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Recommended Reading lists have been over the years among the most popular features in this publication. It is therefore fitting that for this last issue of ACS Surgery News, we have once again imposed upon our Editorial Advisory Board to come up with their choice of the most important studies published in 2018. They were asked to choose a few studies that they consider most significant in their subspecialties and to explain why these studies should matter to all surgeons.
Some editorial advisers for some publications fill honorary positions with no real responsibility or work involved. Not so for the Editorial Advisory Board of ACS Surgery News. Each member provided a steady stream of commentaries, recommendations, and advice. The publication and the managing editor would have been lost without their kind and willing assistance. In their busy professional lives, they somehow found the time to contribute their expertise to assist their colleagues and their profession. We all owe them a debt of gratitude for their many years of service.
We hope our readers will find the list and the comments of interest.
Otolaryngology
St. Laurent J et al. HPV vaccination and the effects on rates of HPV-related cancers. Curr Probl Cancer 2018; https://doi.org/10.1016/j.currproblcancer.2018.06.004
As a head and neck surgeon over the past 30+ years, I have seen the dramaticrise of one form of HPV-related cancer in the United States, namely, HPV-associated oropharyngeal cancer. This is a true epidemic. It is also a cancer that may well be preventable through vaccination. We have slowly made progress over the past 4 decades in reducing the number of tobacco- and alcohol-related cancers. Here is another cancer that truly falls within the category of a public health problem for which public health solution of vaccination is clearly the most rational approach. Everyone should be aware of these virally induced cancers and what can be done to prevent them. This article presents the “state of the art” knowledge about these cancers and what we can hopefully accomplish through worldwide public health initiatives.
Mark C. Weissler, MD, FACS
Palliative Care
Kopecky KE et al. Third-year medical students’ reactions to surgical patients in pain: Doubt, distress, and depersonalization. J Pain and Symptom Manage. 2018;56(5):719-26.
This insightful study done by surgeons, two of them possessing palliative care and bioethics expertise, is a qualitative analysis of the content of 341 essays written by third-year medical students who described their experiences with surgical patients in pain. Students found it difficult to reconcile patient suffering with the therapeutic objective of treatment. As a result they learned constrained empathy and preference for technical solutions and because they feared an empathic response to pain might compromise the fortitude and efficiency required to be a doctor they pursued strategies to distance themselves from these feelings. The authors note, “Although doctors frequently interact with patients who have serious emotional and physical pain, few have received formal instruction on how to attend to these needs or developed a personal approach to cope with the tragedy of patient illness. Instead, the physician’s response to patients in pain is learned passively and perpetuated through generations. Students now seek to suppress empathy to get the job done. These observations have important implications for physicians, patients, and educators.” For me the study is like a parachute flare illuminating the landscape of early surgical educational experience during which the seeds for future problems such as lost patient trust and burnout are sown. It offers the hope that structured introspective activities may mitigate this.
Su A et al. Beyond pain: Nurses’ assessment of patient suffering, dignity, and dying in the intensive care unit. J Pain Symptom Manage. 2018;55:1591-98.
After reading this sobering study, my reaction was, “If the gold rusts what will happen to the iron?” In this study using chart abstraction, nurses caring for 200 patients in a tertiary care cardiac ICU and a surgical ICU were interviewed about their assessment and perception of the physical and psychosocial dimensions of ICU patients’ experiences in their final week of life. The authors note that nursing symptom assessments have been previously shown to be highly reliable and end-of-life comfort and dignity have been shown to be compatible with ICU level of care. Despite this and the availability of extensive interdisciplinary support from palliative care teams, chaplains, and social workers, dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. The study found that attention to symptoms such as dyspnea and edema might improve the quality of death in the ICU. It is small wonder that moral fatigue and burnout have become prevalent themes of ICU caring.
Balboni T et al. The spiritual event of serious illness. J Pain Symptom Manage. 2018;56(5):816-22.
An ashen-faced dear friend gently reminded me as he was hemorrhaging from an advanced gastric cancer, “Geoff, lets make this a spiritual event, not a medical one.” This paper conjured up this memory with the thoughtful, in-depth account and analysis of patients’ experiences and attitudes that shaped the authors concept of illness as a spiritual event. The idea of spirituality as a basic component of consciousness, especially as it relates to suffering, has been present from the very beginning of modern palliative care and can be traced back to the concept of “total pain” introduced by Dame Cicely Saunders in 1963. The capacity to reframe biophysical calamity as spiritual opportunity is the signature of the most skilled and adroit supportive care we can offer our patients and their families.
Geoffrey P. Dunn, MD, FACS
Colorectal Surgery
Cercek A et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol. 2018;4(6):e180071. doi:10.1001/jamaoncol.2018.0071.
This moderate sized retrospective study demonstrates a single-institution’s experience with total neoadjuvant therapy (TNT) with chemoradiation and chemotherapy as opposed to traditional chemoradiation, surgery, and chemotherapy in patients with locally advanced rectal cancer. They demonstrate equivalent or potentially better outcomes including better complete response rate – 36% versus 21% and rates of chemotherapy completion. While further studies are needed to understand long term outcomes, this study support the use of TNT for locally advanced rectal cancer as now supported by the National Comprehensive Cancer Network guidelines.
Brouquet A et al. Anti-TNF therapy is associated with an increased risk of postoperative morbidity after surgery for ileocolonic Crohn disease: Results of a prospective nationwide cohort. Ann Surg. 2018 Feb;267(2):221-228. doi: 10.1097/SLA.0000000000002017.
This large prospective study of almost 600 consecutive Crohn’s disease patients with surgery at 19 French specialty centers demonstrates that anti-TNF therapy less than 3 months prior to ileocolic surgery to be an independent risk factor of the overall postoperative morbidity, preoperative hemoglobin less than10 g/dL, operative time more than180 min, and recurrent Crohn’s disease, as well as a higher risk of overall and intra-abdominal septic postoperative morbidities.
Howard R et al. Taking control of your surgery: Impact of a prehabilitation program on major abdominal surgery. J Am Coll Surg. 2018 Oct 22; https://doi.org/10.1016/j.jamcollsurg.2018.09.018
Results from the Michigan Surgical and Health Optimization Program (MSHOP) are reported in colectomy patients. This prehabilitation program engages patients in four activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. MSHOP patients were matched to emergency and elective, non-MSHOP patients. Overall, 70% of MSHOP patients complied with the program. MSHOP patients were more likely to have improved blood pressure and heart rate intraoperatively, reduction in Clavien-Dindo class 3-4 complications in the MSHOP group (30%), compared with the nonprehabilitation (38%) and emergency (48%) groups (P = .05), as well as average savings of $21,946 per patient.
Genevieve Melton-Meaux, MD, PhD, FACS
Bariatric Surgery
Kalff MC et al. Diagnostic value of computed tomography for detecting anastomotic or staple line leakage after bariatric surgery. Surg Obes Relat Dis. 2018;14(9):1310-16
The most dreaded complication in the current era of metabolic and bariatric surgery, from a technical point of view, remains an anastomotic or staple-line leak. The authors present their findings corresponding to a multivariable regression analysis of a retrospective review of all CT abdomen and pelvis scans conducted from November 2007 to August 2016 at their large teaching hospital and Bariatric Center of Excellence. A CT is especially useful at ruling out low-suspicion cases of leaks, when the surgeon is trying to decide if a diagnostic laparoscopy is indicated, with a sensitivity of 90%-100%, and a negative predictive value of 97%-100%. A negative CT scan is highly accurate for ruling out a leak, especially in those patients without co-existing tachycardia and tachypnea. With caution based on clinical expertise, it may serve to prevent unnecessary diagnostic laparoscopy when appropriately indicated.
