Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.
March 1, 2022
Schellenberg M, Owattanapanich N, DuBose JJ, et al. Resuscitative endovascular balloon occlusion of the aorta in penetrating trauma. J Am Coll Surg. [In press 2022].
Murphy PB, Finding the right patient for REBOA. J Am Coll Surg. [In press 2022].
Retrograde endovascular balloon occlusion of the aorta (REBOA) is used to obtain emergency control of hemorrhage by occluding the aorta with an endovascular balloon. Most available data support the use of REBOA placed during early resuscitation in the emergency department for blunt trauma patients with hemorrhage from abdominal and/or pelvic injuries. Depending on the location of the bleeding source, the occluding balloon can be placed in one of several areas starting in the thoracic aorta (Zone 1) with other locations located distally. The study reported in this article used data from the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) database sponsored by the American Association for the Surgery of Trauma to compare outcomes in patients who had REBOA placement for life-threatening hemorrhage resulting from penetrating trauma with patients who had sustained blunt force injuries.
The study cohort consisted of 759 patients with 152 (20%) sustaining penetrating injuries. Penetrating injury patients were less severely injured, most often they had abdominal sources of bleeding, and had REBOA catheters placed more often in the operating room. Zone 1 balloon deployment was used most often for patients with penetrating injuries. Improvement or stabilization of hemodynamics was less common in patients with penetrating injuries compared with blunt injuries with stabilization occurring in 23% of penetrating injury patients compared with 41% of blunt injury patients. Stabilization or improvement was more common in patients arriving alive with detectable hemodynamic parameters. The authors concluded that additional research is warranted to determine the best use of REBOA in penetrating trauma patients, but the benefit was in patients arriving alive with detectable vital signs.
In the editorial accompanying the article, Murphy stressed that rapid operative control of abdominal hemorrhage in penetrating trauma patients may be preferable to using REBOA because of the delays encountered in catheter placement. In addition, further research is necessary to identify distinct groups of penetrating trauma patients most likely to respond to REBOA so that delays in hemorrhage control and the various ischemic complications of REBOA can be minimized.
Brajeich BC, Stigall K, Walsh DS, et al. Preoperative nutritional optimization of the oncology patient: a scoping review. J Am Coll Surg. [In press 2022].
The authors reported a “scoping” review to identify preoperative nutritional interventions most likely to benefit patients with cancer. It should be noted that a scoping review is one subtype of systematic reviews of the literature that is used for topics where datasets are large, heterogeneous, and with few, if any, previous systematic reviews. From a group of 5,505 publications, 69 were chosen for inclusion in the review.
The analysis showed that strong data support the use of preoperative nutritional assessments and counseling (with interventions focused on improving physical fitness, smoking cessation, and protein supplementation) as a means of improving outcomes and shortening hospital lengths of stay.
Protein/calorie nutritional supplementation was determined to be a useful preoperative intervention in malnourished patients with data supporting a reduction in infectious complications. Preoperative immunonutrition (arginine, omega-3 fatty acids, dietary nucleotides) was not supported by strong data but should be considered for patients with gastrointestinal malignancies. Available data supported the use of probiotics or synbiotics for patients with colorectal cancers.
The authors encouraged surgeons caring for patients with cancer to incorporate nutritional assessment and intervention protocols into their practices.
Greene F. Surgical palliative care: A coming of age. BMJ Support Palliat Care. Mar 2022;12(1):46-48.
In this article, Frederick Greene, MD, FACS, recounts his personal journey leading to an understanding of the benefits of a comprehensive approach to surgical palliative care. Early in his career, Dr. Greene was taught that palliative surgery (procedures to relieve pain, improve wounds, restore bowel function) was employed as isolated events, where the surgeon provided the service and then left the care of the patient to other healthcare professionals. As his professional life progressed, he learned that surgeons should maintain relationships with and provide long-term care for patients who require help and that a consistently present surgeon can maximize quality of life and minimize suffering during the entire course of an incurable disease.
Dr. Greene emphasized the need to incorporate education on surgical palliative care beginning at the medical student level and noted that the mortality and morbidity conference is an ideal setting to demonstrate the benefits of surgical palliative care. He stressed the need to be certain that all providers understand the distinction between surgical palliative care and hospice (end of life) care. Efforts by organizations such as the ACS and leaders such as Olga M. Jonasson, MD, FACS, to provide this education were recounted in the article.
Currently, it is possible for interested surgeons who are certified by the American Board of Surgery to complete a 1-year fellowship and become certified by the American Board of Hospice and Palliative Care Medicine as a surgical palliative care specialist. The goal for all surgeons to understand that a comprehensive, integrated approach to surgical palliative care that extends throughout the patient’s entire disease course is most likely to provide maximum benefits and will assist surgeons as they strive to achieve the stated goal of the ACS: “To heal all with skill and trust.”