The incidence of recurrence in incisional hernia prosthetic surgery is markedly lower than in direct plasties. Indeed after the autoplasties of the preprosthetic period, the recurrence rate ranged from 35% for ventral hernias. Chevrel and Flament, in 1990, reported on 1,033 patients who had undergone laparotomy. The recurrence rate at 10-year follow-up was 14–24% for patients treated without the use of prostheses but only 8.6% for those in whom a prosthesis was implanted. A similar incidence was reported by Chevrel in 1995: 18.3% recurrence without prostheses, 5.5% with prostheses. Likewise, Wantz, in 1991, noted a recurrence rate of 0–18.5% in prosthetic laparo-alloplasties.
At the European Hernia Society (EHS)-GREPA meeting in 1986, the recurrence rate without prostheses was reported to be between 7.2 and 17% whereas in patients who had been treated with a prosthesis the recurrence was between 1 and 5.8%. A case study published by Flament in 1999 showed a 5.6% recurrence rate for operations with prostheses placed behind the muscles and in front of the fascia, and a 3.6% of such figure consisted of a small-sized lateroprosthetic recurrence. These rates were in contrast to the 26.8% recurrence reported by other surgeons for operations without prostheses.
Studies of recurrence are, of course, influenced by the size of the initial defect and the length of follow-up. Nevertheless, it is beyond dispute that the use of prostheses is associated with a lower rate of recurrence independent of the nature of the incisional hernia. The factors that lead to relapse are recognisable in the original features of the ventral hernia, i.e. combined musculo-aponeurotic parietal involvement, septic complications in the first operation, the nature and appropriateness of treatment, the kind of prosthesis and its position. Also important is whether the surgery was an emergency case and the relation to occlusive phenomena, visceral damage
and whether these problems were addressed at the same time.
Obesity is also an important risk factor for recurrence. In addition to its association with a higher surgical complications rate, related to the high intraabdominal pressure, there are deficits in wound cicatrisation as well as respiratory and metabolic pathologies. In such patients, the laparoscopic approach is very useful to significantly reduce the onset of general and wall complications, and the data concerning recurrence are encouraging, ranging between 1 and 9% in the largest laparoscopic case studies. The important multicentric study of Heniford et al., in 2000, reported a recurrence rate of 3.4% after 23 months. In 2003, the same author, in a study with an average follow-up of 20 months (range 1–96) showed a recurrence rate of 4.7% for different, identifiable causes: intestinal iatrogenic injuries and mesh infection with its removal, insufficient fixation of the prosthesis and abdominal trauma in the first postoperative period.
The incidence of recurrence after laparoscopic treatment may also be related to general patient factors and to the onset of local complications, mistakes in opting for laparoscopic treatment and deficits in implanting and fixing the prosthesis. With respect to the latter, it is very important to allow a large overlap compared to the diameter of the defect. Long-term data analysis, with large case studies, is still needed to obtain detailed information about recurrence, and this is particularly true in the assessment of relatively new techniques.
Gallbladder cancer is uncommon disease, although it is not rare. Indeed, gallbladder cancer is the fifth most common gastrointestinal cancer and the most common biliary tract cancer in the United States. The incidence is 1.2 per 100,000 persons per year. It has historically been considered as an incu-rable malignancy with a dismal prognosis due to its propensity for early in-vasion to liver and dissemination to lymph nodes and peritoneal surfaces. Patients with gallbladder cancer usually present in one of three ways: (1) advanced unresectable cancer; (2) detection of suspicious lesion preoperatively and resectable after staging work-up; (3) incidental finding of cancer during or after cholecystectomy for benign disease.
Although, many studies have suggested improved survival in patients with early gallbladder cancer with radical surgery including en bloc resection of gallbladder fossa and regional lymphadenectomy, its role for those with advanced gallbladder cancer remains controversial. First, patients with more advanced disease often require more extensive resections than early stage tumors, and operative morbidity and mortality rates are higher. Second, the long-term outcomes after resection, in general, tend to be poorer; long-term survival after radical surgery has been reported only for patients with limited local and lymph node spread. Therefore, the indication of radical surgery should be limited to well-selected patients based on thorough preoperative and intra-operative staging and the extent of surgery should be determined based on the area of tumor involvement.
Surgical resection is warranted only for those who with locoregional disease without distant spread. Because of the limited sensitivity of current imaging modalities to detect metastatic lesions of gallbladder cancer, staging laparoscopy prior to proceeding to laparotomy is very useful to assess the
abdomen for evidence of discontinuous liver disease or peritoneal metastasis and to avoid unnecessary laparotomy. Weber et al. reported that 48% of patients with potentially resectable gallbladder cancer on preoperative imaging work-up were spared laparotomy by discovering unresectable disease by laparoscopy. Laparoscopic cholecystectomy should be avoided when a preoperative cancer is suspected because of the risk of violation of the plane between tumor and liver and the risk of port site seeding.
The goal of resection should always be complete extirpation with microscopic negative margins. Tumors beyond T2 are not cured by simple cholecystectomy and as with most of early gallbladder cancer, hepatic resection is always required. The extent of liver resection required depends upon whether involvement of major hepatic vessels, varies from segmental resection of segments IVb and V, at minimum to formal right hemihepatectomy or even right trisectionectomy. The right portal pedicle is at particular risk for advanced tumor located at the neck of gallbladder, and when such involvement is suspected, right hepatectomy is required. Bile duct resection and reconstruction is also required if tumor involved in bile duct. However, bile duct resection is associated with increased perioperative morbidity and it should be performed only if it is necessary to clear tumor; bile duct resection does not necessarily increase the lymph node yield.
Portal vein Embolizations (PVE) is commonly used in the patients requiring extensive liver resection but have insufficient Future Liver Remanescent (FLR) volume on preoperative testing. The procedure involves occluding portal venous flow to the side of the liver with the lesion thereby redirecting portal flow to the contralateral side, in an attempt to cause hypertrophy and increase the volume of the FLR prior to hepatectomy.
PVE was first described by Kinoshita and later reported by Makuuchi as a technique to facilitate hepatic resection of hilar cholangiocarcinoma. The technique is now widely used by surgeons all over the world to optimize FLR volume before major liver resections.
PVE works because the extrahepatic factors that induce liver hypertrophy are carried primarily by the portal vein and not the hepatic artery. The increase in FLR size seen after PVE is due to both clonal expansion and cellular hypertrophy, and the extent of post-embolization liver growth is generally proportional to the degree of portal flow diversion. The mechanism of liver regeneration after PVE is a complex phenomenon and is not fully understood. Although the exact trigger of liver regeneration remains unknown, several studies have identified periportal inflammation in the embolized liver as an important predictor of liver regeneration.
PVE is technically feasible in 99% of the patients with low risk of complications. Studies have shown the FLR to increase by a median of 40–62% after a median of 34–37 days after PVE, and 72.2–80% of the patients are able to undergo resection as planned. It is generally indicated for patients being considered for right or extended right hepatectomy in the setting of a relatively small FLR. It is rarely required before extended left hepatectomy or left trisectionectomy, since the right posterior section (segments 6 and 7) comprises about 30% of total liver volume.
PVE is usually performed through percutaneous transhepatic access to the portal venous system, but there is considerable variability in technique between centers. The access route can be ipsilateral (portal access at the same side being resected) with retrograde embolization or contralateral (portal access through FLR) with antegrade embolization. The type of approach selected depends on a number of factors including operator preference, anatomic variability, type of resection planned, extent of embolization, and type of embolic agent used. Many authors prefer ipsilateral approach especially for right-sided tumors as this technique allows easy catheterization of segment 4 branches when they must be embolized and also minimizes the theoretic risk of injuring the FLR vasculature or bile ducts through a contralateral approach and potentially making a patient ineligible for surgery.
However, majority of the studies on contralateral PVE show it to be a safe technique with low complication rate. Di Stefano et al. reported a large series of contralateral PVE in 188 patients and described 12 complications (6.4%) only 6 of which could be related to access route and none precluded liver resection. Site of portal vein access can also change depending on the choice of embolic material selected which can include glue, Gelfoam, n-butyl-cyanoacrylate (NBC), different types and sizes of beads, alcohol, and nitinol plus. All agents have similar efficacy and there are no official recommendations for a particular type of agent.
Proponents of PVE believe that there should be very little or no tumor progression during the 4–6 week wait period for regeneration after PVE. Rapid growth of the FLR can be expected within the first 3–4 weeks after PVE and can continue till 6–8 weeks. Results from multiple studies suggest that 8–30% hypertrophy over 2–6 weeks can be expected with slower rates in cirrhotic patients. Most studies comparing outcomes after major hepatectomy with and without preoperative PVE report superior outcomes with PVE. Farges et al. demonstrated significantly less risk of postoperative complications, duration of intensive care unit, and hospital stay in patients with cirrhosis who underwent right hepatectomy after PVE compared to those who did not have preoperative PVE. The authors also reported no benefit of PVE in patients with a normal liver and FLR >30%. Abulkhir et al. reported results from a meta-analysis of 1088 patients undergoing PVE and showed a markedly lower incidence of Post Hepatectomy Liver Failure (PHLF) and death compared to series reporting outcomes after major hepatectomy in patients who did not undergo PVE. All patients had FLR volume increase, and 85% went on to have liver resection after PVE with a PHLF incidence of 2.5% and a surgical mortality of 0.8%. Several studies looking at the effect of systemic neoadjuvant chemotherapy on the degree of hypertrophy after PVE show no significant impact on liver regeneration and growth.
The volumetric response to PVE is also a very important factor in understanding the regenerative capacity of a patient’s liver and when used together with FLR volume can help identify patients at risk of poor postsurgical outcome. Ribero et al. demonstrated that the risk of PHLF was significantly higher not only in patients with FLR ≤ 20% but also in patients with normal liver who demonstrated ≤5% of FLR hypertrophy after PVE. The authors concluded that the degree of hypertrophy >10% in patients with severe underlying liver disease and >5% in patients with normal liver predicts a low risk of PHLF and post-resection mortality. Many authors do not routinely offer resection to patients with borderline FLR who demonstrate ≤5% hypertrophy after PVE.
Careful analysis of outcome based on liver remnant volume stratified by underlying liver disease has led to recommendations regarding the safe limits of resection. The liver remnant to be left after resection is termed the future liver remnant (FLR). For patients with normal underlying liver, complications, extended hospital stay, admission to the intensive care unit, and hepatic insufficiency are rare when the standardized FLR is >20% of the TLV. For patients with tumor-related cholestasis or marked underlying liver disease, a 40% liver remnant is necessary to avoid cholestasis, fluid retention, and liver failure. Among patients who have been treated with preoperative systemic chemotherapy for more than 12 weeks, FLR >30% reduces the rate of postoperative liver insufficiency and subsequent mortality.
When the liver remnant is normal or has only mild disease, the volume of liver remnant can be measured directly and accurately with threedimensional computed tomography (CT) volumetry. However, inaccuracy may arise because the liver to be resected is often diseased, particularly in patients with cirrhosis or biliary obstruction. When multiple or large tumors occupy a large volume of the liver to be resected, subtracting tumor volumes from liver volume further decreases accuracy of CT volumetry. The calculated TLV, which has been derived from the association between body surface area (BSA) and liver size, provides a standard estimate of the TLV. The following formula is used:
TLV (cm3) = –794.41 + 1267.28 × BSA (square meters)
Thus, the standardized FLR (sFLR) volume calculation uses the measured FLR volume from CT volumetry as the numerator and the calculated TLV as the denominator: Standardized FLR (sFLR) = measured FLR volume/TLV Calculating the standardized TLV corrects the actual liver volume to the individual patient’s size and provides an individualized estimate of that patient’s postresection liver function. In the event of an inadequate FLR prior to major hepatectomy, preoperative liver preparation may include portal vein embolization (PVE).
This page provides links to prerecorded webcasts of surgical procedures. These are actual operations performed at medical centers in the Brazil. Please note that you cannot send in questions by email, though the webcast may say that you can, because you are not seeing these videos live. The videos open in a second window. If you have a pop-up blocker, you will need to disable it to view the programs.
Cholangiocarcinoma (CCA) is a rare but lethal cancer arising from the bile duct epithelium. As a whole, CCA accounts for approximately 3 % of all gastrointestinal cancers. It is an aggressive disease with a high mortality rate. Unfortunately, a significant proportion of patients with CCA present with either unresectable or metastatic disease. In a retrospective review of 225 patients with hilar cholangiocarcinoma, Jarnagin et al. reported that 29 % of patients had either unresectable disease were unfit for surgery. Curative resection offers the best chance for longterm survival. Whereas palliation with surgical bypass was once the preferred surgical procedure even for resectable disease, aggressive surgical resection is now the standard.
In both the UK and the USA the annual death rate due to inguinal and femoral hernia has decreased in the last two to three decades. In the UK, deaths for inguinal and femoral hernia declined from 22 to 55% respectively from 1975 to 1990. The annual deaths in the USA per 100,000 population for patients with hernia and intestinal obstruction decreased from 5.1 in 1968 to 3.0 in 1988. For inguinal hernia with obstruction, 88% of patients underwent surgery with a mortality rate of 0.05%. These figures could be interpreted as showing that elective groin hernia surgery has reduced overall mortality rates.
In support of this contention is the fact that strangulation rates are lower in the USA than in the UK, which could be a consequence of the three times higher rate of elective hernia surgery in the USA. Even so, the available statistics show that rates of elective hernia surgery in the USA per 100,000 population fell from 358 to 220 between 1975 and 1990, although this may be an artifact of the data collection systems rather than a real decline.
During the period 1991–1992, 210 deaths occurring following inguinal hernia repair and 120 deaths following femoral hernia repair were investigated by the UK National Confidential Enquiry Into Perioperative Deaths. This enquiry is concerned with the quality of delivery of surgery, anesthesia, and perioperative care. Expert advisers compare the records of patients who have died with index cases. In this group of 330 patients many were elderly (45 were aged 80–89 years) and significantly infirm unfit; 24 were ASA grade III and 21 ASA grade IV. Postoperative mortality was attributed to preexisting cardiorespiratory problems in the majority of cases. In a nationwide study in Denmark of 158 patients dying after acute groin hernia repair, Kjaergaard et al. also found that these patients were old (median age 83 years) and fragile (>80% with significant comorbidity), with frequent delay in diagnosis and subsequent treatment. Clearly this group of patients requires high-quality care by an experienced surgeon and anesthetist with skills equivalent to that of the ASA grade of the patient.
Postoperative care should necessarily take place in a high-dependency unit or intensive therapy unit; this may necessitate transfer of selected patients to appropriate hospitals and facilities. Sensible decisions must be made in consultation with relatives of extremely elderly, frail, or moribund patients to adopt a humane approach, which may rule out interventional surgery.
