Front Matter| Volume 56, ISSUE 1, Pxiii-xxvi, September 2022


        Associate Editors viii
        Contributors ix

        Failure to Rescue After the Whipple: What Do We Know?

        Elizabeth M. Gleeson and Henry A. Pitt
        Mortality after pancreatoduodenectomy has improved over time. This progress is likely related to advancements in failure to rescue (FTR—the percentage of patients who die after developing a major complication). Several factors associated with FTR include patient-specific risks, development of certain postoperative complications, surgeon-specific factors, hospital-specific factors, rescue techniques, and regional differences. Efforts should be made to explore additional factors such as the influence of safety culture in the postoperative setting. Improvement in FTR may be better explored through randomized controlled postoperative management trials. In stable patients, management of complications by interventional radiology is preferred over reoperation.
         Introduction 2
         What do we know? 2
        Patient Factors 2
        Surgeon factors 4
        Hospital Factors 5
        Regional Factors 6
        Rescue Techniques 7
        Safety Culture 7
         Discussion 8
         Summary 8
         Clinics care points 9
        Disclosure 9

        Management of Necrotizing Pancreatitis

        Thomas K. Maatman and Nicholas J. Zyromski
        Necrotizing pancreatitis affects 10% to 15% of all patients with acute pancreatitis. Despite improved understanding of this complex disease, it is still attended by up to 15% mortality. Necrotizing pancreatitis provides the clinical challenges of working in a multi-disciplinary group, determining proper timing for intervention, and identifying appropriate intervention approaches. The step-up approach consists of supportive care initially. When there is documented infected necrosis, treatment begins with antibiotics, progressing to minimally invasive mechanical necrosis intervention, and reserving surgery as the final treatment modality. However, treatment must be tailored to the individual patient. This article provides an overview of necrotizing pancreatitis.
         Introduction 13
         Incidence and cause 14
         Pathophysiology 14
         Definitions 15
        Clinical course 18
        Early phase 18
        Late phase 20
         Intervention in necrotizing pancreatitis 23
        Evolution in treating necrotizing pancreatitis 23
        Indications and goals of intervention 23
        Natural history of pancreatic necrosis 24
        Percutaneous drainage 25
        Transgastric debridement 26
        Open pancreatic debridement 27
         Outcomes, including long-term sequelae 28
         Summary 30
         Clinics care points 30
         Disclosure 30

        Should We Utilize Routine Cholangiography?

        L. Michael Brunt
        Intraoperative cholangiography (IOC) is an essential skill that surgeons need for the safe performance of cholecystectomy and intraoperative diagnosis and management of bile duct stones. Whether it should be performed routinely or selectively is an ongoing debate that goes back to the early days of laparoscopic cholecystectomy (LC). Benefits of IOC include ability to detect bile duct stones, recognition of aberrant anatomy, and, in some circumstances, mitigation of the risk of bile duct injury. In this review, key aspects of this debate, technical aspects of performing IOC, evidence regarding its benefits, and imaging alternatives to IOC during LC are presented.
         History of cholangiography 38
         Rationale for IOC 38
         Indications for cholangiography 38
         Technique 39
         Prevention of BDI 42
         Alternatives to IOC 43
         CBD stones 46
         Summary 47
         Clinics care points 47
         Disclosure 48

        Reducing Firearm Injury and Death in the United States

        Joseph V. Sakran and Nicole Lunardi
        Firearms injury is a major cause of American morbidity and mortality. Although the firearm is a common vector, the intentions with which it is used represent a wide array of social ills—suicide, community violence, domestic violence, mass shootings, legal intervention, and unintended injury. The political and social underpinnings of this epidemic are inseparable from its prevention measures. Surgeons have an important role in firearm policy, research, prehospital and hospital advances, trauma survivor networks, and hospital-based violence prevention programs. It is only through interdisciplinary, multilevel, evidence-based prevention measures that the tides will turn on American firearm injury.
         Burden of disease 50
        Suicide 51
        Homicide 51
        Unintentional 56
        Legal intervention 57
         Cause of firearm injury 57
        Political determinants of firearm injury 57
        Access to firearms 58
        Firearm research 58
        Social determinants of firearm injury 59
         Firearm injury prevention 59
        Primary prevention 59
        Secondary prevention 61
        Tertiary prevention 62
         Summary 63
        Disclosure 63

        Reducing Complications After Surgery for Benign Anorectal Conditions

        Alton Sutter and Vitaliy Poylin
        While generally perceived as mundane and low-risk procedures, anorectal surgeries by virtue of their anatomic real-estate—dense with nerves, blood supply, and structures critical to the quality of life—are fraught with the potential for complications. While these complications are generally not life-threatening, their impact to the quality of life can be severe. Furthermore, the sheer volume of anorectal procedures performed each year means that even low complication rates or less severe complications can have significant economic impact.
         Introduction 69
         Complications 70
         Anal fistula 75

        Private Equity and Its Increasing Role in US Healthcare

        Kristen M. Beyer, Lyudmyla Demyan, and Matthew J. Weiss
        Private equity investments in health care and surgery are on the rise. There are potential advantages and drawbacks of private equity investment in health care. However, if done under the right parameters, PE investment may have the potential to address some of the challenges and inefficiencies of the current health care system.
         Introduction 79
         Health care and PE firms 80
         Potential drawbacks of PE investments in health care 81
         Potential advantages of PE investment in health care 84
         Summary 85
        Disclosure 85

        Facts and Fallacy of Benchmark Performance Indicators

        James P. Byrne and Elliott R. Haut
        Efforts to improve quality in healthcare have arisen from the recognition that the quality of care delivered and resulting outcomes are highly variable. Performance benchmarking using high-quality data to compare risk-adjusted outcomes between hospitals and surgeons has been widely adopted as one means for addressing this problem. In this article we discuss the history, current state, methodologies, and potential pitfalls of benchmarking efforts to improve quality of healthcare in the United States.
         Background 89
        The case of need to improve quality in health care 89
        Defining quality in modern health care: structure, process, and outcome 90
        Evolution of benchmarking: from private industry to health care 90
         Quality measurement and performance improvement 91
        A national framework for evaluating and improving quality in health care 91
        The performance improvement process 93
         Methodologies for performance benchmarking in surgery 95
        Data collection and management 95
        Estimating risk-adjusted performance: O/E ratios and hierarchical models 95
         Successful performance benchmarking initiatives in surgery 97
        Cardiac surgery 97
        Elective non-cardiac surgery 97
        Trauma 98
        Other surgical disciplines 99
         Fallacies in performance benchmarking: pitfalls and misperceptions 100
        Never events 100
        Apples to oranges? 101
        Public reporting of outcomes and risk aversion 102
         Evolving uses of Big Data 103
        Research 103
        Data-driven outcome prediction 104
         Summary 104
         Clinics care points 104
        Disclosure 105

        Transcarotid Artery Revascularization: Is It Better than Carotid Endarterectomy?

        Patric Liang and Marc L. Schermerhorn
        Transcarotid artery revascularization (TCAR) is a novel carotid stenting method that avoids the manipulation of the aortic arch and uses a flow-reversal neuroprotection system that effectively reduces the risk of embolic events during carotid intervention. Studies have shown a lower risk of stroke or death compared with the transfemoral carotid stenting approach, and an equivalent risk of stroke or death compared with traditional carotid endarterectomy. TCAR has added benefits of lower risk of myocardial infarction, cranial nerve injuries, and shorter operative times compared with endarterectomy. TCAR has become widely adopted by vascular surgeons in the United States for the treatment of patients with high-risk medical comorbidities and those with challenging surgical anatomy.
         Introduction 111
         The history and limitations of carotid endarterectomy 112
         The shortcomings of transfemoral carotid artery stenting 114
         Development of transcarotid artery revascularization and the resurgence of carotid artery stenting 117
         Anatomic considerations for transcarotid artery revascularization 121
         Summary 123
         Clinics care points 123
         Disclosure 124

        Endovascular Repair of Descending Thoracic Aortic Aneurysms

        Michol A. Cooper, Zain Shahid, and Gilbert R. Upchurch Jr.
        Descending thoracic aortic aneurysms (DTAAs) are an important cause of morbidity and mortality in the elderly. Once diagnosed, they should be surveilled and then repaired at a diameter of 5.5 to 6 cm, depending on the individual patient's physiologic and anatomic risk of repair. Thoracic endovascular aortic repair (TEVAR) is the preferred approach for repair and there are multiple procedural adjuncts that can expand indications for and use of TEVAR. Spinal cord injuries are an important and highly morbid complication after TEVAR and it is imperative to mitigate this risk.
         Introduction 129
        Epidemiology 130
        Anatomy 131
        Diagnosis and preoperative surveillance 134
        Indications for repair 136
        Repair types 137
        Thoracic endovascular aortic repair 137
        Thoracic endovascular aortic repair adjuncts 138
        Spinal cord protection 142
        Surveillance after thoracic endovascular aortic repair 146
         Summary 146
         Clinics care points 146
         Disclosure 147

