Ebook Surgical decision making beyond the evidence based surgery: Part 2

(BQ) Part 2 book Surgical decision making beyond the evidence based surgery presentation of content: Difficult clinical based surgical decisions, special issues in surgical decision making, the final word.

Part II Diffi cult Clinical-Based Surgical Decisions

© Springer International Publishing Switzerland 2016

R Latifi , Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_9

Surgical Decision-Making Process and Damage Control: Current Principles and Practice

Ruben Peralta , Gaby Jabbour , and Rifat Latifi

Introduction

Traditionally, the common surgical practice

included the completion of the operation

regard-less of the physiologic condition of the patient

However, in trauma patients this can be

challeng-ing Therefore, multiple strategies were

devel-oped to avoid this dilemma

While the damage control (DC) has become

popular in the last few decades, this is not a new

concept Historically, the management of

devastat-ing abdominal injuries has been documented by

the work of others, but the most well-known

sur-geon is Pringle, who described the use of packs and

digital compression of the portal triad in large liver

injuries more than a century ago [ 1 ] Ogilvie during

World War II described the use of open abdomen technique in severely injured patients [ 2 ] Lucas and Ledgerwood reported the management of liver injuries with temporary perihepatic packings in

1976 [ 3 ] Stone described the modern concept of abbreviated laparotomy in 1983 [ 4 ]: hemorrhage was controlled by tamponade; bowel injuries were resected; noncritical injured vessels were ligated; and biliopancreatic injuries were drained Later, these patients underwent defi nitive repairs The term “damage control” was popularized by Rotondo

in the 1990s [ 5 ], and has become a powerful tool in the management of severely injured patients

Indications and Timing of Damage Control

Damage control includes the termination of the surgery after controlling bleeding and contami-nation, and before the patient physiological reserve is exhausted and frequently manifested

by the developing of the lethal triad of acidosis, coagulopathy, and hypothermia Defi nitive repair

is delayed until the patient is stabilized

When a surgeon is operating in a patient with hemodynamic instability, hypothermia (<35 °C), coagulopathy, severe metabolic acidosis (pH < 7.2

or base defi cit >8), multiple injuries, massive transfusion requirements (>10 units packed red blood cells), and long operative time (>90 min) for trauma or emergency, he or she should think

of abbreviating the procedure [ 6 7 ]

R Peralta , M.D., F.A.C.S (*)

Department of Surgery , Division of Trauma Surgery,

Hamad General Hospital and Hamad Medical

Corporation , Al Rayyan Rd ,

PO Box 3050 , Doha , Qatar

e-mail: rperaltamd@gmail.com

G Jabbour , M.D

Division of Trauma Surgery, Department of Surgery ,

Hamad Medical Corporation ,

Al Rayyan Rd , PO Box 3050 , Doha , Qatar

e-mail: Jabbourgaby9@hotmail.com

R Latifi , M.D., F.A.C.S

Department of Surgery , Westchester Medical Center,

New York Medical College , 100 Woods Road ,

The Damage Control Operation

for Trauma

While DC may be performed in any part of the

body from craniotomies to orthopedic injuries,

most commonly it is done in abdominal trauma,

both penetrating and blunt In general, most

fre-quently it is done in liver injuries and vascular

injuries [ 4 , 5] Initial hemorrhagic control is

achieved by packing of the liver, and most

vascu-lar injuries can be treated by packing, simple

ligation, or temporary intraluminal shunts [ 6 , 7 ]

Hollow viscus injuries are treated by resection of

affected areas, and anastomosis is postponed

until the patient is stabilized The majority of

bil-iopancreatic injuries can be treated with closed

suction drainage [ 8 ] Pre-peritoneal packing has

gained popularity in recent years and is

per-formed when there is signifi cant pelvic fracture

with hemodynamic instability requiring an

oper-ation and embolizoper-ation [ 9 ] One other historical

indication of DC use is the inability to close the

abdomen, in order to avoid abdominal

resuscitation

By using hemostatic resuscitation instead of

massive crystalloid resuscitation, the need for

leaving the abdomen open has decreased

sig-nifi cantly, and, thus, DC, once overused, is

being used less Another new technique in the

management of trauma patients that has become

more popular is permissive hypotension

when-ever clinical conditions permit

Signifi cantly less frequently, DC is done in

isolated chest injuries, with exception for a

short period of DC during emergency

resusci-tative thoracotomy, clamping the pulmonary

hilum, or twisting the lung along its hilar axis

to stop bleeding from the pulmonary

paren-chyma [ 10 – 12 ] Occasionally, one has to pack

the chest wall temporarily due to massive rib

fractures associated with chest wall soft tissue

destruction Other compartments where DC

may be done are extremity soft tissue injuries,

particularly associated with vascular injuries,

requiring revascularization

Hemostatic Resuscitation

During the initial evaluation and management, intraoperatively and following termination or abbreviated surgery, resuscitation continues This includes resuscitation with intravenous fl u-ids and early administration of blood products and prevention of and correction of the lethal triad Warm room and airway circuit should be instituted in the ICU, and warmer device should

be applied to the patient A level I rewarmer device is useful at this time where all fl uids and blood products should be infused warmed into the patient In rare cases, described continuous arteriovenous rewarming can be used, a tech-nique that permits rapid rewarming of hypother-mic patients without requiring cardiopulmonary bypass or heparinization in severely hypothermic patients as described by Gentilello et al [ 13 , 14 ] Damage control resuscitation (DCR) in brief consists of the following: (1) Avoiding or minimiz-ing crystalloid resuscitation; (2) Treatment of aci-dosis requires optimization of oxygen delivery by providing optimizing cardiac output, hemoglobin, and oxygen saturation Acute traumatic coagulopa-thy is a frequent occurrence in severely injured patients [ 15 ] It is corrected by aggressive blood product replacement with fresh frozen plasma, platelets, and cryoprecipitate A hemostatic adju-vant that has been shown effective in the correction

of acquired coagulopathy of trauma is tranexamic acid (TXA) [ 16 ] We recommend the use of TXA

in bleeding trauma patients, and it is part of our MTPs Regarding prothrombin complex concen-trates (PCCs) , clinical data are still lacking for use

in massively bleeding trauma patients [ 17 ] Recombinant factor VIIa has been shown to reduce the transfusion requirement [ 18 , 19 ]

Defi nitive (Injury Repair) Operation

After stabilization and the restoration of the ological reserve, the patient is returned to the oper-ating room for defi nitive management Studies have shown that when patients are returned earlier

physi-R Peralta et al.

than 72 h, they have a lower rate of morbidity and

mortality compared with patients who return later

[ 20 ] In our practice, we return the patient to the

operating room within 12–24 h One cannot,

how-ever, wait for complete normalization of all

resus-citative indicators before returning to the OR, as

there may be a missed injury that is causing the

patient not to have normal physiology

During the defi nitive procedure, a complete

exploration is performed, packs are removed, and

bleeding sites are controlled This procedure in

fact can be called a tertiary operative survey Small

bowel continuity is restored, and patients with

colonic injuries are treated with stoma or repair

Closing the abdominal fascia is considered at this

time if the patient’s clinical condition allows

Other important elements that need to be

consid-ered at this stage are long-term nutritional access,

completing orthopedic repairs and even potential

for tracheostomies, if one suspects long

hospital-ization or long ICU stay

Management of Open Abdominal

Wound and Defi nitive Abdominal

Closure

Staged abdominal reconstruction has three main

functions: washout to reduce contamination ,

debridement of devitalized tissue , and

appropri-ate reconstruction This is usually done after

correction of the physiological derangement or

within 36 h, and helps improve the outcomes in

severe injuries Preoperative patient

optimiza-tion is conducted in order to create an ideal

set-ting for reconstruction (optimal nutritional

status, resolution of sepsis, correction of

acido-sis, hypothermia, and coagulopathy) Delaying

primary fascial closure is considered according

to abdomen condition (edema, viability) [ 21 ,

22 ] The surgical decision-making process on

abdominal wall reconstruction has been

addressed in more details in Chap 11 In this

section, we will describe temporal abdominal

closure ( TAC) Most commonly, the so-called

“ poor man VAC ” is used (Figs 9.1 , 9.2 , 9.3 ,

and 9.4 ) In our practice, if we expect to bring

the patient back to the operating room within 12

to 24 h, we do not use VAC; instead, we use

the poor man technique On occasion, the tines are so swollen or there is continuation of intra-abdominal pathology (such as pancreati-tis); thus, we are unable to close the fascia at all

intes-In these cases, we have adopted the technique that uses temporary vicryl mesh , followed by wound VAC (Fig 9.5 ) and eventually skin graft, with delayed reconstruction Often, as in Fig 9.6 , the abdomen is covered with skin only

Fig 9.1 Intestines are covered with sterile plastic bag

Fig 9.2 Additional cuts may be required on the plastic

bag to allow better drainage of fl uid

Fig 9.3 Most Kerlix™ (Covidien, Dublin, Ireland)

gauze is placed over the plastic bag, and two drains are

placed between gauzes

Fig 9.4 Finally the gauze and the drains are covered

with sticky plastic

Fig 9.5 Wound VAC , used even for smaller wounds

that are left open

Fig 9.6 Closure of the skin only in a patient who had

abdominal catastrophe managed with open abdomen for weeks

R Peralta et al.

Postoperatively , patients should have good

pain control (epidural anesthesia or patient

con-trolled analgesia), antibiotic treatment until

packs are removed, appropriate nutrition, and

deep venous thrombosis prophylaxis The

wound should be inspected daily, and the drains

left in place until there is minimum drainage

Damage Control for Abdominal Sepsis

Patients with a septic abdomen have similar

man-agement focuses as the damage control trauma

patient; however, the sequence differs A longer

initial resuscitation phase is used in the septic

abdomen The operative goal at the initial

laparot-omy is control of the infectious source In general,

a temporary abdominal closure is used at the end

of the initial laparotomy A second resuscitative

phase is then performed in the ICU in preparation

for further surgery If control of the septic source

is not done, then subsequent interventions are

required Common complications include

entero-cutaneous fi stula and intra-abdominal infections

(tertiary peritonitis) [ 23 ]

Complications associated with damage

con-trol can be classifi ed as local (abscess, fi stula, and

intestinal necrosis) or systemic complications

(ARDS and MOF) They are also divided into

early (missed injuries, infections, and

compart-ment syndrome) and late (fi stula, dehiscence)

Several studies have shown improved

out-comes since the widespread institution of

dam-age control techniques [ 24 , 25 ]

Vascular Interventions

The most commonly used damage control

inter-ventions in major vascular injuries are the

follow-ing: TIVS (temporary intravascular shunt) , where

the operating surgeon can place shunts in patients

with complex vascular injuries in the neck,

abdo-men and extremities, and proceed with the

vascu-lar anastomosis or reconstruction procedure

when the patient has reached a more reasonable

hemodynamic stability [ 26 ] Most recently, the use

of resuscitative endovascular balloon occlusion

of the aorta (REBOA) has emerged as a ing alternative to packing in the setting of severe ongoing noncompressible major torso hemor-rhage [ 27 – 31 ]

Orthopedic Interventions

The damage control orthopedics (DCO) concepts refer to the initial rapid skeletal stabilization with external fi xation, followed by intramedullary nailing after the systemic infl ammatory response has subsided [ 32 – 36 ] External fi xation is also used in open book pelvic fractures and helps limit venous bleeding (Fig 9.7 ) Arterial bleeding is treated by angiographic embolization External

fi xation and temporary soft tissue coverage in open fractures are the standard of treatment in critically ill trauma patients Fasciotomy is per-formed in vascular injuries and in ischemia reper-fusion injuries [ 37 ]

Fig 9.7 External fi xation for severe pelvic fractures, as

part of damage control, in a patient with hemodynamic instability, bleeding perineal injury, and large sigmoid colon devascularization, requiring diversion

Summary

In summary, damage control is a staged approach

to severely injured patients Initially, life-

threatening injuries are managed rapidly with

appropriate abbreviated procedures The patient is

then stabilized in the ICU Later, defi nitive

surgi-cal management is performed This strategy is

benefi cial and results in improved outcomes This

approach is still evolving, and many studies are

done to implement it as a standard management

approach to trauma patients It requires a

multidis-ciplinary team to achieve better outcomes

References

1 Pringle J Notes on the arrest of hepatic hemorrhage

due to trauma Ann Surg 1908;48:541–9

2 Ogilvie WH The late complications of abdominal

war-wounds Lancet 1940;2:253–6

3 Lucas CE, Ledgerwood AM Prospective evaluation

of hemostatic techniques for liver injuries J Trauma

1976;16(6):442–51

4 Stone HH, Strom PR, Mullins RJ Management of the

major coagulopathy with onset during laparotomy

Ann Surg 1983;197(5):532–5

5 Rotondo MF, Schwab W, McGonigal MD, et al

Damage control: an approach for improved survival

in exsanguinating penetrating abdominal injury

J Trauma 1993;35(3):375–83

6 Roberts DJ, Bobrovitz N, Zygun DA Indications for

use of thoracic, abdominal, pelvic, and vascular

dam-age control interventions in trauma patients: a content

analysis and expert appropriateness rating study

J Trauma Acute Care Surg 2015;79(4):568–79

7 Peralta R, Vijay A, El-Menyar A, et al Trauma

resus-citation requiring massive transfusion: a descriptive

analysis of the role of ratio and time World J Emerg

Surg 2015 Aug 14;10:36

8 Burch JM, Ortiz VB, Richardson RJ, et al Abbreviated

laparotomy and planned reoperation for critically

injured patients Ann Surg 1992;215(5):476–84

9 Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk

JW, Collier BR, Como J, Holevar M, Sabater EA,

Sems SA, Vassy WM, et al Eastern Association for

the Surgery of Trauma Practice management

guide-lines for hemorrhage in pelvic fracture: update and

systematic review J Trauma 2011;71(6):1850–68

10 Caceres M, Buechter KJ, Tillou A, Shih JA, Liu D,

Steeb G Thoracic packing for uncontrolled bleeding

in penetrating thoracic injuries South Med

J 2004;97(7):637–41

11 Moriwaki Y, Toyoda H, Harunari N, Iwashita M,

Kosuge T, Arata S, Suzuki N Gauze packing as

dam-age control for uncontrollable haemorrhdam-age in severe

thoracic trauma Ann R Coll Surg Engl 2013;95(1):20–5

12 Rizzo AG, Sample GA Thoracic compartment drome secondary to a thoracic procedure: a case report Chest 2003;124(3):1164–8

