Scientific surgery

Schiavone D, Crimì F, Cabrelle G, Pennelli G, Sacchi D, Mian C et al.

Br J Surg 2024; 111: znae196.

In this study that included 56 patients, preoperative use of Lugol’s significantly reduced T3 and T4 levels, but had no effect on clinical outcomes, including blood loss (80.5 versus 94ml with no Lugols’s) and duration of surgery.

Comment: Is the trial large enough to wave goodbye to Lugol’s?

Reinforcement of Closure of Stoma Site (ROCSS) Collaborative and West Midlands Research Collaborative.

Br J Surg 2024; 111: znae159.

Some 598 of the original 790 patients were available for analysis. Patients who had mesh had fewer stoma site complications in the first three years, and fewer reinterventions (incidence rate ratio 0.55, 95 per cent confidence interval 0.31 to 0.97, P=0.04), but overall cost effectiveness rates were similar.

Comment: Complex trial; no overall advantage for the expensive mesh, but most complications occurred in the first three years after surgery.

Ozcan C, Colak T, Turkmenoglu O, Berkesoglu M, Ertas E.

Br J Surg 2024; 111: znae189.

Use of the small bite technique reduced the rate of surgical site infection (18 versus 31 per cent, P=0.03) and the incisional hernia rate after two years (9 versus 31 per cent, P<0.001).

Comment: Small bites strongly recommended.

Mohamed AH, Howitt A, Rae S, Cai PL, Hitchman L, Wallace T et al.

Br J Surg 2024; 111: znae195.

Some 206 of the original 280 patients were available for analysis. Both procedures resulted in durable improvements in disease-specific quality of life (P<0.001). Clinical recurrence was lower after endothermal ablation: 37 versus 59 per cent, P=0.005.

Comment: Endothermal ablation has real long term advantages.

The following countdown highlights the top 20 tweets that reached wide audiences during August 2024, measured on September 8^th. These tweets from @BJSurgery, @BJSOpen, and @BJSAcademy showcase content that educates, informs, and engages.

Let’s explore the stories behind the impressive numbers

#1 With 16K impressions – @BJSurgery, posted on Aug 30

#2 With 15K impressions – @BJSAcademy, posted on Aug 2

#3 With 9.7K impressions – @BJSurgery, posted on Aug 7

#4 With 9.6K impressions – @BJSurgery, posted on Aug 13

#5 With 9K impressions – @BJSurgery, posted on Aug 20

#6 With 8K impressions – @BJSurgery, posted on Aug 21

#7 With 7.9K impressions – @BJSurgery, posted on Aug 27

#8 With 6.8K impressions – @BJSurgery, posted on Aug 29

#9 With 6.3K impressions – @BJSAcademy, posted on Aug 1

#10 With 6.2K impressions – @BJSurgery, posted on Aug 14

#11 With 6.1K impressions – @BJSurgery, posted on Aug 29

#12 With 5.3K impressions – @BJSurgery, posted on Aug 8

#13 With 4.6K impressions – @BJSurgery, posted on Aug 15

#14 With 4.1K impressions – @BJSurgery, posted on Aug 17

#15 With 4.1K impressions – @BJSurgery, posted on Aug 7

#16 With 4.1K impressions – @BJSAcademy, posted on Aug 4

#17 With 4.1K impressions – @BJSurgery, posted on Aug 1

#18 With 4K impressions – @BJSurgery, posted on Aug 18

#19 With 3.8K impressions – @BJSurgery, posted on Aug 22

#20 With 3.8K impressions – @BJSurgery, posted on Aug 19

Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Kärnsund S et al.  

Br J Surg 2024; 111: znae130.

A single dose of dexamethasone given at the start of emergency laparotomy reduced the mean C-reactive protein level after 24h from  220 to 170 mg/l, P=0.015. It also reduced postoperative major complications (27 versus 45 per cent, P=0.032) and 90-day mortality (7 versus 23 per cent, P=0.023).

Comment: Is there enough evidence yet for this to be the standard of care?

Labori KJ, Bratlie SO, Andersson B, Angelsen J-H, Biorserud C, Bjornsson B et al, for the Nordic Pancreatic Cancer Trial-1 study group.

Lancet Gastrohepatol 2024; 9: 205-217.

