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Cookie policySurgical science advances at an extraordinary pace, and all surgeons have a duty to keep up to date to offer their patients treatment based on the latest research.
Surgical science advances at an extraordinary pace, and all surgeons have a duty to keep up to date to offer their patients treatment based on the latest research.
Explore another category:
Fawzy A, Balbaa MA, Hagag M.
BJS Open 2023; 7: zrac173.
There was no difference in the rate of patient satisfaction between these two procedures in the 78 patients studied. Most patients in both groups considered the result excellent.
Comment: Both these new techniques are effective.
29 August 2023
Schrag D, Uno H, Rosovsky R, Rutherford C, Sanfilippo K, Villano JL et al, for the CANVAS Investigators.
JAMA 2023; 329: 1924-1933.
This study included 671 patients with cancer and a new episode of VTE. After six months, the risk of recurrent VTE was not inferior with oral anticoagulation (6.1per cent), compared to those receiving low molecular weight heparin (8.8 per cent). Bleeding complication rates were similar.
Comment: Reassuring, and easier for patients.
29 August 2023
Welcome to the July 2023 edition of the @BJSAcademy social media review!
Here, we spotlight captivating and popular posts from the BJS community accounts on X.
Continuing the #AI series on @BJSAcademy, the article “The role of artificial intelligence in diagnostic imaging” authored by Barbara Seeliger, Alexandros Karargyris, and Didier Mutter was shared on July 1st on X. This post garnered 2,204 views by Aug 14th:
Read the article here.
On July 2nd, @BJSOpen initiated a poll on X, seeking readers’ opinions on recently published impact factors, given the consistent drop in numbers. Results showed that most respondents (39.7% out of 68 votes) found the outcome as expected. Interestingly, 35.3% opined that the impact factor is overrated. By Aug 14th, the post accumulated 5,589 views:
In part 6 of the @BJSAcademy series, the article “Opportunities, functions and three wise monkeys” by Ameera AlHasan was shared on July 4th on X:
Read the article here.
On the same day, @BJSOpen posted an #openaccess article link, reporting results from a retrospective cohort study on the effects of preoperative polypharmacy or hyper-polypharmacy on surgical patient outcomes:
Read the article here.
@BJSOpen shared the paper “What’s the influence of #obesity on perioperative outcomes after gastrointestinal #surgery?” on July 11th. Surprisingly, this meta-analysis challenges assumptions about higher postoperative mortality in patients with obesity:
Read the article here.
On July 12th, @BJSurgery posted the Cutting Edge review on gut microbiota, faecal transplantation, and surgical outcomes. The post garnered 3,671 views:
Read the paper here.
Exploring the theme of efficient resource utilization and environmental sustainability, on July 13th, @BJSOpen shared the #openaccess article titled “Waste not, want not: orthopaedic waste data,” which amassed 1571 views by Aug 14th:
Read the article here.
On July 14th, @BJSurgery linked to the #openaccess article “Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases.”:
Read the article here.
The review of recent #RandomizedClinicalTrials for June was shared on X on July 19th:
Read the article here.
On July 22nd, @BJSOpen quoted a previous X post on gene signature analysis and outcome prediction in patients with early pancreatic cancer who underwent R0 resection:
Read the article here.
Interventional oncology for liver tumours was spotlighted on July 24th by @BJSAcademy in a surgical digest titled “Image-guided ablation for liver tumours.” The post garnered 3286 views by Aug 14th:
Read the article here.
Finally, on July 30th, @BJOpen posted the most-viewed post of the month on X (22.7K views). The poll questioned when surgeons perform prophylactic mesh augmentation after laparotomy, with 65.3% of 147 votes leaning towards “Never!”:
15 August 2023
https://doi.org/10.58974/bjss/azbc026
This article highlights the close relation between the central nervous system and peripheral immune system, forming a neuroimmune axis that has clinical implications we are just beginning to understand. This article from the journal Science and Translational Medicine couples both patient data and a mouse model of intracranial haemorrhage (ICH) to explore the influence of ICH on haematopoietic stem cells (HSC) and the subsequent impact of HSCs on the brain.
In the first experiment, bone marrow cells were harvested from skull flaps of patients requiring decompressive craniotomies for ICH and compared with cells from patients with unruptured aneurysms. In the second, ICH was induced in a mouse model by injection of autologous blood into brain parenchyma and subsequent harvest of femur bone marrow cells. Both the human and mouse data demonstrated increased myeloid progenitor cells and haematopoiesis with ICH. Adrenergic innervation through the β3 receptor on haematopoietic cells promotes production of Ly6Clow , a patrolling non-classical monocyte (NCM), in the bone marrow, which rapidly travels to the brain after ICH. Through transcriptomic analysis of the HSCs after ICH, Cdc42 (cell division cycle 42) was identified as an upregulated gene. Cdc42 was noted to be ablated in β3-adrenergic knockout mice, Adrb3-/-, linking the relationship of Cdc42 and adrenergic innervation. Treatment with a Cdc42 inhibitor led to decreased bone marrow proliferation, reduced Ly6Clow monocytes, and exacerbated brain injury. Given the role of the β3 receptor in proliferation and targeting of haematopoietic cells, mice were treated with a US Food and Drug Administration approved β3 receptor agonist, mirabegron. As expected, mirabegron treatment increased the Cdc42 activity in HSCs and increased Ly6Clow production and concentration in the brain. Most importantly mirabegron treatment reduced functional neurological deficits, perihaematomal oedema, and overall brain oedema after ICH.
This article demonstrates that brain injury leads to a cascade of mechanisms modulated by β3-adrenergic innervation in which an NCM population provides protective effects to the brain. Lastly, the authors tested a potential targeted therapy upregulating the pathway and demonstrated improvement in brain injury outcomes.
Brain injuries have unique mechanisms that differ from peripheral organ injury. In normal conditions, the brain is sheltered within the blood brain barrier (BBB); endothelial cells and the microvasculature tightly regulate the exchange of molecules, ions, and cells from the blood to the brain.2 When the brain is injured, in particular in traumatic brain injury (TBI), there is a combination of mechanical disruption and endothelial dysfunction leading to BBB permeability. Disruption of the BBB leads to the circulation of brain-derived damage associated molecular patterns (DAMPs) in the peripheral circulation.3 At the same time, the injured brain is exposed to the peripheral circulation, due to BBB disruption. The complex interplay and cross-talk between the injured brain and the distant organs is just beginning to be investigated.
Shi et al1 add to the body of literature evaluating the connection between brain injury and the immune system. Given the relatively broad potential aetiologies of ICH (e.g. trauma, aneurysm rupture, tumour, coagulopathy), this article is widely applicable and should stimulate future questions in understanding brain injury. Severe TBI has been associated with a systemic inflammatory response syndrome with downstream effects that can lead to multi-organ dysfunction (MOD). The systemic response provides notable clinical evidence for the interactions between the brain and periphery. In 2021, Yang et al evaluated the role of the Ly6clow NCM in the mechanisms of pulmonary oedema following TBI.4 Their group demonstrated that there is a significant increase in Ly6clow NCM in the lungs of mice after TBI. Upon depletion of NCMs, there was a decrease in pulmonary oedema suggesting that NCMs contribute to post-TBI lung injury. Taken together, these articles show that NCMs are stimulated in the bone marrow following TBI. Subsequently, their response plays a role in both local brain inflammation, as well as distant organ injury. Interestingly, while the Ly6clow NCM migration appears to improve brain injury,1 the increase of Ly6clow in the lungs was associated with worse outcomes. Given the interconnected nature of the immune system, these findings raise many more questions than answers. Among the many are: what the NCM response is in other organs, what downstream cell type do they effect, and how do the NCMs migrate to the distant organs?
