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aims to preserve the greatest possible length of viable intestine.
This concept, which in theory at least is attractive, motivates many
surgeonstore-exploretheirpatientsroutinelyafter24to48hours.Thisis
anideal situationfor an‘abbreviatedlaparotomy’at theinitial surgery.
Thesectionsofbowelthataredefinitely deadare excisedafter stapling
anddividingthe bowel. The stapled ends aresimplydroppedback into
theperitonealcavity.
A24-hourintervalallowsthepatient’sderangedphysiologytorecover
before a second look. The finding of completely normal bowel at
reoperation is of course reassuring and allows an anastomosis to be
fashioned with confidence (but the anastomosis may still leak 5 days
later).Ifyouplanasecond-lookoperationthereisnoneedtoclose
the abdomen at the end of the first procedure; instead, treat the
abdomenasalaparostomyuntilre-exploration,relievinganyintraabdominalhypertensiontoimprovemesentericbloodflowfurther.
Analternativewouldbetoclosetheabdomen,andperformasecondlooklaparoscopy (ifyou haveheard aboutleaving laparoscopicportsat
the first operation to be used the next day — just forget about this
unnecessarygimmick).
To sum up — it appears that in most patients a second-look
procedure is indicated, even in those who have a stoma but with
whomyouarenottotallyhappy.Thosewithviablestomas,whoare
otherwisewell,canbeobserved.However,wewouldnotsellthemany
lifeinsurancepolicyatthisstage.Inpatientswhoseischemiawasdueto
embolism,apostoperativesearchforsourcesofemboliseemsprudent.
Mesentericvenousthrombosis
In this rarer condition, the so-called ‘DVT of the abdomen’, the
venousoutflowofthebowelisoccluded.The clinicalpresentationis
less striking and non-specific. Abdominal pain and varying
gastrointestinal symptoms may last a few days until eventually the
intestinesarecompromisedandperitonealsignsdevelop.
Mesentericvenousthrombosismaybeidiopathic(i.e.thedoctorisan
idiot— ignorant oftheunderlying reason), butcommonly an underlying
hypercoagulable state (such as polycythemia rubra vera) or sluggish
portalflowduetohepaticcirrhosis,ispresent.Ithasalsobeendescribed
in the postoperative phase after upper abdominal procedures such as
splenectomy. It can be iatrogenic as well, due to operative injury and
ligationoftheSMV.
Typically,manyofthesepatientsareadmittedtothemedicalfloorwith
a surgeon consulted much later — to operate for non-viable bowel.
However,anearlytriptoacontrast-enhancedCTscanmayachieve
an earlier diagnosis, helping toavoid an operation altogether and
improvingsurvival.
CharacteristicfindingsonCTconsistofatriad:
Ahypodensityinthetrunkofthesuperiormesentericvein.
Associatedintraperitonealfluid.
Thickenedsegmentofsmallbowel.
Thus, anytime we review a CT in a patient with a non-specific
abdominalpicture(e.g.allegedileus),wemakethepointtolookatthe
SMV,andforcetheradiologisttolookatit.Remember:radiologistsread
numeorusimagesaday;ifyoudonotaskthemquestionstheycanmiss
significantfindings…
Withtheabovefindings, and in the absence of peritoneal signs,
full systemic anticoagulation with heparin may result in a
spontaneous resolution of the process. The role of systemic or
selectiveangiographicthrombolysisisnotclear. Failure to improve or
thedevelopmentofperitonealsignsmandatesanoperation.
At surgery, you’ll find some free serosanguinous peritoneal fluid; the
smallbowelwillbethick,edematous,darkbluebutnotfranklydead,with
the involved intestinal segment poorly demarcated. Arterial pulsations
will be present and thrombosed veins seen. You’ll need to resect
irretrievablyischemicbowel;gutofquestionableviabilitymaybeleftfora
‘second look’. As to whether or not to anastomose and theneed for a
secondlook—applythesamejudgmentasdiscussedaboveforarterial
insufficiency. Postoperative anticoagulation is mandatory to prevent
progressionofthethromboticprocess.Addingavenousthrombectomyis
advocatedby some, soisintra-operative thrombolysis; therealbenefits
ofthesecontroversialapproachesareunknown.
Tosumup…
Inmostplacesthe mortalityrateofacutemesentericischemiais
stillprohibitive.Why?Becausesurgeonsfailtodothefollowing:
Suspectischemiabeforeintestinalgangrenedevelops.
Proceedwithdiagnostic/therapeuticangiography.
Improveintestinalperfusionduringlaparotomy.
Exteriorizethebowelorexecuteasecond-lookoperation.
Sohereisthe‘catch22’:ifyouwishtoseesurvivorsofthishorrendous
condition you will have to be aggressive. On the other hand, the
presentationof thesepatientsis sonon-specific and,frequently,the CT
findingssosubtlethatifanaggressiveapproachistaken,manypatients
with self-limiting minor abdominal complaints will have unnecessary
investigations and operations, and yet cases will still be missed.
