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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1100_Библиотеки_им_академика_М_И_Перельмана.pdf
476 M. F. Brennan
Discussion of Unresectability or Metastatic Disease that Precludes Resection
Much of this can be anticipated if one characterizes the potential duration of the intended procedure. The simple approach of preemptively
defining that “finding of disease spread outside
of the primary site will mean that I cannot and
should not proceed to remove the tumor. This
will mean a much shorter procedure.” Often this
concept is not understood and so any ability to
explain prior to the procedure that an operation
that fails to remove the entire visible tumor does
not help the patient is a preemptive strike that improves understanding.
Discussion of a Postoperative Complication
The defined willingness to let the patient and his
or her family understand when you will make
rounds each day is most valuable. It can preclude
much anxiety and many unnecessary phone calls.
If you are organized and your staff and office
support understand that on each nonoperative
day you will make rounds at a specified time,
the family can be encouraged to be present and
efficient communication of information readily
delivered. If you are concerned about the progress that the patient is making, that should be
conveyed prior to the identification of a defined
complication. The willingness to convey that you
are concerned that the patient is not recovering
as fast as one had hoped often sets the stage for
understanding of any potential situation particularly for other invasive procedures such as interventional radiology. It is far better to convey that
you are concerned and have the patient improve
the next day than to be happily reassuring the patient and the family that everything is fine only
to have a major complication occur and appear to
be completely unanticipated by the surgical team.
Genuine concern equates with empathetic care.
Discussion of the Unanticipated Major Postoperative Complication
Often the scenario occurs outside of the normal
working day and is precipitated by some untoward event that results in the need for resuscitation or intubation and the direct admission to the
intensive care unit. On all occasions, the family
understands the seriousness of being transferred
from the floor to the Intensive Care Unit (ICU).
The ability of the primary responsible surgeon
to convey that information is important but not
always possible. Most importantly, once such
an event occurs and the patient is in the ICU,
a formal meeting with the family as early as is
possible is crucial. This needs to be led by the
responsible surgeon, requires the responsible
intensivist and his or her staff to be present so
as to ensure that only one definable message is
identified. Nothing creates greater anxiety and
potential for a subsequent lawsuit than for the
communication to be poor or for communication
from junior members of the staff to be in sharp
contradistinction to that provided by the senior
staff. It is essential in the absence of the family
to discuss with the responsible intensivist and
his or her staff just what you anticipate and what
you will convey to the family. There should be no
attempt to hide the realities of the situation, but
everyone will perform better if given an awareness of what is and is not the issue. In institutions
where the intensive care unit is not controlled by
surgeons, this can be a complicating matter not
readily understood by those not intimately involved with major unanticipated and catastrophic
postoperative complications. The attributions of
hemodynamic, respiratory or renal failure, to pulmonary embolus, cardiac ischemia or drug toxicity, following a major intraabdominal procedure,
should always be questioned. Much more likely
is that the instability is a sign of an underlying
intraabdominal event. Resolution of organ failure
will be difficult or impossible if the underlying
cause is not addressed. How many times have
you seen the first manifestation of an anastomotic leak, be an arrhythmia, hypoxia, or decreased
renal output!
47745 Delivering Bad News: Conversations with My Surgeon
Discussion of Operative Findings
Every patient and their family deserve a clear
enunciation of the findings and clear description
of what was performed. The extent to which this
is provided will vary from patient to patient and
provides an opportunity to set the stage for what
can be anticipated at the time of the pathology report. If tumor was left behind, there is no advantage to pretend that the scenario was better than
it really was. “The surgeon said he got it all,”
should never be implied if known to be untrue, or
if positive residual even microscopic disease is
anticipated. Even if complete resection has been
obtained but discontiguous disease was identified
and the risk of subsequent recurrence is known
to be high, that too should be conveyed, not in
fatalistic terms but in realistic terms as to what
the consequences are. Such discussions are often
held better at the bedside on day 1 or 2 predicated
by, “Let me tell you what we found at the time
of operation.” If that can be done with the family present and with the senior resident or fellow
helping to care for the patient, then no confusion
should occur. Currently many operative reports
are synoptic; they define the “bare facts” and
may not convey the complexities seen in a verbose descriptive report. Verbal communication
of the operative findings thereby assumes greater
importance.
