Issue #17: January 17th, 2025

"Beauty is truth, truth beauty,—that is all

Ye know on earth, and all ye need to know." - John Keats. Ode on a Grecian Urn, 1819

Women living with PCOS: Can bariatric surgery improve their reproductive health? By Samantha Redden Source: https://pubmed.ncbi.nlm.nih.gov/38782004/ Polycystic ovarian syndrome (PCOS) is one of most common endocrine disorders among women. Its effects on the overall health of reproductive-aged women are well-documented and can lead to a range of challenges, including psychological, financial, and social issues, as well as infertility. Obesity is a common comorbidity associated with PCOS, and exacerbates the challenges faced by these women. Currently, first-line treatments to improve reproductive health include medical management and lifestyle modifications. However, maintaining these changes in the long term has proven to be unsustainable for many. This study is the first to compare the effectiveness of bariatric surgery with standard medical care in women with PCOS, obesity, oligomenorrhea, or amenorrhea. In this multicenter, open-label, randomized controlled trial, 80 adult women with PCOS and a BMI of at least 35 kg/m² were recruited via social media. Median age was 31 years, and 79% identified as white. Patients were randomly assigned in a 1:1 ratio to either vertical sleeve gastrectomy (n=40) or behavioral interventions combined with medical therapy (n=40). The study measured two primary endpoints. First, the number of biochemically confirmed spontaneous ovulatory events assessed through weekly serum progesterone levels. This was expressed as an incidence ratio over a period of 52 weeks, as this was considered the best predictor for achieving pregnancy. Second endpoints included anthropometric measurements, cardiometabolic risk factors, levels of biochemical hyperandrogenism, quality of life, and psychological health. The trial found that women who underwent vertical sleeve gastrectomy experienced a significantly higher rate of spontaneous ovulatory events, approximately 2.5 times greater than that of the medical group over the 52-week follow-up period (95% CI 1.5-4.2, p<0.0007). Although behavioral modification is considered the cornerstone of treatment for obesity in women with PCOS, surgery was associated with more significant improvements in the rate of spontaneous ovulation, cardiometabolic risk factors, psychological health, and overall quality of life at the 52-week follow-up. Given the promising results, future studies could potentially show a synergistic effect with combined surgery and medical management.

Bilateral MRgFUS Thalamotomy: A Promising Approach for Medication-Resistant Essential Tremor By Riva Kelly Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC11287440/ Essential tremor is a common movement disorder with various treatment options depending on symptom severity. When essential tremor worsens despite pharmacological treatment, magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy may be used to alleviate symptoms. This procedure uses sound waves to target the thalamus, a brain region responsible for relaying sensation and movement. The sound waves generate heat, which damages specific brain tissue to reduce tremors. Currently, the FDA approves MRgFUS thalamotomy for unilateral treatment of essential tremors in the dominant hand. However, since most patients experience bilateral essential tremors, they often continue to have symptoms on the untreated side. Bilateral MRgFUS is associated with higher risks, including speech and language disturbances, compared to unilateral procedures. This randomized controlled trial investigates the safety and efficacy of bilateral MRgFUS thalamotomy in patients with medication-resistant essential tremor who had previously undergone unilateral MRgFUS thalamotomy. After the bilateral procedure, follow-up assessments were conducted at 48 hours, and at 1, 3, 6 and 12 months. These evaluations measured physical and neurological functions, speech, Montreal Cognitive Assessment scores, Clinical Rating Score for Tremor (CRST), and adverse effects. The primary efficacy endpoint was the change in tremor/motor function of the contralateral hand, measured by CRST scores from baseline to three months. The secondary endpoint assessed upper-extremity postural tremor on the treated side during the same timeframe. At three months, the mean CRST scores for tremor/motor function decreased from 17.4 to 6.4 (95% CI, 59.8-72.2; P < .001), with continued improvement at six and twelve months. Mean postural tremor scores also improved, decreasing from 2.5 (95% CI, 2.3 to 2.7 ) to 0.6 (95% CI, 0.3 to 0.8) at three months (P < .001) and showing further reductions at subsequent follow-ups. Although adverse effects were noted, the most common was numbness or tingling. These were resolved in most participants by the 12-month follow-up. These findings suggest that bilateral MRgFUS thalamotomy effectively reduces tremor severity, with mild and temporary side effects, making it a promising treatment option for medication-resistant essential tremor.

Should a well-reduced medial malleolus be fixed in unstable ankle fractures? By Benjamin Lee Crews Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC10797457/#zoi231502r23 Unstable ankle fractures are routinely managed operatively with open reduction and internal fixation of each affected malleoli. The minimal soft tissue coverage over fixation implants often results in prominent and symptomatic hardware. Recent studies have supported conservative management of well-reduced (<2mm displacement) medial malleolus fractures following fixation of the lateral malleolus to decrease complications and operative time. However, there is limited evidence to support this practice.

This 154-person randomized control trial sought to assess the superiority of internal fixation of well-reduced medial malleolus fractures compared to nonoperative management. Patients were randomized into fixation vs nonfixation group of the medial malleolus after the lateral malleolus was appropriately stabilized. The Olerud-Molander Ankle Score (OMAS) is a widely accepted system for evaluating symptoms after ankle trauma. At 52 weeks, there was no statistically significant difference in the OMAS between the fixation (80.0; IQR, 60.0-90.0) and non-fixation (72.5; IQR, 55.0-90.0) groups (p=0.17). However, the non-fixation group had a 20% radiographic nonunion rate compared to the fixation group. Of note, this was largely asymptomatic and had a low intervention rate.