In understanding the mechanisms and pathways driving the brain and peripheral cross-talk, we may begin to not only investigate therapies and diagnostics in brain injury, but also target the associated MOD. Currently, the treatment for brain injury is largely supportive, with no interventions that target the underlying mechanisms. These mechanisms provide promising avenues for future research and the potential for advancing the clinical management of TBI and other brain injuries.
An additional future application may be in the field of transplantation. Solid organ allografts from donation after brain death, the leading source of donor organs, have been noted to have inferior graft survival compared to those from living donors.5 Given the systemic nature of brain injury and brain death, it is likely that the organs similarly undergo immune and inflammatory responses, potentially predisposing the allograft to dysfunction post-transplantation.
Thus, a better understanding of what happens at the cellular and molecular levels following brain injury may have wide-reaching clinical benefits. In addition to the potential to improve outcomes for patients with brain injury, the effects on post-transplantation organ function highlight the central role of basic and translational investigation in the development of novel therapies. This sentiment was probably best captured by the Noble Laureate Francis Crick (1916-2004) when he wrote “Almost all aspects of life are engineered at the molecular level, and without understanding molecules we can only have a very sketchy understanding of life itself.” What Mad Pursuit (1988).
10 August 2023
Maemoto R, Noda H, Ichida K, Miyakura Y, Kakizawa N, Machida E et al.
Ann Surg 2023; 277: 727-733.
Lavage with povidone iodine before skin closure for 1 min was compared to saline lavage in this study that included 941 procedures. The rate of surgical site infection was similar: 7.6 per cent with iodine and 5.1 per cent with saline, P=0.154.
Comment: the fact that the wound is flushed may be more important than what with.
19 July 2023
Welcome to the @BJSAcademy social media review for June 2023, where we highlight some of the most interesting and relevant posts from BJS community accounts. In fact, we have chosen some tweets with 15 or more likes.
Whether you are a trainee, a consultant, or a researcher, we hope you will find something useful and inspiring in this digest. Please feel free to share your feedback and suggestions with us on Twitter, Facebook, or Instagram. Thank you for your support and engagement!
On June 3rd, @BJSurgery tweeted a retrospective study comparing endoscopic retrograde appendicitis therapy with antibiotics for uncomplicated appendicitis:
The manuscript can be accessed here
Mechanical bowel preparation and antibiotics is a never-ending story. On June 5th, @BJSOpen shared the link to a metanalysis on this topic. It is worth reading:
The manuscript can be accessed here.
Breaking news! On June 6th @BJSAcademy announced the recipient of inaugural BJS Society Award: Prof. Henrik Kehlet:
@BJSurgery shared an open access paper reporting the results of the international Watch and Wait registry on June 9th. A must-read paper for colorectal surgeons:
The paper can be accessed here.
No doubt fluorescence-guided surgery is a hot topic. You can read an outstanding review by @BJSurgery editor Paul Sutton that was tweeted by @BJSOpen on June 10th:
The paper can be accessed here.
On June 11th, @BJSurgery shared an open access paper on diagnosis and treatment for gastro-oesophageal cancer in England and Wales. What’s the most important finding? Little improvements in early diagnosis:
The paper can be accessed here.
The #openaccess leading article titled “Bi-directional chemotherapy for peritoneal metastases” was tweeted by @BjSurgery on June 14th:
The paper can be accessed here.
The BJS Society Award Ceremony was held at the Olympic Museum in Lausanne on June 16th. On that same date, @BJSAcademy tweeted “A surgical life by Henrik Kehlet”. We highly recommend you read it if you want to know more about Prof. Kehlet and how surgeons can translate knowledge into impact:
The article can be accessed here:
Simultaneously, @BJSOpen shared a tweet congratulating Prof. Kehlet, the BJS Society Award winner:
@BJSAcademy also tweeted pictures of the ceremony on June 17th. In fact, it was truly a fantastic event:
Little is known about the impact of cognitive biases on surgical outcomes. On June 20th, @BJSurgery shared a metanalysis of studies that investigated cognitive bias in surgery:
The paper can be accessed here.
On June 23rd, @BJSurgery announced the three successful applicants for @BJSurgery and @BJSOpen editor assistant positions. Congratulations @mikeboland86, @PhilipMueller_1 and @TejedorPat:
A very much liked @BJSurgery tweet shared an article by @swexner’s group reporting a propensity score-matched outcomes study for robotic and laparoscopic colectomy from a national cancer database on June 27th:
The article can be accessed here.
Last but not least, @BJSOpen took advantage of its blue tick and tweeted the abstract of the paper titled “Global cost of postoperative ileus following abdominal surgery: meta-analysis” on June 28th. It has received 33 likes by July 2nd:
The article can be accessed here.
3 July 2023
This is a selection of tweets posted by @BJSurgery @BJSOpen and @BJSAcademy between May 1st and May 30th 2023. We hope you enjoy them and would like to read your comments.
On May 1st, @BJSAcademy tweeted an important announcement: the new BJS Institute online #postgrad programme – Surgical Writing and Evidence-Based Practice.
You can find further information here.
On the same day, @BJSAcademy posted the article of the month for April: Basic Introduction to Artificial Intelligence by @tejedorpat. It is part of the @BJSAcademy #AI series:
The article can be read here.
One day later, May 2nd, @BjsOpen tweeted: “#RCT from China with n=96 shows that single ivof 1.5mg/kg lignocaine 10min b.f. tourniquet inflation in arthroscopic surgery inhibits tourniquet hypertension by TNF-α release & has beneficial effects on postop pain and recovery!”
The paper can be read here.
Coinciding with #EuroHernia2023, @BjsOpen quoted a tweet: “Our editor assistant, hernia enthusiast and collagen nerd @DrHenriksen talking about state of the art #hernia surgery at @BarcelonaEhs!!! #SoMe4Surgery @eurohernias @BJSAcademy @young_bjs:
The interview with Donald E. Low was tweeted by @BJSAcademy on May 5th: “Have the right partner at home and have the right partners at work.”
The interview can be read here.
On the same day, @BJSurgery shared a free access paper: Early-onset sporadic colorectal cancer: key question of early diagnosis and screening strategies:
The paper can be read here.
Two days later, May 7th, @BJSurgery tweeted a very interesting paper on machine learning-based prediction models in the perioperative setting:
The paper can be read here.
On May 9th, @BJSAcacemy announced that the second article in the AI series was available. The authors are @irene_spiridon and @DocSeeliger and the paper is about the optimisation of surgical pathology and the potential role of AI:
The paper can be read here.
@BjsOpen tweeted a must-read review about hereditary colorectal, gastric and pancreatic cancer on May 11th:
The manuscript can be read here.
On May 13th, an open access paper titled “Timing of symptomatic venous thromboembolism after surgery: meta-analysis” was shared by @BJSurgery:
The paper can be read here.
Four days later, on May 17th, @BJSurgery shared two important papers:
A #RCT investigating prophylactic onlay mesh placement techniques for optimal abdominal wall closure in an ex vivo biomechanical model:
The paper can be read here.
An #OpenAccess paper titled “Surgical Outcome Risk Tool to predict 30-day postop mortality in a mixed surgical population in Swedish tertiary hospitals”:
The paper can be read here.
On the same day, @BjsOpen shared a paper reviewing the current state of fluorescence-guided surgery by @BJSurgery editor @paulo_sutt et al.
The paper can be read here.
On May 18th, @BjsOpen added more fuel to the “volume debate” in colorectalsurgery with these questions: What’s the correlation of surgical specialization and surgeon resection volume on short-term outcome after emergent colon cancer resections? Differences between colorectal, general and acute care surgeons?
The paper can be seen here.
