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Recommended Reading lists are something of a tradition for ACS Surgery News. This feature has appeared several times over the years and it has always proved among the most popular items in the publication. But the project hinges on input from our Editorial Advisory Board, the members of which are already regularly called upon to help vet the publication’s content and give their advice. They have gone the extra mile and have once again chosen their “Best of 2017” studies in their own specialty areas, along with commentary on why their choices should be of interest to all surgeons. We hope our readers will find the list and the comments of interest.
General surgery
Cogbill TH et al. Rural general surgery: A 38-year experience with a regional network established by an integrated health system in the Midwestern United States. J Am Coll Surg. 2017;225(1):115-24.
This article is of particular interest because it provides details of an innovative, regional system of surgical care at the critical access hospitals and referral centers that cooperate seamlessly to improve quality of care and quality of practice for rural surgeons. It could serve as a model for similar independent hospitals and practices in a region to improve the practice lives of the surgeons in rural communities and preserve access to local care for rural patients.
Dimou FM et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: A propensity score analysis. J Am Coll Surg. 2017;224(4):502-14.This study is valuable because it sheds light on the current status of treatment of severe acute cholecystitis in the United States and reports outcomes of patients who get initial tube cholecystostomy. It demonstrates potential drawbacks of following the Tokyo Guidelines: fewer patients receiving definitive treatment (cholecystectomy) and higher mortality rates and readmissions.
Karen E. Deveney, MD, FACS 
Palliative Care
Gani F et al. Palliative care utilization among patients admitted for gastrointestinal and thoracic cancers. J Palliat Med. 2017 Nov 3; doi: 10.1089/jpm.2017.0295; epub ahead of print.
Is this a matter of “too little too late”? This retrospective cross-sectional analysis of patients identified in the National Inpatient Sample database admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer determined that only 8.5% of patients admitted received palliative care services. Surgical patients were 79% less likely to have received a palliative care consultation, and then only after a prolonged length of stay or postoperative complication. Is referral to palliative care services hindered by its stigmatization with these outcomes?
Taylor LJ et al. A framework to improve surgeon communication in high-stakes surgical decisions: Best Case/Worst Case. JAMA Surgery. 2017;152(6):531-8.
My chief used to say, “You might not be teachable, but you are trainable!” After surgeons received training in the Best Case/Worst Case framework described in this paper, they demonstrated that it was possible to successfully change the focus of decision-making conversations from an isolated surgical problem – with its menu of technical solutions – instead into a discussion about treatment alternatives and outcomes. This intervention is a useful tool for one of the most invasive procedures of all – an exploration of a patient’s preferences and values that is necessary for shared decision making within the acute setting.
Makhani SS et al. Cognitive impairment and overall survival in frail surgical patients. J Amer Coll Surg. 2017 Nov;225(5):590-600.
In my preoperative discussions with families of frail patients, it is often quite evident that the factor driving their decision is the cognitive state of the patient and the consequences of its further decline, even when they are willing to accept the risks of physical frailty. This study in a large multidisciplinary cohort of patients undergoing major operations determined that a combined frailty (Fried frailty score) and cognitive assessment score (Emory Clock Draw Test) has a more powerful potential to predict adult patients at higher risk of overall survival than does either measurement alone. Dual frailty and cognitive screening appears to be a promising adjunct to the shared decision-making process.
Geoffrey P. Dunn, MD, FACS 
Wilson DG et al. Patterns of care in hospitalized vascular patients at end of life. JAMA Surg. 2017;152(2):183-90.
This thoughtful study and the excellent accompanying invited commentary by William Schecter, MD, FACS, address a major, difficult issue that faces all physicians as our patients become older and sicker and our ability to keep them alive expands: How do we speak honestly with patients about their prognosis and likely outcomes and honor their autonomy in decision making?
Karen E. Deveney, MD, FACS
Practice Management
Robinson JR et al. Complexity of medical decision making in care provided by surgeons through patient portals. Surg Res. 2017;214:93-101.
This article describes an analysis of the content of patient portal messages exchanged between surgical providers and patients. The study demonstrates that more than 90% of these exchanges involved the delivery of medical care, and more than two-thirds of the messages contained medical decision making, which might have generated charges if done in a face-to-face outpatient encounter. The articles argues that surgeons are providing substantial medical care to their patients through patient portal message exchanges and suggests that models for compensation of this type of online care should be developed.
Gretchen Purcell Jackson, MD, FACS 
Vascular Surgery
Bennett KM et al. Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg. 2017 Sep;66(3):794-801.
This article uses the ACS NSQIP database to assess outcomes of women undergoing intervention for carotid stenosis in a real-world setting and finds that major adverse cardiac events in the first 30 days is higher for carotid artery stenting (12.2%), compared with carotid endarterectomy (5.2%). What we need to keep in mind is that the practice of any intervention for asymptomatic carotid stenosis is being reevaluated in the new CREST study, which will compare current best medical management with carotid stenting and carotid endarterectomy. The indications are likely to change for all, but because women had less relative risk reduction in the early studies, we can expect that the benefits for intervention for women will continue to be less than those for men, calling to question when we should truly intervene, and how best to do so.
