akut buk göteborg 2007a - amazon web servicesh24-files.s3.amazonaws.com/110213/296279-jq4ty.pdf ·...

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Catchmentarea

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Teamwork radiology and surgery

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Jigsaw

OP

Endoscopy

X-ray

TRAUMA

Abdominal wall

Cholecystitis Perforation

Appendicitis

GI bleeding

IleusPancreatitisDiverticulitis

Complex and timeconsuminginvestigations

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Be realistic – but recognisethe cangoroo

Surgeons without guidelines

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Concensus 2007

•Smart surgeons learn from their ownmistakes

•Smarter surgeons learn from mistakes of others

•Some never learn……

The CT makes it easier and improves quality

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Guidelines

• Routines• Guidelines• Development

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Surgeons with guidelines

Jays ace Roy Halladay has appendicitis

Toronto Blue Jays starting pitcher Roy

Halladay throws duringfirst inning AL action

against the Boston Red Sox on Thursday, May10, 2007, in Toronto,

Canada

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Appendicit

Acute appendicitis can mimicvirtually any intra-abdominalprocess: therefore to know acuteappendicitis is to know well the diagnosis of acute abdominal pain. (Z.Cope)

History

200 Aretaios1492 da Vinci1734”paratyflitis”1880 The first operation1889 The first op in Sweden, Lennander1983 The first lap-app-op in Sweden

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Peritonitis

• Harry Hodini died from an appendicitis -26

Appendicitis

• Development of pain• Location• Local tenderness• Developemnt of CRP

and LPK

• Exclusion of alternatediagnoses

• Need to operate

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Diagnostics

Why?Avoid unnessecary operationsReduce the risk of missing importantdiagnoses

Indicator of quality

Earlier 25-30% healthy appNow 5-10%

Appendicitis – diagnostic tools

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Assessment and reassessment

Observation

Repetivite assessmentsCRP-LPK

CRP

LPK

Tid

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Our ”golden-standard”appendicitis

• Clinical diagnosis• Ultrasound in children• Diagnosis after CT in patients with

”unclear” conditions.• Laparoscopy in women

– And sometimes in men

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Diverticulitis

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Diverticulitis

• Mild to moderate– Clinical diagnosis– Confirmed later by imaging or colonoscopy– Rule out malignancy

• Moderate to severe– Clinical findings– CT– CT findings are prognostic

Diverticulitis

• Mild to moderate– Clinical diagnosis– Confirmed later by imaging or colonoscopy– Rule out malignancy

• Moderate to severe– Clinical findings– CT– CT findings are prognostic– Ambrosetti classification

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Treatment

• Mild to moderate– Fasting?– Antibiotics?

• Moderate to severe– Antibiotics– Operation

• Resection

Resection with peroperative lavage

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Happy colorectal surgeons after the procedure

Jejunumdivertikulis

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Obstruction

Colocolic invagination

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Gallstone ileus

Diffuse ischemia

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Adhesive band

Bowel ischemia

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Strangulation

Operation

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Internal mesenteric hernia

Emergency operation

Surgeon on call operates an emergency case

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Second look

Surgeon on call reoperates an emergency case

Postoperative complications

• Always suspect surgical reasons

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Postoperative complications

• Always suspect surgical reasons– (at least when other surgeons have operated)

AssessPostop complications

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Assess

Think

Postop complications

Assess

Think

ActPostop complications

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Postoperative complicationsTime-span

• Immediate• Within days• Within weeks-months

Postoperative complicationsCPBF

• Cardiac• Pulmonary• Bleeding• Fluid retention

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Postoperative complicationsPeritonitis

• Anastomotic leakage• Following perforated ulcer – incopmlete

raphi• Deep infection• Abscess

Postoperative complicationsAbdominal wall

• Subcutaneous wound rupture• Early incarceration

– Following laparoscopy• Infection

– Mild– Severe

• With flegmone• Clostridie infection

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Severe pain – out of proportion

• Strangulation• Gas gangraene

Postoperative complicationsBile ducts

• Bile leakage• Bile duct obstruction

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Postoperative complicationsBariatric surgery

• Internal hernias• Incarceration of bowels in troacar incisions

Postoperative complicationsBleeding

• Procedure– Elective– Emergency

• Due to bleeding

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PEG and complications

PEG complications

• Immediate complications– Perforation of organs– Bleeding

• Displacement• Non-functioning• Peritonitis• Leakage

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WSACSWorld Society of the Abdominal

Compartment Syndrome

Abdominal compartment

Intensive care

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Abdominal compartment• Reasons

– Intraabdominal complications– Reperfusion– Ileus– Post major intra- and retroperitoneal bleeding– Severe pancreatitis

• Correlates to– High BMI– Extensive fluid resuscitation

Abdominellt compartment

How to measure the abdominal pressure

KAD, 25 ml water into the bladder

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Jejunumdivertikulit

Ileus

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Colocolisk invagination

TunntarmsinvaginationMetastaserande lungcancer

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The bowel mesentery gets a broad attachment to the back abdominal wall

Malrotation

Gör en nonrotation

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Malrotation

Mesenterica superior syndrom

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Richter-bråck

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Diffus tarmischemi

Questions/discussion