Acs0827 Blood Cultures And Infection In The Patient With The Septic Response
Acs9905
1. www.acssurgery.com
WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor May 2008
THE BEST THIS MONTH’S UPDATES
SURGICAL 1 Basic Surgical and Perioperative from infectious agents is also of
concern.
THINKING Considerations
2 Infection Control in
The Study on the Efficacy of
Nosocomial Infection Control,
conducted in U.S. hospitals between
Surgical Practice 1976 and 1986, showed that
Volunteerism: The Senior surgical patients were at increased
Vivian G. Loo, MD, MSc, FRCPC
Visiting Surgeon Program risk for all types of infections. The
McGill University Health Centre nosocomial, or hospital-acquired,
William H. Pearce, MD, FACS infection rate at that time was
DOI 10.2310/7800.S01C02
Northwestern University Feinberg estimated to be 5.7 cases out of
School of Medicine Protecting patients from surgical every 100 hospital admissions.
site infections and medical These infections included SSIs, as
DOI 10.2310/7800.2008.NCmay personnel from bloodborne and well as bloodstream, urinary, and
n the past 24 months, I have had other infectious agents in the respiratory infections. Today, the
I the opportunity to volunteer to
care for the wounded of Operation
operative setting can be ad-
dressed with proper surveillance,
increased use of minimally invasive
surgical procedures and early
Iraqi Freedom and Operation environmental control and discharge from the hospital
Enduring Freedom at both Walter education; doing so can have a necessitates post-discharge
Reed Army Medical Center and substantial impact on morbidity surveillance in addition to
Landstuhl Regional Medical Center and mortality. in-hospital surveillance for the
(LRMC). The medical care the tracking of nosocomial infections.
urgical procedures, by their very
injured received is remarkable. From
the medics in the field, to the
S nature, interfere with the normal
protective skin barrier and expose
The Joint Commission on
Accreditation of Healthcare
physicians and nurses in the regional Organizations (JCAHO) strongly
the patient to microorganisms from
hospitals, to Landstuhl, and finally
back to the United States (Walter both endogenous and exogenous
sources. Infections resulting from continued on page 2
Reed, Bethesda National Naval
Medical Center, and Brooke this exposure may not be limited to
the surgical site but may produce
Army Medical Center), the care is
nothing less than spectacular. The widespread systemic effects.
Prevention of surgical site infections
In This Issue
physicians, nurses, and staff are
(SSIs) is therefore of primary The Best Surgical Thinking
dedicated and committed to their Volunteerism: The Senior Visiting
mission. For example, at LRMC, concern to surgeons and must be Surgeon Program 1
a trauma critical care team of addressed in the planning of any
1 Basic Surgical and Perioperative
surgeons, pulmonologists, infectious operation. Standards of prevention Considerations
disease specialists, internists, have been developed for every step 2 Infection Control in Surgical
nutritionists, pharmacists, and of a surgical procedure to help Practice 1
others make daily rounds, sharing reduce the impact of exposure to 5 Gastrointestinal Tract and
ideas and developing treatment microorganisms. Traditional control Abdomen
plans. War injuries are of a different measures include sterilization of 7 Surgical Treatment of Morbid
Obesity 4
magnitude than those seen in surgical equipment, disinfection
civilian practice, and the complexity of the skin, use of prophylactic 6 Vascular System
20 Lower-Extremity Amputation
antibiotics, and expeditious opera- for Ischemia 7
continued on page 2 tion. Protecting medical personnel
3. www.acssurgery.com What’s New in ACS Surgery 3
They occur in 2 to 5% of patients 3. The use of prophylactic
undergoing clean procedures and in
as many as 20% of patients under- 4.
antibiotics,
Techniques for preparation of This Month’s CME
going intra-abdominal operations.
The risk of development of an SSI 5.
the operative site,
Management of the postopera- Chapters
depends on host and operative risk tive site if drains, dressings, or
ACS Surgery offers CME in
factors. Host risk factors to infec- both are in place, convenient online format. As
tion can be estimated according to 6. Standards of behavior and many as 60 AMA PRA Category
the following variables: older age, practice for the operating team 1 credits can be earned at
severity of disease, physical-status (e.g., the use of gown, mask, any time during the year. The
classification, prolonged preopera- and gloves), following chapters are available
tive hospitalization, morbid obesity, 7. Special training of the operating for CME credit this month:
malnutrition, immunosuppressive team, and
therapy, smoking, preoperative 8. Sterilization and disinfection of 1 Basic Surgical and Perioperative
Considerations
colonization with Staphylococcus instruments.
