A clinical question for our holiday weekend.

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SLUser11

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I was thinking today about the unproven nature of much of our surgical doctrine. There are ubiquitous one-liners that we are all told as students and residents, which we then accept at face value and regurgitate frequently with authority through our careers.

Examples:

Don't F with the pancreas.
Never go to bed on a complete small bowel obstruction.
If the topic of intubation/fasciotomy/etc is brought up on a patient, then it should probably be done.

Many of these one-liners are based on facts, but we have just been too busy or too lazy to go back and explore the evidence. Others are expert opinion or attending bias (which are sometimes the same thing). However, they're not limited to word of mouth, but frequently show up in textbooks, tests, etc.

This occurred to me as I was reading SESAP today. There's a question that mentions a 24 yo male with perforated appendicitis, and the answer clearly explains that interval appendectomy is no longer recommended based on current evidence, but an interval colonoscopy should be performed to rule out cancer.

I'm obviously familiar with this train of thought, and I've read the literature on interval appendectomy (we've discussed incidental appy here before but not interval appy). However, the part that struck me as odd was the need to do colonoscopy on a 24 year old. What if he was 20? What if he was 16? When is he young enough to skip the scope?

Another similar side topic: 45 year old male comes in with rectal bleeding and complaints that his "hemorrhoids are acting up." Haven't we all been taught that hemorrhoids can be a scapegoat, and we should do colonoscopy to rule out a malignancy? What if he was 35? What about 30? Surely, we've all unfortunately come across 30 year old males with bad colon and rectal cancers. I've even seen a couple in their 20's.....

So, what do you guys think? If a 24 year old has perforated appendicitis, do you skip the interval appy? Do you perform colonoscopy? What's your age cutoff for colonoscopy in an otherwise risk-free patient?

What about for rectal bleeding? Does a 25 year old with hemorrhoids on exam need a scope? Can you individualize it based on the characteristics of the bleeding?

Something to think about. I'm not sure I've ever gotten a clear answer on these sort of questions, and I've been looking around for a while....


Also, feel free to add your own examples of surgical doctrine that we've blindly followed. Maybe it will result in a lit search by one of the young and eager SDNers and we'll all learn something....
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I can't answer questions about bad things that happen on the inside . . . my aphorism of choice is, "Nothing good happens once you enter a body cavity."

When it comes to compartment syndrome/fasciotomy, I'd say that you don't have to proceed directly to fasciotomy, but you'd better measure a compartment pressure. You're never wrong to get out the Stryker. Of course, if you're in the OR and a limb has been revascularized, you'd be stupid to not open the compartments.
 
Every GI tract case needs a bowel prep.
NG tubes reduce the risk of aspiration.
Low-dose dopamine has "renal" effects.
Bowel resection patients should be kept NPO with an NGT immediately post-op.
Octreotide helps shorten the duration to fistula closure.
You should leave a drain in thyroid/parathyroid cases.
All NPO patients need an H2B/PPI.
Atelectasis can cause fever on POD #1.
 
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Buzz Me said:
Every GI tract case needs a bowel prep.
NG tubes reduce the risk of aspiration.
Low-dose dopamine has "renal" effects.
Bowel resection patients should be kept NPO with an NGT immediately post-op.
Octreotide helps shorten the duration to fistula closure.
You should leave a drain in thyroid/parathyroid cases.
All NPO patients need an H2B/PPI.
Atelectasis can cause fever on POD #1.
Click to expand...

....and the world is flat. I've been luck to not deal with too many dinosaurs leaving NGs and drains everywhere. However, I have to admit that I still tell patients and nurses that their fever is from atelectasis. Sure, it may not be accurate, but it gets nursing and patient buy-in on the incentive spirometer.

Here's a few article links discussing these mysterious mast cells in the lungs:

A recent review on atelectasis and fever

Lack of association between atelectasis and fever

Another one

The real cause of postop fever
 
SLUser11 said:
....and the world is flat. I've been luck to not deal with too many dinosaurs leaving NGs and drains everywhere. However, I have to admit that I still tell patients and nurses that their fever is from atelectasis. Sure, it may not be accurate, but it gets nursing and patient buy-in on the incentive spirometer.

Here's a few article links discussing these mysterious mast cells in the lungs:

A recent review on atelectasis and fever

Lack of association between atelectasis and fever

Another one

The real cause of postop fever
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I can't help but notice that most/all of the articles that fail to find any association between atelectasis and fever are published by people who never do surgery (or at least in journals in principally non-surgical fields).


We've got one attending who leaves drains everywhere. Drives all the residents crazy :p
 
I don't think I have ever done an interval colonoscopy for a patient with a perforated appy, but it has only been recently that we have stopped automatically doing an interval appy. I have one guy that I plan to scope, but that is because of the history of chronic diarrhea and the extensiveness of the inflammation (big abscess between the prostate and rectum with inflammation of prostate/bladder/everything else in vicinity of the abscess and the appy.

As far as the hemorrhoid thing goes, if they are actually anemic I probably wouldn't care how old they were (assuming I don't see blood pouring out of it on my exam). If they aren't anemic, have no family history that is concerning, and only complain of some red on the tissue or a streak on a firm brown stool I would probably not jump to a colonoscopy for anyone not close to 50 (but I don't know for sure what I would define as not close to 50-we don't deal with this much since the usual rectal bleed patient will have gone through medicine and GI before finding hemorrhoids on a scope and getting sent to us)
 
dpmd said:
I don't think I have ever done an interval colonoscopy for a patient with a perforated appy, but it has only been recently that we have stopped automatically doing an interval appy......

As far as the hemorrhoid thing goes, if they are actually anemic I probably wouldn't care how old they were (assuming I don't see blood pouring out of it on my exam).
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Well, I think colonoscopy is definitely the standard of care for older patients with perforated "appendicitis." I would start doing that. It's the younger patients that are difficult to manage. I think my arbitrary cutoff would be around 30 years old.

As for hemorrhoids, I'm not sure if anemia or "blood pouring out" are going to be sensitive enough to pick up occult malignancies. I do agree, though, that need for colonoscopy should be individualized. However, once they get above 30-35, anything beyong spotting on the toilet paper would probably get scoped by me.
 
SLUser11 said:
However, once they get above 30-35, anything beyong spotting on the toilet paper would probably get scoped by me.
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*until you've satisfied all of your numbers or are out in private practice.


I kid, I kid!
 
TheProwler said:
*until you've satisfied all of your numbers or are out in private practice.


I kid, I kid!
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You kid, but it's partially true, although my motivation is different. I'm not out to make money or get numbers, but I've been brainwashed over the last 5 years into practicing overly-defensive medicine.

There have been plenty of things I've done, either through my own decision making or (more often) at the demand of a higher-up power, with very little true clinical suspicion.

An example would be the hundreds of Head CTs I've ordered on anybody that got "knocked out" and end up in the trauma bay, despite a GCS of 15.

To be honest, if I lived in a world without litigation, and I was more pressed to conserve resources, I would treat the patient's hemorrhoids, and then scope them if their symptoms did not resolve.
 
This just reminds me though about the cost of even simple anoscopy: I saw a bill for anoscopy (no intervention) as an outpatient on some guy's insurance EOB. We were charging $250 for it, and another $300 for the rigid procto that came right after the anoscope.
 
SLUser11 said:
Well, I think colonoscopy is definitely the standard of care for older patients with perforated "appendicitis." I would start doing that. It's the younger patients that are difficult to manage. I think my arbitrary cutoff would be around 30 years old.
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Well, I can't think of any that I had that were much older than 30 so that is probably why it never came up with any of my attendings. The older folks tend to come in with diverticulitis and those all get their delayed scopes.

I guess where you train makes a difference. I'm at a county facility where patient's don't always follow up anyway, or if they do they have no funding to get outpatient stuff (not all, but enough that our management strategies are a little different for a lot of stuff-how many cirrhotic GI bleeders have you done a portocaval shunt on?)
 
