Current Issue

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.

Citation of Articles Reviewed:

Peacock O, Manisundaram N, Dibrito SR, et al. Magnetic Resonance Imaging Directed Surgical Decision Making for Lateral Pelvic Lymph Node Dissection in Rectal Cancer After Total Neoadjuvant Therapy (TNT). Ann Surg. 2022;276(4):654-664. doi:10.1097/SLA.0000000000005589

Commentary by: Gerald A. Isenberg, MD, FACS, FASCRS

A recent article presented at an ASA meeting explored the use of MRI in guiding surgical decisions for rectal cancer patients with lateral pelvic lymph node (LPLN) involvement. Subsequent discussion clarifies several important points.

Management of LPLN in rectal cancer presents two primary strategies:

• Combined surgery and dissection: Lateral pelvic lymph node dissection (LPLND) performed concurrently with total mesorectal excision (TME) for rectal cancer.
• Radiation-focused: Treatment of lateral nodes through radiation therapy.

Preoperative MRI may assist in tailoring the treatment approach to individual patients. While LPLND is standard in Japan, it is less common in Western settings. In this retrospective review, Peacock employs MRI criteria—short-axis size, malignant signal characteristics, and margin features—to aid in identifying LPLN positivity. The study compared outcomes between two groups with preoperative scans indicating possible LPLN involvement: those who underwent LPLND and those who did not.

Median follow-up was 20 months (considered short by this author). LPLND resulted in longer operative time, but blood loss and major complications were similar between groups. Lateral recurrence rates were nearly identical. As expected, patients meeting the MRI criteria were more likely to receive LPLND. The authors conclude that MRI can aid in the appropriate selection of patients for LPLND.

Unfortunately, the study does not provide a definitive answer regarding the necessity of LPLND. It does highlight the potential of MRI with a rectal cancer protocol as a decision-making aid for surgeons. Further studies should explore the specific indications for LPLND and identify training needs for surgeons who are less familiar with the procedure. Importantly, standard TME addresses most lymph node metastases due to its mesorectal focus.

References

1. Ogawa S, Itabashi M, Inoue Y, et al. Lateral pelvic lymph nodes for rectal cancer: A review of diagnosis and management. World J Gastrointest Oncol. 2021;13(10):1412-1424. doi:10.4251/wjgo.v13.i10.1412
2. Sluckin TC, Couwenberg AM, Lambregts DMJ, et al. Lateral Lymph Nodes in Rectal Cancer: Do we all Think the Same? A Review of Multidisciplinary Obstacles and Treatment Recommendations. Clin Colorectal Cancer. 2022;21(2):80-88. doi:10.1016/j.clcc.2022.02.002
3. Otero de Pablos J, Mayol J. Controversies in the Management of Lateral Pelvic Lymph Nodes in Patients With Advanced Rectal Cancer: East or West? [published correction appears in Front Surg. 2020 Jul 22;7:41]. Front Surg. 2020;6:79. Published 2020 Jan 17. doi:10.3389/fsurg.2019.00079

The SRGS Recommended Reading List is a summary of the most pertinent articles cited in each issue; 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 abstracts on PubMed, and free full texts are 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.

Radmayr C, Dogan HS, Hoebeke P, et al. Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines [published correction appears in J Pediatr Urol. 2017 Apr;13(2):239. doi: 10.1016/j.jpurol.2017.02.011.]. J Pediatr Urol. 2016;12(6):335-343. doi:10.1016/j.jpurol.2016.07.014

Radmayr and colleagues advocate for clinical observation of retractile testes and recommend orchidopexy for undescended testes before 12 months of age. For non-palpable testes, they state that evaluation for disorders of sex development is indicated; if this is unrevealing, laparoscopic exploration should be pursued. The guidelines advise against hormonal therapy and include diagnostic and therapeutic algorithms.

Antala S, Taylor SA. Biliary Atresia in Children: Update on Disease Mechanism, Therapies, and Patient Outcomes. Clin Liver Dis. 2022;26(3):341-354. doi:10.1016/j.cld.2022.03.001

Antala and Taylor provide a comprehensive update on biliary atresia, detailing its potential multifactorial etiology, including genetic predispositions, in utero injuries, viral infections, and aberrant immune responses. The authors emphasize the necessity of immediate Kasai portoenterostomy upon diagnostic confirmation, while acknowledging that progressive hepatic injury frequently occurs post-procedure despite establishment of biliary drainage.

Russell RT, Esparaz JR, Beckwith MA, et al. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg. 2023;94(1S Suppl 1):S2-S10. doi:10.1097/TA.0000000000003805

Russell and coauthors, in their consensus statement, address key aspects of managing pediatric traumatic hemorrhagic shock, including: hemostatic resuscitation strategies utilizing blood products, prehospital care considerations (airway management, blood pressure targets, tourniquet application), the role of hemostatic adjuncts, and coagulation monitoring during resuscitation. The recommendations strongly support blood product-based resuscitation over crystalloid infusions, citing evidence of reduced mortality and decreased ventilator requirements. A 1:1 plasma-to-red blood cell (RBC) ratio and a high platelet-to-RBC ratio are advocated for resuscitating injured children.