2 Infection Control in Surgical Practice
aureus, and coexistent infection at a
remote body site. Operative risk The health care team has a primary 5 Gastrointestinal Tract and
role in the prevention of infection. Abdomen
factors include method of hair 7 Surgical Treatment of Morbid Obesity
removal (and likelihood of conse- Continued education and reinforce-
quent skin injury), inappropriate use ment of policies are essential: the 6 Vascular System
team must be kept well informed 20 Lower-Extremity Amputation for
of antimicrobial prophylaxis, Ischemia
duration of the operation, and and up-to-date on concepts of
wound classification. infection control. droplet precautions, and contact
The Centers for Disease Control Hospitalized patients are not the precautions.
and Prevention established the only concern. Protecting medical
National Nosocomial Infections personnel from infection is of vital
Surveillance (NNIS) system in 1970 importance. Preventive measures, Infectious Agents
nfection may arise from exposure
to create a national database of
nosocomial infections. The NNIS
such as immunizations and pre-
employment medical examinations, I to bloodborne pathogens. In
addition, antimicrobial-resistant
system has been used to develop should be undertaken at an
definitions of infections and indices employee health care center staffed microorganisms may be to blame.
for predicting the risk of nosocomial by knowledgeable personnel. When Bloodborne pathogens. For active
infection in a given patient. NNIS exposure to contagious infections is surgeons and other members of the
developed a composite risk index unavoidable, susceptible personnel health care team, hepatitis B virus
composed of the following criteria: should be located, screened, and given (HBV) infection continues to pose a
American Society of Anesthesiolo- prophylactic treatment if necessary. major risk. Hepatitis B vaccination
gists score, wound class, and Inadvertently, team members may has proved safe and protective and is
duration of surgery. The NNIS also be the source of, or the vector highly recommended for all high-risk
includes a basic risk index, which is in, transmission of infection. employees; it should be made
a useful method of risk adjustment CDC guidelines have been available through the employee health
for a wide variety of procedures. developed to prevent the transmis- care center.
There is also a Modified NNIS Basic sion of infections. These isolation The risk of hepatitis C virus (HCV)
Risk Index for certain procedures guidelines promote two levels of transmissions is less prevalent. The
using laparoscopes, as the use of isolation precautions: standard average incidence of seroconversion
laparoscopes can lower the risk of precautions and transmission-based after percutaneous exposure from an
SSI within each NNIS risk index precautions. The standard precau- HCV-positive source is 1.8%.
category. tions, which incorporate the main Exposure to blood and body
features of the older universal substances of patients who have AIDS
Preventive Measures precautions and body substance or who are seropositive for HIV
isolation guidelines, were developed constitutes a health hazard to hospital
n any surgical practice, policies
I and procedures should be in place
pertaining to the making of a
to reduce the risk of transmission of
microorganisms for all patients,
employees. The magnitude of the risk
depends on the degree and method of
regardless of their diagnosis. exposure. Because screening for HIV
surgical incision and the prevention Standard precautions apply to infection is not mandatory among
of infection. These policies and
blood, all body fluids, secretions and patients, the CDC recommends
procedures should govern the
excretions, and mucous membranes. following the same guidelines for
following:
Transmission-based precautions all patients undergoing invasive
1. Skin disinfection and were developed for certain epide- procedures that one would use in
hand-washing practices of the miologically important pathogens cases of known HIV-infected patients.
operating team, or clinical presentations. These In studies of health care workers,
2. Preoperative preparation of the precautions comprise three the incidence of positive results on
patient’s skin (e.g., hair removal categories, based on the mode of tuberculin skin testing have ranged
and use of antiseptics), transmission: airborne precautions, from 0.11 to 10%. Health care
4. 4 What’s New in ACS Surgery • May 2008 www.acssurgery.com
workers who are immunocompro- 1. Total, or hospital-wide, updates on infection prevention
mised are at high risk for the surveillance: collection of measures (especially during and
development of disease after comprehensive data on all after an outbreak), updates on
exposure. infections in the facility, with preventive policies pertaining to
Antimicrobial-resistant the aim of correcting problems hand hygiene, isolation precautions,
microorganisms. Hospitals and as they arise. and other areas of concern.
communities worldwide are also 2. Surveillance by objective, or Establishing an infection control
facing the challenge posed by the targeted surveillance, in which a program can greatly benefit a
spread of antimicrobial-resistant specific goal is set for reducing hospital. It supports patient safety
microorganisms. Strains of certain types of infection. and is a means for continuous
methicillin-resistant S. aureus (MRSA) 3. Periodic surveillance: intensive quality improvement in the care that
are increasing in hospitals and are an surveillance of infections and is given, in addition to being an
important cause of nosocomial accreditation requirement.
patient-care practices by unit or
infections; in a sample of intensive The chair of any infection control
by service at different times of
care units in the United States in committee should have an ongoing
the year.
2003, approximately 59.5% of interest in the prevention and
S. aureus isolates were resistant to 4. Prevalence survey: the counting
and analysis of all active control of infections. Members
methicillin or oxacillin. should represent administration,
Vancomycin-resistant Enterococcus infections during a specified
time period. infectious diseases, microbiology,
(VRE) accounts for 38.2% of all nursing, the OR, central supply,
enterococci in the ICUs participating 5. Outbreak surveillance: the
identification and control of medicine, surgery, pharmacy, and
in the NNIS program. Transmission housekeeping. This multidisciplinary
usually occurs through contact with outbreaks of infection.
group becomes the advocate for the
the contaminated hands of a health Environmental control. Control of entire hospital.
care worker. the microbial reservoir of the In addition, according to existing
The CDC has developed strategies patient’s immediate environment in public health acts, certain infectious
for preventing and controlling the the hospital is also a goal of an diseases must be reported by law.
