van der Heijden JAG, Kalkdijk-Dijkstra AJ, Pierie JPEN, van Westreenen HL, Broens PMA, Klarenbeek BR, et al on behalf of the FORCE trial group.
AnnSurg 2022; 276: 38-45.
Overall, a course of pelvic floor rehabilitation did not improve continence compared to usual care (Wexner score) in this study that included 128 patients. However, several subgroups were identified that did benefit: those with urgency and moderate incontinence postoperatively.
Comment: This sounds like valuable research for patients with a troublesome problem. More research into the subgroups that may benefit is indicated.
Mohamed AH, Thadani S, Mohamed SH, Sidapra M, Smith G, Chetter I, et al.
Br J Surg 2022; 109: 679-685.
There were 18 studies including 2584 legs. Use of compression for 1 to 2 weeks after intervention was associated with improved comfort and quality of life. Use of compression after 1-2 weeks was not beneficial.
Comment: This is helpful, but not novel. Focus should turn to which is the best form of compression.
Toesca A, Sangalli C, Maisonneuve P, Massari G, Girardi A, Baker L, et al.
Ann Surg 2022; 276: 11-19.
Eighty women were included in this study. Robotic surgery took one hour and 18 minutes longer, but was associated with improved postoperative satisfaction, physical and sexual well-being. Complication rates were similar.
Comment: A cost effectiveness analysis is needed here.
Tie J, Cohen JD, Lahouel K, Lo SN, Wang Y, Kosmider S et al, for the DYNAMIC Investigators.
N Engl J Med 2022; 386: 2261-2272.
Patients were randomized to adjuvant chemotherapy depending on the presence of circulating DNA (n=302), or a control group (n=153). Fewer patients in the DNA group had chemotherapy (15 versus 28%), without compromising the rate of recurrence-free survival at a median of 37 months.
Comment: The optimal adjuvant treatment for surgically treated colorectal cancer continues to evolve. This study is another step forwards, and helps limit adjuvant therapy to those who will benefit most.
The first @BJSurgery tweet of the month (August 1st) was about a paper on pain in people with intermittent claudication. A network meta-analysis showed that “There is strong evidence in support of use of structured high-pain exercise, and some evidence in support of structured low-pain exercise, to improve walking ability in people with IC compared with usual-care control”. The tweet is here:
On August 2nd, @BJSurgery tweeted the link to a very interesting narrative review on organ preservation in rectal cancer management. This is a hot topic, as shown by 39 likes, 21 retweets and 2 quote tweets by Sept 6th. The tweet is here:
Ron Barbosa @rbarbosa91 announced the @BJSurgery series “The instrumentalist” on Twitter on August 6th. His first entry was “Scalpel handles and blades”. Surgeons are deeply fond of surgical instruments, and Ron’s tweet has been highly engaging with 832 likes,13 quote tweets, and 152 by Sept 6th 2022. The tweet is here:
On August 11th, @BJSAcademy tweeted about the free videos available on its website, and particularly about Martyn Evan’s @evanscolorectal “How to write a clinical paper” The tweet has had 40 retweets, 5 quote tweets and 60 likes by Aug 7th, and it is here:
Understanding how competent surgeons get their skills is not easy. On August 13th @BJSOpen tweeted the link to a paper by Kjetil Soreide and Benedicte Skjold-Ødegaard, who used an innovative approach to analyze surgical trainees’ skill acquisition during real-life lap appendectomies. The tweet can be seen here:
The availability of kidney grafts for transplantation is limited. Living kidney donation is an excellent option, but it is not risk-free for donors who are otherwise healthy. On August 22nd, @BJSurgery shared a meta-analysis carried out to identify risk factors for living kidney donors. The study found that obesity and male sex are associated with poorer outcomes. The tweet is here:
It is not unusual to come across a difficult situation in the operating theater while performing a surgical procedure. Should I fix it by myself or ask for help? On August 24th, @BJSAcademy tweeted a new chapter of #ASurgicalLife by Takeshi Sano MD PhD, who reminds us “to never hesitate to call other people and ask for help instead of trying to solve a problem alone”. The tweet is here:
Timing matters in surgery. What’s the optimal time to do an appendectomy after hospital admission? On August 28th, @SurgJournal shared a study on the association between time from admission to appendectomy on perioperative outcomes to determine the optimal time-to-surgery window. The tweet is here:
There is no monthly surgical #some review without a paper on drains. This time it was about the HPB surgeons’ dilemma”. On the last day of the month, @BJSurgery tweeted a propensity score-matched study showing that if a pancreatic resection is complex (multivisceral resections and those that took longer), surgeons are reluctant to omit drainage. The tweet is here:
Sanabria A, Betancourt-Agüero C, Sánchez-Delgado J, García-Lozano C.
