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  • 1. www.acssurgery.com WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor May 2008 THE BEST THIS MONTH’S UPDATES SURGICAL 1 Basic Surgical and Perioperative from infectious agents is also of concern. THINKING Considerations 2 Infection Control in The Study on the Efficacy of Nosocomial Infection Control, conducted in U.S. hospitals between Surgical Practice 1976 and 1986, showed that Volunteerism: The Senior surgical patients were at increased Vivian G. Loo, MD, MSc, FRCPC Visiting Surgeon Program risk for all types of infections. The McGill University Health Centre nosocomial, or hospital-acquired, William H. Pearce, MD, FACS infection rate at that time was DOI 10.2310/7800.S01C02 Northwestern University Feinberg estimated to be 5.7 cases out of School of Medicine Protecting patients from surgical every 100 hospital admissions. site infections and medical These infections included SSIs, as DOI 10.2310/7800.2008.NCmay personnel from bloodborne and well as bloodstream, urinary, and n the past 24 months, I have had other infectious agents in the respiratory infections. Today, the I the opportunity to volunteer to care for the wounded of Operation operative setting can be ad- dressed with proper surveillance, increased use of minimally invasive surgical procedures and early Iraqi Freedom and Operation environmental control and discharge from the hospital Enduring Freedom at both Walter education; doing so can have a necessitates post-discharge Reed Army Medical Center and substantial impact on morbidity surveillance in addition to Landstuhl Regional Medical Center and mortality. in-hospital surveillance for the (LRMC). The medical care the tracking of nosocomial infections. urgical procedures, by their very injured received is remarkable. From the medics in the field, to the S nature, interfere with the normal protective skin barrier and expose The Joint Commission on Accreditation of Healthcare physicians and nurses in the regional Organizations (JCAHO) strongly the patient to microorganisms from hospitals, to Landstuhl, and finally back to the United States (Walter both endogenous and exogenous sources. Infections resulting from continued on page 2 Reed, Bethesda National Naval Medical Center, and Brooke this exposure may not be limited to the surgical site but may produce Army Medical Center), the care is nothing less than spectacular. The widespread systemic effects. Prevention of surgical site infections In This Issue physicians, nurses, and staff are (SSIs) is therefore of primary The Best Surgical Thinking dedicated and committed to their Volunteerism: The Senior Visiting mission. For example, at LRMC, concern to surgeons and must be Surgeon Program 1 a trauma critical care team of addressed in the planning of any 1 Basic Surgical and Perioperative surgeons, pulmonologists, infectious operation. Standards of prevention Considerations disease specialists, internists, have been developed for every step 2 Infection Control in Surgical nutritionists, pharmacists, and of a surgical procedure to help Practice 1 others make daily rounds, sharing reduce the impact of exposure to 5 Gastrointestinal Tract and ideas and developing treatment microorganisms. Traditional control Abdomen plans. War injuries are of a different measures include sterilization of 7 Surgical Treatment of Morbid Obesity 4 magnitude than those seen in surgical equipment, disinfection civilian practice, and the complexity of the skin, use of prophylactic 6 Vascular System 20 Lower-Extremity Amputation antibiotics, and expeditious opera- for Ischemia 7 continued on page 2 tion. Protecting medical personnel
  • 2. 2 What’s New in ACS Surgery • May 2008 www.acssurgery.com THE BEST SURGICAL THINKING continued from page 1 Owned and published by BC Decker Inc of care requires input from not only The program established by the trauma surgeons and burn surgeons American College of Surgeons (ACS) EDITORIAL CHAIR: Wiley W. Souba, MD, SCD, FACS, Columbus, OH but also orthopedists, urologists, and described by Moore in a recent FOUNDING EDITOR: and neurosurgeons. Despite this issue of New England Journal of Douglas W. Wilmore, MD, FACS, Boston busy environment of patient care, Medicine1 has served as a model for EDITORIAL BOARD: there is also time to care for their other specialties to volunteer in the Mitchell P. Fink, md, facs, Pittsburgh Gregory families. From the time of the care of the American soldiers. The J. Jurkovich, md, facs, Seattle Larry R. Kaiser, md, facs, Philadelphia William H. Pearce, md, patient’s arrival at LRMC, the Society for Vascular Surgery offers a facs, Chicago John H. Pemberton, md, facs, patient’s family is made aware of the similar program, as do orthopedic Rochester, MN Nathaniel J. Soper, md, facs, Chicago patient’s injuries and progress. and neurosurgical societies. During As one can imagine, the logistics my rotation at LRMC, I worked COUNCIL OF FOUNDING EDITORS: Murray F. Brennan, md, facs, New York of such a system are enormous. with a volunteer orthopedic Laurence Y. Cheung, md, facs, Kansas City The patients are evacuated from surgeon. The chief of surgery, Alden H. Harken, md, facs, San Francisco James W. Holcroft, md, facs, Sacramento Afghanistan and Iraq to LRMC and Stephen Flaherty, MD, and Jonathan L. Meakins, md, dsc, facs, Oxford then to the United States. At LRMC, Raymond Fang, MD, a flight PUBLISHER: the patient’s records and images are surgeon, are remarkable individuals President, Brian C. Decker available prior to the patient’s who have cared for these patients Vice President, Sales, Rochelle J. Decker Vice President and Publisher, Liz Pope arrival. In addition, weekly televised over many years, and they allowed Managing Editor, Susan Cooper rounds are made from hospitals in me to come into their world for 2 Manager, Special Sales, Jennifer Coates Iraq and Afghanistan, LRMC, and weeks. As volunteer surgeons, we Manager, Customer Care and Distribution, Marie Moore hospitals in the United States. This can help by functioning as first Rights and Permissions, Paula Mucci program provides real-time feedback assistants, provide educational Director, Digital Publishing, David Love Electronic Media Systems Analyst, Jeff Ferguson not only on patient progress but also grand rounds, and help in their Senior Web/IT Developer, Faisal Shah on process improvement. It is very research efforts. ACS Surgery: Principles & Practice (bound easy for surgeons and physicians to volume: ISBN 978-1-55009-399-5; CD-ROM: After my experiences at Walter track the progress and care of their ISBN 978-1-55009-421-3; quarterly CD ROM: Reed and LRMC, I feel that I have ISSN 1538-3210; online: ISSN 1547-1616) is patients from one site to the