In this episode our team dives into the diagnosis, workup and management of malignant pleural mesothelioma. Listen as we debate the pros and cons of surgical management of this disease with extrapleural pneumonectomy versus pleural decortication and discuss the nuances of choosing the right approach for the right patient.



Learning Objectives

- Describe the workup and staging of a patient with malignant pleural mesothelioma

- List the subtypes of malignant pleural mesothelioma, characteristics of resectable disease, and patient factors which impact surgical candidacy 

- Describe the approach to an extrapleural pneumonectomy and pleural decortication

- Analyze which surgical approach is best for various subsets of patients

- Describe the adjuvant treatment for malignant pleural mesothelioma



Hosts

Kelly Daus MD, Adam Bograd MD, Peter White MD, Brian Louie MD



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Clinical Challenges in Thoracic Surgery: Malignant Pleural Mesothelioma

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How is each release of the TAR contributing to the final tension on the anterior and posterior fascia? Join Drs. Michael Rosen, Benjamin T. Miller, Sara Maskal, and Ryan C. Ellis as they discuss their group’s recent cohort study of tensiometry in 100 TARs. 



Hosts: 

- Michael Rosen, Cleveland Clinic

- Benjamin T. Miller, Cleveland Clinic

- Sara Maskal, Cleveland Clinic

- Ryan C. Ellis, Cleveland Clinic, @ryanellismd



Learning objectives: 

- Review the steps of a TAR

- Understand the changes in tension on the anterior and posterior fascia with each step of the TAR

- Think about the application this data has to similar operations



References: 



Miller BT, Ellis RC, Petro CC, Krpata DM, Prabhu AS, Beffa LRA, Huang LC, Tu C, Rosen MJ. Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release. JAMA Surg. 2023 Dec 1;158(12):1321-1326. doi: 10.1001/jamasurg.2023.4847. PMID: 37792324; PMCID: PMC10551814. https://pubmed.ncbi.nlm.nih.gov/37792324/



Miller BT, Ellis RC, Walsh RM, Joyce D, Simon R, Almassi N, Lee B, DeBernardo R, Steele S, Haywood S, Beffa L, Tu C, Rosen MJ. Physiologic tension of the abdominal wall. Surg Endosc. 2023 Dec;37(12):9347-9350. doi: 10.1007/s00464-023-10346-w. Epub 2023 Aug 28. PMID: 37640951. https://pubmed.ncbi.nlm.nih.gov/37640951/



Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990 Sep;86(3):519-26. doi: 10.1097/00006534-199009000-00023. PMID: 2143588. https://pubmed.ncbi.nlm.nih.gov/2143588/



Hope WW, Williams ZF, Rawles JW 3rd, Hooks WB 3rd, Clancy TV, Eckhauser FE. Rationale and Technique for Measuring Abdominal Wall Tension in Hernia Repair. Am Surg. 2018 Sep 1;84(9):1446-1449. PMID: 30268173. https://pubmed.ncbi.nlm.nih.gov/30268173/



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Journal Review in Hernia Surgery: Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release

Welcome to Humanism in Surgery, a new series where we take a deep dive into the extremes of humanity within the field of surgery. As surgeons, there are times when we feel deeply human and times when we feel we have lost our humanity. These experiences impact us immensely and shape our careers in important ways. It's time these stories are told! For those of you who are fans of NPR, think of this as Story Core for surgery. 



Today, Dr. Patrick Georgoff is joined by Dr. Tamara Fitzgerald, Associate Professor of Pediatric Surgery at Duke University, and Dr. Ted Pappas, Professor of Surgery and Master Surgeon at Duke University. 



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HuMaNiSm + Surgery # 1

A patient with a large TBSA burn injury presents to a local emergency department and you are the only surgeon on duty that evening. With snow covered roads and poor visibility, the patient requires initial stabilization prior to transfer to the regional burn center. You are faced with some difficult clinical decisions as you begin their resuscitation. Join Drs. Tam Pham, Rob Cartotto, Julie Rizzo, Alex Morzycki and Jamie Oh as they discuss the clinical challenges in initiating burn resuscitation, pitfalls in long-distance transport, and more. 



Hosts:

·       Dr. Tam Pham: UW Medicine Regional Burn Center



·       Dr. Robert Cartotto: University of Toronto, Ross Tilley Burn Centre 



·       Dr. Julie Rizzo: Brooke Army Medical Center 



·       Dr. Alex Morzycki: UW Medicine Regional Burn Center



·       Dr. Jamie Oh: UW Medicine Regional Burn Center



Learning Objectives:

·       Describe initial fluid strategies, including the recommendations of the Advanced Burn Life Support (ABLS) course, traditional resuscitation formulas, and the Rule of 10.  



·       Describe logistical and medical challenges of long-distance transport to a regional burn center.



·       Understand recent advances learned from recent conflicts in military burn casualty care. 



·       List options for intravenous access. 



·       Understand endpoints of resuscitation, including adjuncts which may help guide fluid titration. 