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TheProwler said:
This just reminds me though about the cost of even simple anoscopy: I saw a bill for anoscopy (no intervention) as an outpatient on some guy's insurance EOB. We were charging $250 for it, and another $300 for the rigid procto that came right after the anoscope.
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The reimbursement for anoscopy is about $80 if done in the office, or $30 if done in the hospital. Did you see what the EOB actually paid for that $250 bill?
 
Winged Scapula said:
The reimbursement for anoscopy is about $80 if done in the office, or $30 if done in the hospital. Did you see what the EOB actually paid for that $250 bill?
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Yes, but anoscopy plus rigid procto combined= less than 2 minutes in the office...and it's usually medically indicated. Seems like easy money if you have a busy office day.

Some colorectal surgeons do 3-4 days a week of clinic and office procedures, and they seem pretty happy. Personally, I have too much of a hero complex, and I'd rather be slaving away in the hospital on big abdominal cases for less money.
 
SLUser11 said:
Yes, but anoscopy plus rigid procto combined= less than 2 minutes in the office...and it's usually medically indicated. Seems like easy money if you have a busy office day.

Some colorectal surgeons do 3-4 days a week of clinic and office procedures, and they seem pretty happy. Personally, I have too much of a hero complex, and I'd rather be slaving away in the hospital on big abdominal cases for less money.
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Oh no doubt...I wasn't suggesting that it wasn't a good moneymaker, as long as you make it up in volume.

I was just curious if Prowler had noted what the insurance actually paid on that EOB (and by way of teaching others that the billed amount is no the reimbursed amount). That was my point in commenting; sorry if it seemed otherwise.
 
Winged Scapula said:
I was just curious if Prowler had noted what the insurance actually paid on that EOB (and by way of teaching others that the billed amount is no the reimbursed amount).
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It's pretty interesting. I broke my wrist in med school and had pins put in (outpatient surgery), and I remember being floored by the stark contrast between the bills and the insurance payments. I was in the hospital for a total of 2-3 hours, and the bills topped $15K.
 
So this is what I have been wondering...if you know insurance or CMS will only reimburse (for this example) $80 for an anoscopy, why the bill for $250? Having had knee and hand surgery myself, I can second SLUser's point. Being so early in this process of training, I dont know the intricacies of billing, etc yet. But maybe WS or others more experienced with this headache can elaborate. I mean, if hospitals/doctors start cutting their bills to 1/10 of the current, to better align with what they actually get reimbursed, what is the drawback? Will the reimbursements then drop as well?
 
DrNick Riviera said:
So this is what I have been wondering...if you know insurance or CMS will only reimburse (for this example) $80 for an anoscopy, why the bill for $250? Having had knee and hand surgery myself, I can second SLUser's point. Being so early in this process of training, I dont know the intricacies of billing, etc yet. But maybe WS or others more experienced with this headache can elaborate. I mean, if hospitals/doctors start cutting their bills to 1/10 of the current, to better align with what they actually get reimbursed, what is the drawback? Will the reimbursements then drop as well?
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You bill for more than they are willing to reimburse, then get paid what they're willing to give you. Most private insurance is going to pay some percentage (hopefully >100%, although not always) of what CMS pays. Rather than bill the patient a different price depending on their insurance, you bill one set price that's higher than any of your payors reimburse so you don't leave money on the table.
 
Winged Scapula said:
The reimbursement for anoscopy is about $80 if done in the office, or $30 if done in the hospital. Did you see what the EOB actually paid for that $250 bill?
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No, I didn't. He was actually complaining about being charged the pathology fee. He had been biopsied at another hospital and been referred to us, and part of his work-up meant that before he got a big cancer whack, they'd make sure his pathology was accurate. They billed $500 for the pathologist to look at previously prepared slides. :eek3: having done a surg path rotation, that was probably 5 minutes work.

SLUser11 said:
Yes, but anoscopy plus rigid procto combined= less than 2 minutes in the office...and it's usually medically indicated. Seems like easy money if you have a busy office day.
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No kidding. The CRS I worked with said that some places have multiple CRSs that just do outpatient proctology work and make monster money.

Then again, the real question is: how much money is it worth to the patient to have someone look "down there" and actually know what they're looking at?
 
TheProwler said:
Then again, the real question is: how much money is it worth to the patient to have someone look "down there" and actually know what they're looking at?
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Priceless. I think we can all get carried away with worrying about what specialist charges for what, but the reality is all physicians are probably underpaid for the sacrifices we take and the risk of being sued all the time
 
Exactly. And that pathologist billing $500 isn't just billing for the 5 min it took to look at those slides, but the liability associated with it if he is wrong.
 
Buzz Me said:
What about those attendings who leave patients on antibiotics as long as they have drains in?
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Just thought of another one that we discussed recently here on SDN:

The CT is a cold, dark, lonely place and you should never take a patient there unless they are rock solid stable. Of course, for that one the board answer would clearly support the one-liner.

How about "The solution to pollution is dilution." What do you guys think about that?
 
SLUser11 said:
Just thought of another one that we discussed recently here on SDN:

The CT is a cold, dark, lonely place and you should never take a patient there unless they are rock solid stable. Of course, for that one the board answer would clearly support the one-liner.
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Our CT is a well-lit room with a lot of support standing right there watching. The CT gantry can be slid out to appropriate CPR levels in seconds. If we're in there for a quick and dirty scan (not a lot of reconstructions or delayed imaging), it can be done very quickly.

How about "The solution to pollution is dilution." What do you guys think about that?
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With regard to what, specifically? irrigating the abdomen after contamination or something?
 
TheProwler said:
With regard to what, specifically? irrigating the abdomen after contamination or something?
Click to expand...

Yes, but not just irrigating the abdomen, but irrigating it with liters and liters of fluid.

I think it causes multiple problems like ileus, electrolyte abnormalities, hypothermia, etc without a lot of added benefit. On the other end, there's also a small subset of surgeons who believe irrigation for peritonitis is bad because it "washes away the WBCs," which also sounds like BS.

I believe there is a place for irrigation, but that people frequently go overboard with it. I've also had several bosses who will copious irrigation even when there's no contamination.

On a side note, irrigation with antibiotic solution is absolutely not indicated, as there's no decrease in deep SSI or sepsis, and there's increased associated intra-abdominal adhesions, but I'm sure there are plenty of SDNers that have witnessed this practice.

Ah, the voodoo that we do.....
 
The classic oral boards scenario: A patient has a colon cancer and a AAA....do you fix them simultaneously or staged...if staged, which one first?

The answer has always been to treat the symptomatic disease first, i.e. if the AAA is 8cm and the colon cancer is small, AAA gets precedence. If the colon cancer is obstructing and the AAA is 5cm, the colon gets the first whack.


However, what if it's a situation that's harder to interpret? What if you're there for an elective Open 8cm AAA, and you find a near-obstructing colon cancer?

You could make the argument to do the colectomy and switch to EVAR, but if you're in there for an open AAA, EVAR was likely not an option. I honestly don't know what the right answer is here. I'd hate to do simultaneous procedures and risk graft infection (although some literature supports its safety)....

Here's an interesting article that discusses it...not exactly new, but new to me.
 
That reminds me of a recent case where an 80 year old guy presents to OSH with abdominal pain. CT shows 10cm infrarenal AAA and gets transferred to us, for some reason to the medicine service. Well he was also anemic so someone decides to do a hemoccult "to rule out bleed from aortoenteric fistula." It's positive so of course the guy gets scoped and boom....colonic perforation. Uh oh.....
 
GregsAnatomy said:
That reminds me of a recent case where an 80 year old guy presents to OSH with abdominal pain. CT shows 10cm infrarenal AAA and gets transferred to us, for some reason to the medicine service. Well he was also anemic so someone decides to do a hemoccult "to rule out bleed from aortoenteric fistula." It's positive so of course the guy gets scoped and boom....colonic perforation. Uh oh.....
Click to expand...