Gargiulo M et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg. 2017 Oct;66(4);1065-72.
This study found that endovascular aneurysm repair, performed in patients with large necks (greater than 28 mm), was associated with further neck enlargement at 2 years, and a higher risk of proximal type I endoleak, with the need for reintervention. This is one of many recent studies, all with similar findings. The issue becomes how we can best address larger infrarenal necks, whether by use of fenestrated grafts, snorkels/chimneys with extension of the seal zone, aptus, or other technologies. The question of whether all grafts have equal impacts on these more dilated necks has still to be elucidated. Nonetheless, when we stretch the instructions for use, there is an increased likelihood for more interventions.
Zettervall SL et al. Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. J Vasc Surg. 2017 Oct;66(4):1305.
This study found that endografts with suprarenal fixation were associated with a greater decline in renal function, compared with those with infrarenal fixation, as well as with a longer length of stay. The reasons for the renal function decline are not entirely clear, and there was a slight increase in contrast use for those with suprarenal fixation but were otherwise similar when comparing comorbidities. Clearly, assessment of any impact on long-term renal function is important, and may affect future choice of endografts.
Linda Harris, MD, FACS
Bariatric Surgery
Rosenthal RJ et al. Obesity in America. Surg Obes Relat Dis. 2017 Oct;13(10):1643-50.
Although much has been reported on the dramatic benefits of bariatric surgery, it remains a matter of deep disappointment that only 1%-2% of the eligible population is receiving this life-saving therapy. This is a paper that reports and analyzes the results of a national survey that was conducted on behalf of the American Society for Metabolic & Bariatric Surgery, in an attempt to identify barriers to access, public misconceptions on obesity and its consequences, and other pertinent factors. Survey results included the findings that, although 80% of Americans considered obesity as the most serious health risk problem, there was a clear overestimation of the effectiveness of diet and exercise alone. The importance of this paper lies in the persistent lack of recognition and/or awareness of proven, safe, and durable medical and surgical options in the lay population, highlighting the importance of aligning efforts and resources toward educating both the public and referring physicians.
Adams TD et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017 Sep 21;377(12):1143-55
This paper reports the results of an observational, prospective study that followed patients who received gastric bypass, in comparison with a group of patients who desired but did not receive gastric bypass, and a third group of obese patients who did not seek surgery. The authors concluded that gastric bypass provided durable, 12-year remission and prevention of such lethal diseases as diabetes, hypertension, and dyslipidemia. The importance of this study is in its detailed follow-up, the exceedingly high retention rate of 90% at 12 years, and the comparisons made between surgical and nonsurgical groups, demonstrating not only the benefits of gastric bypass, but as importantly, the hazards of not receiving this treatment.
Schauer PR et al. Bariatric surgery versus intensive medical therapy for diabetes – 5-year outcomes. N Engl J Med. 2017 Feb 16;376(7):641-51.This paper is the latest installment of the long-term results from the STAMPEDE trial conducted at the Cleveland Clinic. STAMPEDE is a randomized, controlled trial that compared the best, most “intensive” medical therapy for type 2 diabetes vs. bariatric surgery (comprising a mix of gastric bypass and sleeve gastrectomy). Prior publications from this group reported 1- and 3-year results, and this paper reported the 5-year results, demonstrating the persistent superiority of bariatric surgery over the most rigorous intensive medical therapy in the resolution or improvement of hyperglycemia in patients with BMI ranges of 27 kg/m2 to 43 kg/m2. Of further significance was the fact that there were no major late surgical complications except for one reoperation.
Samer Mattar, MD, FACS 
Colon & Rectal Surgery
Jayne D et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: The ROLARR randomized clinical trial. JAMA. 2017;318(16):1569-80.
This trial of 471 rectal cancer patients demonstrated similar conversion rates for robotic (8.1%) and laparoscopic (12.2%) surgery. Of the other secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups.
Marshall JR et al. Laparoscopic lavage in the management of Hinchey grade III diverticulitis: A systematic review. Ann Surg. 2017;265(4):670-6.While there have been a number of groups using laparoscopic lavage in the setting of acute diverticulitis, including Hinchey grade III disease, several recent studies question this approach. This meta-analysis includes three recent randomized, controlled trials and analysis of 48 studies – demonstrating that rates of reintervention within 30 days to be 28.3% in the lavage group and 8.8% in the resection group. Other outcomes – including ICU admissions, 30- and 90-day mortality, or stoma rates at 12 months – were similar between groups.
Denost Q et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: The GRECCAR 5 randomized trial. Ann Surg. 2017;365(3):474-80.
