March 7, 2023
Marwahah JS, Beaulieu-Jones BR, Berrigan M, et al. Quantifying the Prognostic Value of Surgeon Intuition: Comparing Surgeon Intuition and Clinical Risk Prediction as Derived from the American College of Surgeons NSQIP Risk Calculator. J Am Coll Surg. 2023, in press.
Surgeon assessment of operative risk is historically thought to be superior to risk calculators, especially for elective operations, because of surgeon experience and their ability to assess patient characteristics not commonly included in the patient attributes and physiologic measures collected by risk calculators. This study sought to compare the predictive utility of the ACS National Surgical Quality Improvement Program (NSQIP) risk calculator with surgeon intuition.
The assessment was based on surgeon responses to survey questions asking if the patient was lower than average, average, or higher than average risk for postoperative complications. Surgeon assessments were obtained for 216 patients, and NSQIP data were obtained for 9,182 patients. Statistical analysis showed that surgeon intuition assessment had an area under curve (AUC) of 0.70; the risk calculator results showed an AUC of 0.83. Combining risk calculator and surgeon intuition did not improve the predictive accuracy.
The authors concluded that the NSQIP risk calculator provided a more robust assessment of operative risk compared with surgeon intuition, but surgeon intuition was sufficiently accurate to be recognized as an acceptable method of assessing surgical risk that should be integrated into surgical care processes.
Hirpara MM, Clark RC, Hogan E, et al. Rise of Acellular Dermal Matrix: Cost Consciousness, Industry Payment, and Publication Productivity. J Am Coll Surg. 2023, in press.
Use of acellular dermal matrix (ADM) in reconstructive surgery, especially breast reconstruction, has become commonplace. This technique has been the subject of more than 500 publications despite ADM not having FDA approval and a lack of evidence supporting superiority of ADM compared with other reconstruction methods. The purpose of this study was to determine if there was a relationship between numbers of articles published and public interest or industry funding.
Articles published in 11 plastic surgery journals were identified (n = 535), and industry funding was quantified for the 17 most productive authors using a national open payments database. The selected authors averaged eight publications per author on ADM, and the total non-consulting industry compensation was $17 million; the median compensation per author was $194,000. The most prolific authors averaged $320,000 in compensation.
The total non-consulting compensation increased linearly with the number of publications per author. The mean percentage of disclosures of industry funding by authors was 65%; an encouraging finding was that the most highly compensated authors disclosed industry relationships in 100% of articles they authored.
Lead author Milan M. Hipara and colleagues recommended increased efforts to encourage open discussions of objectivity in clinical research and potential hazards of financial relationships with industry.
Loria A, Glance LG, Melucci AD, et al. Low Preoperative Serum Creatinine is Common and Associated with Poor Outcomes After Nonemergent Inpatient Surgery. Ann Surg. 277(2): 246-251.
Surgeons are familiar with the assessment and implications of elevated serum creatinine, but the clinical implications of low serum creatinine levels are less clear. The precursor of creatinine is synthesized in the liver and transported to skeletal muscle where creatinine is generated at a constant rate. Serum creatinine is not bound to albumin and is freely filtered at the glomerulus; a small proportion is secreted in the proximal renal tubules. Serum creatinine is routinely used to quantify renal function and diagnose acute kidney injury (AKI).
This study hypothesized that low serum creatinine could be a marker for decreased muscle mass. Data from the ACS NSQIP database were used to determine the association of low serum creatinine with outcomes of surgical procedures in a cohort of 1,809,576 patients. Low serum creatinine was diagnosed in 27.8% of male patients and 23.5% of female patients, and the data analysis showed that low serum creatinine increased risk of mortality by nearly 50% and risk of complications by 75%.
The authors noted that low serum creatinine is likely a marker for decreased muscle mass; this finding is not equivalent to a diagnosis of “frailty” because frailty determination includes assessment of other factors such as functional status and cognition. However, low serum creatinine can provide evidence to support additional evaluation and interventions to improve nutrition and optimize preoperative status.
Crawford CB, Schuh LM, Inman MM. Revision Gastrojejunostomy versus Suturing With and Without Omental Patch for Perforated Marginal Ulcer Treatment After Roux-en-Y Gastric Bypass. J Gastrointest Surg. 2023;27(1):1-6.
Roux-en-y gastric bypass (RYGB) is a common bariatric surgical procedure. Marginal ulcer is a complication of this procedure and, according to data cited in this report, is diagnosed in 6% of patients within 30 days of the procedure and 0.6% at 17 months or more postoperatively. Perforation of a marginal ulcer is rare, occurring in 0.6% to 0.8% of patients, but is a potentially life-threatening event that requires emergent surgical intervention. Perforations may be managed with suture closure of the perforation with or without omental buttressing (SGP) or revision gastrojejunostomy (RG).
The focus of this study was to compare outcomes for these two approaches. This retrospective, single institution study included 144 patients with marginal ulcer perforation following RYGB. SGP was used in 72 patients, and RG in 72. The outcome of interest was recurrence of the marginal ulcer. The data analysis showed that patients treated with RG had an ulcer recurrence rate of 11.1% compared with SGP patients who experienced recurrence in 41.7%. There were no significant differences in morbidity (leak, length of stay, readmissions) or need for repeat surgical interventions when the groups were compared.
The authors concluded that RG was a safe and effective treatment for perforated marginal ulcer with comparable morbidity risk when compared with SGP.