next. received much more than I have owned and published by BC Decker Inc, 50 King What makes the program work are St. E., 2nd Floor, PO Box 620, LCD1, Hamilton, the weekly flights of large C17 given. It was a remarkable experi- ON L8N 3K7, Canada, Web site: http://www. transport planes equipped for ence, and we should be proud of the bcdecker.com. © 2008 BC Decker Inc. All rights reserved. No part of this issue may be reproduced medical evacuation. The critically military surgeons and physicians. I by any mechanical, photographic, or electronic injured are transferred by Critical would encourage civilian surgeons process or in the form of a phonographic recording, nor may it be stored in a retrieval Care Air Transport (CCAT) teams. to volunteer through either the ACS system, transmitted, or otherwise copied for These self-contained intensive care or their specialty societies. public or private use without written permission of the publisher. units transfer critically injured Annual subscription rates in Canada and the patients from Germany to the Reference USA: Quarterly CD-ROM: $209 (individual), United States with flight surgeons 1. Moore EE, Knudson MM, Schwab $709 (institutional); Online: $189 (individual). and intensive care nurses. Institutional Web site license pricing available on CW, et al. Military-civilian collabora- request. Please e-mail acssurgery@bcdecker.com. There has been a long history of tion in trauma care and the senior Separate shipping and handling apply. All prices collaboration between civilian visiting surgeon program. N Engl J subject to change without notice and quoted in US dollars. surgeons and military surgeons. Med 2007;357:2723–7. POSTMASTER: Send address changes to BC Decker Inc, PO Box 758, Lewiston, NY 14092- 0785. FOR ASSISTANCE WITH YOUR SUBSCRIPTION THIS MONTH’S UPDATES continued from page 1 Please address all inquiries to Fulfillment Department, BC Decker Inc, P.O. Box 758, Lewiston, NY 14092- 0785, or call us at 905-522-7017 or 800-568-7281, or fax us at 905-522-7839 or 888-311-4987, or email us at acssurgery@bcdecker.com. For change of address, recommends that the reduction of costs associated with treating please provide both your new and your old addresses; be sure to notify us at least six weeks before you healthcare associated infections be bloodstream infections in an expect to move to avoid interruptions in your service. prioritized as a national patient intensive care setting were estimated YOUR FEEDBACK IS WELCOME safety goal. Besides the impact of to be $40,000 per survivor. • E-mail: acssurgery@bcdecker.com morbidity and mortality on patients, • Write: BC Decker Inc P.O. Box 620, LCD 1 there is the cost of treating nosoco- Hamilton, ON L8N 3K7 mial infections, which is a matter of Nosocomial Infections Canada osocomial infections are defined concern for surgeons, hospital administrators, insurance compa- N as infections acquired in the hospital, and SSIs account for 14 nies, and government planners alike. In one study, for example, the extra to 16% of all nosocomial infections. www.acssurgery.com
  • 3. www.acssurgery.com What’s New in ACS Surgery 3 They occur in 2 to 5% of patients 3. The use of prophylactic undergoing clean procedures and in as many as 20% of patients under- 4. antibiotics, Techniques for preparation of This Month’s CME going intra-abdominal operations. The risk of development of an SSI 5. the operative site, Management of the postopera- Chapters depends on host and operative risk tive site if drains, dressings, or ACS Surgery offers CME in factors. Host risk factors to infec- both are in place, convenient online format. As tion can be estimated according to 6. Standards of behavior and many as 60 AMA PRA Category the following variables: older age, practice for the operating team 1 credits can be earned at severity of disease, physical-status (e.g., the use of gown, mask, any time during the year. The classification, prolonged preopera- and gloves), following chapters are available tive hospitalization, morbid obesity, 7. Special training of the operating for CME credit this month: malnutrition, immunosuppressive team, and therapy, smoking, preoperative 8. Sterilization and disinfection of 1 Basic Surgical and Perioperative Considerations colonization with Staphylococcus instruments. 2 Infection Control in Surgical Practice aureus, and coexistent infection at a remote body site. Operative risk The health care team has a primary 5 Gastrointestinal Tract and role in the prevention of infection. Abdomen factors include method of hair 7 Surgical Treatment of Morbid Obesity removal (and likelihood of conse- Continued education and reinforce- quent skin injury), inappropriate use ment of policies are essential: the 6 Vascular System team must be kept well informed 20 Lower-Extremity Amputation for of antimicrobial prophylaxis, Ischemia duration of the operation, and and up-to-date on concepts of wound classification. infection control. droplet precautions, and contact The Centers for Disease Control Hospitalized patients are not the precautions. and Prevention established the only concern. Protecting medical National Nosocomial Infections personnel from infection is of vital Surveillance (NNIS) system in 1970 importance. Preventive measures, Infectious Agents nfection may arise from exposure to create a national database of nosocomial infections. The NNIS such as immunizations and pre- employment medical examinations, I to bloodborne pathogens. In addition, antimicrobial-resistant system has been used to develop should be undertaken at an definitions of infections and indices employee health care center staffed microorganisms may be to blame. for predicting the risk of nosocomial by knowledgeable personnel. When Bloodborne pathogens. For active infection in a given patient. NNIS exposure to contagious infections is surgeons and other members of the developed a composite risk index unavoidable, susceptible personnel health care team, hepatitis B virus composed of the following criteria: should be located, screened, and given (HBV) infection continues to pose a American Society of Anesthesiolo- prophylactic treatment if necessary. major risk. Hepatitis B vaccination gists score, wound class, and Inadvertently, team members may has proved safe and protective and is duration of surgery. The NNIS also be the source of, or the vector highly recommended for all high-risk includes a basic risk index, which is in, transmission of infection. employees; it should be made a useful method of risk adjustment CDC guidelines have been available through the employee health for a wide variety of procedures. developed to prevent the transmis- care center. There is also a Modified NNIS Basic sion of infections. These isolation