What is the recommended surgical management for acute care surgical patients?

Surgical Management for the Acute Care Surgical Patient

Hemodynamic status is the primary determinant for immediate surgical intervention in acute care surgical patients, with TACS class 1 and 2 patients requiring surgery within a very short delay, while uncomplicated intra-abdominal infections may be managed non-operatively with close surveillance. 1

Initial Triage and Risk Stratification

Hemodynamic assessment drives the decision:

• Patients with hemodynamic instability after adequate resuscitation require immediate surgical exploration without delay 1, 2
• The Timing of Acute Care Surgery (TACS) classification system stratifies patients based on hemodynamic and clinical parameters to prioritize surgical timing 1
• TACS class 1 and 2 patients (life-threatening complications, high-risk patients, hemodynamic compromise, or shock) require surgical treatment in a very short delay 1

Key assessment parameters include:

• Vital signs with specific attention to hypotension, tachycardia, fever, or signs of septic shock 2
• Clinical examination for signs of localized or generalized peritonitis 1
• Inflammatory biomarkers including C-reactive protein, procalcitonin, and lactate levels 1
• ASA score, age, and comorbidities (obesity, diabetes, COPD) 1

Disease-Specific Management Algorithms

Acute Appendicitis

Uncomplicated appendicitis:

• Laparoscopic appendectomy remains the gold standard treatment 1
• Non-operative management with broad-spectrum antibiotics (piperacillin-tazobactam or cephalosporins/fluoroquinolones with metronidazole) is appropriate for selected patients, achieving success in approximately 70% 3
• An "antibiotic first" policy achieves significantly lower overall complication rates at 5 years and shorter sick leave compared to surgery 1
• Recurrence risk is up to 39% after 5 years with antibiotic treatment 1

Complicated appendicitis with abscess:

• Manage with percutaneous drainage (if available) plus IV antibiotics 1
• Patients with perforation may be managed with percutaneous drainage or operation based on patient condition 1
• Patients who fail non-operative management should proceed to surgery expeditiously 1

High-risk CT findings predicting antibiotic failure (≈40% failure rate):

• Appendicolith presence 3
• Mass effect 3
• Appendiceal diameter ≥13 mm 3
• These patients should undergo surgical management if fit for surgery 3

Acute Cholecystitis

Surgical approach:

• Early laparoscopic cholecystectomy is superior to delayed surgery, associated with shorter hospital stay without increased complications or conversion rates 1

Non-operative alternatives:

• IV antibiotics and analgesics to delay surgery may be considered when resources are limited 1
• Percutaneous cholecystostomy with IV antibiotics is reserved for critically ill patients unfit for surgery 1
• The 2016 WSES guidelines do not recommend percutaneous cholecystostomy as an alternative to laparoscopic cholecystectomy except in the most unfit patients due to significantly higher mortality rates 1

Acute Diverticulitis

Uncomplicated disease (Hinchey I-II):

• IV antibiotics with transition to oral antibiotics as soon as possible 1
• Percutaneous drainage plus antimicrobial therapy for abscesses >4 cm 1
• If percutaneous drainage unavailable, manage with antibiotics but consider surgery for signs of sepsis or shock 1

Complicated disease with generalized peritonitis:

• Urgent surgical treatment is mandatory 1
• Hartmann's procedure for diffuse peritonitis in critically ill patients and those with multiple comorbidities 1, 4
• Primary resection with anastomosis (with or without diverting stoma) for clinically stable patients without major comorbidities 1
• Emergency laparoscopic sigmoidectomy should be avoided, especially if prolonged operative duration is expected 1

Perforated Viscus with Pneumoperitoneum

Immediate surgical intervention is required:

• Every hour of delay from admission to surgery decreases survival probability by 2.4% 4
• Laparoscopic approach is preferred for stable patients with perforated peptic ulcer 4
• Open approach for unstable patients or when laparoscopic expertise is unavailable 4
• Sealed perforated peptic ulcer confirmed on water-soluble contrast study may be managed non-operatively 4

Post-Bariatric Surgery Complications

Peritonitis management:

• Immediate surgical exploration for unstable patients without delay 1
• Assess all anastomoses after LRYGB, the remnant stomach, and the excluded duodenum 1
• Primary suture with omental patch via laparoscopy for stable patients with perforated marginal ulcer or gastric remnant perforation <1 cm 1
• Damage control surgery with open abdomen for hemodynamically unstable patients with severe peritonitis and septic shock 1

Non-Operative Management Principles

When non-operative management is selected:

• Close clinical and radiological surveillance at 12-24 hour intervals from initiation of IV antibiotic therapy 1
• Surgical treatment cannot be postponed if the patient presents with persistent abdominal pain, fever, or signs of shock 1
• Broad-spectrum antibiotics covering gram-negative bacteria and anaerobes are essential 2, 5

Antibiotic Regimens

Recommended broad-spectrum coverage:

• Piperacillin-tazobactam monotherapy 3
• Cephalosporins or fluoroquinolones combined with metronidazole 3
• Ceftriaxone for intra-abdominal infections caused by susceptible organisms including E. coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species, or Peptostreptococcus species 5
• Adjust for renal function in patients with renal impairment 2

Critical Pitfalls to Avoid

Common errors in acute care surgery:

• Delaying surgery in patients with peritonitis leads to increased morbidity and mortality 4
• Underestimating the severity of peritonitis may necessitate more aggressive surgical approaches 4
• Attempting complex resections in hemodynamically unstable patients is contraindicated 4
• Discharging high-risk patients without 24-hour surgical emergency contact information 2
• Failing to provide adequate wound care supplies and monitoring for post-operative complications 2

Damage Control Surgery Indications

Consider damage control with open abdomen for:

• Hemodynamic instability secondary to intra-abdominal infection 1
• Extensive intestinal ischemia 1
• Massive hemoperitoneum 1
• Severe peritonitis with septic shock and persistent physiological derangement 1
• Need for deferred intestinal anastomosis or planned second-look for intestinal ischemia 1