Emergency War Surgery 5th Edition Pdf

[Erminia Scharnberg]

Inthis newly revised edition of Surgical Critical Care and Emergency Surgery, a distinguished team of emergency surgeons deliver a one-of-a-kind question-and-answer book on the growing specialty of surgical critical care and acute surgery, ideal for those caring for the critically ill and injured surgical patient.

This book reviews surgical critical care, emergency surgery, burns and trauma, and includes full color, high-quality surgical photographs to aid understanding. Readers will also benefit from access to a website that offers additional topics and tests, as well as an archive of all test questions and answers from previous editions.

Perfect for the acute care surgeon, surgical intensivist and those in training, Surgical Critical Care and Emergency Surgery will also earn a place in the libraries of those working in or with an interest in critical care.

Carlos J. Rodriguez, DO, is Associate Professor of Surgery at the TCU & UNTHSC School of Medicine, and is Director of Emergency General Surgery and Surgical Research at John Peter Smith Hospital in Fort Worth, Texas, USA.

Emergency abdominal surgery is a battlefield for the surgeon - providing character-building experiences, and opportunities for triumph and disaster. In the second edition of this 'simple' book, emergency abdominal surgery is discussed in an informal and no nonsense fashion - as practiced in the 'trenches' of the ER and the OR. The preferred approach for a given situation is discussed in context; it has to fulfill certain prerequisites: save life, decrease morbidity, be cost effective and be performed correctly.

"What makes this book very readable are the 'pregnant' citations, aphorisms and 'smart savings', which are often heard at the bedside and operation rooms but almost never reach the pages of a book". (P. Klein, Chirurg, 2000)

In low- and middle-income countries (LMICs), at least 60 percent of the surgical operations performed are for emergencies. Contrary to widespread belief, it has been shown that the provision of treatment, which is often lifesaving for these patients, can be inexpensive. The staff and equipment required at first-level facilities for all categories of surgical emergency, including trauma (chapter 3) and obstetrics (chapter 5), are essentially the same. Accordingly, the treatment of general surgical emergencies requires little additional cost and should be part of the services offered at first-level facilities. This chapter

The chapter is written for two primary audiences, health planners and surgeons in LMICs, to show each group how much can be provided and accomplished in very simple facilities, given adequate training and support.

The annual death rate from acute abdominal conditions in the United States in 1935 was 38 per 100,000 population, or 3 percent of all deaths in that year. General practitioners performed most surgeries; formal surgical training did not begin until 1937, when the American Board of Surgery was formed. By 1990, the death rate for acute abdominal conditions had fallen to 4 per 100,000 (CDC 1990; U.S. Department of Commerce 1935). The 90 percent reduction in mortality was due to increased access to operations, made possible by new facilities and more skilled staff in combination with the availability of antibiotics for infection, safer anesthesia, and blood for transfusions. The operations were not complicated. They are available today in LMICs, as are low-cost antibiotics, competent anesthesia, and blood; however, as in the United States in 1935, access to these operations is very limited. In the United States and in many other high-income countries (HICs) in 1935, all general surgical emergencies were responsible for 3 percent to 5 percent of deaths. This estimate may be as good as any other estimate of the burden of disease from these causes in LMICs, where there is little or no available surgical treatment.

Despite these handicaps, much can be done and is being done in very simple facilities with minimal support. This progress is possible because many of the important surgical problems can be resolved with uncomplicated, well-standardized procedures. A fully equipped, modern hospital is not essential to remove an appendix, close a perforated ulcer, drain an abscess, or even resolve most causes of intestinal obstruction.

Definitions of the levels of hospital care were delineated in Disease Control Priorities in Developing Countries, second edition (Jamison and others 2006); as adapted, these levels are shown in table 4.1.

The list of surgically treatable emergencies commonly seen in LMIC hospitals is not long, but it includes problems that fall within the purview of several different specialties (Abdullah and others 2011; Curci 2012; Lavy and others 2007; McCord and Chowdhury 2003). Fortunately, 90 percent of the operations can be mastered by a person without full specialty qualification, so it is not necessary to have fully qualified surgeons, obstetricians, and traumatologists in every first-level hospital. With even a very limited ability to refer patients and intermittent supervision by qualified specialists, a very productive network for surgical care can be established (box 4.1).

