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Issue #12: August 15th, 2024

Updated: Sep 25, 2024

My heart aches, and a drowsy numbness pains

My sense, as though of hemlock I had drunk,

Or emptied some dull opiate to the drains

One minute past, and Lethe-wards had sunk:

'Tis not through envy of thy happy lot,

But being too happy in thine happiness,—

That thou, light-winged Dryad of the trees

In some melodious plot

Of beechen green, and shadows numberless,

Singest of summer in full-throated ease.

— John Keats, 1819, "Ode to a Nightingale"


By Amy Sequeria

To inject or not to inject? Esophageal varices are a common adverse side effect that plagues patients with cirrhosis. Mainstream treatment of esophageal varices is ligation treatment using the multi-band ligature technique. This procedure is not without its complications. Patients frequently complain of rebleeding of the varices, resulting in recurrence of the varices and eventually another procedure. The current literature suggests that the multi-band ligation technique only resolves the varices in a local setting, leaving the surrounding vessels able to form varices in the future. This original research study aimed to investigate whether endoscopic injection sclerosis therapy could decrease the recurrence and rebleeding rate of esophageal varices when combined with the current multi-band ligation therapy. The study included 136 patients with esophageal varices undergoing the standard multi-band ligation therapy acting as the control group, and 174 patients with esophageal varices who received multi-band ligation followed by endoscopic injection sclerosis therapy as the interventional group. The primary endpoint was the difference in efficacy and side-effects between the two groups. The patients were examined 2 weeks post procedure, and had follow up examinations at 6, 8, and 12-months post procedure. After statistical analysis of the study was performed, the interventional group showed significant success compared to the control group at follow-up appointments. At 12 months, the interventional group had 3 patients experience rebleeding (2.6% of the group), compared to 14 patients in the control group (10.3% of the group) [p=0.029]. Variceal recurrence was also lower in the interventional group at 12 months, with 24 patients having recurrence of varices (20.7%), and 51 patients in the control group (37.5%) [p=0.006]. Further randomized control trials on a larger scale are required for deeper investigation into this technique. However, given the success of the treatment seen in this study, it is likely that endoscopic injection sclerosis in addition to multi-band ligation will be considered by gastroenterologists and general surgeons as a first line therapy for treatment of esophageal varices secondary to cirrhosis. 


By Jordan Palmer

Historically, post-surgery treatments aimed at preventing the return of localized renal-cell carcinoma (RCC) haven't seen much success. Among VEGF receptor-tyrosine kinase inhibitors (VEGFR-TKIs), sunitinib stood out for its ability to improve disease-free survival (DFS) in the S-TRAC trial, though it didn't show the same results in the larger ASSURE trial. No overall survival (OS) benefit was seen with any VEGFR-TKIs. Until 2021, sunitinib was the only FDA-approved adjuvant treatment for patients with high-risk RCC after nephrectomy. That changed in 2021 when pembrolizumab, an anti-PD-1 antibody, was approved by the FDA after showing significant DFS improvement in the phase 3 KEYNOTE-564 trial. This study found that the 24-month DFS rate for patients on pembrolizumab was 77.3%, compared to 68.1% for those on placebo. Other immune checkpoint inhibitors like atezolizumab and the nivolumab plus ipilimumab combination did not show DFS benefits in their trials. The KEYNOTE-564 trial was a double-blind, randomized, placebo controlled study involving RCC patients who had undergone surgery. Participants received either pembrolizumab (200 mg IV every 3 weeks for up to 17 cycles) or a placebo, with randomization based on factors like metastatic stage, ECOG performance status, and geographic region. The main goal was to assess DFS, with OS as an important secondary endpoint. After a median follow-up of 57.2 months, pembrolizumab showed a 38% reduction in the risk of death compared to placebo, with OS rates at 48 months of 91.2% for pembrolizumab and 86% for placebo (p=0.005). The DFS rates at 48 months were 64.9% for pembrolizumab and 56.6% for placebo. The rates of subsequent therapies were similar in both groups. Safety data indicated that adverse events were more common with pembrolizumab, including more severe adverse events and immune related events. While more patients on pembrolizumab stopped treatment due to adverse events, no treatment related deaths were reported. Patient reported outcomes remained stable, suggesting that quality of life was acceptable. In conclusion, the KEYNOTE-564 trial demonstrated that adjuvant pembrolizumab significantly improves both DFS and OS in RCC patients at high risk of recurrence after surgery, making it a strong option for adjuvant treatment with a manageable safety profile.