Survival after 18 months was not improved after neoadjuvant chemotherapy (73 per cent, versus 60 per cent in controls, P=0.050) in this study that included 140 patients.

Comment: Negative result here, but more data for a larger meta-analysis.

Koh J-M, Song K, Kwak MK, Suh S, Kim B-J, Sung T-Y et al.

Ann Surg 2024; 279: 945-952.

This study included 132 patients with an asymptomatic incidental adrenaloma, but raised serum cortisol. Adrenalectomy improved weight control and diabetes control (both P=0.002) compared with the control group.

Comment: Good evidence upon which to base treatment in these patients.

Huang Z-N, Tang Y-H, Zhong Q, Li P, Xie J-W, Wang J-B et al.

Ann Surg 2024; 279: 923-931.

In this study that included 236 patients, the number of lymph nodes retrieved was significantly higher in the indocyanine green group: 48 versus 38, P<0.001.

Comment: Clinical outcomes awaited.

Heemskerk SC, Dirksen CD, van Kuijk SMJ, Benninga MA, Baeten C, Masclee AAM et al.

Ann Surg 2024; 279: 746-754.

Sacral neuromodulation improved the number of patients able to defaecate on average at least three times a week (53.5 versus 3.8 per cent in controls, P=0.003), and improved their quality of life (P<0.001),  in this study that included 67 patients followed for six months.

Comment: Promising, minimally invasive treatment.

Kikuchi S, Matsusaki T, Mitsuhashi T, Kuroda S, Kashima H, Takata N et al.

BJS Open; 8: zrad161.

Pain scores at rest 48h after surgery were lower after epidural (1.94 versus 2.63, P=0.043) in this study that included 129 procedures.

Comment: Epidural remains optimal.

DOI: https://doi.org/10.58974/bjss/azbc055

Article review

Long, D. R. et al. Contribution of the patient microbiome to surgical site infection and antibiotic prophylaxis failure in spine surgery. Sci. Transl. Med. 16, eadk8222 (2024). https://www.science.org/doi/10.1126/scitranslmed.adk8222

Surgical site infection (SSI), historically was considered the greatest contributor to in-hospital mortality during the pre-antibiotic and pre-antiseptic surgery era. European SSI surveillance data today demonstrate a marked improvement in the rate of SSIs, with current rates ranging from 0.6%-1.2% for clean orthopaedic procedures to 1.5%-9.5% or more for clean-contaminated abdominal surgery.¹ Especially for clean procedures, preventative measures focus on antiseptic approaches directed at keeping exogenous infectious agents out of the surgical field. The elegant study by Long et al. forces surgeons, microbiologist, infection prevention experts and infectious diseases physicians to consider endogenous sources of infection for SSI pathogens and to consider prevention measures beyond those limited to the external environment alone.²

In this study, pre-operative nasal, rectal and skin swabs were taken from 210 patients that underwent instrumented posterior spinal fusion surgery. Clinical isolates from the 14 (6.8%) patients who developed an SSI were stored. Whole genomes of isolates and metagenomes of pre-operative swabs were compared using multiple bio-informatics approaches. Results indicated that 86% of SSI strains were present in the patient’s preoperative microbiome, raising the possibility that common exogenous sources of infection may be excluded as indicated, by comparing the metagenomes of clinical SSI isolates with those from 59 other patients that underwent spinal fusion surgery. Also, the antimicrobial resistance (AMR) genes present in the patient’s microbiome were comparable with the phenotypic resistance profiles of the SSI isolates. As mentioned by Drs Gilbert and Dr. Alverdy in their associated commentary, these findings might encourage surgeons to shift their choice of antibiotics from a “one-size fits all” approach towards one in which antibiotics are tailored to the individual patient using a pre-operative diagnostic approach involving metagenomics, microbiome prehabilitation and targeted prophylaxis.³

Establishing causation, however, is critical when interpreting these results. Members of the Enterobacterales order (Citrobacter, Enterobacter, Escherichia coli, Proteus and Serratia species) were most frequently identified as the cause of SSIs (55%), followed by Staphylococcus aureus (23%) and Enterococcus species (9%). All 14 patients who had an SSI had received cefazolin as peri-operative prophylaxis, which mainly covers virulent Staphylococci and Streptococci, but not Enterobacterales species. This study also demonstrated the existence of an anatomical cervico-lumbar gradient of microbes, ranging from gram-positive to gram-negative as dominant species. These findings could be considered as justification to extend the spectrum of prophylactic antibiotics depending on the location of the surgical wound. Interestingly, a significant portion of the pre-operative skin abundance consisted of anaerobes, however, no anaerobic coverage was applied against the SSI isolates. The authors did not use culture-independent methods to analyze wound cultures to rule out (co-)infection with uncultured anaerobes.