While many studies have confirmed infectiveness of drainage after colectomy, there is still some controversy of the role of pelvic drainage after rectal surgery. A multicenter randomized, controlled trial with two parallel arms (drain vs. no drain) was conducted in 469 patients after rectal surgery for cancer. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Rates of pelvic sepsis were similar between drain and no drain: 16.1% vs. 18.0% (P = .58), and there was no difference in surgical morbidity, rate of reoperation, length of hospital stay, and rate of stoma closure between groups. Overall, this trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit.
Genevieve Melton-Meaux, MD, FACS
Breast Surgery
Giuliano AE et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 randomized clinical trial. JAMA. 2017 Sep 12;318(10):918-926.
Long-term outcomes from the practice-changing ACOSOG Z0011 (Alliance) trial confirming the safety of omitting completion axillary lymph node dissection in women with T1/T2 tumors treated by lumpectomy and whole-breast radiation when metastatic disease is identified in one or two sentinel nodes.
Masuda N et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017 Jun 1;376(22):2147-59.
Breast cancer patients that achieve a complete pathologic response after receiving neoadjuvant chemotherapy have a survival advantage, and patients found to have residual disease represent a higher-risk population subset. This prospective randomized clinical trial (known as the CREATE-X study) revealed that adjuvant capecitabine can significantly mitigate this risk, especially for patients with triple-negative breast cancer.
Curigliano G et al. De-escalating and escalating treatments for early stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol. 2017 Aug 1;28(8):1700-12.
This summary of the 2017 St. Gallen Conference proceedings provides a comprehensive yet concise review of contemporary standards of care in managing early stage breast cancer. Issues reviewed include lumpectomy margins, extent of breast/axillary surgery following neoadjuvant chemotherapy, options for breast radiation schedules following lumpectomy, and application of currently available gene expression profiles.
Troester MA et al. Racial differences in PAM50 subtypes in the Carolina Breast Cancer Study. J Natl Cancer Inst. 2018 Feb 1;110(2);doi: 10.1093/jnci/djx135; epub ahead of print (Aug 2017).
Breast cancer outcome disparities related to racial/ethnic identity are well documented, with African American patients experiencing higher mortality rates, compared with White Americans. This disparity is partly explained by differences in tumor biology, since triple-negative breast cancer (TNBC) is twice as common in African American patients. Troester et al. conducted RNA expression-based PAM-50 tumor subtyping to demonstrate significantly higher rates of biologically aggressive tumor subtypes among African Americans breast cancer patients, compared with white Americans.
Lisa Newman, MD, FACS 
Foregut
Teitelbaum EN et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2017 Jun 29. doi: 10.1007/s00464-017-5699-2 ; epub ahead of print.
This provides the longest follow-up to date regarding clinical efficacy of peroral endoscopic myotomy (POEM) in the United States. Although not a panacea, POEM appears to provide substantial durable clinical improvement in patients suffering from esophageal motility disorders.
Kevin Reavis, MD, FACS
Yufei Chen et al. Primary lymph node gastrinoma: A single institution experience. Surgery 2017 Nov;162(5):1088-94
This article retrospectively review a rare neuroendocrine (gastrinoma) tumor over a 25-year period at a single institution, noting all demographics and outcomes. Great update and refresher. The article then went farther, evaluating an even rarer occurrence of a primary lymph node gastrinoma within this patient population and followed those patients outcomes as well. Two “values” for the “price of one.”
Haisley KR et al. Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States. Am J Surg. 2017 Aug;214(2):299-302.
Gary Timmerman, MD, FACS
Recommended Reading lists are something of a tradition for ACS Surgery News. This feature has appeared several times over the years and it has always proved among the most popular items in the publication. But the project hinges on input from our Editorial Advisory Board, the members of which are already regularly called upon to help vet the publication’s content and give their advice. They have gone the extra mile and have once again chosen their “Best of 2017” studies in their own specialty areas, along with commentary on why their choices should be of interest to all surgeons. We hope our readers will find the list and the comments of interest.
General surgery
Cogbill TH et al. Rural general surgery: A 38-year experience with a regional network established by an integrated health system in the Midwestern United States. J Am Coll Surg. 2017;225(1):115-24.
This article is of particular interest because it provides details of an innovative, regional system of surgical care at the critical access hospitals and referral centers that cooperate seamlessly to improve quality of care and quality of practice for rural surgeons. It could serve as a model for similar independent hospitals and practices in a region to improve the practice lives of the surgeons in rural communities and preserve access to local care for rural patients.
Dimou FM et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: A propensity score analysis. J Am Coll Surg. 2017;224(4):502-14.This study is valuable because it sheds light on the current status of treatment of severe acute cholecystitis in the United States and reports outcomes of patients who get initial tube cholecystostomy. It demonstrates potential drawbacks of following the Tokyo Guidelines: fewer patients receiving definitive treatment (cholecystectomy) and higher mortality rates and readmissions.
Karen E. Deveney, MD, FACS
Palliative Care
Gani F et al. Palliative care utilization among patients admitted for gastrointestinal and thoracic cancers. J Palliat Med. 2017 Nov 3; doi: 10.1089/jpm.2017.0295; epub ahead of print.
