Search for tag: "general"

Interviewer: Will a hernia go away on its own? Dr. Rodney Barker is a hernia expert. So do hernias eventually heal without surgery?

Dr. Barker: No, they don't. It's a defect in the abdominal wall. It's a mechanical issue, and it needs a mechanical fix. Physical therapy, medication won't do anything for it.

Interviewer: If a person has a hernia, should they go in and get it fixed right away?

Dr. Barker: Not necessarily right away. They should have it checked and make sure that's what it is and it's not some other diagnosis. The repair will be a discussion between them and the surgeon as to when it's most desirable to do it.

Interviewer: And sometimes, if somebody notices a small bump that's not giving them any problem that's a hernia, do you ever take a wait-and-see approach?

Dr. Barker: We do. Again, we want to confirm that small bump is a hernia and not an enlarged lymph node or something else. But watchful waiting is an appropriate response.

updated: October 28, 2021
originally published: August 21, 2019

Dr. Miller: You've been told that you might need a Whipple. What does that mean? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, here with Dr. Courtney Scaife. She is a professor of surgery here in the Department of Surgery at the University of Utah. And she also specializes in cancer surgery. Courtney, what is a Whipple?

Dr. Scaife: A Whipple is an operation on the pancreas when you have a neoplasm, which can be a mass or a tumor or a cyst, those are all synonyms, in the proximal part or we call it the head of your pancreas. And the Whipple removes that part of the pancreas.

Dr. Miller: So the Whipple is the name of the type of surgery that you do. Is that pretty typical as pancreatic surgery goes?

Dr. Scaife: That's correct. Well, the Whipple is the only surgical procedure of the pancreas that's named after the doctor who first described the operation. Other pancreas surgeons are often more anatomically referenced, such as a distal pancreatectomy or an enucleation of a tumor out of the pancreas.

Dr. Miller: So Whipple has been a surgery that's been practiced for many years, I think. Is that right?

Dr. Scaife: Dr. Whipple first described the operation in the 1950s. And as first described, it was a two-day operation where the pancreas was taken apart, and the next day, everything was put back together.

Dr. Miller: My understanding is that Whipple surgery is a curative surgery for some patients with pancreatic cancer.

Dr. Scaife: That's correct. So again, Whipples are done for all types of neoplasms. And again, neoplasms can be masses, tumors, cysts in the pancreas. And so a Whipple for a non-cancerous neoplasm is obviously curative. And a Whipple for pancreas cancer can also be curative.

Dr. Miller: If one has a pancreas cancer and they're going to undergo Whipple, the purpose of that would be to cure the cancer, I think, obviously, right?

Dr. Scaife: Yes.

Dr. Miller: And once that takes place, what can the patient expect after a Whipple surgery?

Dr. Scaife: So a Whipple operation is complex. It's a six- to eight-hour operation.

Dr. Miller: That's a big operation.

Dr. Scaife: Yeah. And because of the location of the head of the pancreas intimately involved with the bile duct and the first part of the small intestine, we have to rebuild all of those. So we rebuild the pancreas. We rebuild the first part of the small intestine. And we rebuild the bile duct. But in the end, the patients can eat normally. They can eat any food they like. And they do quite well after recovering from the operation.

Dr. Miller: Is there anything that you tell your patients in that preoperative period when you first meet them before they undergo the surgery?

Dr. Scaife: We frequently tell patients that the surgery, again, takes six to eight hours. They'll be in the hospital for approximately seven days. For a month after a big surgery like this, their appetite, their energy, and their strength will all be much lower than they normally expect. And it usually recovers four to six weeks after surgery.

Anything someone has before surgery gets a little bit worse and harder to manage after surgery. So diabetes, high blood pressure are all a little bit harder to manage after a big operation like this. But it recovers about a week or two after surgery and goes back to their baseline.

Dr. Miller: So that's interesting. Do you use a team approach with another physician such as an internist to help manage the patient after the surgery if they have diabetes or other complications?

