Should More Patients Continue Aspirin Therapy Perioperatively?: Clinical Impact of Aspirin Withdrawal Syndrome^-www.drkeyurbhatt.in*

Annals of Surgery:

May 2012 - Volume 255 - Issue 5 - p 811–819

doi: 10.1097/SLA.0b013e318250504e

Feature

Gerstein, Neal Stuart MD^*; Schulman, Peter Mark MD^¶; Gerstein, Wendy Hawks MD^†; Petersen, Timothy Randal PhD^‡,*; Tawil, Isaac MD^§

Abstract

Objective: To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal.

Background: For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned.

Methods: We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion.

Results/Conclusions: Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

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CASE: RECURRENT FECAL FISTULA^-www.drkeyurbhatt.in*

Old aged male with h/o trauma 8 months back and operated for resection of 3.5 feets of ileum due to mesenteric tare..developed low level fistula from wound....discharging pus...

Was not subsided even after 6 months of surgery...worked up again and fistulogram suggested communication with bowel..taken up Unfortunately scrapping...and biopsy...and some resection was done (exact data not available)  Bx was sent from the fistula site: s/o tuberculosis!!

Following this surgery presented after 20 days of hospital stay with bile discharging from main wound

TLC:  22,000 , And hypotension with tachycardia and distension

CECT : plain and oral contrast demonstrated leak near terminal ileum....

surgery: exploration and removal of of dead omentum, lump, debridment of obscess, Rt quarter colectomy and ileostomy and mucus fistula...wound healed and pt discharged on POD 7 to home.

on exploration, with chronic fistulous tracts and dirty abscesses...

after clearing , lavage and resection...the relatively healthy looking bowel

HPE: s/o  atypical tuberculosis with granuloma p/o M. Kansasi

pt now started on COMBINATION AKT.

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Timing of Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review^-www.drkeyurbhatt.in*

Annals of Surgery:

May 2012 - Volume 255 - Issue 5 - p 860–866

doi: 10.1097/SLA.0b013e3182507646

Reviews

van Baal, Mark C. MD^*; Besselink, Marc G. MD, PhD^†; Bakker, Olaf J. MD^†; van Santvoort, Hjalmar C. MD, PhD^†; Schaapherder, Alexander F. MD, PhD^‡; Nieuwenhuijs, Vincent B. MD, PhD^§; Gooszen, Hein G. MD, PhD^*; van Ramshorst, Bert MD, PhD^‖; Boerma, Djamila MD, PhD^‖; for the Dutch Pancreatitis Study Group

Abstract

Objectives: To determine the risk of recurrent biliary events in the period after mild biliary pancreatitis but before interval cholecystectomy and to determine the safety of cholecystectomy during the index admission.

Background: Although current guidelines recommend performing cholecystectomy early after mild biliary pancreatitis, consensus on the definition of early (ie, during index admission or within the first weeks after hospital discharge) is lacking.

Methods: We performed a systematic search in PubMed, Embase, and Cochrane for studies published from January 1992 to July 2010. Included were cohort studies of patients with mild biliary pancreatitis reporting on the timing of cholecystectomy, number of readmissions for recurrent biliary events before cholecystectomy, operative complications (eg, bile duct injury, bleeding), and mortality. Study quality and risks of bias were assessed.

Results: After screening 2413 studies, 8 cohort studies and 1 randomized trial describing 998 patients were included. Cholecystectomy was performed during index admission in 483 patients (48%) without any reported readmissions. Interval cholecystectomy was performed in 515 patients (52%) after 40 days (median; interquartile range: 19–58 days). Before interval cholecystectomy, 95 patients (18%) were readmitted for recurrent biliary events (0% vs 18%,P < 0.0001). These included recurrent biliary pancreatitis (n = 43, 8%), acute cholecystitis (n = 17), and biliary colics (n = 35). Patients who had an endoscopic retrograde cholangiopancreatography had fewer recurrent biliary events (10% vs 24%, P = 0.001), especially less recurrent biliary pancreatitis (1% vs 9%). There were no differences in operative complications, conversion rate (7%), and mortality (0%) between index and interval cholecystectomy. Because baseline characteristics were only reported in 26% of patients, study populations could not be compared.

Conclusions: Interval cholecystectomy after mild biliary pancreatitis is associated with a high risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis. Cholecystectomy during index admission for mild biliary pancreatitis appears safe, but selection bias could not be excluded.

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CASE: Strange case of duodenal third part perforation - close loop obstruction^-www.drkeyurbhatt.in*

22 yrs male with h/o corrosive ingestion 3 months back
with residual gastric and esophagial scaring

FJ was done for the same 3 months back..

patient presented with sever agonizing pain in abdomen for last 2 days with shock

P: 170/min BP: 70 systolic
resuscitation and
CT SCAN S/O : Retro peritoneal collection with free gas..and dilated duodenum and proximal jejunum till FJ site..distal loops collapsed   ? duodenal perforation

exploration: reveled the same a large perforation in D 3 Bellow the vessels with retroperitoneal sepsis.

primary closure , detwisting of jejunal loop , and a new feeding jejunostomy and drainage was done.

Fortunately pt survived..

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CASE: Chronic alcoholic pancreatitis with pseudocyst in head^-www.drkeyurbhatt.in*

Middle aged male with severe pain in central abdominal pain severe in intensity ,  for 6 months and 25 kg wt loss. DM II For last 6 months..

evaluated and diagnosed as Chronic alcoholic calcific pancreatitis with pseudo cyst in uncinate process of pancreas..

CECT:

SURGERY: LPJ With head coring...

Patient discharged on POD 6. without pain.

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