Avoiding post-operative narcotics

Avoiding post-operative narcotics

Narcotics or opiate pain medications have a role in pain management after surgery, but I, like many others, would like to see that role diminish. Opiate pain medications are growing in scrutiny, and duly so due to an epidemic of narcotic addiction as well as side effects like nausea and constipation. 

These five little pills pictured can have a dramatic effect on your post operative pain. Surprisingly, patients always seem more hesitant to take acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) than narcotic pain medication. Most healthy individuals can take acetaminophen and NSAIDs with little risk of complication.  Individuals with liver disease or cirrhosis should limit their daily intake of acetaminophen to 3,000 mg per day. Normal individuals should take no more than 4,000 mg. Acetaminophen comes in different strengths including 325 mg, 500 mg, and 650 mg. Check your bottle and keep track of the amount and times on a sheet of paper. 

Ibuprofen typically comes in 200 mg.  Most everyone can take up to 1,200 mg per day with little risk. Most healthy individuals can take up 2,400 mg of ibuprofen per day, which is 12 pills, on a short term basis. People with certain condition should be more cautious taking NSAIDs. Those conditions include history of stomach ulcers, high blood pressure, bleeding problems, heart disease, kidney disease, age older than 60 or if taking a diuretic. You should also be careful combining NSAIDS with anticoagulants like warfarin, Eliquis, Plavix or aspirin. Examples of other NSAIDs, or non-steroidal anti inflammatory medications, are Aleve, Motrin, Advil, ibuprofen, and naproxen. 

Narcotics, acetaminophen and NSAIDs all have different mechanisms of action and can be safely taken together. Just be careful that your narcotic medication doesn’t already have acetaminophen or NSAIDs in it. Many times patients are prescribed medicines like Norco or Percocet which have acetaminophen in them. If your medicine has two names and two numbers like: 5/325, it’s likely it contains acetaminophen.  

Narcotics, acetaminophen and NSAIDs have a synergistic effect on each other, meaning that they make each other work better. For example, 2 + 2 = 5. Meaning that their combined effect is more than the sum of their individual effect. Even If I were undergoing surgery, I would take two 500 mg acetaminophen and three 200 mg ibuprofen every 6 hours. Save the narcotic medication for break through pain when this regimen doesn’t work. 

Appendectomy or Antibiotics?

Appendectomy or Antibiotics?

There’s been a lot of conversation about the treatment of appendicitis recently. 5 year results were recently published in JAMA Surgery regarding the Swedish study in treatment of appendicitis with primarily antibiotics alone.  The conclusion of the study was that appendicitis could be safely treated with antibiotics alone.  The problem is many people are reading the conclusion alone, when the problem is more complex than this simple conclusion. Here is a surgeon’s perspective. 

Exclusion criteria

Firstly, this conclusion does not apply to all patients with appendicitis. The study has exclusion criteria, which means that there are certain patients that are not a candidate for antibiotic treatment. Examples of patients excluded are those with perforation, an abscess, appendicolith, renal insufficiency, or systemic illness. I have already seen patients inappropriately treated outpatient with antibiotics who were shown to have an appendicolith on their CT scan. An appendicolith is hard petrified stool in the lumen of the appendix that obstructs the appendix and makes antibiotic treatment more likely to fail.  

Inpatient treatment

The patients in the study were treated inpatient (in the hospital) in a monitored setting for signs of deterioration that would require surgery for 3 days. There has been no recommendation to treat appendicitis with outpatient oral antibiotics alone. Furthermore, 10% of those treated with antibiotics required surgery within the first 24 hours. 

Duration of Treatment

Patients were treated in the hospital with IV antibiotics for 3 days. Most patients with uncomplicated appendicitis who undergo laparoscopic appendectomy are home within 6-8 hours of arrival and are cured of their appendicitis, unlike with antibiotics. 

Recurrence and Treatment failure

Initial  data  showed that 10% of patient went on to have complicated appendicitis. 27% of patient with antibiotic treatment had an appendectomy within one year of diagnosis.  Data 5 years out shows that 39% of those patients went on to have recurrent appendicitis.  That number will likely continue to rise at 10 and 20 years. Meaning the chance of a 20 year old having appendicitis again in ten years is probably anywhere from 50-80%. 

Tumors

Approximately 1% of appendicitis is caused by a benign or malignant tumor of the appendix. These are not usually seen on CT scan or intraoperatively, but found after the fact by the pathologist under the microscope. Appendectomy is usually curative of these tumors, such as carcinoid. However, if treated with antibiotics, these small tumors may go from curable to incurable if not removed.  

