What’s new in Surgery for June features:

– Transplant Immunology: Basic Immunology and Clinical Practice

– Lymphatic Mapping and Sentinel Node Biopsy

– Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

– Perioperative Management of Patients on Steroids Requiring Surgery

– Transplantation Ethics and Policy

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Presence of lymphocytes within tubular epithelium-Tubulitis. It is one of the pathological feature of acute cellular rejection, Department of Pathology, Calicut Medical College

 

Scientific Foundations

LUNG-YI LEE, MD
DAVID P. FOLEY, MD
Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

 

Transplant Immunology: Basic Immunology and Clinical Practice

Belatacept, a human fusion protein that combines a modified extracellular portion of CTLA-4 with the constant region fragment (Fc) of human IgG1, is a novel agent that was approved by the US Food and Drug Administration in June 2011 to be used to prevent acute rejection in renal transplant patients. Belatacept confers better renal function compared with cyclosporine, with a comparable safety profile, and no differences have been found between belatacept and calcineurin inhibitors in the prevention of acute rejection, graft loss, and death. However, belatacept treatment is associated with less chronic kidney scarring and better renal transplant function.

 


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Lymphatic mapping and sentinel lymph node (SLN) biopsy for melanoma.

 

Breast, Skin, and Soft Tissue

DAVID W. OLLILA, MD, FACS
University of North Carolina, Chapel Hill, Chapel Hill, NC
KARYN B. STITZENBERG, MD, MPH
University of North Carolina, Chapel Hill, Chapel Hill, NC
KRISTALYN GALLAGHER, DO, FACS
University of North Carolina, Chapel Hill, Chapel Hill, NC

 

Lymphatic Mapping and Sentinel Node Biopsy

The dual-tracer technique of lymphatic mapping has the highest accuracy rates, and most melanoma surgeons prefer this method. Methylene blue is generally avoided due to the high rate of skin necrosis at the site of injection. It should not be considered in melanoma patients in whom the injection site is not going to be excised and should not be considered in breast cancer patients unless a total mastectomy is being performed. Isosulfan blue is most commonly used but is associated with a rare incidence of anaphylaxis. Thus, isosulfan blue should never be used in a setting without direct anesthesia care provided.

 


 

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Computed tomographic angiogram of fibromuscular dysplasia of an internal carotid artery.

 

Vascular System

KENNETH R. ZIEGLER, MD, RPVI
THOMAS C. NASLUND, MD
Division of Vascular Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN

 

Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

One of the key advances in the diagnosis of carotid artery stenosis is the use of carotid duplex imaging. Duplex ultraso¬nography provides the most rapid and efficient means of identifying significant extracranial vascular atherosclerosis and can image the common, internal, and external carotid arteries. It is a highly accurate test to detect and characterize carotid artery lesions; meta-analyses of published studies have revealed sensitivities and specificities of greater than 80% and greater than 90%, respectively.

 


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Scientific Foundations

DAWN M. ELFENBEIN, MD, MPH
Endocrine Surgery, University of California, Irvine, Irvine, CA
ALEXANDRA REIHER, MD
Clinical Endocrinologist, St. Anthony’s Hospital Centura Health, Lakewood, CO
REBECCA S. SIPPEL, MD, FACS
Chief, Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

 

Perioperative Management of Patients on Steroids Requiring Surgery

Weighing the risks and benefits of glucocorticoid supple¬mentation for surgery is quite difficult, and optimal dosing regimens remain controversial. Once it is determined that a patient will require periopera¬tive glucocorticoid replacement, the dose of glucocorticoids must be determined. Optimal dosing of perioperative steroids will mimic a normal physiologic response to stress, taking into account a patient’s preoperative dose of glucocorticoid, the duration of use, and the anticipated duration and physiologic stress related to surgery.

 


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Transplantation

ANJI ELIZABETH WALL, MD, PHD
Vanderbilt University Medical Center, Nashville, TN
J. MICHAEL MILLIS, MD
Vice Chair of Global Surgery, University of Chicago, Chicago, IL

 

Transplantation Ethics and Policy

The dead donor rule states that a donor must be dead prior to the procurement of the essential organs. This rule is essential for continued public buy-in: there must be assurance from the transplant community that persons are not being killed for their organs. An individual is dead either when the heart and lungs stop or when there is complete and irreversible cessation of brain function. When either of these criteria is met, the individual can be an organ donor under the dead donor rule. Of note, transplant physicians and surgeons are not part of the team that decides when a patient is dead.

 


 

As seen in Scientific American™ Surgery, teaching principles and practice of General Surgery.