Author Archives: John

Air Embolism: Diagnosis, Clinical Management and Outcomes

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“Air embolism is a rare but potentially fatal complication of surgical procedures. Rapid
recognition and intervention is critical for reducing morbidity and mortality.”

“Iatrogenic procedures are the main cause of vascular air embolism (VAE). This rare complication can arise in a wide range of clinical scenarios involving line placement, trauma, barotrauma, and several types of surgical procedures including cardiac, vascular, and neurosurgery. Traditionally, surgery and trauma were the most significant causes of systemic and cerebral air embolism; however, endoscopy, angiography, tissue biopsy, thoracocentesis, hemodialysis, and central/peripheral venous access now comprise a greater proportion. The insertion and maintenance of advanced vascular
access devices are increasingly being performed within multiple clinical specialties. Moreover, the bulk of interventional radiology (IR) procedures commence with the placement of an intravascular sheath, which is a major risk factor for air embolism throughout the duration of the procedure. Endovascular procedures complicated by an intravascular air embolism result in significant morbidity and mortality.
VAE is a potentially preventable condition, which arises as a result of a pressure gradient that allows air to enter the blood stream, which can subsequently cause blockages in blood flow. VAE has an estimated incidence of 1 in 772 according to one series, while another study found that the incidence of iatrogenic gas embolism complicates 2.65 per 100,000 hospitalizations; however, these figures are considered lower than the true incidence due to many unreported instances and undiagnosed asymptomatic patients.”

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A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections

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“There is a need for strategies to reduce the risk of ureteric injury, and to facilitate immediate recognition, during colorectal procedures. The preoperative placement of prophylactic ureteric stents or catheters has long been discussed as a technique that may assist colorectal surgeons in identifying and avoiding the ureters, and in recognising ureteric injury when it occurs.
Debate surrounds this topic, however, with no consensus on the precise benefit of prophylactic ureteric stents, and some concerns regarding potential stent-related complications. Whilst the European Association of Urology (EAU) guidelines state that ‘visual identification of the ureters and meticulous dissection in their vicinity are mandatory
to prevent ureteral trauma during abdominal and pelvic surgery’ (grade A recommendation), the use of ‘preoperative prophylactic stents’ are recommended only ‘in selected cases (based on risk factors and surgeon’s experience)’ (grade B). The American Society of Colon and Rectal Surgeons guidelines in surgery for diverticulitis state ‘ureteral stents are used at the discretion of the surgeon’ (grade 2C).

Table 4 Type of repair and outcomes of ureteric injuries

StudyInjuries (n)Stented and recognised intraoperativelyStented and recognised postoperativelyUnstented and recognised intraoperativelyUnstented and recognised postoperatively
Bothwell [41](open)4/5611/4—primary repair over stent1/4 (stent insertion had failed)—nephrostomy + stent1/4—stent inserted and repair performed1/4 re-exploration and ureteroureterostomy
Beraldo [32](laparoscopic)1/891/89—repair technique not specified–––
Boyan [34] (laparoscopic)None––––
Chahin [35]1/66–1/66 recognised day 2, managed by retrograde stent reinsertion––
Chiu [8]2503/811,071Not evaluated–––
Coakley [3]333/51,125Not evaluated–––
Chong [29]None––––
Hassinger [38]Not evaluated––––
Kutiyanawala [44]5/251No stented patientsNo stented patients3/5—ureteric re-implant × 2 and ureteroureterostomy over stent in × 12/5Nephrostomy + JJ stent × 1 (prolonged recovery, fistula)Relaparotomy + removal of ligasure × 1
Kyzer [33]1/1181/1 repair technique not specified–––
Leff [19]4/1943/4OPEN intraoperative repair1/4—delayed presentation as ureteral-cutaneous fistulaNot evaluatedNot evaluated
Luks [39]2/2612/2 intraoperative repair, type unspecified–––
Merola [28]1/374None1 injury, recognised postoperatively—re-operation (repair not specified)NoneNone
Nam [27]None––––
Pathak [42]None––––
Palaniappa [45] 2012(Open arm)7/46691/7Ureteroneocystostomy1/7Nephrostomy3/7Ureteroneocystostomy × 1, ureteroureterostomy × 22/7Bilateral nephrostomies × 1Ureteroureterostomy × 1
Palaniappa [45]2012(Laparoscopic arm)7/10601/7 Ureteroureterostomy1/7 Ureteroneocystostomy2/7Ureteroneocystostomy × 1Ureteroureterostomy × 13/7Ureteroneocystostomy × 1Nephrostomy × 2
Pokala [30]0––––
Sahoo [40]0    
Senagore [36]0––––
Sheikh [43]Not reported––––
Speicher [31]Not reported––––
Tsujinaka [37]0––––

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Routine evaluation of the distal colon remnant before Hartmann’s reversal is not necessary in asymptomatic patients

