Core Topics in General & 

Emergency Surgery: Companion

to Specialist Surgical Practice 
Paterson-Brown MBBS MPhil MS FRCS, Simon 
Elsevier Health Sciences UK 

 
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Chapter 1: Evidence-based practice in surgery 

 

19
  One of the first systematic reviews of RCTs was of the u
of corticosteroid therapy to improve lung function in 
threatened premature birth. 

April 10, 2016 

For an RCT to be ethical there needs to be a clinical  21

equipoise. That is, there needs to be a sufficient level of
uncertainty about an intervention before a trial can b
considered 
April 10, 2016 

The first stage is always to pose a clinically relevant  23

question for which an answer is required 

April 10, 2016 

One way of formulating questions is to think of them a 23

having four key elements (PICO): • the population to w
the question applies; • the intervention of interest (and
other interventions with which it is to be compared); •
comparison (the main alternative); • the outcome of 
interest. 

April 10, 2016 

Published trials must be critically appraised to assess 24

whether they possess internal and external validity in
answering the question posed ( internal validity is whe
the effects within the study are free from bias and 
confounding; external validity is where the effects wit
the study apply outside the study and the results are 
therefore generalisable to the population in question) 

April 10, 2016 

Chance – random variation, leading to imprecision. • B 31

systematic variation leading to inaccuracy. • Confoun
– systematic variation resulting from the existence of 
extraneous factors that affect the outcome and have 
distributions that are not taken into account, leading
bias and invalid inferences. 

April 10, 2016 

It also requires the reviewer to consider aspects such a 31

sponsorship and vested interests that may introduce 
sources of bias. 

April 10, 2016 

A meta-analysis is a specific statistical strategy for  35

assembling the results of several studies into a single 
estimate, which may be incorporated into a systematic
literature review. 

April 10, 2016 

a horizontal line showing the 95% confidence interval 36

If the line does not cross the line of no effect, then ther
95% chance that there is a real difference 

April 10, 2016 

between the groups.  36

April 10, 2016 

 Audit is the systematic critical analysis of the quality 52
medical care, including the procedures used for diagn
and treatment, the use of resources, and the resulting 
outcome and quality of life for the patient. 

April 10, 2016 

Chapter 2: Outcomes and health economic issues in surgery 

 

72
  Pain can manifest itself in a 
April 10, 2016 

variety of qualities, and one of the most widely used to 72

the McGill Pain Questionnaire. 

April 10, 2016 

In those patients who are critically ill or unconscious, 72

Behavioural Pain Score (BPS) was developed to assess 
response to pain. BPS is based on three items: facial 
expression, movement of upper limbs and compliance
mechanical ventilation 

April 10, 2016 

Chapter 4: Abdominal hernias 
 

142
  A hernia is defined as an abnormal protrusion of a ca
contents, through a weakness in the wall of the cavity,
taking with it all the linings of the cavity, although the
may be markedly attenuated. 

April 6, 2016 

inguinal (75%), umbilical (15%) and femoral (8.5%)  142

April 6, 2016 

In essence, hernias can be considered design faults, eit 142

anatomical or through inherited collagen disorders, 
although these two aetiological factors probably work
together in the majority of patient 

April 6, 2016 

The genetic code for fascia is coded on DNA, and withi 143
fibroblasts the sequence is messenger RNA, transfer RN
peptide formation, with fusion of peptides into 
approximately 1000-amino-acid polypeptides called alp
chains. 

April 6, 2016 
Procollagen is the large building block of collagen,  143
comprising triple-helix strands, stabilised by hydroxyl
of proline and lysine, which is vitamin C dependent. Th
triple-helix strands form microfibrils, then fibrils, the
fibres and finally bundles. These collagen bundles 
surrounded by extracellular matrix comprise fascia 

April 6, 2016 

The current notion is that the majority of hernias are 144

disease of collagen metabolism. One of the key factors
this is the type I to III collagen ratio. The lower this rat
from an average of around 5, the more likely the indiv
is to develop a hernia. Currently, collagen typing is no
used in clinical practice to help decide perhaps which 
patients merit a mesh as opposed to a suture repair, b
this may well be a development in the near future 

April 6, 2016 

These are either synthetic (man made) or biological  144

(preparations from animal or human tissue) 

April 6, 2016 

It goes without saying that any mesh should have the u 144
properties of any implant, including being non-allerge
non-carcinogenic, have good incorporation into tissue
mimic the tissue it is replacing or reinforcin 

April 6, 2016 
There are no strict definitions of light weight and heav 145
weight but a reasonable guideline is that mesh of 40–80
g/m 2 is medium weight and < 40 g/m 2 is light weight 

April 6, 2016 

Increasing the macroporosity of the mesh produces a s 145

net, rather than a scar plate, with normal tissue in bet
the fibre/scar complex, reducing mesh/scar shrinkage
improving flexibility ( 

April 6, 2016 

If the micropore size is smaller, bacteria can harbour 145

the pores out of reach of the larger inflammatory cells

April 6, 2016 

Polyester-based meshes are gaining popularity and ha 146

some advantages over polyproplyene but are multifila
rather than monofilament. 

April 6, 2016 

The multifilament arrangement increases the develope 146

surface of the mesh (around 2000 mm 2 per cm 2 mesh
compared to 200 mm 2 per cm 2 for polypropylene) and
thus improves tissue incorporation 
April 6, 2016 

Preferred mesh should be lightweight (< 80 g/m 2 ), larg 147

pore (> 1 mm) and macroporous (> 10 µm). 

April 6, 2016 

A number of tissue-separating meshes are available, w 147

the intra-abdominal side of the mesh is coated with a 
product to minimise adhesion formation. It would be f
to say that while such coatings do reduce adhesion 
formation, in the majority of patients significant adhe
to such coatings still occurs 

April 6, 2016 

The author's opinion is that there is no good evidence  148

available to suggest that biological mesh is superior or
even as good as polypropylene in clean/contaminated 
operations 

April 6, 2016 

During abdominal distension, the linea alba must incr 149

in both dimensions, the resulting tearing of fibres poss
leading to the development of an epigastric hernia. 

April 6, 2016 
the defect is small (< 2 cm), repair by primary suture  150
closure using non-absorbable material is usually suffi

April 6, 2016 

If the defect is large (> 6 cm 2 ), or occurs within a  150

divarification of the recti, the hernia should be repair
with prosthetic mesh. 

April 6, 2016 

At laparoscopic repair, it is important to take down th 150

falciform ligament and remove any pre-peritoneal fat 
above the linea alba, otherwise the ‘hernia’ may still b
palpable following the alleged repair. 

April 6, 2016 

Normally, the gut returns to the abdominal cavity at 1 151

weeks of gestation. If this fails to occur, normal rotati
and fixation of the intestine are prevented, the umbilic
absent and a funnel-shaped defect in the abdominal w
present through which viscera protrude into the umbi
cord 

April 6, 2016 

Antenatal knowledge of the existence of a congenital  151

hernia can allow for the birth of the child at a tertiary
institution with the appropriate neonatal and paediat
surgical expertise (see also Chapter 12 ). 

April 6, 2016 

The sac should be wrapped in moist sterile gauze and  152

covered with impervious plastic sheeting or aluminium
foil. Mother and baby should then be transferred as so
as feasible to a tertiary centre for further managemen

April 6, 2016 

Infantile umbilical hernias occur when the umbilical  152

vessels fail to fuse with the urachal 

April 6, 2016 

remnant and umbilical ring.  152

April 6, 2016 

Infantile umbilical hernias rarely enlarge over time an 152

90% disappear by the time the child is 2 years of age, 
although they are unlikely to close spontaneously if th
persist to the age of 5 years. 11 Spontaneous resolution
umbilical hernias appears to be directly influenced by
size of the umbilical ring 

April 6, 2016 
Repair is by simple fascial apposition using horizonta 153
mattress sutures of absorbable material. 