Dr. Scaife: Generally we manage it on our own. Because they're short-lived, we're able to manage it on our own.

Dr. Miller: Do they ever experience diarrhea following pancreatic surgery? Is that something that they need to worry about?

Dr. Scaife: Yeah, chronic diarrhea after a Whipple operation is extremely uncommon, but not zero. Some patients get dumping syndrome, which happens in less than 10% of our patients.

Dr. Miller: What is that? What's dumping syndrome?

Dr. Scaife: It's from operating on the stomach and re-plumbing it effectively to the small intestine or rebuilding that first part of the small intestine. Some patients can have a syndrome where they eat rich foods, and the foods go through the stomach. And the next part of the small intestine, it's not used to seeing such rich foods, reacts by pouring a lot of water into the intestine.

And that neurologic response can result in almost like a hot flash-type symptom. And then after all of that water gets emptied into the intestine, 30 to 60 minutes after a meal, patients can have diarrhea from the water flushing through their system.

Dr. Miller: Now, generally, that resolves in a couple of weeks? Or does that continue?

Dr. Scaife: In 10% of our patients, after the Whipple surgery, they experience that. Fewer than 1% of the patients have a long-term problem with that. It normally resolves on its own and the few patients that it doesn't, learn to eat around it so they don't stimulate those symptoms.

Dr. Miller: So over time, people who have a Whipple procedure, they potentially are cured of their cancer. Do they end up keeping the same weight that they had before? Do they lose weight after a Whipple where part of the pancreas is taken out? And as I understand it, the pancreas is very important in digestion.

Dr. Scaife: That's right. So the answer to the first part of your question is that most of our patients, 80% of our patients, do well and maintain their normal appetite, normal diet, and normal weight. We do have different ends of the spectrum, obviously. There are some people who gain weight and some people who don't eat as well after the operation, but that's very unusual.

The second part of your question, the pancreas does two things. It manages your blood sugars and it helps you with digestion. And so after we remove part of the pancreas, it's very uncommon to cause someone to be a diabetic from a pancreas surgery. You only need 10% of a normal pancreas to manage your blood sugars normally. So very few people become diabetic as a result of the operation.

Dr. Miller: So you're not taking out the entire pancreas during the Whipple.

Dr. Scaife: Correct, correct. And really about a third to only 20% of the pancreas comes out with the operation.

Dr. Miller: Now, this is a big operation, as you've outlined. Do patients experience much pain postoperatively or in the several months following surgery?

Dr. Scaife: No, we're really able to manage the pain very well. We use local anesthesia in the incision or an epidural in the postoperative care. And then patients actually recover quite well in usually one to two weeks out from surgery. They're off of any pain medications and starting to resume their normal activities and functions.

Dr. Miller: Can you give us a wrap-up about who comes to you for potential surgery?

Dr. Scaife: Most of our consults for pancreas neoplasms are simple cysts or benign cysts in the pancreas. And so 80% of our patients don't need an operation, even though they're referred to us for evaluation. Of the few that do need an operation, those patients do extremely well. They don't all need Whipples. There are other less invasive operations of the pancreas that can be done. And all of those patients, including the patients who do Whipples, ultimately return to a very normal lifestyle.

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Dr. Miller: Fecal incontinence, oops, that happened again. We're going to talk about how to treat that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi I'm here with Dr. Bartley Pickron, and he's a surgeon here at the University of Utah and specializes in colorectal surgery. Bartley, tell us a little bit about how you fix fecal incontinence, and for the audience fecal incontinence is leakage of stool.

Dr. Pickron: Well it ultimately depends on what the cause is. I mean most of the time we see patients with either weak or damaged anal sphincter muscles, and we have to go about and try to restore that normal anatomy.

Dr. Miller: Fecal incontinence usually occurs in people who are a bit older.

Dr. Pickron: Usually, but we're also starting to see it in some of the younger patients as well, as it gets a little bit more . . . a little bit less public taboo.