emergence and spread of
infection control program. Environ- Differences exist between the
antimicrobial-resistant microorgan-
mental control begins with design of reporting systems of one country
isms. These include optimizing
the hospital’s physical plant. The and those of another, but on the
antimicrobial prophylaxis for
surgical procedures, optimizing the design must meet the functional whole, diseases such as tuberculosis,
choice and duration of empirical standards for patient care and must sexually transmitted diseases, and
therapy, and improving antimicro- be integrated into the architecture to meningococcal meningitis are
bial prescribing patterns by provide traffic accessibility and reported for community follow-up.
physicians. control. Since the 1960s, the
In the past few years, Costridium practice of centralizing seriously ill
difficile-associated infection (CDI) patients in intensive care, dialysis, 5 Gastrointestinal Tract and
outbreaks, which have also caused and transplant units has accentuated
increased morbidity and mortality the need for more careful analysis Abdomen
have been reported in the United and planning of space. The primary
standards for these special care units
7 Surgical Treatment of
States, Canada, and Europe. These
outbreaks have been attributed to and ORs require planning of floor Morbid Obesity
the emergence of a hypervirulent space, physical surfaces, lighting, Eric J. Demaria, MD, FACS, and
strain of C. difficile. ventilation, water, and sanitation to Christopher J. Myers, MD
For control of CDI outbreaks, a facilitate easy cleaning and disinfect-
multifaceted approach is required, ing of surfaces, sterilization of Duke University, School of
including close attention to hand instruments, proper food handling, Medicine
hygiene, use of contact precautions and garbage disposal. These DOI 10.2310/7800.2008.S05C07
when providing care to CDI activities should then be governed
patients, environmental disinfection, by practical policies that are Bariatric surgery—open or
antibiotic restriction, and rapid understandable to the staff. Preven- laparoscopic--has the greatest
laboratory diagnosis. tive maintenance should be a basic and longest-lasting success in
and integral activity of the physical achieving weight loss for the
Infection Control Programs plant department. morbidly obese; preoperative
Education. A strategy for routine evaluation and postoperative
urveillance. The cornerstone of
S an infection control program is
surveillance. This process depends
training of the health care team is
necessary at every professional
management are crucial to
successful outcomes.
level. The process may vary from t is clear that severe obesity is
on the verification, classification,
analysis, reporting, and investigation
of infection occurrences, with the
institution to institution, but some
form of communication should be
I associated with a significant increase
in morbidity and a decreased life
intent of generating or correcting established for the dissemination of expectancy. Morbid obesity is defined
policies and procedures. Five information about endemic infection as a body weight that exceeds the
surveillance methods can be applied: rates, endemic bacterial trends, ideal body weight by 100 lb. or more
5. www.acssurgery.com What’s New in ACS Surgery 5
or a body mass index (BMI) greater suspected SAS should undergo Anesthesia. Morbidly obese
than 35 kg/m2. preoperative polysomnography at a patients can be intimidating to the
sleep center to confirm the diagno- anesthesiologist because they are at
Preoperative Evaluation sis. significant risk for complications
Obesity hypoventilation syndrome from anesthesia, especially during
any surgeons are afraid to
M operate on the morbidly obese
patient because they presuppose a
(OHS) is a condition associated with
morbid obesity in which a person
induction. The risk is particularly
great for obese patients with
suffers from hypoxemia and respiratory insufficiency. An obese
marked increase in perioperative hypercapnia when breathing room patient often has a short, fat neck
morbidity and mortality. It is now air while awake but resting. Chron- and a heavy chest wall, which
possible, however, to stratify the ic, severe hypoxemia is associated make intubation and ventilation a
mortality risk for patients undergoing with three complications that challenge.
gastric bypass (GBP) by using a put patients with OHS at risk: If endotracheal intubation proves
scoring system known as the polycythemia, pulmonary arterial difficult, however, such a patient can
Obesity Surgery Mortality Risk Score vasoconstriction, and pulmonary usually be well ventilated with a
(OS-MRS), which includes five hypertension. Patients with OHS mask. Awake intubation can be
independent variables that can be respond rapidly to supplemental performed, with or without
identified preoperatively: (1) BMI oxygen. However, oxygen adminis- fiberoptic aids, but is quite unpleas-
greater than or equal to 50 kg/m2, (2) tration is occasionally associated ant and rarely necessary. It is
male gender, (3) hypertension, (4) with significant CO2 retention, extremely important that at least
pulmonary embolus risk (including which necessitates intubation and two anesthesia personnel be present
previous thrombosis, pulmonary mechanical ventilation. during induction and intubation
embolus, inferior vena cava [IVC] Both SAS and OHS can be for patients with respiratory
filter, right-side heart failure, and completely corrected with weight insufficiency of obesity.
