Active surveillance of patients who have sentinel node positive melanoma: An international, multi-institution evaluation of adoption and early outcomes after the Multicenter Selective Lymphadenectomy Trial II (MSLT-2).

Background: For patients with sentinel lymph node (SLN)-positive cutaneous melanoma, the Second Multicenter Selective Lymphadenectomy trial demonstrated equivalent disease-specific survival (DSS) with active surveillance using nodal ultrasound versus completion lymph node dissection (CLND). Adoption and outcomes of active surveillance in clinical practice and in adjuvant therapy recipients are unknown.

Methods: In a retrospective cohort of SLN-positive adults treated at 21 institutions in Australia, Europe, and the United States from June 2017 to November 2019, the authors evaluated the impact of active surveillance and adjuvant therapy on all-site recurrence-free survival (RFS), isolated nodal RFS, distant metastasis-free survival (DMFS), and DSS using Kaplan-Meier curves and Cox proportional hazard models.

Intraoperative Localization Using an Implanted Radar Reflector Facilitates Resection of Non-Palpable Trunk and Extremity Sarcoma.

Background: Resecting non-palpable soft tissue tumors presents a unique challenge, particularly with recurrent disease in which surrounding tissue has been surgically manipulated and often irradiated. SAVI SCOUT is a radar-based localization device that was developed for breast tumor localization and was recently FDA-approved for localization of soft tissue tumors. Application of this technology to soft tissue sarcoma has not been previously reported.

Utility of Taking Additional Margins When Performing Breast-Conserving Surgery with Intraoperative Radiation Therapy for Early Breast Cancer.

Introduction: Intraoperative radiation therapy (IORT) is an alternative to external beam radiation therapy (EBRT) after lumpectomy, in which radiation is delivered before the final margin analysis. Practices vary regarding excision of close or positive margins pre- and post-IORT.

Materials And Methods: In a retrospective cohort of women with hormone receptor-positive, clinically node-negative breast cancer undergoing lumpectomy with IORT and selective EBRT at our institution from 2011 to 2015, we compared the impact of pre- and post-IORT margin excisions on in-breast tumor recurrence.

Update on BRAF and MEK inhibition for treatment of melanoma in metastatic, unresectable, and adjuvant settings.

Introduction: Selective inhibition of the MAPK pathway with BRAF and MEK inhibitors has emerged as a key component of the treatment of BRAF-mutant unresectable/locally advanced metastatic melanoma.

Areas Covered: Current data are presented on the efficacy and safety of BRAFi + MEKi combination therapy (dabrafenib/trametinib, vemurafenib/cobimetinib, and encorafenib/binimetinib) from phase I, II, and III trials in the unresectable/locally advanced metastatic setting, as well as neoadjuvant and adjuvant applications. The theoretical basis, pre-clinical findings, clinical trial results and current ongoing clinical studies of combined BRAF/MEK inhibition with immunotherapy, also known as 'triplet therapy,' are also explored.

Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections.

Importance: Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients' electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice.

Objective: To determine how wound photography affects surgeons' abilities to diagnose SSIs in a pragmatic setting.

Surgical Transfer Decision Making: How Regional Resources are Allocated in a Regional Transfer Network.

Background: Tertiary care centers often operate above capacity, limiting access to emergency surgical care for patients at nontertiary facilities. For nontraumatic surgical emergencies there are no guidelines to inform patient selection for transfer to another facility. Such decisions may be particularly difficult for gravely ill patients when the benefits of transfer are uncertain.

Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial.

Background: Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term.

Methods: We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging.

Identifying Futile Interfacility Surgical Transfers.

Surgeons perceive that some surgical transfers are futile, but the incidence and risk factors of futile transfer are not quantified. Identifying futile interfacility transfers could save cost and undue burdens to patients and families. We sought to describe the incidence and factors associated with futile transfers.

Implementation of telehealth is associated with improved timeliness to kidney transplant waitlist evaluation.

Introduction The United States Department of Veterans Affairs (VA) National Transplant Program has made efforts to improve access by introducing Web-based referrals and telehealth. The aims of this study were to describe the programmatic implementation and evaluate the effectiveness of new technology on the timeliness to kidney transplant evaluation at a VA medical centre. Methods Between 1 January 2009 and 31 May 2016, 835 patients were approved for evaluation.

Interhospital transfer for acute surgical care: does delay matter?

Background: Delays to definitive care are associated with poor outcomes after trauma and medical emergencies. It is unknown whether inter-hospital transfer delays affect outcomes for nontraumatic acute surgical conditions.

Methods: We performed a retrospective cohort study of patient transfers for acute surgical conditions within a regional transfer network from 2009 to 2013.

Hidden Morbidity of Ventral Hernia Repair with Mesh: As Concerning as Common Bile Duct Injury?

Background: Ventral hernia repair with mesh is increasingly common, but the incidence of long-term complications that necessitate mesh explantation is unknown. We aimed to determine the epidemiology of mesh explantation after ventral hernia repair and to compare this with common bile duct injury, a dreaded complication of laparoscopic cholecystectomy.

Study Design: We evaluated a retrospective cohort of patients undergoing ventral hernia repair by linking the all-payers State Inpatient Databases and State Ambulatory Surgery Databases for New York, California, and Florida.

Unnecessary Transfers for Acute Surgical Care: Who and Why?

Interhospital transfers for acute surgical care occur commonly, but without clear guidelines or protocols. Transfers may subject patients and delivery systems to significant burdens without clear clinical benefit. The incidence and factors associated with unnecessary transfers are not well described.

Implementation of a Telephone Postoperative Clinic in an Integrated Health System.

Background: Earlier work suggested that telephone follow-up could be used in lieu of in-person follow-up after surgery, saving patients time and travel and maximizing use of scarce surgeon and facility resources. We report our experience implementing and evaluating telephone postoperative follow-up within an integrated health system.

Study Design: We conducted a pre-post evaluation of a general surgery telephone postoperative clinic at a tertiary care Veterans Affairs facility from April 2015 to February 2016.

Identification of postoperative care amenable to telehealth.

Background: Postoperative follow-up using telehealth may increase patient access and decrease resource use. We aimed to define patient and operative criteria likely to be associated with successful telehealth follow-up (telehealth-amenable).

Methods: We assembled a retrospective cohort of veterans who underwent general operations between September 2012 and July 2013 to characterize telehealth-amenable postoperative follow-up, excluding patients with sensitive operative sites (breast, anus) and postoperative inpatient complications.

Characterizing the Clamor: An In-Depth Analysis of Inpatient Paging Communication.

Purpose: Communication failures contribute to adverse clinical events and health care inefficiencies. Paged messaging remains a predominant communication mechanism at many academic medical centers. An interprofessional, institutionally sponsored initiative to improve inpatient care team communication sought to understand the content and quantity of paged messages.

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery.

Background: Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency.

Insurance status influences emergent designation in surgical transfers.

Background: There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs.