Article of interest: Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium.

Aucoin VJ, Eagleton MJ, Farber MA, et al. Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium. J Vasc Surg. 2021 Jan;73(1):323-330. doi: 10.1016/j.jvs.2020.07.107.

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Results: The most common practices routinely included blood pressure elevation (7 of 8; 87.5%), with most having a mean arterial pressure goal of not less than 90 mm Hg in the perioperative period (5 of 7; 71%), a hemoglobin goal intra- and postoperatively of not less than 10 mg/dL (6 of 8; 75%), and the use of prophylactic spinal drains in high-risk patients (6 of 8; 75%). Significant variation was found among the group for the timing of the resumption of antihypertensive medications, duration of hemoglobin goals after the procedure, and management of spinal drains. Many methods described in reported studies were not routinely used by most of the group, including a perioperative steroid bolus (1 of 8; 12.5%), mannitol (2 of 8; 25%), and naloxone infusion (1 of 8; 12.5%). Rescue maneuvers included placement of a cerebrospinal fluid (CSF) drain if not already present (8 of 8; 100%), decreasing the target CSF drain pop-off pressure (6 of 8; 75%), increasing the CSF drainage volume (5 of 8; 62.5%), increasing the mean arterial pressure goal (8 of 8; 100%), increasing the hemoglobin goal (8 of 8; 100%), and imaging the spine using computed tomography or magnetic resonance imaging (7 of 8; 87.5).

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Janeway Gastrostomy

Gastrostomy. Ellison E, & Zollinger R.M., Jr.(Eds.), (2016). Zollinger’s Atlas of Surgical Operations, 10e. McGraw-Hill. Emory login required.

“As a temporary gastrostomy, the Witzel or the Stamm procedure is used frequently and is easily performed. A permanent type of gastrostomy, such as the Janeway and its variations, is best adapted to patients in whom it is essential to have an opening into the stomach for a prolonged period of time. Under these circumstances, the gastric mucosa must be anchored to the skin to ensure long-term patency of the opening. Furthermore, the construction of a mucosa-lined tube with valve-like control at the gastric end tends to prevent the regurgitation of the irritating gastric contents. This allows periodic intubation and frees the patient from the irritation of a constant indwelling tube.”

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Delayed gastric emptying after Whipple procedure

Mirrielees JA, et al. Pancreatic Fistula and Delayed Gastric Emptying Are the Highest-Impact Complications After Whipple. J Surg Res. 2020 Jun;250:80-87.

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Results: About 10,922 patients undergoing pancreaticoduodenectomy were included for analysis. The most common postoperative complications were DGE (17.3%), POPF (10.1%), incisional SSI (10.0%), and organ/space SSI (6.2%). POPF and DGE were the only complications that demonstrated sizable effects for all clinical and resource utilization outcomes studied. Other complications had sizable effects for only a few of the outcomes or had small effects for all the outcomes.

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Utility of thromboelastography to guide blood product transfusion in surgical settings.

Selby R. “TEG talk”: expanding clinical roles for thromboelastography and rotational thromboelastometry. Hematology Am Soc Hematol Educ Program. 2020 Dec 4;2020(1): 67-75.

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“Viscoelastic assays (VEAs) that include thromboelastography and rotational thromboelastometry add value to the investigation of coagulopathies and goal-directed management of bleeding by providing a complete picture of clot formation, strength, and lysis in whole blood that includes the contribution of platelets, fibrinogen, and coagulation factors. Conventional coagulation assays have several limitations, such as their lack of correlation with bleeding and hypercoagulability; their inability to reflect the contribution of platelets, factor XIII, and plasmin during clot formation and lysis; and their slow turnaround times. VEA-guided transfusion algorithms may reduce allogeneic blood exposure during and after cardiac surgery and in the emergency management of trauma-induced coagulopathy and hemorrhage. However, the popularity of VEAs for other indications is driven largely by extrapolation of evidence from cardiac surgery, by the drawbacks of conventional coagulation assays, and by institution-specific preferences. Robust diagnostic studies validating and standardizing diagnostic cutoffs for VEA parameters and randomized trials comparing VEA-guided algorithms with standard care on clinical outcomes are urgently needed. Lack of such studies represents the biggest barrier to defining the role and impact of VEA in clinical care.”

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Announcement: Thomas F. Dodson Surgical History Society Lecture Series

The 5th meeting of the Thomas F. Dodson Surgical History Society will take place on Monday, March 15th @ 6:30pm via Zoom. The mission of the Society is to foster interest and collaboration centered on the rich, meaningful, and colorful history of our field.

