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JACS CME Featured Articles, Volume 217, October 2013
CONTINUING MEDICAL EDUCATION PROGRAM
JACS CME Featured Articles, Volume 217, October 2013 Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets Fischer JP, Nelson JA, Kovach SJ, et al J Am Coll Surg 2013;217:656e664 Intrahepatic cholangiocarcinoma: management options and emerging therapies Dodson RM, Weiss MJ, Cosgrove D, et al J Am Coll Surg 2013;217:736e750 Additional Articles for October 2013 Online at: http://jacscme.facs.org Cost effectiveness of intraoperative pathology examination during diagnostic hemithyroidectomy for unilateral follicular thyroid neoplasms Zanocco K, Heller M, Elaraj D, Sturgeon C J Am Coll Surg 2013;217:702e710 Is it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery Koch CG, Li L, Hixson E, et al J Am Coll Surg 2013;217:628e635
Objectives: After reading the featured articles publi-
articles are available each month in the print version, more may be available at jacscme.facs.org. Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME). Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
shed in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two
Learning Objectives: Readers should understand the relationship between progressive body mass index (BMI) and obesity and surgical and medical morbidity after immediate breast reconstruction (IBR), and the significant risk associated with morbid obesity (BMI 40 kg/m2) as it relates to implant or flap loss, unplanned reoperations, and wound and medical complications. Readers should recognize that obesity is independently associated with added wound, medical, and surgical risk after IBR and that patients with
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets Fischer JP, Nelson JA, Kovach SJ, et al J Am Coll Surg 2013;217:656e664
ª 2013 by the American College of Surgeons Published by Elsevier Inc.
757
ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.06.016
758
Continuing Medical Education Program
BMI in these ranges should be appropriately counseled regarding risk. Finally, they should appreciate current limitations in using the ACS-NSQIP datasets to assess outcomes in breast reconstruction as they relate to complications and modality. Question 1 The most common type of complication in immediate breast reconstruction (IBR) based on this analysis is: a) b) c) d) e)
Wound complications Medical complications Major surgical complication Readmission Venous thromboembolism
Critique: Immediate breast reconstruction is associated with added risk of surgical morbidity, particularly when a donor site harvest is required for reconstruction (free or pedicle transverse rectus abdominis myocutaneous [TRAM], latissimus, etc). Although the psychological benefits of having a breast mound immediately after surgery are established, there is an associated risk of complication. Our analysis assessed a variety of complication types, and the most common complications were major surgical complications (8.5%), defined as graft or prosthetic loss, deep infection, or unplanned return to the operating room. It is important to explain to patients seeking IBR that risk of serious complication can approach 8% to 9% and that progressive BMI is associated with added risk. Question 2 Morbidly obese (BMI 40 kg/m2) patients were at an absolute greatest risk for which of the following complications relative to nonobese patients: a) b) c) d) e)
Venous thromboembolism Unplanned return to the operating room Wound complications Medical complications Reintubation
Critique: Morbid obesity is established as a significant risk factor associated with surgical morbidity after a variety of surgical interventions, but importantly, is associated with higher rates of complications after breast reconstruction. Morbid obesity is a severe form of obesity often associated with multisystem disease, which impairs wound healing and places patients at added risk for wound complications. Our analysis demonstrated that relative to nonobese patients, those with a BMI 40 kg/m2 were at an 8% higher risk of wound complication (2.4% vs 10.4%, p < 0.0001).