Forty percent of patients with femoral hernia are admitted as emergency cases with strangulation or incarceration, whereas only 3% of patients with direct inguinal hernias present with strangulation. This clearly has implications for the prioritization on waiting lists when these types of hernia present electively to outpatient clinics. A groin hernia is at its greatest risk of strangulation within 3 months of its onset. For inguinal hernia at 3 months after presentation, the cumulative probability of strangulation is 2.8%, rising to 4.5% after 2 years. For femoral hernia the risk is much higher, with a 22% probability of strangulation at 3 months after presentation rising to 45% at 21 months. Right-sided hernias strangulate more frequently than left-sided hernias; this is possibly related to mesenteric anatomy.
In a randomized trial, evaluating an expectative approach to minimally symptomatic inguinal hernias, Fitzgibbons et al. in the group of patients randomized to watchful waiting found a risk of an acute hernia episode of 1.8 in 1,000 patient years. In another trial, O’Dwyer and colleagues, randomizing patients with painless inguinal hernias to observation or operation, found two acute episodes in 80 patients randomized to observation. In both studies, a large percentage of patients randomized to nonoperative care were eventually operated due to symptoms. Neuhauser, who studied a population in Columbia where elective herniorrhaphy was virtually unobtainable, found an annual rate of strangulation of 0.29% for inguinal hernias.
Management of Strangulation
Diagnosis is based on symptoms and signs supplemented by diagnostic imaging when indicated. Pain over the hernia site is invariable, and obstruction with strangulation of intestine will cause colicky abdominal pain, distension, vomiting, and constipation. Physical examination may reveal degrees of dehydration with or without CNS depression, especially in the elderly if uremia is present, together with abdominal signs of intestinal obstruction. Femoral hernias can be easily missed, especially in the obese female, and a thorough examination should be performed in order to make the correct diagnosis. Frequently, however, physical examination alone is insuf fi ciently accurate to con fi rm the presence of a strangulating femoral hernia vs. lymphadenopathy vs. a lymph node abscess. In these instances, one may elect to perform radiographic studies such as an ultrasound or a CT scan on an urgent or emergent basis.
The choice of incision will depend on the type hernia if the diagnosis is confi dent. When the diagnosis is in doubt, a half Pfannenstiel incision 2 cm above the pubic ramus, extending laterally, will give an adequate approach to all types of femoral or inguinal hernia. The fundus of the hernia sac can then be approached and exposed and an incision made to expose the contents of the sac. This will allow determination of the viability of its contents. Nonviability will necessitate conversion of the transverse incision into a laparotomy incision followed by release of the constricting hernia ring, reduction of the contents of the sac, resection, and reanastomosis. Precautions should be taken to avoid contamination of the general peritoneal cavity by gangrenous bowel or intestinal contents. In the majority of cases, once the constriction of the hernia ring has been released, circulation to the intestine is reestablished and viability returns. Intestine that is initially dusky, aperistaltic, or dull in hue may pink up with a short period of warming with damp packs once the constriction band is released. If viability is doubtful, resection should be performed. Resection rates are highest for femoral or recurrent inguinal hernias and lowest for inguinal hernias. Other organs, such as bladder or omentum, should be resected, as the need requires. After peritoneal lavage and formal closure of the laparotomy incision, specific repair of the groin hernia defect should be performed. In this situation prosthetic mesh should not be used in an operative fi eld that has been contaminated and in which there is a relatively high risk of wound infection. The hernia repair should follow the general principles for elective hernia repair. It should be kept in mind, that in this group of predominantly frail and elderly patients with a very high postoperative mortality risk, the primary objective of the operation is to stop the vicious cycle of strangulation, and only secondary to repair the hernia defect.
The risk of an acute groin hernia episode is of particular relevance, when discussing indication for operation of painless or minimally symptomatic hernias. A sensible approach in groin hernias would be, in accordance with the guidelines from the European Hernia Society to advise a male patient, that the risk of an acute operation, with an easily reducible (“disappears when lying down”) inguinal hernia with little or no symptoms, is low and that the indication for operation in this instance is not absolute, but also inform, that usually the hernia after some time will cause symptoms, eventually leading to an operation. In contrast, female patients with a groin hernia, due to the high frequency of femoral hernias and a relatively high risk of acute hernia episodes, should usually be recommended an operation.
The abdomen is the lower part of the trunk below the diaphragm. Its walls surround a large cavity called the abdominal cavity. The abdominal cavity is much more extensive than what it appears from the outside. It extends upward deep to the costal margin up to the diaphragm and downward within the bony pelvis. Thus, a considerable part of the abdominal cavity is overlapped by the lower part of the thoracic cage above and by the bony pelvis below. The abdominal cavity is subdivided by the plane of the pelvic inlet into a larger upper part, i.e., the abdominal cavity proper, and a smaller lower part, i.e., the pelvic cavity. Clinically the importance of the abdomen is manifold. To the physician, the physical examination of the patient is never complete until he/she thoroughly examines the abdomen. To the surgeon, the abdomen remains an enigma because in number of cases the cause of abdominal pain and nature of abdominal lump remains inconclusive even after all possible investigations. To summarize, many branches of medicine such as general surgery and gastroenterology are all confined to the abdomen.
The incidence of choledocholithiasis in patients undergoing cholecystectomy is estimated to be 10 %. The presence of common bile duct stones is associated with several known complications including cholangitis, gallstone pancreatitis, obstructive jaundice, and hepatic abscess. Making the diagnosis early and prompt management is crucial. Traditionally, when choledocholithiasis is identified with intraoperative cholangiography during the cholecystectomy, it has been managed surgically by open choledochotomy and place- ment of a T-tube. This open surgical approach has a morbidity rate of 10–15 %, mortality rate of <1 %, with a <6 % incidence of retained stones. Patients who fail endoscopic retrieval of CBD stones, as well as cases in which an endoscopic approach is not appropriate, should be explored surgically.
Acute obstruction of the bile duct by a stone causes a rapid distension of the biliary tree and activation of local pain fibers. Pain is the most common presenting symptom for choledocholithiasis and is localized to either the right upper quadrant or to the epigastrium. The obstruction will also cause bile stasis which is a risk factor for bacterial over- growth. The bacteria may originate from the duodenum or the stone itself. The combination of biliary obstruction and colo- nization of the biliary tree will lead to the development of fevers, the second most common presenting symptom of cho- ledocholithiasis. Biliary obstruction, if unrelieved, will lead to jaundice. When these three symptoms (pain, fever, and jaundice) are found simultaneously, it is known as Charcot’s triad. This triad suggests the diagnosis of acute ascending cholangitis, a potentially life-threatening condition. If not treated promptly, this can lead to hypotension and decreased metal status, both signs of severe sepsis. When combined with Charcot’s triad, this constellation of symptoms is commonly referred to as Reynolds pentad.
Laparoscopic common bile duct exploration
Laparoscopic common bile duct exploration (LCBDE) allows for single stage treatment of gallstone disease, reducing overall hospital stay, improving safety and cost-effectiveness when compared to the two-stage approach of ERCP and laparoscopic cholecystectomy. Bile duct clearance can be confirmed by direct visualization with a choledochoscope. But, before the advent of choledochoscope, bile duct clearance was uncertain, and blind instrumentation of the duct resulted in accentuated edema and inflammation. Due to advancement in instruments, optical magnification, and direct visualization, laparoscopic exploration of the CBD results in fewer traumas to the bile duct. This has led to an increasing tendency to close the duct primarily, reducing the need for placement of T-tubes. Still, laparoscopic bile duct exploration is being done in only a few centers. Apart from the need for special instruments, there is also a significant learning curve to acquire expertise to be able to perform a laparoscopic bile duct surgery.
Morbidity and mortality rates of laparoscopic exploration are comparable to ERCP (2–17 and 1–5 %), and there is no clear difference in primary success rates between the two approaches. However, the endoscopic approach may be preferable for elderly and frail patients, who are at higher risk with surgery. Patients older than 70–80 years of age have a 4–10 % mortality rate with open duct exploration. It may be as high as 20 % in elderly patients undergoing urgent procedures. In comparison, advanced age and comor- bidities do not have a significant impact on overall complication rates for ERCP. A success rate of over 90 % has been reported with laparoscopic CBD exploration. Availability of surgical expertise and appropriate equipment affect the success rate of laparoscopic exploration, as does the size, number of the CBD stones, as well as biliary anatomy. Over the years, laparoscopic exploration has become efficient, safe, and cost effective. Complications include CBD laceration, stricture formation, bile leak, abscess, pancreatitis, and retained stones.
In cases of failure of laparoscopic CBD exploration, a guidewire or stent can be passed through the cystic duct, common bile duct, and through the ampulla into the duodenum followed by cholecystectomy. This makes the identification and cannulation of the ampulla easier during the post- operative ERCP. Laparoscopic common bile duct exploration is traditionally performed through a transcystic or transductal approach. The transcystic approach is appropriate under certain circumstances. These include a small stone (<10 mm) located in the CBD, presence of small common bile duct (<6 mm), or if there is poor access to the common duct. The transductal approach is preferable in cases of large stones, stones in proximal ducts (hepatic ducts), large occluding stones in a large duct, presence of multiple stones, or if the cystic duct is small (<4 mm) or tortuous. Contraindications for laparoscopic approach include lack of training, and severe inflammation in the porta hepatis making the exploration difficult and risky.
With advancement in imaging technology, laparoscopic and endoscopic techniques, management of common bile duct stone has changed drasti- cally in recent years. This has made the treatment of this condition safe and more efficient. Many options are now available to manage this condition, and any particular modality for treatment should be chosen carefully based on the patient related factors, institutional protocol, available expertise, resources, and cost-effectiveness.
Patients with acute appendicitis can present at different stages of the disease process, ranging from mild mucosal inflammation to frank perforation with abscess formation. The reported overall incidence of acute appendicitis varies with age, gender, and geographical differences. Interestingly, while the incidence of non-perforated appendicitis in the United States decreased between 1970 and 2004, no significant decline in the rate of perforated appendicitis was observed despite the increasng use of computed tomography (CT) and fewer negative appendectomies.
Of 32,683 appendectomies sampled from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) hospitals between 2005 and 2008, 5,405 patients (16.5%) had a preoperative diagnosis of acute appendicitis with peritonitis/abscess.
The definition of complicated appendicitis varies slightly in the literature. Clinicopathological diagnoses (gangrenous, perforated, appendiceal abscess/phlegmon) of acute appendicitis are commonly used for its definition. Classically, patients at the extremes of age are more likely to present with complicated appendicitis. Similarly, pre-morbid conditions including diabetes and type of medical insurance are significantly associated with the risk of perforation.
The importance of early appendectomy has also been emphasized to prevent perforation of the appendix and the sub- sequent negative impact on patient outcomes. However, more recent meta-analysis data supports the safety of a relatively short (12–24 h) delay before appendectomy, which was not significantly associated with increased rate of complicated appendicitis. Teixeira et al. also showed that the time to appendectomy was not a significant risk factor for perforated appendicitis but did result in a significantly increased risk of surgical site infection.
The outcome of patients with complicated appendicitis is significantly worse than patients with uncomplicated appendicitis. A population-based study from Sweden showed that, in a risk-adjusted model, patients with perforated appendicitis were 2.34 times more likely to die after appendectomy than non- perforated appendicitis patients. Because of its higher mortality and morbidity in patients with complicated appendicitis, the management of complicated appendicitis has evolved significantly over the last few decades.
Open or Laparoscopic Surgery
Since the first laparoscopic appendectomy was described by Semm in 1983, multiple studies have compared operative time, complication rates, length of hospital stay, hospital cost, and other outcomes between open and laparoscopic appendectomy for acute appendicitis. The most recent Cochrane review included 67 studies showing that laparoscopic appendectomy was associated with a lower incidence of wound infection, reduced postoperative pain, shorter postoperative length of hospital stay, and faster recovery to daily activity. In contrast, reduced risk of intra-abdominal abscesses and shorter operative time were found as the advantages of open appendectomy.
Due to increased surgeon experience in uncomplicated appendicitis, laparoscopic appendectomy is more frequently attempted even in complicated appendicitis cases as an alternative approach to open appendectomy. Although the general surgical steps for complicated appendicitis are similar to those for uncomplicated appendicitis, the laparoscopic procedure can be more technically demanding. Therefore, conversion from laparoscopic appendectomy to open appendectomy can be expected.
Despite these concerns, the laparoscopic approach in patients with com- plicated appendicitis has been proven to be safe and comparable to open appendectomy. Retrospective studies using a large database in the United States uniformly showed more favorable clinical outcomes (mortality, morbidity, length of hospital stay, readmission rate) and hospital costs in patients who underwent laparoscopic appendectomy when compared to open appendectomy. The real risk of developing an intra- abdominal abscess after laparoscopic appendectomy remains unclear. A meta-analysis by Markides et al. found no significant difference in the intra-abdominal abscess rate between laparoscopic and open appendectomy for complicated appendicitis, whereas Ingraham et al. showed a higher likelihood of developing an organ-space surgical site infection in patients undergoing laparoscopic appendectomy.
The spleen, an important component of the reticuloendothelial system in normal adults, is a highly vascular solid organ that arises as a mass of differentiated mesenchymal tissue during early embryonic development. The normal adult spleen weighs between 75 and 100 g and receives an average blood flow of 300 mL/min. It functions as the primary filter of the reticuloendothelial system by sequestering and removing antigens, bacteria, and senescent or damaged cellular elements from the circulation. In addition, the spleen has an important role in humoral immunity because it produces immunoglobulin M and opsonins for the complement activation system.
The increased availability of high-resolution CT scan and advances in arterial angiography and embolization techniques have contributed to the success of nonoperative management of splenic injuries.
The hemodynamically stable patient with blunt splenic trauma can be adequately managed with bed rest, serial abdominal exams, and hemoglobin and hematocrit monitoring. This approach, in combination with occasional angiography, especially for grade III and IV injuries, confers a splenic salvage rate of up to 95%.
In the setting of expectant management, indications for angiography have been delineated by several studies and include the following CT scan features: contrast extravasation, the presence of a pseudoaneurysm, significant hemoperitoneum, high-grade injury, and evidence of a vascular injury. The goal of angiography is to localize bleeding and embolize the source with coils or a gelatin foam product. Embolization can occur either at the main splenic artery just distal to the dorsal pancreatic portion of the vessel—known as proximal embolization—or selectively at the distal branch of the injured vessel. The goal behind the former technique is to decrease the perfusion pressure to the spleen to encourage hemostasis. The disadvantage to this technique is global splenic ischemia, and many have questioned the spleen’s immunocompetence following proximal embolization.
Malhotra et al. examined the effects of angioembolization on splenic function by examining serum levels of a particular T-cell line. T-cell proportions between patients who had undergone splenic embolization with asplenic patients and healthy controls were similar suggesting some degree of splenic immunocompetency was maintained. A Norwegian study comparing blood samples from patients who had undergone angioembolization with healthy controls demonstrated that the study samples had similar levels of pneumococcal immunoglobulins and no Howell-Jolly bodies, suggesting normal splenic function. Although these preliminary studies remain encouraging, there is no definitive evidence that splenic immunocompetency is fully maintained following angio-embolization.