Ann Surg 2022; 276: 66-73.
There were five RCTs with 763 treated patients. Rates of recurrence were similar: 2.7 per cent after additional node dissection and 2.5 per cent after thyroidectomy alone. Node dissection increased the rate of permanent hypoparathyroidism: risk difference 3 per cent.
Meima-van Praag LM, van Rijn KL, Wasmann KAT, Snijder H, Stoker J, D’Haens GR et al.
Lancet Gastroenterol Hepatol 2022; 7: 617-626.
Some 95 patients were included in this trial. After 18 months, radiological (MRI) healing was higher after surgery with anti-TNF (32 per cent) than anti-TNF alone (9 per cent); P=0.005. In contrast, clinical closure rates were reported as similar: 68 versus 52 per cent, respectively.
Comment: Shouldn’t there have been a surgery only arm for the perfect trial?
Hosoi T, Abe T, Higaki E, Fujieda H, Nagao T, Ito S, et al.
Ann Surg 2022; 276: 30-37.
In this study of 100 oesophagectomies, the rate of postoperative anastomotic stricture was 42 per cent after stapled and none after the Collard technique. Anastomotic leak rates were similar. Quality of life domains concerning swallowing were also significantly better after three months.
Forsberg A, Westerberg M, Metcalfe C, Steele R, Blom J, Engstrand L et al.
Lancet Gastroenterol Hepatol 2022; 7: 513-521.
This study included 278,280 people. More people accepted the faecal testing than colonoscopy (55.5 versus 35.1 per cent). Similar rates of cancer were detected (0.16 and 0.2 per cent, respectively). More advanced adenomas were detected by colonoscopy (2.05 versus 1.61 per cent, respectively).
Comment: Overall, more cancers were found by the method that was more acceptable to people. Late benefits in disease-specific mortality will be used to decide on the method of choice.
Some 185 Patients with suspected appendicitis were randomised to imaging with ultrasound followed by CT if needed, or observation. More patients in the imaging group had treatment for appendicitis (72 versus 57 per cent; difference 15, confidence interval 1 to 29 per cent). Rates of complicated appendicitis and negative appendicectomy were similar.
Comment: Some patients with appendicitis do not need surgery; I think we knew that, but this is good science.
Paper for discussion: Fachi JL, Felipe JS, Pral LP, Silva BK, Correa RO, Cristiny M et al.Butyrate Protects Mice from Clostridium difficile-Induced Colitis through an HIF-1-Dependent Mechanism. Cell Rep. 2019 Apr 16; 27: 750-761.e7.
Although rare, Clostridium difficile-induced diarrhoea or colitis can complicate what otherwise appeared to be an uneventful elective operation. This rare, but potentially lethal complication results from multiple factors inherent to performing surgery, such as prolonged periods of starvation, antibiotic exposure, major physiological stress, and sleep deprivation1. C. difficile spores can spread easily, can resist multiple methods of decontamination and can remain viable for long periods of time. In many cases, the bacteria can remain hidden within the host’s gut microbiome and transferred to the healthcare setting by the patient themselves, rather than vice versa.
While prevention is the best treatment, C. difficile infections (CDI) often prove resistant to antibiotics, and other modalities may be needed to restore homeostasis to the gut microbiome. Although faecal microbiota transplant has been proposed as a method for both prevention and treatment of CDI, even when severe colitis is present, many believe the most important action of the microbiome is to preserve its ability to produce key multifunctional metabolites 2. For example, the ability of the microbiota to produce the short-chain fatty acids (SCFAs) acetate, propionate, and butyrate has been identified to be an important therapeutic aspect in the prevention and treatment of CDI. SCFAs are absorbed by host intestinal epithelial cells (IECs) and participate in several immunoregulatory roles that influence the host response to inflammation and infection. Past studies have detected reduced SCFA concentrations, particularly butyrate, in patients with CDI3. Elevation of butyrate via dietary modulation or provision of SCFA-producing bacteria has been shown to attenuate CDI severity in animal studies4,5.
