“The excellence of every art is its intensity”.
--John Keats, 1817
The Keats
Surgery Research Newsletter
Welcome--we’re so happy you’re here! We’ve built The Keats to help medical students and residents stay informed with the latest research in surgery. With our newsletter, you can now easily learn about the newest topics in surgery.
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Sleeve Gastrectomy or Gastric Bypass: Which is the Best Option for Treatment of Type 2 Diabetes Mellitus?
Bariatric surgery has more to it than meets the eye--especially with regards to type 2 diabetes (T2DM) management. Both sleeve gastrectomy and gastric bypass have been shown to improve diabetes management and remission via a variety of mechanisms. The most common ones are due to an induction of changes in hormones (e.g., ghrelin, GIP, peptide YY (PYY) and glucagon-like peptide-1 (GLP-1)), effects on serum primary bile acid levels, and alterations in the gut microbiome. The authors in these analyses targeted recent randomized controlled clinical trials aimed at examining potential clinical differences between sleeve gastrectomy and gastric bypass in the long-term control and resolution of diabetes.
The multiple studies reviewed revealed no significant difference between sleeve gastrectomy and gastric bypass in terms of A1C reduction in patients with T2DM after surgery. For instance, Murphy et al conducted a randomized trial of 114 patients with T2DM assigned to sleeve gastrectomy or gastric bypass and the main outcome evaluated was diabetes remission, (defined as A1C < 6% without the use of antidiabetic medications). There was statistically significant change in the form of decreased postoperative A1C levels or antidiabetic medication use (p = 0.85) in either group. Murphy et al's study was a demonstration of the authors’ general conclusion that there is no distinct efficacious advantage between sleeve gastrectomy or gastric bypass with regards to treatment of T2DM. It is suggested that clinicians and patients should base the decision on what specific procedure to use on factors beyond the long-term control of diabetes. And yet, the paper derived its conclusions on studies which utilized small sample sizes ranging from 49 to 240 patients. This weakness is acknowledged, and should not be ignored if further investigation is to be considered..
Effects of Early or Late Supplemental Parenteral Nutrition on Abdominal Postoperative Patients
Is it possible that introducing supplemental parenteral nutrition (SPN) earlier in postoperative courses could impact the risk of infection? Currently, guidelines recommend the use of enteral nutrition (EN) as soon as possible after surgery. There has been much debate on when to make the switch from parental nutrition (PN) to EN, especially due to the concern that PN has increased risk for postoperative infection. In this open-label, multicenter, randomized clinical trial of patients undergoing resections for GI cancers, the effects of early SPN (ESPN) were compared to that of late SPN (LSPN). ESPN was initiated 3 days after surgery, whereas LSPN was started 8 days after surgery. All patients had poor tolerance to EN and required PN. Gao et al. found that patients who were in the ESPN group demonstrated significantly decreased rates of nosocomial infections (8.7% vs 18.4%; p=0.04), and fewer days on therapeutic antibiotics (0.8% vs 1.1%; p=0.01) compared to LSPN.
After surgery, the body undergoes catabolic processes that cause nutritional deficits which alter required metabolic energy levels needed for healing and recovery, and thus, there is an increased risk for infections. This study suggests a possible redirection in nutritional management with the dual goal at combating postoperative infection. Depending on the abdominal surgery, any reduction in infectious risk could be lifesaving for a patient. However, given that this trial was conducted in China with a homogenous population and healthy BMIs, it is important to question how the results would change if the trial was repeated in Western society/diet with patients who tend to have higher BMIs (e.g., BMI >35). Obesity, especially visceral adiposity, is a well-known marker of inflammation and influences the healing process. Though the study did account for co-morbidities (type 2 diabetes and hypertension), there was no subgroup analysis for BMI as the patient population and diet was homogenous in that regard. Nonetheless, initiating ESPN for patients who are at high-risk for malnutrition and can’t tolerate EN after major abdominal surgery proves to have its benefits over LSPN to avoid postoperative infection.
Can an implementation of a pneumothorax size threshold of 35-mm decrease chest tube placement in trauma patients?
