Handbook of reoperative general surgery

Brand new: Lowest price The lowest-priced brand-new, unused, unopened, undamaged item in its original packaging where packaging is applicable. Emphasizing the complications of each disease as well as the actual reoperative procedures, this indispensable text is extensively referenced with pertinent current and classical literature.

Buy It Now. Add to cart. Sold by simplybestpricesto20dayshipping Emphasizing the complications of each disease as well as reoperative procedures, this indispensable text is extensively referenced with pertinent current and classical literature.

Organized primarily by body system, the Handbook of Reoperative General Surgery covers the spectrum of conditions faced by general surgeons today, including: Diagnoses and operative strategy critical for breast cancer Coverage of reoperative of the liver, biliary tract, and pancreas Approaches to dealing with reoperations on all areas of gastrointestinal tract Strategies for care of the patient with recurrent hernias and pain An overview of reoperative bariatric surgery Combining the expertise and advice of over thirty practicing surgeons from some of the finest medical centers in the United States, the Handbook of Reoperative General Surgery offers a practical, instructive manual for residents, attending, and surgery practitioners.

Aucar JA, Hirshberg A. Damage control for vascular injuries. Firoozmand E,Velmahos GC. Extending damage-control principles to the neck.

Endovascular techniques in the damage control setting. Radiographics ; Adverse effects of hypothermia in postoperative patients. Is hypothermia in the victim of major trauma protective or harmful? A randomized, prospective study. Damage control surgery. Scand J Surg ; Base deficit as a guide to volume resuscitation.

Serum lactate and base deficit as predictors of mortality and morbidity. Maintaining survivors' values of left ventricular power output during shock resuscitation: a prospective pilot study.

Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock. Lactate clearance and survival following injury. Chapter 2: Reoperative Surgery in Trauma 29 Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit.

Predictive model for survival at the conclusion of a damage control laparotomy. Effect of hypothermia on the coagulation cascade. Crit Care Med ; Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels. Circ Shock ; The staged celiotomy for trauma. Issues in unpacking and reconstruction. HirshbergA,Walden R. Damage control for abdonlinal trauma. Krishna G, Sleigh p, Rahman H. Physiological predictors of death in exsanguinating trauma patients undergoing conventional trauma surgery.

Aust N Z J Surg ; Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. Staged physiologic restoration and damage control surgery World J Surg ; End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation.

A prognostic indicator for survival. JAMA ; Operative management and outcomes in AASTs grades IV andV complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps. A prospective study on the safety and efficacy of angiographc embolization for pelvic and visceral injuries. Skin only or silo closure in the critically patient with an open a b d 0 m e n. Myers JA. Latenser BA. Vacuum-assisted wound closure provides early fascia1 reapproximation in trauma patients with open abdomens.

Reinforced silicone elastomer sheeting, an improved method of temporary abdominal closure in damage control 1aparotomy. AmJ Surg ; Damage control in trauma surgery Curr Opin Crit Care ; Management of the complex abdominal wall wound. Adv Surg ; Challenging abdominal wall defects. Moldovan S. Granch TS, Hirshherg A. Bilateral temporary aortoiliac shunts for vascular damage control. Teniporary vascular continuity during damage control: intralunliiial shunting for proximal superior mesenteric artery injury.

Early intramedullar nailing of femoral shaft fractures: a cause of fat enibolism syndrome. Am J Surg lY83;O Burns HJ, et al. Response of serum interleulun-6 in patients undergoing elective surgery of varying severity. Clin Sci Lond ; Biochemical changes after trauma and skeletal surgei-y of the lower extremity: quantification of the operative burden Crit Care Med ; Evolving concepts in the pathogenesis of postinjury multiple organ failure.

Surg CIin North Am J Bone Joint Surg Am ; Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: determination of the clinical relevance of biochemical markers. Chrurg ; Tinling of femur fracture fixation: effect on outcome in patient9 with thoracic and head injuries.

J Trauma Murr, MD, FACS Prkcis mportant principles of reoperative gastric surgery transcend the cyclical nature of surgical diseases of the stomach such as peptic ulcer.

