New this month in Scientific American Surgery:

  • Small Intestinal and Multivisceral Transplantation
  • Postoperative Management of the Hospitalized Patient
  • Injuries to Great Vessels of the Abdomen
  • Lower Gastrointestinal Bleeding


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TRANSPLANTATION

Small Intestinal and Multivisceral Transplantation

B. John DuBray
The Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
Douglas G. Farmer
The Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA

 

One of the most feared and deadly complications of prolonged total parenteral nutrition (TPN) use is liver disease. Intestinal failure–associated liver disease (IFALD) is estimated to affect 40 to 60% of children and 15 to 40% of adults on prolonged TPN. If untreated, IFALD can lead to fibrosis and, eventually, cirrhosis. Therapies include compression of TPN infusion, alteration in the amount and formulation of lipid, administration of ursodiol, and, finally, cessation of TPN if at all possible. Fish oil–based lipid emulsions and lipid-sparing protocols have reduced lipid-related complications in patients with intestinal failure.

 


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Basic Surgical and Perioperative Considerations

Postoperative Management of the Hospitalized Patient

Edward Kelly, MD, FACS
Assistant Professor of Surgery, Harvard Medical School, Division of Burn, Trauma and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, MA

 

Enhanced recovery after surgery (ERAS) pathways have been advanced for the purposes of cost containment, standardization of care, and standardization of surgical outcomes. Adoption of an ERAS pathway has been associated with a shortened length of hospital stay and improved outcomes in colorectal surgery in randomized prospective trials, which has led to the implementation of the ERAS approach in other procedures. Each pathway is specific to a given procedure, and no universal postoperative pathway has been proposed or investigated.

 


TRAUMA AND THERMAL INJURY

Injuries to Great Vessels of the Abdomen

David V. Feliciano, MD
Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
Juan A. Asensio, MD
Department of Surgery, Creighton University School of Medicine, Omaha, NE

 

Originally described during the Korean War, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been revivified over the past 20 years. Proposed indications for the use of REBOA in profoundly hypotensive patients currently include the following: ruptured abdominal aortic aneurysms; penetrating or blunt abdominal trauma (get a chest x-ray to rule out blunt rupture of the descending thoracic aorta above the balloon); and pelvic fractures. If successfully placed, REBOA raises blood pressure in patients with hemorrhagic shock. Data are currently limited in injured patients, and more studies will have to be performed to document improved survival in these patients.

 


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(a) Baseline tagged red blood cell (RBC) scan. (b) Tagged RBC scan (arrow denotes active bleeding in the ascending colon and sigmoid).

GASTROINTESTINAL TRACT AND ABDOMEN

Lower Gastrointestinal Bleeding

Jennifer Nayor, MD
Clinical Research Fellow, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA
John R. Saltzman, MD
Director of Endoscopy, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, Associate Professor of Medicine, Harvard Medical School, Boston, MA

 

In patients with ongoing bleeding despite negative colonoscopy or with massive gastrointestinal (GI) bleeding that precludes visualization with colonoscopy, technetium-99m–labeled erythrocyte scintigraphy (tagged red blood cell scan) can be performed to localize GI bleeding. A radiotracer is injected intravenously, and images are captured to identify extravasation of blood into the GI lumen. A bleeding rate of at least 0.1 to 0.5 mL/min is required to detect bleeding. Typically, imaging takes place over a 90-minute period (the diagnostic yield subsequently declines). However, the radiotracer remains active for 24 hours, which allows for repeat imaging if the initial image is negative and the patient has a recurrence of bleeding.


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Written By

decker

The Decker Team