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PITTFALLS ON ACUTE ABDOMEN 1 st Surabaya Gastrointestinal and Emergency Surgery (SuGIES), Hotel Novotel Surabaya, 19 – 20 May 2017 Prof. Dr. P. Soetamto Wibowo, Sp.B-KBD – Dep/SMF I. Bedah FK. Unair/RSUD Dr. Soetomo Surabaya An error the breath of a single hair can lead one a thousand miles astray Chinese Proverb

Transcript of PITTFALLS ON ACUTE ABDOMEN -...

PITTFALLS ON ACUTE ABDOMEN

1st Surabaya Gastrointestinal and Emergency Surgery (SuGIES), Hotel Novotel Surabaya, 19 – 20 May 2017

Prof. Dr. P. Soetamto Wibowo, Sp.B-KBD – Dep/SMF I. Bedah FK. Unair/RSUD Dr. Soetomo Surabaya

An error the breath of a single hair can lead one a thousand miles astray Chinese Proverb

WHY ?

Medicine : High Risk System with High Error Rate

Cross Industry Comparison of size, productivity and efficiency (the Advisory Board Company 2005 )

Complications and Adverse Events

in Surgery

10% of hospital admission suffer harm, half is preventable [1,2]

50% - 75% of hospital wide adverse events are attributable to surgical care.

Most errors occur in the OR [3]

[1] Thomas EJ, Clinical Risk Management Enhancing Patient Safety, BMJ Publ. 2001 : 31-44 [2] Vincent C. System Approaches to Surgical

Quality and Safety, Ann. Surg. 2004; 239 : 475-482 [3] Healey MA, Complications of Surgical Patients, Arch Surg. 2002; 137 : 611 – 618

Insurance Premium $ 30,000 - $ 300,000 / yr

Health Cost

Rising Cost of Health Care is just a symptom

WHAT IS THE REAL DISEASE ?

→ GREED and INCOMPETENCE ?

Do not count for double digit

(Thomas A Lee, HBR, Apr 2010)

Pitfalls on Acute Abdomen

The Paradox

Institute of Medicine (IOM) 1999 :

“To Err is Human” (1)

not an explanation accepted by the media, the public, the insurance companies, or lawyer.

(1) Institute of Medicine. To Err is Human. Washington DC. National Academies Press, 2000.

Pitfalls on Acute Abdomen

Taking Ownership

Leape and Berwick (1) 2004 :

“ We will not became safe until we chose to become safe” → Patient’s safety.

(1) Leape L, Berwick D. Five years after To Err is Human – What we have learned ? JAMA 2005 : 293 : 2384 – 2390

Leadership

Performance

Pitfalls on Acute Abdomen

Errors in Human Performance

Errors Categories (1) :

Knowledge base

Lack of experience or knowledge or misintepretation of the problem

Rules based

Misperception or misapplication of the rule

Skill based = “slips”

Reason J. Human error. Cambridge, MA. Cambridge University Press 1992

Case 1

54 years old man with sudden right upper abdominal pain for 5 days

Fever + → ED

PE : Abdomen – RUQ

Rigidity +

Murphy signs +

General peritonitis −

USG : Gallbladder – stone +

Thicken wall

Double layer

Pericystic fluid

Perforated gallbladder ?

Rules Tokyo Guidelines → Surgery ?

Evidence Based Golden Rules

Emergency Surgery

Usually doing less is betterbut

Occasionally doing more may be life saving

Acute Abdomen :Operate only when necessary and do the minimum possible

butDo not delay a necessary operation

and do the maximum when indicated

Pitfalls on Acute Abdomen

Errors Training

Whoever refuses to admit error may be a great scholarbut

He is not a great learnerJohann Wolfgang von Goethe 1749 – 1832

Fitts and Posner Model (1) :

If you commit any mistake – there are 3 things to do :

Admit it

Learn from it

Don’t repeat it

(1) Fitts P, Posner MI. Human Performance, Belmont, CA : Brooks / Cole Publ. 1969

Compassion

Pitfalls on Acute Abdomen

Acute Abdomen

Definition :

Pain of non traumatic origin with a maximum

duration of 5 days (1)

Account 7 – 10 % of all Emergency Department

(ED) (2)

(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31

(2) Hasting RS, Power s RD. Abdominal pain in the ED. A 35 years retrospective . Am.J. Emerg.Med 2011; 29 711 – 716.