Lessons learned from peptic ulcer surgery and its associated complications are employed in reoperative gastric procedures. Much has been written about gastric reoperative procedures, especially for complications and sequelae of the treatment of peptic ulcer disease. However, most of that information has become nearly irrelevant and relegated to historical significance because of the paucity of peptic ulcer operations that are undertaken in this era.

However, some important principles of reoperative gastric surgery transcend the cyclical nature of diseases and can be applied to the current approach to reoperative gastric surgery. Recurrent Ulcer Disease and Its Complications The management of peptic ulcer disease has paralleled the evolution and understanding of anatomy, physiology, and pathophysiology of acid secretion, and more recently, of Helicobacter pylori infection. Fortunately, the incidence of peptic ulcer disease has been steadily decreasing over the last 50 years.

Currently, the necessity for primary, elective operations for peptic ulcer disease has become rare. Nonetheless, the incidence of operations for specific complications of peptic ulcer disease and of previous peptic ulcer operations has remained unchanged. Duodenal stump blowout, gastric perforations, and anastomotic leaks usually require urgent reoperation, whereas rebleeding and gastroparesis can usually be managed nonoperatively. Early gastroparesis or delayed gastric emptying , particularly following operations for indications that included gastric outlet obstruction, should be managed nonoperatively and with the utmost patience, as it nearly always resolves with prolonged gastric decompression, with nasogastric tube, or, preferably, through a surgically placed gastrostomy tube.

Recurrent hemorrhage from the ulcer bed may be evaluated and controlled endoscopically or sometimes angiographically. Attention to technical considerations in placing hemostatic sutures may minimize bleeding from collateral vessels to the gastroduodenal artery Figure Gastric pedoration and anastomotic leaks are best treated with closure of the defect and decompression of the stomach either with a nasogastric tube or a surgically placed gastrostomy tube.

The use of drains is controversial in uncomplicated leaks, but is required for intra-abdominal abscesses. Diroderzal stirrng bloiuoirt is a dreaded complication of foregut operations and requires urgent celiotomy to prevent its usually severe sequelae. A duodenal stump blowout can result either from ischemia secondary to overly aggressive dissection of the duodenum during the initial operation, or as a result of complete obstruction of the aborad enteroenterostomy and ultimately a closed-loop obstruction that decompresses through the duodenal stump.

Primary closure of the dehisced duodenal stump may not be feasible because of fi-iable or devitalized tissue. Alternatives include closing the stump around a duodenostomy tube with a purse string, or using tissue in approximation such as an omental patch or a jejunal serosal patch, otherwise known as aThal patch. Routine use of drains is recommended to prevent or minimize the consequences of further and common, problematic leakage of duodenal contents. A gastrostomy and a feeding jejunostomy tube should be strongly considered.

Inspection of the aborad enteroenterostomy should also be routine to ensure and document adequate patency. The best advice when considering the approach to a d f l c i d t dirodenurn stump is not to create one.

Meticulous attention to technique and familiarity with this anatomically complex area cannot be overstated. Nevertheless, longstanding structuring ulcer disease and severe inflammatory changes can impose limitations to safe handling of the duodenum, especially in posterior penetrating ulcers that have eroded into the pancreas. In these instances, it is recommended that the duodenum be divided as close as possible to the pylorus, leaving sufficient anterior duodenal wall that can cover the ulcer bed, which may communicate with the duct of Santorini and can withstand sutures to the bed of the ulcer and pancreas, to close the duodenotomy.

In patients with severe inflammatory changes that preclude safe dissection of the duodenum, transecting the antrum in the context of an antrectomy proximal to the pylorus and undertaking a mucosectomy of the antrum Bancroft-Plenck procedure will avoid creating a difficult duodenal stump while removing all of the antral mucosa, thereby eliminating acid secretion and preserving adequate tissue to close the duodenum Figure Alternatively, a jejunal serosal patch Thal patch can be undertaken by approximating the open edges of a duodenotomy to the serosal outer layer of the jejunum, using full thickness and water-tight sutures.