13 Gentilello LM, Rifl ey WJ Continuous arteriovenous rewarming: report of a new technique for treating hypothermia J Trauma 1991;31:1151–4

14 Gentilello LM, Cobean RA, Offner PJ, et al Continuous arteriovenous rewarming: rapid reversal

of hypothermia in critically ill patients J Trauma 1992;32(3):316–27

15 Brohi K, Singh J, Heron M, et al Acute traumatic coagulopathy J Trauma 2003;54(6):1127–30

16 CRASH-2 trial collaborators Effect of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with signifi cant haem- orrhage (CRASH-2): a randomized, placebo- controlled trial Lancet 2010;376(9734):22–32

17 Al-Majzoub O, Rybak E, Reardon DP, Krause P, Connors JM Evaluation of Warfarin Reversal with 4-Facto Prothrombin Complex Concentrate Compared

to 3-Factor Prothrombin Complex Concentrate at a Tertiary Academic Medical Center J Emerg Med

2015 Sep 30 [Epub ahead of print]

18 Schreiber MA, Holcomb JB, Hedner U, et al The effect of recombinant factor VIIa on coagulopathic pigs with grade V liver injuries J Trauma 2002;53:252–9

19 Martinowitz U, Kenet G, Segal E, et al Recombinant activated factor VII for adjunctive hemorrhage control

in trauma J Trauma 2001;51:431–9

20 Abikhaled JA, Granchi TS, Wall MJ, et al Prolonged abdominal packing is associated with increased mor- bidity and mortality Am Surg 1997;63(12):1109–13

21 Diaz Jr JJ, Cullinane DC, Dutton WD, Jerome R, Bagdonas R, Bilaniuk JW, Collier BR, Como JJ, Cumming J, Griffen M, Gunter OL, Kirby J, Lottenburg L, Mowery N, Riordan Jr WP, Martin N, Platz J, Stassen N, Winston ES The management of the open abdomen in trauma and emergency general surgery: part 1-damage control J Trauma 2010

;68(6):1425–38

22 Peralta R, Latifi R Perioperative surgical ation of patient undergoing abdominal wall recon- struction In: Latifi R, editor Surgery of complex abdominal wall defects New York: Springer; 2013

consider-p 173–7

23 Waibel BH, Rotondo M Damage control for intra- abdominal sepsis Surg Clin North Am 2012 Apr;92(2):243–57 viii

24 Johnson JW, Gracias VH, Schwab CW, et al Evolution

in damage control for exsanguinating penetrating abdominal injury J Trauma 2001;51(2):261–71

25 Chovanes J, Cannon JW, Nunez TC The evolution of damage control surgery Surg Clin North Am 2012;92(4):859–75 vii-viii

26 Davis TP, Feliciano DV, Rozycki GS, et al Results with abdominal vascular trauma in the modern era

Am Surg 2001;67:565–70

R Peralta et al.

27 Stannard A, Eliason JL, Rasmussen TE Resuscitative

endovascular balloon occlusion of the aorta (REBOA)

as an adjunct for hemorrhagic shock J Trauma

2011;71:1869–72

28 Morrison JJ, Ross JD, Houston R, Watson JDB, Sokol

KK, Rasmussen TE Use of resuscitative

endovascu-lar balloon occlusion of the aorta (REBOA) in a

highly lethal model of non-compressible torso

hemor-rhage Shock 2014;41:130–7

29 Morrison JJ, Percival TJ, Markov NP, Villamaria C,

Scott DJ, Saches KA, Spencer JR, Rasmussen

TE Aortic balloon occlusion is effective in

control-ling pelvic hemorrhage J Surg Res 2012;177:341–7

30 Brenner M, Moore L, Dubose J, Tyson G, McNutt M,

Albarado R, Holcomb JB, Scalea TM, Rasmussen TE A

clinical series of resuscitative endovascular balloon

occlusion of the aorta for hemorrhage control and

resus-citation J Trauma Acute Care Surg 2013;75:506–5011

31 Morrison JJ, Ross JD, Rasmussen TE, et al

Resuscitative endovascular balloon occlusion of the

aorta: a gap analysis of severely injured UK combat

casualties Shock 2014;41:388–93

32 Scalea TM, Boswell SA, Scott JD, et al External fi tion as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics J Trauma 2000;48(4):613–21

33 Balogh ZJ, Reumann MK, Gruen RL, et al Advances and future directions for management of trauma patients with musculoskeletal injuries Lancet 2012;380(9847):1109–19

34 Pape HC, Tornetta 3rd P, Tarkin I, et al Timing of fracture fi xation in multitrauma patients: the role of early total care and damage control surgery J Am Acad Orthop Surg 2009;17:541–9

35 Shapiro MB, Jenkins DH, Schwab CW, Rotondo

MF Damage control: collective review J Trauma Inj Infect Crit Care 2000;49(5):969–78

36 Lichte P, Kobbe P, Dombroski D, Pape HC Damage control orthopedics: current evidence Curr Opin Crit Care 2012;18(6):647–50

37 Porter JM, Ivatury RR, Nassoura ZE Extending the horizons of “damage control” in unstable trauma patients beyond the abdomen and gastrointestinal tract J Trauma 1997;42:559–61

© Springer International Publishing Switzerland 2016

R Latifi , Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_10

Reoperative Surgery in Acute Setting: When To Go Back?

Elizabeth M Windell and Rifat Latifi

Introduction

Most surgical procedures done either electively or

emergently go well, and, postoperatively, patients

recover nicely However, despite our best efforts

and highest levels of preparation, complications

can and do occur These complications can be

simple and easily remedied, but they can also be

serious and life threatening, and at times patients

need to be returned to the operating room at once

or acutely, or in less urgent basis in a semi-planned

fashion, but still need reoperation The profi les of

these patients or these procedures that are likely to

undergo reoperation, that is, unplanned operation,

have not been clearly defi ned

When the unplanned return to the operating

room becomes necessary, such as in the case of

early hemorrhage or profound abdominal sepsis ,

there are a number of issues that surgeons need to

address Discussing the plan with a patient and

his/her family as well as other members of the

surgical and anesthesia team is paramount If the situation is clearly emergent, this conversation may not happen preoperatively, but needs to occur after the procedure Other times, the clues are subtle, and the decision to return early to the operating room needs to be taken in a timely fashion, rather than procrastinating the inevita-ble, and is a matter of combination of art and sci-entifi c evidence Unplanned trips to the operating room are not very common, some sources in the literature describe a rate of <3.5 % [ 1 3 ], but we will all encounter this at some point in our careers and knowing when and how best to perform these operations can make the difference in the survival and outcomes of our patients

The purpose of this chapter is to describe the times when a repeat operation is necessary and when the best time is for performing these opera-tions As there is a lack of paucity of good evi-dence behind this question in the literature, this chapter will focus more on this decision-making process from an anecdotal standpoint rather than from a standpoint of level one evidence

Reasons for Reoperative Surgery

in the Early Postoperative Period

The need to return to the operating room in the early postoperative period can be for a variety of reasons and it also depends on the surgical discipline We will divide these reasons into the acute phase unplanned and planned return to

E M Windell , D.O

Department of Trauma, Surgical Critical Care, and

General Surgery , Legacy Emanuel Medical Center ,

Portland , OR , USA

e-mail: ewindell@lhs.org

R Latifi , M.D., F.A.C.S (*)

Department of Surgery , Westchester Medical Center,

New York Medical College , Valhalla , NY , USA

Department of Surgery , University of Arizona ,

Tucson , AZ , USA

e-mail: latifi @surgery.arizona.edu ; Rifat.latifi @

gmail.com

10

the operating room While we will concentrate on

the unplanned return, the planned return to the

operating such as continuous management

(dam-age control, burn, multiple reconstruction) will

be discussed as well Later on, the unplanned

return to the operating room can also happen,

such as hernia recurrence, need for revision of

grafts in vascular surgery or tumor resection, but

this is not a subject of this chapter As a rule, the

more common causes for reoperative surgery are

ongoing management after initial damage control

laparotomy, infectious complications,

hemor-rhage, early bowel obstructions from both

adhe-sions and hernias, and positive margins on the

initial fi eld of resection We will explore each of

these topics in more detail

Damage Control Laparotomy

Occasionally in trauma and emergency general

surgery, performing a defi nitive operation may

not be safe at the initial procedure This is often

due to physiologic instability in the patient

mani-fested grossly as the lethal triad of coagulopathy,

hypothermia, and acidosis Damage control

sur-gery can be used as a temporizing measure to

control hemorrhage, prevent ongoing

contamina-tion, and to prevent further issues from profound

systemic infl ammatory response When damage

control laparotomy is utilized though, one must

consider at the initial operation at what point you

plan to go back for your defi nitive repair While

the “norm” is normalization of end point

resusci-tations, one cannot and should wait more than 36

h to bring back the patient for another exploration

or defi nitive surgery [ 4 5 ]

The major tenant of a damage control

lapa-rotomy is that the underlying problems that are

leading to the lethal triad need to be corrected

The coagulopathy, acidosis, and hypothermia

need to be resolving if not already corrected

before a defi nitive operation is safe In the

instance of a damage control laparotomy,

tempo-rizing measures are applied to the abdomen, and

the patient is taken to the ICU for rewarming,

ongoing fl uid and blood product resuscitation,

and shock management [ 6 ]

Depending on the severity of the injury or infection, most of these issues start improving within 12–48 h of the initial operation The best times for considering a second operation tend to

be in the 24–48 h window Prior to the 24 h dow, patients may still be too unstable for an operation, and subjecting them to prolonged sur-geries or anesthesia is not advisable At the same time, waiting longer than 48 h may increase fur-ther morbidity and mortality as it can lead to organ failures, prolonged need for ventilatory support, nutritional defi cits, open abdomens which are a source of fl uid loses, and it puts patients at higher risk for serosal injuries, EC

win-fi stulas and anastomotic leaks Loss of domain is also a concern with an open abdomen, and delay-ing closure of the abdominal wall past 48 h may lead to large hernias and need for future surgeries for abdominal wall reconstruction [ 5 6 ]

One caveat to the 24–48 h window is when source control has not been established, such as with profound contamination or necrotizing soft tissue infections or in the case of ongoing hemor-rhage Often in these cases, patients continue to

do poorly or worsen in the fi rst 12 h after the initial operation, and they may need a second procedure sooner to establish better source con-trol or complete disruption of infectious cascade

In these cases, the risk of a second surgery is less than the risk of death from ongoing septic shock and a second operation should be performed befor e 12 h

Infection Complications: Source Control

Unfortunately, despite having perioperative mization, infectious complications such as wound infection and other intra-abdominal catas-trophes do occur Anastomotic leaks range any-where from 3–15 % of all bowel anastomoses [ 7 10 ], and the morbidity and mortality associ-ated with this complication make appropriate management crucial Management of this dreaded complication can range anywhere from observation to IR drainage to need for repeat surgery, and it can be diffi cult sometimes to

determine how best to approach this You also

must take into consideration what resources you

have available to you in your institution to

deter-mine how to approach management

Other situations where patient needs to be

taken back are missed enterotomies or intestinal

perforation manifested clinically and/or

demon-strated by imaging techniques (CT scan images

and intraoperative picture os Picotte)

Most anastomotic failures occur around day

3–7 after initial resection and anastomosis There

have been cases reported though, of late

anasto-motic failures occurring weeks after the primary

operation [ 11] Missed enterotomies typically

declare themselves within 24–48 h from surgery,

and intra-abdominal abscesses typically present

about 5–7 days from surgery The approach to

these complications depends on the severity of the

leak and the clinical presentation of the patient

In the case of patients who are

hemodynami-cally stable and who have small, contained leaks

or easily accessible abscesses, there may be a

place for observant management This type of

management typically requires antibiotics to be

administered, serial abdominal exams to be

per-formed and consideration of drain placement by

interventional radiologists to help provide source

control, but this depends on available resources

[ 12 ] If you decide that your patient is a candidate

for observant management, you need to be

vigi-lant to continually reassess for any clinical

wors-ening or instability If at any point your patient

clinically worsens, he or she has worsening

sep-sis, and/or has failure to thrive, an operative

intervention should be strongly considered

Anastomotic leaks, intra-abdominal

infec-tions, and missed enterotomies can be life

threat-ening and if the initial presentation of the patient

in the postoperative period is that of

hemody-namic instability, severe acidosis, or shock, the

best way to proceed would be for a re-exploration

as soon as possible Immediate source control is

necessary, with or without temporary diverting

ostomy as needed

Most of these life-threatening leaks or infections

occur within the fi rst week of initial operation

Rarely, but defi nitely occurring, these tions c an occur weeks out [ 11 ] As is well known

complica-in the literature, adhesions and complica-infl ammation after surgery are at their worst 10 days to 3 months after the initial operation If a serious complication occurs within the fi rst week to 10 days from the original surgery, most of the times the re-operation is safe Occasionally, infectious complications occur after this period, and the management depends on clinical presentation

