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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.

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Literature Selections

Current Literature

March 19, 2024

Regulations Requiring Physical Exam 30 Days before In-Patient Operations Should Be Reconsidered

Ballester JMS, Ginzberg SP, Finn CB, et al. Should I See You Again Soon? A Multispecialty Assessment of the Impact and Burden of Preoperative History and Physical Update Visits. J Am Coll Surg. 2024, in press.

Federal healthcare regulations require an updated history and physical examination within 30 days of a planned operative procedure. Although these regulations have recently become more flexible regarding outpatient procedures, updated history and physical examinations are still required for inpatient operations. Surgeons and healthcare systems satisfy these regulations by scheduling repeat examinations prior to or on the day of the procedure. This practice is burdensome to patients because of travel time and expense. This study sought to quantify the burden of these practices. A group of 362 preoperative update visit episodes were analyzed; changes in patient history occurred in 60.8% of episodes but changes in physical examination findings and findings and changes in operative plans were documented in less than 12% of episodes.

In aggregate, patients spent 7,000 hours and traveled more than 142,000 miles to complete the update visits. Visits were considered appropriate for completion via telehealth in 99.2% of episodes. The authors concluded that these regulations should be reconsidered; flexibility in scheduling and shifts to telehealth visits could significantly reduce travel time, distance traveled, and expenses. Potential cost savings could approach $1.7 billion annually.

Selective Strategy Is Warranted when Imaging Patients with Parathyroidectomy

Lunardi N, Jacob A, Elfenbein D, et al. Don't Chase the Adenoma: A Probabilistic Approach to Imaging before Parathyroidectomy. Surgery. 2024.

Preoperative imaging is employed to localize parathyroid adenomas and reduce the risk of bilateral neck explorations. The authors hypothesized that accurate preoperative prediction of the presence of parathyroid adenoma(s) could reduce the need for preoperative imaging. Using logistic regression statistical techniques, the authors created a system based on clinical and laboratory findings to predict the presence of adenoma(s) versus parathyroid hyperplasia. They assessed the helpfulness of imaging based on the probability of adenoma presence. The analysis showed that the probability of helpful imaging increased from 12% to 65% as the probability of adenoma increased from 30% to 90% based on scoring. The authors concluded that basing the use of imaging on the probability of adenoma presence would significantly reduce radiation exposure and imaging costs.

TNT with Induction Chemoimmunotherapy and Long-Course Chemoradiation Appears Effective in High-Risk Rectal Cancer Patients

Li Y, Pan C, Gao Y, et al. Total Neoadjuvant Therapy with PD-1 Blockade for High-Risk Proficient Mismatch Repair Rectal Cancer. JAMA Surg. 2024.

This article presented data from a prospective trial that evaluated the safety and efficacy of total neoadjuvant therapy with induction immunotherapy followed by chemoradiation therapy in patients with high-risk proficient mismatch repair (pMMR) rectal cancer. The end point of interest was pathologic complete response. Patients (n = 25) were enrolled; 22 patients completed the therapy protocol and underwent surgical resection; R0 resection was achieved in 21 patients. Complete pathologic response was confirmed in 48% of patients. Higher rates of complete pathologic response were associated with presence of the LRP1B genetic mutation. The authors noted that the extended time required to complete this preoperative regimen could result in a higher risk of surgical complications although the rate of serious complications in this small cohort was low.

They concluded that studies with larger sample sizes and longer follow-up intervals are needed and research to validate the predictive value of the LRP1B mutation is required.

Robotic Surgery May Offer Better Surgical Outcomes in Emergent General Surgery

Lunardi N, Abou-Zamzam A, Florecki KL, et al. Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery. JAMA Surg. 2024.

Invited Commentary: Sheetz KH, Telem DA, Feldman LS. Robotics for Emergency General Surgery-Selecting the Right Tool. JAMA Surg. 2024.

The research reported in this article sought to identify temporal trends and outcomes of urgent and emergent general surgery performed using robotic instruments compared to laparoscopic and open approaches. Using data from a large national database (829 hospitals) for the interval 2013-2021, 1,067,263 urgent or emergent procedures (cholecystectomy, colectomy, inguinal hernia, ventral hernia) were identified.

Outcomes of interest were temporal trends in usage of robotic platforms, rates of conversion to open surgery, and hospital length of stay. Propensity score matching was used to improve accuracy of the comparisons. The data analysis showed that use of robotic approaches increased significantly over the study interval with a corresponding reduction in open procedures. Use of robotic techniques was associated with fewer conversions to open procedures, and shorter hospital lengths of stay.

The authors concluded that use of robotic techniques is increasing and may be associated with improved outcomes. In the editorial that accompanied this article, Sheetz and coauthors noted that the observed rate of conversion from laparoscopic to open procedures for colectomy (25%) is higher than expected and may indicate inappropriate use of laparoscopy. They also emphasized that levels of experience with robotic techniques by surgeons included in the study may influence outcomes and these data were not reported in the article. Finally, rates of specific technical outcomes such as bile duct injury, and hernia recurrence were not available in the dataset used by the authors. Additional studies focusing on these topics will provide valuable perspective on the potential value of robotic approaches for urgent and emergent general surgery procedures.