The risk of hepatitis C virus (HCV) Risk Index for certain procedures guidelines promote two levels of transmissions is less prevalent. The using laparoscopes, as the use of isolation precautions: standard average incidence of seroconversion laparoscopes can lower the risk of precautions and transmission-based after percutaneous exposure from an SSI within each NNIS risk index precautions. The standard precau- HCV-positive source is 1.8%. category. tions, which incorporate the main Exposure to blood and body features of the older universal substances of patients who have AIDS Preventive Measures precautions and body substance or who are seropositive for HIV isolation guidelines, were developed constitutes a health hazard to hospital n any surgical practice, policies I and procedures should be in place pertaining to the making of a to reduce the risk of transmission of microorganisms for all patients, employees. The magnitude of the risk depends on the degree and method of regardless of their diagnosis. exposure. Because screening for HIV surgical incision and the prevention Standard precautions apply to infection is not mandatory among of infection. These policies and blood, all body fluids, secretions and patients, the CDC recommends procedures should govern the excretions, and mucous membranes. following the same guidelines for following: Transmission-based precautions all patients undergoing invasive 1. Skin disinfection and were developed for certain epide- procedures that one would use in hand-washing practices of the miologically important pathogens cases of known HIV-infected patients. operating team, or clinical presentations. These In studies of health care workers, 2. Preoperative preparation of the precautions comprise three the incidence of positive results on patient’s skin (e.g., hair removal categories, based on the mode of tuberculin skin testing have ranged and use of antiseptics), transmission: airborne precautions, from 0.11 to 10%. Health care
  • 4. 4 What’s New in ACS Surgery • May 2008 www.acssurgery.com workers who are immunocompro- 1. Total, or hospital-wide, updates on infection prevention mised are at high risk for the surveillance: collection of measures (especially during and development of disease after comprehensive data on all after an outbreak), updates on exposure. infections in the facility, with preventive policies pertaining to Antimicrobial-resistant the aim of correcting problems hand hygiene, isolation precautions, microorganisms. Hospitals and as they arise. and other areas of concern. communities worldwide are also 2. Surveillance by objective, or Establishing an infection control facing the challenge posed by the targeted surveillance, in which a program can greatly benefit a spread of antimicrobial-resistant specific goal is set for reducing hospital. It supports patient safety microorganisms. Strains of certain types of infection. and is a means for continuous methicillin-resistant S. aureus (MRSA) 3. Periodic surveillance: intensive quality improvement in the care that are increasing in hospitals and are an surveillance of infections and is given, in addition to being an important cause of nosocomial accreditation requirement. patient-care practices by unit or infections; in a sample of intensive The chair of any infection control by service at different times of care units in the United States in committee should have an ongoing the year. 2003, approximately 59.5% of interest in the prevention and S. aureus isolates were resistant to 4. Prevalence survey: the counting and analysis of all active control of infections. Members methicillin or oxacillin. should represent administration, Vancomycin-resistant Enterococcus infections during a specified time period. infectious diseases, microbiology, (VRE) accounts for 38.2% of all nursing, the OR, central supply, enterococci in the ICUs participating 5. Outbreak surveillance: the identification and control of medicine, surgery, pharmacy, and in the NNIS program. Transmission housekeeping. This multidisciplinary usually occurs through contact with outbreaks of infection. group becomes the advocate for the the contaminated hands of a health Environmental control. Control of entire hospital. care worker. the microbial reservoir of the In addition, according to existing The CDC has developed strategies patient’s immediate environment in public health acts, certain infectious for preventing and controlling the the hospital is also a goal of an diseases must be reported by law. emergence and spread of infection control program. Environ- Differences exist between the antimicrobial-resistant microorgan- mental control begins with design of reporting systems of one country isms. These include optimizing the hospital’s physical plant. The and those of another, but on the antimicrobial prophylaxis for surgical procedures, optimizing the design must meet the functional whole, diseases such as tuberculosis, choice and duration of empirical standards for patient care and must sexually transmitted diseases, and therapy, and improving antimicro- be integrated into the architecture to meningococcal meningitis are bial prescribing patterns by provide traffic accessibility and reported for community follow-up. physicians. control. Since the 1960s, the In the past few years, Costridium practice of centralizing seriously ill difficile-associated infection (CDI) patients in intensive care, dialysis, 5 Gastrointestinal Tract and outbreaks, which have also caused and transplant units has accentuated increased morbidity and mortality the need for more careful analysis Abdomen have been reported in the United and planning of space. The primary standards for these special care units 7 Surgical Treatment of States, Canada, and Europe. These outbreaks have been attributed to and ORs require planning of floor Morbid Obesity the emergence of a hypervirulent space, physical surfaces, lighting, Eric J. Demaria, MD, FACS, and strain of C. difficile. ventilation, water, and sanitation to Christopher J. Myers, MD For control of CDI outbreaks, a facilitate easy cleaning and disinfect- multifaceted approach is required, ing of surfaces, sterilization of Duke University, School of including close attention to hand instruments, proper food handling, Medicine hygiene, use of contact precautions and garbage disposal. These DOI 10.2310/7800.2008.S05C07 when providing care to CDI activities should then be governed patients, environmental disinfection, by practical policies that are Bariatric surgery—open or antibiotic restriction, and rapid understandable to the staff. Preven- laparoscopic--has the greatest laboratory diagnosis. tive maintenance should be a basic and longest-lasting success in and integral activity of the