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51. Winzer R, Fedders D, Backes M, Ittermann T, Gründling M, Mensel B, Held H, Kromrey
M, Weitz J, Hoffmann R, Bülow R, Kühn J.Local intra-arterial vasodilator infusion in nonocclusive mesenteric ischemia signicantly increases survival rate. Cardiovasc Interv Radiol.
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56. Hayashi K, Hayashi K, Narita M, Tsunoda A, Kusanagi H.Still time to perform intestinal
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L. R. Howroyd et al.
Chapter 27
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Options onConservative Treatment
inAcute Surgical Emergencies
LeandroStollCoelho, ViniciusRocha-Santos, andJoelFaintuch
Introduction
Along surgical history, decreasing tissue damage through less invasive techniques
was always on the scope of the surgeons. Approaches never dreamed before like
laparoscopic surgery, image guided percutaneous procedures, angioembolizations
to treat aneurisms and hemorrhage, and the cutting-edge technology of robotic
assisted surgery remarkably contributed to lessen tissue damage and consequently
the immune and metabolic response to trauma, with the same safety and efcacy as
conventional open surgeries. The Hippocratic motto primum non nocere worked
like a moral compass. It probably played a major role on the mental drive of surgeons committed to good medical practice, pushing toward the use of minimally
invasive techniques, in order to keep risks and complications at bay.
Can we go further and take one more step into non-invasiveness? Is there any more
room for conservative treatment within contexts in which surgery would be rst choice?
High-denition imaging devices like CT scan, MRI, advanced ultrasound, and PET
scan, complemented by cutting-edge PET/MRI, laser-CT scan, laser ultrasound, and
Reproduced from Acute Care Surgery in Geriatric Patients , Petrone P (ed), Springer, 2024, as
granted by Springer Bookpermissions on March 31, 2023
L. S. Coelho
Regional Hospital of Registro, Sao Paulo and Regional Hospital Dr. Leopoldo Bevilacqua,
Pariquera-Acu, Sao Paulo, Brazil
V. Rocha-Santos
Liver Transplantation Unit, Gastroenterology Division, University of Sao Paulo,
Sao Paulo, Brazil
e-mail: vinicius.rocha@hc.fm.usp.br
J. Faintuch (
Department of Gastroenterology, Sao Paulo University Medical School, Sao Paulo, Brazil
e-mail: j.faintuch@hc.fm.usp.br
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_27
*)
457© The Author(s), under exclusive license to Springer Nature
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L. S. Coelho et al.
Table 27.1
Intensive monitoring (invasive and noninvasive)
Hemodynamic, respiratory, gastrointestinal, neurological
Clinical management
Fluid replenishment, shock management, coagulation factors, antibiotics, antacids,
Interventional radiology
Drainage, embolization, stenting, clot removal
Local bleeding control
Abdominal or thoracic packing, brin glue, and hemostatic patches
Endoscopic maneuvers
Blood vessel sclerosis, stricture dilatation, obstruction stenting, collection drainage,
Hyperbaric oxygen therapy
Refractory anaerobic infections, ischemic lesions and grafts, necrotic wounds
Other options (benign and cancerous lesions)
Radiofrequency ablation
Laser hemostasis
Cryotherapy
Conservative pathways for traditional surgical emergencies
hormones
visceral by-pass, stula occluders, and sponges
endoscopic ultrasound, are making it possible to access body structures with unparalleled precision and reliability, allowing the surgeon to feel more condent with periodic
surveillance only. They enabled multiple conservative changes in the handling of traumatic and nontraumatic disorders of gastrointestinal, biliopancreatic, and colorectal
viscera. In such circumstances the otherwise uncontested immediate surgical indication
gave place to less invasive or completely conservative options (Table27.1).
Gastroduodenal Problems
Complications of peptic ulcers such as perforation, bleeding, or obstruction have
become much less common after the advent of H2 receptor antagonists and notably
proton pump inhibitors, associated with wider employment of endoscopy and breath
tests which increased Helicobacter pylori diagnosis and treatment. Medical and endoscopic treatment is nowadays, by far, the best option of treatment for peptic disease,
even in the face of complications such as partial obstruction and limited hemorrhage.
Perforated Peptic Ulcer
One should admit that acute abdomen caused by ulcer perforation, although infrequent still carries serious morbidity, mainly in those with associated health conditions including the elderly patients. Surgical repair is the best option in most cases;
however in selected patients conservative management is possible.
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According to some sources, in 1870 Redwood reported a patient successfully
treated without surgical intervention. It is true that at those early times surgical
mortality was so prohibitive that not operating, although fraught with obvious danger, seemed rather natural. Yet even in the rst half of the twentieth century with a
number of advances in anesthesia, blood and uid replacement, and antibacterial
sulfonamide drugs, Wangensteen defended nonsurgical treatment after spontaneous
healing of a perforated ulcer. Taylor rst reported a series of 28 patients receiving
non-operative management in 1946 naming it the Taylor method, which consisted
of nasogastric aspiration, antibiotic therapy, and intravenous uid replacement.
More recently Helicobacter Pylori eradication was added to that therapeutic protocol [1].
The Taylor rationale is based on gastric decompression and continuous external
drainage which promotes healing. Of course nutritional support was the weak point,
in case a prolonged fasting period was required, as modern enteral and parenteral
nutrition were not available in the 1940s. Nevertheless Edward Crisp in 1843 had
already noticed that inammatory adhesions and adjacent tissues often blocked perforated ulcers after just a few days, thus preventing uids spreading into peritoneal
cavity. A much more recent French prospective study published by Songne etal.
demonstrated a 50% success rate of conservative treatment in a series of 82 consecutive patients.
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Clinical Phases ofAcute Perforated Ulcer
Phase 1: Chemical peritonitis caused by gastric acid. The leaked uids have rela-
tively scarce bacteria.
Phase 2: Occurs 6–12h after the perforation. Pain diminishes somewhat probably
due to dilution of the irritating gastric contents by the peritoneal exudates.
Phase 3: Peritoneal infection. Occurs after 12–24h, whereas bacterial growth and
sepsis are the main features [2].
Eligibility toNon-operative Treatment
The candidate should be within the rst 12h after symptom onset, a period in which
the abdomen is still sterile or minimal bacterial contamination is present, abdominal
pain is limited to the upper abdomen, and hemodynamic variables are stable. Oral
food and uids should be discontinued and a decompressive gastric tube must be
used to prevent additional gastric content leak. Intravenous uids, antibiotics, and
injectable proton pump inhibitors must be started. Close surveillance comprising
vital signs, physical examination, and pain evaluation at least every 6h is of vital
importance.
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Upon signs of hemodynamic instability, worsening of pain suggestive of generalized peritonitis, or any other clinical deterioration, the patient should be taken to the
operating room to be surgically treated, preferentially by the laparoscopic approach.
Special attention must be given to frail or elderly individuals in whom proportionally minor cardiac, circulatory, or metabolic imbalances could be life-threatening.
In principle those admitted with signs of shock, tachycardia, hypotension, generalized peritonitis, fever, or history of onset of symptoms longer than 12h should not
undergo conservative treatment.
L. S. Coelho et al.
Endoscopic Closure ofthePerforation
Over-the-scope-clips (OTSC) are a recent attempt to close the ulcer through an
endoscopic approach. It is minimally invasive and takes little time (around 10min)
[3]. The peritoneal cavity is supposed not to be infected, otherwise, surgical treatment is the best option. Further prospective randomized studies must be conducted
as current evidence is limited.
Acute Appendicitis
With a lifetime risk ranging from 7% to 8%, acute appendicitis is the most common
surgical emergency and the most frequent cause of surgical acute abdomen worldwide. McBurney was the rst to describe appendectomy in 1894 and the classical
abdominal incision bears his name. The laparoscopic approach is related to less
wound infections, less postoperative morbidity, shorter hospital stays, and better
quality of life, being recommended by the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) and the European Association for Endoscopic
Surgery (EAES) as the gold standard. Mortality of appendectomy is lower than in
the past however not negligible, around 0.5%.
Non-operative Handling
Harrington in 1953 and Coldrey in 1959 were among the rst to advocate nonoperative treatment. Coldrey reported 471 patients treated with antibiotics suffering
low mortality (0.2%) and low recurrence rate (14%). Such success notwithstanding,
very few followed his lead.
The advantages of conservative treatment would be no wound infection, adhesions, and incisional hernias. Anesthesia-associated risks would also be excluded
which could play a positive role on comorbid patients. Furthermore, it presumes
shorter hospital stays, lower costs, and shorter absences from work. Failure of
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antibiotic therapy should not be overlooked, exposing the patient to complicated
appendicitis including perforation, fecal peritonitis, and sepsis leading to greater
morbidity and mortality. Moreover without removal of the diseased organ, the lifetime risk of appendicitis would remain. Another risk for prolonged use of antibiotics
during acute appendicitis would be bacterial resistance.
In the meta-analysis conducted by Prechal, 63% of the non-operated patients
were successfully treated within the rst year of follow-up. In the surgical (control)
group, the success rate was 96%. In the patients who needed secondary appendectomy for failure of antibiotic treatment, the complications were statistically the
same as from primary appendectomy. There was no difference in the duration of
hospital stay, and absence of work was signicantly shorter in the antibiotic group.
Surgery provided denitive cure however the conservative did not expose the
patients to increased risk.
Long-term effects of nonsurgical antibiotic therapy need to be further studied.
The incidence of cancer in uncomplicated appendicitis is very low; however, it still
has to be taken into account as it can play a role in prognosis. Given the higher rate
of failure of conservative treatment and of recurrence [2], the indication for conservative treatment in this setting should be tailored according to the patient’s needs
and expectations.
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Colonoscopy Perforation
Colonoscopy is a widely performed procedure throughout the world, with over 15
million yearly interventions just in the USA.Although safe and with minimal associated morbidity the technique is not risk-free. Iatrogenic colon perforation (ICP) is
probably the most dreaded complication for patients undergoing diagnostic screening or therapy. Reported frequencies are 0.019–0.8% and 0.1–3.0% for diagnostic
and therapeutic colonoscopy, respectively. This complication can lead to prolonged
hospital stay, emergency surgery with or without a stoma, and sepsis. Mortality
range is 5–7% and up to one-third of those requiring operation get a stoma.
Therapeutic colonoscopies have a higher probability of perforation both because
they may deal with an already diseased organ, and on account of occasionally complex manipulations. Other aspects contributing to colon perforation include pneumatic dilatation of strictures in Crohn’s disease, advanced age (over 75 years),
endoscopic mucosal and submucosal dissection for colorectal neoplasia, multiple
comorbidities, and female gender.
Up to 60% of ICPs are promptly detected by the endoscopist [4], such as when
an intraperitoneal structure appears on the screen during endoscopic examination.
Abdominal pain (up to 95% of the cases) and deranged laboratory and radiologic
tests demand urgent awareness and should be actively investigated in suspicious
circumstances. Such encompass distention, rebound tenderness, fever, diffuse peritonitis, tachycardia, rectal bleeding, along with elevated white blood cell count and
C-reactive protein and pneumoperitoneum. If suspicion of perforation persists,
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computed tomography scan should be done as it can detect not only free air, but also
free uid. Double contrast tomographic colonic imaging (intravenous and rectal)
sometimes demonstrates sealed perforations, which may be eligible for nonoperative treatment [5].
Signs of sepsis or diffuse peritonitis, immunosuppressed individuals, large perforations (such as those easily identied by the endoscopist during the primary
examination), or those related to cancer almost invariably demand immediate
surgery.