Alizadeh RF et al. Risk factors for gastrointestinal leak after bariatric surgery: MBSAQIP analysis. J Am Coll Surg. 2018;227(1):135-141.
The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 database of accredited centers was the object of study. Multivariate logistic regression analysis was used to examine risk factors for GI leaks that are not typically included in similar studies. Of particular interest is finding that Roux-en-Y gastric bypass comes with a higher risk for leak, compared with a sleeve gastrectomy, but with an overall leak rate for both of 0.7% based on current results. In addition, the study found that use of an intraoperative provocative leak test and placement of a surgical drain are associated with a higher leak rate. The same is not true of a postoperative swallow contrast study, which has no effect on the incidence of leaks.
Altieri MS et al. Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures. Surg Endosc. 2018;32(12):4805-4812.
The field of venous thromboembolism prevention after bariatric surgery remains a challenging one due to the lack of consensus among surgeons. This study analyzes the Cerner Health Facts database from 2003 to 2013, particularly with ICD-9 codes, for patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy. While the authors confirm the statement that there is a lack of consistency and, therefore, there is ample variability among bariatric centers and surgeons, the use of postoperative VTE chemoprophylaxis leads to a lower incidence of VTE events, and less frequent bleeding episodes, compared with pre-operative chemoprophylaxis. Finally, mixed therapy using heparin and enoxaparin led to more bleeding complications and blood transfusion requirements.
Rodolfo J. Oviedo, MD, FACS, FASMBS
Cardiothoracic Surgery
Stone GW et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23; doi:10.1056/NEJMoa1806640.
This study, known as the COAPT trial, assessed the value of adding transcatheter mitral valve repair to best medical therapy for the treatment of moderate-to-severe or severe functional mitral regurgitation in patients with symptomatic heart failure. Not only was transcatheter mitral valve repair exceedingly safe (more than 96% freedom from device-related complications at 12 months), patients were hospitalized less for heart failure management and had lower all-cause mortality compared with best medical therapy alone. The results of the COAPT trial are an important step forward for transcatheter therapies, which are rapidly becoming an integral part of the treatment algorithms for structural heart disease.
Gaudino M et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med. 2018;378(22):2069-77.
This analysis of randomized trials comparing radial artery to saphenous vein grafts for coronary artery bypass surgery is quite possibly a practice-changing publication. Routine use of the left internal thoracic (mammary) artery is commonplace among cardiac surgeons; however, the debate over conduit choice for additional bypass grafts is a “tale as old as time.” This study, part of the RADIAL project, combined patient-level data from six trials in order to achieve adequate power to identify differences in clinical outcomes. The use of radial artery grafts as opposed to saphenous vein grafts was associated with less adverse cardiac events, a lower incidence of repeat revascularization, and a higher patency rate at 5 years. Although there was no difference in all-cause mortality, the results of this study support the use of radial artery grafts when additional conduits are needed in coronary artery bypass surgery.
Irving L. Kron, MD, FACS, and Eric J. Charles, MD, PhD
Vascular Surgery
Anand SS. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: An international, randomised, double-blind, placebo-controlled trial. Lancet 2018;391(10117):219-29.
This landmark study was terminated early due to a significant difference in outcomes. Prior to this point, aspirin and statins have been the mainstay of decreasing long-term adverse outcomes for patients with vascular disease. The COMPASS study has found a decrease in combined cardiovascular adverse events when rivaroxaban 2.5 mg was combined with low-dose aspirin in patients with stable PAD or CAD over aspirin alone. This is the first major change supporting use of additional medications for PAD in over 2 decades, when statins were found to impact outcomes. The differences were not impacted by gender, age, or race. Patients with end-tage renal disease were excluded, so it is unclear whether it would be beneficial in this population. The higher rate of bleeding, 3.1% vs 1.9%, was primarily GI, so caution should be used if patients are felt to be at increased risk of bleeding.
These findings suggest the need for a major change in the guidelines and management for the majority of our patients with PAD. Certainly we should look to add this data point to the Vascular Quality Initiative to gather further data and confirm the findings in real world use. It is unclear whether this benefit will be unique to rivaroxaban, or whether other Direct Xa inhibitors will have similar effects. I will certainly be adding ribaroxaban to patients at low risk for bleeding based on this data. Further, rivaroxaban alone did not reduce major cardiovascular adverse events, but did reduce major adverse limb events.
Gohel MS et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378:2105-14.
This multicenter study in the UK looked at over 450 patients with venous ulceration. Deep-venous reflux was also present in one-third of patients in each group. The median time to ulcer healing was decreased significantly from 82 days to 56 days. This study demonstrates the importance of early intervention for superficial reflux to enhance ulcer healing and decrease risk of recurrence. This study found that early endovenous ablation resulted in faster healing of venous ulcers, and more ulcer-free time than delayed intervention in patients treated with maximal medical therapy, including appropriate compression therapy. Previously, ablation was typically planned after ulcers healed to decrease risk of recurrence. Based on these findings, ablation should be offered to patients with nonhealing venous ulcers early in the course of therapy, in addition to standard wound care.
Linda Harris, MD, FACS
Surgical Education
Ellison EC. Ten-year reassessment of the shortage of general surgeons: Increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons. Surgery. 2018 Oct;164(4):726-32.
Ellison EC et al. The impact of the aging population and incidence of cancer on future projections of general surgery workforce needs. Surgery. 2018 Mar;163(3):553-59.
In 2008, Ellison et al. projected that a deficit in the general surgery workforce would grow to 19% by 2050. The group recently re-examined this projection by reviewing Census Bureau data, the available pool of surgeons with both allopathic and osteopathic degrees and factored in the losses of new surgeons who subspecialize and older surgeons who retire every year. Their conclusion states that, without increasing future general surgeons training numbers, the projected future general surgery workforce shortage will continue to grow.
A second paper by the same group reviewed population and age-adjusted incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. The total number of new patients with cancers treated by general surgeons is projected to increase 56% in that time span. This would require an increase of over 9,000 general surgeons over that based on current training numbers. Together, the papers predict that there will be an ever-increasing demand for general surgeons in the near future and that general surgeons, currently caring for over 50% of cancer patients in the US, will play an even more important role in surgical cancer treatment.
Michael D. Sarap, MD, FACS
General Surgery
Takada T. Tokyo Guidelines 2018 (TG18). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):1-2.
This is the updated set of guidelines, awaited since 2013, regarding treatment of acute cholecystitis and cholangitis, with updated management strategies from an international panel of experts. The most significant change, and considered overdue by some surgeons, is the modification of the management algorithm to propose that some patients with Grade III acute cholecystitis (severe cholecystitis with evidence of organ dysfunction) may be treated with immediate laparoscopic cholecystectomy, rather than percutaneous cholecystostomy, “when performed at advanced centers with specialized surgeons experienced in this procedure.” As cholecystectomy is the most common general surgery procedure in the United States, most community surgeons have expertise. Whether there is truly need of a specialized gallbladder surgeon at an advanced center to safely complete a laparoscopic cholecystectomy can still be debated. But the change in recommendation from the experts is welcome.
Acuna SA. Operative strategies for perforated diverticulitis: A systematic review and meta-analysis. Dis Colon Rectum. 2018 Dec; 61(12):1442-53.