In this study, Fachi et al. investigate how butyrate potentially alters the course of CDI in mice6. Oral administration of butyrate protects against CDI, improving both clinical symptoms and colonic histological score, with evidence of reduced ulceration and leukocyte infiltration within two days of the onset of infection. Similar effects were observed both with addition of tributyrin, a pro-drug of butyrate, as well as with inulin, a fibrous substrate for SCFA production, which both increased colonic butyrate levels. Once confirming butyrate’s protective effects against CDI, the investigators examined butyrate’s effect on four key parameters of CDI: the growth of C. difficile itself and the viability of the surrounding gut microbiota, IECs, and various other immune cells adjacent to the intestinal track. Although, butyrate was demonstrated to interfere with C. difficile growth and toxin production in vitro, these findings were not observed in vivo, suggesting that butyrate’s protective effects against CDI may not be a function of its direct action on C. difficile colonization or virulence. Furthermore, while butyrate affected overall gut microbiota community structure, it also maintained its protective effects in germ-free mice, indicating some of its protective effects extended beyond its influence on the gut microbiota. In turn, Fachi et al. then examined the effect of butyrate on immune cells, where they observed that butyrate administration reduced colonic pro-inflammatory cytokines IL-6, IL-1b, and Cxcl-1, as well as increased colonic anti-inflammatory cytokines such as IL-10. Also observed were elevated regulatory T cells, Foxp-3, and IL-10 in the mesenteric lymph nodes, supporting an overall anti-inflammatory influence. Even in Rag1- or IL-10-deficient knockout (KO) mice, butyrate still maintained its protective effect, suggesting that pathways independent of regulatory T cell or IL-10 signaling are involved.
Finally, when examining the interaction of C. difficile and butyrate on IECs in this study, investigators observed that butyrate could attenuate the intestinal permeability defects induced by CDI using FITC-dextran as a permeability probe. C. difficile dissemination from the gut was also decreased, as judged by fewer C. difficile colony-forming units in the liver and spleen in butyrate-treated mice. Gene expression studies and immunostaining revealed that butyrate increased key paracellular junction proteins Claudin-1 and Occludin that maintain the gut barrier. To further understand how permeability might be altered by C. difficile and/or butyrate functionally, investigators measured transepithelial/transendothelial electrical resistance (TEER) across cells, which demonstrated that butyrate partially prevented the increased IEC permeability caused by exposure to C. difficile supernatant. Previous studies had shown butyrate could stabilize the transcription factor HIF-1α, which is involved in regulating IEC permeability. To confirm this, the group showed that oral butyrate increased colonic HIF-1α and downstream gene expression. Using a LysMCre mouse model that selectively knocked out HIF-1α expression in IECs, they showed that butyrate no longer prevented the intestinal permeability defect and also failed to attenuate C. difficile dissemination to the liver and spleen. Furthermore, in the HIF-1α IEC KO mice, butyrate no longer reduced CDI severity. In the aggregate, these studies indicate that the permeability defect induced by CDI requires participation by key regulatory elements in the host cellular response to this pathogen, which can be modulated by gut microbiota-derived metabolites such as butyrate.
Several conclusions can be made that may be relevant to the surgical patient. First, it may be important to know a patient’s colonic (faecal) butyrate level before surgery. This should not only be able to be easily measured as a point-of-care assay, but should also be easily modifiable via dietary prehabilitation. This may involve dietary consultation, attention to when antibiotics have been most recently prescribed, changes in life-style (smoking cessation, reducing alcohol consumption) and removal of unnecessary medication until which time it can be determined that a patient’s microbiome is “ready” for a major operative intervention7. Second, over the course of surgery when butyrate and other relevant microbiome metabolites may become deficient, it may be possible to develop a protocol of microbiome maintenance that involves orally administered butyrate with specific release patterns packaged in microparticles. Studies such as the one highlighted above demonstrate that defining microbiome “readiness” for surgery, identifying the metabolites that activate immune function, and validating their role in CDI and other infection-related complications after surgery is now within our reach. This approach is not only exciting as a countermeasure to the fact that we are often operating on sicker, older patients with advanced disease, but also as a potential solution to many of the most dreaded infection-related complications that can occur when we perform what otherwise is expected to be an uneventful surgical procedure.
It had 10 retweets and 13 likes by August 7th 2022.
On July 1st the European Hernia Society @eurohernias announced that they offered a EHS member a place in ‘Writing in Surgery’ course, organised by @BJSurgery.
The tweet is here:
with 8 retweets, 1 quote and 13 likes by August 7th 2022.
