Emergency Surgery Flashcards
Scoring system for Perf Peptic Ulcer
Manheim Peritonitis index
Body score and PULP (peptic Ulceration Perforation) score
Lap vs Open PU
Tan et al - Meta analysis of 5RCTs 2016
Less post op pain, shorter NG time, Less SSI
Treatment of Giant Ulcer
Patch still an option is healthy tissue around edge - leak rate high
If stable - consider resection - partial distal gastrectomy/duodenectomy with Billroth 1/2
Closure around a T tube to convert to fistula is an option if unwell
Evidence for early vs delayed Cholecsytectomy
Cochrane 2013 not much difference.
Nice guidelines lap Chloe within 1 week of diagnosis. SWORD database
Management of CBD stones
ERCP
Lap CBD exploration
Open CBD exploration
Lap CBD exploration safe with similar results to ERCP
Open CBD exploration superior to ERCP in achieving duct clearance
Incidence of bile duct injury
Incidence in Lap Chole is aroumnd 1in 500 (dholes study)
Usually assocaiated with R hepatic artery damage
Management of CBD injury
Early recogn either intra or post. If not a HPB surgeon do not attempt repair
If transection or excision do not attempt repair - highly likely to fail
T tube into bile duct is recognised intra-op
Partial injury can be repaired primarily (T-tube or not) if surgeon experienced
Classification of bile duct injury
Bismuth
1- Low common hepatic - stump >2cm
2- Proximal CHD -stump <2cm
3- Hilar no residual CHD
4: Destruction of HD confluence
5 Involvement of aberrant R sectoral duct only
Strasburg
A - Leakage from cystic duct/subvesical duct
B Occlusion of par of Hillary tree (usually RHD)
C- Type B involves transection without ligation
D- latreal injury to binary tree
E- Bismuth (E1-5)
Boarders of the femoral canal
Anterior - Inguinal ligament
Medial - Lacumar ligament
posterior - Pectineal ligament, pectinous muscle and superior rami of pubic bone
Lateral - Femoral vein
Conents - Lymphatic vessels, Deep LN (Cloquets), loose connective tissue, empty space
Diagnostic Criteria for Acute Panc
Revised Atlanta Criteria 2012 - at least 2 of the 3
1- Abdo pain cosistent with pancreatic
2- Serum amylase 3x upper limit of normal
3-Findings consistent with Panc on imaging
Scoring systems for Panc
Acute Physiology and Chronic Health Evaluation 2 (APACHE2)
Ranson Score - alcohol related Panc
SIRS
Bedside Index for the severity in Acute Panc
Harmless Acute Panc Score
Cap good indicator of severity (CRP <110 signifies low risk of necrosis)
The scores help triage patients to appropriate levels of care
Mortality for predicted severe panic is significantly higher (10%) than those with mild (<1%)
Causes of Pancreatitis
Gallstones 50%
Alcohol 25%
ERCP 3%
Less common hypercalcaemia, hypertriglyceridaemia, mediations, trauma, malignancy, infection
Feeding in acute Panc
Cochraine review 2010 - Early feeding leads to lower rates of infection, organ failure and death (Entral vs TPN)
Mild should resume asap when symptoms allow
Consider NG/NJ feeding (non-superior) if not making calorific requirement 3-5days
ERCP in pancraetiis
Only for severe
IAP/APA 2013 and WSES 2019 guidline) urgent ERCP within 24hrs and sphincterotomy for patients with acute pancreatic and co-existent acute cholangitis
Grading of acute Panc compciations
Balthazar CT severity index 1994
Based on level of Panc inflammation, necrosis and extra-pancreatic complication - Mild, Mod or severe
Pancreatic Pseudocysts
Approx 25% of people develop fluid collections.- encapsulate or resolve - 4-6weeks
Symptomatic pseudocysts - manage conservatively for 12weeks - 50% resolve
If not can drain percutaneous trans gastric - fluid dominant (risk of fistula)
Endoscopically + stent and washout
Surgically
Pancreatic Necrosis
If sterile -conservative
Approx 1/3 of collections get infected.
