REBOA May Be Superior to Resuscitative Thoracotomy for Managing Non-Compressable Hemorrhage in Abdomen
Brenner M, Zakhary B, Coimbra R, et al. Balloon Rises Above: REBOA at Zone 1 May be Superior to Resuscitative Thoracotomy. J Am Coll Surg. 2023, in press.
Retrograde endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving intervention for management of non-compressible hemorrhage from blunt and penetrating injuries of the abdomen. This study reported an analysis of data from the AORTA database that focused on outcomes of REBOA versus resuscitative thoracotomy for hemorrhage control during the early phase of resuscitation.
Patients who were treated with REBOA (n = 531) were compared with patients treated with resuscitative thoracotomy (n = 1,603); propensity score matching was used to improve accuracy of the comparison.
Mortality risk for patients with noncompressible abdominal hemorrhage and severe hemorrhagic shock was significantly lower with REBOA use; this was true for all injury patterns. REBOA aortic occlusion of 30 minutes of less was associated with the best outcomes. Additional analysis confirmed that REBOA was safe to use in patients with traumatic brain injury.
The authors concluded that REBOA is the preferable aortic occlusion approach for initial resuscitation of patients with noncompressible abdominal hemorrhage.
Laparoscopic Cholecystectomy Is Safer and More Effective than Robotic-Assisted, Study Suggests
Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg. 2023;158(12):1303-1310.
Editorial: Feldman LS, Brunt LM. New Technology and Bile Duct Injuries. JAMA Surg. 2023;158(12):1311.
Robotic-assisted minimally invasive techniques have been shown to be equivalent or superior to other approaches for procedures such as prostatectomy. Robotic-assisted approaches are increasingly used for cholecystectomy and hernia repair, but high-quality data showing equivalent or superior outcomes compared with laparoscopic techniques has not been available.
This study reported an analysis of outcomes data for patients listed in the Medicare Claims Database over the interval 2010–2019 (n = 1,026,088) that sought to compare outcomes of laparoscopic cholecystectomy with robotic-assisted cholecystectomy. Outcomes were recorded out to 12 months postoperatively; outcomes of interest included bile duct injury, operative, endoscopic, or radiologic biliary interventions, and rates of postoperative complications.
Over the course of the study interval, use of robotic-assisted cholecystectomy increased 37-fold. The data analysis showed that robotic-assisted cholecystectomy was associated with an increased risk for bile duct injury (0.7% versus 0.2%), overall rates of postoperative biliary interventions were significantly higher in patients undergoing robotic-assisted cholecystectomy.
The authors concluded that given the safety and effectiveness of laparoscopic cholecystectomy, decisions to use robotic-assisted procedures for cholecystectomy should be reconsidered.
In the editorial that accompanied the article, Liane S. Feldman, MD, and Michael Brunt, MD, emphasized that the principles of “safe cholecystectomy” (confirmation of anatomy and use of bail-out procedures when the hepatocystic triangle is inflamed) should be used regardless of the operative approach. They noted that use of intraoperative cholangiography and near-infrared imaging technology are potentially beneficial adjuncts to robotic-assisted cholecystectomy.