The Need for Reoperation
Return of the postoperative patient to the operating room, no matter how appropriate, is perceived
as a failure of the first procedure. We should accept that as correct, not that anything was done
with malicious intent, but to think everything
would always proceed satisfactorily on the first
occasion is not realistic. If there is any thought
at the time of leaving the operating room that a
future operation or reoperation is anticipated, that
should be conveyed to the patient, and the family
immediately. It is invariably better to convey the
possibility of a further procedure being required
than the converse. Today reoperation is less common than in the past because of the availability
of sophisticated imaging and the ability of interventional radiologists to address issues that previously required a return to the operating room.
On occasions, an interventional radiological procedure does not solve the problem. It is far better
to forewarn the patient that they are going for an
interventional radiology (IR) procedure with an
understanding that if that should not be successful then further operation will be contemplated.
When major IR procedures are performed,
having a member of the surgical team, known by
the patient, accompany the patient to the imaging suite is great reassurance. The appearance of
the senior surgeon at the time of such procedure
to convey the intent of the intervention to the
interventionist colleague is most valuable. That
the family sees the surgeon entering the IR suite
is both reassuring and emphasizes the care intended. A similar explanation by the surgeon (not
the most junior IR staff) of the findings and consequences of a procedure can do much to retain
patient and family confidence.
A frank and honest appraisal of the need for
reoperation will be appreciated and understood.
If there is uncertainty as to the operative findings,
then that should be conveyed. The communication that you care for and are worried about the
patient and are taking them back to the operating
room because of your concern that some problem has occurred related to the procedure you
performed but not necessarily caused is far better
than trying to explain subsequently why nothing
was found and why you took the patient to the
operating room.
Complications that Occur in your Absence from the Hospital
This is a most challenging event. We all have
demands placed on us by commitments to other
professional societies and our families that necessitate at least sometime where we are not directly
seeing the patient on a daily basis or being directly involved in their care. Preparation for your
absence should be discussed freely. The patient
should know before they agree to an operation if
you are not going to be there in the days follow-
478 M. F. Brennan
ing the procedure, even to the extent that you can
offer to reschedule if there is sufficient patient or
family concern as to consequences of your absence. The informed patient or family may have
already established your future absence with
your staff. For patients to discover that subsequent to the procedure is perceived as deliberate
obfuscation.
Judicious decisions as to the nature of operations that you would do when you anticipate
being away from the institution for any length of
time following them should always be made. It is
not appropriate to do a high-risk procedure which
becomes prolonged when you have an evening
flight. Such behavior only engenders enmity and
should a complication occur, is an almost certain
prescription for a lawsuit.
Complications do occur in your absence, and
the patient should be made aware prior to your
leaving just exactly who is covering you, who
can be anticipated to see them on a daily basis,
and be made aware that you will continue to be
in communication. Whenever possible, making
rounds prior to your departure and introducing
the patient to your colleague is a sensitive and
important anticipatory event. The somewhat light
hearted, “If I was sick, Dr. X is who I would have
care for me,” is valuable. A simple note in the
medical record the morning of your departure,
describing the anticipated progress and formally
identifying the senior surgeon covering you, is
essential. With modern communication, it is very
simple to be sure that you are completely in touch
with your patients. A phone call from you to the
patient or the family from a remote site to say
that you are aware of what is taking place and
reinforcing your agreement with the manner with
which the complication is being managed can
defer both anxiety and unhappiness.