This analysis of the literature considers the three predominant operations for Hinchey III and Hinchey IV perforated diverticulitis: Hartmann procedure, resection and primary anastomosis, and laparoscopic lavage. The importance of this review is that it considers the initial operation and the downstream procedures when determining overall morbidity and mortality. Laparoscopic lavage did not fare well in this review of randomized controlled trials, resulting in higher morbidity than resection in Hinchey III patients. Interestingly, none of the individual studies analyzed had shown a statistical difference, but in the meta-analysis, the number of patients was sufficient to show statistical significance. The other important conclusion was that primary resection with anastomosis (possibly with diverting ileostomy) was superior to Hartmann procedure, when the likelihood of stoma reversal and the morbidity of the second operation was taken into account.
Mark Savarise, MD, FACS
Foregut
Alicuben ET. Worldwide experience with erosion of the magnetic sphincter augmentation device. J Gastrointest Surg. 2018; 22(8):1442-47.
Although magnetic sphincter augmentation of the lower esophageal sphincter initially appeared to provide excellent reflux control with essentially no risk of erosion, there have now been multiple reports throughout the world of device erosion over time. Fortunately, most erosions occurred with the smallest available device which is no longer on the market and the erosions currently being treated are usually done so with endoscopic/laparoscopic removal without the need for major esophageal resection.
Xiong YQ. Comparison of narrow-band imaging and confocal laser endomicroscopy for the detection of neoplasia in Barrett’s esophagus: A meta-analysis. Clin Res Hepatol Gastroenterol. 2018 Feb;42(1):31-9.
The days of endoscopic screening and surveillance of patients at risk for the development of Barrett’s esophagus via four-quadrant biopsy every couple of centimeters are numbered. The use of confocal laser microscopy to provide accurate real-time visual data regarding the areas of interest in the esophagus is showing promise and gaining traction compared to standard biopsy techniques and narrow-band imaging.
Borbély Y. Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy. Surg Obes Relat Dis. 2018 May;14(5):611-5.
The development of GERD following sleeve gastrectomy is a real problem in a substantial minority of patients due to structural compromise of the lower esophageal sphincter during the procedure. Conversion to gastric bypass as a way to alleviate acid regurgitation has been the mainstay of treatment; however, many patients selected sleeve gastrectomy specifically because they did not want to undergo gastric bypass. For those patients a sleeve preserving procedure such as magnetic sphincter augmentation (currently in clinical trial), Hill procedure, or remnant gastric fundoplication are potential options. Electrical stimulation of the lower esophageal sphincter is revealing itself to be another exciting option (currently in clinical trial) which can be used in patients with as few as 30% peristaltic swallows thus expanding the treatment options for these deserving patients.
Kevin M. Reavis, MD, FACS
Trauma/Critical Care
Teixeira PGR et al. Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury . J Am Coll Surg. 2018;226(5):769-76.
The use of tourniquets for hemorrhage control in trauma patients has been widely condemned in the past because of concerns regarding complications and potential limb loss. However, evidence from liberal tourniquet use in combat situations documenting survival benefits has continued to accumulate. Prompt hemorrhage control in trauma patients, including the use of tourniquets where applicable, has been validated by recent combat zone studies but improved survival hasn’t yet been shown in the civilian setting. In this multicenter, retrospective study of 1,026 patients with peripheral vascular injuries, only a relatively small number (17.6%) had pre-hospital tourniquets applied, yet multivariable analysis showed a significant survival benefit (odds ratio, 5.86). Importantly, no difference was seen in delayed amputation rates, of approximately 1% in both groups. This study helps to emphasize the importance of the Stop the Bleed (STB) campaign which includes education on the effective and safe use of tourniquets for prehospital hemorrhage. The STB program offers surgeons the opportunity to educate members of their own communities in effective bystander first aid.
Pileggi C et al. Ventilator bundle and its effects on mortality among ICU patients: A meta-analysis. Crit Care Med. 2018;46(7):1167-74.
Critically ill patients requiring mechanical ventilation are at risk for a number of complications, including ventilator-associated pneumonia (VAP) (now a subset of ventilator-associated events (VAE) which prolong ventilator and ICU time and contribute to further complication. Ventilator “bundles,” incorporating simple measures such as elevation of the head of the bed; daily “sedation holidays”; and evaluation of readiness for extubation, peptic ulcer, and DVT prophylaxis have been widely used in ICUs for nearly 20 years. Effective implementation has also emphasized multidisciplinary teamwork. Reductions in ventilator-associated pneumonia (VAP) incidence have been widely demonstrated but mortality benefits have been inconsistent. In this meta-analysis of 13 studies, 6 in Europe, 6 in the US and 1 in Brazil, an overall reduction in mortality (odds ratio, 0.9) was demonstrated. The effect was even larger when limited to studies with patients with VAP (OR, 0.71). This study both validates the effectiveness of relatively simple and inexpensive measures and emphasizes the benefits of a team approach to the care of ICU patients.
Krista L. Kaups, MD, FACS
Recommended Reading lists have been over the years among the most popular features in this publication. It is therefore fitting that for this last issue of ACS Surgery News, we have once again imposed upon our Editorial Advisory Board to come up with their choice of the most important studies published in 2018. They were asked to choose a few studies that they consider most significant in their subspecialties and to explain why these studies should matter to all surgeons.
Some editorial advisers for some publications fill honorary positions with no real responsibility or work involved. Not so for the Editorial Advisory Board of ACS Surgery News. Each member provided a steady stream of commentaries, recommendations, and advice. The publication and the managing editor would have been lost without their kind and willing assistance. In their busy professional lives, they somehow found the time to contribute their expertise to assist their colleagues and their profession. We all owe them a debt of gratitude for their many years of service.
We hope our readers will find the list and the comments of interest.
Otolaryngology
St. Laurent J et al. HPV vaccination and the effects on rates of HPV-related cancers. Curr Probl Cancer 2018; https://doi.org/10.1016/j.currproblcancer.2018.06.004
As a head and neck surgeon over the past 30+ years, I have seen the dramaticrise of one form of HPV-related cancer in the United States, namely, HPV-associated oropharyngeal cancer. This is a true epidemic. It is also a cancer that may well be preventable through vaccination. We have slowly made progress over the past 4 decades in reducing the number of tobacco- and alcohol-related cancers. Here is another cancer that truly falls within the category of a public health problem for which public health solution of vaccination is clearly the most rational approach. Everyone should be aware of these virally induced cancers and what can be done to prevent them. This article presents the “state of the art” knowledge about these cancers and what we can hopefully accomplish through worldwide public health initiatives.
Mark C. Weissler, MD, FACS
Palliative Care
Kopecky KE et al. Third-year medical students’ reactions to surgical patients in pain: Doubt, distress, and depersonalization. J Pain and Symptom Manage. 2018;56(5):719-26.
This insightful study done by surgeons, two of them possessing palliative care and bioethics expertise, is a qualitative analysis of the content of 341 essays written by third-year medical students who described their experiences with surgical patients in pain. Students found it difficult to reconcile patient suffering with the therapeutic objective of treatment. As a result they learned constrained empathy and preference for technical solutions and because they feared an empathic response to pain might compromise the fortitude and efficiency required to be a doctor they pursued strategies to distance themselves from these feelings. The authors note, “Although doctors frequently interact with patients who have serious emotional and physical pain, few have received formal instruction on how to attend to these needs or developed a personal approach to cope with the tragedy of patient illness. Instead, the physician’s response to patients in pain is learned passively and perpetuated through generations. Students now seek to suppress empathy to get the job done. These observations have important implications for physicians, patients, and educators.” For me the study is like a parachute flare illuminating the landscape of early surgical educational experience during which the seeds for future problems such as lost patient trust and burnout are sown. It offers the hope that structured introspective activities may mitigate this.
