What’s new in Surgery for March features: Breast Cancer, Professionalism in Surgery, The Impaired Surgeon, Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care, Management of the Patient with Thermal Injuries, Injuries to the Spleen and Diaphragm

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Breast, Skin, and Soft Tissue

Lindi VanderWalde, MD, FACS, Breast Surgical Oncologist, Baptist Cancer Center, Baptist Memorial Health Care Corporation, Memphis, TN

Alyssa D. Throckmorton, MD, FACS, Breast Surgical Oncologist, Baptist Cancer Center, Baptist Memorial Health Care Corporation, Memphis, TN; Clinical Assistant Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN

Stephen B. Edge, MD, FACS, Director, Baptist Cancer Center, Baptist Memorial Health Care Corporation, Memphis, TN; Adjunct Professor, Department of Surgery, Vanderbilt Univer­sity School of Medicine, Nashville, TN.

 

Breast Cancer

Genomic profiling of cancers or evaluation of the expression of multiple genes allows for the stratification of women with hormone receptor-positive breast cancer by risk of distant disease. It also identifies some who get no benefit and, conversely, those who get a major benefit from adding chemotherapy to endocrine therapy. The most widely used genomic profiling system in breast cancer in 2015 is OncotypeDx. Those women with a low OncotypeDx recurrence score benefit from adjuvant endocrine therapy and get no further improvement from adding chemotherapy. Conversely those with a high recurrence score have a dramatic reduction in recurrence risk by adding chemotherapy.

 


Competency-Based Surgical Care

The Impaired Surgeon

Krista L. Kaups, MD, MSc, FACS, Professor of Clinical Surgery, UCSF Fresno, Department of Surgery

David B. Hoyt, MD, FACS, Executive Director, American College of Surgeons, Chicago, IL

 

An examination of physicians disciplined by medical boards revealed that nearly three-fourths of the actions were due to professionalism issues. In this case-control study, a strong association was shown with unprofessional behavior identified during medical school. Medical school behaviors that most strongly predicted subsequent disciplinary action were irresponsibility and “diminished capacity for self-improvement” (“failure to accept constructive criticism, argumentativeness, and display of a poor attitude”). Additionally, the likelihood of disciplinary action increased markedly with the documented frequency of the behaviors in medical school.

 


Scientific Foundations

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

Laura Stafman, MD, Resident, Department of Surgery, University of Alabama, Birmingham, AL

Sushanth Reddy, MD, FACS, Assistant Professor, Department of Surgery, University of Alabama, Birmingham, AL

 

Advance directives such as a living will, a do not resuscitate order, and a designation of a power of attorney for health care are legally binding mechanisms to preserve patient autonomy when patients have lost decision-making capacity. Although these directives are frequently used to make decisions regarding life-supporting therapy, surgeons may also need to refer to these documents or to patients’ surrogates for surgical decision making to treat patients in accordance with their autonomous wishes. There is some information to suggest that surgeons value the utility of an advance directive as it can serve as a guide to patients’ preferences in the postoperative setting when life-supporting therapy has become ineffective or patient survival is unlikely.

 


Trauma and Thermal Injury

Management of the Patient with Thermal Injuries

Michael J. Mosier, MD, FACS, FCCM, Associate Professor of Surgery, Loyola Burn Center, Loyola University Medical Center, Maywood, IL,

Nicole S. Gibran, MD, FACS, Professor of Surgery and Director, University of Washington Burn Center, Harborview Medical Center, Seattle, WA

 

Inhalation injuries occur in approximately one-third of all major burns, and mortality is more than double that of cutaneous burns. Curiously, isolated inhalation injuries do not result in high mortality. Presumably, the combination of inhalation injury and cutaneous thermal injury creates a double insult in which recurrent or persistent bacteremia aggravates the pulmonary injury. Diagnosis of an inhalation injury requires a thorough history of the circumstances surrounding the injury and is often suggested by fire in a closed space, carbonaceous sputum, and an elevated carboxyhemoglobin level (> 15%).

 

Injuries to the Spleen and Diaphragm

Andrea M. Long, MD, Clinical Instructor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC

Jason Hoth, MD, PhD, FACS, Associate Professor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC

Preston R. Miller III, MD, FACS, Associate Professor, Department of Surgery, Research Director, Acute Care Surgery, Wake Forest School of Medicine, Winston-Salem, NC

 

Although controversial, multiple institutions have increasingly used angiography routinely in higher-grade spleen injuries undergoing nonoperative management (NOM). A meta-analysis published in 2011 and a subsequent prospective study in 2014 highlighted the higher splenic salvage rate during NOM when angioembolization is employed in all grade IV and V injuries. This is echoed in a Level 2 recommendation in the Eastern Association for the Surgery of Trauma practice management guidelines from 2012. Subcapsular hematomas also may be at higher risk for delayed rupture, and special consideration should be given to patients with this injury pattern. Also currently controversial is the superiority of proximal embolization versus distal embolization.

 


As seen in Scientific AmericanTM Surgery.