A new systematic review regarding the use of social media as a tool for general surgery education was tweeted on July 3rd by Surgical Endoscopy @SurgEndosc. Disseminating high-quality content on social media must be a priority for content creators and institutions.
The tweet is here:
with 16 retweets, 2 quote tweets and 43 likes by August 7th 2022.
@BJSOpen celebrated its new impact factor (IF) with a tweet on July 5th. The journal IF raised to 3.875 and it becomes a Q1 #openaccess journal. This is a fantastic achievement and the authors, the BJS Open editorial team and its readers must be congratulated.
The tweet is here:
The tweet had 17 retweets and 28 likes by August 7th.
On the same day, Rebecca Grossman @rebgross launched a poll on Twitter on July 5th. The drain debate never goes out of fashion, and she was interested in knowing more about her followers’ position after the publication of a @EuroSurg collaborative paper in @BJSurgery. The poll received 302 votes and you can see the results here:
On July 7th, @BJSurgery tweeted the link to the @reacctcollab paper titled “Impact of microsatellite status in early-onset colonic cancer”, which highlights the increased incidence of early-onset colonic cancer worldwide.
The tweet had 11 retweets, 1 quote tweet and 15 likes and is here:
On July 10th, @BJSOpen launched a poll on Twitter about the expected recurrent laryngeal nerve injury rate after a minimally invasive hemithyrodectomy via the axilla. The most voted response was 1.5% (33.3% of 36 votes).
The tweet is here:
with 5 retweets, 1 quote tweet, and 4 likes.
@BJSurgery announced on Twitter on July 8th, that the journal is looking for an Associate Editor.
The tweet is here:
with 30 retweets, 5 quote tweets and 48 likes.
On July 11th, @BJSOpen tweeted a paper on variation in the treatment of varicose veins in England. Unwarranted variation in access, quality and outcomes of surgical treatment is one of the key problems of modern healthcare systems. A population-based study published in @BJSOpen showed that geographic variation in the provision of treatment of varicose veins exists in England, and it is not due to demographic differences.
A new strategy to improve outcomes after rectal cancer surgery attracted attention a lot of attention with a tweet on July 22nd (24 retweets, 1 quote tweet and 52 likes by August 7th 2022). @BJSurgery tweeted a link to the paper “Inferior mesenteric artery embolization ahead of rectal cancer surgery: AMIREMBOL pilot study”
The announcement of the #monkeypox outbreak becoming a public health emergency of international concern was tweeted by @WHO on July 23rd 2022. @DrTedros, Director-General of the World Health Organization @WHO, declared #monkeypox outbreak a public health emergency of international concern.
Last but not least, a systematic review of compression after superficial venous insufficiency (SVÏ) treatment. On July 31st, @BJSurgery tweeted a link to a systematic review showing that although postprocedural compression after SVI treatment is beneficial, the optimal pressure and type of compression remain unclear.
The tweet (8 retweets and 13 retweets by August 7th) is here:
The trial was terminated after 240 patients were included and analysed. Compliance with supervised exercise was 50 per cent at six months. After one year, mean maximum walking distance improved similarly in both groups (P=0.69).
Comment: The authors conclude that supervised exercise should be the initial treatment, followed by revascularisation if that is not successful.
Ashrafi M, Ahmad SA, Antoniou SA, Khan T, Antoniou GA.
Eur J Vasc Endovasc Surg 2022; 63: 323-334.
Seven RCTs were examined. Active clot removal strategies resulted in higher patency than anticoagulation alone for proximal (iliofemoral) DVTs. Complication rates were similar. Active treatments have not been shown to reduce post thrombotic syndrome.
Comment: Lots more work to be done here before active clot removal can be recommended routinely.
Takii Y, Mizusawa J, Kanemitsu Y, Komori K, Shiozawa M, Ohue M et al.
Ann Surg 2022; 275: 849-855.
Use of the no touch technique during colon cancer resection failed to improve three year disease-free survival in this multicentre study that included 853 procedures: hazard ratio 1.03, 95 per cent confidence interval 0.8 to 1.3, P=0.59.
Comment: Perhaps other factors are just more important.
Smith S, Ridley S, Gani, J, Carroll, R, Lott, N, Hampton, et al.
Ann Surg 2022; 275: 842-848.
In this study that included 3123 procedures, surgical site infection rates were similar with all skin preparations: povidone iodine with alcohol 10.9 per cent; chlorhexidine with alcohol 11.1 per cent; aqueous povidone iodine 12.6 per cent. There were no adverse events or differences in secondary outcomes.
