General and Visceral Surgery Review E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 636

Veröffentlichungsjahr: 2011

Beschreibung

It's your job to do the learning - it's our job to make it easier!

This book serves as a simple review of selected general surgery topics in outline format. The illustrations are exceptionally good, displaying sufficient detail to depict the important anatomy without unnecessary distractions. -- Kevin Helling, MD, University of Iowa Hospitals and Clinics

Covering all the main topics and latest operative techniques, General and Visceral Surgery Review is a compact, highly structured review book designed to maximize your study time for the medical residency board exams. It pinpoints only the information you need to master the exam—enhanced by highlighted key words, summary tables, outline lists, and sidebar notes that make understanding and retention fast and easy.

Features:

• Succinctly covers the major areas in general and visceral surgery—anatomy, etiology,disease patterns, symptoms, diagnosis, and therapy—with a focus on "what you need to know" for the exam
• Provides nearly 200 instructive surgical descriptions and clear operative illustrations
• Includes state-of-the-art minimally invasive and fast-track surgical techniques
• Breaks topics into concise, digestible chunks of information that facilitate quick memorization
• Offers targeted information that is comprehensive but not excessive—does not overload you with extraneous material

Optimally structured, clearly presented, and packed with helpful study aids, this book is the go-to companion for all students and residents specializing in general and visceral surgery and preparing for the medical residency board exams. It is also useful as a general study aid and a distillation of key points in conjunction with larger, more detailed texts.

Leseprobe

General and Visceral Surgery Review

Nicolas T. Schwarz, MD

Associate ProfessorFriedrich Ebert HospitalSurgical ClinicNeumünsterGermany

Karl-Heinz Reutter, MD

StuttgartGermany

With contributions byHinrich Brunn, Ronald J. Elfeldt, Michael Fuchs,Jan M. Mayer, Ingo L. Schmalbach, Nicolas T. Schwarz,Alexander Selch, Burkhard Thiel, Michael Voelz

185 illustrations

Thieme Stuttgart · New York

Library of Congress Cataloging-in-Publication Data

Allgemein- und Viszeralchirurgie. English.

General and visceral surgery review/[edited by] Nicolas T. Schwarz, Karl-Heinz Reutter; with contributions by Hinrich Brunn … [et al.]; [translator, Geraldine O’Sullivan; illustrators, P. Gusta … et al.].

p.; cm.

Originally published in German as: Allgemein- und Viszeralchirurgie. 6th ed. 2009.

ISBN 978-3-13-154311-0 (pbk.: alk. paper) 1. Operations, Surgical–Handbooks, manuals, etc. 2. Viscera–Surgery–Handbooks, manuals, etc. I. Schwarz, Nicolas T. II. Reutter, Karl-Heinz. III. Brunn, Hinrich. IV. Title.

[DNLM: 1. Surgical Procedures, Operative–methods–Handbooks. 2. Viscera–surgery–Handbooks. WO 39]

RD32.A56513 2011

617'.9–dc23

2011015799

This book is an authorized translation of the 6th German edition published and copyrighted 2009 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Allgemein-und Viszeralchirurgie.

Translator: Geraldine O’Sullivan, Dublin, Republic of Ireland

Illustrators: P. Gusta, Champigny sur Marne, France; J. and K. Hormann, Stuttgart, Germany; Christiane and Dr. Michael von Solodkoff, Neckargemünd, Germany

© 2012 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germanyhttp://www.thieme.de Thieme New York, 333 Seventh Avenue,http://www.thieme.com

Cover design: Thieme Publishing Group Typesetting by Druckhaus Götz, Ludwigsburg, Germany Printed in China by Everbest Printing Co. Ltd.

ISBN: 978-3-13-154311-0123456

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

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List of Contributors

Hinrich Brunn, MD Friedrich Ebert Hospital Surgical Clinic Department of Vascular Surgery Neumünster Germany

Ronald J. Elfeldt, MD Associate Professor Friedrich Ebert Hospital Surgical Clinic Department of Thoracic Surgery Neumünster Germany

Michael Fuchs, MD Associate Professor Friedrich Ebert Hospital Trauma and Orthopedic Clinic, Sports Trauma Clinic Neumünster Germany

Jan M. Mayer, MD Friedrich Ebert Hospital Surgical Clinic Neumünster Germany

Ingo L. Schmalbach, MD Friedrich Ebert Hospital Surgical Clinic Neumünster Germany