Apples to Oranges

The only reason this study showed non-inferiority to surgery is it was compared to OPEN appendectomy, which in their hands carried a complication rate of 25%! My own complication rate (and for all of my colleagues) for LAPAROSCOPIC appendectomy is somewhere on the order of <1%.  

My Conclusions:

  • If you’re on a submarine, antibiotics may be the treatment of choice. 
  • High risk individuals such as those too sick to undergo anesthesia may be treated in an inpatient setting with antibiotics with monitoring by a surgeon.  
  • If I’m traveling in a third world country, antibiotic treatment may give enough time to return to the United States for an appendectomy.
  • The recommendation of the American College of Surgeons is still that appendectomy is the preferred treatment modality. 

Read more on the benefits of laparoscopy

HerniaSurge Inguinal Hernia Guidelines

HerniaSurge Releases Inguinal Hernia Treatment Guidelines

HerniaSurge just released a comprehensive treatment guideline regarding best practices in inguinal hernia repair. HerniaSurge is an international collection of major hernia societies from the Americas, Asia, Europe, and Australia. The highlights and my takeaways from the guidelines are below:

  • Ultrasound is rarely needed
  • Asymptomatic individuals may be managed with “watchful waiting”, however, the majority will eventually require surgery
  • Mesh repair is recommended as first choice
  • Flat mesh is recommended, plugs and other configurations are not
  • Surgeons should offer both anterior (open) and posterior (laparoscopic) repairs. One technique for all hernias does not exist
  • Laparoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective
  • The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques
  • It is suggested that women with groin hernias undergo laparoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia

I agree with the findings here and my practice choices align with them. While not every patient fits into the mold of a guideline, the majority of hernias should be repaired following these criteria unless specific situations or indications warrant deviating from them.

The guidelines have been endorsed by the following societies: European Hernia Society (EHS), Americas Hernia Society (AHS), Asia Pacific Hernia Society (APHS), Afro Middle East Hernia Society (AMEHS), Australasian Hernia Society, International Endo Hernia Society (IEHS), European Association for Endoscopic Surgery and Other Interventional Techniques (EAES).

Read the guidelines here.

Super Doctors

Super Doctors Rising Stars - Texas 2018

Dr. Mark Glover has once again been to the Texas Super Doctors® Rising Stars as one of the top doctors in Austin, TX for 2018. 

“The Rising Stars edition looks to the future of medicine by recognizing outstanding physicians who have been fully licensed to practice medicine in their respective specialty for approximately 10 years or less. These doctors have made noteworthy achievements early in their careers and are rising through the ranks of their field.” 

Each year, MSP Communications undertakes a rigorous multi-phase selection process that includes a survey of doctors, independent evaluation of candidates by the research staff, a peer review of candidates by practice area, and a good-standing and disciplinary check. As a part of this evaluation, physicians are asked to consider the following question: ‘‘If you needed medical care in one of the following practice areas, which doctor would you choose?’’ Only doctors who acquired the highest total points from the surveys, research, and blue-ribbon panel review were selected to theTexas 2018  Rising Stars list. 

Since 2005, MSP Communications, has published Super Doctors lists across the country. Honorees are also found online at www.superdoctors.com, where selected doctors can be searched by name, medical specialty and location.Look for the listing in the July 2018 issue of Texas Monthly. 

What’s the deal with mesh?

What's the deal with mesh?

Patients in my clinic are consistently asking more about mesh and its implications. Discussing the benefits and risks of mesh is a discussion I have on a daily basis.  A recent mesh recall last year heightened the public’s attention to mesh, due to the onslaught of lawyer firms seeking clients with Physiomesh. 

 

The origin of mesh began in an attempt to decrease the unacceptably high rates of hernia recurrence. Hernia recurrence refers to the hernia coming back after it is repaired. As our society has become on average more overweight and more obese, this is needed even more.  Closing large hernia defects with suture only puts tension and stress on the repair that make it highly likely to tear and to fail, leading to hernia recurrence. Mesh acts to reinforce the repair and disperse the forces placed on the repair to the surrounding abdominal wall. 

 

Many patients hear anecdotal stories found on the internet or from friends.  Mesh has several uses in surgery and those uses carry very different risks. For example, mesh is often used in the pelvis as a bladder sling and placed near the vagina.  Mesh reacts differently and has very different risks depending on whether it is placed in the pelvis, the groin or in the abdominal wall.  