Dr. Miller: Right, well it's obviously an embarrassing subject for people who have it. They're going to feel guilty but if they make their way to your office, what kinds of treatments do you offer to them?

Dr. Pickron: Well it depends on the underlying problem. I mean, what we would like to do if at all possible is if the muscle is torn and damaged then there is surgery to repair that. There are also other options if it's just some weakness problems, for example, we can put in a device called a Sacral Nerve Stimulator.

Dr. Miller: And that is a device that uses electric current to tighten muscle. Is that what that does?

Dr. Pickron: Yeah it's pretty similar to . . . it kind of works along the same principles a pace maker does for the heart. This is a little device, it's implanted in a little tissue pocket on the buttock, and it has a lead that goes through one of the holes in the tail bone, and it just adds an extra stimulus to the nerves that go to the pelvic muscles to add some extra tone and strength.

Dr. Miller: In 2015 these are new treatments? I mean is the field advanced since the middle of the last decade?

Dr. Pickron: The Sacral Nerve Stimulator is certainly a new treatment for fecal incontinence. The urologist have been using it for urinary incontinence for some time, and one of the side benefits they saw when they first started using it was an improvement in bowel function, so then is subsequently got approved for the treatment of fecal incontinence too.

Dr. Miller: Do you use and sling procedure like the gynecologists use for urinary incontinence sometimes?

Dr. Pickron: Not currently. There's a couple of those coming down the pipeline through still in the experimental phase, but hopefully in the next couple of years we'll have an answer on that.

Dr. Miller: Now once you're working with people with fecal incontinence, how well do these treatments work? I mean can they expect to be incontinence free, or can they expect to have no leakage after these surgeries or treatments?

Dr. Pickron: You know, making a bad muscle perfect is a big challenge.

Dr. Miller: But you can definitely make it a little better with some.

Dr. Pickron: We can definitely make it a lot better.

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Dr. Miller: I'm here today with Dr. Bartley Pickron and he is a surgeon in the department of surgery. He is also a specialist in colorectal surgery. It's good to see you. I have patients that come to me and they ask, "I've got this pain in my bottom/rectum," and they say, "I think I have a hemorrhoid." How often is it a hemorrhoid or is it something else?

Dr. Pickron: Most of the patients we see for anorectal pain don't have hemorrhoids, but everybody has hemorrhoids to some degree.

Dr. Miller: Most don't.

Dr. Pickron: Most don't, but the real causes of pain are more things like fissures, an abscess, and other things that aren't hemorrhoids.

Dr. Miller: Fissures can be incredibly painful.

Dr. Pickron: They're horrible.

Dr. Miller: What causes a fissure?

Dr. Pickron: Usually it's a tear and it happens directly in the front or directly in the back. Most of the time these things heal up just fine, but if they don't and they get deep enough to where the anal sphincter gets irritated . . .

Dr. Miller: Ouch.

Dr. Pickron: . . . then you get a spasm of that muscle and that prevents the tear from healing and then you just enter this vicious cycle that just won't quit.

Dr. Miller: So you use different therapies to try to repair that.

Dr. Pickron: Yeah, generally we focus not so much on the tear but on the muscle itself because if we could make the muscle relax and stop the spasm then the tear generally heals just fine on its own.

Dr. Miller: While hemorrhoids aren't the usual cause, as you pointed out, they're both internal and external hemorrhoids, my understanding is that the external hemorrhoids can be painful.

Dr. Pickron: They certainly can. The most common thing we see when they are painful is a thrombosis, where you get a big blood clot with the pain and swelling.

Dr. Miller: Ouch. How do you treat that?

Dr. Pickron: Most of the time, we let them these reabsorb on their own. If patients come in within the first two or three days after the event happens, then there is some benefit to removing it surgically because they'll get better faster, but usually once they're kind of over the pain curve and their symptoms are getting better, then the pain and swelling will generally just take care of itself.