Nicolas T. Schwarz, MD Associate Professor Friedrich Ebert Hospital Surgical Clinic Neumünster Germany

Alexander Selch, MD Friedrich Ebert Hospital Surgical Clinic Department of Vascular Surgery Neumünster Germany

Burkhard Thiel, MD Friedrich Ebert Hospital Surgical Clinic Neumünster Germany

Michael Voelz, MD Friedrich Ebert Hospital Surgical Clinic Neumünster Germany

Preface

General and Visceral Surgery Review was originally published in German in 1996 as a revision aid for surgery in general. Since then, as the individual surgical subspecialties continue to develop, and today’s medical training is built around the “Common Trunk” (as it is called in Germany), with subsequent specialist training, it has been necessary to continually update and adapt the higher-training content according to the various surgical specialties. General and Visceral Surgery Review was published in its sixth German-language edition in 2009.

Karl-Heinz Reutter, MD, created General and Visceral Surgery Review and continued it through five successful editions in the German language. I am not only happy to take over the task of editor from him for further German language editions, I am also highly delighted to be able to present the first English-language edition.

The purpose of this textbook is higher training and examination preparation in general and visceral surgery. We have made every effort to include up-to-date information and to present this information in a concise and succinct format, thus enabling colleagues to acquire the necessary theoretical knowledge in the shortest possible time.

This book is designed to place emphasis on core statements, and includes suggestions for further reading to help consolidate what has been learned. Contributions were provided by surgeons actively working in this field. By calling on their own practical experiences they have produced an ideal learning tool suited to the current requirements of higher training and examination preparation.

Nicolas T. SchwarzNeumünster, Germany

Acknowledgements

I thank my colleague K.-H. Reutter, MD, for giving me the opportunity to take over the editorship of this book. My special thanks also go to my medical colleagues in the Departments of Surgery and Trauma Surgery in Neumünster. We owe the production of this new edition to their enthusiasm for general and visceral surgery and to their constant thirst for knowledge, coupled with the desire to pass on this interest and their love of the specialty to their many colleagues.

Contents

1    Perioperative Medicine     N.T. Schwarz

Preoperative Phase

Intraoperative Phase

Postoperative Period

Fast-Track Surgery

2    Thyroid      B. Thiel

Anatomy

Physiology

General Epidemiology

General Diagnostic Approach

General Treatment Approach

Diseases of the Thyroid

Euthyroid Goiter

Hyperthyroidism

Graves Disease, Immunogenic Hyperthyroidism

Thyrotoxic Crisis

Thyroiditis

Thyroid Carcinoma

3    Parathyroid      B. Thiel

Anatomy

Physiology

Primary Hyperparathyroidism

Secondary Hyperparathyroidism

Tertiary Hyperparathyroidism

Parathyroid Carcinoma

Hypoparathyroidism

4    Thorax (Pleura, Lung)      R.J. Elfeldt

Anatomy

Pleural Effusion

Pleural Empyema

Chest Trauma: Blunt Chest Injuries

Chest Contusion

Chest Compression

Rib Fractures

Fracture of the Sternum

Lung Contusion

Chest Trauma: Penetrating Chest Injuries

Traumatic Pneumothorax

Hemothorax

Chylothorax

Tracheal and Bronchial Injuries

5    Mediastinum      R.J. Elfeldt

Anatomy

Mediastinoscopy

Subcutaneous Emphysema

Mediastinal Emphysema

Mediastinitis

6    Diaphragm      I.L. Schmalbach

Anatomy

Diaphragmatic Hernias

Rare Disorders of the Diaphragm

7    Hernias      J.M. Mayer

Inguinal Hernias

Femoral Hernias

Incisional Hernias

Umbilical Hernia

Epigastric Hernia

Internal Hernias

8    Esophagus      M. Voelz

Anatomy

Histology

Physiology

Functional Disorders

Achalasia

Other Functional Disorders

Esophageal Diverticulum

Cervical Pulsion Diverticulum (Zenker Diverticulum)

Epiphrenic Pulsion Diverticulum

Traction Diverticulum

Gastroesophageal Reflux Disease (GERD)

Esophageal Carcinoma

Injuries of the Esophagus

Corrosive Injuries

Traumatic Perforation of the Esophagus

Spontaneous Esophageal Rupture (Boerhaave Syndrome)

