1. Aspiration of a hydrocele is contraindicated. Persistent hydroceles beyond age 1, or communicating hydroceles should be repaired via an inguinal approach.

Regardless of the etiology, patients with thoracic surgical pathology should be transferred to facilities with pediatric surgeons and the ability to provide multidisciplinary and critical care. This transfer should occur as soon as the patient has been stabilized, even if a definitive diagnosis has not been reached.

46.6 Pediatric Trauma 46.6.1 Initial Assessment

46.5 Thoracic Pathology 46.5.1 Evaluation and Differential Diagnosis There are a number of congenital thoracic abnormalities that may occur in a neonate, including diaphragmatic hernia, lobar emphysema, cystic adenomatoid malformation, pulmonary sequestration, bronchogenic cysts, esophageal atresia, and tracheoesophageal fistula. Esophageal atresia is strongly suggested when there is difficulty in passing a nasogastric tube, and the tube is seen to coil in the proximal esophageal pouch on X-ray. Congenital diaphragmatic hernia may be suspected in a neonate with respiratory distress, and may be confirmed with X-ray findings of air/fluid filled loops of bowel in the chest and mediastinal shift. In general, clinical clues to thoracic pathology include difficulty with breathing and oral intake. Helpful information may be found on plain radiograph alone, but diagnosis may require further studies such as a water soluble upper GI contrast series and chest tomography.

46.5.2 Stabilization Patients unable to ventilate independently should have definitive airways established and receive ventilatory

Children with traumatic injuries should be evaluated under the same principles of Advanced Trauma Life Support which are used for adults, beginning with a primary survey and adjunctive studies, followed by a secondary survey.

46.6.2 Primary Survey During the primary survey, the patient is examined systematically, with efforts directed toward identifying life threatening injuries and addressing them immediately as they are found. It is always conducted in the same sequence, easily remembered by alphabetical order: (1) Airway, (2) Breathing, (3) Circulation, (4) Disability, and (5) Exposure, where stabilization of the cervical spine takes place as part of the airway evaluation.

46.6.3 Airway The first priority in managing an injured child (or any patient) is establishment and maintenance of an adequate airway. This may be as simple as performing a jaw thrust maneuver or placement of a nasal/oral airway. Children with cyanosis, tachypnea, GCS < 8, or otherwise unable to protect their own airway require intubation. A good rule is to use ETT size of child’s fifth finger. With severe maxillofacial trauma or

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inability to place endotracheal tube, a surgical airway may be needed. All patients should have supplementary oxygen and cardiopulmonary monitoring. A chest X-ray confirms endotracheal tube placement and can be used to rule out hemo/pneumothoraces.

as appropriate. Children should also be assessed at this time for gross sensorimotor deficits and have a pupillary examination.

46.6.7 Exposure 46.6.4 Breathing Children should have breathing assessed by inspection for asymmetrical chest wall excursion, increased work of breathing, nasal flaring, retractions, anxiety, and tachypnoea. Subsequent auscultation confirms appropriate breathing mechanics. Chest X-rays may reveal hemoor pneumothoraces. Tension pneumothoraces should be immediately managed by needle thoracostomy in the second intercostal space, mid-clavicular line, followed by tube thoracostomy, the definitive management for hemothorax and pneumothorax. This should be placed in the fifth intercostals space at the midaxillary line. Because of pliability of a child’s ribs, significant pulmonary injury can occur without rib fracture.

46.6.5 Circulation Children may demonstrate normal blood pressures despite losses of up to 40% of their blood volume; therefore, clinical indicators can be helpful in determining the volume status in a pediatric patient. These include level of consciousness, temperature/mottling of extremities, capillary refill, pulse pressure, heart rate, and respiratory rate. During assessment, venous access should be obtained with two large-bore IV’s. Difficulty with obtaining peripheral venous access should not delay resuscitation. In difficult cases, saphenous vein cut-down, femoral venous cannulation, and interosseous catheters can provide vascular access. Fluid resuscitation should be initiated with 20 ml/kg of crystalloid, which may be repeated once. Subsequent fluid resuscitation, if needed, should include 10 ml/kg of type-specific red blood cells.

46.6.6 Disability In the primary survey, the disability evaluation involves assignment of a Glasgow Coma Score, using a modified version of the scoring system for young children

All items of clothing are removed, the child is ­carefully examined for outward signs of injury, and care is taken to warm the child and maintain normothermia.

46.6.8 Secondary Survey The secondary survey consists of a systematic head-totoe physical examination to recognize all injuries, including minor or occult injuries that may not have been apparent on the primary survey.

46.6.9 Stabilization If, at any point during evaluation, the child decompensates or deteriorates in any way, the primary survey should be repeated, going back systematically to airway first. Prior to transferring a child to definitive care, the airway should be secured, the child should be adequately breathing or receiving ventilatory support, fluid resuscitation should be initiated through appropriate vascular access, and the child should be exposed and warmed. Obtaining a chest X-ray as part of the airway and breathing evaluation, placing a nasogastric tube with intubation, and placement of a Foley catheter during evaluation of circulation are all additional appropriate steps. Transfer to definitive care should not be delayed for any detailed imaging or further workup.

46.6.10 When to Transfer Children with significant injury should be transferred to trauma centers as soon as they are stabilized. Transfer should be preceded by physician-to-physician communication.

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Recommended Reading American College of Surgeons Committee on Trauma: Extremes of age: pediatric trauma. In: Advanced Trauma Life Support for Doctors Student Course Manual, 7th edn. American College of Surgeons, Chicago (2004) Dalla Vecchia, L.K., Grosfeld, J.L., West, K.W., et al.: Intestinal atresia and stenosis: a 25-year experience with 277 cases. Arch. Surg. 133, 490–497 (1998) Kavoussi, L.R., Novick, A.C., Partin, A.W., et  al.: Wein: Campbell-Walsh Urology, 9th edn. Saunders Elsevier, Philadelphia (2007) Kleigman, R.M., Behrman, R.E., Jenson, H.B., et  al.: Nelson Textbook of Pediatrics, 18th edn. Saunders Elsevier, Philadelphia (2007) Ladd, W.E.: Congenital obstruction of the duodenum in children. N. Engl. J. Med. 206, 277–283 (1932)

T.T. Marquez et al. McCollough, M., Sharieff, G.Q.: Abdominal pain in children. Pediatr. Clin. N. Am. 53, 107–137 (2006) Mittenburg, D.M., Nuchtern, J.G., Jaksic, T., et al.: Laparoscopic evaluation of the pediatric inguinal hernia-a meta-analysis. J. Pediatr. Surg. 33(6), 874–879 (1998) Ravitch, M.M.: Intussusception in infancy and childhood: an analysis of seventy-seven cases treated by barium enema. N. Engl. J. Med. 259, 1058 (1958) Stone, K., Humphries, R.: Current Essentials of Emergency Medicine. McGraw-Hill, New York (2005) Tepas, J.J., Ramenofsky, M.L., et al.: The pediatric trauma score as a predictor of injury severity: an objective assessment. J. Trauma 28, 425–429 (1988) Young, D.G.: Intussusception. In: O’Neill Jr., J.A., et al. (eds.) Pediatric Surgery, 5th edn, pp. 1185–1198. Mosby, St Louis (1998) Ziegler, M.M., Azizkhan, R.G., Weber, T.R.: Operative Pediatric Surgery. McGraw-Hill, New York (2003)

Vascular Surgery: Acute Limb Ischaemia

47

Mark Hamilton

47.1 Introduction The management of the acutely ischaemic limb remains a challenge for even experienced vascular surgeons. This chapter aims to give rural or remote surgeons a straightforward algorithm for the management of the acutely critical ischaemic limb, and some guidance in the operative techniques utilised in the management of these patients. Clearly many of these issues are best dealt with in a more appropriate centre; however, we recognise that this is not always feasible and this chapter aims to assist in the local management of these problems.

47.2 Acute Upper Limb Ischaemia Acute upper limb ischaemia is a less common presentation than lower limb acute ischaemia and remains a relatively prevalent presentation in the elderly population with underlying cardiac co-morbidity in particular. The natural history of upper limb acute ischaemia is more benign than lower limb acute ischaemic insult due to the presence of extensive collaterals around the shoulder and elbow; however, it still requires operative intervention in a significant proportion of presentations. The indications to intervene in the acute setting are similar to those in the lower limb, particularly, advanced signs of ischaemia including ischaemic rest pain, numbness and paraesthesia and evidence of evolving muscle damage (muscle tenderness). M. Hamilton Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

The vast majority of upper limb ischaemic events are related to embolisation; however, trauma is also a common presentation.

47.3 Acute Lower Limb Ischaemia 47.3.1 Definition/Classification See Rutherford scale (Table 47.1).

47.3.2 Aetiopathogenesis The common aetiologies of acute limb ischaemia include embolism, trauma, thrombosis, arterial dissection and the rarer and more esoteric causes such as the non-atherosclerotic popliteal artery pathologies. The commonest cause of acute limb ischaemia is embolism, the predominant pathology being atrial fibrillation (AF), and is prevalent in the elderly population. Approximately 80% of acute limb ischaemia from embolic sources is related to AF. Other pathologies causing embolic ischaemia include patients post acute myocardial infarction (MI). This usually occurs within the first few days to weeks post MI and is associated with the increased thrombogenicity of infarcted myocardium, as well as areas of dyskinesia or akinesis within the ventricle. Embolic events secondary to rheumatic fever, streptococcal valvular disease and septic emboli from subacute bacterial endocarditis (SBE) have become uncommon.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_47, © Springer-Verlag Berlin Heidelberg 2011

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Table 47.1  Rutherford scale for classification of acute limb ischaemia Category Description Capillary Muscle return paralysis

Sensory loss

Doppler signals Arterial Venous

I – Viable

Not immediately threatened

Intact

None

None

Audible

Audible

IIa – Threatened

Salvageable if treated promptly

Intact/slow

None

Partial

Inaudible

Audible

IIb – Threatened

Salvageable if treated immediately

Slow/absent

Partial

Partial/complete

Inaudible

Audible

III – Irreversible

Unsalvageable

Absent/dermal fixed staining

Complete/tense compartment

Complete

Inaudible

Inaudible

Atheroembolic disease from aortic plaque or thrombus is more commonly a cause of lower limb than upper limb symptoms, the presentation is more classically that of the ‘blue toe syndrome’ or small areas of infarcted or ischaemic digital skin. Imaging often reveals a significantly diffusely diseased aorta from arch through the thoracic and abdominal segments. Atheroembolic disease of the arch and ascending aorta may present as TIA or upper limb acute ischaemic symptoms. Aneurysm disease and post stenotic dilatation of arteries is most commonly seen in patients with popliteal or aortic aneurysmal disease where chronic embolisation from a thrombus-lined aneurysm is the primary pathology. This also occurs in the upper limb in patients with thoracic outlet syndromes and subclavian/axillary artery compression and stenosis. Development of a post stenotic aneurysm is more common in the upper limb than true aneurysms, which are rare. Acute on chronic occlusive disease occurs as a cause of acute ischaemia in patients with established peripheral arterial disease where they develop acute deterioration in their limb perfusion secondary to occlusion of a pre-existing stenosis or extension of a segmental occlusion. This will occasionally occur in association with an inciting stimulus such as intercurrent surgery or illness, or prothrombotic state. Often this situation does not lead to immediately limb-threatening ischaemia and the situation can be managed conservatively with anticoagulation and re-assessment. It does make diagnosis of the primary aetiologic mechanism difficult. Thrombotic causes are mainly related to acute occlusion of either vascular grafts or limb aneurysms. Graft thrombosis/occlusion occurs in the setting of a patient with a pre-existing bypass graft where there

are a number of possible causes of acute graft thombosis. These include failure of the runoff or inflow of the graft, or in-graft stenosis. Patients with severe peripheral arterial disease (PAD) often develop deterioration of their distal circulation over time and in the absence of graft surveillance, the graft may fail. Similarly with vein grafts, in-graft stenosis may go unnoticed in the absence of surveillance until such a time as flow rates within the graft fall below the thrombotic threshold velocity with subsequent graft occlusion. Development of further occlusive disease proximal to the graft can similarly lead to graft occlusion. Unfortunately, in grafts that have been performed for critical limb ischaemia, the limb is often profoundly ischaemic when the graft occludes, compared with grafts performed for claudication. Thrombosis of peripheral arterial aneurysms, in particular popliteal aneurysms, occurs because aneurysm of the popliteal artery often goes unnoticed until such time as it thromboses and the limb becomes acutely ischaemic. Unfortunately, by the time this occurs, it is usually the sequela of chronic embolisation to the tibial arteries and if this is the case, there are frequently no or very limited reconstructive options.

Note: Early detection of popliteal aneurysms, and elective treatment of aneurysms >2–2.5  cm in diameter or with significant thrombus load remains the ideal treatment. Occasionally, in the setting of a preserved runoff circulation, a non-threatened limb (Rutherford Grade  1) and the availability of interventional radiology facilities,

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intra-arterial thrombolysis may be a useful adjunct to limb salvage surgery in acute thrombosis of the popliteal artery. Thrombophilias and Paraneoplastic syndromes are another non-mechanical cause of thrombosis of the arterial tree. The treatment of these pathologies is based on managing the underlying disorder when the acute limb has been managed. The outcomes from patients presenting with these pathologies are generally worse than those from trauma or embolism due to the other systemic aspects of their underlying condition. Thrombophilias in particular pose problems in regards to revascularisation and maintenance of patency of grafts in the perioperative period. The paraneoplastic thrombophilias usually improve once the underlying malignancy is dealt with. Dissection of the thoracic aorta can lead to either visceral or lower limb ischaemic symptoms that can be either fixed or dynamic in nature. The most common scenario causing acute lower limb ischaemic is the extension of the dissection into the iliac artery and compression of the true lumen by a pressurised false lumen. Less commonly, the dissection may extend to the femoral vessels. Embolisation may also occur from dissection flaps or rupture of the false lumen. Traumatic dissection of the abdominal aorta as an isolated pathology is seen in relation to seatbelt injuries in motor vehicle accidents and should always be considered in patients with significant seat belt bruising, lumbar spine fractures or other visceral injuries consistent with a compressive mechanism. Acute lower limb ischaemia in this setting is sometimes mistaken for traumatic paraplegia/paralysis. The non-atherosclerotic/aneurysmal popliteal artery pathology includes popliteal artery entrapment and adventitial cystic disease. These are relatively rare and the management of an acutely ischaemic limb in these situations should follow standard management principles with heparinisation and revascularisation as required. Compartment syndrome is a further cause of acute limb ischaemia. Acute compartment syndrome is defined as an elevation in intra-compartmental pressures to above the normal physiological pressure within that tissue compartment, leading to a detrimental effect on tissue perfusion in that compartment. Compartment syndrome in the setting of orthopaedic or vascular trauma, or reperfusion injury can have catastrophic consequences if not recognised. A low threshold for performing fasciotomy is necessary in the acutely ischaemic limb.

Note: Reperfusion after >6 h of ischaemia almost mandates fasciotomy at the time, and certainly regular clinical assessment of the patient in the first 24–48 h post-revascularisation is required to minimise the risk of missed compartment syndrome.

47.3.3 Diagnosis The diagnosis of acute limb ischaemia remains largely a clinical diagnosis, with investigations augmenting the history where it is unclear what is going on. The history is usually quite classical and is that of an acute onset painful limb with altered sensorium and motor impairment. There is usually a temperature discrepancy described by the patient. This may be worse than the pre-existing symptoms in patients that have claudication or a past history of Peripheral Arterial Disease (PAD). Pain is often resistant to opioid analgesia. The clinical findings are those of a pulseless cool limb with some difference to the contralateral limb. There will be sensorimotor abnormalities that progress over time, and are worse with more proximal large vessel occlusion. With advanced ischaemia, skin changes occur with initial reversible mottling advancing to fixed staining (this sometimes appears similar to a ‘port wine stain’). A number of investigations are useful and include bedside tests, and imaging procedures. Bedside tests include the use of a hand held static/pencil Doppler to determine the presence or absence of distal pulse wave forms. In an ischaemic limb, this is helpful in differentiating the degree of severity using the Rutherford criteria. It is also a useful tool to determine whether there is likely to be a target vessel to revascularise in the situation of an acutely ischaemic limb. Occasionally placing the limb in a dependant position and checking the Doppler signals over the dorsalis pedis, peroneal or posterior tibial arteries can demonstrate a signal in a patent vessel where none was audible with the patient supine. Non-invasive imaging modalities include ultrasound, CT and MR Angiography. Duplex ultrasound has the limitation of being operator dependant, but it does give useful information about level of occlusion, and presence of other disease. It is useful in the diagnosis of peripheral aneurysmal disease, and offers the

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ability to scan for a conduit for repair of a vessel if required. It has limited utility in the diabetic patient, those with extensive calcification, and of obese body habitus (particularly in imaging proximal or abdominal vessels). It can be time consuming to perform and should only be utilised in patients with a minimally ischaemic limb. CT Angiography has become the imaging modality of choice in many institutions, and has the advantage of being able to image from the aortic arch to the foot in one to two acquisitions, taking minimal time. It is able to be reformatted into coronal, sagittal and 3D formats on readily accessible workstations and allows planning of intervention with a high degree of accuracy. Most institutions now have a multi-detector spiral CT scanner that will allow 1-mm slices, and thus, the spatial resolution of CT is almost as good as catheter angiography. It is sometimes limited by the presence of heavy calcification, and does require a contrast bolus, so it may be relatively contraindicated in patients with renal impairment. In these patients, however, the utility of the modality sometimes outweighs the risk of worsening renal function, employing adjunctive measures such as prehydration, N-acetyl cysteine, etc. The patient with mild-to-moderate impairment of renal function can still be safely imaged using CTA. MR Angiography shares a number of similarities to CT Angiography and has the ability to acquire volumetric data which can be formatted in a number of planes. It gives similar anatomical detail, and is less limited by moderate calcification. There are limitations in the patients who can have MRI scans (pacemaker, claustrophobia, metal foreign body, etc.), and Gadolinium contrast is not as benign as previously thought – especially in patients with established dialysis-dependant renal failure in whom nephrogenic systemic fibrosis (NSF) has been reported. Invasive imaging with catheter angiography remains the gold standard investigation for both chronic and acute limb ischaemia and can be performed either prior to an intervention or after revascularisation to confirm adequate clearance of clot from distal vessels. Catheter studies can be performed in a dedicated angio suite, or on-table at the time of surgery with a portable C-arm image intensifier. Catheter angiography also allows for the administration of intra-arterial thrombolytic agents and the placement of balloons and stents; thus, it has the advantage of being a therapeutic as well as diagnostic modality.

