Recommended reading: top papers in the surgical literature
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.
