What are the management strategies for common surgical emergencies such as acute appendicitis, intestinal obstruction, and perforated viscus?

Management Strategies for Common Surgical Emergencies

In patients presenting with common surgical emergencies such as acute appendicitis, intestinal obstruction, and perforated viscus, immediate surgical intervention is mandatory for life-threatening conditions, while non-operative management can be considered for select uncomplicated cases to reduce morbidity and mortality. 1

Acute Appendicitis Management

Uncomplicated Appendicitis

• Non-operative management (NOM) with antibiotics is a valid first-line option for uncomplicated appendicitis 1
  • Intravenous antibiotics with close clinical and radiological surveillance at 12-24 hour intervals
  • Patients must be informed of recurrence risk (up to 39% after 5 years)
  • Benefits include lower overall complication rate and shorter sick leave compared to surgery

Complicated Appendicitis

• Appendiceal abscess: Percutaneous drainage + IV antibiotics if technically feasible 1
• Perforated appendicitis:
  • Surgical approach based on patient condition:
    • Open approach preferred in COVID-19 positive patients 1
    • Laparoscopy if adequate equipment available and patient is stable
  • Patients with evidence of perforation and peritonitis require immediate surgical exploration 1

Pitfalls to Avoid

• Delayed diagnosis can lead to extraperitoneal compartmentalized abscess, which may be misdiagnosed as other conditions 2
• Unusual presentations occur in 20-40% of cases, requiring high index of suspicion 2
• Intestinal obstruction can be a rare complication of appendicitis 3

Intestinal Obstruction Management

Initial Assessment

• Hemodynamic status assessment is crucial for risk stratification 1
• CT scan is the diagnostic test of choice 4
• Laboratory tests: WBC count and CRP to assess infection/inflammation 4

Management Algorithm

1. Small Bowel Obstruction (SBO):

   • Conservative management for adhesive SBO with:
     • Nasogastric decompression (with appropriate PPE as this may be aerosol-generating) 1
     • IV fluids
     • Electrolyte correction
   • Surgical intervention indicated for:
     • Failed conservative management
     • Signs of strangulation/ischemia
     • Complete obstruction
     • Fibrotic or medically-resistant stenosis 1

2. Large Bowel Obstruction:

   • Decompression via colonoscopy or stenting as bridge to surgery in select cases
   • Surgical resection for malignant obstruction
   • Hartmann procedure preferred over anastomosis in unstable patients 1

3. Specific Scenarios:

   • Intussusception: Reduction if bowel is viable; resection recommended to prevent recurrence 1
   • Bezoar: Endoscopic approach for gastric bezoars; surgical intervention (enterotomy or milking into cecum) for small bowel bezoars 1

Surgical Approach

• Laparoscopic approach recommended for adhesiolysis and bowel resection if expertise exists 1
• Open approach preferred in hemodynamically unstable patients 1
• Consider ICG fluorescence angiography to evaluate bowel viability when available 1

Perforated Viscus Management

Initial Assessment

• Immediate surgical exploration in unstable patients presenting with peritonitis 1
• Assess all potential sites of perforation based on clinical presentation 1

Management by Site

1. Gastroduodenal Perforation:

   • Laparoscopic primary repair with omental patch in stable patients 1
   • Consider gastrostomy tube placement if significant peritonitis is present 1

2. Small Bowel Perforation:

   • Resection with primary anastomosis in hemodynamically stable patients 4
   • Damage control surgery with temporary abdominal closure in unstable patients 4

3. Colonic Perforation:

   • Diverticulitis:

     • Conservative approach (IV antibiotics + percutaneous drainage) for Hinchey class 1-2 1
     • Surgery for purulent or fecal peritonitis (Hinchey 3-4) 1
     • Hartmann procedure preferred over anastomosis in unstable patients 1

   • Free perforation:

     • Open approach preferred for large bowel perforation 1
     • Avoid colorectal anastomosis in high-risk patients due to increased complication risk 1

Antibiotic Therapy

• Administer appropriate antibiotics for 4-7 days based on clinical condition 4
• Recommended regimens:
  • Piperacillin/tazobactam 4g/0.5g q6h or 16g/2g by continuous infusion
  • Eravacycline 1 mg/kg q12h for patients with beta-lactam allergy 4

Critical Considerations

• Timing is crucial: Delay in surgical intervention beyond 48 hours significantly increases mortality 4
• Decision-making: Initial assessment by senior clinician to promptly recognize surgical necessity 1
• Multidisciplinary approach: Surgical decisions should be shared with anesthesia team given potential resource limitations 1
• COVID-19 considerations: All acute patients should be considered COVID-19 suspected cases until proven otherwise 1
• Damage control surgery: Consider in hemodynamically unstable patients with extensive contamination 1, 4

Remember that gastrointestinal symptoms may be manifestations of other conditions, including COVID-19, requiring thorough evaluation before determining final management strategy 1.