in discussions of withdrawal of active intervention is often being supplanted by the fact that the
patient is in the intensive care unit and can be
maintained on life support, even when that may
not be in the patient’s best interest and may have
no possible hope of ever being reversed. The involvement of the primary surgeon in these decisions should be mandatory. No one should know
the patient better than the person who first made
the diagnosis, brought them to the operation, and
performed the initial procedure. The willingness
of surgeons to assume this role is progressively
diminished. This, I believe, is a great retrograde
step. The patient trusted you enough to place his
or her life in your hands; you should be strong
and willing enough to assume the responsibility
when therapeutic measures are futile. The religious and ethnic mores of each patient have to
be considered in such discussion. As has been reiterated, preparation for this event is the way in
which it is made easier. An awareness of the facts
that confront the patient, that is, the likelihood of
the patient ever leaving the hospital, can be readily described in general, although statistically
precise terms for the individual family member
may be difficult. The patients are often not participants in this discussion, being intubated, ventilated, and sedated. The presence of an advance
directive is helpful, and the identification of the
primary spokesperson for the family is crucial.
Failure to appreciate that there is one dominant
person within the family who is making the decisions can be a critical factor in developing this
trust. Bad outcome and poor communication are
the two events that summate to the accusation of
malpractice. Good communication, preparation,
and anticipation even in the presence of a bad
outcome is valuable both for the comfort of the
family and avoidance of accusations of malpractice.
Withdrawal of Life-Sustaining Measures
It is a frightening thought that 8 % of Medicare
patients in the United States undergo an operation in their last week of life and 18 % in the last
month of life [3]! The classic role of the surgeon
Discussing the Pathology Report
Today the pathology report is often not back before the patient leaves the hospital. The first postoperative visit then becomes a seminal event, and
time should be placed such that that visit is not
47945 Delivering Bad News: Conversations with My Surgeon
rushed. If anything, the first postoperative visit
will be longer than any subsequent follow-up
visit, not just a “post op check.” If the pathology
report is available before the patient leaves the
hospital, it should be discussed at that time. The
patient will have ultimate access to the pathology
report, and those that feel there have been any
attempt to confuse or minimize the findings will
readily be challenged. A brief note in the record
of when and what was described to the patient
as to the pathologic findings is helpful when patients and families complain, “they were never
informed,” enabling you to point out the date it
was provided.
In either event, such discussion should be
held in a calm and controlled environment. If it
is the patient’s room, then the surgeon must not
be standing hovering over the supine patient like
the sword of Damocles. Preferably the patient
and surgeon are seated. The same applies in the
outpatient department. Direct eye-to-eye contact
is important, and on occasions, if the results have
ominous findings, gentle but physical contact is
often reassuring. Most patients or their families
will have requested or subsequently request a
copy of the pathology report. They should be encouraged if there is any confusion either at that
time or subsequently to return to discuss the findings. The pathological report that is read and well
interpreted can avoid subsequent confusion and
denial.
Discussion of Long-term Survival Prospect
One of the more difficult things in the management of patients, particularly the patient with
cancer, is the discussion of long-term survival.
Sadly, much of our information is not precise
and not patient specific. Staging systems vary
widely and prognosis within stage is extraordinarily variable [4]. Nevertheless, precise scoring
systems, and increasingly nomograms, can give
realistic statistical predictions for the individual
patient [5].
Absolute precision is never possible. There is
the patient anticipated to die in weeks to months
who lives years, and the patient, one would anticipate to live for years, having an early or even
very late recurrence from their original tumor.
Delivering bad news, that is following an operation in which unresectable metastatic disease
was encountered, is highly dependent on the
availability of alternate treatment and more importantly, the likelihood that that alternate treatment will benefit. Data from prospective randomized trials allow us to say with some confidence
that one can or cannot be anticipated to benefit.
Unfortunately, we all predict that the advantages
of additional treatment or of surgical operations
are better than they really are. Physicians want
to promise their patients that the outcome will be
better than the knowledge base would suggest.
This, when taken to extremes, results in the unrealistic expectations of the patient and, progressively, dissatisfaction by the family.