Dr. Miller: After you do the treatment, is there any kind of change in diet that they might need to make? My understanding is that constipation, straining, those things can contribute to external hemorrhoids. What's your thought on that?

Dr. Pickron: Absolutely. Constipation and particularly straining or sitting on the toilet for a long time during bowel movements reading the magazine, for example, all tend to predispose people to hemorrhoids. We recommend a change in bowel habits, usually by the addition of fiber or stool softeners and staying hydrated.

Dr. Miller: When do you treat a fissure or hemorrhoids with a procedure?

Dr. Pickron: I'll talk about the fissures first and probably maybe 10 or 20% of those are actually treated surgically. We have creams that we can use that generally take care of things. If that doesn't work, Botox injection is an option. If those don't work, then the last resort is certainly surgery.

Dr. Miller: So that's treatment for fissures, how do you treat hemorrhoids?

Dr. Pickron: Again, most of these are treated non-operatively. There are procedures in the office we do. The most common thing we do is a procedure called rubber band ligation, where we put rubber bands around the hemorrhoids on the inside. That sounds pretty painful, but truthfully the internal hemorrhoids really have no sensation, so it's a very easy procedure to do and very well tolerated. It's usually just some mild pressure for about 24 hours and that's it. The ones that do need to be treated surgically, like I said, are typically the external ones and those are, fortunately for patients, fairly rare.

Dr. Miller: It would seem to me to be rare, but are there times that the pain could be induced by something like a cancer?

Dr. Pickron: It is. That's certainly one reason that these symptoms need to be evaluated very thoroughly.

Dr. Miller: So if they're going on for weeks, that's something that probably ought to be looked at?

Dr. Pickron: Right. So any combination of pain and bleeding and particularly if there is a little mass or something that just doesn't feel right, then that absolutely needs to be checked out.

Dr. Miller: Any other causes of rectal pain? I know that there's one that is a spasm that occurs from time to time in some people.

Dr. Pickron: Some people get this kind of vague rectal pain, which as you mentioned is just kind of a spasm, it's fairly poorly understood. There are some options for it such as physical therapy, biofeedback, but these can be challenging things to treat.

Dr. Miller: It comes on suddenly and then goes away over seconds to minutes, I think, sometimes.

Dr. Pickron: Yeah, usually happens in the middle of the night. People kind of wake up and they feel this intense pressure almost like a Charley horse in their rectum, which not a pleasant sensation.

Dr. Miller: Any other causes of pain?

Dr. Pickron: Those are primarily the big ones, infections, abscesses are fairly common and those are typically treated with surgical drainage.

updated: November 25, 2020
originally published: September 22, 2015

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Sedation is commonly used in the intensive care unit to make patients that require mechanical ventilation more comfortable and less anxious. What many don't realize is that sedation can have side effects that can endanger the patient's life. My guest is Dr. Richard Barton, Director of Surgical Critical Care at the University Hospital, and Nick Lonardo, Pharmacy Clinical Coordinator are investigating best practices for sedation use in the ICU.

Dr. Barton, what is the problem that you're concerned with?

Dr. Richard Barton: First, let me describe the patients that we have in the surgical and intensive care units. We can have patients with trauma, with sepsis, with major surgical complications. In other words, I'm describing to you some of the sickest patients in the world. Many have respiratory failure to a varying degree. Those patients require mechanical ventilation.

What really does that mean? That means we have a machine that helps the patient breathe, but in order to do this these people have an endotracheal tube, which is stiffer and bigger than a soda straw, smaller than a garden hose. But the point is it is through the patient's open mouth, through their vocal chords, and into their trachea.

Interviewer: Very uncomfortable, I bet.

Dr. Richard Barton: Yes, well, imagine what it feels like when you stick your finger down your throat; it makes you throw up. Imagine having that sensation for hours, days, weeks. So it's very uncomfortable, and yet their very life depends on these monitoring devices, and particularly upon the ventilator and the tube that's in their windpipe.