9    Stomach and Duodenum      N.T. Schwarz

Anatomy

Ulcer

Bleeding from the Stomach and Duodenum

Gastric Carcinoma

MALT Lymphoma

10  Small Intestine      I.L. Schmalbach

Anatomy

Crohn Disease

Meckel Diverticulum

Jejunal Diverticulum

11  Vermiform Appendix      I.L. Schmalbach

Anatomy

Acute Appendicitis

Rare Diseases of the Appendix

Endometriosis of the Appendix

Crohn Disease

Diverticulitis of the Appendix

Appendix Carcinoid

Mucinous Cystadenoma / Pseudomyxoma Peritonei

Appendix Carcinoma

12  Colon      J.M. Mayer

Anatomy

Anastomosis Techniques

Minimally Invasive Colon Surgery

Diverticulosis and Diverticulitis

Ulcerative Colitis

Polyps of the Colon

Colon Cancer

13  Rectum      J.M. Mayer

Anatomy

Rectal Cancer

Pelvic Floor Insufficiency

14  Anus      J.M. Mayer

Anatomy

Hemorrhoids

Perianal Vein Thrombosis

Anal Fissure

Abscesses and Anal Fistulas

Fecal Incontinence

Anal Carcinoma

15  Intestinal Obstruction      H. Brunn

16  Spleen      H. Brunn

Anatomy

Physiology

Hypersplenism Syndrome

17  Liver      M. Voelz

Anatomy

Benign Liver Tumors

Focal Nodular Hyperplasia (FNH)

Hepatocellular Adenoma

Hepatic Hemangioma

Hepatic Cysts

Malignant Liver Tumors

Primary Hepatic Carcinoma

Liver Metastases

Hydatid Disease of the Liver (Echinococcosis)

Portal Hypertension

Liver Trauma

18  Gallbladder and Biliary Tract      M. Voelz

Anatomy

Cholecystolithiasis

Acute Cholecystitis

Gallbladder Carcinoma

Extrahepatic Bile Duct Carcinoma

19  Pancreas      N.T. Schwarz

Anatomy

Physiology

Acute Pancreatitis

Chronic Pancreatitis

Pancreatic Pseudocysts

Carcinoma of the Pancreas

Endocrine Pancreatic Tumors

Pancreatic Trauma

20  Transplantation      N.T. Schwarz

21  Peritonitis      B. Thiel

22  Neuroendocrine Tumors and Gastrointestinal Stromal Tumors      J.M. Mayer

Neuroendocrine Tumors

Stomach

Duodenum and Pancreas–Insulinoma

Duodenum and Pancreas–Gastrinoma

Ileum

Vermiform Appendix

Colon

Rectum

Gastrointestinal Stromal Tumors

23  Soft-Tissue Tumors      H. Brunn

24  Vascular Surgery      A. Selch

Arteries

Vascular Injuries

Aneurysms

Acute Limb Artery Occlusion

Acute Mesenteric Artery Occlusion

Chronic Arterial Disease of the Limbs

Subclavian Steal Syndrome

Veins

Varicose Veins

Phlebothrombosis

25  Emergency and Trauma Surgery      M. Fuchs

Polytrauma

Head Injury

Fractures

Dislocations

Soft-Tissue Injuries

Bone Infection

Nerve Injury

Tendon Rupture

Illustration Credits

Index

1     Perioperative Medicine

N.T. Schwarz

• Perioperative course has multifactorial influences.

• A patient’s postoperative recovery has multifactorial influences (Fig. 1.1). The perfect surgical technique on its own does not suffice. The patient’s progress is influenced particularly by physiological and psychological factors. “Evidence-based medicine” casts new light on traditional perioperative measures to produce new treatment concepts, the aim of which is to preserve or restore patient autonomy and homeostasis.

Fig. 1.1 Multifactorial influences on homeostasis.

Preoperative Phase

Risk Assessment

• The perioperative risk increases as the number of individual risk factors increases. Patients are classified prior to anesthesia according to the ASA (American Society of Anesthesiologists) classification (Table 1.1).

• In addition, a distinction can be made between patient-specific (Table 1.2) and operation-specific (Table 1.3) risks. Accordingly, preoperative investigations are necessary to assess the operative risk. In general, they are ordered when the results are likely to affect the management of the patient.