@BJSurgery congratulated Candice Downey on winning the BJS Prize at the ASGBI Surgical Congress in Harrogate, UK! #ASGBI2023 on May 19th:
An interesting poll was tweeted by @BjsOpen on May 21st: Leftsided colorectal leading to bowel obstruction -> What type of stoma you prefer as to surgery?
The results can be seen here:
On May 22nd, @BJSurgery shared another “Free to access” paper in the BJS May issue: Practice of changing gloves and its effect on surgical-site infections.
The paper can be read here.
A tweet to thank all the speakers and participants who contributed to the @BJSAcademy workshop – “how to referee a paper” was posted on May 27th:
The last tweet of the month was posted on May 30th by @BJSurgery and shared the manuscript titled: “Clinical outcomes following mechanochemical ablation of superficial venous incompetence compared with endothermal ablation”:
The paper can be read here.
13 June 2023
The following tweets were posted between April 1st and April 29th, 2023. They contain useful information and insights about various topics related to surgery. You can browse through them and find the ones that are most relevant to your interests and needs.
Coping with anastomotic leaks, harder when older? Tweeted by @BJSurgery on April 1st:
The paper can be read here.
Lies, damn lies, and statistics. On April 3rd @BJSurgery shared a paper on probability, P values, and statistical significance: instructions for use by surgeons:
The paper can be read here.
On April 4th, @BJSurgery shared a Young BJS paper: hiatal hernia:
The paper can be read here.
What did you learn in the operating room? Soft skills @BJSAcademy:
The post can be read here.
The instrumentalist: Weitlaner retractor. Tweeted by @BJSurgery on April 17th:
The paper can be seen here.
It may not sound sophisticated, but it is extremely important. On April 10th, @BJSurgery shared the NINJA multicentre randomized clinical trial investigating the effectiveness of nail bed repair in children with or without replacing the fingernail:
The paper can be read here.
On April 11th, a randomized trial on the use of haemostatic patches to prevent pancreatic fistula after pancreatic resections was shared by @BJSOpen:
The paper can be read here.
@BJSOpen ran a Twitter poll on the use of ursodeoxycholic acid to treat gallstone disease on April 16th. Of the 269 participants, 52.8% voted that they do not use it:
The paper can be read here.
On the same day, @BJSurgery tweeted an open access paper on double faecal immunochemical testing in patients with symptoms suspicious of colorectal cancer:
The manuscript can be read here.
On April 17th, @BJSAcademy announced the launch of the AI series on Twitter. These are the topics:
An interesting #systematicreview and meta-analysis of machine learning models in kidney TPL found they could improve prediction of graft survival. An overall model including 29 models showed sens & spec of 0.81 and AUC of 0.82. It was tweeted by @BJSOpen:
The manuscript can be read here.
On April 25th, @BJSAcademy tweeted the first of a series on AI: “Basic Introduction to Artificial Intelligence” The aim is to describe how it works and its importance to healthcare:
The post can be read here.
@BJSAcademy tweeted #BJSBookshelf: Top Knife: The Art and Craft of Trauma Surgery, on April 28th. We recommend you read the review by Teresa Perra & Alberto Porcu:
The post can be read here.
On April 29th, @BJSOpen tweeted a #systematicreview of training surgeons to optimize communication and symptom management in patients with life-limiting conditions:
The paper can be read here.
On the same date, @BJSurgery shared the international guidelines on management of general surgical emergencies in the pregnant or breastfeeding woman:
The paper can be read here.
16 May 2023
Patel SP, Othus M, Chen Y, Wright GP, Yost KJ, Hyngstrom JR et al.
N Engl J Med 2023; 388: 813-823.
Some 313 patients with advanced melanoma undergoing surgical resection followed by one year of adjuvant Pembrolizumab, were randomly allocated three additional doses of Pembrolizumab preoperatively. After two years, event-free survival was significantly better with the neoadjuvant treatment: 72 versus 49 per cent, P=0.004.
Comment: This is important evidence for the benefit of neoadjuvant treatment for melanoma.
26 April 2023
Kimball AB, Jemec GBE, Alavi A, Reguiai Z, Gottlieb AB, Bechara FG et al.
Lancet 2023; 401: 747-761.
This analysis of two identical trials included over one thousand patients. Secukinumab given fortnightly was more effective in both trials at reducing the signs of symptoms of hidradenitis than placebo (or Secukinumab every four weeks).
Comment: Effective, with good safety profile.
26 April 2023
The TRACE Study Investigators.
Ann Surg 2023; 277: 375-380.
Over 5000 patients were included in this multicentre trial. Thirty-day mortality was 0.56 per cent (n = 14) in the control and 0.44 per cent (n = 12) in the intervention group (odds ratio 0.74, 95% Confidence interval 0.34–1.62).
Comment: Would results have been different if the focus had been on high risk patients only?
26 April 2023
Jain A, Greig AVH, Jones A, Cooper C, Davies L, Greshon A for the NINJA Collaborative.
Br J Surg 2023, 110: 432-438.
In this study that included 451 children, discarding the nail after repair was not associated with an inferior outcome (infection/cosmesis), but reduced overall costs by a mean of 84 euros.
Comment: The nail can be discarded.
26 April 2023
Almeida I, Gonqalves AC, Corrêa FB, Castro J, Guirro E, Farina JA et al.
Ann Surg 2023; 277: 198-205.
Patients with burn contractures at least one year old were randomized to split skin grafting alone, or with the addition of one of three dermal matrix preparations. Detailed scar assessment showed no improvement over skin grafting alone with any of the dermal matrices.
Comment: Disappointing outcome for the dermal matrices.
26 April 2023
On March 1st, the second @BJSAcademy essay writing competition was launched. All medical students and young trainees are invited to send their essays on “Something interesting I learnt in the operating room”:
On the 3rd of March, comments related to the variation in limb amputation rates in Denmark and it’s becoming a national scandal were discussed. In the age of tweets and fast responses, it is sometimes necessary to take a moment to carefully analyse results that can become great reasons for debate:
The article can be read here.
Gender stereotypes and bias continue to prevail in our culture, and Medicine and Surgery are no exception. On the 5th of March, ‘Gender divergence: scoping the surgical gap’ was published on @BJSurgery:
The article can be read here.
March is the #ColorectalCancerAwarenessMonth, and several publications have appeared on @BJSurgery and @BJSOpen to highlight relevant research regarding this prevalent disease:
The article can be read here.
Do operative volumes influence outcomes in cholecystectomy? Read this interesting study published on @BJSurgery and tweeted on March 15th:
The article can be read here.
Early-onset colorectal cancer (#EOCRC, <50y) is increasing worldwide with many underlying reasons not yet elucidated. A thread of @OUPMedicine covering @BJS articles which shed light on this important issue has been published during #ECCAM2023:
Again, studies regarding outcomes based on surgical volume are a matter of debate. In this case, bariatric surgery is s in the spotlight. You can see more on @BJSurgery, and it was tweeted on March 22nd:
The article can be read here.
On March 30th, @BJSAcademy tweeted the last call for applications for a BJS Society Social Media Lead who will coordinate activity across @BJSurgery @BjsOpen and @BJSAcademy:
19 April 2023
Wei Y, Wu J, Yuxin C, Fan K, Yu X, Li X et al, on behalf of the PL-5 Investigators.
Ann Surg 2023; 277: 43-49.
This study examined the use of a new antimicrobial spray compared to silver sulphadiazine in 220 patients with a skin wound infection. Use of the spray at four varying doses all improved healing rates significantly (P<0.05).
Comment: This seems to be working more like an antiseptic.
22 March 2023
February was only 28 days, but it was a particularly busy month for @BJSurgery, @BJSOpen and @BJSAcademy on social media.