We recommend attempting conservative, vant management if patient is hemodynamically stable and responds to conservative management

obser-At times, however, the most conservative agement in fact is taking the patient back to the operating room, for what we call “an eye scan.” If the patient, though, is hemodynamically unstable one needs to proceed with an operation

Depending on the clinical situation, one can approach reoperative surgery in the acute set-ting laparoscopically or open This question is greatly up for debate, and has a lot of bearing

on each individual surgeon’s technical skills and the approach at the original operation If your original operation was done using mini-mally invasive technique ( bariatric surgery , for example), there could be consideration of man-aging the complications with a laparoscopic approach A takedown of an anastomosis, abdominal washout, and reconstruction of a new anastomosis can feasibly be done using minimally invasive techniques At the same time, drainage of a large intra-abdominal abscess or identifi cation of a source of enter-otomy can be done laparoscopically as well The threshold to convert to an open technique should be very small Identifying a small enter-otomy or source of leak can be diffi cult laparo-scopically, so a low threshold for opening should be maintained if you are unable to fi nd the source of infection If you started your original operation open, it would be advised to reuse those previous incisions for your re- exploration This will provide you with maxi-mal visualization and ability to address the complications before you

10 Reoperative Surgery in Acute Setting: When To Go Back?

Postoperative Hemorrhage : Need

to Stop the Bleeding

Bleeding can and does occur in the perioperative

period Typically, bleeding will present or recur

within the fi rst few hours to days from surgery

The mainstay of treatment really depends on a

number of factors: hemodynamic stability of the

patient, resources available in your institution,

and location and cause of the bleeding

Postoperative hemorrhage can be from a

num-ber of sources, and identifying the source can

often help determine which management will be

appropriate [ 13 – 15] In the instance of arterial

bleeding, these patients are often acutely unstable,

showing evidence of hemorrhagic shock

(tachy-cardia, hypotension, altered mental status,

oligu-ria, palor), and they are often non- responders vs

transient responders to blood transfusions In

these cases, patient needs to be brought back for

an immediate reoperation Depending on the

situ-ation (pelvic trauma, solid organ injuries),

embo-lization therapy can be considered If you do

decide to proceed with IR intervention, you need

to be constantly monitoring your patient and

pro-viding aggressive resuscitation If at any point

your patient is no longer responding to blood

transfusions or medical management in the

prepa-ration of doing an IR intervention, then the patient

should be taken immediately for surgery [ 13 ]

Occasionally, postoperative hemorrhage can

be due to venous bleeding or oozing from raw

operative surfaces Typically, patients with this

type of bleeding will be more responsive to fl uid

resuscitation and overall tend to be more

hemo-dynamically stable, although not always This

type of bleeding is not amenable to direct

inter-ventional radiology interventions; therefore, the

options for management are observation vs re-

exploration Most of this bleeding tends to be

self-limiting, unless there is an injury to large

veins, and will often resolve with appropriate

fl uid resuscitation with balanced transfusions,

utilizing clotting factors, allowing for mild

per-missive hypotension, and correction of

coagu-lopathies If the patient responds to resuscitation,

we would consider observation and correction

of coagulation factors A repeat operation often

may not identify the source of bleeding and patients need to be packed and his or her coagu-lopathy reversed

There may be a role of nonselective angio- embolization for management of venous bleed-ing, especially in the setting of pelvic injury or surgery with ongoing hemorrhage Access to the region can be diffi cult and identifi cation of the source of bleeding can often be near impossible with an open procedure This technique has gar-nered a lot of attention in the literature in recent years and involves nonselective embolization of the feeding artery with a temporary substance, typically Gelfoam ® (Pfi zer, New York, NY) The site of where the operative bleeding is occurring from can also be a guide to manage-ment In the case that the bleeding is coming from the pelvis, a strong consideration should be for IR intervention to address this As previously discussed, access and visibility within the pelvis can often be diffi cult, even in the situation of an open laparotomy Pre-peritoneal packing may be required as well

If the bleeding occurs from the intestines or a staple line from a bowel resection, reoperation is required The use of embolization for manage-ment of bleeding after an anastomosis would be ill-advised Embolization, either selective or non-selective, can compromise blood fl ow to the area

of the healing anastomosis If this occurs, an anastomotic leak or breakdown can occur and would lead to life-threatening complications Also, expanding hematomas in and around the intestines could lead to compression of the lumen and bowel obstructions In this instance, we would recommend re-exploration

Early Bowel Obstruction : When Waiting Is No Longer an Option

The most common unplanned reason for tion after abdominal surgery is adhesive small bowel disease Just the opening of the peritoneal cavity leads to adhesions forming in 95 % of patients Of this, approximately 4 % of all patients who undergo abdominal surgery will go on to have a clinically signifi cant bowel obstruction

These obstructions often occur months to years

after an operation Occasionally, these

obstruc-tions occur within the fi rst few days to weeks

after initial surgery It has been reported that 30

% of all bowel obstructions occur within the fi rst

30 days of surgery, but the way to manage this is

heavily debated [ 16 ]

Adhesion formation occurs from a local

response of the peritoneum and serosa to

isch-emia, desiccation, and trauma that can originate

from the primary disease process or surgery itself

(contact with instruments, gloves, sponges,

suture, or other irritants) When this occurs, the

normally fl uid bowel can become twisted or

kinked leading to a bowel obstruction Adhesions

and infl ammation tend to be at their worst at 14

days to one month post-op, and then slowly

improve over months

Post-op ileus is unfortunately a frequently

encountered condition after intra-abdominal

sur-gery The symptoms of ileus (distention, lack of

fl atus, belching, abdominal pain, nausea, and

vomiting) mimic that of bowel obstruction, often

leading to some confusion on practitioner’s part

as how best to proceed with management It is

recommended that to start, NG tube

decompres-sion and bowel rest should be utilized If

symp-toms persist, consideration should be given to GI

imaging, starting fi rst with abdominal x-ray and

then a CT scan with oral contrast versus small

bowel follow through, looking for potential

sources of obstruction If a diagnosis of ileus is

decided, watchful waiting is recommended

Typically, this will resolve within 3 days to 7

days

In the setting of an early small bow el

obstruc-tion, the majority of these will also resolve within

7–14 days after initial surgery A study by

Chessin et al showed that the need for

reopera-tion on early small bowel obstrucreopera-tion was only

0.8 % [ 17 ] With that being said, though, if a

bowel obstruction persists beyond 14 days

op, the likelihood it will resolve without a

reop-eration is extremely low, <10 % [ 18 ], and

reoperation should be strongly considered With

these statistics in mind, if imaging reveals that a

patient has a bowel obstruction, especially within

the fi rst 10 days of surgery, it would be

recom-mended to proceed with watchful waiting and conservative management which includes NG tube decompression, limitation of narcotics, TPN and serial abdominal exams, as the majority of these will resolve with this treatment [ 19 ] Again, very rarely, these obstructions will show no improvement at the 10–14 day point When this occurs, reoperation needs to be heavily consid-ered as again, >90 % of these will not resolve without an operation Delaying beyond this point leaves the patient at high risk or complications due to dense adhesions and increased diffi culty with surgery We recommend conservative man-agement for 7–10 days post-op If the patient still shows no improvement or resolution, and imag-ing suggests a bowel obstruction, we recommend re-exploration at this point One point that is extremely important to remember, though, is if at any point the patient shows evidence of bowel ischemia (increasing abdominal pain, elevated WBC, increasing lactate, evidence of sepsis), immediate operative intervention should be undertaken to prevent irreversible bowel death and or perforation

If a patient is over 14 days out from his or her initial operation and develops a bowel obstruc-tion at that point, unless there is evidence of bowel ischemia or abdominal sepsis, it would be advised to consider conservative management Conservative management would consist of NG tube decompression, bowel rest, and initiation of TPN If partial obstruction does not resolve entirely, we recommend re-exploration Studies have shown that early postoperative bowel obstructions that persist beyond 10 days post-op typically will not resolve without operative inter-vention Operating before 6 weeks again puts a patient at high risk for complications due to dense adhesions

With the advancements in surgeon’s skills with performing primary operations laparoscopi-cally, the incidence of postoperative bowel obstructions has greatly decreased, thought to be due to less adhesion formation One must be aware though, that bowel obstructions do occur after laparoscopic surgery, and the causes of these are often very different from open surgery

In open laparotomy, adhesions occur due to the

10 Reoperative Surgery in Acute Setting: When To Go Back?

trauma from a large open incision with signifi cant

exposure of both the bowel and peritoneum [ 20 ]

In a study from the French Association for

Surgical Research, only 50 % of postoperative

bowel obstructions after laparoscopic surgery

were due to adhesions, signifi cantly less than the

75 % from open procedures [ 21 ] New

opportuni-ties for problems occur with laparoscopic

sur-gery, problems such as internal hernias and

hernias from trocar port sites These types of

obstructions are of immediate concern as they

often lead to bowel ischemia if not addressed

early In the setting of an early postoperative

bowel obstruction after a laparoscopic surgery, it

would be recommended for immediate re-

exploration One could consider doing this

reop-eration laparoscopically, but if the bowel is

markedly distended, visualization may be diffi

-cult and an adequate pneumoperitoneum may not

be possible In this case, an open exploration

should be performed Another reason to avoid a

laparoscopic approach is the fact that the

intes-tines may be injured during manipulation with

instruments as they are fi lled with fl uids If you

do proceed laparoscopically, one has to carefully

examine all surfaces of bowel as partial ischemia

of the bowel wall may be present from a port- s ite

Richter’s hernia

Reoperation : Positive Margins

of Resection

You operate on a patient You notice a large

mass You perform the appropriate en bloc

resec-tion, but your fi nal pathology comes back 7 days

after your initial operation: you have positive

margins You thought you had it all, but the

microscopic disease is telling you otherwise

What should your approach be in this situation?

Ultimately, the answer to this can be very

differ-ent depending on the clinical pathology that you

are addressing, something that is beyond the

scope of this text Questions that you can ask to

help guide your therapy though are: Will doing a

second operation improve the outcomes of the

cancer, or is systemic therapy the way to go? Can

radiation be utilized for treatment for local

regional control? Will not doing the operation delay the patient’s ongoing cancer therapy? Will performing a second operation delay medical management of the cancer further? Will the risk

of adhesions and the possibility of a fi stula or enteric leakage occurring delay ongoing treat-ment for the patient? You should address these questions prior to considering an early second operation It may also be well advised to discuss the case with the oncologist or surgical oncolo-gist to bes t answer this

Summary

The need for early reoperation after primary intra-abdominal surgery is rare, but can be due to multiple different etiologies We have discussed the situations of damage control laparotomy, infectious complications, postoperative hemor-rhage, early bowel obstruction, and positive mar-gins Determination of the specifi c etiology will help to guide appropriate management, and we hope that our insights into these various compli-cations will help in management of your patients With damage control laparotomy, reoperation

is always necessary to fi nalize defi nitive repairs and to assess for ongoing bleeding In these cases, a surgeon should plan for the second look and if able defi nitive repair 24–48 h after the ini-tial operation Again, if initial source control has not been obtained and the patient continues to show signs of instability and non-progression with medical management, it may be necessary for re-exploration prior to 24 h

In the instance of infectious complications or postoperative hemorrhage, surgery is always a recommended approach Occasionally, if the patient is stable and not overtly toxic, consider-ation can and should be placed on medical man-agement with or without the assistance of interventional radiology If at any point, though, your patient worsens or does not improve, then heavy consideration to reoperate is necessary Management of early postoperative bowel obstruction has a lot to do with initial operative approach With an open laparotomy, unless the patient has evidence of bowel ischemia, watchful

waiting with decompression and TPN should be

initiated, but if it persists beyond 10–14 days then

reoperation should be considered In the setting

of laparoscopic surgery at the initial operation,

immediate re-exploration would be

recom-mended by these authors due to the high potential

of closed loop obstructions or port-site hernias

Lastly, in the event of positive margins in the

setting of cancer, reoperation depends on the

ini-tial pathology and it would be advised to discuss

management as a multidisciplinary approach

If you do fi nd yourself in the situation of

needing to reoperate, we hope this will be a

guide for you, and remember to be meticulous

and slow in your dissections to prevent

additional injury

References

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and post-operative complications of radical

retropu-bic prostatectomy in a consecutive series of 1,000

cases J Urol 2001;166(5):1729–33

2 Nelson J Reoperations within the fi rst 30 days after

pelvic surgery In: Billingham RP, Kobashi K, Peters

WA, editors Reoperative pelvic surgery New York:

Springer; 2009

3 Augustin T, Aminian A, Romero-Talamas H, Rogula

T, Schauer PR, Brethauser SA Reoperative surgery

for management of early complications after gastric

bypass Obes Surg 2016;26(2):345–9

4 Sharrock AE, Barker T, Yuen HM, Rickard R, Tai

N Management and closure of the open abdomen

after damage control laparotomy for trauma A

sys-tematic review and meta-analysis Injury 2015; Sept

30 [Epub ahead of print]

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Okoye O, Inaba K, Bee TK, Fabian TC, Whealan J,

Ivatury RR AAST Open Abdomen Study Group

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ther-apy Philadelphia: Lippincott Williams & Wilkins;

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7 Brundage SI, Jurkovich GJ, Hoyt DB, Patel NY, Ross

SE, Marburger R, Stoner M, Ivatury RR, Ku J, Rutherfort

EJ, Maier RV Stapled versus sutured gastrointestinal

anastomoses in the trauma patient: a multicenter trial

J Trauma Acute Care Surg 2001;51:1054–61

8 Catena F, La Donna M, Gagliardi S, Avanzolini A, Taffurelli M Stapled versus hand-sewn anastomosis

in emergency intestinal surgery: results of a tive randomized study Surg Today 2004;34:123–6

9 Farrah JP, Lauer CW, Bray MS, McCartt JM, Chang

MC, Meredith JW, Miller PR, Mowery NT Stapled versus hand-sewn anastomosis in emergency general surgery: a restrospective review of outcomes in a unique patient population J Trauma Acute Care Surg 2013;74(5):1187–94

10 Shekarriz H, Eigenwald J, Shekarriz B, Upadhyay J, Shekarriz J, Zoubie D, Wedel T, Wittenburg

H Anastomotic leak in colorectal surgery: are 75% preventable? Int J Colorectal Dis 2015;30(11): 1523–31

11 Hyman N, Manchester TL, Osler T, et al Anastomotic leaks after intestinal anastomosis: it’s later than you think Ann Surg 2007;245(2):254–8

12 Nicksa GA, Dring RV, Johnson KH, et al Anastomotic leaks: what is the best diagnostic imaging study? Dis Colon Rectum 2007;50(2):197–203

13 Young JL, Lachance JA, Rice LW, Foley

EF Reoperation and management of postoperative pelvic hemorrhage and copagulopathy In: Billingham

RP, Kobashi K, Peters WA, editors Reoperative Pelvic Surgery New York: Springer; 2009

14 Oderich GS, Panneton JM, Hofer J, et al Iatrogenic operative injuries of abdominal and pelvic veins: a potentially lethal complication J Vasc Surg 2004;39(5):931–6

15 Haneya A, Diez C, Kolat P, Suesskind-Schwendi M, Ried M, Schmid C, Hirt SW Re-exploration for bleeding or tamponade after cardiac surgery: impact

of timing and indication on outcome Thorac Cardiovasc Surg 2015;63(1):51–7

16 Duron JJ, Da Silva NJ, Tezenas du Montcel S, Berger

A, Muscari F, Hennet H, Veyrieres M, Hay

JM Adhesive postoperative small bowel obstruction: incidence and risk factors of recurrence after surgical treatment Ann Surg 2006;244:750–7

17 Chessin DB, Enker BD, Wong WD, Guillem

JG Complications after preoperative combined modality therapy and radical resection of locally advanced rectal cancer: a 14 year experience from a specialty service J Am Coll Surg 2005;200:876–82

18 Pickleman J, Lee RM The management of patients with suspected early postoperative small bowel obstruction Ann Surg 1989;210(2):216–9

19 Bauer J, Keeley B, Krieger B, et al Adhesive small bowel obstruction: early operative versus observa- tional management Am Surg 2015;81:614–20

20 McCormick JT, Simmang CL Reoperation following minimally invasive surgery: are the “rules” different? Clin Colon Rectal Surg 2006;19(4):217–22

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10 Reoperative Surgery in Acute Setting: When To Go Back?

© Springer International Publishing Switzerland 2016

R Latifi , Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_11

Surgical Decision-Making Process and Defi nitive Abdominal Wall Reconstruction

Rifat Latifi , Ruben Peralta , and John A Stroster

Introduction

Reconstruction of complex abdominal wall

defect s and recreating functional abdominal wall

represent major challenges, often requiring

surgi-cal creativity, and a strategy that involves

differ-ent aspects of care along the various stages of

treatment [ 1 ] These challenges need to be

under-stood primarily by the surgeon, but by the patient

as well The issues range from defi ning the

pathology to understanding the impact of the

clinical condition, physiology, nutritional status,

and wound care Redefi ning the anatomy and

physiology, timing the defi nitive surgery,

execut-ing the operative plan, makexecut-ing intraoperative

decisions that are often considered “outside gical dogma,” long-term follow-up, and ensuring full recovery of the patient to normal functional status are all basic requirements One very impor-tant factor is the dedication of the surgeon to these patients and to their surgical problems, and these operations are not to be performed by an

sur-“itinerary surgeon.”

The management of these patients should be approached in a step-wise fashion, ensuring that each phase is truly understood by the surgeon, as well as by the patient and their family While there is always room for a discretionary surgical approach, disciplined protocols and a well- planned surgical strategy, particularly in patients with abdominal wall defects complicated by fi s-tulas or stomas, make the intraoperative manage-ment process easier and may improve postoperative outcomes Such a strategy has been described in a six-step strategy for management

of enterocutaneous fi stulas (ECFs), known as

“SOWATS” (S = Sepsis Control, O = Nutrition Optimization, W = Wound Care, T = Timing,

A = Anatomy, and S = Surgery) [ 2 ] Use of this approach on 79 patients led to spontaneous clo-sure in 23 (29 %) patients after a median period

of 39 (range 7–163) days Forty-nine patients required operative repair after median period of

101 (range 7–374) days; closure was achieved in

47 (96 %) patients The reported mortality was

10 % during the study period, although in a rate publication, the authors reported that 44/135

sepa-or 32.5 % of patients died [ 3 ] While this strategy

11

R Latifi , M.D., F.A.C.S

Department of Surgery , Westchester Medical Center,

New York Medical College , 100 Woods Road,

Department of Surgery, Division of Trauma Surgery ,

Hamad General Hospital and Hamad Medical

Corporation , Al Rayyan Rd , PO Box 3050 ,

Doha 3050 , Qatar

e-mail: rperaltamd@gmail.com

J A Stroster , Ph.D

Department of Surgery , Banner University Medical

Center , 172 S Bonanza Ave ,

Tucson , AZ 85748 , USA

e-mail: stroster@surgery.arizona.edu

is applicable in the acute setting, it does not

address important aspects of the management of

these patients as part of the continuum of care

Initial diagnosis, the immediate postoperative

period, postoperative care following defi nitive

surgery, and fi nally long-term follow-up are all

equally important to consider To address these

aspects, our surgical practice group has expanded

the six-step strategy to nine steps, and call it

“ISOWATS PL” [ 4 ] where I = Identifi cation and

diagnosis of the postoperative fi stula; S = Sepsis

and Source Control; O = Optimization of Nutrition;

A = Redefi ning the anatomy and understanding

the pathology at hand; T = Timing of defi nitive

surgery and/or takedown of fi stulas; S = Defi nitive

surgery and surgical creativity; P = Postoperative

care; and L = Long-term follow- up We adhere to

the “ISOWATS PL” strategy as much as possible,

although we sometimes cannot strictly follow all

nine steps in certain patients, as some often require

emergency surgery In this chapter, we will

dis-cuss the decision- making process for parts of our

nine-step approach, which deal with timing of the

surgery, and the methods and techniques used to

reconstruct the complex abdominal wall defect s

Timing to Defi nitive Repair

We have previously described that the decision if

and when to reoperate on patients with complex

abdominal wall defect s should be individualized,

and represents one of the most important steps in

the surgical management of these patients [ 4 ]

We base this decision on many factors, but

par-ticularly on the comorbid diseases and on the

anatomy of the surgical problem In addition to

considering the clinical status and physiology of

the patient, one has to remember that these large

defects can be functionally devastating and lead

to further weight gain and more problems, and

potentially may lead to major morbidity If

patients have serious comorbid diseases such as

extreme obesity, severe heart disease, high-grade

liver cirrhosis or lung disease (dependent upon

oxygen therapy at home), and do not have

symp-toms of obstructions, one should carefully

evalu-ate the decision of whether to operevalu-ate, except in situations involving intestinal obstruction not responding to conservative treatment While not all surgeons agree, at times the strategy for these patients should be “more is less,” and often the defi nitive surgery is the only choice and should

be performed We prefer to operate earlier rather than later, assuming that the patient is not pro-hibitively at high risk for major complications While timing when to repair large abdominal wall hernias is less debatable [ 5 7 ], operating on

fi stulas and knowing how long a surgeon should wait until takedown are more contentious Delaying surgery anywhere from 12 to 36 months

to improve the outcomes in patients with ECF has been suggested [ 8 ], although prolonging sur-gery for longer than 1 year following ECF diag-

refi stulization [ 9], and waiting longer than 36 weeks increases the reported risk for fi stula recur-rence by fi ve times [ 10 ] There are no solid data

to inform such decisions, and thus the individual patient’s condition is the main factor that should

be used as a guide

Surgical Approach

Once the decision to operate has been made jointly by both the patient and the surgeon, decid-ing on the defi nitive reconstruction technique is the next challenge faced Most patients who have previously undergone large abdominal surgeries have a midline abdominal incision, so their lat-eral abdominal wall is usually free of scars and defects, thereby providing a well-vascularized soft tissue donor site There are a number of exceptions, however, especially when the patient has had any lateral incision or stomas Unless the patient has a giant hernia with loss of abdominal domain, the abdominal wall can be anatomically restored with minimal tension and without com-promising the integrity of the abdominal muscles, vessels, and nerves The surgical goals are to establish gastrointestinal (GI) tract continuity, obtain full closure of the abdominal wall, avoid the postoperative abdominal compartment syndrome, minimize the formation or recurrence

R Latifi et al.

of fi stulas, hernias, wound infections, and strive

to restore the patient’s functionality In patients

with frozen abdomen, or when a split-thickness

skin graft (STSG) exists, dealing with adhesions,

resecting fi stulas, and performing the

anastomo-sis require experience, and even entering the

abdomen may prove cha llenging

Defi nitive Abdominal Wall

Reconstruction

Creating a new abdominal wall may represent a

serious surgical challenge, and both the surgeon

and the patient should be prepared for a lengthy

procedure (i.e., entering the abdomen, lysis of

adhesions, resecting the fi stulas, and performing

the anastomosis) Some authors have suggested

that reconstruction should be performed by another

team, such as plastic surgeons [ 11 ] On occasion,

the primary author (R.L.) has used the principle

of damage control on demand, returning the next

day or so to completely inspect the anastomosis

again, ensuring that there are no missed

enteroto-mies before performing the fi nal closure

If native tissue can be used without undue

ten-sion, then it should be utilized If that is not

pos-sible, a synthetic or biologic prosthesis can be

used instead In most patients, some sort of

com-bination of reconstruction techniques will be

needed If the midline tissue cannot be easily

approximated, or if mesh reinforcement is needed

(as it is in almost all abdominal wall defects

larger than 6 cm), then other techniques must be

considered For example, if midline tissue cannot

be easily approximated, in order to avoid undue

tension on the tissue and postoperative

compart-ment syndrome, the lateral components,

bilater-ally, need to be released and a neo-abdominal

wall created Tissue transposition of

myocutane-ous fl aps through lateral component separation is

the procedure of choice [ 12 , 13 ] Component

separation results in medial advancement of

intact rectus myofascial units bilaterally, enabling

the closure of defects of up to 10 cm in the upper

abdomen, 20 cm in the mid-abdomen, and

6–8 cm in the lower abdomen The component

separation technique is based on an enlargement

of the abdominal wall surface by separating and advancing the muscular layers Some form of component separation, alone or in combination with other adjunct procedures, has become com-mon practice

Other methods can be used to reconstruct the abdominal wall complex defects such as local advancement or regional fl aps, distant fl aps, or combined fl ap and mesh; however, which tech-nique is used will depend on the pathology at hand In Type I defects with stable skin coverage, bridging the fascial gap with prosthetic mate-rial or autologous tissue is suffi cient, whereas in Type II defects with absent or unstable skin cov-erage, fascial repair alone is inadequate, and the repair must be done with skin utilizing more complex reconstruction techniques (e.g., regional

or distant fl aps, either alone or in combination with mesh) Vascularized fl aps provide healthy autologous tissue coverage and usually do not require any implantation of foreign material at the closure site Small and midsize defects can be repaired with pedicle fl aps within the arch of the rotation of the fl ap In extensive upper midline abdominal wall and thoraco-abdominal defects, a free fl ap that offers a completely autologous, single- stage reconstructive solution is the best option available

Timing of the procedure depends on the operative evaluation, the physiological condition

pre-of the patient, and the anatomical condition pre-of the tissues The presence of the so-called “pinch sign” (i.e., easy retraction of the skin or skin graft over the defect) is a good indicator that the adhe-sions are subsiding, and that it is appropriate to schedule the abdominal reconstruction In our experience, the optimal time for abdominal wall reconstruction is 6–12 months after the fi rst pro-cedure (when adhesions are less prominent)

