![]()
PART I
General considerations
![]()
Chapter 1
General philosophy
Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin and Jonathan E. Efron
Wisdom comes alone through suffering.
Aeschylus, Agamemnon
Good judgment comes from experience, experience comes from bad judgment.
Surgeons are internists who operate…
At this moment — just as you pick up this book and begin to browse through its pages — there are many thousands of surgeons around the world facing a patient with an abdominal catastrophe. The platform on which such an encounter occurs differs from place to place — a modern emergency department in London, a shabby casualty room in the Bronx, or a doctor’s tent in the African bush. But the scene itself is amazingly uniform. It is always the same — you confronting a patient, he suffering, in pain, and anxious. And you are anxious as well: anxious about the diagnosis, concerned about choosing the best management, troubled about your own abilities to do what is correct.
We are in the 21st century but this universal scenario is not new. It is as old as surgery itself. You are perhaps too young to know how little some things have changed — or how other things have changed, and not always for the better — over the years. Yes, your hospital may be in the forefront of modern medicine; it has a team of subspecialists on call to provide advice (it has an even larger administrative team of functionaries to monitor you…), its emergency room has standby, state-of-the-art spiral computed tomography and magnetic resonance imaging machines, but, practically, something has not changed: it is the patient and you (often with the entire ‘system’ against you) — you who are duty bound to provide a correct management plan and execute it. And it often feels lonely out there; even we, experienced old farts, can feel the loneliness.
The ‘best’ management of an abdominal emergency
It is useful to compare the emergency abdominal surgeon to an infantry soldier (
Figure 1.1). Away from the limelight and glory that surrounds cardiac or neurological surgeons, emergency abdominal surgery is closer to infantry than it is to airborne action.
A war cannot be won by remote control with cruise missiles, or robots, but with infantry on the ground. Likewise, technological gimmicks have a limited place in emergency abdominal surgery, which is the domain of the surgeon’s brain and hands.
To achieve the final ‘victory’ someone has to agonize, sweat, bleed, and wet his hands — remember the bad smell from your hands after operating on a perforated colon? Some readers may struggle with this military metaphor but the truth of the matter is that emergency abdominal surgery shares a few simple rules with infantry action — developed in the trenches and during offensives — rules that are the key to survival and victory (
Table 1.1). Such a code of battle echoes the ‘best’ management of abdominal emergencies.
Figure 1.1. “Think as an infantry soldier...”
There are many ways to skin a cat and you know from your various surgical mentors that different clinical pathways may arrive at a similar outcome. However, one of the diverse pathways is the ‘best’ — thus, the ‘correct’ one!
To be considered as such, the preferred pathway has to save life and decrease morbidity in the most efficient way. Look at the following example.
You can manage
perforated acute appendicitis using two different pathways (
Chapter 23) — both leading to an eventual recovery and both considered absolutely appropriate (
Table 1.2).
Both the above pathways are ‘OK’, right? Yes, but pathway 2 clearly is the ‘best’ one: safer, faster and cheaper.
Today many options exist to do almost anything. Any search on Google or PubMed will overwhelm you with papers that can justify almost any management pathway, with people practicing surgical acrobatics for the mere sake of doing so. Data and theory are everywhere: the sources are numerous but what you really need is wisdom — to enable you to apply correctly the knowledge you already have and constantly gather. And wisdom is what we are trying to provide. So please open your mind.
General philosophy ( Figure 1.2)
Figure 1.2. “Each of us has a different ‘general philosophy’…”
“There is nothing new in the story…,” Winston Churchill said, “want of foresight, unwillingness to act when action would be simple and effective, lack of clear thinking, confusion of counsel until the emergency comes, until self-preservation strikes its jarring gong…”. How true is this Churchillian wisdom when applied to emergency surgery. How often do we forget old — written in stone — principles while reinventing the wheel?
The ‘best’ management in each section of this book is based on the following elements.
| Old-established principles (don’t reinvent the wheel). |
| Modern-scientific understanding of inflammation and infection. |
| Evidence-based surgery (see below). |
| Personal experience. |
The inflamed patient
Think about your patient as being INFLAMED by myriad inflammatory mediators, generated by the primary disease process, whether inflammatory,
infectious or traumatic — so if you measure C-reactive protein (CRP) in these patients, in most it will be elevated! Local inflammation (e.g. peritonitis) and
systemic inflammatory response syndromes (SIRS) may lead to organ dysfunction or failure, and the eventual demise of your patient.
The greater the inflammation — the sicker the patient and the higher the expected morbidity and mortality.
Consider also that anything you do in attempting to halt your patient’s inflammation may in fact contribute to it — adding fuel to the inflammatory fire. Excessive surgery, inappropriately performed, and too late, just adds nails to your patient’s coffin. Remember also that SIRS is antagonized by the so-called compensatory anti-inflammatory response syndrome (CARS), mediated by anti-inflammatory cytokines, which in turn promotes immune suppression and facilitates infections that are so common after major operations and severe trauma (
Figure 1.3).
Figure 1.3. The inflamed surgical patient. SIRS = systemic inflammatory response syndrome; CARS = compensatory anti-inflammatory response syndrome. (Read the classic by the late Roger Bone: Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med 1996; 24: 1125-8.)
The philosophy of treatment that we propose maintains that in order to cure or minimize the inflammatory processes and the anti-inflammatory response, management should be accurately tailored to the individual patient’s disease; as the punishment fits the crime, so should the remedy fit the disease. A well-trained foot soldier does not fire indiscriminately in all directions. These days he can summon the drones for a surgical strike!
Evidence
Economic considerations sometimes motivate the physicians to accept that part of the scientific evidence that best supports the method that gives him the most money.
George Crile
A few words about what we mean when we talk about ‘evidence’. Many formal classifications of scientific evidence are in circulation. Here is one version along with what some people think about it (
Table 1.3).
To the above ‘official’ classification we wish to add a few more categories frequently used by surgeons around the world.
| V — “In my personal series of X patients (never published) there were no complications.” |
| VI — “I remember that case… forty years ago…” |
...