There is no question that advancements in interventional techniques have contributed to the successful nonoperative management of splenic injuries. This has certainly changed the strategy, but it has not completely replaced operative intervention. The challenge now remains predicting those patients who will ultimately require splenectomy.
Many groups have studied potential predictors of nonoperative failure. Earlier studies found that a higher injury grade, increased transfusion requirement, and hypotension on initial presentation consistently predicted failure of nonoperative management. More recent literature reflects the use of advanced imaging techniques for predicting which patients will ultimately require splenectomy. Haan looked at the overall outcomes of patients admitted with blunt splenic trauma and reported several radiographic findings that were prevalent among patients requiring splenectomy after angioembolization:
- contrast extravasation,
- significant hemoperitoneum,
- and arteriovenous fistula.
Among these characteristics, an arteriovenous fistula had the highest rate of nonoperative failure at 40%. Nonradiographic features associated with significant risk of nonoperative failure include age greater than 40, injury severity score of 25 or greater, or presence of large-volume hemoperitoneum.
Aside from radiographic findings, some groups have also examined the mechanism of injury and its association with nonoperative failure. Plurad et al. conducted a retrospective review over a 15-year period and found that patients who were victims of blunt assault were more likely to fail nonoperative management: 36% of these patients required splenectomy versus 11.5% of patients from all other mechanisms combined. These findings suggest that regardless of overall injury severity, individuals who sustain a direct transfer of injury to the left torso are more likely to require splenectomy.
Currently, the accepted standard of care for most splenic trauma is expectant management with close observation. Operative intervention is reserved for the hemodynamically labile patient who shows signs of active hemorrhage and who does not respond appropriately to fluid resuscitation. Although these clinical scenarios seem straightforward, it is often the condition of the patient who falls in between the two ends of the spectrum that can be the most challenging to manage. In the setting of advanced imaging techniques and interventional radiology, the trauma surgeon has more diagnostic information and more treatment options for the patient with splenic trauma.
IPMNs were first recognized in 1982 by Ohashi, but the term IPMN was not officially used until 1993. IPMNs are defined in the WHO Classification of Tumors of the Digestive System as an intraductal, grossly visible epithelial neoplasm of mucin-producing cells. Using imaging and histology, IPMNs can be classified into three types based on duct involvement:
1. Main-duct IPMN (approximately 25% of IPMNs): Segmental or diffuse dilation of the main pancreatic duct (>5 mm) in the absence of other causes of ductal obstruction.
2. Branch-duct IPMN (approximately 57% of IPMNs): Pancreatic cysts (>5 mm) that communicate with the main pancreatic duct.
3. Mixed type IPMN (approximately 18% of IPMNs): Meets criteria for both main and branch duct.
Due to the asymptomatic nature of the disease, the overall incidence of IPMNs is difficult to define but is thought to account for approximately 3% to 5% of all pancreatic tumors. Most IPMNs are discovered as incidental lesions from the workup of an unrelated process by imaging or endoscopy. IPMNs are slightly more prevalent in males than in females, with a peak incidence of 60 to 70 years of age. Branch-duct IPMNs tend to occur in a slightly younger population and are less associated with malignancy compared with main-duct or mixed variants.
Because a majority of IPMNs are discovered incidentally, most are asymptomatic. When symptoms do occur, they tend to be nonspecific and include unexplained weight loss, anorexia, abdominal pain, and back pain. Jaundice can occur with mucin obstructing the ampulla or with an underlying invasive carcinoma. The obstruction of the pancreatic duct can also lead to pancreatitis. IPMNs may represent genomic instability of the entire pancreas. This concept, known as a “field defect,” has been described as a theoretical risk of developing a recurrent IPMN or pancreatic adenocarcinoma at a site remote from the original IPMN. The three different types of IPMNs, main duct, branch duct, and mixed duct, dictate different treatment algorithms.
MAIN DUCT IPMNs
Main-duct IPMNs should be resected in all patients unless the risks of existing comorbidities outweigh the benefits of resection. The goal of operative management of IPMNs is to remove all adenomatous or potentially malignant epithelium to minimize recurrence in the pancreas remnant. There are two theories on the pathophysiologic basis of IPMNs. The first groups IPMNs into a similar category as an adenocarcinoma, a localized process involving only a particular segment of the pancreas. The thought is that removal of the IPMN is the only treatment necessary. In contrast, some believe IPMNs to represent a field defect of the pancreas. All of the ductal epithelium remains at risk of malignant degeneration despite removal of the cyst. Ideally, a total pancreatectomy would eliminate all risk, but this is a radical procedure that is associated with metabolic derangements and exocrine insufficiency. Total pancreatectomy should be limited to the most fit patients, with a thorough preoperative assessment and proper risk stratification prior to undertaking this surgery.
There is less uncertainty with treatment of main-duct IPMNs. The high incidence of underlying malignancy associated with the IPMNs warrants surgical resection. IPMNs localized to the body and tail (approximately 33%) can undergo a distal pancreatectomy with splenectomy. At the time of surgery, a frozen section of the proximal margin should be interpreted by a pathologist to rule out high-grade dysplasia. A prospective study identified a concordance rate of 94% between frozen section and final pathologic examination. If the margin is positive (high-grade dysplasia, invasion) additional margins may be resected from the pancreas until no evidence of disease is present. However, most surgeons will proceed to a total pancreatectomy after two subsequent margins demonstrate malignant changes. This more extensive procedure should be discussed with the patient prior to surgery, and the patient should be properly consented regarding the risks of a total pancreatectomy.
IPMNs localized to the head or uncinate process of the pancreas should undergo a pancreaticoduodenectomy. A frozen section of the distal margin should be analyzed by pathology for evidence of disease. As mentioned before, after two additional margins reveal malignant changes, a total pancreatectomy is usually indicated (approximately 5%). The absence of abnormal changes in frozen sections does not equate to negative disease throughout the pancreas remnant. Rather, skip lesions involving the remainder of the pancreas can exist and thus patients ultimately still require imaging surveillance after successful resection. A prophylactic total pancreatectomy is rarely performed because the subsequent pancreatic endocrine (diabetes mellitus) and exocrine deficits (malnutrition) carry an increased morbidity.
BRANCH DUCT IPMNs
Localized branch-duct IPMN can be treated with a formal anatomic pancreatectomy, pancreaticoduodenectomy, or distal pancreatectomy, depending on the location of the lesion. However, guidelines were established that allow for nonoperative management with certain branch- type IPMN characteristics.
These include asymptomatic patients with a cyst size less than 3 cm and lack of mural nodules. The data to support this demonstrate a very low incidence of malignancy (approximately 2%) in this patient group. Which nearly matches the anticipated mortality of undergoing a formal anatomic resection. In approximately 20% to 30% of patients with branch- duct IPMNs, there is evidence of multifocality. The additional IPMNs can be visualized on high-resolution CT or MRI imaging. Ideally, patients with multifocal branch-duct IPMNs should undergo a total pancreatectomy. However, as previously mentioned, the increased morbidity and lifestyle alterations associated with a total pancreatectomy allows for a more conservative approach. This would include removing the most suspicious or dominant of the lesions in an anatomic resection and follow-up imaging surveillance of the remaining pancreas remnant. If subsequent imaging demonstrates malignant charac- teristics, a completion pancreatectomy is usually indicated.
Recurrence rates with IPMNs are variable. An anatomic resection of a branch-duct IPMN with negative margins has been shown to be curative. The recurrence of a main- duct IPMN in the remnant gland is anywhere from 0% to 10% if the margins are negative and there is no evidence of invasion. Most case series cite a 5-year survival rate of at least 70% after resection of noninvasive IPMNs. In contrast, evidence of invasive disease, despite negative margins, decreases 5-year survival to 30% to 50%. The recurrence rate in either the pancreatic remnant or distant sites approaches 50% to 90% in these patients. Histopathologic subtype of the IPMN is correlated with survival. The aggressive tubular subtype has a 5-year survival ranging from 37% to 55% following surgical resection, whereas the colloid subtype has 5-year survival ranging from 61% to 87% post resection. Factors associated with decreased survival include tubular subtype, lymph node metastases, vascular invasion, and positive margins. IPMNs with evidence of invasion should be treated similar to pancreatic adenocarcinomas. Studies show that IPMNs tend to have better survival than pancreatic adenocarcinoma. This survival benefit may be secondary to the less aggressive tumor biology or the earlier diagnosis of IPMNs.
All patients who have a resected IPMN should undergo imaging surveillance. There is continual survival benefit with further resection if an IPMN does recur. International Consensus Guidelines published in 2017 offer recom- mendations for the frequency and modality of imaging surveillance after resection. Routine serum measurement of CEA and CA 19-9 has a limited role for detection of an IPMN recurrence. Of note, a new pancreatic lesion discovered on imaging after resection could represent a postoperative pseudocyst, a recurrence of the IPMN from inadequate resection, a new IPMN, or an unrelated new neoplastic process. IPMNs may also be associated with extrapancreatic neoplasms (stomach, colon, rectum, lung, breast) and pancreatic ductal adenocarcinoma. It is unclear if this represents a true genetic syndrome. However, patients with IPMNs should have a discussion about the implications of their disease with their physician and are encouraged to undergo colonoscopy to exclude a synchronous neoplastic process.
The incidence of PANCREATIC CYSTIC LESIONS will continue to increase as imaging technology improves. EUS, cytology, and molecular panels have made differentiating the type of PCN less problematic. The importance of an accurate preoperative diagnosis ensures that operative management is selectively offered to those with high-risk lesions. Management beyond surgery, including adjuvant therapy and surveillance, continue to be active areas of research.
Surgery and anesthesia profoundly alter the normal physiologic and metabolic states. Estimating the patient’s ability to respond to these stresses in the postoperative period is the task of the preoperative evaluation. Perioperative complications are often the result of failure, in the preoperative period, to identify underlying medical conditions, maximize the patient’s preoperative health, or accurately assess perioperative risk. Sophisticated laboratory studies and specialized testing are no substitute for a thoughtful and careful history and physical examination. Sophisticated technology has merit primarily in confirming clinical suspicion.
Hepatocellular carcinoma is the second most common cause of cancer mortality worldwide and its incidence is rising in North America, with an estimated 35,000 cases in the U.S. in 2014. The best chance for cure is surgical resection in the form of either segmental removal or whole organ transplantation although recent survival data on radiofrequency ablation approximates surgical resection and could be placed under the new moniker of “thermal resection”. The debate between surgical resection and transplantation focuses on patients with “within Milan criteria” tumors, single tumors, and well compensated cirrhosis who can safely undergo either procedure. Although transplantation historically has had better survival outcomes, early diagnosis, reversal of liver disease, and innovations in patient selection and neo-adjuvant therapies have led to similar 5-year survival. Transplantation clearly has less risk of tumor recurrence but exposes recipients to long term immunosuppression and its side effects. Liver transplantation is also limited by the severe global limit on the supply of organ donors whereas resection is readily available. The current data does not favor one treatment over the other for patients with minimal or no portal hypertension and normal synthetic function. Instead, the decision to resect or transplant for HCC relies on multiple factors including tumor characteristics, biology, geography, co-morbidities, location, organ availability, social support and practice preference.
Resection Versus Transplantation
The debate between resection and transplantation revolves around patients who have well compensated cirrhosis with Milan criteria resectable tumors. Patients within these criteria represent a very small proportion of those who initially present with HCC. This is especially true in western countries where hepatitis C is the most common cause of liver failure and HCC is a result of the progressive and in most cases advanced cirrhosis.
Given the need for a large number of patients to show statistical significance, it would be difficult to perform a high-quality prospective randomized controlled trial comparing resection and transplantation. In fact the literature revealed that no randomized controlled trials addressing this issue exist. Instead, outcomes of surgical treatment for HCC stem from retrospective analyses that have inherent detection, selection and attrition biases.
Given the numerous articles available on this subject, several meta-analyses have been published to delineate the role of transplantation and resection for treatment of HCC. However, there is reason to be wary of these meta-analyses because they pool data from heterogeneous populations with variable selection criteria and treatment protocols. One such meta-analysis by Dhir et al. focused their choice of articles to strict criteria which excluded studies with non-cirrhotic patients, fibrolamellar HCC and hepato-cholangiocarcinomas but included those with HCC within Milan criteria and computation of 5-year survival; between 1990 and 2011 they identified ten articles that fit within these criteria, of which six were ITT analyses, six included only well-compensated cirrhotics (Child-Pugh Class A without liver dysfunction) and three were ITT analyses of well-compensated cirrhotics.
Analysis of the six ITT studies that included all cirrhotics (n = 1118) (Child-Pugh Class A through C) showed no significant difference in survival at 5 years (OR = 0.600, 95 % CI 0.291– 1.237 l; p=0.166) but ITT analysis of only well-compensated cirrhotics (Child- Pugh Class A) revealed that patients undergoing transplant had a significantly higher 5-year survival as compared to those with resection (OR=0.521, 95 % CI 0.298–0.911; p=0.022).
A more recent ITT retrospective analysis from Spain assessed long-term survival and tumor recurrence following resection or transplant for tumors <5 cm in 217 cirrhotics (Child-Pugh Class A, B and C) over the span of 16 years. Recurrence at 5 years was significantly higher in the resection group (71.6 % vs. 16 % p<0.001) but survival at 4 years was similar (60 % vs. 62 %) which is likely explained by the evolving role of adjuvant therapies to treat post-resection recurrence.
- Patients with anatomically resectable single tumors and no cirrhosis or Child-Pugh Class A cirrhosis with normal bilirubin, HVPG (<10 mmHg), albumin and INR can be offered resection (evidence quality moderate; strong recommendation).
- Patients with Milan criteria tumors in the setting of Child- Pugh Class A with low platelets and either low albumin or high bilirubin or Child-Pugh Class B and C cirrhosis, especially those with more than one tumor, should be offered liver transplantation over resection (evidence quality moderate; strong recommendation).
- Those with Milan criteria tumors and Child-Pugh Class A cirrhosis without liver dysfunction should be considered for transplantation over resection (evidence quality low; weak recommendation).
- No recommendation can be made in regard to transplanting tumors beyond Milan criteria (evidence quality low) except to follow regional review board criteria.
- Pre-transplant therapies such as embolic or thermal ablation are safe and by expert opinion considered to be effective in decreasing transplant waitlist dropout and bridging patients to transplant (evidence quality low, weak recommendation). These interventions should be considered for those waiting longer than 6 months (evi- dence quality low, moderate recommendation).
- Living donor liver transplantation is a safe and effective option for treatment of HCC that are within and exceed Milan criteria (evidence quality moderate, weak recommendation).
