Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
.pdf
Figure20.5.“Eureka,wefoundit!”
Start conservative treatment as described in Chapter19. In most
patientsresolution oftheclinical featuresof pancreatitisoccurswithin a
few days and is marked by normalization of white cell count and
pancreaticandliverenzymes.Itisthen—withinaweekorso—thatyou
want to go ahead with laparoscopic cholecystectomy — preventing
recurrent biliary pancreatitis by removing the source of the problem.
Thereisnoneedtowaitlonger—oncesignsofpancreaticinflammation
havesubsided and chemicalcholestasisis improving —youcan safely
go ahead with surgery. The aim should be to perform
cholecystectomy during the same hospital admission as the
episodeofpancreatitis.
Whatabout ‘suspected’CBD stones?How canyou besurethat
theyhaveindeedmigratedintotheduodenum?
•
Ifthe CBD isnotdilated on USandliver enzymes arebackto
normalthereisnoneedforanypre-operativeimagingoftheCBD.
Adding a routine intra-operative cholangiogram in this situation is
controversial. Cholangiography may indeed demonstrate small
stones, but stones which would pass spontaneously in most
instances.
•
IftheCBDisdilatedandliverfunctionisdeterioratingyouhave
tosuspectimpactedCBDstones(oftenassociatedwithcholangitis).
An urgent therapeutic ERCP may be needed and, if successful,
followed a day or so later by LC. Whether an early endoscopic
sphincterotomy to remove an impacted stone is beneficial in
aborting the episode of acute pancreatitis is controversial. Some
claimitis—ifperformedearlyenough(withinafewhours…)—but
try and find a center where patients undergo ERCP within a few
hoursaftertheirpainshavestarted?!
•
Nowadays,MRCPisagoodoption,selectingwhichpatientsneed
to undergo invasive ERCP before cholecystectomy. If normal you
canproceedwithLC.
Whattodowithpatientswithcomplicatedacutepancreatitis?You
surely do not want to operate on them. Treat conservatively as
describedin Chapter19.Delay thecholecystectomy untilpancreatitis
anditscomplicationsareresolved.
WhattodowithpatientswhoarenotfitforLC?Clearly,youdonot
havetorushwithLCinmedicallyunfitpatients.Letthemrecuperatefrom
the acute disease and try to improve their general condition before
proceedingwith cholecystectomy.Donote, however,thatsome patients
may suffer recurrent acute pancreatitis during the waiting period.
Anotheroption(asinhigh-riskpatientswithcholangitis)isERCP+S
—leavingthegallbladderinsitu. Nowthe stonescan entertheCBD
andrapidlyfallintotheduodenumwithoutproducingpancreatitis.Thisis
aviable optionon thevery old,frailandmedicallyunfit andit hasbeen
showntoreducetheriskofrecurrentacutepancreatitis.
Inshort:inmostpatientsletthepancreaticinflammationsubside,waitfortheCBDstones
topassspontaneouslyandthenremovethegallbladder.Somepatientsneedbileductimaging
andpossiblyERCPand sphincterotomy.Inafewpatientsyouwillhaveto wait longerforthe
acutepancreatitistoresolve.
Sothisis the end of the long spiel. You surely understand that there
aremanywaystocatchthefishandonehastofindthebestoptionfor
thespecificcasescenario.Thisiswhatwedidwhilewritingthechapter
—debatingtheoptimalapproach…( Figure20.6).
Figure20.6.DannyandMoshe in a typical biliary debate (with Pushkinsnoozingonthe
stairs).
“Themostimportantaiminthisoperationistonotinjure
theCBD,thesecondmostimportantaimistorelieveany
sepsis. The third — if it can be done safely — is to
removethegallbladder.”
KristofferLassen
1
TroublesinYiddish.
2
Schein’s Common Sense Prevention and Management of Surgical Complications.
Shrewsbury,UK:tfmpublishing,2013;Chapter16:315.
Chapter21
Smallbowelobstruction
MosheScheinandDannyRosin
It is less dangerous to leap from the Clifton Suspension
Bridge than to sufferfrom acute intestinal obstructionand
declineoperation.
FredrickTreves
Byfar,themostcommoncausesofsmallbowelobstruction(SBO)are
postoperative adhesions and hernias. Other less common mechanical
etiologiesarebolusobstruction(e.g.bezoar),malignant orinflammatory
(e.g. Crohn’s disease) or intussusception. Hernias causing SBO are
discussedinthe next chapter ( Chapter22) whileearly postoperative
small bowel obstruction (EPSBO) and paralytic ileus are discussed
elsewhere ( Chapter 45). For SBO developing in the aftermath of
bariatric abdominal surgery please consult Chapter 23 in our book on
surgical complications1. Mention will be made below of SBO in the
‘virgin’ abdomen, intussusception, the cancer patient, radiation enteritis
and gallstone ileus. Peritoneal tuberculosis as a cause of SBO is
mentioned in the chapter covering abdominal emergencies in Asia (
Chapter38,Section1).Thebulkofthischapteris,however,devoted
tothemostcommontypeofSBO—adhesiveSBO.
