Issue #7: January 25th, 2023
- Nour Atassi
- Jan 25, 2023
- 10 min read
I.
“Can death be sleep, when life is but a dream,
And scenes of bliss pass as a phantom by?
The transient pleasures as a vision seem,
And yet we think the greatest pain’s to die.
II.
How strange it is that man on earth should roam,
And lead a life of woe, but not forsake
His rugged path; nor dare he view alone
His future doom which is but to awake.”
--John Keats, 1814
HAPPENINGS THIS MONTH:
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Our Surgeon of the month is Robert Milton Zollinger
Can opting for a laparoscopic approach be more beneficial for hilar lymphadenectomy in advanced Gastric Cancer (GC)? In recent years the incidence of GC has been increasing, with the metastasis rate to the splenic lymph nodes (No. 10 LNs) getting as high 27.9% for advanced proximal GC (APGC). The current NCCN guidelines recommend No. 10 LN dissection for APGC reaching the greater curvature. And yet, recent studies have made it plain that No.10 LN dissection accompanied with splenectomy should be avoided when there is no invasion into the greater curvature for its link to higher morbidity. With the advancement of laparoscopic techniques, retrospective studies have stated that spleen-preserving splenic hilar lymphadenectomy (LSTG) may improve survival in patients with APGC. But the lack of prospective studies could uncover more.
In this open-label prospective randomized clinical trial, researchers compared the long term and short-term efficacy of LSTG (D2 + No.10 group) and conventional laparoscopic total gastrectomy (D2 group) for 536 patients with APGC with no invasion into the greater curvature. The primary outcome was 3-year disease free survival (DFS), while secondary outcomes include 3-year overall survival (OS) and morbidity and mortality within 30 days after surgery. The 3-year DFS was 70.3% (95% Cl, 64.8-75.8) for D2 + No. 10 group and 64.3% (95% CI, 58.4-70.2; P = .11) for the D2 group. Further analysis found the 3-year OS in the D2 + No. 10 group was better than that in the D2 group (75.7% [95% CI, 70.6-80.8] vs 66.5% [95% CI, 60.8-72.2]; P = .02). Using multivariate analysis, splenic hilar lymphadenectomy was seen to not be a independent protective factor for DFS (hazard ratio [HR], 0.86; 95%, Cl, 0.63-1.16) or (OS (HR, 0.81; 95% CI, 0.59-1.12). Interestingly, patients with posterior gastric cancer in the D2 + No. 10 group had a better 3-year DFS (92.9% vs 39.3%; P < .001) and OS (92.9% vs 42.9%; P < .001) than the D2 group. Analysis revealed a survival benefit to No.10 lymph node dissection in patients with posterior gastric cancer (DFS: HR, 0.10; 95% CI, 0.02-0.46; OS: HR, 0.12; 95% CI, 0.03-0.52).
Some limitations of this study considered include low number of patients with posterior GC and inconsistent number of patients receiving neoadjuvant therapy. Although the data does not show that LSTG significantly improves 3-year DFS patients with APGC without invasion into the greater curvature, benefits were found. LSTG may be the answer for APGC primarily located posterior to the gastric wall. However, due to the limitations and low volume of this specific patient population, further studies need to be conducted to assess the redirection towards laparoscopy.
Burn, baby burn—the iconic life of a surgical resident. Burnout has become increasingly prevalent amongst resident physicians. According to the literature, female trainees have presented with higher rates of burnout all attributed to elements such as gender bias, work-life integration challenges, issues with pay equity, and challenges in mentorship. Studies have introduced structured coaching programs as a way for residents to decrease emotional exhaustion and improve goal setting, but have been restricted to cohort studies. Typically, coaching, and mentoring programs have been placed in the context of in-person interaction and facilitated with a faculty member within a similar institution. This hurdle has been overcome by the introduction of virtual coaching. In this randomized clinical trial, women surgical residents within the Association of Women Surgeons were compared using a virtual coaching program on trainee well-being (3 one on one coaching sessions over 9 months) versus emailed wellness resources (control). Utilizing surveys, the goal was to use the comparison to evaluate the impact of coaching on female surgical residents when addressing burnout, self-valuation, resilience, and fulfillment. The survey responses in the intervention group (n=4) was 69.4% (p=0.050 while the control group (n=66) was 56.9%. The participants utilizing the virtual training program showed statistically significant improvement in burnout (p=0.026), self-valuation (p=0.003), well-being (p=0.015), and fulfillment (p=0.021). And yet, the control group demonstrated a significant decrease in resilience (p=0.025). A particular weakness to pay attention to is the generalizability due to the reliance on surveys and self inspection in addition to the large amount of subjective metrics used.