• Postoperative nausea and vomiting (PONV syndrome) are observed more

in females,

in nonsmokers,

with travel sickness,

with intraoperative opioid administration, and

with addition of nitrous oxide.

• PONV syndrome can be prevented effectively by various drugs (serotonin antagonists, dexamethasone, droperidol, propofol).

Table 1.1 ASA classificationGroupDescriptionIHealthy, not taking any medicationIIMild disease without functional limitation and need for medicationIIIDisease requiring medication, mild limitation of activityIVSevere disease, permanent severe limitation of capacityVMoribund, life expectancy < 24 hVIEmergency surgery regardless of I-V

Source: ACC/AHA guideline update for perioperative cardiovascular evaluation for non-cardiac surgery. Circulation 2002:103:1257–1267.

Table 1.2 Patient risk factorsLow riskMedium riskHigh risk

• Advanced age

• ECG abnormalities

• Rhythms other than sinus rhythm

• Low functional capacity

• History of stroke

• Poorly controlled hypertension

• Mild angina pectoris

• Previous myocardial infarction

• Compensated or early heart failure

• Diabetes mellitus

• Unstable coronary syndrome

• Decompensated heart failure

• Severe arrhythmias

Source: ACC/AHA guideline update for perioperative cardiovascular evaluation for non-cardiac surgery. Circulation 2002:103:1257–1267.

Table 1.3 Operation risk factorsLow riskMedium riskHigh risk

• Endoscopic and superficial procedures

• Cataract surgery

• Breast surgery

• Carotid endarterectomy

• Head and neck surgery

• Intraperitoneal, intrathoracic and orthopedic procedures and prostate surgery

• Surgery on the aorta, other major vascular surgery and operations on peripheral vessels

• Prolonged operations with major “volume shift” and/or blood loss

Source: ACC/AHA guideline update for perioperative cardiovascular evaluation for non-cardiac surgery. Circulation 2002:103:1257–1267.

Fasting

• Patients may generally drink low-fat liquids up to 2 hours preoperatively

• Patients fast preoperatively to protect against aspiration. Aspiration of solid food can lead to vagal reactions, bradycardia, and asystole, and aspiration of liquids can also lead to pneumonia, respiratory insufficiency and, in extreme cases, to ARDS (adult respiratory distress syndrome). Adequate preoperative hydration is an important requirement for maintaining perioperative homeostasis.

•Less than 6 hours preoperatively: no high-fat liquids or solid foods

•Up to 2 hours preoperatively: clear fluids

• Deviations in the case of:

emergency surgery,

massive obesity,

gastric emptying disorder,

pyloric stenosis,

gastric atony,

esophageal stenosis and diverticula,

certain neurological diseases, and

apparent hypothyroidism

• Prevention of stress-induced postoperative insulin resistance has been investigated in numerous studies. There is evidence that preoperative high-carbohydrate liquids, which are consumed up to 2 hours before the procedure, have a positive effect.

Patient-Informed Consent

• Apart from the legal requirement for patients to give informed consent, preoperative discussion of how patients can take an active part in their postoperative recovery is often positively motivating. Patients and relatives are given comprehensive information so that they are prepared as well as possible and can provide mutual support.

Bowel Preparation

• Orthograde bowel irrigation is virtually obsolete, and laxatives, enemas, or osmotically active solutions are used instead.

• Orthograde bowel irrigation for bowel preparation before major abdominal surgery is obsolete. Like osmotically active irrigation fluids, they can lead to measurable electrolyte shifts and thus to fluid losses into the bowel lumen, which can be hazardous for patients with cardiovascular risks.

• In elective colorectal procedures using fast-track surgery, preparation with a laxative and an enema on the previous evening has proved to be sufficient.

Premedication

• Apart from the anesthetic risk work-up and legal obligations, premedication serves to establish the perioperative anesthesiological treatment plan, particularly analgesia. The patient is given drug premedication for anxiolysis and sedation.

Pre- and Postoperative Anticoagulation

• The incidence of perioperative thrombosis in abdominal surgery averages 25% in studies. There are predisposing risk factors, which, together with the exposure factors (Table 1.4), define the individual’s thrombosis risk (Table 1.5).