Comment: This challenges the perceived benefits of alcoholic skin preparation.
Gao X, Liu Y, Zhang L, Zhou D, Tian F, Gao T et al.
JAMA Surg 2022; 157: 384-393.
The study included 230 patients undergoing major abdominal surgery. Early (three days after surgery) feeding reduced the rate of nosocomial infection from 18.4 to 8.7 per cent (P=0.04) compared with late feeding (eight days after surgery).
Comment: The findings in many studies are consistent: early feeding is beneficial.
This multicentre study included 1748 pancreatic resections. Use of the algorithm reduced the composite risk of complications from 14 to 8 per cent, relative risk 0.48, 95 per cent confidence interval 0.38 to 0.61, P<0.0001.
Comment: There is no substitute for specialist care.
Of the 5013 patients studied, those who had warming had a higher core temperature at the end of the surgery (37.1 versus 35.6 degrees C). Warming did not reduce the rate of complications: 9.9 versus 9.6 per cent, respectively, P=0.69.
Comment: This does not confirm previous studies of benefits from heating, maybe because the unheated patients did not get too cold.
Devereaux PJ, Marucci M, Painter TW, Conen D, Lomivorotov V, Sessler DI et al, for the POISE-3 Investigators.
N Engl J Med 2022; 386: 1986-1997.
A total of 9535 procedures were studied. Tranexamic acid reduced bleeding complications (11.7 versus 9.1 per cent, P<0.001), but slightly increased the risk of cardiovascular complications (14.2 versus 13.9 per cent, P=0.04).
Comment: Is the trade-off worth it, except for specific procedures with high blood loss?
Goodwin PJ, Chen BE, Gelmon KA, Whelan TJ, Ennis M, Lemieux J et al.
JAMA 2022; 327: 1963-1973.
This study included 3643 non diabetic women, who were followed for a median of 96.2 months. Metformin did not have any advantage for women with ER positive (hazard ratio for invasive disease-free survival 1.01, 95 per cent confidence interval 0.84 to 1.21, P=0.93) or ER negative breast cancer (1.01, 0.79 to 1.3, P=0.92).
Comment: Science is the destruction of a beautiful idea by an ugly fact.
Salminen P, Sippola S, Haijanen J, Nordström P, Rantanen T, Rautio T et al.
Br J Surg 2022: 109: 503-509.
Seventy-two patients with CT confirmed uncomplicated appendicitis for non operative treatment were included. The ten day successful treatment rate was 87 per cent with placebo and 97 per cent with antibiotics, (P=n.s)
Comment: So how would a surgeon today choose to be treated if they had uncomplicated appendicitis?
June 2022 has been an important month for colorectal research in @BJSurgery, attested by high social media activity on this topic.
It all started with a tweet about a paper on the response to neoadjuvant immunotherapy in patients with mismatch repair-deficient/microsatellite instability colorectal cancer. The tweet had 21 likes and 16 retweets by July 7th, and it can be seen here:
On the same day, the @BJSOpen published a systematic review on specimen extraction after colorectal resections. Access the article here. This is the tweet:
Postoperative complications after colorectal cancer surgery have also attracted significant social media attention.
On June 6th, @martin_rutegard tweeted a paper published in @BJSOpen, which found that two chemokines (CXCL6 and CCL11) might predict leakage in rectal cancer. The paper is open access and can be read here. This is the tweet:
The day after, @BJSurgery posted a tweet about the core outcome set for clinical studies of postoperative ileus after intestinal surgery. This is a frequent postoperative complication that still puzzles us. You can read about it here.
The tweet had had 16 retweets and 23 likes by July 7th:
Anything related to intraperitoneal drains always attracts lots of attention. On June the 9th, @BJSOpen shared another paper with predictor factors of anastomotic leakage, but now found in the abdominal drain on postoperative day 3. The article can be accessed here. This is the tweet:
However, drains seem to not be associated with earlier detection of postoperative collections, as shown in an open access paper tweeted by @BJSurgery. You can read more here. This was a very popular tweet. It had 25 likes and 17 retweets by July 7th:
June was also a memorable month for the BJS community because after two previous cancellations in June 2020 and June 2021, Madrid received the BJS Society Council meeting and General Assembly amidst a heat wave. And social media echoed the joy.
