Abdominal surgery in neutropenic patients

Jolissaint JS, et al. Timing and Outcomes of Abdominal Surgery in Neutropenic Patients. J Gastrointest Surg. 2019 Apr;23(4):643-650.

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Results: Amongst 237 patients, mortality was 11.8% (28/237) and morbidity 54.5% (130/237). Absolute neutrophil count < 500 cells/μL (50% vs. 20.6%, P < 0.01) and perforated viscus (35.7% vs. 14.8%, P = 0.01) were associated with mortality. Perforated viscus (25.4% vs. 7.5%) was also associated with morbidity. Urgent operations were associated with higher morbidity (63.6% vs 34.7%, P < 0.001) and mortality (16.4% vs 1.4%, P = 0.002) when compared to elective operations. Transfer from an outside hospital (22.3% vs. 11.2%, P = 0.02) and longer median time from admission to operation (2 days (IQR 0-6) vs. 1 day (IQR 0-3), P < 0.01) were associated with morbidity. An ANC threshold of 350 provided the best discrimination for mortality.

Conclusions: Elective surgery in the appropriately chosen neutropenic patient is relatively safe. For patients with obvious surgical pathology, we advocate for earlier operation and a lower threshold for surgical consultation in an effort expedite the diagnosis and necessary treatment.

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Videos: The Ladd Procedure for Adult Malrotation With Volvulus

Brady JT, Kendrick DE, Barksdale EM, Reynolds HL. The Ladd Procedure for Adult Malrotation With Volvulus. Dis Colon Rectum. 2018 Mar;61(3):410.

“Intestinal malrotation is a rare condition that develops during fetal development because of incomplete intestinal rotation or a lack of intestinal rotation around the superior mesenteric artery. Presentation in adulthood, in general, is abnormal and presentation with volvulus is rare. We demonstrate an open Ladd procedure with inversion appendectomy and reduction of paraduodenal hernia of an adult with malrotation with volvulus.”

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Management of enterocutaneous fistulas

Owen RM, Love TP, Perez SD, Srinivasan JK, Sharma J, Pollock JD, Haack CI, Sweeney JF, Galloway JR. Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience. JAMA Surg. 2013 Feb;148(2):118-26.

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Figure 1. Causes of enterocutaneous fistula between 1987 and 2010. IBD indicates inflammatory bowel disease; other includes radiation, neoplasm, and trauma. Percentages may total more than 100% owing to the fact that some patients’ ECFs were secondary to multiple causes.

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Mortality and treatment outcome following surgical interventions for acute mesenteric ischemia.

Beaulieu RJ, et al. Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg. 2014 Jan;59(1):159-64. Erratum in: J Vasc Surg. 2014 Jul;60(1):273.

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Results: Of 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment overall during the study period. The proportion of patients undergoing endovascular repair increased from 11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups. Mortality was significantly more commonly associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P = .01). Length of stay was also significantly longer in the patient group undergoing open revascularization (12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular procedures required bowel resection compared with 33.4% for open revascularization (P < .001). Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs 24.4%; P = .025).

Conclusions: Endovascular intervention for AMI had increased significantly in the modern era. Among AMI patients undergoing revascularization, endovascular treatment was associated with decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring vascular repair for AMI.

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Step-up vs open necrosectomy for pancreatitis: the PANTER trial’s 2019 followup

One discussion this week included the question of step-up approach versus open necrosectomy for pancreatitis.


Summary: 

BACKGROUND: The 2010 randomized PANTER trial in (infected) necrotizing pancreatitis found a minimally invasive step-up approach to be superior to primary open necrosectomy for the primary combined endpoint of mortality and major complications, but long-term results are unknown.

NEW FINDINGS: With extended follow-up, in the step-up group, patients had fewer incisional hernias, less exocrine insufficiency and a trend towards less endocrine insufficiency. No differences between groups were seen for recurrent or chronic pancreatitis, pancreatic endoscopic or surgical interventions, quality of life or costs.

IMPACT: Considering both short and long-term results, the step-up approach is superior to open necrosectomy for the treatment of infected necrotizing pancreatitis.

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Use of DOTATATE in the surgical management of small bowel neuroendocrine tumors

A discussion this week included the use of DOTATATE in the surgical management of small bowel neuroendocrine tumors.


Reference: Howe JR et al. The surgical management of small bowel neuroendocrine tumors: consensus guidelines of the North American Neuroendocrine Tumor Society (NANTES). Pancreas. 2017 Jul;46(6):715-731. doi:10.1097/MPA.0000000000000846

Summary: The three most commonly used 68Ga-labeled somatostatin receptor PET imaging agents are 68Ga-DOTATATE, 68Ga-DOTATOC and 68Ga-DOTANOC. Despite the slight variation of the somatostatin receptor affinity of these agents, all of them have shown excellent sensitivity in detection of NETs. At this time, there is no evidence of significant diagnostic superiority of one agent over the others.

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