By Barbara Buccilli

Burr-hole drainage is a neurosurgical procedure designed to relieve brain pressure by draining accumulated blood, which facilitates the removal of inflammatory factors from the subdural space, and thereby reducing the likelihood of recurrences. The benefits of burr-hole drainage are evident, however, it is not without its risks and complications. Potential issues include direct cortical injury, which can occur if the surgical procedure inadvertently damages the brain’s surface, intracranial hemorrhage, which can arise from bleeding during or after the surgery, and pneumocephalus, which can complicate recovery and potentially increase the risk of recurrence. The randomized, controlled FINISH trial aimed to compare burr-hole drainage with or without irrigation in adults with chronic subdural hematomas. Primary endpoint was reoperation rates between the irrigation vs no irrigation groups within 6 months. They also assessed functional outcomes, mortality, and adverse events over six months, with a 7.5% non-inferiority margin for key outcomes.During the 6-month follow-up, reoperation rates were 6% higher in the non-irrigation group. Interestingly, the functional outcomes, mortality rates, and adverse event incidences were similar between the groups. The non-irrigation group had a significantly shorter median operation time, but no differences were observed in drainage volumes, hospital stay, further care needs, or hematoma width. The FINISH trial brings light to the advantages of intraoperative irrigation in subdural hematoma evacuation. It would be interesting to explore how this technique performs in combination with or in comparison to IRRAFLOW EVDs, which appears to follow a similar trajectory with a focus on postoperative management. 


By Tsion Teshome

Most coronary artery bypass grafting (CABG) procedures conducted today still need a full sternotomy, which puts patients through significant stress and prolongs recovery. Transitioning to less traumatic approaches is highly desirable for all parties involved — patients, the healthcare system, and the community at large — as it can allow for quicker recovery and earlier return to society. Even in the robotic era, sternal-sparing techniques cannot replace the traditional CABG due to the challenge of suturing anastomoses in small spaces. Although automated coronary anastomotic connection devices exist, they’re not widely used. This meta-analysis reviewed 14 studies that used a connector device for anastomosis and compared it to handsewn. The primary outcome of the study was the patency of connector device anastomoses vs handsewn anastomosis across various timelines (<30 days, 30 days to 1 year, and >1 year follow-up). Across the 14 studies, over 4000 patients had undergone CABG. A total of 4,328 anastomoses were performed (674 connector devices vs  3,654 handsewn). When comparing the connector device anastomosis to the handsewn anastomosis across all timelines, the connector device was found to be non-inferior to the handsewn anastomosis (RR 0.90, 95% CI: 0.56–1.44). Given these study findings, it is worth considering the use of connector device anastomosis in CABG. 


By Sherine Thomas

Previous animal models have indicated that exposure to high-altitude hypoxia may have a protective effect on the cardiovascular system.  However, the extent of these cardioprotective effects in clinical settings has remained largely unexplored until recently. A retrospective cohort study conducted in southwest China further examined this, revealing significant differences in surgical outcomes between high-altitude and low-altitude residents who underwent cardiac surgery. Data on patients who underwent cardiopulmonary bypass and cardioplegia was collected from 2013 to 2022. The patients were divided into a high-altitude group (residing at 1,500 meters or above) and a low-altitude group (residing at 1,500 meters or below). To ensure statistical validity, 377 patients from each group were matched at a 1:1 ratio. The primary outcome was the incidence of major adverse cardiovascular events (MACE). MACE was defined as having at least one of the following: myocardial infarct requiring percutaneous intervention or CABG reoperation, cardiac arrest requiring resuscitation, and/or acute heart failure requiring extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pump (IABP). Secondary outcomes defined as in-hospital mortality and level of creatinine kinase muscle-brain isoenzyme levels postoperative day 1. Two key outcomes were highlighted in this study. First, high-altitude residents showed a 44.5% lower incidence of MACE both during and after the surgery compared to low-altitude residents. Additionally, at least one MACE occurred in 45 of the 377 lowlanders compared to just 25 of the 377 highlanders (11.9% vs. 6.7%; p<0.05). In both groups, the majority of MACE patients required IABP (10.1% vs. 5.8%; p=0.043). In-hospital mortality rates in the highlanders was lower than the lowlanders, but there was no statistical significance (1.3% vs. 3.2%; p=0.14). Secondly, highlanders showed noticeably lower levels of CK-MB on the morning after surgery (66.5 U/L vs 69.5 U/L; p=0.003). These findings are consistent with previous studies suggesting that exposure to high-altitude conditions may have protective effects on the heart. Earlier studies propose that long-term residents at high altitudes require metabolic adjustments in low-oxygen conditions to maintain proper cardiac performance. This adjustment causes myocardial metabolism to prioritize glucose as its main source of energy when oxygen is limited. Furthermore, some studies propose elevated levels of circulating nitric oxide are found in high altitude communities, thus suggesting it may prevent heart damage and improve oxygen delivery. The physiological mechanism for this study remains unknown. However, this research strengthens the evidence for the positive effects of high-altitude environments on heart health in the context of cardiac surgery. Overall, this study paves the path for further research on how these protective effects might be utilized in broader medical practice, thus potentially changing how one approaches cardiac care and prevention.


By Ishrar Shaid

HIV has been a disease with a negative connotation since its discovery. Although advancements in treatment have increased, patients with HIV still suffer from end stage renal disease (ESRD). Access to renal transplantation is thus crucial to increasing chances of survival in this patient population.In this Canadian database-driven study spanning from 2007-2020, over 40,000 patients with ESRD on chronic dialysis were analyzed. Only 173 patients in this population were HIV positive. The primary endpoint was the number of renal transplants in patients with and without HIV. 13.1% of HIV-negative patients received renal transplant vs 12.1% of HIV positive, which was not statistically significant (p= 0.7). However, when a subanalysis was done with a subdistribution hazard ratio (sdHR) to determine likelihood of transplantation, there was a statistically significant difference in who receives transplant. It was determined that patients with HIV had a much lower chance of receiving renal transplant compared to those without HIV (sdHR, 0.46 [95% CI, .30-.70]; P < .001)).  This study also showed that there was no significant difference between allograft failure rates in the subanalysis group. Given these findings, transplant committees should consider closing this gap to improve overall survival of patients with HIV. 


By Annie Pham


Anterior cruciate ligament (ACL) tears are the most prevalent knee ligament injuries. This is primarily due to the comparatively thinner and weaker nature of the ACL in comparison to the posterior cruciate ligament (PCL). For optimal visualization of the torn ACL, MRI with T2-weighted imaging is preferred. The increased signaling on T2-weighted images indicates the presence of fluid accumulation within the injured ACL. The relationship between the ACL and the Blumensaat line, observed on lateral knee imaging, is assessed to evaluate the injury. Normally, the ACL follows a steep trajectory in relation to the Blumensaat line. However, in cases of ACL tears, the Blumensaat angle, measured as the angle between the intercondylar line and the ACL, is greater than 15°. ACL reconstruction, utilizing autografts, allografts, or synthetic grafts, is a commonly performed procedure to reduce instability and prevent further damage.



By Shawn Kaura



Dr. Percival Pott is perhaps most widely known for his contribution to public health and epidemiology. A pioneer in public health, epidemiology, medicine, and surgery, he lived and worked in London, United Kingdom from 1714 to 1788. Back then, medical school and residency training were not formalized avenues for aspiring surgeons. At that time, education followed an apprenticeship model. Dr. Pott trained under Edward Nourse, a surgeon at St. Bartholomew’s Hospital in London. 

Dr.Pott was one of the first to make a connection between environmental exposures (e.g. chimney soot) and disease onset. Chimney sweeping was a common occupation in the 18th century. In his practice, he saw an increasing number of scrotal cancers in patients who were chimney sweepers. In 1775, he wrote extensively about the role that “soot” plays as an environmental risk factor for scrotal cancer. His advocacy and work led to the establishment of regulatory standards and awareness for occupational health and safety, which influenced many practices that are in place today. His work outlined that it is possible that long-term exposure to certain substances can lead to the development of disease.

As a surgeon, Dr. Pott was also influential in the field of orthopedic surgery. He provided groundbreaking work with identifying and classifying different fracture patterns as well as their treatment. During his time, there was little understanding of the importance of immobilization in fracture management. Dr. Pott discovered that stabilizing a broken bone will aid in the healing process, which is a standard practice of today. Additionally, he was adept at treating various spinal disorders such as spinal tuberculosis and spinal deformity. His contributions to spinal tuberculosis, also known as Pott’s disease, include the identifying the spread of tuberculosis to the spine, manifestations of the disease in the spinal cord, and that spinal deformity in the form of kyphosis is a notable result of the disease.

In summary, Dr. Pott showcased the importance of paying attention to how disease processes start and how the world around us can contribute to it. His observations will forever be pinnacles in preventive medicine, orthopedic surgery, and infectious disease. We can all only hope to contribute as greatly as he did to the health and wellness of society. 


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FUTURE OPPORTUNITIES & REMINDERS






 
 
 

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