Recurrent Peptic Ulcer Disease-Initial evaluation of recurrent peptic ulcer disease begins with a thorough history and physical examination, specifically including a search for ulcerogenic substances and a family history of multiple endocrine neoplasia MEN. Secondly, the details of the initial operations must be thoroughly reviewed, including indications, operative notes, pathology reports, prior contrast studies, and discussion with the operating surgeon, if possible.

Following vagotomy and antrectomy, the evaluation algorithm and differential diagnosis are succinct. First and foremost, the most likely explanation is an intact vagus nerve incomplete vugotomy , which can be attributed to aberrant nerve location or incomplete transection at the initial operation. Reoperation to completely divide the abdominal vagi may prove technically difficult and unrewarding; the medwedi. B Intraoperative picture after an antral niucosectomy has been completed n-ith e1ectrocauter -to the level of the pylorus.

Chapter 3: Reopemtive Gastric Surgery 37 esophagus must be circumferentially skeletonized to ensure division of all vagal branches. Alternatively, a transthoracic vagotomy may be undertaken.

A chemical vagotomy proton pump inhibitor may prove satisfactory and appealing to patients, and therefore many consider it as first-line therapy for uncomplicated recurrent peptic ulcers.

Retained gasfric antriirii is a rare but important consideration during the evaluation of recurrent peptic ulcer disease. When the excluded or retained antrum is continuously exposed to the alkaline duodenal and pancreatic fluids, gastrin inappropriately induces acid hypersecretion.

The diagnosis can be confirmed with a sodium 99m-technetium pertechnetate scan that localizes retained antral niucosa within the closed end of the afferent p. History of MEN, multiple or jejunal ulcerations often in atypical locations, and rugal hypertrophy are diagnostic clues.

Recommendations for serum gastrin as a screening tool have been summarized in a thought-provoking review by Ellison et al. Patients with proximal gastric vagotomy and recurrent ulcers may require an antrectomy with either a total abdominal or a transthoracic vagotomy.

Postvagotorny and Postgastrectorny Castroparesis-The preponderance of postgastrectomy syndromes and the unpleasant side effects have driven a shift toward proximal gastric vagotomy as the preferred denervation procedure, with its lower incidence of these complications.

Secondly, a large body of evidence from Roux-en-Y gastric bypass for obesity suggests that the Roux stasis syndrome is not clinically apparent or s i m c a n t.

I7 Completion gastrectomy is recommended for patients who have clear and objective evidence of severe postvagotomy, postgastrectomy gastric stasis and have failed exhaustive attempts at nonoperative management. Alkaline Reflux Gastritis-Otherwise known as bile acid reflux, is the most common postgastrectomy syndrome requiring reoperation.

A thorough evaluation, including endoscopy and radiography, is essential to correlate symptoms with the appropriate findings. Conversion of a loop gastrojejunostomy Billroth 11 to Roux-en-Y anatomy will alleviate the symptoms of bile reflux. Because of concerns for dysmotility and delayed emptying, the technically cumbersome uncut Roux limb that interrupts luminal flow but maintains neuromuscular transmission, and hence eliminates the Roux stasis syndrome, can be constructed.

Early dumping symptoms occur within minutes after a meal both vasomotor and gastrointestinal symptoms , whereas late dumping symptoms occur within hours after a meal, and are typically limited to vasomotor symptoms that are relieved by ingesting carbohydrates.

With the development of octreotide, although expensive, few patients progress to operative management. Relief with operative treatment such as an antiperistaltic interposition is anecdotal. Postvagotorny Diarrhea-Nonoperative and dietary manipulations have become the mainstay of treatment for postvagotomy diarrhea.

In addition, fiber supplementation and cholestyramine are useful adjuncts. As with dumping syndrome, relief with operative treatment is anecdotal. Afferent and Efferent Loop Syndromes-The afferent loop syndrome projectile emesis of bile and the efferent loop syndrome emesis of gastric contents are a consequence of anastomotic strictures of the gastrojejunostomy and respond to operative intervention.

