Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (27 page)
69.
Anyanwu, A.C., Moalypour, S.M. Are abdominal radiographs still overutilised in the assessment of acute abdominal pain? A district general hospital audit.
J R Coll Surg Edinb Irel
. 1998;43:267–270.
70.
Bell, D.J., Woo, E.K. Are abdominal radiographs still overutilised in the assessment of acute abdominal pain? (letter).
Surgeon
. 2006;4:60–61.
71.
Royal College of Radiologists working party Making the best use of a department of clinical radiology: guidelines for doctors. 5th ed. 2003. [London].
72.
Traill, Z.C., Nolan, D.J., Imaging of intestinal obstruction.
Br J Hosp Med
1996;55:267–271.
8777519
73.
Ott, D.J., Gelfand, D.W., Gastrointestinal contrast agents: indications, uses and risks.
JAMA
1983;249:2380–2384.
6834637
74.
Wellwood, J.M., Wilson, A.N., Hopkinson, B.R., Gastrografin as an aid to the diagnosis of perforated peptic ulcer.
Br J Surg
1971;58:245–249.
5572320
75.
Crofts, T.J., Park, K.G.M., Steele, R.J.C., et al, A randomized trial of non-operative treatment for perforated peptic ulcer.
N Engl J Med
1989;320:970–973.
2927479
76.
Stewardson, R.H., Bombeck, C.T., Nyhus, L.M., Critical operative management of small bowel obstruction.
Ann Surg
1978;187:189–193.
629620
77.
Ogata, M., Mateer, J.R., Condon, R.E., Prospective evaluation of abdominal sonography for the diagnosis of bowel obstruction.
Ann Surg
1996;223:237–241.
8604902
78.
Brochwocz, M.J., Paterson-Brown, S., Murchison, J.T., Small bowel obstruction: the water-soluble follow-through revisited.
Clin Radiol
2003;58:393–397.
12727169
79.
Lee, J.F.-Y., Meng, W.C.-S., Leung, K.-L., et al. Water soluble contrast follow-through in the management of adhesive small bowel obstruction: a prospective randomized trial.
Ann Coll Surg HK
. 2004;8:120–126.
A randomised prospective trial of 150 patients with suspected adhesive small-bowel obstruction demonstrated that the group given water-soluble contrast studies received surgery significantly sooner (42 vs. 65 h) and had a significantly shorter hospital stay (5 vs. 7 days) than the group treated conventionally. The incidence of surgical intervention in both groups was the same.
80.
Burge, J., Roadley, G., Donald, J., et al. Randomised controlled trial of gastrografin in adhesive small bowel obstruction.
Aust N Z J Surg
. 2005;75:672–674.
A randomised trial of 40 patients with suspected adhesive small-bowel obstruction treated conventionally or given gastrografin. Four patients in each group required surgery. Time to resolution of symptoms was significantly quicker in the group given gastrografin.
81.
Sajja, S.B.S., Schein, M., Early postoperative small bowel obstruction.
Br J Surg
2004;91:683–691.
15164435
82.
Branco, B.C., Barmparas, G., Schnuriger, B., et al. Systematic review and meta-analysis of the diagnostic and therapeutic role of water soluble contrast agent in adhesive small boiwel obstruction.
Br J Surg
. 2010;97:47–48.
Fourteeen prospective studies were analysed and confirmed that water-soluble contrast radiography predicted the need for surgery, reduced the need for surgery and shortened hospital stay in patients with adhesive small-bowel obstruction.
83.
Dudley, H.A.F., Paterson-Brown, S. Pseudo-obstruction.
Br Med J
. 1986;292:1157–1158.
Leading article that provides the history of pseudo-obstruction and the relevant papers in relation to diagnosis and treatment.
84.
Ambrosetti, P., Becker, C., Terrier, F., Colonic diverticulitis: impact of imaging on surgical management. A prospective study of 542 patients.
Eur Radiol
2002;12:1145–1149.
11976860
85.
Laing, F.C., Federie, M.P., Jeffrey, R.B., et al, Ultrasonic evaluation of patients with acute right upper quadrant pain.
Radiology
1981;140:449–455.
7255722
86.
Samuels, B.L., Freitas, J.E., Bree, R.L., et al. A comparison of radionuclide hepatobiliary imaging and real-time ultrasound for the detection of acute cholecystitis.
Radiology
. 1983;47:207–210.
87.
Peng, W.K., Sheikh, Z., Nixon, S.J., et al, Role of laparoscopic cholecystectomy in the early management of acute gall bladder disease.
Br J Surg
2005;92:586–591.
15779079
88.
