Trees old and young, sprouting a shady boon
For simple sheep; and such are daffodils
With the green world they live in; and clear rills
That for themselves a cooling covert make
'Gainst the hot season; the mid forest brake,
Rich with a sprinkling of fair musk-rose blooms:
And such too is the grandeur of the dooms
We have imagined for the mighty dead;
All lovely tales that we have heard or read:
An endless fountain of immortal drink,
Pouring unto us from the heaven's brink.
— from Endymion by John Keats, published in 1818
Sewn or Stapled? A Look into the Future of Anastomosis Closure in Ileocolic Resections in Crohn’s Disease
By: Amy Sequeira
Crohn’s Disease is part of the inflammatory bowel disease family. Crohn’s is a chronic disease of the intestines affecting over half a million people in the United States. This disease commonly presents as cramping abdominal pain, diarrhea, fatigue, and weight loss. Due to the chronicity of the inflammation in Crohn’s disease, over 60% of those affected with this disease will undergo surgical resection of portions of their intestinal tract due to stricturing or functional disability of the intestines. The standard of care in ileocolic resection is to create the anastomosis with the side-to-side stapled anastomotic method. The end-to-end handsewn anastomosis is less commonly used due to the difficulty of the procedure. Two randomized control clinical trials are underway right now, the HAND2END and End2End trials, aimed at examining the effectiveness of the two methods of anastomosis closure in ileocolic resection. The HAND2END trial aims to investigate the rate of recurrence of disease identified by endoscopy at 6 months post-operative. The results of this trial are being directly compared to the results of the End2End trial which is investigating the rate of recurrence at 6 months of end-to-end hand sewn anastomosis closure. The results of the trials will be considered clinically significant if the recurrence of disease in the area surrounding the resection detected histologically through samples obtained in post-operative endoscopy, is 25% or less. The current literature has a gap in evidence suggesting the superiority of either of the two anastomosis closures. These two clinical trials will offer further insight into the future of surgical treatment of Crohn's disease, and methods to reduce the risk of recurrence following surgical intervention.
Boosting Bladder Cancer Outcomes With Perioperative Durvalumab
By: Jordan Palmer
Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2408154
The standard treatment for patients with muscle-invasive bladder cancer (MIBC) typically consists of neoadjuvant chemotherapy with cisplatin-based regimens followed by radical cystectomy. However, even with this approach, approximately 50% of patients experience cancer recurrence within three years. Recent research has indicated that incorporating immunotherapy alongside platinum-based chemotherapy could potentially improve patient outcomes. The NIAGARA trial, a phase 3 study, was designed to assess the effectiveness and safety of perioperative durvalumab, an anti-PD-L1 immunotherapy, in combination with neoadjuvant gemcitabine–cisplatin chemotherapy, compared to chemotherapy alone, in cisplatin-eligible MIBC patients. The trial enrolled 1,063 patients, who were randomly assigned to either the durvalumab plus chemotherapy group or the chemotherapy only group, with both groups undergoing radical cystectomy. The main goals of the trial was to evaluate pathological complete response and event-free survival (EFS), with the secondary outcomes being overall survival (OS) and safety. The results demonstrated the group receiving durvalumab had a higher pathological complete response rate compared to the control group (33.8% vs. 25.8%). Event-free survival at 24 months was also significantly better in the durvalumab group (67.8%) compared to the control group (59.8%), with a hazard ratio of 0.68. Additionally, overall survival at 24 months was improved in the durvalumab group, with a survival rate of 82.2% compared to 75.2% in the control group. These findings indicate that adding durvalumab to chemotherapy in the perioperative setting can enhance both pathological response rates and survival outcomes. The occurrence of adverse events was similar between the two groups, although a significant number of patients discontinued treatment due to toxicity. While the trial highlights the potential benefits of combining durvalumab with neoadjuvant chemotherapy for MIBC patients, further research is necessary to determine the long-term impact of this treatment approach.
Is Spinal Cord Stimulation the Future of Treating Chronic Low Back Pain?
By: Barbara Buccilli Source: https://pubmed.ncbi.nlm.nih.gov/39139617/ Chronic low back pain (LBP) is a common, disabling condition, and patients without surgically correctable pathology often struggle with ineffective treatment options. The DISTINCT study examined whether spinal cord stimulation (SCS) could offer better outcomes compared to conventional medical management (CMM) for chronic, refractory LBP.
