November 2018

Background: The opioid epidemic has had a devastating impact throughout the United States. As surgeons, we frequently prescribe opioids postoperatively with little evidence based guidance. Methods: Thiels et. al. performed a prospective, multi-institutional telephone survey of postoperative patients about opioid prescribing and usage to begin to format prescribing guidelines. The cohort consisted of patients that underwent 1 of 25 operations at 3-Mayo affiliated hospitals over a 9-month period with a goal to reach 100 patients per operation-type. Operations most relevant to general surgery included Whipple, LAR, partial colectomy, mastectomy, breast lumpectomy, inguinal hernia repair (MIS and open), laparoscopic cholecystectomy, and parathyroidectomy. Results: Of the included patients, 2566/3412 completed the survey. Approximately 90% of patients were prescribed opioids (83% opioid naïve) at discharge with an average of 43 Morphine Milligram Equivalents (MME) consumed for 225 MME prescribed; with 1/3 of patients not consuming any opioids and over 75% with opioids leftover. Over 90% of patients described their postoperative pain as well-controlled. For general surgery cases, 75% of patients were off opioids by POD 3 for MIS inguinal hernia repair, lumpectomy, and parathyroidectomy. Patients that were older, had BMI<30, did not have depression/anxiety, or had longer length of stay were likely to take fewer opioids after discharge. Almost 80% of patients also used non-prescription pain medications. Discussion/Conclusion: There was large variation in use between operation-types and patients so blanket recommendations may lead to both over and under prescribing, although the current trend is still towards overprescribing. Limitations include that the cohort was all from Mayo-based institutions and may not be completely generalizable. As a survey based study, there are limitations in response rate (relatively high: 75%) and bias, especially as the opioid epidemic has been increasingly publicized. Also, patients used varying amounts of non-prescription pain medication but it is unclear how recommendations differed. 

Synopsis: In patients with heart failure and left ventricular dilatation, mitral regurgitation (MR) may develop secondary to impaired coaptation of the mitral leaflets. This is in contrast to primary MR, which is more common and regarded as an age-related, degenerative process. Although mitral-valve surgery is curative for primary/degenerative MR, those with secondary MR have limited therapeutic options as surgical repair and replacement do not improve survival. The MitraClip device (Abbott) is a percutaneous option for reducing the degree of MR by approximating the anterior and posterior mitral leaflets, and forming a double-orifice valve. The COAPT trial was a multicenter RCT of transcatheter mitral-valve repair with the MitraClip device vs. medical management alone in in patients with heart failure and moderate/severe secondary MR who remained symptomatic despite the use of guideline-directed medical therapy. Amongst 614 study patients (302 device, 312 medical management), the MitraClip reduced the rate of all heart failure hospitalizations (within 24 months: 35.8% per patient-year vs. 67.9% per patient-year, p<0.001) and all cause mortality (within 24 months: 29.1% vs. 46.1%, p<0.001). While mitral-valve surgery is still the gold standard for primary (degenerative) mitral regurgitation, this percutaneous option provides a significant improvement over best practice medical therapy. 

Synopsis: Antibiotics alone have been proposed as a possible alternative to appendectomy for the treatment of acute appendicitis. When discussing this option, patients often ask about the risk of recurrence or need for future surgery if they choose antibiotics as the initial treatment. The APPAC trial, performed in Finland from 2009 to 2012 and published in JAMA in 2015, randomized 530 patients aged 18 to 60 with CT-confirmed uncomplicated acute appendicitis to surgery (largely open appendectomy) versus antibiotic therapy with three days of IV ertapenem (1g/day) followed by 7 days of oral levofloxacin (500mg/day) and metronidazole (500mg TID). The initial study report included one year of follow-up and reported a success rate of 99.6% in the appendectomy group, whereas 27.3% (70/256) of the antibiotics alone patients crossed over to have an appendectomy within the first year. Notably, there were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in this group. The current report details the results of five-year follow-up for these patients. In addition to the 70 patients in the antibiotics alone group who had surgery in the first year of the trial, an additional 30 patients had surgery between years 1 and 5. The cumulative incidence of appendicitis recurrence was 34% at 2 years, 35.2% at 3 years, 37.1% at 4 years, and 39.1% at 5 years. At 5 years, the overall complication rate (SSI, incisional hernia, abdominal pain, and obstructive symptoms) was 24.4% in the appendectomy group versus only 6.5% in the antibiotic group. Notably, there was not a statistically significant difference in overall complications between the patients from the antibiotics group who had surgery and the patients randomized to appendectomy up front. Although there are limitations to applying this study in our practice, it should prove useful in counseling patients on future expectations for those who are interested in initially selecting antibiotic therapy for appendicitis. 

Synopsis: Colon cancer is one of the most common cancers worldwide, yet there have been few studies prognosticating survival after postoperative recurrence. Additionally, nomograms have increased in popularity as prognostic statistical models with user friendly interfaces. This retrospective, multicenter study developed an internally validated nomogram based on survival data following recurrence in patients with Stage I-III colon cancer treated at one of 23 Japanese referral hospitals enrolled in the Japanese Study Group for Postoperative Follow-Up of Colorectal Cancer from January 1997 to December 2008. Of these hospitals, 15 were placed within the training cohort used to construct a prognostic nomogram for predicting survival and 8 were assigned to the nomogram validation cohort. Among the 24,864 patients registered in the database, 2,563 patients with colonic adenocarcinoma experienced recurrence. Univariate and multivariate analyses demonstrated 8 dominant clinical variables that were selected as predictors for shorter survival including age ≥60 (HR 1.17; 95% CI 1.01-1.35; p=0.0339), right colon as the primary location (HR 1.35; 95% CI 1.18-1.55; p<0.0001) (defined as cecum to splenic flexure), histologic subtype other than well- or moderately-differentiated (HR 1.08; 95% CI 0.94-1.23; p=0.2942), lymph node metastasis (HR 1.30; 95% CI 1.18-1.51; p=0.0006) (N≥1), presence of peritoneal metastasis (HR 1.55; 95% CI 1.31-1.83; p=0.0025), recurrence in ≥2 organs (HR 1.55; 95% CI 1.31-1.83; p<0.0001), initial treatment type following recurrence (HR 0.27; 95% CI 0.23-0.31; p<0.0001) (surgical vs other), and interval between initial surgery and recurrence >2 years (HR 0.77; 95% CI 0.66-0.91; p<0.0001). Notably, while ≥N2b-stage patients had worse prognosis and N0 had better prognosis, N1 and N2a subjects showed similar prognosis following recurrence and were therefore grouped together on the nomogram. Concordance indices (C-index) over a 3-year survival period for the training model and validated model were 0.744 and 0.730, respectively, suggesting overall good prediction, likely due to well established factors predicting outcomes. The study also established that while adjuvant therapy reduces the risk of recurrence, once recurrence has occurred, chemotherapy-naive versus -treated patients do not exhibit a difference in survival. The study is limited as it was conducted between 1997 and 2008 as more advanced chemotherapeutic agents and multidisciplinary therapies may have improved. It additionally fails to investigate factors such as microsatellite instability, Ras mutations and molecular subtypes which can have prognostic implications. The study successfully identified factors affecting survival after recurrence and established the worlds first validated nomogram to assist providers in counseling patients with colon cancer recurrence on survival.