American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

Pair of JACS

New Study Analyzes Effectiveness of Home Recovery Program for Mastectomy for Breast Cancer

Vuong B, Dusendang JR, Chang SB, et al. Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care. J Am Coll Surg. 2021;232(1):35-44.

The authors presented outcomes data from a group of 1,689 patients managed within a surgical home recovery program in a single institution over a two-year interval. The recovery program permitted discharge to home on the day of surgery for patients undergoing mastectomy for breast cancer with or without reconstruction. Logistic regression analysis was used to identify risk factors for failure of the home recovery program (return to inpatient care).

The failure rate of the surgical home recovery program was 7 percent. Bilateral mastectomy, immediate reconstruction, inadequate pain control and ASA class 3 or 4 were factors associated with increased risk for return to inpatient care. After multiple logistic regression analysis, ASA class 3 or 4 and failure of the multimodal pain control program were the main risk factors for return to inpatient care. The data showed that African-American race/ethnicity was associated with failure of the multimodal pain control protocol and the data suggested that this patient group was not adequately educated in the features of the protocol.

The authors concluded improved educational efforts regarding postoperative pain control were indicated.

Effectiveness of Surveillance versus Completion Node Dissection in High-Risk Melanoma Patients

Broman KK, Hughes TM, Dossett LA, et al. Surveillance of Sentinel Node-Positive Melanoma Patients with Reasons for Exclusion From MLST-II: Multi-Institutional Propensity Score Matched Analysis. J Am Coll Surg. December 11, 2020.

Broman and coauthors presented data from a multi-institutional propensity matched cohort that compared surveillance with completion node dissection in patients with melanoma who had high-risk findings on sentinel node biopsy, such as microsatellites, extranodal extension, or greater than three positive sentinel lymph nodes. The authors emphasized that randomized trials have shown equivalent outcomes for surveillance and completion node dissection, but patients with high-risk characteristics were excluded from these trials.

The data analysis showed that recurrences were frequent, but most commonly occurred outside of the nodal basin. All-site recurrence and overall mortality rates were similar in patients who had surveillance compared to completion node dissection. The authors emphasized that the main benefit of surveillance was expedited adjuvant therapy that was not possible in patients who underwent completion node dissection because of the time needed for recovery from the node dissection procedure.

Other Articles

Report Suggests Implementation of COVID-19 Vaccination Program May Be More Important than Vaccine Efficacy

Paltiel AD, Schwartz JL, Zheng A, Walensky RP. Clinical Outcomes of A COVID-19 Vaccine: Implementation over Efficacy. Health Aff (Millwood). November 19, 2020.

The report provided a provocative and potentially valuable analysis of factors that could influence the success of a population-based COVID-19 vaccination program. Factors considered were vaccine effectiveness and various implementation factors, including manufacturing problems, delays in vaccine deployment and inadequate adherence to public health measures for mitigation of the spread of infection (physical distancing, mask wearing, avoidance of crowds and hand hygiene). The analysis showed that even with maximum vaccine effectiveness, control of the pandemic will likely be determined mainly by the success of the implementation processes.

Original Investigation Suggests Commercially Available Masks Important to Stop COVID-19 Spread, but Not Universally Effective

Clapp PW, Sickbert-Bennett EE, Samet JM, et al. Evaluation of Cloth Masks and Modified Procedure Masks as Personal Protective Equipment for the Public During the COVID-19 Pandemic. JAMA Intern Med. December 10, 2020.

Steinbrook R. Filtration Efficiency of Face Masks Used by the Public During the COVID-19 Pandemic. JAMA Intern Med. December 10, 2020.

The study reported by Clapp and coauthors tested the filtration efficacy of various types of commercially available masks in a single individual during a series of head and facial movements. Saline particles that were slightly smaller than COVID virions were used to quantify filtration; filtration efficacy in the commercially available masks was compared to N-95 medical masks. The data analysis showed that none of the tested masks, including the N-95 mask, were universally effective for all head and facial movements. Most of the commercially available masks were at least 50 percent effective.

In the accompanying editorial by Steinbrook, the author emphasized that the data regarding commercially available masks were encouraging but wearing any type of mask will contribute significantly to reducing COVID-19 transmission only if combined with other interventions such as crowd avoidance, hand hygiene and physical distancing.

Enteric Fistulas: A Hidden Health Care Burden in the U.S.? Article Explores the Data

Brooks NE, Idrees JJ, Steinhagen E, Giglia M, Stein SL. The Impact of Enteric Fistulas On U.S. Hospital Systems. Am J Surg. 2021;221(1):26-29.

Hu KY, Peterson CY. Enteric fistula: An Overlooked but Significant Healthcare Burden. Am J Surg. 2021;221(1):25.

The authors used data from the National Inpatient Sample database over a 10-year interval to determine the financial impact and resource use associated with the care of patients with enteric fistulas. More than 300,000 admissions were evaluated. The annual impact on the health care system in terms of days of inpatient care was 230,000 days/year. Annual costs of care averaged $500 million; overall inpatient mortality was 4.1 percent. The authors concluded that research to identify risk factors for development of enteric fistula and to develop measures for prevention of this complication would have significant benefits for patients and the health care system.

The editorial by Hu and Peterson noted that the reported costs likely underestimate actual costs since patients managed in outpatient settings were not included in the analysis. They also emphasized the fact that the data showed that admissions for enteric fistula are increasing nationwide. These observations provided further support for the need to increase understanding of causes and effective preventive measures for these complications.

Specialty Article

Musculoskeletal Tumor Surgery Review

Rose PS. What's New in Musculoskeletal Tumor Surgery. J Bone Joint Surg Am. 2020;102(24):2111-2119.

The concise and informative review by Rose provided an update on management of musculoskeletal tumors. Recent data, cited in the article, supported the value of prophylactic resection of metastatic lesions in the femur and hip region rather than delaying treatment until a fracture occurs. The author emphasized the current debate and uncertainty regarding use of chemotherapy for osteosarcoma; recent data, however, supports the use of chemotherapy and stem cell transplantation for Ewing's sarcoma. Data were presented that support the benefit, in terms of overall tumor-related mortality, for tumor resection in patients with extremity soft tissue sarcomas. In the last section of the article, the author cited recent data that indicate a shift away from resectional therapy for desmoid tumors of the lower extremity. Surgeons called upon to counsel patients with musculoskeletal neoplasms will find valuable guidance in this review article.