Patient Selection for Total Pancreatectomy with Islet Autotransplantation in the Surgical Management of Chronic Pancreatitis

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Morgan KA, Lancaster WP, Owczarski SM, et al. Patient Selection for Total Pancreatectomy with Islet Autotransplantation in the Surgical Management of Chronic Pancreatitis. J Am Coll Surg. 2018 Apr;226(4):446-451.

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Results: One hundred and ninety-five patients (141 women, aged 40.3 years, BMI 26.5 kg/m2) underwent TPIAT. Mean duration of disease before operation was 8.1 years. Fifty-six (29%) patients had pancreatic operations before TPIAT, 37 (19%) patients were diabetic preoperatively, and 52 (27%) patients were smokers. A mean of 3,253 islet equivalents transplanted/kg were harvested. Insulin independence was achieved in 29%, 28%, and 23% of patients at 1, 2, and 5 years postoperative. Nonsmokers with a shorter duration of chronic pancreatitis and no earlier pancreas operation were more likely to be insulin free. Median number of preoperative emergency department visits and hospitalizations were 6.6 and 4.3 annually, respectively, compared with 0 at 1, 2, and 5 years postoperative. Median oral morphine equivalents were 214 mg/kg preoperation and 60, 64, 69, at 1, 2, 5 years postoperative. Preoperative, 1, 2, 5 years postoperative QOL scores were 29, 36, 34, and 33 (physical; p < 0.01) and 39, 44, 42, and 42 (mental health; p < 0.02). Genetic pancreatitis patients were more often narcotic free and had better QOL than patients with pancreatitis of other causes. At 5 years, overall survival was 92.3%.

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Crohn’s Disease: Biologics and immunomodulators

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Hazlewood GS, et al. Comparative effectiveness of immunosuppressants and biologics for inducing and maintaining remission in Crohn’s disease: a network meta-analysis. Gastroenterology. 2015 Feb;148(2):344-54.e5; quiz e14-5.

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Key Findings: 

“One good-quality RCT and one poor-quality RCT were included. Intravenous infliximab was compared to oral ciclosporin, azathioprine, and the combination of azathioprine and infliximab among moderate-to-severe ulcerative colitis patients without adequate response to corticosteroid treatment. In a pragmatic trial, there was no significant difference in quality-adjusted survival, mortality, colectomy rates, time to colectomy, lengths of hospital stay after randomization, severe adverse reactions or severe adverse effects, and quality of life measures. However, ciclosporin was associated with longer log-transformed hospital stays than infliximab. In the same trial, the UK resource use was considered. It was concluded that the total health service costs for ciclosporin were considerably lower than infliximab and ciclosporin was not less effective than infliximab.

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Article of Interest: Avoiding Pitfalls in Insulinomas by Preoperative Localization with a Dual Imaging Approach

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Ramonell KM, Saunders ND, Sarmiento J, Bercu Z, Martin L, Weber CJ, Sharma J, Patel SG. Avoiding pitfalls in insulinomas by preoperative localization with a dual imaging approach. Am Surg. 2019 Jul 1;85(7):742-746.

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15-Year Patency and Life Expectancy After Primary Stenting Guided by Intravascular Ultrasound for Iliac Artery Lesions in Peripheral Arterial Disease

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Kumakura H, et al. 15-Year Patency and Life Expectancy After Primary Stenting Guided by Intravascular Ultrasound for Iliac Artery Lesions in Peripheral Arterial Disease. JACC Cardiovasc Interv. 2015 Dec 21;8(14): 1893-901.

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Methods: EVT was performed for 507 lesions in 455 patients with PAD. The 15-year endpoints were primary, primary-assisted, and secondary patency; overall survival; freedom from major adverse cardiovascular events (MACE); and freedom from major adverse cardiovascular and limb events (MACLE).

Results: The 5-, 10-, and 15-year primary and secondary patencies were 89%, 83%, and 75%, respectively, and 92%, 91%, and 91%, respectively. There were no significant differences among TASC-II categories.

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Coronary-artery revascularization before elective major vascular surgery

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McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004 Dec 30;351(27):2795-804.

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Results: Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs Medical centers, 510 (9 percent) were eligible for the study and were randomly assigned to either coronary-artery revascularization before surgery or no revascularization before surgery. The indications for a vascular operation were an expanding abdominal aortic aneurysm (33 percent) or arterial occlusive disease of the legs (67 percent). Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the group not undergoing revascularization (P<0.001). At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.70 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37). Continue reading →

Aortic stenosis and noncardiac surgery: risks and postoperative outcomes

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Pislaru SV, et al. Aortic stenosis and noncardiac surgery: managing the risk. Curr Probl Cardiol. 2015 Nov;40(11):483-503.

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“In summary, the mortality risk at contemporary noncardiac surgery has followed the general trend of decreasing surgical mortality rate, and is currently at 1.5%-4% for elective procedures, significantly lower than those in the early reports (Fig 1). Presence of severe AS does not result in increased mortality rates, but rather in excess cardiovascular morbidity (most notably myocardial infarction [13] or new or worsening heart failure [14]). Symptomatic patients have worse outcomes.” (pg. 488) Continue reading →

The safety of enteral and parenteral nutrition in ICU patients receiving vasopressors

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Patel JJ, et al. Phase 3 Pilot Randomized Controlled Trial Comparing Early Trophic Enteral Nutrition With “No Enteral Nutrition” in Mechanically Ventilated Patients With Septic Shock. JPEN J Parenter Enteral Nutr. 2020 Jul;44(5):866-873.

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Results: One hundred thirty-one patients were eligible for enrollment, and 49 were available for consent. Thirty-one (86%) consented and were randomized and 100% of patients in the early EN arm and 94% in the “no EN” arm completed their protocols. While on vasopressors, early EN group received median 384 kcal, and the “no EN” group received median 0 kcal. Contamination rate was 0 in the early trophic EN arm and 6% in the “no EN” arm. The early EN group had median 25 intensive care unit-free days, as compared with 12 in the “no EN” arm (P = .014). The early EN arm had median 27 ventilator-free days, compared with 14 in “no EN” arm (P = .009).

Conclusion: Our protocol comparing early trophic EN with “no EN” in septic shock was feasible. Early trophic EN may be beneficial, but a larger multicenter trial is warranted to confirm the observed clinical benefits seen in this trial.

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