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47.3.4 Initial Management Simple medical therapy should not be neglected in these patients; they usually have multisystem disease processes and the overall optimisation of the patient’s medical status is imperative. Analgesic therapy in critical limb ischaemia will usually require intravenous opioid analgesia to alleviate symptoms. In proximal acute vessel occlusion, this will still often be inadequate and the rapid restoration of arterial supply is the best therapy. Antiplatelet therapy should be instituted as part of an overall best medical therapy approach to managing patients with peripheral arterial disease, and likely underlying cardiac co-morbidity. Aspirin, dipyridamole in combination with aspirin, or clopidogrel are all appropriate depending on the situation. Anticoa­ gulation utilising Heparin in the acutely ischaemic limb is used to prevent extension of thrombus into previously unaffected vessels. It is not a thrombolytic agent and does not ‘dissolve’ clots. It is not a substitute for prompt revascularisation in the ischaemic limb. Heparin can be utilised in upper limb ischaemia in patients with a viable limb if the patient requires preoperative medical optimisation as a temporising measure, and some patients will improve with heparin therapy alone. In this setting, intravenous unfractionated heparin is used in preference to Fractionated/ LMW Heparin. Thrombolytic agents such as urokinase or rTPA can be utilised as a therapy for acute limb ischaemia as either a primary treatment modality in the Rutherford Grade 1 ischaemic limb, or as an adjunct in the setting of surgical thrombectomy to clear thrombus from small distal vessels. As a primary therapy, they are most useful in clearing prosthetic or vein grafts with occlusion for <24 h. These agents have the risk of haemorrhage from the infusion site, and most catastrophically intracerebral haemorrhage. This is a less common complication in the era of intra-arterial catheter-directed thrombolysis. The requirement for interventional radiology facilities and staff reduces the utility of percutaneous thrombolysis. On-table thrombolysis intra-operatively can assist in maximising clot clearance from tibial vessels and may demonstrate runoff that was not previously seen. Optimal medical management of these patients includes the appropriate use of ACE inhibitors, beta blockers and statins in the perioperative period and on an ongoing basis. It should be remembered that patients

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who develop critical limb ischaemia will also commonly have underlying cardiac co-morbidity and will therefore require management of cardiovascular risk factors for primary and secondary prevention of cardiovascular and cerebrovascular complications. Preoperative workup and resuscitation includes adequate expedient assessment of the patient’s fitness for surgical intervention, and need for appropriate resuscitation. These remain integral parts of the treatment algorithm and should not be neglected; however, definitive surgical intervention is the mainstay of treatment and should not be unnecessarily delayed.

47.3.5 Decision Making Assessing the severity of ischaemia and the likely viability of limb requires some experience; however, there are several objective assessments that can assist here. The history of the patient’s symptoms, including duration of symptoms, and severity of symptoms, including altered sensation, pain and loss of function, all influence the likelihood of limb salvage. The patient who has a Rutherford Grade I limb can be managed in a less urgent fashion, and allows the opportunity for timely imaging to be performed, and on occasion a catheter-directed interventional procedure to be utilised. Rutherford II limbs require expedient intervention, with a IIb limb requiring immediate revascularisation to prevent progression to irreversible limb damage and amputation. Rutherford III limbs are unsalvageable and will usually have established fixed skin staining, paralysis and numbness. These limbs should have primary amputation or the patient should be palliated.

Note: The optimal time period for revascularisation of an acutely ischaemic limb is within 6 h of onset of symptoms.

This minimises the risk of reperfusion-related compartment syndrome and improves likelihood of limb salvage and patient survival. Clearly, the more ischaemic is a limb, the greater the urgency. Although the preoperative optimisation of the patient’s medical condition is important, intervention should not be unnecessarily delayed for this to occur.

Which intervention should be utilised is not clearly defined in all cases. Often the underlying anatomy of the lesion and primary pathology will be the factor which defines mode of intervention. In the setting of a patient with no previous history of PAD, and an obvious embolic source (e.g. AF or thrombus load in a documented aortic aneurysm), and normal contralateral pulses, embolisation is the most likely cause and urgent operation is the intervention of choice. This can involve on-table angiography subsequent to thromboembolectomy, but should not be delayed for preoperative imaging. The patient who has a more lengthy history of chronic symptoms and who develops new acute symptoms requires expedient imaging to determine whether the patient has a reconstructible lesion that can be treated surgically. The ability to base operative intervention on appropriate imaging is useful, and may allow a planned bypass if appropriate. Occasionally, preoperative imaging will allow a planned percutaneous intervention with the possibility of surgical intervention as a fallback position. These decisions are more complex and must take into account the experience of the surgeon or interventionalist, and the availability of appropriate infrastructure for percutaneous intervention. In some cases, palliation is the most appropriate treatment. Amputation can be an appropriate damage control or palliative strategy in patients with multiple comorbidities in whom revascularisation would carry prohibitive risk. This is particularly the case in patients with a delayed presentation in whom a bail out or damage control procedure is preferable to a lengthy attempt at revascularisation with the concomitant risk of reperfusion injury and compartment syndrome, along with myocardial depression from metabolites from the ischaemic limb.

47.3.6 Operative Management In general terms, the main objective of treating acute limb ischaemia is to restore pulsatile flow of oxygenated blood to the target tissue in an expedient fashion. There is minimal time for delay, and attempts to postpone surgery on patients with a critical acutely ischaemic limb to allow for ‘medical optimisation’ should be resisted within reason. This may mean surgery being performed under local anaesthetic or regional anaesthesia; however,

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this is preferable to delaying revascularisation of a borderline limb until the limb is unsalvageable and requires amputation. Similar principles to all vascular surgery apply: obtaining adequate safe proximal inflow control (including slinging the vessels with a silastic loop or similar), identifying target vessels for revascularisation and appropriate conduit or material for patching or grafting. In broad terms, this will often not be necessary as the vast majority of patients only require simple embolectomy; however, it is wise to be prepared for the possibility of needing to bypass an occlusion to salvage a limb. This involves prepping the entire ipsilateral limb, and in the situation of trauma, the contralateral limb as a vein donor site. The foot/hand should always be visible to assess adequacy of reperfusion at the end of the case, prior to undraping the patient. The utilisation of on-table completion angiography is almost mandatory in lower limb embolectomy, particularly where there is a pattern of contralateral PAD (suggesting the presence of symmetrical pattern ipsilateral disease) and assessment of the adequacy of revascularisation is complicated by the presence of chronic disease.

47.3.7 Anatomic Approaches The most common sites accessed for revascularisation are laid out below. It would be unusual for access to the following vessels to not allow restoration of some inflow to a target tissue.

47.3.7.1 Brachial Artery The brachial artery is most commonly approached via a transverse incision across the cubital fossa just below the elbow crease. This allows mobilisation and identification of both the inflow artery, and also the origins of the radial and ulnar arteries with a view to being able to pass a Fogarty catheter down both vessels in a directed fashion. The artery lies deep to the bicipital aponeurosis which should be incised carefully. There will be a number of brachial venae comitantes around and crossing the artery which should be carefully divided ­during mobilisation to allow adequate mobilisation with minimal risk of troublesome

M. Hamilton

venous bleeding. The brachial bifurcation will sometimes also have a recurrent radial or posterior interos­ seous artery off the back of the main brachial artery and this will occasionally require separate control. Care should be taken if the brachial artery in the cubital fossa appears very small, as this is sometimes an anatomical variant with a high brachial bifurcation (in the upper arm). In the presence of reliable imaging, this is unlikely to be an issue; however, it may be discovered at the time of surgery if there has been no prior imaging.

47.3.7.2 Femoral Artery The artery is best approached via longitudinal incision directly over the artery, or when the artery is not palpable due to proximal thrombosis, at the midinguinal point. The incision should come from just above the inguinal ligament to the apex of the femoral triangle to allow adequate exposure of all major vascular structures in the region. The artery lies deep to the deep fascia of the leg within the femoral sheath, and is bounded medially by the femoral vein in close proximity to the artery. Proximal control should be gained at the level of the inguinal ligament and care should be taken to control the four or five branches that come off the common femoral artery. Passing a silicone loop around the Common Femoral Artery (CFA) allows the artery to be controlled using digital pressure while performing embolectomy. The objective of dissection should be to mobilise the artery closely on its surface, within the areolar tissue around the vessel, and dissect the patient’s tissues away from the vessel. The superficial femoral artery passes distally in the thigh exiting at the apex of the femoral triangle and is the direct continuation of the CFA. The profunda femoris artery on the other hand is quite variable in its position and number of branches. There are often two main profunda branches and care should be taken to clearly identify all deep posterior branches off the CFA at the level of the bifurcation. While mobilising profunda, care should be taken to avoid inadvertent injury to the lateral circumflex femoral vein and profunda vein as it passes in the crutch of the SFA and PFA. Minimal mobilisation of the PFA is probably desirable in less experienced hands.

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47  Vascular Surgery: Acute Limb Ischaemia

Again, the use of the silicone loop around all vessels allows control using traction and digital compression if required.

47.3.7.3 Popliteal Artery In the event that embolectomy from the CFA is not able to reperfuse a foot, an approach to the popliteal artery and the tibial trifurcation is sometimes required. This is performed via a medial approach in the upper calf from the level of the insertion of the pes anserinus. The skin and subcutaneous tissues are incised, taking care not to injure the great saphenous vein in the process as it may be required as a conduit, and the fascia of the leg is incised. The Gastrocnemius should be reflected posteriorly and the popliteal fossa should be entered. The popliteal vein is commonly adherent to the medial side of the artery and should be mobilised off the artery which can then be traced distally to the level of the anterior tibial artery takeoff. The anterior tibial artery commonly passes anterolaterally off the popliteal artery at an almost perpendicular angle away from the operator. The anterior tibial vein also crosses the tibioperoneal trunk at around this level, and occasionally needs to be divided to allow loop control and identification of the artery. Similarly, the soleus muscle will occasionally need to be taken down from the tibia to allow adequate exposure of this area. This should be done with electrocautery as close to the tibia as possible to minimise soleal venous bleeding. To allow better exposure of the proximal below knee popliteal artery, the pes anserinus can be taken down off the tibia – there is not usually any need to formally reconstruct this at the completion of the case.

47.3.7.4 Thromboembolectomy In broad terms, the use of a Fogarty type balloon catheter to remove thrombus from the vessel is relatively straightforward. The decision as to whether to perform transverse or longitudinal arteriotomy is often difficult and is largely defined by the likely aetiology of the acute ischaemic insult. In the instance of a clearly embolic cause where imaging reveals an isolated embolic lesion, transverse arteriotomy will usually suffice. This provides the opportunity to close the arteriotomy primarily using a 5/0 or 6/0 polypropylene

suture – either interrupted or continuous. On the other hand, where there is extensive underlying atherosclerotic arterial disease and the possibility of a patch angioplasty and/or bypass graft being required to restore adequate flow, a longitudinal arteriotomy should be performed. This will require repair with a patch to minimise arterial narrowing around the site. The arteriotomy should be positioned to allow access to the origins of all vessels distal to the occlusion, to facilitate the passage of a Fogarty catheter down these vessels for removal of clot. The catheter is introduced with the balloon deflated, passed down the vessel and then the balloon is gently hand inflated to a set volume while withdrawing the catheter. Several passes may be required for adequate clot removal. Appropriate sizes include 3Fr for tibial and forearm vessels, and proximal brachial in women, 4Fr for superficial and profunda femoris and proximal brachial in men, 5Fr for iliacs. The vessels should then be flushed with heparinised saline. On-table angiography should be considered when available at the end of the case prior to closing the groin. This allows the possibility of defining ­remnant occlusions, and may facilitate a further embolectomy.

47.3.7.5 Interposition Grafting In the setting of acute ischaemic injury related to trauma, interposition grafting may be required to bypass an occluded vessel. The preferred conduit for all infrainguinal grafts is autogenous saphenous vein. In the setting of trauma, it is preferred that this be taken from the contralateral limb. In non-traumatic acute limb ischaemia, the ipsilateral Great Saphenous Vein (GSV) may be utilised. The technique for interposition grafting using an end-to-end anastomosis and reverse vein is well described in a number of operative texts (refer to recommended reading list at end of chapter). Other techniques, including end-to-side anastomosis, are also utilised on occasion, in particular for bypass grafting to the popliteal artery in a femoro-popliteal bypass graft.

47.3.7.6 Intraoperative Imaging When available, the use of completion angiography is a useful adjunct to revascularisation of the limb, particularly in patients who have pre-existing PAD and

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where the surgeon may not be able to feel peripheral pulses due to pre-existing occlusive disease. The simplest method of performing on-table angiography utilises a 20  G IV cannula placed directly in the artery after closing the arteriotomy, and injecting 50:50 solution of IV contrast and Heparinised saline, and using a C-arm capable of digital subtraction angiography.

47.3.7.7 Damage Control Options In the setting of a patient with significant and prolonged limb ischaemia, revascularisation may not be the most appropriate procedure. The revascularisation of an infarcted limb may lead to significant washout of toxic metabolites including potassium and lactate, and may cause cardiac arrest. In this situation, the most appropriate damage control manoeuvre is often primary amputation at a level that is well vascularised. This may be above the knee in a significant proportion of patients with acute lower limb ischaemia. Individuals with injuries to the lower limb resulting in a denervated and devascularised limb that has had lengthy ischaemic time, an amputation and re-look at 24 h with the aim of delayed primary closure at this or a later time may be an appropriate technique.

47.3.8 Complications of Revascularisation The inflammatory and metabolic mediators which are released from revascularising an acutely ischaemic limb are beyond the scope of this chapter to discuss and are well described in other works; however, acute compartment syndrome is a common consequence of restoration of blood supply to an ischaemic limb. Compartment syndrome is defined as a clinical syndrome associated with an acutely elevated tissue pressure in a non-expansile space. It applies predominantly to muscle compartments; however, it also occurs in the abdomen. Compartment syndrome results from intracompartmental pressure increasing above venous closing pressure (4–7  mmHg). Consequent to this, an increase in capillary pressure leads to increased transudation and further swelling. The recognition of compartment syndrome is based on clinical assessment and a high index of suspicion. It is characterised by poorly localised, non-specific and severe pain in the

M. Hamilton

region concerned, which is worse on passive stretching of the muscles in that compartment. There is often pain on palpation of the compartment. Sensory neurological dysfunction is an early sign with motor signs coming later. Compartment pressure measure­ment may be useful, and compartment pressures over 30 mmHg or pressures within 25 mmHg of diastolic pressure/30  mmHg of MAP mandate intervention by  fasciotomy. Early four compartment fasciotomy through large incisions is the treatment of choice, and in many situations of revascularisation of the acutely ischaemic limb, fasciotomy at the time of initial surgery is preferable to delayed presentation and the development of established muscle death/dysfunction. This is particularly true in patients with a lengthy delay prior to revascularisation. It is important to remember that distal pulses may still be present in compartment syndrome. Other tests such as ultrasound/MRI/CTA do not add to diagnosis and should be avoided.

47.3.9 Peri and Post Operative Care and Management Adequate management of pain and other organ systems is vital in the perioperative period. Ongoing washout of metabolites such as lactate, myoglobin and potassium can lead to significant derangement in cardiac and renal functions and an awareness of the strategies for optimising the function of these systems is necessary to optimise these patients care. Cardiovascular optimisation includes appropriate heart rate control and anticoagulation in the setting of patients with AF, and the management of underlying ischaemic events which have led to AMI. The presence of cardiac valvular lesions and mural thrombus needs to be elucidated with echocardiography to plan longterm goals in relation to anticoagulation and treatment of valvular disease. The acute renal sequelae from the acute insult of myoglobinuria from reperfusion rhabdomyolysis can be minimised by ensuring adequate hydration, active diuresis and alteration of the pH of the urine to minimise precipitation of myoglobin in the tubule. There are some instances in which the immediate deterioration in renal function may require acute dialysis. It should also be remembered that reperfused muscle can absorb large volumes of fluid and that standard maintenance IV fluid therapy is usually inadequate for these

47  Vascular Surgery: Acute Limb Ischaemia

patients and IV therapy should be aimed at producing an adequate urine output.

