Article of interest: Comparison of open gastrostomy tube to percutaneous endoscopic gastrostomy tube in lung transplant patients.

Taghavi S, et al. Comparison of open gastrostomy tube to percutaneous endoscopic gastrostomy tube in lung transplant patients. Ann Med Surg (Lond). 2015 Dec 23;5 :76-80.

Introduction: Lung transplant patients require a high degree of immunosuppression, which can impair wound healing when surgical procedures are required. We hypothesized that because of impaired healing, lung transplant patients requiring gastrostomy tubes would have better outcomes with open gastrostomy tube (OGT) as compared to percutaneous endoscopic gastrostomy tube (PEG).

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Tumor Necrosis Factor (TNF) Antagonists in Treatment of Internal Fistulizing Crohn’s Disease

Bouguen G, et al.; GETAID. Efficacy and Safety of Tumor Necrosis Factor Antagonists in Treatment of Internal Fistulizing Crohn’s Disease. Clin Gastroenterol Hepatol. 2020 Mar; 18(3):628-636.

Results: After a median follow-up period of 3.5 years, 68 patients (43.6%) underwent a major abdominal surgery. The cumulative probabilities for being surgery-free were 83%, 64%, and 51% at 1, 3, and 5 years, respectively. A concentration of C-reactive protein >18 mg/L, an albumin concentration <36 g/L, the presence of an abscess at the fistula diagnosis, and the presence of a stricture were associated independently with the need for surgery. The cumulative probabilities of fistula healing, based on imaging analyses, were 15.4%, 32.3%, and 43.9% at 1, 3, and 5 years, respectively. Thirty-two patients (20.5%) developed an intestinal abscess and 4 patients died from malignancies (3 intestinal adenocarcinomas). One patient died from septic shock 3 months after initiation of anti-TNF therapy.

Conclusions: In a retrospective analysis of data from a large clinical trial, we found that anti-TNF therapy delays or prevents surgery for almost half of patients with CD and luminal fistulas. However, anti-TNF therapy might increase the risk for sepsis-related death or gastrointestinal malignancies.

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Brain Death Determination

Clinical diagnosis of brain death: Prerequisites and criteria (UpToDate – login required.)

Prerequisites
Clinical or neuroimaging evidence of an acute central nervous system (CNS) catastrophe (eg, traumatic brain injury, subarachnoid hemorrhage)
Exclusion of complicating medical conditions that may confound clinical assessment (no severe electrolyte, acid-base, endocrine, or circulatory [ie, shock] disturbance)
No drug intoxication or poisoning, including any sedative drug administered in hospital, which may confound the clinical assessment
Core temperature >36°C (97°F)
Systolic blood pressure >100 mmHg; vasopressors may be required
Examination findings
Coma
Absent brain-originating motor response, including response to pain stimulus above the neck or other brain-originating movements (eg, seizures, decerebrate or decorticate posturing)
Absent pupillary light reflex; pupils are midposition (3.5 to 4 mm)
Absent corneal reflexes
Absent oculocephalic (doll’s eyes) and oculovestibular reflexes (caloric responses)
Absent jaw jerk
Absent gag reflex
Absent cough with tracheal suctioning
Absent sucking or rooting reflexes (in neonates)
Apnea as demonstrated by apnea test
Observation period
At least 6 hours; longer time periods recommended in children and for certain conditions such as after cardiac arrest
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Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Associated Euglycemic Diabetic Ketoacidosis

Thanks to LeslieAnn S. Kao, MD (General Surgery PGY-4) for suggesting this topic.


Somagutta MR, et al. Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers. Cureus. 2021 Mar 3;13(3):e13665.

The underlying mechanism is mainly enhanced lipolysis and ketone body reabsorption. SGLT2i also stimulates pancreatic alpha cells and inhibits beta cells, causing an imbalance in glucagon/insulin levels, further contributing to lipolysis and ketogenesis. Most patients were diagnosed with blood glucose less than 200 mg/dL, blood pH <7.3, increased anion gap, increased blood, or urine ketones. Perioperative fasting, pancreatic etiology, low carbohydrate or ketogenic diet, obesity, and malignancy are identified precipitants in this review. As normoglycemia can conceal the underlying acidosis, physicians should be cognizant of the EDKA diagnosis and initiate prompt treatment. Patient education on risk factors and triggers is recommended to avoid future events.