obesity hypoventilation syndrome reduction after gastric operation for Insulin administration. Patients
[OHS]), and (5) patient age greater morbid obesity. with type 2 diabetes may require
than or equal to 45 years. Morbidly obese patients are also large amounts of insulin for blood
Although the morbidly obese at significant risk for coronary glucose control because of signifi-
patient is certainly at greater risk, artery disease as a result of an cant insulin resistance. It is not
this risk can be markedly reduced by increased incidence of systemic unusual, however, to note a com-
paying careful attention to detail in hypertension, hypercholesterolemia, plete absence of the requirement for
preoperative and postoperative care. and diabetes. Because of this insulin in the immediate postopera-
The increased risks encountered in increased risk for cardiac tive period in morbidly obese
these patients include wound dysfunction, preoperative electrocar- patients. Therefore, insulin should
infection, dehiscence, thrombophle- diography should be performed on be withheld on the morning of
bitis, pulmonary embolism, anes- all obese patients 30 years of age or
thetic calamities, acute postoperative operation. In morbidly obese
older. patients who have undergone GBP,
asphyxia in patients with obstructive In additional to respiratory
sleep apnea syndrome, acute there is often a marked reduction
difficulties, the morbidly obese are in the requirement for insulin
respiratory failure, right ventricular also predisposed to other conditions,
or biventricular cardiac failure, and throughout the postoperative period
including thrombophlebitis, venous and even at discharge, possibly
missed acute catastrophes of the stasis ulcers, pulmonary embolism,
abdomen (e.g., anastomotic leak- because of increased release of
gallstones, pseudotumor cerebri, and gastric inhibitory peptide from the
age). degenerative osteoarthritis. All of
Obese patients are at risk for proximal small bowel.
these conditions need to be Choice of surgical procedure. The
respiratory difficulties, which may addressed, and the subsequent post-
be present before operation or may gastric operations performed for
surgery weight reduction may morbid obesity include both GBP
be exacerbated by an operation. It is greatly reduce the pain, immobility,
important to emphasize that procedures and gastric restrictive
and even morbidity of these procedures (i.e., gastroplasty and
morbidly obese patients, especially conditions.
those with respiratory insufficiency,
should be placed in the reverse
Trendelenburg position to maximize Preoperative Planning
diaphragmatic excursion and to
increase residual lung volume. I n planning for bariatric surgery,
surgeons (in conference with
Coming in June
Sleep apnea syndrome (SAS) is a Elements of Contemporary Practice
patients) must determine the
potentially fatal complication of 3 Benchmarking Surgical Outcomes
appropriate choice of surgical
morbid obesity. Patients with SAS procedure. Anesthesia in the 1 Basic Surgical and Perioperative
are at high risk for acute upper morbidly obese patient is also a Considerations
1 Prevention of Postoperative
airway obstruction and respiratory concern. Another issue to consider Infection
arrest when undergoing an in the pre-operative stage is the
6 Vascular System
operation and general anesthesia. administration of insulin for patients 12 Aortoiliac Reconstruction
Therefore, any patients with with type 2 diabetes.
6. 6 What’s New in ACS Surgery • May 2008 www.acssurgery.com
gastric banding). Randomized, not to the stomach—in such a Open Proximal Gastric
prospective trials have conclusively way as to create an outlet with a
shown that GBP is as effective for circumference of 5 cm for the small Bypass
roximal GBP results in greater
weight control as the malabsorptive
jejunoileal (JI) bypass is, while
upper gastric pouch. Silastic ring
gastroplasty is a variant of VBG that P weight loss than the gastric
restrictive procedures described
resulting in significantly fewer uses a vertical staple line and a
complications. JI bypass is associ- stoma reinforced with Silastic earlier and carries a lower incidence
ated with a substantial incidence of tubing. of weight regain; consequently, it is
Complications of VBG include often considered the gold standard
both early complications (e.g., acute
erosion of the polypropylene mesh for bariatric surgery. The current
cirrhosis, electrolyte imbalance, and
used to restrict the gastroplasty operative technique involves placing
fulminant diarrhea) and late
stoma into the gastric lumen, three superimposed 55 or 90 mm
complications (e.g., cirrhosis,
enlargement of the pouch, stomal staple lines across the proximal
interstitial nephritis, arthritis,
stenosis, reflux esophagitis, and mild stomach in such a way as to create a
enteritis, nephrocalcinosis, and gastric pouch no larger than 30 ml
vitamin deficiencies.
recurrent oxalate renal stones). If with a Roux limb at least 45 cm
evidence of cirrhosis, renal failure long and a stoma no larger than
secondary to interstitial nephritis, or Laparoscopic Adjustable 1 cm. This anatomic situation is
other complications mandates Gastric Banding largely replicated when GBP is done
reversal of a JI bypass, the patient, aparoscopic adjustable gastric laparoscopically, but an isolated
if not extremely ill, should be
converted to a GBP; otherwise, all
L banding (LAGB) is significant
advance over open gastric banding
gastric pouch is created with stapled
transection of the stomach.
the lost weight is sure to be procedures, primarily because of the In addition to being associated
regained, and the obesity-related adjustability of the band. In a 2006 with all of the complications that
comorbidity will return. Admittedly, study comparing outcomes, LAGB are seen after GBP, proximal GBP is
however, some patients have done proved to be just as safe as, cheaper associated with a significant inci-
well after JI bypass and do not need than, and almost as effective as dence of stomal stenosis and with
to have the operation reversed. laparoscopic Roux-en-Y gastric marginal ulcer. The former responds
Bariatric surgical procedures, like bypass (LRYBG). to endoscopic stomal dilatation, and
most other general surgical proce- LAGB is performed by using a the latter usually responds to proton
dures, have undergone a transition five-port technique. Initial abdomi- pump inhibitor therapy. Iron,
from an open approach to one that nal access is obtained via a supra- vitamin B12, and folic acid
places more emphasis on minimally umbilical trocar, and the remaining deficiencies may occur but can
invasive or laparoscopic techniques. ports are placed sequentially along usually be corrected with oral
Thus, in choosing the appropriate the right and left costal margins. supplementation.