The Component Separation Technique

During the component separation technique ( CST ) for abdominal wall rec onstruction, the anterior abdominal skin fl aps are developed and dissected out laterally from the chest wall to the

anterior superior spine, then the aponeurosis of

the external oblique muscle is divided

longitudi-nally 2 cm laterally to the lateral edge of the

rec-tus sheath, which will allow the mobilized recrec-tus

myofascial component to be mobilized medially

and facilitate the approximation of the midline

with sutures (Figs 11.1 , 11.2 , 11.3 , and 11.4 )

There are various modifi cations of the

compo-nent separation procedures A popular modifi

ca-tion was described by a Memphis group as the

“separation of parts.” Another variation is the

“open book” technique described by a group at

the University of Virginia: in addition to the

lat-eral release of the external oblique, the rectus

fas-cia is fl ipped into the midline using the linea alba

as the fulcrum to extend the midline [ 14 – 22 ];

when a minimally invasive surgical technique is

employed, the rates of recurrence are similar

[ 23 ] Other tissue transfer techniques have been

utilized and described as well Vascularized fl aps

provide autologous tissue coverage and help

avoid the use of foreign material In general,

Fig 11.1 Completed closure of the abdominal defect

after underlay mesh placement and bilateral component

release

Fig 11.2 Drains are placed under the skin and

subcuta-neous tissue to reduce seromas

Fig 11.3 Underlay mesh placement , before the newly

created abdominal wall is closed

R Latifi et al.

icle fl aps are an alternative option for small defect

repair Free fl aps cover large thoraco-abdominal

wall defects in a single stage reconstructive

pro-cedure; however, they are complex procedures

and require institutional expertise [ 24 – 35 ]

The placement of some sort of synthetic or

biologic graft, that is a mesh, is recommended

even if you perform lateral component release

[ 36 ] The question of whether the mesh should be

biologic or synthetic mesh depends mostly on its

availability and patient’s clinical profi le, although

deciding how to place the mesh should be given

special consideration Deciding between the

three most common techniques used to place a

mesh during abdominal wall reconstruction (i.e.,

onlay, underlay, and interposition or bridge

placement) depends on the surgeon’s expertise

and the clinical status of the patient For most of

our patients who experienced major abdominal

wound contamination in the past or at the time of

reconstruction, we prefer biologic mesh, although

the data to support this decision, while intuitive,

are not solid Each of these techniques has their own pros and cons, and should be used based on one’s surgical expertise and patient selection

Onlay Placement

From a technique standpoint, onlay placement is the easiest way to situate the mesh When the abdominal wall edges are easily approximated, free of defects and contamination, there is no contraindication to using synthetic mesh In these situations with synthetic mesh, preference should be given to the onlay placement tech-nique, although there is concern for higher risk

of seroma formation There is always a small risk of wound infection, and one needs to remove the mesh if it gets infected, but currently this is a standard of care The key element of this approach is fi xing the mesh both laterally and over the edge of midline We prefer fi xing the mesh to fascia using absorbable sutures (Vicryl ® (Ethicon, Edinburgh, UK) 2.0 or 3.0), either interrupted or continuous The main objective is

to reestablish closure, and the primary author uses 3 or 4 large, closed-suction drains (19 French) under the subcutaneous tissue, and keeps the drains in until the individual drain out-put is less than 25 mL over 24 h

Underlay Placement

Underlay graft placement (Figs 11.3 and 11.4 ) has now become the main technique in all high- risk and complex ventral hernia defect recon-structions It is more involved, but once it is mastered and perfected, it does not add signifi -cant operative time Although it is believed that that underlay graft placement is associated with lower incidence of seroma, in our practice the determining factor is the thickness of the pan-nus over the fascia The decision to perform underlay technique is an important one, and should be done after freeing the abdominal wall entirely from any adhesions, as far laterally as possible both on the posterior and anterior aspect

Fig 11.4 Underlay mesh needs to feel like a drum when

all sutures are placed under some tension and pulled

laterally

Placement of the interrupted sutures should

ensure complete stretching of the mesh once

sutures are tight Sutures are placed using the

“parachuting” technique under direct vision at all

times The direct-vision parachuting technique

minimizes the potential for bowel injury during

fi xing of graft on the abdominal wall When

lat-eral component release is used, sutures in the

anterior abdominal wall are placed as far laterally

as possible, and must include the medial edge of

the external oblique fascia Doing so prevents

bulging laterally at the release component site,

which the patient might think the bulging is a

new hernia It is important to ensure that sutures

are close enough to each other to prevent

intesti-nal herniation between the sutures A number of

techniques of “underlay” placement have been

described, including retro-rectus and sublay, as

well as release of posterior aspect of the rectus If

the peritoneum is intact and not violated from

stoma placement of other reason, retro-rectus and

preperitoneum mesh placement may have

advan-tages [ 37 ]

While retromuscular mesh repair has gained

popularity, a number of associated complications

have been reported, including surgical site

infec-tions (SSI) in 19.6 % of cases, and the overall

recurrence rate was 16.9 % In one study, the

highest rate of recurrence (25 %) occurred when

hernia was repaired with biologic mesh, followed

by synthetic mesh (16.2 %), and bio-absorbable

mesh (17.1 %) The lightweight mesh use was

associated with 22.9 % vs mid-weight mesh

(10.6 %) ( p = 0.045) The only predictor of

recur-rence was the presence of an SSI (OR 3.1, 95 %

CI 1.5–6.3; p < 0.01) Similarly, after

multivari-ate analysis, diabetes, hernia width >20 cm, and

use of biologic mesh were statistically associated

with the development of a surgical-site

occur-rence (SSO) ( P < 0.05) Notably, the mere

pres-ence of contamination was not independently

associated with wound morbidity ( P = 0.11) SSO

and SSI rates anticipated by a recent risk

predic-tion model were 50–80 % and 17–83 %,

respec-tively, compared with our actual rates of 20 –46 %

and 7–32 % [ 38 ]

Bridge Mesh Placement

In patients with a major loss of abdominal wall domain, approximating the medial edges of the abdominal wall may be impossible, despite per-forming bilateral anterior or posterior compart-ment release In this situation, the only remaining option is to use mesh as a bridge (Fig 11.3 ), but patients should be advised that there is high chance of hernia recurrence and/or wall laxity that will mimic hernia (Fig 11.5 ) The suture bites are placed at least 2 or 3 cm into the muscles and fascia One should avoid tacking the mesh on the edge of the fascia, given the risk of herniation

or suture failure If at all possible, the “bridge” should be covered with native skin and subcuta-neous tissue However, when mesh is used as a bridge and there is no skin or subcutaneous tissue

to cover the mesh, then the use of a wound Vacuum-Assisted Closure (VAC) with continu-ous irrigation is very useful to keep the mesh moist and to speed up the process of granulation for later skin grafting Based on the extent of the operation and dissection, the postoperative course can be quite complicated Wound infec-tion, necrosis of mucocutaneous fl aps, seroma, and long-term open wounds are common and the patient should be prepared for these possibilities

in advance

Fig 11.5 Laxed abdominal wall after AlloDerm ® (LifeCell, Bridgewater, NJ) reconstruction

R Latifi et al.

Summary

The management of complex abdominal wall

defect s continues to evolve and still poses a

major challenge for the clinical surgeon

Successful abdominal wall reconstruction relies

primarily on good judgment, careful

periopera-tive preparation, expertise on performing the

sur-gical technique, and close follow-up Physiology

of the patient, defect size, its location, and level

of contamination are considerations that infl

u-ence the management of abdominal wall defects

Acknowledgements There are no identifi able confl icts

of interests to report

The authors have no fi nancial or proprietary interest

in the subject matter or materials discussed in the

chapter

References

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13 Ramirez OM, Ruas E, Dellon AL “Components aration” method for closure of abdominal-wall defects: an anatomic and clinical study Plast Reconstr Surg 1990;86(3):519–26

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20 Kushimoto S et al Usefulness of the bilateral anterior rectus abdominis sheath turnover fl ap method for early fascial closure in patients requiring open abdom- inal management World J Surg 2007;31(1):2–8

21 Sailes FC et al Synthetic and biological mesh in ponent separation: a 10-year single institution review Ann Plast Surg 2010;64(5):696–8

22 Espinosa-de-los-Monteros A et al Components- separation technique for closure of transverse non- midline abdominal wall incisional hernia J Plast Reconstr Aesthet Surg 2011;64(2):264–7

23 Harth KC, Rosen MJ Endoscopic versus open ponent separation in complex abdominal wall recon- struction Am J Surg 2010;199(3):342–7

24 den Hartog, D, et al Open surgical procedures for incisional hernias Cochrane Database Syst Rev 2008;(3):CD006438

25 Muramatsu K, Ihara K, Taguchi T Selection of cutaneous fl aps for reconstruction following onco- logic resection of sarcoma Ann Plast Surg 2010;64(3):307–10

26 Servant JM et al Reconstruction of large dominal defects using two-stage free tissue transfers and prosthetic materials J Plast Reconstr Aesthet Surg 2006;59(4):360–5

27 Erni D, Harder Y The dissection of the rectus inis myocutaneous fl ap with complete preservation of the anterior rectus sheath Br J Plast Surg 2003;56(4):395–400

28 Fulda GJ, Khan SU, Zabel DD Special issues in

plas-tic and reconstructive surgery Crit Care Clin

2003;19(1):91–108

29 Arnez Z et al Breast reconstruction using the free

superfi cial inferior epigastric artery (SIEA) fl ap Br

J Plast Surg 1999;52(4):276–9

30 Wei CY et al The versatility of free rectus femoris

muscle fl ap: an alternative fl ap Microsurgery

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31 Hill HL, Nahai F, Vasconez LO The tensor fascia lata

myocutaneous free fl ap Plast Reconstr Surg

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32 Nahai F, Hill LH, Hester RT Experiences with the

tensor fascia lata fl ap Plast Reconstr Surg

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33 Wong C-H et al Reconstruction of complex abdominal

wall defects with free fl aps: indications and clinical

outcome Plast Reconstr Surg 2009;124(2):500–9

34 Tukiainen E, Leppäniemi A Reconstruction of sive abdominal wall defects with microvascular tensor fasciae latae fl ap Br J Surg 2011;98(6):880–4

35 Björck M et al Classifi cation—important step to improve management of patients with an open abdo- men World J Surg 2009;33(6):1154–7

36 Richmond B et al Component separation with cine acellular dermal reinforcement is superior to tra- ditional bridged mesh repairs in the open repair of signifi cant midline ventral hernia defects Am Surg 2014;80(8):725–31

37 Cobb WS et al Open retromuscular mesh repair of complex incisional hernia: predictors of wound events and recurrence J Am Coll Surg 2015;220(4):606–13

38 Petro CC et al Risk factors for wound morbidity after open retromuscular (sublay) hernia repair Surgery 2015;158(6):1658–68

R Latifi et al.

© Springer International Publishing Switzerland 2016

R Latifi , Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_12

Dealing with the Most Diffi cult Situations in Abdominal Surgery

Rifat Latifi and John A Stroster

Epigraph

You get a phone call from your resident that the

patient on whom you performed an abdominal

exploration 7 days earlier for mechanical

intesti-nal obstruction and severe adhesive disease now

has some murky fl uid coming out of the lower

portion of the incision The resident adds “do not

worry, he is looking good, although his body

tem-perature is slightly up, and the WBC count is

17,000 this morning.” You know exactly what will

happen next, or at least you fear you know what

will happen next: fascial dehiscence, a missed

intestinal injury, which you caused while

dissect-ing those severe adhesions What else it could be?