Puylaert, I.B.C.M., Rutgers, P.F., Lalisang, R.I., et al, A prospective study of ultrasonography in the diagnosis of appendicitis.
N Engl J Med
1987;317:666–669.
3306375
89.
Gallego, M.G., Fadrique, B., Nieto, M.A., et al. Evaluation of ultrasonography and clinical diagnostic scoring in suspected appendicitis.
Br J Surg
. 1998;85:37–40.
90.
Douglas, C.D., Macpherson, N.E., Davidson, P.M., et al. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score.
Br Med J
. 2000;321:919–922.
91.
McGrath, F.P., Keeling, F., The role of early sonography in the management of the acute abdomen.
Clin Radiol
1991;44:172–174.
1914392
92.
Ogata, M., Mateer, J.R., Condon, R.E., Prospective evaluation of abdominal sonography for the diagnosis of bowel obstruction.
Ann Surg
1996;223:237–241.
8604902
93.
Klingler, P.J., Wetscher, G., Glaser, K., et al, The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders.
Surg Endosc
1999;13:1129–1134.
10556453
94.
Stengel, D., Bauwens, K., Sehouli, J., et al, Systematic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma.
Br J Surg
2001;88:901–912.
11442520
95.
Rao, P.M., Rhea, J.T., Novelline, R.A., et al, Effect of computed tomography of the appendix on treatment of patients and use of hospital resources.
N Engl J Med
1998;338:141–146.
9428814
96.
Unlu, C., de Castro, M.M.N., Tuynman, J.B., et al, Evaluating routine diagnostic imaging in acute appendicitis.
Int J Surg
2009;7:451–597.
19559106
97.
Molstrom, C., Johar, S., Is contrast needed for CT in the diagnosis of appendicitis? A systematic review of the literature. AccessMedicine from McGraw-Hill; 2011.
www.AccessMedicine.com
[[accessed 10.11.12]].
98.
Sala, E., Watson, C.J.E., Beadsmoore, C., et al, A randomized, controlled trial of routine early abdominal computed tomography in patients presenting with non-specific acute abdominal pain.
Clin Radiol
. 2007;62(10):961–969.
17765461
99.
Sala, E., Beadsmoore, C., Gibbons, D., et al, Unexpected changes in clinical diagnosis: early abdomino-pelvic computed tomography compared with clinical evaluation.
Abdom Imaging
. 2009;34(6):783–787.
17901913
100.
Nguyen, L.K., Wong, D.D., Fatovich, D.M., et al. Low-dose computed tomography versus plain abdominal radiography in the investigation of an acute abdomen.
Aust N Z J Surg
. 2012;82(1–2):36–41.
101.
Imatu, M., Awai, K., Nakayama, Y., et al, Multidetector CT findings suggesting a perforation site in the gastrointestinal tract: analysis in surgically confirmed 155 patients.
Radiat Med
. 2007;25(3):113–118.
17450335
102.
Chou, C.K., Mak, C.W., Tzeng, W.S., et al, CT of small bowel ischemia.
Abdom Imaging
. 2004;29(1):18–22.
15160748
103.
Thoeni, R.F., Cello, J.P., CT imaging of colitis.
Radiology
. 2006;240(3):623–638.
16926320
104.
Old, J.L., Dusing, R.W., Yap, W., et al. Imaging for suspected appendicitis.
Am Fam Physician
. 2005;71(1):71–78.
105.
Nitta, N., Takahashi, M., Furukawa, A., et al, MR imaging of the normal appendix and acute appendicitis.
J Magn Reson Imaging
. 2005;21(2):156–165.
15666398
106.
Pedrosa, I., Levine, D., Eyvazzadeh, A.D., et al, MR imaging evaluation of acute appendicitis in pregnancy.
Radiology
. 2006;238(3):891–899.
16505393
107.
Jaffe, T.A., Miller, C.M., Merkle, E.M., Practice patterns in imaging of the pregnant patient with abdominal pain: a survey of academic centers.
AJR Am J Roentgenol
. 2007;189(5):1128–1134.
17954650
108.
Paterson-Brown, S. Emergency laparoscopic surgery.
Br J Surg
. 1993;80:279–283.
Review article showing the overwhelming evidence in support of diagnostic laparoscopy in the assessment of patients with acute abdominal pain, particularly when the diagnosis and decision to operate is in doubt.
109.
Paterson-Brown, S., Thompson, J.N., Eckersley, J.R.T., et al. Which patient with suspected appendicitis should undergo laparoscopy?
Br Med J
. 1988;296:1363–1364.
110.
Decadt, B., Sussman, L., Lewis, M.P.N., et al. Randomised clinical trial of early laparoscopy in the management of acute non-specific abdominal pain.