The opening @BJSurgery tweet of the month was about surgical knives:
On February 2nd, @BJSurgery shared an article on oncovascular surgery for advanced pelvic malignancy, published in the February issue:
The article can be accessed here https://doi.org/10.1093/bjs/znac414
@BJSurgery tweeted an article reporting the results of transanal vs. laparoscopic TME on February 4th:
The article can be read here https://twitter.com/BJSurgery/status/1621950466140807169?s=20
Caffeine and postop ileus after lap colorectal surgery: yes or no? Marcel André Schneider @MA_Schneider shared a @BJSurgery article reporting the results of a RCT:
The article can be read here https://doi.org/10.1093/bjs/znac265
On February 6th, Jonathan Earnshaw @JJEarnshaw invited the surgical community on Twitter to join the @BJSAcademy:
On February 11th, Prof. Jose Balibrea @BalibreaJose tweeted a comment in Spanish about a @BJSOpen #researchletter on gastroparesis and bezoar formation in patients with GLP-1 antagonists and the potential implications of MBS patients:
The paper can be read here https://doi.org/10.1093/bjsopen/zrac169
How to manage general surgical emergencies in pregnant and breastfeeding woman? @BJSurgery recently published the international guidelines and they were shared by @drnaumanAhmed on Twitter on February 13th:
The article can be read here https://doi.org/10.1093/bjs/znac450
Gianluca Pellino @GianlucaPellino shared his interest in an overview about #diverticulardisease in @BJSAcademy:
@BJSAcademy shared a #CuttingEdge blog video by Alan Batt regarding a paper on CONFERD-HP on February 23rd:
The video can be viewed here https://www.bjsacademy.com/conferd-hp-recommendations-for-reporting-competency-framework-development-in-health-professions
@BJSOpen tweeted the results of a poll for endocrine surgeons with the following question “What is the most important consideration when choosing your skin closure after thyroid/parathyroid surgery?” on February 26th:
On February 27th, Prof. Russell Petty @RussellPetty19 tweeted a summary of a @BJSurgery paper on the impact of Covid19 on gastroesophageal cancer patients:
The article can be read here https://doi.org/10.1093/bjs/znad003
15 March 2023
For the first time since 1913, @BJSurgery was not printed in January 2023. Now, it will only be published online. The two journals, BJS and BJS Open, together with the BJS Academy, are leading the digital transformation of surgical research dissemination. Many changes will be announced soon, but in the meantime, let’s focus on the excellent articles shared on social media.
The first tweet of the year from @BJSurgery was on pancreatic cancer!
The article can be accessed here.
An interesting article regarding #QoL in patients with colostomies after #rectalcancer was published on @BjsOpen on January 3rd:
The paper can be found here.
#BariatricSurgery is still a matter of debate. Long-term effects of BS are discussed in this new paper @BJSurgery. The tweet was published on January 6th:
The paper can be read here.
Artificial Intelligence #AI is beginning to play an increasingly real role in our daily lives! Can we even co-author articles with GPT3?
The ERAS recommendations for renal transplantation were tweeted by @BJSurgery on January 16th:
The article can be read here.
A highly engaging tweet by @BJSurgery shared the “Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies” on January 20th.
The article can be read here (Open Access).
A systematic review of PIPAC following the IDEAL framework was shared on Twitter by @BJSurgery on January 26th:
You can read the article here (Open Access).
On January 29th, @BJSAcademy shared Professor Derek Alderson’s post “Life in Surgery”. Prof. Alderson is Vice Chair of the BJS Society Executive Committee:
You can read the post here.
On January 30th, @BJSOpen tweeted: “How does #digital #consent impact informed consent?” A #systematicreview of 40 papers found a generally positive effect on early and delayed comprehension. Few studies cover all aspects of informed consent:
You can read the paper here.
On the same day, @BJSAcademy shared a post under the title “A surgical life” by Adesoji Ademyuiwa:
You can read the post here.
13 February 2023
Sali L, Ventura L, Mascalchi M, Falchini M, Mallardi M, Carozzi F et al.
Lancet Gastro Hepatol 2022; 7: 1016-1023.
Some 15,000 people were randomized and invited. Attendance was lower for CT colonography (26.7 per cent versus 33.4 per cent who participated in all three faecal testing rounds). Although the detection rate was higher with CT colonography (5.2 versus 3.1 per cent, P=0.0002). Overall detection (referral to work-up) was higher after three rounds of faecal testing (7.5 versus 2.7 per cent, P<0.0001).
Comment. Interesting that compliance with screening may be more important than the accuracy of the test.
26 January 2023
Albers KI, Polat F, Helder L, Panhuizen IF, Snoeck MMJ, Polle S et al, for the RECOVER Study Collaborators.
Ann Surg 2022; 276: e664-e673.
A total of 178 patients were randomized to high or low pressure pneumoperitoneum. Quality of recovery score was significantly improved on day one after low pressure pneumoperitoneum (167 versus 159, P=0.005). Inflammatory markers were also reduced. Pain scores were lower and there were fewer infectious complications.
Comment: But is the view as good?
26 January 2023
Abbassi F, Muller SA, Steffen T, Schmied BM, Warschkow R, Beutner U et al.
Br J Surg 2022; 109: 1216–1223.
Sixty patients were randomized to one of two caffeine doses given three times a day, or a control group. There was no measurable effect from caffeine; time to first bowel movement was not improved: 68.2 h after caffeine versus 67.3 h in controls (P=0.887).
Comment; Well there goes the excuse to ask for a coffee after your operation.
26 January 2023
Kang B, Ibrahim S, Weil A, Reynolds K, Johnson T, Wilson S et al.
Ann Surg 2022; 276: 975-980.
Patients who had skin surgery with primary wound closure were randomly allocated to one of two different laser therapies for eight weeks or a control group. Fifty-two patients were eligible for analysis. Laser treatment improved wound score after 36 weeks, particularly with regards to scar thickness, stiffness and erythema.
Comment: Whether laser treatment improves wound healing still remains unproven.
26 January 2023
https://doi.org/10.58974/bjss/azbc019
With the advent of cellular targets and immunotherapy, cancer treatment has undergone significant improvement over the past several decades. While curative treatment of malignancy often relies on surgical excision, adjuvant modalities such as loco-regional irradiation remain important tools in comprehensive cancer care. Adjuvant radiotherapy (RT) is highly effective in reducing cancer burden, limiting the need for extensive surgery and decreasing the risk of local recurrence.1-3 However, RT brings collateral damage to the healthy surrounding soft tissues. Exposure to ionizing radiation results in a series of tissue changes marked by erythema, ulceration and oedema in the acute phase, followed by chronic inflammation and skin fibrosis, which may persist after treatment 4,5. As cancer survival rates continue to improve, an increasing number of patients are living with chronic morbidity related to RT.
Autologous fat transfer (AFT) has emerged as a possible treatment to the harmful effects of irradiation.6,7 Here, adipose tissue is suctioned from one part of the body, processed and then injected in small aliquots directly into the irradiated tissues.8 The mechanism through which lipoaspirate exerts a reparative effect is poorly understood but thought to be through direct and indirect actions: direct differentiation of transferred adipose-derived stem cells (ASCs) into new adipocytes, and paracrine signalling of cytokines and growth factors (HGF, TGF-ß, FGF-1,2, VEGF) that inhibit profibrotic signalling pathways and contribute to the recruitment of proangiogenic cells 9.
