Article of interest: A systematic review of pre-surgical exercise intervention studies with cancer patients

Singh F, et al. A systematic review of pre-surgical exercise intervention studies with cancer patients. Surg Oncol. 2013 Jun;22(2):92-104. Full-text for Emory users.

Results: Eighteen studies were included consisting of a total of 966 participants. Lung cancer studies were the predominant group represented. Most of the studies prescribed an aerobic intervention programs done prior to surgery. Mode, frequency, duration, and intensity of exercise intervention varied across the different cancer groups. The majority of studies showed preliminary positive change in clinical outcomes with significant improvements in the rate of incontinence, functional walking capacity and cardiorespiratory fitness.

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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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