Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (26 page)
Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
With the increased use of CT in the investigation of the acute abdomen it was only a matter of time before attention turned to the role of MRI, which is not associated with the radiation exposure of CT. MRI can undoubtedly differentiate an acutely inflamed appendix from a normal one
105
and therefore is useful in pregnant patients, where the diagnosis of acute appendicitis can be difficult.
106
However, a review of academic centres in North America reported that radiologists still preferred CT to MRI in the second and third trimester to investigate acute abdominal pain.
107
Laparoscopy is now an integral part of the emergency surgeon's armamentarium, for both diagnosis and treatment of acute abdominal conditions. Laparoscopy significantly improves surgical decision-making when used as a diagnostic tool,
108
particularly when the need for operation is uncertain.
56
With the increasing use of laparoscopic appendicectomy (see
Chapter 9
), most patients with suspected appendicitis can now undergo diagnostic laparoscopy followed by laparoscopic appendicectomy if the diagnosis of acute appendicitis is confirmed (
Fig. 5.15
). Even if a policy of laparoscopic appendicectomy is not followed, all females with suspected acute appendicitis should still undergo diagnostic laparoscopy because the diagnostic error is more than twice that of males,
109
usually due to underlying gynaecological conditions (
Figs 5.16
and
5.17
). When used as a diagnostic tool in patients admitted to hospital with suspected acute non-specific abdominal pain, some of whom of course subsequently turn out to have a surgical cause, early laparoscopy versus observation has been shown to be of benefit. Two randomised studies
110,
111
have demonstrated that the associated improved diagnostic accuracy in the patients undergoing laparoscopy converts to a reduced hospital stay, and in one of the studies
110
an improved quality of life (assessed 6 weeks after discharge from hospital).
Figure 5.15
Laparoscopy showing an acutely inflamed appendix with pelvic peritonitis.
Figure 5.16
Laparoscopic view of a torsion of the right fallopian tube with ischaemia of the distal tube and ovary.
Figure 5.17
Laparoscopic view of a haemorrhagic ovarian cyst.
The decision on what to do if a normal appendix is seen at laparoscopy is discussed in detail in
Chapter 9
, and there are differing arguments for and against its removal. What is essential is that the patient must be clearly told the diagnosis made at laparoscopy and the procedure performed. It has been shown that around 27% of patients undergoing laparoscopy for acute abdominal pain could either not remember what had happened or their recall was incorrect.
112
This included knowledge as to whether the appendix had been removed or not.
It is clear that there is now overwhelming evidence in support of the use of diagnostic laparoscopy in the management of patients with acute abdominal pain in whom the need for surgery is uncertain and particularly women with suspected appendicitis.
108,
110,
111
Key points
The art of good management of patients with acute abdominal pain lies in an accurate history, careful examination and logical decision-making, taking into account results from all appropriate and available investigations.
Regular reassessment of patients is an essential part of this process and facilities should be provided so that emergency patients are kept in an area of the hospital where regular review is facilitated.
The ability to provide adequate emergency surgical care, with careful observation, reassessment and early access to the operating theatre, is best provided by dedicated emergency surgical teams without elective commitments.
Swift access to investigations and an emergency theatre is an essential requisite for the appropriate management of patients with acute abdominal pain.
Although emergency subspecialisation has great attractions for the overall care of the emergency patient with complex problems, this area of development will depend very much on local resources, requirements and workload.
1.
Ingraham, A.M., Cohen, M.E., Bilimoria, K.Y., et al. Comparison of 30-day outcomes after emergency general surgical procedures: potential for targeted improvement.
Surgery
. 2010;148:217–238.
2.
Senate of Surgery of Great Britain and Ireland. Reconfiguration of surgical, accident and emergency and trauma services in the UK, 2004.
http://www.rcseng.ac.uk/publications/docs/reconfiguration.html
3.
Black, A. Reconfiguration of surgical, accident and emergency and trauma services in the UK.
Br Med J
. 2004;328:178–179.
4.
Watkin, D.F.L., Layer, G.T., A 24-hour snapshot of emergency general surgery in the UK.
Ann R Coll Surg Engl
. 2002;84(Suppl):194–199.
12398119
5.
Beecham, L. New Scottish CMO criticises training reforms.
Br Med J
. 1996;313:947.
6.
Campling, E.A., Devlin, H.B., Hoile, R.W., et al.