The topics to be discussed are:

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Temperature Management After Cardiac Arrest

Nielsen N, Wetterslev J, Cronberg T, et al.; TTM Trial Investigators. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17. PMID: 24237006.

Results: In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar.

Conclusions: In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C. (Funded by the Swedish Heart-Lung Foundation and others; TTM number, NCT01020916.).

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Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection

1: Ambe PC, Rombey T, Rembe JD, Dörner J, Zirngibl H, Pieper D. The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis. Patient Saf Surg. 2020 Dec 22;14(1):47. doi: 10.1186/s13037-020-00274-2. PMID: 33353558; PMCID: PMC7756962.

2: Strobel RM, Leonhardt M, Krochmann A, Neumann K, Speichinger F, Hartmann L,
Lee LD, Beyer K, Daum S, Kreis ME, Lauscher JC. Reduction of Postoperative Wound Infections by Antiseptica (RECIPE)?: A Randomized Controlled Trial. Ann Surg.
2020 Jul;272(1):55-64. doi: 10.1097/SLA.0000000000003645. PMID: 31599810.

3: Thom H, Norman G, Welton NJ, Crosbie EJ, Blazeby J, Dumville JC. Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection: Systematic Review and Network Meta-Analysis. Surg Infect (Larchmt). 2021 Mar;22(2):144-167. doi: 10.1089/sur.2019.318. Epub 2020 Apr 29. PMID: 32352895.

4: Maatman TK, Weber DJ, Timsina LR, Qureshi B, Ceppa EP, Nakeeb A, Schmidt CM,
Zyromski NJ, Koniaris LG, House MG. Antibiotic irrigation during pancreatoduodenectomy to prevent infection and pancreatic fistula: A randomized controlled clinical trial. Surgery. 2019 Oct;166(4):469-475. doi: 10.1016/j.surg.2019.05.053. Epub 2019 Aug 2. PMID: 31383465.

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The anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades

Kumar KH, et al. Anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades in the human pancreas: a cadaveric study. Surg Radiol Anat. 2021 Mar;43(3):367-375.

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Results: The gastroduodenal (GDA), anterior superior pancreaticoduodenal (ASPD), and anterior inferior pancreaticoduodenal (AIPD) artery was found in all the cases, whereas the posterior superior pancreaticoduodenal (PSPD) and posterior inferior pancreaticoduodenal (PIPD) artery was present in 93.34% cases. The ASPD artery originated from GDA in all the cases. Two types of variations were observed in the origin of PSPD artery and four types each in the origin of AIPD and PIPD artery. Anatomical and numerical variations were observed in both anterior and posterior arches, posterior arch being absent in 20% cases.

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Surgical management of pheochromocytoma

Fu SQ, Wang SY, Chen Q, Liu YT, Li ZL, Sun T. Laparoscopic versus open surgery for pheochromocytoma: a meta-analysis. BMC Surg. 2020 Jul 25;20(1):167.

Results: Fourteen studies involving 626 patients were included in this meta-analysis. LS was associated with lower rates of intraoperative haemodynamic instability (IHD) [odds ratio (OR) = 0.61, 95% CI: 0.37 to 1.00, P = 0.05], less intraoperative blood loss [weighted mean difference (WMD) = – 115.27 ml, 95% confidence interval (CI): – 128.54 to – 101.99, P < 0.00001], lower blood transfusion rates [OR = 0.33, 95% CI: 0.21 to 0.52, P < 0.00001], earlier ambulation (WMD = – 1.57 d, 95% CI: – 1.97 to – 1.16, P < 0.00001) and food intake (WMD = – 0.98 d, 95% CI: – 1.36 to – 0.59, P < 0.00001), shorter drainage tube indwelling time (WMD = – 0.51 d, 95% CI: – 0.96 to – 0.07, P = 0.02) and postoperative stay (WMD = – 3.17 d, 95% CI: – 4.76 to – 1.58, P < 0.0001), and lower overall complication rates (OR = 0.56, 95% CI: 0.35 to 0.88, P = 0.01). However, no significant differences in operative time, postoperative blood pressure control, rates of severe complications, postoperative hypotension or cardiovascular disease (CVD) were found between the two groups.

Conclusions: LS is safe and effective for PHEO resection. Compared with OS, LS caused less IHD, providing an equal chance to cure hypertension while also yielding a faster and better postoperative recovery.

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