Similar complaints or symptoms that are not attributable to a correctable anatomic abnormality, such as a mechanical obstruction, usually do not respond to any of a multitude of interventions designed to relocate the anastomosis, since they typically have gastric stasis or paresis as the underlying etiology.

Postgastrectorny Cancer-Postgastrectomy cancer is relatively uncommon, yet it is 3- to 5-fold more common than that observed in age- and sex-matched controls. Persistent, nonhealing ulcers should be excised. The location, number, and distribution of ulcers as well as retained food gastric bezoar or a stenotic anastomosis can be visuahzed. Endoscopic therapy for hemorrhage and stenotic anastomosis can be applied.

Biopsy of all gastric ulcers is mandatory. However, radiography is notoriously insensitive for detecting small or multiple ulcers, emphasizing the prior suggestion to routinely include endoscopy during the evaluation of recurrent ulcer disease. Meticulous technique in adhesiolysis in the upper abdomen should be undertaken to delineate the anatomic reconstruction as usual landmarks are less apparent.

The liver edge is usually one of the more consistent and early landmarks encountered. The liver edge left lobe can be followed to the gastroesophageal junction and anterior surface of the stomach.

Caution should be exercised not to avulse the capsule of the liver or spleen, which can result in unnecessary and troublesome bleeding. However, it is better to dissect into the liver parenchyma to avoid multiple gastrotomies in the thin wall of the adherent hndus of the stomach. Information about prior handling of the left gastric artery and short gastric vessels is important in planning resection of the gastric remnant.

Liberal use of stapling devices will facilitate and expedite resection of the stomach and division of the duodenum. The routine placement of drains during uncomplicated procedures is not warranted; however, placement of a jejunostomy feeding tube facilitates delivery of postoperative nutrition and is strongly recommended. Although the average medwedi. These patients generally experience symptoms consistent with delayed esophageal emptying: dysphagia and recurrence of GERD-like symptoms Figure Figure A contrast radiograph demonstrating the gastroesophageal junction below the diaphragm.

The gastroesophagealjunction and wrap are below the diaphragm; however, the posterior fundus migrated into the chest s d a r to a paraesophageal hernia. Given that the gastroesophageal junction in these patients is often in the normal position, these failures are sometimes misclassified as paraesophageal hernias Figure Because the herniated fundus leads to compression of the distal esophagus, dysphagia is a dominant compliant of these patients.

Less commonly patients complain of reflu-like symptoms. CUS, q p e 3 is used to describe a malformation of the fundic wrap. The malformation involves incorrect utilization of the midbody of the stomach in constructing the fundoplication instead of the true anterior fundus. This leads to redundant fundus and may promote delayed esophageal emptymg.

In general, causes of failure of primary antireflux operations are different for open and laparoscopic procedures. Failure of laparoscopic fundoplication is frequently associated with unwinding of the wrap, while open fundoplications frequently fail through disruption of the hiatal reconstruction. In addition, patient selection is quite important and worth noting here.

Obesity should be considered a relative contraindication for primary and reoperative antireflux procedures, given its frequent association with failure. Endoscopy is more accurate than radiography in determining the anatomic location of the wrap and distinguishing whether a slipped Nissen or a tight fundoplication is present. These studies are particularly important in patients who do not have an apparent anatomic cause for their symptoms.

Results of the most recent p H studies should be compared to the prefundoplication studies, because some patients will have persistent symptoms of reflux despite an anatomically intact Chapter 3: Reoperative Gastric Surgery 43 fundoplication, and this will be reflected through a remarkable improvement in their p H studies. Similarly, esophageal manometry can be used to locate the lower esophageal sphincter LES and confirm the presence of an excessively tight wrap, changes consistent with achalasia, or generalized, poor esophageal motility.

Manometrically, an LES constructed via fundoplication should not relax, as would be expected with a normally functioning sphincter mechanism. Patients with recurrent or new symptoms following an antireflux operation are initially treated nonoperatively; however, symptoms of dysphagia will ultimately require revision.