 

Some patients with inguinal hernias come to me wanting to have a tissue repair done. Many are surprised to find that the same material is used for both procedure. “Tissue” repairs still require polypropylene, permanent suture, or in the case of the Shouldice clinic, stainless steel wire. Mesh is generally made of polypropylene or polyester. 

So many patients are surprised to find out that even if they have a tissue repair, they still will have permanent polypropylene suture in their groin

Mesh is not alway necessary. Some hernias, such as small umbilical hernias may be repaired without mesh placement. A discussion is had preoperatively regarding the patient’s goals and personal preference and a treatment plan is formulated together. 

Dr Glover named to SuperDoctors 2017

Super Doctors Rising Stars - Texas 2017

Dr Mark Glover has been named by Texas Super Doctors® Rising StarsSM 2017 as one of the top doctors in Austin, TX for 2017. The Rising Stars edition looks to the future of medicine by recognizing outstanding physicians who have been fully licensed to practice medicine in their respective specialty for approximately 10 years or less. These doctors have made noteworthy achievements early in their careers and are rising through the ranks of their field. 

Each year, MSP Communications undertakes a rigorous multi-phase selection process that includes a survey of doctors, independent evaluation of candidates by the research staff, a peer review of candidates by practice area, and a good-standing and disciplinary check. As a part of this evaluation, physicians are asked to consider the following question: ‘‘If you needed medical care in one of the following practice areas, which doctor would you choose?’’ Only doctors who acquired the highest total points from the surveys, research, and blue-ribbon panel review were selected to theTexas 2017  Rising Stars list. 

Since 2005, MSP Communications, has published Super Doctors lists across the country. Honorees are also found online at www.superdoctors.com, where selected doctors can be searched by name, medical specialty and location.

Check out this month’s issue of Texas Monthly in print. 

March is colorectal cancer awareness month

March is Colorectal Cancer Awareness Month

March is Colorectal Cancer Awareness Month, and a good time to learn more about colorectal cancer (cancer of the colon and rectum) and how it can be prevented or best treated. Colorectal cancer is the second leading cause of cancer-related deaths in the United States for both men and women combined. This year, approximately 140,000 new cases of colorectal cancer will be diagnosed and 56,000 people will die from the disease. But colorectal cancer is a disease that can be prevented through regular screenings, a healthy diet and regular exercise. 

 

How can I lower my risk? 

To lower your risk of colorectal cancer, the American Society of Colon and Rectal Surgeons recommends that you: Get regular colorectal cancer screenings after age 50. Between 80-90% of colorectal cancer patients are restored to normal health if their cancer is detected and treated in the earliest stages. 

 

  • Eat a low-fat, high-fiber diet. 
  • If you use alcohol, drink only in moderation. 
  • If you use tobacco, quit. If you don’t use tobacco, don’t start. Alcohol and tobacco in combination are linked to colorectal cancer and other gastrointestinal cancers. Exercise for at least 20 minutes three to four days each week. 
  • Moderate exercise such as walking, gardening or climbing steps may help. 

Can colorectal cancer be cured? 

 

Since there are very few symptoms associated with colorectal cancer, regular screening is essential. Screening is beneficial for two main reasons: colorectal cancer is preventable if polyps that lead to the cancer are detected and removed, and it is curable if the cancer is detected in its early stages. 

 

“If detected, colorectal cancer requires surgery in nearly all cases for complete cure, sometimes in conjunction with radiation and chemotherapy,” says Dr. Mark Glover.  “Between 80-90% of patients are restored to normal health if the cancer is detected and treated in the earliest stages. However, the cure rate drops to 50% or less when diagnosed in the later stages.” Who is at risk for colorectal cancer? 

 

The risk of developing colorectal cancer increases with age. All men and women aged 50 and older are at risk for developing colorectal cancer, and should be screened. Some people are at a higher risk and should be screened at an age younger than 50, including those with a personal or family history of inflammatory bowel disease; colorectal cancer or polyps; or ovarian, endometrial or breast cancer. 

 

Current screening methods include fecal occult blood testing (a simple chemical test that can detect hidden blood in the stool), flexible sigmoidoscopy (a visual examination of the rectum and lower portion of the colon, performed in a doctor’s office), double contrast barium enema (barium x-ray), colonoscopy (a visual examination of the entire colon) and digital rectal exam. Colorectal cancer screening costs are covered by Medicare and many commercial health plans. You should find out from your surgeon or other healthcare provider which screening procedure is right for you and how often you should be screened.