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   Perianal  Choosing Wisely preoperative reminders  The 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%   Myocardial infarction  Small 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  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, , 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 analgesicslidocaine 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  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  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 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 , foreign bodies and actinomycosis are less common and we should consider them if the are complex, recurrent or nonhealing. CLINICAL SYMPTOMS

 Non healing abscess  Chronic purulent drainage  Pustule like lesion in perianal area   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 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 .  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.