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You get consulted on a 34-year-old with ileocolic Crohn’s disease on Humira. You determine he needs surgery for recurrent partial obstructions. When do you do the surgery? How long should he be off his biologic medication? When to restart it post op? Join Drs. Abelson, Marcello and Aulet as they take us through two articles to help us figure it out!
Learning Objectives:
1.     Describe the complications of biologic medications in the peri-operative period
2.     List the different classifications of medications for Crohn’s disease
3.     Discuss the approach to managing timing of surgery for patients with crohn’s disease
Articles:
Cohen BL, Fleshner P, Kane SV et al. Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intra-abdominal Surgery. Gastroenterology. 2022 Apr 10;S0016-5085(22)00359-6. doi: 10.1053/j.gastro.2022.03.057. Online ahead of print.
Brouquet A, Maggiori L, Zerbib P, Lefevre JH, Denost Q, Germain A, Cotte E, Beyer-Berjot L, Munoz-Bongrand N, Desfourneaux V, Rahili A, Duffas JP, Pautrat K, Denet C, Bridoux V, Meurette G, Faucheron JL, Loriau J, Guillon F, Vicaut E, Benoist S, Panis Y; GETAID chirurgie group. Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort. Ann Surg. 2018 Feb;267(2):221-228. doi: 10.1097/SLA.0000000000002017. PMID: 29300710.
Steele S, et al. The ASCRS Textbook of Colon and Rectal Surgery, fourth ed. 2022.  https://link.springer.com/book/10.1007/978-3-030-66049-9
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Episode Title: Journal Review in Colorectal Surgery: Timing of Biologics and Surgery in the Setting of Crohn’s Disease
Want to learn more about achalasia and its procedural management? Excited about the POEM procedure?  Learn what the current literature says when it comes to recommending POEM or the tried-and-true Heller myotomy from the Swedish Thoracic surgery team.

Learning objectives
–        Review basics of achalasia
–        Discuss the current literature comparing POEM and Heller myotomy with fundoplication
–        Understand the major differences in outcomes for these procedures

Hosts:
Peter White, MD
Megan Lenihan, MD
Brian Louie, MD
Kelly Daus, MD

Referenced Material
Werner YB, Hakanson B, Martinek J, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med. 2019 Dec 5;381(23):2219-2229. doi: 10.1056/NEJMoa1905380. PMID: 31800987.

Gu L, Ouyang Z, Lv L, et al. Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-naïve patients with type II achalasia: a prospective randomized trial. Gastrointest Endosc. 2021 Jun;93(6):1304-1312. doi: 10.1016/j.gie.2020.10.006. Epub 2020 Oct 13. PMID: 33058884.

Shemmeri E, Aye RW, Farivar AS, Bograd AJ, Louie BE. Use of a report card to evaluate outcomes of achalasia surgery: beyond the Eckardt score. Surg Endosc. 2020 Apr;34(4):1856-1862. doi: 10.1007/s00464-019-06952-2. Epub 2019 Jul 8. PMID: 31286258.

Mota RCL, de Moura EGH, de Moura DTH, Bernardo WM, de Moura ETH, Brunaldi VO, Sakai P, Thompson CC. Risk factors for gastroesophageal reflux after POEM for achalasia: a systematic review and meta-analysis. Surg Endosc. 2021 Jan;35(1):383-397. doi: 10.1007/s00464-020-07412-y. Epub 2020 Mar 23. PMID: 32206921.

McKay SC, Dunst CM, Sharata AM, Fletcher R, Reavis KM, Bradley DD, DeMeester SR, Müller D, Parker B, Swanström LL. POEM: clinical outcomes beyond 5 years. Surg Endosc. 2021 Oct;35(10):5709-5716. doi: 10.1007/s00464-020-08031-3. Epub 2021 Jan 4. PMID: 33398572.

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The utilization of point-of-care ultrasound and other non-invasive cardiac output monitoring technologies varies because of knowledge, resource availability and cultural practices. In this  Clinical Challenge in Surgery episode from the Surgical Critical Care team at Behind the Knife, we provide a brief history of the use of cardiac-output monitoring in the ICU, introduce a few clinical scenarios in the context of point of care ultra-sound and other less-invasive cardiac-output monitoring technologies.
Learning Objectives: 
In this episode, we review the historical uses of central venous pressure monitoring, pulmonary-artery catheters and the more frequently utilized point-of-care-ultrasound (or POCUS) in managing complex ICU patients. We review the outcomes behind these technologies, describe the views and utility of POCUS, and introduce less-invasive or completely non-invasive ways to measure cardiac-output monitoring. 