April 6, 2016 

Umbilical hernias classically produce a symmetric bul 154

with the protrusion directly under the umbilicus. This
contrast to para-umbilical hernias, where about half t
fundus of the sac is covered by the umbilicus and the 
remainder is covered by the skin of the abdomen direc
above or below the umbilicus( Fig. 4.3 ). 

April 6, 2016 

The classic Mayo approach 12 overlaps the edges, but t 155

has never been any demonstration that the bursting 
strength of the wound is improved by imbrications and
may actually be impaired to a degree proportional to t
amount of overlapping and tension 

April 6, 2016 

If a new  155

April 6, 2016 
umbilicus is to be created, care should be taken as  155
recurrences may occur at the point on the linea alba w
the new umbilicus is fixed to the fascia. 

April 6, 2016 

An indirect hernia travels down the canal on the outer 157

(lateral and anterior) side of the spermatic cord. A dir
inguinal hernia comes out directly forwards through t
posterior wall of the inguinal cana 

April 6, 2016 

The presence of an empty scrotum should alert the  158

examining surgeon to a possible undescended or ectop
testis, which is associated with an inguinal hernia in m
than 90% of patient 

April 6, 2016 

In contrast to the adult with an incarcerated hernia, i 159

children testicular ischaemia is far more common tha
intestinal ischaemia, and it is therefore appropriate to
aggressive about reducing the hernia (see Chapter 

April 6, 2016 

Surgical access is achieved through a short (2–3 cm)  160

transverse incision in the lowest inguinal skin crease 
April 6, 2016 

Free ties should not be used because of the risk of them 161
becoming dislodged if abdominal distension occurs 

April 6, 2016 

A rapid return of pink colour, sheen, peristalsis and  161

palpable or visible pulsations at the mesenteric border
should be observed. If there is any question regarding 
intestinal viability, resection and anastomosis should
carried out and hernial repair accomplished 

April 6, 2016 

Intraoperative complications include: division of the  162

ilioinguinal nerve, which can be avoided if the externa
oblique fascia is elevated before incision; division of th
deferens, which should be repaired with interrupted 7–
monofilament sutures; and bleeding, which is usually 
secondary to needle-hole injury and can usually be 
controlled with withdrawal of the suture and the 
application of pressure. 

April 6, 2016 

Unrestricted activity is encouraged and patients are  167

expected to return to their normal activity 2–7 days af
surgery. 
April 6, 2016 

The prolene hernia system is two flat meshes secured  167

together by a small cyclinder of mesh. The aim is to ins
one mesh into the pre-peritoneal space and the other is
secured akin to the Lichtenstein technique. 

April 6, 2016 

It has the disadvantage of leaving the prosthetic mater 168

exposed within the peritoneal cavity and has a higher 
recurrence rate 

April 6, 2016 

The disadvantage is that a wider dissection is required 169

accommodate the mesh than is used in the intraperito
onlay procedure. 

April 6, 2016 

The pre-peritoneal space is dissected towards the  170

symphysis pubis, Cooper's ligament 

April 6, 2016 

and the iliac vessels with a blunt instrument or  170

space-making balloon. Carbon dioxide is insufflated in
the pre-peritoneal space to maintain exposure. Care m
be taken to avoid entering the peritoneum; if this occu
loss of pressure in the pre-peritoneal space can result,
making exposure more difficul 

April 6, 2016 

The key landmark here is the vas. The indirect hernial 170
lies above and lateral to the vas, taking the dissection
from the iliac vessels, preventing their inadvertent inj

April 6, 2016 

In all circumstances tacks are placed medial to the inf 171

epigastric vessels and superior to the pubic bone only.

April 6, 2016 

It is currently the preferred technique recommended b 171

National Institute for Clinical Excellence (NICE) for 
recurrent inguinal hernias and bilateral primary ingu
hernias, and an alternative operation for primary 

April 6, 2016 

Risk factors for chronic pain include nerve damage,  172

preoperative pain in the hernia, young age, pain at oth
sites of the body, postoperative complications and 
psychosocial features. 28 Pain response to a standard
heat stimulus appears to be a useful tool in assessing r
of postoperative chronic pain. 29 

April 6, 2016 

It is, however, the preferred technique for the repair of 173

recurrent and bilateral hernias. 

April 6, 2016 

The transinguinal pre-peritoneal prosthetic repair/Riv 174

procedure tends to be reserved for selected cases and i
indicated for the majority of recurrent inguinal hernia

April 6, 2016 

The advantages of the laparoscopic approach include: 175

elimination of one of the commonest causes of recurre
the missed hernia; allowing the surgeon to identify tho
patients with complex hernias; and covering the entire
myopectineal orifice, buttressing the intrinsic collagen
deficit, thereby overcoming one of the causes of late 
recurrence 

April 6, 2016 

It is the author's opinion that an open mesh repair is t 175

best option following a failed TAPP repair, and a TAPP
repair for a failed TEP repair. The TAPP approach allo
assessment as to why the TEP repair failed, and maint
the speedier recovery of the laparoscopic approach ov
open repair. However, the significant adhesions follow
a TAPP make a redo TAPP much more difficult, but stil
possible in experienced hands. 

April 6, 2016 

Thus, following informed consent, surgery or watchfu 176

waiting for an asymptomatic hernia is appropriate. Th
younger the patient, or less fit the patient on presentat
then perhaps the earlier surgery should be offered, wi
suitable informed consent of the risks, benefits and 
alternatives to the proposed surgery. 

April 6, 2016 

It is closed above by the septum crurale, a condensatio 177

extraperitoneal tissue pierced by lymphatic vessels, an
below by the cribriform fascia. 

April 6, 2016 

A postulated mechanism is the insinuation of fat into t 177

femoral ring secondary to raised intra-abdominal 
pressure. This bolus of fat drags along pelvic peritoneu
develop a peritoneal sac 

April 6, 2016 

A postulated mechanism is the insinuation of fat into t 177

femoral ring secondary to raised intra-abdominal 
pressure. This bolus of fat drags along pelvic peritoneu
develop a peritoneal sac 

April 6, 2016 

In women of all ages, the muscle mass is not as great a 177

men. Consequently, women are predisposed to femora
hernias with any condition that increases intra-abdom
pressure, such as pregnancy or obesity. 

April 6, 2016 

This technique usually involves ligation and division o 178

inferior epigastric vessels at the medial border of the 
internal inguinal ring followed by incision of the 
transversalis fascia to expose the 

April 6, 2016 

extraperitoneal space and the femoral hernia sac.  178

April 6, 2016 

The femoral hernia sac is identified medial to the iliac 179

vessels and reduced by traction. If the hernia is 
incarcerated, the sac may be released by incising the 
insertion of the iliopubic tract into Cooper's ligament a
medial margin of the femoral ring. 

April 6, 2016 
A recent review 49 proposed mass closure (as compare 180
layered closure), continuous (as compared to interrup
sutures) absorbable monofilament (as compared to 
non-absorbable monofilament and absorbable 
multifilament) with a suture length to wound length ra
of 4:1. 

April 6, 2016 

Closure of a laparotomy wound to minimise incisional 181

hernia formation includes: 49 1. mass closure; 2. simp
running technique; 3. absorbable monofilament; 4. sut
length to wound length ratio of at least 4:1. 

