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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Thursday, April 03, 2014
Moderator: Dr. Mary Hawn


The study population for this current study is a subset of 264 (69%) of the 366 patients in the watchful waiting group from the original study that agreed to participate in a registry.  The main finding is that while watchful waiting remains a safe strategy with a very low rate of subsequent presentation for an incarcerated hernia, most hernias became increasingly symptomatic ultimately leading to elective repair.  Nearly 70% of patients in the watchful waiting arm crossed over to repair during the 10 year follow-up period.  In Cox proportional hazards analysis, age greater than 65 was the single factor identified with cross over.  The cross over rate for men greater than 65 was 79% versus 62% for men younger than 65.  Thus while watchful waiting is safe, most men, especially older men will ultimately elect to undergo repair of their inguinal hernia.   


The findings in this study are useful for shared decision making with men about whether and when to get their inguinal hernia fixed. 


While the authors do not specifiy why they chose to dichotomize the age variable at 65 years, it cannot be overlooked that two major policies go into effect in the United States at this age:  eligibility for (1) retirement with social security benefits and (2) Medicare healthcare benefits.



1.  Based on the observation of the association between age >65 and crossover to surgery, do you think that age is the determinant of whether men will chose to have their hernia repair, or perhaps is the time available for recovery an important variable? 


2.  When discussing management strategies with patients, should we focus on their employment status, disability coverage and activity level in determining the optimal time for elective hernia repair?


3.  This study did not report on outcomes of surgery for those men that underwent delayed hernia repair compared with their counterparts that underwent immediate hernia repair.  What could the effects of delayed hernia repair have on ultimate hernia outcomes?


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

Friday, March 07, 2014
Moderator: Dr. Mark Malangoni
Featured Article: General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a Survey of Fellowship Program Directors by SG Mattar etal. Ann Surg 258:440 - 449, 2013.

Mattar and coauthors have surveyed a select group of fellowship program directors (FPDs) regarding their opinions about the capabilities of those entering advanced training following completion of a general surgery residency.  Using a Likert scale to assess multiple domains, they report mixed results.  Their opinions of fellows in the domains of professionalism and clinical evaluation were very good with less than 5% of FPDs expressing significant concerns in these areas.  In contrast, more than 25% of FPDs felt that incoming fellows required more supervision than expected, including 18% who believed their fellow could not perform a laparoscopic cholecystectomy - the most common operation done in surgery residency - without supervision.  Concerns about basic and advanced minimally invasive skills were also prevalent and there was great concern about fellows’ interest and abilities in academic and scholarly pursuits.

These concerns are neither novel nor recent; however, this article emphasizes the ongoing unease about the preparedness of surgery residents to pursue further training (the focus of this report) or enter practice.  Proponents pile on with anecdotes reinforcing these findings while others blame duty hours requirements and the need to return to “the good old days,” alleging that these issues didn’t exist in decades past.  While time clouds all memories, most surgeons recognize that the majority of residency graduates, present or past, need some guidance and mentoring in the early years of practice.  If there was nothing further to learn during fellowship, why would these advanced training programs exist?  More importantly, Mattar et al ask an important question: can we do better in training surgery residents for their eventual careers, whether as specialist or sub-specialist surgeons?

This article presents the opinions of one group, the FPDs.  The results and conclusions should give us pause to reexamine the current training paradigm for surgery and use the collective will to provide the best possible training.


1.      Do you believe that graduated residents should be capable of unsupervised practice either when entering additional training or going into clinical practice?  Is ongoing mentoring a necessity that should be acknowledged and supported?

2.      Do you agree with the opinions of the fellowship program directors that a large percentage of residents lack appropriate minimally invasive skills at the completion of training?  If you agree, what needs to change to remedy this problem?

3.      Does the presence of a minimally invasive surgery fellowship program interfere with the training of surgery residents?

4.      Would rotations where residents perform a large volume of operations (e.g., in community hospitals) improve training? 

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.


