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

No Increased Risk of Postoperative Bleeding with Use of NSAID for Pain Management

Bongiovanni T, Lancaster E, Ledesma Y, et al. Systematic review and meta-analysis of the association between non-steroidal anti-inflammatory drugs and operative bleeding in the perioperative period. J Am Coll Surg. January 27, 2021 [Epub ahead of print].

Current approaches to postoperative pain management stress reduction of opioid use by employing alternative analgesics including nonsteroidal anti-inflammatory agents; concerns over bleeding risk have limited uptake of protocols that include NSAID. The authors conducted a systematic review of available literature to provide guidance regarding the question of whether postoperative administration of NSAID as a component of a multimodal pain control protocol is associated with an increased risk of perioperative bleeding.

The systematic review included 74 studies (observational and randomized trials) involving more than 151,000 patients. Definitions of significant bleeding included hematoma formation, return to the operating room for bleeding and the need for postoperative blood transfusion. The data analysis showed that there was no increased risk of postoperative bleeding with the use of NSAID for pain management. The authors noted that the inclusion of observational studies, short postoperative follow up in some included studies and the lack of data on bleeding risk in patients with a history of preoperative NSAID use were limitations to their study. Despite these limitations, the evidence supports the conclusion that postoperative NSAID use is not associated with increased bleeding complications.

Increased Firearm Injuries during the COVID-19 Pandemic Suggest a Hidden Burden

Abdallah HO, Zhao C, Kaufman E, et al. Increased firearm injury during the COVID-19 pandemic: A hidden urban burden. J Am Coll Surg. 2021;232(2):159-168 e3.

Sarani B. COVID-19 and firearm injury: A uniquely American problem. J Am Coll Surg. 2021;232(2):168-169.

Abdallah and coauthors reported data from a retrospective cohort study of patients cared for in a Level 1 urban trauma center. Injury mechanisms in 357 patients cared for prior to the COVID-19 lockdown were compared with 480 patients seen after the lockdown was imposed. Patients in the post-lockdown group were older and more likely to be female. The data analysis showed that intentional firearm injuries were significantly increased in the post-lockdown group.

In the editorial that accompanied this article, Sarani noted that the observed increase in firearm injuries has been confirmed in data from trauma centers in several U.S. cities. Other western countries, in contrast, have not recorded similar increases in firearm injuries. Additional data reported in the editorial confirmed that legal firearm sales increased in the post-lockdown period; background check requests prior to firearm purchase increased by 1.2 million following the lockdown. Given the fact that many firearms are obtained outside of the legal sales system, the increase in firearm acquisition is likely higher. Sarani noted that accurate data on suicides during the post-lockdown period are not available, so data comparing intentional violence and suicide have not been reported. The study authors and the editorialist concluded that an increase in firearm injury, unique to the U.S., may be linked to the psychological effects of social isolation and the availability of firearms.

Other Articles

Does Police Transport Change Survival of Patients with Penetrating Trauma?

Winter E, Hynes AM, Shultz K, Holena DN, Malhotra NR, Cannon JW. Association of police transport with survival among patients with penetrating trauma in Philadelphia, Pennsylvania. JAMA Netw Open. 2021;4(1):e2034868.

Inaba K, Jurkovich GJ. Police transport for penetrating trauma-lessons from patients in Philadelphia. JAMA Netw Open. 2021;4(1):e2035122.

Police transport of patients with penetrating injuries may reduce transport time. Outcomes of patients injured in a single city (Philadelphia, PA) and transported by police to Level 1 and 2 trauma centers were compared with patients that were transported by emergency medical services. A statewide trauma registry was queried, and outcomes over a four-year interval were recorded; a total of 3,313 patients were included, with 1,970 patients transported by police. Patients were matched for comparison using patient age, injury mechanism, injury severity score, presenting systolic blood pressure and Glasgow coma score.

The data analysis showed that 24-hour mortality rates were equivalent in both groups. When outcomes in the most severely injured patients were examined, the data showed that patients transported by police were significantly more likely to arrive at the trauma center alive. The authors concluded that police transport was safe and effective for patients with penetrating injuries sustained in an urban trauma system.