Recommended Reading Fitridge, R.A., Thompson, M.M.: Mechanisms of Vascular Disease: A Textbook for Vascular Surgeons. Cambridge University Press, Cambridge (2007)

367 Norgren, L., Hiatt, W.R., Dormandy, J.A., Nehler, M.R., Harris, K.A., Fowkes, F.G., et al.: Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur. J. Vasc. Endovasc. Surg. 33(Suppl 1), S1-75 (2007). PMID 17140820 Rutherford, R.B.: Vascular Surgery, 6th edn. Elsevier Saunders, Philadelphia (2005) Valentine, R.J., Wynd, G.G.: Anatomical Exposures in Vascular Surgery, 2nd edn. Lippincott Williams & Wilkins, Philadelphia (2003)

 

Vascular Surgery: Management of the Diabetic Foot

48

Mark Hamilton

48.1 Introduction The diabetic foot can be defined as a constellation of clinical findings that are usually (but not exclusively) seen in diabetic patients that include particular morphologic, vascular, neurological, and biomechanical changes.

48.2 General Principles of Assessment 48.2.1 Vascular The assessment of adequacy of perfusion of the diabetic foot is a vital component of all parts of management in the acute and chronic phases of the diabetic foot. A combination of varying degrees of severity of large vessel atherosclerotic disease, small vessel disease, and microangiopathic changes may be present in the diabetic foot. These may range from what is clinically a normally perfused foot that suffers the consequences of autonomic neuropathy and subsequent cutaneous shunting, to the foot with demonstrable critical ischaemia. Clinical examination is reliable to assess large vessel circulation; however, it is limited in patients with extensive vascular calcification, which is often present in long-standing diabetes. This vascular calcification is worse in combination with renal impairment and chronic renal failure. The characteristic of the

M. Hamilton Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

Doppler signal (triphasic/monophasic) is also helpful in assessing presence of proximal or distal disease. The use of toe pressures is preferable to ankle-brachial indexes (ABI); however, it requires the use of appropriate cuffs and photoplethysmography (PPG) probes to assess perfusion. Toe pressures are more consistently reliable in diabetics than ABI and are a better indicator of likelihood of healing. Critical limb ischemia (CLI) is defined as persistent, recurring ischemic rest pain requiring opiate analgesia for at least 2 weeks, ulceration, or gangrene of the foot or toes, and ankle systolic pressure less than 50 mmHg or toe systolic pressure less than 30 mmHg; therefore, the utility of doppler pressures is clear in defining those patients requiring revascularisation. The absence of pedal pulses in diabetic patients is also considered a marker for CLI.

48.2.2 Neurological The diabetic foot is partly a consequence of the development of diabetic peripheral neuropathy. This is a combination of autonomic, sensory, and motor neuropathy. The presence of autonomic neuropathy can be assessed by the loss of eccrine and sebaceous gland activities with dry cracked and flaky skin, and increase in callus formation. Skin wrinkling on immersion in warm water is also predictably absent in patients with auto-sympathectomy. The presence of significant cutaneous shunting (a warm pink looking foot even in the absence of a pedal pulse) is also characteristic. The situation is worsened considerably by the presence of stocking/glove sensory neuropathy. It is common for diabetic foot patients to report they are

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completely unaware of the presence of a noxious stimulus or wound on the foot. This loss of protective sensation and blunting of nociception leads to repetitive trauma and the development of skin damage secondary to pressure or trauma. Sensory neuropathy causes blunting of the normal neurohormonal res­ ponse to noxious stimulus. The normal response to trauma includes release of substance P, neuropeptide Y and calcitonin gene–related peptide. These mediators cause mast cell degranulation; release of histamine, TNF-alpha; and promote white cell migration to the area of trauma. Neuropeptide Y also causes ischaemia-stimulated angiogenesis. The loss of these mediators causes an alteration in the neurohormonal response to injury. These changes are able to be demonstrated prior to the presence of sensory neuropathy and many of the other components of the diabetic foot. The use of a Semmes Weinstein 10 g monofilament for assessment of sensory neuropathy is necessary to quantify neuropathy objectively. Motor neuropathy causes abnormality of innervation to the intrinsic muscles of the foot, predominantly lumbricals, and causes the characteristic claw-like appearance of the advanced diabetic foot. Subluxation of the metatarsal (MT) heads leads to alteration in the biomechanics of the foot, repetitive trauma over the MT heads and the development of callus and potential ulceration of the overlying skin in the region. A neuropathic foot also requires more perfusion than a normally innervated foot to resist ulceration, presumably secondary to the neurohormonal abnormalities described above.

48.2.3 Biomechanical Assessment of the gait pattern and pressure loading of the sole of the foot is an important part of development of a biomechanical offloading strategy. The typical biomechanical features of the diabetic foot are clawing of the forefoot with plantar subluxation of the metatarsal heads, and dorsal clawing of the toes. This is accompanied by shortening of the Achilles tendon and increased loading of the forefoot. The alterations in skin flexibility, eccrine and sebaceous activities lead to increased callus formation with the effect of a foreign body under these increased pressure loading areas.

M. Hamilton

48.2.4 Endocrine Optimisation of glycaemic control and related endocrine abnormalities including vitamin D, Parathyroid hormone and vitamin C are vital for the ongoing prevention of complex foot problems. There is a link between poor glycaemic control and the development of alterations in collagen crosslinking. This glycation of collagen is implicated in the development of the cheiroarthropathy of the diabetic foot syndrome and also the development of shortening of the tendo achilles. Optimal management of glucose levels is also implicated in reducing infection risk, and the development of advanced foot sepsis. Measurement of HbA1C levels is a useful indicator of long-term glycaemic control, and provides a target for control. Patients with poor glycaemic control also present with other endocrine abnormalities, and vitamin D and C deficiencies are a common finding. This has an impact on bone mineralisation and also collagen strength. They may also have other coexistent endocrinopathy such as hypothyroidism which would otherwise go undiagnosed. These factors should be addressed by an endocrinologist.

48.2.5 Microbiological Infection of diabetic foot ulcers is a common consequence of the disease process. This can be limited to polymicrobial colonisation of the wound bed, or can involve invasive infection and systemic sepsis. Diabetic foot infections can be life or limb endangering if not managed aggressively. The polymicrobial nature of diabetic foot infection and the blunted neurohormonal response to injury along with coexistent ischaemia mean that infection in a foot may worsen rapidly to the point where the foot becomes unsalvageable. The key components to assessing infection in the foot include adequate clinical examination, probing the ulcer or cavity to demonstrate likely underlying osteomyelitis (probing to bone carries a >90% positive predictive value for osteomyelitis in a chronic foot ulcer) and determining the presence of collections or tenosynovitis. Microbiological sampling with superficial wound swabs may be of some use; however, these swabs commonly grow a broad array of bacteria, and do not always point to the

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primary causative organism. Deep swabs or tissue specimens are required to direct appropriate antibiotic therapy. These can be obtained at the time of surgical debridement of an infected wound or abscess. Early involvement of the infectious diseases team is mandatory in patients with advanced diabetic foot sepsis. Radiological imaging of the soft tissues is useful in the patient with foot cellulitis. MRI of the foot may demonstrate underlying osteomyelitis or collections that are not appreciable clinically. MRI can guide degree of debridement required in some patients.

48.2.6 Classification Diabetic foot lesions are often classified using the University of Texas Wound Classification System (UTWCS) (Table 48.1), or the Wagner scale (Table 48.2). The UTWCS has the advantage to include information about the degree of infection.

48.3 Acute Management The acute management of the diabetic foot is based on the principle of providing adequate tissue perfusion, and managing septic complications of the underlying pathology, along with immediate offloading and pressure management. These rely on adequate assessment of the patients need for revascularisation, the presence of sepsis and the biomechanics of the foot. The quantification of the relative contributions of ischaemia, infection, biomechanics and endocrine allows prioritisation of management of each of these issues. The most common surgically acute presentation in the ­diabetic foot is that of limb-threatening foot sepsis. In general, the principle

Table 48.1  University of Texas wound classification system 0 I

here is that of immediate broad-spectrum antibiotic therapy, and aggressive drainage and debridement of the foot sepsis and necrotic tissue. The key points are that all devitalised or necrotic tissue should be removed, to a level where healthy bleeding tissue is present, and that all sinus tracts should be laid open to drain. This may involve long plantar or lateral drainage incisions, and may also involve amputation of digits. The temptation to salvage a significantly marginal digit should be avoided. The debridement of infected and necrotic tissue should not be delayed to allow revascularisation, but rather the decision be made to perform an acute sepsis control debridement then a subsequent revascularisation procedure when the patient has stabilised enough to allow safe performance of a larger procedure. The debridement site should be re-examined at 12–24 h to reassess the viability of remaining tissue and the presence of further sepsis. Deterioration may require further debridement. It is also quite common for the wounds to deteriorate somewhat prior to improving when the limb is reperfused.

Note: In general, drainage of foot lesions should be through plantar or lateral surfaces, and dorsal incisions are largely avoided except where drainage of extensor tendon sheaths is required and as a component of digital amputation. If possible some effort should be made to minimise plantar skin loss.

Digital amputation may be required to allow adequate drainage of web spaces and the forefoot. Wounds should be left open to drain, and are generally left to granulate with a regular review to ensure progress. If toes are amputated, the cartilage from the metatarsal head should be removed entirely to avoid a sequestrum of cartilage that will prevent granulation. This can be achieved while preserving a component of the metatarsal head to

II

III

A

No open lesion

Superficial ulcer

Ulcer deep to tendon, joint or fascia

Ulcer penetrating joint or bone

B

+ Infection

+ Infection

+ Infection

+ Infection

C

+ Ischaemia

+ Ischaemia

+ Ischaemia

+ Ischaemia

D

+ Infection and ischaemia

+ Infection and ischaemia

+ Infection and ischaemia

+ Infection and ischaemia

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Table 48.2  Wagner scale Definition Depth classification

Treatment

0

At risk foot, no ulceration

Education, footwear, clinical assessment

1

Superficial ulceration, not infected

Total contact cast (TCC), offloading

2

Deep ulceration exposing tendons and joints

Debridement, wound care, offloading, Antibiotics

3

Extensive ulceration or abscess

Debridement, partial amputation, offloading

4

Forefoot gangrene

Amputation

5

Hindfoot gangrene

Major amputation

maintain foot morphology and spacing. In the diabetic foot where the amputation is for acute or chronic sepsis, there is probably little benefit in preserving part of a phalanx, as these proximal phalangeal components add little to foot function, and are often involved in the septic process. On occasion, a formal ray amputation may be required through the metatarsal body, and in advanced forefoot sepsis involving several toes, a guillotine transmetatarsal amputation is the procedure of choice, leaving the wound open. It is preferable to attempt to leave some plantar flap component if possible as this aids in closure at a later date, and assists in mobilisation long term. Extensive wounds can be managed with a negative pressure (VAC) dressing and subsequently skin grafted if required. In patients with extensive foot sepsis involving the midfoot, who have evidence of midfoot and or hindfoot necrosis or sepsis and who are systemically unwell, the procedure of choice is probably major amputation. The level of major amputation will be largely defined by the extent of sepsis, the patient’s comorbidities and the consequent likelihood of the patient being able to mobilise with a prosthesis at a later date, and the presence of adequate perfusion to heal the amputation. In general terms, the presence of a popliteal pulse means a below knee amputation is likely to heal, its absence decreases this likelihood significantly. Frail and obtunded patients who are unlikely to mobilise on a prosthesis in the future should be considered for above knee amputation as this has the highest healing potential in these patients and maximises the likelihood of them leaving hospital.

48.3.1 Investigations During the initial phase of management, objective assessment of perfusion with toe pressures and ABIs is necessary when pulses are not clearly palpable. In the presence of ischaemia, some form of angiography should be performed, either MRA CTA, or occasionally DSA with a view to intervention at the time. Duplex has somewhat limited utility in diabetics due to the presence of significant vascular calcification in the tibial vessels which limits the ability to insonate these vessels. Duplex is however useful for assessment of the more proximal and larger vessels with a view to delineating the presence of a potentially treatable large vessel lesion. Anatomical imaging allows the surgeon to plan an appropriately staged revascularisation procedure with the aim of healing the tissue loss. The optimal distal target vessel is that which is most likely to allow pulsatile perfusion to the area concerned. On occasion this may be a dorsalis pedis or posterior tibial artery. Microbiological assessment at the time of acute management should involve sending deep tissue specimens of the infected area, including bone, and if managing an episode of digital sepsis, an amount of ‘clean’ deep tissue to define the post drainage or debridement microbiological flora. This allows the optimisation of antibiotic therapy and the minimisation of use of overly broad-spectrum antibiotics for long periods of time. In the initial 24–48 h, the use of broad-spectrum agents is appropriate; the choice of agent will depend on institutional preferences and the local microbiologic milieu, and the likelihood of the presence of multiresistant organisms. Some appropriate agents include triple antibiotic therapy with Amoxicillin or Flucloxacillin 1 g q6H, Gentamicin 5–7 mg/kg ideal body weight q24h and Metronidazole 500  mg q12h; Timentin is also ­utilised as a first-line agent on occasion, and in the situation where the organism is known to be a methicillin-resistant staphylococcus, Vancomycin is added to the regime. Clindamicin has utility in MRSA also, and has excellent tissue penetration. Ciprofloxacin or some of the newer fluoroquinolone agents such as moxifloxacin are useful for these commonly polymicrobial infections; however, their gram-positive cover is relatively poor, and they also promote emergence of resistance in Pseudomonas when used as a single agent to treat this organism. Largely their use should be

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48  Vascular Surgery: Management of the Diabetic Foot

restricted to combination antipseudomonal therapy in this setting. The early involvement of a microbiologist or infectious diseases specialist is vital in guiding appropriate therapy for these complex patients. Imaging of the diabetic foot for delineation of septic complications and delineation of the presence of Charcots neuroarthropathy versus acute foot sepsis has advanced significantly in the era or magnetic resonance imaging. MRI has the ability to differentiate between changes of osteomyelitis or acute infection, and Charcots degenerative change, and also to determine the presence of underlying septic arthritis or the presence of soft tissue infections only. In the presence of a red swollen foot, but a medically stable patient, the time taken to perform MRI is justified in that it may prevent unnecessary operation. Nuclear medicine and in particular labelled white cell scans for osteomyelitis still remain useful in patients who have contraindication to MR imaging; however, these are not always useful in differentiating Charcot changes from osteomyelitis. Plain radiography of the foot is useful when other modalities are unavailable, and when serial examinations are performed for follow-up of chronic changes in patients being managed conservatively or with antibiotic therapy only. There is unfortunately a significant lag time between clinical osteomyelitis and the appearance of classical plain radiograph findings. There is some utility in plain x-ray to exclude the presence of radio-opaque foreign body in the acutely septic foot with a history of trauma in particular. It should be a standard component of the initial assessment of the diabetic foot and will also demonstrate other bony changes of the chronic diabetic foot including midfoot collapse, MTP joint subluxation and clawing of the toes. Ultrasound is a useful modality to image for echogenic but non-radio-opaque

foreign material which may be present in a case of diabetic foot sepsis. The proviso on all imaging of the foot is that it should not delay the timely drainage of foot sepsis.

48.4 Chronic Management Once identified as being high risk, diabetic patients benefit from being enrolled in a high-risk foot surveillance programme with multidisciplinary input from podiatry, orthotics, infectious diseases, endocrinology, vascular and orthopaedic surgery. The aim of these programmes is to optimise the component management of the patients’ foot, with the benefit of regular reassessment of the foot by multiple teams in one sitting. The aim is that patients have a plan in place that allows optimisation of all risk factors and that once the foot is healed it can be kept healed.

