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.

Bariatric Surgery Indications Acute and long term complications

Benign anorectal disease Anal fissure Hemorrhoids Perianal abscess Fistula

Choosing Wisely preoperative reminders The Hernia

Objectives

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

BARIATRIC SURGERY

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

Blood work

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 SURGERY

Abdominal exam is unreliable

May not have vomiting with SBO or internal hernia

NG decompression**

Bariatric patient presenting with tachycardia should be investigated.

ANASTOMOTIC LEAK

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

BARIATRIC SURGERY

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.

MARGINAL ULCER

GASTRIC BAND EROSION

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

Supplements

BENIGN ANORECTAL DISEASE

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

ANAL FISSURES

Vicious cycle of tearing causing spasm of the internal anal sphincter.

Causing further pain, increased tearing and decreased blood supply.

PATHOPHYSIOLOGY

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

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.

TREATMENT

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

HEMORRHOIDS

CLINICAL SYMPTOMS

Hard stools

Bleeding

Anal pruritis

Pain due to thrombosis

Stool leakage

Fiber Metamucil 30g/day

Warm sitz baths and mild soap

Oral and topical analgesicslidocaine gel or cream

Stool softeners

Antispasmodics?

Thrombosed hemorrhoids evacuate clot

CONSERVATIVE 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.

ADVANCED TREATMENT

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.

ANORECTAL ABSCESS

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

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.

DIAGNOSIS

Incise and drain

Sitz baths

When do you give antibiotics?

Valvular heart disease

Immunosuppression

Extensive cellulitis

Necrotizing infection

Diabetes

TREATMENT

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.

ANTIBIOTICS

TREATMENT

Outpatient drainage

Local anesthetics: lidocaine with bicarbonate

Cruciate incision

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.

ANORECTAL FISTULA

Non healing abscess

Chronic purulent drainage

Pustule like lesion in perianal area

Rectal pain

Intermittent drainage

Pruritis

CLINICAL SYMPTOMS

CLINICAL SIGNS

Perianal excoriation

External opening with purulent fluid

DRE for abscess

Do not probe fistula!

5%

23% 70%

2%

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.

TREATMENT

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

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.

THE HERNIA WORKUP

THANK YOU!

QUESTIONS?

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.

REFERENCES: