Abdominal surgical controversies in the ICU patient

Abstract

The optimal management of patients in intensive care presenting with acute abdominal disorders requires the cooperation of physicians, surgeons, anaesthetists and radiologists from the start, because their vigilance, expertise and contributions are complementary. Unfavourable pre-existing factors, the severity of the primary pathology and its complications, as well as the presence of multiorgan failure frequently contribute to an individualized approach in critically ill patients. Ethical aspects, though very important, are beyond the scope of this chapter, which reviews actual surgical problems and controversies. In order to identify an abdominal source of sepsis, ultrasound is the imaging modality of choice for the right upper quadrant, flanks and pelvis in the presence of localizing signs. If an ultrasound scan is negative, computed tomography should be performed in order to detect suspected but more subtle abnormalities. In the absence of localizing signs, but with signs of clinical instability, an eventually positive blood culture or some degree of multiple organ failure, an ultrasound scan of the right upper quadrant, flanks and pelvis should be followed by CT scanning of the upper and middle abdomen. If, by exclusion, the septic state is suspected to be of abdominal origin, peritoneal lavage should be considered in the non-surgical patient and a complete exploratory laparotomy in the postoperative patient. Multiple planned reoperations are required to treat the local pathology of advanced diffuse peritonitis or pancreatic necrosis. They allow early detection and correction of poorly controlled septic foci and secondary abdominal sepsis. Mycotic infection and increased intra-abdominal pressure deserve more attention and early treatment. Abdominal abscesses are drained percutaneously when appropriate, surgically when necessary. A septic state should resolve within 1–2 days after drainage; if not, comprehensive abdominal exploration has to be considered after exclusion of a causative extra-abdominal focus. Percutaneous cholecystostomy is the treatment of choice for uncomplicated acalculous cholecystitis; cholecystectomy is mandatory if gangrenous cholecystitis or perforation is suspected. Massively bleeding stress ulcers fortunately have become very rare since the introduction of routine ‘prophylaxis’; however, where this complication does occur, it frequently represents a final event. Colonic pseudo-obstruction can usually be managed by non-operative measures, including endoscopy; when this fails, surgery is indicated, certainly if caecal gangrene and perforation are suspected.