In the editorial that accompanied this report, Inaba and Jurkovich noted that Philadelphia is unique in the degree of acceptance and use of police transport. They emphasized the fact that even though the authors applied a matching algorithm, unmeasured differences in the cohorts could not be accounted for. One important piece of missing data were the times from injury to arrival of police and EMS personnel. Inaba and Jurkovich noted that these data are important, but that barriers to implementing police transport include reduced police funding as well as liability and training concerns. They encouraged further study of the use of police transport for severely injured patients.

Acute Care Surgery Services Provide Necessary Care during COVID-19

Bugaev N, Hojman HM, Breeze JL, et al. Acute care surgery service is essential during a nonsurgical catastrophic event, the COVID-19 pandemic. Am Surg. 2020;86(12):1629-1635.

Provision of care for surgical patients and for critically ill COVID-19 patients during the COVID-19 pandemic has been a significant challenge for many health care institutions. This study analyzed data on patients cared for by the acute care surgery service in a single institution. A two-month interval prior to the onset of the pandemic was compared with a two-month interval after the onset. The data analysis showed that surgical procedures performed in the study institution decreased by more than 50 percent, but procedures performed by the acute care surgery service increased by 27 percent. During the pandemic, the service cared for 23 percent of the critically ill patients in the institution, including patients with COVID-19 infection. The authors concluded that the acute care surgery service was an important asset that contributed significantly to the hospital response to the COVID-19 pandemic.

Destigmatizing Mentorship: Benefits of Senior Surgeon Mentorship to Younger Colleagues Are Valuable

Dickinson KJ, Sachdeva AK, Bass BL. It's ok to ask for help: Destigmatizing mentoring for junior surgeons. Ann Surg. 2021;273(2):e52-e54.

Surgeons preparing to perform independent operative procedures during the early interval after completing training regularly experience anxiety, pride, apprehension and self-doubt. Surgeons have recognized this period of vulnerability and, traditionally, many senior surgeons have provided mentoring and served as surgical assistants to their younger colleagues. The pressures of modern surgical practice and the perception that a significant proportion of young surgeons are not adequately prepared for independent practice because of a lack of autonomy during residency training have contributed to a culture where senior surgeon mentoring and assistance is not readily available. As a result, young surgeons may experience increased stress. The fear of being labeled as “unable to cope” or “lacking competence” may cause young surgeons to be reluctant to ask for help, which may lead to adverse patient outcomes.

The authors described a program developed within an academic surgery department that was designed to provide senior surgeon assistance to young surgeons whenever it was needed. The components of the program included routine mentoring and the development of an “open OR” culture. Dialogue and intraoperative collaboration were important parts of this initiative. Assistance and mentoring were provided for elective and emergency procedures during regular work hours as well as evening and night hours. Senior surgeons who assisted younger colleagues were fully credited with surgical assistant RVUs.

The authors concluded that such programs have significant potential benefits for patients and surgeons and deserve support from surgical service leaders, institutional administrators and health care payors.

Specialty Society Guidelines for Addressing Pancreatic Cysts

Ayoub F, Davis AM, Chapman CG. Pancreatic cysts—An overview and summary of society guidelines, 2021. JAMA. 2021;325(4):391-392.

The authors noted that pancreatic cysts are observed in 8 percent of abdominal imaging episodes. Given the high prevalence and significant risk of malignancy harbored within a pancreatic cyst, surgeons are encouraged to familiarize themselves with data and national practice guidelines relevant to these lesions.

The clinical features of pancreatic cysts and the available practice guidelines are reviewed in this article. High-risk features of pancreatic cysts include concurrent jaundice, new onset diabetes, recurrent pancreatitis and an elevated serum CA 19-9 level. Imaging features include cyst diameter > 3 cm, pancreatic ductal dilation and presence of solid components or mural nodules within the cyst. Presence of high-grade dysplasia or neoplasia on cytologic examination is also a finding associated with increased risk. The authors noted that a significant proportion of pancreatic cysts can be managed with surveillance, but that presence of high-risk features should be an indication for surgical consultation.