How many times you have taught your

resi-dents that wound dehiscence is almost always

from the intra-abdominal infection and not simply

from the superfi cial wound infection? But, those

infections have always happened in the patients of

your partners Now it may be your turn The next

phone call confi rms all your fears: multiple fl uid

collections fi lled with air, too many to be drained percutaneously The situation is made even worse

if you are at a conference or perhaps on vacation with your family Your rule is to never do a “big case” before leaving town, but this happened to be

an emergency when you were last on-call

In this chapter, we will address a few diffi cult situations with which a general surgeon must deal with increasing frequency

Introduction

Other chapters in this text dealt with the most

dif-fi cult situations in trauma and oncological gery, respectively and therefore this chapter will refrain from most of the cross-over between abdominal surgery and oncologic or trauma causes Instead, this chapter will emphasize some

sur-of the most complicated situations faced by eral surgeons including enterocutaneous fi stulas, necrotizing soft tissue infections, postoperative anastomotic leaks, and delayed recognition of intestinal ischemia in order to shed light on how

gen-we surgeons handle serious situations

Enterocutaneous Fistulas

Enterocutaneous fi stulas (ECF) are arguably one

of the most complex issues a surgeon can treat and given that more than three-quarters of fi stulas are postoperative complications , surgeons also

R Latifi , M.D., F.A.C.S (*)

Department of Surgery , Westchester Medical Center,

New York Medical College , 100 Woods Road,

Valhalla , New York , NY 10595 , USA

Department of Surgery , University of Arizona ,

Tucson , AZ , USA

e-mail: Rifat.latifi @gmail.com

J A Stroster , Ph.D

Department of Surgery , Banner University Medical

Center , 172 S Bonanza Ave , Tucson , AZ 85748 , USA

e-mail: stroster@surgery.arizona.edu

12

play a role in their origin [ 1 ] Since the overall

incidence of ECF is low [ 2 ], and their etiology

varies, there is a lack of randomized trials in the

literature, and therefore management guidelines

tend to be based upon expert opinion rather than

evidence-based, grade-A recommendations A

15-year study reviewing the application of the

SOWATS treatment guideline (comprised of:

Sepsis, Optimization of nutritional state, Wound

care, Anatomy [of the fi stula], Timing of surgery,

and Surgical strategy) in 135 patients treated for

ECFs demonstrated an overall closure rate of

87.4 % ( n = 118) [ 3] Spontaneous closure

occurred in 21 patients which was usually those

with an intact abdominal wall and on total

paren-teral nutrition (TPN) , while surgical closure was

achieved in the remaining 97 individuals [ 3 ] Our

guideline to nine steps and we call it “ISOWATS

PL,” where the additional components are

I = Identifi cation and diagnosis of postoperative

fi stula, P = Postoperative care, and L = Long-term

follow-up [ 4 ]

While the reported mortality rate resulting

from treating ECFs has dropped from 44 % in

1960 [ 5] to around than 10 % presently [ 6 ],

patients with ECFs still present the most diffi cult

and complex challenge to any general surgeon,

not to mention the patient Despite the

develop-ments in surgical techniques, wound care,

nutri-tional support, and overall intensive and surgical

care, patients with high-output fi stulas (>500

mL/day) are still at risk of severe malnutrition,

blood stream catheter-related sepsis, intra-

abdominal sepsis, and death [ 2 7 ] Dealing with

ECF or enteroatmospheric (EAF) is considerably

complex and will test the skills of even most

experienced surgeon [ 8 ]

Identifi cation and Diagnosis

of Fistulas

The diagnosis, which is the early identifi cation of

the fi stulas, needs to be established in a timely

fashion and without much delay, while the

pre-sentation depends on the clinical situation [ 9 ]

The cause of postoperative wound infections and

abdominal dehiscence is not straightforward, and one has to fear intra-abdominal catastrophe before “blaming” technical reasons for suture failure of the closure The fi rst cause of abdomi-nal wound dehiscence, after the creation of a single or multiple anastomoses, with or without lysis of adhesions, should be sought in some other sort of abdominal catastrophe, such as severe infection (abscess), or a fi stula due to missed injury or anastomotic leak

The choices of action are: some sort of ing such as computerized tomography (CT) scan ; upper gastrointestinal (UGI) series with small bowel follow-through; a fi stulogram; enemas; or

imag-an “eye-scimag-an” that is intraoperatively performed

We prefer that would exploration should be done

in the operating room in fresh postoperative patients in order to completely assess the wound

as well as the subfascial collections and tines lying under the sutures, which could easily erode into the lumen and cause new fi stulas Most

intes-of these patients in practice receive a CT scan as well, although magnetic resonance imaging (MRI) is being increasingly used as well [ 10 ] The CT scan or MRI will identify any deep peri-toneal or pelvic collections that could be drained

or guided by CT, MRI, or ultrasound In the fi rst few postoperative days (and in my experience, the fi rst 10–14 days), one should not hesitate to take the patient back to the operating room for an exploration and direct assessment, if clinically warranted

Over the years, the senior author (RL) has observed an interesting phenomenon in surgeons’ behavior As surgeons, we not only behave differ-ently in novel situations, but we also vary our behavior in the same scenarios with different patients The best examples are among acute care surgeons or trauma surgeons When a trauma patient is not doing well postoperatively, we the trauma surgeons immediately think that we have missed an injury or there is something new hap-pening, and taking the patient back to the operat-ing room for an “eye-scan exploration” is almost the fi rst thought in our minds And we do that exact thing, most of the time Yet, when we per-form an elective surgery, such as the patient with elective colostomy take down described at the

R Latifi and J.A Stroster

onset of this chapter, and they develop a severe

complication like a wound infection, even with

questionable fascial integrity , we use any possible

imaging technique to avoid returning to the

oper-ating room, often causing signifi cant delays in

dealing with the problem at hand I cannot entirely

explain such a change in a surgeon’s behavior

The basic treatment strategy for patients with

acute postoperative wound dehiscence, severe

soft tissue infections, or simple wound infections,

as well as of those with ECFs (and/or EAFs)

include source control; proper antibiotic therapy;

electrolyte and fl uid normalization; correction of

coagulation factors and hemoglobin levels;

achievement of hemodynamic stability; and

pro-vision of nutritional support while patient

under-goes diagnostic or therapeutic interventions or

simply being observed for any reason In the last

few decades, the achievement of sepsis and source

control has undergone signifi cant changes [ 8 ]

Provision and Optimization

of Nutrition

Initiating, maintaining, and optimizing the

nutri-tion for patients with fi stulas or other

postopera-tive complications are not easy matters Let us

consider our patient with take down colostomy

again Most of us have changed the practice when

we do straightforward colon surgery, and we no

longer leave a nasogastric (NG) tube in for 7

days, starving the patient until the

gastrointesti-nal function is returned postoperatively before

initiating oral or enteral nutrition Yet, when we

lyse adhesions, which seem to be almost 90 % of

the time, we take down stomas and even if we do

not leave an NG tube, we often will not advance

the feeding for days

The patient from our example was barely

started on a clear liquid diet by day 5 On the sixth

postoperative day, she was not feeling well and

now you receive the call on day 7 By this point,

the patient has developed complications and this

process of starvation will be prolonged ever

fur-ther One has to remember that we should initiate

and maintain nutritional therapy enterally or

par-enterally throughout the hospitalization However,

in a very busy practice, it is easily forgotten that a patient who underwent a major surgical operation needs aggressive nutrition support

Management for Fistulas

One of the most important elements in the agement of complex open wounds, with or with-out fi stula and/or stomas, is continuous wound care and reduction of the overall infectious bio-burden Therefore, avoiding skin excoriations from the bile salts, intestinal fl uids, or stool is essential The vacuum-assisted closure (VAC) and proper stoma equipment have revolutionized wound care However, collecting all the fl uids from patients with large open abdominal wall defects (which we have termed “fi stula city”) may prove extremely diffi cult Controlling sep-sis, providing adequate wound care and tissue coverage (native or biologic) of the abdominal wall, and maintaining nutritional support will result in patient improvement They may eventu-ally develop a major hernia that also needs to be

man-fi xed at a later time, but at least they will be alive One major aspect of this surgical decision- making process is the involvement of the patient and their families in every aspect of care Remember, the patient is the main decision maker in this triangle consisting of the disease process, the patient and their family, and the sur-geon We need to make sure that all work together

to both inform and empower the patient, while

we the surgeons are merely the advisers and implementers of such decisions

Factors that favor surgical treatment of a fi tula include high output and the presence of mul-tiple fi stulas [ 1] To reestablish intestinal continuity, the bowel segment giving rise to the

s-fi stula is resected, and some have recommended long intestinal tube stenting of the entire small bowel afterward [ 11] The surgery for ECFs should be timed after sepsis has been addressed and nutritional status has been improved In order

to protect the surrounding skin from the caustic effects of intestinal contents, the output of the fi s-tula needs to be controlled [ 12 ] For patients with

an abdominal wound that cannot immediately be

closed and are at high risk for complications, a

vacuum-assisted closure (VAC) device can be

utilized both pre- and postoperatively, and

main-tained on a continuous mode with a negative

pressure from −75 to −125 mmHg Dressings are

to be changed every 2 days, and the use of such

devices reduces the number of required dressing

changes [ 7 , 12 ] For high-output ECFs, a 10-year

review of vacuum-compaction devices

demon-strated that the treatment was effective in

con-trolling output among 89 out of 91 (97.8 %)

patients, with output being entirely suppressed

within a week for 37 patients (40.7 %), and

spon-taneous closure being achieved in 42 patients

(46.2 %) [ 2 ] Knowing the anatomy of the fi stula

is also important to the surgeon as visualization

of the complete bowel tract informs both the

complexity of the fi stula and also the length and

quality of the remaining bowel [ 3 ] The incidence

of spontaneous closure for a fi stula is greater

when there is a greater distance between the

bowel and the skin; therefore, estimating the

length of the fi stula is important when

determin-ing the course of treatment [ 7 ]

In summary, when one is dealing with diffi

-cult situations such as postoperative fi stulas, the

priorities are management of sepsis, nutritional

optimization (including rehydration and

electro-lyte correction), and wound care, while you

pre-pare the patient for the defi nitive surgery Sources

of sepsis should be identifi ed and treated quickly

by using appropriate radiological investigation

and culture of all potential sites of infection [ 7 ]

Necrotizing Soft Tissue Infections

The Patient

I performed a take down colostomy on a 51-year-

old female in whom one of my partners did an

end colostomy for perforated diverticulitis (I

took over her care because she no longer wanted

to deal with him after he advised her to stop

smoking and stop taking drugs!) This was a very

low handsewn two layers anastomosis, but there

was a large uterus lying right on top of the

anas-tomosis I considered inviting the gynecologist to

take her uterus out, but decided not to I packed the stoma site with gauze soaked in betadine and normal saline and put in four sutures for a delayed closure on day 5 or 6

She did well until postoperative day 4, when she developed a fever and a foul smelling wound The fi rst thought that came to my mind was that the anastomosis has fallen apart I ordered and arranged an emergency rectal contrast study and repacked the wound About 1 h later, the contrast study was normal and there was no leak from the recto-sigmoid anastomosis I concluded it is just

a wound infection that can be treated tively The fascia at the stoma site felt good, and the sutures were still in place But the smell: it was an awful smell

Later that evening, my partner called to tell that the patient has coughed vigorously, as her tracheostomy was clogged—she had a tracheos-tomy for many years due to some unclear immune disease—with a mucus plug and she eviscerated most of her intestines through midline incision

He took her to the operating room, but was really surprised when he found a necrotizing soft tissue infection of her stoma site and had to resect a large portion of her left abdominal wall I used the antibiotics perioperatively as recommended and packed the stoma site with betadine and saline I did not get any sleep that night The patient underwent multiple debridements, skin coverage of the defect, wound VAC, and now is awaiting repair of large abdominal defect, for which she will need complex abdominal reconstruction

The Disease

Necrotizing soft tissue infections (NSTIs) are rapidly progressing conditions with high mortal-ity, which include fasciitis, gas gangrene, Fournier gangrene, or anaerobic myositis [ 13 ] These life-threatening emergencies are usually caused by gas-forming bacteria that often spare the skin and underlying muscle and instead involve the superfi cial fascia and subcutaneous tissue [ 14 ] Patients often fi rst perceive a trivial lesion (e.g., insect bite, boil, injection site) that

R Latifi and J.A Stroster

becomes a blue or purple spot and then melts

within a day, leaving a nearly black area that

spreads rapidly in expanding circles They

classi-cally present with fever, signs of systemic

toxic-ity, and severe pain that is disproportionate to the

clinical fi ndings [ 14 – 16 ] Common risk factors

include diabetes mellitus, obesity, peripheral

vas-cular disease, chronic renal failure, intravenous

drug use (particularly black tar heroin),

alcohol-ism, immunosuppression, and old age (>50

years) [ 15 – 17 ] While the overall

pathophysiol-ogy is common among all necrotizing infections,

the rate at which clinical symptoms develop is

dependent upon the particular pathogen [ 15 ]

The U.S Food and Drug Administration

(FDA) excludes necrotizing soft tissue infections

from therapeutic trials, and therefore current

rec-ommendations have been inferred from

compli-cated skin and soft tissue infections (cSSTIs)

[ 18 ] Complicated SSTIs are generally classifi ed

either by their anatomical site, microbial

etiol-ogy, or severity, with complicated cases being

those requiring surgery [ 14 ] The management of

necrotizing infections normally involves a

com-bination of wound drainage, aggressive surgical

debridement, and antibiotic management

adher-ing to empirical guidelines [ 14 , 19 , 20 ] The

prompt recognition of NSTIs is essential, but in

their early stages they can be mistaken for

cellu-litis However, a delay in treatment often means

the difference between life and death for this

patient group [ 13 , 16 ] The patient can rapidly

develop sepsis and/or multiple organ failure,

which needs to be intensively corrected before

surgery can be performed, but if essential surgery

is postponed for too long, there is a signifi cant

increase in both morbidity and mortality [ 13 , 18 ]

Antibiotic therapy should initially be broad, as

the necrotizing infection may be the result of

multiple organisms, and targeted at the most

likely pathogen, but should then be quickly

adjusted after culture and sensitivity laboratory

results become available [ 20 , 21 ]

When attempting to diagnose the condition,

the presence of gas in the soft tissues is specifi c

for necrotizing infections and is more sensitive

than physical examination alone [ 18 ] While

plain radiographs may detect the presence of gas

that is produced by clostridial or polymicrobic infections, they are of no value for other causes

of necrotizing infections [ 16 ] Instead, computed tomography (CT) and more often magnetic reso-nance imaging (MRI) is being used [ 14 , 18 ]

