Recommended reading: top papers in the surgical literature

Members of the Surgery News Editorial Advisory Board and their colleagues contributed to the list below, which represents articles from the recent surgical literature that they found particularly interesting. We hope readers across surgical specialties will find this information useful.

Bariatric surgery

"Surgical skill and complication rates after bariatric surgery" (N. Engl. J. Med. 2013;369:1434-2).

The authors conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass, which was rated in various domains of technical skill on a scale of 1-5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. The relationships between these skill ratings and risk-adjusted complication rates were assessed with data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients. The mean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. The bottom quartile of surgical skill, compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%; P less than .001) and higher mortality (0.26% vs. 0.05%; P = .01). The lowest quartile of skill also was significantly associated with longer operations and higher rates of reoperation and readmission. The findings suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon’s proficiency, the authors wrote.

Dr. Caprice Greenberg is an ACS Fellow, associate professor of surgery, and director of the Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison.

Dr. Henry A. Pitt is an ACS Fellow and chief quality officer, Temple University Health System, Philadelphia.

Bioinformatics

"The Randomized Registry Trial – The Next Disruptive Technology in Clinical Research?" (N. Engl. J. Med. 2013;369:1579-81).

This editorial discusses the emergence of randomized registry trials, scientific studies that leverage clinical information collected in observational registries to expedite the process the conducting of large-scale randomized controlled trials. Randomized registry trials are described as potentially "disruptive technologies," which may transform existing standards, procedures, and cost structures for comparative-effectiveness research.

"Telemedicine as a potential medium for teaching the advanced trauma life support (ATLS) course"(J. Surg. Educ. 2013;70:258-64).

This article describes a controlled trial that compared the performance of first-year family practice residents who were randomized to traditional in-person or telemedicine ATLS courses. There were no statistically significant differences between the groups in terms of post-ATLS multiple-choice question test performance, instructor evaluation of student skill station performance, and overall pass rate, nor were there significant differences in the participant evaluations of course components and overall course quality.

Dr. Grace Purcell Jackson is an ACS Fellow and assistant professor of surgery, pediatrics, and biomedical informatics, Vanderbilt University, Nashville, Tenn.

Endocrine surgery

"A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy" (Surgery 2013;154:1158-65).

This year there has been increased debate about the role of pre and postoperative laryngoscopy for patients undergoing thyroidectomy. An alternative to laryngoscopy that is garnishing a great deal of attention and interest in the endocrine surgery community is the use of transcutaneous ultrasound to evaluate vocal cord function. In this study of a series of 204 patients, the surgeons were able to visualize the vocal cords in 95% of patients. In their hands, ultrasound had a sensitivity of 93.3% and a negative predictive value of 99.4%. As many surgeons already use ultrasound regularly in their practice, this technique offers great promise for helping to identify patients who may benefit most from a laryngoscopic examination.

"Association Between BRAF V600E Mutation and Mortality in Patients With Papillary Thyroid Cancer" (JAMA 2013;309:1493-1501).

BRAF V600E is an important oncogene in papillary thyroid cancer. While it has been shown to play a useful role in the diagnosis of thyroid cancer, its impact on tumor behavior and patient outcomes is a matter of great debate. While several studies have shown that BRAF V600E is associated with a higher rate of nodal disease and recurrence, it hadn’t been shown to impact survival. This study included 1,849 patients from more than 13 centers and 7 countries. The researchers in this large study that BRAF V600E was associated with an increased incidence of cancer-related death, adjusted HR 2.66 (95% CI, 1.4-4.55). However, when they controlled for other known prognostic factors such as lymph node metastases, extrathyroidal extension, and distant metastases, they found that significance was lost. While BRAF V600E may lead to a worse prognosis, it may not add additional information beyond the already known prognostic factors in papillary thyroid cancer.

Dr. Rebecca Sippel is an ACS Fellow and chief of endocrine surgery, University of Wisconsin-Madison

General surgery

"Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before" (JAMA 2013; 310:1837-41).

In total, 94,183 eligible elective laparoscopic cholecystectomies were performed between 2004 and 2011. Of these surgeries, there were 2,078 procedures in which 331 different surgeons across 102 community hospitals had operated between midnight and 7 a.m. the night before. Each "at-risk" surgery was randomly matched with four other elective laparoscopic cholecystectomies (n = 8,312) performed by the same surgeon, who had no evidence of having operated the night before. No significant association was found in conversion rates to open operations between surgeons when they operated the night before compared with when they did not operate the previous night. There was also no association between operating the night before vs. not operating the night before, and the risk of iatrogenic injuries.

This study showed that elective surgery on a day following a night operation did not suffer from increased technical complications. Work-hour restrictions have never been based on good science, and this good study goes a long way to support the community surgeon who performs emergency surgery at night, then works a regular schedule during the day. The authors used a clever approach, reasoning that conversion to open surgery, iatrogenic injury, or death were markers of technical complications, then compared patients who had their lap choles the day after their surgeons had operated the night before with matched controls, showing no increase in complications or deaths. For many surgeons in smaller communities, an acute care surgical service is not practical, and surgeons routinely have elective patients post call. Surgeons can use evidence like this to justify their practice decisions.