Report of the National Confidential Enquiry into Perioperative Deaths 1990
. London: HMSO; 1992.
7.
Association of Surgeons of Great Britain and Ireland. Emergency general surgery: the future. A consensus statement, June 2007.
www.asgbi.org.uk
[[accessed 10.11.12]].
This consensus statement provides details of the current problems in the provision of emergency general surgery and recommendations for improving practice.
8.
Anderson, I.D. ASGBI emergency surgery survey 2010.
Association of Surgeons of Great Britain and Ireland Newsletter
. 2010;31:12–159.
9.
Hilton, J.R., Shiralkar, S.P., Samsudin, A., et al. Disruption of the on-call surgical team.
Ann R Coll Surg Engl
. 2002;84(Suppl.):50–53.
10.
Ledwidge, S.F.C., Bryden, E., Halestrap, P., et al. Continuity of care of emergency surgical admissions:impact on SPR training.
Surgeon
. 2008;6:136–138.
11.
Kelly, M.J. Off-duty for consultants in the week? It can be done!.
Ann R Coll Surg Engl
. 1995;77(Suppl.):257–259.
12.
Addison, P.D.R., Getgood, A., Paterson-Brown, S., Separating elective and emergency surgical care (the emergency team).
Scott Med J
2001;46:48–50.
11394338
13.
Tincknell, L., Burton, S., Cooke, C., et al. The emergency surgical team – the way forward in emergency care?
Ann R Coll Surg Engl
. 2009;91:18–22.
14.
Emergency surgery.
J Assoc Surg Great Britain and Ireland
. 2012;36:2–19.
15.
Anderson, I.D., Markham, N.I., Cripps, N., et al, Issues in professional practice: emergency general surgery. London: Association of Surgeons of Great Britain and Ireland; May 2012.
http://www.asgbi.org.uk/en/publications/issues_in_professional_practice.cfm
[[accessed 10.11.12]].
16.
The Royal College of Surgeons of England. Separating emergency and elective surgical care: recommendations for practice, 2007.
http://www.rcseng.ac.uk/publications/docs/separating_emergency_and_elective.html
Strong support and recommendations for the separation of emergency and elective surgical care.
17.
Calder, F.R., Jadhav, V., Hale, J.E., The effect of a dedicated emergency theatre facility on emergency operating patterns.
J R Coll Surg Edinb
1998;43:17–19.
9560500
18.
Thomson, H.J., Jones, P.F., Active observation in acute abdominal pain.
Am J Surg
1986;152:522–525.
3777331
19.
Halm, E.A., Lee, C., Chassin, M.R., Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.
Ann Intern Med
2002;137:511–520.
12230353
20.
Hannan, E.L., Radzyner, M., Rubin, D., et al. The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy and lung lobectomy in patients with cancer.
Surgery
. 2002;131:6–15.
21.
Paterson-Brown, S., Surgical volume and clinical outcome.
Br J Surg
2007;94:523–524.
17443849
22.
Smith, J.A.E., King, P.M., Lane, R.H.S., et al, Evidence of the effect of ‘specialisation’ on the management of surgical outcome and survival from colorectal cancer in Wessex.
Br J Surg
2003;90:583–592.
12734867
23.
Mercer, S.J., Knight, J.S., Toh, S.K.C., et al, Implementation of a specialist-led service for the management of gallstone disease.
Br J Surg
2004;91:504–508.
15048757
24.
Young, A.L., Cockbain, A.J., White, A.W., et al. Index admission laparoscopic cholecystectomy for patients with acute biliary symptoms: results from a specialist centre.
HPB (Oxford)
. 2010;12:270–276.
25.
Darby, C.R., Berry, A.R., Mortensen, N., Management variability in surgery for colorectal emergencies.
Br J Surg
1992;79:206–210.
1555084
26.
Dawson, E.J., Paterson-Brown, S. Emergency general surgery and the implications for specialisation.
Surgeon
. 2004;2:165–170.
27.
Simpson, D.J., Wood, A.M., Paterson, H.M., et al, Improved management of acute gallstone disease after regional surgical subspecialisation.
World J Surg
2008;32:2690–2694.
18855046
28.
Robson, A.J., Richards, J.M.J., Nixon, S.J., et al, The effect of surgical subspecialisation on outcomes in peptic ulcer disease complicated by perforation and bleeding.
World J Surg
2008;32:1456–1461.
18246388
29.