Surgeons and consulting (laboratory) specialists know how difficult it can be to 1) determine if a wound is truly infected, and 2) determine if a cultured microbe represents the disease-causing agent or a contaminant from the surrounding skin. When in doubt, physicians often decide on a defensive treatment strategy that includes prolonged antibiotic treatment directed at all cultured potential pathogens, especially when prosthetic material is implanted during surgery. During this study, clinical isolates were classified as SSI-causing pathogens if found in multiple independent wound cultures, preferably excised tissue or deep swab cultures. However, superficial swab cultures were included if the interdisciplinary treatment team considered them as potential pathogens that required antibiotic treatment. The authors did not describe how many times the SSI causing pathogen was based on a tissue biopsy, deep or superficial swab culture. Although reflective of generally accepted clinical practice, the lack of a standard algorithm in this study introduced the problem of inconsistent and misclassification of isolates as SSI causing pathogens versus wound contaminants. This is important since the authors argue that endogenous skin microbes cause the majority of SSIs.

While it is not surprising that wounds can become contaminated with strains from the patient’s own flora, making this distinction, although difficult, is necessary to claim causality. The authors could have reduced this bias by excluding isolates from superficial swabs and by solely relying on multiple tissue and /or fluid cultures. As a matter of practical importance, treatment decisions concerning antibiotic treatment are often not based on culture results alone, but are also influenced by the patient medical history, the physician and patient preference and many other factors. Also, there is no description of a protocol that recommends the minimum number of tissue biopsies and biopsy handling (clean surgical instrument for each biopsy), which is customary in the treatment of fracture-related and prosthetic joint infections.^4-6 Taken together, generalizations and reproducibility of the results, especially considering the small number of events remains problematic. The proximity of the incision of especially lumbar spinal fusion to the rectal microbiome, and the presence of foreign material (plates, screws, etc.) limit extrapolation of the current findings to SSIs related to other surgical procedures.

Nonetheless, studies such as presented by Long et al. have the potential to cause a paradigm shift in SSI prevention measures. Pre-operative screening for Staphylococcus aureus carriage and subsequent decolonization has shown to decrease SSIs and is recommended by the WHO for cardiothoracic and orthopaedic procedures.⁷ One might consider extending this strategy to, for example, Enterobacterales in thoracic and lumbar spinal fusion procedures. Since the main reservoir for Enterobacterales is the gastrointestinal tract (in contrast to S. aureus which mainly colonized the nasal cavity), selective decontamination of the digestive tract (SDD) might be justified in selected patients. However, the expected high number needed to treat (if effective) and micro-ecological effects must be considered as important downsides. Also, coverage of anaerobes is (intentionally) not included in SDD regimes with the goal of preserving the commensal microbiome to promote colonisation resistance. Finally, determining pre-operative antimicrobial resistance among strains in one’s microbiome might be useful as an approach to customise peri-operative antibiotic prophylaxis to the individual patient.

Strategies to nourish the beneficial commensal members of the microbiome while at the same time inhibiting or attenuating the virulence of potential pathogenic microbes seems to be a more sustainable approach to SSI prevention. For example, faecal microbiota transplantation is successfully used to restore gastro-intestinal microbial balance in patients with therapy-resistant Clostridium difficile infection. However, conceptually it is not a rational strategy to reduce colonisation with Enterobacterales as they are, in small abundance, part of the healthy commensal flora. Modulating the skin microbiota before surgery is an attractive alternative. Topical applications of coagulase-negative Staphylococci to provide protection against S. aureus infection is currently under investigation but remains experimental.⁸ Pre-habilitation of the surgical patient including dietary changes, smoke cessation and medication changes offer additional opportunities, given that a patient’s lifestyle is associated with the changes in gastrointestinal⁹ as well as skin microbiota composition.¹⁰ Next-generation antimicrobials, agents that target bacterial virulence without growth inhibition or bacterial killing, have gained attention over the last several decades but have not yet been fully established to be clinically useful.¹¹ Application of these strategies for SSI prevention have not been investigated so far.

Future pre-operative interventions tailored to the individual patient’s micro-environment seem to be more promising and most eco-neutral (i.e. sustainable). While expensive and time-consuming, the benefit of metagenomic screening, as used in this study, versus culture-based techniques, remains to be proven. Fast, cheap and small size sequencing platforms, such as Oxford Nanopore sequencing, combined with advanced, easy-to-use bioinformatic pipelines are needed. These next generation approaches will need to include surgeons, molecular and medical microbiology and infectious diseases specialists to advise on treatment decisions, including specific prophylaxis, lifestyle adjustments or postponing surgery based on individual dynamic risk profiles.

Today, limiting contamination by infectious agents from the surgical field has led to a drastic reduction of SSIs. Yet at the same time, it is clear that surgeon-scientists need to explore the role of the microbiome on SSI prevention given its emerging role as a potential source of infection. Approaches such as personalized SDD and peri-operative prophylaxis based on anatomical location of the surgical incision and microbial tracking using next generation sequencing is now possible and should remain under investigation. One lesson learned from this study is the importance of procuring samples from SSI wounds and to identify the causative organisms so that one can differentiate between those that are contaminants versus those that are actually driving the pathology. Future studies must be optimised and standardised so that the representative materials procured are properly analysed to avoid their misclassification. Despite its limitations, this well executed study shows the potential of unleashing advanced NGS strategies to drive SSI rates toward zero.

Mueller C, Kehl V, Dimpel R, Blankenstein C, Egert-Schwender SE, Strudthoff J, Lock JF et al, for the IOWISI Study Group.

JAMA Surg. 2024;159: 484-492.

This three armed RCT included 689 patients randomized to saline, polyhexanide or no wound irrigation. Respective wound infection rates were 12.5, 10.6 and 12.8 per cent. Compared to controls, polyhexanide did not reduce infection rates: hazard rate 1.23, 95 per cent confidence interval 0.64 to 2.36.

Comment: Wound irrigation remains controversial, and unproven.

Kumar M, Patil NS, Mohapatra N, Sindwani G, Dhingra U, Yadav A et al.
Ann Surg 2024; 279: 932-944.

A temporary shunt reduced intra-operative blood loss (P=0.004) and need for transfusion in this study of 60 procedures. The shunted patients were also more haemodynamically stable in the anhepatic phase, requiring less vasopressor support, with better postoperative renal function. There were no other differences in postoperative outcomes.

Comment: The observed advantages should improve outcomes, but perhaps the study was too small to be definitive.

Bang JY, Lakhtakia S, Thakkar S, Buxbaum JL, Waxman I, Sutton B et al, on behalf of the United States Pancreatic Disease Study Group.

Lancet Gastrohepatol 2024; 9: 22-33.

Seventy patients were included. Upfront necrosectomy resulted in fewer reinterventions (median 1 vs 2, P=0.003), but did not reduce mortality (none versus 2, respectively, P=0.22), or adverse events.

Comment: Smallish study, but indications of advantage for earlier intervention, rather than wait and see.

Kimball AB, Jemec GBE, Sayed CJ, Kirby JS, Prens E, Ingram JR et al.

Lancet 2024;  403: 2504-2519.

These two RCTs included over 1000 patients randomized to different doses of bimekizumab for up to 48 months. Responder rates were superior in those who received bimekizumab in both trials over placebo (I – 48 versus 29 per cent, P=0.006; II – 52 versus 32 per cent, P=0.0032). Side effects were infrequent.

Comment: At last, a meaningful treatment compared with surgery. Now for the direct comparison?

Terlouw LG, van Dijk LJD, van Noord D, Bakker OJ, Bijdevaate DC, Erler NS et al, on behalf of the Dutch Mesenteric Ischemia Study Group.

Lancet Gastrohepatol 2024; 9: 299-309.

Ninety-four patients with chronic mesenteric ischaemia were included. Only one patient died. After 24 months, the patency of covered stents was better than bare metal stents: 81 versus 49 per cent, P<0.0001. Access site adverse events were more common in covered stent procedures.

Comment: This study does not address whether symptoms were improved alongside patency.