Recommended Reading Beard, J.D., Gaines, P.A.: A Companion to Specialist Surgical Practice: Vascular and Endovascular Surgery, 3rd edn. Elsevier Saunders, Philadelphia (2006) Fitridge, R., Thompson, M.: Mechanisms of Vascular Disease. Cambridge Press, Cambridge (2007) Norgren, L., Hiatt, W.R., Dormandy, J.A., Nehler, M.R., Harris, K.A., Fowkes, F.G., et  al.: Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur. J. Vasc. Endovasc. Surg. 33(Suppl 1), S1–75 (2007). PMID 17140820 Rutherford, R.B.: Vascular Surgery, 6th edn. Elsevier Saunders, Philadelphia (2005) Wagner FW. The dysvascular foot: a system for diagnosis and treatment. Foot and Ankle. 2(2):64–1 22 (1981)

 

Minor Procedures

49

Eric Mooney

49.1 Skin Grafts and Flaps Skin grafting and flaps are means to an end: replacing lost or deficient tissue. This is true when dealing with either wound closure or reconstructive cases. When dealing with open wounds, it is best to consider the repair in terms of reconstructive options so that the best choice can be made. A useful conceptual tool is the “reconstructive ladder” (Fig. 49.1). The reconstructive ladder represents a hierarchy of closure techniques proceeding from the least complex to the most complex procedures as one progresses up each “rung” of the ladder. Thus, one proceeds from healing by secondary intention as the ground floor to direct closure as the

COMPLEX

DISTANCE FLAP/FREE FLAP REGIONAL FLAP LOCAL FLAP SKIN GRAFT

SIMPLE

DIRECT CLOSURE SECONDARY INTENTION

Fig. 49.1  The Reconstructive Ladder: each ascending “rung” on the ladder is becomes more complex. Normally, the simplest procedure that will accomplish the job is chosen unless the more complex procedure offers compelling advantages

E. Mooney Department of Surgery, Bassett Healthcare, One Atwell Rd, Cooperstown, NY 13326, USA e-mail: [email protected]

first rung and subsequently to the higher “rungs” of skin grafting, local flaps, regional flaps and, ­ultimately free tissue transfer. One usually considers each rung of the ladder and used the lowest rung applicable to the wound under consideration unless a higher rung, or more complex technique offers specific advantages. A common example would be an open avulsion of the dorsal hand with exposed ­tendons. Healing by secondary intention will lead to contracture. Grafting will not work over the relatively avascular tendons. The next step up the ladder, local flaps, are rarely large enough or dependable enough for coverage. One then proceeds to regional flaps and finds that a radial forearm flap based on the radial artery will often suffice for coverage. In addition, this flap will provide normal skin and subcutaneous fat for tendon gliding. However, because this type of flap is often bulky, one may want to consider the highest “rung” as well: free flap coverage. Perhaps a free ­fasciocutaneous flap will allow for better, thin, and vascularized closure. The important point about the reconstructive ladder is not to become a lexicon of flaps but to be able to ­consider wound closure options in a systematic way. In this way, optimum closure for the available skills can be chosen. For most surgeons in a rural setting, the choices will usually be between primary/ nondary intention, grafting, local flaps, or perhaps simple regional flaps. Lastly, wound bed preparation is of paramount importance. No matter what technique is chosen, all dead tissue and eschar must be removed before ­closure. This includes nonviable longitudinal structures such as nerves and tendons as well. All infection should be  controlled through debridement and antibiotics ­(systemic or topical). When operating for tumor, all ­margins should be cleared before coverage. Tempo­ rary coverage with appropriate dressings or biologic

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devices can temporize the wound until ­pathologic confirmation of margins is obtained. In summary: • Before closure, control infection and remove all nonviable tissue. • Consider each wound in terms of the reconstructive ladder, choosing the lowest “rung” unless a higher one has specific advantages.

49.2 Skin Grafting Skin grafting is the most basic and broadly useful of wound closure techniques and should be part of every rural surgeon’s tool kit. It is also the “escape hatch” or “plan B” used when more complicated procedures fail. While it is often obvious that large wounds that will not heal secondarily will need grafting, in smaller wounds that would otherwise heal, some judgement is required to decide which would benefit from early grafting. Some judgement is required for smaller wounds that would otherwise heal by themselves. The decision to graft is based on wound size and time to closure as well as anticipated morbidity of contracture entailed in healing by secondary intention. When dealing with open wounds, a rule of thumb has been that any wound that does not heal by 4 weeks is at risk for healing with significant scar and contracture if at all. These wounds should be considered for early grafting. Because of the risk for contracture with subsequent distortion and loss of mobility, wounds in certain anatomic regions such as the periorbital area, hands, and joints should be considered for early grafting. Full thickness grafts contract less than split thickness grafts and should be considered for these areas. Skin grafts require a noninfected, well-vascularized wound bed. One should always aim for 100% graft take and not use a graft to “clean up” a wound. Wounds should be thoroughly debrided of all necrotic and nonviable tissue. Infection should be controlled with local and systemic antibiotics as appropriate. Appropriate dressings should be used until the wound shows signs of granulation with the exception of areas where early grafting prevents delayed functional problems (such as the hand or eyelids). Skin grafts will not “take” or grow on poorly vascularized tissue such as cartilage or bone. These will require flap coverage. A vacuum assisted closure device may be used to assist granulation and control drainage before

E. Mooney

grafting. When possible, edema should be controlled with pressure garments before grafting chronic wounds. When deciding between graft thickness, several factors are entertained. Split thickness grafts are those that contain part of the dermis while full thickness grafts incorporate the entire dermis. The skin itself ranges from 17 thousandths to 150 thousandths of an inch (0.43–3.81 mm) in thickness so that the usual split thickness graft is taken at 12–18 thousandths of an inch thickness. Split thickness grafts contract more than full thickness grafts. In general, though, larger donor sites are more available (thigh, buttocks, etc.) for split thickness grafts. Full thickness grafts incorporate more dermis proportionately and are therefore more mobile and pliable than split thickness grafts. As alluded to above, they are more appropriate for the eyelids, periorbita, joints, hands, and areas of cosmetic concern where contracture is to be avoided and mobility is at a premium. A disadvantage of full thickness grafts is that they are less likely to take on suboptimal wound beds. For example, one might consider a relatively thin, meshed split thickness graft on an exudative trunk wound. An example of full thickness grafting would be a defatted full thickness graft harvested from the beltline of the abdomen (a crescent excision across the abdomen just above the inguinal creases) for grafting neck contractures or dorsal hand burns. Large donor site areas for full thickness grafts are limited (groin, lower abdomen, neck, retroauricular sulcus). Lastly, the rule of “like replaces like” should be considered. A full thickness graft taken from the contralateral upper eyelid is most appropriate for an excisional eyelid defect due to the need for thin, mobile, uncontracted skin at the eyelids and periorbita.

49.2.1 Mechanics of the Operation Before the operation, the wound is inspected and assessed specifically for cellulitis (infection), vascularity and granulation (adequate wound bed), and eschar or areas of devitalized tissue requiring further debridement. Next, potential donor sites are inspected with regard to patient positioning. Postoperative wound care instructions are given at this time while the patient is alert and perhaps accompanied by a caregiver. The operation proceeds by first addressing the wound, finishing any required debridement down to

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49  Minor Procedures

healthy bleeding tissue. Hemostasis must be achieved to prevent hematoma beneath the graft. Post-debridement cultures and pulsed lavage may be considered. The most common donor site for a split thickness graft is the anterior and lateral thigh. The illiotibial tract provides a convenient flat surface for harvesting. Both the dermatome and the donor site are lubricated (mineral oil or K-Y jelly). When using the dermatome, it is important to put the donor site under tension and to let the machine do the work by applying only moderate pressure. The graft is most often harvested at a thickness of 12–18 one-thousandths of an inch (0.36– 0.45  mm) (skin itself ranges from 17 thousandths to 150 thousandths of an inch in thickness). A gauze or Telfa soaked in a dilute epinephrine solution is applied to the donor site while the graft is meshed and inset. The donor site is best dressed with an occlusive dressing (such as Tegaderm®). Petrolatum impregnated gauze may also be used. The buttock area is often considered a donor site for young females but is harder to harvest than the thigh. If a dermatome is not available, a split thickness graft can be harvested by hand with a Humby knife. Reasons for meshing the graft are (1) to expand the graft, (2) to allow the graft to conform to the complex surface of the wound, and (3) to facilitate serous drainage. Meshing the graft will not prevent hematoma. Most frequently, a 1:1½ ratio is chosen. A ratio of 1:3 is very difficult to handle. Make sure the dermis side of the graft is applied to the wound bed. With experience, this can be judged by the surface markings, color, and sheen of the epidermis when viewed obliquely to the light source. Staples or sutures are used generously to ensure that the graft conforms to the wound bed. Slow setting fibrin glue may be used as an adjunct for graft adherence particularly in edematous wounds or areas of high mobility where dressings are difficult. The fibrin glue has not been shown to affect adversely imbibition or graft take. In order to hold the graft against the wound bed, a bolster is often fashioned by sandwiching moist cotton or a surgical sponge between two layers of petrolatum impregnated gauze. Silk sutures are placed around the circumference and tied over the bolster. A vacuum assisted closure device can also be used on a low setting (100 mmHg) to hold a graft in place. The donor site is dressed with an occlusive dressing such as tegaderm. This is simply left in place until the donor site heals. Any blood collections can be needle

aspirated and patched with a smaller tegaderm. Alternately, petrolatum gauze can be used to dress the wound. This should be exposed on the first postop day and gently dried with a hairdryer on a low setting if necessary. While this process is painful, once the dressing is dry, it forms a comfortable “man-made scab” that can be trimmed as the underlying epithelialization loosens it. The donor site should be monitored for infection, in particlular, pseudomonal colonization or infection. Full thickness grafts are usually harvested from the upper eyelid, the preauricular cheek, a neck fold in the elderly, or the lower abdomen and inguinal crease. A “pinch test” is performed to gauge how much skin can be removed and still obtain primary closure. The graft is harvested through the subcutaneous fat plane and then defatted with scissors. Full thickness grafts are inset and bolstered in the same fashion as split thickness grafts. Dressings applied to the grafted wounds must ­conform so as not to create shear. Immobilization with splints and bed rest should be considered.

49.2.2 Postoperative Care The most common reasons for graft failure are: (1) inadequate wound bed, (2) shear forces, (3) infection, and (4) hematoma. Postoperative care can be facilitated by keeping these in mind and avoiding them. For instance, as noted above, immobilization and bed rest help to prevent shear. Antibiotics should be considered for 3–5 days as the wound revascularizes. Bolsters are usually removed on postoperative day 5. At this time, a non-adherent daily dressing is then used. One may consider removing a bolster somewhat earlier on postoperative day 3 or 4 if the wound bed is exudative or overgrown with pseudomonas. If a VAC® (vacuum) device was placed, it should be removed on day 3 or 4 as prolonged use may adversely affect the graft and even lead to granulation of the graft interstices. For legs, a graduated progressive scheme of gravitational dependency may be started around postoperative day 5 but attention should be paid to edema. Grafts are typically adherent enough to withstand showering around postoperative day 10. Around this time, if the interstices of the mesh pattern are epithelialized, dressings can be discontinued and a simple hydrating lotion

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or petrolatum may be used on the grafted site. If hypertrophic areas of granulation occur, these can be treated with topical silver nitrate. Occupational therapy can be started around day 10 but in areas such as the hand where more aggressive motion is needed, starting on postoperative day 5 with monitoring of the stress placed on the graft may be considered. While healing, grafts should be protected from strong sunlight to ­prevent hyperpigmentation. The donor site is often healed around day 10 or 12. At this time, the occlusive dressing may be removed and hydrating lotion applied to the epithelium.

49.3 Flaps Flaps are used for coverage in situations where poorly vascularized tissues are exposed in the wound bed. Grafts will not take on cartilage, tendons, or bone. Flaps are also used in areas where the contraction of a graft cannot be tolerated, such as the hands, periorbita, etc. A further application of flap closure is in areas of cosmetic concern. Flaps are classified into various ways. As mentioned above, the reconstructive ladder conceptualizes flap options in terms of local, regional, and distant flap options. Flaps may be classified by blood supply: random or axial. The majority of local flaps are based on a random blood supply. In this situation, the base of the flap must not be unduly narrowed. The old rule of thumb that the flap length should not exceed three times the base is unreliable. An axial flap is a flap based on a known cutaneous artery. These arteries are limited in distribution. An example would be a radial forearm flap based on the radial artery or a groin flap based on the superficial inferior epigastric artery. These flaps are, in general, highly reliable. Flaps may also be classified by advancement or movement technique: advancement (e.g., V-Y), rotation

RANDOM

(bilobe), transposition (Z-plasty, rhomboid), etc. Lastly, flaps may be classified by their components: cutaneous, fasciocutaneous, musculocutaneous, etc. When planning a wound for flap coverage, it is best to apply the principles of the reconstructive ladder as discussed above. Use the simplest, most dependable flap that will fulfill the requirements of reconstruction. Note that the term reconstruction, rather than “wound closure” is used. Another reconstructive concept to keep in mind when planning a flap is that “like replaces like.” For instance, a pedicle flap from the upper eyelid can be used to reconstruct a lower eyelid defect. Wound bed requirements are similar to those of grafting. Infections must be controlled and all nonviable tissue must be debrided. Since flaps bring their own blood supply to the wound bed, prior vascularization of the wound bed (granulation) is not necessary. When closing oncologic defects, all tumor should be removed and margins cleared, particularly in recurrent or locally aggressive tumors (e.g., morpheaform basal cell carcinoma). In areas where mobility is a premium, all scar should be removed when possible.

49.3.1 Particular Local Flaps 49.3.1.1 V-Y A V-Y advancement flap is performed by cutting a flap in the shape of a V and then advancing the flap, closing the wound behind the advancing apex. The result is a Y-shape. A classic example, if not a large one, is closing a sacral decubital ulcer as two V-Y flaps based on the glutei. Another application is closure of a fingertip wound by either advancing the volar tuft as a so-called Kleinert flap, or by using two axial V-Y flaps.

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A disadvantage of the flap is that the blood supply to the flap comes from a central pedicle directly beneath the flap. Therefore, the mobility of the underlying subcutaneous tissues limits the amount of advancement achieved. The flap is best performed in areas of high skin mobility, typically where subcutaneous fat is rather ample. Advancement is often disappointing in the fingertips.

49.3.1.2 Z-plasty A Z-plasty is a form of transposition. It is used to “break up” linear contractures, to lengthen and reorient scars. Z-plasties work by transposing the longer

TRANSPOSITION

base of two triangles into the axis of the contracture or scar. Ideally, normal supple skin is transposed into the axis at the same time, allowing for distensibility and motion. This should be kept in mind when planning Z-plasties, particularly near joint or flexion creases: plan the Z-plasty in a way that incorporates normal skin when possible. Theoretically, a 90° angle at each limb provides the most lengthening. However, 90° limbs are hard to rotate and difficult to work with. 60° or so is more clinically useful and have been shown mathematically to provide the maximum practical scar lengthening. A 30° angle will provide 25% lengthening; a 45° provides 50%; and a 60° angle will achieve 75% lengthening. Z-plasties are particularly

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important in burn reconstruction. A classic example of a Z-plasty is release of axillary webbing after postburn contraction. Flaps should be kept relatively thick and broad-based when dealing with such scars or in smokers. Multiple Z-plasties can be planned along a single long scar to release it over its entire length. Multiple small Z-plasties or a W-plasty can be used to reorient and camouflage scars such as those that have “pincushioned.” A “jumping man flap” is a special variant of Z-plasty and useful for curved or web-like scars. An example of its use is in breaking up a first web space contracture of the hand or in correcting a medial canthal web. 49.3.1.3 Rhomboid A rhomboid flap is useful in areas where adjacent distensible skin is available for transposition into a defect. A classic application of the rhomboid flap is the temple. The lesion (such as a carcinoma) is excised in a rhomboid in shape and the adjacent flap is transposed into the defect by first cutting the flap as a parallelogram at one of the vertices of the defect. Each rhomboid shaped defect has eight associated possible flap orientations (two at each vertex). The key to planning is to make sure there is enough skin to close the flap donor site by pinching along the axis of the diagonal base of the flap. This will also be the line of maximum tension. Several possible rhomboid flaps are possible around the margin of the defect. In choosing the location of the particular flap to be used, the residual lax skin is gauged by a pinch test as noted above. An advantage of the rhomboid flap is that it transposes adjacent skin of similar thickness and pigmentation

B

into the wound, obeying the principle “like replaces like.” A classic example is closure of a temporal forehead defect.

49.3.1.4 Bilobe Flap A bilobe flap is used for roughly circular shaped defects. The bilobe flap is composed of a primary lobe and a secondary lobe attached at a broad base. The primary lobe is slightly smaller than the defect and planned adjacent to it. The secondary lobe is about half the width of the primary lobe. As the primary lobe is rotated into the defect, the secondary lobe is rotated into the primary lobe defect. The secondary defect is then closed primarily. The bilobe flap is really a means of rotating lateral skin into the primary defect in “stages.” For the flap to be successful, the secondary flap must come from an area of loose skin. A classic example is closure of a dorsolateral nasal defect. Cosmetic results are usually excellent especially in the older patient. 49.3.1.5 Regional Flaps Regional flaps are those brought from an area near, but not adjacent to the defect itself, contrary to local flaps that are adjacent to the defect (for example, rhomboid or V-Y) and distant flaps (free tissues transfer, groin flap, cross-leg flaps, etc.). Regional flaps are based on a sound knowledge of the blood supply to the flap and are designed specifically to incorporate that blood supply. Regional flaps may be axial, or based on a known cutaneous artery such as a forehead flap based on the supratrochlear artery branches or a radial forearm flap based on the radial artery.

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The flap is delayed for several weeks before cutting and insetting the base. 2

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49.3.1.6 Forehead Flap A classic reconstruction of large dorsal nasal or nasal tip defects is the forehead flap (midline or paramedian). The flap is designed with the supratrochlear vessels at its base. Usually, the contralateral vessels are used to facilitate flap rotation. The flap is very hardy and quickly elevated. If the flap is kept 2–3 cm in width, the donor site can be primarily closed by broadly undermining the forehead.