SirWilliamOslerusedtosaythat“intestinaladhesionsaretherefuge
of the diagnostically destitute” while the truth of the matter is that
iatrogenic surgeon-made adhesions are responsible formore thantwothirds of episodes of obstruction, whatever the exact mechanisms are,
but in the absence of obstruction they are NOT a cause of abdominal
pain. Remember, however, that upper abdominal, supracolic
procedures (e.g. cholecystectomy) are much less likely to be
associatedwithsmallboweladhesionsthaninfracolicones.Finally,
asyouarenotaninternist,wescarcelyneedremindyouthatadhesions
almostnever(neversayneverinsurgery)causecolonicobstruction.
Please note thatin this era oflaparoscopic surgery some patients
maynotvolunteerahistoryofprevioussurgeryandtheabdominalscaris
often almost invisible when the previous operation has been, say,
something as banal as laparoscopic tubal ligation. Banal — yes; but it
couldhavecreatedasingle‘band’adhesioncausingcompleteSBO.On
theotherhandtherisk ofadhesive obstructionis lowafter laparoscopy,
soassuming‘adhesion’(andtreatingconservatively)mayleadtomissed
pathology.ForthisreasonweprefertoconsiderSBOinpatientswith
ahistoryoflaparoscopicsurgerymorelikea‘virginabdomen’and
lookforadiagnosisbyCTscan—asdiscussedbelow.
Thedilemma
The majority of adhesive SBO patients (at least half of them,
perhaps many more) respond to conservative (non-operative)
treatment.Butperseveringwithconservativemanagementin SBOmay
delaytherecognitionofcompromised (strangulated)bowel,leadingtoa
poor outcome. Faced with this dilemma, your task is to resolve the
followingissues.
Which patients need an urgent laparotomy for impending or established bowel
strangulation?Andwhenisinitial,conservativetreatmentappropriateandsafe?
Once instituted, how long should conservative treatment be continued before an
operation is deemed necessary? In other words,
howdo you avoid an
operationwithoutriskingintestinalcompromise?
Allsurgeons acknowledge that symptoms and signssuggesting
that the bowel may be compromised call for an immediate
operation.Youknowthesigns—severeconstantpain,peritonealsigns
(but remember that distended loops of small bowel can be tender),
clinicalandlaboratoryfeaturesofSIRS,elevatedlacticacid,andsoforth.
However, surgeons across the world tend to offer a wide range of
opinionsastothedurationofnon-operativetherapybeforedeclaringthat
ithasfailed.Somestillpreachtheoutdateddictum“neverletthesunset
or rise over intestinal obstruction”, while others persist in avoiding an
operationseeminglyuntilthenextRamadanseasonorChristmas.
Weaimtoprovideyouwith guidelinestoanswerthesequestionsand
helpyoudevelopacommonsenseapproach.Butfirstweneedtoclarify
someterminology.
Definitions
•
Simpleobstruction: the bowelis blocked, compressed orkinked,
butitsvascularsupplyisnotthreatened.
•
Strangulationobstruction: the vascular supply to the segment of
obstructedboweliscompromised.
•
Closed-loopobstruction:asegmentofbowelisobstructedatboth
aproximalanddistalpoint—typicalexampleswouldbeavolvulus
or a loop of bowel incarcerated within a tight hernial defect.
Commonly,theinvolvedbowelisstrangulated.
Understanding the terms ‘partial’ versus ‘complete’ obstruction is
crucial to the planning of treatment. Some surgeons offer definitions
basedonsymptoms(mildvs. severe) which are notoriously inaccurate.
Others consider patients who pass flatus as having partial obstruction,
whereas to us the sound of farting is a happy indication that the
obstructionhasresolvedorisresolving.Webelievethatthebestwayto
distinguishbetween partialand completeSBO isradiology,startingwith
the humble plain abdominal X-ray, but better observed on the CT (
Chapter5):
•
Partial obstruction: there is gas seen in the colon, in addition to
smallboweldistensionwithfluidlevels.
Completeobstruction:nogasisseeninthecolon.
•
Most episodesof partial SBO will resolve without an operation,
while the majority of patients presenting with a complete
obstructionwillrequireone.
