GENERAL SURGERY FOR SMART PEOPLE JOE NOLD MD, FACS WICHITA SURGICAL SPECIALISTS

GENERAL SURGERY FOR SMART PEOPLE JOE NOLD MD, FACS WICHITA SURGICAL SPECIALISTS

CONFLICTS/DECLARATIONS I have no financial conflicts or declarations I AM always willing to see a consult for you

TEXT TOPICS Common consultations Ileus/Small bowel obstruction Gallstones/Cholecystitis Diverticulitis PEG indications/risks

SMALL BOWEL OBSTRUCTION Common problem, usually managed non-operatively High quality data is sparse EAST guidelines World Society of Emergency Surgery

SMALL BOWEL OBSTRUCTION Acute small bowel obstruction- admitted Imaging IVF resuscitation Electrolyte replacement Chronic small bowel obstruction- might be observed OP Crohn s disease Radiation enteritis

SMALL BOWEL OBSTRUCTION Admission to a surgical service or early surgical consultation Shorter length of stay Lower hospital charges Shorter time to surgery Lower mortality Oyasiji T, Am Surg 2010;76;687

SMALL BOWEL OBSTRUCTION If the patient is NOT admitted to a surgical service, a SBO protocol is recommended Decreases time to operation Decreases LOS

SMALL BOWEL OBSTRUCTION PROTOCOL- EVALUATION Symptoms of SBO Complete history and physical including rectal exam Plain films- abdominal series CBC, CMP, lactate and UA

SMALL BOWEL OBSTRUCTION PROTOCOL- INITIAL TREATMENT High grade/complete SBO NG, IVF, NPO, I/O Serial exams and general surgery evaluation Partial SBO NG if vomitting, IVF, NPO, I/O Serial exams, general surgery consult if not better in 48 hours or if their exam worsens

SMALL BOWEL OBSTRUCTION PROTOCOL- ADMISSION Admit to surgery Transition point Surgery within 30 days Emergent operative need Admit to medicine Dysmotility issues Inflammatory bowel disease Chronic narcotic use Metastatic disease Acute severe medical conditions

SMALL BOWEL OBSTRUCTION Aggressive fluid resuscitation May need LITERS of fluid Potassium replacement NPO NG tube IF Very distended Persistent nausea and/or emesis Pain control- limit narcotics

SMALL BOWEL OBSTRUCTION Indications for surgery Complete obstruction Closed loop obstruction Bowel ischemia/necrosis/perforation Obstruction in a virgin abdomen

SMALL BOWEL OBSTRUCTION Concerning signs/symptoms Pneumatosis intestinal, portal venous gas, mesenteric vessel swirl Fever, tachycardia, increasing pain, metabolic acidosis, SIRS

SMALL BOWEL OBSTRUCTION Non-operative management Usually in partial SBO, chronic intermittent obstruction Risk of bowel ischemia 3-6% during observation Nonoperative success in 40-75% Appropriately patients should improve within 2-5 days Lab studies- lactate (poor), WBC (poor), PCT- >0.17 has an 85% NPV for need for surgery

SMALL BOWEL OBSTRUCTION Failure to improve warrants CT scan if not already done Gastrograffin SBFT- Hypertonic contrast draws fluid into the bowel lumen, decreasing edema and promoting peristalsis Significantly decreases the number of people requiring surgery (21 vs 30%)

CHOLELITHIASIS 6% of men, 9% of women Higher in Caucasian, Hispanic and Native Americans 15-25% will become symptomatic within 15 years Once symptoms start, they tend to recur; 70% within 2 years 1-2% chance to have surgery per year

CHOLELITHIASIS Usually removed when symptoms develop or worsen. Usually removed at the time of gastric bypass, ulcer surgery, etc Prophylactic cholecystectomy in those at higher risk for cancer: Porcelain GB and large stones, >3cm, and some hematologic diseases (sickle cell)

BILIARY DYSKINESIA Biliary colic without stones 8% of men and 21% of women with biliary type pain and no stones Diagnosed by history and HIDA scan w/ CCK ejection fraction Abnormal <35% + symptoms Need to rule out peptic ulcer disease and cardiac disease?? Biliary hyperkinesia- EF >65%??

BILIARY DYSKINESIA >95% of patients with biliary symptoms and low EF improve after cholecystectomy <20% of these patients improved with medical management alone

PEG TUBES General indications Head injury Prolonged ICU stay CVA w/ dysphagia Head and neck CA Palliative for many conditions

PEG TUBES Selection No clear guidelines on who needs a feeding tube Need to define pt/family expectations and goals Contra-indications Hostile abdomen High dose steroids?? Ascites

PEG TUBES Survival High in the short term, poor long term survival Mixed population 80-90% at 1 month 40% at 12-18 months 20% at 3 years

PEG TUBES Medicare population, >75 y/o In hospital mortality 15% 1 year survival 37% 3 year survival 19%

PEG TUBES Do they decrease mortality 1,300 patients in whom PEG tube was recommended 23% declined to have the procedure Mortality at 30 days 36% vs 11% Mortality at 1 year 75% vs 41%

PEG TUBES Complications Infection Usually local, <10% Prophylactic abx and good prep Necrotizing fasciitis Abdominal abscess

PEG TUBES Complications Bleeding Usually minor Hold anticoagulation? Leakage Do NOT place a larger tube Maybe remove and leave a wire for 48 hrs

PEG TUBES Complications Gastric outlet obstruction Gastric ulcerations Inadvertent removal Trans-hepatic placement Colocutaneous fistula Tumor seeding Gastro-cutaneous fistula Ileus Buried bumper

TEXT PEG TUBES Management PEG tube order set

TEXT DIVERTICULITIS Managed as an out patient if stable, reliable and abdominal pain not severe No evidence that anti-inflamatories like Mesalamine improve outcome Clear liquid diet x 2-3 days, then slowly advance High fiber diet; no clear evidence but it cant hurt

DIVERTICULITIS Avoidance of seeds/nuts is an old wives tale; actually an inverse relationship between nut/seeds and recurrence Follow up colonoscopy about 6 weeks after resolution 26% had polyps 3-5% chance of colon cancer

DIVERTICULITIS Recurrence rate of 20-40% Higher with multiple episodes, family history, L>R, and retroperitoneal abscess Low rate (4%) of recurrences are complex? Earlier surgery in those <40 y/o Earlier surgery in immunocompromised

COMPLICATED DIVERTICULITIS Peritonitis Obstruction Free perforation- Micro or macro Abscess Colovesical, colovaginal, colocutaneous fistula

COMPLICATED DIVERTICULITIS Indications for surgery Peritonitis Failed abscess drainage Fistula More than 2 episodes of diverticulitis

COMPLICATED DIVERTICULITIS Hinchey Classification Stage I- peri-colonic or mesenteric abscess only Stage II- walled off pelvic abscess Stage III- generalized purulent peritonitis Stage IV- generalized feculent peritonitis

COMPLICATED DIVERTICULITIS Elective Lap or open sigmoid colon resection to the proximal rectum Emergent Stable- Resection and ostomy or resection/anastomosis and protection with a loop proximal ostomy Unstable- Resection and ostomy vs irrigation and drainage without resection

TEXT SUMMARY There is a method to our madness Always feel free to call. we d much rather be called early and not be needed than too late If you want something specific, please just ask Just be sure to speak slowly and use small words