American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Daily Highlights: Wednesday, October 7

Breaking down the hottest topics in general surgery

What are general surgeons talking about most this year? From detecting intimate partner violence and endoluminal stents for gastrointestinal leaks, to robotic inguinal hernia repair, Drs. Kenneth Sharp and Chris Ellison discuss highlights, surprises, and key takeaways from this year's Hot Topics in General Surgery session.

Watch the full session, PS513: Hot Topics in General Surgery, on the virtual ACS Clinical Congress site.


Trending topics in acute care surgery

From treating hidradenitis to using a circulation-first approach to stop bleeding in trauma patients, lively debate continues around many topics in trauma, surgical critical care, and emergency general surgery. Drs. Paula Ferrada and David Spain break down some of this year's hottest topics in emergency acute care surgery.

Watch the full session, PS546: Hot Topics in Emergency Acute Care Surgery, on the virtual ACS Clinical Congress site.

Cancer care: Medicine meets math

For 32 years, exemplary leaders in cancer management and research have presented the Commission on Cancer (CoC) Lecture to large auditoriums in a variety of Clinical Congress venues. Although the current global pandemic has necessitated a virtual, computer-assisted meeting to maintain social distancing, the CoC Lecture this year given by Professor Sir Murray Brennan, MD, FACS of the Memorial Sloan Kettering Cancer Center, New York, was no less impactful.

In his lecture, "Cancer Care: Medicine Meets Math," Dr. Brennan enumerated the difficult issues faced by all Americans, and especially those with cancer, relating to health care economics. He argued that over diagnosis, leading to potential over treatment, contributes to the high cost of cancer care in the United States, especially for breast and prostate cancer.

Dr. Brennan then asked the seminal question, "Does over investigation change outcomes?" Aggressive approaches to cancer diagnosis may correlate with increased relative survival, possibly because those who undergo regular screening generally take better care of their health. But Dr. Brennan showed data suggesting increased diagnosis of early-stage cancer does not substantially influence disease-specific survival.

He urged us to "look at the math" very carefully, and to consider another fact: over treatment is not without risk. Radiation therapy for early-stage breast cancer, for example, increases risk for heart disease, pulmonary embolism and future cancers in other sites.

Relating to clinical trials, we are admonished to look with a critical eye at small increases in progression-free survival. Professor Brennan reminded us that the "p" value is not the overarching consideration if the total benefit to patients is small.

Dr. Brennan introduces the terms "silent neglected majority (or minority)," to describe the fraction of patients in the treatment arm of a trial who would have had a positive outcome, even if they had been controls. These people may be pleased with their outcome, he said, but it is important to recognize they are subject to whatever side effects may be associated with the treatment. These need to be considered, because they may be substantial enough to negate some or all of the benefit to those whose outcome was improved by treatment. He used the example of his own past trials that test the practice of aggressive margin resection for adenocarcinoma of the pancreas to illustrate the principle, showing that even though margins might be negative, this approach has had no effect on overall outcomes for the vast majority of patients.

Dr. Brennan also warned us against "focusing on the wrong end of the curves" when looking at trial results. Rather, we should be vigilant in finding ways to determine beforehand which patients truly need and will benefit from a given cancer treatment strategy.  We need to have greater reliance on prognostic indicators such as nomograms and support of artificial intelligence. Our lecturer told us that "cancer care has evolved from being discipline-specific, to organ-specific, to disease-specific, to molecular-specific, to pathway-specific."

As a true champion of the randomized controlled trial concept, Dr. Brennan urged us to look carefully at the important and meaningful endpoints of every trial. No matter the trial result, we need to accurately predict individual outcomes using prognostic indices. We must select patients for trials based on molecular diagnostics. We must evaluate technology for its benefit for the individual patient and for society. Finally, in trials, we must use surrogate indicators that accurately determine response, efficacy and disease progression.

The wisdom shared in this 2020 Commission on Cancer lecture by a true giant in cancer care will give us a road map forward and, importantly, will always remind us to consider the math.

Watch the full session, NL11: Commission on Cancer Oncology Lecture, on the virtual ACS Clinical Congress site.

