American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

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Small Intestine

Small Intestine V45N1Vol. 45, No. 1, 2019

  • Embryology, Anatomy, and Physiology of the Small Intestine
  • Congenital Small Bowel Disorders in Adult Patients
  • Short Bowel Syndrome
  • Small Bowel Obstruction
  • Enterocutaneous Fistula
  • Radiation Enteropathy
  • Bleeding in the Small Intestine
  • Small Bowel Tumors
  • Crohn Disease
  • Intestinal Failure and Rehabilitation

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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.


Waks AG, Winer EP. Breast Cancer Treatment: A Review. JAMA. 2019;321(3):288-300.

Commentary by: Christine Laronga, MD, FACS

The article by Waks et al. serves as an excellent resource guide for trainees (medical, surgical, and radiation oncology) and practicing physicians. The tables and figures, in particular, can serve as at-a-glance summaries of the molecular subtypes of breast cancer, outcomes, and treatment strategies based on current relevant clinical trials and large meta-analyses. The authors also point out areas of active investigation and evolution that will most likely change the future of breast cancer treatment.

The article began with the identification of the three main molecular subtypes of breast cancer: hormone-receptor positive/ERBB2-negative, ERBB2-positive, and triple-negative. The diagnosis and pathophysiology, anticipated outcomes, and final medical management strategies were based on the molecular subtypes. Mechanisms of actions of the medications, in general, were provided to relay a clear understanding of why the data supports their usage; toxicities commonly associated with these medications were also stated in order to weigh risks versus benefits in terms of survival and quality of life. Embedded within the hormone-receptor positive/ERBB2 section was a summary of genomic assays and how they guide management decisions in terms of adjuvant chemotherapy. Novel targeted drugs under investigation were also mentioned.

The surgical and radiation management of breast cancer was discussed next. Management of node-negative breast cancer is now well-established, with minimally invasive treatment being the hallmark, especially in terms of the axilla (NSABP B32). Clinically node-negative found to be node-positive on sentinel lymph node biopsy also has strong support for omission of an axillary node dissection for N1 disease (ACOSOG Z0011, AMAROS, IBCSG 23-01). However, management of clinically node-positive breast cancer is rapidly changing and, in many cases, occurring ahead of evidence-based data from large prospective clinical trials (Alliance A011202, NSABP B51).

Finally, the paper discussed systemic treatment of stage IV breast cancer. By tying this back to molecular subtypes and anticipated outcomes, the reader can appreciate the various medical strategies outlined. Table 4 listed the plethora of drugs approved by the FDA in the past six years for metastatic breast cancer outlining mechanism of action, indications, and toxicities. The authors ended with a brief overview of genomics (such as PARP inhibitors for BRCA germline mutations) and disparities in breast cancer.

Overall, this is an excellent, succinct overview of the current landscape of breast cancer management and will serve as a reference guide for trainees of various disciplines and practicing physicians now and for the next few years to come.

Recommended Reading

The editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstract on PubMed; free full-text is available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Bharadwaj S, Tandon P, Gohel TD, et al. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf). 2017;5(1):20-28.

Evenson AR, Fischer JE. Current management of enterocutaneous fistula. J Gastrointest Surg. 2006;10(3):455-464.

Giuliano K, Ejaz A, Reames BN, et al. Comparing the long-term outcomes among patients with stomach and small intestine gastrointestinal stromal tumors: An analysis of the National Cancer Database. J Surg Oncol. 2018;118(3):486-492.

Isaksson K, Montgomery A, Moberg AC, et al. Long-term follow-up for adhesive small bowel obstruction after open versus laparoscopic surgery for suspected appendicitis. Ann Surg. 2014;259(6):1173-1177.

Jeppesen PB. Gut hormones in the treatment of short-bowel syndrome and intestinal failure. Curr Opin Endocrinol Diabetes Obes. 2015;22(1):14-20.

Matsushima K, Sabour A, Park C, et al. Management of adhesive small bowel obstruction: A distinct paradigm shift in the United States. J Trauma Acute Care Surg. 2019;86(3):383-391.

Ten Broek RPG, Krielen P, Di Saverio S, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2018;13:24.