J Am Coll Surg
This difference is statistically and clinically relevant, particularly when counseling a morbidly obese patient regarding risk of wound morbidity because our analysis demonstrated a 4.3-times greater risk of complications. Question 3 A study design limitation of 30-day outcomes likely creates the following: a) Falsely elevated complication rate in implant reconstruction b) Lower than expected complication rate in autologous reconstruction c) Expected complication rate for both implants and autologous reconstruction d) Lower than expected complication rate in implantbased reconstructions e) Lower than expected complication rates in both modalities Critique: One of the inherent limitations of this study was the 30-day follow-up period. Patients undergoing 2-stage breast reconstruction compared with those undergoing immediate autologous reconstruction will usually have at least 1 more planned operation in the form of an implant exchange procedure once expansion is completed. In addition to the risk conferred by 1 additional operation, patients who have implants are at risk from formation of capsules that require intervention, as well as long-term implant malposition or implant exposure. For these reasons, the implant group had a lower than expected complication rate; with time, more complications would be anticipated. Question 4 In counseling a morbidly obese patient (BMI > 40 kg/m2) regarding her outcome after free tissue transfer, which of the following is supported by these data: a) Long-term outcomes will be better using your own tissue. b) Short-term you will have a lower rate of surgical morbidity. c) Your risk of complication is higher because you are seeking autologous reconstruction. d) Your current weight places you at added risk for postoperative complications. e) It would be better to delay your reconstruction because your risk is too high. Critique: These data support only the outcomes at 30 days, and therefore any conclusion regarding longterm morbidity after immediate breast reconstruction using the ACS-NSQIP is not justified or supported
Vol. 217, No. 4, October 2013
by the analysis. However, what can be said is that BMI confers a direct and proportional increase in surgical risk. These findings are particularly important to explain to morbidly obese patients who are at greater risk for device or flap loss, wound complications, and overall medical and surgical morbidity. Early management of expectations and risk counseling may translate into improved outcomes and satisfaction.
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Intrahepatic cholangiocarcinoma: management options and emerging therapies Dodson RM, Weiss MJ, Cosgrove D, et al J Am Coll Surg 2013;217:736e750 Learning Objectives: After studying this article, readers should be able to explain the epidemiology, management, and survival outcomes of patients with intrahepatic cholangiocarcinoma (ICC) and be able to compare differences in these factors between patients with ICC and hepatocellular carcinoma (HCC). Question 1 Which factor is NOT associated with the increasing incidence of ICC in the United States? a) Hepatitis C infection b) Obesity c) Parasite infections (Clonorchis sinensis and Opistorchis viverrini) d) Nonalcoholic liver disease e) Diabetes mellitus Critique: Recent studies using population-based national databases have linked the rising incidence of ICC in the United States to hepatitis exposure, diabetes mellitus, obesity, nonalcoholic liver disease, and smoking. Well-established factors including primary sclerosing cholangitis, intrahepatic lithiaisis, congenital malformations, and hepatits C virus are present in a minority of patients, while the overwhelming majority of patients with ICC present with no identifiable risk factors. Question 2 In comparison with HCC, which of the following is associated with ICC: a) It is 5 times more predominant in men than women.
Continuing Medical Education Program
759
b) Alpha-fetoprotein is a useful tumor marker in diagnostic work-up. c) Size is a significant prognostic factor. d) Lymph nodes are present in up to 30% to 40% of patients at resection. e) Liver transplantation is the preferred surgical management. Critique: Intrahepatic cholangiocarcinoma is only slightly more predominant in men than women; HCC is 5 to 6 times more predominant in men than women. Alpha-fetoprotein is often elevated in patients with HCC, while only 5% of patients with ICC may present with a level >200 ng/mL. CA19-9 is elevated in nearly half of patients with ICC. Size is not included as a prognostic factor in the staging of ICC in the 7th edition of American Joint Committee on Cancer (AJCC) manual due to its lack of prognostic discrimination; multifocal disease and lymph node status have significant effects on survival. At resection, patients with HCC have a low (5% to 10%) incidence of positive lymph nodes; studies have suggested that the incidence of lymph node metastasis may be as high as 30% to 40% for ICC patients. The results of liver transplantation for patients with ICC have been poor, while the outcome for transplantation in patients with early-stage HCC has been associated with excellent long-term results. Question 3 Which of the following is NOT true with respect to lymphadenectomy among patients with ICC? a) Lymphadenectomy allows for appropriate staging b) Routine lymphadenectomy has not traditionally been done for ICC c) Provides no prognostic value d) May decrease the risk of locoregional recurrence e) There is a 30% to 40% incidence of lymph node metastasis on final pathology Critique: Although routine lymphadenectomy has traditionally not been performed in the United States and other western countries, growing evidence supports its use for staging purposes and prognostic value. Several groups have even suggested that lymphadenectomy may have therapeutic value in patients with solitary tumors and 1 to 2 involved lymph nodes. These groups report that lymphadenectomy may prevent locoregional recurrences. Unlike HCC, ICC has early involvement of regional lymph nodes in up to one-third of patients. Lymph node metastasis has clear prognostic importance because these patients have a worse long-term outcome.
