Temperature Management After Cardiac Arrest

Nielsen N, Wetterslev J, Cronberg T, et al.; TTM Trial Investigators. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17. PMID: 24237006.

Results: In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar.

Conclusions: In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C. (Funded by the Swedish Heart-Lung Foundation and others; TTM ClinicalTrials.gov number, NCT01020916.).

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Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection

1: Ambe PC, Rombey T, Rembe JD, Dörner J, Zirngibl H, Pieper D. The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis. Patient Saf Surg. 2020 Dec 22;14(1):47. doi: 10.1186/s13037-020-00274-2. PMID: 33353558; PMCID: PMC7756962.

2: Strobel RM, Leonhardt M, Krochmann A, Neumann K, Speichinger F, Hartmann L,
Lee LD, Beyer K, Daum S, Kreis ME, Lauscher JC. Reduction of Postoperative Wound Infections by Antiseptica (RECIPE)?: A Randomized Controlled Trial. Ann Surg.
2020 Jul;272(1):55-64. doi: 10.1097/SLA.0000000000003645. PMID: 31599810.

3: Thom H, Norman G, Welton NJ, Crosbie EJ, Blazeby J, Dumville JC. Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection: Systematic Review and Network Meta-Analysis. Surg Infect (Larchmt). 2021 Mar;22(2):144-167. doi: 10.1089/sur.2019.318. Epub 2020 Apr 29. PMID: 32352895.

4: Maatman TK, Weber DJ, Timsina LR, Qureshi B, Ceppa EP, Nakeeb A, Schmidt CM,
Zyromski NJ, Koniaris LG, House MG. Antibiotic irrigation during pancreatoduodenectomy to prevent infection and pancreatic fistula: A randomized controlled clinical trial. Surgery. 2019 Oct;166(4):469-475. doi: 10.1016/j.surg.2019.05.053. Epub 2019 Aug 2. PMID: 31383465.

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The anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades

Kumar KH, et al. Anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades in the human pancreas: a cadaveric study. Surg Radiol Anat. 2021 Mar;43(3):367-375.

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Results: The gastroduodenal (GDA), anterior superior pancreaticoduodenal (ASPD), and anterior inferior pancreaticoduodenal (AIPD) artery was found in all the cases, whereas the posterior superior pancreaticoduodenal (PSPD) and posterior inferior pancreaticoduodenal (PIPD) artery was present in 93.34% cases. The ASPD artery originated from GDA in all the cases. Two types of variations were observed in the origin of PSPD artery and four types each in the origin of AIPD and PIPD artery. Anatomical and numerical variations were observed in both anterior and posterior arches, posterior arch being absent in 20% cases.

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Surgical management of pheochromocytoma

Fu SQ, Wang SY, Chen Q, Liu YT, Li ZL, Sun T. Laparoscopic versus open surgery for pheochromocytoma: a meta-analysis. BMC Surg. 2020 Jul 25;20(1):167.

Results: Fourteen studies involving 626 patients were included in this meta-analysis. LS was associated with lower rates of intraoperative haemodynamic instability (IHD) [odds ratio (OR) = 0.61, 95% CI: 0.37 to 1.00, P = 0.05], less intraoperative blood loss [weighted mean difference (WMD) = – 115.27 ml, 95% confidence interval (CI): – 128.54 to – 101.99, P < 0.00001], lower blood transfusion rates [OR = 0.33, 95% CI: 0.21 to 0.52, P < 0.00001], earlier ambulation (WMD = – 1.57 d, 95% CI: – 1.97 to – 1.16, P < 0.00001) and food intake (WMD = – 0.98 d, 95% CI: – 1.36 to – 0.59, P < 0.00001), shorter drainage tube indwelling time (WMD = – 0.51 d, 95% CI: – 0.96 to – 0.07, P = 0.02) and postoperative stay (WMD = – 3.17 d, 95% CI: – 4.76 to – 1.58, P < 0.0001), and lower overall complication rates (OR = 0.56, 95% CI: 0.35 to 0.88, P = 0.01). However, no significant differences in operative time, postoperative blood pressure control, rates of severe complications, postoperative hypotension or cardiovascular disease (CVD) were found between the two groups.

Conclusions: LS is safe and effective for PHEO resection. Compared with OS, LS caused less IHD, providing an equal chance to cure hypertension while also yielding a faster and better postoperative recovery.

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Article of interest: Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial.

Azhar N, Johanssen A, Sundström T, et al. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial. JAMA Surg. 2021 Feb 1;156(2):121-127.

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Results: Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups.

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Management of enterocutaneous fistulas

Owen RM, Love TP, Perez SD, Srinivasan JK, Sharma J, Pollock JD, Haack CI, Sweeney JF, Galloway JR. Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience. JAMA Surg. 2013 Feb;148(2):118-26.

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Figure 1. Causes of enterocutaneous fistula between 1987 and 2010. IBD indicates inflammatory bowel disease; other includes radiation, neoplasm, and trauma. Percentages may total more than 100% owing to the fact that some patients’ ECFs were secondary to multiple causes.

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Article of interest: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

Rhodes A, Evans LE, Alhazzani W, Levy MM, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017 Mar;45(3):486-552.

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Methods: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.

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Article of interest: Randomized placebo-controlled study of intravenous methylnaltrexone in postoperative ileus.

Viscusi ER, Rathmell JP, Fichera A, et al. Randomized placebo-controlled study of intravenous methylnaltrexone in postoperative ileus. J Drug Assess. 2013 Aug 27; 2(1):127-34.

Results: A total of 65 patients (methylnaltrexone, n = 33; placebo, n = 32) were randomized. Mean time to first bowel movement was accelerated by 20 h (p = 0.038) and time to discharge eligibility was accelerated by 33 h (p = 0.049) with methylnaltrexone vs placebo. Opioid use was similar between groups until postoperative day 4, then fluctuated in the placebo group. Methylnaltrexone was generally well tolerated.

Conclusions: In this study, intravenous methylnaltrexone significantly decreased time to postoperative bowel recovery and eligibility for hospital discharge by ∼1 d, with an adverse event profile similar to placebo. These were two of several exploratory endpoints; not all efficacy endpoints showed a significant difference between methylnaltrexone and placebo. The efficacy results in this trial were not seen in two subsequent large-scale studies.

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T-Tubes

Dageforde LA, Lillemoe KD. (2020). Management of Acute Cholangitis. In: Cameron JL, Cameron AM (Eds), Current Surgical Therapy, 13th ed. Elsevier: Philadelphia.

“Recent literature advocates for primary closure of the common bile duct after elective CBDE because of complications from T-tube placement. But in patients with cholangitis, placement of a T-tube is necessary for biliary decompression and allows easy access for future cholangiogram if the obstruction does not resolve. T-tube drainage has been associated with bile leak and requires externalization of the tube for several days until postoperative cholangiography demonstrates resolution of obstruction. Primary closure can lead to stricture and bile leak and result in no direct access to the biliary tree for future investigations.”

Fig. 2. Insertion of a T-tube in the common bile duct with subsequent closure using absorbable monofilament suture (4-0 or 5-0). The T-tube is prepared in one of the ways shown. From: Zollinger RM, Jr, Zollinger RM. Atlas of Surgical Operations. 7th ed. New York: McGraw-Hill; 1993.

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