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Operative Exposure of Abdominal Injuries and Closure of the Abdomen

    • Prehospital control of bleeding with tourniquets, and permissive hypotension until operative bleeding control improve survival.
    • Damage control resuscitation and surgical principles improve outcomes in patients with abdominal trauma, impaired physiology.
    • Resuscitative Endovascular Balloon Occlusion of the Aorta, may aid the hemorrhaging abdominal trauma patient.

Compartment Syndrome

    • Compartment syndrome of the extremity is a clinical diagnosis in an awake and alert patient.
    • Measurement of intracompartmental pressures should be performed in the obtunded patient or if clinical assessment is inconclusive.
    • Once the diagnosis is made, emergent fasciotomy is the treatment of choice as time to fasciotomy is the most important factor determining outcome.
    • Any patient with risk factors for developing abdominal hypertension should have intra-abdominal pressure assessed, preferably via intermittent or continuous transbladder pressure.
    • Patients diagnosed with abdominal compartment syndrome require emergent decompressive laparotomy and the creation of a temporary abdominal closure.

Sleep Disorders

    • The MSLT is essential in documenting pathologic sleepiness (e.g., sleep-onset latency of less than 8 minutes) and in diagnosing narcolepsy. The presence of two sleep-onset REMs on four or five nap studies and sleep-onset latency of less than 8 minutes strongly suggests a diagnosis of narcolepsy in the context of an appropriate history.
    • RLS is a lifelong sensorimotor neurologic disorder with a severe impact on sleep and quality of life that may begin at any age. RLS is most severe in middle-aged or elderly persons, in whom it has a chronic, progressive course. The overall prevalence of RLS for the adult population has been estimated to be about 7.2%, particularly in those of European descent, but the prevalence of the most severe cases (severe symptoms occurring at least two nights a week) is approximately 2.7%
    • For transient insomnia or insomnia of short duration, treatment with sedative-hypnotics (e.g., zolpidem, zolpidem extended release, zolpidem tartrate sublingual tablets, zaleplon, eszopiclone, or low-dose doxepin) or short- or intermediate-acting benzodiazepines (e.g., temazepam), as well as ramelteon, a melatonin receptor (MT1 and MT3) agonist, for a few nights to a few weeks is appropriate.

Bleeding and Transfusion

    • When massive bleeding exists and direct control of the site of bleeding is under way, the decision to transfuse should be based primarily on hemodynamic status rather than on the hemoglobin or hematocrit level. These laboratory values do not reflect acute hemorrhage because there is a time lag before these levels equilibrate from fluid shift between the extravascular and vascular compartments and from administration of IV fluids.
    • The concept of liberal, early use of plasma and platelets developed in large part from the recent US-led military campaigns in Iraq and Afghanistan. Initially in those conflicts, the lack of a reliable supply of blood products near the scene of injury—and platelets especially—led to the use of fresh whole blood transfusion. Although fresh whole blood would be impractical in the civilian setting because of logistical issues and the risk of transmitting transfusion-related infections, the perception of improved outcomes associated with its use prompted military surgeons to advocate 1:1:1 transfusion.
    • Beyond recognition and correction of the underlying problem causing DIC and the associated coagulopathy, the diagnosis of DIC represents something of an academic exercise because there is no specific treatment for the condition. Scoring systems that assess the severity of DIC are most useful for distinguishing DIC from other causes of coagulopathy (e.g., hypothermia, dilution, and drug effects).

Bleeding and Transfusion

    • When massive bleeding exists and direct control of the site of bleeding is under way, the decision to transfuse should be based primarily on hemodynamic status rather than on the hemoglobin or hematocrit level. These laboratory values do not reflect acute hemorrhage because there is a time lag before these levels equilibrate from fluid shift between the extravascular and vascular compartments and from administration of IV fluids.
    • The concept of liberal, early use of plasma and platelets developed in large part from the recent US-led military campaigns in Iraq and Afghanistan. Initially in those conflicts, the lack of a reliable supply of blood products near the scene of injury—and platelets especially—led to the use of fresh whole blood transfusion. Although fresh whole blood would be impractical in the civilian setting because of logistical issues and the risk of transmitting transfusion-related infections, the perception of improved outcomes associated with its use prompted military surgeons to advocate 1:1:1 transfusion.
    • Beyond recognition and correction of the underlying problem causing DIC and the associated coagulopathy, the diagnosis of DIC represents something of an academic exercise because there is no specific treatment for the condition. Scoring systems that assess the severity of DIC are most useful for distinguishing DIC from other causes of coagulopathy (e.g., hypothermia, dilution, and drug effects).

Pancreatitis

    • The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Over the last several decades, mortality related to acute pancreatitis has decreased substantially, which likely reflects improved critical care and better strategies for operative management.
    • Recent guidelines identify the SIRS criteria as the best and most pragmatic predictor of severe acute pancreatitis at admission and at 48 hours. A 1991 consensus committee first coined the term SIRS as the clinical manifestation of the hypermetabolic response to infection or a noninfectious insult. SIRS criteria include (1) temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F); (2) heart rate greater than 90 beats/min; (3) tachypnea with a respiratory rate greater than 20 breaths/min or hyperventilation with arterial carbon dioxide tension (PaCO2) less than 32 mm Hg; and (4) a white blood cell count greater than 12,000/µL or less than 4,000/µL or greater than 10% immature neutrophils (“bands”).
    • The optimal ­strategy for intervention in patients with confirmed infected ­necrotizing pancreatitis is initial image-guided percutaneous retroperitoneal catheter drainage or endoscopic transluminal drainage, followed, when necessary, by minimally invasive endoscopic or surgical necrosectomy. 

Locally Advanced Rectal Cancer

    • Total neoadjuvant therapy (neoadjuvant chemotherapy and chemoradiation prior to total mesorectal excision)
    • Minimally invasive techniques for surgery of rectal cancer (laparoscopy, robotic surgery, and transanal total mesorectal excision)
    • A novel PD-1 blocker, dostarlimab, has shown very promising results in a phase 2 trial, current demonstrating a 100% clinical remission rate; further study is required to ascertain if this result lasts

Locally Advanced Rectal Cancer

    • Total neoadjuvant therapy (neoadjuvant chemotherapy and chemoradiation prior to total mesorectal excision)
    • Minimally invasive techniques for surgery of rectal cancer (laparoscopy, robotic surgery, and transanal total mesorectal excision)
    • A novel PD-1 blocker, dostarlimab, has shown very promising results in a phase 2 trial, current demonstrating a 100% clinical remission rate; further study is required to ascertain if this result lasts
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