Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
GERD after Peroral Endoscopic Myotomy (POEM): Assessment of Incidence and Predisposing Factors
Abu-Nuwar MR, Eriksson SE, Sarici IS, et al. GERD after Peroral Endoscopic Myotomy (POEM): Assessment of Incidence and Predisposing Factors. J Am Coll Surg. 2022, in press.
Gastroesophageal reflux (GERD) is an important complication of the treatment of achalasia. The condition may be present without overt symptoms, which raises the risk for subsequent mucosal dysplasia and esophageal malignancy. This article reported findings from a single-institution retrospective study of patients who underwent peroral endoscopic myotomy (POEM) for treatment of achalasia; the study cohort consisted of 183 patients. The objectives of the study were to characterize post-POEM GERD and identify preoperative or technical factors impacting the development and severity of the complication.
GERD was categorized as “subjective” if typical symptoms were present; “objective” GERD was defined as significant evidence of reflux (using accepted severity scales) present on endoscopic examination. Overall, 93.4% of patients had a favorable outcome. Over a 22-month follow up interval, subjective, objective, and severe objective GERD were diagnosed in 38.8%, 50.5%, and 19.2% of patients, respectively. Of patients with objective GERD, 24% had no symptoms. Predictive factors for GERD included normal pre-treatment esophageal diameter and lower esophageal sphincter pressure <45 mmHg. Indications for POEM and length of the myotomy were not associated with GERD risk.
The authors concluded that patients should be counselled regarding the risk for GERD and monitored closely so that timely treatment of GERD can be implemented.
Editorial
Schirmer BD. Postoperative GERD after Peroral Endoscopic Myotomy Is an Issue. J Am Coll Surg. 2022, in press.
In the editorial that accompanied the article, Schirmer recommended close monitoring of post-POEM patients with endoscopy and pH studies so that appropriate treatment can be implemented and additional data on incidence, risk factors, and management can be provided.
Using Right-Sided Roll to Improve Reliability of the Focused Assessment with Sonography in Trauma
Shumway MC, Granet J, Solomon RJ, et al. Using Right-Sided Roll to Improve Reliability of the Focused Assessment with Sonography in Trauma: An Eastern Association for the Surgery of Trauma Multicenter Prospective Study. J Am Coll Surg. 2022, in press.
Focused Assessment Sonography in Trauma (FAST), a standard examination for detection of hemoperitoneum in injured patients, is highly specific, but sensitivity is suboptimal. Improved sensitivity could expedite treatment of bleeding and reduce the radiation exposure by reducing use of computed tomography (CT) imaging. This study evaluated use of a right-sided roll during the secondary survey examination with a repeat sonography examination following FAST.
A multicenter prospective study approved by the Eastern Association for the Surgery of Trauma involving hypotensive adult trauma patients (N=182) was reported; presence of hemoperitoneum was confirmed by CT imaging or intraoperative findings; hemoperitoneum was confirmed 35.7% of the study cohort. The data analysis showed that sensitivity of the FAST examination improved from 40% to 47.7% with the addition of the right-sided roll. Analysis of the receiver operating characteristics showed improved test accuracy that was not statistically significant. The authors concluded that the addition of the right-sided roll was a potentially useful maneuver that could be easily implemented.
Editorial
Salcedo E, Rinderknecht TN. The Right Kind of Roll? Expediting Care for Bleeding Trauma Patients. J Am Coll Surg. 2022, in press.
In the editorial that accompanied the article, Salcedo and Rinderknecht agreed with these conclusions and opined that the right-sided roll with repeat FAST maneuver was “free, fast, and helpful” and should be implemented in clinical practice.
American Thyroid Association Guidelines and National Trends in Management of Papillary Thyroid Carcinoma
Gordon AJ, Dublin JC, Patel E, et al. American Thyroid Association Guidelines and National Trends in Management of Papillary Thyroid Carcinoma. JAMA Otolaryngol Head Neck Surg. Nov 3 2022;doi:10.1001/jamaoto.2022.3360
Alex J. Gordon and coauthors noted that clinical practice guidelines for management of papillary thyroid cancer have progressively promoted more limited treatments for this condition. The purpose of their study was to determine whether guidelines promulgated by the American Thyroid Association were associated with significant changes in management on a national scale.
The authors used data from the National Cancer database over the interval 2004–2019 for patients with papillary thyroid cancers up to 4 cm in diameter and without metastases or nodal spread. Rates of thyroid lobectomy (TL), total thyroidectomy (TT), and TT plus radioactive iodine (RAI) were assessed; data on 194,254 patients (80.2% female) were analyzed. The data analysis showed that rates of TL decreased after the 2009 guidelines but increased significantly following publication of the 2015 guidelines. Rates of RAI use after TT decreased significantly after publication of both guidelines. Notably, the largest increases in use of TL were in patients with smaller tumors and in patients treated in academic institutions.
The authors concluded that there is an opportunity for quality improvement efforts to increase use of TL in community healthcare institutions.