The sadly neglected approach is the approach
where available adjuvant therapy is statistically
shown to improve survival, but that survival benefit is extraordinarily small, but we convey that
that benefit is of more clinical significance than
is justified. With large often industry-supported
clinical trials, small benefits to 5-year survival
from 90 to 92 % are often expressed as a 20 %
benefit. Physicians rarely point out that in this
situation 100 patients have to be treated for two
to benefit. No one discusses that should we treat
there is a statistical benefit, but there are at least
49 chances out of 50 that there will be no benefit, mainly because the patient was never going
to recur. The judgment in that situation should
be taken based on the side effects of the treatment being offered. There is no treatment that is
without side effects. This approach is essentially
ignored by all physicians. We invariably and appropriately want to make the intervention that
“will make a difference.” We do not want to face
the fact that there is a silent majority in any situation where untreated survival is greater than 50 %
who cannot possibly benefit from the treatment
and can only be harmed. Such thinking requires
a radical change in how we present outcome information.
But what if the patient does have terminal and
essentially untreatable disease, or at least disease
480 M. F. Brennan
not treatable with any meaningful response? The
most important issue is not to say, “I cannot help
you, please go away.” The thing to say is, “Further operations will not help you, but I will take
care of you.” It is equally inappropriate to absolve your responsibility for this by saying, “You
need to see the medical oncologist for treatment.”
Making unrealistic expectations for the patient
and asking your colleague to deliver such unrealistic expectations are unprofessional, unkind, and
should be avoided at any cost.
What if there truly is no effective treatment.
How do you answer the question, “How long will
I live?” This is not a situation where we could
anticipate and prepare the patient; one has to give
a realistic estimation. It should always be commenced with, “I will help take care of you; there
are many things we can do.” If a patient becomes
relentless, then you have to give some realistic
expectations. You will know from statistical outcomes and can use the obvious disclaimer of, “I
do not know, as every patient is different,” but a
helpful approach, if forced into a situation, is to
describe, “I cannot say for certainty in your case
but similar patients with the problem that you
have, have lived weeks, months or years.” This is
almost always satisfactory. The optimistic patient
will fasten onto the years as being many, and the
pessimistic patient will focus on the weeks as a
week or two.
Management of the Difficult Family
We all encounter families who can be “difficult.”
(Think of your own!). Much can be done to defray this. Much of the difficulty revolves around
the internal dynamics between patient and family. This cannot be something that you are com-
pletely aware of, and you should tread warily in
this minefield. The key to the management of the
difficult family is consistency. They need to have
a solid understanding of the initial expectations
with no false promises and no unrealistic plans
for miracles, and this should be consistently reinforced. No matter how you feel, getting angry
does not solve anything. The moment that you
are angry this is demonstrated and confirms for
the family that it is not they that are a difficult
family, it is you who are a difficult surgeon. Regular but not too frequent meetings are important.
They should be at defined times, controlled in
length, and require constant repetition of the facts
of the matter not the incriminations of the various
professional care providers.
Delivery of “bad news” is a part of surgical
life; it needs to be embraced as part of caring for
another human being. Much can be anticipated
and much can be shared. It is all part of the privilege of caring.
References
1. Cressey D. Informed consent on trial. Nature.
2012;482(7383):16.
2. Grobmyer SR, Pieracci FM, Allen PJ, Brennan MF,
Jaques DP. Defining morbidity after pancreaticoduo-
denectomy: use of a prospective complication grading
system. J Am Coll Surg. 2007;204(3):356–64.
3.
Kwok AC, Semel ME, Lipsitz
AE, Gawande AA, et
surgical care at the end of life: a retrospective cohort
study. Lancet. 2011;378(9800):1408–13.
4. Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart
LH. Clinical score for predicting recurrence after
hepatic resection for metastatic colorectal can-
cer: analysis of 1001 consecutive cases. Ann Surg.
1999;230(3):309–18.
5. Brennan MF, Kattan MW, Klimstra D, Conlon K.
Prognostic nomogram for patients undergoing resec-
tion for adenocarcinoma of the pancreas. Ann Surg.
2004;240(2):293–8.
al. The intensity and variation
SR, Bader AM, Barnato
of
Index
A
Abdominal
abscess, 139, 161
sepsis, 155, 156, 298
Abdominoperineal resection (APR) closure, 408
Ablation of the pylorus, 121
Acute normovolemic hemodilution (ANH), 207
Advancement flap
lateral mucosal, 463
mucosal–submucosal flap, 387, 388
transanal sleeve, 388
V-Y advancement flap, 444, 464
Y-V advancement flap, 463, 465
Afferent loop syndrome (ALS)
clinical history, 139
diagnosis, 139, 140
endoscopic/interventional radiology, 140
epidemiology, 137
etiology, 138
medical treatment, 140
noninvasive imaging studies, 140
pathophysiology, 138
physical finding in, 139
surgical intervention, 142
Anal fissure, 447
Anal fistula, 393, 425, 450, 451
Anal stenosis, 459–467
Anastomotic leak
cause, 159
characterize, 339
esophageal
presentation and identification, 26–28
prevention and management of, 28–30
rates, 24
risk factors for, 23–26
prevention of, 339
types
generalized peritonitis, 341
localized pelvic abscess, 342
fistula, 342
Anastomotic strictures, 237–244, 250
cause of, 343
etiology of, 349–351
presentation and diagnosis, 351
treatment
nonoperative, 352
operative, 353
Angiography, 31, 87, 95, 218, 219, 262, 274–276, 299,
329
Angioplasty, 242, 263, 264
ANH. See Acute normovolemic hemodilution (ANH)
Anti-reflux surgery (ARS), 13, 19, 75, 77, 78, 80, 83
peptic strictures, 16
APR closure. See Abdominoperineal resection (APR)
closure
Arterial injury, 223, 239
Arterial ligation, 219, 224, 459
Ascites, 38, 162, 169, 179, 261, 284, 292, 301, 302,
308–313, 362, 427
Aspiration, 27, 65–70, 75, 79, 80, 112, 113, 184, 230–
234, 252, 287
Autotransplantation,, 363, 364
Avoidance, 23, 50, 110, 111, 231, 353, 416, 459–467,
473, 476
B
Balloon dilation, 251, 252, 352–355, 367
Bancroft, 150, 153, 157
Bariatric surgery, 127, 135
Barium swallow, 68, 80
Barrett’s esophagus (BE), 74–82
Basivertebral veins, 397, 398, 400–402
Benign esophageal stricture, 14–17
Bile duct injury, 180, 191–199, 230, 238, 239, 241, 244
Bile reflux, 79, 119–125, 139, 142, 282
Biliary anatomic variation, 191, 198
Biliary fistula, 181, 184, 186, 189, 194, 228
Biliary leak
controlled and uncontrolled, 180
definitions, 179
diagnosis, 184
intraoperative tests, 183, 184
investigations
fistulogram, 185
HIDA, 185, 186
MRC, ERC, and PTC, 185
ultrasonography ot CT scan, 184
risk factors and prevention, 180–183
source, 180
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9
© Springer Science+Business Media New York 2015
481
482 Index
Bilioenteric anastomosis, 181–184, 186, 240, 242
Billroth II, 121, 123–125, 127, 129, 130, 137, 140, 142
conversion to Billroth I anastomosis, 134
Boari flap, 364, 365, 367
Bougies, 14, 79, 352, 383
Bowel necrosis, 109, 113, 138
Bowel obstruction, 110, 139, 340, 425, 436
Breakdown of perineal wound, 405–413
Bronchus, 3–6, 8, 9, 27, 43, 47, 48, 50, 188
C
Celiac artery stenosis, 218, 222, 224
Cholangitis, 139, 182, 237–239, 244
Chyle, 57–61, 307–313
Chyle leak, 309, 310, 312, 313
Chylothorax, 53, 55, 57–60, 62
Chylous ascites, 308–311, 313
Chylous effusion, 57
Coagulopathy, 208, 276, 282, 286, 401
Coloanal anastomosis, 330, 332, 343, 353, 354, 392
Colorectal anastomosis, 336, 343
Colorectal anastomotic (CRA) strictures, 349, 350
Communication, 39, 93, 94, 162, 180, 188, 194, 218,
295, 473–476
Complications of esophagectomy, 78
Continence, 78, 343, 353, 372, 374, 388, 389, 421, 448,
450, 452–455, 462
D
Difficult
duodenum, 148–150, 157
families, 478
situations, 150
Distal
gastrectomy, 129, 135, 137, 141, 149, 150
pancreatectomy, 260, 271–273, 276, 293, 296, 297,
300–303, 316–322
Dumping syndrome, 36, 124, 128–134
Duodenal
fistula, 155, 156, 181
stump blowout, 142, 147, 156, 157
Dysphagia, 14–18, 31, 36, 68, 75, 77, 79, 80
E
Early recognition, 31, 61, 103, 227, 371
Embolization, 59, 174, 182, 220, 221, 223, 274, 275,
298, 312
Endoscopic ablative techniques, 81
Endoscopy, 6, 15, 16, 28, 75, 78–82, 103, 105, 160, 238,
242, 275, 343
Enteral feeding, 29, 120, 124, 134, 161, 287, 299, 308,
320, 406
Enterostomal therapy, 444
Esophageal
adenocarcinoma, 18, 82
cancer, 6, 10, 18, 19, 37, 58, 94
conduit necrosis, 103
conduits, 23, 25, 26, 90, 102
dilatation, 16
replacement, 17, 39, 40, 43, 45, 49, 87, 89, 94, 95,
101, 104
sten, 6, 10, 15, 17, 18, 30, 80
stenting, 6, 15, 80
Esophagectomy, 4–7, 10, 13, 17, 18, 25–27,
29, 31, 36–38, 44, 46, 48, 50, 57, 67,
94, 96
Excluded segment, 185, 187
F
Falciform ligament, 197, 204, 271, 272, 276
Fecal incontinence, 343, 374, 389, 421, 450, 453, 454,
462
Feeding intolerance, 113
Fistulotomy, 389, 450, 451–455
Flap closure, 412
Fundoplication, 17, 19, 39, 77, 78
Future liver remnant, 171, 172, 222, 243
G
Gastrectomy, 89, 90, 120–124, 129, 130, 134, 135, 142,
150, 161, 250
Gastric
cancer, 108, 111, 130, 140, 141, 156
outlet obstruction, 134, 139, 279
resection, 119, 120, 125, 149, 156, 157
surgery, 25, 87, 111, 128, 131, 138, 162
Gastro-duodenal
artery stump blowout, 270
reflux, 78
resection, 269
Gastroepiploic artery, 24, 29, 31, 39, 98, 221
Gastrointestinal continuity, 104, 142, 337, 382
Gastrojejunostomy, 121, 124, 129, 134, 142, 270, 275,
276
Gastroparesis, 119–122, 124, 297
Gracilis
interposition, 373–375
muscle interposition flap, 390
Graciloplasty, 373, 374
Grade C, 170, 179, 280, 282, 292, 293, 296, 299, 316
H
Haemostatic agents, 399, 400
Hand-sewn, 25, 32, 88, 90, 104, 148, 294, 318, 332, 335,
350
Hemorrhage, 6, 18, 36, 78, 79, 201, 203, 207–209, 219,
298, 420
Hemorrhoidectomy, 459, 460, 466
Hepatectomy, 171, 172, 182, 183, 196–198, 204, 208,
222, 260
Index
483
Hepatic
abscess, 161, 228, 230
artery, 93, 195, 196, 202, 206, 210, 217, 221, 222,
272
Hepaticojejunostomy, 181, 182, 187, 256, 275, 282, 284
Hepatobiliary surgery, 169, 176
Hiatal hernia, 17, 19, 36, 39, 75, 77, 79, 80
Hoarseness, 66, 67, 75
