The risk of injury to inferior epigastric artery (IEA) subjects during abdominal procedure

“The anatomical position of the inferior epigastric artery (IEA) subjects it to risk of injury during abdominal procedures that are close to the artery, such as laparoscopic trocar insertion, insertion of intra-abdominal drains, Tenckhoffâ catheter (peritoneal dialysis catheter) and paracentesis. This article aims to raise the awareness of the anatomical variations of the course of the IEA in relation to abdominal landmarks in order to define a safer zone for laparoscopic ancillary trocar placement. Methods of managing the IEA injury as well as techniques to minimise the risk of injury to the IEA are reviewed and discussed.”

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Lithotomy-related complications in the lower limbs after colorectal surgery

Sajid MS, Shakir AJ, Khatri K, Baig MK. Lithotomy-related neurovascular complications in the lower limbs after colorectal surgery. Colorectal Dis. 2011 Nov;13(11):1203-13. Full-text for Emory users.

Results: LRNVC after prolonged lithotomy position during colorectal surgery can be classified into vascular, neurological and neurovascular combined. Compartment syndrome (CS) is the most common clinical presentation. Seven case reports and 10 case series on 34 patients (27 men, 6 women) with CS have been reported. Risk factors included the lithotomy position and duration of surgery of more than 4 h.

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The utility of intraoperative perfusion assessment during resection of colorectal cancer

De Nardi P, et al. Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc. 2020 Jan;34(1):53-60.

Full-text for Emory users.

Results: After randomization, 12 patients were excluded. Accordingly, 240 patients were included in the analysis; 118 were in the study group, and 122 in the control group. ICG angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection in 13 cases (11%). An anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.).

Conclusions: Intraoperative ICG fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. This method led to further proximal bowel resection in 13 cases, however, there was no statistically significant reduction of anastomotic leak rate in the ICG arm.

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Article of interest: A systematic review of pre-surgical exercise intervention studies with cancer patients

Singh F, et al. A systematic review of pre-surgical exercise intervention studies with cancer patients. Surg Oncol. 2013 Jun;22(2):92-104. Full-text for Emory users.

Results: Eighteen studies were included consisting of a total of 966 participants. Lung cancer studies were the predominant group represented. Most of the studies prescribed an aerobic intervention programs done prior to surgery. Mode, frequency, duration, and intensity of exercise intervention varied across the different cancer groups. The majority of studies showed preliminary positive change in clinical outcomes with significant improvements in the rate of incontinence, functional walking capacity and cardiorespiratory fitness.

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Periprocedural bridging anticoagulation

Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. J Am Coll Cardiol. 2015 Sep 22;66(12):1392-403.

Full-text for Emory users.

Conclusions: Periprocedural anticoagulation management is a common clinical dilemma with limited evidence (but 1 notable randomized trial) to guide our practices. Although bridging anticoagulation may be necessary for those patients at highest risk for TE, for most patients it produces excessive bleeding, longer length of hospital stay, and other significant morbidities, while providing no clear prevention of TE. Unfortunately, contemporary clinical practice, as noted in physician surveys, continues to favor interruption of OAC and the use of bridging anticoagulation. While awaiting the results of additional randomized trials, physicians should carefully reconsider the practice of routine bridging and whether periprocedural anticoagulation interruption is even necessary.

Central Illustration. Bridging Anticoagulation: Algorithms for Periprocedural Interrupting and Bridging Anticoagulation. Decision trees for periprocedural interruption of chronic oral anticoagulation (top) and for periprocedural bridging anticoagulation (bottom). OAC = oral anticoagulation.

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Obstructive jaundice and coagulation disturbances

Pavlidis ET, Pavlidis TE. Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobiliary Pancreat Dis Int. 2018 Feb;17(1):17-21.

Full-text for Emory users.

“Proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.”

“The coagulation disorders and the resulting hemostasis impairment have been attributed to the complement activation by endotoxin as well as to the reduced synthesis of prothrombin (factor II) in the liver and the other vitamin K depended coagulation factors i.e. VII, IX, X and proteins C, S, Z. The absence of bile salts in the gut prevents the absorption of vitamin K, which is a fat-soluble vitamin. In addition, the endogenous microbial flora produces small amounts of vitamin K. Subsequently the reduced vitamin K absorption results in its deficiency. The latter predisposes to bleeding diathesis, despite the normal laboratory indices such as prothrombin time (PTT) and international normalized ratio (INR). Likewise, the other fat-soluble vitamin D and lipids absorption is diminished resulting in their deficiency and calcium reduction.” (Pavlidis, et al., p. 19.)

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