Hosts:

Brittany Bankhead, MD, MS (@BBankheadMD) is an Assistant Professor of Surgery at Texas Tech University Health Sciences Center.
Ryan Dumas, MD, FACS (@PMH_Trauma_RPD) is an Assistant Professor of Surgery at the University of Southwestern Medical Center and Parkland Memorial Hospital.
Caroline Park, MD, MPH, FACS (@CPark_MD) is an Assistant Professor of Surgery at the University of Southwestern Medical Center and Parkland Memorial Hospital.
Links to Papers Referenced in this Episode:
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006 May 25;354(21):2213-24. doi: 10.1056/NEJMoa061895. Epub 2006 May 21. PMID: 16714768.
Yildizdas D, Aslan N. Ultrasonographic inferior vena cava collapsibility and distensibility indices for detecting the volume status of critically ill pediatric patients. J Ultrason. 2020 Nov;20(82):e205-e209. doi: 10.15557/JoU.2020.0034. Epub 2020 Sep 28. PMID: 33365158; PMCID: PMC7705480.
Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990 Aug 15;66(4):493-6. doi: 10.1016/0002-9149(90)90711-9. PMID: 2386120.
Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013 Jul;41(7):1774-81. doi: 10.1097/CCM.0b013e31828a25fd. PMID: 23774337.
Acknowledgements: 
We would like to acknowledge Dr. Hassan Mashbari and the Department of Surgical Critical Care and Anesthesia at the Massachusetts General Hospital and Dr. Christopher Choi and the Department of Anesthesiology at the University of Texas Southwestern for their ultra-sound video contributions.

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Kevin interviews Dr. Adam Tanious a Vascular Surgeon at MUSC about the ins and outs of managing student debt.
Adam is passionate about personal finance and student debt and is happy to discuss further with our listeners, please reach out at [email protected] .
Want to learn more at student debt? Check out White Coat Investor resources on student debt. 
https://www.whitecoatinvestor.com/ultimate-guide-to-student-loan-debt-management-for-doctors/

Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

It’s 1AM and the emergency department is calling about *insert terrifying foregut problem you haven’t seen since you were an intern here* and you wake up in a cold sweat to realize it was just a dream…this time. Tune in to this clinical challenge episode for some tips and tricks for managing foregut nightmares with Drs. Mike Weykamp, Nicole White, Andrew Wright, and Nick Cetrulo from the University of Washington’s Minimally Invasive Surgery team. 

Referenced articles and videos: 

1.     Rodriguez-Garcia HA, Wright AS, Yates RB. Managing obstructive gastric volvulus: challenges and solutions. Open Access Surgery. 2017
2.     Yates RB. Giant PEH: Management Principles for Unique Clinical Circumstances. 2017 SAGES Annual Meeting. Houston, TX. 2017
3.     Millet I, Orliac C, Alili C, Guillon F, Taourel P. Computed tomography findings of acute gastric volvulus. Eur Radiol. 2014. 
4.     Mazaheri P, Ballard DH, Neal KA, Raptis DA, Shetty AS, Raptis CA, Mellnick VM. CT of Gastric Volvulus: Interobserver Reliability, Radiologists’ Accuracy, and Imaging Findings. AJR Am J Roentgenol. 2019. 
5.     Barmparas G, Alhaj Saleh A, Huang R, Eaton BC, Bruns BR, Raines A, Bryant C, Crane CE, Scherer EP, Schroeppel TJ, Moskowitz E, Regner JL, Frazee R, Campion EM, Bartley M, Mortus JR, Ward J, Margulies DR, Dissanaike S. Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer. Trauma Surg Acute Care Open. 2021.
6.     Horn CB, Coleoglou Centeno AA, Rasane RK, Aldana JA, Fiore NB, Zhang Q, Torres M, Mazuski JE, Ilahi ON, Punch LJ, Bochicchio GV. Pre-Operative Anti-Fungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers. Surg Infect (Larchmt). 2018.
7.     Wee JO. Gastric Volvulus in Adults. In: UpToDate, Louie BE (Ed), UpToDate, Waltham, MA. (Accessed on May 15, 2022.)
https://www.uptodate.com/contents/gastric-volvulus-in-adults

Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

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