        What Surgeons Need to Know About Gene Therapy for Cancer

        Shanmugappiriya Sivarajah, Kevin Emerick, and Howard L. Kaufman
        The broad field of gene therapy offers numerous innovative approaches for cancer treatment. An understanding of the different modalities including gene replacement therapy, cancer vaccines, oncolytic viruses, cellular therapy, and gene editing is essential for managing patients with neoplastic disease. As in other areas of oncology, the surgeon plays a pivotal role in the diagnosis and treatment of the disease. This review focuses on what the clinical surgeon needs to know to optimize the benefit of gene therapy for patients with cancer.
         Introduction 151
        What is gene therapy of cancer? 153
        Gene replacement therapy 154
        Cancer vaccines 156
        Oncolytic virus therapy for cancer 158
        Talimogene laherparepvec 159
        Cellular therapy of cancer 160
        Gene editing 162
        The surgeonâ.s role in gene therapy of cancer 163
         Summary and future directions 166
         Clinics care points 166
         Disclosure 167

        Is There a Place for Hyperbaric Oxygen Therapy?

        Kinjal N. Sethuraman, Ryan Smolin, and Sharon Henry
        Hyperbaric oxygen therapy (HBOT) involves treating patients by providing 100% oxygen through inhalation while inside a treatment pressurized chamber. The oxygen acts as a drug and the hyperbaric chamber as the dosing device. The effect of hyperbaric hyperoxia is dose dependent and, therefore, treatment depth and duration are important when considering its use. HBOT can either be the primary method of treatment or used adjunctively to medications or surgical techniques. The underpinning physiology is to bring oxygen-rich plasma to hypoxic tissue, preventing reperfusion injury, strengthening immune responsiveness, and encouraging new collagen deposition as well as endothelial cell formation.
         Introduction 169
         Overview 170
         Contraindications and complications 172
         Clinical indications 175
        Problem wounds 175
         Pathophysiology 175
         Why it works 177
         Evidence for problem wounds 177
         Treatment 181
         Osteomyelitis 181
         Treatment 182
         Summary 182
         Gas gangrene and necrotizing soft tissue infections 184
        Pathophysiology 184
         Why it works 185
         Evidence for necrotizing soft tissue infection and gas gangrene 185
        Treatment 188
         Acute traumatic peripheral ischemias 188
        Pathophysiology 188
        Why it works 189
        Evidence for crush injury 190
        Which patients benefit? 191
         Treatment 191
        Evidence for compartment syndrome 192
         Treatment 193
         Evidence for compromised flaps 193
         Thermal burns 193
        Evidence for thermal injury 194
         Which patients benefit? 195
        Treatment 195
         Soft tissue radionecrosis and delayed effects of radiation 195
        Treatment 196
         Other areas of interest 197
         Summary 198
         Clinics care points 198
        Disclosure 198

        Endoscopic Treatment of Gastroesophageal Reflux Disease

        William S. Richardson, Jessica Koller Gorham, Nicole Neal, and Robert D. Fanelli
        Video content accompanies this article at
        There have been many devices and ideas to treat reflux disease endoscopically. Several devices have been tried and even FDA approved but now are no longer used. The push for these therapies is to find effective reflux control with lower risk and faster recovery. In this article we describe an endoscopic suturing device (TIF), radiofrequency device (Stretta) and a newer technique that has a lot of promise called antireflux mucosectomy. All these procedures seem to help control reflux at a minimum of morbidity given current information. As reflux is so prevalent a shift to these techniques for appropriate patients is likely to improve patient care.
         Radiofrequency energy 205
        Introduction 205
        Indications and contraindications 206
        Mechanism of action 207
        Procedure 207
        Outcomes 207
        Durability 209
        Radiofrequency energy for gerd after other operations 209
         Transoral incisionless fundoplication (TIF) 209
        Introduction 209
        Patient selection 211
        The TIF procedure 213
        The cTIF procedure 215
        Outcomes 215
        Important clinical trials 215
         Summary 216
         Antireflux mucosectomy 220
        Introduction 220
        Patient selection 220
        Procedure 220
         Cap assisted (ARMS-C) 221
        Antireflux mucosal ablation 221
        Outcome 221
         Summary 224
         Clinics care points 224
         Disclosure 224
         Supplementary data 224

