September 13, 2022
Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Feldt, SL, Keskey R, Krishnan P, et al. Is Previous Postoperative Infection an Independent Risk Factor for Postoperative Infection after Second, Unrelated Abdominal Operation? J Am Coll Surg. 2022, in press.
Postoperative infection continues to have significant negative impacts on patient health and costs of healthcare. Antibiotic prophylaxis protocols have been proven to reduce postoperative infection, but the emergence of infections caused by organisms that are resistant to the antibiotics used reduces the effectiveness of these protocols. The authors noted that 50% of patients who undergo an abdominal operation will have a second procedure during their lifetime, and the focus of this study was to discover if there is an effect of postoperative infection occurring after a prior abdominal procedure on the risk for and severity of a postoperative infection following a second unrelated procedure.
In the patient cohort used for this study (N=758), the authors found an infection rate of 15% following the index abdominal procedure. Data cited in the article showed that a second, unrelated abdominal procedure also had significant morbidity due to postoperative infection. Of note was the fact that infections following a second abdominal procedure were frequently caused by organisms that were resistant to antibiotics used for prophylaxis. The important message conveyed by the authors is that examination of the microbiology of the infection and the antibiotic prophylaxis protocol used in patients who develop infection following an abdominal procedure may lead to improved choices of antibiotics for prophylaxis if a second, unrelated procedure is necessary.
Byrne JP, Kaufman E, Scantling D, et al. Association between Geospatial Access to Care and Firearm Injury Mortality in Philadelphia. JAMA Surg. Published online August 24, 2022. doi:10.1001/jamasurg.2022.3677
James P. Byrne, MD, PhD, and co-authors noted that prolonged transport time to the nearest trauma center negatively affects survival from firearm injuries. Because firearm trauma is increasing in the US and data on alternative transport methods, such as transport by primary police responders, are lacking, research that provides insight into the effects of evacuation times on injury outcomes is important for planning that is necessary to improve trauma systems.
The authors conducted a retrospective cohort study of patients who sustained firearm injuries in a single city over a 5½ year interval. The study reported data on 10,105 patients; the overall mortality was 20%. The median predicted transport time to the nearest trauma center was 5.6 minutes. The data analysis showed that for each minute of increased transport time, mortality increased by 3%. The authors estimated that 23% of fatalities could be attributed to prolonged transport time. They concluded that improvements in trauma system response that lead to reduced transport time could have potential benefit for patients who sustain firearm injuries.
Brown JB. Firearm Injury—When Minutes Really Matter in the Field. JAMA Surg. Published online August 24, 2022. doi:10.1001/jamasurg.2022.3684
In the editorial that accompanied this article, Brown emphasized that a limitation of this study was that mortality risk adjustment was not performed. Nonetheless, the study adds important information that can be used to improve trauma systems.
Multicenter Selective Lymphadenectomy Trials Study Group. Therapeutic Value of Sentinel Lymph Node Biopsy in Patients with Melanoma: A Randomized Clinical Trial. JAMA Surg. Published online August 03, 2022. doi:10.1001/jamasurg.2022.2055
This study aimed to determine the effect of sentinel lymph node biopsy without lymph node dissection on outcomes for patients with cutaneous melanoma and documented lymph node metastasis. Data on 823 patients (855 lymph node basins) were reported; the principal outcome studied was regional nodal recurrence. Follow-up data at 10 years was available for the entire cohort; the analysis showed that 80.2% of patients who had sentinel lymph node biopsy but no lymph node dissection was alive without recurrence.
After multivariable statistical adjustment, absence of nodal recurrence was associated with younger age at the time of initial sentinel lymph node biopsy, thinner primary melanoma lesion, sentinel lymph node metastasis less than 1 mm in diameter, and metastasis area of less than 5%. The authors emphasized that risk of nodal recurrence increased in a linear fashion with increasing risk factors (age >50 years, increasing primary melanoma thickness, and ulceration of the primary melanoma). The authors concluded that sentinel lymph node biopsy can potentially control melanoma nodal basin recurrence risk in most patients.
Rhodin KE, Beasley GM, Tyler DS. Prognostic or Therapeutic—The Role of Sentinel Lymph Node Biopsy in Contemporary Practice. JAMA Surg. Published online August 03, 2022. doi:10.1001/jamasurg.2022.2054
In the editorial that accompanied the article, Kristen E. Rhodin, MD, and coauthors noted that added protection against nodal basin recurrence in patients with grade IIB/C melanoma can be achieved with adjuvant therapy, providing additional protection when used in properly selected patients.