Chen WY, Ballman KV, Partridge AH, Hahn OM, Briccetti FM et al.

JAMA 2024; 331: 1714-1721.

Some 3020 women with non-metastatic breast cancer were enrolled. The study was terminated after the first interim analysis for futility. 300mg aspirin per day for a median of 33.8 months did not improve breast cancer recurrence (hazard ratio 1.27, 95 per cent confidence interval 0.99 to 1.63, P=0.06) or survival (1.19, 0.82 to 1.72).

Comment: Theoretical advantage not proven.

From insightful discussions to ground-breaking announcements, the following countdown highlights the top 20 tweets that not only reached wide audiences, as measured on August 12^th, but also made a significant impacts. These tweets from @BJSurgery, @BJSOpen and @BJSAcademy have set the bar high, showcasing content that educates, informs and engages.

Join us as we dive into each tweet, exploring the stories behind the impressive numbers and the content that captivated so many.

1.  Leading the pack with 49K impressions, a viral sensation on July 28 by @BJSurgery steals the spotlight with its insightful content.

2.  An impressive 13K impressions on July 22 by @BJSurgery highlights a moment that captivated thousands.

3.  With 10K views, a tweet from July 13 by @BJSurgery resonated widely.

4.  With 8.9K impressions, a July 3 post by @BJSAcademy offers deep insights, drawing a significant audience.

5.  Rounding out the top five, an 8.8K impression gem on July 23 by @BJSOpen engaging a diverse audience.

6.  7.8K impressions on July 7 make this @BJSAcademy tweet a must-read.

7. 7.7K impressions from @BJSurgery on July 6 reflect a highly engaging post.

8. With equal appeal, another @BJSurgery post on July 26 nets 6.7K impressions, showcasing a consistent ability to engage.

9. Matching the above, @BJSurgery’s July 12 tweet also captures 6.7K impressions.

10. Completing the top ten, @BJSAcademy’s July 4 tweet garners 5.9K impressions, demonstrating strong engagement.

And the countdown continues…

11. With 5.5K impressions, posted on July 30 by @BJSurgery.

12. With 5.3K impressions, posted on July 13 by @BJSAcademy.

13. With 5.2K impressions, posted on July 10 by @BJSurgery.

14. With 4.4K impressions, posted on July 13 by @BJSurgery.

15. With 4.2K impressions, posted on July 6 by @BJSOpen.

16. With 4.1K impressions, posted on July 11 by @BJSAcademy.

17. With 4K impressions, posted on July 26 by @BJSAcademy.

18. With 3.9K impressions, posted on July 24 by @BJSurgery.

19. With 3.6K impressions, posted on July 27 by @BJSAcademy.

20. With 3.6K impressions, posted on July 20 by @BJSOpen.

Chao Y-K, Li Z, Jiang H, Wen Y-W, Chiu C-H, Li B et al.

Br J Surg 2024; 111: znae143.

This study included 203 patients with tumour lymph nodes near the recurrent laryngeal nerve. Successful removal of lymph nodes adjacent to the nerve was more likely with robotic dissection (88.3 versus 69 per cent video-assisted, P<0.001). The rate of recurrent laryngeal nerve palsy after surgery was also reduced by robotic dissection: 20.4 versus 34 per cent, P=0.029.

Comment: Surgery was more accurate with the robot, with reduced recurrent laryngeal nerve damage.

Traeger L, Bedrikovetski S, Fitzsimmons T, Nguyen T-M, Moore JW, Lewis M et al.

Br J Surg 2024; 111: znae121.

Pyridostigmine 60mg given orally twice daily after surgery reduced the duration of ileus by one day, measured by the GI-2 tool (P=0.015) in this study that included 130 patients, but did not affect the duration of hospital stay.

Comment: Apart from speeding return of bowel function, it is not clear what the benefit is overall.

Xie D, Shen J, Liu L, Cao B, Xiao A, Qin J et al.

Br J Surg 2024; 111: znae106.

In this study that included 169 patients, the addition of complete mesogastric excision improved 3-year disease-free survival (85 versus 75.5 per cent, P=0.042), but not quite overall survival (85.8 versus 77.5 per cent, P=0.058).

Comment: It remains unknown whether this makes a big enough difference.

Croghan SM, O’Meara S, Cunnane EM, Purtill H, Walsh MT, O’Brien FJ et al.