surgical approach, it is important to Ultimately, a specially designed Nevertheless, neither the data
take into account the tremendous implement is inserted behind the from a randomized, prospective trial
surgical revolution that laparoscopy nor the data from selective studies
stomach from the lesser curvature to
has brought about in the treatment support the contention that VBG is
the angle of His and used to grasp
of morbid obesity. Now that every safer than GBP. Although GBP
the tubing of the banding device and
operation performed to treat obesity includes one more anastomosis than
pull it around the stomach. The
can be done laparoscopically, VBG, complications such as leaks
banding device is then locked into
laparoscopic bariatric surgery is not and peritonitis occur with both
place at the chosen location on the
only common but, in many centers, operations.
proximal stomach.
predominant. For this reason, as It is essential to place the band
well as because laparoscopic obesity properly during the initial proce- Laparoscopic Gastric
treatment requires advanced dure. The results to date suggest that Bypass
technical skills, minimally invasive the proximal pouch must be very aparoscopic GBP is currently the
bariatric procedures have become a
cornerstone of training for surgeons
small to optimize weight loss. In
addition, proper placement mini-
L most popular bariatric procedure
in the United States, both because of
now learning laparoscopic surgery. mizes—though it does not elimi- the rapid weight loss it achieves and
nate—the risk of band slippage and because of the strong overall
the complications thereof. Band surgical trend toward minimally
Vertical Banded slippage (anterior, posterior, or invasive approaches. As noted
Gastroplasty concentric) may occur even after earlier, laparoscopic GBP achieves
enerally, the surgical procedure proper placement, resulting in
G for vertical banded gastroplasty
(VBG) involves wrapping a strip of
intolerance of oral intake and
vomiting. However, the incidence of
the same weight-loss results as open
GBP but yields less pain, reduced
disability, and a shorter duration of
polypropylene mesh around the slippage does appear to decrease as hospitalization. Physiologically,
gastrogastric outlet on the lesser the surgeon’s experience with the laparoscopic GBP results in less
curvature and sutured to itself—but procedure increases. operative trauma than open GBP,
7. www.acssurgery.com What’s New in ACS Surgery 7
less impairment of pulmonary The complications observed to distention, which occurs in the distal
function, and a less pronounced date after laparoscopic GBP include bypassed stomach, sometimes leading
stress response. In addition, the the usual problems that occur in to a gastric perforation or disruption
laparoscopic technique is associated some patients after open GBP, of the gastrojejunostomy.
with lower incidences of major including marginal ulcer and A postoperative problem that
wound infections and incisional stenosis at the gastrojejunal anasto- deserves special mention is the risk of
hernias. Accordingly, we recom- mosis necessitating dilatation. On failed weight loss or weight regain.
mend laparoscopic GBP over any rare occasions, a gastrogastric fistula This is one of the most difficult
other bariatric procedure. may lead to a treatment-resistant problems associated with bariatric
Most of the variations seen at marginal ulcer. The major advan- surgery and may arise after any gastric
different institutions are related to tage of laparoscopic GBP over open procedure for morbid obesity. Patients
various techniques for creation of GBP is likely to be reduced wound who have undergone gastroplasty or
the gastrojejunal anastomosis, with complications (e.g., major wound gastric banding may have difficulty
some groups using a circular stapler, infection and incisional hernia). with solid foods and come to exhibit
others a linear stapler, and still maladaptive eating behavior involving
others a handsewn technique. frequent ingestion of high-calorie
As far as operative technique,
Postoperative Management liquid carbohydrates (a common
fter operation, the obese patient reason for failure of a bariatric
initial access to the abdomen is
obtained through a small left A should be kept in the reverse
Trendelenburg position and should
procedure).
We make clear to patients, well in
subcostal incision. The surgeon then
creates a roux limb and jejunojeju- not be extubated until he or she is advance of the operation, that
nostomy. Next, the greater omen- fully alert and showing evidence of bariatric surgery is designed to
tum is divided from its free edge to adequate ventilatory effort. Patients provide them with a tool that will
with obstructive SAS may have to be assist them in behavior modification
its junction with the transverse
managed with overnight mechanical and thereby help them help them-
colon so that the limb can be
ventilation in the ICU, particularly if selves. Obesity can be beaten by
brought up in an antecolic fashion
an open bariatric procedure was surgical treatment, but patients must
between the divided halves of the
performed. Patients with OHS may continue to make good food choices.
omental “apron,” which reduces
tension on the limb. require prolonged mechanical
Once the stomach is visible, it is ventilation until the pain of
grasped and elevated through the breathing resolves, particularly after 6 Vascular System
mesocolic window, and the end of open procedures.