L. S. Coelho et al.
Conservative Treatment
Localized pain, free air but no free uids in the abdominal cavity, hemodynamic
stability, and absence of fever are usually associated with good prognosis without
operation. Intravenous uids and nutrients, bowel rest, and broad-spectrum antibiotics are mandatory along with close clinical and laboratory surveillance. If the pneumoperitoneum impairs respiration it should be percutaneously needle- or
catheter-drained, a maneuver that could help closing the perforation [5]. Initial
improvement does not rule out the need for subsequent surgery, therefore the patient
should be monitored for several days in the hospital. This means a longer total hospital stay than when primary operation is conducted [4].
Endoluminal Repair
Endoscopic treatment is a minimally invasive and effective alternative. Ideally the
damage should be recognized during the procedure and bowel preparation should
be adequate. Clip closures are reported since 1997, sealing and healing perforations
without surgery [4
scope clips (OTSC) are highly successful in closing ICP . Perforations larger than
1 cm are better treated with such modality which includes more tissue within
the clips.
Through-the-scope clips are used primarily for hemostasis; however, they are
able to seal full thickness perforations as well. Yet because of the smaller size only
submucosa and mucosa tend to be reached. Nevertheless with small defects success
rates as encouraging as of 84% have been demonstrated.
If OTSC is the option, a more difcult advance of the colonoscope mounted with
the OTSC system could occur in the right colon; however, not in more distal parts
of the large bowel. Such barrier notwithstanding, given the overall high success
rates in treating ICP, the OTSC system might become the standard approach for this
lesion in the near future.
]. Devices such as through-the-scope (TTS) clips and over-the-
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Endoscopic Band Closure
Band-ligation technique was also reported as a method of closing small perforations
when the use of an endoscopic clip is difcult. Surrounding tissue and the perforation site are sucked into the banding cap and the band is deployed as usual.
Post-endoscopy management of an ICP should include broad-spectrum antibiotics and bowel rest. A close surveillance is important to prevent clinical deterioration, and surgery must be carried out if severe abdominal pain, peritonitis, or
sepsis ensues.
Acute Diverticulitis
Diverticulosis of the sigmoid colon is common in the elderly, affecting approximately 33% of persons older than 60years of which up to 15% will proceed with an
episode of diverticulitis [6]. According to some groups acute diverticulitis is increasing more swiftly than the expected aging of the population, as much as 26% between
1998 and 2005. Complicated diverticulitis can include abscess, stula, stricture, and
partially blocked or free perforation. For a long time treatment of acute diverticulitis
with extraluminal air has been emergent resection with or without colostomy, which
is associated with high morbidity and mortality (40–44% and 4–24%, respectively).
Fortunately recurrence rates are lower compared to younger patients, those free
from recurrence representing 83% of those>67years of age [7].
Non-operative Treatment
Acute left colon diverticulitis (ALCD) is associated with abscess in 20% of the
cases. For small collections recommendation is broad-spectrum antibiotic therapy
with close clinical monitoring. This approach has a failure rate of 19% if the median
size is 4cm. Larger abscesses are best handled by percutaneous drainage associated
with antibiotics, which still carries a failure rate of 21% for abscesses with a median
size of 6.1cm. Surgery should be avoided in stable, younger patients, becoming
more urgent in the elderly whenever refractory to the conservative approach, as it is
associated with higher mortality [7].
In circumstances of distant free intraperitoneal air and no intraperitoneal uid,
non-operative management is still a possibility if hemodynamic stability and no
signs of sepsis are conrmed. The failure rate ranges from 10 to 43%, and experience with the elderly is limited [7]. With just about 2cm of air in the absence of
peritonitis or uid effusions, 86% success rate and no mortality have been observed.
If pericolic air only is detected, as much as 99% healing could be possible.
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L. S. Coelho et al.
Trauma—Spleen
The spleen is involved in around 32% of the events of major abdominal trauma.
Over the last 40years, splenic injuries evolved from a mainly surgical to a fundamentally non-operative management (NOM) aiming at spleen conservation in
hemodynamically stable patients, thus preventing long-term risks of splenectomy
[8] which include immunological impairment and lifelong threat of severe infectious diseases. Moreover, NOM avoids anesthesia, operation, and complication
costs and success rate can be as high as 97%, especially with lower injury grades.
