Recommended reading: Board picks the ‘best of 2018’

Cardiothoracic Surgery

Stone GW et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23; doi:10.1056/NEJMoa1806640.

This study, known as the COAPT trial, assessed the value of adding transcatheter mitral valve repair to best medical therapy for the treatment of moderate-to-severe or severe functional mitral regurgitation in patients with symptomatic heart failure. Not only was transcatheter mitral valve repair exceedingly safe (more than 96% freedom from device-related complications at 12 months), patients were hospitalized less for heart failure management and had lower all-cause mortality compared with best medical therapy alone. The results of the COAPT trial are an important step forward for transcatheter therapies, which are rapidly becoming an integral part of the treatment algorithms for structural heart disease.

Gaudino M et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med. 2018;378(22):2069-77.
 

This analysis of randomized trials comparing radial artery to saphenous vein grafts for coronary artery bypass surgery is quite possibly a practice-changing publication. Routine use of the left internal thoracic (mammary) artery is commonplace among cardiac surgeons; however, the debate over conduit choice for additional bypass grafts is a “tale as old as time.” This study, part of the RADIAL project, combined patient-level data from six trials in order to achieve adequate power to identify differences in clinical outcomes. The use of radial artery grafts as opposed to saphenous vein grafts was associated with less adverse cardiac events, a lower incidence of repeat revascularization, and a higher patency rate at 5 years. Although there was no difference in all-cause mortality, the results of this study support the use of radial artery grafts when additional conduits are needed in coronary artery bypass surgery.

Irving L. Kron, MD, FACS, and Eric J. Charles, MD, PhD
 

Vascular Surgery

Anand SS. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: An international, randomised, double-blind, placebo-controlled trial. Lancet 2018;391(10117):219-29.

This landmark study was terminated early due to a significant difference in outcomes. Prior to this point, aspirin and statins have been the mainstay of decreasing long-term adverse outcomes for patients with vascular disease. The COMPASS study has found a decrease in combined cardiovascular adverse events when rivaroxaban 2.5 mg was combined with low-dose aspirin in patients with stable PAD or CAD over aspirin alone. This is the first major change supporting use of additional medications for PAD in over 2 decades, when statins were found to impact outcomes. The differences were not impacted by gender, age, or race. Patients with end-tage renal disease were excluded, so it is unclear whether it would be beneficial in this population. The higher rate of bleeding, 3.1% vs 1.9%, was primarily GI, so caution should be used if patients are felt to be at increased risk of bleeding.
 

These findings suggest the need for a major change in the guidelines and management for the majority of our patients with PAD. Certainly we should look to add this data point to the Vascular Quality Initiative to gather further data and confirm the findings in real world use. It is unclear whether this benefit will be unique to rivaroxaban, or whether other Direct Xa inhibitors will have similar effects. I will certainly be adding ribaroxaban to patients at low risk for bleeding based on this data. Further, rivaroxaban alone did not reduce major cardiovascular adverse events, but did reduce major adverse limb events.

Gohel MS et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378:2105-14.

This multicenter study in the UK looked at over 450 patients with venous ulceration. Deep-venous reflux was also present in one-third of patients in each group. The median time to ulcer healing was decreased significantly from 82 days to 56 days. This study demonstrates the importance of early intervention for superficial reflux to enhance ulcer healing and decrease risk of recurrence. This study found that early endovenous ablation resulted in faster healing of venous ulcers, and more ulcer-free time than delayed intervention in patients treated with maximal medical therapy, including appropriate compression therapy. Previously, ablation was typically planned after ulcers healed to decrease risk of recurrence. Based on these findings, ablation should be offered to patients with nonhealing venous ulcers early in the course of therapy, in addition to standard wound care.

Linda Harris, MD, FACS

Surgical Education

Ellison EC. Ten-year reassessment of the shortage of general surgeons: Increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons. Surgery. 2018 Oct;164(4):726-32.

Ellison EC et al. The impact of the aging population and incidence of cancer on future projections of general surgery workforce needs. Surgery. 2018 Mar;163(3):553-59.

In 2008, Ellison et al. projected that a deficit in the general surgery workforce would grow to 19% by 2050. The group recently re-examined this projection by reviewing Census Bureau data, the available pool of surgeons with both allopathic and osteopathic degrees and factored in the losses of new surgeons who subspecialize and older surgeons who retire every year. Their conclusion states that, without increasing future general surgeons training numbers, the projected future general surgery workforce shortage will continue to grow.