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“Hartmann’s procedure involves segmental colonic resection with end-colostomy or end-
ileostomy and closure of the distal colonic/rectal remnant (DCRR), which remains in the
pelvis or abdomen as a blind-ending pouch (Hartmann’s pouch). This procedure is
commonly performed in emergency situations in patients who require partial colectomy and
are deemed to be at high risk of complications from a primary bowel anastomosis. The number of patients who undergo takedown of their stoma as a second-stage procedure varies between 56% and 100%.
Preoperative DCRR evaluation by means of contrast and/or endoscopic studies is routinely
requested by many surgeons to exclude leak, stricture, inflammation, and tumors, which
could preclude Hartmann’s reversal. DCRR evaluation is safe and has only minor
disadvantages including cost, radiation exposure, and patient discomfort. However, there is
no clear evidence that this practice affects surgical management or benefits patients. A
previous study reported abnormalities in 16% of routine contrast DCRR studies, although
these altered treatment in only a small minority of cases. In addition, the role of endoscopy
in this setting has not been defined.”

“Between 1993 and 2008, 203 patients underwent reversal of Hartmann’s at a tertiary
referral center. Sixty-eight patients (33%) did not undergo preoperative DCRR evaluation and had comparable demographic characteristics, comorbidities, DCRR length, and perioperative outcomes to 135 patients who underwent preoperative contrast and/or endoscopic studies. After evaluation, 125 (93%) patients had normal findings, seven (5%) patients had abnormal studies that did not impact their management, and three (2%) patients underwent additional procedures.”

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Laparoscopic parastomal hernia repair: keyhole, Sugarbaker, sandwich, or hybrid technique with 3D mesh?

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“The most commonly reported approaches for stomal hernia repair include stoma relocation, fascial repair using sutures, and fascial repair using prosthetic mesh with either open or minimally invasive surgery. At present, suture repair for elective surgery is no longer recommended due to high recurrence rates, except in specific circumstances such as
strangulation and contamination of the surgical field, where the use of mesh application should be avoided. In the last decade, many minimally invasive procedures have been
reported in the literature with varying results. In a previous systematic review in 2015, DeAsis et al. investigated the role of laparoscopic surgery in parastomal hernia repair and
concluded that the modified Sugarbaker technique demonstrated superior performance compared to other techniques. Likewise, the sandwich technique showed positive outcomes with low recurrence rates. In another study published in 2015, Szczepkowski et al. described an alternative approach called hybrid with three-dimensional (3D) meshes with promising results.

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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids

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“Hemorrhoids are vascular structures that arise from a channel of arteriovenous connective tissues and drain into the superior and inferior hemorrhoidal veins. Although hemorrhoids are categorized as external or internal based on their relationship with the dentate line, they communicate with one another and often coexist. Symptoms related to hemorrhoids are very common in the Western hemisphere and other industrialized societies. Although published estimates of prevalence vary, hemorrhoidal disease represents one of the most common medical and surgical disease processes encountered in the United States, resulting in more than 2.2 million outpatient evaluations per year. Many diverse symptoms may be, correctly or incorrectly, attributed to hemorrhoids by both patients and referring physicians. As a result, it is important to identify symptomatic hemorrhoids as the underlying source of the
anorectal report and to have a clear understanding of the evaluation and management of this disease process. These guidelines address diagnostic and therapeutic modalities
in the management of hemorrhoidal disease.”

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Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT)

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“Acute severe gastrointestinal bleeding is a common cause of death worldwide. Bleeding can occur from the upper or lower gastrointestinal tract, but upper gastrointestinal bleeding is more common. The leading causes are peptic ulcer, oesophageal varices, and malignancy. The case fatality rate is approximately 10% for upper gastrointestinal bleeding and 3% for lower gastrointestinal bleeding. Many patients re-bleed after initial haemostasis and those that do have a four times increased risk of death. Patients with acute severe gastrointestinal bleeding usually present with haematemesis or melaena. Patients are often haemodynamically unstable and in need of urgent resuscitation. Acute management
of gastrointestinal bleeding includes blood product transfusion, medical or endoscopic therapy, and surgery.”

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Central Venous Catheter Guidewire Retention: Lessons From England’s Never Event Database

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“Central venous catheters (CVC) are commonly used for monitoring and administering medication. The Seldinger technique is routinely used for CVC insertion; however, this technique has an inherent risk of guidewire retention. The mechanism behind guidewire retention is debated, with some authors reporting cases where guidewires “slip” or are sucked into the vasculature at the point of insertion, presumably due to physiological blood flow exhibiting a force on the guidewire that overcomes the frictional force between the guidewire and the CVC lumen, which should prevent guidewire slippage. This is the basis for widely adopted guidance that mandates that operators should hold onto the guidewire at all times while it remains intravascular during CVC insertion. However, this may be an
oversimplification of retention events, as most guidewires are likely to remain intraluminally should the operator inadvertently take their hand off them during the procedure. Indeed, the forces exerted by blood flow and pressure differentials are much greater during arterial
procedures, although in the opposite direction. If these forces were sufficient to overcome friction, guidewires would be ejected from catheters whenever the operator took his/her hand off the guidewire. When retention occurs, the guidewire can migrate from the catheter
into the patient’s vasculature and heart and may cause complications such as arrhythmia, vascular damage, thrombosis, cardiac perforation, and tamponade.”

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