Table 1.4 Exposure factorsLow riskMedium riskHigh risk

• Minor or medium surgery with low trauma

• Injuries without or with minor soft tissue damage

• No additional or slight predisposing risk

• More prolonged surgery

• Lower limb immobilization in a cast including a joint

• Low thromboembolism risk due to operation or injury and additional predisposing thromboembolism risk

• Major surgery in the abdomen and pelvis for malignant or inflammatory disease

• Polytrauma, severe injuries of the spine, pelvis and/or lower limb

• Major surgery on the spine, pelvis, hip and knee

• Major surgery in the chest, abdominal and/or pelvic body cavities

• Medium risk due to operation or injury and additional predisposing risk

• Patients with a history of thrombosis or pulmonary embolism

Source: AWMF (Working Group of German Specialist Scientific Medical Societies) guidelines: Inpatient and Outpatient Thromboembolism Prophylaxis in Surgery and Perioperative Medicine (April 24, 2003).On the Internet: http://www.awmf-leitlinien.de/003-001.htm; revised February 28, 2009 [in German].

Predisposing Risk Factors

• Thrombophilia:

History of venous thromboembolism

Congenital or acquired thrombophilic defects of hemostasis (e.g., anti-phospholipid syndrome, antithrombin, protein C or protein S deficiency, activated protein C resistance / factor V Leiden mutation, thrombophilic prothrombin polymorphism, etc.)

• Malignant disease

• Pregnancy and the postpartum period

• Advanced age (> 50 years; risk increases with age)

• Therapy with or block of sex hormones (including contraceptives and hormone replacement therapy)

• Chronic venous insufficiency

• Severe systemic infection

• Severe overweight (body mass index >30)

• Heart failure: NYHA (New York Heart Association) grade III or IV

• Nephrotic syndrome

• Thrombosis prophylaxis consists of physical measures and, if necessary, medical thromboembolism prophylaxis.

• In patients with a low thrombosis risk, physical measures and early mobilization suffice, but in patients with a medium and higher thrombosis risk, medical thrombosis prophylaxis is usually indicated in addition.

Medical Thrombosis Prophylaxis

• Perioperative thrombosis prophylaxis usually begins preoperatively.

• In contrast to the common practice in North America, thrombosis prophylaxis in Europe is started on the evening before surgery, using unfractionated heparin (UFH) or low molecular weight heparin (LMWH).

• The duration of the medical thrombosis prophylaxis depends on predisposing risk factors, the degree of operative trauma, and postoperative immobilization. After major surgery for malignant disease in the abdomen, it lasts for an average of 4–5 weeks, but so far there are no binding recommendations.

• Current medications for thrombosis prophylaxis:

Heparins

– UFH

– LMWH

Danaparoid

Fondaparinux

Thrombin inhibitors

Hirudin

Vitamin K antagonists (coumarin)

Intraoperative Phase

• Most of the changes in recent years have been made in this phase.

Operation Technique

• Minimally invasive operation techniques have functional postoperative benefits compared with laparotomy, such as

less pain,

less postoperative intestinal atony,

altered postoperative immune response and inflammatory reaction, and

less postoperative pulmonary dysfunction.

• When laparotomy is performed, transverse incisions have proved to be superior compared with midline and paramedian laparotomy in respect of postoperative pain and pulmonary function. In general, they result in fewer incisional hernias.

Drains and Nasogastric Tubes

• Perioperative nasogastric tubes should remain in place for as short a time as possible.

• Experience has shown that anastomotic leaks and secondary hemorrhage are not identified despite intraperitoneal drains. This has also been confirmed in randomized controlled studies.

• The benefit of routine placement of a nasogastric tube has not been confirmed either. It does not prevent, but rather promotes, postoperative intestinal atony and may enable silent aspiration to occur.

Anesthesia

• Anesthesia and analgesia have an important influence on the postoperative course following general and visceral surgical procedures. The following are beneficial for these procedures:

Rapidly controllable anesthetics

Increase in the inspiratory oxygen concentration

Normothermia

Regional anesthesia methods (epidural anesthesia → analgesia and sympathetic block)

Calculated intraoperative fluid replacement

Intraoperative Fluid Replacement

• Preoperative normovolemia is important for perioperative hemostasis.

• Maintenance of normovolemia and electrolyte balance is the most important goal High infusion volumes were usual in the past to compensate assumed “third space” fluid losses. Avoidance of preoperative hypovolemia allows a restrictive fluid infusion regimen with complete electrolyte solution and colloid solution in a ratio of 2:1.

