Your SlideShare is downloading. ×
Bowel injury 2013
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply

Bowel injury 2013

397
views

Published on

Published in: Health & Medicine

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
397
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Bringing cutting edge to daily practice in gynecological cancer surgery January 2013 Murad Aljiffry MD, MSc, FRCSC HPB and Transplant Surgery General Surgery Bowel Injury and Bowel Anastomosis
  • 2. Objectives ¨  Introduction ¨  Preoperative preparation ¨  Operative management ¤  Small bowel ¤  Colorectal ¨  Current techniques of bowel anastomosis
  • 3. Background ¨  The incidence of intestinal injury in gynecologic surgery is 0.1–0.7% ¨  The commonest site of injury is small bowel (60-70%) ¨  Most injuries are minor with uncomplicated clinical outcome ¨  Immediate VS delayed presentation (15-40% delayed) Vilos GA, J Obstet Gynaecol Can Erratum, Am J Obstet Gynecol
  • 4. Background ¨  Risks: ¤  Previous surgery ¤  Prior infection ¤  Radiation ¤  Endometriosis ¤  Obesity ¨  Commonly during entrance into the peritoneal cavity (45%), adhesiolysis (35%) and pelvic dissection (10%) RVan der Voort, Br J Surg Alan Lam, Best Practice & Research Clinical Obstetrics and Gynaecology
  • 5. Background ¨  Mechanisms: ¤  Sharp ¤  Rough handling of tissue (tear) ¤  Thermal (25%) à usually late Michael J, Rev Obstet Gynecol. Diamantis T, Surg Today.
  • 6. Background ¨  An open entry technique has not been shown to reduce the incidence of entry related bowel injury ¨  BUT allow immediate recognition of the bowel injuries Ahmad G, Cochrane Database Syst Rev. Penfield AJ, J Reprod Med Hashizume M , Surg Endosc
  • 7. Recognition ¨  Return of bowel contents ¨  Foul-smelling gas ¨  Serosal tears ¨  Hematomas wall or mesentery ¨  Laparoscopy à high insufflation pressures, asymmetric distension ¨  Good exercise to run the bowel after extensive dissection
  • 8. Delayed diagnosis ¨  The later the diagnosis, the higher the morbidity and mortality associated with bowel injury ¨  Time of recognition is variable depends on type: ¤  Small bowel 4 days ¤  Colon 5.5 days ¨  Presentation range from septic shock to localized abscess Brosens I, J Am Assoc Gynecol Laparosc. BishoffJT, J Urol
  • 9. Background ¨  Early diagnosis is critical ¨  If suspecting bowel injury: ¤  Admit pt for close monitoring ¤  Use blood test and CT when indicated ¤  Low threshold for exploration ¤  Ask for help if not clear
  • 10. Don t let the abdominal wall stand between you and the diagnosis
  • 11. Preparation ¨  Multidisciplinary approach for complex cases ¨  Proper pt education and communication ¨  Prophylactic antibiotics (within 30 min)
  • 12. Mechanical bowel prep (MBP) ¨  Bottom line no need ¨  Paucity of literature specific to gynecologic surgery, it is reasonable to extrapolate from the colorectal data against MBP Sarah L. Cohen, Rev Obstet Gynecol. 2011
  • 13. No Statistically Significant Difference Between MBP and No-MBP 2003 No Difference 2005 Statistically Significant Increase in Anastomotic Leak with MBP 2009 No Difference 14 RCTs with > 4500 Pts Primary outcome anastomotic leakage Secondary outcome measures surgical site infection Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.
  • 14. Mechanical bowel prep (MBP) ¨  There is sufficient evidence to abandon MBP ¨  MBP Has Been Shown to be harmful in few studies ¨  No-MBP is (or becoming) the standard for colorectal surgery ¨  Side Does Not Matter (Right v. Left, Colon v. Rectum) Sarah L. Cohen, Rev Obstet Gynecol. 2011
  • 15. Mechanical bowel prep (MBP) At Least From the Patients Perspective MBP Should Be Abandoned ¨  Quality of life and patient preference ¨  Dehydration and electrolyte disturbance ¨  Bacterial translocation ¨  Spillage with Bowel Prep (17%) v. NO Bowel Prep (12%) Mahajna A, Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005 Slim K, Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg Feb 2009