Furthermore, these patients rarely have simple pathology. They
commonlysufferfrommultisystemdiseaseandeveninreceiptofoptimal
caretheywillhaveahighmortality.Regrettably,inthemajorityofpatients
this condition seems likely to remain an agonal complaint. As our
mentorstaughtus:“youcan’tsave‘emall!”
“Themanisasoldashisarteries.”
ThomasSydenham
Chapter25
Hepaticemergencies
ErikSchadde
Theliverconfoundsthesurgeon’sdependenceonanatomy.
J.Foster
When I was an intern I overheard a mid-level resident saying to the
chief resident that there is a ‘liver patient’ in the emergency room. My
chiefresidentappearedgloomyandconcerned.Ididn’tunderstandwhat
‘liverpatient’referred to in this context.Everypatientintheemergency
roomhas aliver— aliver trauma?A livertumor? SoonIlearned: ‘liver
patient’ refers to those with chronic liver disease: cirrhosis and portal
hypertensionorafteralivertransplant.Inshort,anypatientwhobelongs
tothehepatologyserviceorisonthelivertransplantservice.
InthischapterIwilladdressfirsttheacuteproblemsarisinginthe
chronicliverpatient.Hepatictraumawillbeaddressednext.Finally,
I will look at somemiscellaneous conditions of the liverthat may
presentasanemergency.
The ‘liver patient’ — chronically diseased hepatic
parenchyma
Intheemergencyroom
The patients with chronic liver disease you are called to see in the
emergency room usually have one of two issues: either they have a
problemthattheinternistscannotmanageanymoreortheyareinsome
wayorother involvedwithlivertransplantation—thesurgicaltreatment
ofend-stageliverdisease sincethe 1980s.Itis importantthat thelatter
group of patients are seen by their respective transplant physicians:
decompensated patients on the liver transplant list might need to be
‘deactivated’ (i.e. removed from that holy list) and their MELD score
1
upgraded. Decompensated liver patients are generally managed by
internistsorevenbetter—hepatologists.
Varicealbleeding
Esophagealvaricesarethe source of upper gastrointestinal (GI)
bleeding in about 90% of patients with cirrhosis and portal
hypertension. The emergency room usually calls the interventional
gastroenterologist, who performs endoscopic variceal rubber band
ligationand(rarely)sclerotherapy.Iftheycan’tvisualizethebleedingand
controlit,you,thesurgeon,maybecalledandaskedwhetheryoucan
offer a surgical solution — an emergency surgical shunt for example.
Youranswer,however,shouldalwaysbe“no”!
The space that surgical shunt procedures still occupy in traditional
surgicaltextbooksisinverselycorrelatedwiththeiruseinreallife.While
youknowthatsurgeryinthissituationisoutofthequestionbecauseyou
willnotfindthesourceofbleedingbyperformingalaparotomybutalmost
certainlybringthepatienttothevergeofdeath,yoursurgicaladviceis
still needed: remember that there is still a minority of patients in
whom the upper GI bleeding is caused by peptic ulcers, MalloryWeisstearsorDieulafoylesionsandnotvaricealdisease—despite
theircirrhosisandportalhypertension.
Your advice should be to perform another round of gastric irrigation
and another endoscopy. You may improve conditions with two simple
interventions before the second endoscopy: i.v. administration of
somatostatin (or equivalent terlipressin) and forced gastric emptying
usingerythromycinandwait30minutes.Ifthisfailsagain—movetothe
angiography suite to perform an emergency TIPS (transjugular
intrahepatic portosystemic shunt) procedure. The TIPS creates a
connection between the hepatic vein and the portal vein to provide
centraldecompressionofthehypertensiveportalvenoussystem.Itmay
increase pre-existing encephalopathy or lead to new-onset
encephalopathy and therefore the indication has to be carefully
considered. In Child-Pugh C cirrhosis (see Table 25.1) patients with
elevatedbilirubin>10mg/dL(171μmol/L)undergoingTIPS,thereisareal
risk that the liver will decompensate. But when sclerotherapy and
variceal banding fail twice, it is the logical next step in an
emergencydespitethisrisk.
However, you might become a little bit more involved if your
interventional radiologist does not routinely do TIPS or (even better…
and more common) there is nobodyaround whohas everheard about
TIPS.Yourhemorrhagingpatientwillhavetobetransferredtoadifferent
center(only God canhelpthe patient ifsucha center doesnotexist in
your country) and a balloon tamponade will be necessary to
temporizethesituation—anditispossiblethatyourgastroenterologist
willneed yourassistancefor that.It israrenowadays tofind any board
certifiedsurgeonwho hasplacedmorethana few,ifany,balloontubes
(Sengstaken-BlakemoreorLinton-Nachlas)inhislife,soherebeloware
afewwordsaboutthetechnique.
Advice on the technique of esophageal balloon catheter
placement:
•
Make sure youinsert balloon tubes onlyafter the patienthas
beenintubatedandtheairwayisprotected.(BTW,patientswith
massiveupperGIhemorrhageshould havealreadybeenintubated
fortheendoscopy.)