1.     Cartotto R, Johnson LS, Savetamal A, et al. American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation. J Burn Care Res 2023



https://pubmed.ncbi.nlm.nih.gov/38051821/



2.     Renz EM, Cancio LC, Barillo DJ, et al. Long-Range Transport of War-Related Burn Casualties. J Trauma 2008 https://pubmed.ncbi.nlm.nih.gov/18376156/



3.     Adibfar A, Camacho F, Rogers AD, Cartotto R. The Use of Vasopressors During Acute Burn Resuscitation. Burns 2021 https://pubmed.ncbi.nlm.nih.gov/33293152/



4.     Chung KK, Wolf SE, Cancio LC, et al. Resuscitaiton of Severely Burned Military Casualties: Fluid Begets More Fluid. J Trauma 2009 https://pubmed.ncbi.nlm.nih.gov/19667873/



5.     Chung KK, Salinas J, Renz EM, et al. Simple Derivation of the Initial Fluid Rate for the Resuscitation of Severely Burned Adult Combat Casualties: in Silico Validation of the Rule of 10, J Trauma 2009 https://pubmed.ncbi.nlm.nih.gov/20622619/



Joint Trauma System Clinical Practice Guideline (CPG)-Burn Care, updated 2022 



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Clinical Challenges in Burn Surgery: Burn Resuscitation - Getting Things Started

Your patient was in a terrible car crash and is currently intubated with multiple traumatic injuries that will need surgery. Family has just arrived and all they’ve heard is that he has a broken leg. How do you share this serious news with family? What do you do when they become angry, cry or bombard you with questions that you don’t have answers to? Join the surgical palliative care team from the University of Washington as we role play a difficult conversation with a standardized patient. We will identify common challenges that arise and discuss key skills to navigate these situations.



Hosts: 



Dr. Katie O’Connell (@katmo15) is an assistant professor of surgery at the University of Washington. She is a trauma surgeon, palliative care physician, director of surgical palliative care, and founder of the Advance Care Planning for Surgery clinic at Harborview Medical Center, Seattle, WA.



Dr. Ali Haruta is a PGY7 current palliative care fellow at the University of Washington, formerly a UW general surgery resident and Parkland trauma/critical care fellow. 



Dr. Lindsay Dickerson (@lindsdickerson1) is a PGY5 general surgery resident and current surgical oncology research fellow at the University of Washington.



Dr. Virginia Wang is a PGY2 general surgery resident at the University of Washington.



Learning Objectives:



·      Identify common pitfalls encountered during difficult conversations

·      Learn how to synthesize complex medical information and construct a succinct headline statement to deliver a digestible take-home message

·      Develop skills to respond to emotional cues using empathetic statements



References:



·      “Responding to Emotion.” Vitaltalk. Accessed March 4, 2024. https://www.vitaltalk.org/guides/responding-to-emotion-respecting/

·      “Serious News.” Vitaltalk. Accessed March 4, 2024. https://www.vitaltalk.org/guides/serious-news/



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Clinical Challenges in Surgical Palliative Care: Communication Skills for Difficult Conversations

Circulating tumor DNA, more commonly referred to as ctDNA, has emerged as an attractive and potentially highly sensitive biomarker for patients with colorectal cancer. But what exactly is ctDNA, does it have any prognostic value for patients with colorectal liver metastasis, and how can it be incorporated into the management of said patients? In this episode from the HPB team at Behind the Knife, listen in on the discussion about ctDNA and its role in the perioperative management of colorectal liver metastasis.  



Hosts

Anish J. Jain MD (@anishjayjain) is a T32 Research Fellow at the University of Texas MD Anderson Cancer Center within the Department of Surgical Oncology.



Timothy E. Newhook MD, FACS (@timnewhook19) is an Assistant Professor within the Department of Surgical Oncology. He is also the associate program director of the HPB fellowship at the University of Texas MD Anderson Cancer Center. 



Jean-Nicolas Vauthey MD, FACS (@VautheyMD) is Professor of Surgery and Chief of the HPB Section, as well as the Dallas/Fort Worth Living Legend Chair of Cancer Research in the Department of Surgical Oncology at The University of Texas MD Anderson Cancer Center



Learning Objectives:

-Develop an understanding of what circulating tumor DNA (ctDNA) is. 

-Develop an understanding of what makes ctDNA unique from other “tumor markers” like CEA.

-Develop an understanding of the prognostic value of ctDNA for colorectal liver metastasis (CRLM). 

-Develop an understanding of the current role of ctDNA in the perioperative treatment of patients with CRLM.

-Develop an understanding of how ctDNA can be incorporated into future treatment algorithms for patients undergoing hepatic resection for CRLM.



Papers Referenced (in the order they were mentioned in the episode):



1)    Newhook TE, Overman MJ, Chun YS, et al. Prospective Study of Perioperative Circulating Tumor DNA Dynamics in Patients Undergoing Hepatectomy for Colorectal Liver Metastases. Ann Surg. 2023;277(5):813-820.

https://pubmed.ncbi.nlm.nih.gov/35797554/



2)    Nishioka Y, Chun YS, Overman MJ, et al. Effect of Co-mutation of RAS and TP53 on Postoperative ctDNA Detection and Early Recurrence after Hepatectomy for Colorectal Liver Metastases. J Am Coll Surg. 2022;234(4):474-483.

https://pubmed.ncbi.nlm.nih.gov/35290266/



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Clinical Challenges in Thoracic Surgery: Malignant Pleural Mesothelioma

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