Offcial Publication

SURGERY
SOCIETY OF UNIVERSITY SURGEONS
CENTRAL SURGICAL ASSOCIATION
AMERICAN ASSOCIATION OF ENDOCRINE SURGEONS

COPYRIGHT © 2023 ELSEVIER INC.

CONTENTS July 2023 Volume 174 Number 1

EDITORS’ NOTE CARDIAC

1 Advances in Research
S.D. Wexner, MD, PhD, K.E. Behrns, MD
BEST IN SURGERY
2 Implementation of a new definition for acute kidney
injury in the National Surgical Quality Improvement
Project: What is the impact?
A. Loria, MD, A.D. Melucci, MD, MS, P.R. Burchard, MD,
A. Ghaffar, BA, E. Levatino, BSN, L.K. Temple, MD, MSc,
F.J. Fleming, MD, MPH
21 Textbook outcomes in heart transplantation: A quality
metric for the modern era
S.S. Bakhtiyar, MD, MBE, S. Sakowitz, MS, MPH, K. Ali,
T. Coaston, A. Verma, N.L. Chervu, MD, P. Benharash, MD
Achieving a textbook outcome after a heart
transplantation is associated with significantly better
patient and graft survival and demonstrates better inter-
hospital variation than the existing one-year survival
metric. This finding supports the use of textbook outcome
as a quality metric in comparing transplant programs at a
national level.

This interrupted time series analysis of two institutions

found that in the 12 months after the definition change for
acute kidney injury in the National Surgical Quality
Improvement Project, there was a 1,700% increase in the
rate, or 26 times increased weighted odds, of an acute
kidney injury despite otherwise stable outcomes
compared to the 12 months before the definition change.
This finding has implications for patient counseling and
risk stratification, research aiming to understand risk
factors of perioperative acute kidney injury, and
institutional quality reporting.
10 National Surgical Quality Improvement Project and
acute kidney injury: Getting with the times
A.C. Filiberto, MD, M. Cooper, MD, PhD
BILIARY
11 Prognostic impact of proximal ductal margin status in
perihilar cholangiocarcinoma according to the
presence or absence of lymph node metastasis
I. Hosokawa, MD, PhD, FACS, T. Takayashiki, MD, PhD,
S. Kuboki, MD, PhD, S. Takano, MD, PhD, K. Togasaki, MD,
M. Miyazaki, MD, PhD, M. Ohtsuka, MD, PhD
We evaluated the prognostic impact of proximal ductal
margin status in perihilar cholangiocarcinoma (PHC)
according to the presence or absence of lymph node
metastasis (LNM). Although proximal ductal margin
positivity worsened survival in LNM-negative PHC cases, it
did not affect the survival of LNM-positive PHC cases.
COLON/RECTUM/ANUS
30 The quality and content of hyperthermic
intraperitoneal chemotherapy information available to
patients: An evaluation of North American
hyperthermic intraperitoneal chemotherapy websites
S.L. Remer, BS, T.M. Connelly, MBBCh, PhD,
C. Clancy, MBBCh, R. DeBernardo, MD, D. Joyce, MBBCh,
S.R. Steele, MD, MBA, M.A. Valente, DO
This study used validated and novel scoring systems to
assess the quality and content of Web-based patient-
directed information regarding hyperthermic
intraperitoneal chemotherapy. The importance of these
findings is that they highlight the variability and often lack
of Web-based information regarding hyperthermic
intraperitoneal chemotherapy and demonstrate the
clinician's role to supplement this information for patients
and direct them to high-quality resources.
36 A socioecological qualitative analysis of barriers to care
in colorectal surgery
B.P. Smith, MD, I. Girling, BS, R.H. Hollis, MD, MSPH,
M. Rubyan, PhD, MPH, C. Shao, MD, MSPH, B. Jones, MD,
A. Abbas, MBBS, I. Herbey, MD, MPH, G.R. Oates, PhD,
M. Pisu, PhD, D.I. Chu, MD, MSPH
Major barriers and facilitators to surgical care exist at each
level of the socioecological model: individual (clear
communication, mental stress), interpersonal (provider
communication and trust, COVID-related visitation
restrictions), organizational (multiple forms of contact,
quality educational materials, scheduling systems,
discrimination), community (community and family
support and transportation), and policy (charity care,
patient advocacy organizations, insurance coverage).
Assessing and addressing these factors will be critical in
efforts to eliminate disparities in surgery.