A second paper by the same group reviewed population and age-adjusted incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. The total number of new patients with cancers treated by general surgeons is projected to increase 56% in that time span. This would require an increase of over 9,000 general surgeons over that based on current training numbers. Together, the papers predict that there will be an ever-increasing demand for general surgeons in the near future and that general surgeons, currently caring for over 50% of cancer patients in the US, will play an even more important role in surgical cancer treatment.

Michael D. Sarap, MD, FACS
 

General Surgery

Takada T. Tokyo Guidelines 2018 (TG18). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):1-2.

 This is the updated set of guidelines, awaited since 2013, regarding treatment of acute cholecystitis and cholangitis, with updated management strategies from an international panel of experts. The most significant change, and considered overdue by some surgeons, is the modification of the management algorithm to propose that some patients with Grade III acute cholecystitis (severe cholecystitis with evidence of organ dysfunction) may be treated with immediate laparoscopic cholecystectomy, rather than percutaneous cholecystostomy, “when performed at advanced centers with specialized surgeons experienced in this procedure.” As cholecystectomy is the most common general surgery procedure in the United States, most community surgeons have expertise. Whether there is truly need of a specialized gallbladder surgeon at an advanced center to safely complete a laparoscopic cholecystectomy can still be debated. But the change in recommendation from the experts is welcome.

Acuna SA. Operative strategies for perforated diverticulitis: A systematic review and meta-analysis. Dis Colon Rectum. 2018 Dec; 61(12):1442-53.

 This analysis of the literature considers the three predominant operations for Hinchey III and Hinchey IV perforated diverticulitis: Hartmann procedure, resection and primary anastomosis, and laparoscopic lavage. The importance of this review is that it considers the initial operation and the downstream procedures when determining overall morbidity and mortality. Laparoscopic lavage did not fare well in this review of randomized controlled trials, resulting in higher morbidity than resection in Hinchey III patients. Interestingly, none of the individual studies analyzed had shown a statistical difference, but in the meta-analysis, the number of patients was sufficient to show statistical significance. The other important conclusion was that primary resection with anastomosis (possibly with diverting ileostomy) was superior to Hartmann procedure, when the likelihood of stoma reversal and the morbidity of the second operation was taken into account.

Mark Savarise, MD, FACS
 

Foregut

Alicuben ET. Worldwide experience with erosion of the magnetic sphincter augmentation device. J Gastrointest Surg. 2018; 22(8):1442-47.

 Although magnetic sphincter augmentation of the lower esophageal sphincter initially appeared to provide excellent reflux control with essentially no risk of erosion, there have now been multiple reports throughout the world of device erosion over time. Fortunately, most erosions occurred with the smallest available device which is no longer on the market and the erosions currently being treated are usually done so with endoscopic/laparoscopic removal without the need for major esophageal resection.

Xiong YQ. Comparison of narrow-band imaging and confocal laser endomicroscopy for the detection of neoplasia in Barrett’s esophagus: A meta-analysis. Clin Res Hepatol Gastroenterol. 2018 Feb;42(1):31-9.

The days of endoscopic screening and surveillance of patients at risk for the development of Barrett’s esophagus via four-quadrant biopsy every couple of centimeters are numbered. The use of confocal laser microscopy to provide accurate real-time visual data regarding the areas of interest in the esophagus is showing promise and gaining traction compared to standard biopsy techniques and narrow-band imaging.

Borbély Y. Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy. Surg Obes Relat Dis. 2018 May;14(5):611-5.
 

The development of GERD following sleeve gastrectomy is a real problem in a substantial minority of patients due to structural compromise of the lower esophageal sphincter during the procedure. Conversion to gastric bypass as a way to alleviate acid regurgitation has been the mainstay of treatment; however, many patients selected sleeve gastrectomy specifically because they did not want to undergo gastric bypass. For those patients a sleeve preserving procedure such as magnetic sphincter augmentation (currently in clinical trial), Hill procedure, or remnant gastric fundoplication are potential options. Electrical stimulation of the lower esophageal sphincter is revealing itself to be another exciting option (currently in clinical trial) which can be used in patients with as few as 30% peristaltic swallows thus expanding the treatment options for these deserving patients.

Kevin M. Reavis, MD, FACS