The Management

The aforementioned case example and data from our own clinical practice demonstrate that surgi-cal intervention within the fi rst 6 h after diagnosis

of NSTIs improves hospital outcomes in terms of shortening both the hospital length of stay (LOS) and intensive care unit (ICU) LOS [ 22 ] In our study, the overall mortality was 12.5 % (or 11/87), which is less than has been reported in many previous studies [ 13 , 23 – 25 ] Although there was a clinically signifi cant difference in the mortality between the groups based on the timing

of surgical intervention (17.5 % in late vs 7.5 %

in early intervention group), this did not reach statistical signifi cance

NSTIs, in particular necrotizing fasciitis, remain the most deadly surgical infections if not treated aggressively with resuscitation and surgi-cal debridement Early diagnosis, early antibiotic treatment, and early surgical debridement remain the cornerstone of care for these patients While

“early” has not been clearly defi ned, we believe that surgery in these patients should be performed within the fi rst few hours and no longer than 6 h [ 22 ] In a study by McHenry et al., the mean time from admission to operation was 45 h (range: 1.7–312 h), while average time from admission

to operation was 90 h for non-survivors versus 25

h in the survivors group ( p = 0.0002) [ 26 ] In our study, we found that patients with NSTIs required

an operation as soon as possible and certainly no later than 6 h after their arrival or presentation to the emergency department In fact, most of our early group patients underwent an operation even earlier, within a mean time of 2.95 ± 1.1 h

In patients with NSTIs, the most common son for a delay in surgery is diffi culty in making the correct diagnosis Erythema, tenderness, and swelling are all common The clinical presenta-tion can be deceiving, particularly in immuno-

compromised patients, ranging from indolent

wound infections to severe gangrene with septic

shock, as defi ned with end organ failure requiring

vasopressors despite adequate fl uid resuscitation

[ 27 ] Often patients seem too sick to be

immedi-ately operated on, so clinicians will attempt to

resuscitate them fi rst, resulting in signifi cantly

delayed surgery or the clinical presentation is

deceiving, particularly in immunocompromised

patients [ 28 ] However, one has to keep in mind

that source control of the infection is the priority

in the management of any critically ill patients

These patients should be treated with the same

urgency as a gunshot wound or any other major

insult to the body

Despite numerous scoring systems and els introduced to discriminate between NSTIs and non-necrotizing soft tissue infections, mak-ing the diagnosis, predicting mortality and limb loss in NSTIs is still diffi cult [ 29 , 30 ] and the most important element remains early clinical recognition (Fig 12.1a–d ) Yet, there can be con-siderable diagnostic challenges when one is faced with “bad-looking” cellulitis and trying to distin-guish it from NSTs While we do not have a set protocol managing these patients, most patients will get a CT scan or more commonly an MRI if

mod-no clear clinical indication for surgery exists As mentioned previously, on occasion, the patient may get a plain fi lm radiograph to rule out gas in

Fig 12.1 ( a ) Neglected Fournier’s gangrene believed to

have been a “coffee burn.” ( b ) Aggressive debridement in

search for health tissue ( c ) Right hip disarticulation on

patient in ( a ) and ( b ) proved to be not enough to save his

life ( d ) Incisional skin necrosis on an obese patient, requiring major debridement

R Latifi and J.A Stroster

the tissue, but this is rare and it is useless for the

most part As a rule, we use imaging techniques

more often to assure ourselves and the patient

that there is no immediate indication for an

oper-ation However, clinical exam remains the most

important (Fig 12.1d ) diagnostic method

Laboratory test results in patients with NSTIs

have been well studied by a number of authors

The Laboratory Risk Indicator for Necrotizing

Fasciitis (LRINEC) scoring system has been

advocated to be helpful in distinguishing between

NSTIs and non-necrotizing soft tissue infections

[ 31 ], as well as in differentiating between severe

and not severe NSTIs However, in our study, we

found that no single laboratory value

indepen-dently predicted early diagnosis of NSTIs

Furthermore, a study of a small group of patients

strongly suggested that the LRINEC system is

too insensitive for diagnosis of NSTIs [ 32 ]

Although hypoalbuminemia (<2 g/dL) is a known

factor for postoperative complications, in our

study, the albumin level did not signifi cantly

dif-fer between our two groups (2.1 ± 0.7 vs 1.9 ± 0.5;

P = 0.579) Our microbiologic fi ndings were

sim-ilar to those of other reported series and refl ected

a wide spectrum of bacteria (data not published)

We believe that our rapid surgical treatment of

our patients, once the diagnosis was

estab-lished—especially our relatively short time to

surgery—was the main reason for our low

mor-tality rate The overall reported mormor-tality rate has

been reported to be very high (up to 72 %) if the

patient does not undergo surgical debridement as

soon as possible A median time to surgery of 8.4

h had a relatively low mortality rate of 16.4 %

[ 23 ], while an interval >14 h from diagnosis to

surgery in patients with septic shock was

inde-pendently associated with in-hospital death [ 13 ]

Hyperbaric oxygen therapy for NSTI, despite

all its commercial activities, continues to be

con-troversial [ 33 ] Our center does not have a

hyper-baric oxygen chamber; so none of our patients

with NSTI undergoes such treatment Although

we have no experience with such treatment, we

believe that hyperbaric therapy may actually

delay treatment of patients with NSTI

Evidence suggests that early surgical

interven-tion is crucial in reducing morbidity and

mortal-ity in necrotizing fasciitis (NF) patients However,

there is still lack of a clear defi nition concerning the exact defi nition of “early.” Therefore, together with future studies, our work may contribute to the defi nition of early intervention McHenry

et al reported that early surgical intervention is associated with survival [ 26 ] The mean time of surgical intervention (interval between diagnosis and surgical treatment) was 25 h in survivors In their study, other risk factors previously associ-ated with the development of NF did not affect mortality Kobayashi et al showed signifi cantly lower mortality in early intervention group [ 34 ]

In summary, early and aggressive emergency debridement of necrotic tissue is a life-saving treatment [ 15 – 17] Enteral nutritional feedings should be initiated as soon as possible to offset malnutrition, but parenteral nutrition support should be undertaken if more aggressive therapy

is warranted after multiple debridements If available, hyperbaric oxygen may be of benefi t to

a hemodynamically stable patient with certain infections, particularly Clostridium species; however, the evidence regarding the benefi t for its use in non-clostridial infections is weak [ 15 ]

Postoperative Anastomotic Leaks

One of the most dreaded complications of eral surgery is the anastomotic leak following small or large bowl resection These postopera-tive anastomotic leaks are serious complications

gen-of colorectal surgery, and, while their incidence

is reported to be below 20 %, their associated mortality can be as high as 39 % [ 35 , 36 ] Advanced tumor stage, distal site (particularly with rectal tumors), and need for postoperative blood transfusion have been independently asso-ciated with increased rates of anastomotic disrup-tion [ 35 ], and the rates of anastomotic dehiscence are similar between open versus laparoscopic techniques [ 36 ] Those leaks that are diagnosed through radiography, without any patient signs or symptoms, are usually considered subclinical whereas clinical leaks present with signs of peri-tonitis or septicemia [ 37 ] While the periopera-tive management of anastomotic disruptions has improved in recent years, they are still a major surgical challenge often resulting in sepsis,

reoperation, and increased length of hospital stay

[ 35 , 36 ] The manner in which the patient presents

will be determined by whether the anastomotic

leak is either intraperitoneal or extraperitoneal

[ 37 ] An anastomotic leak may present early and

dramatically, or more subtly and later in the

post-operative period, making them diffi cult to

distin-guish from other infectious complications [ 38 ]

The decision of how to approach this

poten-tially catastrophic complication is not entirely

straightforward For patients with previous

surger-ies and intestinal resection and/or obese patients,

an anastomotic leak may be lethal if not

recog-nized immediately Patients with intraperitoneal

leaks with clinical generalized peritonitis or

high-grade sepsis require immediate surgical

interven-tion after receiving appropriate resuscitainterven-tion [ 37 ]

If there is evidence of ischemia at the site of

anas-tomosis recognized following the anasanas-tomosis, it

should be redone immediately (Fig 12.2 ),

other-wise it will leak and cause signifi cant morbidity

and mortality if not corrected before the abdomen

is closed When there is signifi cant peritoneal

con-tamination or if the anastomotic defect is large,

the patient should undergo a resection of the

anas-tomosis with the formation of an end stoma [ 37 ]

If the leak is at the sigmoid colon or rectum, a

Hartmann’s procedure may minimize the ity of further abdominal catastrophe Some sur-geons may instead opt to perform a re-anastomosis with a proximal section of bowel, but this should only be attempted in those patients who are asep-tic, well-nourished, and do not suffer from infl am-matory bowel disease In this situation, our preference is to divert the patient, either totally or using some sort of loop diversion Regardless of the technique, a tension-free anastomosis is a must While others suggest the use of drains [ 37 ], this is not our practice

If the intraperitoneal leakage is instead panied with localized peritonitis or abscess, a diagnostic imaging workup using computerized tomography (CT) scan of the abdomen and pelvis should be performed (Figs 12.3 and 12.4 ); CT scanning appears to be far more helpful than con-trast enema in diagnosing a leak [ 38 ] If a large abscess or multiple abscesses are noted, then the patient should be managed surgically as described before if the site of the abscess is inaccessible for draining However, if the abscess is small (<3 cm), broad spectrum intravenous antibiotics are recommended instead [ 37] Distinguishing an anastomotic leak from a postoperative abscess can be diffi cult [ 38] Occasionally, following Hartman’s procedure, closure of the rectal rem-nant may prove challenging

The basic principles of patient management are similar to fi stulas management for the most part At times, surgeon may get “too close” to the patient and family over the long course of their care and it may be really benefi cial to have a partner look after the patient for a while This is not an abandonment of the patient, but simply taking a “break” to gain some perspective, and later approach the case more objectively to pre-vent a potentially catastrophic event

Intestinal Ischemia

Every general surgeon has had a memorable case

of intestinal ischemia, either because s/he missed the diagnosis altogether or simply intervened too late (Fig 12.1a–d ) Intestinal ischemia, particularly acute mesenteric ischemia (AMI) , is a complex

Fig 12.2 An 84-year-old female underwent proximal

small bowel resection for spontaneous perforation due to

severe hemorrhagic necrotizing pancreatitis Ischemia of

the one side of the anastomosis was recognized

intraop-eratively and resected Ischemic segment lies superiorly

to the anastomosis for illustration

R Latifi and J.A Stroster

problem still commonly faced by general

sur-geons Despite decades of treatment

advance-ments, AMI still has a high risk for complications

and a mortality rate upward of 60 % [ 39 ] Patients

are typically elderly, with clinical histories

con-sisting of atrial fi brillation, recent myocardial

infarction, congestive heart failure, or other risks

for superior mesenteric artery (SMA) embolism

[ 40 ] There are a number of underlying causes for

AMI, but arterial thrombosis is the most common

pathophysiology, accounting for about half of the

cases [ 40 ]; other causes include arterial or venous

thrombosis, and non-obstructive causes (such as

systemic coagulation disorders) All these gies can lead to intestinal hypoxia, irreversible bowel damage, and potentially death [ 39 ] The blood supply to the intestines is mainly pro-vided by three large vascular systems stemming from the abdominal aorta: the superior mesenteric artery (SMA) , the inferior mesenteric artery (IMA) , and the celiac axis Arterial emboli are more com-monly localized in the SMA due to its wider angle of origin compared with the celiac artery and parallel course to the abdominal aorta [ 39 ] The SMA and celiac axis systems communicate via the gastrodu-odenal artery and pancreaticoduodenal arcades at

Fig 12.3 Post operative leak

following sigmoid resection and

primary stapler anastomosis in a

patient with gunshot wound to the

pelvis

Fig 12.4 Abdominal catastrophe

following total colectomy with

spontaneous perforation of small

intestines

the pancreatic head region, and, since routine

pan-creaticoduodenectomy (PD) involves resection of

these branches, ischemic complications may also

arise in this patient group [ 41 ]

Timely diagnosis is critical to prevent

isch-emic complications and improve odds of

sur-vival; however, the diagnosis of patients with

AMI can be diffi cult, as the abdominal pain is

often accompanied by nonspecifi c symptoms

such as fever, vomiting, diarrhea, and loss of

bowel sounds Therefore, the patient’s history is

important to consider, particularly if he or she is

elderly and has cardiovascular or peripheral

vas-cular disease [ 39 ] Computerized tomography

(CT) scan is both highly sensitive and specifi c for

diagnosing AMI and can visualize both the

occlu-sions as well as the consequences of the intestinal hypoxia; in situations where it is not available, mesenteric angiography or duplex ultrasonogra-phy can be utilized [ 39 , 40 ]

Particularly diffi cult is the situation of a patient with multiple abdominal surgeries, requir-ing signifi cant amounts of pain medication When these patients develop ischemia, it is diffi -cult to discern pain associated with ischemia from their “usual pain.” Such an example is an obese patient with multiple previous abdominal operations and large ventral hernia, who pre-sented with the exacerbation of the abdominal pain, which turned out to be intestinal ischemia due to thrombosis of SMA (Fig 12.5a–c )

Fig 12.5 ( a ) CT scan demonstrating a large thrombus in superior mesenteric artery ( b ) Same patients as in ( a ) Giant hernia and “frozen” abdomen from multiple operations ( c ) Intraoperative view of intestines of patient in ( a ) and ( b )