Su A et al. Beyond pain: Nurses’ assessment of patient suffering, dignity, and dying in the intensive care unit. J Pain Symptom Manage. 2018;55:1591-98.
After reading this sobering study, my reaction was, “If the gold rusts what will happen to the iron?” In this study using chart abstraction, nurses caring for 200 patients in a tertiary care cardiac ICU and a surgical ICU were interviewed about their assessment and perception of the physical and psychosocial dimensions of ICU patients’ experiences in their final week of life. The authors note that nursing symptom assessments have been previously shown to be highly reliable and end-of-life comfort and dignity have been shown to be compatible with ICU level of care. Despite this and the availability of extensive interdisciplinary support from palliative care teams, chaplains, and social workers, dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. The study found that attention to symptoms such as dyspnea and edema might improve the quality of death in the ICU. It is small wonder that moral fatigue and burnout have become prevalent themes of ICU caring.
Balboni T et al. The spiritual event of serious illness. J Pain Symptom Manage. 2018;56(5):816-22.
An ashen-faced dear friend gently reminded me as he was hemorrhaging from an advanced gastric cancer, “Geoff, lets make this a spiritual event, not a medical one.” This paper conjured up this memory with the thoughtful, in-depth account and analysis of patients’ experiences and attitudes that shaped the authors concept of illness as a spiritual event. The idea of spirituality as a basic component of consciousness, especially as it relates to suffering, has been present from the very beginning of modern palliative care and can be traced back to the concept of “total pain” introduced by Dame Cicely Saunders in 1963. The capacity to reframe biophysical calamity as spiritual opportunity is the signature of the most skilled and adroit supportive care we can offer our patients and their families.
Geoffrey P. Dunn, MD, FACS
Colorectal Surgery
Cercek A et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol. 2018;4(6):e180071. doi:10.1001/jamaoncol.2018.0071.
This moderate sized retrospective study demonstrates a single-institution’s experience with total neoadjuvant therapy (TNT) with chemoradiation and chemotherapy as opposed to traditional chemoradiation, surgery, and chemotherapy in patients with locally advanced rectal cancer. They demonstrate equivalent or potentially better outcomes including better complete response rate – 36% versus 21% and rates of chemotherapy completion. While further studies are needed to understand long term outcomes, this study support the use of TNT for locally advanced rectal cancer as now supported by the National Comprehensive Cancer Network guidelines.
Brouquet A et al. Anti-TNF therapy is associated with an increased risk of postoperative morbidity after surgery for ileocolonic Crohn disease: Results of a prospective nationwide cohort. Ann Surg. 2018 Feb;267(2):221-228. doi: 10.1097/SLA.0000000000002017.
This large prospective study of almost 600 consecutive Crohn’s disease patients with surgery at 19 French specialty centers demonstrates that anti-TNF therapy less than 3 months prior to ileocolic surgery to be an independent risk factor of the overall postoperative morbidity, preoperative hemoglobin less than10 g/dL, operative time more than180 min, and recurrent Crohn’s disease, as well as a higher risk of overall and intra-abdominal septic postoperative morbidities.
Howard R et al. Taking control of your surgery: Impact of a prehabilitation program on major abdominal surgery. J Am Coll Surg. 2018 Oct 22; https://doi.org/10.1016/j.jamcollsurg.2018.09.018
Results from the Michigan Surgical and Health Optimization Program (MSHOP) are reported in colectomy patients. This prehabilitation program engages patients in four activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. MSHOP patients were matched to emergency and elective, non-MSHOP patients. Overall, 70% of MSHOP patients complied with the program. MSHOP patients were more likely to have improved blood pressure and heart rate intraoperatively, reduction in Clavien-Dindo class 3-4 complications in the MSHOP group (30%), compared with the nonprehabilitation (38%) and emergency (48%) groups (P = .05), as well as average savings of $21,946 per patient.
Genevieve Melton-Meaux, MD, PhD, FACS
Bariatric Surgery
Kalff MC et al. Diagnostic value of computed tomography for detecting anastomotic or staple line leakage after bariatric surgery. Surg Obes Relat Dis. 2018;14(9):1310-16
The most dreaded complication in the current era of metabolic and bariatric surgery, from a technical point of view, remains an anastomotic or staple-line leak. The authors present their findings corresponding to a multivariable regression analysis of a retrospective review of all CT abdomen and pelvis scans conducted from November 2007 to August 2016 at their large teaching hospital and Bariatric Center of Excellence. A CT is especially useful at ruling out low-suspicion cases of leaks, when the surgeon is trying to decide if a diagnostic laparoscopy is indicated, with a sensitivity of 90%-100%, and a negative predictive value of 97%-100%. A negative CT scan is highly accurate for ruling out a leak, especially in those patients without co-existing tachycardia and tachypnea. With caution based on clinical expertise, it may serve to prevent unnecessary diagnostic laparoscopy when appropriately indicated.
Alizadeh RF et al. Risk factors for gastrointestinal leak after bariatric surgery: MBSAQIP analysis. J Am Coll Surg. 2018;227(1):135-141.
The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 database of accredited centers was the object of study. Multivariate logistic regression analysis was used to examine risk factors for GI leaks that are not typically included in similar studies. Of particular interest is finding that Roux-en-Y gastric bypass comes with a higher risk for leak, compared with a sleeve gastrectomy, but with an overall leak rate for both of 0.7% based on current results. In addition, the study found that use of an intraoperative provocative leak test and placement of a surgical drain are associated with a higher leak rate. The same is not true of a postoperative swallow contrast study, which has no effect on the incidence of leaks.
Altieri MS et al. Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures. Surg Endosc. 2018;32(12):4805-4812.
The field of venous thromboembolism prevention after bariatric surgery remains a challenging one due to the lack of consensus among surgeons. This study analyzes the Cerner Health Facts database from 2003 to 2013, particularly with ICD-9 codes, for patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy. While the authors confirm the statement that there is a lack of consistency and, therefore, there is ample variability among bariatric centers and surgeons, the use of postoperative VTE chemoprophylaxis leads to a lower incidence of VTE events, and less frequent bleeding episodes, compared with pre-operative chemoprophylaxis. Finally, mixed therapy using heparin and enoxaparin led to more bleeding complications and blood transfusion requirements.
Rodolfo J. Oviedo, MD, FACS, FASMBS
Cardiothoracic Surgery
Stone GW et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23; doi:10.1056/NEJMoa1806640.
This study, known as the COAPT trial, assessed the value of adding transcatheter mitral valve repair to best medical therapy for the treatment of moderate-to-severe or severe functional mitral regurgitation in patients with symptomatic heart failure. Not only was transcatheter mitral valve repair exceedingly safe (more than 96% freedom from device-related complications at 12 months), patients were hospitalized less for heart failure management and had lower all-cause mortality compared with best medical therapy alone. The results of the COAPT trial are an important step forward for transcatheter therapies, which are rapidly becoming an integral part of the treatment algorithms for structural heart disease.
Gaudino M et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med. 2018;378(22):2069-77.