Patients who present with symptoms other than reflux or dysphagia rarely require or benefit from reoperation. Detailed information from the previous abdominal operations and the previous fundoplication is essential to the conduct of the revisional operation and should be sought as part of the initial evaluation.

The left crus is more easily and safely approached along the greater curvature of the stomach, taking down the short gastric vessels if not already divided during the primary operation. Once the hiatus and the esophagus are identified, the distal esophagus is mobilized up into the mediastinum in order to reestablish cm of intra-abdominal esophagus whde reducing any hiatal hernia. Once the anatomy medwedi. Revision is tailored to correct the anatomic cause of the failed fundoplication.

If the wrap was completely disrupted or incorrectly constructed, a new fundoplication is created over a bougie dilator. If the wrap was partially undone, then the original wrap is repaired over a bougie dilator. For posterior wraps, the posterior fundus of the fundoplication is sewn to the diaphragmatic crura to secure the wrap in the abdomen and to minimize tension. If a slipped Nissen is present, the wrap must be taken down, the gastroesophageal junction identified, and the fundoplication reconstructed around the esophagus.

Occasionally, the original wrap is too tight and, therefore, needs to be converted to a ' Toupet fundoplication. A pyloroplasty may be added when preoperative gastric emptying studies indicate delayed emptying. Not uncommonly, incidental gastrotomies are made during dissection of the wrap, from either vigorous dissection or retraction.

All gastrotomies are closed primarily. Air can be insufflated in the stomach under water seal to locate any unidentified defects. Drains and nasogastric tubes are utilized at the discretion of the operating surgeon. The complications of revisional surgery are summarized in Table Incidental gastrotomies and esophagotomies are not uncommon and require immediate attention and closure.

Similarly, pneumothorax is common, especially with extensive dissection into the chest where the pleura is adherent to the herniated stomach; it can be evacuated intraoperatively at the conclusion of the operation with a small-caliber catheter. The most dreaded long-term sequelae of revisional surgery is recurrence of symptoms or the onset of new symptoms such as dysphagia as a consequence of a tight wrap.

Severe dysphagia may not be amenable to endoscopic dilatation and may require operative intervention. Summary and Future Directions Reoperative gastric surgery is being revived by the explosion in antireflux surgery and bariatric surgery. Understanding the principles of gastric physiology and its anatomical considerations is paramount to successful outcomes.

Selection of patients based on objective and reproducible diagnostic studies may improve long-term outcomes. Clear understanding of the endpoints of treatment by both surgeons and patients may be achievable with nonoperative treatment and should be considered in the context of an interdisciplinary approach. The application of minimally invasive surgery may reduce the morbidity of reoperative gastric surgery and should be undertaken by technically adept surgeons.

Trends in peptic ulcer surgery: a population-based study in Rochester, Minnesota, Gastroenterology ; Surgical management of peptic ulcer disease today-indication, technique and outcome. Langenbecks Arch Surg ; Eur J Surg ; Poor outcome and quality of life in female patients undergoing secondary surgery for recurrent peptic ulcer disease.

Turnage KH. Sarosi G. Cryer B, et al. Evaluation and manasement of patients with recurrent peptic ulcer disease after acid-reducing oper. Browder W: Thompson J. Younberg G, Walters D.

Delayed ulcer recurrence after gastric resection: a new posrgastrectoniy syndrome? Trout HH. Ulcer occurrence morbidity and mortality after Jperations for duodeiial ulcer. Stabile BE. Passaro E. Duodenal ulcer: a disease in evolutioi.

Curr Prob Surg h. Holscher AH. Klingele C. Bollschweiler E, et al. Chirurg SlCS Latias A. Intractable upper gastrointestinal ulceration due to aspirin in patients who haw undergone surgery for pepnc ulcer. Gastroenterology 1 SS Ellison EC. Sparks J. Am Surg 3 Kr EUlsoii EC. Carey LC. Spai-ks J. A m J Med suppl 5B :lT Forty year appraisal ofgastrinoma: back ro the t:. Norton JA. Fraker KL. Alexander HR. Surgery to curt Zollinger-Elhson syndrome. N Engl J M e d Johnston D.

