The Acute Management of Surgical Disease

Emergency General Surgery has become a cornerstone of Acute Care Surgery over the past decade. Once the scope of community general surgeons, the growing complexity of patients with acute surgical diseases has increasingly driven their care to tertiary referral centers. The aging population confounds this problem further as these patients present with more complex comorbidities, life-threatening physiology, and progressively severe anatomic disease severity. To ensure better outcomes, the practice has evolved to focus on evidence-based practice management guidelines in order to standardize care and optimize outcomes. The purpose of this text is to be a comprehensive volume for patients with acute surgical diseases. There will be three sections, each comprised of multiple chapters. The first section will be a comprehensive analysis of the background of Emergency General Surgery. The goal of this section will be to provide the reader background into the acute surgical practice and to introduce the reader to the important concepts discussed in the remainder of the textbook. The second section will be the largest and will discuss specific acute surgical diseases. Individual chapters will outline the diagnostic approach, current treatment standards, operative approaches, and expected outcomes with an emphasis on practice management guideline implementation into practice. As acute surgical diseases and surgical critical care are integral to each other, the last section will be Critical Care for the Acute Care Surgeon. These topics will focus on the critical care concepts essential to surgeons who care for acute diseases. This comprehensive text is targeted to any surgeon who takes emergency call for any of the listed diseases including community and referral general and vascular surgeons. In addition, this would be an excellent resource for all general surgery residents. Lastly, this would also serve as a resource to intensivists who care for acute surgical patients. Preface Contents Contributors 1: Emergency General Surgery: A Paradigm Shift to Meet the Demands of an Evolving Discipline The Changing Role of the General Surgeon The Crucial Role of the Rural Surgeon The Emergence of the Modern Acute Care Surgeon The Evolution of Trauma Care The Development and Evolution of Emergency General Surgery References 2: Assessment of the Patients with an Acute Abdomen Introduction Important Consideration Initial Evaluation History Physical Exam Acute Cholecystitis Acute Appendicitis Acute Pancreatitis Laboratory Test Imaging References 3: Development of the AAST Disease Severity Stratification System Introduction History of Scoring Systems Scoring Systems for Physiologic Derangement Evolution of Scoring Systems for Emergency General Surgery Definition and Burden of Emergency General Surgery Diseases Disease-Specific Scoring Systems Development of AAST EGS Anatomic Grading Scales Disease-Specific Data Dictionaries Validation of the AAST Anatomic Grading Scales Limitations of Solely Anatomic-Based Grading Applications of the AAST EGS Grading Scales Conclusions References 4: Infectious Disease Considerations Introduction Surgical Site Infections (SSIs) in Acute Care Surgery Optimal Choice and Timing of Perioperative Prophylactic Antibiotics Respecting Sterility Optimizing the Operating Room Environment Skin Preparation Perioperative Glucose, Temperature, and Oxygen Optimization Antimicrobial Management in Emergency Surgery Duration of Antibiotic Therapy Antibiotics in Patients with Organ Failure Special Consideration: Necrotizing Soft Tissue Infection (NSTI) References 5: Damage Control Surgery Historical Basis Pathophysiology Indication for Damage Control Surgery Damage Control Laparotomy Damage Control Laparotomy for Emergency General Surgery Patients Damage Control Laparotomy Operative Sequence Damage Control Laparotomy Outcomes