April 6, 2016 

However, incisional hernia should be  182

April 6, 2016 

considered an incurable disease, mesh just increasing 182

time from repair to recurrence. 56 Although suture rep
is now rarely indicated, it might still have a role in you
women who wish repair of an incisional hernia but ar
also contemplating further pregnancy 

April 6, 2016 
The open sublay technique for incisional hernia repair 185
a lower recurrence rate and wound complication rate
compared to onlay or inlay repair techniques. 58, 59 
Randomised trials comparing the three mesh position 
techniques are lacking 

April 6, 2016 

The current consensus is that if the colon is injured, th 187

should be repaired, laparoscopically or open, accordin
the skills of the surgeon and no mesh inserted at this t

April 6, 2016 

If the small bowel is injured with minimal contaminat 187

then laparoscopic repair, washout and mesh insertion
acceptable. If there is significant small-bowel injury an
risk of failure of the bowel repair, then no mesh should
inserted 

April 6, 2016 

If the bowel is compromised, then resect the bowel thro 188

a small incision and return 6 weeks later for a TEP 

April 6, 2016 

The author uses a gentamicin solution (240 mg gentam 189

in 250 mL normal saline) to irrigate larger meshes 
 following insertion, although there is no evidence-base
medicine to support this manoeuvre. 

April 6, 2016 

Antibiotic prophylaxis is unnecessary for uncomplicat 190

elective hernia surgery to the groin and ventral region

April 6, 2016 

Chapter 5: Organisation of emergency general surgical 

services and the early assessment and investigation of the 
acute abdomen 
 

207
  detection of abdominal wall tenderness (increased 
abdominal pain on tensing the abdominal wall muscle
may be a useful diagnostic test. 36 

April 1, 2016 

In other words, the presence or absence of guarding an 210

rebound tenderness, and a history of pain on coughing
correlates well with the presence of peritonitis 

April 1, 2016 
Rectal examination can therefore be avoided in such  210
patients and reserved for those patients without rebou
tenderness or where specific pelvic disease needs to be
excluded. 

April 1, 2016 

Clearly, further investigations in the first category are 211

unlikely to influence management, with the exception o
serum amylase level, which may reveal acute pancrea
55 F 

April 1, 2016 

Early diagnosis in patients with mesenteric ischaemia 211

particularly important as survival after surgery is mu
better in those with venous thrombosis than those with
arterial thrombosis. 58 

April 1, 2016 

Studies examining the influence of white cell concentra 211

60 and C-reactive protein 61, 62 in patients with ‘query
appendicitis’ have concluded that serial white cell cou
are useful (compared with a single measurement). 
Although isolated C-reactive protein levels may also be
fairly non-discriminatory, when they are interpreted w
white cell count and both are normal, acute appendici
unlikely. 

April 1, 2016 
A recent study, however, has demonstrated the use of 212
combined clinico-radiological score for predicting the
of strangulation in small-bowel obstruction 

April 1, 2016 

Until recently there was general consensus that the er 213

chest radiograph was the most appropriate investigat
for the detection of free intraperitoneal gas, with use o
lateral decubitus film if either the erect chest film coul
be taken (due to the patient's condition) or was equivo
This no longer seems to be true following a report from
Taiwan, where ultrasonography was shown to be supe
to the erect chest radiograph, with a sensitivity of 92%
the detection of pneumoperitoneum compared with on
78% for plain radiology. 68 Undoubtedly there will be 
operator dependence and for now the erect chest 
radiograph should still be the initial test for suspected
perforation ( Fig. 5.1 ). 

March 26, 2016 

Patients who might be considered for non-operative  215

treatment of their perforation should have a contrast
to confirm spontaneous sealing of the perforation. Thi
topic is discussed in more detail in Chapter 6 . 

March 26, 2016 

Surgery for small-bowel obstruction is performed for o 216

of two reasons: first, there has been failure of 
non-operative management; second, there is clinical 
suspicion of impending strangulation 

March 26, 2016 

The criteria on which strangulated intestine must be  216

suspected are well established: peritonism, fever, 
tachycardia and leucocytosis. 

March 26, 2016 

There is little doubt that water-soluble contrast studie 216

patients with small-bowel obstruction are useful in 
detecting those patients who are not likely to settle wit
non-operative management. 78 

March 26, 2016 

Water-soluble contrast material also allows quicker  217

resolution of symptoms. 80 In general, failure of 
water-soluble contrast to reach the caecum by 4 hours
strongly suggests that surgical intervention is likely to
required, and better sooner than later ( 

March 26, 2016 

The decision that all patients with suspected large-bow 219

obstruction should now undergo a contrast enema ( Fi
5.6c,d ) before laparotomy has probably been the most
important factor in reducing not only the unnecessary
operation rate for pseudo-obstruction, but also the 
associated mortality. 

March 26, 2016 

Overall, CT has been shown in a prospectively random 221

trial to be superior to contrast enemas in both the 
evaluation of inflammation and identification of a 
collection. 84 

March 26, 2016 

A clinicoradiological score has recently been develope 225

predict the risk of strangulated small-bowel obstructio
using duration of pain (lasting 4 days or more), elevat
C-reactive protein (> 75 mg/L), leucocyte count (> 10 × 1
/L), the presence of guarding, at least 500 mL of fluid a
seen on CT and reduced enhancement of the small bow
CT 

March 26, 2016 

MRI can undoubtedly differentiate an acutely inflamed 227

appendix from a normal one 105 and therefore is usefu
pregnant patients, where the diagnosis of acute 
appendicitis can be difficul 

March 26, 2016 

most patients with suspected appendicitis can now  228

 undergo diagnostic laparoscopy followed by laparosco
appendicectomy if the diagnosis of acute appendicitis
confirmed 

March 26, 2016 

Chapter 8: Pancreaticobiliary emergencies 

 

316
  Although termed ‘colic’, the pain is usually constant w
present, but remits after a period of minutes to hours.

March 26, 2016 

Classically, Murphy's sign (acute tenderness during  316

palpation below the tip of the right ninth rib elicited on
inspiration) can be observed in patients with acute 
cholecystitis. 

March 26, 2016 

Transabdominal ultrasound is the initial investigation 317

choice in both biliary colic and acute cholecystitis and
a sensitivity of greater than 95% for detecting gallston
(see also Chapter 5 ). 

March 26, 2016 

Radionucleotide scintigraphy has historically been  318
reported to have greater accuracy in diagnosing acute
cholecystitis than standard US techniques. However, th
techniques are time-consuming, involve the use of 
radiopharmaceuticals, and their use is now generally 
restricted to individuals who are clinically suspected o
having abnormal gallbladder function in the presence
normal ultrasound scan (gallbladder dyskinesia). 

March 26, 2016 

Nowadays, ERCP is reserved for therapeutic interventi 319

e.g. sphincterotomy and stone removal or stenting, rat
than for diagnosis ( Fig. 8.4 ). 

March 26, 2016 

If a ductal stone is demonstrated on intraoperative  322

cholangiography, the options are to undertake 
laparoscopic CBD exploration, convert to an open 
procedure with exploration of the CBD or to perform a
postoperative ERCP or, in some cases, intraoperative E

March 26, 2016 

Although opiate analgesia is widely prescribed,  324

non-steroidal anti-inflammatory drugs (NSAIDs) are a
effective in relieving pain. Moreover, studies have 
suggested that NSAIDs can reduce the number of patie
progressing from biliary colic to acute cholecystitis. Ea
laparoscopic cholecystectomy should be offered. 

March 26, 2016 

Several randomised trials over the last 15 years compa 325
early versus late laparoscopic cholecystectomy for acu
cholecystitis have now confirmed that early laparosco
cholecystectomy is both safe and has significant benef
for patient 

April 7, 2016 

Antibiotic therapy following successful early  326

cholecystectomy for acute non-gangrenous cholecystit
does not need to be continued beyond 12 hours. 

April 7, 2016 

A change in technique to US transhepatic placement of 328

locking drains helped to lower procedure-related 
complications. 

April 7, 2016 

In critical illness states, gallbladder microvascular  330

ischaemia probably occurs as a manifestation of the 
systemic inflammatory response syndrome 

April 7, 2016 
Cholescintigraphy may be the most accurate method of 331
identifying AAC 

April 7, 2016 

In all patients, broad-spectrum antibiotic therapy sho 331

be instituted as 65% of bile cultures will be positive, wi
Escherichia coli the most common organism. 