Pitfalls on Acute Abdomen

Acute Abdominal Pain (AAP)

Great caution – Problem

AAP can be caused by variety of diseases from mild –self limiting – live threatening diseases

Early – accurate diagnosis → better outcomes

Diagnostic practice varies within hospitals and within specialities

Despite substantial improvement in diagnostic approach, pitfalls remain → misdiagnosis → error

Medicolegal Litigation

Pitfalls on Acute Abdomen

Cause of Acute Abdomen (1)

Urgent – Treatment within 24 hours

Non Urgent – Not requiring treatment within 24 hours

(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31

Pitfalls on Acute Abdomen

Diagnostic Pathway

Step 1 :

Medical History

Physical Examination

Laboratory : CRP > 100 mg/dl

WBC > 15x109/L

Correct Diagnosis in 46% - 48% (1,2)

Higher sensitivity for differentiating urgent from non urgent than for specific diagnosis (EL A2) (1,2)

(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31

(2) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

Pitfalls on Acute Abdomen

Medical History – History – History

Previous similar pain

Previous abdominal surgery

Previous major illness

Gynecologic history

Drug history

nset sudden – chronicrovocative Progress What make it better – worse

no change – movement uality Colicky – sharp – burning egion General – localized

radiated – migrated – reverseverity Mild – moderate - severe ime begin - duration

O

P

QR

S

T

Pitfalls on Acute Abdomen

Medical History

Case 1

9 yrs old boy – abdominal discomfort

+ diarrhoea → ED : Dx gastroenteritis

The clinical notes did not cerroberate

4 days → no better → ED : ongoing GE

Overnight the boy deteriorated → ED

ED → Dx : burst appendix abscess → surgery

→ 2 weeks discharge

claim → out of court settlement

Pitfalls on Acute Abdomen

Medical History

Case 2

70 yrs old woman with sudden abdominal pain for one day + fever + vomiting

→ ED : there was no written note to support the doctor in charge contention that the abdomen was examined.

Lab : WBC 13x109/L Blood sugar 250 gm/dl

→ Consult internist : urine shutdown, s.creatinine 2.5 gm/dl

→ Consult Nephrologist resuscitation – ICU

Day 1 → GCS → Consult Neurologist

Day 2 → her condition deteriorated → ?

Abd X-ray : Free air : positive → surgeon : perforated peptic ulcer

Pitfalls on Acute Abdomen

Diagnostic Pathway

Step 2

Urgent condition → imaging :

1. Conventional Radiography

Plain chest x-ray

Plain abdomen : upright position

supine

left lateral decubitus

Diagnostic accuracy 47% - 56% (ELA2) (1,2)

No added value on top of clinical assessment

in discriminating urgent or non urgent causes (ELA2 (1,2)

Only for bowel obstruction

(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31

Pitfalls on Acute Abdomen

Diagnostic Pathway

2. Ultrasound (US)

Advantages : widely available

no risk of radiation

no risk of nephropathy

Downside : operator dependent

Clinical + USG dx accuracy 53% - 83% (ELA2 (1,2)

(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31

Pitfalls on Acute Abdomen

Diagnostic Pathway

3. Computed Tomography (CT)

Clinical + Radiography + CT accuracy final diagnosis 61.6% - 96%

(ELA2) (1,2)

Prefer i.v. contrast → eGFR > 45 ml/min/1.73m2 (3)

Recom (1,2) :

USG CT (conditional)

Laparoscopy : No Research (1,2)

MRI : No place yet (1,2) → non urgent

Pregnant woman

(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31

(3) Katzberg RW, New house JH : Intravenous contrast medium induced nephro toxicity is the medical risk really as great as we have come to

believe ? Radiology 2010 ; 256 : 21 – 28.

inconclusive

Pitfalls on Acute Abdomen

Cause of AAP – Evidence

n %

Nonspecific Abdominal Pain (NSAP) 1.680 31.46

Renal Colic 1.665 31.18

Biliary 411 7.70

Appendicitis 203 3.80

Diverticulitis 194 3.63

Urologic 147 2.75

Peptic Ulcer 143 2.68

Others

Cervellin G (1) – Parma – Italy 2014 N = 5,340 = 5.76% ED visit

(1) Cervellin G, Mora R, Ticinesi A et al . Epidemiology and Outcomes of acute abdominal pain in a large urban Emergency Department

: retrospective analysis of 5,340 cases. Ann Transl Med 2016; 4(19) : 362.

Pitfalls on Acute Abdomen (ED) (1)

Laurell – Sweden 1997 – 2000 (n=2851)

Accuracy of Diagnosis

n Accuracy

NSAP 1058 0.48

Appendicitis 277 0.74

Gallstone 208 0.84

Diverticulitis 134 0.91

Constipation 130 0.88

Ureteric stone 107 0.94

Cholecystitis 100 0.88

Gyn. Diagnosis 101 0.94

Pancreatitis 92 0.93

Intestinal Obstruction 78 0.93

Gastro Enteritis 64 0.94

Peptic Ulcer 34 0.93

Incarcerated hernia 22 0.99

Colonic Obstruction 14 0.97

Laurell H., Hanson LE, Gunnarsson V : Diagnostic pitfall and accuracy of diagnosis in acute abdominal pain. Scandinavian J.G.enterol

2006; 41 : 1126 – 1131

Pitfalls on Acute Abdomen

Final Diagnosis Correlated to the preliminary diagnosis

Laurell H. Sweden 1997 – 2000 (n=2851)

Preliminary Diagnosis

NSAP n=1058

Appendicitis n=277

Gallstone n=208

Colonic Obstr. n=14

Peptic Ulcer n=34

NSAP 458 (43%) 24 (9%) 19 (9%)

