Acute Care Surgery

Contents
Foreword: Acute Care Surgery

ix

Ronald F. Martin
Preface: Acute Care Surgery: From De Novo to De Facto

xiii

George C. Velmahos
Acute Inflammatory Surgical Disease

Peter J. Fagenholz and Marc A. de Moya

Infectious and inflammatory diseases comprise some of the most common
gastrointestinal disorders resulting in hospitalization in the United States.
Accordingly, they occupy a significant proportion of the workload of the
acute care surgeon. This article discusses the diagnosis, management,
and treatment of appendicitis, acute cholecystitis/cholangitis, acute pancreatitis, diverticulitis, and Clostridium difficile colitis.
Gastroduodenal Perforation

31

Raminder Nirula
The cause and management of gastroduodenal perforation have changed
as a result of increasing use of nonsteroidal antiinflammatories and improved pharmacologic treatment of acid hypersecretion as well as the recognition and treatment of Helicobacter pylori. As a result of the reduction in
ulcer recurrence with medical therapy, the surgical approach to patients
with gastroduodenal perforation has also changed over the last 3 decades,
with ulcer-reducing surgery being performed infrequently.
Esophageal Perforation

35

Raminder Nirula
Esophageal perforation is uncommon but carries a high morbidity and
mortality, particularly if the injury is not detected early before the onset
of systemic signs of sepsis. The fact that it is an uncommon problem
and it produces symptoms that can mimic other serious thoracic conditions, such as myocardial infarction, contributes to the delay in diagnosis.
Patients at risk for iatrogenic perforations (esophageal malignancy) frequently have comorbidities that increase their perioperative morbidity
and mortality. The optimal treatment of esophageal perforation varies
with respect to the time of presentation, the extent of the perforation,
and the underlying esophageal pathologic conditions.
Upper Gastrointestinal Bleeding

Marcie Feinman and Elliott R. Haut

Upper gastrointestinal (GI) bleeding remains a commonly encountered
diagnosis for acute care surgeons. Initial stabilization and resuscitation
of patients is imperative. Stable patients can have initiation of medical
therapy and localization of the bleeding, whereas persistently unstable

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patients require emergent endoscopic or operative intervention. Minimally

invasive techniques have surpassed surgery as the treatment of choice for
most upper GI bleeding.
Lower Gastrointestinal Bleeding

55

Marcie Feinman and Elliott R. Haut

This article examines causes of occult, moderate and severe lower
gastrointestinal (GI) bleeding. The difference in the workup of stable vs
unstable patients is stressed. Treatment options ranging from minimally
invasive techniques to open surgery are explored.
Spontaneous Hemoperitoneum

65

George Kasotakis
Spontaneous hemoperitoneum is a rare, but life-threatening condition
usually caused by nontraumatic rupture of the liver, spleen, or abdominal
vasculature with underlying pathology. Management revolves around
angioembolization or surgical intervention. This article provides a brief
overview of the diagnosis and treatment of this disorder.
Retroperitoneal and Rectus Sheath Hematomas

71

George Kasotakis
The retroperitoneum is rich in vascular structures and can harbor large hematomas, traumatic or spontaneous. The management of retroperitoneal
hematomas depends on the mechanism of injury and whether they are pulsatile/expanding. Rectus sheath hematomas are uncommon abdominal
wall hematomas secondary to trauma to the epigastric arteries of the rectus muscle. The common risk factors include anticoagulation, strenuous
exercise, coughing, coagulation disorders, and invasive procedures on/
through the abdominal wall. The management is largely supportive, with
the reversal of anticoagulation and transfusions; angioembolization may
be necessary.
Acute Obstruction

77

Jason Sperry and Mitchell Jay Cohen

Acute obstruction of the gastrointestinal or biliary tract represents
a common problem for acute care surgeons. It is with appropriate clinical
evaluation, planning, and physical examination follow-up that acute care
surgeons are able to appropriately diagnose, manage, and resolve this difficult group of surgical problems and minimize the morbidity associated
with each.
Hernia Emergencies

D. Dante Yeh and Hasan B. Alam

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles
are constant: address the life-threatening problem first, then perform
the safest and most durable hernia repair possible. Mesh reinforcement
provides the most durable long-term results. Underlay positioning is

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associated with the best outcomes. Components separation is a useful

technique to achieve tension-free primary fascial reapproximation. The
choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia
emergencies, morbidity is high, and postoperative wound complications
should be anticipated.
Management of the Open Abdomen

131

Demetrios Demetriades and Ali Salim

The open abdomen has become the standard of care in damage-control
procedures, the management of intra-abdominal hypertension, and in
severe intra-abdominal sepsis. This approach has saved many lives but
has also created new problems, such as severe fluid and protein loss,
nutritional problems, enteroatmospheric fistulas, fascial retraction with
loss of abdominal domain, and development of massive incisional hernias.
Early definitive closure is the basis of preventing or reducing the risk of
these complications. The introduction of new techniques and materials
for temporary and subsequent definitive abdominal closure has improved
outcomes in this group of patients.
Necrotizing Skin and Soft Tissue Infections

155

Haytham M.A. Kaafarani and David R. King

Necrotizing skin and soft tissue infections are severe bacterial infections
resulting in rapid and life-threatening soft tissue destruction and necrosis
along soft tissue planes.
Acute Mesenteric Ischemia

165

Michael J. Sise
Acute mesenteric ischemia is uncommon and always occurs in the setting
of preexisting comorbidities. Mortality rates remain high. The 4 major types
of acute mesenteric ischemia are acute superior mesenteric artery thromboembolic occlusion, mesenteric arterial thrombosis, mesenteric venous
thrombosis, and nonocclusive mesenteric ischemia, including ischemic
colitis. Delays in diagnosis are common and associated with high rates
of morbidity and mortality. Prompt diagnosis requires attention to history
and physical examination, a high index of suspicion, and early contract
CT scanning. Selective use of nonoperative therapy has an important
role in nonocclusive mesenteric ischemia of the small bowel and colon.
Thoracic Emergencies

183

Stephanie G. Worrell and Steven R. DeMeester

This article discusses thoracic emergencies, including the anatomy,
pathophysiology, clinical presentation, examination, diagnosis, technique,
management, and treatment of acute upper airway obstruction, massive
hemoptysis, spontaneous pneumothorax, and pulmonary empyema.
Index

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