Gigantic AAA and a 1/1000 chance colon perf....that guy has some bad luck.

Either way, if I were in that situation, I would look very closely at why he had abdominal pain (i.e. impending AAA rupture). If the pain was benign/not related to the AAA, I would likely do a smash and grab colon resection with ostomy, then tee the guy up for a possible AAA repair.

If the AAA was about to burst, I would probably resect the bowel, oversew the infrarenal aorta and do extra-anatomic (axillo-bifem) bypass.

The question would be: Is there such thing as a 10cm AAA that's not about to burst.....
 
Ok I've got one somewhat along this theme, that I dont know what the right answer is. Pt is a 79F with a highly symptomatic colovesical fistula from diverticular disease, who also has a right-sided colon cancer which is large and near-obstructing on colonoscopy. She has some coagulopathy which makes her a modestly elevated bleeding risk, and has the typical medical problems of a 79F. What operation does she get? Subtotal colectomy? R hemi/sigmoidectomy/ileocolic anastomosis/Hartmans? In the case of synchronous cancers its a bit different and probably subtotal colectomy is the clearly correct answer, but she has one benign pathology and one cancer, and minimizing on-table time would be great.
 
vhawk said:
Ok I've got one somewhat along this theme, that I dont know what the right answer is. Pt is a 79F with a highly symptomatic colovesical fistula from diverticular disease, who also has a right-sided colon cancer which is large and near-obstructing on colonoscopy. She has some coagulopathy which makes her a modestly elevated bleeding risk, and has the typical medical problems of a 79F. What operation does she get? Subtotal colectomy? R hemi/sigmoidectomy/ileocolic anastomosis/Hartmans? In the case of synchronous cancers its a bit different and probably subtotal colectomy is the clearly correct answer, but she has one benign pathology and one cancer, and minimizing on-table time would be great.
Click to expand...

She probably gets a total colectomy....not subtotal because you can't leave behind any distal sigmoid unless you want a diverticular recurrence. I would take down the colovesicular fistula and oversew the bladder (if there was anything to sew to), then leave a foley in for a while.

The remainder of the decision making should depend on the patient's functional status. If she has multiple medical problems and is non-ambulatory, she would likely get an ileostomy. I think ileostomies are very morbid in this age group, mostly due to dehydration and electrolyte abnormalities, but if you do an ileo-rectostomy, the patient might be running to the bathroom 5-6 times a day, and that's not an option for the wheelchair-bound.

The hard part is sacrificing your normal transverse and descending colon....however, remember that you're taking a lot of the blood supply when you do your right and sigmoid colon resections (assuming you're doing a correct cancer surgery with high ligation)....and, you would have 2 anastomoses which is another problem.

I think in real life there may occasionally be a role for transverse/descending salvage, but in an oral boards situation, the answer is total colectomy.
 
SLUser11 said:
Gigantic AAA and a 1/1000 chance colon perf....that guy has some bad luck.

Either way, if I were in that situation, I would look very closely at why he had abdominal pain (i.e. impending AAA rupture). If the pain was benign/not related to the AAA, I would likely do a smash and grab colon resection with ostomy, then tee the guy up for a possible AAA repair.
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What about just a local colorrhaphy? Or is that putting him at a higher risk for an abscess/leak than proximal diversion and thereby delaying treatment for the AAA?

If the AAA was about to burst, I would probably resect the bowel, oversew the infrarenal aorta and do extra-anatomic (axillo-bifem) bypass.

The question would be: Is there such thing as a 10cm AAA that's not about to burst.....
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I've never seen a good outcome from a bilateral ax-fem, but I've only seen three. Two of them died after a month, and the other one lost both legs.