Dr. Mark Savarise is an ACS Fellow and clinical assistant professor of surgery, University of Utah, South Jordan Health Center, Salt Lake City.

Head and neck surgery

"Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer" (J. Clin. Oncol. 2013;7:845-52).

The authors analyzed 520 patients with stage III or IV glottic or supraglottic squamous cell cancer who were randomly assigned to induction cisplatin/fluorouracil (PF) followed by radiation therapy (control arm), concomitant cisplatin/RT, or RT alone. The composite end point of laryngectomy-free survival (LFS) was the primary endpoint. Both chemotherapy regimens significantly improved laryngectomy-free survival (LFS) compared with RT alone. Overall survival did not differ significantly, although there was a possibility of worse outcome with concomitant relative to induction chemotherapy. Concomitant cisplatin/RT significantly improved the larynx preservation rate over induction PF followed by RT and over RT alone, whereas induction PF followed by RT was not better than treatment with RT alone. No difference in late effects was detected, but deaths not attributed to larynx cancer or treatment were higher with concomitant chemotherapy (30.8% vs. 20.8% with induction chemotherapy and 16.9% with RT alone).The authors concluded that these 10-year results show that induction PF followed by RT and concomitant cisplatin/RT show similar efficacy for the composite endpoint of LFS. Locoregional control and larynx preservation were significantly improved with concomitant cisplatin/RT compared with the induction arm or RT alone.

Dr. Mark Weissler is an ACS Fellow, the J.P. Riddle Distinguished Professor of Otolaryngology – Head and Neck Surgery at the University of North Carolina, Chapel Hill, and vice-chair of the Board of Regents of the ACS.

Infections

"Effect of daily chlorhexidine bathing on hospital-acquired infection" (N. Engl. J. Med. 2013;368:533-42).

The authors conducted a multicenter, cluster-randomized, nonblinded crossover trial of 7,727 patients to evaluate the effect of daily bathing with chlorhexidine-impregnated washcloths on the acquisition of multidrug-resistant organisms (MDROs) and the incidence of hospital-acquired bloodstream infections. Nine intensive care and bone marrow transplantation units in six hospitals were randomly assigned to bathe patients either with no-rinse 2% chlorhexidine–impregnated washcloths or with nonantimicrobial washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months. The overall rate of MDRO acquisition was 5.10 cases per 1,000 patient-days with chlorhexidine bathing versus 6.60 cases per 1,000 patient-days with nonantimicrobial washcloths (P = .03), the equivalent of a 23% lower rate with chlorhexidine bathing. The overall rate of hospital-acquired bloodstream infections was 4.78 cases per 1,000 patient-days with chlorhexidine bathing versus 6.60 cases per 1,000 patient-days with nonantimicrobial washcloths (P = .007), a 28% lower rate with chlorhexidine-impregnated washcloths. No serious skin reactions were noted during either study period.

In a world of $2 million robots seeking better outcomes and cost-effectiveness, it is important to remember that simple maneuvers like using patient baths may do more to alleviate suffering and death than the latest Buck Rogers equipment. Every hospital large and small can do this and make a difference right away without a large capital expense or a steep learning curve.

Dr. Tyler G. Hughes is an ACS Fellow and is with the department of general surgery at McPherson (Kan.) Hospital, editor of the Rural Surgery Community website for the ACS, and chair of the ACS Advisory Council on Rural Surgery.

Lung cancer surgery

"Treatment of stage I and II non–small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines" (Chest 2013;143:e278S-313S).

Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Among their conclusions: Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving.

This past year, the American College of Chest Physicians updated its guidelines on the management of lung cancer. These collective manuscripts have been vetted by its distinguished membership and represent the most up-to-date evidence-based guidelines for lung cancer treatment. An entire supplement of CHEST has been devoted to this third iteration of lung cancer guidelines and includes recommendations spanning the entire gamut of disease, from surgical resection to definitive chemoradiotherapy to palliative interventions. This represents the most significant literature contribution to the field in 2013.

Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.

Pediatric surgery

"Multicenter Study of Pectus Excavatum, Final Report: Complications, Static/Exercise Pulmonary Function, and Anatomic Outcomes" (J. Am. Coll. Surg. 2013;217:1080-9).

Pectus excavatum, or funnel chest, has long been a frequently-performed operation by pediatric and thoracic surgeons. It represents a significant psychological and sometimes physical burden for patients with the deformity. However, the literature has not previously provided definitive evidence of improved physiologic function after repair of pectus excavatum, despite unquestionable cosmetic and psychological improvements that accompany correction. For this reason, health care payers have been resistant to approve surgery for pectus excavatum. This multicenter study – of more than 300 patients who underwent pectus repairs via the Nuss technique or some form of open correction – for the first time demonstrates a significant improvement in pulmonary function, VO₂ max, and O₂ pulse in patients with a CT index of greater than 3.2 (considered severe), with normal being less than 2.5. This data should provide ample physiological evidence to support the repair of severe pectus deformities.

"Risk-Adjusted Hospital Outcomes for Children’s Surgery" (Pediatrics 2013;132:e677-88).