April 7, 2016 

It would therefore appear reasonable to manage AAC 332

critically ill patients with initial percutaneous 
cholecystostomy, but in the absence of rapid clinical 
improvement a complication should be presumed and 
cholecystectomy carried out. 

April 7, 2016 

Acute cholangitis may be defined as an acute pyogenic 332

infection within the biliary tree 

April 7, 2016 

Acute cholangitis arises as a consequence of biliary st 332

with subsequent bacterial infection 

April 7, 2016 
In those progressing to acute cholangitis, cholangioven 332
reflux of bacteria and bacterial products occurs becau
increasing hydrostatic pressure within the biliary tree

April 7, 2016 

Aerobic Gram-negative bacilli ( E . coli , Klebsiella ,  333

Pseudomonas species), enterococcus and anaerobes ar
most common organisms cultured from the bile of pat
with acute cholangitis. 36 In up to 50% of patients, 
anaerobic organisms may be associated with aerobic 
organisms 

April 7, 2016 

Charcot's triad: upper abdominal pain, jaundice and  333

pyrexia. 

April 7, 2016 

Deranged coagulation tests can occur,  334

April 7, 2016 

either as a consequence of prolonged biliary obstructi 334

resulting in vitamin K deficiency, or due to disseminat
intravascular coagulation. 

April 7, 2016 
Mild acute pancreatitis Minimal organ dysfunction an 337
uneventful recovery Severe acute pancreatitis Associa
with organ failure and/or local complications such as 
necrosis, abscess or pseudocyst Acute fluid collections
Occur early in the course of acute pancreatitis, are sit
in or near the pancreas, and always lack a wall of 
granulation or fibrous tissue Pancreatic necrosis Diffu
focal areas of non-viable pancreatic parenchyma, typi
associated with peripancreatic fat necrosis Acute 
pseudocysts Collection of pancreatic juice surrounded
wall of fibrous or granulation tissue 

April 7, 2016 

This systemic inflammatory response is characterised 339

the systemic activation of leucocytes and endothelial c
and the secretion of proinflammatory cytokines, and i
responsible for the development of the organ dysfunct
that characterises severe acute pancreatitis. 

April 7, 2016 

Examination may reveal abdominal signs ranging from 339

localised epigastric tenderness to generalised peritoni

April 7, 2016 

More specific signs of severe acute pancreatitis includ 339

periumbilical bruising (Cullen's sign) and flank bruisi
(Grey Turner's sign; Fig. 8.9 ) 
April 7, 2016 

detection of a serum amylase concentration more than 340

three times the upper limit of normal 

April 7, 2016 

However, very high levels of serum amylase on admiss 340

are often suggestive of a gallstone aetiology. 

April 7, 2016 

The decision to undertake diagnostic laparotomy shou 341

not be made lightly as there is evidence that early 
operation has an adverse effect on outcome in acute 
pancreatitis 

April 7, 2016 

It should be noted that the Ranson score is based on a  343

North American population with alcohol as the 
predominant aetiological agent, whereas the Glasgow
score is designed for use in a typical British population
gallstone-predominant disease. 

April 7, 2016 
An APACHE II score of 9 or more has been validated  343

April 7, 2016 

for predicting prognostic severity in acute pancreatiti 343

April 7, 2016 

The importance of vigorous volume resuscitation and  345

careful monitoring and treatment for metabolic, 
respiratory, renal and cardiac complications cannot b
overemphasised. 

April 7, 2016 

Rationalisation of the results of the fully reported tria 347

suggests that early ERCP/ES is of benefit in patients wi
prognostically severe gallstone-induced acute pancrea
with evidence of cholangitis or biochemical evidence of
obstructive liver function tests (serum bilirubin > 90 
µmol/L). 75 – 79 

April 7, 2016 

At present, a pragmatic approach is that routine  351

administration of prophylactic antibiotics to all patien
with predicted severe acute pancreatitis is not indicat
but should be considered in those patients with eviden
pancreatic necrosis who appear septic (with leucocyto
fever and/or organ failure). If blood and other culture
subsequently found to be negative and no source of 
infection is identified, antibiotics should be discontinu
positive microbiological cultures are obtained, approp
antibiotics should be continued based on microbiologi
sensitivities. 88 

April 7, 2016 

Early nasogastric and nasojejunal feeding appear  355

equivalent in patients with objectively graded severe a
pancreatitis. 10 

April 7, 2016 

It has been demonstrated that a nil-by-mouth regimen 355

the institution of parenteral nutrition in normal volun
is associated with an increased inflammatory respons
following a stimulus, 106 and malnourished patients h
an impairment of intestinal function and increased 
markers of the acute-phase response 

April 7, 2016 

Although there is no definitive evidence demonstrating 356

early enteral nutrition improves outcome in severe ac
pancreatitis, all published studies 

April 7, 2016 

demonstrate that enteral nutrition is feasible, safe an 356

does not exacerbate the disease process. 

April 7, 2016 

As a result of the current evidence available, the use of 357

probiotics in patients with severe acute pancreatitis ca
be recommended. 10 

April 7, 2016 

British Society of Gastroenterology guidelines recomm 359

that patients with gallstone-induced mild acute 
pancreatitis should undergo cholecystectomy 
(laparoscopic) during the same hospital admission un

April 7, 2016 

clear plan for definitive treatment within the following 359

weeks has been made. 51 In patients with severe comor
disease contraindicating cholecystectomy, definitive 
treatment may be provided by ERCP and ES. In those w
gallstone-induced severe disease, cholecystectomy sho
be delayed until disease resolution or undertaken as a
additional procedure during surgery for a complicatio
the acute pancreatitis 

April 7, 2016 

Once the bleeding vessel is localised, directed transart 360

embolisation can be attempted and, in many cases, 
 obviates the need for a technically challenging laparot
in an unwell patient with a ‘hostile abdomen 

April 7, 2016 

The most common complications of ERCP and ES are  360

pancreatitis, cholangitis, haemorrhage and duodenal 
perforation 

April 7, 2016 

CT is the preferred modality for diagnosis of perforati 361

the perforation is frequently retroperitoneal 

April 8, 2016 

Chapter 9: Acute conditions of the small bowel and appendix 

 

377
  i) obstruction, (ii) peritonitis and (iii) haemorrhage. 
February 6, 2016 

the commonest cause in the developed world is adhesio 377

secondary to previous surgery (approximately 60% of 
episodes), followed by malignancy. By comparison, in
developing world the most common cause is hernia. 
February 6, 2016 

This produces colicky pain, usually in the central abdo 378

as the small bowel is of midgut embryological origin 

February 6, 2016 

As the process continues the risk of complications  378

increases and if the blood supply is compromised, 
infarction and perforation will occur. 

February 6, 2016 

Vomiting may be less of a feature and a greater degree 379

abdominal distension observed if the blockage is in the
distal ileum – in which case the vomiting often become
‘faeculant’ as the stagnant small-bowel contents becom
degraded by bacterial colonisation. 

February 6, 2016 

The presence of surgical scars is important, as is any  379

history of previous intra-abdominal pathology 

February 6, 2016 

There is less urgency in the recognition of  379

non-strangulating obstruction, and a period of 
decompression and intravenous fluid resuscitation ma
allow resolution to occur without surgery. However, 
failure of the obstruction to resolve after 48–72 hours
usually an indication for surgical intervention. 