physical achieving weight loss for the Infection Control Programs plant department. morbidly obese; preoperative Education. A strategy for routine evaluation and postoperative urveillance. The cornerstone of S an infection control program is surveillance. This process depends training of the health care team is necessary at every professional management are crucial to successful outcomes. level. The process may vary from t is clear that severe obesity is on the verification, classification, analysis, reporting, and investigation of infection occurrences, with the institution to institution, but some form of communication should be I associated with a significant increase in morbidity and a decreased life intent of generating or correcting established for the dissemination of expectancy. Morbid obesity is defined policies and procedures. Five information about endemic infection as a body weight that exceeds the surveillance methods can be applied: rates, endemic bacterial trends, ideal body weight by 100 lb. or more
  • 5. www.acssurgery.com What’s New in ACS Surgery 5 or a body mass index (BMI) greater suspected SAS should undergo Anesthesia. Morbidly obese than 35 kg/m2. preoperative polysomnography at a patients can be intimidating to the sleep center to confirm the diagno- anesthesiologist because they are at Preoperative Evaluation sis. significant risk for complications Obesity hypoventilation syndrome from anesthesia, especially during any surgeons are afraid to M operate on the morbidly obese patient because they presuppose a (OHS) is a condition associated with morbid obesity in which a person induction. The risk is particularly great for obese patients with suffers from hypoxemia and respiratory insufficiency. An obese marked increase in perioperative hypercapnia when breathing room patient often has a short, fat neck morbidity and mortality. It is now air while awake but resting. Chron- and a heavy chest wall, which possible, however, to stratify the ic, severe hypoxemia is associated make intubation and ventilation a mortality risk for patients undergoing with three complications that challenge. gastric bypass (GBP) by using a put patients with OHS at risk: If endotracheal intubation proves scoring system known as the polycythemia, pulmonary arterial difficult, however, such a patient can Obesity Surgery Mortality Risk Score vasoconstriction, and pulmonary usually be well ventilated with a (OS-MRS), which includes five hypertension. Patients with OHS mask. Awake intubation can be independent variables that can be respond rapidly to supplemental performed, with or without identified preoperatively: (1) BMI oxygen. However, oxygen adminis- fiberoptic aids, but is quite unpleas- greater than or equal to 50 kg/m2, (2) tration is occasionally associated ant and rarely necessary. It is male gender, (3) hypertension, (4) with significant CO2 retention, extremely important that at least pulmonary embolus risk (including which necessitates intubation and two anesthesia personnel be present previous thrombosis, pulmonary mechanical ventilation. during induction and intubation embolus, inferior vena cava [IVC] Both SAS and OHS can be for patients with respiratory filter, right-side heart failure, and completely corrected with weight insufficiency of obesity. obesity hypoventilation syndrome reduction after gastric operation for Insulin administration. Patients [OHS]), and (5) patient age greater morbid obesity. with type 2 diabetes may require than or equal to 45 years. Morbidly obese patients are also large amounts of insulin for blood Although the morbidly obese at significant risk for coronary glucose control because of signifi- patient is certainly at greater risk, artery disease as a result of an cant insulin resistance. It is not this risk can be markedly reduced by increased incidence of systemic unusual, however, to note a com- paying careful attention to detail in hypertension, hypercholesterolemia, plete absence of the requirement for preoperative and postoperative care. and diabetes. Because of this insulin in the immediate postopera- The increased risks encountered in increased risk for cardiac tive period in morbidly obese these patients include wound dysfunction, preoperative electrocar- patients. Therefore, insulin should infection, dehiscence, thrombophle- diography should be performed on be withheld on the morning of bitis, pulmonary embolism, anes- all obese patients 30 years of age or thetic calamities, acute postoperative operation. In morbidly obese older. patients who have undergone GBP, asphyxia in patients with obstructive In additional to respiratory sleep apnea syndrome, acute there is often a marked reduction difficulties, the morbidly obese are in the requirement for insulin respiratory failure, right ventricular also predisposed to other conditions, or biventricular cardiac failure, and throughout the postoperative period including thrombophlebitis, venous and even at discharge, possibly missed acute catastrophes of the stasis ulcers, pulmonary embolism, abdomen (e.g., anastomotic leak- because of increased release of gallstones, pseudotumor cerebri, and gastric inhibitory peptide from the age). degenerative osteoarthritis. All of Obese patients are at risk for proximal small bowel. these conditions need to be Choice of surgical procedure. The respiratory difficulties, which may addressed, and the subsequent post- be present before operation or may gastric operations performed for surgery weight reduction may morbid obesity include both GBP be exacerbated by an operation. It is greatly reduce the pain, immobility, important to emphasize that procedures and gastric restrictive and even morbidity of these procedures (i.e., gastroplasty and morbidly obese patients, especially conditions. those with respiratory insufficiency, should be placed in the reverse Trendelenburg position to maximize Preoperative Planning diaphragmatic excursion and to increase residual lung volume. I n planning for bariatric surgery, surgeons (in conference with Coming in June Sleep apnea syndrome (SAS) is a Elements of Contemporary Practice patients) must determine the potentially fatal complication of 3 Benchmarking Surgical Outcomes appropriate choice of surgical morbid obesity. Patients with SAS procedure. Anesthesia in the 1 Basic Surgical and Perioperative are at high risk for acute upper morbidly obese patient is also a Considerations 1 Prevention of Postoperative airway obstruction and respiratory concern. Another issue to consider Infection arrest when undergoing an in the pre-operative stage is the 6 Vascular System operation and general anesthesia. administration of insulin for patients 12 Aortoiliac Reconstruction Therefore, any patients with with type 2 diabetes.
