Ed Shlasko MD . Medical School: Columbia University . Fellowships: SUNY NIH National Cancer Institute . Chief of Pediatric Surgery at Maimonides Medical Center Brooklyn,NY
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Appendicitis is a terrible topic, because everybody, every doctor, every nurse, everyone's grandmother, thinks they know what the treatment for appendicitis is. And we were all taught sort of the same thing, that appendicitis is an emergency, that if you have right lower quadrant belly pain, you have to run to the OR and save the poor innocent patient before their appendix ruptures. It's a very interesting thing if you think about it, and you read about it, to find where that idea came from, and to realize that it's just a bit of mass delusion. Now, this is not a discussion that is unique to New York or unique to Brooklyn or unique to the Department of Pediatrics. In fact, I am here in San Francisco and I am at the American College of Surgery, Meeting. So I have the program book; can you see this, The American College of Surgery, Clinical Congress. See, they are pretty surgeons and nurses. And if you look, I don't know if this will project fairly clearly, but this was the talk yesterday morning at 9:45. It's all about appendicitis, acute appendicitis. Does everyone need an operation? So this is an international discussion, and I think that it helps if you take a deep breath and erase all of your preconceived notions and think about what the disease is. So there are corollaries, there are analogies, there are other diseases that are almost exactly the same. Think about how we treat them. So Sigmoid Diverticulitis. When I was a medical student, when I was a resident, which was not 100 ago, it was about two decades ago, the treatment for sigmoid diverticulitis was clear. You gave people antibiotics. Their diverticulitis usually got better, except in the rare patient who had free perforation. The patients who got better would go home. And then we were taught that if they had a second or third episode of diverticulitis, their risk of perforation would go up, and that then you should operate and resect the sigmoid colon. Well, even that is now being challenged, and there is a great deal of recent evidence that the patients who have perforated diverticulitis are the patients who present at their first presentation with perforation, and patients who present a second or third or fourth time actually need an operation less often than those who present just once. But the bottom line is that, if you have little outpouchings from your colon and it's on the left side of your body, it's clear that the treatment is antibiotics. We have great antibiotics now that do wonders. Think about another hollow viscus. You could argue that sigmoid diverticulitis is not a true diverticulum of the colon. If you remember, diverticulitis is a pseudo diverticulum. It does not hold the layers of the - polycystitis, the gallbladder is a hollow viscus with a complete wall. Think about what the treatment for polycystitis is. When I was a medical student, then the resident, a controversy was whether it was better to treat patients with antibiotics, and then sometime within the succeeding two or three days operate on, during the first hospitalization, or whether it was better to treat them with antibiotics and not operate on them until all of the inflammation had resolved six to eight weeks later. Now, that controversy has been resolved, not on the basis of success in treatment, but on the basis of cost, that it's better to give them antibiotics for a day or two, take them to the operating room and discharge them. Their length of hospital stay is shorter than if you treat them with antibiotics and then go back and operate six or eight weeks later. But the treatment is antibiotics. Antibiotics make polycystitis go away. And it has always bothered me that we think that appendicitis is different, that we think that appendicitis for some reason has a different natural history than these two really very similar diseases.
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