SURGICAL POTPOURRI
Huntsville 2018 Erika Allard-Ihala PGY2 General Surgery Conflict of Interest Declaration: Nothing to Disclose
I have no financial or personal relationships to disclose. Objectives
Bariatric Surgery Indications Acute and long term complications Benign anorectal disease Anal fissure Hemorrhoids Perianal abscess Fistula Choosing Wisely preoperative reminders The Hernia BARIATRIC SURGERY BARIATRIC SURGERY
INDICATIONS: BMI >40 with no comorbidities BMI >35 with comorbidities Age < 65
In 18 months, the cost of the surgery will be equivalent to the patients health care costs from medical issues. In 1-2 months the patients may no longer need oral hypoglycemics or antihypertensive medications. Less chronic disease overall. BARIATRIC SURGERY
CONTRAINDICATIONS: Age <18y or >65 (controversial) Untreated depression or psychosis Uncontrolled eating disorders Substance use Severe cardiac disease that prohibits them from an anesthetic Severe coagulopathy Inability to comply with nutritional requirements Blood work
Pre-op the patient must have thiamine, vitamin B12, folate, iron, vitamin ADEK, calcium, and copper levels. Post-op the above nutrient levels should be monitored q3-6m
BARIATRIC SURGERY
ACUTE COMPLICATIONS Anastomotic leak 0.8-6% Pulmonary embolism 0.3-1.2% Hemorrhage 0.4-4% * Internal hernia 0-5% Gastric band slippage 0-20% Dumping syndrome Myocardial infarction Small bowel obstruction Bariatric patient presenting with tachycardia should be investigated. Abdominal exam is unreliable May not have vomiting with SBO or internal hernia NG decompression**
ANASTOMOTIC LEAK
BARIATRIC SURGERY
CHRONIC COMPLICATIONS Vitamin and mineral deficiencies Marginal ulcer 0.6-16% Internal hernia Small bowel obstruction (adhesive or stenotic) Cholelithiasis requiring cholecystectomy Erosion or slippage of lap band Dumping syndrome GERD MARGINAL ULCER
No NSAIDS No smoking If patients are on prednisone or ASA they must be on PPI to prevent marginal ulcers
These commonly occur with Roux en Y bypass.
GASTRIC BAND EROSION
Supplements
Recommended supplements: Vitamin C 500mg daily Vitamin B12 500mcg daily Calcium carbonate 500mg daily Ferrous fumarate 325mg daily Vitamin D 2000 units daily **for sleeve gastrectomy** extra Vitamin B12 and iron BENIGN ANORECTAL DISEASE ANAL FISSURES
Tear in the anoderm that is distal to the dentate line More common in children and middle aged adults Acute <6 weeks Chronic >6 weeks and fails conservative management Causes: Primary: local trauma from hard stool or prolonged diarrhea Secondary: medical/surgical condition, IBD or malignancy PATHOPHYSIOLOGY Vicious cycle of tearing causing spasm of the internal anal sphincter. Causing further pain, increased tearing and decreased blood supply.
SYMPTOMS AND FINDINGS Majority of tears are posterior midline, 15% anterior midline and <1% off midline Tearing pain with stools that may last hours, hematochezia, pruritis, or irritation Skin tags TREATMENT
INITIAL Stool softeners and high fiber diet Avoid straining and trauma to the anus Sitz baths MEDICATIONS Nitro ointment 0.2-0.4% QID Diltiazem 2% gel TID x 8 wks Nifedipine 0.2% TID x 8 wks TREATMENT
If there is bleeding, then consider endoscopy. If the fissure persists > 6 weeks then lateral internal sphincterotomy by dividing a portion of the muscle. Healing is achieved with >95% of the patients. HEMORRHOIDS HEMORRHOIDS
Cushions of submucosal tissue containing venules, arterioles and smooth muscle fibers. Function to be part of the continence mechanism External: distal to the dentate line Internal: proximal to the dentate line CLINICAL SYMPTOMS
Hard stools Bleeding Anal pruritis Pain due to thrombosis Stool leakage
CONSERVATIVE TREATMENT
Fiber Metamucil 30g/day Warm sitz baths and mild soap Oral and topical analgesicslidocaine gel or cream Stool softeners Antispasmodics? Thrombosed hemorrhoids evacuate clot
ADVANCED TREATMENT
External hemorrhoids do not usually require minimally invasive or surgical treatment BUT if bleeding or thrombosed they may require surgical excision.