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Videos: The Ladd Procedure for Adult Malrotation With Volvulus

Brady JT, Kendrick DE, Barksdale EM, Reynolds HL. The Ladd Procedure for Adult Malrotation With Volvulus. Dis Colon Rectum. 2018 Mar;61(3):410.

“Intestinal malrotation is a rare condition that develops during fetal development because of incomplete intestinal rotation or a lack of intestinal rotation around the superior mesenteric artery. Presentation in adulthood, in general, is abnormal and presentation with volvulus is rare. We demonstrate an open Ladd procedure with inversion appendectomy and reduction of paraduodenal hernia of an adult with malrotation with volvulus.”

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Article of interest: Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients

Havens JM, Columbus AB, Olufajo OA, Askari R, Salim A, Christopher KB. Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients. JAMA Surg. 2016 Jul 20;151(7):e160789. doi: 10.1001/jamasurg.2016.0789.

Results: A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98).

Conclusions and relevance: In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.

Commentary: Zarrinpar A. Mind MELD or Ignore It at Your Peril. JAMA Surg. 2016 Jul 20;151(7):e160839. doi: 10.1001/jamasurg.2016.0839.

NIH Treatment Guidelines: Antithrombotic Therapy in Patients With COVID-19

Antithrombotic Therapy in Patients With COVID-19

(Last Updated: February 11, 2021.)

For hospitalized patients with COVID-19, prophylactic dose anticoagulation should be prescribed unless contraindicated (e.g., a patient has active hemorrhage or severe thrombocytopenia) (AIII). Although data supporting this recommendation are limited, a retrospective study showed reduced mortality in patients who received prophylactic anticoagulation, particularly if the patient had a sepsis-induced coagulopathy score ≥4.4 For those without COVID-19, anticoagulant or antiplatelet therapy should not be used to prevent arterial thrombosis outside of the standard of care (AIII). Anticoagulation is routinely used to prevent arterial thromboembolism in patients with heart arrhythmias. Although there are reports of strokes and myocardial infarction in patients with COVID-19, the incidence of these events is unknown.

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Management of malignant hyperthermia

Hopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, McGrady E. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2021 May;76(5):655-664. Free full-text.


Kim KSM, Kriss RS, Tautz TJ. Malignant Hyperthermia: A Clinical Review. Adv Anesth. 2019 Dec;37:35-51. Full-text for Emory users.

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For your review: Desmoplastic melanoma

Nicolson NG, Han D. Desmoplastic melanoma. J Surg Oncol. 2019 Jan;119(2):208-215. doi: 10.1002/jso.25317. Epub 2018 Nov 27.

Desmoplastic melanoma (DM) is a rare melanoma variant that has unique biology and pathology compared with conventional melanoma (non-DM). Importantly, DM is classified into pure and mixed histologic subtypes, which have been correlated with outcomes. Management of DM broadly mirrors that of non-DM; however, there are unique considerations for DM that influence treatment approaches. This paper will provide a contemporary overview of this disease and will review the literature regarding the management of DM.

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Article of interest: Spotlight on the utility of the Oncotype DX ® breast cancer assay.

Siow ZR, De Boer RH, Lindeman GJ, Mann GB. Spotlight on the utility of the Oncotype DX® breast cancer assay. Int J Womens Health. 2018 Feb 21;10:89-100.

Summary: Genomic assays such as Oncotype DX have changed the landscape for the treatment of ER-positive early breast cancer. In a USA-based study, there has been a 13% decline in the use of adjuvant chemotherapy in 2006–2008, which has been largely attributed to the introduction of the Oncotype DX in 2004.78 While the Oncotype DX is expensive, the potential cost savings from chemotherapy avoidance and reduced exposure to the side effects of cytotoxic therapy appear to be cost-effective in most jurisdictions. The development and eventual validation of other genomic assays could potentially reduce test costs. While Oncotype DX is currently well validated in the node-negative population, its optimal use remains to be defined for cohorts of patients with intermediate-risk RS, as well as for patients with lymph node-positive disease. Results from the prospective TAILORx and RxPONDER trials will help shed light on these questions.