Improving quality of life for transplant patients

Immune suppression advances allow transplants to improve quality of life for more patients

Since transplants were first used during World War II, decades of progress have placed surgeons closer to transplanting a wider range of fully functioning organs and tissues. At a Tuesday panel session, surgeons discussed advances, including immunosuppression, that are helping expand the possibilities for vascularized composite allotransplantation and allowing surgeons to offer more options for improved quality of life to their patients.   

The challenge of immune rejection was first discovered by Joseph E. Murray, MD, FACS, a pioneer of transplantation who performed skin grafts on World War II soldiers burned in battle. He would ultimately address rejection with the use of immunosuppressive drugs in 1962, during the first successful kidney transplant from a donor unrelated to the patient. But rejection continues to be a significant challenge as transplant expands, panelists said. 

"It's critical that we make sure the benefits of transplant, including function, independence, and quality of life, outweigh the toxicities of long-term, high-dose, systemic immunosuppression," said W. P. Andrew Lee, MD, FACS, University of Texas Southwestern Medical Center, Dallas, who showed that hand and arm transplants are now able to restore motor and sensory function in recipients, improving their quality of life. Dr. Lee said hematopoietic stem cell transplants from the donor to the recipient prior to the limb allograft, in combination with immunosuppressive drugs, have increased survival of the limbs.

Two key allotransplantation advances that are improving quality of life for patients are in penile reconstruction/transplantation and whole uterus transplantation. Historically, microvascular free tissue transfers from the arm have been used to reconstruct a partially functional penis, which is then transplanted, said Richard J. Redett, MD, FACS, Johns Hopkins University School of Medicine, Baltimore. However, issues with lack of donor tissue, implant complications, and lack of full sexual function led his team to begin full penile transplantation in 2018. The achievement required his team to carefully research how to perfuse the tissue, including the penis, scrotum, and lower abdominal wall.

Dr. Anji Wall, MD, PhD, Baylor Simmons Transplant institute, Dallas, discussed how uterine transplants have restored fertility in 20 patients, resulting in 11 births. Still, ethical questions remain, including whether surgeons should perform an operation requiring immunosuppression on a healthy woman for the chance at pregnancy. According to Dr. Wall, early evidence shows women who have given birth after uterus transplant benefit from a "remarkably similar" pregnancy experience, increased bonding with their baby, and the ability to breastfeed immediately after delivery.

A major future achievement in vascularized composite allotransplantation will be a whole eye transplant, and research presented by Kia Washington, MD, FACS, University of Colorado School of Medicine, Denver, takes us one step closer. While the eye's complex web of muscles, blood vessels, and nerves — connected directly to the brain — has made eye transplantation a moonshot, Dr. Washington presented research on the first successful model of a rodent eye transplant that allowed the study of anatomy, blood flow, fluid dynamics, and restorative function. The rats showed normal eye pressure and blood flow, as well as restoration of gross morphology. Dr. Washington has funding from the Department of Defense to further the work with eye transplantation, including restoring function and optic nerve regeneration.

"I'm hopeful that in a decade or two, we will be doing eye transplants in humans," Dr. Washington said.

Watch the full session, PS566: New Frontiers in Transplantation, on the virtual ACS Clinical Congress site.

Fighting the VTE epidemic in surgery patients

Why are rates of venous thromboembolism (VTE) continuing to climb in surgery patients, and what steps can surgeons implement in their practice to reverse this trend? Dr. Elliott Haut discusses the reasons for rising VTE rates, the value of risk stratification and decision support tools, and the importance of engaging patients around VTE prevention.

Watch the full session, PS582: Venous Thromboembolism Prophylaxis: Translating Quality Improvement Programs to Bedside Practice, on the virtual ACS Clinical Congress site.

How COVID-19 is impacting the global surgical community

From new safety protocols, to delays in cancer care, to questions about data integrity, COVID-19 has had significant impacts on surgery. Dr. Daniela Molena discusses highlights from an international panel on the long-term effects of the pandemic on surgery, as well as immediate steps surgeons can take to allay patients' fears about the safety of resuming surgical care.

Watch the full session, PS584: COVID-19 and Surgery: The International Perspective, on the virtual ACS Clinical Congress site.