We are excited to share a new section titled “Essential Articles for Surgical Residents.”
Keeping up with surgical literature in residency can be challenging. This list was created to serve as an easily accessible, up-to-date, and evidence-based resource for residents.
The content has been curated by faculty from each department and is intended to supplement the standard educational curriculum of each rotation with current and relevant literature.
Continue reading“Direct oral anticoagulants, including rivaroxaban and apixaban, are the most frequently prescribed treatments for acute venous thromboembolism. In randomized clinical trials, rivaroxaban at a dose of 15 mg twice daily for 21 days followed by 20 mg daily and apixaban at a dose of 10 mg twice daily for 7 days followed by 5 mg twice daily were noninferior to vitamin K antagonists regarding efficacy (risk of recurrent venous thromboembolism). These trials showed that clinically relevant bleeding, a composite of major bleeding or clinically relevant nonmajor bleeding, occurred in 4.3% of the patients who received apixaban as
compared with 9.7% of those who received vitamin K antagonists9 and in 8.1% of patients who received rivaroxaban as compared with 8.1% of those who received vitamin K antagonists. The difference between apixaban and rivaroxaban therapy regarding the risk of clinically relevant bleeding was hypothesized to be related to heterogeneity in the patient populations and differences in the trial designs. Owing to a lack of trials that have compared rivaroxaban with apixaban regarding the risk of bleeding, clinical practice guidelines do not recommend one anticoagulant over the other.”
“Tissue biopsy remains essential for the histopathologic and immunophenotypic evaluation of DLBCL, as treatment decisions hinge on diagnostic accuracy. Steroids induce cytolysis of malignant B cells, resulting in apoptosis and tumor necrosis, and are therefore hypothesized to compromise diagnostic yield. Steroid-induced B-cell lysis can lead to increased infiltration by reactive macrophages and lymphocytes, potentially obscuring diagnostic features.8-10 In addition, steroids may alter cluster of differentiation (CD20) immunoreactivity—a key diagnostic marker—leading to patchy or atypical staining patterns. Radiologically, this effect has been observed as rapid tumor involution on imaging, earning the descriptor ghost tumor. Nonetheless, more recent evidence suggests that a steroid administration before baseline positron emission tomography or computed tomography does not diminish diagnostic yield in DLBC.”
“Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on
1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit;
2. The duration of such MAP augmentation; and
3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets.”
Kwon, Brian K et al. “A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management.” Global spine journal vol. 14,3_suppl (2024): 187S-211S.
“For recommendation #1, 89% of the GDG voted to accept and endorse this 2013 statement regarding the use of cardiac, hemodynamic and respiratory monitoring devices. The GDG
agreed that patients with SCI often require a higher level of care and close monitoring in an ICU setting given increased rates of respiratory insufficiency, cardiac dysfunction and
systemic hypotension. Patients with cervical SCI may require mechanical ventilation. Early detection of cardiopulmonary dysfunction and hemodynamic instability may allow for
timely implementation of effective and life-saving strategies. The GDG acknowledged that some patients with less severe SCI, such as those with a mild “central cord syndrome” pattern of incomplete tetraplegia, may be safely monitored and managed in a step down or acute care unit. Furthermore, it was recognized that providing ICU level care for every SCI patient might not be feasible in resource-limited clinical settings (eg low or middle-income countries).
For recommendation #2, 84% of the GDG voted to accept and endorse this 2013 statement regarding the correction of hypotension to a systolic blood pressure above 90 mmHg. As
stated previously, the injured spinal cord is particularly susceptible to decreases in systolic blood pressure given impaired vascular reactivity and loss of auto-regulation. Given that
small changes in the perfusion of the spinal cord can worsen ischemia and propagate secondary injury, the GDG agreed that systemic hypotension should be avoided or corrected as soon as possible. Furthermore, the GDG recognized that maintaining a systolic blood pressure over 90 mmHg represents standard of care for most patients admitted to the hospital to ensure adequate systemic perfusion and limit end-organ damage.
