What are the surgical options?

From the Guidelines

Surgical procedures for colon and rectal cancer emergencies, such as obstruction and perforation, should prioritize Hartmann’s procedure as the procedure of choice for left-sided perforation, considering the high risk of anastomotic leakage (AL) and mortality in emergency settings. When deciding on the surgical approach, it is crucial to consider the location of the tumor, the patient's comorbidities, and their clinical status at presentation 1. For right-sided lesions, a definitive treatment such as right colectomy (RC) and ileocolic anastomosis can be considered, but the surgeon should be aware of the higher risk of AL and mortality in emergency cases compared to elective cases 1. In cases where the clinical condition suggests avoiding the creation of an anastomosis, a terminal ileostomy is recommended, with the transverse colon stapled or a mucous fistula created occasionally 1. Loop ileostomy should be reserved for obstruction when the tumor is not easily resectable or in cases requiring a very abbreviated laparotomy 1. The decision on the type of surgical procedure depends on various factors, including the size, location, and etiology of the perforation, the viability of the surrounding colon and mesocolon, the degree of peritonitis, the patient's general status, and the presence of comorbidities 1. In the management of iatrogenic colonoscopy perforation, explorative laparoscopy is indicated for both diagnostic and therapeutic purposes, allowing for the evaluation of the perforation and the potential for definitive surgical procedures 1. The therapeutic decision remains essentially empirical, based on the perforation characteristics, the patient's general status, and the availability of adequate technology and surgical devices 1. Close monitoring of the patient is crucial to detect clinical deterioration, which may signal the need for emergency surgery, and timely decisions for proceeding with the operation are important to improve outcomes 1. Key considerations in surgical management include:

• The size and location of the perforation
• The degree of peritonitis and the patient's hemodynamic stability
• The presence of comorbidities and the patient's overall health status
• The availability of adequate technology and surgical expertise
• The potential for anastomotic leakage and the need for damage control surgery. By prioritizing these factors and considering the most recent and highest-quality evidence, surgeons can make informed decisions to optimize patient outcomes in emergency surgical situations 1.

From the Research

Surgical Management of Acute Appendicitis

• Acute appendicitis is a common abdominal surgical emergency, with an annual incidence of 96.5 to 100 cases per 100,000 adults 2.
• The diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging, with laparoscopic appendectomy being the most common treatment 2.
• However, broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients, and may be considered as first-line therapy in selected patients 2, 3.

Treatment Options

• Appendectomy remains the first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis 2, 3.
• The choice between appendectomy and antibiotics depends on various factors, including the patient's overall health, the severity of the appendicitis, and the presence of high-risk CT findings 2.
• CT findings such as appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with a higher risk of treatment failure with an antibiotics-first approach 2.

Surgical Techniques

• Laparoscopic appendectomy is the most commonly used technique, with a reported rate of up to 86% in recent literature 4.
• Open appendectomy remains a safe and effective technique, while single port laparoscopic appendectomy and NOTES-appendectomy are newer developments that require further evaluation 4.
• The choice of surgical technique depends on various factors, including the patient's overall health, the severity of the appendicitis, and the surgeon's expertise 4.

Ethical Considerations

• Shared decision making between patients and surgeons is essential in the acute care surgical setting, taking into account the patient's goals, values, and preferences 5.
• Ethical challenges may arise in the acute care surgical setting, including the time-sensitive and life-threatening nature of acute surgical disease, absence of a patient's decision-making capacity, and lack of a preexisting relationship between the patient and surgeon 5.
• A model for the institutional adoption of innovative surgical techniques can assist surgeons and institutions in safely implementing new techniques, including the introduction of new surgical procedures and technologies 6.