Is this a matter of “too little too late”? This retrospective cross-sectional analysis of patients identified in the National Inpatient Sample database admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer determined that only 8.5% of patients admitted received palliative care services. Surgical patients were 79% less likely to have received a palliative care consultation, and then only after a prolonged length of stay or postoperative complication. Is referral to palliative care services hindered by its stigmatization with these outcomes?
Taylor LJ et al. A framework to improve surgeon communication in high-stakes surgical decisions: Best Case/Worst Case. JAMA Surgery. 2017;152(6):531-8.
My chief used to say, “You might not be teachable, but you are trainable!” After surgeons received training in the Best Case/Worst Case framework described in this paper, they demonstrated that it was possible to successfully change the focus of decision-making conversations from an isolated surgical problem – with its menu of technical solutions – instead into a discussion about treatment alternatives and outcomes. This intervention is a useful tool for one of the most invasive procedures of all – an exploration of a patient’s preferences and values that is necessary for shared decision making within the acute setting.
Makhani SS et al. Cognitive impairment and overall survival in frail surgical patients. J Amer Coll Surg. 2017 Nov;225(5):590-600.
In my preoperative discussions with families of frail patients, it is often quite evident that the factor driving their decision is the cognitive state of the patient and the consequences of its further decline, even when they are willing to accept the risks of physical frailty. This study in a large multidisciplinary cohort of patients undergoing major operations determined that a combined frailty (Fried frailty score) and cognitive assessment score (Emory Clock Draw Test) has a more powerful potential to predict adult patients at higher risk of overall survival than does either measurement alone. Dual frailty and cognitive screening appears to be a promising adjunct to the shared decision-making process.
Geoffrey P. Dunn, MD, FACS
Wilson DG et al. Patterns of care in hospitalized vascular patients at end of life. JAMA Surg. 2017;152(2):183-90.
This thoughtful study and the excellent accompanying invited commentary by William Schecter, MD, FACS, address a major, difficult issue that faces all physicians as our patients become older and sicker and our ability to keep them alive expands: How do we speak honestly with patients about their prognosis and likely outcomes and honor their autonomy in decision making?
Karen E. Deveney, MD, FACS
Practice Management
Robinson JR et al. Complexity of medical decision making in care provided by surgeons through patient portals. Surg Res. 2017;214:93-101.
This article describes an analysis of the content of patient portal messages exchanged between surgical providers and patients. The study demonstrates that more than 90% of these exchanges involved the delivery of medical care, and more than two-thirds of the messages contained medical decision making, which might have generated charges if done in a face-to-face outpatient encounter. The articles argues that surgeons are providing substantial medical care to their patients through patient portal message exchanges and suggests that models for compensation of this type of online care should be developed.
Gretchen Purcell Jackson, MD, FACS
Vascular Surgery
Bennett KM et al. Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg. 2017 Sep;66(3):794-801.
This article uses the ACS NSQIP database to assess outcomes of women undergoing intervention for carotid stenosis in a real-world setting and finds that major adverse cardiac events in the first 30 days is higher for carotid artery stenting (12.2%), compared with carotid endarterectomy (5.2%). What we need to keep in mind is that the practice of any intervention for asymptomatic carotid stenosis is being reevaluated in the new CREST study, which will compare current best medical management with carotid stenting and carotid endarterectomy. The indications are likely to change for all, but because women had less relative risk reduction in the early studies, we can expect that the benefits for intervention for women will continue to be less than those for men, calling to question when we should truly intervene, and how best to do so.
Gargiulo M et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg. 2017 Oct;66(4);1065-72.
This study found that endovascular aneurysm repair, performed in patients with large necks (greater than 28 mm), was associated with further neck enlargement at 2 years, and a higher risk of proximal type I endoleak, with the need for reintervention. This is one of many recent studies, all with similar findings. The issue becomes how we can best address larger infrarenal necks, whether by use of fenestrated grafts, snorkels/chimneys with extension of the seal zone, aptus, or other technologies. The question of whether all grafts have equal impacts on these more dilated necks has still to be elucidated. Nonetheless, when we stretch the instructions for use, there is an increased likelihood for more interventions.
Zettervall SL et al. Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. J Vasc Surg. 2017 Oct;66(4):1305.
This study found that endografts with suprarenal fixation were associated with a greater decline in renal function, compared with those with infrarenal fixation, as well as with a longer length of stay. The reasons for the renal function decline are not entirely clear, and there was a slight increase in contrast use for those with suprarenal fixation but were otherwise similar when comparing comorbidities. Clearly, assessment of any impact on long-term renal function is important, and may affect future choice of endografts.
Linda Harris, MD, FACS
Bariatric Surgery
Rosenthal RJ et al. Obesity in America. Surg Obes Relat Dis. 2017 Oct;13(10):1643-50.
