Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.
March 15, 2022
Davis CH, Beane JD, Gazivoda VP, et al. Neoadjuvant therapy for pancreatic cancer: Increased use and improved optimal outcomes. J Am Coll Surg. 2022 [In press].
Over the study interval, use of neoadjuvant therapy increased from 24.2% in 2014 to 42.7% in 2019. Use of neoadjuvant therapy was associated with reduced morbidity (especially pancreatic fistula and organ space infection) and shorter hospital length of stay. Optimal pancreatic surgery (OPS) was defined as absence of postoperative mortality, serious morbidity, percutaneous drainage, and reoperation while achieving a length of stay equal to or less than the 75th percentile (12 days for pancreaticoduodenectomy) with no readmissions. OPS was observed significantly more often in patients who received neoadjuvant therapy.
The authors concluded that neoadjuvant therapy was safe, that the delay in operative treatment necessary to receive the therapy was not associated with worse outcomes, and that the desired level of treatment quality was achieved more often in the neoadjuvant therapy patients.
Finfer S, Micallef S, Hammond N, et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med. 2022;386(9):815-826. doi:10.1056/NEJMoa2114464
Ostermann M, Randolph AG. Resuscitation Fluid Composition and Acute Kidney Injury in Critical Illness. N Engl J Med. 2022;386(9):888-889. doi:10.1056/NEJMe2200294
Finfer and colleagues performed a randomized, double-blind, controlled trial that compared normal saline with balanced salt solution for intravenous fluid therapy in critically ill patients. The trial included 5,037 patients from 53 intensive care units (ICUs) in Australia and New Zealand. Patients were included if ICU stay was estimated to be greater than 3 days; patients with brain injury or elevated risk of cerebral edema were excluded. Outcomes of interest included mortality, rates of renal replacement therapy, and maximum increase in serum creatinine levels; outcomes were assessed out to 90 days following admission to the ICU.
The data analysis showed that there was no difference for any of the outcomes of interest when the two groups were compared. The authors concluded that risk for mortality and renal injury were similar for the two types of fluid.
In the accompanying editorial, Ostermann and Randolph cited data that confirmed significant variability in multiple, high-quality studies that sought to determine benefits, in terms of reduced mortality and reduced renal dysfunction of various types of fluid therapy in critically ill adults. The uncertainties arose mainly depending on the types of patients included in the available trials and the tests used to diagnose renal injury. Several trials showed benefit from balanced salt solution, whereas others showed no difference between normal saline and balanced electrolyte solutions. They concluded that outcomes improvement from use of balanced electrolyte solution is possible in some patient groups, but the cost of these solutions reduces availability for some ICUs. Ostermann and Randolph advised that clinicians determine the optimum type of fluid therapy based on thorough and careful assessment of each patient.
Loggers SAI, Willems HC, Van Balen R, et al. Evaluation of Quality of Life after Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study. JAMA Surg. Mar 2 2022;doi:10.1001/jamasurg.2022.0089
This article reported data from a study that compared operative repair to no operation in institutionalized elderly patients who sustained proximal femoral fractures and met standard criteria for the diagnosis of frailty. A shared decision-making process was used to assist patients and surrogate caregivers in determining the most appropriate treatment choice. The main outcome of interest was quality of life (assessed by a standard instrument); secondary outcomes included mortality, morbidity, and pain levels. Operative treatment was chosen by 84 patients, and 88 patients chose nonoperative treatment.
Quality of life assessments conducted out to 6 months of follow-up showed that nonoperative treatment was not inferior to operative treatment. Satisfaction with the treatment choice was high in both groups. Pain levels, judged by analgesic use rates, were equivalent in both groups. Mortality in the nonoperative group at 30 days postoperatively was significantly higher compared with the operative group. This outcome was expected because the nonoperative group was frailer and had higher estimated operative risk than the operative group. The authors concluded that nonoperative treatment was an acceptable alternative for management of proximal femur fractures in frail, high-risk patients.