© Springer International Publishing Switzerland 2016
Abe Fingerhut, Ari Leppäniemi, Raul Coimbra, Andrew B. Peitzman, Thomas M. Scalea and Eric J. Voiglio (eds.)Emergency Surgery Course (ESC®) Manual10.1007/978-3-319-21338-5_33. Management Options: Nonoperative Versus Operative Management
(1)
Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid Head of General Surgery II and Emergency Surgery, University General Hospital Gregorio Marañón, Madrid, Spain
(2)
Department of Surgery, University Hospital, San Juan de Alicante, Alicante, Spain
Objectives
To review the indications for nonoperative management of the more common “surgical” emergencies.
To define the role of interventional radiology and endoscopic techniques as alternatives to surgical management.
To describe some less frequently encountered conditions and the specifics involved in their management.
The decision to operate or observe a patient is at times one of the more challenging decisions the acute care surgeon must make. To help us make that decision in the best interest of our patient, we have to consider our personal experience and clinical judgment, the natural history of the underlying disease, and its different clinical presentations, patient comorbidity and his/her surgical risk, the availability of interventional radiology or endoscopic procedures, and the information provided by imaging.
In practice, comorbidities and a high-surgical/anesthetic risk are probably the most important factor to consider in nonoperative management (NOM) for a specific patient. The anesthetic risk should be evaluated in collaboration with the anesthetist involved, using the ASA classification system, the APACHE II (Acute Physiological and Chronic Health Evaluation II), or p-POSSUM, according to individual practice and preferences.
In this chapter, we will review the indications for NOM of the more frequent “surgical” emergencies encountered in clinical practice, acknowledging that some of the assertions and recommendations contained are also mentioned in other chapters of this manual. By NOM or conservative approach, we refer to a nonsurgical therapy, even though some interventional radiologic or endoscopic procedure might be used at times.
3.1 Acute Appendicitis
Despite the fact that early appendectomy has been advocated as the gold standard of therapy to avoid perforation, recent evidence has shown that acute appendicitis (AA) can be successfully treated nonoperatively.
Several studies, including five randomized trials, have suggested that antibiotic treatment should be the first line of treatment for uncomplicated AA and at times can cure AA.
The results from two meta-analyses showed that NOM for uncomplicated or complicated AA was associated with reduced risk of complications and had a similar duration of hospital stay compared with appendectomy.
The duration of antibiotic treatment has not been consensual;
The failure rate (reported to be between 10 and 38 %) can be reduced to 3 % with a longer antibiotic regimen (specifically 9–14 days).
The necessity of an interval appendectomy after successful NOM is controversial but is usually advocated for patients with an appendicolith or an abscess on initial CT scan.
NOM should be the first-line treatment
When appendiceal phlegmon is suspected (clinical diagnosis)
Rationale: avoids the risk of right hemicolectomy for a benign condition.
CT scan is indicated to:
Rule out an abscess within the phlegmon, in which case percutaneous drainage is indicated
Detect complicated AA surrounded by an inflammatory phlegmon (no clinical mass palpated on the RLQ), for which surgery is indicated.
NOM is not indicated in the pregnant woman because of increased morbidity and fetal loss.
3.2 Acute Cholecystitis
NOM can be considered in high-risk patients, irrespective of the grade of the Tokyo Guidelines.
Clinical improvement can be expected in 87 % patients.
Predictors of failure include age >70 years, history of diabetes, and persistent leukocytosis >15,000/mm3 at 48 h. These patients or those who fail to respond rapidly (within 48–72 h) to medical management should undergo percutaneous drainage or operation.
AC that develops during the first or third trimester of pregnancy is best treated conservatively with antibiotics, with delayed cholecystectomy either during the second trimester or the postpartum period, respectively.
3.3 Gastrointestinal Perforations
Gastroduodenal
NOM in the healthy patient with an early healed perforation and no signs of peritonitis.
Should be successful in most cases.
Contrast CT should document sealing of the perforation.
NOM in the extremely high-surgical risk patient presenting with peritoneal signs
Treatment consists of NPO, NG tube, antibiotics, thromboembolic prophylaxis, and acid-reducing medication.
Development of abscesses can be drained percutaneously.
Low threshold for surgical intervention if clinical deterioration occurs, especially in patients age 70 or greater.
Leakage after percutaneous endoscopic gastrostomy (PEG)
Diagnosis: contrast study through the PEG tube (to eliminate intraperitoneal spillage).
Treatment: attach tube to gravity drainage, antibiotics, and i.v. fluids.
Post–ERCP perforations
Occur in 0.5–1.2 % of procedures with mortality as high as 15 %
NOM:
Nasogastric tube.
Broad-spectrum antibiotics.
Repeat ERCP with insertion of a stent is an option for expert endoscopists.
Ideal conditions for NOM:
Absence of free leakage on contrast examination
Absence of systemic inflammation or clinical peritonitis
Absence of large or increasing pneumo-peritoneum
Colonoscopy perforations
Common causes: barotrauma from excessive insufflation of air, excessive use of cautery, or overzealous dilatation of strictures
NOM
Indicated for patients who have had previous bowel preparation, are minimally symptomatic, without fever or tachycardia, and with a benign abdominal exam, typically after small perforations following therapeutic colonoscopy (e.g., polypectomy or biopsy)
Treatment: nothing by mouth and broad-spectrum antibiotics. Patients who respond to conservative management typically have no or minimal pneumoperitoneum and no or minimal leak of contrast on CT. Perforations that follow are usually small and more amenable to NOM.
Perforations following diagnostic colonoscopy often result in sizable rents in the colonic wall and thus require prompt surgical treatment.
Postoperative anastomotic leaks
Get Clinical Tree app for offline access
NOM is possible and the most reasonable course of action in many anastomotic leaks, provided that there are no signs of generalized peritonitis or sepsis.
Biliary leaks:
Most are amenable to NOM, provided interventional radiology and endoscopic therapy are available.
Of note, the presence of free bile in the peritoneal cavity can occasionally be very poorly tolerated with rapid sepsis warranting rapid surgical intervention.
Cystic duct stump leaks and ducts of Luschka leaks:
Most common postcholecystectomy causes of bile leaks.
Low-grade leaks (identified after opacification of intrahepatic radicals): sphincterotomy alone.
High grade (detected before radical opacification): biliary stenting.
Refractory leaks may require surgery.
Main bile duct injuries may also sometimes be treated with stents, while others require hepatobiliary expertise surgery.
Multiple studies have now documented a 90–100 % resolution rate for bile leaks posthepatic resection treated with sphincterotomy and stenting.
Pancreatic leaks:
Many pancreatic-enteric anastomoses, usually less ominous events than in the past, will resolve with NOM and percutaneous techniques.
Reoperation may be required either due to inaccessibility of an infected fluid collection to percutaneous drainage or due to clinical instability associated with uncontrolled sepsis. As early reoperation carries a significant risk of mortality, it should be avoided if reasonable nonoperative alternatives exist.
Anastomotic leaks after esophagectomy:
Of critical importance: differentiate between leaks and conduit necrosis, especially after colonic interposition, and endoscopic examination is the best method for making this assessment.
Clinically stable patients (controlled leaks or contained anastomotic disruptions) may be treated nonoperatively: endoscopically placed removable expandable stents are first-line treatment options
Leaks are controlled in 70–100 % of patients.
Stent migration may occur in 20–40 % of cases.Related posts:
Full access? Get Clinical Tree