Although much has been reported on the dramatic benefits of bariatric surgery, it remains a matter of deep disappointment that only 1%-2% of the eligible population is receiving this life-saving therapy. This is a paper that reports and analyzes the results of a national survey that was conducted on behalf of the American Society for Metabolic & Bariatric Surgery, in an attempt to identify barriers to access, public misconceptions on obesity and its consequences, and other pertinent factors. Survey results included the findings that, although 80% of Americans considered obesity as the most serious health risk problem, there was a clear overestimation of the effectiveness of diet and exercise alone. The importance of this paper lies in the persistent lack of recognition and/or awareness of proven, safe, and durable medical and surgical options in the lay population, highlighting the importance of aligning efforts and resources toward educating both the public and referring physicians.
Adams TD et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017 Sep 21;377(12):1143-55
This paper reports the results of an observational, prospective study that followed patients who received gastric bypass, in comparison with a group of patients who desired but did not receive gastric bypass, and a third group of obese patients who did not seek surgery. The authors concluded that gastric bypass provided durable, 12-year remission and prevention of such lethal diseases as diabetes, hypertension, and dyslipidemia. The importance of this study is in its detailed follow-up, the exceedingly high retention rate of 90% at 12 years, and the comparisons made between surgical and nonsurgical groups, demonstrating not only the benefits of gastric bypass, but as importantly, the hazards of not receiving this treatment.
Schauer PR et al. Bariatric surgery versus intensive medical therapy for diabetes – 5-year outcomes. N Engl J Med. 2017 Feb 16;376(7):641-51.This paper is the latest installment of the long-term results from the STAMPEDE trial conducted at the Cleveland Clinic. STAMPEDE is a randomized, controlled trial that compared the best, most “intensive” medical therapy for type 2 diabetes vs. bariatric surgery (comprising a mix of gastric bypass and sleeve gastrectomy). Prior publications from this group reported 1- and 3-year results, and this paper reported the 5-year results, demonstrating the persistent superiority of bariatric surgery over the most rigorous intensive medical therapy in the resolution or improvement of hyperglycemia in patients with BMI ranges of 27 kg/m2 to 43 kg/m2. Of further significance was the fact that there were no major late surgical complications except for one reoperation.
Samer Mattar, MD, FACS
Colon & Rectal Surgery
Jayne D et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: The ROLARR randomized clinical trial. JAMA. 2017;318(16):1569-80.
This trial of 471 rectal cancer patients demonstrated similar conversion rates for robotic (8.1%) and laparoscopic (12.2%) surgery. Of the other secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups.
Marshall JR et al. Laparoscopic lavage in the management of Hinchey grade III diverticulitis: A systematic review. Ann Surg. 2017;265(4):670-6.While there have been a number of groups using laparoscopic lavage in the setting of acute diverticulitis, including Hinchey grade III disease, several recent studies question this approach. This meta-analysis includes three recent randomized, controlled trials and analysis of 48 studies – demonstrating that rates of reintervention within 30 days to be 28.3% in the lavage group and 8.8% in the resection group. Other outcomes – including ICU admissions, 30- and 90-day mortality, or stoma rates at 12 months – were similar between groups.
Denost Q et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: The GRECCAR 5 randomized trial. Ann Surg. 2017;365(3):474-80.
While many studies have confirmed infectiveness of drainage after colectomy, there is still some controversy of the role of pelvic drainage after rectal surgery. A multicenter randomized, controlled trial with two parallel arms (drain vs. no drain) was conducted in 469 patients after rectal surgery for cancer. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Rates of pelvic sepsis were similar between drain and no drain: 16.1% vs. 18.0% (P = .58), and there was no difference in surgical morbidity, rate of reoperation, length of hospital stay, and rate of stoma closure between groups. Overall, this trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit.
Genevieve Melton-Meaux, MD, FACS
Breast Surgery
Giuliano AE et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 randomized clinical trial. JAMA. 2017 Sep 12;318(10):918-926.
Long-term outcomes from the practice-changing ACOSOG Z0011 (Alliance) trial confirming the safety of omitting completion axillary lymph node dissection in women with T1/T2 tumors treated by lumpectomy and whole-breast radiation when metastatic disease is identified in one or two sentinel nodes.
Masuda N et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017 Jun 1;376(22):2147-59.
Breast cancer patients that achieve a complete pathologic response after receiving neoadjuvant chemotherapy have a survival advantage, and patients found to have residual disease represent a higher-risk population subset. This prospective randomized clinical trial (known as the CREATE-X study) revealed that adjuvant capecitabine can significantly mitigate this risk, especially for patients with triple-negative breast cancer.
Curigliano G et al. De-escalating and escalating treatments for early stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol. 2017 Aug 1;28(8):1700-12.
This summary of the 2017 St. Gallen Conference proceedings provides a comprehensive yet concise review of contemporary standards of care in managing early stage breast cancer. Issues reviewed include lumpectomy margins, extent of breast/axillary surgery following neoadjuvant chemotherapy, options for breast radiation schedules following lumpectomy, and application of currently available gene expression profiles.