Like a skin graft, the adipose graft in AFT is dependent on the recipient tissue bed for nutrition and engraftment to achieve adequate ‘take.’ One of the challenges of fat grafting, in particular into a poorly perfused, irradiated tissue bed, is its unreliable retention rate, which is cited at between 30%-70%. Repeat procedures are often performed.10,11 As an alternative to AFT, decellularized adipose matrices (DAM) derived from discarded lipoaspirate have been developed. The allografts are processed through physical, chemical, and enzymatic purification techniques to develop decellularized scaffolds that retain the complex macromolecular architecture of the adipose tissue, and potentially its paracrine function via key growth factors retained in the graft. In recent studies, DAMs have been shown to promote adipose tissue regeneration, and have become a promising alternative to traditional fat grafting for soft tissue defects. 12 However, DAMs have not been studied in the context of radiation or a former tumour bed.
In the current study, Adem et al. compared the effectiveness of DAMs with autologous fat grafts in treating radiation injury in both murine and human tissue by analyzing the dermal architecture and vascular density of irradiated skin.13 First, immunocompromised mice were divided into several treatment conditions: radiation only, radiation with AFT, radiation with DAMs, and a control group that received neither radiation nor grafting. In grafted mice, volumetric analysis was conducted using micro-computed tomography (CT) at baseline and every two weeks for a total of eight weeks. Irradiated mice were sacrificed after twelve weeks, at which time the scalp skin and explanted fat were subjected to histological and mechanical analysis. Next, human skin samples (including nonirradiated, irradiated, and irradiated with grafting) were obtained from three women who had undergone grafting with autologous fat or DAM following breast cancer excision with radiation, during subsequent autologous breast reconstruction.
Both AFT and DAM grafts were found to have significant reparative effects on irradiated skin compared to controls in both murine and human tissue. However, AFT was superior to DAM in all metrics investigated. Tissue from mice injected with autologous fat had greater adipocyte integrity, greater vascularity, less inflammation, and less fibrosis compared to those grafted with DAMs. Both fat grafted and DAM grafted skin showed a decrease in dermal thickness, collagen density, and stiffness when compared to irradiated, non-grafted skin, though AFT showed significantly superior results to DAM. The authors observed high levels of factors known to regulate adipogenesis and increase angiogenesis such as FGF2, EGF2, and PDGF compared to the controls. Longitudinal CT analysis of graft retention in irradiated sites found a decrease in both AFT- and DAM-graft volume, though retention in DAM-injected mice was significantly lower. Analysis of human skin had similar findings. AFT and DAM significantly reduced dermal thickness and collagen density, with increasing tissue vascularity, when compared to irradiated, non-grafted skin.
The similar findings between the murine model and proof-of-concept human tissue lays a promising groundwork for necessary randomized control clinical trials. It remains unclear whether the decellularized matrix serves merely as an extracellular scaffold that becomes repopulated with native adipocytes, or whether the growth factors and cytokines embedded in the graft contribute to remodelling and angiogenesis observed. Previous studies suggest that it may be a combination of the two processes.14 As such, it will be critical to ascertain the oncogenic properties, if any, of the DAMs when delivered to a former tumour bed. Furthermore, given that chronic radiation effects can develop over the course of months to years after initial injury, a longer duration of study is required to substantiate the effects of DAM. Despite these drawbacks, this study provides encouraging evidence that DAM use in irradiated skin can improve and reverse several of the negative effects seen with RT, and provides a good translational model for future work in the field.
The study by Adem and colleagues has important implications for the use of DAM in clinical practice. Though it was found to be inferior to AFT, DAM showed a significant improvement in fibrosis, dermal thickness, and vascularity compared to non-grafted controls without the additional donor site or soft tissue requirement. This would have particular value in patients who may not have excess fat stores following oncological treatment. While there is much work to be done, this study provides encouraging evidence to support to the use of DAM in soft tissue reconstruction and offers a suitable translational model.
12 January 2023
Social media brought our attention to excellent content during the last month of 2022. Here is our review.
Let’s start with @BJSAcademy that on December 1st tweeted a new Surgical Science Post titled “Creeping fat” by Alison Kim and Lilias H. Maguire:
The paper can be read here ://bjsacademy.com/creeping-fat
On the same day @BJSOpen shared a paper on the impact of renal failure on emergency general surgery outcomes:
The paper can be read here https://doi.org/10.1093/bjsopen/zrac130
And also on December 1st, @BJSurgery tweeted an #openacces paper published in the December 2022 issue on the impact of tranexamic acid on surgical bleeding during general surgery procedures:
The paper can be read here https://doi.org/10.1093/bjs/znac252
“Textbook outcomes” is a hot topic and both @BJSurgery and @BJSOpen tweeted about it on December 4th. @BJSurgery shared an #openaccess paper titled “A call for patient-centred textbook outcomes for emergency surgery and trauma”:
The article can be read here https://doi.org/10.1093/bjs/znac271
@BJSOpen tweeted the following poll: “What outcomes would/should feature in a “textbook” outcomes for #HPB #surgery? Survival was the most voted option:
The Essay Competition “The day I decided surgery was for me” deadline closed on December 31st and @BJSAcademy did not miss the chance of reminding us on Twitter on December 5th:
On December 8th @BJSOpen shared a systematic review including 30 papers on #HPBSurgery textbook outcomes:
The paper can be read here https://doi.org/10.1093/bjsopen/zrac149
@BJSAcademy tweeted another #Bookshelf review. On this occasion, “One more ride on the merry-go-round” is reviewed by Gianluca Pellino:
The post can be read here https://www.bjsacademy.com/bjs-bookshelf-one-more-ride-on-the-merry-go-round
What are the minimum standards of pelvic exanterative procedures? @BJSurgery tweeted about it the Pelvex Collaborative Guideline on December 12th:
The article can be seen here https://doi.org/10.1093/bjs/znac317
In December, a new author video was posted on the BJS YouTube Channel. @BJSurgery tweeted it on Dec 12th: CONFERD-HP: recommendations for reporting COmpeteNcy FramEwoRk Development:
The paper can be read here https://doi.org/10.1093/bjs/znac394
From December 17th to December 19th, @BJSAcademy announced the #MyNightonCall series winning submissions:
In third place, “My night on call…surgery saves lives” by @SaraSaeidi92:
The post can be read here https://www.bjsacademy.com/my-night-on-call-surgery-saves-lives
In second place, “My night on call…fight or flight” by @MoAbouelazayem:
The post can be read here https://www.bjsacademy.com/my-night-on-call-fight-or-flight
In first place, “A night on call…that changed my lift” by @Becsjlittle:
The post can be read here https://www.bjsacademy.com/a-night-on-call-that-changed-my-life
There is an opportunity for prevention of early-onset colorectal cancer. @BJSurgery tweeted about it on December 19th:
The paper can be accessed here https://doi.org/10.1093/bjs/znac322
On December 21st, @BJSurgery announced with a tweet that the journal will be online only starting January 2023. Things have greatly changed since the publication of the first issue in 1913:
A high-impact tweet “Surgical knives: the scalper” was posted by @BJSurgery on December 24th:
The paper can be read here https://doi.org/10.1093/bjs/znac344
On December 28th, @BJSurgery tweeted an #openaccess paper titled “ Prognostic role of preoperative circulating systemic inflammatory response markers in primary breast cancer: meta-analysis”:
The article can be read here https://doi.org/10.1093/bjs/znac319
And the last tweet of 2022 was shared by @BJSurgery on December 30th: Ultrasound-assisted carbon nanoparticle suspension mapping vs dual tracer-guided sentinel lymph node biopsy:
The article can be accessed here https://doi.org/10.1093/bjs/znac311
9 January 2023
NIHR Global Research Health Unit on Global Surgery.
Lancet 2022; 400: 1767-1776.
In this study that included over 13,000 procedures, this simple change reduced the rate of surgical site infection from 18.9 to 16 per cent, P=0.0032.
