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New Crucial Literature: The Science You Need to Know

New from JACS: Report Surveys Residency Program Directors to Find Impact of COVID-19 on Graduate Surgical Education

Ellison EC, Spanknebel K, Stain SC, et al. Impact of the COVID-19 Pandemic on Surgical Training and Learner Well-Being: Report of a Survey of General Surgery and Other Surgical Specialty Educators. J Am Coll Surg. September 12, 2020 [Epub ahead of print].

The disruption of clinical services that has accompanied the COVID-19 pandemic has, unsurprisingly, affected graduate surgical education. Obvious effects on operative experience for trainees occurred when elective surgery was stopped, but the impact on other aspects of education was more subtle. Ellison and coauthors sought to assess this impact with a survey of general surgery and surgical specialty residency program directors. The results of the survey, which was sponsored by the ACS Academy of Master Surgeon Educators, are reported in the article. The value of this report was increased by the inclusion of an informative visual abstract that is reproduced below.

Levels of impact were staged according to the three-stage system developed by the Accreditation Council for Graduate Medical Education. Stage 1 was "business as usual," stage 2 was "increased but manageable," and stage 3 was "extraordinary circumstance requiring reconfiguration of clinical services." As noted in the abstract, reductions in operative experience increased with increasing stage; this resulted in the most notable impact on core competencies in the technical skills area. Of interest was that most respondents felt that progression to autonomy was not severely affected. Impact on non-procedural education also increased by stage, as did adverse effects on trainee well-being. Encouraging data were reported regarding innovations that were implemented to maintain educational activities (virtual conferences, interviews, and so on). Also encouraging was the observation that most training programs had implemented plans to protect trainee well-being. Additional innovations to make simulation and cadaver laboratory training available are needed.

The authors emphasized that inclusion of measures to manage training disruptions and their effects should become integral parts of institutional disaster plans.

New from JACS: Systematic Review Seeks to Discern Benefit of Prehabilitation on Major Abdominal Surgery

Lyons NB, Bernardi K, Olavarria OA, Dhanani N, Shah P, Holihan JL, Ko TC, Kao LS, Liang MK. Prehabilitation among Patients Undergoing Non-Bariatric Abdominal Surgery: A Systematic Review. J Am Coll Surg. 2020 Oct;231(4):480-489. doi: 10.1016/j.jamcollsurg.2020.06.024. [Epub July 24, 2020].

This article reported a systematic review of available literature that attempted to quantify the potential benefit of "prehabilitation" on outcomes of major abdominal procedures. Prehabilitation is a component of several programs that seek to optimize patient factors that could increase the risk of postoperative morbidities such as surgical site infections, pulmonary complications, renal failure and delirium. One such program is the Strong for Surgery protocol sponsored by the ACS. Prehabilitation includes such measures as smoking cessation, nutritional optimization, increasing physical activity, pulmonary rehabilitation and stress reduction. These interventions have been shown to improve outcomes of cardiac, bariatric and orthopaedic surgical procedures. Potential disadvantages of these approaches include the time required for interventions to take effect and the necessity for high levels of compliance among participating patients.

The authors reviewed nearly 400 manuscripts and chose 14 for the final analysis; 12 of the included articles reported randomized trials. The results showed that no benefit could be established for prehabilitation prior to major non-bariatric abdominal operations. The authors noted that heterogeneity of the included studies and variation in duration of, level of supervision, and compliance with the prescribed prehabilitation protocols likely made discovery of any beneficial effects impossible. The authors emphasized the facts that surgeons are likely to continue to believe in prehabilitation because the concept is biologically plausible, the benefits of diet and exercise in other areas of medical care have been demonstrated, and the benefits have been documented in cardiac, orthopaedic and bariatric surgery. Additional, carefully designed studies are clearly needed.

Randomized Trial Compares Antibiotics with Appendectomy for Appendicitis

CODA Collaborative, Flum DR, Davidson GH, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. October 5, 2020 [Epub ahead of print].

Jacobs D. Antibiotics for Appendicitis—Proceed with Caution. N Engl J Med. October 5, 2020 [Epub ahead of print].

Available data have supported nonoperative management with antibiotics for mild forms of acute appendicitis. Most of the reported studies focused on very low-risk patient groups. This randomized, non-blinded, noninferiority trial included a higher risk patient cohort (clinical evidence of microperforation and/or appendicolith noted on imaging). The primary outcome was 30-day health status as determined by a standard quality-of-life assessment tool; secondary outcomes included the frequency of appendectomy in the antibiotic group and complications as assessed over a 90-day interval.

Outcomes from 776 patients in each group were reported. Laparoscopic appendectomy was the most common operative approach used. The primary outcome analysis showed that antibiotic therapy was non-inferior to immediate appendectomy. Of note was the observation that 29 percent of patients in the antibiotic group underwent appendectomy during the 90-day follow-up period. Complications were documented in 8.1 percent of the antibiotic group versus 3.5 percent of the appendectomy group. Appendectomies and complications clustered in patients with appendicoliths.

The authors concluded that counseling of patients on the potential benefits and hazards of the nonoperative approach was worthwhile. In the accompanying editorial, Jacobs stressed the fact that the excellent results of laparoscopic appendectomy would probably lead most surgeons to recommend this approach for acceptable risk patients, especially those with appendicoliths discovered on imaging.

Viewpoint Articles Discuss Health Effects of Delaying Elective Surgeries in the COVID-19 Era

Meredith JW, High KP, Freischlag JA. Preserving Elective Surgeries in the COVID-19 Pandemic and the Future. JAMA. October 5, 2020 [Epub ahead of print].

This report provided a valuable perspective on the effects of the COVID-19 pandemic on surgical patient care. The authors emphasized that the term "elective surgery" is misleading since it does not stimulate consideration of the effects of delaying or eliminating necessary surgical procedures on overall patient health, instead encouraging the use of the term "non-emergency" instead. Significant adverse effects on community well-being due to the economic impact of curtailing surgical procedures have been documented.

Data cited in the report noted that of 534 patients with breast cancer from a single institution, nearly 32 percent reported delays in screening or treatment caused by the pandemic. Additional data cited in the report showed that there was a 10 percent reduction in breast cancer survival and a 16 percent reduction in colon cancer survival when routine screening was suspended. The long-term consequences of curtailing surgery may not be known for some time since the case backlog is estimated to be nearly 5 million procedures. Delays in seeking care because of patient concerns regarding the risk of contracting virus infection have been noted. Recent data demonstrating that focused efforts to control transmission and implementation of aggressive COVID-19 testing can create an inpatient environment that is safe for patients are encouraging. The authors urged that these measures be implemented at the institutional level nationwide with a sense of common purpose and accountability. Combining these efforts with community-wide measures such as masking, hand-washing and social distancing can create a culture of safety and make non-emergency procedures available to patients.