It is extremely important to 20 Lower-Extremity
the Penrose drain is grasped and
brought through the mesocolic encourage early postoperative Amputation for Ischemia
defect into the lesser sac. Ultimately, ambulation for the morbidly obese William C. Pevec, MD, FACS
the mesentery of the lesser curvature patient. These patients often experi-
ence less pain than one might expect, University of California, Davis,
is transected. Stapling of the gastric
and it is frequently possible to get School of Medicine
pouch (circular or linear) can then
proceed. Some surgeons employ motivated patients up and walking in DOI 10.2310/7800.2008.S06C20
laparoscopic suturing techniques to the afternoon or early evening after a
major abdominal procedure. Lower extremity amputation can
create a handsewn gastrojejunos-
These basic principles of postop- be difficult and frightening for a
tomy. In every case, regardless of
erative management generally apply patient to accept, but can be
which anastomotic technique is
to laparoscopic cases as well, but accomplished with few complica-
employed, flexible upper GI endos-
with some differences. Unlike tions if timed and performed
copy is performed to confirm that
patients who have undergone open properly and restore patients to
the anastomosis does not leak.
GBP, those who have undergone independence.
Because total intracorporeal
laparoscopic GBP is such a challeng- laparoscopic GBP usually do not atients with infected, painful, or
ing technical adventure, a hand-
assisted version of the procedure
have a nasogastric tube left in place.
The patient may begin to drink
P necrotic lower extremities can be
restored to a better functional level
was developed. This technique small amounts of liquids on postop- by means of a properly selected and
served as a bridge to the total erative day 1 and may be kept on a performed amputation. These
intracorporeal approach, in that it liquid diet with liquid protein procedures should be considered
made it possible to learn the supplementation for several weeks. reconstructive and restorative.
technical aspects of a difficult, Nevertheless, the following are
highly advanced laparoscopic some of the main complications that
procedure while enjoying the may be associated with any abdomi- General Operative Planning
electing the appropriate level of
security provided by the presence of
a hand within the abdomen for
nal operation in a severely obese
patient: abdominal catastrophe S amputation is of primary impor-
tance for healing and preservation of
palpation and manipulation during (perforated duodenal ulcer, ruptured
the procedure. This added security diverticulum or peritonitis); internal function. Generally, adjuncts such as
is the major advantage of the hernia (which can lead to bowel transcutaneous oxygen tension and
hand-assisted approach. strangulation); or acute gastric segmental arterial pressure can
8. 8 What’s New in ACS Surgery • May 2008 www.acssurgery.com
reliably determine a level of amputa- great toe or of more than one Transmetatarsal Amputation
tion at which healing is virtually smaller toe is called for, it may be
ransmetatarsal amputation is
ensured, but they cannot reliably
determine the level at which an
preferable to perform a transmeta-
tarsal amputation of the forefoot.
T indicated if there is tissue loss in
the forefoot involving the first
amputation will not heal. Conse-
metatarsal head, two or more of the
quently, reliance on such measures Transphalangeal Amputation other metatarsal heads, or the dorsal
to select the level of amputation will
igital block anesthesia is ideal for
result in an unnecessarily high
percentage of more proximal
D transphalangeal amputation. If
multiple toe amputations are
forefoot. It is contraindicated if
there is extensive skin loss on the
plantar surface of the foot or on the
amputations.
required, an ankle block, epidural dorsum proximal to the midshaft of
In most cases, definitive amputation
anesthesia, spinal anesthesia, or the metatarsal bones.
can be accomplished in a single stage.
general anesthesia may be used. Spinal, epidural, or general
Local cellulitis can usually be con-
An incision is made to create anesthesia may be employed for
trolled beforehand with bed rest and
systemic administration of antibiotics. dorsal and plantar skin flaps. transmetatarsal amputation.
Undrained pus or recalcitrant Typically, these flaps are equal in An incision is made across the
cellulitis, however, must be treated length; however, depending on the dorsum of the foot at the level of the
with débridement and drainage in location of the skin lesion, either the middle of the shafts of the metatar-
advance of definitive amputation. dorsal flap or the plantar flap can be sal bones, extending medially and
Careful preoperative medical left longer. laterally to the level of the center of
assessment is essential. Lower- The incision is extended down to the first and fifth metatarsal bones,
extremity amputation for ischemia is the phalanx, and the soft tissues are respectively. The dorsal incision is
associated with a mortality of 4.5 to gently separated from the bone with curved proximally at the medial and
18%, owing to the poor overall a small periosteal elevator. All lateral edges to ensure that no dog-
condition of the patient population. tendons and tendon sheaths are ears remain at the time of closure.