This analysis of randomized trials comparing radial artery to saphenous vein grafts for coronary artery bypass surgery is quite possibly a practice-changing publication. Routine use of the left internal thoracic (mammary) artery is commonplace among cardiac surgeons; however, the debate over conduit choice for additional bypass grafts is a “tale as old as time.” This study, part of the RADIAL project, combined patient-level data from six trials in order to achieve adequate power to identify differences in clinical outcomes. The use of radial artery grafts as opposed to saphenous vein grafts was associated with less adverse cardiac events, a lower incidence of repeat revascularization, and a higher patency rate at 5 years. Although there was no difference in all-cause mortality, the results of this study support the use of radial artery grafts when additional conduits are needed in coronary artery bypass surgery.
Irving L. Kron, MD, FACS, and Eric J. Charles, MD, PhD
Vascular Surgery
Anand SS. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: An international, randomised, double-blind, placebo-controlled trial. Lancet 2018;391(10117):219-29.
This landmark study was terminated early due to a significant difference in outcomes. Prior to this point, aspirin and statins have been the mainstay of decreasing long-term adverse outcomes for patients with vascular disease. The COMPASS study has found a decrease in combined cardiovascular adverse events when rivaroxaban 2.5 mg was combined with low-dose aspirin in patients with stable PAD or CAD over aspirin alone. This is the first major change supporting use of additional medications for PAD in over 2 decades, when statins were found to impact outcomes. The differences were not impacted by gender, age, or race. Patients with end-tage renal disease were excluded, so it is unclear whether it would be beneficial in this population. The higher rate of bleeding, 3.1% vs 1.9%, was primarily GI, so caution should be used if patients are felt to be at increased risk of bleeding.
These findings suggest the need for a major change in the guidelines and management for the majority of our patients with PAD. Certainly we should look to add this data point to the Vascular Quality Initiative to gather further data and confirm the findings in real world use. It is unclear whether this benefit will be unique to rivaroxaban, or whether other Direct Xa inhibitors will have similar effects. I will certainly be adding ribaroxaban to patients at low risk for bleeding based on this data. Further, rivaroxaban alone did not reduce major cardiovascular adverse events, but did reduce major adverse limb events.
Gohel MS et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378:2105-14.
This multicenter study in the UK looked at over 450 patients with venous ulceration. Deep-venous reflux was also present in one-third of patients in each group. The median time to ulcer healing was decreased significantly from 82 days to 56 days. This study demonstrates the importance of early intervention for superficial reflux to enhance ulcer healing and decrease risk of recurrence. This study found that early endovenous ablation resulted in faster healing of venous ulcers, and more ulcer-free time than delayed intervention in patients treated with maximal medical therapy, including appropriate compression therapy. Previously, ablation was typically planned after ulcers healed to decrease risk of recurrence. Based on these findings, ablation should be offered to patients with nonhealing venous ulcers early in the course of therapy, in addition to standard wound care.
Linda Harris, MD, FACS
Surgical Education
Ellison EC. Ten-year reassessment of the shortage of general surgeons: Increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons. Surgery. 2018 Oct;164(4):726-32.
Ellison EC et al. The impact of the aging population and incidence of cancer on future projections of general surgery workforce needs. Surgery. 2018 Mar;163(3):553-59.
In 2008, Ellison et al. projected that a deficit in the general surgery workforce would grow to 19% by 2050. The group recently re-examined this projection by reviewing Census Bureau data, the available pool of surgeons with both allopathic and osteopathic degrees and factored in the losses of new surgeons who subspecialize and older surgeons who retire every year. Their conclusion states that, without increasing future general surgeons training numbers, the projected future general surgery workforce shortage will continue to grow.
A second paper by the same group reviewed population and age-adjusted incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. The total number of new patients with cancers treated by general surgeons is projected to increase 56% in that time span. This would require an increase of over 9,000 general surgeons over that based on current training numbers. Together, the papers predict that there will be an ever-increasing demand for general surgeons in the near future and that general surgeons, currently caring for over 50% of cancer patients in the US, will play an even more important role in surgical cancer treatment.
Michael D. Sarap, MD, FACS
General Surgery
Takada T. Tokyo Guidelines 2018 (TG18). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):1-2.
This is the updated set of guidelines, awaited since 2013, regarding treatment of acute cholecystitis and cholangitis, with updated management strategies from an international panel of experts. The most significant change, and considered overdue by some surgeons, is the modification of the management algorithm to propose that some patients with Grade III acute cholecystitis (severe cholecystitis with evidence of organ dysfunction) may be treated with immediate laparoscopic cholecystectomy, rather than percutaneous cholecystostomy, “when performed at advanced centers with specialized surgeons experienced in this procedure.” As cholecystectomy is the most common general surgery procedure in the United States, most community surgeons have expertise. Whether there is truly need of a specialized gallbladder surgeon at an advanced center to safely complete a laparoscopic cholecystectomy can still be debated. But the change in recommendation from the experts is welcome.
Acuna SA. Operative strategies for perforated diverticulitis: A systematic review and meta-analysis. Dis Colon Rectum. 2018 Dec; 61(12):1442-53.
This analysis of the literature considers the three predominant operations for Hinchey III and Hinchey IV perforated diverticulitis: Hartmann procedure, resection and primary anastomosis, and laparoscopic lavage. The importance of this review is that it considers the initial operation and the downstream procedures when determining overall morbidity and mortality. Laparoscopic lavage did not fare well in this review of randomized controlled trials, resulting in higher morbidity than resection in Hinchey III patients. Interestingly, none of the individual studies analyzed had shown a statistical difference, but in the meta-analysis, the number of patients was sufficient to show statistical significance. The other important conclusion was that primary resection with anastomosis (possibly with diverting ileostomy) was superior to Hartmann procedure, when the likelihood of stoma reversal and the morbidity of the second operation was taken into account.
Mark Savarise, MD, FACS
Foregut
Alicuben ET. Worldwide experience with erosion of the magnetic sphincter augmentation device. J Gastrointest Surg. 2018; 22(8):1442-47.
Although magnetic sphincter augmentation of the lower esophageal sphincter initially appeared to provide excellent reflux control with essentially no risk of erosion, there have now been multiple reports throughout the world of device erosion over time. Fortunately, most erosions occurred with the smallest available device which is no longer on the market and the erosions currently being treated are usually done so with endoscopic/laparoscopic removal without the need for major esophageal resection.
Xiong YQ. Comparison of narrow-band imaging and confocal laser endomicroscopy for the detection of neoplasia in Barrett’s esophagus: A meta-analysis. Clin Res Hepatol Gastroenterol. 2018 Feb;42(1):31-9.
The days of endoscopic screening and surveillance of patients at risk for the development of Barrett’s esophagus via four-quadrant biopsy every couple of centimeters are numbered. The use of confocal laser microscopy to provide accurate real-time visual data regarding the areas of interest in the esophagus is showing promise and gaining traction compared to standard biopsy techniques and narrow-band imaging.
Borbély Y. Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy. Surg Obes Relat Dis. 2018 May;14(5):611-5.
The development of GERD following sleeve gastrectomy is a real problem in a substantial minority of patients due to structural compromise of the lower esophageal sphincter during the procedure. Conversion to gastric bypass as a way to alleviate acid regurgitation has been the mainstay of treatment; however, many patients selected sleeve gastrectomy specifically because they did not want to undergo gastric bypass. For those patients a sleeve preserving procedure such as magnetic sphincter augmentation (currently in clinical trial), Hill procedure, or remnant gastric fundoplication are potential options. Electrical stimulation of the lower esophageal sphincter is revealing itself to be another exciting option (currently in clinical trial) which can be used in patients with as few as 30% peristaltic swallows thus expanding the treatment options for these deserving patients.