Troester MA et al. Racial differences in PAM50 subtypes in the Carolina Breast Cancer Study. J Natl Cancer Inst. 2018 Feb 1;110(2);doi: 10.1093/jnci/djx135; epub ahead of print (Aug 2017).
Breast cancer outcome disparities related to racial/ethnic identity are well documented, with African American patients experiencing higher mortality rates, compared with White Americans. This disparity is partly explained by differences in tumor biology, since triple-negative breast cancer (TNBC) is twice as common in African American patients. Troester et al. conducted RNA expression-based PAM-50 tumor subtyping to demonstrate significantly higher rates of biologically aggressive tumor subtypes among African Americans breast cancer patients, compared with white Americans.
Lisa Newman, MD, FACS
Foregut
Teitelbaum EN et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2017 Jun 29. doi: 10.1007/s00464-017-5699-2 ; epub ahead of print.
This provides the longest follow-up to date regarding clinical efficacy of peroral endoscopic myotomy (POEM) in the United States. Although not a panacea, POEM appears to provide substantial durable clinical improvement in patients suffering from esophageal motility disorders.
Kevin Reavis, MD, FACS
Yufei Chen et al. Primary lymph node gastrinoma: A single institution experience. Surgery 2017 Nov;162(5):1088-94
This article retrospectively review a rare neuroendocrine (gastrinoma) tumor over a 25-year period at a single institution, noting all demographics and outcomes. Great update and refresher. The article then went farther, evaluating an even rarer occurrence of a primary lymph node gastrinoma within this patient population and followed those patients outcomes as well. Two “values” for the “price of one.”
Haisley KR et al. Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States. Am J Surg. 2017 Aug;214(2):299-302.
Gary Timmerman, MD, FACS
Recommended Reading lists are something of a tradition for ACS Surgery News. This feature has appeared several times over the years and it has always proved among the most popular items in the publication. But the project hinges on input from our Editorial Advisory Board, the members of which are already regularly called upon to help vet the publication’s content and give their advice. They have gone the extra mile and have once again chosen their “Best of 2017” studies in their own specialty areas, along with commentary on why their choices should be of interest to all surgeons. We hope our readers will find the list and the comments of interest.
General surgery
Cogbill TH et al. Rural general surgery: A 38-year experience with a regional network established by an integrated health system in the Midwestern United States. J Am Coll Surg. 2017;225(1):115-24.
This article is of particular interest because it provides details of an innovative, regional system of surgical care at the critical access hospitals and referral centers that cooperate seamlessly to improve quality of care and quality of practice for rural surgeons. It could serve as a model for similar independent hospitals and practices in a region to improve the practice lives of the surgeons in rural communities and preserve access to local care for rural patients.
Dimou FM et al. Outcomes in older patients with grade III cholecystitis and cholecystostomy tube placement: A propensity score analysis. J Am Coll Surg. 2017;224(4):502-14.This study is valuable because it sheds light on the current status of treatment of severe acute cholecystitis in the United States and reports outcomes of patients who get initial tube cholecystostomy. It demonstrates potential drawbacks of following the Tokyo Guidelines: fewer patients receiving definitive treatment (cholecystectomy) and higher mortality rates and readmissions.
Karen E. Deveney, MD, FACS
Palliative Care
Gani F et al. Palliative care utilization among patients admitted for gastrointestinal and thoracic cancers. J Palliat Med. 2017 Nov 3; doi: 10.1089/jpm.2017.0295; epub ahead of print.
Is this a matter of “too little too late”? This retrospective cross-sectional analysis of patients identified in the National Inpatient Sample database admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer determined that only 8.5% of patients admitted received palliative care services. Surgical patients were 79% less likely to have received a palliative care consultation, and then only after a prolonged length of stay or postoperative complication. Is referral to palliative care services hindered by its stigmatization with these outcomes?
Taylor LJ et al. A framework to improve surgeon communication in high-stakes surgical decisions: Best Case/Worst Case. JAMA Surgery. 2017;152(6):531-8.
My chief used to say, “You might not be teachable, but you are trainable!” After surgeons received training in the Best Case/Worst Case framework described in this paper, they demonstrated that it was possible to successfully change the focus of decision-making conversations from an isolated surgical problem – with its menu of technical solutions – instead into a discussion about treatment alternatives and outcomes. This intervention is a useful tool for one of the most invasive procedures of all – an exploration of a patient’s preferences and values that is necessary for shared decision making within the acute setting.
Makhani SS et al. Cognitive impairment and overall survival in frail surgical patients. J Amer Coll Surg. 2017 Nov;225(5):590-600.
In my preoperative discussions with families of frail patients, it is often quite evident that the factor driving their decision is the cognitive state of the patient and the consequences of its further decline, even when they are willing to accept the risks of physical frailty. This study in a large multidisciplinary cohort of patients undergoing major operations determined that a combined frailty (Fried frailty score) and cognitive assessment score (Emory Clock Draw Test) has a more powerful potential to predict adult patients at higher risk of overall survival than does either measurement alone. Dual frailty and cognitive screening appears to be a promising adjunct to the shared decision-making process.