The timing of elective amputation is débrided because the poor vascular- The dorsal incision is continued
also crucial. The loss of a limb is a perpendicularly through the soft
ity of these tissues may compromise
difficult and frightening thing for a tissues on the dorsum down to the
the healing of the toe. The phalanx
patient to accept. There is a natural metatarsal bones. The plantar
is transected at the level of the
tendency to delay amputation for as incision is extended distally to a
apices of the skin incisions. The best
long as possible. This tendency is point just proximal to the toe crease.
way of transecting the phalanx is to
understandable but must be weighed A plantar flap is created by making
use a pneumatic oscillating saw. an incision with the scalpel adjacent
against the potential problems
associated with delay. A preoperative to the metatarsophalangeal joints; the
consultation with a psychiatrist can Ray Amputation incision is then carried more deeply to
or ray amputation, spinal, the level of the midshafts of the
allay some of the patient’s anxiety by
addressing the expected postoperative
course of rehabilitation and thereby
F epidural, or general anesthesia
may be employed. A so-called
metatarsal bones on their plantar
surfaces. The periosteum of the first
removing some of the fear of the tennis-racket incision is made—that metatarsal bone is scored circumferen-
unknown. is, a straight incision along the tially with the scalpel, and the soft
dorsal surface of the affected tissue is dissected away from the first
metatarsal bone coupled with a metatarsal bone with a periosteal
Toe Amputation circumferential incision around the elevator to a point about 1 cm
mputation of the toe can be done
A either across a phalanx or across
a metatarsal bone; the latter
base of the toe. The goal is to save
all available viable skin on the toe;
proximal to the dorsal skin incision.
The first metatarsal bone is then
this skin is used to ensure a tension- transected perpendicular to its shaft at
procedure is commonly referred to free closure, and any excess skin can the level of the dorsal skin incision
as a ray amputation. be débrided later, at the time of with a pneumatic oscillating saw. This
For a toe amputation to heal closure. The metatarsal bone is process is repeated for each individual
properly, there must be either a transected across the shaft with a metatarsal bone.
palpable pulse over the dorsal pedal pneumatic oscillating saw. The Because intraoperative blood loss
or posterior tibial artery or a tendons and the tendon sheaths are can be substantial, good communica-
functioning bypass graft to an débrided. tion between the surgeon and the
infrapopliteal artery. If tissue Complications of toe amputation anesthesiologist is crucial for prevent-
necrosis or infection is confined to include bleeding, infection, and ing ischemic complications secondary
the distal or middle phalanx, failure to heal. For optimal healing, to hemorrhage.
transphalangeal amputation is there must be an extended period (2 Postoperative complications
appropriate; if tissue loss or necrosis to 3 weeks) during which no weight is include bleeding, infection, and
involves the proximal phalanx, ray borne by the foot that underwent toe failure to heal, all of which are likely
amputation is indicated. amputation. Once healing is complete, to result in more proximal amputa-
Multiple transphalangeal amputa- the patient should be able to walk tion. For proper healing, postopera-
tions are functionally well tolerated. normally, with no need for orthotic or tive edema must be avoided and the
If, however, ray amputation of the assist devices. plantar flap protected against shear
9. www.acssurgery.com What’s New in ACS Surgery 9
forces. To prevent swelling, the reconstruction or by amputation of placed on gentle traction and
patient is kept on bed rest with the one or more of the toes or the clamped proximally. The nerves are
foot elevated for the first 3 to 5 forefoot. Healing can be expected if transected and ligated, and the
days. This step is particularly there is a palpable femoral pulse proximal nerves are allowed to
important if the transmetatarsal with at least a patent deep femoral retract into the soft tissues so as to
amputation was performed simulta- artery, provided that the skin is prevent painful neuromas at the end
neously with arterial reconstruction. warm and free of lesions at the of the stump.
Once healed, patients should be distal calf. Before formal below-the- The most common complications
able to walk independently with knee amputation, infection should after below-the-knee amputation are
standard shoes. There is, however, a be controlled with antibiotic bleeding, infection, and failure to heal,
risk that they may trip over the therapy, débridement, and, if all of which are likely to result in a
unsupported toe of the shoe. indicated, guillotine amputation. It more proximal amputation, frequent-
is advisable to obtain consent to ly accompanied by loss of the knee.
Guillotine Ankle Amputation possible above-the-knee amputation To walk with a prosthetic leg, the
beforehand in case unexpected patient must be capable of fully
uillotine amputation across the
G ankle is indicated when a patient
presents with extensive wet gan-
muscle necrosis is encountered
below the knee.
extending and locking the knee;
thus, flexion contracture at the knee
Epidural, spinal, or general is a major complication. Such
grene that precludes salvage of a anesthesia is appropriate for below- contractures are usually attributable
functional foot (e.g., wet gangrene
the-knee amputation. The lines of either to poor pain control or to
that destroys the heel, the plantar
incision should be marked on the noncompliance with knee extension
skin of the forefoot, or the dorsal
skin. The primary level of amputa- exercises. Once a flexion contracture
skin of the proximal foot). In such
tion is determined by measuring a happens, the patient may find it very
patients, initial guillotine amputa-
distance of 10 cm from the tibial difficult to regain full knee exten-
tion through the ankle is safer than
tuberosity. The circumference of the sion, and without full knee exten-
extensive débridement: the opera-
leg at this level is then measured by sion, prosthetic limb rehabilitation is
tion is shorter, less blood is lost, the
passing a heavy ligature around the impossible.
risk of bacteremia is reduced, and
leg and cutting the ligature to a Phantom sensation is a common
better control of infection is pos-
length equal to the circumference. complication after below-the-knee
sible. Guillotine amputation is also
The ligature is folded into thirds and amputation but is rarely of any
indicated in patients with foot
cut once more at one of the folds, so consequence. Phantom pain, on the
infections who have cellulitis
that two segments of unequal length other hand, can be devastating.