February 6, 2016 

Fluid lost from the nasogastric tube should be replace 380

with additional intravenous crystalloids (normal salin
Hartmann's solution) and potassium supplements 

February 6, 2016 

increasing amounts of opiate analgesia is a strong sig 380

that underlying strangulation is a possibility and surg
indicated 

February 6, 2016 

The investigations undertaken in patients with small-b 381

obstruction are aimed at: 1. assessing the general stat
the patient; 2. confirming the diagnosis of small-bowel
obstruction; 3. identifying which patients should unde
early surgery (those with a high risk of strangulation)
those in whom a non-operative approach is appropria

February 6, 2016 

CT features of intraperitoneal free fluid, mesenteric  381

oedema and lack of the ‘small-bowel faeces sign’, in 
combination with a history of vomiting 

February 6, 2016 

identifying patients with possible strangulation remai 381

difficult, and the surgeon must base much of the 
decision-making on clinical assessmen 

February 6, 2016 

Intravenous fluids and nasogastric aspiration are the 382

components of the ‘drip and suck’ regimen, which is th
first-line treatment for most patients with obstruction

February 6, 2016 

surgical exploration is generally indicated if the  382

obstruction fails to resolve after 48–72 hours. 

February 6, 2016 

Generally, a midline incision is the most flexible when 383

diagnosis is unknown. I 

February 6, 2016 

Having entered the abdominal cavity, the first step is t 383

identify the point at which the dilated bowel proximal
the obstruction changes to collapsed distal bowel. 

February 6, 2016 

If the viability of a segment of bowel is unclear then it  384

should be wrapped in warm moist swabs for several 
minutes and re-examined. 

February 6, 2016 

An ileostomy may be indicated in patients with Crohn' 385

disease as part of their long-term management, and th
possibility of such a step should be recognised, conside
and discussed with the patient before undertaking the
laparotomy 

February 6, 2016 

CT is important in identifying a single area of obstruct 386

which might be amenable to surgery, as compared to 
extensive intra-abdominal disease without a single po
obstructio 

February 6, 2016 

The principles involve the use of fluid diet, steroids an 387

octreotide 

February 6, 2016 
necessary. A Richter hernia involves part of the  387
circumference of the bowel wall and the lumen is not 
obstructed. Infarction of the trapped bowel wall segme
can still occur and there will be exquisite localised 
tenderness over a potential hernia site 

February 6, 2016 

In the presence of obstruction necessitating bowel  388

resection, it is probably best to avoid the use of a prost
mesh if possible. When there has been gross contamina
of the surrounding area, the risk of complications is 
increased and a full treatment course of antibiotics sh
be given 

February 6, 2016 

For a strangulated femoral hernia a ‘high’ McEvedy  389

approach usually provides optimum access for both he
repair and bowel resection if required. 

February 6, 2016 

It is worth obtaining a plain abdominal radiograph in 389

patients with an irreducible hernia and apparent bow
obstruction. The absence of dilated small-bowel loops,
the presence of a dilated colon, should suggest the 
possibility that the apparently ‘incarcerated’ hernia is
secondary effect of some other intra-abdominal patho

February 6, 2016 
At surgery the stone should be removed via a proxima 390
enterotomy and the intestine proximal to the obstruct
carefully palpated to exclude the presence of a second 
stone. In these circumstances the gallbladder should b
alone, as cholecystectomy can be difficult and is usual
unnecessary. 

February 8, 2016 

In patients who genuinely have a mechanical obstruct 391

appropriate surgical intervention is frequently delaye
result of this diagnostic dilemma. In these patients, th
of water-soluble contrast small- 

February 8, 2016 

bowel studies and contrast-enhanced CT is often helpf 391

and should be considered early. 11 

February 8, 2016 

Open surgery is the preferred method for surgical  391

treatment of strangulating small-bowel obstruction as
as after failed non-operative management. 

February 8, 2016 
The small bowel alone is affected in approximately 30% 392
patients and the small bowel and colon together in 50%

February 8, 2016 

It is thought that the disease is most likely due to an  392

immunological disorder, although the exact mechanis
remains unclear although the final pathway is probab
microvasculitis in the bowel wall. 

February 8, 2016 

Second, entero-enteric or enterocutaneous fistula occu 393

Crohn's disease because of the transmural inflammat
that is a characteristic histological finding. 

February 8, 2016 

An ultrasound scan may show thickening of the bowel 393

or a mass, and contrast-enhanced CT will provide mor
detailed informatio 

February 8, 2016 

In the presence of a localised inflammatory mass or  393

stricture, resection and primary anastomosis may be 
appropriate. If surgery has been carried out for suspe
appendicitis and a normal appendix with ileocaecal 
Crohn's disease is discovered, the appendix should be 
removed with careful repair of the caecum, so that the
possible diagnosis of acute appendicitis is ruled out of
future attacks of pain. 

February 8, 2016 

Chronic mesenteric ischaemia is also termed ‘mesente 394

claudication’ and is usually caused by a stenosis in the
proximal part of the superior mesenteric artery. 

February 8, 2016 

the investigation of choice is mesenteric angiography  394

February 9, 2016 

Venous thrombosis in the distribution of the superior  394

mesenteric vein is a less common cause of acute 
small-bowel ischaemia but may be related to increased
blood coagulability, portal vein thrombosis, dehydrati
infection, compression and vasoconstricting drugs. 

February 9, 2016 

If embolectomy and reconstruction have been perform 396

or there is doubt about the margins, then anastomosis
should be deferred. In this situation the distal and 
proximal ends of bowel should be stapled off and retur
to the abdomen, with re-exploration planned within 48
hours 
February 9, 2016 

CT angiography is recommended ( Fig. 9.7a ), 18 and if 398

bleeding point is found, formal angiography may allow
catheter to be passed into the mesenteric branches as
as possible to the bleeding point and left in position to
surgical localisation ( Fig. 9.7b ). 

February 26, 2016 

Occasionally, the only option is to place segmental sof 398

bowel clamps throughout the small intestine, resecting
segment that fills up with blood after a period of waiti

February 26, 2016 

or divide the small bowel around its midpoint, bringin 398

two stomas. Subsequent bleeding can then be identified
one or other side and enteroscopy used to localise it 
further. 

February 26, 2016 

The risk of morbidity and mortality is significantly  401

increased if the appendix perforates; thus, to err on th
side of overdiagnosing acute appendicitis remains acc
best surgical practice 

February 26, 2016 

Acute salpingitis, Mittelschmerz pain and complicatio 403
ovarian cyst may all be difficult to differentiate. Torsi
an ovarian cyst usually presents with a notable acute
of pain and may sometimes be distinguished on clinica
grounds 

February 26, 2016 

Although it is clearly advantageous to spare patients  403

unnecessary surgery, the morbidity and mortality of f
to diagnose appendicitis until perforation has occurre
greater than that associated with the removal of a nor
appendix. 

February 26, 2016 

If the appendix is macroscopically normal, examinatio 404

should be undertaken of the terminal ileum (for at lea
cm to exclude an inflamed Meckel's diverticulum) and
small-bowel mesentery and pelvis, both by palpation a
direct visualisation 

February 26, 2016 

A thorough lavage is essential in contaminated cases t 407

prevent postoperative abscess formation 

March 1, 2016 
a normal appendix should probably be removed in eve 407
patient, including those with Crohn's disease that affe
the caecum, in order to prevent future diagnostic dilem

March 1, 2016 

The main long-term complication is small-bowel  408

obstruction. 

March 1, 2016 

In this scenario, there are two arguments in favour of 408

removing the appendix. (i) There is a small incidence o
appendicitis on histological examination of a 
macroscopically normal appendix. 42 , 43 One study 
evaluating the ability of laparoscopy to discriminate 
between a normal and an inflamed appendix demonst
a sensitivity of 92% and a specificity of 85% if an appen
with isolated mucosal inflammation was considered to
inflamed. 44 (ii) Removal of the appendix prevents 
diagnostic dilemma in a patient who continues to suffe
from abdominal symptoms and signs following 
laparoscopy 

March 1, 2016 

The differential diagnosis includes Crohn's disease in  410

younger patients and carcinoma of the caecum in olde
patients. 