The National Surgical Quality Improvement Program (NSQIP) has unequivocally been shown to provide adult hospitals with actionable quality data that can lead to improved surgical outcomes, and to discriminate between high and low performing hospitals. Similar data for pediatric hospitals have not been as compelling. In this study, more than 46,000 patients were entered into Pediatric NSQIP and analyzed. Not surprisingly, the overall mortality rate (0.3%), cumulative morbidity (5.8%), and surgical site infection rate (1.8%) were quite low. As has been shown in the trauma literature, mortality is not a discriminating factor for quality between pediatric institutions. However, the data from this study suggest that models can be developed wherein cumulative morbidity and surgical site infection rates can differentiate between institutions, and should lead to successful efforts to improve surgical outcomes in children.

Dr. Dennis Lund is an ACS Fellow and executive vice president, Phoenix Children’s Medical Group, surgeon-in-chief, Phoenix Children’s Hospital, and professor of child health and surgery, University of Arizona College of Medicine–Phoenix.

Trauma surgery

"Outcomes following ‘rescue’ superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients" (J. Trauma Acute Care Surg. 2013;75:398-403).

The authors conducted a 10-year retrospective review of all hemodynamically unstable patients (systolic blood pressure less than 90 mm Hg and ongoing transfusion requirement) who underwent "rescue" SSAE for GIH after failed endoscopic management was performed. A total of 98 patients underwent SSAE for GIH; 47 were excluded because of lack of active contrast extravasation. Of the remaining 51 patients, 22 (43%) presented with a lower GIH and 29 (57%) with upper GIH. The majority (71%) underwent embolization with a permanent agent, while the remaining patients received a temporary agent (16%) or a combination (14%). The overall technical and clinical success rates were 98% and 71%, respectively. Of the 14 patients with technical success but clinical failure (rebleeding within 30 days) and the 1 patient with technical failure, 4 were managed successfully with reembolization, while 2 underwent successful endoscopic therapy, and 9 had surgical resections.

The authors concluded that SSAE, with reembolization if necessary, is an effective rescue treatment modality for hemodynamically unstable patients with active GIH. Of the patients, 20% will fail SSAE and require additional intervention. Ischemic complications were extremely rare.

"Platelets are dominant contributors to hypercoagulability after injury" (J. Trauma Acute Care Surg. 2013;74:756-65).

The authors randomized 50 surgical intensive care unit trauma patients to receive 5,000 IU of low-molecular-weight heparin (LMWH) daily (controls) or to thrombelastography (TEG)–guided prophylaxis, up to 5,000 IU twice daily with the addition of aspirin. Patients were followed up for 5 days. The control (n = 25) and TEG-guided prophylaxis (n = 25) groups were similar in age, body mass index, Injury Severity Score, and male sex. Fibrinogen levels and platelet counts did not differ, and increased LMWH did not affect clot strength between the control and study groups. The correlation of clot strength (G value) with fibrinogen was stronger on days 1 and 2 but was superseded by platelet count on days 3, 4, and 5. The authors concluded that increased LMWH seemed to increase platelet contribution to clot strength early in the study but failed to affect the overall rise clot strength. Over time, platelet count had the strongest correlation with clot strength, and in vitro studies demonstrated that increased platelet counts increase fibrin production and thrombus generation. These data suggest an important role for antiplatelet therapy in VTE prophylaxis following trauma, particularly after 48 hours, they stated.

Dr. Grace S. Rozycki is an ACS Fellow, Willis D. Gatch Professor of Surgery, executive vice chair of the department of surgery, and director of the Indiana Injury Institute, Indiana University, Indianapolis.

Members of the Surgery News Editorial Advisory Board and their colleagues contributed to the list below, which represents articles from the recent surgical literature that they found particularly interesting. We hope readers across surgical specialties will find this information useful.

Bariatric surgery

"Surgical skill and complication rates after bariatric surgery" (N. Engl. J. Med. 2013;369:1434-2).

The authors conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass, which was rated in various domains of technical skill on a scale of 1-5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. The relationships between these skill ratings and risk-adjusted complication rates were assessed with data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients. The mean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. The bottom quartile of surgical skill, compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%; P less than .001) and higher mortality (0.26% vs. 0.05%; P = .01). The lowest quartile of skill also was significantly associated with longer operations and higher rates of reoperation and readmission. The findings suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon’s proficiency, the authors wrote.

Dr. Caprice Greenberg is an ACS Fellow, associate professor of surgery, and director of the Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison.

Dr. Henry A. Pitt is an ACS Fellow and chief quality officer, Temple University Health System, Philadelphia.

Bioinformatics

"The Randomized Registry Trial – The Next Disruptive Technology in Clinical Research?" (N. Engl. J. Med. 2013;369:1579-81).

This editorial discusses the emergence of randomized registry trials, scientific studies that leverage clinical information collected in observational registries to expedite the process the conducting of large-scale randomized controlled trials. Randomized registry trials are described as potentially "disruptive technologies," which may transform existing standards, procedures, and cost structures for comparative-effectiveness research.

"Telemedicine as a potential medium for teaching the advanced trauma life support (ATLS) course"(J. Surg. Educ. 2013;70:258-64).

