Latest Updates

Management of Complicated Gallstone Disease

    • Laparoscopic cholecystectomy is one of the most frequently performed operations in the United States, with nearly 800,000 cholecystectomies performed annually. The laparoscopic cholecystectomy is an intriguing operation because of its perception as a technically simple procedure. 
    • Although the goal is to always obtain the critical view of safety and perform a cholecystectomy, there are instances (increased inflammation, fused structures, and variant anatomy) in which this view cannot safely be obtained. In the setting of chronic inflammation, structures contract and fuse together, often obliterating clear planes between different structures.
    • There are myriad causes of pancreatitis such as alcohol and trauma, but one common cause is gallstones, which is believed to cause up to 60% of the cases of pancreatitis.

Subarachnoid Hemorrhage

    • Computed tomographic angiography (CTA) has the advantage of being noninvasive, but there are very limited data to compare a CTA approach with the current standard diagnostic approach. A methodological review supported CTA in patients presenting within 48 hours of symptoms and with a neurologically intact examination. CTA has not replaced the current approach but has gained more acceptance; its use is center specific and more prevalent in continued management than initial diagnosis. CTA sensitivity decreases with aneurysms less than 4 mm in size and carries the risk of contrast-induced nephropathy, especially if digital subtraction angiography is performed after CTA.
    • Current data suggest that very short courses of antifibrinolytics may reduce rebleeding without causing ischemia. Rapid diagnosis of SAH and early definitive repair probably remain the best strategy for prevention. Fibrinolytics should be used in consultation with the neurosurgeon and may be most beneficial in instances of delayed definitive repair.
    • The mortality from aSAH appears to have declined in industrialized nations over the past 25 years. The case-fatality rate for aSAH, although still high worldwide, appears globally to be minimally on the decline despite significant regional differences in reporting of mortality.

Epilepsy and Related Disorders

    • Brain imaging has made significant progress in recent years and is a cornerstone of diagnosis and characterization of epilepsy.
    • The diagnosis and management of psychogenic non-epileptic seizures has significantly evolved in recent years.
    • Current practice is to use the drug as monotherapy. The dose is progressively increased until seizures are controlled or adverse effects develop. If seizure control cannot be achieved without significant adverse effects, the drug is considered a failure, and a second drug is chosen and the process is repeated. If the second drug fails, either a third monotherapy trial or a combination therapy can be attempte­d. 

Epilepsy and Related Disorders

Barbara Dworetzky, MD, Jong Woo Lee, MD, PhD
    • Brain imaging has made significant progress in recent years and is a cornerstone of diagnosis and characterization of epilepsy.
    • The diagnosis and management of psychogenic non-epileptic seizures has significantly evolved in recent years.
    • Current practice is to use the drug as monotherapy. The dose is progressively increased until seizures are controlled or adverse effects develop. If seizure control cannot be achieved without significant adverse effects, the drug is considered a failure, and a second drug is chosen and the process is repeated. If the second drug fails, either a third monotherapy trial or a combination therapy can be attempte­d. 

Epilepsy and Related Disorders

    • Brain imaging has made significant progress in recent years and is a cornerstone of diagnosis and characterization of epilepsy.
    • The diagnosis and management of psychogenic non-epileptic seizures has significantly evolved in recent years.
    • Current practice is to use the drug as monotherapy. The dose is progressively increased until seizures are controlled or adverse effects develop. If seizure control cannot be achieved without significant adverse effects, the drug is considered a failure, and a second drug is chosen and the process is repeated. If the second drug fails, either a third monotherapy trial or a combination therapy can be attempte­d. 

Subarachnoid Hemorrhage

    • Computed tomographic angiography (CTA) has the advantage of being noninvasive, but there are very limited data to compare a CTA approach with the current standard diagnostic approach. A methodological review supported CTA in patients presenting within 48 hours of symptoms and with a neurologically intact examination. CTA has not replaced the current approach but has gained more acceptance; its use is center specific and more prevalent in continued management than initial diagnosis. CTA sensitivity decreases with aneurysms less than 4 mm in size and carries the risk of contrast-induced nephropathy, especially if digital subtraction angiography is performed after CTA.
    • Current data suggest that very short courses of antifibrinolytics may reduce rebleeding without causing ischemia. Rapid diagnosis of SAH and early definitive repair probably remain the best strategy for prevention. Fibrinolytics should be used in consultation with the neurosurgeon and may be most beneficial in instances of delayed definitive repair.
    • The mortality from aSAH appears to have declined in industrialized nations over the past 25 years. The case-fatality rate for aSAH, although still high worldwide, appears globally to be minimally on the decline despite significant regional differences in reporting of mortality.

Diarrheal Illness

    • Emphasizes bayesian approach to testing and treatment for infectious and noninfectious diarrheal illnesses
    • Identifies and directs readers to reliable online resources that are kept current by trusted entities (e.g., CDC.gov)
    • Encourages the use of smartphone and Web-based tools for calculations rather than providing formulae that lead to mistakes
    • Describes a modern approach to diarrhea in patients with acute exacerbations of chronic conditions, such as HIV, inflammatory bowel disease, and others who may be immunocompromised
    • Provides modern information on symptomatic treatment of diarrhea (including probiotics and traditional modalities), with special attention to contraindications
    • Special focus on diarrhea caused by medications and overdoses
    • Includes a section on natural and human-made disasters, zoonotic infections, and travel medicine that reflects modern practices
    • Provides guidance on reconciling government guidelines and patient safety when in conflict

     

Renal Support Therapy

    • CRRT is indicated to correct metabolic or fluid derangements associated with acute renal failure in hemodynamically unstable patients
    • Continuous venovenous hemofiltration (CVVH) is the most common mode used in surgical intensive care units
    • The right internal jugular vein is the first choice for CRRT catheter access, followed by the femoral vein and the left jugular vein
    • Anticoagulation of the CRRT circuit with citrate has been found to be superior in terms of safety, efficacy, and cost compared to heparin
    • Criteria for terminating CRRT: spontaneous urine output > than 400 mL/day, correction of metabolic derangements, no need for clearance, and stabilization of fluid balance
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