September 2018

Synopsis: The use of minimally invasive distal pancreatectomy (MIDP) has become increasingly popular with several observational studies from high-volume centers showing shorter hospital stays and decreased complications. Given the complex nature of pancreatic surgery, however, the use of minimally invasive techniques has lagged relative to other abdominal resections. The LEOPARD trial is a multi-center RCT conducted in 14 Dutch centers following implementation of a nationwide training program in MIDP. Amongst 111 patients (51 MIDP, 57 open distal pancreatectomy [ODP]), minimally invasive resection required longer operative time (217 min vs 179 min, p = 0.005) but had less blood loss (150 cc MIDP vs 400 cc ODP, p<0.001). The conversion rate was 8.5%. The primary outcome (time to functional recovery) was 2 days less in MIDP (4 vs. 6 days, p<0.001) with each parameter of functional recovery (restored mobility, adequate pain control, 50% caloric intake, no need for intravenous fluid, and no signs of infection) significantly less (all p<0.01). MIDP also decreased the rate of delayed gastric emptying (6% vs 19%, p=0.04) but a higher rate of pancreatic fistula (39% vs 23%, p=0.07). However, the rate of percutaneous drainge in both groups was comparable (22% vs 20%, p=0.77), suggesting that the overall difference in fistual rates may have been driven by earlier hospital discharge with drain in place. This study supports the use of MIDP for selected patients, within the context of appropriately trained minimally invasive surgeons. Notably, the long-term oncologic outcomes were not explored in this study. 

Synopsis: In infants and children, there are multiple sites for veno-arterial (VA) extracorporeal life support (ECLS), including the right common carotid artery, aorta, and femoral artery. Prior research has suggested that cannulation of the carotid results in higher rates of neurologic injury, which occurs in 20% of pediatric patients on VA ECLS, a devastating complication. Using almost 25 years of data from the largest ECLS data registry in the world, the authors sought to determine if there was truly a difference in neurological complications across cannulation sites for different age groups. In their review of n=30,282 ECLS runs, they noted that although carotid ligation was associated with a higher rate of stroke (OR 1.37), when using a multivariate analysis to adjust for other covariates, there was no difference across sites and age groups for neurologic complications or stroke [19% and 4.5% respectively (p > 0.05 for each)]. The authors conclude that surgeons should consider carotid cannulation as a viable option in all pediatric patients, not just neonates. 

Synopsis: The post-thrombotic syndrome (PTS) is a condition that can occur as a long-term complication of deep vein thrombosis (DVT) characterized by the presence of lower extremity skin changes, swelling, pain, and varicosities. Patients with iliofemoral DVT (i.e., proximal DVT) have the highest risk of developing PTS, with a rate near 50%. The standard-of-care for proximal DVT has historically been anticoagulation, but active removal of acute thrombus may preserve venous function and prevent PTS. The Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was a RCT of 692 patients with acute proximal DVT receiving either anticoagulation alone (control group) or anticoagulation plus PCDT (pharmacomechanical catheter-directed thrombolysis = tPA +/-thrombus aspiration +/- venoplasty/stenting). Over 24 months, there was no significant difference between groups in the percentage of patients who developed PTS (47% vs. 48%; RR 0.96, 95% CI 0.82–1.11). However, there were significant differences between the groups in clinical severity scores for PTS: the PCDT group was associated with less moderate-to-severe PTS (18% vs. 24%; RR 0.73 95% CI 0.54 to 0.98), as well as lower scores at 6, 12, 18, and 24 months of follow up (P<0.01 at each time point). Yet PCDT was associated with a higher rate of major bleeding (within 10 days of treatment) relative to anticoagulation alone (1.7% vs 0.3%; P=0.049). The authors concluded that among patients with acute proximal DVT, the addition of PCDT to anticoagulation did not result in a lower risk of PTS, but did result in a higher risk of major bleeding. There are, however, important limitations to address. First, only 1-in-50 patients screened ended up meeting inclusion criteria for randomization, which limits the generalizability of the results. Additionally, a disproportionate number of patients with no PTS assessments were in the control group (66% control group vs. 33% treatment group), which may have led to an underestimation of the benefit of PCDT. Lastly, PCDT was not standardized across all practitioners, which makes the true effect of PCDT difficult to interpret. As such, venous intervention may still be warranted while taking into account a patient’s bleeding risk. 

Synopsis: Critical illness predisposes patients to secondary gastrointestinal bleeding (GIB) via a number of mechanisms, including splanchnic hypoperfusion, shock/low cardiac output, reperfusion injury and a pro-inflammatory state. The incidence of clinically significant bleeding which results in hypotension, hemoglobin drop by >2g/dl, requires a blood transfusion or invasive procedure occurs in 1.5-3.5% ICU patients and results in an increased ICU length-of-stay and mortality. Several large, multi-center studies have identified important risk factors for secondary GIB, including invasive mechanical ventilation >48 hr, coagulopathy, >3 co-existing diseases, liver disease and high organ-failure score. The first-choice medication for prophylaxis is not clearly defined. In this meta-analysis of 57 trials (N=7293 patients) comparing the efficacy of proton-pump inhibitors (PPI), histamine-2 receptor antagonists (H2RA) and sulcrafate, PPIs were more effective than H2RAs (OR 0.38; 95% CI 0.2-.073), sulcrafate (OR 0.30; 95% CI 0.13-0.69) and placebo (OR 0.24; 95% CI 0.10-0.60). Notably, PPI were associated with an increased risk of nosocomial pneumonia compared to H2RA (OR 1.27; 95% CI 0.96-1.68) and placebo (OR 1.52; 95% CI 0.95-2.42) but neither were statistically significant. This effect estimate is similar to a previously published cohort study of 35,312 mechanically ventilated patients that showed an increased risk of pneumonia in those receiving PPIs (OR 1.2; 95% CI 1.03-1.41).

Clinical bottom line: PPI should be used preferentially, in lieu of H2RA or sulcrafate, due to increased efficacy as prophylaxis for GIB in critically ill patients. Given the probable increased the risk of nosocomial pneumonia, PPI prophylaxis should be done judiciously and limited to those patients at highest risk, including those receiving invasive mechanical ventilation >48 hr, coagulopathy, liver disease and high organ-failure scores.