The 2021 American College of Surgeons Clinical Congress was a hive of virtual activity, but one session proved particularly interesting to clinicians. During “Hot Topics in General Surgery,” a lineup of six expert speakers used a rapid-fire approach to give a brief overview of several timely issues.
As co-moderator E. Christopher Ellison, MD, explained, “I have worked with Dr. Ken Sharp over the past nine years to select the topics where surgeons share common thoughts, ideas and questions with one another. We keep tabs on that and pick the most interesting ones, reflecting a broad swath of topics in general surgery.”
1. Nonoperative Management Of Appendicitis
Liane Feldman, MD, the Edward W. Archibald Professor and Chair, Department of Surgery at McGill University, in Montreal
According to Dr. Feldman, there are various benefits in nonoperative management, such as surgery avoidance and preservation of the appendix, but there are also drawbacks, including initial treatment failure, disease recurrence, potential for complicated surgery and missed neoplasm. Nevertheless, there is recent evidence supporting nonoperative management of uncomplicated appendicitis, including a systematic review and meta-analysis (Ann Surg 2019;270[6]:1028-1040) and a randomized controlled trial (N Engl J Med 202012;383[20]:1907-1919).
“In summary, most patients with appendicitis can safely avoid immediate surgery,” Dr. Feldman said. “There’s an early failure rate of at least 10%, and recurrence of about 30% at one year and 40% at five years. Appendicolith is associated with complicated disease, early surgery and complications. In terms of neoplasms, there is about a 1% incidence of missed neoplasms in patients with uncomplicated disease, in which the clinical impact is unknown. However, there is a much higher rate (10%-30%) for patients with complicated disease, in whom interval appendectomy is recommended.”
2. Pheochromocytoma and Paraganglioma: More Genetic Than You Think
Nancy D. Perrier, MD, the Ruth and Walter Sterling Endowed Professor of Surgery at The University of Texas MD Anderson Cancer Center, in Houston
According to Dr. Perrier, the clinical manifestations of these conditions are “pretty classic” and include headaches, palpitations and diaphoresis. Biochemical diagnosis is confirmed with very high sensitivity and specificity when plasma-free metanephrines are obtained. Historically, pheochromocytomas have fallen into the rule of 3: About 30% of all adrenal tumors are of inherited origin; nine genes (and counting) have been confirmed to participate in tumorigenesis; and germline mutations are found in 100% of syndromic cases and up to 90% in patients with a strong family history. For these reasons, genetic testing is recommended for all patients.
“We live in an era of targeted therapies, and deciding which antiangiogenic drugs are useful should be prioritized, particularly in patients who have a hypoxia predisposition,” Dr. Perrier added. “Again, I remind you that genetic testing is important when we see patients with pheochromocytoma. It should be done preoperatively so that preoperative imaging can be personalized, as well as assessment for multiple tumors and tumors at other sites. Also, the genetic determinants will help personalize the operative plan, as well as with appropriate surveillance strategies for follow-up care.”
3. Management of Ingested Foreign Bodies in Children
Harold N. Lovvorn III, MD, professor of pediatric surgery at Vanderbilt University Medical Center, in Nashville, Tenn.
Dr. Lovvorn said button batteries can cause severe tissue burns in as fast as two hours, in addition to lifelong injuries. An ingested battery can induce a hydroxide-rich alkaline burn that dissolves the esophageal mucosa, resulting in liquefaction necrosis. Batteries can also be very difficult to find, and once removed, can leave a large erosive crater behind. However, after removal, it’s important to irrigate with approximately 150 mL of 0.25% acetic acid. Other objects that children may ingest can include magnets, jewelry and toys.
“In summary, we can often retrieve these ingested foreign bodies using minimally invasive techniques—either endoscopy or laparoscopy. However, sometimes we do have to be maximally invasive,” Dr. Lovvorn said. “Remember that long-term esophageal complications can arise from button batteries, and magnets can pose significant acute problems, which need to be monitored according to symptoms.”