For recommendation #3 on the MAP target of 85-90 mmHg for 7 days, 84% of the GDG voted to revise this recommendation based on the reasons outlined in the introduction.
The GDG then aimed to establish a new recommendation by addressing 3 key components of hemodynamic management: (i) the upper and lower limits of a MAP target range; (ii) the
optimal duration of MAP augmentation; and (iii) the choice of vasopressor or inotrope for pharmacologic support of MAP.”
Kwon, Brian K et al. “A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management.” Global spine journal vol. 14,3_suppl (2024)
Continue reading“Appendectomy has long been the standard treatment for appendicitis, even though successful use of antibiotic therapy as an alternative was reported more than 60 years ago. Although there have been several randomized trials of antibiotics for appendicitis
in adults, exclusion of important subgroups (in particular, patients with an appendicolith, who
may be at an increased risk for complications), small sample sizes, and questions about applicability to the general population have limited the use of this treatment. As recently as 2014, more than 95% of U.S. patients with appendicitis underwent appendectomy. However, with the pandemic of coronavirus disease 2019 (Covid-19), health systems and professional societies such as the American College of Surgeons have suggested reconsideration of many aspects of care delivery, including the role of antibiotics in the treatment of appendicitis.”
“Uncomplicated and complicated appendicitis are currently distinguished as 2 different disease entities that require different treatments. The role of antibiotic treatment as an alternative for surgery in simple or uncomplicated appendicitis has been studied in adults and, more recently, in children. Acute complicated appendicitis with necrosis or perforation of the appendix is treated by appendectomy and usually followed by additional antibiotic
treatment aimed at reducing postoperative infectious complications. Restriction and proper use of antibiotics are important for reducing and preventing harmful adverse effects to the patients and preventing antibiotic resistance. In American guidelines, an antibiotic length of 4 to 7 days is advised after complicated appendicitis. To our knowledge, few studies have
investigated the reduction of antibiotic administration after appendectomy and these were mostly performed in children. Restricting antibiotic duration to fewer than 5 days after surgery in complicated appendicitis is seldom done, fearing infectious complications. However, 3 days of antibiotic treatment has been observed to be feasible and safe in a retrospective cohort of adults with complicated appendicitis.”
“Acute appendicitis is a prevalent acute abdominal condition necessitating emergency surgical intervention. Laparoscopic appendectomy (LA) has rapidly evolved as the standard of care treatment for acute appendicitis. For decades, placing an intra-abdominal drainage tube following LA has been perceived as beneficial in averting the development of postoperative abdominal abscesses, monitoring postoperative abdominal bleeding, and preventing postoperative appendix stump leakage. The rationale behind peritoneal drainage stemmed from the widespread belief among surgeons that the accumulation of inflammatory exudate within the abdominal cavity escalated the risk of postoperative complications, including intra-abdominal abscesses, appendix stump leakage, wound infections, and intestinal obstructions. However, the past few years have witnessed unprecedented scientific progress, which has translated into improved surgical, and the necessity of peritoneal drainage following LA has come under increasing scrutiny.”
“Venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disorder with an annual incidence of 0.1%, affecting approximately 5% of the population.1 Upper extremity DVT (UEDVT) has been thought to account for 4e10% of all cases of DVT and may involve the radial, ulnar, brachial, axillary, subclavian, brachiocephalic, or internal jugular veins.
Historically, UEDVT has been considered a relatively benign event. However, as the incidence of UEDVT increases, so do its subsequent complications including PE, venous access difficulties, superior vena cava syndrome, postthrombotic syndrome, and bleeding on therapeutic anticoagulation therapy, suggesting an insufficient understanding and management of UEDVT.
Management guidelines, with the exception of those for thoracic outlet syndrome, are largely
extrapolated from lower extremity DVT (LEDVT) and PE management.”
Surgical Focus 