Comment: I really like studies that appear simple and generalisable. Hospitals around the world with the highest infection rates stand to see the biggest differences.
27 December 2022
Tandon S, Ensor ND, Pacilli M, Laird AJ, Bortagaray JI, Stunden RJ et al.
Br J Surg 2022; 109: 1087-1095.
After six weeks, cosmetic scores were best with sutures and worst with glue (P=0.014), but the differences were no longer apparent in this study that included 295 children (333 surgical wounds).
Comment: No strong conclusion about which method should be used.
27 December 2022
Sevinç B, Damburaci N, Karahan O.
Dis Colon Rectum 2022; 65:735-741.
Two hundred patients had their pilonidal sinus curetted and then treated with either plasma gel or phenol crystals. Healing was more likely after a single application of plasma – 96 versus 53 per cent; it was also quicker (6 versus 10 days, P<0.001) and recurrence after one year was lower (4 versus 12 per cent).
Comment: Extraordinary result that needs confirmation to ensure it is generalisable.
21 December 2022
November 2022 was a special month for the BJS community.
The BJS Society Council winter meeting was again held in London on November 1t6th. It was a fantastic opportunity to meet the new Council members and to learn how the editorial teams are reimagining the future of surgical publishing. In addition, the BJS Society International Award nomination deadline was November 30th.
On social media, we would like to highlight the following tweets and post:
On November 1st, Rebecca Grossman @rebgross tweeted a short report published in @BJSurgery: “Paediatric #appendicitis: international study of management in the #COVID-19 pandemic”. The tweet is here:
The paper can be read here https://doi.org/10.1093/bjs/znac239
Almost simultaneously, @BJSAcademy announced that the final part of “How to write a clinical paper” titled “Completion and submission” by @des_winter, @BJSurgery Editor-in-Chief, is available as a free video. The tweet can be seen here:
The link to the video is here https://www.bjsacademy.com/how-to-write-a-clinical-paper-part-4-of-4
On the same day, Irene Bello @Dra_Belloirene commented a @BJSurgery tweet sharing a leading article on frailty and surgery. Dr. Bello stated that “Frailty shouldn’t be a contraindication for cancer surgery, it should be an indication to increase ERAS protocol”. The tweet can be seen here:
The @BJSurgery leading article can be read here https://doi.org/10.1093/bjs/znac294
One day after, an open access article on postoperative delirium after elective orthopedic surgery was tweeted by @BJSurgery. The tweet can be seen here:
The article can be read here https://doi.org/10.1093/bjs/znac197
An educational platform needs a bookshelf, and the @BJSAcademy has got a big one. @GianlucaPellino reviewed “War doctor. Surgery on the front line” and it was tweeted on November 3rd. The tweet can be seen here:
The review can be read on @BJSAcademy here https://www.bjsacademy.com/bjs-bookshelf-war-doctor-surgery-on-the-front-line
In addition to a bookshelf, @BJSAcademy proudly runs a Surgical Science blog. On November 7th, the link to a post by @gmboland and @dedeilia on personalized neoadjuvant immunotherapy for stage III malignant melanoma was tweeted. The tweet is here:
The post can be read here https://www.bjsacademy.com/personalized-neoadjuvant-immunotherapy-for-stage-iii-malignant-melanoma-notes-on-the-prado-study
Innovation is using knowledge to generate value. Is robotic cholecystectomy an IDEAL surgical innovation? A systematic review was tweeted by @BJSOpen on November 7th. The tweet is here:
The manuscript can be read here https://doi.org/10.1093/bjsopen/zrac116
On November 12th @BJSurgery tweeted the link to an open access article from Sweden: major surgical postoperative complications and survival after breast surgery. The tweet is here:
The article can be read here https://doi.org/10.1093/bjs/znac275
Shall we continue stenting left-sided obstructed colon cancer? On November 22nd, @BJSurgery shared the link to the paper reporting the results of the CREST randomized trial. The tweet is here:
The article can be accessed here https://doi.org/10.1093/bjs/znac141
On November 23rd, Ernesto Sparrelid @Sparrelid tweeted their comprehensive review on posthepatectomy liver failure published in @BJSOpen. Tweet:
Read the paper here https://doi.org/10.1093/bjsopen/zrac142
Nov 28th @BjsOpen: High hospital volume is associated with improved outcomes in locally advanced colon cancer. Should complex procedures be centralized? You can see the tweet here:
The article reporting the results of a nationwide analysis can be read here https://academic.oup.com/bjsopen/article/6/6/zrac140/6843377?login=false
Nov 29th @BjsOpen: How to recruit patients for RCT in the emergency setting? patients’ and clinicians’ perspective:
Results of the #LaCeS trial at https://t.co/lA3P6PnmSf
On Nov 30th @BJSOpen tweeted a systematic review that answers a relevant question for HPB surgeons: How to maximise functional liver remnant ahead of #hepatectomy – Portal vein or dual vein embolisation? The tweet can be seen here:
The article is available here https://doi.org/10.1093/bjsopen/zrac131
On the same day, a short video reporting the results of a meta-analysis clinical and oncological outcomes after laparoscopic vs open colectomy for locally advanced T4 colonic cancer was posted on the BJS YouTube channel. You can see the video here:
The article was published in March 2022 and it can be read here https://doi.org/10.1093/bjs/znab464
On the last day of November 2022 we were reminded by Giovanni Marchegiani @Gio_Marchegiani that an era is coming to an end. No more paper copies of @BJSurgery. The tweet and the results of the Twitter poll can be seen here:
13 December 2022
Moncrieff MD, Bastiaannet E, Underwood B, Francken AB, Garioch J, Damude S et al.
Ann Surg 2022; 276: e208-e216.
Some 388 patients were enrolled into a study comparing standard follow-up with a reduced frequency schedule. There was no difference in recurrence rates between the groups. Three quarters of patients in both groups found their recurrence by self-examination.
Comment: Routine follow-up may not help patients with melanoma; perhaps an approach teaching them self-examination would be better.
17 November 2022
Livingstone E, Zimmer L, Hassel JC, Fluck M, Eigentler TK, Loquai C et al, on behalf of the Dermatologic Cooperative Oncology Group.
Lancet 2022; 10358: 1117-1129.
Some 175 patients were randomized into one of three treatment arms. After a median of 49.2 months, recurrence-free survival was 64.2 per cent after the combination of nivolumab and ipilimumab, 31.4 per cent after nivolumab alone and 15 per cent after placebo; P<0.0001. Combination treatment also improved overall survival.
Comment; Combination treatment should be standard in this group.
17 November 2022
On October 3rd, the link to the article “Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial” was tweeted by @BJSurgery. The tweet can be seen here:
The paper can be read here (open access) https://doi.org/10.1093/bjs/znac225
Some interesting debate followed the new #SurgicalPoll tweeted by Rebecca Grossman @rebgross on October 3rd: To pack or not to pack abscess cavities? That was the question after the publication of the PPAC2 randomized clinical trial in @BJSurgery. And the winner was…
The tweet can be seen here:
The paper can read here (open access) https://doi.org/10.1093/bjs/znac225
On October 12th, the nomination window for the BJS Society Award opened:
It has been considered the biggest prize in the modern history of surgery. Whom would you nominate? The nomination window closes on November 30th!
On Oct 16th, @BJOpen posted a poll on Twitter: Do you listen to music when operating? We would like to hear your opinion. The tweed and the results can be seen here:
On October 21st, New ASMBS/IFSO Guidelines – 2022 were published, expanding patient eligibility for weight-loss surgery.