4. Cologuard Versus Colonoscopy: Choosing Wisely
Sandra Kavalukas, MD, colorectal surgeon at the University of Louisville, in Kentucky
In 2014, Cologuard (Exact Sciences) gained FDA approval as a colon cancer screening test. It is an assay for different DNA mutations in a stool sample; it detects methylation, mutation and hemoglobin, and the result that comes back is simply a positive or negative. In comparing the numbers, colonoscopy has a 95% detection sensitivity versus a comparable 92% for Cologuard. However, in terms of polyp detection, colonoscopy has a 75% to 93% sensitivity (adenomas >6 mm), whereas Cologuard has a 42% sensitivity. Finally, there is one other very important caveat to this decision, and that’s financial consideration, according to Dr. Kavalukas. For the uninsured patient, the cost of Cologuard is around $500, while a colonoscopy can be up to $3,000, she reported.
“Colonoscopy isn’t just diagnostic of cancers, but it’s preventative of cancers by removing all polyps found,” Dr. Kavalukas said. “Nevertheless, as healthcare practitioners, some screening is better than no screening. In other words, the best test is the test that’s going to get done. However, keep in mind that Cologuard is only tested and indicated for the average-risk individual with no semblance of risk factors for colon cancer.”
5. Current Use of Neoadjuvant Chemo for Breast Cancer
Ingrid Meszoely, MD, associate professor of clinical oncology at Vanderbilt University Medical Center, in Nashville, Tenn.
Historically, The initial goal of neoadjuvant therapy was to convert unresectable to resectable disease, particularly in cases of inflammatory or locally advanced breast cancer, according to Dr. Meszoely. “We then realized that it can decrease the size of the primary tumor and convert mastectomy only to breast conservation candidates,” she said. This resulted in better cosmetic outcomes and improved negative margin resection rates. Researchers have since learned that it can also convert N2/N3 stage disease to N1, can potentially convert node-positive patients to node-negative, and omit axillary node dissection for sentinel lymph node biopsy only, Dr. Meszoely said. Response can be seen in up to 90% of patients; less than 5% of tumors will progress; and complete pathologic response in all comers is achieved in 20% to 30% of patients. Nevertheless, neoadjuvant therapy should only be considered in a multidisciplinary approach.
“Over time, the use of neoadjuvant therapy in breast cancer has become more compelling with more indications for its use,” Dr. Meszoely said. “In conclusion, neoadjuvant therapy offers multidisciplinary tools for tailoring therapy and allowing for less surgery with improved outcomes. It can convert unresectable to resectable disease, and decrease the burden of disease to allow for less surgery.”
6. Current Use of REBOA In Trauma
Joseph V. Sakran, MD, MPH, MPA, associate professor of surgery and nursing at Johns Hopkins Medicine, in Baltimore
When surgeons consider hemorrhage in trauma, it is clear that hemorrhagic shock is the most preventable cause of death, according to Dr. Sakran. Many physicians struggle with noncompressible torso hemorrhage—the traditional approach to aortic occlusion is resuscitative thoracotomy—but advances in technology have resulted in alternative solutions, with resuscitative endovascular balloon occlusion of the aorta (REBOA) being one of them. Like any new technology, there are always pitfalls to overcome, and in this case it’s incorrect inflation of the balloon in the wrong zone. There are three zones in the aortic occlusion: Zone I is from the left subclavian to the celiac trunk; Zone II is from the celiac trunk to the lowest renal artery; and Zone III is from the lowest renal artery to the aortic bifurcation. And you typically want to avoid Zone II inflation because this is a perivisceral segment that involves blood supply to the liver and kidneys, etc.
A nationwide analysis of REBOA in civilian trauma (JAMA Surg 2019;154[6]:500-508) found no significant difference in four-hour blood transfusion, but the REBOA group had a higher rate of acute kidney injury, lower leg amputation and mortality. This led researchers to needing to better define the specific population. When surgeons consider when to use REBOA, it really comes down to those injured patients who have life-threatening hemorrhage below the diaphragm and are refractory to resuscitation, according to Dr. Sakran. He also noted that REBOA is contraindicated in the setting of major thoracic hemorrhage or pericardial tamponade.
“REBOA should be thought of as a tool that is employed as part of a larger system of damage control, and that’s a really important thing to keep in the back of our minds,” Dr. Sakran said. “As time goes on, we’re going to have a better idea of the specific patient populations where this will be most applicable.”
This article is from the March 2022 print issue.
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