Researchers conducted a multicenter, randomized trial comparing SCS with CMM in patients who were not candidates for lumbar spine surgery. 85.3% of the SCS group achieved a 50% reduction in pain, while only 6.2% of the CMM group saw similar results. Many CMM patients later crossed over to try SCS, with 71.4% also reporting pain reduction at 12 months. Significant improvements in disability and quality of life were noted in the SCS group.
This study highlights SCS as a promising therapy for patients with chronic LBP, providing substantial and lasting pain relief. Further consideration of SCS should be given to those unresponsive to conservative treatment, and new strategies are needed to identify the patients who will benefit the most from the treatment.
Is There a Risk Associated with Using Long-Stored pRBC in Cardiac Surgery Patients Receiving Transfusions?
By: Sherine Thomas
Blood transfusions are crucial in cardiac surgeries due to the high risk associated with blood loss and anemia. However, prolonged blood storage can cause changes that alter its composition and efficacy. These changes include the depletion of 2,3-disphosphoglycerate, an essential chemical for regulating oxygen release from hemoglobin, and changes in the structure of red blood cells, thus compromising its function. This study investigates whether using long-stored packed red blood cells (pRBCs) increases complications in cardiac surgery patients.
A retrospective cohort study was conducted in Queensland public hospitals from 2007 to 2013, examining cardiac surgery patients aged 16 or older who received pRBC transfusions. Participants were excluded if they did not receive at least one unit of pRBC transfusion. The study compared two outcomes: in-hospital mortality and complications associated with pRBCs nearing shelf expiration (35 days) and dose-dependent transfusion (4 units). There was no significant difference in mortality and complications between patients receiving pRBCs stored <35 days vs. ≥35 days. The in-house mortality for pRBCs stored <35 days was 2.5% vs. pRBCs stored ≥35 days was 1% (OR 0.63; CI = 0.18-2.18; p = 0.46. Additionally, there was no significance in dose-dependent differences in mortality. A 5.6% in-hospital mortality for patients who received ≥5 units was observed vs. 1.3% for patients who received <4 units of pRBCs (OR 1.08; CI = 0.56-2.09; p = 0.81). Interestingly, significance was reported in hospital stay and frequency of complications between dose-dependent groups. Hospital stay for patients receiving ≥5 units pRBCs was an average of 15 days vs. a 10 day median in the <4 unit group (estimate = 6.02; CI = 5.36-6.69; p = 0.001). When combined, the frequency of acute kidney failure (17.6% vs. 8%), infections (10% vs. 3.4%), and cardiac arrest/acute myocardial infarction (AMI) (9.2% vs. 4.3%) demonstrated significance (p < 0.0011). However, when assessing each complication individually, no significance was demonstrated: acute kidney failure (OR 1.06; CI = 0.78-1.45; p = 0.7), infection (OR 1.37; CI = 0.9-2.09; p = 0.14), and cardiac arrest/AMI (OR 1.05; CI0.71-1.56; p = 0.8).
These results align with previous studies, suggesting that prolonged pRBC storage does not significantly compromise the outcomes for cardiac surgery patients. Studies that reported contradictory findings typically used pRBCs stored for 2 weeks. It is shown that at 2 weeks, stored RBCs undergo significant chemical and morphological changes, potentially contributing to the complications reported in those studies. Beyond this timeframe, the rate of change in stored RBCs diminishes, which may explain the lack of findings supporting increased mortality observed in cardiac surgery patients receiving older units of blood. It is important to note the limitations of this study, particularly the inability to determine the causal relationship between patient health outcomes and transfusion volume. While prolonged pRBC storage does not increase mortality in cardiac surgical patients, the study suggests dose-dependent differences in adverse outcomes related to transfusion volume when combining frequency of complications. Understanding this is crucial to realizing the various factors that could influence patient outcomes in transfusion medicine.
Will AI Assisted Surgery Be the Future of Transplant Surgery?
By: Ishrar Shaid
Artificial intelligence (AI) has been an upcoming performer in the medical field from radiology to surgery. One of the uses of AI can be seen in liver transplant surgeries, specifically during Pure Laparoscopic Donor Hepatectomy (PLDH). PLDH allows a living donor to donate part of their functioning liver to a matched recipient with a failing liver. While this surgery is complicated, AI can provide real time anatomy guidance of the donor’s biliary structures, which can greatly reduce risk of bile duct injuries.