March 1, 2016 
routine interval appendicectomy is no longer  411
recommended. 

March 1, 2016 

A systematic review has confirmed that non-operative 411

management of an appendix mass will be successful in
majority of patients and recurrence of symptoms is low
a result the routine use of interval appendicectomy is
longer justified. 

March 1, 2016 

magnetic resonance imaging can be accurate in exclud 414

appendicitis where the ultrasound exam does not visu
a normal appendix’. 

March 1, 2016 

One recent large observational study has reported a h 414

risk for laparoscopy, with an odds ratio of 2.3 for foeta
loss compared to conventional surgery, 58 and this ha
influenced the results of a subsequent systematic revie
57 The result of this single study does not contraindica
laparoscopic appendicectomy in pregnancy, but does 
indicate a need for further research on the subject 

March 1, 2016 
 ultrasound and often CT is required for diagnosis and 416
pus is aspirated, a percutaneous drain should be place
possible 

March 1, 2016 

Chapter 10: Colonic emergencies 

 

424
  The operative mortality for emergency colon resection
two to three times that associated with elective resecti

March 1, 2016 

When emergency surgery is necessary, there has been 424

clear trend towards single rather than staged procedu
for large-bowel disorders. 

March 1, 2016 

Patients requiring emergency large-bowel surgery sho 424

be marked for potential stoma sites and if possible 
participation of a stoma therapist arranged 

March 1, 2016 

Anatomical locations that have the potential to be  425

vulnerable to ischaemic disease include: Griffith's poin
the splenic flexure (junction of the superior mesenteric
artery (SMA) and the inferior mesenteric artery (IMA)
Sudeck's critical point at the mid-sigmoid colon (juncti
the IMA and hypogastric vasculature); and the caecum
(distal distribution of the SMA). 

March 1, 2016 

Most cases are the milder self-limiting variety that are 427
typically seen in middle-aged or elderly patients, often
following episodes of dehydration 

March 1, 2016 

most commonly in the sigmoid colon (76%), but also in 429

caecum (22%) and the transverse colon (2%). 8 One rep
suggested that 40–60% of patients have had previous 
episodes of obstruction. 

March 17, 2016 

A narrowed sigmoid mesocolon provides a pedicle for  430

rotation. The condition is occasionally associated with
Chagas' disease and Hirschsprung's disease, in which 
redundancy of the colon is a feature, in addition to 
non-specific motility disorders of the colon. 12 

March 21, 2016 

Massive distension of the sigmoid colon is  430

March 21, 2016 

the bowel loses its haustration and extends in an inver 430

U from the pelvis to the right upper quadrant of the 
abdomen ( Fig. 10.3 ). Fluid levels are seen in both limb
the loop on the erect film, commonly at different levels
(‘pair of scales’) 

March 21, 2016 

In one-third of patients, the appearances are atypical 430

water-soluble contrast enema should be carried out. T
may demonstrate narrowing of the contrast column a
point of twisting, which has been described as resembl
the beak of a bird of prey. 

March 21, 2016 

the most widely recommended procedure is a segment 431

colectomy with an end colostomy and closure of the re
stump (Hartmann's operation) 

March 21, 2016 

Intraoperative colonic irrigation may facilitate prima 432

anastomosis in patients with sigmoid volvulus who req
emergency operation, since faecal loading proximal to
volvulus may increase the risk of anastomotic dehisce
However, it is still important that only patients who ar
generally fit and without systemic sepsis and peritone
contamination are selected for this procedure. 

March 21, 2016 

recurrent volvulus after decompression and de-rotatio 432

has been reported to be between 40% and 60%, 9 electiv
surgery to prevent further volvulus should always be 
considered 

March 21, 2016 

Predisposing conditions include pregnancy, chronic  434

constipation, distal colonic obstruction and previous 
gastric surger 

March 21, 2016 

Operative choices include a transverse colectomy or a 434

extended right hemicolectomy 

March 21, 2016 

Conditions that alter the normal anatomy may predisp 434

to caecal volvulu 

March 21, 2016 

As it twists, the caecum comes to occupy a position abo 435
and to the left of its original position. A similar condit
which is seen very occasionally, is ‘caecal bascule’. In
condition, the caecum folds upwards on itself, produci
sharp kink in the ascending colon 

March 21, 2016 

On the supine abdominal radiograph, a ‘comma’-shap 435

caecal shadow in the mid-abdomen or left upper quad
with a concavity to the right iliac fossa is diagnostic ( F

March 21, 2016 

A single, long fluid level on the erect film is characteri 435

If doubt persists, a contrast enema will show a beaked
appearance in the ascending colon at the site of the 
volvulus ( F 

March 21, 2016 

CT is now the favoured modality for acute investigatio 453

suspected acute colonic diverticultis. 

March 22, 2016 

It should be remembered that the anastomosis  464

March 22, 2016 

 may leak any time during the first 2–3 weeks after  464
operation. 

March 22, 2016 

Chapter 12: Paediatric surgical emergencies 

 

510
  Common 
March 23, 2016 

Chapter 13: Abdominal trauma 

 

543
  CT may also miss a pancreatic injury early in its cours
March 23, 2016 

is expensive and has the potential to create a tension  544

pneumothorax 26 or air embolus during insufflation 

March 23, 2016 

 The first clinical reports of postoperative increased IA 557
were often after aortic surgery, with postoperative 
haemorrhage f 

March 23, 2016 

If the fracture lines are parallel, these have been dubb 568
‘bear claw’-type injuries and probably represent wher
ribs have been compressed directly into the parenchym

March 24, 2016 

The surgeon should be aware that penetrating injuries 568

the right lower chest, presenting with haemothorax, m
have penetrated the diaphragm, with the bleeding 
originating from the liver. 

March 24, 2016 

Chapter 14: Venous thromboembolism: prevention, diagnosis 

and treatment 
 

620
  Patients with distal iliac or femoral vein thromboses c
present with a very painful, swollen, white leg (phlegm
caerulea alba). A rare but dramatic presentation is th
‘phlegmasia caerulea dolens’, which occurs when the w
iliac system is thrombosed. The entire leg is swollen, 
acutely painful, dusky blue in colour and patchy areas
 venous gangrene can develop. The cyanosis and swelli
distinguish this from arterial ischaemia (in which the
is white and rarely is there any swelling). 

May 1, 2016 

Chapter 15: Patient assessment and surgical risk 

 

650
  Despite this, POSSUM is the most widely applied, valida
surgical risk scoring system in the UK and has been 
modified by several authors to provide speciality-spec
information. 

April 8, 2016 

Twelve physiological and six operative parameters we 650

identified, and each of these factors were weighted to a
value of 1, 2, 4 or 8 to simplify the calculation 

April 8, 2016 

April 8, 2016  651

April 8, 2016  651

Neither the V-POSSUM nor P-POSSUM models appear to 654
accurate in predicting mortality in the context of rupt
aortic aneurysms. 24 

April 8, 2016 

Note: If the surgery is an emergency, the ASA grade is  656

followed by ‘E’ (for emergency), for example ‘3E’. Categ
5 is always an emergency so should not be written with
‘E’. 

April 8, 2016 

April 8, 2016  657

Six independent predictors of complications were iden 658

and included high-risk type of surgery, history of ischa
heart disease, history of heart failure, history of strok
diabetes requiring insulin, and elevated baseline serum
creatinine 

April 8, 2016 

It is fair to say that at present there is no single model 659

can accurately predict surgical risk for all patient 
populations. 

April 8, 2016 
Metabolic equivalent of tasks (METs) is a measure of  660
energy expenditure related to physical activity. One M
may be considered as the resting metabolic rate (RMR)
is defined as energy consumption at a rate of 3.5 mL O
per kg per minute. 