Damage Control Laparotomy Complications Damage Control Vascular Procedures Extremity Vascular Injuries Intra-Abdominal Vascular Damage Control Damage Control Thoracotomy References 6: Radiology of Emergency Surgery Introduction Imaging Modalities Radiography Ultrasound Magnetic Resonance Imaging Computerized Tomography Important Principles of CT Critical Findings on CT Free Air Hemorrhage Tissue Enhancement Inflammatory Fat Stranding Imaging Examples of Acute Surgical Emergencies Gastrointestinal Gastric and Duodenal Perforation Gastric Outlet Obstruction Small Bowel Obstruction Appendicitis Bowel Ischemia Diverticulitis Biliary Tract Cholecystitis Emphysematous Cholecystitis Gangrenous Cholecystitis and Perforation Acute Cholangitis Genitourinary Acute Renal Obstruction Emphysematous Pyelonephritis Ovarian Torsion Tubo-Ovarian Abscess Ectopic Pregnancy Testicular Torsion Conclusion References 7: A Primer on Practice Management Guidelines Practice Management Guidelines (PMGs) and Systematic Reviews The Need for PMGs Historical Perspectives of PMGs The Role of the Agency for Health Research and Quality The Need for High-Quality PMGs Transparency Managing Conflicts of Interest PMGs and the Systematic Review Rating the Quality of the Evidence Rate the Strength of the Recommendations Clear Articulation of Recommendation External Review Planned Updates GRADE Methodology Framing the Question and Rating the Outcomes of Interest Quantitative and Qualitative Analysis of the Literature Making Recommendations Translating Guidelines into Clinical Practice References 8: Quality Assessment in Acute Surgical Disease Introduction Quality Assessment in Surgery Quality Metrics Assessing Quality in Acute Care Surgery Quality Initiatives in Emergency General Surgery Creating an EGS Quality Program Surgical Leadership and Accountability Tools for Quality Improvement and Organizational Discipline Change Management and Performance Data Institutional Commitment and Resources Conclusions References 9: Concepts in Emergency Research Exception from Informed Consent Introduction History of Informed Consent History of Informed Consent for Research Emergency Research References 10: Design and Impact of the American Association for the Surgery of Trauma Acute Care Surgery Fellowship Introduction History Program Requirements Step-by-Step Fellowship Establishment Impact Future Directions Conclusion References 11: Surgical Rescue and Failure to Rescue Introduction Epidemiology and Causes of Failure to Rescue Surgeon and Hospital Factors Patient Factors The Way Forward Rescue After Procedural Complications Bile Duct Injury During Cholecystectomy Gastrostomy Tube Complications Line Complications Anastomotic Leak Enterocutaneous Fistulae Opportunities for Surgical Rescue in Medical Patients Clostridium difficile Colitis Mesenteric Ischemia Abdominal Compartment Syndrome Case Resolution References 12: Small Bowel Obstruction Overview Etiology Diagnosis History and Physical Exam Laboratory Workup Imaging Management Outcomes Our Practice References 13: Large Bowel Obstruction Etiology/Pathology Diagnosis/Pathology Abdominal Computed Tomography Hydrosoluble Contrast Enema Colonoscopy Staging Specific Pathologic Considerations Obstructing Colon Cancer Treatment Nonoperative Observation Endoscopic Intervention: Benign Disease Endoscopic Intervention: Malignant Disease Operative Intervention Preoperative Bowel Preparation Benign Disease Malignant Obstruction Proximal Colonic Obstruction Distal Colonic Obstruction The Three-Stage Management Hartmann’s Procedure (Two-Stage Procedure) Resection and Primary Anastomosis Subtotal Colectomy with Ileosigmoid or Ileorectal Anastomosis Resection and Primary Anastomosis with Intraoperative “on Table” Irrigation Resection and Primary Anastomosis with Intraluminal Device Resection and Primary Anastomosis with Proximal Diverting Stoma Laparoscopic Versus