POINTER trial (Dutch) - Step-up approach of percutaneous drainage then video assisted debridement if not settling s laparotomy - Reduced death and major complications
Tension (Dutch) 2018 Endoscopic treatment not superior but reduced risk of fsiulta and length of stay
Sigmoid volvulus
AXR only 30% sensitivity for sigmoid Volvulus so CT recommended on 1st occurrence (rules out malignancy
High recurrent rate - 90%
Classification of limb ischaemia
Rutherford classification
1) Viable
2) Threaten a)marginally
b)immediately
3)Irreversible
Lower limb fasciotomy
Consider if ischaemic time >6hrs
Lateral incision accesses the lateral and anterior compartments
Medial incision - superficial and deep compartments
Thrombolysis
Surgery 3-5x more common
Can be used as a bridge to revascularisation in acute on chronic
Review on 42 studies shows lower rate of mortality and better rates of limb salvage
Contraindications - recent internal bleeding, pregnancy, stroke, TIA, craniotomy in last 2 months, Intracerebral tumour, aneurysm, AVM, severe bleeding tendency, vascular/abdo surgery in last 2 weeks, puncture of non-compressible artery, previous GI bleed or trauma in last 10 days
Perianal abscess packing/seeton
PPAC and PPAC2 trials showed no need for long term packing
Approx 1/3 of fistulas found at initial EUAs would close spontaneously so no seton required as converts a potential fistula to an actual
Approx 1/3 will develop a fistula long term
Pathophysiology of perianal abscess
Cryptoglandular theory
infection starts in obstructed perianal glands
Abscess may drain via crypts of Margani or externally leading to fistula
Common organism include E. coli, Bacteroides, Enterococci
Swallowed FB
Series AXR - every 2-3days - is remains in stomach >48hrs then needs OGD to remove
IF stuck in oesophagus need emergency OGD 2-6hrs
narrow points of GI tract
Upper OG sphincter, aortic arch, Left main stem bronchus, Lower OG sphincter, pylorus, IVC
Once past oesophagus most past within 48hrs
Objects >2.5cm not pass pylori or ICVand 5-6cm not pass through duodenal angulation
Damage control Laparotomy
Aim to stop bleeding and limit containingation
Avoid triad of coagulopatcy, hypothermia and acidosis
Pringle maneouver
Traction on stomach to bring down, finger through foramen of Winslow and create window through pars flaccid with thumb - compress Portal vein and hepatic artery. - release every 15-20mins
IVC injury
Exposure using right medial visceral rotation - Cattel Branch manoeuvre
Kockerise duodenum, mobilise Right colon and small bowel mesentery.
Gain proximal and distal control
Liver injury grading
American Association for the surgery of trauma Liver injury scale
1) Haematoma is sub capsular and <10% surface area or laceration is capsular tear <1cm depth
2) haematoma 10-50% or intraparenchymal <10cm diameter or laceration 1-3cm depth <10cm length
3) haemtoma>50% surface area, >10cm diameter intraparenchymal, laceration >3cm
4) Laceration with parenchymal disruption 25-75% hepatic lobe or involves 1-3 couinaud segments
5)Laceration with parenchymal disruption >75% of lobe or involving ?3 segments (within 1 lobe. Vascular juxtahepatic venous injury (retrohepatic vena or major veins
6) vascular hepatic avulsion
Blunt trauma injuries
Spleen 40-55%
Liver35-45%
small bowel 5-10%
15% incidence of retroperitoneal haematoma
Crohns disease o diagnostic Lap
ECCO-ESCP guidelines 2017 - Not in favour of resecting and not removing healthy appendix as risk of fistulation
CT in pregnancy
Ionising radiation so avoid if possible
Doubles risk of childhood cancer (baseline 1in500)
dose is 10-30milligrays for Ct A/P- stillbirths at >50
Delaying is greater risk - 66% increased risk of perforation at 24hrs delay, foetal loss 20-35% (risk of perforation is double in third trimester
Lap Surgery in Pregnancy
Possible increased risk of foetal loss
Tilt patient to left 30 Degree to move uterus of IVC
first port midline cm above the gravid uterus - open Hasson) insertion
Hinchey Classification
1) Localised abscess (parabolica)
2)Pelvic abscess
3)Purulent peritonitis
4) Faecal peritonitis
IR drain for diverticular abscess
Consider if >4cm
If not feasible and not responding to IV abx then consider Lap washout
Evidence for Lap washout in perf sigmoid diverticultitis (Hinchey 3
LOLA arm of Ladies was stopped early due to safety concerns
SCANDIV trial showed higher reoperation rates in Lap peritoneal lavage group - stoma rates lower in lavage group and no difference in major complciationbv.
DILALA trial initially showed equivalent re-operation rates at 30days and similar complications at 30 and 90days, shorter operative and hospital stays - 2yr data on mortality for grade 3 showed no difference
Surgical approach for Hinchey 3
Traditional approach would be Hartmans but significant morbidity and mortality with 30-60% never reversed
Can consider primary resection and anastomosis with/without ileostomy after colonic lavage.
ABC for uncomplicated Diverticulitis
Swedish AVOD RCT 2012 and Dutch DIABLO RCT 2017 showed omitting ABC did not prolong recovery or prevent complications or reoccurance
If admitted would start
Well leg compartment syndrome
Fascial compartment pressure exceeds perfusion pressure causing tissue ischaemia and necrosis. This occurs in the abscess of trauma and may occur without pre-existing vascular disease
Riglers triad
1) Pneumobilia
2 Small bowel obstruction
3) Ectopic calcified gallstone (usually RIF)
Chest drain >1.5L
Massive haemothorax is defined as >1500ml or >1/3 of blood volume in chest cavity
Indication for surgical intervention
Likely sources are:
-Intercostal vessels
-Pulmonary parenchyma
-Major thoracic vessels or mediastinal injury
Complications of subclavian artery injury
Early - persistent haemorrhage or recurrent bleeding, haemothorax, brachial plexus injury, thrombosis or embolus, SSI or mediastinitis
Late - Pseudoaneurysm formation, arterial stenosis (chronic limb ischaemia), chronic pain/functional impairment, post traumatic AV fistula