Interviewer: Sedation is important so that they can basically receive the care that they need.

Dr. Richard Barton: Yes.

Interviewer: What can you tell us about the sedatives that are commonly used in the ICU?

Dr. Richard Barton: This all really began 10 years or more ago when we had patients who had received continuous infusions of benzodiazapine drugs, who would then take days and sometimes even weeks to wake up.

Interviewer: And do you have anything to add to that?

Nick Lonardo: Patients with renal failure, patients with liver dysfunction don't clear benzodiazepines rapidly, and those patients have a prolonged, almost an oversedation picture. These patients will first of all say on a ventilator longer, because they have to be cleared mentally in order to get the endotracheal tube pulled out. And so by staying on a ventilator longer, this put them at risk for ventilator associated pneumonia and all of the other complications that come from being bedridden in an ICU, not getting up early enough and ambulating, so a lot of these things. And delirium in particular, patients would stay delirious and agitated for days on end sometimes.

Interviewer: Well, that was something I wanted to talk about. Something I find interesting is that benzodiazapine more frequently causes delirium and patients with long bouts of delirium are more likely to have an extended hospital stay or even die. I'm wondering what the link is between delirium and these terrible outcomes?

Dr. Richard Barton: There have been associations in other studies, other situations, showing that delirium, which is really altered thought, almost like psychosis, that delirium is associated with not only poor immediate outcomes, but with actual decrease in mental function, if you will, over the long term. In other words, you don't want to be delirious for long periods of time. It literally seems to permanently alter brain function.

Interviewer: And is it the delirium that directly harms the individual, or is the delirium an indicator that something else is wrong?

Dr. Richard Barton: I think that's an excellent question, and I'm not sure that I know the answer.

Nick Lonardo: Do you know what? There is no answer. We don't know. We simply don't know. We know that the duration of delirium that we see in the ICU is strongly independently associated with increased six month mortality. But we do not know the mechanism of why that is so. The age old question is do you die with delirium or do you die because of it? And I do not believe anybody has been able to discern that.

Interviewer: So you've found that patients fared better with one sedative, Propofol, than with benzodiazepines.

Nick Lonardo: Propofol is a drug that has a very rapid onset, but a very short duration of action and so it is much more predictable in terms of its sedative effects. You can keep propofol on literally for days, and turn it off and your patient will awaken usually within an hour or so.

So we looked at data from 2003 through 2009 in the Project Impact Database that came out of 104 ICUs throughout the country. And when they met inclusion/exclusion criteria there were 13,692 patients. And when we did the statistics, we were able to see a decrease in mortality associated with the propofol group, decreased time on the ventilator, decreased time in the ICU, and increased ventilator associated pneumonias associated with the benzodiazepines. The most unexpected thing that we saw was a reduction in mortality, and that had not been shown before.

Interviewer: Are these changes that are taking place across the country, or is it kind of tricky to enforce these recommendations?

Nick Lonardo: That's a good question. I looked at some surveys, I think, as recently as 2006, but at that time there were still quite a few hospitals still using benzodiazepines. The 2013 guidelines have come out from the Society of Critical Care Medicine and they have now encouraged going away from benzodiazepines for sedation and are now recommending either propofol or dexmedetomidine. So the entire world, really, of critical care is becoming more aware of the potential dangers of sedatives in the ICU.

I think our paper is just one more of many that have really highlighted the dangers of benzodiazepines in particular, but I would also say oversedation in general. We now only lightly sedate our patients. The standard of practice is to wake them up once or twice a day, and to try to get the patient up and walking as soon as possible, and to avoid all these neuro-active drugs if at all possible.

Dr. Richard Barton: The only thing that I would have to say is that if you're still using benzodiazepines, don't. There are really better ways to sedate people, more safe ways to sedate people. You can still deliver all the sedation you need, but at the same time minimize some of the complications associated with sedation and with mechanical ventilation.

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updated: February 26, 2019
originally published: August 29, 2014