The radial forearm flap is a fasciocutaneous flap based distally on the radial artery. The flap is used extensively as a free flap but can be used to provide thin coverage of hand defects. A skin island slightly larger than the defect is marked on the volar forearm distal to the antecubital fossa centered on the radial artery. The radial artery is mapped by doppler and by palpation. An Allen’s test is performed to ensure adequate perfusion of the hand through the superficial palmar arch and the ulnar artery. The length of the pedicle is measured to ensure adequate rotation to the defect without kinking. A tourniquet may be used to facilitate dissection. Some surgeons prefer to not use the tourniquet so as to be able to palpate the radial pulse. The radial artery is located beneath the brachioradialis muscle in the proximal forearm. The brachioradialis is swept radially to expose the vascular bundle. The radial artery and venae comitantes are transected and dissected from proximal to distal, protecting the superficial branch of the radial nerve distally. Care is taken to preserve the septum running between the artery and skin lying between the brachioradialis and flexor carpi radialis muscles. The superficial fascia is dissected off these muscles in continuity with the intermuscular septum in order to preserve the septum. Several muscular branches are ligated during dissection. The entire vascular bundle should be taken; the artery should not be skeletonized so as to preserve venous drainage through the venae comitantes.

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49.3.1.8 Groin Flap

49.3.1.10 Distant Flaps

The groin flap is a fasciocutaneous flap based on the superficial circumflex iliac artery (SCIA) and vein. The flap is a hearty flap that has been used to provide urgent hand coverage. The flap is typically very bulky and often requires thinning and revision in a delayed fashion. A line is drawn from the anterior superior iliac spine (ASIS) to the pubic tubercle. The axis of the pedicle lies 3 cm inferior to this line and parallel to it. Standard flap elevation is lateral to medial, from the ASIS to the medial border of the sartorius muscle. The plane of dissection is just superficial to the fascia lata until sartorius muscle is encountered. Here, dissection is just under the superficial muscle fascia. Dissection stops at the medial edge of the muscle where the pedicle lies. The flap is left inset for about 3  weeks and before dividing the pedicle, the vascularity is tested by constricting the base with a penrose drain for 5 min. The classic application of this flap is an avulsion injury of the dorsum of the hand.

The last category of flap coverage is that of distant flaps. Current usage of this term usually refers to free tissue transfer (free flaps) in which the flap and its blood supply are completely disconnected from the donor site and then reattached using microsurgical techniques at the recipient site. Free tissue transfer is beyond the scope of this chapter but it is worthwhile noting what kind of defects should be referred for free tissue transfer consideration. These defects are usually composite defects of bone and soft tissue; defects which have poorly vascularized wound beds and insufficient regional flap options; wounds requiring specialized contours, gliding surfaces (for tendons excursion), or cosmesis which cannot be met by locoregional flaps. When considering free tissue transfer, form and function of the deficit are analyzed and an attempt is made to reconstitute them. It is worth noting that many wounds which would have required free tissue transfer in the past, particularly those with poorly vascularized wound beds, are now vascularized using a vacuum assisted closure device followed by grafting (such as wounds of the distal third of the lower extremity). Historically, other distant flaps were designed and transferred based on the delay principle. In the delay procedure, a flap is incised and then inset into the recipient site without cutting the blood supply from the donor site. A time period is then allowed to pass in order to allow a blood supply to grow in from the recipient site wound bed. After this has occurred, the original blood supply or pedicle from the recipient site is cut, leaving the flap to live off its new blood supply. Examples of this procedure would be a cross-finger flap, a groin flap (for hand coverage), nasolabial flaps, forehead flaps, and cross-leg transfers. A key to this

49.3.1.9 Muscle Flaps Muscle flaps are used where a copious blood supply is needed, such as open fractures, osteomyelitis, irradiated tissue, exposed prosthetics (including vascular prosthetics), and seroma (particularly the groin). Flap viability relies on preservation of the blood supply. A classic and relatively straightforward muscle flap is the rectus flap. The flap may be based superiorly (on the superior epigastric vessels) or inferiorly (based on the deep inferior epigastric vessels). Other readily usable muscle flaps are Pectoralis major, Latissimus dorsi, and Gastrocnemius.

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procedure is to leave the flap in the defect for at least 2–3 weeks before transecting the original blood supply. Do not be in a hurry! Smokers, and scarred wound beds require longer periods of delay. The blood supply can be tested by occluding the original blood supply with an elastic vascular loop or noncrushing clamp for a few minutes before transection. Be sure the flap remains pink without venous (dusky) insufficiency. The flaps are usually less technically demanding than free tissue transfer and can often replace it in underserved areas. The disadvantage of these flaps is that they are often bulky with poor contour, requiring revision.

49.4 Circumcision The American Academy of Pediatrics Task Force on Circumcision published a policy statement in 1999 stating: “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current wellbeing, parents should determine what is in the best interest of the child.” The potential medical benefits are those of decreased incidence of UTI and penile carcinoma in circumcised males. It is not clear what the role of circumcision plays in sexually transmitted disease (STD) transmission. Indications beyond the newborn period may include phimosis, paraphimosis, balanoposthitis (infected loculations of smegma), and condylomata. It is inadvisable to perform urgent circumcision at the time of paraphimosis because of the attendant edema. Neonatal circumcision should not be performed in infants with hypospadias, epispadias, chordee, or megalourethra. Local regional anesthetic should be used and is considered more effective than EMLA (eutectic mixture of lidocaine/prilocaine) used as a topical anesthetic. Using a 27-gauge needle, 0.4 cc of 1% lidocaine is injected dorsolaterally at the 10 o’clock and 2 o’clock positions at the base of the penis. The needle is angled posteriomedially until Buck’s fascia is entered. Alternately, a subcutaneous ring block of 0.8  ml 1% lidocaine can be injected at midshaft. Typically, a device such as a Gomco or Plastibell is

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used. In 90% of neonates, the glans is fused to the prepuce and is not retractable. The first step is to release the preputial adhesions to the glans. A dorsal slit is often necessary to place the bell over the glans. With a Gomco, a plate is placed over the bell and glans. The prepuce is then fed through the hole to the level of the previously marked coronal ring. The screw is used to tighten the plate over the bell and is left in place several minutes. The prepuce is then excised sharply (do not use electrocautery with a metal bell in place). The plate and bell are then removed. The most common complication is bleeding which is usually controlled with gentle pressure. Cautery, suture, or topical hemostatic agents may be used. Other complications include infection, penile adhesions, removal of too much or too little skin, phimosis, and injury to the glans, urethra, or shaft. If too much shaft skin is removed, ­healing by secondary intention usually provides a satisfactory result rather than attempts at grafting or primary closure. In adult circumcision, the level of the coronal ridge is marked circumferentially around the shaft. The prepuce is retracted, bluntly lysing adhesions between the glans and prepuce. A dorsal slit may be necessary if phimosis is present. This may be accomplished by inserting one limb of a straight clamp beneath the prepuce to the level of the coronal ring and, making sure the clamp is not in the urethra, closing and crushing the prepuce for a few minutes before dividing the prepuce with a scissors. The proposed line of incision in the inner preputial sac is then marked 3 mm below the coronal sulcus. Both circumferential lines (the shaft and the subcoronal lines) are incised and the skin is removed between them. Hemostasis is obtained and the skin is closed with absorbable sutures.

49.5 Vasectomy Vasectomy is the only form of male birth control currently available. It is advisable to involve the spouse or significant other in the decision making process and in witnessing the consent. The genitalia should be examined for the presence of large varicocele or hydrocele as this may indicate the need for doing the procedure in the operating room rather than a procedure room. After shaving and prepping the scrotum, the right vas is manipulated to the midline raphe, using the thumb and

49  Minor Procedures

the index finger to drape and tense it over the long finger held behind it. The overlying scrotum is injected with 2% lidocaine. The needle is then directed parallel to the vas in the direction of the external inguinal ring and the external spermatic sheath is injected as the needle is withdrawn. The left vas is then manipulated to the midline wheal and similarly injected. The right vas is again brought to the midline and a 1 cm incision is made transversely over it, continuing down to the vasal sheath. The sheath is then incised vertically and the vas is gently grasped. It should be easily pulled from the sheath and if it is not, the sheath may need deeper incision. A small mosquito clamp is then used to gently dissect the vessels from the posterior aspect of the vas. The testicular end is then ligated and the vas is transected at least 1 cm above the ligature. A handheld cautery is then used to cauterize 1 cm of the lumen of the abdominal end of the vas. This is to cause fibrosis of the lumen. The abdominal end is allowed to retract and the vasal sheath is closed over the stump with a gut suture. A 1  cm segment of the testicular end of the vas is then transected and sent for pathological inspection. The scrotum may be closed with dissolvable sutures but meticulous hemostasis should be first obtained. The patient should lie supine for 12–24 h and intermittent ice packs (packages of frozen peas do well) are helpful. Scrotal contraction may decrease hematoma rates. Patients should abstain from sexual intercourse for at least 1 week to allow for lumenal fibrosis. The time to azoospermia is most dependant on the  number of ejaculations. Ninety-eight percent of patients are azoospermic after 24 ejaculations. Sixtyseven to ninety-eight percent of patients are azoospermic at 3 months. Therefore, patients are scheduled for the first semen analysis at 3  months and 24 ejaculations. They return at 4  months for the second semen analysis. Patients should use contraception until two azoospermic semen analyses are achieved. Recanalization rates or failure are less than 1%. Scrotal hematoma rates may be 3%. Complications such as sperm granuloma and chronic scrotal pain are rare.

49.6 Lymph Node Biopsy Perhaps the most important consideration in undertaking lymph node biopsy is to carefully consider the differential diagnosis and to seek out regional causes of

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the lymphadenopathy. For instance, one should never embark upon removing a solitary jugular chain node before a complete examination of the head and upper aerodigestive are performed. The face, parotid, and scalp should be examined for primary lesions. The role of radiologic evaluations such as CT, MRI, and PET scan should be entertained as well. If the lymph node is low in the cervical chain, evaluation of the chest should be included. In a large review of neck masses, Skandalakis found 3% to be inflammatory, 85% to be malignant, and 12% to be congenital, emphasizing the importance of regional workup particularly in the adult patient. Fine needle aspiration should be performed before open lymph node biopsy. Open biopsy should only be performed when the nature of the mass remains unconfirmed despite exhaustive clinical, laboratory, and radiologic evaluation. Patterns of metastasis to the neck nodes are predictable and can be used to focus clinical exam. The floor of the mouth, anterior tongue, and buccal cavity all drain to the submaxillary, submental, and upper jugular lymph node group. The nasopharynx tends to drain to the upper posterior triangle. The larynx, hypopharynx, and thyroid drain to the midjugular group. The upper esophagus, hypopharynx, and thyroid gland drain to the lower group. The lung, ovary, breast, stomach, and prostate may drain to the supraclavicular ­triangle (Virchow’s node). Once an open biopsy is performed, the surgeon should be prepared to perform a neck dissection if frozen section reveals squamous cell cancer. Neck dissection is contraindicated if special stains reveal lymphoma. If frozen section results are equivocal or reveal an undifferentiated cancer, therapy must await the final pathologic reading. In performing lymph node biopsy of the neck, the initial incision is either made in Langer’s lines (relaxed skin tension lines) or planned so as to be extended into a neck dissection if necessary. The subcutaneous fat and platysma are then incised. Superficial veins are ligated and divided as necessary. These veins are tethered to the cervical fascia and tend to remain open and bleed when cut. As the node is dissected free, all lymphatics to it are ligated. The superficial sensory nerves to the neck, scalp, and ear pierce the cervical fascia at the posterior border of the sternocleidomastoid muscle halfway between the mastoid and the clavicle (Erb’s point). They should be preserved when possible. In particular, the greater auricular nerve travels craniad on the superficial aspect of the sternocleidomastoid

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from Erb’s point to the ear and its lobule. Should the biospy occur near the venous angle of the internal jugular and the subclavian veins, particularly on the left, the presence of the terminal thoracic duct complex should be remembered. The complex can be plexiform in 7–26% of the cases so an effort should be made to tie off all transected lymphatics so as to avoid wound complications and lymphatic leak. Lastly, in the inferior neck and the posterior triangle, the brachial plexus should be avoided by bluntly performing dissection of the posterior aspect of the node to be removed.

49.7 Ingrown Toenail (Onychocryptosis) Ingrown toenail may occur as a result of trauma, tightly fitting shoes, or improper trimming. Most ingrown nails respond to conservative treatment starting with identifying and correcting the underlying problem. The nail is then separated from the nail fold so that it has an unobstructed path for growth. Warm soaks may help. If this treatment does not work partial nail removal with or without germinal matrix ablation may be necessary. A digital block of 1% or 2% lidocaine is administered. A penrose tourniquet may be used at the base of the toe. Fine scissors are inserted under the portion of nail to be removed so as to separate it right down to the base of the nail fold. A #15 blade can be used as well, keeping the belly of the blade against, and visible through the nail. Once the nail is separated, a partial removal is completed by scissors. Alternately, a mosquito clamp may be used to grasp the nail all the way to the base. The entire nail is then removed by rolling the nail out of the fold from side to side in the same fashion that one opens a can of sardines with a key. Partial or total nail bed ablation is performed by applying phenol to the germinal matrix for at least two cycles, 1 min each. Bleeding is controlled with pressure or silver nitrate.

Recommended Reading Grafts Aston, S.J., Beasley, R.W., Thorne, C. (eds.): Grabb and Smith’s Plastic Surgery, 5th edn. Lippincott-Raven, Philadelphia (1997)

E. Mooney Mathes, Stephen (ed.): Plastic Surgery, vol. 1, 2nd edn. W. B. Saunders, Philadelphia (2006)

Circumcision Elder, J.S.: Abnormalities of the genitalia in boys and their surgical management. In: Walsh, P.C. (ed.) Campbell’s Urology, 8th edn, pp. 2334–2337. W.B. Saunders, Philadelphia (2002) Lannon, C.M., Bailey, A.G.D., Fleischman, A.R., et al.: Circumcision policy statement. Pediatrics 103(3), 686–693 (1999) McAleer, I.M., Kaplan, G.W.: Circumcision. In: Graham, S.D. (ed.) Glenn’s Urologic Surgery, 6th edn, pp. 8522–8526. Lippincott, Williams, & Wilkins, Philadelphia (2004) Skoog, S.J., Scherz, H.C.: Office pediatric urology. In: Gillenwater, J.Y. (ed.) Adult and Pediatric Urology, 4th edn, pp. 2675– 2676. Lippincott, Williams, & Wilkins, Philadelphia (2002)

Vasectomy Pryor, J.L.: Vasectomy. In: Graham, S.D. (ed.) Glenn’s Urologic Surgery, 6th edn, pp. 450–454. Lippincott, Williams, & Wilkins, Philadelphia (2004)

Lymph Node Biopsy Cohen, M., Dolezal, R.F.: Diagnostic approach to neck masses. In: Nyhus, L.M., Baker, R.J. (eds.) Mastery of Surgery, 2nd edn, pp. 147–162. Little, Brown, and Co, Boston (1992) Monsen, H.: Anatomy of the anterior and lateral triangles of the neck. In: Nyhus, L.M., Baker, R.J. (eds.) Mastery of Surgery, 2nd edn, pp. 145–146. Little, Brown, and Co, Boston (1992) Skandalakis, J.E., Gray, S.W., et al.: Tumors of the neck. Surgery 48, 375 (1960) Skandalakis, J.E., Skandalakis, L.J., Skandalakis, P.N.: Anatomy of the lymphatics. Surg. Oncol. Clin N. Am. 16(1), 1–16 (2007) Stiernberg, C.M., Mostert, J.F.: Unknown primary lesion. In: Shockley, W.W., Pillsbury, H.C. (eds.) The Neck. Diagnosis and Surgery, pp. 431–437. Mosby, St. Louis (1994)

IGTN Chavez, M.C., Maker, V.J.: Office surgery. In: Rakel, R.E. (ed.) Textbook of Family Practice, pp. 662–663. W.B. Saunders, Philadelphia (2002)

Part Relevant Orthopaedics for General Surgeons

IV

 

Simple Orthopaedic Procedures and Common Diagnoses

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50.1 General Assessment of Injuries to the Extremities A history must be taken from the patient or a witness to the injury. The limb should be inspected prior to a systematic palpation and assessment for stability and range of motion. Open wounds should be washed thoroughly and dressed with gauze soaked in an antiseptic solution. The primary goal of the emergency treatment of limb injuries is reduction and splinting of fractures and dislocations. By reducing the displaced bone, further insult to the soft tissues can be avoided. Reduction will improve local and peripheral vascularisation. Exact reposition is secondary at this time. Put the extremity into axial alignment, restore the local and peripheral vascularisation and treat the pain with analgesia. Open fractures can be treated like closed fractures after the application of a sterile dressing.

50.2 Principles of Closed Reduction and Non-operative Fracture Treatment 50.2.1 Closed Reduction Whether a fracture is treated operatively or not, a fracture with unacceptable displacement of fragments must be reduced to decrease the pressure

D. Wysocki and R. Zellweger (*) Department of Orthopaedic Surgery, Royal Perth Hospital, Wellington Street Perth, WA, Australia e-mail: [email protected]

on the soft tissue, vessels and nerves as soon as possible. To effectively reduce a fracture, the mechanism of injury should be understood. For example, an external rotation injury to the ankle may produce a spiral distal fibula fracture and dislocation of the talus laterally. It is tempting to simply force the talus back underneath the tibia with lateral force. While this may achieve reduction to some extent, by placing traction and internally rotating the foot a more anatomical reduction can be achieved. All manoeuvres should be done slowly, not with sudden force. Care should be used if latex gloves are worn, especially in the elderly, as skin tears can be created. Prerequisites for a closed reduction include sufficient analgesia and enough staff to apply traction, countertraction and create the plaster. Reduction radiographs in two planes must follow to ensure adequate position.