This article describes a controlled trial that compared the performance of first-year family practice residents who were randomized to traditional in-person or telemedicine ATLS courses. There were no statistically significant differences between the groups in terms of post-ATLS multiple-choice question test performance, instructor evaluation of student skill station performance, and overall pass rate, nor were there significant differences in the participant evaluations of course components and overall course quality.

Dr. Grace Purcell Jackson is an ACS Fellow and assistant professor of surgery, pediatrics, and biomedical informatics, Vanderbilt University, Nashville, Tenn.

Endocrine surgery

"A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy" (Surgery 2013;154:1158-65).

This year there has been increased debate about the role of pre and postoperative laryngoscopy for patients undergoing thyroidectomy. An alternative to laryngoscopy that is garnishing a great deal of attention and interest in the endocrine surgery community is the use of transcutaneous ultrasound to evaluate vocal cord function. In this study of a series of 204 patients, the surgeons were able to visualize the vocal cords in 95% of patients. In their hands, ultrasound had a sensitivity of 93.3% and a negative predictive value of 99.4%. As many surgeons already use ultrasound regularly in their practice, this technique offers great promise for helping to identify patients who may benefit most from a laryngoscopic examination.

"Association Between BRAF V600E Mutation and Mortality in Patients With Papillary Thyroid Cancer" (JAMA 2013;309:1493-1501).

BRAF V600E is an important oncogene in papillary thyroid cancer. While it has been shown to play a useful role in the diagnosis of thyroid cancer, its impact on tumor behavior and patient outcomes is a matter of great debate. While several studies have shown that BRAF V600E is associated with a higher rate of nodal disease and recurrence, it hadn’t been shown to impact survival. This study included 1,849 patients from more than 13 centers and 7 countries. The researchers in this large study that BRAF V600E was associated with an increased incidence of cancer-related death, adjusted HR 2.66 (95% CI, 1.4-4.55). However, when they controlled for other known prognostic factors such as lymph node metastases, extrathyroidal extension, and distant metastases, they found that significance was lost. While BRAF V600E may lead to a worse prognosis, it may not add additional information beyond the already known prognostic factors in papillary thyroid cancer.

Dr. Rebecca Sippel is an ACS Fellow and chief of endocrine surgery, University of Wisconsin-Madison

General surgery

"Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before" (JAMA 2013; 310:1837-41).

In total, 94,183 eligible elective laparoscopic cholecystectomies were performed between 2004 and 2011. Of these surgeries, there were 2,078 procedures in which 331 different surgeons across 102 community hospitals had operated between midnight and 7 a.m. the night before. Each "at-risk" surgery was randomly matched with four other elective laparoscopic cholecystectomies (n = 8,312) performed by the same surgeon, who had no evidence of having operated the night before. No significant association was found in conversion rates to open operations between surgeons when they operated the night before compared with when they did not operate the previous night. There was also no association between operating the night before vs. not operating the night before, and the risk of iatrogenic injuries.

This study showed that elective surgery on a day following a night operation did not suffer from increased technical complications. Work-hour restrictions have never been based on good science, and this good study goes a long way to support the community surgeon who performs emergency surgery at night, then works a regular schedule during the day. The authors used a clever approach, reasoning that conversion to open surgery, iatrogenic injury, or death were markers of technical complications, then compared patients who had their lap choles the day after their surgeons had operated the night before with matched controls, showing no increase in complications or deaths. For many surgeons in smaller communities, an acute care surgical service is not practical, and surgeons routinely have elective patients post call. Surgeons can use evidence like this to justify their practice decisions.

Dr. Mark Savarise is an ACS Fellow and clinical assistant professor of surgery, University of Utah, South Jordan Health Center, Salt Lake City.

Head and neck surgery

"Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer" (J. Clin. Oncol. 2013;7:845-52).

The authors analyzed 520 patients with stage III or IV glottic or supraglottic squamous cell cancer who were randomly assigned to induction cisplatin/fluorouracil (PF) followed by radiation therapy (control arm), concomitant cisplatin/RT, or RT alone. The composite end point of laryngectomy-free survival (LFS) was the primary endpoint. Both chemotherapy regimens significantly improved laryngectomy-free survival (LFS) compared with RT alone. Overall survival did not differ significantly, although there was a possibility of worse outcome with concomitant relative to induction chemotherapy. Concomitant cisplatin/RT significantly improved the larynx preservation rate over induction PF followed by RT and over RT alone, whereas induction PF followed by RT was not better than treatment with RT alone. No difference in late effects was detected, but deaths not attributed to larynx cancer or treatment were higher with concomitant chemotherapy (30.8% vs. 20.8% with induction chemotherapy and 16.9% with RT alone).The authors concluded that these 10-year results show that induction PF followed by RT and concomitant cisplatin/RT show similar efficacy for the composite endpoint of LFS. Locoregional control and larynx preservation were significantly improved with concomitant cisplatin/RT compared with the induction arm or RT alone.

Dr. Mark Weissler is an ACS Fellow, the J.P. Riddle Distinguished Professor of Otolaryngology – Head and Neck Surgery at the University of North Carolina, Chapel Hill, and vice-chair of the Board of Regents of the ACS.

Infections

"Effect of daily chlorhexidine bathing on hospital-acquired infection" (N. Engl. J. Med. 2013;368:533-42).

