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Pancreatico-biliary emergencies

Introduction As a general surgeon it is important to be competent in the management of the common emergency presentations associated with calculous biliary disease as these patients comprise a significant component of the acute workload. In addition, recognising the patient who will benefit from specialised hepato-biliary-pancreatic (HPB) surgical care and transferring the patient after appropriate initial management is a key component of this process. The aim…

Acute non-variceal upper gastrointestinal bleeding

Introduction A major audit of upper gastrointestinal (UGI) bleeding in the UK carried out over 20 years ago reported an incidence of 103 patients per 100 000 adults per year. There is a twofold increase in likelihood of requiring hospitalisation among those residents from more deprived socioeconomic areas. Overall mortality from an episode of UGI bleeding was 14% in the UK study and a marked increase…

Perforations of the upper gastrointestinal tract

Overview Perforation of the upper gastrointestinal (UGI) tract is a relatively common surgical emergency. Most cases are due to peptic ulceration, but other causes, although uncommon, may be challenging to diagnose and manage (e.g. oesophageal perforation). Perforation secondary to endoscopic procedures is also increasingly seen in recent times due to technological advancement and more widespread integration of these techniques into mainstream practice. Perforation can be free…

Early assessment of the acute abdomen

The acute abdomen may be defined as ‘abdominal pain of non-traumatic origin with a maximum duration of 5 days’. There is a long list of causes ranging from the entirely benign, requiring no particular management other than reassurance, to the rapidly fatal where swift diagnosis and appropriate surgical treatment is life-saving. Abdominal symptoms may be manifested by conditions that are entirely extra-abdominal, and intra-abdominal conditions may…

Principles of organ donation and transplantation

Introduction Organ transplantation has revolutionised the treatment of end-stage organ failure and is arguably one of the greatest medical advances of the last century. Practice in organ donation and transplantation continues to evolve as a result of remarkable innovations in surgical technique, immunosuppression and organ perfusion and preservation. This has led to excellent post-transplantation survival rates ( Table 10.1 ) that have improved year on year.…

Human factors and patient safety in surgery

The scale of medical error As surgeons, we are arguably practitioners of one of the most entitled, rewarded and rewarding occupations in the world. We are empowered to the completely legal action of putting a knife to work in a human body. Unfortunately … our patients are frequently caught in the ‘friendly fire’ of surgical care – health care providers causing unintentional harm when their only…

Neck surgery for the general surgeon

Introduction A neck mass is a common clinical presentation. Surgeons should be familiar with common causes, red flag symptoms and characteristic examination findings. A wide range of conditions can present with a neck mass and an exhaustive explanation of investigation and management of all such conditions is beyond the scope of this text. Instead, the aim of this chapter is to review the surgical investigation of…

Abdominal hernias

Introduction A hernia is defined as an abnormal protrusion of a cavity’s contents through a weakness in the wall of the cavity, taking with it all the linings of the cavity, although these may be markedly attenuated. With any definition, there will be exceptions to the rule—is a lipoma of the cord a hernia? A hernia can be described as reducible, incarcerated or strangulated. A reducible…

Surgical nutrition

INTRODUCTION Perioperative nutrition is a critical aspect of surgical care. Surgical teams should screen elective patients for existing malnutrition or risk of developing malnutrition postoperatively. Optimising macronutrient anabolism and correcting micronutrient deficiencies are important goals for elective and emergency surgical patients. In this chapter, we will describe: Preoperative screening for malnourished patients or patients at risk of malnutrition How to optimise nutritional support during hospital admission…

Perioperative and intensive care management of the surgical patient

Introduction The incidence of death directly attributable to anaesthesia has decreased significantly over the last 60 years. In the 1950s, several studies demonstrated that the postoperative mortality solely associated with anaesthesia was approximately 1 in 2500, 1–3 but by 1987, in the UK Confidential Enquiry into Perioperative Death (CEPOD), this had decreased to an estimate of 1:185000. Whilst anaesthetic practice has continued to evolve over the…

Patient assessmentand surgical risk

Introduction Few patients do not survive an operation, but many will incur significant morbidity around the time of surgery. These adverse outcomes are considered together as perioperative risk . Patient assessment is the process of gathering information to determine the particular risk for a given individual undergoing an operation, which carries distinct procedural risks . Care of the patient is also dependent on the system in…

Organisation and quality improvement in emergency general surgery

Introduction Emergency general surgery (EGS) is a core component of general surgical practice. The challenges of caring for such patients include time-sensitive conditions, additional morbidity and mortality commensurate with this particular patient population, frequent diagnostic uncertainty, unpredictability, and the irregular consumption of hospital resources. EGS patients are increasingly managed by a multidisciplinary emergency surgical team requiring appropriate resources. Given the importance of this patient population and…

Perioperative care and enhanced recovery

Introduction Updated guidelines focus on comprehensive protocols for each step of the perioperative ‘journey’ in various abdominal procedures. Several reviews confirm an association between the use of an enhanced recovery protocol (ERP) and improved outcomes in abdominal surgery. While some results indicate gains from adhering to specific protocols (e.g. Enhanced Recovery After Surgery [ERAS] guidelines) and aiming for an optimal compliance, others suggest that it is…

Evaluation of surgical evidence

Introduction to surgical evidence Evidence-based medicine is a relatively recent innovation. It has only been over the past two centuries that scientific methods have become the accepted means of establishing the most effective treatments and tests. Nowhere in medicine has this transformation been more vibrant than in surgical disciplines, where numerous innovations have paved the way for the modern treatments of today. The generation of high-quality…

Antibiotic Overview

Penicillins The penicillin family, including primarily penicillin V and amoxicillin, has long been the mainstay in the antibiotic treatment of odontogenic infections. Randomized controlled clinical trials comparing a penicillin with other newer antibiotics have found no statistically significant differences in clinical cure rates. (Note that the correct generic name of phenoxymethyl penicillin potassium is penicillin V. It is not penicillin VK.) The antibacterial spectrum of penicillins…

Drug Enforcement Administration Schedule of Drugs and Examples

Schedule I: Controlled Substances Substances in this schedule have a high potential for abuse and have no currently accepted medical use in treatment in the United States. Accepted safety for use of the drug or other substance under medical supervision is lacking. Some examples of substances listed in schedule I are heroin, lysergic acid diethylamide, marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“ecstasy”). You’re Reading a Preview…

Management of Temporomandibular Disorders

Patients frequently consult a dentist because of pain or dysfunction in the temporomandibular region. The most common causes of temporomandibular disorders (TMDs) are muscular disorders, which are commonly referred to as myofascial pain and dysfunction . These muscular disorders are generally managed with a variety of reversible nonsurgical treatment methods. Other causes of temporomandibular pain or dysfunction originate primarily within the temporomandibular joint (TMJ). These causes…