Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Study Suggests Compliance with Enhanced Recovery Protocols Can Improves Outcomes, Lower Costs
Wiener J, Bellido D, Smolinsky T, et al. Retrospective Evaluation of Short-Term Outcomes of an Enhanced Recovery Protocol for Patients Undergoing Complex Abdominal Wall Reconstruction. J Am Coll Surg. 2022, in press.
In this article, Jameson Weiner, GD, MD, and co-authors reported data from a single institution retrospective study performed over a 2-year interval; a before and after model was used, and patient outcomes were compared for the year prior to implementation of an enhanced recovery protocol with the year following implementation. Repair of complex abdominal wall defects was the surgical procedure studied.
The enhanced recovery protocol included 14 in-hospital interventions such as body temperature control, deep vein thrombosis prophylaxis, early feeding, pain control, and early removal of bladder catheters, among others. The data analysis showed that patients who were compliant with the enhanced recovery protocol had significantly lower complication rates, shorter hospital length of stay, and received fewer doses of opioid analgesics compared with the pre-implementation group. The authors concluded that compliance with the enhanced recovery protocol improved patient outcomes and reduced hospital costs.
Editorial
Bizarian A, Nikolian VC. Enhanced Recovery Protocols in Contemporary Abdominal Wall Reconstruction. J Am Coll Surg. 2022, in press.
In the editorial that accompanied the above article, the editorialists noted that this report differed from others in the literature in that a substantial proportion of the reported patients underwent minimally invasive abdominal wall reconstruction. They stressed, however, that this study focused only on in-hospital interventions; to achieve maximum benefit from enhanced recovery protocols for elective surgical procedures, prehospital interventions such as smoking cessation, diabetes control, and weight loss in overweight and obese patients should be included in the protocol.
Can Organ-Sparing Treatment of Malignant Colorectal Polyps Be Safe and Effective?
Affi Koprowski M, Sutton TL, Brinkerhoff BT, Chen EY, Nabavizadeh N, Tsikitis VL. Conservative Management of Malignant Colorectal Polyps in Select Cases is Safe in Long-Term Follow-Up: An Institutional Review. Am J Surg. Aug 2022;224(2):658-663. doi:10.1016/j.amjsurg.2022.02.059
In this study, the authors tested the hypothesis that properly staged colorectal polyps that displayed malignant features but were completely removed could be treated without colorectal resection (organ sparing) without increasing risk for colorectal cancer-related mortality. Obvious advantages of the organ-sparing approach included maintenance of rectal function and avoidance of ostomy. Staging was based on the presence of polyp characteristics such as depth of invasion, degree of differentiation, presence of lymphovascular invasion, and resection margins.
The study cohort included 78 patients; 41 patients were assigned to the organ-sparing group based on the absence of high-risk histologic features. Patients in both study groups received adjuvant chemotherapy according to evidence-based protocols. The median follow-up interval was 52 months. Data analysis showed that patients who qualified for the organ-sparing strategy had similar outcomes in terms of overall and cancer-free survival compared with patients who underwent resection. The authors concluded that properly selected patients could be spared the morbidity and diminished quality of life associated formal resection.
Surgeons Encouraged to Review Clinical Algorithm Focused on Safe, Effective Trauma Care for Women in Late Pregnancy
Rizzo AG, Martin MJ, Inaba K, et al. Pregnancy in Trauma—A Western Trauma Association Algorithm. J Trauma Acute Care Surg. Jul 8, 2022.
Anne Rizzo, MD, FACS, and co-authors presented a clinical decision-support algorithm developed by members of the Western Trauma Association that focused on the provision of safe and effective care for women who are in the later stages of pregnancy (presence of a potentially viable fetus) at the time of injury. They noted that prospective randomized trials that could potentially generate strong evidence-based recommendations are not available; the included recommendations were developed after review of available prospective and retrospective observational studies and final recommendations were developed by expert consensus.
The algorithm recommends that all pregnant patients with significant injuries receive Rho-gam if the blood type is unknown. Emergent Cesarean section is recommended if fetal distress develops in a hemodynamically stable patient. In unstable patients, conventional resuscitation is recommended with Cesarean section conducted (when indicated by evidence of fetal distress) when an adequate response to resuscitation is observed or during trauma laparotomy. Cesarean section is also recommended for patients who require interventional radiologic control of pelvic hemorrhage; the decision to perform Cesarean section in patients with complex pelvic injuries should be made based on the hemodynamic stability of the patient and the potential for fetal radiation exposure. In patients who sustain penetrating injury, Cesarean section is recommended if laparotomy for peritonitis is performed. The full algorithm is included in the article and provided clear guidance for the management of these challenging patients. Readers are encouraged to review this information.
