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

Article Examines Use of Ethical Framework to Guide Decisions of Treatment over Objections

Fischkoff D, Prager K, Dastidar J, et al. Ethical Framework to Guide Decisions of Treatment Over Objection. J Am Coll Surg. July 22, 2021 [Epub ahead of print].

Surgeons often face situations where permission to perform a needed surgical procedure is denied by a patient who lacks the necessary mental capacity to make a truly informed decision. Available data show that up to 25 percent of preoperative psychiatric consultations are ordered to deal with these problems. Guidance as to how to proceed in an ethically rigorous and consistent fashion is lacking in the surgical literature. The objective of the decision-making process is to balance the need to recognize the patient's autonomy against the need to provide treatment to preserve health (beneficence) and protect the patient from harm (non-maleficence).

The authors used the seven-question Rubin/Prager decision support instrument in a cohort of 41 treatment decision events; in considering the importance of each question in reaching a final decision, there were statistically significant differences in question two (imminence of harm) and question seven (logistical issues). The main logistical issues considered were the patient's ability to cooperate with treatment, frequency of the proposed intervention, and complexity of post-procedural care. A decision to proceed with the procedure was made in 63 percent of patients. Participants in the decision process concluded that a decision to proceed with the proposed treatment was more likely if harm to the patient was imminent and less likely if logistical barriers were high. The authors concluded that the Rubin/Prager scale was helpful in facilitating a decision process based on sound ethical principles.

Dose-Adjusted Enoxaparin According to Anti-factor Xa Levels Beneficial in Reducing Postoperative VTE in Surgical Oncology Patients

Kramme K, Sarraf P, Munene G. Prophylactic Enoxaparin Adjusted by Anti-Factor Xa Peak Levels Compared with Recommended Thromboprophylaxis and Rates of Clinically Evident Venous Thromboembolism in Surgical Oncology Patients. J Am Coll Surg. 2020;230(3):314-321.

The authors reported a prospective study of a cohort of patients undergoing abdominal surgical procedures for malignant diseases; venous thromboembolism (VTE) prophylaxis with enoxaparin was used and dosage adjustment was performed based on anti-factor Xa levels with a target of >0.20 IU/mL. The primary outcomes of interest were inhospital VTE diagnosis and significant bleeding events. Diagnosis of VTE events was based on symptom assessment with confirmation by diagnostic ultrasound and/or chest CT angiography. Outcomes in the prospective intervention cohort (n = 64) were compared with an historical control group (n = 133). The only significant baseline difference between the two groups was a significantly higher Caprini score for the intervention group. The data analysis showed that the rate of VTE events was lower in the intervention group (0 percent versus 8.27 percent), whereas bleeding events were not statistically different. The authors acknowledged that a limitation in their study was the absence of assessment of post-discharge VTE events. They concluded that dose adjustment of enoxaparin according to anti-factor Xa levels was beneficial.

Other Article

Single-Session Physical Therapy versus Progressive Exercise for Treatment of Rotator Cuff Disorders: Which Is Most Effective?

Hopewell S, Keene DJ, Marian IR, et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): A multicentre, pragmatic, 2 x 2 factorial, randomised controlled trial. Lancet. 2021;398(10298):416-428.

Hopewell and coauthors performed a randomized, controlled trial to evaluate the effectiveness of a single best practice advice physical therapy session compared with multiple progressive exercise sessions for treatment of rotator cuff disorders. Corticosteroid injections were combined with a single session approach and multiple sessions in separate groups. A total of 708 patients were randomized and group size in the four comparison groups ranged from 174 to 182. The data analysis showed that a multiple session, progressive physical therapy program was not superior to a single session protocol for improvement of shoulder pain and range of motion. Of interest was the observation that corticosteroid injections did not have significant long-term beneficial effect on pain and range of motion, but the injections improved pain temporarily and, when used, patients were more likely to complete the assigned exercise program. The authors concluded that a single-session, best advice physical therapy program was the most effective treatment for rotator cuff disorders.