Blackett RL. Delcore R. Cheung LY. Surg Clin North Am Forstiier-Barthell AW. Murr hlhl. Sarr MG. J GastroiiitrSurg Vogel SB. Braun W-E. Woodn-ard ER. Ann Surg IS-ih6.

Kelly KA. Surgical treatment of R o u z srasis s! Toftgaard C. Gastric cancer after peptic ulcer surgen-. A historic prospective cohort investigation. Watson DI. Hunter JG. Snlirh Cll. Brariiini GD. Lciparoscopic hndaplication failures: p'itterns of fiiilure and rrvponse to fundoFliration revision. Ann Surg M. Chapter 3: Reoperative Gastric Surgery 47 Hinder RA.

Klingler PJ. Perdikis G. Smith SL. Management of the failed antireflus operation: surgen- ofthe esophagus. Surg Clin North Am ; I O'Hanrahan T.

Marples M. Bancewicz J. Recurrent reflux and wrap disruption after Nisen fundoplication: detection, incidence and timing. Reiger NA. Jamieson GG. Britten-Jones R,Tew S. Reoperation after failed antireflux surgery. Br J Surg Sien-ert IR. Isolauri J, Feussner H. Reoperation following failed fundoplication. Surg Skinner DB. Surgical managenient after failed antireflus operations. World J Surg Serafini FM. Bloomston M.

Zervos E. Laparoscopic revision of failed andreflu operations. J Surg Res ; Carlson in. Frantzides CT. J An1 Coll Surg 1: 1' What's new in surgery: gastrointestinal conditions. J Am Coll Surg 1 Floch hR. Is laparoscopic reoperation for failed antireflcs surgen- feasible? Granderath FA. Kamolz T. Schweiger UM, Pointner R. Laparoscopic refundoplicarion with prosthetic hiatal closure for recurrent hiatal hernia after prlmar - faded antireflus surgery.

Pellegr:li C, Horgan S. Pohl D. Curer h 1J. Schoeb 0. Zucker KA. Laparoscopic reoperation for failed a:itireflus procedures. Bais JE. Horbach TL. Masclee Ail. Both are often challenging disease entities in the operating roomCrohn's because of the associated features of fistula, stricture, abscess, phlegmon, and the propensity for multiple areas of disease, and U C as a result of the extent of the disease coupled with the complexity of procedures that restore intestinal continuity after excision of the entire colon and rectum.

Reoperative surgery is even more challenging. In general, reoperative surgery for C D involves the complexities associated with recurrence of the disease, whereas reoperative intervention for U C entails management of complications from a preceding operation: Many series detail the frequency of reoperative procedures, and somewhat sparser data are available regarding outcomes.

There is, however, a dearth of practical "how-to" information on the thought processes used as patients are evaluated for operation, the practicalities of re-do surgery, and the intraoperative decision-making that often is required as the procedure unfolds. This review is thus not an encyclopedic review of every topic, but hopefully a collection of practical advice gleaned from wise colleagues and patients with complex operative problems. In addition are included pointers regarding technical aspects at the initial procedure that may help to avoid a reoperation or facilitate a subsequent procedure.

With current measures, the disease is incurable by medical or surgical means, and thus the goals of therapy are control of symptoms with minimal morbidity, while maintaining quality of life and continuity of the gastrointestinal tract when possible. Emergent indications include high-grade obstruction, uncontrolled sepsis, toxic megacolon, hemorrhage, or perforation. Medical therapy has failed and surgical intervention is warranted if the response to medical treatment is incomplete, maintenance medications cannot be discontinued as planned, or significant medication-related side effects develop.

If a laparoscopic approach is being considered, this author adds two tablets 10 mg of bisacodyl, to minimize the amount of retained fluid that makes loops of small bowel difficult to handle. With chronic obstructive symptoms, a modified preparation consists of clear liquids and nutritional supplements for 2 to 3 days preoperatively.