The BJS Society and its strategic partners shared the sad news of the passing of Kees Dejong on Oct 21st. The tweet by the Sociedad Española de Investigaciones Quirúrgicas be seen here:
@ProfW_edinsurg tweet can be seen here:
Are eight weeks enough? On Oct 24th @BJSOpen shared the link to an open-access paper reporting a single-center randomized clinical trial of surgery for T3/4 N+ #rectalcancer before or after eight weeks of chemoradiotherapy. Are you interested in the results? The tweet can be seen here:
The manuscript can be read here https://doi.org/10.1093/bjsopen/zrac107.
It seems that #bariatricsurgery may decrease the risk of non-hormonal cancer, as was posted on @BJSurgery on October 26th:
The paper can be seen here https://academic.oup.com/bjs/advance-article-abstract/doi/10.1093/bjs/znac343/6763294?redirectedFrom=fulltext&login=false
Why and when did you decide surgery was for you? @JJEarnshaw tweeted about the new @BJSAcademy “Medical Student and Young Trainee essay writing competition” and the outstanding piece by @Dami_Jesuyajolu on Oct 27th The tweet can be seen here:
The post can be read here https://www.bjsacademy.com/the-day-i-decided-surgery-was-for-me-a-new-arm
Managing colorectal anastomotic leaks is quite a challenge. The link to an expert consensus paper on endoluminal vacuum therapy for colorectal anastomotic leaks was shared by @BJSOpen on Oct 27th. The tweet can be seen here:
The paper can be read here (open access) https://doi.org/10.1093/bjsopen/zrac123
“Be a doctor, as well as a surgeon,” Michael G. Sarr, a world-renowned surgical leader, wrote in his “Surgical Life” post on @BJSAcademy. It was tweeted on Oct 31st. The tweet is here:
The post can be read here https://www.bjsacademy.com/a-surgical-life-by-michael-g-sarr
14 November 2022
https://doi.org/10.58974/bjss/azbc017
Background
While significant changes have occurred in the management of microscopic stage III disease due to the data from MSLT-21, the current standard of care for macroscopic stage III nodal malignant melanoma consists of initial surgical treatment with therapeutic lymph node dissection (TLND), followed by consideration for adjuvant therapy consisting of either anti-PD-1 monotherapy2 or BRAF/MEK inhibitors3. This results in improved relapse-free survival, but recurrence is still observed in almost half of the patients within 3-5 years4-6. Preclinical trials7-9 and emerging clinical data10 suggest that neoadjuvant immune checkpoint inhibition may have clinical benefit over adjuvant approaches. Given increasing enthusiasm for adjuvant and neoadjuvant approaches, the OpACIN (NCT02437279, phase I) and OpACIN-neo (NCT02977052, phase II) studies were established to investigate the safety and efficacy of neoadjuvant treatment with immune checkpoint inhibitors (ICI) combination, and to establish optimal dosing regimens to maximize clinical benefit while minimizing toxicity in patients with stage III melanoma.
The OpACIN and OpACIN-neo trials
The OpACIN study, a two-arm phase Ib trial, evaluated the efficacy of the combination of ipilimumab (anti-cytotoxic T-cell lymphocyte antibody – anti-CTLA) and nivolumab (anti-programmed cell death protein 1 – anti-PD-1) in an adjuvant or split neoadjuvant-adjuvant fashion for a limited number of patients (10 patients in each arm). Primary data from that study in 201811 demonstrated the remarkable efficacy of the neoadjuvant-adjuvant combinations, with a pathological response rate (pRR) of 78% after neoadjuvant therapy. However, toxicity was a significant concern, as grade 3 and 4 adverse events related to the immunotherapy affected 90% of the participants. For comparison, the pRR and adverse events (AE) in the adjuvant arm of the study were 60% and 70%, respectively. These results are comparable with the results of other trials12.
The subsequent phase II OpACIN-neo trial further investigated the safety and efficacy of neoadjuvant combinations of ipilimumab and nivolumab for stage III melanoma at varying doses. The randomized multicenter study comprised three arms with different neoadjuvant combination doses (Arm A: 2 courses of ipilimumab 3mg/kg and nivolumab of 1mg/kg; Arm B: 2 courses of ipilimumab 1mg/kg and nivolumab 3mg/kg; Arm C: 2 courses of ipilimumab 3mg/kg followed by 2 courses of nivolumab 3mg/kg). The 86 patients enrolled in the study were randomized in a 1:1:1 fashion, with almost 30 patients per arm (A:30, B:29, C:24). At a follow-up of 24 months, the AE related to the immunotherapy course and pRR were: Arm A: 40% irAE and 80% pRR, Arm B: 20% irAE and 77% pRR, and Arm C: 50% irAE and 65% pRR. Based on this the Arm B, often termed flip-dose Ipi/Nivo (IPI 1mg/kg, NIVO 3mg/kg), was identified as the optimal dosing regimen since it demonstrated the lowest toxicity (20%) with an equivalent pathological response rate (77%).
The MeMaLoc substudy
Within the OpACIN-neo study, 12 patients were enrolled in the MeMaLoc pilot trial (Magnetic Seed Localization for Melanoma, NL58293.031.16), a substudy examining whether the pathological response of the index lymph node (ILN) to treatment could accurately predict the response of the total lymph node basin. A magnetic seed was placed in the ILN in a similar fashion to breast surgery13, and the data demonstrated 100% concordance between the magnetically marked and resected ILN with the entire basin after neoadjuvant therapy (12/12 cases)14. This proved that the localization and resection of the index node is safe, feasible, and reliable, thus paving the way for patients with a complete response potentially to avoid a TLND in the future.
The PRADO extension cohort of OpACIN-neo
The extension cohort of the OpACIN-neo trial called PRADO constitutes a multicenter cohort study that assessed the effect of personalized surgical and adjuvant treatment based on the response of patients with stage III melanoma to the neoadjuvant therapy after 2 cycles of “flip-dose Ipi/Nivo”, i.e. ipilimumab 1mg/kg and nivolumab 3mg/kg (the most successful arm of the OpACIN-neo trial). The response to the neoadjuvant immune checkpoint inhibitor (ICI) combination was measured through ILN assessment with the use of a magnetic seed (52%) (in the fashion of the MeMaLoc study), a nitinol marker (34%), a radioactive I125 seed (9%), or a hydrogel marker (4%).
If the ILN had a major pathological response (MPR), i.e. a complete response (CR) or near CR (nCR), with <10% viable tumour cells remaining, TLDN was omitted along with any further adjuvant immunotherapy or radiotherapy. If the ILN showed a pathological partial response (PR), with 10-50% of viable tumour cells left, then TLDN followed the neoadjuvant therapy, but no further adjuvant immune or radiotherapy was offered. Lastly, in the case of non-response (NR, >50% viable tumour cells left in the ILN), TLDN took place, followed by standard-of-care adjuvant therapy consisting of either nivolumab (for BRAF wild-type tumours) or the BRAF/MEK inhibitors dabrafenib and trametinib (for BRAFV600E/K-mutated tumours), along with the possible addition of local radiotherapy.
A total of 99 patients who met the RECIST 1.115 criteria were enrolled. After 6 weeks of neoadjuvant therapy, 62% achieved MPR (49% CR, 12% nCR) and thus avoided TLND, 11% achieved PR and thus underwent only TLND, and 21% had NR and underwent TLND. Of the 21 patients with NR who underwent TLDN, only 17 followed with adjuvant therapy ( 7 of them with nivolumab and 10 with a combination of the BRAF/MEK inhibitors). Furthermore, 8 out of 17 patients received additional local radiotherapy.
The first outcome of the study was the evaluation of the morbidity of TLND. Avoiding TLDN resulted in a significant reduction of morbidity as there was a significantly lower rate of surgery-related adverse events (based on the CTCAE v4 criteria) in patients who underwent ILN resection alone compared to those with ILN and TLND (46% versus 84%, p<0.001). There was the same trend shown with the Clavien-Dindo classification (52% vs 93%, p<0.001). Similarly, the HRQoL rates were significantly increased in the group that omitted the TLND.
