Author Archives: E. Lawson

Colorectal surgery in cirrhotic patients

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Paolino J, Steinhagen RM. Colorectal surgery in cirrhotic patients. ScientificWorldJournal. 2014 Jan 15;2014:239293. Free full-text.

Patients with cirrhosis have a greater risk of morbidity and mortality following colorectal surgery. Therefore, preoperative medical optimization and risk assessment using criteria such as the MELD score are vital in preventing complications. Some risk factors include age, urgency of surgery, and ASA score. Postoperative morbidity and mortality are related to portal hypertension, ascites, infection, and anastomotic and stomal complications. This review highlights the assessment of risk and perioperative management of cirrhotic patients undergoing colorectal surgery.

ISPD peritonitis guideline recommendations: 2022 update on prevention & treatment

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Li PK, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022 Mar;42(2):110-153. Free full-text.

Abstract: The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year.

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Loeys-Dietz Syndrome

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Velchev JD, Van Laer L, Luyckx I, Dietz H, Loeys B. Loeys-Dietz Syndrome. Adv Exp Med Biol. 2021;1348:251-264. Full-text for Emory users.

From: Table 11.1. Clinical features at initial diagnosis of LDS. (Velchev JD, et al., p. 253.)

  • Vascular findings
    • Arterial tortuosity 92%
      • Most common in head and neck vessels
        • Carotids (55%)
        • Vertebral (56%)
        • Intracranial (37%)
        • Ascending aorta (5%), aortic arch (10%)
        • Descending thoracic (4%) or abdominal
        • (7%) Ao, also other vessels (e.g. iliacs)
  • Aneurysms
    • Aorta
      • Root 87%
      • Ascending 27%
      • Arch 10%
      • Desc thoracic 15%
      • Abdominal 12%
    • Vessel beyond Ao 30%
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Step-up vs open necrosectomy for necrotizing pancreatitis

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Here are recent publications on the management of necrotizing pancreatitis.

BACKGROUND: The 2010 randomized PANTER trial in (infected) necrotizing pancreatitis found a minimally invasive step-up approach to be superior to primary open necrosectomy for the primary combined endpoint of mortality and major complications, but long-term results are unknown.

NEW FINDINGS: With extended follow-up, in the step-up group, patients had fewer incisional hernias, less exocrine insufficiency and a trend towards less endocrine insufficiency. No differences between groups were seen for recurrent or chronic pancreatitis, pancreatic endoscopic or surgical interventions, quality of life or costs.

IMPACT: Considering both short and long-term results, the step-up approach is superior to open necrosectomy for the treatment of infected necrotizing pancreatitis.

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Management of pancreatic injuries

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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

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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

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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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