For the second question, a cursory review found this:

http://jama.ama-assn.org/content/287/22/2968.abstract
Results Outcome ascertainment was complete for all patients. There were 112 deaths (57%) and the autopsy rate was 46%. Forty-five patients had probable AAA rupture. The 1-year incidence of probable rupture by initial AAA diameter was 9.4% for AAA of 5.5 to 5.9 cm, 10.2% for AAA of 6.0 to 6.9 cm (19.1% for the subgroup of 6.5-6.9 cm), and 32.5% for AAA of 7.0 cm or more. Much of the increased risk of rupture associated with initial AAA diameters of 6.5-7.9 cm was related to the likelihood that the AAA diameter would reach 8.0 cm during follow-up, after which 25.7% ruptured within 6 months.
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According to Rutherford's, this article "115.. Lederle FA, Johnson GR, Wilson SE, et al: Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA 2002; 287:2968-2972." says that the group with a "AAA diameter of 6.5 to 6.9 cm had an annual rupture risk of 19%."

Wikipedia has this, which of course is lacking a citation....
Although the current standard of determining rupture risk is based on maximum diameter, it is known that smaller AAAs that fall below this threshold (diameter<5.5 cm) may also rupture, and larger AAAs (diameter>5.5 cm) may remain stable.[40][41] In one report, it was shown that 10 - 24% of ruptured AAAs were less than 5 cm in diameter.[41] It has also been reported that of 473 non-repaired AAAs examined from autopsy reports, there were 118 cases of rupture, 13% of which were less than 5 cm in diameter. This study also showed that 60% of the AAAs greater than 5 cm (including 54% of those AAAs between 7.1 and 10 cm) never experienced rupture.[citation needed]
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GregsAnatomy said:
That reminds me of a recent case where an 80 year old guy presents to OSH with abdominal pain. CT shows 10cm infrarenal AAA and gets transferred to us, for some reason to the medicine service. Well he was also anemic so someone decides to do a hemoccult "to rule out bleed from aortoenteric fistula." It's positive so of course the guy gets scoped and boom....colonic perforation. Uh oh.....
Click to expand...
Oh man, I thought you were going to say that they got into the aortoenteric fistula and had him exsanguinate in the endoscopy suite.

SLUser11 said:
If she has multiple medical problems and is non-ambulatory, she would likely get an ileostomy. I think ileostomies are very morbid in this age group, mostly due to dehydration and electrolyte abnormalities, but if you do an ileo-rectostomy, the patient might be running to the bathroom 5-6 times a day, and that's not an option for the wheelchair-bound.
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Plus, these little old multiparous ladies with a weak pelvic floor have poor sphincter control, and they functionally end up with an ileostomy draining into their diaper. It's a complete disaster. One example comes to mind...

Funny how you really start to remember names.
 
TheProwler said:
Plus, these little old multiparous ladies with a weak pelvic floor have poor sphincter control, and they functionally end up with an ileostomy draining into their diaper. It's a complete disaster.
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This. It may be anecdotal bias, but both of the ileorectal anastomoses I've done in patients over 65 have had to be converted to ileostomies for hygeine purposes.

On the boards, I'd go with a total colectomy/ileostomy. IRL?....I've done a couple transverse salvages that have done fine.
 
MediCane2006 said:
This. It may be anecdotal bias, but both of the ileorectal anastomoses I've done in patients over 65 have had to be converted to ileostomies for hygeine purposes.

On the boards, I'd go with a total colectomy/ileostomy. IRL?....I've done a couple transverse salvages that have done fine.
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How much colon do you need as a general rule (if your small bowel is intact) to not have watery stools?
 
Guile said:
How much colon do you need as a general rule (if your small bowel is intact) to not have watery stools?
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There's no magic number, and it really depends on the functional capacity of the remaining bowel. There are plenty of patients walking around with no colon at all that have controlled BMs, i.e. all FAPs and UCs that get total proctocolectomy and ileal pouch anal anastomosis.

There are lots of things you can do to make the stools less watery, starting with fiber and imodium. There's also Tincture of Opium which works well.
 