extending into the leg.
remain. The longer segment of the Medical personnel should take great
General anesthesia is preferred for
guillotine ankle amputation; ligature, which is equal in length to care to distinguish between the two
regional anesthesia is relatively two-thirds of the leg’s circumference entities and can also help by
contraindicated for critically ill 10 cm below the tibial tuberosity, is encouraging early amputation in a
patients who are in a septic state. used to measure the anterior patient with a hopelessly ischemic
A circumferential incision is made transverse incision; this incision is foot, providing good pain control in
at the narrowest part of the ankle centered not on the tibial crest but the early postoperative period, and
(i.e., at the proximal malleoli) on the gastrocnemius-soleus muscle assuring the patient that phantom
regardless of the level of the celluli- complex. The shorter segment, sensation after a below-the-knee
tis. This placement takes the line of which is one-third of the leg’s amputation is common and that any
incision across the tendons, thereby circumference at this level, is used to discomfort in the foot immediately
preventing bleeding from transected measure the posterior flap; the line after the operation period will
muscle bellies. The incision is then of the posterior incision runs vanish once he or she begins
carried through the skin and soft parallel with the gastrocnemius- walking again with a prosthetic leg.
tissues to the bone. If the arteries are soleus complex. Ulceration of the skin over the
patent, the assistant applies circum- The tibia is scored circumferen- transected anterior portion of the
ferential pressure to the distal calf. tially, and a periosteal elevator is tibia is another serious complication
The distal tibia and fibula are then used to dissect the soft tissues away that may preclude successful
divided with a Gigli saw. from the tibia for a distance of prosthetic limb fitting.
After the procedure, the patient is approximately 3 to 4 cm. The tibia Shortly after the amputation, the
kept on bed rest and given systemic is then transected just proximal to patient should be encouraged to
antibiotics. the transverse skin incision. The start working on strengthening the
tibia can be transected with either a upper body; upper-body strength is
Gigli saw or an oscillating saw. critical for making transfers and for
Below-The-Knee The anterior tibial, posterior using parallel bars, crutches, or a
Amputation tibial, and peroneal arteries and walker.
elow-the-knee amputation is veins are clamped, and the tourni- Prosthetic rehabilitation begins
B indicated when the lower
extremity is functional but the foot
quet is released. Clamps are placed
on all other bleeding vessels. The
when the stump achieves a conical
shape. Unfortunately, a number of
cannot be salvaged by arterial posterior tibial and sural nerves are patients who have undergone
10. 10 What’s New in ACS Surgery • May 2008 www.acssurgery.com
amputation for ischemia are unable The flaps should be wide and long, over the stump. The cuff of the
to walk with a prosthetic limb and their apices should be centered stockinette is cut medially at the
because of comorbid medical on the line dividing the anterior and groin, and the stockinette is rolled
conditions and general debility. posterior muscle compartments. The laterally above the hip, where the
skin incisions are carried through cuff is then cut on the midaxillary
Above-The-Knee the dermis, and the skin edges are line. This process yields two strips of
allowed to separate and expose the cloth, one anterior and one poste-
Amputation subcutaneous fat. rior, which are passed around the
bove-the-knee amputation is If the superficial femoral artery is
A indicated if the lower extremity is
unsalvageable and there is no
patent, the artery and vein are
isolated and clamped after the
patient’s waist and tied on the
anterior midline.
If the patient is a candidate for
femoral pulse, if there is tissue sartorius is divided but before the prosthetic limb rehabilitation, a
necrosis or uncontrollable infection remainder of the anterior muscles traction rope is passed through a
extending cephalad to the midleg, are divided. The femur is scored hole cut in the distal end of the
and in the case of gangrene or circumferentially. The soft tissues
stockinette and tied. The rope is
ulceration of a completely are dissected away from the femur
hung over the end of the bed and
nonfunctional lower extremity. to the level of the apices of the flaps,
tied to a 5 lb weight; this step helps
Epidural, spinal, or general and the femur is divided with an
prevent flexion contracture at the
anesthesia may be used for above-the- oscillating saw at this level. The
hip.
knee amputation. For the best deep fascia is approximated with
interrupted absorbable sutures, with Postoperative complications
functional results, it is desirable to
keep the femur as long as possible. A adjustments made for any discrep- include bleeding, infection, and
longer stump improves the prognosis ancy in length between the two failure to heal, all of which are likely
for prosthetic limb rehabilitation and flaps. to result in the need for surgical
provides better balance for sitting and A nonadherent dressing is placed revision of the amputation stump.
transfers. Healing potential, however, on the suture line and covered with Flexion contracture of the hip is a
is lower with a longer stump; there- dry, fluffed gauze bandages. An major complication of above-the-
fore, if the pelvic circulation is aerosol tincture of benzoin is knee amputation. Such contractures
severely compromised, a shorter sprayed on the thigh, the hip, and preclude successful prosthetic limb
stump should be fashioned. the lower abdomen. When the rehabilitation. In dealing with this
Anterior and posterior flaps of benzoin is dry, a cloth stockinette complication, prevention is far more
equal length are marked on the skin. with a diameter of 4 in. is stretched effective than treatment.