Minimally invasive surgery, a widely adopted tool for most domains of gastrointestinal surgery, has been relatively slow to evolve in the field of pancreatic surgery. The reasons include proximity to the great vessels, retroperitoneal location, need for advanced intracorporeal suturing skills and increased risk of complications associated with these procedures. With enormous development in surgical technology coupled with improved anatomical knowledge and refined skills, minimally invasive pancreatic surgery has grown out of its infancy and is an established specialty in hepato-pancreato-biliary surgery today. As a result, the initial scepticism and reluctance associated with minimally invasive pancreatic resections has decreased and many surgeons are attempting to enter this difficult terrain. Recent publications highlight potential advantages of minimally invasive pancreatic resection (MIPR) over open pancreatic resection (OPR). These include reduced pain, decreased blood loss and need for transfusion, an earlier return of bowel function, decreased wound infection rates and shorter intensive care unit and overall hospital stays. Though the number of minimally invasive pancreatic resections performed for benign and malignant diseases of the pancreas has increased in recent years, cost considerations and financial implications of these new approaches need to be well defined. Clear guidelines and standardization of surgical technique are paramount for the safe and steady expansion of this novel surgical approach.
Minimally Invasive Pancreaticoduodenectomy
Gagner and Pomp reported the first LPD in 1994. They felt that laparoscopy was not useful for such a major resection and reconstruction. However, their initial patients included those with chronic pancreatitis, where LPD is considered difficult to do even at present. With this background, we began doing LPD after sufficient experience had been gained in other major laparoscopic procedures such as colectomy, gastrectomy and choledochal cyst excision. During the initial phase, LPD was attempted in only periampullary tumours or small pancreatic head masses. With increasing experience, the indications for LPD were expanded to include carcinoma head of the pancreas and larger tumours.
Over the years, numerous technical modifications in terms of surgeon comfort, use of energy source, radicality of surgery, type of reconstruction and specimen extraction were made. These refinements resulted in better outcomes as was evident in the next publication in 2009 which included 75 patients. Oncologically, the resection status and lymph nodal yield were comparable with the open approach and would translate to equal survival outcomes. Recently, Asbun et al. compared their open PDs and LPDs and found that LPD had better perioperative outcomes in terms of blood loss and ICU and hospital stays.
In 2015, Palanivelu reported that the pathological radicality of LPD was comparable to that of the open approach when performed by experienced minimal access surgeons. And analysed yours long-term outcomes following LPD in 130 patients with pancreatic and periampullary cancers. This study, one of the largest published series so far, showed excellent short-term results and acceptable long-term survival. The pancreatic fistula rate was 8.5%, mean (SD) operating time was 310 (34) min, and mean blood loss was 110 (22) ml with a mean hospital stay of 8 (2.6) days. The resected margins were positive in 9.2% with an overall 5-year actuarial survival of 29.4% and a median survival of 33 months.
Published outcomes of LPD have shown that it is feasible and safe when done in high-volume institutions by expert surgeons. In a recent systematic review of LPD, Boggi et al. identified 25 articles with 746 patients who had LPD for both malignant and benign indications. The mean operative time and estimated blood loss were 464 min and 321 ml, respectively. Conversion to open surgery was required in 9% of patients. The average hospital stay was 14 days. The overall morbidity, mortality and pancreatic fistula rates were 41.2, 1.9 and 22.3%, respectively. The majority of surgeons did a pancreaticojejunostomy (84%), whereas a small number did pancre- aticogastrostomy (9.8%) or duct occlusion (6.8%). A slight majority did pylorus preservation (55%) instead of hemigastrectomy (45%). No major differences in outcomes were seen for laparoscopic, robotic, laparoscopic-assisted or hand-assisted methods.
Similarly, no significant differences were seen between high-volume (>30 cases) and low-volume centres other than longer operative times and higher estimated blood loss in the low-volume ones. The average number of lymph nodes recovered was 14.4 and the negative margin rate was 95.6%. Although the data were heterogeneous with a high likelihood for selection bias, the results for LPD appear to be at least comparable to those in patients undergoing open PD.
In general, LPD was associated with reduced blood loss and hospital stay; however, operative times tend to be longer. The longer operative times associated with LPD tend to reduce with increasing experience. In a series by Kim et al., the median operative time for LPD was 7.9 h and decreased with accumulating experience of the surgeon doing this procedure from 9.8 h for the first 33 cases to 6.6 h for the last 34 cases.
Since the introduction of polypropylene (PP) mesh for hernia repair, surgeons continue to discuss the use of mesh in a variety of settings for one of the most common operations performed by general surgeons—hernia repair. This discussion has involved raw materials, cost, and outcomes and for many years referred to only a few products, as manufacturing was limited. Nowadays, with multiple permanent, absorbable, biologic, and hybrid products on the market, the choice of mesh for a hernia repair can be daunting. Increasing clinical complexity further emphasizes the need for individualizing care, but more frequently, hospital supply chain personnel institute product procurement procedures for cost control, limiting mesh choice for surgeons. This can force surgeons into a “one-size-fits-all” practice regarding mesh choice, which may not be ideal for some patients. Conversely, current literature lacks definitive evidence supporting the use of one mesh over another, a fact that has not escaped the radar screen of the hospital supply chain and mesh industry, both of which attempt to limit vendor and mesh choice for financial gain. It is unlikely that this type of “proof” will ever come to fruition. This leaves us with choosing a mesh based on an algorithm that is centered on the patient and the patient’s unique clinical scenario.
Surgical stereotypes are remnants of the days of pre-anaesthesia surgery and include impulsivity, narcissism, authoritativeness, decisiveness, and thinking hierarchically. Medical students hold these stereotypes of surgeons early in their medical training. As Pearl Katz says in the The Scalpel’s Edge: ‘Each generation perpetuates the culture and passes it on by recruiting surgical residents who appear to resemble them and training these residents to emulate their thinking and behaviour.’ The culture of surgery has evolved, and certain behaviours are rightly no longer seen as acceptable, Non-technical skills such as leadership and communication have become incorporated into surgical training. Wen Shen, Associate Professor of Clinical Surgery at University of California San Francisco, argues that this has gone too far: ‘Putting likeability before surgical outcomes is like judging a restaurant by the waiters and ignoring the food,’ I would argue that operative and communication skills are indivisible, An aggressive surgeon is a threat to patient safety if colleagues are frightened to speak up for fear of a colleague shouting or, worse, throwing instruments. Conversely, a flattened hierarchy promotes patient safety.
Surgery is an extremely enjoyable, intellectually demanding and satisfying career, and many more people apply to become surgeons each year than there are available places.
Those who are successful have to be ready not just to learn a great deal, but have the right kind of personality for the job.
Is a surgical career right for you?
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Operations on the gallbladder and bile ducts are among the surgical procedures most commonly performed by general surgeons. In most hospitals, cholecystectomy is the most frequently performed operation within the abdomen. Pancreatic surgery is less frequent , but because of the close relation between the biliary system and the pancreas, knowledge of pancreatic problems is equally essential to the surgeon. Acute and chronic pancreatitis and cancer of the pancreas are often encountered by surgeons, with apparently increasing frequency; their treatment remains difficult and perplexing. This review demonstrates the modern aspects of pancreatic surgery. Good study.
Postoperative delirium is recognized as the most common surgical complication in older adults,occurring in 5% to 50% of older patients after an operation.With more than one-third of all inpatient operations in the United States being performed on patients 65 years or older, it is imperative that clinicians caring for surgical patients understand optimal delirium care. Delirium is a serious complication for older adults because an episode of delirium can initiate a cascade of deleterious clinical events, including other major postoperative complications, prolonged hospitalization, loss of functional independence, reduced cognitive function, and death. The annual cost of delirium in the United States is estimated to be $150 billion. Delirium is particularly compelling as a quality improvement target, because it is preventable in up to 40% of patients; therefore, it is an ideal candidate for preventive interventions targeted to improve the outcomes of older adults in the perioperative setting. Delirium diagnosis and treatment are essential components of optimal surgical care of older adults,yet the topic of delirium is under-represented in surgical teaching.
Acute pancreatitis is more of a range of diseases than it is a single pathologic entity. Its clinical manifestations range from mild, perhaps even subclinical, symptoms to a life-threatening or life-ending process. The classification of acute pancreatitis and its forms are discussed in fuller detail by Sarr and colleagues elsewhere in this issue. For the purposes of this discussion, the focus is on the operative interventions for acute pancreatitis and its attendant disorders. The most important thing to consider when contemplating operative management for acute pancreatitis is that we do not operate as much for the acute inflammatory process as for the complications that may arise from inflammation of the pancreas. In brieSurgical treatment of acute pancreatitisf, the complications are related to: necrosis of the parenchyma, infection of the pancreas or surrounding tissue, failure of pancreatic juice to safely find its way to the lumen of the alimentary tract, erosion into vascular or other structures, and a persistent systemic inflammatory state. The operations may be divided into three major categories: those designed to ameliorate the emergent problems associated with the ongoing inflammatory state, those designed to ameliorate chronic sequelae of an inflammatory event, and those designed to prevent a subsequent episode of acute pancreatitis. This article provides a review of the above.
Templo (do latim templum, “local sagrado”) é uma estrutura arquitetônica dedicada ao serviço religioso. O termo também pode ser usado em sentido figurado. Neste sentido, é o reflexo do mundo divino, a habitação de Deus sobre a terra, o lugar da Presença Real. É o resumo do macrocosmo e também a imagem do microcosmo: ‘o corpo é o templo do Espírito Santo’ (I, Coríntios, 6, 19).
Dos locais especiais, O corpo humano (morada da alma), a Cavidade Peritoneal e o Bloco Cirúrgico, se bem analisados, são muito semelhantes e merecem atitudes e comportamentos respeitáveis. O Templo, em todos os credos, induz à meditação, absoluto silêncio tentando ouvir o Ser Supremo. A cavidade peritoneal, espaço imaculado da homeostase, quando injuriada, reage gritando em dor, implorando uma precoce e efetiva ação terapêutica.
O Bloco Cirúrgico, abrigo momentâneo do indivíduo solitário, que mudo e quase morto de medo, recorre à prece implorando a troca do acidente, da complicação, da recorrência, da seqüela, da mutilação, da iatrogenia e do risco de óbito pela agressiva intervenção que lhe restaure a saúde, patrimônio magno de todo ser vivo.
O Bloco Cirúrgico clama por respeito ao paciente cirúrgico, antes mesmo de ser tomado por local banal, misturando condutas vulgares, atitudes menores, desvio de comportamento e propósitos secundários. Trabalhar no Bloco Cirúrgico significa buscar a perfeição técnica, revivendo os ensinamentos de William Stewart Halsted , precursor da arte de operar, dissecando para facilitar, pinçando e ligando um vaso sangüíneo, removendo tecido macerado, evitando corpos estranhos e reduzindo espaço vazio, numa síntese feita com a ansiedade e vontade da primeira e a necessidade e experiência da última.
Mas, se a cirurgia e o cirurgião vêm sofrendo grande evolução, técnica a primeira e científica o segundo, desde o início do século, a imagem que todo doente faz persiste numa simbiose entre mitos e verdades. A cirurgia significa enfrentar ambiente desconhecido chamado “sala de cirurgia” onde a fobia ganha espaço rumo ao infinito. O medo prepondera em muitos.
A confiança é um reconhecimento e um troféu que o cirurgião recebe dos pacientes e seus familiares. Tanto a CONFIANÇA quanto a SEGURANÇA têm que ser preservadas a qualquer custo. Não podem correr o risco de serem corroídas por palavras e atitudes de qualquer membro da equipe cirúrgica. Não foi tarefa fácil transformar, para a população, o ato cirúrgico numa atividade científica, indispensável, útil e por demais segura. Da conquista da cirurgia, como excelente arma terapêutica para a manutenção de um alto padrão de qualidade técnica, resta a responsabilidade dos cirurgiões, os herdeiros do suor e sangue, que se iniciou com o trabalho desenvolvido por Billroth, Lister, Halsted, Moyniham, Kocher e uma legião de figuras humanas dignas do maior respeito, admiração e gratidão universal.
No ato operatório os pacientes SÃO TODOS SEMELHANTES EM SUAS DIFERENÇAS, desde a afecção, ao prognóstico, ao caráter da cirurgia e especialmente sua relação com o ato operatório. Logo o cirurgião entra no bloco cirúrgico com esperança e não deve sair com dúvida. Nosso trabalho é de equipe, cada um contribui com uma parcela, maior ou menor, para a concretização do todo, do ato cirúrgico por completo, com muita dedicação e sabedoria. Toda tarefa, da limpeza do chão ao ato de operar, num crescendo, se faz em função de cada um e em benefício da maioria, o mais perfeito possível e de uma só vez, quase sempre sem oportunidade de repetição e previsão de término.
O trabalho do CIRURGIÃO é feito com carinho, muita dignidade, humildade e executado em função da alegria do resultado obtido aliado a dimensão ética do dever cumprido que transcende a sua existência. A vida do cirurgião se materializa no ato operatório e o bloco cirúrgico, palco do nosso trabalho não tolera e jamais permite atitudes menores, inferiores, ambas prejudiciais a todos os pacientes e a cada cirurgião. Como ambiente de trabalho de uma equipe diversificada, precisa manter, a todo custo, o controle de qualidade, por lidar com o que há de mais precioso na Terra: o ser humano.
Over the past decade, following the publication of several long-term outcome studies that showed a significant improvement in cardiovascular risk and mortality after bariatric surgery, the number of bariatric procedures being carried out annually in the UK has grown exponentially. Surgery remains the only way to produce significant, sustainable weight loss and resolution of comorbidities. Nevertheless, relatively few surgeons have developed an interest in this field. Most bariatric surgery is now performed in centres staffed by surgeons with a bariatric interest, usually as part of a multidisciplinary team.
The commonest weight loss procedures performed around the world at present are the gastric band, the gastric bypass and the sleeve gastrectomy. In very obese patients, an alternative operation is the duodenal switch, while the new ileal transposition procedure represents one of the few purely metabolic operations designed specifically for the treatment of type II diabetes. Older operations such as vertical banded gastroplasty and jejuno-ileal bypass are now obsolete, although patients who have undergone such procedures in the distant past may still present to hospital with complications. The main endoscopic option at present is insertion of a gastric balloon, with newer procedures like the endoscopic duodenojejunal barrier and gastric plication on the horizon. Implantable neuroregulatory devices (gastric ‘pacemakers’) represent a new direction for surgical weight control by harnessing neural feedback signals to help control eating.
