Igami T, et al. Using the greater omental flap to cover the cut surface of the liver for prevention of delayed gastric emptying after left-sided hepatobiliary resection: a prospective randomized controlled trial. J Hepatobiliary Pancreat Sci. 2011 Mar; 18(2):176-83.
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Zasowski EJ, et al. Identification of Vancomycin Exposure-Toxicity Thresholds in Hospitalized Patients Receiving Intravenous Vancomycin. Antimicrob Agents Chemother. 2017 Dec 21;62(1):e01684-17.
Evidence supports vancomycin therapeutic-drug monitoring by area under the concentration-time curve (AUC), but data to establish an AUC upper limit are limited and published nephrotoxicity thresholds range widely. The objective of this analysis was to examine the association between initial vancomycin AUC and nephrotoxicity. This was a multicenter, retrospective cohort study of adult patients receiving intravenous vancomycin from 2014 to 2015. Nephrotoxicity was defined as a serum creatinine increase of 0.5 mg/liter and 50% from baseline on consecutive measurements. Vancomycin exposure profile during the initial 48 h of therapy was estimated using maximum a posteriori probability Bayesian estimation. Vancomycin AUC and minimum-concentration (Cmin) thresholds most strongly associated with nephrotoxicity were identified via classification and regression tree (CART) analysis. Predictive performances of CART-derived and other candidate AUC thresholds was assessed through positive and negative predictive value and receiver operating characteristic curves. Poisson regression was used to quantify the association between exposure thresholds and nephrotoxicity while adjusting for confounders. Among 323 patients included, nephrotoxicity was significantly higher in patients with AUCs from 0 to 48 h (AUC0-48) of ≥1,218 mg · h/liter, AUC0-24 of ≥677 mg · h/liter, AUC24-48 of ≥683 mg · h/liter, and day 1 Cmin (Cmin24) of ≥18.8 mg/liter. Vancomycin exposure in excess of these thresholds was associated with a 3- to 4-fold-increased risk of nephrotoxicity in Poisson regression. The predictive performance of AUC for nephrotoxicity was maximized at daily AUC values between 600 and 800 mg · h/liter. Although these data support an AUC range for vancomycin-associated nephrotoxity rather than a single threshold, available evidence suggests that a daily AUC limit of 700 mg · h/liter is reasonable.
Katsargyris A, et al. Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther. 2013 Apr;20(2):159-69.
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Results: A total of 2465 vessels were targeted with fenestrations and 151 with chimney grafts (CG); intraoperative target vessel preservation was 98.6% and 98.0%, respectively. Cumulative 30-day mortality was 3.4%, 2.4%, and 5.3% for open surgery, F-EVAR and Ch-EVAR, respectively (p=NS). Impaired renal function was noted in 18.5%, 9.8%, and 12% following open surgery, F-EVAR, and Ch-EVAR, respectively (open vs. F-EVAR: p<0.001). New-onset dialysis was required postoperatively in 3.9%, 1.5%, and 2.1%, respectively (open vs. F-EVAR: p<0.001). Postoperative cardiac complications were noted in 11.3%, 3.7%, and 7.4%, respectively (open vs. F-EVAR: p<0.001). The incidence of ischemic stroke was 0.1% and 0.3% following open surgery and F-EVAR, but 3.2% after Ch-EVAR (open vs. Ch-EVAR: p=0.002; F-EVAR vs. Ch-EVAR: p=0.012). Early proximal type I endoleak was lower after F-EVAR compared to Ch-EVAR (4.3% vs. 10%, respectively, p=0.002).
Xie M, et al. Does ileoanal pouch surgery increase the risk of desmoid in patients with familial adenomatous polyposis? Int J Colorectal Dis. 2020 Aug;35(8):1599-1605.
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Results: Eight retrospective studies with a total of 1072 patients were identified: 491 underwent IPAA and 581 IRA. There was no significant difference in the incidence of DTs between IPAA and IRA (11.81% vs. 9.47%, OR 0.95, P = 0.85). Meanwhile, the overall complication (42.97% vs. 36.76%, OR 1.32, P = 0.11), incidence of cancer (4.88% vs. 8.37%, OR 0.28, P = 0.26), and overall mortality (0.33% vs. 5.20%, OR 0.49, P = 0.53) were comparable too.
Conclusion: Ileoanal pouch surgery is associated with similar risk of desmoid in patients with FAP after surgery.
Ng KS, Gonsalves SJ, Sagar PM. Ileal-anal pouches: A review of its history, indications, and complications. World J Gastroenterol. 2019 Aug 21;25(31):4320-4342.
As the IPAA celebrated its 40th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.
Groth CM, Acquisto NM, Khadem T. Current practices and safety of medication use during rapid sequence intubation. J Crit Care. 2018 Jun;45:65-70.
“A total of 404 patients from 34 geographically diverse institutions were included (mean age 58 ± 22 years, males 59%, pediatric 8%). During RSI, 21%, 87%, and 77% received pre-induction, induction, and paralysis, respectively. Significant differences in medication use by provider type were seen. Etomidate was administered to 58% with sepsis, but was not associated with adrenal insufficiency. Ketamine was associated with hypotension post-RSI [RR = 1.78 (1.36–2.35)] and use was low with traumatic brain injury/stroke (1.5%). Succinylcholine was given to 67% of patients with baseline bradycardia and was significantly associated with bradycardia post-RSI [RR = 1.81 (1.11–2.94)]. An additional 13% given succinylcholine had contraindications. Sedation practices post-RSI were not consistent with current practice guidelines and most receiving a non-depolarizing paralytic did not receive adequate sedation post-RSI.”
COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020 Jul 4;396(10243):27-38. Erratum in: Lancet. 2020 Jun 9.
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Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047).
Hodari A, et al. Assessment of morbidity and mortality after esophagectomy using a modified frailty index. Ann Thorac Surg. 2013 Oct;96(4):1240-1245.
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Results: A total of 2,095 patients were included in the analysis. Higher frailty scores were associated with a statistically significant increase in morbidity and mortality. A frailty score of 0, 1, 2, 3, 4, and 5 had associated morbidity rates of 17.9% (142 of 795 patients), 25.1% (178 of 710 patients), 31.4% (126 of 401 patients), 34.4% (48 of 140 patients), 44.4% (16 of 36 patients), and 61.5% (8 of 13 patients), respectively. A frailty score of 0, 1, 2, 3, 4, and 5 had associated mortality rates of 1.8% (14 of 795 patients), 3.8% (27 of 710 patients), 4% (16 of 401 patients), 7.1% (10 of 140 patients), 8.3% (3 of 36 patients), and 23.1% (3 of 13 patients), respectively. When using multivariate logistic regression for mortality comparing age, functional status, prealbumin, emergency surgery, wound class, American Society of Anesthesiologists score, and sex, only age and frailty were statistically significant. The odds ratio was 31.84 for frailty (p = 0.015) and 1.05 (p = 0.001) for age.
Surgical Focus 