Geoffrey P. Dunn, MD, FACS
Wilson DG et al. Patterns of care in hospitalized vascular patients at end of life. JAMA Surg. 2017;152(2):183-90.
This thoughtful study and the excellent accompanying invited commentary by William Schecter, MD, FACS, address a major, difficult issue that faces all physicians as our patients become older and sicker and our ability to keep them alive expands: How do we speak honestly with patients about their prognosis and likely outcomes and honor their autonomy in decision making?
Karen E. Deveney, MD, FACS
Practice Management
Robinson JR et al. Complexity of medical decision making in care provided by surgeons through patient portals. Surg Res. 2017;214:93-101.
This article describes an analysis of the content of patient portal messages exchanged between surgical providers and patients. The study demonstrates that more than 90% of these exchanges involved the delivery of medical care, and more than two-thirds of the messages contained medical decision making, which might have generated charges if done in a face-to-face outpatient encounter. The articles argues that surgeons are providing substantial medical care to their patients through patient portal message exchanges and suggests that models for compensation of this type of online care should be developed.
Gretchen Purcell Jackson, MD, FACS
Vascular Surgery
Bennett KM et al. Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg. 2017 Sep;66(3):794-801.
This article uses the ACS NSQIP database to assess outcomes of women undergoing intervention for carotid stenosis in a real-world setting and finds that major adverse cardiac events in the first 30 days is higher for carotid artery stenting (12.2%), compared with carotid endarterectomy (5.2%). What we need to keep in mind is that the practice of any intervention for asymptomatic carotid stenosis is being reevaluated in the new CREST study, which will compare current best medical management with carotid stenting and carotid endarterectomy. The indications are likely to change for all, but because women had less relative risk reduction in the early studies, we can expect that the benefits for intervention for women will continue to be less than those for men, calling to question when we should truly intervene, and how best to do so.
Gargiulo M et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg. 2017 Oct;66(4);1065-72.
This study found that endovascular aneurysm repair, performed in patients with large necks (greater than 28 mm), was associated with further neck enlargement at 2 years, and a higher risk of proximal type I endoleak, with the need for reintervention. This is one of many recent studies, all with similar findings. The issue becomes how we can best address larger infrarenal necks, whether by use of fenestrated grafts, snorkels/chimneys with extension of the seal zone, aptus, or other technologies. The question of whether all grafts have equal impacts on these more dilated necks has still to be elucidated. Nonetheless, when we stretch the instructions for use, there is an increased likelihood for more interventions.
Zettervall SL et al. Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. J Vasc Surg. 2017 Oct;66(4):1305.
This study found that endografts with suprarenal fixation were associated with a greater decline in renal function, compared with those with infrarenal fixation, as well as with a longer length of stay. The reasons for the renal function decline are not entirely clear, and there was a slight increase in contrast use for those with suprarenal fixation but were otherwise similar when comparing comorbidities. Clearly, assessment of any impact on long-term renal function is important, and may affect future choice of endografts.
Linda Harris, MD, FACS
Bariatric Surgery
Rosenthal RJ et al. Obesity in America. Surg Obes Relat Dis. 2017 Oct;13(10):1643-50.
Although much has been reported on the dramatic benefits of bariatric surgery, it remains a matter of deep disappointment that only 1%-2% of the eligible population is receiving this life-saving therapy. This is a paper that reports and analyzes the results of a national survey that was conducted on behalf of the American Society for Metabolic & Bariatric Surgery, in an attempt to identify barriers to access, public misconceptions on obesity and its consequences, and other pertinent factors. Survey results included the findings that, although 80% of Americans considered obesity as the most serious health risk problem, there was a clear overestimation of the effectiveness of diet and exercise alone. The importance of this paper lies in the persistent lack of recognition and/or awareness of proven, safe, and durable medical and surgical options in the lay population, highlighting the importance of aligning efforts and resources toward educating both the public and referring physicians.
Adams TD et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017 Sep 21;377(12):1143-55
This paper reports the results of an observational, prospective study that followed patients who received gastric bypass, in comparison with a group of patients who desired but did not receive gastric bypass, and a third group of obese patients who did not seek surgery. The authors concluded that gastric bypass provided durable, 12-year remission and prevention of such lethal diseases as diabetes, hypertension, and dyslipidemia. The importance of this study is in its detailed follow-up, the exceedingly high retention rate of 90% at 12 years, and the comparisons made between surgical and nonsurgical groups, demonstrating not only the benefits of gastric bypass, but as importantly, the hazards of not receiving this treatment.
Schauer PR et al. Bariatric surgery versus intensive medical therapy for diabetes – 5-year outcomes. N Engl J Med. 2017 Feb 16;376(7):641-51.This paper is the latest installment of the long-term results from the STAMPEDE trial conducted at the Cleveland Clinic. STAMPEDE is a randomized, controlled trial that compared the best, most “intensive” medical therapy for type 2 diabetes vs. bariatric surgery (comprising a mix of gastric bypass and sleeve gastrectomy). Prior publications from this group reported 1- and 3-year results, and this paper reported the 5-year results, demonstrating the persistent superiority of bariatric surgery over the most rigorous intensive medical therapy in the resolution or improvement of hyperglycemia in patients with BMI ranges of 27 kg/m2 to 43 kg/m2. Of further significance was the fact that there were no major late surgical complications except for one reoperation.
