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

Exploring the Use of Shared Decision-Making in the Informed Consent Conversation

Long KL, Ingraham AM, Wendt EM, et al. Informed Consent and Informed Decision-Making in High-Risk Surgery: A Quantitative Analysis. J Am Coll Surg. June 4, 2021 [Epub ahead of print].

Publications such as Crossing the Quality Chasm from the Institute of Medicine have stressed the importance of making the informed consent conversation more collaborative by including discussions of patient values and preferences, as well as family opinions; these topics are categorized as "Shared Decision-Making." Traditionally, the informed consent process has focused on providing information such as choices of treatment, expected outcomes and potential complications. Shared decision-making has generally not been a part of the informed consent interaction.

This report provided results of a secondary analysis of 90 video recordings of informed consent interactions. Surgeons and other health professionals were trained to analyze the conversations and grade each video according to accepted rating scales to determine the extent to which elements of shared decision-making were included. The results showed that surgeons included components of shared decision-making most often when patients refused the initial proposed procedure. In most situations, the interaction focused on features, outcomes and potential complications of the proposed procedure. The authors concluded that additional education of surgeons in the components and value of shared decision-making could potentially improve the informed consent process.

Frequency and Risk Factors for Long-Term Mesh Explantation from Infection after Hernia Repair

Dipp Ramos R, O'Brien WJ, Gupta K, Itani KMF. Incidence and Risk Factors for Long-Term Mesh Explantation Due to Infection in More than 100,000 Hernia Operation Patients. J Am Coll Surg. 2021;232(6):872-880 e2.

Dr. Ramos and coauthors analyzed data from the Veterans Affairs Surgical Quality Improvement Program database to determine the frequency and risk factors for long-term mesh explantation following hernia repair. Data from nearly 104,000 procedures were reviewed.

Explantation was more likely after ventral (1.5 percent) or umbilical (0.6 percent) hernia repair. Risk of explantation was increased in patients with any degree of obesity, an American Society of Anesthesiologists score above 3 and contaminated or dirty wound status at the time of hernia repair. The median interval from initial hernia repair to explantation was 208 days and deep incisional infection was the most common cause of explantation. The authors noted that obesity and tobacco use reduce wound oxygen levels and increase risk for infection; they concluded that preoperative measures such as weight loss and smoking cessation combined with efforts to improve primary hernia wound status could potentially reduce risk of infection and mesh explantation. Additional research is necessary to determine whether factors such as mesh type and preoperative optimization pathways alter risk of explantation.

Other Article

Cautery Smoke a Low Risk for COVID-19 Transmission

Sowerby LJ, Nichols AC, Gibson R, et al. Assessing the Risk of SARS-CoV-2 Transmission via Surgical Electrocautery Plume. JAMA Surg. May 21, 2021 [Epub ahead of print].

The COVID-19 virus is present in saliva, sputum, bile, feces, tissue and blood. The virus has been shown to remain viable and transmissible in aerosols for more than three hours. Virus in tissues encountered during surgical procedures can potentially be transmitted to members of a surgical team during operative procedures. Smoke from electrocautery contact with tissue has been suggested as one potential transmission pathway. Available data suggest that temperatures at the cautery instrument-tissue interface exceed 1200° C, which could potentially inactivate the virus.

The authors analyzed smoke generated from cautery-tissue contact in nonhuman tissue that had been contaminated with live COVID-19 virus. Evidence of live virus was recovered from tissue and associated liquids, but analysis of cautery smoke disclosed no evidence of viral contamination. The authors concluded that their data suggest that cautery smoke has a low risk for viral transmission. They recommended additional research to analyze smoke from procedures performed on patients known to be infected with the COVID-19 virus.