To test the ability of AI, one institution conducted a retrospective feasibility analysis by taking 30 intraoperative PLDH videos and extracted them to create image frames which were then used to train a software called DeepLabV3+ on the procedure. This allowed for modeling of biliary structures from a surgeon’s perspective. Performance of the software models was evaluated with the Dice Similarity Coefficient (DSC). DSC compared the model’s predictions to the real image, and found the models had a mean DSC of 0.728 ± 0.01 for the bile duct and 0.429 ± 0.06 for the anterior wall. This means that AI can correctly predict the area of these structures in a picture 73% of the time for the bile duct, and 43% of the time in the anterior wall of the abdomen. The model's ability to infer data in real time from the videos took about 15.3 seconds to understand each frame.
Although we need more data, this research study suggests the potential for AI to synergize the work of surgeons by providing real time data of structures specific to the patient on the operating table. Additionally, precision needs to improve regarding understanding orientation of the surgical field, especially given the low percentage for understanding the abdominal wall. Eventually, this information can enhance surgical precision, leading to better outcomes for donors that give part of their body to others.
Ankle Antics: Is Managing Diabetes the Key to TAA Success?
By: Emma Barham
End-stage ankle arthritis is more commonly being treated with total ankle arthroplasty (TAA) due to successful patient outcomes. Though, the efficacy of operative repair depends upon numerous patient factors including the underlying cause of end-stage ankle arthritis, state of deformity pre- and post-operatively, and more recently, it is presumed that diabetes mellitus (DM) could also play a role in mitigating TAA outcomes. The retrospective study presented evaluated patient outcomes and complication rates relative to TAA in patient populations presenting with and without controlled DM. A total of 252 patients (266 ankles) were divided into two groups: patients with DM (59 patients, 67 ankles) and patients without DM (193 patients, 199 ankles). After TAA was performed in all patients, clinical outcomes were predominately measured based on preoperative and follow-up assessments and the pain and disability sub scores of the Ankle and Osteoarthritis Scale (AOS). Complication rates following TAA were categorized as either major or minor complications; periprosthetic osteolysis and deep infection constituted major complications, whereas heterotopic ossification and superficial wound problems were classified as minor complications. The mean preoperative and follow-up AOS pain scores improved from 54.9 to 18.7 in the DM group and from 56.4 to 21.8 in the non-DM group, while mean AOS disability scores improved from 69.1 to 29.7 in the DM group and from 66.7 to 29.5 in the non-DM group. Additionally, there was no significant difference in number of osteolysis cases in the group with DM (19) and the group without DM (54) (P=0.846) and only two patients developed wound problems in the DM group, demonstrating no significant difference between the two groups (P=0.157). Thus, TAA outcomes in patients with controlled DM showed similar clinical outcomes and complication rates to the patient population without DM. Although TAA can successfully be accomplished in patients with controlled DM, the study failed to evaluate outcomes in uncontrolled DM patients. Further studies would benefit from increasing the overall sample size of patients presenting with DM and including potential outcomes and complications of TAA specific to patients with uncontrolled DM.
A Painful Surprise: Acute Appendicitis
By: Annie Pham
Source links:
https://radiopaedia.org/articles/acute-appendicitis-2?lang=us https://litfl.com/abdominal-ct-appendicitis/
Appendicitis is normally caused by obstruction of the appendiceal lumen leading to congestion, secondary infection, and ischemia. The classical presentation is referred periumbilical pain that localizes to McBurney point along with fever, nausea, and vomiting. Treatment is an appendectomy performed either open or laparoscopically with mortality from simple appendicitis being ~0.1%. The location of the appendix tip is variable, but the most common position is behind the cecum. CT is highly sensitive and specific for diagnosing appendicitis, and oral contrast has not been shown to increase sensitivity.
Findings on CT include:
Dilated appendix (>6mm) with intraluminal fluid >2.6mm without periappendiceal inflammation
Wall thickening >3 mm
Thickening of the cecal apex
Periappendiceal inflammation indicated by fat stranding
Increased appendiceal diameter of >8-9mm outer-to-outer diameter is the suggested cut-off value (but note these overlaps with the upper limit of the normal appendiceal diameter of ~9.5mm)
Less specific sign includes appendicolith
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