Endoscopic assessment
INTERNAL HEMORRHOIDS PRINCIPLE: Remove or to cause sloughing of excess hemorrhoidal tissue. Healing and scarring fixes the residual tissue to underlying anorectal ring Rubber band ligation, bipolar diathermy, laser photocoagulation, sclerotherapy, cryosurgery Hemorrhoidectomy usually reserved for grade 4, combined internal/external or significant prolpase.
ANORECTAL ABSCESS
Acute collection of purulent material. M : F-- 2:1 8-10 anal cryptoglands are arranged circumferentially around the internal sphincter. If the gland becomes obstructed with debris, bacterial growth occurs and abscess forms.
CLINICAL SIGNS & SYMPTOMS
Anal pain not associated with BM Palpable mass in perianal area Purulent drainage Area of fluctuance Patch of erythematous and indurated skin Fevers and malaise
DIAGNOSIS
Often no imaging is needed. CT or MRI can be useful in supralevator or horseshoe abscess EUS Necrotizing infections do occur and the patient present with necrotic skin, bullae or crepitus. They will appear septic and will need early debridement. TREATMENT
Incise and drain Sitz baths When do you give antibiotics? Valvular heart disease Immunosuppression Extensive cellulitis Necrotizing infection Diabetes ANTIBIOTICS
Clavulin 10d was found to increase fistula rate.
Ciprofloxacin and Flagyl 10 d decreases fistula rate from 30% to 15%
There has been some research to demonstrating that antibiotics along with drainage reduces the rate of fistula formation. TREATMENT
Outpatient drainage Local anesthetics: lidocaine with bicarbonate Cruciate incision ANORECTAL FISTULA
Epithelialized track connecting the abscess to perirectal skin Drainage of anorectal abscess results in cure for 50% of patients, the rest develop a fistula in ano. M:F, 2:1 Causes: abscess is most common. Crohn’s disease, chlamydia, radiation proctitis, foreign bodies and actinomycosis are less common and we should consider them if the fistulas are complex, recurrent or nonhealing. CLINICAL SYMPTOMS
Non healing abscess Chronic purulent drainage Pustule like lesion in perianal area Rectal pain Intermittent drainage Pruritis CLINICAL SIGNS
Perianal excoriation External opening with purulent fluid DRE for abscess Do not probe fistula! 5% 2% 23% 70% TREATMENT
Referral to surgeon. Goals of treatment are to eradicate sepsis without sacrificing continence. MRI or CT to help further delineate the anatomy. Majority of cases undergo EUA and seton placement.
Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy less than 10 years AND no family or personal history of CRC. Avoid preoperative CXR for patients with an unremarkable history and physical exam.
THE HERNIA
THE HERNIA WORKUP
Groin ultrasounds, who orders these before sending to see the surgeon? For the surgeons in the room, does this change your management? THE HERNIA WORKUP
In a recent study from Calgary, they assessed 400 patients (90% male) who underwent assessment for possible groin hernia. 75% had groin ultrasound prior to surgical consultation. Of the ultrasounds performed 1.7% affected surgical management. In Alberta, the cost of US for groins that did not affect surgical management was $1.6 million. THE HERNIA WORKUP
In 2011, Denmark assessed 10 000 inguinal hernias. They found clinical examination to be the best diagnostic tool.
In 2018, the five continental hernia societies, have agreed that ultrasound is rarely needed. THE HERNIA WORKUP
When the diagnosis is not apparent or there may be an occult hernia, ultrasound is recommended.
THANK YOU! QUESTIONS? REFERENCES:
Up to date Bariatric Complications and Emergencies Sabistons Surgical Textbook Schwartz’s Principles of Surgery International guidelines for groin hernia management Retrieved from https://link.springer.com/article/10.1007/s10029-017-1668-x The role of groin ultrasound imaging in the management of inguinal hernias. R. Tong, E. Debru, R. Gill, P. Mitchell, N. Church, A. Reso. From the University of Calgary, Calgary, Alta.