50.2.2 Plaster Casting With the advent of modern methods of internal fixation, the application of a good plaster is a skill, which has become somewhat overlooked. However, the application of an appropriate plaster, which prevents loss of reduction, can often negate the need for a patient to have surgery. A full plaster should never be placed on a patient in the acute setting. As the limb swells, a complete cast could create a compartment syndrome. A cylinder plaster, which is split, is the only safe method of immobilisation. As the swelling subsides, the plaster can become loose allowing the fracture to lose posi­ tion.  The patient should be advised to re-tighten the

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overlying bandage every 48 hours. A good plaster will only immobilise the required joints. A common mistake is extending a plaster designed for a distal radius fracture past the metocarpophalangeal joints. Patients should be encouraged to move the non-splinted joints to prevent stiffness. If a patient complains of pain in a plaster, it should always be removed and examined for pressure sores.

50.2.3 Traction Traction is a simple way of initially managing most lower limb and humeral fractures. The principal disadvantage of traction treatment is a longer confinement of the patient to bed. With today’s modern methods of internal fixation, traction is rarely used to treat a fracture until complete union. It remains a useful method to provide analgesia to patients who require transfer or bed rest while awaiting surgery. There are two major types of traction: skin and skeletal tractions. Skin traction employs tapes, boots or straps. Skeletal traction requires a surgical procedure to insert a metal pin through the bone enabling larger forces to be applied to the injured limb. The pins must always be clean to avoid infection, and traction equipment should be checked regularly to ensure proper position and exertion of force. The amount of traction required will vary with the method of traction, the size of the patient and the type of fracture.

50.3 Operative Treatment: External Fixator and Osteosynthesis 50.3.1 External Fixation The concept of external fixation is rather simple. Metal frames are placed outside the skin, which stabilise the bone fragments through wires or pins ­connected to one or more longitudinal bars. The advantages are less damage to the blood supply of the bone and minimal interference with the soft tissue cover. The rigidity of the fixation is adjustable without surgery and the technique requires less experience

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and surgical skills than does internal fixation. These advantages are offset by the complications related to the pins in the bone. Indications: • Open fractures • Damage control orthopaedic surgery in severe ­multiple-trauma patients • Bone infections or increased risk of infections

50.3.2 Principles of Osteosynthesis Osteosynthesis refers to operative stabilisation of a fracture, which can be achieved with two different biomechanical principles: anatomical reduction and absolute stability, which creates union through direct healing of the two bone ends, or relative stability and bone healing through callus formation. The two principles are determined by either compression between the two fragments for stability or no interfragmentary compression. The selected way of fracture treatment can be achieved using various techniques of osteosynthesis. The decision of which technique to choose from a biomechanical point of view depends on the possible accompanying soft tissue injury, the nature of the fracture, the direction of the fracture line and the number of bone fragments. The principles stated by the AO Group (working group for osteosynthesis) formed in Switzerland in 1958 have remained consistent and clear over the last 60 years. Their principles relating to anatomy, stability, biology and mobilisation still stand as fundamentals today. AO principles: 1.  Preservation of the blood supply to soft tissue and bone 2.  Anatomic reduction of the fracture fragments 3.  Stable internal fixation or splintage 4.  Early active mobilisation Indications for internal fixation are fractures that cannot be reduced and held with conservative measures, fractures that have failed conservative treatment by progressing to a nonunion or by losing acceptable reduction, open fractures, pathological fractures or fractures that if treated conservatively, will result in an unacceptable period of recumbence.

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50.4 Distal Radial Fractures

ubiquitous in clinical practice. Four commonly used include (See Fig. 50.1): Colles fracture (see Fig. 50.1a): This injury is classically seen in patients suffering with osteoporosis and presents with a dinner fork deformity. The fracture occurs within approximately 2.5 cm of the wrist joint. The most obvious features are dorsal displacement and dorsal angulation of the distal segment. This is usually accompanied with elements of radial displacement, radial angulation of the distal fragment and also impaction and comminution of the dorsal cortex. The fracture can also extend into the joint surface. Volar Barton’s fracture (see Fig. 50.1b): This fracture extends from the volar cortex into the wrist joint. The fracture is usually unstable demonstrated by volar displacement. Often subluxation of the carpus follows. Smith’s fracture (see Fig. 50.1c): This is an extraarticular fracture of the distal radius with volar displacement of the ­distal segment. Chauffeur’s fracture (see Fig. 50.1d): This is a fracture of the radial styloid. The injury occurs due to a fall onto the outstretched hand but has classically been described as being caused by the kickback of starting an engine with a handle. The fracture is often associated with injury to the scapho-lunate ligaments, as seen on radiographs by widening of the joint space between the ­scaphoid and the lunate. This injury usually requires surgical repair.

50.4.1 Introduction Distal radial fractures account for approximately 15% of all fractures seen and treated in emergency departments. The incidence of distal radius fractures peaks in two age groups: between 6 and 10  years of age and between 60 and 80 years of age. It is associated with moderate to severe trauma in young adults.

50.4.2 Mechanism of Injury The classical trauma resulting in a distal radius fracture is a fall on the outstretched hand. Depending on the position of the hand, there are different bending and compression forces, which cause different fracture types.

50.4.3 Classification System There are many classifications used for distal radial fractures but none have been accepted as the standard method. However, there are eponyms that are

a

b

Fig.  50.1  Common distal radial fractures. (a) Colles fracture (b) Volar Barton’s fracture (c) Smith’s fracture (d) Chauffeurs fracture The existing figure will be replaced by a new one which

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d

my wife will draw and then send to Springer to have it modified by their grafic’s department

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50.4.4 Examination and Diagnosis Swelling, deformity and painful restriction of movement are common features of all fractures of the distal radius. Examination should rule out wounds, which may represent an open fracture. Careful examination of the neurovascular status of the hand is important. The median nerve runs across the volar aspect of the wrist and is at risk from sharp fracture edges and also stretching injures from displaced fractures. Persisting or progressing median nerve symptoms after reduction is an indication for emergency carpal tunnel release. Radiographs should be taken in anterior–posterior and lateral planes. Examination should also exclude associated injuries such as scaphoid fractures, dislocation of the distal radio-ulnar joint and proximal upper limb fractures.

50.4.5 Treatment The emergency treatment includes the reduction of dislocations and displaced fractures and application of an appropriate split plaster. Indications for operative treatment must be individualised based on the nature of the injury, general health and functional requirements of the patient. The restoration and maintenance of anatomy will enhance the potential for a full functional outcome. The normal radiographic features of the wrist include approximately 10° of volar tilt, 20–25° of radial inclination and a radial styloid length of approximately 10  mm. Indications for open reduction and internal fixation in an otherwise healthy patient include a step or gap in the articular surface of greater than 1  mm, loss of radial length greater than 2 mm, obvious loss of volar tilt or radial inclination.

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4–6 weeks then a radiograph out of plaster should be taken to assess for callus. If clinical examination to assess for union is reassuring, then the patient can begin gentle motion of the wrist.

50.4.5.2 Operative Treatment There are three commonly used methods of surgical fixation: Kirschner wires, external fixation and fixation with plates. They can be used separately or in combination. Kirschner wires are a minimally invasive, cheap method of fixation and, if used in isolation, usually require an additional 6-week plaster fixation. The wires should be inserted to penetrate the proximal cortex. They are normally removed after a period of 6 weeks. It can be difficult to hold osteoporotic bone in position with Kirschner wires alone. An external fixator is used as primary stabilisation if there is an accompanying severe soft tissue injury or in highly comminuted fractures. Two pins are inserted into the distal third of the radial shaft and two into the lateral aspect of the metacarpal shaft of the index finger. With pull and positioning of the hand, the reduction is mainly achieved with ligamentotaxis. The main disadvantage of this treatment is that it is a joint-bridging fixation and therefore functional rehabilitation is not possible until the fixator can be removed, which can result in significant stiffness of the joint. Therefore after healing of the soft tissue, a definitive fixation with a plate is advisable. Plate osteosynthesis is usually done with volarly or dorsally positioned plates. With the advent of locking plate technology, volar plates can be used very successfully in osteoporotic fractures. They also allow early mobilisation of fractures in patients with good bone quality. Dorsal plating is associated with significant risk of tethering the extensor tendons, is only indicated in highly comminuted fractures and must be done by experienced orthopaedic trauma surgeons.

50.4.5.1 Non-operative Treatment The undisplaced or reduced fracture is initially held in a well-moulded split plaster to allow for swelling. Radiographs taken through the plaster at 1 and 2 weeks will detect loss of reduction of the fracture. If a new plaster is applied, radiographs in that plaster should be taken. The fracture should be immobilised for

50.4.6 Complications Median nerve injury and compartment syndrome need to be considered when patients present with the injury. Stiff wrist joints are common following immobilisation,

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and it is important that plasters leave the metacarpal joints free to prevent unnecessary stiffness in the hand. Reflex sympathetic dystrophy is a serious complication of both operative and non-operative treatment, which needs to be treated with attentive hand therapy and specialised pain management. Rupture to the extensor tendons can occur early or later due to abrasion on screws passing through the dorsal cortex. Later complications include post-traumatic osteoarthritis from damage to the joint surface or malunion. Nonunion is rare.

50.5 Clavicle Fracture 50.5.1 Introduction Clavicle fractures account for approximately 5% of all fractures seen in the emergency department. The clavicle serves as the primary connection between the thorax and the upper limb, connecting the sternoclavicular joint medially to the acromioclavicular joint laterally. Associated damage to the underlying neurovascular structures, scapula, ribs or lungs is uncommon.

50.5.3.2 Fracture of the Lateral Third Lateral third injuries account for 10–15% of clavicle fractures. The proximal portion may be displaced upwards if the coracoclavicular ligaments are ruptured.

50.5.3.3 Fracture of the Medial Third Medial third fracture is a rare injury associated with high energy and often other concomitant injuries.

50.5.4 Examination and Diagnosis The patient will typically present holding the injured limb with the unaffected side. Localised tenderness over the fracture is typical. There may be a deformity of the clavicle and occasionally the skin will be tented by the fracture. An open clavicle fracture is rare, as is associated neurovascular damage. However, if the fracture is severely displaced, damage can occur to the medial cord of the brachial plexus so that a neurological assessment has to be performed to exclude this. The fracture is best visualised with an anterior–­posterior radiograph.

50.5.2 Mechanism of Injury Most clavicular fractures result from a fall on to the shoulder or a direct blow to the clavicle or shoulder. Less commonly, the impact can be transmitted up the arm from a fall on the outstretched hand.

50.5.3 Classification Clavicle fractures are classified by their location: medial, middle and lateral thirds.

50.5.5 Treatment The majority of clavicle fractures can be treated nonoperatively (see Fig.  50.2). Strong indications for operative treatment include open fractures, neurovascular compromise and  symptomatic nonunion. Displaced lateral clavicle fractures with associated coracoclavicular ligament rupture should be treated operatively as should clavicle fractures associated with a glenoid neck fracture. Relative indications for surgery include 2 cm of shortening, 1 cm of displacement or significant clinical deformity. These have even more relevance to overhead athletes and manual labourers.

50.5.3.1 Fracture of the Middle Third Middle third fractures are the most common, accounting for approximately 80% of clavicle fractures. Generally, the lateral portion is pulled down by the weight of the arm and the proximal portion is pulled upward by the sternocleidomastoid muscle.

50.5.5.1 Non-operative Treatment Non-operative treatment involves early immobilisation in a broad arm-sling, usually for 2–3 weeks. Once the patient’s pain begins to settle, they can proceed with a

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1 5

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the patient should be encouraged to begin moving the shoulder and the arm. Usually callus can be seen on x-ray after 4–6 weeks.

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50.5.6 Complications

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Fig. 50.2  Non-operative treatment: 1 - medical clavicle fracture, 2 - lateral clavicle fracture, 3 - glenoid, 4 coracoid, 5 - acromion

Fractures, which are widely displaced, are at risk of soft tissue interposition and can have higher rates of nonunion. Significantly shortened clavicles will result in asymmetry of the shoulders and are at risk of reduced overhead function. The surgical approach can create a numb area over the anterior wall of the chest, as low as the nipple if the supra-clavicular nerves are cut. Patients often feel discomfort of the palpable plate under the skin. It is important to advise them that fixation of the fracture will likely require removal of the metalwork in the future.

50.6 Shoulder Dislocation 50.6.1 Introduction

gentle range of motion. Despite deformity, healing usually proceeds rapidly. Union occurs with prominent callus seen on radiographs. Distal clavicle fractures may have a higher incidence of nonunion, but most of these are asymptomatic. A small number will require surgery.

50.5.5.2 Operative Treatment Operative treatment can be done with either a plate or elastic nailing. With plate fixation, a large strong plate is required to overcome the bending and torsional forces on the clavicle. Therefore, plates can be prominent and often have to be removed after 12–18 months. Elastic nailing is an option, which is less invasive and avoids most of the problems of the plate. However, migration of the nail can require further unplanned surgery. The nail can be inserted at the sternal or lateral end of the clavicle. Removal of the nail is necessary after 3 months. The patient should be advised to wear a broad armsling for some days after the surgery, mainly for comfort and better wound healing. After that time period,

The shoulder joint is the most commonly dislocated joint, making up 50% of all dislocations presenting to the emergency department. The shoulder has both static restraints (labrum and capsular ligaments) and dynamic restraints (rotator cuff and long head of biceps) that contribute to its stability. The shoulder has little in the way of osseous restraints, making it both the most mobile and inherently the most unstable joint in the body. In more than 90% of cases, the first dislocation of the shoulder is traumatic. The majority of all shoulder dislocations happen before the age of 30.

50.6.2 Classification The relation of the humeral head to the glenoid classifies shoulder dislocations: anterior, posterior and inferior dislocation of the shoulder. Anterior shoulder dislocations account for approximately 85% of all shoulder dislocations.

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50.6.3 Mechanism of Injury Anterior dislocations occur due to falls or being struck on the externally rotated and abducted shoulder. The supero-lateral aspect of the humeral head may strike the antero-inferior glenoid causing fracture of the greater tuberosity, impaction of the cortical bone over the tuberosity (Hills Sachs lesion), rupture of the anterior capsule and labrum (Bankart lesion) or fracture of the glenoid (bony Bankart lesion). Muscle spasm will pull the humeral head medial to the glenoid. This injury is common in the age group of 18–25 years of age due to highenergy motorcycle and athletic injuries, and also in the elderly where the stability of the shoulder may be impaired by muscle degeneration. The older population will either fracture the greater tuberosity or rupture the rotator cuff. In rare cases, there can be damage to the neurovascular structures, particularly the axillary nerve. Posterior dislocations occur due to falls on the ­internally rotated shoulder or from direct blows on the anterior shoulder. Inferior dislocations (luxatio erecta) occur due to falls onto the abducted shoulder or hyper abduction, with the humeral shaft levering on the ­acromion, dislocating the shoulder inferiorly.

50.6.4 Examination and Diagnosis With anterior and posterior dislocations, patients will typically present supporting the injured arm at the elbow with the other hand. The lateral contour of the shoulder is lost, with a palpable gap beneath the acromion. The humeral head should be palpable either anterior or posterior to its normal position. In a doubtful case, palpation of the humeral head in the axilla will confirm anterior dislocation. Inferior dislocations will present with the patient unable to lower the arm from an abducted position. Before attempting reduction, it is important to take radiographs to confirm the diagnosis and to exclude further osseous injures. The majority of anterior dislocations show quite clearly on the standard anterior–posterior radiograph, unless the humeral head has minimal medial displacement. Posterior dislocations are evidenced by rotation of the humeral head on anterior–posterior radiographs; however this can be easily missed (See Fig. 50.3). Both anterior and posterior ­dislocations can be confirmed on an axillary view radiograph.

N

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Fig.  50.3  Dislocation of the shoulder: N normal, 1 anterior d­ islocation, 2 posterior dislocation, 3 luxation erecta

Fracture of the greater tuberosity does not ­influence the initial treatment, but will require subsequent attention following reduction. Often an anatomical reduction of the greater tuberosity fracture will be achieved with reduction of the dislocated shoulder.

50.6.5 Treatment 50.6.5.1 Anterior Dislocation In total there are more than 20 different reposition techniques. By far the most common are (1) the Kocher method and (2) the Hippocratic method. Excessive force should not be applied with any method, as further injury to the limb, such as damage to neurovascular structures or fracture to the neck of the humerus, is possible. It is important to relocate the shoulder as soon as possible to prevent articular cartilage necrosis and palsy of the surrounding nerves. All reduction methods will require analgesia and perhaps sedation. In muscular patients it may be necessary to give neuromuscular blockade.

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1.  Kocher’s method: Apply traction and begin to rotate the arm externally. Take plenty of time for external rotation. In the conscious patient, if muscle resistance is felt, stop for a moment while distracting the patient’s attention. It should be possible to reach 90° of external rotation. The shoulder frequently reduces with a clear ‘clunking’ sensation during the external rotation procedure. If this does not happen, adduct the shoulder so that the elbow starts to come across the chest. Then internally rotate the shoulder bringing the patient’s hand towards the opposite shoulder. If reduction has not occurred, repeat all stages, attempting to get more external rotation in the initial stage. If severe pain and muscle spasm prevent rotation, or reduction has not been achieved in the sedated patient, a general anaesthesia will be required. Complete failure is rare under general anaesthesia. 2.  Hippocratic method: Place the patient in a supine position. Apply traction on the forearm while either the clinician’s foot or a looped sheet is placed in the axilla for counter traction. The dislocated shoulder is held in abduction and external rotation and moved into adduction and internal rotation during the procedure.