Open Resection Perforation Specific Surgical Considerations for Benign Disease Sigmoid Volvulus Cecal Volvulus Pseudo-Obstruction Benign Stricture Colonic Anastomosis in Open Abdomen Palliative Patients Conclusions References 14: Abdominal Wall Hernias Introduction Hernia Presentation and Diagnostic Approach Ultrasonography Computed Tomography (CT) Additional Diagnostic Adjuncts Indications for Emergent Repair Groin Hernia Surgical Approach Ventral Hernia Surgical Approach Parastomal Hernia Hernia in Cirrhotic Patients Flank Hernia Mesh Characteristics Permanent Synthetic Mesh Absorbable Synthetic Mesh Biologic Mesh Conclusion References 15: Acute Cholecystitis Introduction Imaging Tokyo Guidelines for Diagnosis of Acute Cholecystitis Management of Acute Cholecystitis Severity Grading Role of Antibiotics for Acute Cholecystitis Perioperative Antibiotic Therapy Antibiotics for Use with Nonoperative Management Timing of Cholecystectomy Operative Technique Robotic Cholecystectomy Subtotal Cholecystectomy Indocyanine Green Cholangiography Cholecystostomy Tube Endoscopic Ultrasound Outcomes References 16: Appendicitis Introduction Workup Diagnosis Prediction Models Imaging Pathology Management Based on Disease Severity Nonoperative Management Acute Appendicitis: AAST Grades I–III Appendicitis with Phlegmon or Abscess: AAST Grade IV Appendicitis Interval Appendectomy Operative Management Open Appendectomy Laparoscopic Appendectomy NOTES Appendectomy Perforated Appendicitis (Grades III–V) Special Populations Pregnancy Obesity Normal-Appearing Appendix Chronic Appendicitis Postoperative Management Outcomes Summary References 17: Acute Colonic Diverticulitis Introduction Grading Scales for Acute Colonic Diverticulitis Risk Factors Presentation and Diagnosis Initial Assessment Imaging Management Medical Management Image-Guided Drainage Surgical Management Laparoscopic Peritoneal Lavage Emergency Surgical Resection Laparoscopic Vs Open Resection Extent of Resection Stomas and Intestinal Continuity Damage Control Diverticular Fistulae Perioperative Considerations Bowel Prep Ureteral Stents Post Recovery and Elective Surgical Resection Elective Resection Uncomplicated Diverticulitis Diverticulitis with Abscess Colonoscopy Summary References 18: Intestinal Ischemia Anatomy Pathophysiology Diagnostic Workup AAST Grading System Management Arterial Mesenteric Ischemia Venous Mesenteric Ischemia Nonocclusive Mesenteric Ischemia Further Considerations References 19: Perforated Peptic Ulcer Introduction Epidemiology Diagnosis Risk Scores Management Trial of Nonoperative Therapy Operative Management Perforated Duodenal Ulcers Illustration Perforated Gastric Ulcers Damage Control Surgery Laparoscopic Surgery Adjuncts to Nonoperative Management and Emerging Therapies Postoperative Management H. pylori Testing Drain Management Conclusion References 20: Acute Pancreatitis: Nonoperative and Operative Management Workup Severity Scoring: Schemata for Prognostication and Classification Management of Acute Pancreatitis Mild Pancreatitis Medical Management of Moderate and Severe Pancreatitis Assessment and Management of Infected Pancreatic Necrosis Technique for Video-Assisted Retroperitoneal Debridement Surgery (VARDS) Technique for Open Necrosectomy Other Local Complications of Pancreatitis Chronic Complications of Acute Pancreatitis Conclusions References 21: Enterocutaneous Fistula Overview Classification and Risk Factors Anatomy Etiology Physiology (Output) Diagnosis and Stabilization Initial Resuscitation and Electrolyte Replacement Treatment of Sepsis Skin Protection and Wound Management Nutritional Support Investigations Laboratory Workup Imaging Medical Management Operative Management References 22: Necrotizing Soft Tissue Infections Incidence, Mortality, and Disease Burden of NSTI Pathophysiology, Bacteriology, and Terminology NSTI Severity Stratification and Prediction