NOM is also associated with a shorter hospitalization period, thus has become the
gold standard for blunt spleen trauma in hemodynamically stable patients, in the
absence of peritonitis or associated injuries requiring laparotomy [9].
Conservative and Minimally Invasive Treatment
It includes clinical and hemodynamic observation with or without angiography and
embolization. For planning NOM, contrast-enhanced CT scan is crucial in grading
lesions with sensitivity and specicity around 96–100% [9]. NOM should only be
attempted in centers capable of precise diagnosis of the severity of spleen and other
injuries and around-the-clock management including close observation, with intensive care and surgery team easily available.
NOM is classically indicated for minor and moderate spleen lesions, as scored
according to the World Society of Emergency Surgery/WSES or the American
Association for the Surgery of Trauma/AAST (WSES I, AAST-II/WSES II, AAST
III). If a positive blush or early aneurism is present in CT scan angiography should
be considered, as those ndings are risk factors for re-bleeding. NOM failure rate
ranges from 4% to 15%. Age over 55years is a risk factor for NOM failure which is
associated with a higher mortality and longer hospital stay [9], even though the
spleen tends to shrink with aging and thus be less vascularized, within the framework of generalized atrophy of immune tissues in the elderly.
Angioembolization
If moderate lesions (WSES III/AAST IV-V) are selected for NOM angiography/
angioembolization (AG/AE) is advised regardless of a CT blush. In AAST injury
grades above IV, the failure rate of NOM may reach 54.6% [9]. AG/AE has become
a powerful ally for spleen trauma treatment enhancing success up to 86–100%. The
earlier AG/AE is performed, the lower are the splenectomy odds. NOM failure in
the presence of CT contrast blush ranges between 67% and 82% so AG/AE is mandatory in those cases. Nevertheless AG/AE is not complication-free, encompassing
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major troubles (3.7–28.5%) such as re-bleeding, splenic infarction, splenic abscess,
pseudocyst, and severe puncture-related complications, especially when conducted
by non-specialized teams or in not well-equipped units. Minor morbidity occurs in
23% to 61% of the candidates including fever, pleural effusion, and coil migration [9].
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Liver Trauma
Because of its large size and location in the upper part of the abdomen, the liver is
one of the most affected organs by abdominal trauma, both penetrating and blunt,
and its rich vascular nature makes it a source of potentially fatal hemorrhage.
Analogous to spleen injuries, NOM depends on grading of the damage by
contrast- enhanced CT scan (gold standard). Hemodynamic stability is mandatory
for such option as well as no other abdominal injuries requiring surgical treatment
like hollow viscus perforation.
Around 80% of blunt hepatic trauma can be conservatively treated and NOM is
similarly the treatment of choice for stable patients with stab and gunshot wounds
[10]. This applies to liver injuries graded as minor or moderate (WSES I–II and
AAST I, II and III), for which success rate reaches around 80% if all modalities of
hepatic trauma are considered. For stab wounds more failures are to be expected
(50% need for interventions if anterior lesions and 25% if posterior ones).
Clinical and hemodynamic monitoring follows the lines of splenic injuries.
Special attention should be given to gunshot wounds as they carry a higher risk of
associated lesions and should be conservatively treated only in specialized trauma
centers [11].
Angiography/angioembolization should be employed when a contrast blush or
early aneurism is present. If NOM is selected for more severe lesions (WSES III and
AAST IV-V), admission to the ICU is advised [10]. Interventional radiology should
be readily available as additional vascular damage could be present. Drops in hematocrit levels even in the absence of shock should raise the suspicion of active bleeding and immediate angiography should be considered.
As in other contexts angioembolization is occasionally followed by adverse
events nominally bile leak, contained biloma, hepatic necrosis, and hepatic abscess.
Pancreatic Trauma
It occurs in less than 1% of all traumas and up to 11% of abdominal trauma. Blunt
injuries are the most frequent ones [12]. Their importance stems from the high risk
of complications and death. Given the limited experience in most centers, treatment
of moderate and severe pancreatic injury (PI) is still a topic of debate. Lesions
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