760
Continuing Medical Education Program
Question 4 In the available literature the most established treatment modality for unresectable ICC is: a) b) c) d) e)
Systemic therapy with gemcitabine and cisplatin Hepatic intra-arterial therapy Radiofrequency ablation Targeted systemic therapy with lapatinib Liver transplantation
Critique: The preferred treatment modality of ICC is resection; however, a minority of patients present with disease amenable to surgery. Current management of unresectable ICC includes systemic chemotherapy, regional chemotherapy, hepatic intra-arterial therapy, ablation, and external beam radiation. There are no randomized controlled studies comparing these modalities, but a recent phase III trial in biliary tract cancers established systemic chemotherapy with
J Am Coll Surg
gemcitabine and cisplatin as the standard chemotherapeutic regimen. Small studies show improved response rates with cetuximab combined with gemcitabine and platinum agent, but trials are needed to define the role of such target therapies. Modalities including intra-arterial therapy and ablation are probably less effective in ICC than HCC due to its nature of being a less vascularized tumor and its larger size at diagnosis. External beam radiation has not been definitely established as therapy for unresectable ICC, but there is increasing evidence to support its use in the adjuvant setting for patients with a positive surgical margin. Although locoregional therapies may hold promise, systemic chemotherapy remains the standard of care for most patients with unresectable ICC. The outcomes of liver transplantation for ICC have been poor and currently do not justify the use of a limited resource.
Vol. 217, No. 4, October 2013
Continuing Medical Education Program
761
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue)
Issues are available for the past 24 months. You can print your certificate immediately. For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
JACS CME Featured Articles, Volume 217, October 2013 Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets Fischer JP, Nelson JA, Kovach SJ, et al. J Am Coll Surg 2013;217:656e664 Intrahepatic cholangiocarcinoma: management options and emerging therapies Dodson RM, Weiss MJ, Cosgrove D, et al. J Am Coll Surg 2013;217:736e750
JACS CME Featured Articles, Volume 217, October 2013 Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets Fischer JP, Nelson JA, Kovach SJ, et al J Am Coll Surg 2013;217:656e664 Intrahepatic cholangiocarcinoma: management options and emerging therapies Dodson RM, Weiss MJ, Cosgrove D, et al J Am Coll Surg 2013;217:736e750 Additional Articles for October 2013 Online at: http://jacscme.facs.org Cost effectiveness of intraoperative pathology examination during diagnostic hemithyroidectomy for unilateral follicular thyroid neoplasms Zanocco K, Heller M, Elaraj D, Sturgeon C J Am Coll Surg 2013;217:702e710 Is it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery Koch CG, Li L, Hixson E, et al J Am Coll Surg 2013;217:628e635
Objectives: After reading the featured articles publi-
articles are available each month in the print version, more may be available at jacscme.facs.org. Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME). Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
shed in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two
Learning Objectives: Readers should understand the relationship between progressive body mass index (BMI) and obesity and surgical and medical morbidity after immediate breast reconstruction (IBR), and the significant risk associated with morbid obesity (BMI 40 kg/m2) as it relates to implant or flap loss, unplanned reoperations, and wound and medical complications. Readers should recognize that obesity is independently associated with added wound, medical, and surgical risk after IBR and that patients with
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets Fischer JP, Nelson JA, Kovach SJ, et al J Am Coll Surg 2013;217:656e664
ª 2013 by the American College of Surgeons Published by Elsevier Inc.
