TY  - BOOK
AU  - Robert Lim Editor
TI  -  Multidisciplinary Approaches to Common Surgical Problems
SN  - 9783030128227
PY  - 2019///
CY  - Department of Surgery Tripler Army Medical Center Honolulu, HI USA
PB  - Springer Nature Switzerland AG 
KW  - Surgery
N1  - Includes Index
N2  - Just two and a half decades ago when I started my residency training, the
decisions made for acute general surgery problems used to require only a
single provider, the general surgeon. While surgery, at that time, often
afforded the patient the best chance to survive a perforated diverticulitis or a
bleeding duodenal ulcer, there was still a high morbidity rate and survivors
endured a long hospitalization and recovery. With the advancement of surgical techniques, radiologic technology, endolumenal therapy, radiation therapy, and chemotherapy, many of the acute surgical diseases require a
multidisciplinary approach and are even now managed primarily by other
specialties. This has changed the skill set of the general surgeon. They now
require more laparoscopic and endolumenal skills and, cognitively, they have
to be familiar and aware of the advantages, disadvantages, and limitations of
other modalities. This can also mean that the patient who eventually comes to
needing urgent surgical intervention will be the sickest population and in the
most urgent need of surgery because all other options have been unsuccessful. The general surgeon will also have to be familiar with the concept and
techniques of damage control surgery in these situations.
In the case of upper gastrointestinal (GI) bleeding, providers used to put a
limit on the number of packed red blood cell transfusions the patient could
receive before deciding to operate. Now patients will often undergo several
attempts at endolumenal and interventional radiology therapy provided they
are resuscitated appropriately and remain hemodynamically stable. Surgery
is reserved, therefore, for the patient who continues to bleed despite the best
efforts of the other specialties or for the patient who is unstable. Prompt intervention will be needed, and therefore the general surgeon must be vigilant
and ready to operate quickly.
The complications of gallstones are another entity that will typically
require a gastroenterologist, a radiologist, and a general surgeon. A similar
team can be utilized for diverticulitis and in the treatment of inflammatory
bowel disease. For the latter, the surgeon should, in particular, be familiar
with the medical treatment modalities and their efficacy when deciding
whether or not to perform surgery.
This multidisciplinary approach can also be seen in GI malignancies that
present with obstruction or bleeding. While the patient may eventually come
to need surgery, the use of endolumenal stents can temporarily treat the
obstruction and allow the use of neoadjuvant chemo- and radiation therapy.
This, in turn, may decrease the tumor burden allowing a less invasive and  earlier approach to ultimately treat the cancer, as with esophageal, liver, and
rectal tumors. In other instances, it may preclude the need for surgery entirely
as with anal cancers.
The ubiquity of bariatric surgery represents another area where a multidisciplinary approach is required. These patients often have multiple comorbidities that need attention and even those with successful weight loss and control
of their comorbidities may have acute nutritional and psychological derangements. These patients often have limited physiologic reserve also, so acute
issues need to be identified and addressed quickly to prevent hemodynamic
collapse. Identification requires an awareness of the possible complications
by an emergency physician and appropriate radiologic testing with attention
paid to the bariatric procedure. Bariatric patients, for instance, will not be
able to take in a liter of oral contrast for an abdominal CT scan. Today’s
endoscopist is typically the first line for treatment of complications like anastomotic strictures, leaks, and marginal ulcers.
There will always be acute nonobstetric surgical issues in the pregnant
patient. Any surgical disease process that risks septic shock or hemodynamic
collapse should supersede any fear that surgery and/or anesthesia will compromise the fetus. This is because the risk of fetal demise increases greatly
when sepsis or perforation occurs. However, this approach does require
knowledge of pregnancy physiology, appropriate diagnostic imaging, and the
clinical acumen of when to best intervene. Surgery, in general, is safe in all
trimesters but again requires a multidisciplinary approach.
Finally, there will be less common but no less dangerous occurrences that
require more than one specialty to successfully treat the patient. This includes
bleeding in cirrhotic patients, strangulated paraesophageal hernias, significant bleeding from idiopathic thrombocytopenia, end-stage achalasia, mesenteric ischemia, complicated empyemas, and a hypertensive crisis from a
pheochromocytoma.
The purpose of this book is to help all members of these multidisciplinary
teams understand the role and the limitations of the other specialties. The
chapters were authored by clinically active specialists in their fields, to
include gastroenterology, interventional radiology, radiology, obstetrics,
endocrinology, medical oncology, and pulmonary/critical care. It is meant to
give the clinician a different perspective of the same disease. It is the hope
that this book will make patient care more efficient, will make consultations
more appropriate, and will help all members recognize when emergent intervention needs to be done and when intervention can be delayed for a few
hours. Ultimately this book is for the patients. While tremendous advancements have occurred in medicine over the past 25 years, emergency general
surgery alone remains an independent risk factor for mortality and
complications.1
With the exception of the pregnant patient, the diseases covered in this
book represent areas where I feel the treatment paradigm has shifted away
from a surgery-first approach. As such, diseases like small bowel obstructions and appendicitis were not covered. Many more diseases could probably be
included and perhaps in the next decade the treatment paradigm will shift
again. But I have also chosen these because they have personally caused me
a lot of sleepless nights wondering what else can be done to improve this kind
of care. As such, this book would not be possible without the love and support
of my beautiful, graceful, and kind-hearted wife Lisa. Her heart is endless
and I owe all of my success to her wonderful spirit
ER  -