Current Literature

Carbohydrate Loading before Bariatric Surgery Does Not Increase Aspiration Risk, Study Suggests

Huang EY, Li JZ, Chung D, et al. Carbohydrate Loading and Aspiration Risk in Bariatric Patients: Safety in Preoperative Enhanced Recovery Protocols. J Am Coll Surg. 2023, in press.

One component of enhanced recovery protocols is the provision of oral nutritional fluid consisting of a 300 mL carbohydrate solution, 2-4 hours prior to the planned surgical procedure. There is ongoing concern for an increased risk for aspiration when this intervention is used in patients undergoing bariatric surgery because of impaired gastrointestinal motility and larger gastric volumes commonly observed in these patients.

The study reported in this article gathered prospective data from 203 patients undergoing bariatric surgery at a single institution; 94 received carbohydrate loading and 109 did not. All patients had an upper gastrointestinal endoscopy immediately prior to the surgical procedure where gastric fluid volumes and pH were measured.

The data showed that gastric volumes were similar in patients who received or did not receive carbohydrate loading. Gastric pH was significantly lower in patients who did not receive carbohydrate loading.

The authors concluded that carbohydrate loading did not increase gastric volumes or lower gastric pH, and these observations suggested that aspiration risk is not increased in patients who received the oral fluid.

Editorial

Ghanem OM. Enhanced Recovery Protocols: The Reward-Risk Tradeoff. J Am Coll Surg. 2023, in press.

In the editorial that accompanied this article, author Omar M. Ghanem, MD, FACS, noted that enhanced recovery programs have permitted improved control of pain and postoperative nausea leading to early discharge in patients undergoing bariatric surgery. Risks of enhanced recovery programs have also been reported and these included bleeding and anastomotic leaks occurring in the first 2-3 days after operation making early discharge risky for some patients. Ghanem urged that early discharge should not be considered the primary goal of an enhanced recovery protocol.

Breast Surgery Could be Eliminated for Invasive Cancer with Exceptional Response to Therapy

Johnson HM, Valero V, Yang WT, et al. Eliminating Breast Surgery for Invasive Cancer with Exceptional Response to Neoadjuvant Systemic Therapy: Prospective Multicenter Trial Planned Initial Feasibility Endpoint. J Am Coll Surg. 2023, in press.

Recognizing that image-guided breast biopsy following neoadjuvant systemic therapy can identify patients with a pathologic complete response, authors of this article conducted a prospective feasibility trial to determine risk of early ipsilateral breast tumor recurrence if surgery was omitted from patient management.

The study cohort consisted of women with unicentric T1-2, N0-1, triple negative, or HER2 positive tumors (n = 13 patients). If no residual tumor was identified on image-guided core biopsy following systemic therapy, breast surgery was omitted, and patients received radiation therapy. The outcome of interest was any tumor recurrence. Seven patients had residual disease discovered on the post-treatment biopsy, and six patients had no residual tumor; at a median follow up of 44 months, no patient who was free of residual disease had tumor recurrence.

The authors concluded that these data suggest omission of surgery in patients with no residual disease following systemic chemotherapy was safe, and they plan to proceed with a larger prospective trial based on these positive feasibility findings.

Time from Breast Cancer Diagnosis to Primary Surgery Affects Mortality Risk

Wiener AA, Hanlon BM, Schumacher JR, Vande Walle KA, Wilke LG, Neuman HB. Reexamining Time from Breast Cancer Diagnosis to Primary Breast Surgery. JAMA Surg. 2023.

Available evidence suggests that longer intervals from diagnosis to the primary surgical procedure are associated with increased risk for mortality in patients with breast cancer. Lead author Alyssa A. Wiener, MD, and coauthors noted that defining an acceptable time interval from diagnosis to surgery would be helpful to patients and surgeons providing care for these patients.

The study used data from the National Cancer Database (NCDB) from 2010 to 2014 and analyzed patient outcomes at 5-years of follow up for a cohort of 373,344 women diagnosed with stage 1–3 ductal or lobular carcinoma. The objective of the study was to determine factors associated with overall survival.

The data analysis showed that time from diagnosis to surgery greater than 9 weeks was associated with increased mortality risk. Risk factors for prolonged time from diagnosis to surgery included younger age, uninsured or Medicaid insured, and lower household income. The authors concluded that a time to surgery interval of 8 weeks or less could potentially be used as a quality of care metric and that longer intervals were associated with adverse social determinants of health.

Editorial

Mukhtar RA, Esserman LJ. Time to Surgery in Breast Cancer—Is Faster Always Better? JAMA Surg. 2023.

In the editorial that accompanied the article, authors Rita A. Mukhtar, MD, and Laura J. Esserman, MD, MBA, emphasized that longer intervals from diagnosis to surgery may be associated with receipt of neoadjuvant therapy which has been shown to improve survival. They also noted that a significant proportion of this study cohort had unfavorable tumor biological markers and could possibly benefit from neoadjuvant therapy. Based on these factors, a potential interpretation of the data from the study could be that operating too soon could be a marker for lower quality of care while operating too late could indicate lack of access to care.