Whip it! The Whipple procedure has one of the highest complication and mortality rates. One particular complication is the fistula resulting from pancreato-duodenal anastomosis—5-30% complication rate. Interestingly, the choice of sutures when operating on the pancreas is paramount for the success of this procedure. The ideal suture material should be non-traumatic, mount a minimal inflammatory response, and be slowly absorbed to prevent anastomotic breakdown—especially in the setting of prolonged healing.
This study aimed to determine the resistance of absorbable sutures when exposed to bile and pancreatic fluids in relation to exposure time. The researchers exposed PDS, Vicryl, Monocryl, and their antibacterial triclosan coated analogues with either sterile bile, contaminated bile, or pancreatic juice. Physiological saline was used as a control solution for comparison. The bile and pancreatic juice was obtained from one patient for four postoperative days and underwent microbiological and microscopic examination for sterility. In order to test samples exposed to contaminated bile and pancreatic juice, the researchers contaminated the sterile samples with Escherichia coli, Klebsiella species, and Enterococcus faecalis. The tensile strength of each suture was measured at day 0 and every seven days after for 28 days. Using a tensile testing machine, the researchers measured the resistance of the various sutures. In addition, they utilized a scanning electron microscope (SEM) to observe the surface of the sutures at the completion of the study.
It was found that PDS and PDS Plus were the only suture materials able to undergo tensile testing at day 28 as the other sutures broke down after being exposed to pancreatic juice and bile for 21 days. Overall, it was noted that the tensile strength of the studied sutures decreased when exposed to pancreatic fluid and bile after 21 days; however, it was noted that the resistance was significantly decreased when exposed to contaminated fluids. Interestingly, it was noted that the contaminated pancreatic juice solution was most aggressive in terms of affecting resistance and degradation of the suture material. Without surprise, the SEM analysis demonstrated the surface of sutures immersed in the contaminated mediums were more degraded than those in saline solutions. It was concluded that the presence of contamination in either the pancreatic juice or bile has a significant influence on degradation of the studied sutures, regardless of composition, and that PDS had the best resistance and longests degradation time.
The management of abdominal aortic aneurysms has drastically changed over the years via use of endovascular aneurysm repair (EVAR). In a previous study, the endovascular aneurysm repair-2 trial (EVAR-2), showed that performing an EVAR in patients was not appropriate for open surgical repair (OSR) and did not show any significant overall survival advantage versus conservative management, such as blood pressure control and frequent monitoring.
In this prospective study, researchers examined patient survival and cost effectiveness in those who either underwent EVAR or were managed conservatively and had poor cardiopulmonary exercise test (CPET) metrics, which is a gold standard for fitness and risk assessment. 1435 patients who underwent a CPET were assessed for preoperative fitness in order to be cleared for abdominal aneurysm repair. Of these patients, 350 were determined unfit for OSR for which they underwent EVAR or were conservatively managed. The National Institute for Health and Care Excellence clinical guideline was used to create the economic model to serve as the basis for the cost-effectiveness analysis. After propensity matching, the researchers had 122 pairs of patients. It was found that the median overall survival was significantly greater in the patients who underwent EVAR compared to those that were managed conservatively (84 vs. 30 months, P < 0.001). It was also noted that the one-, three-, and five-year mortality was significantly lower in those in the EVAR group (all P < 0.001). In regards to the cost-effectiveness analysis, there was a greater cost-effectiveness in those that underwent EVAR ($11,644 USD per quality-adjusted life year gained) vs conservative management ($624,967 USD per quality-adjusted life year gained). Interestingly, the authors noted drawbacks in the cost-analysis, such that the extrapolated data was not based on a randomized controlled trial. Overall, the authors concluded that EVAR appears to have a greater overall survival rate and cost-effectiveness compared to conservative management in those who do not qualify for OSR.
Subspecialties: Cardiothoracics
At present, aortic valve (AV) disease is increasing with advancing age. Historically, the treatment for AV disease has been surgical replacement. Though a sternotomy AV replacement (SAVR) has been the common standard, there is a shift towards a two-port thoracoscopic AV Replacement (TTAVR). In this retrospective study, nine patients who underwent TTAVR under a single operator were examined to determine its safety and efficacy. Out of the nine patients, five had severe aortic stenosis (AS), and four had severe aortic regurgitation (AR). The outcomes evaluated included baseline characteristics, operative data, postoperative complications, and short term outcomes. With TTVAR, there were no conversions to SAVR; and complication and mortality rates were 0%. Additionally, ventilation time was only 6.13 hours (4.43, 19.99) and eight out of nine patients were extubated within 24 hours. Thus, the length of ICU stay was also short (2.68 + 1.30 days). In essence, TTAVR is safe and efficacious compared to SAVR. TTAVR should be considered more for the treatment of severe AV disease. However, one of its major limitations is that the study had a small sample size of only nine patients. The other limitation is that it was a retrospective study which bars complete comprehension of potential complications. Further efforts should be taken to determine TTAVR’s safety in a large, randomized clinical trial.
