Lymphedema After Breast Cancer Treatment —Not Just the Surgeon’s Fault
In the Halstedian era (1920-1970s), women with breast cancer were treated with mastectomy and full axillary dissection, usually without radiotherapy or chemotherapy. Thus, the lymphedema of the arm that occurred during this period was primarily and appropriately blamed on the surgeon. In the current non-Halstedian era of multimodality therapy, lymphedema can be blamed on everyone. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

More Objective Data to Determine RVUs for Surgical Effort
How should a surgeon ’s time in the operating room be compensated? Based on the complexity of the procedure? The risk? The length of the operation? What if the procedure is extremely complex or high risk but is of short duration? Should such a case have a higher relative value than a long but low-risk procedure? These are but a few of the controversies related to relative value units (RVUs), the current basis for payment for surgeons’ services by Medicare and other third-party payers. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

Assessment of Routine Esophagram for Detecting Anastomotic Leak After Esophagectomy
This study assesses the value of routine esophagrams in detecting anastomotic leaks after esophagectomy. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

Prediction of Lymph Node Metastasis in Early Gastric Cancer by Collagen Signature —Endoscopists’ Viewpoint
To the Editor We read with great interest the article by Chen et al reporting a prediction model based on collagen architecture and morphology to estimate the risk of lymph node metastasis (LNM) in patients with early gastric cancer (EGC). The newly developed tools were suggested to be useful in decision-making in the choice of surgical or endoscopic submucosal dissection (ESD) treatment in patients with T1 gastric cancer. However, we have some concerns about this study from the perspective of endoscopists. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

Prediction of Lymph Node Metastasis in Early Gastric Cancer by Collagen Signature —Endoscopists’ Viewpoint—Reply
In Reply We have read the comments from Min et al about our recently published article in JAMA Surgery. We appreciate their comments and reply to their concerns from the perspective of surgeons. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

Lymphedema in Women With Node-Positive Breast Cancer
This cohort study examines factors associated with lymphedema after neoadjuvant chemotherapy and axillary lymph node dissection in women with node-positive breast cancer. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

Association of Surgical Work Measures and Specialty With Relative Value Units
This cross-sectional study evaluates the current system for generating and updating the data used to quantify the relative value unit of a surgeon ’s work for each surgical procedure. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

How Implementation Science in Surgery is Done
This Viewpoint describes implementation science research as it applies to surgical topics. (Source: JAMA Surgery)
Source: JAMA Surgery - July 17, 2019 Category: Sports Medicine Source Type: research

The True Outcomes of Geriatric Trauma —If We Do Not Count Them, We Will Never Know
This article also reiterates the National Academies of Science, Engineering, and Medicine ’s emphasis of long-term follow-up after trauma; more than 80% of deaths within 1 year occurred in patients who were not included in the trauma registry. These data show that the current registry approach vastly underestimates the magnitude and overall burden of geriatric trauma. (Source: JAMA Surgery)
Source: JAMA Surgery - July 10, 2019 Category: Sports Medicine Source Type: research

Trends in the Inclusion of Black and Female Surgeons in Invited Visiting Professorships
This study examines the changes in the composition of visiting professorships by race and sex at 25 academic surgical programs from 2007 through 2017. (Source: JAMA Surgery)
Source: JAMA Surgery - July 10, 2019 Category: Sports Medicine Source Type: research

Heart Failure and Postoperative Mortality After Ambulatory Noncardiac Surgery
This study compares the postoperative mortality risk among patients with vs without heart failure who undergo elective ambulatory surgery. (Source: JAMA Surgery)
Source: JAMA Surgery - July 10, 2019 Category: Sports Medicine Source Type: research

Comparison of Injured Older Adults Included in vs Excluded From Trauma Registries With 1-Year Follow-up
This cohort study evaluates patient characteristics, injury patterns, surgical interventions, mortality, and causes of death up to 1 year after the index event among injured older adults who were included in compared with those who were excluded from trauma registries. (Source: JAMA Surgery)
Source: JAMA Surgery - July 10, 2019 Category: Sports Medicine Source Type: research