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July 2023 A2 SURGERY

CONTENTS continued
46 Preoperative assessment of blood supply and its role in
predicting anastomotic leak
S.M. Khan, MBBS, C. Wells, MBChB, BMedSc (Hons),
N. Christou, MD, PhD, Docent (HDR), C.Y. Tan, MBBS,
P. Mathur, MBBS, MS, FRCS (Gen.surg),
A. El-Hussuna, MBChB, PhD
This is the first systematic review to collect evidence about
the impact of blood supply on anastomotic integrity as
assessed preoperatively. We found that it could impact the
integrity of the anastomosis.
ENDOCRINE
52 Thyroid surgery outcomes in octogenarians: A national
analysis
S. Sakowitz, MS, MPH, S.S. Bakhtiyar, MD, MBE,
B. Khoraminejad, S. Ebrahimian, MS, J. Madrigal, MD,
P. Benharash, MD, J. Wu, MD
Octogenarian patients undergoing thyroidectomy for
benign and malignant thyroid disease demonstrate greater
mortality, complications, resource use, and nonelective
readmission, relative to nonoctogenarians. This work is
important because it identifies increased perioperative
risk among this cohort and could influence shared
decision-making regarding surgical versus nonsurgical
treatments.
OUTCOMES
59 Acute clinical and financial outcomes of on- versus off-
pump coronary artery bypass grafting in octogenarians
S. Sakowitz, MS, MPH, S.S. Bakhtiyar, MD, MBE,
S. Sareh, MD, K. Ali, A. Verma, N. Chervu, MD,
Y. Sanaiha, MD, P. Benharash, MD
Octogenarian patients undergoing off-pump coronary
artery bypass grafting demonstrate an increased likelihood
of ventricular tachycardia and myocardial infarction but no
difference in mortality relative to those experiencing on-
pump procedures. The importance of this work is that it
underscores the safety of on-pump coronary artery bypass
grafting in octogenarians and suggests that the choice of
technique should stem from operator experience and
anatomic optimization.
66 Development and validation of a multivariable
preoperative prediction model for postoperative length
of stay in a broad inpatient surgical population
E.M. Mason, MSCS, W.G. Henderson, PhD, MPH,
M.R. Bronsert, PhD, MS, K.L. Colborn, PhD, MSPH,
A.R. Dyas, MD, A. Lambert-Kerzner, PhD, MSPH,
R.A. Meguid, MD, MPH, FACS
We aimed to determine whether the seven-variable
Surgical Risk Preoperative Assessment System model can
accurately predict the postoperative length of stay up to 30
days in a broad inpatient surgical population. The
parsimonious Surgical Risk Preoperative Assessment
System model can preoperatively predict the
postoperative length of stay almost as accurately as a
model using all 28 American College of Surgeons National
Surgical Quality Improvement Program preoperative
nonlaboratory variables and has shown acceptable
internal chronological validation.
SURGERY
PANCREAS
75 Long-term (10-year) outcomes and prognostic factors in
resected intraductal papillary mucinous neoplasm
tumors in Finland: A nationwide retrospective study
Y. Vaalavuo, MD, M. Vornanen, MD, R. Ahola, MD, PhD,
A. Antila, MD, PhD, I. Rinta-Kiikka, MD, PhD,
J. Sand, MD, PhD, J. Laukkarinen, MD, PhD
This is a retrospective nationwide cohort study of resected
intraductal papillary mucinous neoplasms with a 10-year
follow-up in Finland. The importance of this report is to
clarify the long-term prognosis and prognostic factors for
patients with resected intraductal papillary mucinous
neoplasm tumors.
83 An analysis of time to treatment in patients with
pancreatic adenocarcinoma
K. Sugumar, MD, S. Gendi, MD, H.A. Quereshy, MD, MBA,
S. Gupta, MD, J.J. Hue, MD, L.D. Rothermel, MD, MPH,
L.M. Ocuin, MD, J.B. Ammori, MD, J.M. Hardacre, MD,
J.M. Winter, MD
Patients with pancreatic adenocarcinoma take about a
month to seek medical attention after symptom onset and
another month to initiate treatment after they visit the
primary provider. Numerous factors are associated with
delay in time to treatment, which is an essential quality-
of-care metric in cancers, including pancreatic
adenocarcinoma.
91 Resection margin status at the portomesenteric axis
may not determine oncologic outcome after
pancreaticoduodenectomy for lymph node-positive
pancreatic ductal adenocarcinoma
S. Katou, MD, A.S. Wenning, MD PhD, P. Aeschbacher, MD,
H. Morgul, MD, F. Becker, MD, A. Pascher, MD, B. Gloor, MD,
B. Strücker, MD, A. Andreou, MD
In patients with pancreatic ductal adenocarcinoma and
lymph nodal positivity, R status at the portomesenteric
axis may not determine the oncological outcome. The
importance of this finding is that radical venous resection
for suspected tumor infiltration, and thereby the
additional morbidity and mortality risk may be avoided.
SPECIAL SERIES: LIVER-DIRECTED
THERAPY FOR COLORECTAL LIVER
METASTASES
100 Introduction: special focused issueeliver-directed
therapy for colorectal liver metastases
L.M. Ocuin, MD
101 Starting a successful hepatic artery infusion pump
program: A practical guide
H.G. McDonald, MD, R.A. Patel, MD, C.S. Ellis, PharmD,
S. Gholami, MD, M. Barry-Hundeyin, MD,
P.K. Pandalai, MD, J. Kim, MD, M.J. Cavnar, MD
Initiating a successful hepatic artery infusion pump
program requires extensive multidisciplinary
collaboration involving surgical oncology, medical
oncology, pharmacy, diagnostic and nuclear medicine
radiology, operating room staff, nursing, interventional
radiology, and gastroenterology. Mentorship for the
program’s surgical and medical oncology leadership is
important to achieve the best patient outcomes.
A3 July 2023
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106 Transplant for colorectal cancer liver metastases SPECIAL SERIES: DE-ESCALATION OF
J.N. Whitrock, MD, S.J. Hartman, MD, S.A. Shah, MD
BREAST SURGERY
Colorectal cancer with unresectable liver metastases is a
disease with poor prognosis with chemotherapy alone. 123 De-escalation of breast cancer surgery
The use of liver transplant as an alternative to S.L. Blair, MD
chemotherapy alone in select patients has demonstrated This is an introduction to the de-escalation in breast
improved outcomes in several studies, and further surgery special edition.
research is underway to evaluate the ideal populations to
receive liver transplants in the setting of unresectable
colorectal liver metastases. 125 Selective surgical excision of high-risk lesions
S. Warwar, MD, S. Kulkarni, MD