It should be within the capability of any abdominal surgeon to manage the general complications of bariatric surgery, which include pulmonary atelectasis/pneumonia, intra-abdominal bleeding, anastomotic or staple-line leak with or without abscess formation, deep vein thrombosis (DVT)/pulmonary embolus and superficial wound infections. Patients may be expected to present with malaise, pallor, features of sepsis or obvious wound problems. However, clinical features may be difficult to recognise owing to body habitus. Abdominal distension, tenderness and guarding may be impossible to determine clinically due to the patient’s obesity. Pallor is non-specific. Fever and leucocytosis may be absent. Wound collections may be very deep. These complications in a bariatric patient should be actively sought with appropriate investigations. In particular, it is vital for life-threatening complications such as bleeding, sepsis and bowel obstruction to be recognised promptly and treated appropriately. A persistent tachycardia may be the only sign heralding significant complications and should always be taken seriously. It is useful to classify complications as ‘early’, ‘medium’ and ‘late’ because, from the receiving clinician’s point of view, the differential diagnosis will differ accordingly.
The professions are the means by which the complex services needed by society are organized. A profession has been defined by the American College of Surgeons as: an occupation whose core element is work that is based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning, or the practice of an art founded upon it, is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism and to the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which, in turn, grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.
1. What are the core elements of a profession? All professions are characterized by four core elements: (1) a monopoly over the use of specialized knowledge; (2) in return for that monopoly that we enjoy, relative autonomy in practice and the responsibility of self-regulation; (3) altruistic service to individuals and society; and (4) responsibility for maintaining and expanding professional knowledge and skills.
3.What is professionalism? Professionalism describes the cognitive, moral, and collegial attributes of a professional. Ultimately, it is all the reasons that your mother is proud to say that you are a doctor and a surgeon.
4. Why do physicians need a code of professional conduct? Trust is integral to the practice of surgery. The Code of Professional Conduct clarifies the relationship between the surgical profession and the society it serves. This is often referred to as a social contract. For patients the code of professional conduct crystallizes the commitment of the surgical community toward individual patients and their communities. Trust is built brick by brick.
5. What is the Code of Professional Conduct ? The Code of Professional Conduct takes the general principles of professionalism and applies them to surgical practice. The code is the foundation on which we earn our professional privileges and the trust of patients and the public. It is our job description. During the continuum of the preoperative, intraoperative, and postoperative care surgeons have the responsibility to:
5.1 Serve as effective advocates for our patients’ needs.
5.2 Disclose therapeutic options including their risks and benefits.
5.3 Disclose and resolve any conflict of interest that might influence the decisions of care.
5.4 Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period.
5.5 Fully disclose adverse events and medical errors.
5.6 Acknowledge patients’ psychological, social, cultural and spiritual needs.
5.7 Encompass within our surgical care the special needs of terminally ill patients.
5.8 Acknowledge and support the needs of patients’ families and
5.9 Respect the knowledge, dignity, and perspective of other healthcare professionals.
6. Why do surgeons need their own code of professionalism? A surgical procedure is an extreme experience. We impact our patients physiologically, psychologically, and socially. When patients submit themselves to a surgical experience, they must trust that the surgeon will put their welfare above all other considerations. The written code helps to reinforce these values.
7. What are the fundamental principles of the Code of Professional Conduct and the codes of other professional societies?
7.1 The primacy of patient welfare.
This means that the patient’s interests always come first. Altruism is central to this concept, and it is the surgeon’s altruism that fosters trust in the physician-patient relationship.
7.2 Patient autonomy.
Patients must understand and make their own informed decisions about their treatment. This is tricky. As physicians we must be honest with our patients so that they make educated decisions. At the same time, we must make sure that their decisions are consistent with ethical practices and do not lead to demands for inappropriate care.
7.3 Social justice.
As physicians we must advocate for our individual patients while at the same time promoting the health of the healthcare system as a whole. We must balance our patient’s needs (autonomy) and not misdirect scarce resources that benefit society (social justice).
A melhor forma de se conhecer as necessidades energéticas é através de sua medida por calorimetria indireta, cada vez mais disponível em nosso ambiente hospitalar. Quando não se dispõe de calorimetria indireta, é possível estimar o gasto energético por meio de fórmulas estimativas que levam em conta, entre outros fatores, o peso e altura corpóreos, idade e sexo. Das diferentes fórmulas disponíveis, a equação de Harris-Benedict tem sido muito usada. Para homens a formula é 66,5 + (13.8 x peso [kg])+(5,0 x altura [cm]) – (6,8 x idade [anos]). Para mulheres a formula é diferente: 655 + (9,6 x peso [kg]) + (1,7 x altura [cm]) – (4,7 x idade [anos]). A regra de bolso (30-35 kcal/kg/dia) é mais prática e também é muito utilizada. No período pré-operatório a oferta de proteína deve ser em torno de 1,0-1,5 g/Kg/dia e, após trauma ou intervenção cirúrgica aumenta, podendo chegar até 2,0 g/Kg/dia. Em pacientes com SIRS moderado, a oferta calórica deve ser menor (25-30 kcal/kg/dia). Pacientes em estresse importante (SIRS grave, sepse) devem receber 20-25 kal/kg/dia e 1,5 a 2,0 g de proteínas/kg/dia. Deve-se evitar em pacientes gravemente desnutridos aporte rápido de calorias e proteínas (síndrome da realimentação). Nesses pacientes a oferta deve ser cautelosa com controle diário de fósforo, magnésio e potássio.
O sistema portal é uma rede venosa de baixa pressão, com níveis fisiológicos <5 mmHg. Desta forma, o termo hipertensão portal (HP) designa uma síndrome clínica caracterizada pelo aumento mantido na pressão venosa em níveis acima dos fisiológicos. Ela é considerada clinicamente significante quando acima de 10 mmHg; neste nível existe o risco de surgimento de varizes esofagogástricas (VEG). Por sua vez, valores acima de 12 mmHg cursam com risco de rompimento dessas varizes, sua principal complicação.
O aumento do fluxo como fator preponderante inicial da HP é raro e representado por fístulas arterioportais congênitas, traumáticas ou neoplásicas. O aumento da resistência é a condição fisiopatológica inicial mais comum e pode ser classificada de acordo com o local de obstrução ao fluxo em: pré-hepática, intra-hepática e pós-hepática. A HP intra-hepática responde pela grande maioria dos casos e pode ser subdividida de acordo com o local de acometimento estrutural no parênquima hepático em: pré-sinusoidal (ex: esquistossomose hepatoesplênica – EHE), sinusoidal (ex: cirrose hepática) e pós-sinusoidal (ex: doença venoclusiva). Em nosso meio, a maioria dos casos é decorrente da EHE e das hepatopatias crônicas complicadas com cirrose.
O tratamento da HP depende da causa subjacente, da condição clínica e do momento em que é realizado. Pacientes com função hepática comprometida têm abordagem diversa daqueles com ela preservada, como os portadores de EHE. Além disso, o tratamento pode ser emergencial (durante episódio agudo de hemorragia) ou eletivo, como profilaxia pré-primária, primária ou secundária. Por essa diversidade de situações clínicas, não existe modalidade única de tratamento.
O objetivo da aula abaixo foi avaliar os avanços e as estratégias atuais empregadas no tratamento emergencial e eletivo da hemorragia digestiva varicosa em pacientes cirróticos e esquistossomóticos.
A avaliação e os cuidados de feridas pós-operatórias deve ser do domínio de todos os profissionais que atuam na clínica cirúrgica. O conhecimento a cerca dos processos relacionados a cicatrização tecidual é importante tanto nos cuidados como na prevenção de complicações, tais como: infecções e deiscência. Como tal, todos os profissionais médicos, sendo eles cirurgiões ou de outras especialidades, que participam do manejo clínico dos pacientes no período perioperatório devem apreciar a fisiologia da cicatrização de feridas e os princípios de tratamento de feridas pós-operatório. O objetivo deste artigo é atualizar os profissionais médicos de outras especialidades sobre os aspectos importantes do tratamento de feridas pós-operatório através de uma revisão da fisiologia da cicatrização de feridas, os métodos de limpeza e curativo, bem como um guia sobre complicações de feridas pós-operatórias mais prevalentes e como devem ser manejados nesta situação.
Estima-se que atualmente 90% das colecistectomias sejam realizadas pela técnica laparoscópica, percentual este atingido nos Estados Unidos da América no ano de 1992. Os motivos para tal preferência na escolha da técnica cirúrgica aplicada são claros: menor dor no pós-operatório, recuperação pós-cirúrgica mais rápida, menor número de dias de trabalho perdidos e menor tempo de permanência hospitalar. A colecistectomia laparoscópica foi claramente estabelecida como padrão-ouro para o tratamento cirúrgico da litíase biliar, no entanto 2 a 15% das colecistectomias vídeolaparoscópicas necessitam de conversão para cirurgia convencional, sendo as razões mais comuns a inabilidade para se identificar corretamente a anatomia, suspeita de lesão da árvore biliar e sangramento. A identificação dos fatores associados a um maior índice de conversão possibilita à equipe cirúrgica estimar o grau de dificuldade do procedimento, preparando melhor o paciente para o risco de conversão e permitindo a participação de um cirurgião mais experiente num procedimento de maior risco.
Relacionados ao Paciente: 1. Obesidade (IMC > 35), 2. Sexo Masculino, 3. Idade > 65 anos, 4. Diabetes Mellitus e 5. ASA > 2.
Relacionadas a Doença: 1. Colecistite Aguda, 2. Líquido Pericolecístico, 3. Pós – CPRE, 4. Síndrome de Mirizzi e 5. Edema da parede da vesícula > 5 mm.
Relacionadas a Cirurgia: 1. Hemorragia, 2. Aderências firmes, 3. Anatomia obscura, 4. Fístulas internas e 5. Cirurgia abdominal prévia.
Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management.
The era of hepatic surgery began with a left lateral hepatic lobectomy performed successfully by Langenbuch in Germany in 1887. Since then, hepatectomy has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity (4.09%-47.7%) and mortality (0.24%-9.7%). This review article focuses on the major postoperative issues after hepatic resection and presents the current management.
The pancreatic pseudocyst is a collection of pancreatic secretions contained within a fibrous sac comprised of chronic inflammatory cells and fibroblasts in and adjacent to the pancreas contained by surrounding structures. Why a fibrous sac filled with pancreatic fluid is the source of so much interest, speculation, and emotion amongst surgeons and gastroenterologists is indeed hard to understand. Do we debate so vigorously about bilomas, urinomas, or other abdominal collections of visceral secretions? Perhaps it is because the pancreatic pseudocyst represents a sleeping tiger, which though frequently harmless, still can rise up unexpectedly and attack with its enzymatic claws into adjacent visceral and vascular structures and cause lifethreatening complications.
Another part of the debate and puzzlement about pancreatic pseudocysts is related to confusion about pancreatic pseudocyst definition and nomenclature. The Atlanta classification, developed in 1992, was a pioneering effort in describing and defining morphologic entities in acute pancreatitis. Since then, a working group has been revising this system to incorporate more modern experience into the terminology. In the latest version of this system, pancreatitis is divided into acute interstitial edematous pancreatitis (IEP) and necrotizing pancreatitis (NP), based on the presence of pancreatic tissue necrosis. The fluid collections associated with these two “types” of pancreatitis are also differentiated. Early (<4 weeks into the disease course) peripancreatic fluid collections in IEP are referred to as acute peripancreatic fluid collections (APFC), whereas in NP, they are referred to as postnecrotic peripancreatic fluid collections (PNPFC). Late (>4 weeks) fluid collections in IEP are called pancreatic pseudocysts, and in NP, they are called walled-off pancreatic necrosis (WOPN).
Acute pancreatitis represents a broad spectrum of disease. Although the disease course may smolder, typically an initial inciting event results in organ injury, which sets into play the evolving clinical course. The early phase of disease is marked by the inflammatory mediators from damaged pancreatic tissue, resulting in variable degrees of systemic inflammatory response. The later phase is determined by the morphology of organ injury, specifically with regard to tissue ischemia and necrosis. The outcome of this later phase is often impacted by local or systemic infection. Peripancreatic fluid collections can occur in both the early and the late phases of disease. They presumably occur from injury to or ischemia of the main pancreatic duct or a side branch duct, although some, particularly early on, may be the result of third-space edema fluid. Peripancreatic fluid collections represent a heterogeneous entity.
The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed: Billroth reported a case of epigastric pain associated with bilious vomiting as a sequel of gastric surgery in 1885. Several classic treatises exist on the subject; we cannot improve on them and merely provide a few references for the interested reader.
However, the indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. The most marked reduction in the frequency of gastric resection has occurred among patients with peptic ulcer disease. For example, in Olmstead County, Minnesota, the incidence of elective operations on previously unoperated patients declined 8-fold during the 30-year study period between 1956 and 1985 and undoubtedly has declined even further since.
One population-based study concluded that elective surgery for ulcer disease had “virtually disappeared by 1992–1996.” Whereas emergency operations for bleeding and perforation are still encountered, acid-reducing procedures are being performed less frequently in these situations in favor of a damage control approach. Even for gastric cancer, resection rates decreased approximately 20% from 1988 to 2000 in the United States.
An estimated 21,000 new cases of stomach cancer occurred in the United States in 2010, so that the number of cases of gastric resection for cancer is probably less than 15,000 per year in the United States. The virtual disappearance of elective surgery for peptic ulcer has also changed the demographic profile of the postgastrectomy patient: patients who have gastric cancer tend to be older and there is only a slight male preponderance.
These significant changes in the gastric surgery population make it worthwhile to revisit postgastrectomy syndromes. The frequency with which postgastrectomy symptoms/syndromes are found can depend on how hard they are looked for. Loffeld, in a survey of 124 postgastrectomy patients, most of whom had undergone surgery more than 15 years earlier, found that 75% suffered from upper abdominal symptoms, and 1 or more symptoms that indicate dumping were found in 70% of patients who had undergone Billroth-II (B-II) reconstruction.
However, the lack of age-matched and sex-matched controls in this study may have overstated the frequency of symptoms caused by the surgical procedure. Mine and colleagues conducted a large survey of 1153 patients after gastrectomy for cancer and found that 67% reported early dumping and 38% late dumping. By contrast, Pedrazzani and colleagues surveyed 195 patients who underwent subtotal gastrectomy and B-II reconstruction for gastric adenocarcinoma for up to 5 years postoperatively, and concluded that “the incidence of late complications was low and the majority of them recovered within one year after surgery.”
This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient’s long-term follow-up and care.
Symptomatic hemorrhoids require a number of therapeutic interventions each of which has its own complications. Office-based therapy such as rubber band ligation carries the risk of pain and bleeding, which are self-limited, but also carries the risk of rare complications such as sepsis, which may be life threatening. Operative treatment of hemorrhoids includes conventional hemorrhoidectomy, stapled hemorrhoidectomy, and the use of energy devices. Complications of pain and bleeding are common but self-limited. Late complications such as stenosis and fecal incontinence are rare. Recurrent disease is related to the initial grade and therapeutic approach. Treatment of recurrent hemorrhoids should be individualized based on previous treatments and the grade of disease. Anesthetic complications, especially urinary retention, are common and related to the anesthetic technique. Practitioners should council their patients as to the risks of the various approaches to treating symptomatic hemorrhoids.