of Mortality Diagnosis of NSTI Treatment Surgery and Debridement Technique Adjunctive Therapies Conclusion References 23: Acute Perianal Disease Introduction Perianal Abscess and Fistula Introduction Work-Up Examination Pathology Non-operative Management Operative Management Outcomes Hemorrhoids Introduction Work-Up Examination Pathology Non-operative Management Operative Management Special Scenarios Outcomes Anal Fissure Introduction Work-Up Examination Pathology Non-operative Management Operative Management Outcomes Rectal Prolapse Introduction Work-Up and Examination Non-operative Management Operative Management Outcomes Sexually Transmitted Infections Genital, Anal, and Perianal Ulcerations Proctitis Anal Condyloma Pilonidal Disease Introduction Work-Up Examination Non-operative Management Operative Management Outcomes Foreign Body Description Work-Up and Examination Management Summary and Key Points References 24: Complications After Metabolic and Bariatric Operations Complications After Metabolic and Bariatric Operations Common of Operations General Postoperative Surgical Complications Nutritional Deficiencies Cholecystitis and Symptomatic Cholelithiasis Procedure-Specific Postoperative Surgical Complications Biliopancreatic Diversion With or Without Duodenal Switch Laparoscopic Adjustable Gastric Band Band Erosion Mega-Esophagus or Pseudo-Achalasia Complications After RYGB Choledocholithiasis Anastomotic Leaks Hemorrhage Marginal Ulcers Anastomotic Strictures (Stenosis) Small Bowel Obstruction Internal Hernia Complications of Gastric Sleeve Surgery Gastroesophageal Reflux Disease Bleeding Leaks Stenosis, Twists, or Kinks Conclusion References 25: Airway Emergencies Preparation Personnel Equipment Medications Airway Assessment General Approach Difficult Airway Algorithm Airway Devices Endotracheal Tubes Supraglottic Devices Surgical Airway Tubes Cricothyrotomy Tubes Cricothyroidotomy Tracheostomy Post-procedure Management Case Conclusion References 26: Non-operative Approaches to the Biliary Tree Introduction Section 1: Acute Biliary Disease Cholecystitis Percutaneous Cholecystostomy Endoscopic Transpapillary Gallbladder Drainage (ERCP with Cystic Duct Stent Placement) EUS-Guided Gallbladder Drainage Choledocholithiasis Cholangitis Endoscopic Transpapillary Biliary Drainage Percutaneous Transhepatic Biliary Drainage (PTBD) EUS-Guided Biliary Drainage Biliary Access in Surgically-Altered Anatomy Section 2: Bile Leaks and Bile Duct Injury Introduction Bile Leak Biloma Biliary Stricture Conclusion References Choledocholithiasis Cholangitis Biliary Access in Surgically-Altered Anatomy Bile Leaks and Bile Duct Injury 27: Acute Urologic Emergencies Introduction Upper Urinary Tract Upper Tract Obstruction Evaluation Management Special Considerations Ureteropelvic Junction Obstruction Renal Colic in Pregnancy Renal and Perinephric Abscesses Evaluation Management Emphysematous Pyelonephritis Evaluation Management Spontaneous Retroperitoneal Hematoma Evaluation Management Bladder Acute Urinary Retention Evaluation Management Scrotum Fournier’s Gangrene Evaluation Management Testicular Torsion Evaluation Management Penis Priapism Evaluation Management Prostate Prostatitis and Prostate Abscess Evaluation Management References 28: Acute Gynecologic Emergencies Introduction Adnexal Torsion Symptoms and Causes Relevant Pelvic Anatomy Surgical Management Abdominal Ovarian Cystectomy Laparoscopic Ovarian Cystectomy Abdominal Oophorectomy Laparoscopic Oophorectomy Oophoropexy Hemorrhagic Ovarian Cysts: Symptoms and Management Vulvar Abscess/Necrotizing Fasciitis Anatomic Considerations Surgical Management Necrotizing Fasciitis Cesarean Delivery Preoperative Preparation Procedure/Surgical Anatomy Management of Postpartum Hemorrhage References 29: Ruptured Abdominal Aortic Aneurysm Introduction Diagnosis Initial Management Intervention vs Palliation Stabilization