Magnesium citrate or phospho-soda ma. Other preoperative preparation includes consideration of the position of a colostomy or ileostomy. Potential sites should be marked, preferably by an enterostoma1 therapist. If time allows, immunosuppressives such as 6-mercaptopurine, azathioprine, and cyclosporine should be stopped 2 weeks prior to operation.

Stress dosing of corticosteroids is necessary if the patient has used corticosteroids withm the preceding 6 months, and should follow published guidelines.

Starting the midline incision either cephalad or caudad to the prior incision may help to identify a portion of the midline that is free of adhesions. C D is often additionally complicated by the presence of fistulas or phlegmon, and carehl dissection is necessary to identi6 and protect adjacent structures.

As C D often affects the small bowel diffusely, it is important to l y e all adhesions completely to evaluate the small bowel in its entirety, unless the risk of doing so in terms of creating enterotomies is considered to outweigh the potential risk of leaving an unidentified stricture. Review of the prior operative reports can be very helpful in identifjnng unexpected anatomy, as may exist, for example, after a previous bypass, and review of pathology reports indicate how much small bowel has already been resected.

Defunct Procedures-Internal bypass, once relatively commonly used, is now rarely recommended due to relatively high recurrence rates and the risk of malignancy. Bypass is acceptable if a phlegmon is densely adherent to other structures such as the retroperitoneum, when dissection is considered hazardous to retroperitoneal structures. Definitive resection and anastomosis should be planned for about 6 months later.

There is, however, a greater imperative to preserve small bowel length at reoperation, and limited areas of disease that might have been treated with resection at a primary procedure are more likely to be treated with strictureplasty. The total length of small bowel remaining at the end of the procedure should be measured and documented in the operative note. Marking the sites of resection and strictureplasty with metal clips may later be helpful in terms of identifylng likely areas of recurrent disease on imaging studies.

Laparoscopic resection has an increasing role in the management of these patients. An additional benefit is that the laparoscopic approach appears to result in fewer adhesions than laparotomy, thus facilitating a subsequent laparoscopic procedure.

In addition, a laparoscopic approach is frequently possible even after a prior laparotomy. Small Bowel Resection-The length of unaffected bowel that should be resected proximal and distal to an area of CD is no longer the subject of controversy. Thus, an anastomosis should be created with bowel that is soft, supple, and free of the macroscopic hallmarks of CD: wall thickening, fat creeping, serositis marked by corkscrew appearance of serosal vessels, and thickening of the mesenteric margin of the intestine.

The mucosal surface should be inspected and should be fiee of frank ulceration; the presence of aphthous ulcers alone in supple bowel does not preclude an anastomosis. It is used for diffuse small bowel involvement with multiple strictures, strictures after medwedi.

Surgery prior major resection or in the presence of short bowel syndrome, and nonphlegmonous fibrotic stricture. At initial operation, resection is often preferred even for short segment disease if it allows complete resection of all disease.

At repeat operation, resection is usually reserved for extensive segments of disease, multiple strictures within a short segment, or a stricture close to a site already requiring resection.

Whether the procedure is performed open or laparoscopically it is important to evaluate the entire small bowel to rule out other sites of disease. This is particularly important in patients who have been on immunosuppression and may have few if any serosal manifestations of the disease at the site of a short stricture. Passing a Baker tube a long tube with an inflatable balloon helps both in identification of other strictures and also in decompressing distended bowel proximal to a stricture.

Recurrence is often limited to the anastomosis itself, and further resection or even strictureplasty may continue to avoid the need for a stoma. The series is overseen by Josef E. Fischer, MD, editor of the classic two-volume reference Mastery of Surgery. Hepatobiliary and Pancreatic Surgery depicts surgery. Authors: Richard L. Whelan, James W. Fleshman, Dennis L. Originally, the goal was to concentrate on tersely covered or often ignored aspects of. Mastery of Surgery. Authors: Josef E.