With intra-abdominal infection being one of the most common reasons for surgical consultation, understanding the evaluation and management of these processes becomes paramount in the day- to-day practice of the surgeon. The very broad nature of who is affected coupled with the interplay of patient comorbidities and their medications make dealing with intra-abdominal infections a challenge. As with most complex problems in medicine, it is often useful to break them down into simpler and smaller parts. One useful way to categorize intra-abdominal infections is to divide them into those originating from previous abdominal trauma or operations and those presenting in a “virgin” abdomen.
The latter group most commonly includes those patients presenting with specific organ-based infectious processes such as appendicitis, cholecystitis, or diverticulitis. These individual diseases are covered extensively in other chapters and are discussed only superficially in this chapter. The former are those patients who have sustained intra-abdominal trauma or have undergone previous abdominal interventions and are not recovering in the usual expected course. It is this group that taxes diagnostic and clinical skills and may require the most complex medical decision making.
Several factors should come into play once suspicion for an intra-abdominal infection is entertained. These include resuscitation, antibiotic usage, and source control itself. Patients who present with either a suspected or diagnosed intra-abdominal infection should have some form of volume resuscitation. Even without hypotension, there are several reasons why these patients might be volume depleted. These include nausea and vomiting, fluid sequestration within the abdominal cavity or lumen of the bowel, and poor oral intake. As the process progresses, the patient may develop tachypnea, which results in an evaporative fluid loss. By this time, one can often elicit orthostatic hypotension in most patients.
Fluid resuscitation should begin with the administration of isotonic crystalloid and in general be guided by evidence of end organ perfusion (adequate mental status, urine output, correction of acidosis). There is no utility-using colloid such as albumin or hetastarch in these circumstances, and some data suggest a worse outcome. Should the patient present with hypotension or evidence of poor perfusion, a more aggressive approach to volume resuscitation should be employed. Our recommendation is to follow the current surviving sepsis guidelines, which include fluid challenges, monitoring/assessment of filling pressures, and the potential use of pressors and steroids.
Alterations in renal function are common after surgical emergencies, trauma, and major operations. In these settings, successful recovery of renal function is dependent on prompt diagnosis and protective management strategies. Acute kidney injury (AKI) is characterized by an acute decrease in glomerular filtration rate (GFR). The true incidence of AKI and acute renal failure (ARF) has been difficult to define, given the broad and various definitions used to quantify and study altered renal function. Relatively recent introduction of consensus definitions, such as RIFLE (risk, failure, loss, and end-stage renal failure) criteria and AKIN (Acute Kidney Injury Network) staging, have provided standard definitions to facilitate more uniform outcome reporting. With use of these definitions, recent studies suggest that AKI occurs in up to two thirds of patients in the intensive care unit (ICU). Moreover, increasing severity of AKI is associated with increasing mortality. AKI is also associated with increased morbidity, such as increased hospital length of stay and cost of care, and has been linked to other in-hospital complications, such as increased difficulty in weaning from mechanical ventilation. Preoperative risk factors for development of AKI include older age, emergent surgery, hepatic disease, obesity, high-risk surgery, vascular disease, and chronic obstructive pulmonary disease (COPD). Prompt recognition of AKI facilitates effective treatment. Although the incidence rate of AKI appears to be rising, overall outcomes from AKI are gradually improving.
The reported mortality rate of AKI is 30% to 60%. If RRT is necessary, reported mortality rates are over 50%. The reason for such high mortality is that AKI now usually occurs as part of a spectrum of multiple organ failure, most often associated with severe sepsis or septic shock. The mortality in this setting is often determined by the underlying septic syndrome, rather than by complications of individual organ failure. Of surviving patients of AKI, a significant number have development of chronic renal insufficiency, which necessitates chronic dialysis. The precise rate of development of chronic renal failure varies greatly in the literature, depending on the patient populations. A recent review of AKI estimates that overall, the risk of necessary chronic dialysis is approximately 12%.
The morbid obesity epidemic continues to spread throughout industrialized nations. It is a condition with a heterogeneous etiology, including genetic, psychosocial, and environmental factors. Prevention methods have currently been unable to halt the further spread of this disease. Obesity has been linked to increased healthcare costs, common physiologic derangements, reduced quality of life, and increased overall mortality. More than one third of adults and almost 17% of children in the United States are obese.
Medical therapy that can cause sustained significant weight loss may be years away. Bariatric surgery, when combined with a multidisciplinary team, continues to be the only proven method to achieve sustained weight loss in most patients. Bariatric procedures modify gastrointestinal anatomy and, in some cases, enteric hormone release to reduce caloric intake, reduce absorption, and alter metabolism to achieve weight loss. Currently, the three most common bariatric operations in the United States are Roux-en-Y gastric bypass, adjustable gastric band, and the vertical sleeve gastrectomy.
O termo “gossipiboma” refere-se a uma matriz de matéria têxtil envolvida por reacção de corpo estranho. O termo é derivado do latim “Gossypium”, algodão, e o Swahili “boma”, que significa “esconderijo”. Também conhecida como textiloma, originada de “textilis” (tecer em latim) e “oma” (doença, tumor ou inchaço em grego). O primeiro caso foi descrito por Wilson em 1884. Gossipibomas foram relatados após operações em muitos processos, e em diferentes órgãos e localização. Mas, o local mais comum é o abdominal. Gaze e compressas são os materiais mais comumente retidos após laparotomia. A incidência de gossipibomas é variável e subnotificada, principalmente devido às implicações legais de sua detecção, mas também porque muitos pacientes permanecem assintomáticos. A apresentação clínica é também variável. O tratamento recomendado é a excisão que pretende evitar as complicações que conduzem a taxa de mortalidade entre11-35%.
Ele ocorre entre 1/1000 a 1/1500 nas operações intra-abdominais. A apresentação clínica é variável e depende da localização do corpo estranho e sobre o tipo de reação inflamatória apresentada pela hospedeiro. Podem existir formas agudas e crônicas. A forma aguda tende a apresentar-se com fístulas e abcessos cutâneos, enquanto que a crônica como massa encapsulada (granuloma de corpo estranho) e sintomas inespecíficos. Gossipibomas ocorrem mais comumente após operação abdominal e pélvica. Eles são mais frequentes em pacientes obesos e quando a operação é realizada em emergência. A incidência é maior em nove vezes após operação de emergência, e de quatro em procedimentos não planejados no decorrer de uma intervenção, mudando o que se pretendia realizar. Outros fatores predisponentes incluem operações em campo de batalha, complicações intra-operatórias, tais como perda intensa de sangue, a incapacidade de realizar contagem de materiais cirúrgicos no final do processo, tempo de operação prolongado e as mudanças no pessoal médico e de enfermagem durante o operação.
O tempo entre a operação e aparecimento de manifestações clínicas de Gossipiboma é variável, em particular se o material permanecer estéril. Ele depende da localização do material retido e do tipo de reação orgânica, e foi estimado em entre 10 dias a vários anos. Em patologia, duas reações de corpo estranho pode occorer. A primeira resposta é a produção asséptica de fibrina, o que leva à formação de aderências, material de encapsulamento e à formação de granulomas de corpo estranho. Nesta apresentação, o paciente pode permanecer assintomático por meses ou anos. A segunda resposta é exsudativa, com formação de abcessos, fístulas aos órgãos internos como o estômago, intestino, bexiga, cólon ou vagina, ou também fístula externa para a parede abdominal. Os sintomas dependem do órgão afetado principalmente e podem resultar da compressão, obstrução, síndrome de má absorção, ou crescimento bacteriano. Eles incluem dor abdominal, tumor palpável, náuseas, vômitos, sangramento retal, diarréia, disúria, piúria, hematúria e urgência urinária. Os sintomas sistêmicos como febre, anorexia, anemia e perda de peso também podem occurer. No entanto, a resposta inflamatória e aderências podem formar uma cápsula com o bloqueio omental e órgãos adjacentes, podendo o paciente permanecer assintomático. A falta de sintomas pode dificultar ou retardar o diagnóstico, que muitas vezes é realizado incidentalmente.
O diagnóstico pode ser difícil. Suspeita clínica e o uso de estudos de imagem são importantes, pois é a regra a inexistência ou inespecificidade de sintomas em vários anos após a operação. No pré-operatório pode ser levantada suspeita por meio de estudos radiológicos ou endoscópicos. Muitos casos só são descobertos no intra-operatório. Tomografia computadorizada é o exame complementar de escolha para o diagnóstico e avaliação dessas complicações. Ele fornece informações detalhadas sobre a lesão na maioria dos casos. A aparência pode ser lesão cística espongiforme, cápsula hiperdensa em camadas concêntricas, ou calcificações murais. A presença de gás é indicativa de perfuração do intestino ou à formação de abcessos. Os principais diagnósticos diferenciais são: aderências pós-operatórias, fecalomas, contusões, hematomas, intussuscepção, volvo, tumores e abscessos intracavitários.
Tratamento e Prognóstico
O tratamento de escolha é a remoção cirúrgica que pode ser realizada por laparoscopia ou laparotomia, e visa prevenir complicações. O prognóstico da gossipiboma é variável com taxas de mortalidade de 11 para 35%. Quando a remoção ocorre no período pós-operatório imediato, a morbidade e mortalidade são baixas; no entanto, se o material foi mantido por um longo tempo a remoção pode exigir operação extensa e ter elevado índice de complicações.
Há muitas implicações médico-legais com gossypiboma. Revisão de negligência médica impetradas entre 1988 e 1994 revelou 40 casos de gossipiboma, que representaram 48% de todos os corpos estranhos. Não foi possível determinar se o material esquecimento representou falta de qualidade do cirurgião ou quadro de enfermagem.
A abordagem mais importante é a prevenção. As medidas preventivas necessárias incluem o uso de material têxtil com marcadores radiopacos e contagem minuciosa de materiais cirúrgicos. São recomendadas quatro contagens: na montagem do material, antes da operação, no início do fechamento da cavidade e durante a síntese da pele. Dhillon e Park reforçam a importância da exploração dos quatro quadrantes abdominais no final da operação em todos os casos, mesmo após a contagem das compressas. No caso de contagem incorreta, a menos que o paciente seja considerado instável, a síntese da cavidade não deve ser realizada até que todas elas estejam localizados.
Gossipiboma é um problema médico-legal sério e sua incidência está aparentemente aumentando. Por isso, os meios e métodos nos procedimentos cirúrgicos durante o ato operatório e no contexto geral da sala de operações precisam ser revistos para tomarem-se medidas preventivas. Formação continuada de profissionais da área médica e estrita adesão à técnica operatória são primordiais para a prevenção de gossipiboma.
A hernia is a weakness or disruption of the fibromuscular tissues through which an internal organ (or part of the organ) protrudes or slides through. Collectively, inguinal and femoral hernias are often lumped together into groin hernias. Surgery remains the only effective treatment, but the optimal timing and method of repair remain controversial. Although strangulation rates of 3% at 3 months have been reported by some investigators, the largest prospective randomized trial of (watchful waiting) men with minimally symptomatic inguinal hernias showed that watchful waiting is safe. Frequency of strangulation was only 2.4% in patients followed up for as long as 11.5 years. Long-term follow-up shows that more than two-thirds of men using a strategy of watchful waiting cross over to surgical repair, with pain being the most common reasons. This risk of crossover is higher in patients older than 65 years. Once an inguinal hernia becomes symptomatic, surgical repair is clearly indicated. Femoral hernias are more likely to present with strangulation and require emergency surgery and are thus repaired even when asymptomatic. Because this article focuses on incarcerated hernias, nonoperative options are not discussed.