Br J Surg
. 1999;86:1383–1386.
A randomised trial that demonstrated the improvements in diagnostic accuracy and subsequent quality of life in the group undergoing laparoscopy.
111.
Morino, M., Pellegrino, L., Castagna, E., et al, Acute non-specific abdominal pain: a randomized, controlled trial comparing early laparoscopy versus clinical observation.
Ann Surg
2006;244:881–888.
17122613
112.
Murphy, S.M., Donnelly, M., Fitzgerald, T., et al, Patients' recall of clinical information following laparoscopy for acute abdominal pain.
Br J Surg
2004;91:485–488.
15048753
Enders K.W. Ng
Foregut perforations are challenging surgical emergencies and the keys to success in managing these potentially life-threatening situations are timely diagnosis and appropriate intervention. This chapter summarises the latest evidence and clinical experience concerning the investigation and therapeutic options for perforation in different parts of the upper gastrointestinal tract. Owing to the potential implications for prognosis and management planning, perforations are conventionally classified according to the anatomical position and causative mechanism.
The estimated lifetime risk of perforation in peptic ulcer disease ranges from 2% to 10%.
1
–
3
Typical presentation includes a sudden onset of epigastric pain, which rapidly generalises to other parts of the abdomen. Some patients may report a history of dyspepsia or peptic ulcer, but such findings are absent in about one-third of the patients.
4
‘Board-like rigidity’ is the most commonly mentioned physical sign, referring to the diffuse peritonitis revealed on abdominal examination. However, in the elderly and the critically ill who develop ulcer perforation during hospitalisation, the presentation can often be atypical and subtle. Diagnosis under such circumstances requires a high index of suspicion. Though subdiaphragmatic free gas on a plain erect chest X-ray (
Fig. 6.1
) is diagnostic, it is seen in no more than 70% of patients.
5
A lateral decubitus X-ray, water-soluble contrast meal, ultrasound scan and computed tomography (CT) of the abdomen are thus invaluable additional investigations when the diagnosis is in doubt (see also
Chapter 5
). However, it is noteworthy that the role of CT may be limited if the onset of symptoms is less than 6 hours.
6
Pneumogastrogram was once advocated for being able to increase the diagnostic yield from 66% on plain erect X-ray to 91%.
7
However, such a practice is now abandoned because forceful intragastric air insufflation is likely to reopen some of the spontaneously sealed-off perforations. For patients with profound peritoneal signs and a serum amylase level not diagnostic of acute pancreatitis, a laparoscopy or laparotomy after resuscitation is indeed the most time-saving and efficient investigation. It has the advantage of being able to execute immediate therapeutic intervention, either laparoscopically or via an open laparotomy, once the pathology is verified.
Figure 6.1
Erect chest radiograph showing right subphrenic free gas shadow associated with a perforated peptic ulcer.
Perforation accounts for the majority of deaths related to peptic ulcer disease.
8,
9
Spillage of gastroduodenal contents through the perforation initiates a chemical peritonitis, which will rapidly be superimposed by bacterial infection if left untreated. This leads in turn to the systemic inflammatory response syndrome and multi-organ dysfunction associated with the bacterial translocation across the peritoneal surface. Despite surgical intervention, mortality rates remain around 5–15%.
9
–
11
The prognostic indicators for ulcer perforation have been widely studied, yet most published series consist of relatively small numbers of patients with marked heterogeneity in both demographics and treatment methods.
Before the era of laparoscopic surgery, significantly higher rates of mortality were reported by Boey et al. in patients with an ulcer perforation who were admitted with major medical illness, preoperative shock and long-standing perforation (more than 24 hours). Those with no, one, two and all three risk factors at presentation were noted to have mortality rates of 0%, 10%, 45.5% and 100%, respectively.
12
This study underscores the importance of stratifying patients with ulcer perforation according to their risk of mortality, which is of relevance to the prognosis and choice of surgical intervention.
Similar findings have been reported by other multivariate analyses. Some also identified that age > 65 years and perforation during hospital stay are additional predictive factors of death.
13,
14
In 2001, Lee et al. compared the APACHE II score with the Boey parameters in a cohort of over 400 patients.
15
An APACHE II score > 5 was found to have predictive value for increasing postoperative complications and death, whereas the Boey score only predicted mortality but not morbidity. Interestingly, in the same study, a higher Boey score was found to be associated with an increased chance of conversion when laparoscopic repair was attempted. Albeit a precise and useful tool for research purposes, the APACHE II system is cumbersome to employ in daily practice, not to mention that the calculated score may vary with different time points of assessment.
