Teamwork radiology and surgery

Transcription

1 Catchment area

2 Teamwork radiology and surgery

3 Jigsaw TRAUMA Cholecystitis Perforation Appendicitis OP X-ray Abdominal wall Endoscopy GI bleeding Diverticulitis Pancreatitis Ileus Complex and timeconsuming investigations

4 Be realistic but recognise the cangoroo Surgeons without guidelines

5 Concensus 2007 Smart surgeons learn from their own mistakes Smarter surgeons learn from mistakes of others Some never learn The CT makes it easier and improves quality

6 Guidelines Routines Guidelines Development

7 Surgeons with guidelines Jays ace Roy Halladay has appendicitis Toronto Blue Jays starting pitcher Roy Halladay throws during first inning AL action against the Boston Red Sox on Thursday, May 10, 2007, in Toronto, Canada

8 Appendicit Acute appendicitis can mimic virtually any intra-abdominal process: therefore to know acute appendicitis is to know well the diagnosis of acute abdominal pain. (Z.Cope) History 200 Aretaios 1492 da Vinci 1734 paratyflitis 1880 The first operation 1889 The first op in Sweden, Lennander 1983 The first lap-app-op in Sweden

9 Peritonitis Harry Hodini died from an appendicitis -26 Appendicitis Development of pain Location Local tenderness Developemnt of CRP and LPK Exclusion of alternate diagnoses Need to operate

10 Diagnostics Why? Avoid unnessecary operations Reduce the risk of missing important diagnoses Indicator of quality Earlier 25-30% healthy app Now 5-10% Appendicitis diagnostic tools

11 Assessment and reassessment Observation Repetivite assessments CRP-LPK CRP LPK Tid

12 Our golden-standard appendicitis Clinical diagnosis Ultrasound in children Diagnosis after CT in patients with unclear conditions. Laparoscopy in women And sometimes in men

13 Diverticulitis

14 Diverticulitis Mild to moderate Clinical diagnosis Confirmed later by imaging or colonoscopy Rule out malignancy Moderate to severe Clinical findings CT CT findings are prognostic Diverticulitis Mild to moderate Clinical diagnosis Confirmed later by imaging or colonoscopy Rule out malignancy Moderate to severe Clinical findings CT CT findings are prognostic Ambrosetti classification

15 Treatment Mild to moderate Fasting? Antibiotics? Moderate to severe Antibiotics Operation Resection Resection with peroperative lavage

16 Happy colorectal surgeons after the procedure Jejunumdivertikulis

17 Obstruction Colocolic invagination

18 Gallstone ileus Diffuse ischemia

19 Adhesive band Bowel ischemia

20 Strangulation Operation

21 Internal mesenteric hernia Emergency operation Surgeon on call operates an emergency case

22 Second look Surgeon on call reoperates an emergency case Postoperative complications Always suspect surgical reasons

23 Postoperative complications Always suspect surgical reasons (at least when other surgeons have operated) Postop complications Assess

24 Postop complications Assess Think Postop complications Assess Act Think

25 Postoperative complications Time-span Immediate Within days Within weeks-months Postoperative complications CPBF Cardiac Pulmonary Bleeding Fluid retention

26 Postoperative complications Peritonitis Anastomotic leakage Following perforated ulcer incopmlete raphi Deep infection Abscess Postoperative complications Abdominal wall Subcutaneous wound rupture Early incarceration Following laparoscopy Infection Mild Severe With flegmone Clostridie infection

27 Severe pain out of proportion Strangulation Gas gangraene Postoperative complications Bile ducts Bile leakage Bile duct obstruction

28 Postoperative complications Bariatric surgery Internal hernias Incarceration of bowels in troacar incisions Postoperative complications Bleeding Procedure Elective Emergency Due to bleeding

29 PEG and complications PEG complications Immediate complications Perforation of organs Bleeding Displacement Non-functioning Peritonitis Leakage

30 Abdominal compartment WSACS World Society of the Abdominal Compartment Syndrome Intensive care

31 Abdominal compartment Reasons Intraabdominal complications Reperfusion Ileus Post major intra- and retroperitoneal bleeding Severe pancreatitis Correlates to High BMI Extensive fluid resuscitation Abdominellt compartment How to measure the abdominal pressure KAD, 25 ml water into the bladder

32 Jejunumdivertikulit Ileus

33 Colocolisk invagination Tunntarmsinvagination Metastaserande lungcancer

34 Malrotation The bowel mesentery gets a broad attachment to the back abdominal wall Gör en nonrotation

35 Malrotation Mesenterica superior syndrom

36 Richter-bråck

37 Diffus tarmischemi Questions/discussion