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

Past Pandemics and Epidemics Contribute to Today's Innovation in Surgery

Hakes NA, Choi J, Spain DA, Forrester JD. Lessons from Epidemics, Pandemics, and Surgery. J Am Coll Surg. 2020;231(6):770-776.

Hakes and coauthors present an informative review of the medical impacts of pandemics and the responses of surgeons to these. The review begins with plague, a bacterial infection spread via flea bites, contaminated fluid or tissue, and infected droplets. The disease was responsible for deaths that devastated Eurasia and North Africa in the 1300s. The authors note that surgeons were not accepted as medical practitioners at the time but failures of the humoral treatments physicians used for plague provided an opportunity for surgeons to organize into professional societies, refine educational requirements and increase recognition of the value of surgical treatments among the populations affected by the pandemic. The authors point out that during other epidemics, surgeons contributed to improvements in public health. During the Spanish Flu epidemic, for example, surgeons supported the use of masks and open-air hospitals that helped control the epidemic. Accomplishments of surgeons in helping control HIV-AIDS, Ebola, and SARS were significant as well. The COVID-19 pandemic has stimulated innovations by surgeons that have helped to control transmission during procedures needed for treatment, provided pathways to preserve and increase supplies of personal protective equipment, repurpose practitioners to care for COVID patients, and create ways to preserve and improve surgical education. The authors conclude that surgeons' ability to react quickly and in constructive ways to unforeseen emergencies contributed materially to the successful responses to pandemics throughout history.

Article Examines Factors Impacting Non-Attendance at Telehealth Visits

Kemp MT, Liesman DR, Brown CS, et al. Factors Associated with Increased Risk of Patient No-Show in Telehealth and Traditional Surgery Clinics. J Am Coll Surg. 2020;231(6):695-702.

Telehealth visits have increased due to restrictions forced by the COVID-19 pandemic. This retrospective cohort study used data from a single institution to determine causes of non-attendance for telehealth (video-based) visits and in-person visits. Data from 12,359 traditional visits and 903 telehealth visits were reviewed. There were 812 non-attendance events. The data analysis showed that the frequency of non-attendance for telehealth visits was twice as high compared with traditional visits. Younger patients had higher rates of non-attendance and the odds of non-attendance decreased linearly with increasing patient age. Patients who were single or legally separated also had higher rates. The data analysis suggested that other demographic factors such as income and education levels, access to and familiarity with technology, and race could also be associated with increased rates of non-attendance. Endocrine surgery and minimally invasive surgery clinics had significantly lower rates of non-attendance compared with other specialty areas. Unfortunately, data on non-attendance rates at initial visits versus repeat visits were not provided. The authors conclude that research that quantifies non-attendance risks for specific groups of patients will lead to discoveries of barriers to visit completion and permit interventions to improve visit completion.

Other Articles

Recommendations for Prevention of Eye Injury in Critically Ill

Sun L, Hymowitz M, Pomeranz HD. Eye Protection for Patients With COVID-19 Undergoing Prolonged Prone-Position Ventilation. JAMA Ophthalmol. November 19, 2020 [Epub ahead of print].

Available data have supported the benefit of prone position ventilation in COVID-19 patients who are refractory to other ventilator support approaches. Many patients undergo prone positioning for 12 hours or more each day. This study reports data on detailed ocular examinations in four patients who were ventilated in the prone position for 16 hours daily. Periorbital edema was observed in all patients. The examinations identified ocular compartment syndrome in two patients; this was the result of prolonged external pressure on the eyes. Other findings included optic disk edema and retinal hemorrhage. The authors note that these findings are consistent with a diagnosis of papillophlebitis that may occur due to microvascular thrombosis, which is a common finding in patients with severe COVID-19 infection. These findings serve to increase awareness of the association of prone position ventilation with eye injury. Use of cushioning to avoid increased ocular pressure is useful for prevention of this damage.

OPSI Might Be Effectively Prevented by Proper Immunization

Casciani F, Trudeau MT, Vollmer CM, Jr. Perioperative Immunization for Splenectomy and the Surgeon's Responsibility: A Review. JAMA Surg. 2020;155(11):1068-1077.

Casciani and coauthors conducted a systematic review of the literature to determine best practices for perioperative immunization in patients undergoing splenectomy or total splenic embolization. The authors note that available evidence is highly variable and generally of poor quality with no highly reliable prospective clinical trials discovered. They note that although guidelines recommend vaccination 14 days or longer after splenectomy or splenic embolization, available evidence strongly suggests that immunization in the early postoperative period is safe and effective. This means that the surgeon caring for the patient is in the best position to dependably supply the vaccination. The article provides valuable and informative data that support an organized approach to immunization of vulnerable surgical patients. Vaccines other than the typical pneumococcal vaccine may be administered during the perioperative period; the article encourages surgical care teams to investigate patient vaccination history and provide vaccines in addition to the customary pneumococcal vaccine based on patient need. Available data on the need for booster vaccinations and repeat administration are provided in the article. Surgeons caring for patients who require splenectomy or total splenic embolization will find valuable guidance in this report.

Necrotizing Pancreatitis Patients Should Be Followed Lifelong by Experienced Clinicians

Maatman TK, Roch AM, Ceppa EP, et al. The Continuum Of Complications in Survivors Of Necrotizing Pancreatitis. Surgery. 2020;168(6):1032-1040.

Patients with necrotizing pancreatitis often require multiple invasive procedures during the acute phase of care. Maatman and coauthors note that data on long-term rates of complications and invasive procedures are lacking. This study uses data from a single-institution prospective database to determine rates of long-term complications and need for invasive procedures in 576 patients followed for a mean interval of 46 months. One or more significant complications occurred in 85 percent of patients. Complications included disconnected pancreatic duct syndrome, splanchnic vein thrombosis, new endocrine and exocrine insufficiency, incisional hernia, chronic pain, gastrointestinal fistula, bile duct stricture and duodenal stricture. Nearly 60 percent of patients required an invasive procedure during the follow-up interval. The observation that splanchnic vein thrombosis occurred in nearly half the patients was surprising given prior reports, cited in the article, that indicated rates of 1 percent–24 percent. The authors stress that the decision to offer systemic anticoagulation requires careful risk assessment. Presinusoidal portal hypertension and gastric varices were identified in 50 percent of patients with splanchnic vein thrombosis but bleeding complications were rare, occurring in 3 percent of patients with splanchnic vein thrombosis. The authors concluded that long-term complications requiring invasive procedures for treatment were frequent following necrotizing pancreatitis and encouraged lifelong follow-up of these patients.