Recognizing and Reacting to Microaggressions in Medicine and Surgery
This Special Communication elaborates on the concept of microaggressions and provides suggestions for how recipients or bystanders can respond to them. (Source: JAMA Surgery)
Source: JAMA Surgery - July 10, 2019 Category: Sports Medicine Source Type: research

Review of the 2018 Tokyo Guidelines: Antimicrobial Therapy for Acute Cholangitis and Cholecystitis
This Clinical Guideline Synopsis reviews the Tokyo Guidelines 2018 on antimicrobial therapy for acute cholangitis and cholecystitis. (Source: JAMA Surgery)
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

Loop Ileostomy vs Total Abdominal Colectomy —A Valid Alternative?
In this issue of JAMA Surgery, Juo et al have presented a study on a US trend in treating fulminant Clostridium difficile colitis with loop ileostomy as an organ-preserving procedure vs performing total abdominal colectomy. With a retrospective cohort study design, Juo et al examined a US national administrative database, the National Inpatient Sample database, with a weighted sampling of treatment choices for C difficile colitis in approximately 20% of associated hospitalizations in nonfederal acute care hospitals in the sampled US states from 2011 through 2015. The study includes 3021 adult patients who underwent surgery...
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

Lateral Lymph Nodes as the Achilles Heel of Low Rectal Cancer Surgery After Neoadjuvant Chemoradiation Therapy
The management of locally advanced rectal cancer has been a topic of debate between surgical schools in the East and the West, and to date, there is still no formal consensus or mutually agreed-on guidelines. While in Western countries, neoadjuvant chemoradiation therapy followed by total mesorectal excision has been the standard of care for 2 decades now, 2 recent studies have demonstrated that this approach does not prevent lateral lymph node recurrence. On the contrary, prophylactic lateral lymph node dissection has been the standard of care for locally advanced rectal cancer in Eastern countries, with predominance in J...
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

Hawthorne Effect Should Be Controlled for in Quality Control Studies
To the Editor We read with great interest the study comparing systematic video documentation with narrative operative report in colorectal cancer surgery by van de Graaf et al and would like to congratulate the authors for a good study. Although we appreciate the work behind the study, we feel that we will be contributing to the overall message of the study with the following methodological comments. (Source: JAMA Surgery)
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

Hawthorne Effect Should Be Controlled for in Quality Control Studies —Reply
In Reply We appreciate the interest in our study expressed by Gachabayov et al, and we welcome their comments. First, our study methodology indeed shares similarities with the before-after design as referred to. However, the current design remains that of a cohort study, given the fact that the cohort includes patients that all share the same characteristics (ie, patients 18 years or older undergoing elective laparoscopic colorectal cancer surgery) apart from the intervention (systematic video recording). It is our belief that in the example of decreased length of hospital stays, sample size is a more substantial part to a...
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

Trends in Diverting Loop Ileostomy vs Total Abdominal Colectomy as Surgical Management for Clostridium Difficile Colitis
This cohort study describes US trends in adopting loop ileostomy for treating fulminant C difficile colitis. (Source: JAMA Surgery)
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

Lateral Nodal Features on Restaging MRI Associated With Lateral Nodes in Low Rectal Cancer After Radiotherapy
This cohort study investigates the factors on primary and restaging magnetic resonance imaging that are associated with lateral local recurrence in low rectal cancer after chemoradiotherapy or radiotherapy and to formulate specific guidelines on which patients might benefit from a lateral lymph node dissection. (Source: JAMA Surgery)
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

From Policy to Patient Care —The Cycle of Health Policy Research
This Viewpoint describes 2 pathways by which surgeons can use their clinical knowledge to advocate for health care policies that will benefit patients. (Source: JAMA Surgery)
Source: JAMA Surgery - July 3, 2019 Category: Sports Medicine Source Type: research

July 2019 In This Issue
(Source: JAMA Surgery)
Source: JAMA Surgery - July 1, 2019 Category: Surgery Source Type: research

JAMA Surgery
Mission Statement: To promote the art and science of surgery by publishing relevant peer-reviewed research to assist the surgeon in optimizing patient care. JAMA Surgery will also serve as a forum for the discussion of issues pertinent to surgery, such as the education and training of the surgical workforce, quality improvement, and the ethics and economics of health care delivery. (Source: JAMA Surgery)
Source: JAMA Surgery - July 1, 2019 Category: Surgery Source Type: research