The authors conducted a multicenter, cluster-randomized, nonblinded crossover trial of 7,727 patients to evaluate the effect of daily bathing with chlorhexidine-impregnated washcloths on the acquisition of multidrug-resistant organisms (MDROs) and the incidence of hospital-acquired bloodstream infections. Nine intensive care and bone marrow transplantation units in six hospitals were randomly assigned to bathe patients either with no-rinse 2% chlorhexidine–impregnated washcloths or with nonantimicrobial washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months. The overall rate of MDRO acquisition was 5.10 cases per 1,000 patient-days with chlorhexidine bathing versus 6.60 cases per 1,000 patient-days with nonantimicrobial washcloths (P = .03), the equivalent of a 23% lower rate with chlorhexidine bathing. The overall rate of hospital-acquired bloodstream infections was 4.78 cases per 1,000 patient-days with chlorhexidine bathing versus 6.60 cases per 1,000 patient-days with nonantimicrobial washcloths (P = .007), a 28% lower rate with chlorhexidine-impregnated washcloths. No serious skin reactions were noted during either study period.

In a world of $2 million robots seeking better outcomes and cost-effectiveness, it is important to remember that simple maneuvers like using patient baths may do more to alleviate suffering and death than the latest Buck Rogers equipment. Every hospital large and small can do this and make a difference right away without a large capital expense or a steep learning curve.

Dr. Tyler G. Hughes is an ACS Fellow and is with the department of general surgery at McPherson (Kan.) Hospital, editor of the Rural Surgery Community website for the ACS, and chair of the ACS Advisory Council on Rural Surgery.

Lung cancer surgery

"Treatment of stage I and II non–small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines" (Chest 2013;143:e278S-313S).

Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Among their conclusions: Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving.

This past year, the American College of Chest Physicians updated its guidelines on the management of lung cancer. These collective manuscripts have been vetted by its distinguished membership and represent the most up-to-date evidence-based guidelines for lung cancer treatment. An entire supplement of CHEST has been devoted to this third iteration of lung cancer guidelines and includes recommendations spanning the entire gamut of disease, from surgical resection to definitive chemoradiotherapy to palliative interventions. This represents the most significant literature contribution to the field in 2013.

Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.

Pediatric surgery

"Multicenter Study of Pectus Excavatum, Final Report: Complications, Static/Exercise Pulmonary Function, and Anatomic Outcomes" (J. Am. Coll. Surg. 2013;217:1080-9).

Pectus excavatum, or funnel chest, has long been a frequently-performed operation by pediatric and thoracic surgeons. It represents a significant psychological and sometimes physical burden for patients with the deformity. However, the literature has not previously provided definitive evidence of improved physiologic function after repair of pectus excavatum, despite unquestionable cosmetic and psychological improvements that accompany correction. For this reason, health care payers have been resistant to approve surgery for pectus excavatum. This multicenter study – of more than 300 patients who underwent pectus repairs via the Nuss technique or some form of open correction – for the first time demonstrates a significant improvement in pulmonary function, VO₂ max, and O₂ pulse in patients with a CT index of greater than 3.2 (considered severe), with normal being less than 2.5. This data should provide ample physiological evidence to support the repair of severe pectus deformities.

"Risk-Adjusted Hospital Outcomes for Children’s Surgery" (Pediatrics 2013;132:e677-88).

The National Surgical Quality Improvement Program (NSQIP) has unequivocally been shown to provide adult hospitals with actionable quality data that can lead to improved surgical outcomes, and to discriminate between high and low performing hospitals. Similar data for pediatric hospitals have not been as compelling. In this study, more than 46,000 patients were entered into Pediatric NSQIP and analyzed. Not surprisingly, the overall mortality rate (0.3%), cumulative morbidity (5.8%), and surgical site infection rate (1.8%) were quite low. As has been shown in the trauma literature, mortality is not a discriminating factor for quality between pediatric institutions. However, the data from this study suggest that models can be developed wherein cumulative morbidity and surgical site infection rates can differentiate between institutions, and should lead to successful efforts to improve surgical outcomes in children.

Dr. Dennis Lund is an ACS Fellow and executive vice president, Phoenix Children’s Medical Group, surgeon-in-chief, Phoenix Children’s Hospital, and professor of child health and surgery, University of Arizona College of Medicine–Phoenix.

Trauma surgery

"Outcomes following ‘rescue’ superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients" (J. Trauma Acute Care Surg. 2013;75:398-403).

The authors conducted a 10-year retrospective review of all hemodynamically unstable patients (systolic blood pressure less than 90 mm Hg and ongoing transfusion requirement) who underwent "rescue" SSAE for GIH after failed endoscopic management was performed. A total of 98 patients underwent SSAE for GIH; 47 were excluded because of lack of active contrast extravasation. Of the remaining 51 patients, 22 (43%) presented with a lower GIH and 29 (57%) with upper GIH. The majority (71%) underwent embolization with a permanent agent, while the remaining patients received a temporary agent (16%) or a combination (14%). The overall technical and clinical success rates were 98% and 71%, respectively. Of the 14 patients with technical success but clinical failure (rebleeding within 30 days) and the 1 patient with technical failure, 4 were managed successfully with reembolization, while 2 underwent successful endoscopic therapy, and 9 had surgical resections.