A necessidade de tratamento cirúrgico é algo que sempre tem conotação ameaçadora para o paciente e familiares. A possibilidade de dor, mutilação ou complicações constitui uma ameaça real ou fantasiosa, mesmo em situações desejáveis, como a correção de malformações, o aperfeiçoamento estético, os partos e outras eventualidades nas quais não exista doença. A anestesia em suas várias modalidades é outro evento preocupante. A lembrança de maus resultados vem sempre a mente quando uma intervenção cirúrgica é cogitada. Nos últimos anos, o progresso tecnológico que atingiu a medicina tem sido extremamente exaltado pela mídia. Este fato tem levado a população leiga à falsa impressão de que a medicina e os médicos são capazes de resolver todas as situações. Quando ocorre reversão desta expectativa fala-se em “erro médico”. Para que não se cometa injustiça, este tema deve ser discutido pela sociedade como um todo, e não somente por setores que vêem nele a possibilidade de auferir lucros. Infelizmente, em lugar de uma análise consequente, tem sido comum denegrir a imagem do médico, atribuindo-lhe responsabilidade exclusiva por todas as falhas do sistema de saúde. Os maus resultados profissionais, comuns em todas as profissões, são “imperdoáveis” em medicina, na visão de pessoas que insistem em elevar os médicos à categoria de “infalíveis”, esquecendo-se de que a medicina e os médicos têm compromisso apenas com os meios adotados para a recuperação dos pacientes, e nunca com os resultados. Com o objetivo de fortalecer o relacionamento médico/paciente em clínica cirúrgica e prevenir insatisfações e petições judiciais, seguem-se algumas sugestões que eventualmente podem ser úteis:
1ª. Jamais ceder às pressões de serviços de saúde que visem impor a mentalidade de “linha de produção”, exigindo o “atendimentos” em série dos pacientes. Nessas circunstâncias não sobra tempo para um relacionamento afetivo e efetivo e este é, sem dúvida, o primeiro passo para acusações injustas ou descabidas diante de adversidades;
2ª. Esclarecer ao paciente e ou aos familiares todos os pormenores do ato cirúrgico. As informações devem ser claras, em linguagem simples e acessível, evitando termos técnicos incompreensíveis. Deve-se entrar em detalhes sobre a operação proposta, suas conseqüências e seus riscos; Conduzir com competência o pré-operatório, lembrando que, na avaliação do paciente, é indispensável o exame clínico completo.Os especialistas que se sentirem inseguros em relação ao mesmo devem solicitar o parecer de um clínico ou internista acostumado a fazê-lo; Lembrar que a avaliação do risco cirúrgico é muito mais abrangente do que o simples exame cardiológico. Existem riscos aumentados também em relação aos outros sistemas e aparelhos. Não negligenciar a avaliação psicológica do paciente; Em relação aos exames subsidiários pré-operatórios, lembrar que existe um consenso na literatura médica que vai desde a sua não realização em casos selecionados, até a sua realização fundamentada no exame clínico e em parâmetros como vulto da intervenção, idade e sexo. Em jovens do sexo masculino, sadios, com exame clínico normal, é perfeitamente justificável não realizar exames complementares em intervenções de pequeno e médio porte;
3ª. Nas intervenções com objetivos estéticos, analisar cuidadosamente as expectativas do paciente em relação aos resultados. Verificar senão são excessivamente fantasiosas, em busca somente de ganhos afetivos. Nestes casos, é freqüente que a não consumação dos mesmos se reverta em sentimen-tos negativos em relação ao cirurgião, que pode torna-se o único “culpado”; Jamais garantir resultados ou minimizar o risco. Em relação ao risco, é compreensível que o paciente e familiares não queiram falar ou ouvir sobre o mesmo. Ainda assim, o profissional deve ter habilidade suficiente para abordar o assunto sem atemorizar ou gerar pânico, porém sem omitir a verdade;
4ª. Na avaliação do risco cirúrgico é indispensávela participação do anestesiologista. A esse profissional compete a avaliação do risco anestésico. O tipo de anestesia não deve ser imposto pelo cirurgião e sim discutido como anestesiologista, respeitando sempre sua indicação ou contra-indicação. A avaliação anestesio-lógica nas situações eletivas deve ser realizada em consulta especializada antes da internação hospitalar. É desejável que o paciente conheça, com antecedência,seu anestesiologista; Alertar o paciente sobre a possibilidade de ocorrências imprevisíveis durante a intervenção cirúrgica. Esclarecer que as mesmas poderão alterar o planejamento cirúrgico e exigir mudanças técnicas ou táticas que, por sua vez, poderão implicar novos desdobramentos, como aumento da permanência hospitalar, maior risco ou maiores custos;
5ª. Lembrar que, salvo em situações de emergência e urgência declaradas, é facultado ao cirurgião usar os dispositivos do parágrafo primeiro do artigo 61 do Código de Ética Médica, ou seja, deixar de operar o paciente com o qual não foi possível estabelecer um relacionamento de confiança recíproca. Nesta situação é necessário garantir a transferência do paciente para outro profissional, que deverá ser informado
sobre os detalhes do caso;
6ª. Diante da possibilidade de futuras incompreensões, queixas ou petições, não hesitar em solicitar ao paciente ou a seu responsável legal a assinatura de um “Termo de Consentimento Esclarecido”, que deverá também ser assinado por duas testemunhas não envolvidas no caso;
7ª. Não deixar de preencher corretamente o prontuário ou a ficha clínica do paciente, na qual deverão constar os dados referentes ao exame clínico, aos exames subsidiários, especificando os resultados, o local e data em que foram realizados e aos esclarecimentos prestados;
8ª. Descrever com detalhes o ato cirúrgico. Caso haja material a ser encaminhado para exame anatomopatológico, preencher o laudo de encaminhamento e cientificar-se de que o material foi corretamente acondicionado e identificado;
9ª. Conduzir o pós-operatório anotando as datas e os horários das visitas médicas, bem como todas as providências tomadas. No momento da alta, reavaliar o paciente e registrar as recomendações em relação ao acompanhamento ambulatorial. Estas sugestões se prestam a qualquer tipo de tratamento cirúrgico. O tempo gasto ao adotá-las é altamente recompensado e pode evitar futuros dissabores e danos morais e ou financeiros para o cirurgião e equipe.
10ª.Lembrar que pacientes emocionalmente instáveis,neuróticos ou psicóticos são maus candidatos às intervenções cirúrgicas. Nestes casos impõem-se medidas suporte conduzidas por especialista na área. A apreensão diante das intervenções cirúrgicas é absolutamente normal. Ao contrário, o total destemor deve ser motivo de suspeita a cerca da integridade emocional do paciente;
O aspecto ético na relação médico paciente, acima de valores ou conceitos morais, pressupõe respeito mútuo entre ambas as partes, para que o produto final seja o melhor possível, a manutenção da saúde e da vida. O médico, como qualquer outro profissional, deve seguir preceitos éticos e legais. Não deve, sob pena de processos e punição, incorrer em desvios de conduta como imperícia, imprudência e negligência. Para o bom exercício da medicina é fundamental o bom preparo cognitivo, técnico, afetivo e moral. No caso particular do ato cirúrgico, o cirurgião deve ser eclético, dominar as várias técnicas cirúrgicas e conhecer suas vantagens e desvantagens, para empregar a mais adequada para cada situação em particular e assim melhor beneficiar seus pacientes.
The creation of a stoma is a technical exercise. Like most undertakings, if done correctly, the stoma will usually function well with minimal complications for the remainder of the ostomate’s life. Conversely, if created poorly, stoma complications are common and can lead to years of misery. Intestinal stomas are in fact enterocutaneous anastomoses and all the principles that apply to creation of any anastomosis (i.e., using healthy intestine, avoiding ischemia and undue tension) are important in stoma creation.
Colon surgery represents a high number of patients treated at a department of gastrointestinal surgery and is not limited to colon cancer. It includes other non-neoplastic pathologies such as inflammatory bowel disease, diverticular disease or colonic volvulus. As with any major procedure, colon surgery patients may present serious or even fatal complications. The incidence of postoperative complications from colon surgery has been estimated at between 10% and 30% according to selected series. Preventive measures against surgical complications include selection of an appropriate procedure for the patient as well as good preoperative care, appropriate surgical technique and good postoperative management. When diagnosis has been established, risks for patient should be assessed according to patient’s health conditions and type of surgery accomplished. When the patient meets the surgical requirements, an appropriate course of preoperative care should be carried out including colon wash antibiotics and antithrombotic prophylaxis. Postoperative period will be equivalent to any major abdominal surgery. Typically, it was considered appropriate to wait a few days before initiating feeding in order to protect anastomosis; however, some authors agree that an early oral diet hours after intervention is not associated with a higher risk of anastomotic dehiscence and other complications.
Obesity is a common disease affecting adults and children. The incidence of obesity in worldwide is increasing. Laparoscopic sleeve gastrectomy (LSG) is a relatively new and effective procedure for weight loss. Owing to an increase in the number of bariatric surgical procedures, general surgeons should have an understanding of the complications associated with LSG and an approach for dealing with them. Early postoperative complications following LSG that need to be identified urgently include bleeding, staple line leak and development of an abscess. Delayed complications include strictures, nutritional deficiencies and gastresophageal reflux disease. We discuss the principles involved in the management of each complication.
“Nos últimos anos percebemos que estávamos na mais profunda crise da existência da medicina, devido a algo sobre o que você normalmente não pensa quando você é um médico preocupado em fazer o bem para as pessoas, que é o custo do tratamento de saúde. Não há um país no mundo que não esteja perguntando agora se podemos custear o que médicos fazem. A luta política que desenvolvemos tornou-se aquela sobre se o governo é o problema ou se as companhias de seguro são o problema. E a resposta é sim e não; é mais profundo que tudo isso. A causa de nossos problemas é, na verdade, a complexidade que a ciência nos deu. E para entender isso, voltarei algumas gerações…”
The risk of complications and mortality in bariatric surgery is associated with certain factors that are common to other patients and procedures, including age above 65 years, the presence of associated diseases (cardiovascular and pulmonary disease, chronic renal failure, liver cirrhosis, etc.), prior abdominal surgery, and the experience of the surgeon and the institution, especially concerning the ability to make an early diagnosis and address complications. The surgical complications observed in the early postoperative period following surgeries performed to treat severe obesity are similar to those associated with other major surgeries of the gastrointestinal tract. However, given the more frequent occurrence of medical comorbidities (such as diabetes, arterial hypertension, and sleep apnea), as well as the difficulty in making an early diagnosis of the complications (due to limitations of the clinical abdominal workup and imaging methods, such as ultrasonography and computed tomography, particularly in highly obese patients with body mass indices >50 kg/m²), these patients require special attention in the early post operative follow-up. Pulmonary thromboembolism, a complication associated with bariatric surgery, also requires greater attention from the medical team given the high mortality rate associated with this condition. Early diagnosis and appropriate treatment of these complications are directly associated with a greater probability of control.
Considera-se que a cirurgia hepática começou após o advento da anestesia e da anti-sepsia. No entanto, muito antes disso, diversos autores já relatavam suas experiências com ressecções do fígado. As primeiras descrições de “cirurgias hepáticas” consistiam no relato de avulsões parciais ou totais de porções do fígado após lesões traumáticas do abdome. O relato de Elliot (1897) exemplifica muito dos temores dos cirurgiões da época: “O fígado (…) é tão friável, tão cheio de vasos e tão evidentemente impossível de ser suturado que parece ser improvável o manejo bem sucedido de grandes lesões de seu parênquima”.
Extent of lymph node dissection has been an area of controversy in gastric adenocarcinoma for many years. Some surgeons believe that cancer metastasizes through a stepwise progression, and an extensive lymphadenectomy is necessary to improve survival and/or cure the patient. Other physicians argue that extensive ly-mphadenectomies only add pe-rioperative morbidity and mor-tality and do not improve survival. Asian countries have been performing extended lymphadenectomies routinely for many years with promising survival data, although Western countries have not been able to reproduce those results. Much of the controversy surrounding lymphadenectomies started in the 1980s when Japanese studies reported superior survival rates matched stage for stage, compared to the United States. This was theorized to be secondary to the more extensive lymphadenectomy performed in Japan compared to the United States.
A United Kingdom study randomized 400 patients to either a D1 or a D2 lymph node dissection. Those patients with tumors in the upper or middle third of the stomach underwent a distal pancreaticosplenectomy to obtain retropancreatic and splenic hilar nodes. While the 5-year survival rates were not statistically significant between the two groups, on multivariate analyses it was noted that those patients in the D2 group that did not undergo the distal pancreaticosplenectomy had an increased survival compared with the D1 group. A trial in the Netherlands randomized 380 gastric cancer patients to a D1 lymphadenectomy and 331 patients to a D2 lymphadenectomy. Similar to the United Kingdom study, there was not a significant difference in survival between the two groups, even when followed out to 11 years. There was a significant increase in postoperative complications in the D2 group compared with the D1 group (43 % vs. 25 %, respectively) as well as mortality (10 % vs. 4 %, respectively).
The data from these two studies suggest that a pancreaticosplenectomy performed to harvest lymph nodes seems to only add morbidity and mortality while not improving survival. One concern raised about the prior two studies was the variation in surgical technique and lack of standardization of surgeon experience. A Taiwanese study accounted for this by performing the study at a single institution with three surgeons, each of whom had completed at least 25 D3 lymph node dissections prior to the study. Patients with gastric cancer were randomized to a D1 lymph node dissection (defined as resection of perigastric lymph nodes along the lesser and greater curves of the stomach) or a D3 lymph node dissection (defined as resection of additional lymph nodes surrounding the splenic, common hepatic, left gastric arteries, nodes in the hepatoduodenal ligament, and retropancreatic lymph nodes). There was an overall 5-year survival benefit with the D3 group of 60 % compared with the D1 group of 54 %. A Japanese study evaluated a more aggressive lymph node dissection and randomized patients to a D2 dissection or a para-aortic lymph node dissection (PAND). There was no significant difference in 5-year survival between the two groups with a trend toward an increase in complications in the PAND group. Multiple studies have shown that the number of positive lymph nodes is a significant predictor of survival. Current AJCC guidelines stipulate that at least 15 lymph nodes are needed for pathologic examination to obtain adequate staging.
Laparoscopic techniques have become an integral part of surgical practice over the past several decades. For gastric cancer, multiple retrospective studies have reported the advantages of laparoscopic gastrectomy (LG) over open gastrectomy (OG). A recent meta-analysis of 15 nonrandomized comparative studies has also shown that although LG had a longer operative time than OG, it was associated with lower intraoperative blood loss, overall complication rate, fewer wound-related complications, quicker recovery of gastrointestinal motility with shorter time to first flatus and oral intake, and shorter hospital stay. A randomized prospective trial comparing laparoscopic assisted with open subtotal gastrectomy reported that LG had a significantly lower blood loss (229 ± 144 ml versus 391 ± 136 ml; P< 0.001), shorter time to resumption of oral intake (5.1 ± 0.5 days versus 7.4 ± 2 days; P< 0.001), and earlier discharge from hospital (10.3 ± 3.6 days versus 14.5 ± 4.6 days; P< 0.001).
Colonoscopy is a commonly performed procedure for the diagnosis and treatment of a wide range of conditions and symptoms and for the screening and surveillance of colorectal neoplasia. Although up to 33% of patients report at least one minor, transient GI symptom after colonoscopy, serious complications are uncommon. In a 2008 systematic review of 12 studies totaling 57,742 colonoscopies performed for average risk screening, the pooled overall serious adverse event rate was 2.8 per 1000 procedures. The risk of some complications may be higher if the colonoscopy is performed for an indication other than screening. The colorectal cancer miss rate of colonoscopy has been reported to be as high as 6% and the miss rate for adenomas larger than 1 cm is 12% to 17%. Although missed lesions are considered a poor outcome of colonoscopy, they are not a complication of the procedure per se and will not be discussed further in this document. Over 85% of the serious colonoscopy complications are reported in patients undergoing colonoscopy with polypectomy. An analysis of Canadian administrative data, including over 97,000 colonoscopies, found that polypectomy was associated with a 7-fold increase in the risk of bleeding or perforation. However, complication data are often not stratiﬁed by whether or not polypectomy was performed. Therefore, complications of polypectomy are discussed with those of diagnostic colonoscopy. A discussion of the diagnosis and management of all complications of colonoscopy is beyond the scope of this document, although general principles are reviewed.
With the introduction of laparoscopic colectomy nearly 20 years ago, a relatively slow adoption of laparoscopic colorectal surgery into surgical practice has taken place. It is estimated that 10% to 25% of all colorectal resections are performed utilizing laparoscopy. The persistent steep learning curve, the lack of high-volume colorectal surgery by general surgeons (who perform the bulk of colonic resection in the United States), and the modest advantages reported are but a few of the reasons that the percentage of laparoscopic colorectal procedures has not dramatically risen. With the publication of several large, prospective randomized trials for colon cancer, along with the interest in single-port surgery and natural orifice surgery, there appears to be a renewed interest in minimally invasive procedures for the colon and rectum. This chapter will provide an overview of these issues and offer a current assessment of the common diseases to which minimally invasive techniques have been applied.