50.6.5.2 Posterior Dislocation Reduction is accomplished by applying traction longitudinally and laterally. Gentle internal rotation may be required to disimpact the head while external rotation and/or posterior force will reduce the head.

50.6.5.3 Inferior Dislocation Reduction is accomplished by applying traction in abduction (the position in which the limb is lying) and gently moving the arm into adduction.

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shoulder should be kept immobile for 3–4  weeks to allow torn tissue to heal. In older age groups, where risk of redislocation is minimal, gentle range of motion should begin as soon as pain allows to prevent stiffness. The risk of redislocation following a traumatic first dislocation decreases as the age of the patient increases. An 18 year old will have a high risk of redislocation which falls to less than 10% by age 40. Young patients with symptomatically instability may require a shoulder stabilization procedure. Older patients with ongoing painful shoulder or reduced range of motion should be investigated for rotator cuff tears, which may need surgical repair. Dislocations of the shoulder with associated fracture of the glenoid (bony Bankart) have a high risk of recurrent dislocation and should be referred to an upper limb specialist. A fracture of the greater tuberosity, which does not reduce after reposition of the shoulder, will require surgical fixation. Reduced fractures should be followed up with regular radiographs to ensure that there is no late displacement due to the pull of the rotator cuff superiorly and posteriorly. These patients should be immobilised in a sling for 6 weeks until signs of union, allowing only passive pendulum exercises after 10–14 days to prevent stiffness.

50.6.7 Operative Treatment Open reduction may have to be considered, if closed reduction fails. This is usually due to interposition of capsule or torn rotator cuff tendon. Shoulders, which have been dislocated for some time, may also require open reduction.

50.7 Humeral Shaft Fractures 50.6.6 Aftercare

50.7.1 Introduction

Post reduction, radiographs should be taken to confirm relocation, before anaesthesia is discontinued if possible. The arm should be supported in a broad arm-sling after reduction to lessen the risks of immediate redislocation and to help relieve pain. In younger patients, the

Humeral shaft fractures account for around 3% of all fractures. The majority of the humeral shaft fractures can be treated non-operatively. However, there are ­certain fracture patterns that are preferably treated surgically.

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50.7.2 Mechanism of Injury Humeral shaft fractures commonly occur with falls on to the outstretched arm, motor vehicle accidents or direct blunt force. The mechanism of injury will be reflected in the pattern of fracture. Torsional injuries will create long spiral fractures, whereas blunt force produces transverse fractures.

50.7.3 Classification System No classification scheme for humeral shaft fractures has gained universal acceptance. Traditionally, humeral shaft fractures have been described according to the anatomical features. The location is described as proximal, middle and distal shaft, the pattern as transverse, oblique, spiral, segmental or comminuted.

50.7.4 Examination and Diagnosis Patients with a humeral shaft fracture present with arm pain, deformity and swelling. The arm is shortened, with movement at the fracture site and crepitus on manipulation. The incidence of associated radial nerve palsy with humeral shaft fractures is almost one in five, so a careful neurological examination of the upper limb must be done.

50.7.5 Treatment Non-operative treatment is the standard treatment for humeral shaft fractures, with high union rates of greater than 90%. In comparison with other shaft fractures, the shaft of the humerus heals relatively quickly and with a good functional result. Acceptable alignment of humeral shaft fractures is considered to be 30° of varus/valgus angulation, 20° anterior–posterior angulation or 3.0 cm of shortening. Indications for operative treatment include inability to maintain an acceptable reduction of the fracture. This can be due to the pattern of fracture, such as ­transverse fractures, open or pathological fractures. Fractures,

which progress to nonunion, and fractures, which cannot be reduced due to soft tissue interposition, will all require surgical intervention. Obesity and non-compliance of the patient can indicate the need for surgery. Associated radial nerve palsy does not necessarily require surgical exploration, as the majority will recover within months. Acute and delayed repairs of the radial nerve have the same outcomes. A radial nerve palsy which develops after fracture reduction is an absolute indication for surgical exploration. Fractures, which extend into the joint surface, creating a step in the articular margin, will require open reduction. Associated injures, such as ipsilateral forearm, contralateral humerus fractures or spinal cord injuries, are relative indications for internal fixation to aid in rehabilitation.

50.7.5.1 Non-operative Treatment Humeral shaft fractures are often initially very painful and require good immobilisation. The ability to make an effective hanging arm cast is an important skill for the emergency physician or rural surgeon. The patient should be advised to sleep propped up on pillows and avoid leaning on the elbow, or placing ­pillows under the elbow as effective reduction relies on the weight of the elbow and forearm supplying traction to the fracture. The hanging arm cast can be replaced with a functional arm brace, such as the Sarmiento brace, at 1–3 weeks. This will allow some movement of the elbow and shoulder. The brace is usually required for a further 6–10 weeks. Regular check radiographs in the cast and brace are required to ensure adequate reduction is maintained. A mild malunion is common, but this will not create a functional deficit or clinical deformity.

50.7.5.2 Operative Treatment The operative treatment options are fixation with a plate, intramedullary nailing or external fixation. Plate fixation will require a strong, usually a broad or narrow 4.5-mm plate. Three or four dual cortical screws are needed on either side of the fracture. The most satisfying results with this method are obtained in patients with a humeral shaft fracture with no comminution and with an oblique component to allow lag screw fixation. In contrast, comminuted fractures are best

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treated with the bridging plate principle. They may also require bone grafting. In proximal third humeral shaft fractures, the plate is most commonly placed on the antero-lateral surface of the humerus. In the case of a segmental fracture, an additional interfragmentary lag screw might be needed. Generally, fractures of the mid and distal shaft should be plated posteriorly. The posterior approach exploits the interval between the lateral and long heads of the triceps. The medial head is then incised down the midline to expose the posterior aspect of the humeral shaft. Some surgeons, however, favour the anterior or antero-lateral approach in order to avoid injury to the radial nerve. Intramedullary nails can be used in multiple-trauma patients, pathological or osteopenic fractures. They have a good healing rate and often allow early weight bearing. Intramedullary nails have certain advantages and disadvantages when compared to fixation with plates and screws. The nails are closer to the normal mechanical axis and are subject to lower bending forces, making implant failure by fatigue less likely to occur. Intramedullary nails can be placed without direct fracture exposure and with much less soft tissue damage. They can be inserted either anterograde or retrograde. The anterograde approach demands splitting the rotator cuff which can compromise shoulder function. Retrograde insertion requires a distal triceps splitting approach. The neurovascular bundle is at risk while locking the distal nail. Also the intramedullary canal narrows distally, which can cause difficulty. This technique should not be used if radial nerve palsy is present. An external fixator can be used with a severe soft tissue injury, gunshot fractures as well as with a multiple injured patient and with open fractures. If used as a primary fixation, it can be changed to a plate or nail after the soft tissue has recovered, usually after 5–14 days.

50.7.6 Complications Nonunion is a rare complication in humeral shaft fractures. It is seen slightly more often in fractures treated surgically. In cases with radial nerve palsy, where no improvement is seen after approximately 6  weeks, electrophysiological studies may be required to predict outcome.

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A note should be made of the position of the radial nerve in relation to the plate at the time of surgery so that reference can be made in cases, which require removal of the metal. In all cases, the patient should be encouraged to begin a gentle range of motion of the shoulder and elbow as soon as sufficient fracture ­stability has been reached to avoid joint stiffness.

50.8 Soft Tissue Knee Injuries 50.8.1 Introduction Soft tissue injuries to the knee account for 15–30% of all sporting injuries. To correctly diagnose knee injuries, it is important to have an understanding of the functional anatomy of the knee. There are four bones that come together at the knee. Movement and weight bearing occur where the femoral condyles match up with the tibial plateaus. The patella sits in the trochlea of the femur, which forms the patellofemoral joint. The patella is stabilised in the trochlea on either side by the retinaculum. The quadriceps tendon contains the patella, which is renamed the patella tendon below the patella. Four major ligaments maintain the stability of the knee joint. The medial collateral ligament (MCL) is the primary stabiliser of the knee joint against valgus stress. The lateral collateral ligament (LCL) prevents the joint from lateral dislocation. The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) form an ‘X’ on the inside of the knee and prevent the knee from anterior and posterior dislocation. They also limit the internal rotation of the knee joint and act as secondary stabilizers to varus and valgus forces. Inside the knee, there are the lateral and the medial shock-absorbing menisci that sit on the top surface of the tibia. The menisci conform to the femoral condyle to distribute weight across the tibial articular surface to reduce friction.

50.8.2 Mechanism of Injury The knee is vulnerable to twisting or stretching injuries, taking the joint through a greater range of motion

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than it can tolerate. If the knee is stressed from one specific direction, the ligament trying to hold it in place against that force can tear. Twisting injuries to the knee also put stress on the cartilage and the menisci. This can create tears in the menisci and damage to the articular cartilage. Fractures of the distal femur and tibial plateau are associated with high-energy injuries such as motorbike accidents and falls from heights.

50.8.3 Examination and Diagnosis Diagnosis can usually be made from a good history and confirmed on examination. Key questions to be asked include the exact mechanism of injury. Valgus force will suggest a MCL injury. Twisting knee injuries are associated with ACL rupture. Patients will describe their knee ‘popping out’ with patella dislocation. The onset of swelling will give a hint to the underlying injury. Instantaneous swelling indicates a haemarthrosis and will point to injury to the ACL, which is contained within the capsule of the joint. Once the patient can begin weight bearing again, they may complain of the sensation of giving way, which may indicate ACL injury or locking that indicates meniscal tear. The knee is then examined, beginning with general inspection. Examine for grazes or bruising. A knee held slightly flexed can be a clue that there is fluid in the joint space. Palpation is the next step in the examination. An effusion is demonstrated with the swipe test or a patella tap. Tenderness over the joint line, most easily felt with the knee flexed to 45°, may indicate meniscal pathology. Tenderness directly over the patella may indicate patella fracture. Tenderness over the medial aspect of the patella may be due to rupture of the medial retinaculum associated with lateral dislocation of the patella. The specific ligaments of the knee should be examined. Comparison to the uninjured side will give the clinician further information for what is normal for that patient. The MCL and LCL are examined under valgus and varus stress respectively, both in full extension and in 30° flexion. By bending the knee, the clinician isolates the ligament, which is assisted by the capsule when the knee is straight. The ACL is assessed

with Lachman test or anterior drawer test. The PCL is assessed with the posterior drawer test. The menisci are examined with McMurray’s test; however, the most reliable sign is joint line tenderness. Close assessment of the distal neurovascular status must be made if a dislocated knee is suspected. Radiographs will exclude fracture or demonstrate avulsion injuries associated with ligamentous instability.

50.8.4 Treatment Immediate treatment is rest, ice, compression and elevation (RICE). The knee should be splinted if ligamentous injury is suspected and the patient kept non-weight bearing. Serial examination of the patient 1 or 2 weeks after injury can be useful in demonstrating clinical signs once the patient has become more comfortable. Treatment will then vary depending on the injury.

50.8.4.1 MCL Injuries The knee should be splinted for 6  weeks. After this period, the knee should be re-examined for ongoing instability and also other associated injuries, which may have initially been missed, especially ACL rupture. A hinged brace will prevent the patient from developing a stiff knee. Protected weight bearing can usually begin after 2 weeks.

50.8.4.2 ACL Injuries Initially the knee is splinted. The patient can begin weight bearing and bending the knee as pain allows. The patient should be referred for physical therapy to build hamstring and quadriceps strength to help stabilise the knee before considering reconstruction. If diagnosis is uncertain, MRI is the investigation of choice to confirm ACL injury.

50.8.4.3 Mensical Tears It may be possible to repair a large tear in the meniscus of a younger patient if the tear occurs in the outer area of the meniscus where there is good blood supply. In patients who

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are troubled by ongoing intermittent swelling, locking or sharp pain with bending or turning, arthroscopic debridement can be offered. Degenerative meniscal tears are common in patients with osteoarthritis.

50.8.4.4 Patella Dislocation The patella invariably dislocates laterally. Often it will reduce spontaneously, but occasionally needs to be reduced with analgesia in the emergency department. Again the knee is splinted, mainly for analgesic purposes, and once the pain settles the patient can start with weight bearing and bending the knee. Physical therapy to build the strength of the medial portion of the quadriceps can help prevent recurrence and also improve the tracking of the patella on the trochlea that often can cause anterior knee pain. Recurrent dislocations may need surgical correction.

50.9 Tibia Shaft Fractures 50.9.1 Introduction High-speed lifestyles with motor vehicles and motorcycles, as well as the increasing popularity of extreme sports, have contributed to the growing occurrence of tibial shaft fractures. Those who sustain them face a slow recovery, with possible permanent deformity and disability. Tibial fractures vary so widely in severity that general prescriptions for treatment are not applicable to each patient. The spectrum of injury extends from trivial enough to be ignored to so severe that amputation is the best treatment.

50.9.2 Mechanism of Injury The tibia is vulnerable to torsional stress (e.g. in sporting injuries like skiing), to force transmitted through the feet (e.g. in falls from a height) and from direct blows (e.g. falling rock). Isolated fractures of either the tibia or fibula may occur from direct force, although this is comparatively uncommon. The type of force placed on the tibia will produce typical fracture patterns, with torsional

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force creating spiral fractures, direct blows transverse or short oblique fractures and higher energy injuries producing more comminuted fractures.

50.9.3 Classification System No classification of tibial fractures has been universally accepted.

50.9.4 Examination and Diagnosis The patient usually reports severe pain. An inability to bear weight on the affected leg and a visible deformity of the leg are often present. In the clinical examination, it is important to assess the neurovascular status of the patient’s injured leg. The overlying skin should also be examined. Due to the subcutaneous nature of the anterior tibia, open fractures or displaced fractures threatening the skin are common. Always obtain radiographs of the whole length of the tibia and the two adjacent joints. If the skin is threatened by displaced bone or the foot is poorly perfused, reduction should not be delayed by getting radiographs.

50.9.5 Treatment The emergency management of tibia fractures is to reduce any deformities and immobilise the fracture in a split plaster. Most displaced fractures of the tibia are so unstable that anatomical reduction with a plaster is impossible. Any open fractures should be thoroughly washed and dressed with antiseptic soaked gauze. In these cases, prophylactic antibiotics and tetanus boosters should also be given. Compartment syndrome should be excluded. Other injuries should be sought due to the high-energy trauma associated with tibia fractures. Undisplaced or minimally displaced tibial shaft fractures can be treated non-operatively. Unlike angulations in femoral shaft fractures, which can be compensated to some extent at the hip, varus, valgus and rotational deformities are poorly tolerated in the tibia. Absolute indications for operative fixation include damage to neurovascular structures, open fractures,

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compartment syndrome or failure of non-operative management to hold position or unite the fracture.

50.9.5.1 Non-operative Treatment A long leg plaster is applied. The cast should extend from the mid thigh to the metatarsal heads. The ankle should be placed in 90° of flexion and the knee in 10 to 15 degrees of flexion. Check radiographs should be taken in plaster to confirm an adequate position and the limb elevated for the first 3–7 days until the swelling has reduced. Check radiographs should be taken for the first 2  weeks to ensure reduction is maintained. Weight bearing can usually begin from 6–8  weeks. Adequate callus formation generally takes 6–8 weeks and on average up to 16 weeks to fully unite. Apparent ­radiological union assessed out of plaster should be confirmed by clinical examination.

50.9.5.2 Operative Treatment Possible surgical treatments are external fixation, Ilizarov frame, intramedullary nailing or fixation with plates. Plating tibial shaft fractures has been the treatment of choice; however, this requires surgical approaches, which may interfere with the vascular supply to the fracture. Therefore, intramedullary nailing is now the fixation of choice when possible in tibial shaft fractures. Nailing cannot be used to correct displaced intra-articular fractures and extreme care must be taken when used with fractures with an undisplaced intra-articular extension. Due consideration must be given before using a nail in an open fracture as an infected implant is difficult to treat. Advantages to tibial nails include a less invasive approach, and therefore less disruption to the blood supply to the bone around the fracture, mechanical stability, allowing early weight bearing, and also the ability to dynamise within the canal of the tibia, compressing the fracture and thus promoting healing. Plates should be considered when fixation is required for fractures of the proximal or distal metaphysis that are not suitable for intramedullary nailing. Good surgical experience and skill, as well as careful judgment, are required for this surgical treatment. This section does not describe further details of this technique, as it might be best to treat the patient temporarily with an

external fixator, and then send the patient to the specialist if there is mechanical benefit of plating in the longterm management of the tibial fracture. The external fixator is a widely used and a successful method of treatment for open fractures, severely comminuted fractures, or fractures with extensive soft tissue injury. It might also be the method of choice for tibiae with a narrow canal. The surgeon must be familiar with the anatomy of the lower leg to avoid injuries to vessels, nerves, muscles and tendons. The pins should be placed so they will not interfere with the surgical approach for open reduction and internal fixation if planned in the future. The fixator is applied after reduction or can be used as a reduction tool. For the latter technique, a pair of pins is inserted into each main fragment and joined by a short rod. The two rods are then connected by a short third rod and two rod-to-rod clamps. This construct allows to manipulate and reduce the fracture and to hold it after reduction (Fig. 50.4a, b).