        Direct Peritoneal Resuscitation for Trauma

        Samuel J. Pera, Jessica Schucht, and Jason W. Smith
        Direct peritoneal resuscitation (DPR) has been found to be a useful adjunct in the management of critically ill trauma patients. DPR is performed following damage control surgery by leaving a surgical drain in the mesentery, placing a temporary abdominal closure, and postoperatively running peritoneal dialysis solution through the surgical drain with removal through the temporary closure. In the original animal models, the peritoneal dialysate infusion was found to augment visceral microcirculatory blood flow reducing the ischemic insult that occurs following hemorrhagic shock. DPR was also found to minimize the aberrant immune response that occurs secondary to shock and contributes to multisystem organ dysfunction. In the subsequent human trials, performing DPR had significant effects in several key categories. Traumatically injured patients who received DPR had a significantly shorter time to definitive fascial closure, had a higher likelihood of achieving primary fascial closure, and experienced fewer abdominal complications. The use of DPR has been further expanded as a useful adjunct for emergency general surgery patients and in the pretransplant care of human cadaver organ donors.
         Introduction 229
         Direct peritoneal resuscitation pathophysiology 230
         Direct peritoneal resuscitation in abdominal trauma 231
        Initial study 231
        Randomized controlled clinical trial 234
        Other applications for direct peritoneal resuscitation 238
        Direct peritoneal resuscitation for emergency general surgery patients 238
        Direct peritoneal lavage to human cadaver organ donor improves organ procurement 240
         Future directions for direct peritoneal resuscitation 242
         Summary 242
         Critical care points 242
        Disclosure 242

        What is the Best Inguinal Hernia Repair?

        Jennwood Chen and Robert E. Glasgow
        As the management of inguinal hernias have evolved over hundreds of years, so too has our paradigm of what constitutes the “best repair.” To best answer what the ideal inguinal hernia repair is, the authors take an in-depth look at considerations to the patient, the provider, and the health care system.
         Introduction 247
         Recurrence 249
        Mesh versus nonmesh 249
        Open mesh versus minimally invasive 250
         Chronic groin pain 252
         Cost and value 253
         Discussion 254
         Clinics care points 255
         Disclosure 255

        Do all Patients Get the Same Care Across Hospitals?

        Adrian Diaz and Timothy M. Pawlik
        There is extensive research demonstrating significant variation in the utilization of surgery and outcomes from surgery, including differences in mortality, complications, readmission, and failure to rescue. Literature suggests that these variations exist across as well as within small area geographies in the United States. There is also significant evidence of variation in access and outcomes from surgery that is attributable to race. Emerging research is demonstrating that there may be some variation attributable to a patient’s social determinants of health and their lived averment. Those affected must work together to determine rate of utilization and how much variation is acceptable.
         Clinical registries 260
         Administrative data 260
         Advanced statistical modeling 261
         Variation in utilization 261
         Variation in outcomes 263
         Disparities in surgical care 264
         Reducing variation and opportunities for improving surgical care 267
         Summary 268
         Clinics care points 269
        Disclosure 269

        What Is the Role of Neoadjuvant Endocrine Therapy for Breast Cancer?

        Anna Weiss and Tari A. King
        There is growing interest in neoadjuvant endocrine therapy (NET) for the treatment of hormone receptor-positive, human epidermal growth factor receptor 2 -negative (HR + HER2-) breast cancer. Expanding the use of genomic assays demonstrates that many patients with HR + HER2-breast cancer do not benefit from chemotherapy, leading to growing interest in NET as a less toxic alternative. Although NET’s ability to downsize breast tumors and achieve breast conservation is well-known, axillary surgery algorithms are not well-defined. Here we review primary endocrine therapy, the landmark NET clinical trials, and management of residual nodal disease following NET.
         Introduction 275
        Backgroundâ.primary endocrine therapy 276
         Discussion 277
        The ability of neoadjuvant endocrine therapy to downsize breast tumors 277
        Axillary lymph node response to neoadjuvant endocrine therapy 278
        Axillary surgery after neoadjuvant endocrine therapy 279
        Remaining questions 281
         Summary 282
         Clinics care points 283
         Disclosure 283

        What Is the Best Treatment for Acute Limb Ischemia?