Kevin M. Reavis, MD, FACS
Trauma/Critical Care
Teixeira PGR et al. Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury . J Am Coll Surg. 2018;226(5):769-76.
The use of tourniquets for hemorrhage control in trauma patients has been widely condemned in the past because of concerns regarding complications and potential limb loss. However, evidence from liberal tourniquet use in combat situations documenting survival benefits has continued to accumulate. Prompt hemorrhage control in trauma patients, including the use of tourniquets where applicable, has been validated by recent combat zone studies but improved survival hasn’t yet been shown in the civilian setting. In this multicenter, retrospective study of 1,026 patients with peripheral vascular injuries, only a relatively small number (17.6%) had pre-hospital tourniquets applied, yet multivariable analysis showed a significant survival benefit (odds ratio, 5.86). Importantly, no difference was seen in delayed amputation rates, of approximately 1% in both groups. This study helps to emphasize the importance of the Stop the Bleed (STB) campaign which includes education on the effective and safe use of tourniquets for prehospital hemorrhage. The STB program offers surgeons the opportunity to educate members of their own communities in effective bystander first aid.
Pileggi C et al. Ventilator bundle and its effects on mortality among ICU patients: A meta-analysis. Crit Care Med. 2018;46(7):1167-74.
Critically ill patients requiring mechanical ventilation are at risk for a number of complications, including ventilator-associated pneumonia (VAP) (now a subset of ventilator-associated events (VAE) which prolong ventilator and ICU time and contribute to further complication. Ventilator “bundles,” incorporating simple measures such as elevation of the head of the bed; daily “sedation holidays”; and evaluation of readiness for extubation, peptic ulcer, and DVT prophylaxis have been widely used in ICUs for nearly 20 years. Effective implementation has also emphasized multidisciplinary teamwork. Reductions in ventilator-associated pneumonia (VAP) incidence have been widely demonstrated but mortality benefits have been inconsistent. In this meta-analysis of 13 studies, 6 in Europe, 6 in the US and 1 in Brazil, an overall reduction in mortality (odds ratio, 0.9) was demonstrated. The effect was even larger when limited to studies with patients with VAP (OR, 0.71). This study both validates the effectiveness of relatively simple and inexpensive measures and emphasizes the benefits of a team approach to the care of ICU patients.
Krista L. Kaups, MD, FACS
Recommended Reading lists have been over the years among the most popular features in this publication. It is therefore fitting that for this last issue of ACS Surgery News, we have once again imposed upon our Editorial Advisory Board to come up with their choice of the most important studies published in 2018. They were asked to choose a few studies that they consider most significant in their subspecialties and to explain why these studies should matter to all surgeons.
Some editorial advisers for some publications fill honorary positions with no real responsibility or work involved. Not so for the Editorial Advisory Board of ACS Surgery News. Each member provided a steady stream of commentaries, recommendations, and advice. The publication and the managing editor would have been lost without their kind and willing assistance. In their busy professional lives, they somehow found the time to contribute their expertise to assist their colleagues and their profession. We all owe them a debt of gratitude for their many years of service.
We hope our readers will find the list and the comments of interest.
Otolaryngology
St. Laurent J et al. HPV vaccination and the effects on rates of HPV-related cancers. Curr Probl Cancer 2018; https://doi.org/10.1016/j.currproblcancer.2018.06.004
As a head and neck surgeon over the past 30+ years, I have seen the dramaticrise of one form of HPV-related cancer in the United States, namely, HPV-associated oropharyngeal cancer. This is a true epidemic. It is also a cancer that may well be preventable through vaccination. We have slowly made progress over the past 4 decades in reducing the number of tobacco- and alcohol-related cancers. Here is another cancer that truly falls within the category of a public health problem for which public health solution of vaccination is clearly the most rational approach. Everyone should be aware of these virally induced cancers and what can be done to prevent them. This article presents the “state of the art” knowledge about these cancers and what we can hopefully accomplish through worldwide public health initiatives.
Mark C. Weissler, MD, FACS
Palliative Care
Kopecky KE et al. Third-year medical students’ reactions to surgical patients in pain: Doubt, distress, and depersonalization. J Pain and Symptom Manage. 2018;56(5):719-26.
This insightful study done by surgeons, two of them possessing palliative care and bioethics expertise, is a qualitative analysis of the content of 341 essays written by third-year medical students who described their experiences with surgical patients in pain. Students found it difficult to reconcile patient suffering with the therapeutic objective of treatment. As a result they learned constrained empathy and preference for technical solutions and because they feared an empathic response to pain might compromise the fortitude and efficiency required to be a doctor they pursued strategies to distance themselves from these feelings. The authors note, “Although doctors frequently interact with patients who have serious emotional and physical pain, few have received formal instruction on how to attend to these needs or developed a personal approach to cope with the tragedy of patient illness. Instead, the physician’s response to patients in pain is learned passively and perpetuated through generations. Students now seek to suppress empathy to get the job done. These observations have important implications for physicians, patients, and educators.” For me the study is like a parachute flare illuminating the landscape of early surgical educational experience during which the seeds for future problems such as lost patient trust and burnout are sown. It offers the hope that structured introspective activities may mitigate this.
Su A et al. Beyond pain: Nurses’ assessment of patient suffering, dignity, and dying in the intensive care unit. J Pain Symptom Manage. 2018;55:1591-98.
After reading this sobering study, my reaction was, “If the gold rusts what will happen to the iron?” In this study using chart abstraction, nurses caring for 200 patients in a tertiary care cardiac ICU and a surgical ICU were interviewed about their assessment and perception of the physical and psychosocial dimensions of ICU patients’ experiences in their final week of life. The authors note that nursing symptom assessments have been previously shown to be highly reliable and end-of-life comfort and dignity have been shown to be compatible with ICU level of care. Despite this and the availability of extensive interdisciplinary support from palliative care teams, chaplains, and social workers, dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. The study found that attention to symptoms such as dyspnea and edema might improve the quality of death in the ICU. It is small wonder that moral fatigue and burnout have become prevalent themes of ICU caring.
Balboni T et al. The spiritual event of serious illness. J Pain Symptom Manage. 2018;56(5):816-22.
An ashen-faced dear friend gently reminded me as he was hemorrhaging from an advanced gastric cancer, “Geoff, lets make this a spiritual event, not a medical one.” This paper conjured up this memory with the thoughtful, in-depth account and analysis of patients’ experiences and attitudes that shaped the authors concept of illness as a spiritual event. The idea of spirituality as a basic component of consciousness, especially as it relates to suffering, has been present from the very beginning of modern palliative care and can be traced back to the concept of “total pain” introduced by Dame Cicely Saunders in 1963. The capacity to reframe biophysical calamity as spiritual opportunity is the signature of the most skilled and adroit supportive care we can offer our patients and their families.
Geoffrey P. Dunn, MD, FACS
Colorectal Surgery
Cercek A et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol. 2018;4(6):e180071. doi:10.1001/jamaoncol.2018.0071.
This moderate sized retrospective study demonstrates a single-institution’s experience with total neoadjuvant therapy (TNT) with chemoradiation and chemotherapy as opposed to traditional chemoradiation, surgery, and chemotherapy in patients with locally advanced rectal cancer. They demonstrate equivalent or potentially better outcomes including better complete response rate – 36% versus 21% and rates of chemotherapy completion. While further studies are needed to understand long term outcomes, this study support the use of TNT for locally advanced rectal cancer as now supported by the National Comprehensive Cancer Network guidelines.