April 9, 2016 

The optimal cut-off value for the anaerobic threshold i 661

generally accepted at 11 O 2 mL/min/kg. 43 It is interes
that this value closely relates to 4 METs (14 O 2 
mL/min/kg) and, in turn, ability to climb two flights of 
stairs. 

April 9, 2016 

Cardiopulmonary exercise testing (CPEX) is the ‘gold  662

standard’ measure of cardiorespiratory function. An 
anaerobic threshold (AT) less than 11 O 2 mL/min/kg h
been associated with increased risk of postoperative 
complications and mortality, although the exact thres
AT value may need to be modified for different patient
groups or different surgical procedures. CPEX testing 
requires specialist equipment and expertise to perform
and it is not widely available in the UK at present, but
likely to be increasingly used for assessment of 
perioperative risk in selected high-risk patient populat

April 9, 2016 
The incremental shuttle walk test (ISWT) and the 6-min 664
walk test are simple tools to objectively assess exercise
capacity. They are indirect tests of oxygen consumptio
and have been shown to correlate with formal exercise
testing values (CPEX). The main value of these tests is t
identify higher-risk patient populations who may bene
from formal exercise testing. 

April 9, 2016 

Brain natriuretic peptide (BNP) and C-reactive protein 664

(CRP) are the most promising biomarkers for risk 
assessment. BNP is released from cardiac ventricles in
response to excessive stretching and elevated serum 
concentrations are correlated with prognosis in heart
failure. 48 Elevated preoperative serum concentration
BNP (> 40 pg/mL) was associated with an increased ris
death and perioperative cardiac events 

April 9, 2016 

CRP is a marker of systemic inflammation and serum  665

concentrations are associated with atherosclerotic dis
and adverse outcomes in cancer. A preoperative serum
CRP concentration greater than 6.5 mg/L was associat
with increased 30-day mortality and postoperative car
complication rates 

April 9, 2016 

Brain natriuretic peptide (BNP) and C-reactive protein 665

(CRP) are the most promising biomarkers for risk 
 assessment. Elevated preoperative serum concentratio
have been associated with increased risk of mortality
cardiac complications in surgical patients; however, t
optimal threshold cut-off value remains unknown. The
value of serum biomarkers may lie in the selection of 
patients into high- or low-risk groups and therefore he
identify which patients merit further assessment. 

April 9, 2016 

Using relativity (comparison with a concept the patien 666

understands) or examples (‘of the last 50 patients this
happened to …’) may also clarify the concept of surgica
risk to the patient. 

April 9, 2016 

Chapter 16: Perioperative and intensive care management of 

the surgical patient 
 

676
  The important point to recognise is that the normal 
response to surgery is to increase the cardiac output a
the delivery of oxygen to the tissues. Any patient who f
whatever reason is unable to develop this response is a
higher risk of subsequent complications 

April 8, 2016 

In particular, elective surgical patients can be assesse 676

cardiopulmonary exercise testing, 14 , 16 in which a st
correlation has been demonstrated between anaerobic
threshold and perioperative mortality 

April 8, 2016 

The anaerobic threshold is the point where aerobic  676

metabolism fails to provide adequate adenosine 
triphosphate and anaerobic metabolism starts to redu
the resultant deficit. The threshold is determined by 
monitoring inhaled and exhaled levels of oxygen and 
carbon dioxide during escalating levels of exercise. Th
provides an objective measure of physiological reserve

April 8, 2016 

One group 5 found that none of the routinely measured 678

variables such as heart rate, blood pressure, central 
venous pressure, urine output or any marker of acid–b
status was able to predict subsequent postoperative 
complications. 

April 8, 2016 

The variables independently associated with subseque 678

significant complications were the central venous oxyg
saturation and the cardiac index. 

April 8, 2016 
It is thought that this splanchnic hypoperfusion leads 679
disruption of the enteric mucosal barrier with 
translocation of endotoxins and micro-organisms into
systemic circulation. 26 – 29 This translocation initiate
cytokine pathway, increasing the risk of sepsis and org
failure 

April 8, 2016 

The concept of augmenting cardiac output in the  679

perioperative period to improve the outcome of surgic
patients has been described by many authors as 
‘optimisation’ or ‘goal-directed therapy’. 

April 8, 2016 

April 8, 2016  680

There are a variety of technologies available to monito 680

cardiac output. Traditionally a pulmonary artery cath
has been used, which enables a thermodilution curve t
constructed across the right ventricle, thus enabling 
cardiac output to be calculated from the Stewart–Ham
equation. In recent times this tool has become highly 
controversial due to a lack of evidence demonstrating
beneficial effect on outcome and the perceived invasiv
of its approach 

April 8, 2016 
Shoemaker et al. 30 utilised targets of cardiac index,  681
oxygen delivery and consumption (4.5 L/min per m 2 , D
> 600 mL/min per m 2 and VO 2 > 170 mL/min per m 2 ) 
that had been previously demonstrated to be the medi
values for survivors following major surgery, in order
show that the repayment of an incurred oxygen debt w
8 hours resulted in an improved outcome. 

April 8, 2016 

April 8, 2016  682

April 8, 2016  683

although it has been suggested that intraoperative flu 684

management can be guided by oesophageal Doppler, 38
this particular monitor is difficult to use in the 
postoperative phase as awake patients do not readily 
tolerate the oesophageal Doppler probe. 

April 8, 2016 

April 8, 2016  684

Perioperative goal-directed therapy 1. Assess the patie 684
preoperatively: where possible perform cardiovascula
measurements to assess cardiac performance. Measur
cardiac output and oxygen delivery. 2. If cardiac index
4.5 L/min per m 2 and/or oxygen delivery > 600 mL/min
m 2 (body surface area), then no further goal-directed
therapy will be 

April 8, 2016 

necessary. Patient can proceed to anaesthesia and sur 684

3. If cardiac index < 4.5 L/min per m 2 and/or oxygen 
delivery < 600 mL/min per m 2 (body surface area), the
further goal-directed therapy may be Indicated either
to surgery or, if this is not possible, then Immediately 
following surgery in a dedicated critical care area. 4. I
cardiac index < 4.5 L/min per m 2 and/or oxygen delive
600 mL/min per m 2 (body surface area): (a) Increase 
intravenous fluids: direct therapy using flow-directed
monitoring equipment to maximise intravascular fillin
pressure. (b) Maintain adequate haemoglobin 
concentration with blood transfusion if necessary. (c) 
Maintain blood oxygen saturation at 95% or greater w
supplemental oxygenation or artificial ventilation. 5. I
despite these measures cardiac index is < 4.5 L/min per
and/or oxygen delivery < 600 mL/min per m 2 (bod 

April 8, 2016 

April 8, 2016  684

 April 8, 2016  685

April 8, 2016  685

Appropriate intraoperative physiological monitoring i 687

required for all high-risk patients and NICE Medical 
Technology Guidance 3 relating to cardiac output 
monitoring should be applied. 

April 8, 2016 

High-risk patients are those at greater risk of death th 687

5% and all should have active consultant input 

April 8, 2016 

and be admitted to a critical care area postoperatively 687

at least 12 hours 

April 8, 2016 

Chapter 17: Surgical nutrition 

 
 694
  1. the ‘ebb’ phase, which is a short-lived response 
associated with hypovolaemic shock, increased 
sympathetic nervous system activity and reduced 
metabolic rate; 2. the ‘flow’ phase, which is associated
a loss of body nitrogen and resultant negative nitrogen
balance 

April 8, 2016 

If the changes of the ‘ebb phase’ are not replaced by th 695

‘flow phase’, then despite any advances in surgery, 
anaesthesia and intensive care support, death of the 
patient is the inevitable outcome 

April 8, 2016 

The magnitude of the nitrogen loss is proportional to t 697

degree of operative trauma or the severity of the sepsi
and the major site of protein breakdown is skeletal mu
(contains 80% of the body's amino acid pool, with 60% 
being glutamine 

April 8, 2016 

Following trauma, there is therefore an increase in the 698

turnover of fatty acids and glycerol, although raised l
of lactate, for example in hypovolaemic shock, induce 
re-esterification leading to raised plasma triglyceride
levels. 

