Recommended reading: top papers in the surgical literature

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.