Saturday, February 01, 2014
Moderator: Dr. Susan Galandiuk
Article: Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis: A Prospective, Multicenter Randomized Clinical Trial (DIVER Trial).
Biondo, Sebastiano; Golda, Thomas; Kreisler, Esther; Espin, Eloy; Vallribera, Francesc; Oteiza, Fabiola; Codina-Cazador, Antonio; Pujadas, Marcel; Flor, Blas
Annals of Surgery. 259(1):38-44, January 2014.
Summary: The authors present a multi-center, randomized controlled trial conducted in Spain between 2009 and 2011 designed to compare outpatient versus inpatient antibiotic treatment of uncomplicated diverticulitis. There were 66 patients in each study arm. Importantly, the 132 randomized patients represent only 29 % of the 453 patients with diverticulitis seen during the study period. The exclusion criteria are extensive and 27 % of eligible patients refused to participate. Patients seem to have been selected largely on CT findings, for evidence of diverticulitis without evidence of pericolic abscess (modified Hinchey classification Ia). All patients received a dose of intravenous (IV) antibiotics in the Emergency Room and were then randomized to hospital admission and IV antibiotics or to hospital discharge and oral antibiotics. Patients were followed out to 60 days, with the primary end point being the failure of outpatient treatment and the need for hospital readmission which was similar between the groups. Quality of life and cost were also evaluated. There was no difference between groups with respect to treatment failure or quality of life; however costs were expectedly lower in the outpatient group. It is important to note, that in this study in contrast to some others 1) follow-up is very short, 2) we are not provided with important clinical data often provided in many studies to assess severity of diverticulitis such as temperature at the time of initial evaluation, degree of abdominal pain, C-reactive protein. The mean leukocyte level of 11.1 seems very modest.


1.       Are patients with such mild diverticulitis even seen by surgeons at your institution? Would such patients seen at your institution agree to outpatient treatment of abdominal pain only with acetaminophen as was done in this study?


2.       How do you explain the results of the much larger trial (reference 30 as quoted) showing that there was no difference in outcome (complications or recurrent diverticulitis) between patients with uncomplicated diverticulitis who were treated in hospital with, as compared to without antibiotics and then followed for a full 1 year?


3.       In one study (Buchs et al, Br J Surg 2013;100:976-979), in which 280 patients with uncomplicated diverticulitis were followed for a median 24 months, only 16 % experienced a second episode of diverticulitis. Given this, are we greatly over-treating these patients?


4.       Finally, do you question patients with diverticulitis regarding bowel habits? Do you assess women with diverticulitis for the presence of a rectocele, the most common cause of constipation in women?


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

Saturday, December 28, 2013
Moderator: Dr. Bruce Schirmer
Article: Early Results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): A Prospective Randomized Trial Comparing Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass. Peterli, Ralph MD*; Borbély, Yves MD*,†; Kern, Beatrice MD*; Gass, Markus MD*; Peters, Thomas MD*; Thurnheer, Martin MD; Schultes, Bernd MD; Laederach, Kurt MD; Bueter, Marco MD, PhD§; Schiesser, Marc MD§.  Ann Surg 258:  690–695.
Summary: This is a prospective randomized trial conducted at four centers in Switzerland over a four year period.  Laparoscopic sleeve gastrectomy (LSG) was compared to laparoscopic  Roux-en-Y gastric bypass (LRYGB) for weight loss, morbidity and mortality, improvement of comorbid medical conditions, and patient satisfaction.  The follow-up at one year is 100% with a 2 year follow-up under 50% and 3 year at 33%.  Some patients have not been enrolled long enough to meet the latter parameters.  The data show that the operations are very comparable in most ways: patient satisfaction, resolution of comorbidities (except GERD), weight loss, and severe complications.  The differences are that LSG is a shorter operation to perform, and has less overall complications (17.2 vs. 8.4%).  The data are very comparable to those presented at the American Surgical Association meeting in 2011, the first major report from the ACS BSCN database, published in the Annals of Surgery (Hutter MM, et al 2011; 254:410-22).  The authors of this article do not cite that article for some reason.  That data, gathered in the same fashion as NSQIP data, represented a large national sample of U.S. bariatric centers of excellence and their outcomes with LSG versus LRYGB and lap band.  The Swiss study concludes that LSG is an appropriate and effective operation for metabolic and bariatric surgeons to use, is associated with less operative time and lower complications, and should be further tested with long term data.