108 Ablative radiotherapy for colorectal liver metastases
and intrahepatic cholangiocarcinoma
J.P. Schiff, MD, A. D’Souza, BS, L.E. Henke, MD, MSCI
Advancements in image guidance and treatment planning
techniques have expanded the role of radiotherapy for the
treatment of colorectal liver metastases and intrahepatic
cholangiocarcinoma. Herein we review some of the
technological advances in radiation oncology that have
paved the way for these new indications as well as a brief
review of relevant data describing their use for the
management of colorectal liver metastases and
intrahepatic cholangiocarcinoma.
113 Surgery and hepatic artery infusion therapy for
intrahepatic cholangiocarcinoma
A. Scott, MD, P. Wong, BS, L.G. Melstrom, MD, MSCI
This article aims to highlight the complexities of the
management of cholangiocarcinomas with a focus on the
role of hepatic artery infusional therapy. Selection of
surgery, systemic therapy, and hepatic artery infusion are
discussed.
Many high-risk breast lesions have a <2% risk of malignant
upgrade and can be safely managed with radiographic and
clinical surveillance. Careful selection of appropriate
patients can reduce the need for routine surgical excision.
129 Shifting paradigms for the treatment of ductal
carcinoma in situ: Less is more
C.A.M. Sauder, MD, MEd, H. Abidi, MD, R.J. Bold, MD, MBA
Ductal carcinoma in situ is a heterogeneous disease in
which only 50% of cases progress to invasive carcinoma,
but unfortunately, all patients receive similar treatment.
This article looks at current de-escalation methods for
surgery, radiation, and endocrine therapy for patients
treated for ductal carcinoma in situ.
LETTERS TO THE EDITOR
131 Letter to the Editor: What is rationality in applying
adhesion barriers during Cesarean sections?
O.A. Mynbaev, MD, PhD, ScD, A. Tzabari, MD,
K.S. Idrissov, MD, PhD, M. Stark, MD

116 Optimizing the future liver remnant: Portal vein 131 Response letter to “Adhesion barriers and
embolization, hepatic venous deprivation, and intraperitoneal or uterine infections after cesarean
associating liver partition and portal vein ligation for section: A retrospective cohort study”
staged hepatectomy Y. Wada, MD, H. Takahashi, MD, PhD
R.I. Ayabe, MD, J.-N. Vauthey, MD, T.E. Newhook, MD
Preservation of an adequate future liver remnant is
paramount when planning any major liver resection and is
132 Response to the commentary for the article
“Conditional cumulative incidence of postoperative
of particular concern in the setting of bilateral colorectal
complications stratified by complexity classification for
liver metastases. In this report, we discuss procedures
laparoscopic liver resection: Optimization of in-
including portal vein embolization and hepatic venous
hospital observation”
deprivation for one- or two-stage hepatectomy and
A.D. Mazzotta, MD, Y. Kawaguchi, MD, PhD, MPH,
associating liver partition and portal vein ligation for
B. Gayet, MD, PhD, O. Soubrane, MD, PhD
staged hepatectomy (ALPPS) that have been developed to
enable curative-intent hepatectomy for colorectal liver
metastases (in patients with an initially insufficient future
liver remnant. READER SERVICES
A1 Information for readers
119 Surgery for colorectal liver metastases: Anatomic and A7 Information for authors
non-anatomic approach 29 Change of address
T. Rengers, BS, S. Warner, MD 122 Surgery is abstracted
As indications for surgery of colorectal liver metastasis
have expanded, preferred techniques and timing have
been debated. This commentary reviews the merits of
anatomic versus non-anatomic approaches to colorectal
liver metastases resection, considering oncologic
outcomes, overall survival, and conflicting theories in the
pathophysiology of metastatic liver spread.

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