SLUser11 said:
There's no magic number, and it really depends on the functional capacity of the remaining bowel. There are plenty of patients walking around with no colon at all that have controlled BMs, i.e. all FAPs and UCs that get total proctocolectomy and ileal pouch anal anastomosis.

There are lots of things you can do to make the stools less watery, starting with fiber and imodium. There's also Tincture of Opium which works well.
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But those patients get a J-pouch right? If you were to just do an ileorectal anastomosis you would get very frequent and loose stools. So there's no magic number like ~90cm for short gut syndrome I take it.
 
Guile said:
But those patients get a J-pouch right? If you were to just do an ileorectal anastomosis you would get very frequent and loose stools. So there's no magic number like ~90cm for short gut syndrome I take it.
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They have a J-pouch, but I'm pretty sure you'd have better function with an ileorectal anastamosis. An IRA has some normal anatomy compared to an IPAA.
 
Guile said:
But those patients get a J-pouch right? If you were to just do an ileorectal anastomosis you would get very frequent and loose stools. So there's no magic number like ~90cm for short gut syndrome I take it.
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Rectum >> J-pouch as far as function. Plus, without the pelvic dissection you can still have boners, which is nice.

There have been some people in the past who would do a J-pouch to the upper rectum, but there was no proven benefit over a straight ileo-rectostomy. The more compelling and controversial literature exists for colonic J-pouches or coloplasty for colo-anal anastomoses.

I don't think there's a magic number similar to short-gut. Some people do well without their colons, others become GI cripples. The outcome is based on several factors including the quality of the anal sphincter, and the quality of the remaining bowel.

This has come up in the past with patients that have colonic inertia. The standard of care is a total colectomy with ileorectostomy, but the fear of diarrhea led some people to advocate subtotal colectomies instead, leaving the distal sigmoid. A lot of those patients with residual sigmoid had recurrent problems with constipation/inertia.

On a side note, I've heard in the past several attendings mention that the anal sphincter is the smartest muscle because it can differentiate between solid, liquid, and gas. However, I don't see how it's any smarter than the upper GI system...it's not like we accidentally throw up all the time when we're trying to burp.
 
SLUser11 said:
On a side note, I've heard in the past several attendings mention that the anal sphincter is the smartest muscle because it can differentiate between solid, liquid, and gas. However, I don't see how it's any smarter than the upper GI system...it's not like we accidentally throw up all the time when we're trying to burp.
Click to expand...

I have burped and had liquid at the back of my mouth before. I have never gambled and lost with a fart. Just saying...
 
SLUser11 said:
On a side note, I've heard in the past several attendings mention that the anal sphincter is the smartest muscle because it can differentiate between solid, liquid, and gas. However, I don't see how it's any smarter than the upper GI system...it's not like we accidentally throw up all the time when we're trying to burp.
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You've got gravity helping with the upper GI. It's working against the anal sphincter. I agree with your attendings. Hold some pebbles, water, and air in your hand and try to only let the air out.
 
dpmd said:
I have burped and had liquid at the back of my mouth before. I have never gambled and lost with a fart. Just saying...
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keep the volume down if you're at work
[YOUTUBE]NiNZdTSH3-A[/YOUTUBE]
 
SLUser11 said:
Either way, if I were in that situation, I would look very closely at why he had abdominal pain (i.e. impending AAA rupture). If the pain was benign/not related to the AAA, I would likely do a smash and grab colon resection with ostomy, then tee the guy up for a possible AAA repair.

If the AAA was about to burst, I would probably resect the bowel, oversew the infrarenal aorta and do extra-anatomic (axillo-bifem) bypass.

The question would be: Is there such thing as a 10cm AAA that's not about to burst.....
Click to expand...

Ax-bifem is probably the safe answer for the boards. In real life I would sew in a graft and cover with omentum as long as there was not tons of gross contamination. Infected grafts are a nuisance compared to an aortic stump blow-out.


.... sorry to resurect an old post, this is the best thread I can see to start some dialog on a boring moonlighting night!
 
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