Affiliation Added and Error in the Introduction
This article has been correc ted online. (Source: JAMA Surgery)
Source: JAMA Surgery - June 26, 2019 Category: Sports Medicine Source Type: research

What US Health Care Can Learn From Ghana
Task shifting is a process whereby specific duties are moved to health care workers with shorter training times and fewer qualifications. The process may also involve delegation of clearly delineated responsibilities to newly created cadres of health care workers after completion of specific competency-based training. In high-income countries, successful, sometimes controversial, examples of task shifting include donor lung procurements by physician assistants, midlevel clinicians performing diagnostic and therapeutic endoscopy, and hernia repairs performed by general practitioners. In resource-limited countries, multiple ...
Source: JAMA Surgery - June 26, 2019 Category: Sports Medicine Source Type: research

Awareness of the Costs of Surgical Instruments
This study surveys surgeons ’ cost knowledge and ability to distinguish subtle price variations between surgical tools with similar functions or indications. (Source: JAMA Surgery)
Source: JAMA Surgery - June 26, 2019 Category: Sports Medicine Source Type: research

Cancer and Other Outcomes After Surgery With Fluoridated Anesthesia
To the Editor I read the article by Perry et al with interest. Several other molecular mechanisms and factors may also play a role in how anesthesia may influence cancer outcomes. First, it is important to distinguish the difference between certain fluoridated anesthesia, such as sevoflurane, from their contribution to higher plasma fluoride levels. For example, it is known that sevoflurane can provide 20-fold the total daily dietary fluoride intake from all sources of fluoridated food and water combined, resulting in peak ionic fluoride levels in the range of 50 μmol/L. Hence, fluoridated anesthesia can result in extre...
Source: JAMA Surgery - June 26, 2019 Category: Sports Medicine Source Type: research

Cancer and Other Outcomes After Surgery With Fluoridated Anesthesia —Reply
In Reply We thank Waugh for the interest he has shown in our article and the Editor for the opportunity to reply to his comments. It is true that serum fluoride levels are elevated during anesthesia with sevoflurane, which occurs as a result of its metabolism by hepatic cytochrome P450 enzymes to yield hexafluoroisopropanol and inorganic fluoride. Indeed, there were well-documented concerns about the potential toxicity of these metabolites when sevoflurane first came into clinical use in the 1990s, although it rapidly transpired that reported cases of nephrotoxicity in rats were actually caused by compound A (fluoromethyl ...
Source: JAMA Surgery - June 26, 2019 Category: Sports Medicine Source Type: research

Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana
This cohort study compares the outcomes associated with inguinal hernia repair performed by medical doctors vs surgeons in Ghana. (Source: JAMA Surgery)
Source: JAMA Surgery - June 26, 2019 Category: Sports Medicine Source Type: research

Time for Changes in the Surgical Community —Promoting Professionalism as #MeToo 2.0
When I (D.C.) was a medical student, a prominent attending surgeon struck my fingers with a surgical instrument because I was not holding the retractor correctly. The same surgeon also threw instruments across the room when he was handed the wrong instrument. Those behaviors were tolerated decades ago, and all incidents were kept behind closed doors. (Source: JAMA Surgery)
Source: JAMA Surgery - June 19, 2019 Category: Sports Medicine Source Type: research

Public Health Tool to Estimate Miles Driven by Intoxicated Drivers
This study uses data from the Place of Last Drink database and Google maps to assess the association of blood alcohol concentration with distance traveled and driver ’s age among intoxicated drivers in Minnesota. (Source: JAMA Surgery)
Source: JAMA Surgery - June 19, 2019 Category: Sports Medicine Source Type: research

Revisions of Gastric Bypass —A Moral Obligation
This article, dealing with reoperations, should have included all kinds of interventions. Ingmar N äslund, MD, PhD, one of the authors, reported increased admissions for gastrointestinal tract surgery (24.4%), gallstone problems (7.3%), and internal hernia (4.3%) following GBP. The combined aspects would boost reoperations to more than 30%. (Source: JAMA Surgery)
Source: JAMA Surgery - June 19, 2019 Category: Sports Medicine Source Type: research