  • 6. 6 What’s New in ACS Surgery • May 2008 www.acssurgery.com gastric banding). Randomized, not to the stomach—in such a Open Proximal Gastric prospective trials have conclusively way as to create an outlet with a shown that GBP is as effective for circumference of 5 cm for the small Bypass roximal GBP results in greater weight control as the malabsorptive jejunoileal (JI) bypass is, while upper gastric pouch. Silastic ring gastroplasty is a variant of VBG that P weight loss than the gastric restrictive procedures described resulting in significantly fewer uses a vertical staple line and a complications. JI bypass is associ- stoma reinforced with Silastic earlier and carries a lower incidence ated with a substantial incidence of tubing. of weight regain; consequently, it is Complications of VBG include often considered the gold standard both early complications (e.g., acute erosion of the polypropylene mesh for bariatric surgery. The current cirrhosis, electrolyte imbalance, and used to restrict the gastroplasty operative technique involves placing fulminant diarrhea) and late stoma into the gastric lumen, three superimposed 55 or 90 mm complications (e.g., cirrhosis, enlargement of the pouch, stomal staple lines across the proximal interstitial nephritis, arthritis, stenosis, reflux esophagitis, and mild stomach in such a way as to create a enteritis, nephrocalcinosis, and gastric pouch no larger than 30 ml vitamin deficiencies. recurrent oxalate renal stones). If with a Roux limb at least 45 cm evidence of cirrhosis, renal failure long and a stoma no larger than secondary to interstitial nephritis, or Laparoscopic Adjustable 1 cm. This anatomic situation is other complications mandates Gastric Banding largely replicated when GBP is done reversal of a JI bypass, the patient, aparoscopic adjustable gastric laparoscopically, but an isolated if not extremely ill, should be converted to a GBP; otherwise, all L banding (LAGB) is significant advance over open gastric banding gastric pouch is created with stapled transection of the stomach. the lost weight is sure to be procedures, primarily because of the In addition to being associated regained, and the obesity-related adjustability of the band. In a 2006 with all of the complications that comorbidity will return. Admittedly, study comparing outcomes, LAGB are seen after GBP, proximal GBP is however, some patients have done proved to be just as safe as, cheaper associated with a significant inci- well after JI bypass and do not need than, and almost as effective as dence of stomal stenosis and with to have the operation reversed. laparoscopic Roux-en-Y gastric marginal ulcer. The former responds Bariatric surgical procedures, like bypass (LRYBG). to endoscopic stomal dilatation, and most other general surgical proce- LAGB is performed by using a the latter usually responds to proton dures, have undergone a transition five-port technique. Initial abdomi- pump inhibitor therapy. Iron, from an open approach to one that nal access is obtained via a supra- vitamin B12, and folic acid places more emphasis on minimally umbilical trocar, and the remaining deficiencies may occur but can invasive or laparoscopic techniques. ports are placed sequentially along usually be corrected with oral Thus, in choosing the appropriate the right and left costal margins. supplementation. surgical approach, it is important to Ultimately, a specially designed Nevertheless, neither the data take into account the tremendous implement is inserted behind the from a randomized, prospective trial surgical revolution that laparoscopy nor the data from selective studies stomach from the lesser curvature to has brought about in the treatment support the contention that VBG is the angle of His and used to grasp of morbid obesity. Now that every safer than GBP. Although GBP the tubing of the banding device and operation performed to treat obesity includes one more anastomosis than pull it around the stomach. The can be done laparoscopically, VBG, complications such as leaks banding device is then locked into laparoscopic bariatric surgery is not and peritonitis occur with both place at the chosen location on the only common but, in many centers, operations. proximal stomach. predominant. For this reason, as It is essential to place the band well as because laparoscopic obesity properly during the initial proce- Laparoscopic Gastric treatment requires advanced dure. The results to date suggest that Bypass technical skills, minimally invasive the proximal pouch must be very aparoscopic GBP is currently the bariatric procedures have become a cornerstone of training for surgeons small to optimize weight loss. In addition, proper placement mini- L most popular bariatric procedure in the United States, both because of now learning laparoscopic surgery. mizes—though it does not elimi- the rapid weight loss it achieves and nate—the risk of band slippage and because of the strong overall the complications thereof. Band surgical trend toward minimally Vertical Banded slippage (anterior, posterior, or invasive approaches. As noted Gastroplasty concentric) may occur even after earlier, laparoscopic GBP achieves enerally, the surgical procedure proper placement, resulting in G for vertical banded gastroplasty (VBG) involves wrapping a strip of intolerance of oral intake and vomiting. However, the incidence of the same weight-loss results as open GBP but yields less pain, reduced disability, and a shorter duration of polypropylene mesh around the slippage does appear to decrease as hospitalization. Physiologically, gastrogastric outlet on the lesser the surgeon’s experience with the laparoscopic GBP results in less curvature and sutured to itself—but procedure increases. operative trauma than open GBP,