and Transfer Operative Management Endovascular Repair Open Surgical Repair Postoperative Complications Abdominal Compartment Syndrome Acute Renal Failure Colonic Ischemia Other Case Conclusion References 30: Management of Esophageal Perforation Overview Etiology Clinical Presentation Diagnosis Treatment Initial Management Primary Repair Traditional “Open” Approach Minimally Invasive Approach Timing of Repair Outcomes of Primary Repair Esophagectomy One-Staged Reconstruction Bipolar Exclusion and Delayed Reconstruction “Non-operative” Hybrid Treatment Endoluminal Stenting Endoscopic Clipping Endoluminal Vacuum-Assisted Closure Nutritional Management: Enteral vs. Parenteral Primary Repair vs Non-operative, Endoscopic Management Conclusion References 31: Introduction to Acute Upper Gastrointestinal Hemorrhage Introduction Incidence, Morbidity and Mortality, and Risk Factors Causes of Upper Gastrointestinal Hemorrhage Early Management Restrictive Versus Liberal Transfusion Breathing and Securing the Airway Nasogastric Decompression Obtaining a History and Physical Exam Assessing Risk of Re-bleeding, Intervention, and Mortality Initial Diagnosis Medical Management Acid-Reduction Pro-kinetics Antibiotic and Other Therapies Diagnostic (and Therapeutic) Modalities Endoscopy Endoscopic Techniques Computed Tomography Angiography (CTA) Percutaneous: Endovascular Techniques Nuclear-Medicine Studies Capsule Endoscopy Specific Considerations for Surgical Management Case #1: Bleeding Gastric Ulcer Case #2: Bleeding Duodenal Ulcer Case #3: Aorto-Enteric Fistula Take-Home Points References 32: Acute Lower Gastrointestinal Hemorrhage Introduction Incidence, Morbidity and Mortality, and Risk Factors. Causes of Lower Gastrointestinal Hemorrhage Early Management Rule Out Upper GIB and Anorectal Etiology Medical Management Endoscopic Management Angiography Approach to the Occult LGIH Provocative Angiography Surgical Management Conclusion References 33: Emergency Surgery as a Team Sport Emergency General Surgery Team Dynamics Case Report Background on Emergency General Surgery An Introduction to Teamwork The Benefits of Team Sports Team Dynamics Failure of the Team Why Medicine Is a Team Sport The Role of Team Sports and the Medical Trainee Surgery as a Team Sport The Surgeon Athlete The Surgical Coach Team Work in the Operating Room The Surgeon’s Playbook Structured Teamwork Training and Simulations Teamwork and Trauma Surgery Teamwork and Cardiac Surgery Teamwork and ECMO Programs Teamwork and Orthopedic Surgery Teamwork and Colorectal Surgery Team Sports and Emergency Surgery: What Is the Future? Conclusion References 34: Sepsis Resuscitation Diagnosis of Sepsis and Septic Shock Evolving Definitions Initial Assessment of Volume Resuscitation History and Physical Exam Early Goal-Directed Therapy Empiric Fluid Administration Goals Over Resuscitation Dynamic Measures of Volume Responsiveness Fluid Challenge Passive Leg Raise End-Expiratory Occlusion Test Pulse Pressure and Stroke Volume Variation Systolic Blood Pressure Variation Inferior Vena Cava Index Static Measures of Volume Responsiveness Central Venous Pressure Pulmonary Artery Occlusion Pressure Inferior Vena Cava Diameter Left Ventricular End-Diastolic Area Choice of Fluid Crystalloid Colloid Blood Products Resuscitation Endpoints Serum Lactate Base Deficit Empiric Antimicrobials Timing Empiric Agents Source Control Case Conclusion References 35: Surgical Approach to Cirrhotic Patients Introduction Causes of Cirrhosis Anatomy of the Liver Severity of Cirrhosis Acute Care Surgery Gallstone Disease Abdominal Wall Hernias Gastric Appendix Colon Trauma Preoperative Optimization Coagulopathy Hepatic Encephalopathy Ascites Renal Function Pulmonary Function Infection Nutrition Managing Cirrhosis Intra- and Post-operatively Anesthesia Critical Care Serum Chemistry Ascites Management Renal Function Nutrition DVT Prophylaxis