Revisions of Gastric Bypass —A Moral Obligation—Reply
In Reply We interpret the letter from Gagner regarding our 26-year report of revisional surgery in the Swedish Obese Subjects (SOS) study as yet another contribution to the current dispute of pros and cons of gastric bypass (GBP) vs sleeve gastrectomy. Gagner is a strong advocate of sleeve gastrectomy, and he predicts that this surgical method will be a “mass treatment for the global epidemic of severe obesity and diabetes.” However, the SOS study was started more than 30 years ago, and sleeve gastrectomy has only been widely used during the last decade. Thus, the results of the SOS study cannot contribute to t...
Source: JAMA Surgery - June 19, 2019 Category: Sports Medicine Source Type: research

Preoperative Opioid and Benzodiazepine Prescriptions and Mortality After Noncardiac Surgery
This cohort study investigates the association between preoperative opioid and/or benzodiazepine use and postoperative mortality and persistent opioid consumption among patients undergoing noncardiac surgical procedures in Iceland. (Source: JAMA Surgery)
Source: JAMA Surgery - June 19, 2019 Category: Sports Medicine Source Type: research

Coworker Reports of Unprofessional Behavior by Surgeons and Surgical Complications in Their Patients
This cohort study assesses the association between surgeons with higher numbers of reports from coworkers about unprofessional behaviors and the risk for postoperative complications in their patients. (Source: JAMA Surgery)
Source: JAMA Surgery - June 19, 2019 Category: Sports Medicine Source Type: research

Use of Artificial Intelligence to Represent Emergent Systems and Augment Surgical Decision Making
This Viewpoint describes the use of artificial intelligence models for phenotyping and assessing sepsis risk as well as enhancing surgical decision making. (Source: JAMA Surgery)
Source: JAMA Surgery - June 19, 2019 Category: Sports Medicine Source Type: research

Error in Abstract
In the Original Investigation titled “Effect of Vein-First vs Artery-First Surgical Technique on Circulating Tumor Cells and Survival in Patients With Non–Small Cell Lung Cancer: A Randomized Clinical Trial and Registry-Based Propensity Score Matching Analysis,” published online May 1, 2019, there was an error in the results subs ection of the Abstract. It contained a typographical error in the sentence “A total of 86 individuals were randomized; 22 patients (25.6%) were younger and 46 (74.4%) older than 60 years.” The correct statement is “…64 (74.4%) older than 60 years.” ...
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Error in Results
In the Special Communication article titled “Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs,” published online May 15, 2019, a sentence in the Results section was incorrect. The phrase “Furthermore, 20 respondents (25%) identified a single policy in place at their institution to help resolve cognitive competency issues…” should have stated “Furthermore, no more than 20 respondents (25%) were able to identify any one policy in place at their institution to help resolve cognitive competency issues….” The error has ...
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Closing the Loop on the Role of Multiparametric Magnetic Resonance Imaging –Targeted Prostate Biopsy
Thirty years have passed since clinicians started using prostate-specific antigen level as a screening tool for prostate cancer. Over the years, the diagnosis of metastatic disease has decreased dramatically, and there has been a considerable decline in mortality. However, clinicians have struggled to find the balance between early diagnoses of lethal prostate cancer and overdiagnoses of clinically insignificant disease. Some lessons have been learned from large clinical trials, leading to the adjustment of the age and rate of screening and the development of better tests. In addition, better understanding of risk stratifi...
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Refining How We Identify High-Value Surgical Care
Over the past 2 decades, continuous quality improvement has become a focus for government agencies, with little guidance offered on how to do it. Programs that provide surgeons with data about their individual performance and how they compare with others in their region are able to truly drive change. Unfortunately, universal participation in national programs has not been achieved because of participation barriers. The greatest of these is cost. Solo practitioners and small groups cannot provide the capital investment to join these programs. In areas where clinicians work at multiple hospitals, additional challenges invol...
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery for Gastric Cancer
This study assesses survival outcomes among patients with gastric adenocarcinoma who received hyperthermic intraperitoneal chemotherapy combined with cytoreductive surgery at US academic centers. (Source: JAMA Surgery)
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Concerning Greater Social Contexts in Bariatric Surgery Availability and Telomere Length Outcomes
To the Editor We read with great interest the Research Letter by Morton et al, which describes the association of surgical loss of weight with lengthening of telomeres in patients who had an adverse cardiometabolic condition prior to surgery. They analyzed telomere length collected from patients with obesity before and after bariatric surgery. The authors recognized “the small study population and a single site intervention” as limitations. (Source: JAMA Surgery)
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Concerning Greater Social Contexts in Bariatric Surgery Availability and Telomere Length Outcomes —Reply
This study population is also representative of the diverse ethnic representation present in the San Francisco Bay Area, as we have cited. While we do have patient zip code data that could be used for income status, this is a broad assessment not appropriate for individual-level analysis. Education is a key parameter that should be measured in the future, and we appreciate the authors ’ suggestion. (Source: JAMA Surgery)
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Targeted vs Systematic Prostate Biopsy in Men Who Are Biopsy Naive
This paired cohort study seeks to determine the cancer detection rate of biopsy methods targeting magnetic resonance imaging –visible lesions vs systematic prostate sampling in the diagnosis of clinically significant prostate cancer in men who were biopsy naive. (Source: JAMA Surgery)
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Assessment of Use of Arteriovenous Graft vs Arteriovenous Fistula for First-time Permanent Hemodialysis Access
This study uses Medicare claims data to explore contemporary practice patterns and physician characteristics associated with high rates of use of arteriovenous grafting compared with arteriovenous fistula for hemodialysis access. (Source: JAMA Surgery)
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Hepatic Artery Infusion Chemotherapy for Initially Unresectable Colorectal Liver Metastases
This narrative review discusses the biological rationale for hepatic arterial infusion chemotherapy, evidence for conversion to resectability using hepatic arterial infusion chemotherapy and systemic chemotherapy, and morbidity and toxic effect profiles of hepatic arterial infusion chemotherapy. (Source: JAMA Surgery)
Source: JAMA Surgery - June 12, 2019 Category: Sports Medicine Source Type: research

