Management of pancreatic injuries

Ho VP, Patel NJ, Bokhari F, et al. Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017 Jan;82(1):185-199. Free-full text.

In summary, we propose the following recommendations:

  1. For adult patients with grade I or II injury to the pancreas identified on CT scan, we conditionally recommend nonoperative management.
  2. For adult patients with grade III or IV injury to the pancreas identified on CT scan, we conditionally recommend operative intervention.
  3. For adult patients with grade I or II injuries to the pancreas who are undergoing an operation, we conditionally recommend non-resectional management.
  4. For adult patients with grade III or IV injuries to the pancreas who are undergoing an operation, we conditionally recommend resectional management.
  5. For adult patients with grade V injuries to the pancreas who are undergoing an operation, we give no recommendation regarding whether a pancreaticoduodenectomy or a surgical procedure other than pancreaticoduodenectomy should be performed.
  6. For adult patients who have undergone an operation for pancreatic trauma, we conditionally recommend against the routine use of octreotide prophylaxis.
  7. For adult patients undergoing a distal pancreatectomy for pancreatic trauma, we give no recommendation regarding whether routine splenectomy or splenic preservation should be performed.

Article of interest: Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar placement

Balzer KM, et al. Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar placement. Surg Radiol Anat. 1999;21(2):87-9. Full-text for Emory users.

Abstract: A knowledge of the parietal structures of the abdominal wall is necessary to minimize risks of operative procedures like laparoscopy. For means to prevent intraoperative bleeding and the occurrence of abdominal wall hematoma, we studied the course of the inferior epigastric arteries and the ascending branch of the deep circumflex iliac artery in 21 human cadavers. The abdominal wall structures were dissected and the distances of the arteries in relation to anatomic structures such as the umbilicus, pubic symphysis, superior ischial spine and lower edge of the rib-cage were measured. Comparison of the morphometric results obtained with the location of 36 trocar incision sites recommended in the common literature yields the information that about half of these incision sites incur the risk of injuring the arteries.

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Remote endarterectomy

Saaya S, et al. A prospective randomized trial on endovascular recanalization with stenting vs. remote endarterectomy for the superficial femoral artery total occlusive lesions. J Vasc Surg. 2022 Feb 26:S0741-5214(22)00380-9. Full-text for Emory users.

Key Findings: In patients with superficial femoral artery total occlusive lesions of size greater than 250 mm, the 1-year and 4-year cumulative primary patencies of stenting (EI) and remote endarterectomy (RE) were 83% vs 82% and 28% vs 46% (P = .04), respectively. Patencies of endovascular reintervention subgroups (65 patients in the EI subgroup and 32 patients in the RE subgroup) were 37% and 60% (P = .04), respectively.

Take Home Message: RE has a better 4-year primary patency compared with stenting in patients with superficial femoral artery total occlusive lesions of size greater than 250 mm. Endovascular reinterventions after RE showed a higher patency compared with reinterventions after EI.

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Does antiseptic irrigation reduce the risk of surgical site infections?

de Jonge SW, et al. Systematic Review and Meta-Analysis of Randomized Controlled Trials Evaluating Prophylactic Intra-Operative Wound Irrigation for the Prevention of Surgical Site Infections. Surg Infect (Larchmt). 2017 May/Jun;18(4):508-519. Full-text for Emory users.

“Although recommendations from existing guidelines are conflicting [9,10] and recent well-designed RCTs are lacking, as many as 97% of surgeons irrigate wounds in an effort to reduce the risk of SSI [6,7]. The most commonly used irrigation solution is saline followed by aqueous PVP-I or antibiotic solutions [6,42,43]. The efficacy and clinical safety of irrigation with these solutions has been the subject of debate [11, 44]. Various concentrations of PVP-I are effective rapidly against a broad spectrum of pathogens, methicillin-resistant S. aureus (MRSA) included [45,46]. However, some in vitro studies [47-49] have reported a negative effect of PVP-I on tissue regeneration, and older case studies describe serum iodine toxicity as a result of irrigation [50-52]. However, these adverse effects could not be substantiated in clinical trials [29-35;41].” (p. 515)

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Laparoscopic cholecystectomy and cirrhosis

Gad EH, et al. Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study. Ann Med Surg (Lond). 2020 Jan 15;51:1-10. Free full-text.

Results: The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities.

Conclusion: LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.

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Sickle Hepatopathy

Praharaj DL, Anand AC. Sickle Hepatopathy. J Clin Exp Hepatol. 2021 Jan-Feb; 11(1):82-96. Free full-text.

“Liver disease may result from viral hepatitis and iron overload due to multiple transfusions of blood products or due to disease activity causing varying changes in vasculature. The clinical spectrum of disease ranges from ischemic injury due to sickling of red blood cells in hepatic sinusoids, pigment gall stones, and acute/chronic sequestration syndromes. The sequestration syndromes are usually episodic and self-limiting requiring conservative management such as antibiotics and intravenous fluids or packed red cell transfusions. However, rarely these episodes may present with coagulopathy and encephalopathy like acute liver failure, which are life-threatening, requiring exchange transfusions or even liver transplantation.” (Praharaj DL, et al., p. 82)

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Article of interest: Clinical practice guideline for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula

Vogel JD, et al. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2016 Dec;59(12):1117-1133. Full-text for Emory users.

Recommendations: Treatment of Rectovaginal Fistulas (p. 1123-1125)

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