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“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.”
“Upper extremity DVT may be complicated by recurrent thrombosis in about 7.5% of cases and by post-thrombotic syndrome in 19.4% of cases, with higher rates of recurrence in patients with cancer-associated thrombosis and of post-thrombotic syndrome in patients with unprovoked thrombosis or related to congenital or anatomical abnormalities. The intensity and duration of anticoagulant treatment need to be balanced against the risk of bleeding
complications, especially in high-risk subgroups like patients with cancer in whom major bleeding events were reported in up to 10%.”
“Surgical site infection (SSI) is the most common complication of surgery around the world, and disproportionately affects patients in low income and middle income countries (LMICs). SSI is unpleasant and harmful for patients, increases the care burden on families and communities, and is very costly for patients and providers. As a result, SSI was highlighted as the highest research priority in surgery in a global co prioritisation exercise. The causes of SSI are multifactorial, and a so called magic bullet to prevent SSI is unlikely to exist. In modern surgical practice, very few interventions to reduce the incidence of SSI have
been shown to be effective when tested robustly.”
“The ChEETAh trial evaluated a change in behaviour across theatre teams to routinely change gloves and instruments at the time of abdominal wound closure. Compared with
previous studies, ChEETAh is large, pragmatic, rigorously conducted, and transparently reported. It also includes a diverse and representative range of patients operated on in
hospitals across middle-income and lower-income settings. The high adherence rate with the intervention shows that routine change of gloves and instruments is deliverable
around the world. ChEETah robustly shows that routine change of gloves and instruments before wound closure reduced surgical site infections in clean–contaminated, contaminated, and dirty surgery, which was consistent across several sensitivity analyses. That there was no evidence to suggest heterogeneity of effect across any of the prespecified subgroups suggests that the effect is consistent across a wide range of patients.”
Surgical Focus 