  • 7. www.acssurgery.com What’s New in ACS Surgery 7 less impairment of pulmonary The complications observed to distention, which occurs in the distal function, and a less pronounced date after laparoscopic GBP include bypassed stomach, sometimes leading stress response. In addition, the the usual problems that occur in to a gastric perforation or disruption laparoscopic technique is associated some patients after open GBP, of the gastrojejunostomy. with lower incidences of major including marginal ulcer and A postoperative problem that wound infections and incisional stenosis at the gastrojejunal anasto- deserves special mention is the risk of hernias. Accordingly, we recom- mosis necessitating dilatation. On failed weight loss or weight regain. mend laparoscopic GBP over any rare occasions, a gastrogastric fistula This is one of the most difficult other bariatric procedure. may lead to a treatment-resistant problems associated with bariatric Most of the variations seen at marginal ulcer. The major advan- surgery and may arise after any gastric different institutions are related to tage of laparoscopic GBP over open procedure for morbid obesity. Patients various techniques for creation of GBP is likely to be reduced wound who have undergone gastroplasty or the gastrojejunal anastomosis, with complications (e.g., major wound gastric banding may have difficulty some groups using a circular stapler, infection and incisional hernia). with solid foods and come to exhibit others a linear stapler, and still maladaptive eating behavior involving others a handsewn technique. frequent ingestion of high-calorie As far as operative technique, Postoperative Management liquid carbohydrates (a common fter operation, the obese patient reason for failure of a bariatric initial access to the abdomen is obtained through a small left A should be kept in the reverse Trendelenburg position and should procedure). We make clear to patients, well in subcostal incision. The surgeon then creates a roux limb and jejunojeju- not be extubated until he or she is advance of the operation, that nostomy. Next, the greater omen- fully alert and showing evidence of bariatric surgery is designed to tum is divided from its free edge to adequate ventilatory effort. Patients provide them with a tool that will with obstructive SAS may have to be assist them in behavior modification its junction with the transverse managed with overnight mechanical and thereby help them help them- colon so that the limb can be ventilation in the ICU, particularly if selves. Obesity can be beaten by brought up in an antecolic fashion an open bariatric procedure was surgical treatment, but patients must between the divided halves of the performed. Patients with OHS may continue to make good food choices. omental “apron,” which reduces tension on the limb. require prolonged mechanical Once the stomach is visible, it is ventilation until the pain of grasped and elevated through the breathing resolves, particularly after 6 Vascular System mesocolic window, and the end of open procedures. It is extremely important to 20 Lower-Extremity the Penrose drain is grasped and brought through the mesocolic encourage early postoperative Amputation for Ischemia defect into the lesser sac. Ultimately, ambulation for the morbidly obese William C. Pevec, MD, FACS the mesentery of the lesser curvature patient. These patients often experi- ence less pain than one might expect, University of California, Davis, is transected. Stapling of the gastric and it is frequently possible to get School of Medicine pouch (circular or linear) can then proceed. Some surgeons employ motivated patients up and walking in DOI 10.2310/7800.2008.S06C20 laparoscopic suturing techniques to the afternoon or early evening after a major abdominal procedure. Lower extremity amputation can create a handsewn gastrojejunos- These basic principles of postop- be difficult and frightening for a tomy. In every case, regardless of erative management generally apply patient to accept, but can be which anastomotic technique is to laparoscopic cases as well, but accomplished with few complica- employed, flexible upper GI endos- with some differences. Unlike tions if timed and performed copy is performed to confirm that patients who have undergone open properly and restore patients to the anastomosis does not leak. GBP, those who have undergone independence. Because total intracorporeal laparoscopic GBP is such a challeng- laparoscopic GBP usually do not atients with infected, painful, or ing technical adventure, a hand- assisted version of the procedure have a nasogastric tube left in place. The patient may begin to drink P necrotic lower extremities can be restored to a better functional level was developed. This technique small amounts of liquids on postop- by means of a properly selected and served as a bridge to the total erative day 1 and may be kept on a performed amputation. These intracorporeal approach, in that it liquid diet with liquid protein procedures should be considered made it possible to learn the supplementation for several weeks. reconstructive and restorative. technical aspects of a difficult, Nevertheless, the following are highly advanced laparoscopic some of the main complications that procedure while enjoying the may be associated with any abdomi- General Operative Planning electing the appropriate level of security provided by the presence of a hand within the abdomen for nal operation in a severely obese patient: abdominal catastrophe S amputation is of primary impor- tance for healing and preservation of palpation and manipulation during (perforated duodenal ulcer, ruptured the procedure. This added security diverticulum or peritonitis); internal function. Generally, adjuncts such as is the major advantage of the hernia (which can lead to bowel transcutaneous oxygen tension and hand-assisted approach. strangulation); or acute gastric segmental arterial pressure can
  • 8. 8 What’s New in ACS Surgery • May 2008 www.acssurgery.com reliably determine a level of amputa- great toe or of more than one Transmetatarsal Amputation tion at which healing is virtually smaller toe is called for, it may be ransmetatarsal amputation is ensured, but they cannot reliably determine the level at which an preferable to perform a transmeta- tarsal amputation of the forefoot. T indicated if there is tissue loss in the forefoot involving the first amputation will not heal. Conse- metatarsal head, two or more of the quently, reliance on such measures Transphalangeal Amputation other metatarsal heads, or the dorsal to select the level of amputation will igital block anesthesia is ideal for result in an unnecessarily high percentage of more proximal D transphalangeal amputation. If multiple toe amputations are forefoot. It is contraindicated if there is extensive skin loss on the plantar surface of the foot or on the amputations. required, an ankle block, epidural dorsum proximal to the midshaft of In most cases, definitive amputation anesthesia, spinal anesthesia, or the metatarsal bones. can be accomplished in a single stage. general anesthesia may be used. Spinal, epidural, or general Local cellulitis can usually be con- An incision is made to create anesthesia may be employed for trolled beforehand with bed rest and systemic administration of antibiotics. dorsal and plantar skin flaps. transmetatarsal amputation. Undrained pus or recalcitrant Typically, these flaps are equal in An incision is made across the cellulitis, however, must be treated length; however, depending on the dorsum of the foot at the level of the with débridement and drainage in location of the skin lesion, either the middle of the shafts of the metatar- advance of definitive amputation. dorsal flap or the plantar flap can be sal bones, extending