The edition · General Surgery
Gastrojejunostomy configuration did not change gastric emptying after Whipple
The IPAD trial found side-to-side and end-to-side anastomoses performed alike. Plus a resource-sensitive HCC guideline, and what bailout looks like in robotic cholecystectomy.
The edition in brief
The IPAD randomised trial in 158 patients at two French pancreatic centres found delayed gastric emptying in 38.0% after side-to-side and 30.4% after end-to-side gastrojejunostomy following pancreatoduodenectomy, a difference compatible with chance (RR 1.25, 95% CI 0.81 to 1.94), with similar fistula, nutrition and quality-of-life outcomes. Surgeons can use the configuration they do best. The IHPBA has issued an HCC guideline for resource-constrained settings: ultrasound-led diagnosis backed by cross-sectional imaging, biopsy not mandatory, resection for single tumours or up to three small lesions with preserved liver function, ethanol injection where thermal ablation is unavailable, and atezolizumab-bevacizumab first line with sorafenib or lenvatinib as alternatives. A US registry of 384,617 emergency cholecystectomies found robotic surgery carried slightly more bailout procedures but similar bile duct injury and higher one-year cost. A six-centre cohort found less objective hiatal hernia recurrence at three years after magnetic sphincter augmentation than fundoplication (6.1% vs 21.0%), with no difference in symptoms. A single-centre Korean cohort found no mortality difference between a 1 g tranexamic acid bolus alone and bolus plus infusion. The pearl covers the critical view of safety and when to bail out.
An HCC guideline written for resource-constrained hospitals
Use this guideline to plan curative HCC treatment with the tools you have, rather than defaulting to supportive care.
Robotic cholecystectomy for acute cholecystitis: more bailouts, higher cost
Do not expect a robot to reduce bile duct injury in acute cholecystitis; the bailout decision matters more than the platform.
Hiatal hernia recurrence after magnetic sphincter augmentation
Fundoplication remains a sound choice; consider magnetic augmentation where available, with recurrence as one factor among several.
Tranexamic acid in trauma: bolus alone versus bolus plus infusion
Keep the full CRASH-2 regimen, and make sure the bolus is given within three hours above all.
The critical view of safety, and when to stop chasing it
Clip nothing until all three elements of the critical view are seen; otherwise bail out.
Side-to-side or end-to-side gastrojejunostomy after Whipple: no difference
Choose gastrojejunostomy configuration after pancreatoduodenectomy by familiarity, not to prevent delayed gastric emptying.
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