Boyce, S.A., Bartolo, D.C.C., Paterson, H.M., The Edinburgh Coloproctology Unit. Subspecialist emergency management of diverticulitis is associated with reduced mortality and fewer stomas.
Colorectal Dis
. 2012. [Sept 11. Epub ahead of print].
30.
Cochrane, R.A., Edwards, A.T., Crosby, D.L., et al, Senior surgeons and radiologists should assess emergency patients on presentation: a prospective randomised controlled trial.
J R Coll Surg Edinb
1998;43:324–327.
9803104
31.
Irvin, T.T., Abdominal pain: a surgical audit of 1190 emergency admissions.
Br J Surg
1989;76:1121–1125.
2597964
32.
Gray, D.W.R., Collin, J., Non-specific abdominal pain as a cause of acute admission to hospital.
Br J Surg
1987;74:239–242.
3555689
33.
Paterson-Brown, S. The acute abdomen: the role of laparoscopy. In: Williamson R.C.N., Thompson J.N., eds.
Baillière's clinical gastroenterology: gastrointestinal emergencies, Part 1
. London: Baillière Tindall; 1991:691–703.
34.
Gallegos, N.C., Hobsley, M., Abdominal wall pain: an alternative diagnosis.
Br J Surg
1990;77:1167–1170.
2145999
35.
Hall, P.N., Lee, A.P.B., Rectus nerve entrapment causing abdominal pain.
Br J Surg
1988;75:917.
2972335
36.
Gray, D.W.R., Seabrook, G., Dixon, J.M., et al, Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain?
Ann R Coll Surg Engl
1988;70:233–234.
2970820
37.
de Dombal, F.T., Matharu, S.S., Staniland, J.R., et al. Presentation of cancer to hospital as ‘acute abdominal pain’.
Br J Surg
. 1980;67:413–416.
38.
Paterson-Brown, S., Eckersley, J.R.T., Dudley, H.A.F., The gynaecological profile of acute general surgery.
J R Coll Surg Edinb
1988;33:13–15.
3418569
39.
Pearce, J.M. Pelvic inflammatory disease.
Br Med J
. 1990;300:1090–1091.
40.
Shanahan, D., Lord, P.H., Grogono, J., et al. Clinical acute cholecystitis and the Curtis–Fitz-Hugh syndrome.
Ann R Coll Surg Engl
. 1988;70:45–47.
41.
Ravichandran, D., Burge, D.M., Pneumonia presenting with acute abdominal pain in children.
Br J Surg
1996;83:1706–1708.
9038544
42.
Blidaru, P., Blidaru, A., Popa, G. False acute abdomen in emergency surgery.
Br J Surg
. 1996;83(Suppl. 2):61–62.
43.
de Dombal, F.T., Leaper, D.J., Staniland, J.R., et al. Computer-aided diagnosis of acute abdominal pain.
Br Med J
. 1972;2:9–13.
44.
Gunn, A.A., The diagnosis of acute abdominal pain with computer analysis.
J R Coll Surg Edinb
1976;21:170–172.
781220
45.
Adams, I.D., Chan, M., Clifford, P.C., et al. Computer aided diagnosis of acute abdominal pain: a multicentre study.
Br Med J
. 1986;293:800–804.
A large study involving eight centres, 250 doctors and 16 737 patients demonstrated an improvement in diagnostic accuracy, reduction in the incidence of perforated appendicitis and bad management errors associated with the use of the computer.
46.
Batstone, G.F. Educational aspects of medical audit.
Br Med J
. 1990;301:326–328.
47.
Marteau, T.M., Wynne, G., Kaye, W., et al. Resuscitation: experience without feedback increases confidence but not skill.
Br Med J
. 1990;300:849–850.
48.
Lawrence, P.C., Clifford, P.C., Taylor, I.F. Acute abdominal pain: computer aided diagnosis by non-medically qualified staff.
Ann R Coll Surg Engl
. 1987;69:233–234.
This paper demonstrates that medical students assessing patients with acute abdominal pain using a structured pro-forma and then CAD have the same diagnostic accuracy as medical staff who use the pro-forma but not CAD.
49.
Paterson-Brown, S., Vipond, M.N., Simms, K., et al. Clinical decision-making and laparoscopy versus computer prediction in the management of the acute abdomen.
Br J Surg
. 1989;76:1011–1013.