medially and Careful preoperative medical left longer. laterally to the level of the center of assessment is essential. Lower- The incision is extended down to the first and fifth metatarsal bones, extremity amputation for ischemia is the phalanx, and the soft tissues are respectively. The dorsal incision is associated with a mortality of 4.5 to gently separated from the bone with curved proximally at the medial and 18%, owing to the poor overall a small periosteal elevator. All lateral edges to ensure that no dog- condition of the patient population. tendons and tendon sheaths are ears remain at the time of closure. The timing of elective amputation is débrided because the poor vascular- The dorsal incision is continued also crucial. The loss of a limb is a perpendicularly through the soft ity of these tissues may compromise difficult and frightening thing for a tissues on the dorsum down to the the healing of the toe. The phalanx patient to accept. There is a natural metatarsal bones. The plantar is transected at the level of the tendency to delay amputation for as incision is extended distally to a apices of the skin incisions. The best long as possible. This tendency is point just proximal to the toe crease. way of transecting the phalanx is to understandable but must be weighed A plantar flap is created by making use a pneumatic oscillating saw. an incision with the scalpel adjacent against the potential problems associated with delay. A preoperative to the metatarsophalangeal joints; the consultation with a psychiatrist can Ray Amputation incision is then carried more deeply to or ray amputation, spinal, the level of the midshafts of the allay some of the patient’s anxiety by addressing the expected postoperative course of rehabilitation and thereby F epidural, or general anesthesia may be employed. A so-called metatarsal bones on their plantar surfaces. The periosteum of the first removing some of the fear of the tennis-racket incision is made—that metatarsal bone is scored circumferen- unknown. is, a straight incision along the tially with the scalpel, and the soft dorsal surface of the affected tissue is dissected away from the first metatarsal bone coupled with a metatarsal bone with a periosteal Toe Amputation circumferential incision around the elevator to a point about 1 cm mputation of the toe can be done A either across a phalanx or across a metatarsal bone; the latter base of the toe. The goal is to save all available viable skin on the toe; proximal to the dorsal skin incision. The first metatarsal bone is then this skin is used to ensure a tension- transected perpendicular to its shaft at procedure is commonly referred to free closure, and any excess skin can the level of the dorsal skin incision as a ray amputation. be débrided later, at the time of with a pneumatic oscillating saw. This For a toe amputation to heal closure. The metatarsal bone is process is repeated for each individual properly, there must be either a transected across the shaft with a metatarsal bone. palpable pulse over the dorsal pedal pneumatic oscillating saw. The Because intraoperative blood loss or posterior tibial artery or a tendons and the tendon sheaths are can be substantial, good communica- functioning bypass graft to an débrided. tion between the surgeon and the infrapopliteal artery. If tissue Complications of toe amputation anesthesiologist is crucial for prevent- necrosis or infection is confined to include bleeding, infection, and ing ischemic complications secondary the distal or middle phalanx, failure to heal. For optimal healing, to hemorrhage. transphalangeal amputation is there must be an extended period (2 Postoperative complications appropriate; if tissue loss or necrosis to 3 weeks) during which no weight is include bleeding, infection, and involves the proximal phalanx, ray borne by the foot that underwent toe failure to heal, all of which are likely amputation is indicated. amputation. Once healing is complete, to result in more proximal amputa- Multiple transphalangeal amputa- the patient should be able to walk tion. For proper healing, postopera- tions are functionally well tolerated. normally, with no need for orthotic or tive edema must be avoided and the If, however, ray amputation of the assist devices. plantar flap protected against shear
  • 9. www.acssurgery.com What’s New in ACS Surgery 9 forces. To prevent swelling, the reconstruction or by amputation of placed on gentle traction and patient is kept on bed rest with the one or more of the toes or the clamped proximally. The nerves are foot elevated for the first 3 to 5 forefoot. Healing can be expected if transected and ligated, and the days. This step is particularly there is a palpable femoral pulse proximal nerves are allowed to important if the transmetatarsal with at least a patent deep femoral retract into the soft tissues so as to amputation was performed simulta- artery, provided that the skin is prevent painful neuromas at the end neously with arterial reconstruction. warm and free of lesions at the of the stump. Once healed, patients should be distal calf. Before formal below-the- The most common complications able to walk independently with knee amputation, infection should after below-the-knee amputation are standard shoes. There is, however, a be controlled with antibiotic bleeding, infection, and failure to heal, risk that they may trip over the therapy, débridement, and, if all of which are likely to result in a unsupported toe of the shoe. indicated, guillotine amputation. It more proximal amputation, frequent- is advisable to obtain consent to ly accompanied by loss of the knee. Guillotine Ankle Amputation possible above-the-knee amputation To walk with a prosthetic leg, the beforehand in case unexpected patient must be capable of fully uillotine amputation across the G ankle is indicated when a patient presents with extensive wet gan- muscle necrosis is encountered below the knee. extending and locking the knee; thus, flexion contracture at the knee Epidural, spinal, or general is a major complication. Such grene that precludes salvage of a anesthesia is appropriate for below- contractures are usually attributable functional foot (e.g., wet gangrene the-knee amputation. The lines of either to poor pain control or to that destroys the heel, the plantar incision should be marked on the noncompliance with knee extension skin of the forefoot, or the dorsal skin. The primary level of amputa- exercises. Once a flexion contracture skin of the proximal foot). In such tion is determined by measuring a happens, the patient may find it very patients, initial guillotine amputa- distance of 10 cm from the tibial difficult to regain full knee exten- tion through the ankle is safer than tuberosity. The circumference