757
ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.06.016
758
Continuing Medical Education Program
BMI in these ranges should be appropriately counseled regarding risk. Finally, they should appreciate current limitations in using the ACS-NSQIP datasets to assess outcomes in breast reconstruction as they relate to complications and modality. Question 1 The most common type of complication in immediate breast reconstruction (IBR) based on this analysis is: a) b) c) d) e)
Wound complications Medical complications Major surgical complication Readmission Venous thromboembolism
Critique: Immediate breast reconstruction is associated with added risk of surgical morbidity, particularly when a donor site harvest is required for reconstruction (free or pedicle transverse rectus abdominis myocutaneous [TRAM], latissimus, etc). Although the psychological benefits of having a breast mound immediately after surgery are established, there is an associated risk of complication. Our analysis assessed a variety of complication types, and the most common complications were major surgical complications (8.5%), defined as graft or prosthetic loss, deep infection, or unplanned return to the operating room. It is important to explain to patients seeking IBR that risk of serious complication can approach 8% to 9% and that progressive BMI is associated with added risk. Question 2 Morbidly obese (BMI 40 kg/m2) patients were at an absolute greatest risk for which of the following complications relative to nonobese patients: a) b) c) d) e)
Venous thromboembolism Unplanned return to the operating room Wound complications Medical complications Reintubation
Critique: Morbid obesity is established as a significant risk factor associated with surgical morbidity after a variety of surgical interventions, but importantly, is associated with higher rates of complications after breast reconstruction. Morbid obesity is a severe form of obesity often associated with multisystem disease, which impairs wound healing and places patients at added risk for wound complications. Our analysis demonstrated that relative to nonobese patients, those with a BMI 40 kg/m2 were at an 8% higher risk of wound complication (2.4% vs 10.4%, p < 0.0001).
J Am Coll Surg
This difference is statistically and clinically relevant, particularly when counseling a morbidly obese patient regarding risk of wound morbidity because our analysis demonstrated a 4.3-times greater risk of complications. Question 3 A study design limitation of 30-day outcomes likely creates the following: a) Falsely elevated complication rate in implant reconstruction b) Lower than expected complication rate in autologous reconstruction c) Expected complication rate for both implants and autologous reconstruction d) Lower than expected complication rate in implantbased reconstructions e) Lower than expected complication rates in both modalities Critique: One of the inherent limitations of this study was the 30-day follow-up period. Patients undergoing 2-stage breast reconstruction compared with those undergoing immediate autologous reconstruction will usually have at least 1 more planned operation in the form of an implant exchange procedure once expansion is completed. In addition to the risk conferred by 1 additional operation, patients who have implants are at risk from formation of capsules that require intervention, as well as long-term implant malposition or implant exposure. For these reasons, the implant group had a lower than expected complication rate; with time, more complications would be anticipated. Question 4 In counseling a morbidly obese patient (BMI > 40 kg/m2) regarding her outcome after free tissue transfer, which of the following is supported by these data: a) Long-term outcomes will be better using your own tissue. b) Short-term you will have a lower rate of surgical morbidity. c) Your risk of complication is higher because you are seeking autologous reconstruction. d) Your current weight places you at added risk for postoperative complications. e) It would be better to delay your reconstruction because your risk is too high. Critique: These data support only the outcomes at 30 days, and therefore any conclusion regarding longterm morbidity after immediate breast reconstruction using the ACS-NSQIP is not justified or supported
Vol. 217, No. 4, October 2013
by the analysis. However, what can be said is that BMI confers a direct and proportional increase in surgical risk. These findings are particularly important to explain to morbidly obese patients who are at greater risk for device or flap loss, wound complications, and overall medical and surgical morbidity. Early management of expectations and risk counseling may translate into improved outcomes and satisfaction.
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Intrahepatic cholangiocarcinoma: management options and emerging therapies Dodson RM, Weiss MJ, Cosgrove D, et al J Am Coll Surg 2013;217:736e750 Learning Objectives: After studying this article, readers should be able to explain the epidemiology, management, and survival outcomes of patients with intrahepatic cholangiocarcinoma (ICC) and be able to compare differences in these factors between patients with ICC and hepatocellular carcinoma (HCC). Question 1 Which factor is NOT associated with the increasing incidence of ICC in the United States? a) Hepatitis C infection b) Obesity c) Parasite infections (Clonorchis sinensis and Opistorchis viverrini) d) Nonalcoholic liver disease e) Diabetes mellitus Critique: Recent studies using population-based national databases have linked the rising incidence of ICC in the United States to hepatitis exposure, diabetes mellitus, obesity, nonalcoholic liver disease, and smoking. Well-established factors including primary sclerosing cholangitis, intrahepatic lithiaisis, congenital malformations, and hepatits C virus are present in a minority of patients, while the overwhelming majority of patients with ICC present with no identifiable risk factors. Question 2 In comparison with HCC, which of the following is associated with ICC: a) It is 5 times more predominant in men than women.