R Latifi and J.A Stroster

Fig 12.6 Super obese patient with

giant hernia undergoing emergency

surgery from Fig 12.1d

Surgical exploration is warranted for all

patients who have any evidence of threatened

bowel, such as suspected mesenteric ischemia

and signs of peritonitis, regardless of its cause

These patients are at high risk for irreversible

bowel infarction and abdominal sepsis and bowel

that is approaching irreparable necrosis can

seem normal in appearance In contrast, bowel

that may appear necrotic may be viable after

revascularization For these reasons, the priority

of the surgeon should be to reestablish

vascular-ization and then reassess the viability of the

bowel (after perhaps 20–30 min) before making

decisions about intestinal resection

Conclusion

Dealing with really diffi cult situations in general

surgery is challenging and requires a thoughtful

and meticulous approach, yet expeditious action

The worst thing that we can do is rush into a

deci-sion that we cannot come back from yet it is also

critical, not to become paralyzed with the fear of

failing or having complication Fistulas,

necrotiz-ing soft tissue infections and intestinal failure are

all dramatic and can have signifi cant mortality if

not addressed appropriately As general surgeons,

we are expected to deal with situations that often are very diffi cult However, when we face a com-plicated patient, either during reoperative surgery (when others have operated beforehand) or for when your patient’s postoperative course gets truly complicated, then things get diffi cult on more than one level They are personal failures These personal complications sometimes make it diffi cult to return to the operating room, but one has to do it and start the fi ght again One thing is very certain: we are operating more and more on super obese patients that have ignored clinical problems (Fig 12.6 ) or have been passed from one surgeon to another surgeon until it becomes

an emergency situation These patients represent some of the most diffi cult cases that we deal with

in general surgery Furthermore, as patients are kept alive in various ways, such as complex heart and lung machines, they will develop decubitus that, if not treated early and appropriately, may develop into necrotizing soft tissue infections that goes beyond any possibility to salvage such patients (Fig 12.7a–c )

Acknowledgments There are no identifi able confl icts of

interests to report

The authors have no fi nancial or proprietary interest in the subject matter or materials discussed in the manuscript

Fig 12.7 ( a ) Decubitus over the upper back in a patient on an artifi cial heart ( b ) Postoperative view at the completion

of aggressive debridement on patient in ( a ) ( c ) Neglected sacral decubitus on the same patient

References

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© Springer International Publishing Switzerland 2016

R Latifi , Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_13

Trauma Surgeon Decision-Making:

Surviving Outside the Realm

of the Evidence Based

Samir M Fakhry

Epigraph

A 65-year-old male is involved in a single- vehicle

high-speed motor vehicle crash approximately

45 min before he was brought to trauma center

He was an unrestrained driver and went off the

road striking a tree head-on He was found

unre-sponsive with a GCS of 5 and shallow

respira-tions The EMS team immobilized him, assisted

his breathing with bag-valve mask, and brought

him promptly to the trauma center as high-level

trauma activation On arrival, the trauma team

performed rapid sequence intubation and

initi-ated ATLS resuscitation His initial BP was 85

systolic and he initially responded to initial

resus-citation A CXR showed a 30 % left-sided

pneu-mothorax and a chest tube was inserted with

return of air and 150 mL of blood He became

hypotensive again 10 min later FAST exam

showed free fl uid in the abdomen and because his

BP was improving slowly he was taken to CT

scan where a ruptured spleen was identifi ed The

rest of the body was not scanned and he was

taken to the OR for exploration A splenectomy

was rapidly performed and his BP stabilized with

three additional units of pRBCs Postoperatively,

he was taken for CT scan of his head and neck

and found to have several areas of sub-arachnoid hemorrhage (SAH) without midline shift He was admitted to the ICU for management

Introduction

Trauma surgery is inherently a decision intense specialty In caring for injured patients, trauma surgeons make impactful decisions on a nearly constant basis Decision-making is not a homo-geneous process with a single pathway that is universally recognized as optimal By its nature, surgical disease, and especially injury, requires a broad repertoire of decision-making skills as differing clinical situations require differing approaches (temporally and in terms

of process)

Rarely are all the “necessary” data and quate” time available to weigh options Trauma surgeons are thus subjected to high-stakes decision- making throughout their careers and probably self-select for a certain comfort with uncertainty and “ pattern recognition ” as opposed

“ade-to the more traditional scientist phenotype In some ways, this is similar to the difference between a fi ne restaurant’s head chef (who relies

on experience, palate, and the learned taste of particular combinations of ingredients) and its pastry specialist (who is committed to precision recipes and exact formulations)

There has been little if any research into how trauma surgeons make decisions and deal with the

S M Fakhry , M.D., F.A.C.S (*)

Department of Surgery , Medical University of South

Carolina , 96 Jonathan Lucas St, CSB 426 MCS 613 ,

Charleston , SC 29425 , USA

e-mail: fakhry@musc.edu

13

dual pressures of incomplete data and pressing

timelines It is also unclear whether recent

advances in diagnostic technology have resulted

in fundamental changes in how trauma surgeons

make care decisions Although there are

increas-ing calls to apply evidence-based practice to

clini-cal care, the relative paucity of methodologiclini-cally

robust and statistically valid studies to guide

sur-gical care makes it unlikely that the majority of

decisions in trauma care can be guided by high

quality data [ 1 6 ] At least one published study

goes further and suggests that due to inherent

bias, most study results are in fact false [ 7 ] As a

result, the care of the trauma patient is often

guided by consensus guidelines and widely

accepted (if not well supported) algorithms and

protocols This is especially apparent in the early

care of the acutely injured patient where the

Advanced Trauma Life Support (ATLS) course of

the American College of Surgeons is the de facto

standard not only in the United States but also

around the world Although ATLS has had a major

impact on trauma care by standardizing early care

of the injured patient, evidence of improved

out-comes remains elusive [ 8 – 10 ], leaving signifi cant

opportunity for the exercise of judgment and the

application of the ill-defi ned skill set of rapid decision-making without adequate data

The example of ATLS is only one of many applicable to decision-making in trauma care This chapter will attempt to provide an overview of some of the theoretical constructs proposed for modeling decision-making, incorporate a brief review of the evolution of modern trauma decision- making, and incorporate personal viewpoints of the author as a practicing trauma surgeon

Decision-Making as a Science?

In addition to drawing on the literature and their accumulated experience, trauma surgeons may refer to “ pattern recognition ,” “fuzzy logic,” and other techniques that they utilize to make clinical decisions often under diffi cult conditions while caring for the acutely injured and/or critically ill

In some areas of clinical care, a deliberate, step- by- step process may be successfully employed (Fig 13.1): identify the decision to be made, gather relevant information, identify alternatives, weigh evidence, choose among alternatives, take action, review decision and consequences Such

1 2

3 4 5 6

Review the Decision

Take Action

Choose From Alternatives

Weigh the Evidence

Identify the Alternatives

a deliberate process is not usually possible in the

care of the acutely ill and injured, and a variety of

methods to shorten the cycle of deliberation and

action are needed

Although most trauma clinicians are not well

versed in the theoretical constructs of decision-

making and more than a few regard their work as

much an art as a science, there is a substantial

body of clinical research in this area In a very

approachable review of decision-making, Stiegler

and Tung [ 9 ] describe commonly accepted

theo-ries of decision-making and comment on the

impact of heuristics, bias, and nonrational factors

that infl uence decision-making

Expected Utility

The Expected Utility (EU) model suggests that a

decision maker considers the expected benefi t of

each choice (its probability x its payoff) and

selects the one with the superior expected value

(EV = probability × payoff) This model assumes

knowledge of the probabilities and payoffs of all

choices and is rarely applicable in its purest sense

in the real world The 1978 Economics Nobel

Laureate, Herbert Simon, proposed a variation

wherein “good enough” solutions replaced ideal

ones if the effort of obtaining the needed

infor-mation was signifi cant, and measurable

“sub-goals” took the place of goals that were more

diffi cult or impossible to determine [ 11 ]

Bayesian Probability

Bayesian Probability (BP) begins with a similar

setup as EU, calculating the expected outcome of

each of the choices It then allows new

informa-tion from diagnostic testing, treatment, and

dis-ease progression to infl uence the decision-making

process By making frequent course adjustments

in response to incoming information, the quality

of the decision-making process is improved

Although favored in many domains, BP suffers

from the same limitations that plague EU in

clini-cal settings: both assume some knowledge of all

relevant outcomes and their individual merits

Formalized Pattern Matching

Formalized Pattern Matching (FMP) is a monly utilized decision-making technique in clinical medicine It consists of grouping data and observations into recognizable subsets (e.g., hypotension, lactic acidosis, tachycardia suggest-ing shock) Pattern matching is then used to select particular characteristics (called “pivots”)

com-of the case in question that seem important, are unique, or do not fi t the pattern The clinician uses “pivots” to ignore or amplify particular diagnostic choices thus narrowing the options being considered The process proceeds as addi-tional data or new observations are added until a

fi nal option is selected When using FMP, nitive shortcuts” are used preferentially over sta-tistical probability as in EU or BP Clinicians who are more experienced are thus more likely

“cog-to employ and benefi t from FMP as they are more likely to have encountered the “patterns” and rec-ognize the “pivots.” These experienced clinicians will thus have a “mental library” of recognizable patterns to draw on and they can accelerate decision- making through these “cognitive short-cuts.” Although generally quite effective, this technique can lead to erroneous diagnostic deci-sions because of inherent biases and minimal reliance on statistical probability

Heuristics

Heuristics are cognitive shortcuts (also referred

to as “decisional shortcuts”) utilized to decrease the cost of decision-making even though they may violate logical concepts and objective data [ 12 , 13 ] Stiegler and Tung [ 1 ] illustrate the use

of heuristics with a classic example: a group of college students are asked whether a meek, tidy man who loves books was a librarian or a sales-man Most choose “librarian” despite the fact that there are statistically few male librarians and many male salesmen Occam’s Razor and the idiom “If it looks like a duck and walks/quack/

fl ies etc like a duck, it is a duck” are examples of heuristics and inductive reasoning where effi -ciency in making a decision is chosen over actual

13 Trauma Surgeon Decision-Making: Surviving Outside the Realm of the Evidence Based

data Heuristics are useful when dealing with

complex clinical scenarios with incomplete

data-sets, but may not always lead to correct choices

because of the inherent biases they may be based

on

Stiegler and Tung also describe more recent

theoretical models such as dual process

reason-ing which is a hybrid of EU and heuristic models

[ 1] In addition, they review other cognitive,

emotional, cultural, and environmental factors

that affect decision-making (Table 13.1 )

Evolution of Trauma Surgical

Decision-Making

Over the past three decades, there has been

sig-nifi cant evolution in the way trauma care is

deliv-ered The broad introduction of computerized

tomography (CT) technology in the 1980s

pro-moted the transition to nonoperative care [ 14 ],

evidence-based medicine began to replace expert

opinion and apprenticeship models, previously

irrefutable standards such as colostomy for all

gunshot wounds of the colon [ 15 ] and the 10/30

rule for transfusion were toppled [ 16 , 17 ] The

management of liver injury is a good example of

how decision-making in trauma care evolved

over the years As a surgical intern in the early

1980s, I was taught that all patients with blunt or

penetrating liver injuries had to undergo

explor-atory laparotomy As a university trauma surgeon

at a busy level 1 trauma center nearly 30 years

later, I have not performed a major liver repair in

the past academic year and our graduating chief

residents have performed many more Whipple’s

procedures than they have major liver repairs for

trauma This is in keeping with trends in

nonop-erative management at nearly all centers [ 18 ] but

also refl ects the dramatic change in trauma

surgi-cal decision-making that has occurred in my

career Perhaps most interesting is the paradigm

shift from operating on large numbers of injured,

frequently stable patients to a near reluctance to

operate on patients without completing a

diag-nostic work-up that includes “pan CT scan.” [ 19 ,

20 ] The former approach may have been

neces-sary in an era of limited availability of specifi c

diagnostic information but was associated with many nontherapeutic laparotomies Current approaches, on the other hand, involve procuring maximal amounts of data on patients before ther-apeutic decisions are made and has resulted in new problems of missed injuries such as blunt small bowel perforation [ 21 ] In addition, some centers have extended the concept of increasing baseline diagnostic data to the point of advocat-ing CT scan even for some unstable patients [ 22 ] One possible explanation for this change in approach is the routine availability of advanced diagnostic tools, primarily CT scan Another plausible hypothesis is that the decision-making approach employed in the 1980s and early 1990s

of necessity more closely approximated the cepts of “pattern recognition” inherent in FPM and required the use of heuristics and associated

con-“shortcuts” given the relative paucity of baseline data and urgent/emergent timelines With the explosion in diagnostic medical technology over the past half-century, most specialties have become highly reliant on these technologies to improve diagnostic accuracy and perhaps out-comes The perceived availability of extensive baseline data may have the effect of changing the manner in which physicians are making deci-sions, making techniques such as the step-by-step approach, EU and BP more feasible Although trauma care still requires more rapid decisions than other specialties, the CT scanners on which

we rely have become exceedingly fast and nearly universally available It may be that the tempta-tion to “know more” and the perception that the time delay is relatively minor is changing the way trauma surgeons approach decision-making and narrowing the difference between decision- making in the acute/emergent setting and that of the elective setting

As we review various decision-making approaches and the utility of increasing baseline data through diagnostic technology, the question

of error rates in decision-making should be sidered Since the Institute of Medicine report

con-“To Err Is Human: Building a Safer Health Syste m” was published, increased attention has been focused on medical errors [ 23 ] The Harvard Medical Practice Study identifi ed adverse events