Appendicitis 132 (12%) 222 (80%) 3 (1%)

Gallstone 75 (7%) 2 (10.5%) 141 (68%) 9 (26%)

Peptic Ulcer 20 (2%) 1 (0,5%) 4 (29%)

Colonic Obstruction

4 (1%) 1 (0,5%)

Laurell H., Hanson LE, Gunnarsson V : Diagnostic pitfall and accuracy of diagnosis in acute abdominal pain. Scandinavian J.G.enterol 2006;

41 : 1126 – 1131

Pitfalls on Acute Abdomen

Emergency General Surgery EGS) USA (2008-2011) (1)

7 types of surgery account 80.1% of EGS

80.3% of deaths

78.9% of complication

80% inpatient cost

Surgery n Mortality Rate (%) Morbidity Rate (%)

Appendectomy 682.043 0.008 7.27

Cholecystectomy 619.197 0.22 8.06

Partial Colectomy 138.992 5.33 42.80

Peritoneal adhesion 102.856 1.59 28.09

Small bowel Resection 78.478 6.47 46.94

Peptic Ulcer disease 31.571 6.83 42.00

Laparotomy 9.412 23.71 40.15

Overall Mortality 1.23%

(1) Scott JW, alufajo DA, Brat GA et al : Use of National burden to define Operative Emergency General Surgery. JAMA Surg 2016 , April 27th

Pitfalls on Acute Abdomen

Surabaya Experience 2016

Emergency General Surgery Dr. Soetomo General Hospital 2016

Digestive Oncology Head & Neck Th. Card .Vasc. General Total

437 (63.80%) 2 (0,3%) 133 (19.4%) 108 (15.8%) 5 (0,7%) 685

Emergency Digestive Surgery

Dr. Soetomo General Hospital – 2016

n %

Appendicitis 87 28.15

Peptic Ulcer Disease 60 19.87

Colorectal Malignancy 57 18.87

Incarcerated Hernia 46 15.23

Intestinal Adhesion 14 4.64

Small Intestine Perforation 10 3.31

Diverticulitis 8 2.65

Intestinal Strangulation 7 2.32

Hepatobiliary pathology 7 2.32

Others 8 2.65

Re-Laparotomy 62 (20.93%)

Pitfalls on Acute Abdomen

Soetomo General Hospital Pitfalls

January – February – March 2017

Primary Dx Final Diagnosis

Perforated Appendix 1 Perforated Diverticulitis

(n = 7) 2 Perforated ileal (Typhoid)

3 Perforated Endometriosis

4 Perforated Endometriosis

5 Perforated Ulcerative Colitis

6 Perforated Crohn Ileitis

7 Gallbladder perforation

Pitfalls on Acute Abdomen

RS. Tulungagung 2016

Emergency Digestive Surgery 580

n %

1 Acute appendicitis / perforation 110 51.89

2 General peritonitis (laparotomy) 44 20.75

3 Incarcerated hernia 32 15.09

4 Intestinal obstruction 19 8.96

5 Peptic Ulcer perforation 7 3.30

Total 212

Pitfalls on Acute Abdomen

Guideline for the Diagnostic Pathway

Pitfalls on Acute Abdomen

Guideline for the Diagnostic Pathway

Pitfalls on Acute Abdomen

Special Case

Obesity

Clinical Diagnostic ? → CT

Pregnancy → Clinical diagnostic : appendicitis

Imaging ? → USG

Operate ?

→ Gallbladder stone

USG

Operate ?

Pitfalls on Acute Abdomen

Antibiotic

Antibiotic therapy within the first hour of recognition of sepsis (1)

Morphin – Analgetic ?

Administration of opioids / analgesic decrease the intensity of the pain and DOES NOT affect the accuracy of physical examination and diagnostic (ELA2) (2,3,4,5)

(1) Intensive Care Medicine : Surviving Sepsis Campaign : International Guidelines for Management of Sepsis and Septic Shock; 2016

(2) Lo Veccio F, Osler N, Sturmann K et al : the use of analgesic in patients with acute abdominal pain. J.Emeg 1997; 15 : 775 – 779

(3) Gallagher EJ, Esses D, Lee C et al : Randomized Clinical Trial of Morphin in acute abdominal pain. Ann Emerg Med 2006; 48 : 150 – 160

(4) GungorF, Kartal M, Bektas F et al : Randomized Controlled Trial of Morphine in elderly patients with acute abdominal pain. Turkish J of

trauma & emergency surgery 2012; 18 (5) : 397 – 404

(5) Gans SL, Pols MA, Stoker J et al : Guideline for the Diagnostic Pathway in Patients with acute abdominal pain. Dig Surg 2015; 32 : 23 – 31.

Pitfalls on Acute Abdomen

Take Home Message

Unconsciously

Incompetent

Consciously

Incompetent

Unconsciously

Competent

Consciously

Competent

IGNORANCE

KNOWLEDGE

(1) Dreytas HE, Dreifus SE. Mind over machine. New York : New York Free Press , 1982

STEPS TO MASTERY (1)

AWAREUNAWARE