Occult pneumothoraces (PTX) are defined as being small enough to only be detected on CT. Management is up to a large amount of debate. Previous researchers established a cutoff threshold of 35-mm to manage conservatively with observation. This single-center retrospective review at a Level I trauma center evaluated the implementation of this treatment guideline. Specifically, patients with a PTX less than 35-mm in size were evaluated before and after being treated with observation alone without chest tube placement. Patients (n=266) who had not received chest tubes or thoracic procedures before their CT scan were placed into 2 groups: those evaluated before or after implementation of the protocol. The outcomes analyzed were observation failure rates, length of hospital or intensive care stay, lung-associated complications, and one-month readmission rates.
It was found that the use of chest tubes decreased after treatment guideline implementation, and the rate of observation increased from 84.4% to 94.6% (p = 0.007). The rate of compliance to the treatment guideline after 24 hours from admission was greater after implementation (p = 0.04). However, there was no difference in observation failure rates or length of hospital stay. Only 6 patients from the study were readmitted within 1-month of discharge, of which only 2 presented with lung-related issues. This study demonstrates that implementation of this treatment guideline allows for more conservative management for those with occult PTX and better compliance. Since this was a single center study, it would be interesting to see the effect of this implementation of this treatment guideline in larger and multicenter institutions.
Long Term Quality of Life in Patients with Breast Conservation Vs Mastectomy
Treatments for breast cancer have been heavily debated. Studies have found similar survival rates in patients who chose mastectomy or breast conserving surgery. Putting efficacy aside for a moment, surgeons must always consider a key point—the patient’s future quality of life (QOL). Surprisingly, not many studies focus on the subject, especially considering the higher rates of surgical intervention for early-stage breast cancer. In this comparative effectiveness study, the effect of breast-conserving surgery with radiation therapy (RT) vs mastectomy and reconstruction without RT on the long-term QOL was evaluated. Patients (n=14,236) diagnosed with stage 0-II breast cancer and treated with breast-conserving surgery or mastectomy & reconstructive were mailed a survey about 10 years after initial diagnosis. Patient satisfaction with their breasts after treatment was reported as the primary outcome measure using a BREAST-Q, which also included secondary elements (i.e., physical, psychosocial, and sexual well-being). Health utility was another target outcome, which was measured using the EuroQol Health-Related Quality of Life 5-Dimension, 3-Level Questionnaire. Of the total 551 patients treated, 57% underwent breast conserving surgery with RT and 42% had mastectomy and reconstruction without RT.
The multivariable analysis found no statistically significant difference in satisfaction with breasts between the two treatment options (95% CI, -2.45 to 7.88; P=.30). However, a key result to note is that psychosocial (95% CI, –13.26 to –3.95; P < .001) and sexual well-being (95% CI, –16.60 to –4.76; P < .001) was significantly worse with patients who chose to undergo mastectomy and reconstruction without RT. No significant distinction was made for health utility or physical well-being. This study validates before drawn conclusions that patients don’t show much difference in physical satisfaction after either treatment.1 However, if patients undergoing mastectomy and reconstructive therapy truly exhibit worsening sexual and psychosocial symptoms, then this paper makes a strong claim towards encouraging breast conserving surgery with RT therapy. And yet, it is important to recognize that the use of surveys approximately 10 years after initial diagnosis exposes the study to several types of biases. Thus, this study’s findings may be used to design future cost effective analyses.
1. Jagsi, Reshma et al. “Patient-reported Quality of Life and Satisfaction With Cosmetic Outcomes After Breast Conservation and Mastectomy With and Without Reconstruction: Results of a Survey of Breast Cancer Survivors.” Annals of surgery vol. 261,6 (2011).
Who is Keats?
The name for our newsletter was inspired by John Keats (1795-1821), a surgeon and English poet of the second generation of Romantic poets, joining the leagues of Lord Byron and Percy Shelley. Keats came from a middle-class background and struggled all throughout his life to make a name for himself and pursue his passions. After years of studying and working to be a surgeon, Keats discovered his other talent—writing poetry. By the end of the century, he was placed in the canon of English literature, strongly influencing many writers. Keats never relinquished the resilience to fulfill passions in both medicine and writing and continued to do so until his untimely death at the age of 25 from tuberculosis.
That intellectual passion was felt in his poetry, and I think such a passion is the very thing that should be remembered and idealized in future surgeons. The drive to discover more and dig deep into difficult questions is what we should all as future surgeons strive to emulate.
John Keats’ memory has led our team’s aim of providing easy access to surgical knowledge, while also creating a community of medical students and residents interested in surgery.
FUTURE OPPORTUNITIES & REMINDERS
NEXT ISSUE: August 10, 2022
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