Associate Editors viii
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.
What do we know? 2
Patient Factors 2
Surgeon factors 4
Hospital Factors 5
Regional Factors 6
Rescue Techniques 7
Safety Culture 7
Clinics care points 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.
Incidence and cause 14
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
Clinics care points 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
Prevention of BDI 42
Alternatives to IOC 43
CBD stones 46
Clinics care points 47
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
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
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.
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.
Health care and PE firms 80
Potential drawbacks of PE investments in health care 81
Potential advantages of PE investment in health care 84
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.
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
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
Data-driven outcome prediction 104
Clinics care points 104
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.
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
Clinics care points 123
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.
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
Clinics care points 146
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.
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
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.
Contraindications and complications 172
Clinical indications 175
Problem wounds 175
Why it works 177
Evidence for problem wounds 177
Gas gangrene and necrotizing soft tissue infections 184
Why it works 185
Evidence for necrotizing soft tissue infection and gas gangrene 185
Acute traumatic peripheral ischemias 188
Why it works 189
Evidence for crush injury 190
Which patients benefit? 191
Evidence for compartment syndrome 192
Evidence for compromised flaps 193
Thermal burns 193
Evidence for thermal injury 194
Which patients benefit? 195
Soft tissue radionecrosis and delayed effects of radiation 195
Other areas of interest 197
Clinics care points 198
Endoscopic Treatment of Gastroesophageal Reflux Disease
William S. Richardson, Jessica Koller Gorham, Nicole Neal, and Robert D. Fanelli
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
Indications and contraindications 206
Mechanism of action 207
Radiofrequency energy for gerd after other operations 209
Transoral incisionless fundoplication (TIF) 209
Patient selection 211
The TIF procedure 213
The cTIF procedure 215
Important clinical trials 215
Antireflux mucosectomy 220
Patient selection 220
Cap assisted (ARMS-C) 221
Antireflux mucosal ablation 221
Clinics care points 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.
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
Critical care points 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.
Mesh versus nonmesh 249
Open mesh versus minimally invasive 250
Chronic groin pain 252
Cost and value 253
Clinics care points 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
Clinics care points 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.
Backgroundâ.primary endocrine therapy 276
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
Clinics care points 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.
Classification and cause 288
Clinical presentation 289
Diagnostic examination 291
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
Clinics care points 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.
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
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.
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