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.

Journal of the American College of SurgeonsPair of JACS

Peer Review, in Review: Examining the Need for Improved Peer Review Process

Richmond BK, Welsh D. Education, Ethics and History: The Peer Review Process in the US. J Am Coll Surg. May 29, 2021 [Epub ahead of print].

Richmond and Welsh noted that peer review is regarded as an essential component of hospital quality improvement and is required for hospital accreditation by The Joint Commission. Although early work by Ernest Codman, MD, FACS, and the ACS emphasized recording of surgical outcomes and peer review based on accurate data as a means of quality improvement, universal adherence to these principles has not occurred.

Available data suggest that the current peer review process (PRP) is inconsistent, lacks standardization and is vulnerable to bias and abuse. Data cited by the authors show that malicious use of PRP occurs in at least 10 percent of peer review events. Factors contributing to a flawed PRP include inadequate resource allocation and bias. Too often, PRP is used to manage people rather than improve quality. Sham and malicious PRP events can lead to significant harm to surgeons and the institutions at which they work. Richmond and Welsh recommend renewed efforts to standardize PRP, educate peer reviewers and conduct PRP at the health system level for the purpose of quality improvement.

Can Mutant kRAS Be Detected Using Peritoneal Lavage in Patients with Pancreatic Ductal Adenocarcinoma?

Yonkus JA, Alva-Ruiz R, Abdelrahman AM, et al. Molecular Peritoneal Staging for Pancreatic Ductal Adenocarcinoma Using Mutant KRAS Droplet-Digital Polymerase Chain Reaction: Results of a Prospective Clinical Trial. J Am Coll Surg. May 20, 2021 [Epub ahead of print].

Peritoneal metastases are common in patients with pancreatic ductal adenocarcinoma (PDAC). Up to 33 percent of patients will develop peritoneal recurrence following curative pancreaticoduodenectomy. Most patients undergo pre-resection laparoscopy to detect peritoneal lesions that may not be detected on preoperative imaging studies. Accurate definition of patients at risk for peritoneal recurrence at the time of laparoscopy could improve staging and refine selection criteria for resection. Yonkus and coauthors noted that > 90 percent of PDAC harbor mutant kRAS; they conducted a prospective trial to determine feasibility of detecting kRAS mutant DNA using peritoneal lavage. kRAS DNA was detected in 70 patients who had clinically negative laparoscopy out of 136 patients enrolled in the trial. The authors concluded that detection of kRAS DNA using peritoneal lavage was feasible but additional long-term follow-up is necessary to determine whether detection of kRAS DNA will improve preoperative staging.

Other Article

Preparing to Manage the Difficult Airway to Prevent Complications

Heidegger T. Management of the Difficult Airway. N Engl J Med. 2021;384(19):1836-1847.

Available data suggest that complications of airway management occur in approximately one out of 5,500 elective surgery cases and that airway management complications are the most common causes of anesthesia-related deaths and permanent brain damage. Additional studies have suggested that significant airway management complications occur 35–55 times more often in the emergency department and intensive care units. Risk factors for difficult mask ventilation and difficult intubation include limited mouth opening, history of neck surgery or irradiation and presence of emesis or blood in the oropharynx; other risk factors are listed in a table included in the article.

The authors provide a clear algorithm for management of patients with anticipated difficult airway anatomy or problems with ventilation. Important steps include appropriate selection of patients for awake intubation and early selection of cricothyroidotomy for patients at high risk for inability to visualize the larynx for intubation or inability to ventilate with a mask. Additional guidance for management of extubation-associated complications is provided; surgeons are encouraged to review the full text of the article.