September 27, 2022
Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Montlione KC, Petro CC, Krpata DM, et al. Open Retromuscular Lateral Abdominal Wall Hernia Repair: An Algorithmic Approach and Long-Term Outcomes at a Single Center. J Am Coll Surg, 2022. In press.
Lateral abdominal wall hernias are infrequently encountered in surgical practice; because of this, a carefully planned approach that considers patient characteristics, patient preferences, anatomic features, and repair techniques is necessary to obtain long-term outcomes that minimize hernia recurrence and provide benefits for quality of life. In this article, the authors described their approach.
Preoperative evaluation includes a detailed history and physical examination, as well as CT imaging to provide anatomic definitions of the hernia related to abdominal fascial layers, muscle locations, and adjacent visceral structures. Because of the risk of nerve injury, patients should be counseled and informed that postoperative bulging is possible even though a successful hernia repair is achieved. Patient positioning for the repair procedure is determined by anatomic factors observed on preoperative imaging. Mesh repair was recommended for all patients. Clear illustrations of the anatomic features of lateral abdominal wall hernias and the elements of the authors’ approach are included, and readers are encouraged to review the full article.
Outcomes on 121 patients followed for a median interval of nearly 3 years were reported. Hernia recurrence was noted in 0.9% of patients and residual bulging was observed in 37%. Significant improvement in quality of life was confirmed using standard rating methods. The authors concluded that their approach produced excellent results in terms of hernia recurrence rates and improved quality of life, but that residual bulging was a frequent negative outcome.
Agarwal A, Basmaji J, Fernando SM, et al. Parenteral Vitamin C in Patients with Severe Infection: a Systematic Review. NEJM Evidence 1(9), 2022
This article reports results of a systematic review of the literature that focuses on the use of vitamin C as treatment for severe infection. Vitamin C has been used, in large part, because of the reductions in inflammation and oxidative damage associated with this treatment that have been reported in numerous animal studies. The authors noted that available research in human subjects has not provided consistent evidence of benefit. Forty-one randomized trials, including one trial reported by the authors of the systematic review, were included. The data showed that low-certainty studies suggested reductions in early mortality associated with vitamin C treatment. When moderate-certainty studies with low risk of bias were analyzed as a subgroup, a 7% increase in overall mortality was associated with vitamin C treatment. The authors concluded that the evidence did not provide sufficient proof of a benefit from vitamin C in patients with severe infection.
Goodwin AJ and Terry C. Vitamin C in Sepsis – No Longer a Benign Intervention? NEJM Evidence. 1(9), 2022.
In the editorial that accompanied this article, Andrew J. Goodwin, MD, MSCR, and Charles Terry, MD, MSCR, noted that enthusiasm for use of vitamin C has persisted since the 1970 publication by Linus Pauling showing that vitamin C might prevent/treat the common cold. The report emphasized the safety of the treatment. They noted that serious questions concerning the quality and accuracy of this report have been raised but enthusiasm for vitamin C treatments has continued. They emphasized the fact that evidence presented in the systematic review by Arnav Agarwal, MD, and colleagues provides a moderately strong suggestion that vitamin C treatment may harm patients and for this reason, treatment of severe infections with vitamin C should not be recommended.
de-Madaria E, Buzbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022;387(11): 989-1000.
This randomized, prospective trial sought to determine whether aggressive fluid resuscitation was beneficial for patients with severe pancreatitis. Large-volume fluid resuscitation has been recommended because of the perception that this approach would reduce the risk of ischemic pancreatic necrosis associated with severe pancreatitis.
For this trial, aggressive resuscitation was defined as a bolus of 20 ml/kg followed by an infusion of 3 ml/kg/hr; moderate resuscitation was defined as a bolus of 10 ml/kg followed by an infusion of 1.5 ml/kg per hour. The authors noted that the study was halted at the time of the first interim analysis because of potential harmful effects detected. A total of 249 patients were randomized. The main outcome of interest was the development of moderately severe or severe pancreatitis and/or diagnosis of fluid overload. The data analysis showed that rates of development of moderately severe or severe pancreatitis were similar in the two groups; fluid overload was diagnosed in 20.9% of patients in the aggressive fluid resuscitation group compared with 6.3% of patients in the moderate resuscitation group. The authors concluded that aggressive resuscitation was associated with an increased risk of harm due to fluid overload.