Brouquet A et al. Anti-TNF therapy is associated with an increased risk of postoperative morbidity after surgery for ileocolonic Crohn disease: Results of a prospective nationwide cohort. Ann Surg. 2018 Feb;267(2):221-228. doi: 10.1097/SLA.0000000000002017.
This large prospective study of almost 600 consecutive Crohn’s disease patients with surgery at 19 French specialty centers demonstrates that anti-TNF therapy less than 3 months prior to ileocolic surgery to be an independent risk factor of the overall postoperative morbidity, preoperative hemoglobin less than10 g/dL, operative time more than180 min, and recurrent Crohn’s disease, as well as a higher risk of overall and intra-abdominal septic postoperative morbidities.
Howard R et al. Taking control of your surgery: Impact of a prehabilitation program on major abdominal surgery. J Am Coll Surg. 2018 Oct 22; https://doi.org/10.1016/j.jamcollsurg.2018.09.018
Results from the Michigan Surgical and Health Optimization Program (MSHOP) are reported in colectomy patients. This prehabilitation program engages patients in four activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. MSHOP patients were matched to emergency and elective, non-MSHOP patients. Overall, 70% of MSHOP patients complied with the program. MSHOP patients were more likely to have improved blood pressure and heart rate intraoperatively, reduction in Clavien-Dindo class 3-4 complications in the MSHOP group (30%), compared with the nonprehabilitation (38%) and emergency (48%) groups (P = .05), as well as average savings of $21,946 per patient.
Genevieve Melton-Meaux, MD, PhD, FACS
Bariatric Surgery
Kalff MC et al. Diagnostic value of computed tomography for detecting anastomotic or staple line leakage after bariatric surgery. Surg Obes Relat Dis. 2018;14(9):1310-16
The most dreaded complication in the current era of metabolic and bariatric surgery, from a technical point of view, remains an anastomotic or staple-line leak. The authors present their findings corresponding to a multivariable regression analysis of a retrospective review of all CT abdomen and pelvis scans conducted from November 2007 to August 2016 at their large teaching hospital and Bariatric Center of Excellence. A CT is especially useful at ruling out low-suspicion cases of leaks, when the surgeon is trying to decide if a diagnostic laparoscopy is indicated, with a sensitivity of 90%-100%, and a negative predictive value of 97%-100%. A negative CT scan is highly accurate for ruling out a leak, especially in those patients without co-existing tachycardia and tachypnea. With caution based on clinical expertise, it may serve to prevent unnecessary diagnostic laparoscopy when appropriately indicated.
Alizadeh RF et al. Risk factors for gastrointestinal leak after bariatric surgery: MBSAQIP analysis. J Am Coll Surg. 2018;227(1):135-141.
The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 database of accredited centers was the object of study. Multivariate logistic regression analysis was used to examine risk factors for GI leaks that are not typically included in similar studies. Of particular interest is finding that Roux-en-Y gastric bypass comes with a higher risk for leak, compared with a sleeve gastrectomy, but with an overall leak rate for both of 0.7% based on current results. In addition, the study found that use of an intraoperative provocative leak test and placement of a surgical drain are associated with a higher leak rate. The same is not true of a postoperative swallow contrast study, which has no effect on the incidence of leaks.
Altieri MS et al. Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures. Surg Endosc. 2018;32(12):4805-4812.
The field of venous thromboembolism prevention after bariatric surgery remains a challenging one due to the lack of consensus among surgeons. This study analyzes the Cerner Health Facts database from 2003 to 2013, particularly with ICD-9 codes, for patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy. While the authors confirm the statement that there is a lack of consistency and, therefore, there is ample variability among bariatric centers and surgeons, the use of postoperative VTE chemoprophylaxis leads to a lower incidence of VTE events, and less frequent bleeding episodes, compared with pre-operative chemoprophylaxis. Finally, mixed therapy using heparin and enoxaparin led to more bleeding complications and blood transfusion requirements.
Rodolfo J. Oviedo, MD, FACS, FASMBS
Cardiothoracic Surgery
Stone GW et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23; doi:10.1056/NEJMoa1806640.
This study, known as the COAPT trial, assessed the value of adding transcatheter mitral valve repair to best medical therapy for the treatment of moderate-to-severe or severe functional mitral regurgitation in patients with symptomatic heart failure. Not only was transcatheter mitral valve repair exceedingly safe (more than 96% freedom from device-related complications at 12 months), patients were hospitalized less for heart failure management and had lower all-cause mortality compared with best medical therapy alone. The results of the COAPT trial are an important step forward for transcatheter therapies, which are rapidly becoming an integral part of the treatment algorithms for structural heart disease.
Gaudino M et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med. 2018;378(22):2069-77.
This analysis of randomized trials comparing radial artery to saphenous vein grafts for coronary artery bypass surgery is quite possibly a practice-changing publication. Routine use of the left internal thoracic (mammary) artery is commonplace among cardiac surgeons; however, the debate over conduit choice for additional bypass grafts is a “tale as old as time.” This study, part of the RADIAL project, combined patient-level data from six trials in order to achieve adequate power to identify differences in clinical outcomes. The use of radial artery grafts as opposed to saphenous vein grafts was associated with less adverse cardiac events, a lower incidence of repeat revascularization, and a higher patency rate at 5 years. Although there was no difference in all-cause mortality, the results of this study support the use of radial artery grafts when additional conduits are needed in coronary artery bypass surgery.
Irving L. Kron, MD, FACS, and Eric J. Charles, MD, PhD
Vascular Surgery
Anand SS. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: An international, randomised, double-blind, placebo-controlled trial. Lancet 2018;391(10117):219-29.
This landmark study was terminated early due to a significant difference in outcomes. Prior to this point, aspirin and statins have been the mainstay of decreasing long-term adverse outcomes for patients with vascular disease. The COMPASS study has found a decrease in combined cardiovascular adverse events when rivaroxaban 2.5 mg was combined with low-dose aspirin in patients with stable PAD or CAD over aspirin alone. This is the first major change supporting use of additional medications for PAD in over 2 decades, when statins were found to impact outcomes. The differences were not impacted by gender, age, or race. Patients with end-tage renal disease were excluded, so it is unclear whether it would be beneficial in this population. The higher rate of bleeding, 3.1% vs 1.9%, was primarily GI, so caution should be used if patients are felt to be at increased risk of bleeding.
These findings suggest the need for a major change in the guidelines and management for the majority of our patients with PAD. Certainly we should look to add this data point to the Vascular Quality Initiative to gather further data and confirm the findings in real world use. It is unclear whether this benefit will be unique to rivaroxaban, or whether other Direct Xa inhibitors will have similar effects. I will certainly be adding ribaroxaban to patients at low risk for bleeding based on this data. Further, rivaroxaban alone did not reduce major cardiovascular adverse events, but did reduce major adverse limb events.
Gohel MS et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378:2105-14.
This multicenter study in the UK looked at over 450 patients with venous ulceration. Deep-venous reflux was also present in one-third of patients in each group. The median time to ulcer healing was decreased significantly from 82 days to 56 days. This study demonstrates the importance of early intervention for superficial reflux to enhance ulcer healing and decrease risk of recurrence. This study found that early endovenous ablation resulted in faster healing of venous ulcers, and more ulcer-free time than delayed intervention in patients treated with maximal medical therapy, including appropriate compression therapy. Previously, ablation was typically planned after ulcers healed to decrease risk of recurrence. Based on these findings, ablation should be offered to patients with nonhealing venous ulcers early in the course of therapy, in addition to standard wound care.
