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Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Clinical experience has documented an increased rate of patient dissatisfaction with anti-reflux procedures if symptoms of colonic dysmotility (constipation) or irritable bowel syndrome (cramping and bloating) are present; however, objective data to document an association of colonic dysmotility with outcomes of anti-reflux surgery have not been produced. In this article, results from a study of whole gut motility using a wireless motility capsule (taken in by mouth) were reported. The study cohort consisted of 48 patients—fundoplication was the procedure performed in 29 patients, and magnetic sphincter augmentation was performed in 19 patients. Female patients composed 87.5% of the study group.
Favorable outcomes of anti-reflux surgery were observed in 87.5% of the cohort. Documentation of prolonged whole gut transit times and colonic transit times was strongly associated with unfavorable outcomes. The authors recommended consideration of wireless capsule motility testing in patients being considered for anti-reflux surgery.
In the editorial that accompanies the article, Andres Latorre-Rodriguez, MD, and Sumeet K. Mittal, MD, FACS, noted that criteria for selection of patients for motility testing were not described and that determination of a history of constipation was based on a single question in the GERD-Quality of Life assessment. They concluded that despite these shortcomings, this report opened an exciting new pathway for improvement of outcomes of anti-reflux surgery.
Synoptic Operative Notes Aid in Meeting ACS Compliance Standards for Cutaneous Melanoma Wide Local Excision
The authors conducted a review of the objectives of standard 5.5 of the ACS Commission on Cancer Operative Standards. This standard provides guidance for the safest and most effective techniques for curative excision of cutaneous melanoma lesions. The standard provided evidence-based recommendations for radial margin width based on Breslow depth of the melanoma. The evidence supporting the recommendations was obtained from randomized prospective clinical trials. An important requirement of the standard is documentation of the surgical technique and intraoperative pathology results using standard formatting of operative reports (synoptic operative notes) so that dependable, accurate data can be available to support quality assessment and outcomes research.
Available evidence has shown a clear association of synoptic operative note use and compliance with quality standards. The recommended margin width for a lesion less than 1 mm thick is 1 cm (margin widths are measured from the edge of the lesion or the edge of the scar for reexcision procedures). For lesions 1-2 mm in thickness, the recommended margin is 1-2 cm; for lesions more than 2 mm thick, the recommended margin is 2 cm. For melanoma in situ lesions the recommended margin is 5 mm. The standard excision depth includes skin and subcutaneous tissue down to the level of the fascia.
In the synoptic operative note, the surgeon can document deviations from the recommendations based on anatomic constraints and/or participation in a clinical trial. Adherence to the standard and compliance with synoptic reporting can potentially improve treatment for cutaneous melanoma.
CHEST Guideline Provides Evidence-Based Recommendations on Perioperative Management of Antithrombotic Therapy
This article provides clear, evidence-based recommendations focusing on the perioperative management of patients who are receiving chronic treatment with anticoagulant and/or antiplatelet agents and are undergoing an elective surgical procedure. Patients with conditions such as atrial fibrillation, who are receiving anticoagulants for treatment of artificial cardiac valves, and who have or require implantation of an indwelling pacemaker or internal cardiac defibrillator are examples the areas of clinical practice discussed in the guideline document. These patients often are receiving vitamin K antagonists, low molecular weight heparin, direct oral anticoagulants, aspirin, or P2Y12 inhibitors (clopidogrel, ticlopidine, ticagrelor, prasugrel, and cangrelor).</p.
Questions regarding these patient groups are faced daily by surgeons and include the need for heparin bridging to avoid thromboembolic events during the perioperative interval; the need for and duration of treatment pauses for anticoagulants, and the safe use of aspirin and P2Y12 inhibitors. Included were recommendations against heparin bridging for patients with mechanical heart valves, atrial fibrillation, and venous thromboembolism. In patients who require pacemaker or internal cardiac defibrillator implantation, the guideline recommended continuation of vitamin K antagonist drugs during the perioperative interval. The guidelines recommended pausing direct oral anticoagulants 1-4 days prior to an elective procedure (pause start times depend upon the drug being used).
Even though evidence supporting most of the recommendations was weak or very weak, the available evidence is presented clearly, and the recommendations are cautious and sensible. Surgeons are encouraged to review the complete guideline document.
