Schein's Common Sense Emergency Abdominal Surgery, 4th Edition

Schein, Moshe, Rogers, Paul N. , Leppäniemi, Ari , Rosin, Danny

• Éditeur: tfm Publishing Ltd
• Année: 2016
• ISBN:
  9781910079126
• Sujet: Medicine
• Sous-sujet: Surgery & Surgical Medicine

This, the fourth edition of Schein's Common Sense Emergency Abdominal Surgery, builds on the reputation of the three previous editions. Already a worldwide benchmark, translated into half a dozen languages, this book guides surgical trainees logically through the minefields of assessment and management of acute surgical abdominal conditions. General surgery as a concept may have been overtaken in many parts of the world by the development of niche specialties, but the need for a cohort of generalists able to deal competently with common surgical emergencies has not gone away. If you recognise this need then this is the book for you! Tyro surgeons and experienced practitioners alike will benefit from the distilled wisdom contained in these pages. The direct, no nonsense, writing style, supported by entertaining cartoons, gives clear guidance while at the same time providing amusing insights into our collective surgical pschye. NOT a standard textbook. Buy it! You'll not regret it. Some new editors and authors enhance the new edition. Almost all chapters have been revised to take account of new concepts and modern developments. New chapters have been added and some completely rewritten often with a new emphasis on the importance of a laparoscopic approach. Reviews of previous editions"This is written with short punchy chapters making it a very difficult book to put down… ".R.A.B. Wood, Journal of the Royal College of Surgeons of Edinburgh"Since Mondor's times in the forties of the last century there was no other book in surgery to be written so easy and witty …".Boris D. Savchuk, World Journal of Surgery"By the end I was a total enthusiast… this is a text like no other I read… Unreservedly recommended to old and young and alike."M. Winslet, Royal Free Hospital, London, Colorectal Disease"The title describes this book perfectly. This is a no-nonsense approach to the sometimes very difficult situations in general surgery.… The authors describe their experiences in tough situations of patient care for residents and young attendings.… the historical quotes add a good amount of insight and interest. I have not come across another book like this.… Focused on the real situations that surgeons come across, the book answers the questions that are not addressed in the major textbooks." Robert A. Hanfland, Doody's Review Service"This book covers emergency abdominal surgery in a useful and interesting way. [It is] a small and handy book yet the coverage is wide. It would be of interest to any general surgeon and should certainly be read by surgical trainees. [It] allows mention of many things which would otherwise be excluded from a more rigidly structured work. I was also glad to be reminded of many things which I had known but forgotten. The writers clearly know what they are talking about." David Evans, Annals of the Royal College of Surgeons of EnglandA sample of testimonials posted on amazon...By Donald Dupuis, MD, Lahey Clinic««««« "A Must Have Book. I am about to end my chief year in general surgery residency — my copy of the first edition shows the wear of half a dozen total read throughs and probably hundreds of referencings. Newest edition is equally good. For the last 3 years I have given this book to our interns if they finish their surgical internship. And I've paid for this myself — if you know how little residents get paid you will know how important I think it is. If you are in surgical training DO NOT WAIT ANOTHER DAY BEFORE YOU BUY THIS BOOK. I do agree with another reviewer who thought a bit of cool surgical technique would have been good too. But, all in all, best, most useful little book on surgery ever. Nuff said."By Chet A. Morrison, Assistant Professor of Surgery, Director of Surgical Critical Care, Michigan State University«««« "A very useful practical guide. This is a fine book in the tradition of 'guides to being on call' — or maybe the 'guide to the perplexed'. I like the straightforward get to the point style, and the directness of the book makes this a useful book to have handy when confronted with some of the emergency surgery problems. I would only say it could have had a bit more on surgical technique, and one or two references would have been useful (instead there was almost a militant insistence on as few as possible). But I would recommend it for any resident who is on call, and I find it useful as a staff sugeon as well."By K. M. Kemp««««« "Love it. I'm a big fan of this book, having just finished it a month ago. It's a good mix of the author's own experience as well as expert commentary when indicated. Compared to a textbook, it's much more engaging and easier to read. Also compared to a text, it seems much more practical in the advice it gives. As a brand new intern, I gleaned a lot from this book. Highly recommended for fellow trainees." By Jendri ««««« "A surgical must have. This is a very well written and very practical guide to emergency surgery. It covers virtually all aspects of emergency general surgery and does it in a very interesting way. I think this is one of the best books on the subject. For me it certainly is a must have. In the next edition, probably the only thing that I would like to add to this book would be the information about the military uniform worn by Dr Karl Schein on the photograph on one of the first pages. Dr Schein is wearing a uniform of the 1st Polish Army formed in Soviet Union in 1943. Altogether a great book."By andreromeo ««««« "A must. Dr. Moshe Schein has a very personal view about medicine and about the art of surgery, and that is why this book is really a must for clinicians and surgeons."By Andy ««««« "Simply perfect. The best choice in surgery for trainees! It makes the more difficult surgery areas very easy to understand. I recommend it to all surgeons." By maxim ««««« "Worth every penny. Invaluable as a guide to assist in the resolution of a broad range of abdominal problems. The book is well structured, running from opening chapters addressing pre-operative issues, and on through a pretty complete spectrum of gut complaints likely to arise in the real world, and how best to sort them out. It's not only useful, but very well written, and, for a text book, an absolute pleasure to read. Short bite size chapters combined with the occasional cartoon make this 3rd edition of Schein well worth the investment. Blend with Cope's Diagnosis of the Acute Abdomen for the ideal cocktail."By J. D. Wassner ««««« "Well-written, easy to read. Should be required reading for any General Surgery resident, & anyone who does acute-care & trauma."

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…”