Clinicalfeatures( Figure21.1)
The three important clinical manifestations of SBO are colicky
abdominal pain, vomiting and abdominal distension. Constipation
andabsenceofflatusarerelativelylate symptomsofSBObutessential
forthediagnosis.Wearealwayssurprisedhowoftennon-surgeonsomit
askingthe patient“when wasthe lasttime yourbowelsmoved andyou
passedwind?” —calling youto “assessSBO”inpatientswith diarrhea,
onlybecauseafewloopsofsmallbowelwereseenontheabdominalXray…Remember:apatientwhocontinuestopassgasand/ormove
hisbowelisnotsufferingfromamechanicalSBO!
Figure21.1.“Isuspectthisisintestinalobstruction.ShouldwetryGastrografin®?”
The pattern of these features depends on the site, cause and
duration of the obstruction. For example, in proximal obstruction,
vomitingisprominentwhilepainanddistensionareabsentormild;asthe
levelofobstructiondescends,thecrampypainbecomesmoremarked.In
distalSBO,distension is a significant symptomwithvomiting appearing
later.Feculentvomitingisthehallmarkoflongstanding,distal,complete
SBOandischaracteristicofmassivebacterialovergrowthproximaltothe
obstruction(remember—themainbulkoffecesismadeofbacteria).It
is a poor prognostic sign — the more thick and smelly the
nasogastricaspirate, the lesschance thereis that the obstruction
willresolvespontaneously.Whenwesees***,sorry,feces coming
from the nasogastric (NG) tube we start preparing the patient for
surgery!
Istherestrangulation?
This is a crucial question. If it is “yes”, not only is an operation
compulsory, but it also needs to be performed promptly. The most
importantclinicalfeatureofstrangulationiscontinuouspain.Signs
ofperitonealirritation(guarding,reboundtenderness)maybepresentbut
rememberthat:
•
Deadbowelcanbepresentinarelatively‘innocent’abdomen.
•
Signs of peritoneal irritation are rarely useful in differentiating
‘simple’ obstruction from strangulation because they may also be
found in ‘simple’ SBO when the distension is severe. As we
mentionedabove,dilatedloopsof intestineare tender— youmust
surely have seen internists poking aggressively into distended
abdomens and diagnosing ‘peritonitis’ in patients suffering from
gastroenteritis?
What about lab tests? Obviously, features of an inflammatory
response (leukocytosis, raised CRP) or indicators of tissue ischemia
(elevated lactate, negative base excess or metabolic acidosis) point to
theexistenceofcompromisedbowel.Butneveruseanysuchtestsin
isolation. Look at thewhole clinical picture — the leukocytosisand
acidosismayimprove after the hypovolemic patient has received a few
litersoffluids. And the lactate levels maynotriseat all if any ischemic
segmentisshort.
Closedloopobstructionalwaysequalsstrangulation!Herealoopofbowelisobstructedat
bothends(volvulus)anditsbloodsupplyiscompromised.PlainabdominalX-rayiscommonly
misleadinginthissituation.Theintestineabovethecompromisedloopmaybefullofliquidand
thus appears opaque — all one sees is a single dilated loop of bowel (but CT would be
diagnostic).Patients with thistypeofobstructiontendtocryoutin pain — likeasiren!
Agonizingabdominalpainmaybethesinglemostimportantclueyouhave.
Having diagnosed strangulation, you will be congratulated forhaving
expeditiously resuscitated and wheeled your patient to the operating
room.However,saveyourselftheembarrassmentofexplaining,thenext
day, the presence of the long midline incision todeal with a knuckleof
ischemicgut trappedin thegroin! Neverforget thatacommoncause
of strangulated bowel is an external hernia. The suspicion of
strangulation must make you examine, or rather re-examine more
carefully,the fiveexternal hernialorifices: twoinguinal,twofemoraland
oneumbilical( Chapter22).Ohyes,dopulloffthosetightjeans—see
thatthepatientisundressedbeforeexamininghim.
Remember:Noisolatedclinicalfeatureorlaboratoryfindingcantellyouiftheintestine
isstrangulatedordead.Onlyfoolsletthemselvesbeguidedbylacticacidlevels.Donotwait
for fever, leukocytosis or acidosis to diagnose ischemic bowel, because when all these
systemicsignsarepresent,theintestineisalreadydead!
Bynowyouunderstandthatnothing,nothingcanaccuratelydistinguish
between ‘simple’ and ‘strangulating’ SBO. So how do you play itsafe?
Let’stakeastepbackanddiscussimaging…
Imaging
PlainabdominalX-rays
Соседние файлы в папке Библиотека им академика М.И. Перельмана