Continuing Medical Education Program
759
b) Alpha-fetoprotein is a useful tumor marker in diagnostic work-up. c) Size is a significant prognostic factor. d) Lymph nodes are present in up to 30% to 40% of patients at resection. e) Liver transplantation is the preferred surgical management. Critique: Intrahepatic cholangiocarcinoma is only slightly more predominant in men than women; HCC is 5 to 6 times more predominant in men than women. Alpha-fetoprotein is often elevated in patients with HCC, while only 5% of patients with ICC may present with a level >200 ng/mL. CA19-9 is elevated in nearly half of patients with ICC. Size is not included as a prognostic factor in the staging of ICC in the 7th edition of American Joint Committee on Cancer (AJCC) manual due to its lack of prognostic discrimination; multifocal disease and lymph node status have significant effects on survival. At resection, patients with HCC have a low (5% to 10%) incidence of positive lymph nodes; studies have suggested that the incidence of lymph node metastasis may be as high as 30% to 40% for ICC patients. The results of liver transplantation for patients with ICC have been poor, while the outcome for transplantation in patients with early-stage HCC has been associated with excellent long-term results. Question 3 Which of the following is NOT true with respect to lymphadenectomy among patients with ICC? a) Lymphadenectomy allows for appropriate staging b) Routine lymphadenectomy has not traditionally been done for ICC c) Provides no prognostic value d) May decrease the risk of locoregional recurrence e) There is a 30% to 40% incidence of lymph node metastasis on final pathology Critique: Although routine lymphadenectomy has traditionally not been performed in the United States and other western countries, growing evidence supports its use for staging purposes and prognostic value. Several groups have even suggested that lymphadenectomy may have therapeutic value in patients with solitary tumors and 1 to 2 involved lymph nodes. These groups report that lymphadenectomy may prevent locoregional recurrences. Unlike HCC, ICC has early involvement of regional lymph nodes in up to one-third of patients. Lymph node metastasis has clear prognostic importance because these patients have a worse long-term outcome.
760
Continuing Medical Education Program
Question 4 In the available literature the most established treatment modality for unresectable ICC is: a) b) c) d) e)
Systemic therapy with gemcitabine and cisplatin Hepatic intra-arterial therapy Radiofrequency ablation Targeted systemic therapy with lapatinib Liver transplantation
Critique: The preferred treatment modality of ICC is resection; however, a minority of patients present with disease amenable to surgery. Current management of unresectable ICC includes systemic chemotherapy, regional chemotherapy, hepatic intra-arterial therapy, ablation, and external beam radiation. There are no randomized controlled studies comparing these modalities, but a recent phase III trial in biliary tract cancers established systemic chemotherapy with
J Am Coll Surg
gemcitabine and cisplatin as the standard chemotherapeutic regimen. Small studies show improved response rates with cetuximab combined with gemcitabine and platinum agent, but trials are needed to define the role of such target therapies. Modalities including intra-arterial therapy and ablation are probably less effective in ICC than HCC due to its nature of being a less vascularized tumor and its larger size at diagnosis. External beam radiation has not been definitely established as therapy for unresectable ICC, but there is increasing evidence to support its use in the adjuvant setting for patients with a positive surgical margin. Although locoregional therapies may hold promise, systemic chemotherapy remains the standard of care for most patients with unresectable ICC. The outcomes of liver transplantation for ICC have been poor and currently do not justify the use of a limited resource.
Vol. 217, No. 4, October 2013
Continuing Medical Education Program
761
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue)
Issues are available for the past 24 months. You can print your certificate immediately. For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
JACS CME Featured Articles, Volume 217, October 2013 Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets Fischer JP, Nelson JA, Kovach SJ, et al. J Am Coll Surg 2013;217:656e664 Intrahepatic cholangiocarcinoma: management options and emerging therapies Dodson RM, Weiss MJ, Cosgrove D, et al. J Am Coll Surg 2013;217:736e750