Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
High Hospital and Surgeon Volume Associated with Improved Mortality Risk in Emergency General Surgery
Rafaqat W, Lagazzi E, Jhanzeb H, et al. Which Volume Matters More? A Systematic Review and Meta-Analysis of Hospital vs Surgeon Volume in Intra-Abdominal Emergency Surgery. J Am Coll Surg. 2023, in press.
This article reported data from a literature review of studies focusing on the impact of surgeon and hospital case volumes on outcomes of emergency general surgery procedures. From a group of 2,153 eligible articles, 22 good quality cohort studies were chosen. A subgroup analysis examined data on high- and low-complexity procedures, including repair of ruptured abdominal aortic aneurysms.
Mortality risk was highest in hospitals with low total and surgeon volumes; mortality was also higher for high-complexity procedures in hospitals with low volume. Outcomes for high-complexity procedures were improved in hospitals with high volume and high surgeon volume in the same institutions. The authors concluded that high hospital and surgeon volume was associated with improved mortality risk.
High complexity procedures require not only surgeon expertise but support from other areas such as anesthesiology, critical care, radiology, and operating room staff; these services are more likely to be found in high volume hospitals. An important area not examined in the study was the impact of delayed transfer on outcomes. This study adds to available evidence that supports the development of effective regional transfer protocols and careful monitoring of patient outcomes.
Appendectomy Is Safe and Effective for Neuroendocrine Tumors of the Appendix
Ahmed FA, Wu VS, Kakish H. Surgical Management of 1- to 2-cm Neuroendocrine Tumors of the Appendix: Appendectomy or Right Hemicolectomy? Surgery. 2023.
The authors used data from the National Cancer Database over a 14-year time interval to determine the usage rates and outcomes of appendectomy or right hemicolectomy for treatment of appendiceal neuroendocrine tumors in the 1 cm–2 cm size range.
Data from 3,189 patients were included in the study. The data showed that appendectomy usage steadily increased over the study interval (37.7% in 2004 to 58.9% in 2018). Oncologic outcomes were similar for the two procedures. Patients with higher grade tumors were more likely to undergo right hemicolectomy, but oncologic outcomes were not improved in this patient group.
The authors concluded that appendectomy was a safe and effective treatment for this category of neuroendocrine tumors.
Perioperative Immunonutrition Has Value for Patients Undergoing Head and Neck or Gastrointestinal Cancer Surgery
Matsui R, Sagawa M, Sano A. Impact of Perioperative Immunonutrition on Postoperative Outcomes for Patients Undergoing Head and Neck or Gastrointestinal Cancer Surgeries: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg. 2023.
This systematic review of the literature sought to determine the benefits of perioperative immunonutrition in patients undergoing treatment for head and neck or gastrointestinal malignancies. The literature analysis included randomized trials reported over the interval 1981–2022; 48 acceptable studies involving 4,825 patients were included in the final analysis. Gastrointestinal cancers were studied in 36 trials, and head and neck cancers in 12 trials.
Immunonutrition included administration of arginine, n-3 omega fatty acids, and/or glutamine administered preoperatively, postoperatively, or during the entire perioperative interval. The data showed that perioperative immunonutrition reduced total complications and infectious complications by more than 20% compared with no immunonutrition. Certainty of evidence was high based on assessment with standard techniques.
The authors concluded that perioperative immunonutrition has significant value for patients with head and neck or gastrointestinal malignancy. Immunonutrition is increasingly used as a component of enhanced recovery programs for high-risk patients with or without documented malnutrition. These data support the conclusion that immunonutrition should be considered for patients with malignant disease undergoing surgical treatment.