Pain Management [55] References 36: Nutrition Considerations in Emergency Surgery Importance of Nutrition Assessing Baseline Nutrition Status Anthropometric Measurements Subjective Global Assessment Albumin Prealbumin Nitrogen Balance How Much Nutrition (Energy) Do Patients Need? Direct Calorimetry Indirect Calorimetry Harris-Benedict Equations Mifflin-St Jeor Equations Swinamer Equation Penn State and Modified Penn State Equations Which Formula to Use? Estimating Protein Needs The Role of Permissive Underfeeding Risk of Overfeeding Choice of Nutritional Route Enteral Oral Nutrition Non-oral Enteral Nutrition Gastric vs Post-pyloric Feeding Gastric vs Post-pyloric Feeding: Equipment Complications of Feeding Tubes Parenteral PN Indications PN Complications What Are the Barriers to Providing Enteral Nutrition in Emergency Surgery Patients? Physiologic Barriers Ileus Obstruction Pancreatitis Enteroatmospheric Fistula Hemodynamic Instability Damage Control Laparotomy and the Open Abdomen Cultural and Logistical Barriers The Dogma of “NPO After Midnight” Nutrition Is “Less Important” Than Other Issues in the Acutely Ill Patient How Do I Calculate TPN? Micronutrients and Immunonutrition Micronutrients Vitamin C Vitamin A Zinc Selenium Immunonutrition Glutamine Arginine Omega-3 Polyunsaturated Fatty Acids Nucleotides Evidence for Immunonutrition Summary References 37: Geriatrics/Frailty and End of Life Care Introduction Frailty and Geriatric Syndromes Management of the Older EGS Patient Preoperative Intraoperative Post-operative Surgical Outcomes Palliative Care Primary Palliative Care vs. Specialty Palliative Care Goals of Care Shared Decision Making A Framework to Navigate GOC Conversations Advance Care Planning Advance Care Directives Resuscitation Orders Family Meetings What Can Go Wrong? Dying with Dignity Optimizing Pain and Symptom Management Withdrawing Life Support Prework The Withdrawal of Life Support Therapy Post Withdrawal Support to Clinical Team, Patient, and Family Hospice Care References Index Emergency General Surgery has become a cornerstone of Acute Care Surgery over the past decade. Once the scope of community general surgeons, the growing complexity of patients with acute surgical diseases has increasingly driven their care to tertiary referral centers. The aging population confounds this problem further as these patients present with more complex comorbidities, life-threatening physiology, and progressively severe anatomic disease severity. To ensure better outcomes, the practice has evolved to focus on evidence-based practice management guidelines in order to standardize care and optimize outcomes. This text provides a comprehensive volume for any surgeon who treats patients with acute surgical diseases. The first section is a comprehensive analysis of the background of Emergency General Surgery. The goal of this section is to provide the reader background into the acute surgical practice and to introduce the reader to the important concepts discussed in the remainder of the text. The second section discuss specific acute surgical diseases. Individual chapters outline the diagnostic approach, current treatment standards, operative approaches, and expected outcomes with an emphasis on practice management guideline implementation into practice. As acute surgical diseases and surgical critical care are integral to each other, the last section will be Critical Care for the Acute Care Surgeon. These topics focus on the critical care concepts essential to surgeons who care for acute diseases. This comprehensive text is targeted to any surgeon who takes emergency calls for any of the listed diseases including community and referral general and vascular surgeons. In addition, this would be an excellent resource for all general surgery residents. Lastly, this would also serve as a resource to intensivists who care for acute surgical patients