Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Serial Venous Ultrasound Exams Are Potentially Safe Approach for Patients with Below-Knee DVT
Kay AB, Morris DS, Woller SC, Collingridge DS, Majercik S. Below the Knee, Let It Be: Management of Calf DVT in Hospitalized Trauma Patients. Am J Surg. 2023.
This article reported findings from a retrospective secondary analysis of data from a prospective randomized trial with the aim to determine the efficacy and safety of observation with serial lower extremity venous ultrasound examinations for patients diagnosed with isolated, below-knee deep vein thrombosis (DVT). Below-knee thromboses were mostly in the soleal, gastrocnemius, and posterior tibial veins.
The primary outcomes of interest were the rates of progression to above-knee thrombosis, pulmonary embolus and post-thrombotic syndrome in the observation group (n = 136) compared to patients initially diagnosed with above-knee thrombosis (n = 23). Progression from below-knee thrombosis to above-knee thrombosis was documented in seven patients (6.9%); four patients were diagnosed with pulmonary embolus. Risk factors for progression to above-knee thrombosis or pulmonary embolus were greater injury severity, longer delay prior to beginning thromboprophylaxis, and longer length of hospital stay.
A significant limitation of this study acknowledged by the authors was the small sample size. The authors concluded that these data suggest that observation with serial venous ultrasound examinations is a potentially safe approach for patients with below-knee venous thrombosis.
Surgeon Pays Tribute to Iconic Acute Abdomen Book
Schwaitzberg S. Celebrating 100 years of Cope’s Early Diagnosis of the Acute Abdomen. Surgery. 2023;174(4): 874-879.
For more than a century and through 22 revisions, The Early Diagnosis of the Acute Abdomen by Sir Vincent Zachary Cope, MD, MS, FRCS, has been an enormously valuable reference for surgeons in training and in practice. Present and past editions are currently found in personal libraries, white coat pockets, and night-call rooms; they are still read and referenced to facilitate diagnosis of abdominal conditions in surgical patients.
Steven Schwaitzberg, MD, FACS, reviewed every edition of the book, later authored by Willam Silen, MD, FACS, and used this knowledge as the foundation for the perspectives offered.
The first issue was published in 1921 and the final issue appeared in 2010. Each of the issues stressed the importance of history and physical examination as the primary means of diagnosing surgical disorders of the abdomen. The main diagnostic adjuncts referenced in early editions of the book were focused laboratory studies; plain radiographs were first introduced in the seventh edition (1935) and barium studies to facilitate the diagnosis of colonic obstruction were first referenced in the ninth edition.
After Dr. Silen took over as primary author of the revisions beginning in 1979, he added discussions of conditions such as inflammatory bowel disease; cross-sectional imaging was added to the diagnostic approaches in 1995. Dr. Silen reminded readers that computed tomography imaging was not without risks such as clinical deterioration during the imaging examination. Discussions of postoperative complications leading to acute abdominal symptoms were added by Dr. Silen in his revision of the 15th edition.
Dr. Schwaitzberg has provided an elegant, clearly written tribute reminding surgeons that The Early Diagnosis of the Acute Abdomen remains a critically important reference work that emphasizes of the central role of clinical diagnostic skills in the care of surgical patients. Surgeons are encouraged to review this valuable article.