The next outcomes of the study were the overall survival (OS), relapse-free survival (RFS), and distant-metastasis-free survival (DMFS) rates of the participants. At a 24-month endpoint, the combined OS for patients was 95%, with RFS rates for the patients with MPR being 93%, PR of 64%, and NR of 71% respectively, with similar DMFS rates observed (MPR: 98%, PR: 64%, and NR: 64%). It was unexpected that the RFS rates for those with a PR was similar to that with neoaduvant pathological NR. However the PR patients had a TLND, but did not (per study protocol) receive adjuvant therapy.
In conclusion, the PRADO study, based on the promising outcomes of the OpACIN and OpACIN-neo, and using the pioneering tools from the MeMaLoc study, made some interesting observations, which can be summarized as follows:
While the encouraging outcomes of those with a major pathological response with focused nodal surgery support consideration for less invasive approaches to surgery after neoadjuvant therapy, the integration of surgery and neoadjuvant/adjuvant choices should be considered thoughtfully. The disappointing outcomes of the PR group who received TLND but did not have additional adjuvant therapy suggests that de-escalation of surgery without adjuvant therapy may be a less optimal approach, since their outcomes paralleled that of the pathological NR group. Future efforts at patient-specific therapy decisions should consider adjuvant therapy for both PR and NR groups. However, this does not dampen the importance of this study in validating the importance of a major pathological response as an opportunity to de-escalate surgery.
Overall, neoadjuvant therapy, ILN assessment and consequent response-directed treatment are significant added tools that could potentially be added to the oncological treatment of stage III melanoma and achieve even better outcomes. Further clinical trials are needed to examine this in more detail, expanding and further illuminating this thought-provoking and noteworthy topic.
7 November 2022
Krige A, Brearley SG, Mateus C, Carlson GL, Lane S.
BJS Open 2022; 6: zrac055.
Pain scores were improved after epidural analgesia for the first 24h (pain score 33 versus 50.5; P=0.018) in this study that included 131 procedures. After 72h, pain control was better with a rectus sheath catheter (4.5 versus 12.5; P=0.019), which was also more cost effective.
Comment: Perhaps the compromise is opiate analgesia to supplement the rectus sheath catheter.
18 October 2022
Fortelny RH, Adrade D, Schirren M, Baumann P, Riedl S, Reisensohn C et al.
Br J Surg 2022; 109: 839–845.
This study included 425 patients who had a midline laparotomy. After one year, the rate of ultrasound-detected incisional hernia was lower after short stitch (5 to 8mm bites every 5mm) than long stitch repair (10mm bites every 10mm): 3.3 versus 6.4 per cent, P=0.173.
Comment: The risk of incisional hernia was low with both methods.
18 October 2022
In September 2022, the first @BJSurgery tweet shared the link to the paper reporting the results of the international EUBREAST survey. The tweet can be seen here:
The article can be read here https://doi.org/10.1093/bjs/znac217
On September 5th, the paper titled “Surgical services during the war in Ukraine” was tweeted by @BJSurgery. This article is free to access. The tweet can be seen here:
The article can be read here https://doi.org/10.1093/bjs/znac168
@BJSurgery tweeted the leading article “Tranexamic acid for safer surgery: the time is now” on September 6th. The tweet can be seen here:
The paper can be read here: https://t.co/jbDyzmlqkh
On September 12th a new meta-analysis on non-operative management of appendicitis was tweeted by @BJSOpen. This was a very popular tweet, which had had 32 likes and 18 retweets by October 9th. You can see the tweet and a video-abstract here:
The paper can be read here: https://t.co/XnLhHaltAr
On September 15th, the BJS Society announced the BJS Society Award for an exceptional surgeon who has made contributions that have changed surgical practice. This international award may very well become the new Surgical Nobel Prize. Nominations will open on October 12th.
Surgeons look for more tailored treatments in their daily clinical practice. On September 16th, @BJSurgery tweeted an article on tailored treatment for gallstone disease. You can see the tweet here:
You can also read the paper https://academic.oup.com/bjs/article-abstract/109/9/832/6595861?redirectedFrom=fulltext&login=false
The @NEJM has launched an explanatory video on early fluid resuscitation for acute pancreatitis:
On September 17th, @BjsOpen shared a very interesting study looking at use of PET-CT in regional lymph node assessment in colorectal cancer. The tweet is here:
The paper can be read here: https://t.co/1WfCQQXrcm
A few days later, on September 24th, the never-ending discussion about lymph nodes continued with @BJSurgery tweeting the article “Lateral local recurrence after total mesorectal excision for mid/low rectal cancer.” The tweet is here:
The paper can be read at the following link: https://academic.oup.com/bjs/article/109/10/904/6591908?login=false
It is always a hot topic: stoma or not stoma after rectal resections? @BJSurgery shared an interesting study titled “Transanal tube versus defunctioning stoma after low anterior resection for rectal cancer: network meta-analysis of RCTs” The tweet can be seen here:
The paper can be read here: https://academic.oup.com/bjs/article/109/10/900/6594873?login=false
The PelvEx collaborative guidelines have been published in @BJSurgery. The tweet can be seen here:
The manuscript can be read here: https://academic.oup.com/bjs/advance-article/doi/10.1093/bjs/znac317/6726465?searchresult=1&login=false
The Spanish Society of Surgical Research @SEIQuirurgica, strategic partner of the BJS Society, held its 26th Congress in Gijon in late September. It began with an interesting session on Research and Surgery:
The @BJSurgery lecture of the 26th Congress of Sociedad Española de Investigaciones Quirúrgicas was introduced by @ProfDemartines and given by doctor Marja Boermeester @safesurg as part of the @BJSurgery session in Gijón on September 30th:
11 October 2022
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:
The paper can be read here https://doi.org/10.1093/bjs/znac134
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:
The paper can be read here https://academic.oup.com/bjs/article-abstract/109/8/695/6594468?redirectedFrom=fulltext&login=false
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:
The paper can be read here (open access): https://doi.org/10.1093/bjs/znac274
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:
Part I video can be accessed here https://www.bjsacademy.com/how-to-write-a-paper-part-1
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 paper can be read here (open access): https://doi.org/10.1093/bjsopen/zrac071
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:
The paper can be read here (open access) https://doi.org/10.1093/bjs/znac114
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:
The post can be read here https://www.bjsacademy.com/a-surgical-life-by-takeshi-sano-md-phd
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:
The paper can be read here https://www.surgjournal.com/article/S0039-6060(22)00251-3/fulltext#%20
How do multidisciplinary tumor boards (MDTs) work? They are frequently challenged by administrative and process issues, as reported in a paper published in @BJSOpen. The tweet is here:
The paper can be read here (open access) https://doi.org/10.1093/bjsopen/zrac093
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:
The paper can be read here: https://doi.org/10.1093/bjs/znac123
13 September 2022
Lastunen KS, Leppäniemi AS, Mentula PJ.
Br J Surg 2022; 109: 588-594.
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.
6 September 2022
Part of the charitable activity of the Society, BJS Academy is an online educational resource for current and future surgeons.
The Academy is comprised of five distinct sections: Continuing surgical education, Young BJS, Cutting edge, Scientific surgery and Surgical news. Although the majority of this is open access, additional content is available to BJS subscribers and strategic partners.
As a registered charity, BJS Society’s mission to improve surgical education is underpinned by its strategic partnerships and its leading surgical journals.
Since its inception in 1913, the readership of BJS has continued to grow across the globe, paving the way for complementary open access journal, BJS Open, in 2017.