Br J Surg 2024; 111: znae137.

Variable intrarenal pressure during endorenal (stone) surgery may affect renal function adversely. An automatic pressurized pump was compared with manual hand-pump irrigation in 38 patients. The automatic pump gave lower (mean 38 versus 62 mmHg, P=0.005) and more consistent intrarenal pressure, and a better view for the surgeon.

Comment: Machine beats human.

The tweet with the highest number of impressions in June 2024 was from @BJSOpen on June 17th, garnering 18K impressions. Below is a ranking of the top 20 tweets by impressions, including the number of impressions, date, account, and a brief comment.

1. @BjsOpen with 18K impressions, posted on June 17th.

2. @BJSAcademy with 13K impressions, posted on June 19th.

3. @BJSurgery with 13K impressions, posted on June 16th.

4. @BJSAcademy with 12K impressions, posted on June 4th.

5. @BJSAcademy with 12K impressions, posted on June 12th.

6. @BJSurgery with 11K impressions, posted on June 26th.

7. @BJSurgery with 8.9K impressions, posted on June 17th.

8. @BJSurgery with 8.5K impressions, posted on June 27th.

9. @BjsOpen with 8.5K impressions, posted on June 4th.

10. @BjsOpen with 8.5K impressions, posted on June 9th.

11. @BJSAcademy with 7.9K impressions, posted on June 18th.

12. @BJSAcademy with 7.8K impressions, posted on June 18th.

13. @BJSAcademy with 7.6K impressions, posted on June 11th.

14. @BjsOpen with 7.4K impressions, posted on June 15th.

15. @BJSAcademy with 7K impressions, posted on June 6th.

16. @BjsOpen with 6.3K impressions, posted on June 23rd.

17. @BjsOpen with 6.3K impressions, posted on June 1st.

18. @BjsOpen with 5.5K impressions, posted on June 9th.

19. @BjsOpen with 5K impressions, posted on June 26th.

20. @BjsOpen with 5K impressions, posted on June 5th.

Popeskou SG, Roesel R, Faes S, Vanoni A, Galafassi J, di Tor Vajana AF et al.

Ann Surg 2024; 279: 196-202.

Thirty-four patients with symptomatic low anterior resection syndrome (LARS) were included. Those randomized to Ondansetron first had improved LARS scores, whereas those who had Ondansetron second, tended to have deteriorating scores. Treatment was safe.

Comment: Good treatment for an unpleasant condition.

Schaller S, Fuest K, Ulm B, Schmid S, Bubb C, Eckstein H-H et al.

Ann Surg 2024; 279: 402-409.

Some 2509 patients having high-risk, non-cardiac surgery with low serum albumin postoperatively were randomized to albumin substitution or treatment only in an emergency. Complication rates were unaffected by the albumin treatment: 84.7 versus 87.3 Percent in controls.

Comment: Another attempt to support albumin treatment in the acute situation fails. It remains unclear why.

Lipping E, Sten S, Reinsoo A, Artjom B, Ülle K, Lepner U et al.

Ann Surg 2024; 279: 191-195.

Some 104 patients who had surgery for complicated appendicitis were randomly allocated intravenous or oral antibiotics for 24h. Complication rates were non-inferior for oral antibiotics.

Comment: Good to avoid intravenous antibiotics.

Fichtinger RS, Aldrighetti LA, Hilal MA, Troisi RI, Sutcliffe RP, Besselink MG et al, for the ORANGE II PLUS Collaborative.

J Clin Oncol 2024; 42: 1799-1809.

In this study of 332 procedures, patients who had the laparoscopic approach had improved functional recovery (4 vs 5 days, P<0.001), and were able to access neoadjuvant treatment earlier: 46.5 versus 62.8 days, P=0.009).

Comment: Perhaps most importantly patients who had laparoscopic surgery were able to have their chemotherapy earlier.

Qin T, Zhang H, Pan S, Liu J, Li D, Chen R et al, for the Minimally Invasive Treatment Group in the Pancreatic Disease Branch of China’s International Exchange and Promotion Association for Medicine and Healthcare (MITG-P-CPAM).

Ann Surg 2024; 279: 605-612. 

This multicentre study from China included 656 procedures. 3-year overall survival was 59.1 per cent after laparoscopic  surgery for malignant disease versus 54.3 per cent after open surgery (P=0.33).