        Elizabeth G. King and Alik Farber
        Acute limb ischemia (ALI) is a vascular emergency associated with high rates of limb loss and mortality. Management of these patients is challenging given the severe systemic illness resulting from tissue ischemia and the high incidence of preexisting comorbid conditions and underlying peripheral arterial disease. Expeditious diagnosis, anticoagulation, and revascularization are of utmost importance in reducing morbidity. Revascularization may be accomplished using open, endovascular, or hybrid techniques. Approach to revascularization depends on the severity of ischemia, location of occlusion, cause, chance of recovery, comorbidities, and available resources.
         Background/overview 287
         Classification and cause 288
        Thrombosis 289
        Emboli 289
         Clinical presentation 289
         Diagnostic examination 291
         Management 292
        Selection of operative approach 292
        Endovascular revascularization 293
        Catheter-directed thrombolysis 293
        Percutaneous mechanical thrombectomy 294
        Open surgical revascularization 296
        Predictors of amputation 298
         Special considerations 298
        Occluded lower-extremity bypass grafts 298
        Popliteal artery aneurysms 299
        Irreversible ischemia 300
         Postoperative management 300
         Summary 301
         Clinics care points 302
        Disclosure 302

        Endovascular Repair of Complex Aortic Aneurysms

        Guilherme B.B. Lima, Marina Dias-Neto, Emanuel R. Tenorio, Aidin Baghbani-Oskouei, and Gustavo S. Oderich
        Fenestrated-branched endovascular aortic repair (FB-EVAR) has gained widespread acceptance in patients with complex aortic aneurysms. It has evolved from an alternative to treat elderly and higher risk patients to the first line of treatment in most patients with suitable anatomy, independent of the clinical risk. Currently, these devices are available off-the-shelf (ready to use) and tailored to the patient anatomy with the options of fenestrated, branched and mixed fenestrated, and branched designs. Reports from single and multicenter experiences and systematic reviews have shown lower mortality and morbidity for FB-EVAR compared with historical results of open surgical repair. The main advantages are noted on mortality, respiratory complications, acute kidney injury, and length of hospital stay. The purpose of this article is to review the advances in the endovascular repair of complex aortic aneurysms exploring the indications for treatment, preoperative evaluation, patient selection, device design, and implantation technique.
         Introduction 306
         Indications 307
         Preoperative evaluation 308
         Endovascular repair 308
        Patient selection 308
        Device design 309
        Arterial access 310
        Implantation technique 311
        Patient-specific 3 or 4-vessel fenestrated stent-graft with preloaded system 311
        Mixed designs with fenestrations and directional branches 312
        Multibranched stent-grafts 314
         Postoperative care 315
         Results 316
         Summary 316
        Disclosure 317

        Is There a Role for Rib Plating in Thoracic Trauma?

        Chaitan K. Narsule and Anne C. Mosenthal
        Rib fractures are a morbid consequence of blunt trauma and are associated with a highly variable clinical presentation ranging from nondisplaced rib fractures causing limited, manageable pain to severely displaced rib fractures with concomitant thoracic injuries leading to respiratory failure. Due to an evolution of techniques, hardware technology, and general acceptance, rib plating has increased substantially at trauma centers all throughout the United States over the past decade. This article aims to review the most recent and current reports for rib plating with respect to indications, preoperative evaluation and imaging, approaches, timing for intervention, outcomes in patients with flail chest and nonflail injuries, and the management of complications. From these data, it becomes clear that the surgical stabilization of rib fractures (SSRF) has a firm place in the management of thoracic trauma.
         Introduction 321
         Indications 323
         Preoperative evaluation and imaging 325
         Aspects of technique and other key points 327
         Summary of select outcomes of surgical stabilization of rib fractures 330
         Managing hardware infections and failures 331
         Summary and future directions 332
         Clinics care points 332
         Disclosure 333