The authors concluded that SSAE, with reembolization if necessary, is an effective rescue treatment modality for hemodynamically unstable patients with active GIH. Of the patients, 20% will fail SSAE and require additional intervention. Ischemic complications were extremely rare.

"Platelets are dominant contributors to hypercoagulability after injury" (J. Trauma Acute Care Surg. 2013;74:756-65).

The authors randomized 50 surgical intensive care unit trauma patients to receive 5,000 IU of low-molecular-weight heparin (LMWH) daily (controls) or to thrombelastography (TEG)–guided prophylaxis, up to 5,000 IU twice daily with the addition of aspirin. Patients were followed up for 5 days. The control (n = 25) and TEG-guided prophylaxis (n = 25) groups were similar in age, body mass index, Injury Severity Score, and male sex. Fibrinogen levels and platelet counts did not differ, and increased LMWH did not affect clot strength between the control and study groups. The correlation of clot strength (G value) with fibrinogen was stronger on days 1 and 2 but was superseded by platelet count on days 3, 4, and 5. The authors concluded that increased LMWH seemed to increase platelet contribution to clot strength early in the study but failed to affect the overall rise clot strength. Over time, platelet count had the strongest correlation with clot strength, and in vitro studies demonstrated that increased platelet counts increase fibrin production and thrombus generation. These data suggest an important role for antiplatelet therapy in VTE prophylaxis following trauma, particularly after 48 hours, they stated.

Dr. Grace S. Rozycki is an ACS Fellow, Willis D. Gatch Professor of Surgery, executive vice chair of the department of surgery, and director of the Indiana Injury Institute, Indiana University, Indianapolis.

Members of the Surgery News Editorial Advisory Board and their colleagues contributed to the list below, which represents articles from the recent surgical literature that they found particularly interesting. We hope readers across surgical specialties will find this information useful.

Bariatric surgery

"Surgical skill and complication rates after bariatric surgery" (N. Engl. J. Med. 2013;369:1434-2).

The authors conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass, which was rated in various domains of technical skill on a scale of 1-5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. The relationships between these skill ratings and risk-adjusted complication rates were assessed with data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients. The mean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. The bottom quartile of surgical skill, compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%; P less than .001) and higher mortality (0.26% vs. 0.05%; P = .01). The lowest quartile of skill also was significantly associated with longer operations and higher rates of reoperation and readmission. The findings suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon’s proficiency, the authors wrote.

Dr. Caprice Greenberg is an ACS Fellow, associate professor of surgery, and director of the Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison.

Dr. Henry A. Pitt is an ACS Fellow and chief quality officer, Temple University Health System, Philadelphia.

Bioinformatics

"The Randomized Registry Trial – The Next Disruptive Technology in Clinical Research?" (N. Engl. J. Med. 2013;369:1579-81).

This editorial discusses the emergence of randomized registry trials, scientific studies that leverage clinical information collected in observational registries to expedite the process the conducting of large-scale randomized controlled trials. Randomized registry trials are described as potentially "disruptive technologies," which may transform existing standards, procedures, and cost structures for comparative-effectiveness research.

"Telemedicine as a potential medium for teaching the advanced trauma life support (ATLS) course"(J. Surg. Educ. 2013;70:258-64).

This article describes a controlled trial that compared the performance of first-year family practice residents who were randomized to traditional in-person or telemedicine ATLS courses. There were no statistically significant differences between the groups in terms of post-ATLS multiple-choice question test performance, instructor evaluation of student skill station performance, and overall pass rate, nor were there significant differences in the participant evaluations of course components and overall course quality.

Dr. Grace Purcell Jackson is an ACS Fellow and assistant professor of surgery, pediatrics, and biomedical informatics, Vanderbilt University, Nashville, Tenn.

Endocrine surgery

"A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy" (Surgery 2013;154:1158-65).

This year there has been increased debate about the role of pre and postoperative laryngoscopy for patients undergoing thyroidectomy. An alternative to laryngoscopy that is garnishing a great deal of attention and interest in the endocrine surgery community is the use of transcutaneous ultrasound to evaluate vocal cord function. In this study of a series of 204 patients, the surgeons were able to visualize the vocal cords in 95% of patients. In their hands, ultrasound had a sensitivity of 93.3% and a negative predictive value of 99.4%. As many surgeons already use ultrasound regularly in their practice, this technique offers great promise for helping to identify patients who may benefit most from a laryngoscopic examination.

"Association Between BRAF V600E Mutation and Mortality in Patients With Papillary Thyroid Cancer" (JAMA 2013;309:1493-1501).

BRAF V600E is an important oncogene in papillary thyroid cancer. While it has been shown to play a useful role in the diagnosis of thyroid cancer, its impact on tumor behavior and patient outcomes is a matter of great debate. While several studies have shown that BRAF V600E is associated with a higher rate of nodal disease and recurrence, it hadn’t been shown to impact survival. This study included 1,849 patients from more than 13 centers and 7 countries. The researchers in this large study that BRAF V600E was associated with an increased incidence of cancer-related death, adjusted HR 2.66 (95% CI, 1.4-4.55). However, when they controlled for other known prognostic factors such as lymph node metastases, extrathyroidal extension, and distant metastases, they found that significance was lost. While BRAF V600E may lead to a worse prognosis, it may not add additional information beyond the already known prognostic factors in papillary thyroid cancer.