•
Findoutwhattypeofballoontubeyouhaveavailable,takethetime
tounderstandthedifferentaccesschannelsandthedifferentballoon
tubes, and test the integrity of the balloons in a small bucket of
water. Itis useful to keep the balloons in the freezer, as it makes
themrigidandeasiertoinsert.
•
Insert the tube with the help of a laryngoscope and a Magill’s
forceps, or — even better — side-by-side with endoscopic
assistance, because your endoscopist is already there. Test the
positionofthegastriclumenwithastethoscope,aswithanNGtube.
IfindoubtaboutthepositiongetanX-ray.
•
Insufflatethegastricballoonstepwisetoa200-250ccfinalvolume;if
necessary stop and readjust if there is resistance. (I recently
admitted an unstable cirrhotic patient with a balloon tube from an
outsidehospital.Hehadatorngastroesophagealjunctionanddied
after salvage surgery.) Adjust thetension to the gastroesophageal
junction by fixingthe tube to the patient (not to the bed), with the
splittennis-ball technique — using a‘biteblock’toprovide counter
resistance.
•
If the patientstabilizes, don’t inflate the esophageal balloon ifyou
have a Senkstaken-Blakemore tube (the Linton-Nachlas doesn’t
have an esophageal balloon, which is why I prefer it — Figure
25.1), but leave it alone.In the vast majority of cases there is no
needtoinflatetheesophagealballoon.Butifyougettheimpression
that the esophageal bleeding hasn’t stopped, connect the
esophagealballoon(withathree-waystopcock)toamanometerand
donotinflateabove35mmHg.
•
Ifthepatientdoesnotstabilize,deflatetheballoon,performanother
endoscopyandifvisualizationisstillbad,performaCTarteriogram
or regular arteriogram, because you might be dealing with a
bleedingpepticulceroraDieulafoygastriclesion.
Figure25.1.Sengstaken-Blakemorevs.Linton-Nachlastubes.
Theesophageal‘hemostatic’stent
Patients do not always survive the ordeal. And there remain difficult
decisions further down the road from this emergency. For example, a
massive hemorrhage from an ulcer developing at the banded variceal
site.Inthissituationwehaveadvocatedanewlyavailablevaricealstent.
Originallydesignedforblindinsertionintheambulance,itwas,however,
neverusedin thatsetting.Butinthe emergencyroomafterintubationit
may be a promising option to stop esophagealbleeding from ulcers or
varices in severe reflux esophagitis, where rubber bands are not
applicable.The devicecomeswith atemporary Linton balloonto define
the esophagogastric junction. The device is introduced over an
endoscopically-placed guidewire. Having inflated the gastric balloon,
under gentle traction, the large (30 x 135mm) covered self-expanding
metalstentisreleased( Figure25.2).Thestentcanbeleftinplacefor1
week.Inmostcasesthistimeintervalisenoughtocomeupwithabetter
treatmentplan…
Figure25.2.Theesophagealhemostaticstent.PromotedandintroducedtomebyChristoph
Gubler,MD,attheUniversityHospitalofZurich.
The patient with cirrhosis and portal hypertension who
needsemergencygeneralsurgery
Theliverpatientdoesnotmakeanattractivesurgicalcandidate—for
any surgery except for one operation; that in which you exchange the
diseased liver with a new, transplanted one. Therefore, all surgery
shouldbeavoidedifpossible;evenadentalproceduremayendup
withabloodtransfusionduetocoagulopathy.However,liverpatients
not infrequently present with general surgery emergencies and those
needtobeaddressed.
Atime-honoredandwell-validatedtooltoassesstheriskofliver
patients is the Child-Pugh Score ( Table 25.1). Although initially
developedinthecontextofsurgeryforportalhypertension,thescorehas
been useful to generations of surgeons to assess the mortality risk of
chronic liver patients undergoing anything from a hernia repair to a
Whippleprocedure.
The score categorizes patients in Child A as those with an
acceptable risk for any general surgery procedure; Child B as those
wheretheindicationshavetobeveryselectiveduetoanincreasedrisk
ofdecompensation;andChildCas those whoshouldnot undergoany
procedure due to veryhigh mortality. Thescore is useful, even though
some of the parameters assessed depend on the clinician’s subjective
judgment. Some authors prefer the MELD score — consisting of three
laboratory values (International Normalized Ratio [INR], bilirubin and
creatinine) and which reflects 3-month mortality on the liver transplant
waitinglist.Manypapershavebeenwrittenonwhichscoreisbetterbut
they don’t pay attention to the fact that the value of the score derives
fromthewayitisused.TheMELDscore( Figure25.3)wasintroduced
to rationalize organ utilization among centers who ‘cheated’ by
transplanting patients who were less sick than others. Such a score
indeed requires minimal subjective judgment. To judge the severity of
liver disease for everyday use and put your patient into one of these
three categories, the Child score is perfect and doesn’t need any
improvement. There are some tools that can hardly be improved
upon,suchashammers—theChildscoreissuchatool.
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