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

Study Examines Effectiveness of Guidelines to Promote Effective and Safe Opioid Use after Inpatient Operation

Porter E, Bessen S, Molloy I, et al. Guidelines for Patient-Centered Opioid Prescribing and Optimal FDA-compliant Disposal of Excess Pills After Inpatient Operation: Prospective Clinical Trial. J Am Coll Surg. 2021;232(6):823-835.

Kaafarani H. Invited Commentary. J Am Coll Surg. 2021;232(6):835-836.

This article describes the development and implementation of a comprehensive program that promotes effective and safe opioid use for post-discharge control of postoperative pain and reduces retention of unused opioid pills. Opioids were prescribed as a component of multi-drug pain control protocols. The number of opioid tablets provided to each patient was calculated based on the amount of opioid medication used during the inpatient stay. Successful pain control was defined as no refills of the opioid medication prescriptions. Return of excess tablets was facilitated by patient education, provision of convenient drop boxes, and reminder phone calls. 

The data analysis showed that 93 percent of patients were satisfied with the program. Overall, 57 percent of patients used some opioid medication after discharge and 93 percent did not refill the prescription. Of 2,604 prescribed tablets, 187 were not recovered. In the editorial comment that accompanied the article, Dr. Kaafarani noted that a significant number of prescribed tablets were not used by patients who had the lowest use of opioids during the inpatient interval; it is possible that selective prescribing based on need would reduce the number of unused tablets in this group. An additional observation is that there was no dependable way to determine if any of the patients received prescriptions from other providers. The report has value in that it confirms the feasibility of developing an effective program for control of postoperative opioid prescribing. 

Sequential Imaging and Biomarker Scoring Feasible to Determine Risk of Pancreatic Cancer Development

Yip-Schneider MT, Wu H, Allison HR, et al. Biomarker Risk Score Algorithm and Preoperative Stratification of Patients with Pancreatic Cystic Lesions. J Am Coll Surg. June 14, 2021 [Epub ahead of print].

The authors noted that precursors of pancreatic cancer such as intraductal papillary mucinous neoplasm and mucinous cystic neoplasm can be detected using advanced imaging techniques. As imaging frequency has increased, detection of pancreatic cystic lesions has increased; available data shows that 13 percent of patients undergoing abdominal imaging have a cystic lesion. Identification of lesions with increased risk for pancreatic cancer is important to improve cancer outcomes and minimize risks for unnecessary surgery. Current availability of ultrasound-guided cyst aspiration provides a means for analyzing cyst fluid to improve risk assessment. 

This article describes the development of a risk score based on the presence of biomarkers such as vascular endothelial growth factor, carcinoembryonic antigen, and DNA mutation to determine risk. The score was tested in a group of patients who had undergone surgery and applied in a group of patients who did not undergo an operation. The data analysis showed that the risk score provided prediction accuracy greater than 90 percent in the study patients. The authors concluded that the combination of sequential imaging and biomarker scoring was feasible and safe for determining risk of cancer development and for identifying lesions that could be managed safely without surgery. 

Other Article

Article Describes Advances in Treatment of Melanoma, Including Surgical Options

Curti BD, Faries MB. Recent Advances in the Treatment of Melanoma. N Engl J Med. 2021;384(23):2229-2240.

This review article noted that a previous review, published in 2004, emphasized the fact that there were no effective systemic therapies for melanoma. In contrast, the current review described data confirming the effectiveness of four regimens of immunotherapy and three regimens of targeted drug therapy. In addition, there are encouraging therapies under development such as vaccination and the infusion of tumor-infiltrating lymphocytes. Surgical therapy has evolved as well. The article noted that more than 90 percent of melanoma patients have localized or regional disease. This understanding has fostered the development of surgical procedures that are less invasive and have very low risks for morbidity. 

Examples of evolution of surgical therapies include reduction in excision margins from 5 cm to 1 cm for thin melanomas and 2 cm for intermediate thickness lesions. The development of sentinel lymph node biopsy provided a means for reducing and possibly eliminating complications of lymph node dissection such as lymphedema; the technique also provided more accurate staging. Currently, patients undergo excision of the primary lesion with selective removal of regional nodes based on lymphatic mapping followed by sentinel node biopsy. Following removal of involved nodes, most patients can now be managed with nodal observation rather than completion lymph node dissection. The review article confirmed considerable progress in the management of melanoma and offered the promise of exciting innovations in the future.