  • 16. Mechanical bowel prep (MBP) So, Who Should we Prep? ¨  Inadequate localization or possibility of intra-op Colonoscopy ¨  Defunctionalized anastomoses? ¨  Low-level rectal resections?
  • 17. Measures may reduce bowel injuries ¨  When entering the abdomen in high-risk patients: ¤  Watch for adhesions to abdominal wall ¤  Extending the previous scar ¨  Routine inspection of the bowel below the entry ¨  Minimize bowel handling
  • 18. Measures may reduce bowel injuries ¨  Use atraumatic instruments for bowel handling ¨  Careful tissue dissection under vision ¨  Limit adhesiolysis to clinically indicated cases only ¨  Limit the use of thermal energy when working close to or on bowel wall
  • 19. Management ¨  The management of bowel injuries depends on the following: ¤  The timing of the diagnosis ¤  The patient s clinical status ¤  Type and site of injury ¤  The available experties
  • 20. Small bowel injuries ¨  Control contamination and assess ¨  Close enterotomies and serosal tears (transversely) ¨  Resection and anastomosis: ¤  >½ diameter ¤  Multiple injuries in a small segment ¤  Devascularized ¨  Avoid multiple resections
  • 21. Colon injuries ¨  Control contamination and assess ¨  Depends on type of injury ¤  (destructive VS non-destructive) ¨  Generally two options: ¤  Primary repair (The Standard) ¤  Resection with anastomosis or diversion ¨  Exteriorization is abandoned à failure and complications
  • 22. Colon injuries Trauma literature ¨  Numerous large retrospective and several prospective studies have demonstrated that primary repair is safe and effective in the majority of patients with penetrating injuries ¨  1% failure rate for all primary repairs The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  • 23. Colon injuries Trauma literature ¨  5-8% failure rate for resection anastomosis ¨  Most failures with resection in: ¤  Significant associated injuries ¤  Hemodynamic unstability ¤  Delayed presentation (peritonitis) ¤  Significant underlying disease The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  • 24. Colon injuries ¨  Primary repair of all repairable injuries: ¤  The decreased morbidity associated with avoidance of colostomy, the disability associated with the interval from creation to closure of the colostomy all support primary repair of non-destructive colon injuries The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  • 25. Colon injuries ¨  Resect all non-repairable injuries ¨  Anastomosis if favorable general condition ¨  Resection + proximal diversion: ¤  Shock (massive transfusion > 6 units) ¤  Significant underlying disease ¤  Significant associated injuries (> 2) ¤  Delay of operation (>12hrs) The eastren association for the surgery of trauma, J Trauma George SM Jr, Ann Surg Gonzalez RP, J Trauma
  • 26. Rectal injury ¨  Intraperitoneal ¤  Similar to colonic injuries ¨  Extraperitoneal ¤  Repair if feasible, avoid unnecessary dissection ¤  Diversion ¤  Drainage ¤  Distal Washout
  • 27. Bowel anastomosis ¨  Pillars of of technically successful anastomosis: ¤  Healthy edges ¤  Adequate blood supply ¤  No tension ¨  Overall suturing or stapling are equally safe in bowel surgery (as long as done properly) ¨  Currently most are done stapled Cochrane Database Syst Rev. 2011 Cochrane Database Syst Rev. 2012
  • 28. Anatomical Side-To-Side / Functional End-To-End Anastomosis
  • 29. Circular Anastomosis
  • 30. Summary ¨  Be familiar with general principles of bowel surgery ¨  Call for help when needed ¨  High index of suspicion in complex cases ¨  No need for routine MBP ¨  Primary repair or resection/anastomosis is the Role ¨  Diversion is the Exception
  • 31. Questions