Linda Harris, MD, FACS
Surgical Education
Ellison EC. Ten-year reassessment of the shortage of general surgeons: Increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons. Surgery. 2018 Oct;164(4):726-32.
Ellison EC et al. The impact of the aging population and incidence of cancer on future projections of general surgery workforce needs. Surgery. 2018 Mar;163(3):553-59.
In 2008, Ellison et al. projected that a deficit in the general surgery workforce would grow to 19% by 2050. The group recently re-examined this projection by reviewing Census Bureau data, the available pool of surgeons with both allopathic and osteopathic degrees and factored in the losses of new surgeons who subspecialize and older surgeons who retire every year. Their conclusion states that, without increasing future general surgeons training numbers, the projected future general surgery workforce shortage will continue to grow.
A second paper by the same group reviewed population and age-adjusted incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. The total number of new patients with cancers treated by general surgeons is projected to increase 56% in that time span. This would require an increase of over 9,000 general surgeons over that based on current training numbers. Together, the papers predict that there will be an ever-increasing demand for general surgeons in the near future and that general surgeons, currently caring for over 50% of cancer patients in the US, will play an even more important role in surgical cancer treatment.
Michael D. Sarap, MD, FACS
General Surgery
Takada T. Tokyo Guidelines 2018 (TG18). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):1-2.
This is the updated set of guidelines, awaited since 2013, regarding treatment of acute cholecystitis and cholangitis, with updated management strategies from an international panel of experts. The most significant change, and considered overdue by some surgeons, is the modification of the management algorithm to propose that some patients with Grade III acute cholecystitis (severe cholecystitis with evidence of organ dysfunction) may be treated with immediate laparoscopic cholecystectomy, rather than percutaneous cholecystostomy, “when performed at advanced centers with specialized surgeons experienced in this procedure.” As cholecystectomy is the most common general surgery procedure in the United States, most community surgeons have expertise. Whether there is truly need of a specialized gallbladder surgeon at an advanced center to safely complete a laparoscopic cholecystectomy can still be debated. But the change in recommendation from the experts is welcome.
Acuna SA. Operative strategies for perforated diverticulitis: A systematic review and meta-analysis. Dis Colon Rectum. 2018 Dec; 61(12):1442-53.
This analysis of the literature considers the three predominant operations for Hinchey III and Hinchey IV perforated diverticulitis: Hartmann procedure, resection and primary anastomosis, and laparoscopic lavage. The importance of this review is that it considers the initial operation and the downstream procedures when determining overall morbidity and mortality. Laparoscopic lavage did not fare well in this review of randomized controlled trials, resulting in higher morbidity than resection in Hinchey III patients. Interestingly, none of the individual studies analyzed had shown a statistical difference, but in the meta-analysis, the number of patients was sufficient to show statistical significance. The other important conclusion was that primary resection with anastomosis (possibly with diverting ileostomy) was superior to Hartmann procedure, when the likelihood of stoma reversal and the morbidity of the second operation was taken into account.
Mark Savarise, MD, FACS
Foregut
Alicuben ET. Worldwide experience with erosion of the magnetic sphincter augmentation device. J Gastrointest Surg. 2018; 22(8):1442-47.
Although magnetic sphincter augmentation of the lower esophageal sphincter initially appeared to provide excellent reflux control with essentially no risk of erosion, there have now been multiple reports throughout the world of device erosion over time. Fortunately, most erosions occurred with the smallest available device which is no longer on the market and the erosions currently being treated are usually done so with endoscopic/laparoscopic removal without the need for major esophageal resection.
Xiong YQ. Comparison of narrow-band imaging and confocal laser endomicroscopy for the detection of neoplasia in Barrett’s esophagus: A meta-analysis. Clin Res Hepatol Gastroenterol. 2018 Feb;42(1):31-9.
The days of endoscopic screening and surveillance of patients at risk for the development of Barrett’s esophagus via four-quadrant biopsy every couple of centimeters are numbered. The use of confocal laser microscopy to provide accurate real-time visual data regarding the areas of interest in the esophagus is showing promise and gaining traction compared to standard biopsy techniques and narrow-band imaging.
Borbély Y. Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy. Surg Obes Relat Dis. 2018 May;14(5):611-5.
The development of GERD following sleeve gastrectomy is a real problem in a substantial minority of patients due to structural compromise of the lower esophageal sphincter during the procedure. Conversion to gastric bypass as a way to alleviate acid regurgitation has been the mainstay of treatment; however, many patients selected sleeve gastrectomy specifically because they did not want to undergo gastric bypass. For those patients a sleeve preserving procedure such as magnetic sphincter augmentation (currently in clinical trial), Hill procedure, or remnant gastric fundoplication are potential options. Electrical stimulation of the lower esophageal sphincter is revealing itself to be another exciting option (currently in clinical trial) which can be used in patients with as few as 30% peristaltic swallows thus expanding the treatment options for these deserving patients.
Kevin M. Reavis, MD, FACS
Trauma/Critical Care
Teixeira PGR et al. Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury . J Am Coll Surg. 2018;226(5):769-76.
The use of tourniquets for hemorrhage control in trauma patients has been widely condemned in the past because of concerns regarding complications and potential limb loss. However, evidence from liberal tourniquet use in combat situations documenting survival benefits has continued to accumulate. Prompt hemorrhage control in trauma patients, including the use of tourniquets where applicable, has been validated by recent combat zone studies but improved survival hasn’t yet been shown in the civilian setting. In this multicenter, retrospective study of 1,026 patients with peripheral vascular injuries, only a relatively small number (17.6%) had pre-hospital tourniquets applied, yet multivariable analysis showed a significant survival benefit (odds ratio, 5.86). Importantly, no difference was seen in delayed amputation rates, of approximately 1% in both groups. This study helps to emphasize the importance of the Stop the Bleed (STB) campaign which includes education on the effective and safe use of tourniquets for prehospital hemorrhage. The STB program offers surgeons the opportunity to educate members of their own communities in effective bystander first aid.
Pileggi C et al. Ventilator bundle and its effects on mortality among ICU patients: A meta-analysis. Crit Care Med. 2018;46(7):1167-74.
Critically ill patients requiring mechanical ventilation are at risk for a number of complications, including ventilator-associated pneumonia (VAP) (now a subset of ventilator-associated events (VAE) which prolong ventilator and ICU time and contribute to further complication. Ventilator “bundles,” incorporating simple measures such as elevation of the head of the bed; daily “sedation holidays”; and evaluation of readiness for extubation, peptic ulcer, and DVT prophylaxis have been widely used in ICUs for nearly 20 years. Effective implementation has also emphasized multidisciplinary teamwork. Reductions in ventilator-associated pneumonia (VAP) incidence have been widely demonstrated but mortality benefits have been inconsistent. In this meta-analysis of 13 studies, 6 in Europe, 6 in the US and 1 in Brazil, an overall reduction in mortality (odds ratio, 0.9) was demonstrated. The effect was even larger when limited to studies with patients with VAP (OR, 0.71). This study both validates the effectiveness of relatively simple and inexpensive measures and emphasizes the benefits of a team approach to the care of ICU patients.
Krista L. Kaups, MD, FACS