Dr. Rebecca Sippel is an ACS Fellow and chief of endocrine surgery, University of Wisconsin-Madison

General surgery

"Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before" (JAMA 2013; 310:1837-41).

In total, 94,183 eligible elective laparoscopic cholecystectomies were performed between 2004 and 2011. Of these surgeries, there were 2,078 procedures in which 331 different surgeons across 102 community hospitals had operated between midnight and 7 a.m. the night before. Each "at-risk" surgery was randomly matched with four other elective laparoscopic cholecystectomies (n = 8,312) performed by the same surgeon, who had no evidence of having operated the night before. No significant association was found in conversion rates to open operations between surgeons when they operated the night before compared with when they did not operate the previous night. There was also no association between operating the night before vs. not operating the night before, and the risk of iatrogenic injuries.

This study showed that elective surgery on a day following a night operation did not suffer from increased technical complications. Work-hour restrictions have never been based on good science, and this good study goes a long way to support the community surgeon who performs emergency surgery at night, then works a regular schedule during the day. The authors used a clever approach, reasoning that conversion to open surgery, iatrogenic injury, or death were markers of technical complications, then compared patients who had their lap choles the day after their surgeons had operated the night before with matched controls, showing no increase in complications or deaths. For many surgeons in smaller communities, an acute care surgical service is not practical, and surgeons routinely have elective patients post call. Surgeons can use evidence like this to justify their practice decisions.

Dr. Mark Savarise is an ACS Fellow and clinical assistant professor of surgery, University of Utah, South Jordan Health Center, Salt Lake City.

Head and neck surgery

"Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer" (J. Clin. Oncol. 2013;7:845-52).

The authors analyzed 520 patients with stage III or IV glottic or supraglottic squamous cell cancer who were randomly assigned to induction cisplatin/fluorouracil (PF) followed by radiation therapy (control arm), concomitant cisplatin/RT, or RT alone. The composite end point of laryngectomy-free survival (LFS) was the primary endpoint. Both chemotherapy regimens significantly improved laryngectomy-free survival (LFS) compared with RT alone. Overall survival did not differ significantly, although there was a possibility of worse outcome with concomitant relative to induction chemotherapy. Concomitant cisplatin/RT significantly improved the larynx preservation rate over induction PF followed by RT and over RT alone, whereas induction PF followed by RT was not better than treatment with RT alone. No difference in late effects was detected, but deaths not attributed to larynx cancer or treatment were higher with concomitant chemotherapy (30.8% vs. 20.8% with induction chemotherapy and 16.9% with RT alone).The authors concluded that these 10-year results show that induction PF followed by RT and concomitant cisplatin/RT show similar efficacy for the composite endpoint of LFS. Locoregional control and larynx preservation were significantly improved with concomitant cisplatin/RT compared with the induction arm or RT alone.

Dr. Mark Weissler is an ACS Fellow, the J.P. Riddle Distinguished Professor of Otolaryngology – Head and Neck Surgery at the University of North Carolina, Chapel Hill, and vice-chair of the Board of Regents of the ACS.

Infections

"Effect of daily chlorhexidine bathing on hospital-acquired infection" (N. Engl. J. Med. 2013;368:533-42).

The authors conducted a multicenter, cluster-randomized, nonblinded crossover trial of 7,727 patients to evaluate the effect of daily bathing with chlorhexidine-impregnated washcloths on the acquisition of multidrug-resistant organisms (MDROs) and the incidence of hospital-acquired bloodstream infections. Nine intensive care and bone marrow transplantation units in six hospitals were randomly assigned to bathe patients either with no-rinse 2% chlorhexidine–impregnated washcloths or with nonantimicrobial washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months. The overall rate of MDRO acquisition was 5.10 cases per 1,000 patient-days with chlorhexidine bathing versus 6.60 cases per 1,000 patient-days with nonantimicrobial washcloths (P = .03), the equivalent of a 23% lower rate with chlorhexidine bathing. The overall rate of hospital-acquired bloodstream infections was 4.78 cases per 1,000 patient-days with chlorhexidine bathing versus 6.60 cases per 1,000 patient-days with nonantimicrobial washcloths (P = .007), a 28% lower rate with chlorhexidine-impregnated washcloths. No serious skin reactions were noted during either study period.

In a world of $2 million robots seeking better outcomes and cost-effectiveness, it is important to remember that simple maneuvers like using patient baths may do more to alleviate suffering and death than the latest Buck Rogers equipment. Every hospital large and small can do this and make a difference right away without a large capital expense or a steep learning curve.

Dr. Tyler G. Hughes is an ACS Fellow and is with the department of general surgery at McPherson (Kan.) Hospital, editor of the Rural Surgery Community website for the ACS, and chair of the ACS Advisory Council on Rural Surgery.

Lung cancer surgery

"Treatment of stage I and II non–small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines" (Chest 2013;143:e278S-313S).

Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Among their conclusions: Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving.