Rebecca Grossman @rebgross and Laura Lorenzon @LauraLorenzonMD kept us updated:
We were also very happy because the @BJSAcademy reached 1000 followers by June 21st:
One more achievement for @BJSAcademy: @jcalverdy opens the Surgical Science section with a post on microbiome and surgery:
This is an open-access post on the BJS Academy website https://www.bjsacademy.com/the-microbiome-and-surgery-breakthrough-or-just-hype
By the end of the month, the appendix gained attention at @BJSurgery and @BjsOpen.
On the 23rd, results of the APPAC III were published: an RCT on uncomplicated diverticulitis. You can learn more here:
Then, on June 25th, an overview of appendix tumors focused on pathology and management is published and available here.
The tweet had 28 likes and 21 retweets by July 7th:
Last, but not least, the Journal of Citation Reports announced the 2-year impact factors of scientific journals in late June 2022. The good news brought joy to both @BJSurgery and @BJSOpen editorial boards.
On Instagram, @BJSurgery proudly announced that, for the first time, its impact factor had gone well over 10 to an amazing 11.112. This is a spectacular achievement.
In addition, the @BJSOpen impact factor went up to 3.875 and led the journal into the first quartile of surgical journals. BJSOpen editor @LauraLorenzonMD tweeted about it. Her tweet had had 45 likes and 16 retweets by July 7th, 2022:
In 1980, the number of studies including the word “microbiome” was around eleven, today using microbiome as a search word in pubmed yields over 100,000 entries. For surgeons, the relevance of the gut microbiome lies in its promise to explain disease pathogenesis (i.e cancer, appendicitis, diverticulitis, surgical site infections) and treatment effects (antibiotic prophylaxis, bowel preparation, etc). Yet because the data output of a typical microbiome analysis can be vast, determining what is signal versus noise has become problematic. Similar to the early days when human gene chips became available, displays of massive datasets indicating that a patient in group A is “different” from patients in group B leaves readers skeptical. For example, when the human gene chip became available, the transcriptome (mRNA expression of nearly 20,000 protein coding genes) of human samples could be compared between patient samples. Yet these initial screens only described “differences” between groups of patients and failed to identify actionable items. The descriptive nature of these studies has forced some, for example, to completely question the genetic basis of cancer. Are we falling into the same trap with microbiome studies?
Why microbiome studies are different. Claims that sequencing of the human genome was going to lead to major cures of complex diseases such as cancer have indeed been disappointing. First we were told that cancer is a genetic disease; once “junk” DNA turned out not to be junk, and once it became clear that gene-environment interactions (via histone modification?) played an important regulatory role in gene expression, the role of “lifestyle” became the new hype1. So where does that leave the microbiome in all of this? Issues such as how indoor and outdoor air quality, smoking, alcohol consumption, dietary choices, etc., influence one’s microbiome and then how in turn, its metabolites change host genetics is now under investigation.
Perhaps one of the most striking examples of the power of microbiome analyses is a study examining the gut microbiome of 34 monozygotic twins discordant for multiple sclerosis; one twin suffered from the disease while the other did not2. Deep analysis of faecal samples from the discordant twins demonstrated clear differences; yet when samples were transferred into germ-free mice, only samples from the affected twin produced an encephalomyelitis-like picture whereas unaffected twin samples did not. The neurotoxic metabolites from the gut microbiome that play a role in this effect are now coming to light3. The fact that monozyotic twins are born with different fingerprints and the genomic identity in their microbiomes is highly variable should diminish our enthusiasm for interrogating host genes only4. Animals are holobionts, consisting of both host and microbial genes, each interacting with one another and with the environment. At the individual patient level, this presents major challenges to understand disease pathogenesis and its treatment.
What is now emerging as centrally important to human health is diet, and the gut microbiome is centre stage in this regard. Relevant to surgical sciences and outcome studies is the role of obesity, smoking, diet and medication use on surgical outcome. As many of such factors are modifiable, surgeons are particularly interested in how such factors can be manipulated to decrease complications. While antibiotic exposures, smoking, and substance abuse are clearly areas that can be preoperatively addressed, both the quality and quantity of an individual’s diet is emerging as most relevant and certainly the most modifiable. For example, mice that consume a western diet are not only more susceptible to anastomotic leak, they can also develop surgical site infections from gut microbiota via the Trojan Horse Hypothesis5. Conversely, patients who consume a diet rich in fibre following curative colon cancer surgery are less likely to develop a recurrence6,7. Taken together, nutritional assessment beyond conventional markers such as serum visceral protein status (i.e., albumin, pre-albumin) and muscle mass (sacropenia, frailty) may involve a comprehensive dietary history, the use of food logs and dietary prehabilitation prior to surgery.