Numerous previous studies have evaluated the learning curve involved in laparoscopic colectomy. It is estimated by conventional laparoscopic techniques that the learning curve for laparoscopic colectomy is at least 20 cases but more likely 50 cases. The need to work in multiple quadrants of the abdomen, the need for a skilled laparoscopic assistant, and the lack of yearly volume has kept the learning curve relatively steep. The surgeon may also need to work in reverse angles to the camera. All of these combined add to the complexity of the procedure and result in the need to perform a number of cases before the surgeon and surgical team become proficient. More recent publications have suggested the learning curve is more than 20 cases. In a prospective randomized study of colorectal cancer in the United Kingdom, the CLASICC trial, surgeons had to perform at least 20 laparoscopic resections before they were allowed to enter the study. The study began in July 1996 and was completed in July 2002. Despite the surgeons’ prior experience, the rate of conversion dropped from 38% to 16% over the course of the study, suggesting that a minimum of 20 cases may not be enough to overcome the learning curve. In the COLOR trial from Europe, another prospective randomized study for colon cancer that required a prerequisite experience in laparoscopic colon resection before surgeons could enter patients in the study, surgeon and hospital volume were directly related to a number of operative and postoperative outcomes. The median operative time for high-volume hospitals (>10 cases/year) was 188 minutes, compared to 241 minutes for low-volume hospitals (<5 cases/year); likewise, conversion rates were 9% versus 24% for the two groups. High-volume groups also had more lymph nodes in the resected specimens, fewer complications, and shortened hospital stays. These two relatively recent multicenter studies suggest that the learning curve is clearly greater than 20 cases and that surgeons need to perform a minimum yearly number of procedures to maintain their skills.
There may not be another area in recent surgical history that has been more heavily scrutinized than laparoscopic colorectal surgery. The plethora of accumulated data allows a careful assessment of all outcome measures for nearly every colorectal disease and procedure. In comparison to conventional colorectal surgery, the benefits of laparoscopy for colorectal procedures compared to open techniques include a reduction in postoperative ileus, postoperative pain, and a concomitant reduction in the need for analgesics; an earlier tolerance of diet; a shortened hospital stay; a quicker resumption of normal activities; improved cosmesis; and possibly preservation of immune function. This is offset by a prolongation in operative time, the cost of laparoscopic equipment, and the learning curve for these technically challenging procedures. When reporting the outcomes of laparoscopic colectomy, a natural selection bias applies when comparing conventional and laparoscopic cases. The most complex cases are generally not suitable for a laparoscopic approach and therefore are performed via an open approach. Also, in many series the results of the successfully completed laparoscopic cases are compared to conventional cases, and the cases converted from a laparoscopic to a conventional procedure may be analyzed separately. Few studies, with the exception of the larger prospective randomized studies, leave the converted cases in the laparoscopic group as part of the “intention to treat” laparoscopic group. This clearly introduces selection bias.
Although the results of prospective randomized trials are available for almost every disease process requiring colorectal resection, the majority of studies of laparoscopic colectomy are retrospective case-control series or noncomparative reports. The conclusions regarding patient outcomes must therefore come from the repetitiveness of the results rather than the superiority of the study design. For any one study, the evidence may be weak; but collectively, because of the reproducibility of results by a large number of institutions, even with different operative techniques and postoperative management parameters, the preponderance of evidence favors a minimally invasive approach with respect to postoperative outcomes.
Nearly all the comparative studies provide information regarding operative times. The definition of the operative time may vary with each series, and there may be different groups of surgeons performing the laparoscopic and conventional procedures. With the exception of a few reports, nearly all studies demonstrated a prolonged operative time associated with laparoscopic procedures. In prospective randomized trials, the procedure was roughly 40 to 60 minutes longer in the laparoscopic groups. As the surgeon and team gain experience with laparoscopic colectomy, the operating times do reliably fall, but rarely do they return to the comparable time for a conventional approach.
Return of Bowel Activity and Resumption of Diet
Reduction in postoperative ileus is one of the proposed major advantages of minimally invasive surgery. Nearly all of the retrospective and prospective studies comparing open and laparoscopic colectomy have shown a statistically significant reduction in the time to passage of flatus and stool. Most series demonstrate a 1- to 2-day advantage for the laparoscopic group. Whether the reduction of ileus relates to less bowel manipulation or less intestinal exposure to air during minimally invasive surgery remains unknown. With the reduction in postoperative ileus, the tolerance by the patient of both liquids and solid foods is quicker following laparoscopic resection. The time to resumption of diet varies from 2 days to 7 days, but in the majority of comparative studies, this is still 1 to 2 days sooner than in patients undergoing conventional surgery. Again, the physician and patient were not blinded in nearly all studies, which may have altered patient expectations. However, the overwhelming reproducible data reported in both retrospective and prospective studies of laparoscopic procedures does likely favor a reduction of postoperative ileus and tolerance of liquid and solid diets.
To measure postoperative pain, a variety of assessments have been performed to demonstrate a significant reduction in pain following minimally invasive surgery; some studies utilize an analog pain scale, and others measure narcotic requirements. Physician bias and psychologic conditioning of patients may interfere with the evaluation of postoperative pain. There are also cultural variations in the response to pain. Three of the early prospective randomized trials have evaluated pain postoperatively, and all three have found a reduction in narcotic requirements in patients undergoing laparoscopic colectomy. In the COST study, the need both for intravenous and oral analgesics was less in patients undergoing successfully completed laparoscopic resections. Numerous other nonrandomized studies have shown a reduction in postoperative pain and narcotic usage.
Length of Stay
The quicker resolution of ileus, earlier resumption of diet, and reduced postoperative pain has resulted in a shortened length of stay for patients after laparoscopic resection when compared to traditional procedures. Recovery after conventional surgery has also been shortened, but in the absence of minimally invasive techniques, it would seem unlikely that the length of stay could be further reduced. In nearly all comparative studies, the length of hospitalization was 1 to 6 days less for the laparoscopic group. Although psychological conditioning of the patient cannot be helped and likely has a desirable effect, the benefits of minimally invasive procedures on the overall length of stay cannot be discounted. The benefit, however, is more likely a 1 to 2 day advantage only. The more recent introduction of clinical pathways, both in conventional and laparoscopic surgery, has also narrowed the gap but appears to be more reliable in patients undergoing a minimally invasive approach.
One of the disadvantages of laparoscopy is the higher cost related to longer operative times and increased expenditures in disposable equipment. Whether the total cost of the hospitalization (operative and hospital costs) is higher following laparoscopic colectomy is debatable. A case-control study from the Mayo Clinic looked at total costs following laparoscopic and open ileocolic resection for Crohn’s disease (CD). In this study, 66 patients underwent laparoscopic or conventional ileocolic resection and were well matched. Patients in the laparoscopic group had less postoperative pain, tolerated a regular diet 1 to 2 days sooner, and had a shorter length of stay (4 vs. 7 days). In the cost analysis, despite higher operative costs, the overall mean cost was $3273 less in the laparoscopic group. The procedures were performed by different groups of surgeons at the institution, and although the surgeons may have introduced biases, this study was undertaken during the current era of cost containment, in which all physicians are encouraged to reduce hospital stays. The results are similar for elective sigmoid diverticular resection with a mean cost savings of $700 to $800. Clearly, if operative times and equipment expenditure are minimized, the overall cost of a laparoscopic resection should not exceed a conventional approach.
O aumento da prevalência de doença diverticular fez o seu adequado manuseio mais um assunto de debate constante.
Especialmente para os casos de diverticulite, progresso considerável tem sido feito em termos de diagnóstico e tratamento. Diagnóstico apropriado em TC e técnicas intervencionistas são agora amplamente disponíveis, bem como agentes antimicrobianos eficazes. Finalmente, como a ressecção cirúrgica do cólon envolvido é a única maneira de erradicar definitivamente essa condição, a colectomia eletiva laparoscópica surgiu como uma opção segura e interessante entre as opções de tratamento. Embora tenha sido recentemente contestada sobre a sua progressão, a história natural da diverticulite é assumida como sendo a de recorrência ao longo do tempo, pelo menos, em um terço dos pacientes. O medo das complicações desta doença benigna e prevalente tem motivado sociedades médicas e cirúrgicas para produzir orientações e consensos sobre o assunto. A mortalidade geralmente vem de sepse recorrente e/ou operações de emergência para casos mais complicados. Como resultado, o procedimento cirúrgico mais realizado, a sigmoidectomia eletiva, é normalmente indicada para todos os casos complicados e muitos dos não-complicados. A abordagem laparoscópica para a colectomia esquerda tem evoluído e condições seguras são oferecidas aos pacientes, quando realizado por cirurgiões experientes em laparoscopia.
Life as a Surgeon
Surgical careers begin long before one is known as a surgeon. Medicine in general, and surgery in particular, is competitive from the start. As the competition begins, in college or earlier, students are confronted with choices of doing what interests them and what they may truly enjoy vs doing what is required to get to the next step. It is easy to get caught up in the routine of what is required and to lose track of why one wanted to become a doctor, much less a surgeon, in the first place. The professions of medicine and surgery are vocations that require extensive knowledge and skill. They also require a high level of discretion and trustworthiness. The social contract between the medical profession and the public holds professionals to very high standards of competence and moral responsibility. Tom Krizek goes on to explain that a profession is a declaration of a way of life ‘‘in which expert knowledge is used not primarily for personal gain, but for the benefit of those who need that knowledge.’’
For physicians, part of professionalism requires that when confronted with a choice between what is good for the physician and what is good for the patient, they choose the latter. This occurs and is expected sometimes to the detriment of personal good and that of physicians’ families. Tom Krizek even goes so far as to question whether surgery is an ‘‘impairing profession.’’ This forces one to consider the anticipated lifestyle. In sorting this out, it is neither an ethical breach nor a sign of weakness to allocate high priority to families and to personal well-being. When trying to explain why surgery may be an impairing profession, Krizek expands with a cynical description of the selection process. Medical schools seek applicants with high intelligence; responsible behavior; a studious, hard-working nature; a logical and scientific approach to life and academics; and concern for living creatures. He goes further to explain that in addition to these characteristics, medical schools also look for intensity and drive, but are often unable to make distinctions among those who are too intense, have too much drive, or are too ingratiating.
There are many ethical challenges confronting medical students. As they start, medical students often have altruistic intentions, and at the same time are concerned with financial security. The cost of medical education is significant. This can encourage graduates to choose specialty training according to what will provide them the most expedient means of repaying their debt. This can have a significant, and deleterious, impact on the health care system in that the majority of medical graduates choose to pursue specialty training, leaving a gap in the availability of primary care providers. As medical students move into their clinical training, they begin interacting with patients. One concern during this time is how medical students should respond and carry on once they believe that a mistake on their part has resulted in the injury or death of another human being. In addition, the demands of studying for tests, giving presentations, writing notes, and seeing patients can be overwhelming. The humanistic and altruistic values that medical students have when they enter medical school can be lost as they take on so much responsibility. They can start to see patient interactions as obstacles that get in the way of their other work requirements. During their clinical years, medical students decide what field they will ultimately pursue. For students to make an informed decision about a career in surgery, they need to know what surgeons do, why they do it, and how surgery differs from other branches of medicine. It is important for them to be aware of what the life of a surgeon entails and whether it is possible for them to balance a surgical career with a rewarding family life.
Beginning residents are confronted with a seemingly unbearable workload, and they experience exhaustion to the point where the patient may seem like ‘‘the enemy.’’ At the same time, they must learn how to establish strong trusting relationships with patients. For the first time, they face the challenge of accepting morbidity and death that may have resulted directly from their own actions. It is important that residents learn ways to communicate their experience to friends and family, who may not understand the details of a surgeon’s work but can provide valuable support. The mid-level resident confronts the ethical management of ascending levels of responsibility and risks, along with increasing emphasis on technical knowledge and skills. It is at this level that the surgical education process is challenged to deal with the resident who does not display the ability to gain the skills required to complete training as a surgeon. Residents at this level also must deal with the increasing level of responsibility to the more junior residents and medical students who are dependent on them as teacher, organizer, and role model. All of this increasing responsibility comes at a time when the resident must read extensively, maintain a family life, and begin to put long-range plans into practice in preparation for the last rotation into the chosen final career path. The senior surgical resident should have acquired the basics of surgical technique and patient management, accepting nearly independent responsibility for patient care. The resident at this level must efficiently and fairly coordinate the functioning team, engage in teaching activities, and work closely with all complements of the staff. As far as ethics education is concerned, residents at this stage should be able to teach leadership, teamwork, and decision-making. They should be prepared to take on the value judgments that guide the financial and political aspects of the medical and surgical practice.
The Complete Surgeon
The trained surgeon must be aware of the need to differentiate between the business incentives of medical care and doing what is right for a sick individual. As financial and professional pressures become more intense, the challenge increases to appropriately prioritize and balance the demands of patient care, family, education, teaching, and research. For example, how does the surgeon deal with the choice between attending a child’s graduation or operating on an old patient who requests him rather than an extremely well-trained associate who is on call? How many times do surgeons make poor choices with respect to the balance of family vs work commitments? Someone else can
competently care for patients, but only parents can be uniquely present in the lives of their children. Time flies, and surgeons must often remind themselves that their lives and the lives of their family members are not just a dress rehearsal.
Knowing When to Quit
A 65-year-old surgeon who maintains a full operating and office schedule, is active in community and medical organizations, and has trained most of her surgical colleagues is considering where to go next with her career. Recently, her hospital acquired the equipment to allow robotic dissection in the area where she does her most complicated procedures. She has just signed up to learn this new technology, but is beginning to reflect on the advisability of doing this. How long should she continue at this pace, and how does she know when to slow down and eventually quit operating and taking the responsibility of caring for patients? Murray Brennan summarizes the dilemma of the senior surgeon well. The senior surgeon is old enough and experienced enough to do what he does well. He yearns for the less complicated days where he works and is rewarded for his endeavors. He becomes frustrated by restrictive legislation, the tyranny of compliance, and the loss of autonomy. Now regulated, restricted, and burdened with compliance, with every medical decision questioned by an algorithm or guideline, he watches his autonomy of care be ever eroded. Frustrated at not being able to provide the care, the education, and the role model for his juniors, he abandons the challenge.
Finishing with Grace
Each surgeon should continuously map a career pathway that integrates personal and professional goals with the outcome of maintaining value, balance, and personal satisfaction throughout his or her professional career. He or she should cultivate habits of personal renewal, emotional self-awareness, and connection with colleagues and support systems, and must find genuine meaning in work to combat the many challenges. Surgeons also need to set an example of good health for their patients. Maintaining these values and healthy habits is the work of a lifetime. Rothenberger describes the master surgeon as a person who not only knows when rules apply, recognizes patterns, and has the experience to know what to do, but also knows when rules do not apply, when they must be altered to fit the specifics of an individual case, and when inaction is the best course of action. Every occasion is used to learn more, to gain perspective and nuance. In surgery, this is the rare individual who puts it all together, combining the cognitive abilities, the technical skills, and the individualized decision-making needed to tailor care to a specific patient’s illness, needs, and preferences despite incomplete and conflicting data. The master surgeon has an intuitive grasp of clinical situations and recognizes potential difficulties before they become major problems. He prioritizes and focuses on real problems. He possesses insight and finds creative ways to manage unusual and complex situations. He is realistic, self-critical, and humble. He understands his limitations and is willing to seek help without hesitation. He adjusts his plans to fit the specifics of the situation. He worries about his decisions, but is emotionally stable.