• Excessive infusion volumes can

cause edema of the bowel wall;

produce protracted postoperative intestinal motility dysfunction;

have effects on cardiac function;

cause pulmonary side effects; and

lead to prolonged convalescence and hospitalization.

Postoperative Period

• Postoperative care is multidisciplinary.

• Postoperative care of patients is multidisciplinary. The postoperative period is characterized by analgesia, diet, mobilization, and discharge planning. The aim is freedom from pain while avoiding the use of systemic opioids. Where possible, mobilization should begin on the day of surgery.

• In meta-analyses of randomized studies, no advantage was found for postoperative fasting compared with early enteral feeding. In particular, anastomosis leak rates are not increased with early enteral feeding and there are fewer general infectious complications.

Fast-Track Surgery

Definition

• Fast-track surgery is evidence-based and is intended to reduce complications.

• “Fast-track” implies an interdisciplinary and multimodal approach to improve and speed up convalescence and reduce postoperative complications, thus shortening hospitalization.

• Fast-track surgery comprises:

Preoperative patient informed consent

Atraumatic surgical technique

Reduction of stress

Elimination of pain, usually by regional anesthesia techniques (especially in the form of thoracic epidural anesthesia)

Optimized fluid and temperature management

Early enteral diet

Prevention of gastrointestinal atony and PONV

Rapid postoperative mobilization

Therapeutic Approach for Colon Surgery

Preoperative

• Informed consent: discussion with the patient and relatives, planned discharge from the third postoperative day

• No bowel lavage, laxative if necessary

• Fasting: 6 hours for solids, 2 hours for liquids

Intraoperative

• Thoracic combined epidural anesthesia (EDA) and local anesthesia (LA)/opioids; coxibs IV, if necessary

• Laparoscopic surgery as far as possible, otherwise transverse or curved laparotomy

• Avoid drains as far as possible

• Remove gastric tube on extubation

Day of Surgery

• Transfer from recovery room to normal ward

• Limit postoperative infusion to 500 mL electrolyte solution

• Continuous thoracic EDA (LA/opioid), coxibs IV if necessary, avoid systemic opiates, morphine sulfate, 5 mg SC only if necessary

• Magnesium oxide or sodium picosulfate daily until first defecation

• Tea (maximum 100 mL), 2 portions of yogurt

• Early mobilization

First Postoperative Day

• Continuous EDA (LA/opioid), oral coxibs, avoidance of systemic opiates; morphine sulfate 10 mg orally, only if necessary

• Magnesium oxide or sodium picosulfate daily until first defecation

• Basic hospital diet, drinking volume > 1500 mL, mobilization out of bed for at least 8 hours or at least twice daily

• Removal of any drains and bladder catheter

Second Postoperative Day

• Removal of epidural and central venous catheters, oral coxibs, avoidance of systemic opiates; morphine sulfate 10 mg orally only if necessary

• Magnesium oxide or sodium picosulfate daily until first defecation, basic hospital diet, drinking volume > 1500 mL

• Full mobilization (retiring to bed only for an afternoon nap and at night)

Third Postoperative Day

• As second postoperative day

• Discuss discharge with patient and relatives, information sheet for post-hospital course (to return immediately if any problems)

• Dietary advice

From Fourth Postoperative Day

• As second postoperative day

• Final discussion with patient and relatives

• Discharge by agreement

Post-Hospital Outpatient Review

• Removal of sutures

• Discussion of histological results; if necessary schedule adjuvant therapy

Further Reading

ACC/AHA guideline update for perioperative cardiovascular evaluation for non-cardiac surgery. Circulation 2002; 105: 1257–1267

Fearon KC et al. Enhanced recovery after surgery : a consensus review of clinical care for patients undergoing colonic resections. Clin Nutr 2005; 24: 466–477

Kehlet H et al. Care after colonic operation – is it evidence based? Results from a multinational survey in Europe and the Unites States. J Am Coll Surg 2006; 202: 45–54

National Collaborating Centre for Acute and Chronic Conditions. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. National Institute for Health and Clinical Excellence (NICE); 2010 Jan. 50 p. (Clinical guideline; no. 92). http://www.guideline.gov/content.aspx?id=24106&search=thrombosis (accessed May 2011)

Schwenk W et al. Wandel der perioperativen Therapie bei elektiven kolorektalen Resektionen in Deutschland 1991 und 2000/2001. Zentralbl Chir 2003; 128: 1086–1092