American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

Pair of JACSJournal of the American College of Surgeons

TQIP Data Suggests Rate of Lower Extremity Limb Salvage Superior in Level 1 Trauma Centers Than Level 2 Centers

Bunn C, Kulshrestha S, DiChiaro B, et al. A Leg to Stand On: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury. J Am Coll Surg. April 19, 2021 [Epub ahead of print].

The authors used data from the ACS Trauma Quality Improvement (TQIP) database to determine whether rates of limb salvage for mangled extremity varied depending on type of trauma center designation (Level 1 versus Level 2). Data from the interval 20072017 were included. A standard definition (Gustilo classification) was used to define “mangled extremity.” A cohort of 712 patient records was analyzed and propensity score matching was used for comparison; patients were matched for age, comorbid conditions, injury severity, presence of associated venous and nerve injury and time from injury to arrival at the trauma center.

The data analysis showed that limb salvage rates were significantly higher in Level 1 trauma centers. Penetrating injuries and injuries involving the distal branches of the popliteal artery were more likely to be salvaged successfully. Of interest was the observation that the difference in outcomes began to emerge after 2014. The authors speculated that the increased limb salvage rates in Level 1 centers could be related to greater availability of surgeons experienced in microsurgical repair techniques.

Lung Transplant Patients Show Higher Rate of Adenomatous Lesions in Colonoscopy

Dameworth JL, Colburn L, Corrigan D, et al. Colorectal Cancer Prevention in Lung Transplant Recipients: The Need for an Enhanced Surveillance Protocol. J Am Coll Surg. 2021;232(5);717-725.

The risk for development of non-cutaneous neoplasms is increased in lung transplant patients. This report presented data from a single-institution retrospective analysis of data on 237 patients cared for over a four-year interval who had undergone pre-transplant colonoscopy. The main outcome of interest was rates of discovery of adenomatous lesions on post-transplant colonoscopy.

Adenomas were diagnosed in 39 percent of patients pre-transplant and in 50 percent of patients during the five-year post-transplant interval. Most lesions were located proximal to the splenic flexure. Risk of adenoma development was higher in patients who had an adenoma identified on pre-transplant colonoscopy. The authors concluded that the risk for adenoma in lung transplant patients was significantly higher compared with the rate of adenoma detection in non-transplant patients undergoing screening colonoscopy (25 percent). They suggested that enhanced surveillance protocols were indicated in this patient group. Additional studies would be helpful to determine whether risk is increased in other groups of transplant patients.

Other article

No Increased Risk of Renal Damage from Intravenous Contrast Exposure, Study Suggests

Goulden R, Rowe BH, Abrahamowicz M, Strumpf E, Tamblyn R. Association of Intravenous Radiocontrast With Kidney Function: A Regression Discontinuity Analysis. JAMA Intern Med. April 5, 2021 [Epub ahead of print].

Because of the long-standing belief that intravenous contrast is nephrotoxic, the authors evaluated risk of renal damage in emergency department patients aged 18 years and older who underwent D-dimer testing and computed tomography pulmonary angiographic evaluation over a five-year interval in a single Canadian province. Estimated glomerular filtration rate evaluated at the time of D-dimer testing and over a six-month interval following exposure to intravenous contrast was the outcome of interest. Other outcomes assessed included mortality and rates of renal replacement therapy. The study cohort consisted of 156,000 patients.

The data analysis showed that there was no association of contrast exposure with significant change in glomerular filtration rate, mortality or risk for renal replacement therapy. In an evaluation of patients felt to be at increased risk for renal damage, there was no evidence of harm from contrast exposure. The authors concluded that there was no increased risk of renal damage after exposure to intravenous contrast.