Surgery

Question 1

What is the rate of bowel anastomotic leaks?

Answer 1

2 - 7% by experienced surgeons ( uptodate)

Question 2

What is the highest risk anastomosis for leakage

Answer 2

Coloanal 10 - 20% ( uptodate)

Question 3

Which anastomosis has the lowest risk of leakage;

Answer 3

Ileocoloic 1 - 3% ( uptodate)

Question 4

How long after OT do leaks normally present?

Answer 4

5 - 7 days

Question 5

What % of leaks present post discharge

Answer 5

~ 50%

Question 6

What % of bowel anastomotic leaks occur after day 30

Answer 6

~ 12% ( up to date)

Question 7

What are the clinical, radiological and intraoperative signs of anastomotic leakage

Answer 7

Clinical signs include:
Pain, fever, tachycardia, peritonitis, feculent drainage, purulent drainage

Radiographic signs include:
Fluid collections, gas containing collections

Intraoperative findings include:
Gross enteric spillage
Anastomotic disruption

Question 8

What are RF for anastomotic leakage?

Answer 8

Distance from anal verge < 5cm highest risk - 8% in one,
Anastomotic ischemia – 2 prospective sutides used laser doppler flow to assess blood flow to the colon and rectum before and after mobilising, dividing and anastomosis – magnitude of decreased perfusion increased risk
Male gender – esp in ultra low resection? Technically more challenging due to the size of the male pelvis.

Obesity – conflicting data

ASA scores III – IV 0.8% in grade II, 4.6% GRADE iii to IV

Emerg OT 4.4 vs 1.0%

Prolonged OT time - >4 hrs significant.

Hand-sewn ileocolic anastomosis – MA of 6 trials with 955 participants 6.0 v 1.4%

Question 9

What is initial management of an anastomotic leak

Answer 9

MDT, IV Fluids, electrolyte replacement, Broad spectrum IV Abx.
Options: Observation, bowel rest, per-cutaneous drainage, colonic stenting, surgical revision, diversion or drainage
Imaging work up: IV, PO and rectal contrast:
Sub clinical leaks - radio-logically detected no symptoms - Mx expectantly
With localized peritonitis and low grade sepsis:
- free leak ID’d –> needs OT
- Small contained abscess (<3cm) conservative Rx with IV Abx and bowel rest
Larger abscess (>3cm) with multiloculated collections - attempted percutaneous drainage. If not possible or pt gets worse –> needs OT.
Generalised peritonitis or high grade sepsis - Resuscitation and then OT>.

Question 10

What are surgical options for management of an anastomotic leak?

Answer 10

If inoperable phlegmon is encountered, safest approach to place a para-anastomotic drain and proximal faecal diversion with a stoma.

Major anastomotic defect >1cm or more than 1/3 of the circumference of the anastomosis options include:

Resection of anastomosis with re-anastomosis and proximal diversion or rarely exteriorisation of both ends of the stoma.

In selected patients with small defects, adequate tissue quality consider repair of the anastomosis with drain placement and proximal diversion.

Question 11

How often will a pt with an anastomosis develop a clinically symptomatic stricture in the joint?

Answer 11

4 - 10%

Question 12

What % of colocutanous fistula will close spontaneously and after how long

Answer 12

about 50% will close after a mean of 30 days (10 - 180)

Question 13

What happens to the risk or mortality after an anastomotic leak?

Answer 13

increases from ~2.5 - 15.8%

Question 14

What is a mnemonic for the treatment of enterocutaneous fistula?

Answer 14

SOWATS
Sepsis - treat aggressively
Optimisation - early TPN, Physical therapy
Wound care - keep enteric contents off wound
Anatomy - PO, PR and fistula contrast to ID anatomy of bowel and fistula
Timing - OTtime when pt well. not septic. keen for OT. bloods improved and pt optimised
Surgery - all bowel mobilised, limit anastomotic number, avoid mesh, consider protective stoma.

Question 15

When operating on a pregnant women is there an increased risk of pregnancy loss?

Answer 15

In a systematic review of 54 studies including over 12,000 pregnancies in women undergoing non-obstetric surgery reported a 10.5 % incidence of miscarriage during the first trimester, and an overall miscarriage incidence of 5.8%. This is similar to the overall rate of pregnancy loss. All retrospective data

Question 16

When operating on a pregnant women is there an increased risk of still birth?

Answer 16

a retrospective cohort study that evaluated over 47,000 nonobstetric surgeries identified from nearly 6.5 million pregnancies estimated the following increased overall risks:
Stillbirth – Every 287 procedures were associated with one additional stillbirth (stillbirth frequency of 0.6 % without surgery and 0.9 % with surgery)

Question 17

What is the rate of pregnancy loss with a ruptured appendix vs a non-ruptured appendix?

Answer 17

In a retrospective study there was a 2.6% rate of pregnancy loss with an appendicectomy without peritonitis vs a 10.9% rate with peritonitis.

Question 18

When operating on pregnant women is there an increased risk of preterm delivery?

Answer 18

A retrospective cohort study that evaluated over 47,000 nonobstetric surgeries identified from nearly 6.5 million pregnancies estimated the following increased overall risks:
- Preterm delivery – Every 31 surgeries were associated with one additional preterm birth (preterm delivery frequency of 7.5 % without and 11.1 % with surgery)

Question 19

What is the role of progesterone in the surgical management of pregnant patients

Answer 19

The corpus luteum is required for progesterone production up to approximately 7 - 9 weeks of gestation, prior to the luteroplacental shift.
Up to 47 days removal of the corpus is astd with a significantly increased risk of foetal loss. this appears to have resolve by 61 days. Consider PV progesterone if corpus disrupted prior to 10 weeks gestation.

Question 20

What are the complications of urinary diversion procedures?

Answer 20

○ Infection:
○ Impaired renal function — Progressive impairment of renal function over time is observed in some patients after urinary diversion. e.g. obstruction, stones, chronic infection.
- Metabolic complications: Absorption of urinary contents in a patient with renal insufficiency can result in chronic acidosis, and in osteopenia/osteoporosis from mobilization of phosphate stores.
- Exclusion of an ileal or colonic segmLatzko
ent of the bowel may result in malabsorption of bile salts and vitamin B12.
- Intestinal cancer — Bowel used are more susceptible to intestinal tumour development than bowel segments in the general population

Question 21

Describe Latzko’s vaginal repair of vesicovaginal fistula

Answer 21

Fistula tract identified and paediatric IDC placed through into bladder. Hydrodissection. 2-3 cm circle cut around centre of fistula. Don’t cut out fistula tract. Remove vagina from underlying tissue
Purse string around fistula remove catheter if closed.
Plicate underlying tissue to close over defect. Close vagina. IDC in situe for 7/10

Question 22

Define a short gut?

Answer 22

the presence of significant malabsorption of both macronutrients and micronutrients. The GI function is inadequate to maintain their nutrient and hydration status without IV or enteral supplementation.