Author Archives: E. Lawson

CME & Education: VTE Prevention in the Hospital: New Approaches and Expert Perspectives

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This continuing education offering is part of Medscape‘s series, Contemporary Topics in Antithrombotic Therapy. (You’ll need a Medscape account to view and/or accrue CME credit.)

Authors: Gary E. Raskob, PhD; Steven B. Deitelzweig, MD; Alex C. Spyropoulos, MD

CME Released: 12/22/2019; Valid for credit through: 12/22/2020

“…[W]e are going to talk about VTE, its importance in the hospital population of patients admitted with medical illness, and how we can work to reduce the burden of disease from this important condition.

About half of all hospitalizations in the United States are for medical illnesses, such as heart failure, pneumonia, stroke, and so on. Of these patients, about half of them are at risk for VTE and about 25% are at high risk for VTE.

Those who develop VTE tend to have pretty severe consequences, and these consequences persist beyond hospitalization.”

Bariatric Surgery vs. Medical Therapy for Diabetes and Obesity

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Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes–5-Year Outcomes.N Engl J Med. 2017;376(7):641–651.

Full-text for Emory users.

“At 5 years, the criterion for the primary end point was met by 2 of 38 patients
(5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass (unadjusted P=0.01, adjusted P=0.03, P=0.08 in the intention to-treat analysis) and 11 of 47 patients (23%) who underwent sleeve gastrectomy (unadjusted P=0.03, adjusted P=0.07, P=0.17 in the intention-to-treat analysis). Patients who underwent surgical procedures had a greater mean percentage reduction from baseline in glycated hemoglobin level than did patients who received medical therapy alone (2.1% vs. 0.3%, P=0.003). At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (−23%, −19%, and −5% in the gastric-bypass, sleeve gastrectomy, and medical-therapy groups, respectively), triglyceride level (−40%, −29%, and −8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (−35%, −34%, and −13%), and quality-of-life measures (general health score increases of 17, 16, and 0.3; scores on the RAND 36-Item Health Survey ranged from 0 to 100, with higher scores indicating better health) (P<0.05 for all comparisons).”

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Open Mesh Vs. Lap Mesh Repair of Inguinal Hernia

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Bullen NL, Massey LH, Antoniou SA, Smart NJ, Fortelny RH. Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis. Hernia. 2019; 23(3):461–472.

Full-text for Emory users.

RESULTS: This study included 12 randomised controlled trials with 3966 patients randomised to Lichtenstein repair (n = 1926) or laparoscopic repair (n = 2040). There were no significant differences in recurrence rates between the laparoscopic and open groups (odds ratio (OR) 1.14, 95% CI 0.51-2.55, p = 0.76). Laparoscopic repair was associated with reduced rate of acute pain compared to open repair (mean difference 1.19, CI - 1.86, - 0.51, p ≤ 0.0006) and reduced odds of chronic pain compared to open (OR 0.41, CI 0.30-0.56, p ≤ 0.00001). The included trials were, however, of variable methodological quality. Trial sequential analysis reported that further studies are unlikely to demonstrate a statistically significant difference between the two techniques.

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Article of interest: Long-term Results of a RCT of a Nonoperative Strategy (Watchful Waiting) for Men With Minimally Symptomatic Inguinal Hernias

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This week’s discussion included what are the best treatment options for asymptomatic and symptomatic inguinal hernias.

Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508–515.

Results: Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.

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Article of interest: Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia

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One discussion this week included a question about the patient outcomes of those undergoing the POEM procedure.

Werner YB, Hakanson B, Martinek J, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med. 2019;381(23):2219–2229.

Full-text for Emory users.

Results: A total of 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM plus Dor’s fundoplication (109 patients). Clinical success at the 2-year follow-up was observed in 83.0% of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval [CI], −8.7 to 11.4; P=0.007 for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. Improvement in esophageal function from baseline to 24 months, as assessed by measurement of the integrated relaxation pressure of the lower esophageal sphincter, did not differ significantly between the treatment groups (difference, −0.75 mm Hg; 95% CI, −2.26 to 0.76), nor did improvement in the score on the Gastrointestinal Quality of Life Index (difference, 0.14 points; 95% CI, −4.01 to 4.28). At 3 months, 57% of patients in the POEM group and 20% of patients in the LHM group had reflux esophagitis, as assessed by endoscopy; at 24 months, the corresponding percentages were 44% and 29%.

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Resource Highlight: Chassin’s Operative Strategy in General Surgery, 4th ed.

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Chassin's Operative Strategy in General Surgery

“The Fourth Edition of Chassin’s Operative Strategy in General Surgery: An Expositive Atlas is designed to expand this comprehensive and unique general surgery reference while remaining true to the special character of the work. This unique text continues to provide an emphasis on surgical strategy that is unmatched by other textbooks of surgical technique.”

Emory users, access Chassin’s online here.

The surgical management of mycotic (infected) aneurysms

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Razavi MK, Razavi MD. Stent-graft treatment of mycotic aneurysms: a review of the current literature. J Vasc Interv Radiol. 2008;19(6 Suppl):S51–S56.

Full-text for Emory users.

“Mycotic aneurysms are rare but are associated with a high risk of rupture if not treated promptly. The early mortality rate associated with traditional surgery depends on patients’ condition and can be as high as 43%. The use of stent-grafts is less invasive but the outcome is unproven in the setting of infected aneurysms. In an attempt to better elucidate the role of stent-grafts in this setting, a literature search was performed to examine 52 articles describing 91 patients with mycotic aneurysms who were treated with stent-grafts. The early mortality rate was 5.6%. Incidences of late aneurysm-related mortality and complications were 12.2% and 7.8%, respectively. The most consistent predictor of poor outcome was development of aortoenteric fistula. Although the 30-day mortality rate associated with the use of stent-grafts appears to be lower than that associated with surgery, late aneurysm-related events are frequent and warrant a more vigilant follow-up regimen than used with noninfected aneurysms.”

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