This past year, the American College of Chest Physicians updated its guidelines on the management of lung cancer. These collective manuscripts have been vetted by its distinguished membership and represent the most up-to-date evidence-based guidelines for lung cancer treatment. An entire supplement of CHEST has been devoted to this third iteration of lung cancer guidelines and includes recommendations spanning the entire gamut of disease, from surgical resection to definitive chemoradiotherapy to palliative interventions. This represents the most significant literature contribution to the field in 2013.

Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.

Pediatric surgery

"Multicenter Study of Pectus Excavatum, Final Report: Complications, Static/Exercise Pulmonary Function, and Anatomic Outcomes" (J. Am. Coll. Surg. 2013;217:1080-9).

Pectus excavatum, or funnel chest, has long been a frequently-performed operation by pediatric and thoracic surgeons. It represents a significant psychological and sometimes physical burden for patients with the deformity. However, the literature has not previously provided definitive evidence of improved physiologic function after repair of pectus excavatum, despite unquestionable cosmetic and psychological improvements that accompany correction. For this reason, health care payers have been resistant to approve surgery for pectus excavatum. This multicenter study – of more than 300 patients who underwent pectus repairs via the Nuss technique or some form of open correction – for the first time demonstrates a significant improvement in pulmonary function, VO₂ max, and O₂ pulse in patients with a CT index of greater than 3.2 (considered severe), with normal being less than 2.5. This data should provide ample physiological evidence to support the repair of severe pectus deformities.

"Risk-Adjusted Hospital Outcomes for Children’s Surgery" (Pediatrics 2013;132:e677-88).

The National Surgical Quality Improvement Program (NSQIP) has unequivocally been shown to provide adult hospitals with actionable quality data that can lead to improved surgical outcomes, and to discriminate between high and low performing hospitals. Similar data for pediatric hospitals have not been as compelling. In this study, more than 46,000 patients were entered into Pediatric NSQIP and analyzed. Not surprisingly, the overall mortality rate (0.3%), cumulative morbidity (5.8%), and surgical site infection rate (1.8%) were quite low. As has been shown in the trauma literature, mortality is not a discriminating factor for quality between pediatric institutions. However, the data from this study suggest that models can be developed wherein cumulative morbidity and surgical site infection rates can differentiate between institutions, and should lead to successful efforts to improve surgical outcomes in children.

Dr. Dennis Lund is an ACS Fellow and executive vice president, Phoenix Children’s Medical Group, surgeon-in-chief, Phoenix Children’s Hospital, and professor of child health and surgery, University of Arizona College of Medicine–Phoenix.

Trauma surgery

"Outcomes following ‘rescue’ superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients" (J. Trauma Acute Care Surg. 2013;75:398-403).

The authors conducted a 10-year retrospective review of all hemodynamically unstable patients (systolic blood pressure less than 90 mm Hg and ongoing transfusion requirement) who underwent "rescue" SSAE for GIH after failed endoscopic management was performed. A total of 98 patients underwent SSAE for GIH; 47 were excluded because of lack of active contrast extravasation. Of the remaining 51 patients, 22 (43%) presented with a lower GIH and 29 (57%) with upper GIH. The majority (71%) underwent embolization with a permanent agent, while the remaining patients received a temporary agent (16%) or a combination (14%). The overall technical and clinical success rates were 98% and 71%, respectively. Of the 14 patients with technical success but clinical failure (rebleeding within 30 days) and the 1 patient with technical failure, 4 were managed successfully with reembolization, while 2 underwent successful endoscopic therapy, and 9 had surgical resections.

The authors concluded that SSAE, with reembolization if necessary, is an effective rescue treatment modality for hemodynamically unstable patients with active GIH. Of the patients, 20% will fail SSAE and require additional intervention. Ischemic complications were extremely rare.

"Platelets are dominant contributors to hypercoagulability after injury" (J. Trauma Acute Care Surg. 2013;74:756-65).

The authors randomized 50 surgical intensive care unit trauma patients to receive 5,000 IU of low-molecular-weight heparin (LMWH) daily (controls) or to thrombelastography (TEG)–guided prophylaxis, up to 5,000 IU twice daily with the addition of aspirin. Patients were followed up for 5 days. The control (n = 25) and TEG-guided prophylaxis (n = 25) groups were similar in age, body mass index, Injury Severity Score, and male sex. Fibrinogen levels and platelet counts did not differ, and increased LMWH did not affect clot strength between the control and study groups. The correlation of clot strength (G value) with fibrinogen was stronger on days 1 and 2 but was superseded by platelet count on days 3, 4, and 5. The authors concluded that increased LMWH seemed to increase platelet contribution to clot strength early in the study but failed to affect the overall rise clot strength. Over time, platelet count had the strongest correlation with clot strength, and in vitro studies demonstrated that increased platelet counts increase fibrin production and thrombus generation. These data suggest an important role for antiplatelet therapy in VTE prophylaxis following trauma, particularly after 48 hours, they stated.

Dr. Grace S. Rozycki is an ACS Fellow, Willis D. Gatch Professor of Surgery, executive vice chair of the department of surgery, and director of the Indiana Injury Institute, Indiana University, Indianapolis.