Samer Mattar, MD, FACS
Colon & Rectal Surgery
Jayne D et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: The ROLARR randomized clinical trial. JAMA. 2017;318(16):1569-80.
This trial of 471 rectal cancer patients demonstrated similar conversion rates for robotic (8.1%) and laparoscopic (12.2%) surgery. Of the other secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups.
Marshall JR et al. Laparoscopic lavage in the management of Hinchey grade III diverticulitis: A systematic review. Ann Surg. 2017;265(4):670-6.While there have been a number of groups using laparoscopic lavage in the setting of acute diverticulitis, including Hinchey grade III disease, several recent studies question this approach. This meta-analysis includes three recent randomized, controlled trials and analysis of 48 studies – demonstrating that rates of reintervention within 30 days to be 28.3% in the lavage group and 8.8% in the resection group. Other outcomes – including ICU admissions, 30- and 90-day mortality, or stoma rates at 12 months – were similar between groups.
Denost Q et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: The GRECCAR 5 randomized trial. Ann Surg. 2017;365(3):474-80.
While many studies have confirmed infectiveness of drainage after colectomy, there is still some controversy of the role of pelvic drainage after rectal surgery. A multicenter randomized, controlled trial with two parallel arms (drain vs. no drain) was conducted in 469 patients after rectal surgery for cancer. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Rates of pelvic sepsis were similar between drain and no drain: 16.1% vs. 18.0% (P = .58), and there was no difference in surgical morbidity, rate of reoperation, length of hospital stay, and rate of stoma closure between groups. Overall, this trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit.
Genevieve Melton-Meaux, MD, FACS
Breast Surgery
Giuliano AE et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 randomized clinical trial. JAMA. 2017 Sep 12;318(10):918-926.
Long-term outcomes from the practice-changing ACOSOG Z0011 (Alliance) trial confirming the safety of omitting completion axillary lymph node dissection in women with T1/T2 tumors treated by lumpectomy and whole-breast radiation when metastatic disease is identified in one or two sentinel nodes.
Masuda N et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017 Jun 1;376(22):2147-59.
Breast cancer patients that achieve a complete pathologic response after receiving neoadjuvant chemotherapy have a survival advantage, and patients found to have residual disease represent a higher-risk population subset. This prospective randomized clinical trial (known as the CREATE-X study) revealed that adjuvant capecitabine can significantly mitigate this risk, especially for patients with triple-negative breast cancer.
Curigliano G et al. De-escalating and escalating treatments for early stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol. 2017 Aug 1;28(8):1700-12.
This summary of the 2017 St. Gallen Conference proceedings provides a comprehensive yet concise review of contemporary standards of care in managing early stage breast cancer. Issues reviewed include lumpectomy margins, extent of breast/axillary surgery following neoadjuvant chemotherapy, options for breast radiation schedules following lumpectomy, and application of currently available gene expression profiles.
Troester MA et al. Racial differences in PAM50 subtypes in the Carolina Breast Cancer Study. J Natl Cancer Inst. 2018 Feb 1;110(2);doi: 10.1093/jnci/djx135; epub ahead of print (Aug 2017).
Breast cancer outcome disparities related to racial/ethnic identity are well documented, with African American patients experiencing higher mortality rates, compared with White Americans. This disparity is partly explained by differences in tumor biology, since triple-negative breast cancer (TNBC) is twice as common in African American patients. Troester et al. conducted RNA expression-based PAM-50 tumor subtyping to demonstrate significantly higher rates of biologically aggressive tumor subtypes among African Americans breast cancer patients, compared with white Americans.
Lisa Newman, MD, FACS
Foregut
Teitelbaum EN et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2017 Jun 29. doi: 10.1007/s00464-017-5699-2 ; epub ahead of print.
This provides the longest follow-up to date regarding clinical efficacy of peroral endoscopic myotomy (POEM) in the United States. Although not a panacea, POEM appears to provide substantial durable clinical improvement in patients suffering from esophageal motility disorders.
Kevin Reavis, MD, FACS
Yufei Chen et al. Primary lymph node gastrinoma: A single institution experience. Surgery 2017 Nov;162(5):1088-94
This article retrospectively review a rare neuroendocrine (gastrinoma) tumor over a 25-year period at a single institution, noting all demographics and outcomes. Great update and refresher. The article then went farther, evaluating an even rarer occurrence of a primary lymph node gastrinoma within this patient population and followed those patients outcomes as well. Two “values” for the “price of one.”
Haisley KR et al. Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States. Am J Surg. 2017 Aug;214(2):299-302.
Gary Timmerman, MD, FACS