Surgeon beware. Surgeons tend to make changes in their practice when the proposed intervention has a strong scientific premise behind it and in some way just seems to “make sense.” Most clinical studies that simply compare one intervention group (i.e bowel prep, symbiotics, probiotics) to another fall short in convincing experts in the field to make a major change in clinical practice. One reason for this is the failure to adequately measure reliable “readouts” that can explain the variance within the group of treated individuals. Comparing mean values only “between treatment groups” without reconciling the differences in outcome “within groups” remains a problem8. Just as it is not helpful to demonstrate that older, sicker patient with more advanced cancer, on average (i.e., mean values comparing between groups) have worse survival compared to younger, healthier patients with less invasive cancer, it is not helpful to present massive datasets from a microbiome study that demonstrate that the microbiomes among those patients with complications are different compared to the microbiomes of patients without complications. Causal inference at the molecular level is needed and within-group variability must be explained.
In summary, microbiome sciences are indeed the next big thing as they are able to explain phenomena at the individual patient level, especially when samples can transferred to mice that phenocopy the disease of interest. How our environment, our life history and the disease process itself affect all genes, be they microbial or host derived, is what matters most. Surgeons recognize that they perturb multiple systems when they operate on patients. As a result, they remain eager to understand, at the individual patient level, how to disentangle the molecular mechanisms that explain why one patient recovers uneventfully while another does not.
May 2022 was a special month for the BJS Community. On May 3rd, the BJS Academy was launched and it was announced with a tweet that attracted a lot of attention, with 57 likes and 44 retweets.
The @BJSAcademy “is an online education resource that supports the professional development of current and future surgeons worldwide by championing research and collaboration”. The website has free content and it is accessible at the link https://www.bjsacademy.com.
BJS Academy leverages social media to disseminate knowledge worldwide. Self-promotion is not always bad, and we tweeted about the @BJSAcademy social media section on May 3rd.
One day later, the BJS European Hernia Society Prize was announced. The EHS 2022 Congress will be held in Manchester, with 2 prizes €3500 and €1500 for the winners. It can be seen here.
@Eurohernias is a strategic partner of BJS Society.
On the same day, the BJS Open presented the outcomes of 263 mucinous rectal cancer from our Sweden colleagues, showing a high percentage of downstaging and pCR. It can be read here:
The tweet had 10 likes and 5 retweets by May 31st.
The @Schoolofsurg also announced on May 4th the winner of the BJS Prize session at the ASGBI conference, which took place in Liverpool. An interesting study aiming to improve muscle function after colorectal surgery.
@SEIQuirurgica is a Spanish scientific organization devoted to promoting surgical research and innovation. It is one of the BJS Society’s strategic partners. Their website can be accessed here: https://www.investigacionesquirurgicas.com
On May 8th, @juliomayol announced on Twitter that the 26th #SEIQ2022 conference will be held in Gijón, Spain, in September 2022. The best oral communications will compete for the BJS Prize. Abstracts can be submitted here: http://www.congresoseiq.com
The tweet had 21 likes and 14 retweets.
In the May 2022 issue, the debate about acute appendicitis treatment and the related risks continues in @BJSurgery
There were seven RCTs including 1146 procedures. Wearing a compression stocking reduced early postoperative pain (P<0.001), but had no effect on complications, quality of life, vein occlusion rates, or time to return to work.
Comment: Post intervention compression is not necessary.
Early Breast Cancer Trialists’ Collaborative Group (EBCTCG).
Lancet Oncol 2022; 23: 382-392.
Aromatase inhibitors were compared with tamoxifen in premenopausal women with ovarian suppression in a study that included 7030 patients followed for a median of eight years. Aromatase inhibitors reduce recurrence, especially in years 1 to 4 (13.2 per cent absolute risk reduction). Recurrence rates were similar in years 5 to 9. Mortality rates were also similar.
Comment: Initial treatment with aromatase inhibitors in this group seems optimal.
Luke JL, Rutkowski P, Queirolo P, Del Vecchio M, Mackiewicz J, Chiarion-Sileni V et al on behalf of the KEYNOTE-716 Investigators.
Lancet 2022; 399: 1718-1729.