1.       Given the low complication rates of LSG, should it be approved  by all major insurance carriers in the U.S. for use in all medical centers, not just those who have achieved a center of excellence designation?

2.       The LSG has gained popularity in a rapid fashion, going from almost never performed in 2006 to rarely done in 2008 to common in 2010 to likely now the most popular procedure done in the U.S. in the last part of 2013.  Why don’t we recommend it for everyone?

3.       The LRYGB has been shown to have metabolic effects beyond just pure weight loss to improve the condition of type 2 diabetes in the severely obese.  Theories involve the fact that the lower stomach and duodenum is bypassed.  How can the LSG be just as effective against diabetes if weight loss is the same but the stomach and duodenum are not bypassed?

4.       Are there any patient populations in the world for whom the LSG is a much preferable operation to the LRYGB?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

Tuesday, November 05, 2013
Moderator: Dr. Matthew M. Hutter
by Lawson, Elise H.; Hall, Bruce Lee; Louie, Rachel; Ettner, Susan L.; Zingmond, David S.; Han, Lein; Rapp, Michael; Ko, Clifford Y published in Annals of Surgery 258: 10-18, 2013.

Summary: Reducing readmissions is a major focus for payers and policymakers who by extension are making this a primary focus for the leadership at our hospitals, and for us the surgeons. Though readmission rates are certainly an imperfect metric for the quality of surgical care, there are many good reasons to focus on readmissions:  they are a marker for some level of harm for our patients, they decrease the patient’s experience and perception of care delivered, and they are costly. Readmissions can be related to complications, and/or coordination of care, and both are reasonable things upon which to improve. 

In this study, the authors use a clever linkage of NSQIP and Medicare (MedPAR) data and thoughtful statistical analyses, to examine the impact of surgical complications on readmission rates, and costs of care. Specifically, by examining 90,932 patients from 214 hospitals with data in the ACS- NSQIP that could be linked to Medicare data, they show that readmitted patients were 3.4 times more likely to have had an ACS-NSQIP postoperative complication compared to non-readmitted patients (53% vs. 16%).  Further analyses demonstrate that a modest 5% relative reduction in complication rates for the 20 procedures with the highest number of readmissions could result in prevention of 2,092 readmissions per year and a savings to Medicare of $31 million per year.

From a practical, boots on the grounds standpoint, this makes sense.  Having worked doggedly at our hospital to reduce readmission rates, we initially addressed some of the low hanging fruit of “placing patients in observation” rather than “readmitting” them, and worked on the often preventable issues with regards to the breakdown of coordination of outpatient care.  However, after those issues were addressed, we know find that reducing complication rates would be the best way to reduce readmissions.  And that is exactly what this paper demonstrates in a thoughtful manner.


1.        Are readmission rates a reasonable metric for quality?  If not, what would be better?


2.       Do you feel that this journal article helps you to focus your Quality Improvement efforts for reducing readmissions?  How could you use these results to reduce readmissions at your hospital?


3.       Do you have any comments on the methodology and style of this paper?  Are the analyses performed and the results displayed in a way that is most effective?  What did you like? What was not helpful and how could you improve on it?


4.       What other important studies would you design using this powerful linkage of ACS-NSQIP and Medicare data?


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.


About the Author

Dr. Mary T. Hawn
Dr. Mary T. Hawn is Professor of Surgery, Chief of the Division of Gastrointestinal Surgery and Vice Chair for Quality and Clinical Effectiveness at the University of Alabama at Birmingham. Her research interests are in the area of safety and effectiveness of surgical procedures and their policy implications.

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