Error in Table and Text
The Original Investigation titled “Association of Race With Bariatric Surgery Outcomes,” published online on March 6, 2019, and in the May 2019 print issue, contained an error in Table 1 and the Results section. In both places, participants’ annual income levels were presented in the category $45 000-$75 999. This category should have been written as $45 000-$75 000. The error has been corrected. (Source: JAMA Surgery)
Source: JAMA Surgery - June 5, 2019 Category: Sports Medicine Source Type: research

Trimodal Therapy for Bladder Cancer
Trimodal therapy (TMT) is a treatment option for some patients with muscle-invasive bladder cancer. This approach combines aggressive transurethral resection, radiation therapy, and radio-sensitizing chemotherapy as an alternative to radical cystectomy with urinary diversion. In the absence of head-to-head level 1 evidence, there is now a growing body of retrospective data suggesting worse survival rates with this technique. Now added to this are data suggesting higher costs as well. (Source: JAMA Surgery)
Source: JAMA Surgery - June 5, 2019 Category: Sports Medicine Source Type: research

New Persistent Opioid Use After Postoperative Intensive Care in US Veterans
This study uses medical records of more than 800  000 US veterans treated in the intensive care unit after surgery to determine the rate at which these patients developed new persistent opioid use. (Source: JAMA Surgery)
Source: JAMA Surgery - June 5, 2019 Category: Sports Medicine Source Type: research

Potential Benefit of Nonsurgical Management to Periappendicular Abscess
To the Editor We thank M ällinen et al for their study questioning the need for interval appendectomy in patients presenting with periappendicular abscess following successful initial nonoperative treatment. The study was terminated at a much earlier stage than anticipated owing to an interim analysis that reported a high incidence rate of appendiceal tumors found, which meant it was no longer ethically viable to have a follow-up group. We therefore urge caution in using the data collected in drawing any form of conclusion. The topic remains controversial, and we therefore wish to encourage more studies to be conduct ...
Source: JAMA Surgery - June 5, 2019 Category: Sports Medicine Source Type: research