Adjuvant treatment with pembrolizumab every three weeks for up to 17 cycles was examined in the study that included 976 patients with median follow-up of 20.9 months. Treatment improved recurrence-free survival: 85 versus 76%, hazard ratio 0.61, 95 per cent confidence interval 0.45 to 0.82.
Comment: This difference is valuable, but again, it remains to be seen how late outcomes are affected.
Early results of this study suggest the robotic approach was quicker: 203.8 versus 244.9 minutes, P<0.001. Lymph node dissection was improved but all other clinical comparators and complication rates were similar.
Comment: modest improvement in dissection and duration of surgery, but the key is longer term outcomes.
Onerup A, Andersson J, Angenete E, Bock D, Börjesson M, Ehrencrona C et al.
Ann Surg 2022; 275: 448-455.
The intervention was physical activity for two weeks before and four weeks after surgery. After four weeks there was no demonstrable improvement in recovery in this study that included 761 randomized patients.
Comment: this model of prehabilitation was not effective in this patient group.
Collaborative research has attracted a lot of attention on social media lately. Its methodological validity and issues with authorship have been the subject of a heated controversy on Twitter in April 2022.
On April 2nd, Kenneth McLean @kennethmclean92 congratulated @EuroSurg on the publication in @BJSurgery of a collaborative study on a controversial matter: the use of intraabdominal drains after elective colorectal surgery.
@EuroSurg is a highly successful European surgical research network of students and surgeons running multicentre studies. Their website can be accessed here https://eurosurg.org/.
The tweet had received 10 retweets, 24 likes and on quote tweet by May 3rd
One day later, Kjetil Soreide @ksoreide wondered if it is appropriate to kill two birds with one stone when treating patients with synchronous primary colorectal cancer and liver metastasis. He was citing a @BJSurgery tweet about this paper https://doi.org/10.1093/bjs/znab457
The tweet had received 1 retweet and 4 likes by May 3rd
A Spanish colorectal surgery, Curro Blanco @Curro_Blanco , tweeted in Spanish to show his interest in the @BJSurgery paper titled “Impact of adverse events on surgeons” by Kevin Turner et al. on April 6th.
The tweet had received 2 retweets and 7 likes by May 3rd
Ruth Blanco Colino @ruthbc93, a brilliant surgical resident at Vall d’Hebron Hospital in Barcelona, also tweeted in Spanish about the @EuroSurg paper “Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study”
Her tweet generated good engagement with 7 retweets and 14 likes by May 3rd
But it was mid-April when a heated debate started on Twitter after a @BJSurgery “Gloves Off” paper by Martin Bjork @mabjo425 (Link to the paper https://doi.org/10.1093/bjs/znac100). Martin questioned some of the statements made by Li and Banghu (https://doi.org/10.1093/bjs/znac099) about collaborative research and questioned its scientific validity and the authorship model used in collaborations.
Dmitri Nepogodiev @dnepo, who has brilliantly spearheaded the largest surgical collaborative to date, @CovidSurg, tweeted his response to Martin Bjork’s criticism on April 15th. The first tweet had received 14 retweets, 43 likes and four quote tweets by May 3rd.
If you are interested in reading Dmitri Nepogodiev’s thread, see below:
On the same day, April 15th, Augustinas Bausys posted his arguments against the authorship model, whereas Ewen Griffiths tweeted in favor of collaborative research.
Bausys’ tweet had received 4 likes by May 3rd and can be accessed here:
Griffiths’ tweet had 7 likes by May 3rd and can be seen here:
On April 17th, the controversy between Martin Björk and Dmitri Nepogodiev continued:
On April 19th, Rebecca Grossman @rebgross shared her first leading article “Harassment in Surgery: line in the sand” published in @BJSurgery on Twitter. (Link to the article https://doi.org/10.1093/bjs/znac085). This is an extremely important issue and action should be taken to change the culture and prevent harassment.
Her tweet was very engaging. It received 33 retweets, 88 likes, and four quote tweets:
@BJSOpen shared a video and the link to a paper on the use of wearables to monitor recovery after surgery on Twitter on April 20th. This #openaccess paper can be read here https://doi.org/10.1093/bjsopen/zrac031
The tweet with the video had five retweets, 12 likes and one quote tweet by May 3rd:
Six days later, on April 26th, @BJSOpen tweeted again a video and the link to a review paper on the definition of futility in emergency laparotomy. The #openaccess paper can be read here https://doi.org/10.1093/bjsopen/zrac023
The tweet had a large repercussion, with 12 retweets, 24 likes and 8 quote tweets by May 3rd