Current Literature

Complete Bowel Preparation May Be Valuable for Sigmoidectomy, but More Research Is Needed

Schudrowitz N, Shahan CP, Moss T, Scarborough JE. Bowel Preparation Prior to Non-Elective Sigmoidectomy for Sigmoid Volvulus: Highly Beneficial but Vastly Underused. J Am Coll Surg. 2023. In press.

The authors of this study used data from the ACS National Surgical Quality Improvement Program (NSQIP) database to compare outcomes in patients with sigmoid volvulus who underwent successful endoscopic detorsion followed by mechanical and antibiotic bowel preparation (complete bowel preparation) and sigmoid resection and anastomosis with patients who had no or only partial bowel preparation prior to sigmoid resection and anastomosis.

Data on 2,429 patients were analyzed; complete bowel preparation prior to sigmoid resection and anastomosis occurred in only 13.3% of patients. Rates of anastomotic leak, mortality, and prolonged hospital length of stay were significantly lower in this group.

The authors concluded that efforts to increase utilization of complete bowel preparation would have potential value for reducing mortality and morbidity in these patients. This paper was presented during the plenary session of the 2022 annual meeting of the Southern Surgical Association. In the discussion following the presentation, questions were raised regarding whether the two patient groups were comparable since significant patient characteristics are frequently not recorded in databases, such as the one utilized. Given the fact that the NSQIP database is risk adjusted, the results do suggest that complete bowel preparation may be valuable and that additional prospective studies are needed.

Neoadjuvant Chemotherapy Prior to Exploration for Pancreatic Cancer Is Safe and Effective

Fong ZV, Verdugo FL, Fernandez-del Castillo C, et al. Tolerability, Attrition Rates, and Survival Outcomes of Neoadjuvant FOLFIRINOX for Non-Metastatic Pancreatic Adenocarcinoma: Intent-to-Treat Analysis. J Am Coll Surg. 2023. In press.

Patients with resectable pancreatic ductal adenocarcinoma frequently undergo neoadjuvant chemotherapy with 5-fluorouracil-irinotecan/oxaliplatin (FOLFORINOX), gemcitabine/nab paclitaxel, or combination chemoradiotherapy to reduce the risk of incomplete resection (positive margins and/or micrometastases) and improve survival rates. The chemotherapy regimens are associated with significant toxicity, and pancreatic resection carries a risk for postoperative complications. The chemotherapy regimens are tolerated by most patients and the delay of surgery while neoadjuvant treatment is administered allows for preoperative diagnosis of disease progression.

This article reported retrospective data on 254 patients from a single institution. Complete neoadjuvant therapy was achieved in 78.3% of patients; grade 3 or 4 toxicity was diagnosed in 42.9% of this patient group. Risk factors for failure to complete neoadjuvant therapy and undergo operative exploration included remote history of chemotherapy, inability to complete FOFORINOX cycles, increased Eastern Cooperative Oncology Group (ECOG) functional status score, and being single or divorced. Of the 199 patients who eventually underwent exploration, successful resection occurred in 71.4% of patients, and 129 patients had negative margins.

Despite significant toxicity in 109 patients, most patients could be successfully managed with a multidisciplinary team care approach and significant family/social support. Rates of interventional procedures, ED visits, and hospital admissions are reported in the article.

The authors concluded that neoadjuvant chemotherapy prior to exploration for pancreatic cancer was safe, effective, and that neoadjuvant treatment-related morbidity could be successfully managed in most patients.

Care Plan Is Outlined for Management of Enteroatmospheric Fistula

Wainstein DE, Calvi RJ, Rezzonico F, Deforel ML, Perrone N, Sisco P. Management of Enteroatmospheric Fistula: A 10-Year Experience Following 15 Years of Learning. Surgery. 2023.

This article reported results of a retrospective study of 77 patients with enteroatmospheric fistula managed by a single care team over a 10-year interval. The article provided a clear description of the fistula care plan used by the authors; the report also discussed the use of three types of negative pressure wound devices and provided useful illustrations of the positioning and arrangement of the surface dressing for optimum negative pressure. Nutritional support was an important component of the care plan.

Closure of the fistula after nonoperative therapy occurred in 18% of patients; predictive factors for nonoperative closure were low fistula output and deep fistula location. Reconstructive surgery was required in 72.7% of patients, and nine patients (16%) experienced postoperative recurrence. Five of the recurrent fistulas closed without further surgical therapy. Overall, fistula closure was achieved in 81.8% of patients with a 9% mortality rate.

Surgeons are encouraged to review the very useful descriptions of care strategies supplied by this article.

Article Reviews Probe and Camera-Based Techniques for Parathyroid Identification, Vascular Assessment in Thyroid Surgery

Silver Karcioglu AL, Triponez F, Solorzano CC, et al. Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review from the American Head and Neck Society Endocrine Surgery Section. JAMA Otolaryngol Head Neck Surg. 2023.

Because of the significant morbidity associated with hypoparathyroidism that results from devascularization or unintentional removal of normal parathyroid glands, techniques for identification of normal glands using imaging modalities, such as near infrared autofluorescence either label free or with indocyanine green (ICG) labelling, are becoming increasingly important. This article reviewed the probe-based and camera-based techniques for parathyroid identification and provided a user manual that can guide efforts to implement successful identification protocols.

The authors emphasized that imaging techniques do not substitute for sound judgment and surgical experience. Identification of parathyroid glands using near infrared technology after exposure of the gland area can be followed with assessments of the location and size of vascular pedicle using ICG fluorescence imaging. The authors emphasized the importance of assessing gland vascularity assessment immediately after ICG injection and noted that near-infrared imaging cannot be used after ICG injection because of residual fluorescence. The article supplied a useful table comparing gland-probe and camera-based near infrared fluorescence testing.

Data from several studies were cited that support the conclusion that use of near infrared fluorescence and ICG injection are associated with significant reductions in postoperative hypoparathyroidism. Studies to document long-term outcomes are needed.