of the sion, and without full knee exten- extensive débridement: the opera- leg at this level is then measured by sion, prosthetic limb rehabilitation is tion is shorter, less blood is lost, the passing a heavy ligature around the impossible. risk of bacteremia is reduced, and leg and cutting the ligature to a Phantom sensation is a common better control of infection is pos- length equal to the circumference. complication after below-the-knee sible. Guillotine amputation is also The ligature is folded into thirds and amputation but is rarely of any indicated in patients with foot cut once more at one of the folds, so consequence. Phantom pain, on the infections who have cellulitis that two segments of unequal length other hand, can be devastating. extending into the leg. remain. The longer segment of the Medical personnel should take great General anesthesia is preferred for guillotine ankle amputation; ligature, which is equal in length to care to distinguish between the two regional anesthesia is relatively two-thirds of the leg’s circumference entities and can also help by contraindicated for critically ill 10 cm below the tibial tuberosity, is encouraging early amputation in a patients who are in a septic state. used to measure the anterior patient with a hopelessly ischemic A circumferential incision is made transverse incision; this incision is foot, providing good pain control in at the narrowest part of the ankle centered not on the tibial crest but the early postoperative period, and (i.e., at the proximal malleoli) on the gastrocnemius-soleus muscle assuring the patient that phantom regardless of the level of the celluli- complex. The shorter segment, sensation after a below-the-knee tis. This placement takes the line of which is one-third of the leg’s amputation is common and that any incision across the tendons, thereby circumference at this level, is used to discomfort in the foot immediately preventing bleeding from transected measure the posterior flap; the line after the operation period will muscle bellies. The incision is then of the posterior incision runs vanish once he or she begins carried through the skin and soft parallel with the gastrocnemius- walking again with a prosthetic leg. tissues to the bone. If the arteries are soleus complex. Ulceration of the skin over the patent, the assistant applies circum- The tibia is scored circumferen- transected anterior portion of the ferential pressure to the distal calf. tially, and a periosteal elevator is tibia is another serious complication The distal tibia and fibula are then used to dissect the soft tissues away that may preclude successful divided with a Gigli saw. from the tibia for a distance of prosthetic limb fitting. After the procedure, the patient is approximately 3 to 4 cm. The tibia Shortly after the amputation, the kept on bed rest and given systemic is then transected just proximal to patient should be encouraged to antibiotics. the transverse skin incision. The start working on strengthening the tibia can be transected with either a upper body; upper-body strength is Gigli saw or an oscillating saw. critical for making transfers and for Below-The-Knee The anterior tibial, posterior using parallel bars, crutches, or a Amputation tibial, and peroneal arteries and walker. elow-the-knee amputation is veins are clamped, and the tourni- Prosthetic rehabilitation begins B indicated when the lower extremity is functional but the foot quet is released. Clamps are placed on all other bleeding vessels. The when the stump achieves a conical shape. Unfortunately, a number of cannot be salvaged by arterial posterior tibial and sural nerves are patients who have undergone
  • 10. 10 What’s New in ACS Surgery • May 2008 www.acssurgery.com amputation for ischemia are unable The flaps should be wide and long, over the stump. The cuff of the to walk with a prosthetic limb and their apices should be centered stockinette is cut medially at the because of comorbid medical on the line dividing the anterior and groin, and the stockinette is rolled conditions and general debility. posterior muscle compartments. The laterally above the hip, where the skin incisions are carried through cuff is then cut on the midaxillary Above-The-Knee the dermis, and the skin edges are line. This process yields two strips of allowed to separate and expose the cloth, one anterior and one poste- Amputation subcutaneous fat. rior, which are passed around the bove-the-knee amputation is If the superficial femoral artery is A indicated if the lower extremity is unsalvageable and there is no patent, the artery and vein are isolated and clamped after the patient’s waist and tied on the anterior midline. If the patient is a candidate for femoral pulse, if there is tissue sartorius is divided but before the prosthetic limb rehabilitation, a necrosis or uncontrollable infection remainder of the anterior muscles traction rope is passed through a extending cephalad to the midleg, are divided. The femur is scored hole cut in the distal end of the and in the case of gangrene or circumferentially. The soft tissues stockinette and tied. The rope is ulceration of a completely are dissected away from the femur hung over the end of the bed and nonfunctional lower extremity. to the level of the apices of the flaps, tied to a 5 lb weight; this step helps Epidural, spinal, or general and the femur is divided with an prevent flexion contracture at the anesthesia may be used for above-the- oscillating saw at this level. The hip. knee amputation. For the best deep fascia is approximated with interrupted absorbable sutures, with Postoperative complications functional results, it is desirable to keep the femur as long as possible. A adjustments made for any discrep- include bleeding, infection, and longer stump improves the prognosis ancy in length between the two failure to heal, all of which are likely for prosthetic limb rehabilitation and flaps. to result in the need for surgical provides better balance for sitting and A nonadherent dressing is placed revision of the amputation stump. transfers. Healing potential, however, on the suture line and covered with Flexion contracture of the hip is a is lower with a longer stump; there- dry, fluffed gauze bandages. An major complication of above-the- fore, if the pelvic circulation is aerosol tincture of benzoin is knee amputation. Such contractures severely compromised, a shorter sprayed on the thigh, the hip, and preclude successful prosthetic limb stump should be fashioned. the lower abdomen. When the rehabilitation. In dealing with this Anterior and posterior flaps of benzoin is dry, a cloth stockinette complication, prevention is far more equal length are marked on the skin. with a diameter of 4 in. is stretched effective than treatment.