50.9.6 Complications Nonunion, malunion, stiffness of the adjacent joints, compartment syndrome and deep vein thrombosis can all follow a tibial shaft fracture.

50.10 Ankle Joint 50.10.1 Introduction The ankle is a complex hinge joint and is the most commonly injured joint in sport. The talus inhabits the bony mortise created by the medial malleolus, tibial plafond and lateral malleolus. The ligaments supporting the ankle are the deltoid ligament medially, the lateral ligament complex and the syndesmotic ligaments. These structures create a ring, which if broken in two or more places can allow the talus to lose its position in the ankle mortise.

50.10.2 Mechanism of Injury The different mechanisms creating ankle injuries have been well studied, allowing prediction of involvement

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a

D. Wysocki and R. Zellweger

b

50.10.3.2 Danis–Weber Classification The Danis–Weber classification is based on the location and appearance of the fibular fracture with regard to the syndesmosis. This classification divides fractures into Types A, B or C (See Fig. 50.5). Type A: Fracture below the syndesmosis. Usually a transverse fracture created by internal rotation on the adducted foot. Fractures are stable unless associated with a medial malleolar fracture. Type B: Fracture at the level of the syndesmosis. Usually a short oblique fracture created by external rotation. It is the most common ankle fracture. Type C: Fracture above the level of the syndesmosis, implies disruption of the syndesmotic ligaments. Note: Beware the isolated medial malleolus fracture, as this can be associated with complete rupture of the syndesmotic ligaments and interosseous membrane up to a high fibular fracture (Maison­neuve’s type ­fracture). This injury does poorly with nonoperative management, so careful physical examination or full-length leg radiographs should be taken. A

B

Fig  50.4  Application of external fixator: (a) Insertion of two pins in each fragment according to the soft tissue conditions (b) After reduction the two bars are united by a third tube and two tube-to-tube clamps

of ligamentous and bony structures with known mechanisms. However, this is rarely of use in everyday practice. The most common mechanism of ankle injury is supination and external rotation, accounting for over three quarters of ankle fractures (see below Weber B).

C

50.10.3 Classification 50.10.3.1 Anatomical Classification An easy descriptive and commonly used classification is simply to divide ankle fractures along anatomical lines as single malleolus fractures, bimalleolar fractures or trimalleolar fractures (i.e. an additional postero-lateral or Volkmann triangle fragment).

Fig. 50.5  Danis-Weber Classification: Type A, B, and C

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50  Simple Orthopaedic Procedures and Common Diagnoses

50.10.4 Examination and Diagnosis Careful note should be taken of the location of swelling, ecchymosis and bruising. All structures should be palpated, including the medial malleolus, the deltoid ligament, the whole length of the fibula and lateral ligament complex and the anterior aspect of the syndesmosis. Swelling or tenderness on both sides of the ankle may indicate an unstable injury. In the deformed ankle, suggesting subluxation or dislocation of the talus, note should be made of the presence of pulses and sensation of the foot. Radiographs of the ankle should include lateral and mortise views. The mortise view (created by internally rotating the leg 15°) allows the clinician to detect any shift of the talus within the mortise by comparing the medial to the superior joint space

Ankle Fractures Small avulsion type injuries to the distal fibula can be treated in a similar manner to ankle sprains. Weber Type A and non-displaced Weber Type B fractures of the lateral malleolus can be treated nonoperatively provided the medial ankle side is not injured. All other fractures usually require surgery. The fracture is treated in a split plaster until swelling has subsided. This can then be changed to a full cast. The total time of immobilisation is between 6 and 8 weeks. Check radiographs in the plaster should be taken at 1 and 2  weeks to ensure the fracture is held in a good position. Radiographs should be taken out of plaster at the end of immobilisation, to look for signs of bony union, and the fractures assessed for ongoing tenderness before beginning weight bearing.

50.10.5.2 Operative Treatment

50.10.5 Treatment Studies have shown that small displacements of the talus within the mortise can create large changes in the contact area of the tibia and the talus. The aim of treatment is to restore and maintain the normal alignment of the talus within the ankle mortise to prevent posttraumatic arthritis. Attempts should be made as soon as possible to reduce any dislocated or subluxated ankles. Dorsiflexion will help reduce any posterior dislocations, whilst inversion and internal rotation may be needed to reduce laterally subluxated ankles.

50.10.5.1 Non-operative Treatment Ankle Sprains Injuries to the ligaments around the ankle can be treated initially with rest, elevation and ice after radiographs have excluded an ankle fracture. Immobilisation in plaster may be appropriate in injuries involving ligaments on both sides of the ankle. Weight bearing can begin as tolerated. Physiotherapy, to prevent recurrent ankle injury via muscle strengthening and proprioception, is recommended.

All displaced ankle fractures should be treated operatively, as minor changes involving the joint mortise can cause chronic pain due to early post-traumatic arthritis. Often the ankle will be too swollen for early fixation and a period of elevation in a split plaster is required. This can be for as long as 2  weeks. Check radiographs may be required during this time as loss of reduction of the ankle fracture may prevent the soft tissue from recovering. In cases with large blisters, or open injuries, external fixation will maintain reduction while allowing the clinician to monitor progress of the soft tissue. The surgical treatment aims to reconstruct the bone anatomically. Injuries, which damage the syndesmosis, will require one or two screws passing from the fibula to the tibia to prevent diastasis of these two bones. The deltoid ligament does not need to be repaired or approached unless it has become interposed in the ankle joint preventing reduction of a lateral ­malleolus fracture.

50.10.6 Complications Fracture healing in a non-anatomical position will likely result in post-traumatic arthritis. Nonunion and ongoing ligamentous instability is very uncommon.

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Persistent swelling for weeks or even months after an ankle injury is so common as to be expected. However, in cases of swelling into the calf, venous thrombosis needs to be considered.

50.11 Achilles Tendon Rupture 50.11.1 Introduction The Achilles tendon is the largest and strongest tendon in the human body. The tendon of the gastrocnemius and the soleus muscles forms it. The principal function of the Achilles tendon is plantar flexion of the ankle joint.

50.11.2 Mechanism of Injury An Achilles tendon rupture typically happens in the 30–50 age group with a peak around 40 years of age. The ratio between men and women is approximately 5:1. The vast majority of injuries occur during sudden muscle contraction while playing sports. Some medications such as corticosteroids may also increase the risk of rupture.

50.11.3 Examination and Diagnosis Patients typically describe hearing a loud snap with the sensation of being struck by something in the back of the calf. Pain and difficulty walking follow. On clinical examination, there is a palpable gap or depression along the Achilles tendon with weakness of plantar flexion against resistance. Standing on the toes of the affected side is impossible. A positive Thompson test for Achilles tendon rupture is obtained by placing the patient in a prone position and squeezing the affected calf. In a patient with a ruptured tendon, there will be no plantar flexion of the ankle with this manoeuvre. In the majority of cases, diagnosis can be confirmed on examination and only in unclear situations is ultrasound required.

D. Wysocki and R. Zellweger

50.11.4 Treatment Initial treatment is to place the patient in split plaster in a plantar flexed position to approximate the ruptured ends of the tendon. There is little evidence to suggest that patients undergoing surgical repair have better function or faster return to normal activities than those treated non-operatively. However, some studies have shown that the risk of re-rupture is slightly reduced for those treated with surgery. In general, it is thought that patients who wish to return to sporting activities and with low risk for surgical complications can be offered surgical repair. Delayed diagnosis or patients with ­re-rupture should also be considered for surgical repair. Care should be taken when selecting patients for surgical intervention, as wound complications can be very difficult to treat.

50.11.4.1 Non-operative Treatment The patient should be placed in a below knee full plantar flexed cast. At 2-week intervals, the plaster should be replaced to gradually bring the ankle to 90° over 6–8 weeks. Walking on the cast is allowed at this time. Cast immobilisation should be for approximately 6–10 weeks. Following cast removal, a heel-lift in the shoe should be worn for an additional 2–4  months. During this time, a rehabilitation programme with the physiotherapist should be initiated to improve the gait pattern and the calf strength.

50.11.4.2 Operative Treatment Open reconstruction is undertaken using a medial longitudinal approach. This approach is made easy in a prone position. The ends are approximated and sutured with a strong suture using a modified Kessler, Krackow or Bunnell suture technique. Care should be taken not to over tighten the tendon. Following surgery, the ankle is placed in a plantar flexed plaster for 2 weeks. Serial plastering can then be done in a similar manner to conservative treatment, or specific orthosis can be used. This allows a staged return to range of motion of the ankle. Following immobilisation, a heel raise is again recommended for 2–4 months.

50  Simple Orthopaedic Procedures and Common Diagnoses

50.11.5 Complications Surgical complications include damage to the sural nerve, wound dehiscence and adhesions. Both operative and non-operative treatment groups are at risk of venous thrombosis.

Recommended Reading Browner, D.: Skeletal Trauma, 4th edn. Saunders, Philadelphia (2008) Hoppenfeld, S., Deboer, P., Buckley, R.: Surgical Exposures in Orthopaedics: The Anatomic Approach, 4th edn. Lippincott Williams & Wilkins, Philadelphia (2009) http://www.aoasif.ch/wps/portal/aofoundation.org

405 McRae, R., Esser, M.: Practical Fracture Treatment, 4th edn. Elsevier Churchill Livingstone, Philadelphia (2002) Sarmiento, A., et al.: Functional bracing of fractures of the shaft of the humerus. J. Bone Joint Surg. Am. 59, 596–601 (1977) Solomon, L., Warwick, D., Nayagam, S.: Apley’s System of Orthopaedics and Fractures, 9th edn. Hodder Arnold, London (2010)

 

51

Carpal Tunnel Release Limited Distal Incision Open Carpal Tunnel Release Hajir Nabi

51.1 Preface As with other procedures in general surgery there are numerous techniques available for the release of the flexor retinaculum to decompress the median nerve at the level of the carpal tunnel [1]. Many surgeons in larger volume centres now advocate the use of endoscopic release of the flexor retinaculum. However, risks of neurovascular damage are increased in inexperienced hands [2]. The procedure described here is a safe and easily reproducible method of releasing the flexor retinaculum using surgical equipment readily available. Through a limited distal skin incision – preserving the skin bridge over the wrist joint – the incidence of complications can be decreased. Advantages include fewer wound healing problems over the wrist, reduced likelihood of damaging the muscular (recurrent) branch and accelerated return to full function [3].

51.2 Anatomy A concave trough is formed on the flexor surface of the  carpal bones. This trough is roofed by the flexor retinaculum forming a fibro-osseous channel known as ‘the carpal tunnel’ [4]. The flexor retinaculum is a strong fibrous band of tissue with four bony attachments (Fig. 51.1):

H. Nabi Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, SA 5011, Australia e-mail: [email protected]

1.  Radial side   (a)  Tubercle of scaphoid   (b)  Ridge of trapezium 2. Ulna side   (a)  Pisiform   (b)  Hook of hamate The carpal tunnel contains the following structures: 1.  Tendons of flexor digitorum profundus All four tendons lie in the same plane, but only the tendon of the index finger has separated at this level. 2.  Tendons of flexor digitorum superficialis All four tendons are separate at this level and are in two rows (middle and ring fingers superficial, and index and little fingers deep). 3.  Tendon flexor pollicis longus 4.  Median nerve Passes beneath flexor retinaculum between tendons of flexor digitorum superficialis of middle finger and flexor carpi radialis (which runs in Vertical groove). The Median nerve divides into three terminal branches after passing through the carpal tunnel: 1.  Medial branch Supplies sensation to palmar skin as well as clefts and adjacent sides of ring to middle and middle to index fingers. Latter branch to second lumbrical muscle. 2.  Lateral branch Supplies sensation to palmar skin and radial side of index finger and thumb. Index branch supplies first lumbrical muscle. 3.  Muscular (recurrent) branchPassing superficial to flexor pollicis longus it supplies the thenar muscles.

M.W. Wichmann et al. (eds.), Rural Surgery, DOI: 10.1007/978-3-540-78680-1_51, © Springer-Verlag Berlin Heidelberg 2011

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408 Fig. 51.1  Bony attachment of flexor retinaculum to (a) distal and (b) proximal rows of carpal bones forming the carpal tunnel

H. Nabi Flexor retinaculum

a Hook of hamate Carpal Tunnel

Vertical groove

Tubercle of trapezium Capitate Trapezoid

b

Flexor retinaculum Pisiform Carpal Tunnel Triquetrium

Tubercle of scaphoid

Lunate

A palmar branch is given off proximal to the carpal tunnel and runs superficial to the flexor retinaculum supplying the thenar eminence. Hence, sensation over the thenar eminence is preserved during compression at the level of the carpal tunnel. In addition to preservation of the palmar cutaneous branch, compression of the median nerve at the level of the carpal tunnel can be distinguished from compression that is more proximal by the preservation of the relevant forearm flexors (notably flexor policis ­longus – flexion terminal phalanx thumb preserved).

51.3 Presentation The term ‘carpal tunnel syndrome’ refers to any condition leading to compression of the median nerve as it is transmitted in the carpal tunnel. Conditions that predispose to diminution in the size of the carpal tunnel include arthritis, hypothyroidism, tenosynovitis, old carpal fractures, and inflammation. However, the majority of cases are idiopathic [5]. Patients describe paraesthesia and anaesthesia over the radial three and a half digits. Due to interpersonal

differences, the pulp of the index finger is the most reliable area of sensory disturbance. Motor losses include weakness in abduction and opposition of the thumb (thumb flexion preserved, flexor pollicis longus intact). Wasting of the thenar eminence is a late sign. Symptoms may be reproduced using Tinel’s test (tapping over carpal tunnel) and Phalen’s test (holding wrist joint in flexion). The author advocates the use of nerve conduction studies to confirm clinical suspicions (particularly in uncertain cases) where available. Given the increasingly litigious nature of our practice, this can prove an important medico-legal document.

51.4 Procedure The procedure can be safely and effectively performed under local anaesthetic. Due to the need for a tourniquet, concurrent intravenous sedation is useful. The author prefers to use a mixture of short and long-acting local anaesthetics (5 ml 1% lignocaine + 5 ml 0.5% bupivacaine).

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A median nerve block can be performed by administering 5  ml of the local anaesthetic mixture 1–2  cm proximal to the proximal wrist crease between palmaris longus (where present) and flexor carpi radialis tendons. One needs to be aware of the risk of infiltrating beneath the perineurium of the median nerve and consequent nerve damage. Consequently, one needs to ensure there is no resistance when infiltrating. The remaining 5 ml of local anaesthetic should then be administered subcutaneously over the planned incision site (Fig. 51.2). Prophylactic antibiotics are not necessary. Once the hand has been prepped circumferentially with antiseptic solution (betadine or chlorhexidine) to the level of the proximal forearm, a hand table should be positioned under the arm. The arm is elevated, an Esmark bandage applied and the tourniquet switched on (at 250 mmHg). The skin incision can then be made over the distal half of the flexor retinaculum in the line of the middle to ring finger web-space. Incisions made in palmar skin creases lead to preferable scarring and wound healing (Fig. 51.2).

Once through the epidermis and dermis a variable depth of subcutaneous tissue is seen and divided leading to the palmar aponeurosis (termination of palmaris longus) – a thin white fibrous layer. The flexor retinaculum is deeper to this, and is composed of thicker fibrous tissue. Retractors (such as Cat’s paws or small Langenbeck’s) held by an assistant (or alternatively a self-retainer) will aid in visualisation. Small bands of muscle may be encountered at this stage, which can be divided. These are the fibres of abductor pollicis brevis and their division leaves no functional deficit. The scalpel blade is then used to pierce a small incision through the retinaculum. Once through the retinaculum a flat bladed retractor (such as McDonald’s or Watson Chain) is inserted through the remaining distal retinaculum and elevated to protect the underlying median nerve. The scalpel can then be reversed so the blade faces up. The scalpel is then run along the retractor to divide the retinaculum fibres. Once divided distally, the retractor is inserted proximally, and the steps repeated to free the proximal retinaculum with a skin retractor inserted under the proximal edge of the skin

Skin Incision Extent of flexor retinaculum not included in skin incision X X

Fig. 51.2  Incision site and landmarks for median nerve block

Site of infiltration for median nerve block

Tendon of palmaris longus Tendon of flexor carpi radialis

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incision to aid with visualisation of the proximal ­retinaculum fibres. Bipolar diathermy to cauterise potential bleeding vessels is recommended to prevent potential postoperative haematomas that could compress the median nerve. Skin closure with interrupted vertical mattress sutures (5-0 nylon sutures) aids in everting skin edges. Hypafix dressing to skin with overlying compressive dressings such as softban and crepe are then applied before the tourniquet is released.

51.5 Post-operative Care Compressive softban and crepe dressings can be remo­ ved 48 h post-op. Hypafix dressing should be left intact until sutures are removed (10 days postoperatively). Patients should be encouraged to continue to use their hand immediately post-op to avoid joint stiffness. It is important to ensure dressings do not restrict movements of the metacarpal joints. After sutures have been removed patients should be encouraged to ret