Itis Update What’s New in General Surgery 2019

1. Itis UpdateWhat’s New in General Surgery 2019 Fernie, Oct 2019

2. Topics • Diverticulitis • Cholecystitis • Perianalitis (perianal abscess and fistula) • Appendicitis

3. Disclosures • None

4. Diverticulitis • 4-15% of pts with diverticulosis • 3rd most common GI illness requiring hospitalization • Most common reason for elective colon resection

5. Diverticulitis • Risk Factors • Diet • Obesity • Inactivity • Smoking • Low Risk lifestyle associated with 50% lower risk of diverticulitis

6. Diverticulitis • Diet • Fiber • High fiber diet likely reduces risk of progression from asymptomatic to symptomatic disease • High fiber diet may not reduce symptoms in pts who already have symptomatic disease • Seeds and Nuts • Health Professionals Follow-up Study (JAMA 2008:300(8):907) • 47,000 men, age 40-75, from 1986-2004 • Inverse association between nut/popcorn consumption and diverticulitis

7. Diverticulitis • Antibiotics • Gold standard despite lack of evidence • Swedish RCT 2012 and Dutch Diabolo Trial 2017 • CT confirmed uncomplicated diverticulitis randomized to antibiotics or placebo • No significant difference in • Abscess/perforation • Chronicity and recurrence • Surgery • readmission

8. Diverticulitis • What I do • Inpatient management: Abx • Outpatient management • Discuss controversy surrounding Abx • Give pt script for Abx to start only if symptoms worsen • Colonoscopy (higher incidence of colon cancer compared with age matched controls)

9. Acute Cholecystitis • Occurs in 10% of pts with symptomatic gallstones over 10yrs • Pathogenesis • Cystic duct obstruction not the only cause • Likely inflammatory mediator contribution • Only 50% of aspirates are culture positive

10. Acute Cholecystitis • Clinical: pain>6 hrs, Murphy’s sign, • Labs:↑ WBC, CRP • Ultrasound: • gallstones, wall edema, pericholecystic fluid • Operator dependant (88% sensitivity, 80% specificity)

11. Acute Cholecystitis • Treatment • Pain Control: • NSAIDs better than opioids • All opioids increase sphincter of Oddi pressure • Abx: • Can be omitted in mild cases

12. Acute Cholecystitis • Surgery • Early surgery • Shorter hospital stay (3 days), fewer work days missed • No increase in complications • ASA I and II pts (?III) • Timing • Ideally within 72 hrs of onset of symptoms • Still ok after 72 hrs of symptoms but higher risk of conversion to open

13. Perianal Abscess • Demographics • 16 per 100,000 per year • Mean age of 40 (range 20-60) • Males 2x more likely than females • Etiology • Obstructed anal crypt gland • 30-50% associated with fistula or go on to develop fistula after I&D

14. Perianal Abscess: Location

15. Perianal Abscess: Treatment • I&D • As close to anal verge as possible • Aspirate with 16 gauge needle before incision • Packing: • 2 RCTs showed no difference in recurrence/fistula formation) • Abx • Reduces fistula rate from 24% to 16% (2 RCTs) No difference in recurrence. • 5 days of Cipro/Flagyl or Clavulin

16. Appendicitis • Demographics • 8.6% lifetime risk for males • 6.7% lifetime risk for females • Mechanism • Luminal obstruction • Lymphoid hyperplasia in younger pts • Fibrosis, fecaliths, tumours more common in older pts • Perforation • 20% perforate within 24 hrs of symptoms

17. Appendicitis

18. Appendicitis • Treatment • Uncomplicated: surgery • Abscess: drainage and abx • Phlegmon: abx • Interval Appendectomy • Colonoscopy before surgery (rule out tumour or IBD) • 20% incidence of neoplasm in this population

19. Appendicitis • Non-operative management • 6 RCTs • 10% failure rate initially, 90% respond • Lower/similar pain scores, quicker return to work • 30% recur within 1st year (avg 5 months) • No long-term follow-up • Risk of missed neoplasm

20. Appendicitis • Timing of Surgery • 12-24 hr delay in surgery not associated with higher risk of perforation • >48 hr delay associated with increase risk

21. Appendicitis - Children • Anatomy • Appendix is funnel-shaped in first year of life (lower risk of obstruction) • Lymphoid follicles reach maximal size during adolescence (peak incidence of appendicitis) • Omentum: underdeveloped in young children so higher risk of diffuse peritonitis

22. Appendicitis - Children • 0-5 years old • <5% of appendicitis • >50% have advanced disease • Variable presentation • localized RLQ pain occurs in <50% of patients • Best managed in pediatric hospital

23. Appendicitis - Children • School-age (5-12 yrs.) • Abdominal pain and emesis are common • May not have typical migration of pain • Adolescent • Similar presentation to adults

24. Appendicitis - Children • Diagnosis • No need to withhold pain medication • Abx may lower confidence regarding exam • Rebound testing unnecessary (high false positive results)

25. Appendicitis - Children • Scoring Systems • Pediatric Appendicitis Score (PAS) • Low-Risk Appendicitis Score • Alvarado score • Pediatric Appendicitis Risk Calculator (pARC) • Reliance on clinical factors (for which there is significant variation) • Low score helpful in ruling out appendicitis • Intermediate score helpful in assessing need for imaging • Not been shown to improve outcomes

26. Summary • Diverticulitis • Lifestyle (obesity, exercise, smoking, diet) • Consider omitting antibiotics • colonoscopy • Cholecystitis • Most patients should have early operative management

27. Summary • Perianal Abscess • Superficial abscess can be drained at bedside • No packing • 5 days of Abx • Appendicitis • Surgery still standard of care; ideally within 24 hrs of presentation • Abx can be an option for select patients • Children<5 should be sent to Children’s Hospital