BOOK REVIEW The Wise Scalpel: Tips & Traps in Liver Gallbladder & Pancreatic Surgery

Review

This useful overview of HRB surgery imparts passion and wisdom, writes Douglas C Morran

The Wise Scalpel: Tips & Traps in Liver, Gallbladder & Pancreatic Surgery

By Francis R Sutherland and Chad G Ball

£42.99 (TFM Publishing)

Written by two expert hepato-pancreato-biliary (HPB) surgeons with a North American practice, The Wise Scalpel: Tips & Traps in Liver Gallbladder & Pancreatic Surgery is the opening book in a new series.

It uses a modern and clear style, where short paragraphs of explanation and example are used, and are summarised throughout the text by bullet-point ‘wisdoms’. These convey a wide range of lessons – some evidently hard-won by the authors – and are collated at the end of each chapter for emphasis and consolidation.

This is not a state-of-the-art description of the field, nor does it focus on the evidence base or technical aspects of modern HPB surgery. Instead it tries to explain the principles and the strategic approach of the specialty and outlines pitfalls encountered by the authors in their practice.

The opening chapters explain the present landscape of modern HPB surgery by recounting some of the historical context through which it developed. What the authors choose to describe in their opening chapters as the craft of modern HPB surgery is also understood as nontechnical skills, and their placement of these elements of modern practice in the forefront of their book demonstrates how important they believe these concepts are to safe surgical practice. These beliefs are becoming more widely shared across all medical fields, but the emphasis is still important. The organ- and operationspecific chapters read as though they are offering mentorship to junior colleagues with an interest in HPB surgery at all levels of experience. They describe a variety of information relating to anatomic interest, the breadth of technical challenges and the delicacy of the work, and ultimately convey some of the passion the authors have for their field. The ‘wisdoms’ they offer come across exactly as intended, not as evidencebased statements, but as advice from experts who have gained experience from salvaging not only their own difficult situations, but also those of their colleagues. They avoid and explicitly advise against unkind judgements, advocating a more supportive approach. Aggressive simplicity is the intent and there is discouragement of heroic or high-risk manoeuvres. The largest part of the book focuses predominantly on elective procedures, which are solely practised by HPB subspecialists so is of most relevance to those recently qualified or intending to qualify in this field.

The topics that will generate the widest interest among general surgeons will be difficult gallstone disease and HPB trauma. The approach to gallstone disease differs globally and the obvious omission in this text is the lack of description of laparoscopic approaches to common bile duct stones, either direct or trans-cystically, which is in contrast to the careful consideration given to approaches to the difficult cholecystectomy.

The management of HPB trauma is largely absent, which seems due to the role of the ‘trauma surgeon’ as a distinct specialisation within North American practice. This is at odds with the majority of UK and global practice, where the general surgical on-call remains part of the role of most GI surgeons, so more detail would have broadened the appeal of the book. Nonetheless, The Wise Scalpel is a useful resource for the right surgeon. It is easy to

They avoid and read, and offers condensed explicitly advise experience and insight into the thought processes of the against unkind judgements '' authors and how they approach their practice. Some deeper understanding can also be gained on rereading and I suspect returning to the book over time will offer further benefits as the reader becomes more experienced in their field.

Douglas C Morran

Consultant Upper GI Surgeon, NHS Ayrshire and Arran

IN BRIEF

The latest guidance, articles and studies

Tranexamic acid for safer surgery: the time is now

This article summarises the evidence that tranexamic acid substantially reduces the risk of surgical bleeding, and highlights the importance of this to anaesthetists, surgeons, patients and healthcare systems. It proposes that tranexamic acid use is considered in all adults having in-patient surgery and that “consideration of tranexamic acid use” is included in the Surgical Safety Checklist of all hospitals. The authors conclude that wider use of tranexamic acid will improve surgical safety, reduce unnecessary blood use and release funds for other purposes within the healthcare system.

UK Royal Colleges Tranexamic Acid in Surgery Implementation Group. Br J Surg 2022; doi.org/10.1093/bjs/znac252

Use of cold-stored whole blood is associated with improved mortality in resuscitation of major bleeding

This observational study looked at outcomes for 1,623 trauma patients whose resuscitation included whole blood (74%) compared with blood-component therapy (24%). Patients who received whole blood had a higher shock index, more comorbidities and more blunt trauma. Whole-blood patients were 9% less likely to experience bleeding complications and were 48% less likely to die. Authors concluded that the study supports the use of whole blood in the resuscitation of trauma patients.

Hazelton JP, Ssentongo A, Oh JS et al. Ann Surg 2022; 276(4): 579-588

Short-term risk prediction after major lower limb amputation: PERCEIVE study

This multicentre study of 537 patients undergoing major lower limb amputation (MLLA) compared the accuracy of preoperative predictions of 30-day mortality, morbidity and MLLA revision by surgeons and anaesthetists with relevant risk-prediction tools. Clinicians predicted mortality and MLLA revision well, but were poor at predicting morbidity. They overpredicted the risk of all outcomes. Most short-term riskprediction tools had poorer discrimination or calibration than clinicians. The best method of predicting mortality was a statistical tool that incorporated clinician estimation.

Carotid

Wider use of tranexamic acid can bring several important benefits, such as endarterectomy, stenting or best reduced blood use medical treatment

alone for asymptomatic carotid artery stenosis

This multicentre, randomised controlled trial evaluated 513 patients with asymptomatic carotid artery stenosis (of at least 70%). Forty per cent were allocated to carotid endarterectomy (CEA) plus best medical treatment (BMT), 38% to carotid artery angioplasty with stenting (CAS) plus BMT, and 22% to BMT alone. The incidence of stroke or death from any cause within 30 days or ipsilateral ischaemic stroke within five years was 2.5% with CEA plus BMT, 4.4% with CAS plus BMT, and 3.1% with BMT alone. Authors concluded that interventional treatments were not found to be superior to BMT alone but, because of the small sample size, results should be interpreted with caution.

Gwilym BL, Pallmann P, Waldron CA et al. Br J Sur; doi.org/10.1093/bjs/znac309

Timing of a major operative intervention after a positive COVID-19 test affects postoperative mortality

This study sought to determine the safest time after COVID-19 for patients to undergo high-risk operations. Between January 2020 and May 2021, 938 COVID-19-positive cases were matched to 7,235 controls. Ninety-day mortality was similar if surgery was nine weeks or longer after a positive test, but higher when the operation was within seven to eight weeks, five to six weeks, three to four weeks, and one to two weeks. Within eight weeks from diagnosis, 90-day mortality was 16.6% versus 5.8% for the controls. Authors concluded patients undergoing major operations within eight weeks after a positive test have higher postoperative mortality. Reiff T, Eckstein H-H, Mansmann U et al. Lancet Neurol 2022; 21(10): 877-888

Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England

This study from the National Joint Registry on primary elective hip (696,504) and knee (833,745) arthroplasties evaluated comorbidities between 2005 and 2018. During this period the proportion of elective patients with one or more comorbidity at the time of their operation increased (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: COPD, diabetes, myocardial infarction and renal disease. Authors concluded that there were significant increases in the number of comorbidities and future research should explore the impact of this on preoperative and postoperative care.