return to: UCSF Sialendoscopy Nov 4 2015 Postoperative Management
Preoperative Counseling
A. Key to Postoperative Management is Preoperative Counseling with involvement of the patient as the key decision-maker to determine which of the more-than-one available approaches to take
1. Valuable to have a friend or family member present during counseling with a recording of their presence and affirmation they (with the patients agreement) could help with intra-operative decision-making in case of unanticipated findings
B. In the past, paternalism dominated surgical conduct
1. Surgeons and others "seemingly acting out of beneficence, chose what to disclose or not..." (Main and Adair 2015)
a. In the past, lack of discussion was designed to reduce anxiety and distress "doctors know best"
b. Current practice identifies that informed consent requires a careful dialogue - with the consent form serving as evidence that this dialogue occurred
C. Current recommendations include 'the medical professionals' duty to frame choices for the patient and offer informed consent according to the dictates of the best practices of the medical profession" (Munoz et al 2015)
1. The concept of 'nudging' (Cohen 2013) is described in detail by Munoz et al through discussion of a practitioners medical knowledge of best practices instrumental in steering decision-making
a. Cohen (Cohen 2013) identifies the surgeon is maleficent if he does not accept his professional duty to 'nudge patients toward the surgical intervention the surgeon believes best" (Munoz et al 2015)
b. In cases where this are no agreed-upon best practices, the informed consent should be more fully 'democratized' in shared decision making
b. The option of obtaining a second opinion is valuable
Postoperative Management
A. Practice in 2008:
Home care: sugar-free lemon drops; gentle massage of affected gland; hydration; consider antibiotics/steroids
B. Practice in 2015:
Dependent on type and extents of sialendoscopy-assisted surgery
1. Home care: sugar-free lemon drops; gental massage of affected gland; hydration; consider antibiotics/steroids
Usual: anti-staph antibiotics for one week; medrol dose pak
2. Oral peridex (chlorhexidine) rinse for 30 seconds then spit four times a day (after every meal) - note side effects of mild irritation, taste changes, tooth staining rare allergic reaction
3. Consider avoiding full face CPAP or BiPAP (recently dilated and manipulated duct may permit retrograde insufflation of air into gland)
4. Follow-up offered as early as several days to a week or two if management of stenosis (re-dilation), stent removal or if extensive open procedure. Most cases with limitied incision at duct orifice (ductoplasty) or no incision are offered 6 week follow-up with many chosing to follow by phone or email (many come from long distances in our practice)
References
Main BGT and Adair SR: The changing face of informed consent. Br Dent JH. 2015 Oct 9,219(7):325-7
Doherty C, Stavropoulou C, Saunders MN and Brown T: The consent process: Enabling or disablihng patients' active participation? Health (london). 2015 Oct 2015 epub
Ricky Munoz, Mark Fox, Michael Gomez & Scott Gelfand (2015) Evidence-Based Nudging: Best Practices in Informed Consent, The American Journal of Bioethics, 15:10,43-45, DOI: 10.1080/15265161.2015.1074311
Cohen S: Nudging and informed consent. American Journal of Bioethics 13(6):3-11
Marchal (editor) Sialendoscopy - The Hands-On Book 2015 printed in France Imprimerie Gutenberg, Meythet, France copyright 2015 by European Sialendoscopy Training Center (ESTC)