It is widely accepted that patient comorbidity, age > 65 years, the presence of preoperative shock and long-standing perforation are associated with an increase in mortality and morbidity following perforated peptic ulcer.
A Danish group has recently published a revised prediction model, the Peptic Ulcer Perforation (PULP) score, based on a multicentre study including more than 2600 patients with perforated gastric or duodenal ulcers treated surgically over a 6-year period.
16
It comprises eight variables including (1) age over 65 years, (2) active malignancy or human immunodeficiency virus (HIV) infection, (3) cirrhosis, (4) steroid use, (5) presentation more than 24 hours after symptom onset, (6) preoperative shock, (7) serum creatinine higher than 130 μM/L and (8) the four levels of ASA score (2–5). In the study, PULP score was reported to predict postoperative 30-day mortality with an area under curve (AUC) of 0.83, which was significantly better than the conventional Boey score (AUC = 0.70) and ASA score alone (AUC = 0.78).
Some 50% of perforated peptic ulcers have spontaneously sealed at the time of admission to hospital.
17
Such an observation has led to the sporadic advocacy of non-operative management, especially for older patients with poor premorbid status.
18
However, the non-operative approach has not been widely accepted, with the exception of a few centres. Donovan et al. were among the first to advocate use of diatrizoate meglumine (Hypaque) water-soluble contrast meal for confirmation of spontaneous sealing of the perforation.
19
In the absence of duodenal scarring and contrast extravasation, patients with subphrenic free gas were managed non-operatively with nasogastric suction and intravenous antibiotics. By implementing this preset policy, these authors were able to report an overall mortality rate of only 4.6% in a series of 249 patients.
20
The non-operative approach to the treatment of perforated peptic ulcers has been studied in a randomised trial consisting of 83 patients, of whom 40 were assigned to non-operative management while the rest underwent immediate laparotomy.
21
After 12 hours, 28% of the patients in the non-operative group failed to improve and required surgery. Though mortality rates were comparable between the two approaches, the incidence of intra-abdominal collections and sepsis was much higher in the non-operative group. Most strikingly, patients over 70 years of age were found to be less responsive to the non-operative approach when compared to the younger patients. In concluding the study, the authors did not recommend routine use of non-operative management for peptic ulcer perforation. However, they recognised that the results suggested that patients (a) did not need to be rushed to the operating theatre and time could be more usefully spent in better preoperative resuscitation, and (b) in selected patients the non-operative approach has a role to play.
Though the majority of surgeons now advocate immediate surgical intervention for perforated peptic ulcers, there remains debate as to what constitutes the most appropriate operation. The omental repair technique first described by Graham in 1937 involves patching the perforation with a piece of detached omentum.
22
It is no longer a common practice nowadays and has been largely replaced by the pedicle omentopexy which is usually secured in place by two to three tie-over sutures (
Fig. 6.2a, b
). For a time such a simple omentopexy repair was associated with a high subsequent ulcer relapse rate.
23
–
25
This resulted in the popularity of adding a definitive acid-reducing procedure, such as distal gastrectomy or vagotomy, to lower ulcer recurrence.
26
–
29
In a prospective follow-up study, 107 selected patients with perforated pyloroduodenal ulcers undergoing omental patch closure and parietal cell vagotomy were evaluated up to 21 years later. The operative mortality was only 0.9% and the recurrent ulcer rate by life table analysis was 7.4%, with a re-operative rate of only 1.9%.
30
As a result, emergency vagotomy was once a standard of care recommended for peptic ulcer perforation.
Figure 6.2
(a)
A small perforation at the juxtapyloric area.
(b)
Pedicle omental patch repair on the perforation site secured with absorbable sutures.
The addition of a truncal or highly selective vagotomy may cause little early morbidity or mortality apart from prolonging the time of anaesthesia. However, resectional surgery in the form of emergency antrectomy or distal gastrectomy has been shown to increase mortality in patients with perforated peptic ulcers, and therefore should be avoided wherever possible.
31
All these ‘definitive’ surgical approaches, however, have changed over the last two decades following better understanding about the pathogenesis of peptic ulcer disease; most surgeons now prefer a much less aggressive ‘damage control’ tactic when treating ulcer perforations.
32,
33
The availability of
Helicobacter pylori
eradication regimens and potent proton-pump inhibitors provides excellent means to alleviate patients' ulcer diathesis without the need for a definitive acid-reducing procedure. A simple omental patch repair and thorough peritoneal toileting are the only key manoeuvres needing to be done during the emergency operation. The only exception is probably those suffering from giant duodenal perforations (> 2 cm), which may not be amenable to a simple patch repair (see below).
34