I
Iatrogenic, 62, 182, 187, 219, 238, 361, 363, 372, 386
injury, 65, 219, 359, 369
Ileal-pouch anal anastomosis (IPAA), 332, 379
Image-guided percutaneous drainage, 228, 282
Inflammatory, 29, 36, 74, 80, 148, 156, 229, 260, 295,
298, 312, 354, 388, 427
Interventional thrombolysis, 263
Intraoperative solutions, 87–91
J
Jejunal feeding tube, 299
K
Keyhole technique, 430, 432
L
Laparoscopy, 104, 108, 110, 261, 340, 430
Lateral internal sphincterotomy (LIS), 447, 448, 462, 463
Liver transplantation (LT), 176, 182, 239, 243, 260, 262
Low anterior resection, 339–345
Low CVP, 203, 204, 208, 213
M
Malignancy, 19, 58, 65, 78, 90, 181, 234, 244, 250, 308,
313, 351, 386, 398
Malignant esophageal stricture, 17, 18
Martius flap, 390, 391, 393
Medialization thyroplasty, 69
Memory shaped alloy, 354, 355
Minimally invasive pancreatectomy, 260, 319, 322
Mobilization, 24, 25, 37–43, 47, 94, 95, 204, 221, 331,
361, 464
Magnetic resonance cholangiopancreatography
(MMRCP), 194, 219, 256, 300, 321, 322
Mucosal
advancement flap, 387, 393, 463
irritation, 122
N
Nausea, 59, 76, 109, 119, 122, 139, 261, 299, 321
Neoadjuvant chemoradiation, 26, 416, 417
Nissen closure, 150, 151, 157
Non-healing perineal wound, 405–413
Not-reaching gastric conduit, 87–91
O
Obstruction, 17, 88, 110, 111, 134, 142, 156, 194, 249,
262, 297, 444
Octreotide, 59, 131, 132, 317, 322
Ostomy
complications, 441, 442, 445
ischemia, 442, 245
retraction, 442–445
stenosis, 238, 245
Outcomes, 5, 10, 134, 198, 286, 367
P
Pancreatectomy, 212, 260, 271–273, 286, 293, 301, 308,
317, 319
Pancreatic
duct stent, 254, 280, 296
fistula, 119, 120, 250, 260, 269, 271–273, 276,
279–283, 285–303, 307, 310, 315–323
resection, 121, 209, 270, 295, 296, 320
stent, 317, 318
strictures, 248, 250, 254, 256, 257
surgery, 208, 317
Pancreaticoduodenectomy, 119, 120, 156, 209, 221, 240,
293, 296, 316, 320
Pancreaticogastrostomy, 280, 285, 286, 296
Pancreaticojejunostomy, 156, 270, 272, 275, 280, 282,
285, 288, 294, 296
Pancreatitis, 139, 181, 247, 256, 286, 307, 316, 317
Pancreatoduodenectomy, 120, 247, 250, 251, 256
Pancreatogastrostomy, 248, 254
Pancreatojejunostomy, 248, 250
PANK technique, 253, 256
Parastomal hernia (PH), 425, 435, 436
Pelvic
abscess, 341, 342, 354, 416
surgery, 369, 370, 398, 401
Percutaneous transhepatic cholangiography (PTC), 238
Perineal
wound, 374, 390, 405, 412
wound closure, 419
Perioperative death, 473
Peritoneal perforation, 418, 419, 421
Portal-mesenteric and splenic vein thrombosis
(PMS-VT), 259
Postoperative
hepatic infection, 227, 230
hepatic insufficiency (PHI), 169
pancreatic complications, 315
pancreatic fistula, 271, 292, 293, 296, 297,
302, 315
Postpancreatectomy
hemorrhage (PPH), 269
nutrition, 315
reoperation, 286
484 Index
Presacral
bleeding, 400, 401
venous plexus, 397, 398, 400–402
Prevention, 9, 28–31, 58, 104, 124, 129, 172, 175,
180–183, 198, 203, 210, 271, 296, 316, 339,