April 8, 2016 
hyponatraemia is more often associated with an exces 699
water than with a deficiency of sodium; hypocalcaemi
does not indicate a deficiency of calcium, but can sugg
deficiency of magnesium. 

April 8, 2016 

A significant abnormality in the patient with sepsis is 699

disruption of the microstructure of the hepatocyte 
mitochondria, particularly of the inner membrane. Th
a block in energy transduction pathways, with conseq
reduction in the aerobic metabolism of both glucose an
fatty acid 

April 8, 2016 

The average daily intake of protein is approximately 8 700

in the UK, with a recommended daily intake of 0.8 g/kg
body weight and with nitrogen comprising approxima
16% of its weight. 

April 8, 2016 

conditionally essential’: L -alanine, L -glutamate and L 700

-aspartate, which are produced by a simple transamin
reaction. These are the three most important amino ac
in times of starvation: • alanine for hepatic 
gluconeogenesis; • glutamate as a fuel source for liver,
enterocytes and white blood cells; • aspartate for 
maintaining renal acid–base balance. 
April 8, 2016 

In contrast, if there is a negative energy balance, then  701

glycogenolysis dominates until glycogen stores are 
depleted, then fat and protein will be broken down to 
provide energy 

April 8, 2016 

In general, micronutrients are classified into: • fat-sol 702

vitamins (A, D, E and K); • water-soluble vitamins (C an
the B vitamins – folic acid, B 12 , B 1 , B 2 , B 3 , pantothe
acid, biotin and B 6 ). • trace elements (iron, zinc, copp
selenium, etc.). 

April 8, 2016 

Importantly, serum albumin acts as a negative marke 704

the acute-phase response, and so is lowered in maligna
trauma and sepsis, even in the presence of an adequat
intake. 

April 8, 2016 

In patients undergoing surgery, handgrip strength (ch 706

and easy to perform) may predict patients who develo
postoperative complications (sensitivity > 90%). 

April 8, 2016 
Alternatively, stimulation of the ulnar nerve at the wr 706
with a variable electrical stimulus results in contracti
the adductor pollicis muscle, the force of which reflect
nutritional intake. 

April 8, 2016 

Thiamine must therefore be replenished before feeding 709

commenced in the starved patient to prevent developm
of Wernicke–Korsakoff syndrom 

April 8, 2016 

There is evidence to suggest that atrophy of the intesti 710

mucosa is associated with loss of intercellular adhesio
and opening of intercellular channels. 

April 8, 2016 

This predisposes to increased translocation of bacteri 710

endotoxin from the gut lumen into portal venous and 
lymphatic systems. 28 Loss of gut integrity may accoun
for a substantial proportion of septicaemic events in 
severely ill patients. However, the extent to which it 
contributes to sepsis in patients is not fully understood

April 8, 2016 
Recent studies have demonstrated this is not required 713
nutritional support can commence using full-strength
at the desired rate in those not at risk of developing 
‘re-feeding syndrome’ 

April 8, 2016 

The stomach contents should be aspirated every 4 hou 713

during feeding and if a residual volume of more than 1
mL is found, enteral nutrition is temporarily discontin

April 8, 2016 

The aspirate is checked again after 2 hours, and when  714

satisfactory volumes are aspirated (< 100 mL) feeding
re-instituted. If more than 400 mL per 24 hours is 
aspirated, then feeding is discontinued. Gastric empty
may be improved by the administration of cisapride or
erythromycin, which may allow feeding to be continue

April 8, 2016 

Some catheters have an antimicrobial cuff, usually ma 716

Dacron, around their external surface. This acts as a 
barrier to micro-organisms, which may migrate from 
subcutaneous tissues along the external aspect of the 
catheter to its tip 

April 8, 2016 
Infection of the catheter tip is the most serious type of  716
infection. 

April 8, 2016 

Rapid infusion of high concentrations of glucose can  720

precipitate hyperglycaemia, which may be further 
complicated by lactic acidosis. 

April 8, 2016 

Biochemical assessments include daily measurements 721

renal and liver function, with twice-weekly checks of 
phosphate, calcium, magnesium, albumin and protein
levels, and haematological indices (haemoglobin, whit
blood cell count, haematocrit), until the patient is 
stabilised. T 

April 8, 2016 

Nutritional support should be given to malnourished  723

patients for at least 7–10 days preoperatively where 
possible to reduce postoperative morbidity. 42 Nutritio
support in the postoperative period should be consider
for: • patients in whom it is anticipated that normal or
intake is unlikely for 7 days or more after surgery; • th
with severe sepsis or burns; • those with enterocutaneo
fistulas (particularly if high output); • patients who ha
lost 15% or more of their usual weight prior to surgery
being undertaken. 

April 8, 2016 
a recent systematic review 46 has shown that patients 724
acute severe pancreatitis should commence enteral 
support early (within 5 days 

April 8, 2016 

Other techniques for providing nutritional support ha 725

included collecting the intestinal output from the prox
end of the fistula and re-infusing it into the distal part
the small intestine or by giving enteral nutrition via th
fistula. 

April 8, 2016 

In patients with burns of greater than 20% of their bod 726

surface area, nutritional support is required, orally o
nasoenteric feeding. 

April 8, 2016 

However, up to 20–25 g of nitrogen per day may be  726

required initially, with a non-protein calorie to nitrog
ratio of 100–200. Energy is provided as carbohydrate a
lipids, with the calorie requirement being 35–50% a 

April 8, 2016 
as lipid  726

April 8, 2016 

• L -arginine – stimulates aspects of immune function,  727

improves nitrogen retention after surgery, enhances 
wound healing; 58, 59 • L -glutamine – stimulates immu
function, reduces nitrogen loss postoperatively, may b
important in maintaining gut-barrier function; 60 • 
branched-chain amino acids – may control protein 
synthesis in muscle and stimulate whole-body protein 
synthesis, especially in severely traumatised patients;
essential fatty acids – stimulation or inhibition of imm
function, anti-inflammatory effects; 62, 63 • 
polyribonucleotides and ribonucleic acid – stimulate 
immune function; • vitamins, trace elements – stimula
of immune function, antioxidant effects, wound healin

April 8, 2016 

• selenium – stimulation of immune function, preventio 727

tissue damage, anti-inflammatory effects; 64 • omega-3
fatty acids – immunomodulatory effect and avoidance
hepatic dysfunction. 65 The clinical benefits of 
supplementation with key nutrients have, however, be
difficult to demonstrate. 

April 8, 2016 

The conclusion drawn from the consensus based on th 729

available evidence was that an immune-modulating 
nutrition (enriched with arginine, nucleotides and om
fatty acids) was beneficial and recommended for the 
 following: • patients with mild sepsis (APACHE II score
15); • patients undergoing elective major intra-abdomi
surgery for cancer to receive 5–7 days of 
immune-enhancing nutrition (arginine, omega-3 fatty
and polyribonucleotides); • patients with acute respira
distress syndrome (ARDS) should receive enteral nutri
supplemented with omega-3 fatty acids and antioxidan

April 8, 2016 

Chapter 18: Abdominal sepsis and abdominal compartment 

syndrome 
 

752
  Ileus may be difficult to distinguish from adhesive 
obstruction, and contrast studies may clarify the situa
(see also Chapter 5 ). 

March 25, 2016 

Clear indications for life-saving surgery include  753

generalised peritonitis, multiple collections and presen
dead tissue. 

March 25, 2016 

Chapter 19: Complications of bariatric surgery presentingto 

the general surgeon 
 

April 23, 2016  790