Incarcerated and Strangulated Inguinal Hernias. Incarcerated hernia, a cause of intestinal obstruction, is very common in Sub-Saharan Africa (Shillcutt, Clarke, and Kingsnorth 2010). About 4 in 1,000 hernias per year will become incarcerated, with a segment of intestine trapped inside the hernia sac; if untreated, these hernias can become gangrenous within several days. In 85 percent of the cases in a large review of incarcerated hernias, the bowel within the hernia sac was viable: it could be returned to the abdomen and the hernia repaired (van den Heuvel and others 2011). If the intestine is not viable, it must be removed and the divided bowel repaired. This is not a complicated procedure for an adequately trained surgeon. If bowel resection is not indicated, 99 percent of patients should survive; if bowel resection is required, 80 percent or more should survive, depending on the experience of the surgeon (Nilsson and others 2007).

Intestinal Obstructions Caused by Adhesions, Volvulus, Worm Infection, or Intussusception. The most common cause of intestinal obstruction in LMICs is incarcerated hernia, but if no inguinal hernia is visible, then several other conditions should be considered. If treated early, all cases can be successfully managed with conservative measures or very simple abdominal operations; these conditions can become difficult problems if allowed to progress to a later stage.

Twisting (volvulus) of the intestine around an adhesion or scar from a previous operation or infection is becoming increasingly common. In many LMICs, it is the second most common cause of blocked intestine. Seen early, it will often resolve with tube decompression of the stomach and intravenous fluids. If an operation is necessary, simple division of the adhesion and untwisting of the intestine will resolve the problem at an early stage; at later stages, the twist can interfere with the blood supply, the intestine will die, and only removal of the dead intestine will prevent death of the patient (Adesunkanmi and Agbakwuru 1996; Madziga and Nuhu 2008).

Less commonly, the lower end of the large intestine can spontaneously twist on itself (sigmoid volvulus), producing an obstructed bowel. In late cases, the twisted intestine can cut off its own blood supply, leading to gangrene and requiring resection and repair. The probability of gangrene cannot be predicted, and early surgery must be the rule. In complicated cases in which no qualified surgeon is available, simple procedures like colostomy (transferring the dead intestine outside of the abdomen by creating a usually temporary artificial anus, without reconstruction of the intestine) will resolve the acute problem, so that patients can be referred for a second operation that restores normal function. An uncomplicated sigmoid volvulus can be untwisted without opening the abdomen, by gently inserting a well-lubricated large rubber tube through an instrument (a proctoscope) inserted into the rectum. Overall survival should exceed 80 percent (Mnguni and others 2012; Nuhu and Jah 2010).

Pelvic Infections with Abscesses. Sexually acquired infections of the fallopian tubes and adjacent organs are common and can usually be successfully treated with antibiotics and without surgery. If an abscess forms and does not respond to medication, simple drainage is usually adequate. In early cases, a trial of antibiotic treatment is the best course; exploratory laparotomy may be necessary for severe, nonresponsive cases. Overall survival should exceed 95 percent. When antibiotic treatment is late or inadequate, death is rare, but infertility and recurrent pelvic pain can ensue, as well as increased incidence of subsequent ectopic pregnancy (Soper 2010).

Peptic Ulcer Complications. Three major advances have reduced the incidence of and mortality rates for peptic ulcers: the discovery that Helicobacter, which can be treated with antibiotics, is a primary cause of ulcers; the development of powerful acid-reducing drugs; and the successful endoscopic control of bleeding from ulcers.

Helicobacter infection is widespread and difficult to prevent, and ulcerogenic medicines like nonsteroidal anti-inflammatory drugs (NSAIDs) are widely available and overused, with and without prescription.

Perforation of a peptic ulcer allows a flood of gastric juice to flow into the peritoneal cavity, resulting in diffuse peritonitis that is almost always fatal if untreated. Surgery within 24 hours, with closure of the perforation and washout of the abdominal cavity, is simple and is almost always successful; if followed by appropriate anti-ulcer medical treatment, it leads to a permanent cure for 95 percent of patients. Delayed operations carry higher risks, with a possibility of subsequent abscesses. Overall, 80 percent to 90 percent of patients are likely to survive (Chalya and others 2011; Ugochukwu and others 2013).

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