442, 461
Pringle maneuver, 196, 202, 206–208, 260
Prostatic urethra, 369, 370, 372, 375
Prosthetic mesh, 427, 430, 436
Proton pumps inhibitors, 16, 18, 36, 74, 129, 153
Pseudoaneurysms, 271, 274, 275, 277
Pseudocyst, 139, 249, 287, 292, 295, 300, 321, 322
Psoas hitch, 364, 365, 367
R
Rectal surgery, 340, 353, 354, 427, 462
Rectovaginal fistula (RVF), 374, 420
Recurrence, 302, 343, 352, 435
Recurrent laryngeal nerve injury, 17
Reflux esophagitis, 75, 78, 82, 130
Rendez-vous
procedure, 16, 19
technique, 242
Reoperative surgery, 155, 156, 353, 356
Resection, 9, 121, 182, 192, 193, 203, 208, 240, 243,
294, 355, 474
Risk
assessment, 169, 176
factors, 23, 38, 170, 180–182, 238, 427
Roux-en-Y hepaticojejunostomy, 181, 187, 237
T
Transanal minimally invasive surgery (TAMIS),
415–422
Transanal endoscopic microsurgery (TEM), 374, 389,
415–422
Tension, 7, 23–26, 29–32, 90, 94, 96–101, 129,
142, 148, 150, 164, 182, 237, 280, 285, 288,
327–339, 349–351, 354, 355, 356, 363–367,
372, 382, 387–392, 405, 407, 418, 441–445,
452, 463, 464
Tension-free anastomosis, 29, 96, 129, 164, 182, 285,
327–336, 339, 350, 356, 364–367, 445
Thoracic duct, 53–62, 309, 312
Thoracobiliary fistula, 179–189
Thrombectomy, 263, 264
Thumbtacks, 400, 402
Total gastrectomy, 89, 90, 121, 161, 162
Trachea, 3–9, 27, 40–43, 47–50
Tracheoesophageal fistula, 3–11, 16, 18
Transanal endoscopic surgery (TES), 374
Transhiatal esophagectomy (THE), 10, 57, 101
intraoperative disasters, 35–50
major intraoperative bleeding, 40, 47
tracheal tears, 36, 38, 47–49
Transureteroureterostomy (TUU), 363–365, 367
Treatment
of chronic anal fissure, 448, 454
of perianal fistula, 389
Tube
duodenostomy, 150–152, 154, 155, 157
dysfunction, 111, 113
jejunostomy, 113, 286, 287
S
Segment 3 bypass, 198
Severe reflux, 82, 89
Stapled, 25, 26, 88–90, 273, 276, 316–320, 332, 335,
350, 351, 379–383, 392, 459
Stents, 242
esophageal stents, 15, 17
role of
pancreatic stenting, 317
preoperative stenting, 359
SEMS, 353
ureteral, placement of, 362
Stoma, 327, 330, 335–343, 346, 349–356, 374, 383, 388,
389, 393, 409, 416, 420, 425–436, 441–445
Stomach, 5, 7, 15, 17, 23–25, 29, 35–45, 73, 77–102,
108, 120–124, 127, 142, 150, 215, 247, 248,
253, 254, 255, 285, 286, 302, 318, 392, 427
Stricture stenting, 237
Stump leak, 129, 137, 152–157, 162, 164, 181, 187, 319,
320, 322
Sugarbaker technique, 430, 432, 435, 436
Surgical
correction of ostomy complications, 445
repair, 237, 239, 366, 383, 444
Suture ligation, 400–402
Systemic anticoagulation, 262, 401
U
Ulcer(s), 10, 75, 78, 138
and strictures, 73, 78
Ureter injury, 361, 362
Ureteral
reimplantation, 365, 367
stents, 359–361, 367
Ureteroureterostomy, 363–365, 367
Urethral repair, 373
V
Vaginal injury, 379–383
Vascular
control, 35, 204, 207, 208
injury, 185, 194, 210, 228, 239, 243, 271
Vomiting, 59, 110, 119, 120, 123, 139, 140, 261, 298,
321
W
Wound dehiscence, 409, 416–418, 420, 421