Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Shirley X. Deng, MD, and coauthors provided a detailed description of the techniques they recommend for management of technically difficult laparoscopic cholecystectomies. They emphasized the value of subtotal cholecystectomy as an approach to achieve removal of gallstones and a portion of the inflamed and/or fibrotic gallbladder in a way that minimizes risk of bile duct injury, injury to the portal vessels, and the liver. Their technique begins with careful inspection of the visible anatomic features followed by dissection of the upper fundus of the gallbladder using the laparoscopic suction irrigator. The anterior portion of the gallbladder wall is then removed, gallstones are evacuated, and the cystic duct opening is sutured to ensure closure.
The steps of their technique are well illustrated in the article, and readers are encouraged to review the entire content. Although no actual data are included in the report, the authors state that they have not documented a bile duct or vascular injury for the last 5 years.
In the accompanying editorial by Adriana Toro, MD, PhD, and coauthors, the authors urge caution in employing the dissection of the fundus approach since liver bleeding can be difficult to control in some patients. They also noted that use of the Endoloop technique for closure of the cystic duct carries a risk for common bile duct stenosis. The information presented in the article and the editorial is clear and valuable for practicing surgeons.
Low-Titer Group O Whole Blood Is Safe for Use Across All Blood Types, Study Finds
Because of the recent promotion of low-titer group O whole blood (LTOWB) as a component of resuscitation of injured patients in the pre-hospital and early hospital phases of care, the authors performed a prospective single-institution cohort study (n = 1075) to determine rates of mortality and major complications in patients receiving LTOWB.
For the data analysis, patients were divided into groups according to blood type. Type O patients composed more than half of the cohort; type A patients (31.6%), type B patients (14%), and type AB patients (4.3%) completed the cohort. After detailed statistical adjustment examining several variables (sex, race, injury severity, pre-hospital vital signs, arrival lactate, arrival systolic blood pressure, and volume of blood products received in the ED), the authors found that patients in group B had evidence of larger blood loss volume and lower systolic pressure.
In the first-pass analysis, it appeared that the rate of acute kidney injury was higher in this group but after statistical analysis this did not reach significance. The authors concluded that LTOWB was safe for use across all blood types.
Comparing Characteristics and Survival of Patients with Invasive Ductal and Lobular Breast Cancer
This report provided data from a large regional cancer database (n = 33,662) to compare various clinical features of invasive lobular carcinoma (ILC) of the breast with invasive ductal carcinoma (IDC) of the breast. Hazards modeling and propensity score adjustment were used to achieve matching of patients according to important risk factors.
The data analysis showed that patients with ILC presented with larger tumors, more often had lymph node involvement, and had estrogen receptor positive tumors more frequently. ILC patients underwent mastectomy more frequently and had lower rates of overall and disease-free survival following treatment. The authors concluded that there is sufficient evidence to suggest that ILC has distinct clinical and biologic characteristics. They recommended additional studies for establishing the value of imaging to achieve early tumor detection and improve rates of early diagnosis.
In the editorial by Lournes Djerroudi, MD, and coauthors, they noted the potential value of genomic characterization of ILC tumors since the presence of an immune transcriptomic signature seems to be frequent in these tumors. This approach could provide improved guidance for development of newer therapeutic avenues. They also noted that careful follow up of ILC patients will be beneficial for detecting and treating disease progression at an early stage.
Review Article Describes Etiology Diagnosis, and Management of Esophageal Perforation
This clear and valuable review article provided important insights into the diagnosis and management of esophageal perforation. The authors noted that this condition is potentially life threatening and that morbidity and mortality rates are influenced by frequent delays in diagnosis.
Management depends on the location and cause of the perforation, the overall medical stability of the patient, as well as the location and volume of extraesophageal fluid collections. Fundamental components of early management include adequate fluid resuscitation, administration of broad-spectrum antibiotics, drainage of fluid collections, relief of distal obstruction, and nutritional support. Localization of the perforation and determination of the size of perforation can be achieved with water soluble contrast imaging using computed tomography or plain film approaches.
The authors noted that the traditional approach to treatment of esophageal perforation has included open operation for closure of the perforation, diversion of the esophagus, or esophageal resection. Currently, endoscopic techniques such as stenting, clipping, suturing, and endoscopic vacuum therapy are increasingly used. According to data presented in this report, the mortality rate for esophagectomy is 11.6%, while reported mortalities for primary repair and stenting are 8.5% and 6.9% respectively. The lower mortality rates for stenting and primary repair are likely influenced by the severity of illness in the patient groups studied.
The article provided clear evaluations of available data concerning these techniques and described clinical situations where endoscopic management may be most appropriate. Surgeons are encouraged to read the entire review article.