Subspecialties: Orthopedics
The anterior cruciate ligament (ACL) is most commonly reported to be injured and also cause recurrent knee instabilities after surgical treatment. It was also discovered that the ACLs may have a significant role in providing proprioception, therefore promoting dynamic stability. Surgical treatment of ruptured ACLs usually involves the implementation of grafts. This study aimed to compare the effectiveness of the autografts vs synthetic grafts in reproducing proprioception of the knee after treatment. 40 patients underwent ACL repair through either the autograft method (n=20) or the synthetic graft method (n=20). Joint position sense (JPS) was used to quantitatively measure the level of proprioception patients perceived after the assigned surgeries. Statistical analyses revealed no statistical differences between the level of proprioception perceived by patients who received autograft versus synthetic grafts for their ACL repairs. One year after surgery, both of the treatment groups reported production of full range of motion and no complications. The study accuracy and significance could be improved by the incorporation of more patients for better statistical analyses, as well as obtaining JPS measurements again after years of treatment to analyze reliability of surgical outcomes in the long term.
SURGEON SPOTLIGHT OF THE MONTH
Robert Milton Zollinger
September 4, 1903 – June 12, 1992
For this issue, we will look at the life and legacy of Dr. Robert Milton Zollinger. His name may sound familiar to those of us who came across the topic of gastrinomas during our gauntlet of USMLE and COMLEX exams. Although Zollinger was a surgeon through and through, his work with gastrinomas had been foundational in the field of pharmaceutical engineering and internal medicine.
Zollinger was, in every sense, a true underdog in the world of medicine and surgery in his time. Unlike his contemporary colleagues of medicine in the 20th century, Zollinger did not graduate from an Ivy League institution. Zollinger is an alumnus of Ohio State University for both his B.A. (1925) and M.D. (1927). Upon graduating medical school, Zollinger trained at the prestigious Peter Bent Brigham Hospital in Boston under Dr. Harvey Cushing in 1928. Zollinger was known as a country boy from Columbus, a “cow town,” among his Ivy League peers. As a result, he had developed a strong drive to prove his competency and the quality of his education to ultimately earn their respect. His endeavors in his solo competition against the rest of the surgical field refined his fundamental knowledge into a firm foundation for his later work. While in Boston, Zollinger met Dr. Elliot C. Cutler. The two would later return to Peter Bent Brigham Hospital as faculty professors of surgery from 1932 to 1939. In their partnership, Zollinger and Cutler will go on to publish the first nine editions of the Atlas of Surgical Operations, a famous and respected reference today.
Zollinger returned to his alma mater, Ohio State University, as the chairman of the Department of Surgery in the late 1940s after his service with the U.S. Army during the Second World War. In 1955, Zollinger’s work with Dr. Edwin Ellison pioneered gastrinoma research, leading to the discovery of the Zollinger-Ellison Syndrome, a condition caused by neuroendocrine tumors that leads to excess production of gastric acid in the stomach. Today, Zollinger-Ellison Syndrome is treated medically with proton pump inhibitors and octreotide. For Zollinger and Ellison, gastrinomas were treated with total gastrectomy. Zollinger’s work with gastrinomas led to the discovery of the hormone gastrin and later influenced the development of proton pump inhibitors.
Despite Zollinger’s humble beginnings and the uphill battle at the start of his surgical career, Zollinger was a perfectionist who expected nothing less from both himself and his students. He was especially hard on his students over minor infractions or mistakes and was feared among those who trained under him. Perhaps the hardship and pressures he faced made him more critical and inpatient towards his students who may or may not have the same background as him. As much as he was feared by his students, Zollinger was equally loved by his patients for his kindness and compassion when interacting with his patients. Still, Zollinger has many facets of life that are beyond research and medicine. His roots in farming fueled his passion for growing award-winning gourds and roses. He remained in Ohio State University and remained active in the Department of Surgery as Professor and Chairman Emeritus up until his death in 1992 from pancreatic cancer.
Today, nearly every medical student will remember Dr. Zollinger’s name as his contributions are ingrained into modern medical education. Zollinger’s journey in medicine is reminiscent of many first generation medical or college students, perhaps an optimistic reminder of how one’s fate can be changed by persistence and excellent competency. Dr. Zollinger left behind a legacy that is hard to forget, especially within modern surgery and medicine.
Sources:
Rodgers, Kristin (April 11, 2011). "Robert M. Zollinger, MD". Ohio State University. Retrieved January 10, 2023.
"Zollinger, Robert Milton (1903 - 1992)". Plarr's Lives of the Fellows. October 13, 2015. Retrieved January 10, 2023.
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