Comment: Big study confirming long term survival after laparoscopic surgery no worse than after open surgery.

Mackay TM, Latenstein AEJ, Augustinus S, van der Geest LG, Bogte A et al, for the Dutch Pancreatic Cancer Group.

JAMA Surg 2024; 159: 429-437.

This study included 5887 patients with pancreatic cancer. One year survival was similar both before and after implementation of a best practice protocol (24 versus 23 per cent). Most patients did not receive any tumour-directed therapy.

Comment: I like that this study has a negative primary result, but shows up how much care for pancreatic cancer is palliative. It will stimulate discussion about how to offer more active therapy.

In May 2024, as assessed on June 13, @BJSOpen demonstrated exceptional engagement on the X platform. Leading the charge was a post on May 11, which achieved an astounding 41K impressions. This post highlighted the account’s influence and reach within the medical and academic communities. Close behind, a May 10 post from @BJSOpen garnered 20K impressions, further solidifying the account’s ability to engage its audience effectively. Additionally, a May 1 post from @BJSOpen secured 18K impressions, showcasing a strong start to the month and consistent performance throughout.

The X post with the highest number of impressions in May 2024 was

1. @BJSOpen, 41K impressions, posted on May 11

Followed by tweets with 9K-39K impressions

2. @BJSOpen, 20K impressions, posted on May 9

3. @BJSOpen, 18K impressions, posted on May 1

4. @BJSurgery, 15K impressions, posted on May 15

5. @BJSOpen, 12K impressions, posted on May 16

6. @BJSurgery, 12K impressions, posted on May 12

7. @BJSOpen, 10K impressions, posted on May 26

8. @BJSAcademy, 9.7K impressions, posted on May 2

9. @BJSurgery, 9.6K impressions, posted on May 10

10. @BJSurgery, 9K impressions, posted on May 13

And the next group with 5K-9K impressions included

11. @BJSurgery, 7.5K impressions, posted on May 26

12. @BJSurgery, 7.1K impressions, posted on May 14

13. @BJSOpen, 7K impressions, posted on May 24

14. @BJSurgery, 6.8K impressions, posted on May 5

15. @BJSurgery, 6.5K impressions, posted on May 2

16. @BJSOpen, 6.4K impressions, posted on May 12

17. @BJSOpen, 6.2K impressions, posted on May 19

18. @BJSurgery, 6.2K impressions, posted on May 7

19. @BJSurgery, 6K impressions, posted on May 15

20. @BJSAcademy, 5.8K impressions, posted on May 28

Slamon D, Lipatov O, Nowecki Z, McAndrew N, Ika-Budny BK, Stroyakovskiy D et al.

N Engl J Med 2024; 390: 1080-1091.

The addition of ribociclib to standard aromatase inhibitor treatment for women with hormone receptor positive, HER2-negative early breast cancer significantly improved 3-year disease-free survival from 87.1 to 90.4 per cent (P=0.003) in this large international study.

Comment: More information towards optimized adjuvant therapy.

Pantiora E, Jazrawi A, Hersi A-F, Abdsaleh S, Ahlstedt H, Molnar E et al.

JAMA Surg 2024; 159: 239-246. 

In this study that included 426 procedures, there were more failed localisation procedures with wire-guided localisation than the magnetic seed method (10.1 versus 1.9 percent of procedures, P<0.001), and it was quicker.

Comment: Magnetic seed method quicker and more effective.

Perez-Garcia JM, Cortes J, Ruiz-Borrego M Colleoni M, Stradella A, Bermejo B et al, on behalf of PHERGain Trial Investigators.

Lancet 2024; 403: 1649-1659.

This complex study that included 356 patients with HER2 +ve breast cancer with visible disease on PET imaging showed that around one third of patients could avoid chemotherapy and just have immunotherapy and hormonal treatment, with similar three-year survival rates.

Comment: Research that reduces the need for chemotherapy is always welcome, and refines the treatment pathway.

HIP Trial Investigators.

JAMA 2024; 331: 1035-1044.

Preterm infants with a hernia were randomly allocated to surgical repair before they left neonatal ICU, or afterwards. Complications rates were lower with delayed surgery: 18 versus 28 per cent.

Comment: If possible, wait until the infant is older.