Akut buk Göteborg 2007a - Amazon Web Servicesh24-files.s3.amazonaws.com/110213/296279-JQ4Ty.pdf ·...
Transcript of Akut buk Göteborg 2007a - Amazon Web Servicesh24-files.s3.amazonaws.com/110213/296279-JQ4Ty.pdf ·...
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Catchmentarea
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Teamwork radiology and surgery
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Jigsaw
OP
Endoscopy
X-ray
TRAUMA
Abdominal wall
Cholecystitis Perforation
Appendicitis
GI bleeding
IleusPancreatitisDiverticulitis
Complex and timeconsuminginvestigations
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Be realistic – but recognisethe cangoroo
Surgeons without guidelines
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Concensus 2007
•Smart surgeons learn from their ownmistakes
•Smarter surgeons learn from mistakes of others
•Some never learn……
The CT makes it easier and improves quality
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Guidelines
• Routines• Guidelines• Development
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Surgeons with guidelines
Jays ace Roy Halladay has appendicitis
Toronto Blue Jays starting pitcher Roy
Halladay throws duringfirst inning AL action
against the Boston Red Sox on Thursday, May10, 2007, in Toronto,
Canada
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Appendicit
Acute appendicitis can mimicvirtually any intra-abdominalprocess: therefore to know acuteappendicitis is to know well the diagnosis of acute abdominal pain. (Z.Cope)
History
200 Aretaios1492 da Vinci1734”paratyflitis”1880 The first operation1889 The first op in Sweden, Lennander1983 The first lap-app-op in Sweden
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Peritonitis
• Harry Hodini died from an appendicitis -26
Appendicitis
• Development of pain• Location• Local tenderness• Developemnt of CRP
and LPK
• Exclusion of alternatediagnoses
• Need to operate
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Diagnostics
Why?Avoid unnessecary operationsReduce the risk of missing importantdiagnoses
Indicator of quality
Earlier 25-30% healthy appNow 5-10%
Appendicitis – diagnostic tools
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Assessment and reassessment
Observation
Repetivite assessmentsCRP-LPK
CRP
LPK
Tid
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Our ”golden-standard”appendicitis
• Clinical diagnosis• Ultrasound in children• Diagnosis after CT in patients with
”unclear” conditions.• Laparoscopy in women
– And sometimes in men
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Diverticulitis
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Diverticulitis
• Mild to moderate– Clinical diagnosis– Confirmed later by imaging or colonoscopy– Rule out malignancy
• Moderate to severe– Clinical findings– CT– CT findings are prognostic
Diverticulitis
• Mild to moderate– Clinical diagnosis– Confirmed later by imaging or colonoscopy– Rule out malignancy
• Moderate to severe– Clinical findings– CT– CT findings are prognostic– Ambrosetti classification
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Treatment
• Mild to moderate– Fasting?– Antibiotics?
• Moderate to severe– Antibiotics– Operation
• Resection
Resection with peroperative lavage
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Happy colorectal surgeons after the procedure
Jejunumdivertikulis
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Obstruction
Colocolic invagination
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Gallstone ileus
Diffuse ischemia
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Adhesive band
Bowel ischemia
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Strangulation
Operation
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Internal mesenteric hernia
Emergency operation
Surgeon on call operates an emergency case
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Second look
Surgeon on call reoperates an emergency case
Postoperative complications
• Always suspect surgical reasons
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Postoperative complications
• Always suspect surgical reasons– (at least when other surgeons have operated)
AssessPostop complications
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Assess
Think
Postop complications
Assess
Think
ActPostop complications
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Postoperative complicationsTime-span
• Immediate• Within days• Within weeks-months
Postoperative complicationsCPBF
• Cardiac• Pulmonary• Bleeding• Fluid retention
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Postoperative complicationsPeritonitis
• Anastomotic leakage• Following perforated ulcer – incopmlete
raphi• Deep infection• Abscess
Postoperative complicationsAbdominal wall
• Subcutaneous wound rupture• Early incarceration
– Following laparoscopy• Infection
– Mild– Severe
• With flegmone• Clostridie infection
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Severe pain – out of proportion
• Strangulation• Gas gangraene
Postoperative complicationsBile ducts
• Bile leakage• Bile duct obstruction
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Postoperative complicationsBariatric surgery
• Internal hernias• Incarceration of bowels in troacar incisions
Postoperative complicationsBleeding
• Procedure– Elective– Emergency
• Due to bleeding
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PEG and complications
PEG complications
• Immediate complications– Perforation of organs– Bleeding
• Displacement• Non-functioning• Peritonitis• Leakage
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WSACSWorld Society of the Abdominal
Compartment Syndrome
Abdominal compartment
Intensive care
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Abdominal compartment• Reasons
– Intraabdominal complications– Reperfusion– Ileus– Post major intra- and retroperitoneal bleeding– Severe pancreatitis
• Correlates to– High BMI– Extensive fluid resuscitation
Abdominellt compartment
How to measure the abdominal pressure
KAD, 25 ml water into the bladder
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Jejunumdivertikulit
Ileus
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Colocolisk invagination
TunntarmsinvaginationMetastaserande lungcancer
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The bowel mesentery gets a broad attachment to the back abdominal wall
Malrotation
Gör en nonrotation
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Malrotation
Mesenterica superior syndrom
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Richter-bråck
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Diffus tarmischemi
Questions/discussion