The addition of structured patient pro-formas without CAD significantly improved clinical decision-making and laparoscopy.
50.
Bennett, D.H., Tambeur, L.J.M.T., Campbell, W.B. Use of coughing test to diagnose peritonitis.
Br Med J
. 1994;308:1336–1337.
51.
Williams, N.M.A., Johnstone, J.M., Everson, N.W., The diagnostic value of symptoms and signs in childhood abdominal pain.
J R Coll Surg Edinb
1998;43:390–392.
9990785
52.
Dixon, J.M., Elton, R.A., Rainey, J.B., et al. Rectal examination in patients with pain in the right lower quadrant of the abdomen.
Br Med J
. 1991;302:386–388.
53.
Howie, C.R., Gunn, A.A., Temperature: a poor diagnostic indicator in abdominal pain.
J R Coll Surg Edinb
1984;29:249–251.
6481676
54.
Manterola, C., Astudillo, P., Losada, H., et al. Analgesia in patients with acute abdominal pain.
Cochrane Database Syst Rev
. (1):2011. [CD005660; PMID 21249672 [update of Cochrane Database Syst Rev 2007; (3):CD005660]].
This Cochrane systematic review analysed 51 papers and concluded that the use of opioid analgesics in patients with acute abdominal pain is helpful in terms of patient comfort and does not adversely affect decision-making.
55.
Clavien, P.A., Burgan, S., Moossa, A.R., Serum enzymes and other laboratory tests in acute pancreatitis.
Br J Surg
1989;76:1234–1243.
2691011
56.
Paterson-Brown, S., Eckersley, J.R.T., Sim, A.J.W., et al, Laparoscopy as an adjunct to decision-making in the acute abdomen.
Br J Surg
1986;73:1022–1024.
2947659
57.
Bradbury, A.W., Brittenden, J., McBride, K., et al, Mesenteric ischaemia: a multi-disciplinary approach.
Br J Surg
1995;82:1446–1459.
8535792
58.
Schoots, I.G., Koffeman, D.A., Levi, M., et al. Systematic review of survival after acute mesenteric ischaemia according to disease aetiology.
Br J Surg
. 2004;91:17–27.
Data from 45 observational studies including 3692 patients were reviewed. Prognosis after acute mesenteric venous thrombosis is better than for arterial ischaemia, and that for arterial embolism is better than that for arterial thrombosis.
59.
Dervenis, C., Johnson, C.D., Bassi, C., et al, Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini Consensus Conference.
Int J Pancreatol
1999;25:195–210.
10453421
60.
Thompson, M.M., Underwood, M.J., Dookeran, K.A., et al, Role of sequential leucocyte counts and C-reactive protein measurements in acute appendicitis.
Br J Surg
1992;79:822–824.
1393485
61.
Davies, A.H., Bernau, F., Salisbury, A., et al, C-reactive protein in right iliac fossa pain.
J R Coll Surg Edinb
1991;36:242–244.
1941740
62.
Gronroos, J.M., Gronroos, P., Leucocyte and C-reactive protein in the diagnosis of acute appendicitis.
Br J Surg
1999;86:501–504.
10215824
63.
Sengupta, A., Bax, G., Paterson-Brown, S., White cell count and C-reactive protein measurement in patients with possible appendicitis.
Ann R Coll Surg Engl
. 2009;91(2):113–115.
19102827
64.
Andersson, R.E.B. Meta-analysis of the clinical and laboratory diagnosis of appendicitis.
Br J Surg
. 2004;91:28–37.
Systematic Medline search of 28 diagnostic variables in 24 studies.
65.
Peng, W.K., Sheikh, Z., Paterson-Brown, S., et al, Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis.
Br J Surg
2005;92:1241–1247.
16078299
66.
Schwenter, F., Poletti, P.A., Platon, A., et al, Clinicoradiological score for predicting the risk of strangulated small bowel obstruction.
Br J Surg
2010;97:1119–1125.
20632281
67.
Cochrane, R.A., Edwards, A.T., Crosby, D.L., et al, Senior surgeons and radiologists should assess emergency patients on presentation: a prospective randomised controlled trial.
J R Coll Surg Edinb
1998;43:324–327.
9803104
68.
Chen, S.-C., Yen, Z.-S., Wang, H.-P., et al, Ultrasonography is superior to plain radiology in the diagnosis of pneumoperitoneum.
Br J Surg
2002;89:351–354.
11872063