Author Archives: John

Frailty and Emergency Surgery

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“Emergency surgery carries higher risk of mortality and morbidity. Appropriate risk assessment, attentive decision-making and carefully selected interventions are the cornerstones of a patient centered management.” (Leiner)

“Frailty, a “syndrome of loss of reserves,” is more than decade old concept. Initially it was used mainly in geriatrics but lately its use has been extended into other specialties including surgery. A meta-analysis demonstrated that frail surgical patients had a higher risk of readmission and increased risk of mortality.” (Leiner)

ACS NSQIP Surgical Risk Calculator

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Delayed Emergence from Anesthesia

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“Despite the medications commonly used in anesthesia allow recovery in a few minutes, a delay in waking up from anesthesia, called delayed emergence, may occur. This phenomenon is associated with delays in the operating room, and an overall increase in costs. Together with the emergence delirium, the phenomenon represents a manifestation of
inadequate emergence. Nevertheless, in delayed emergence, the transition from unconsciousness to complete wakefulness usually occurs along a normal trajectory, although slowed down. On the other hand, this awakening trajectory could proceed abnormally, possibly culminating in the manifestation of emergence delirium. Clinically, delayed emergence often represents a challenge for clinicians who must make an accurate diagnosis of the underlying cause to quickly establish appropriate therapy.”

Cascella
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Carotid endarterectomy for symptomatic carotid stenosis

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“Stroke is the third leading cause of death and the most common cause of long‐term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of a Cochrane Review, originally published in 1999, and most recently updated in 2017.” (Rerkasem)

Rerkasem
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Direct Anastomosis of Recurrent Laryngeal Nerves Injured During Thyroidectomy

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“Recurrent laryngeal nerve (RLN) paralysis is the most common and significant complication of thyroid or parathyroid cancer surgery. Unilateral RLN paralysis is often due to the adhesions that accompany thyroid cancer. Even with no signs of paralysis preoperatively, a cancerous thyroid gland may be found firmly adherent to RLN intraoperatively, in which case a segment of RLN must be sacrificed for the sake of cancer eradication.””Recurrent laryngeal nerve (RLN) paralysis is the most common and significant complication of thyroid or parathyroid cancer surgery. Unilateral RLN paralysis is often due to the adhesions that accompany thyroid cancer. Even with no signs of paralysis preoperatively, a cancerous thyroid gland may be found firmly adherent to RLN intraoperatively, in which case a segment of RLN must be sacrificed for the sake of cancer eradication.”

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Refractory Variceal Bleed in Cirrhosis

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Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endo-scopic treatment has reduced the mortality of variceal bleeding from 50% to 10–20%. The refractory variceal bleedis either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standardmedical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metalstents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS),balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling.

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Indication of a Modified Sugiura Procedurein the Management of Variceal Bleeding

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“Study results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.”

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