This study fails to prove the superiority of either fixation method. While the focus on biological preservation and reduced surgical intervention is commendable, the high risk of post-traumatic arthritis following ankle fractures underscores the need for long-term data before widespread adoption of nonoperative management.

Robotic-assisted Simple Prostatectomy: analysis of functional outcomes By Santosh Parajuli Source: https://journals.sagepub.com/doi/10.1177/17562872221147104 Benign prostatic hyperplasia (BPH) is a common disorder among men that often leads to bladder obstruction. Depending on severity of obstruction, treatment may require surgical intervention to remove the prostate. In the past, prostatectomy was done as an open procedure. Now with the advent of surgical technology, robotic assisted simple prostatectomy (RASP) is the mainstay approach. The three main techniques utilized in RASP include the Freyer (transvesical), Millin (transcapsular), and Madigan (near-infrared fluorescence imaging guided urethral sparing).

In this single-center retrospective study with 72 patients, the goal was to evaluate long-term outcomes of RASP among the three techniques. These techniques were compared based on two sets of composite scores (trifecta and pentafecta). Trifecta composite score accounted for the postoperative peak flow rate Qmax>15ml/s, international prostatic symptoms score <8, and lack of complications. The pentafecta composite score included the trifecta in addition to the persistence of antegrade ejaculation and erectile function maintenance. Out of the 72 patients, 37 patients (51%) underwent RASP-Millin, 18 patients (25%) underwent RASP-Madigan, and 17 patients (24%) underwent RASP-Freyer.

Trifecta was achieved in 43 cases (60%), but this was unrelated to surgical technique (p=0.85). The pentafecta was achieved in 14 cases (20%), with a higher association with the Madigan technique (p<0.01). No matter the RASP technique, there was a significant improvement in symptoms after prostatectomy. In both trifefcta and pentafecta analysis, the postoperative international prostate symptoms score and male sexual health questionnaire had statistically significant improvements (p <0.01). In conclusion, patients with obstructive BPH symptoms will most likely benefit from RASP with improved long-term functional outcomes.

Does laparoscopic appendectomy during pregnancy increase risks?

By Kelsey Lane Source: https://onlinelibrary.wiley.com/doi/abs/10.1002/wjs.12422 Acute appendicitis is the most common non-obstetric surgical condition during pregnancy, occurring 101/100,000 births, and it presents challenges when selecting surgical approach. While laparoscopic appendectomy (LA) is becoming the standard due to fewer complications, concerns remain about potential risks of fetal loss. This retrospective cohort study in Japan analyzed 1,624 pregnant women undergoing open appendectomy (OA) or LA between 2010 and 2022. Patients were categorized by trimester, and outcomes like preterm labor, preterm delivery, and abortion were assessed. In the 1st trimester, there was no significant difference in outcomes between OA or LA. In the 2nd and 3rd trimester, LA was associated with higher rates of preterm delivery (10.6%) and spontaneous abortions (24.2%) compared to OA rates of preterm delivery (3.6% ) and spontaneous abortions (11.3%) (p<0.001 vs p=0.021). Although LA was associated with shorter hospital stays during later trimesters, the operative time was consistently longer. This raises concerns about intra-abdominal pressure and uterine irritability. Although LA is increasingly prevalent, it may not always yield better outcomes, particularly in later trimesters. It is essential to take gestational age into consideration when planning treatment. Echinococcosis: The Rise of the Echinococcus Tapeworm By Ryan Liengswangwong Echinococcosis occurs due to the consumption of Echinococcus tapeworm larvae. The liver is the most common site of infection, followed by the lungs and spleen. If clinical presentation raises suspicion for Echinococcosis, laboratory tests including serology and imaging can assist in the diagnostic process. A fine needle biopsy utilizing ultrasound may also be performed; however, there is risk of cyst rupture and dissemination of its contents. The above CT showcases hypodense, non-uniform, multiloculated cysts with septations that may be seen in Echinococcosis. If interventional treatment modalities are indicated, surgical excision or PAIR (Percutaneous Aspiration, Injection of chemicals, and Re-aspiration) may be performed. Additionally, pharmacotherapy treatment with an anthelmintic agent may increase the efficacy of the treatment when combined with the aforementioned interventions.

Sources: 1. Article: Gaillard F, Walizai T, Mazini B, et al. Hydatid disease. Reference article, Radiopaedia.org (Accessed on 11 Jan 2025) https://doi.org/10.53347/rID-4875 2. Image: Asadov D Echinococcus alveolaris (multilocularis). Case study, Radiopaedia.org (Accessed on 11 Jan 2025) https://doi.org/10.53347/rID-8275 3. Clinical presentation and diagnosing Echinococcosis: Centers for Disease Control and Prevention. Reference article, cdc.gov (Accessed on 11 Jan 2025) https://www.cdc.gov/dpdx/echinococcosis/index.html 4. Supplemental information on Echinococcosis: Di Muzio B, Walizai T, Elfeky M, et al. Alveolar echinococcosis. Reference article, Radiopaedia.org (Accessed on 12 Jan 2025) https://radiopaedia.org/articles/64334

Dr. Jane C. Wright: The Visionary Who Revolutionized Cancer Treatment By Michael Yacoub

Dr. Jane Cooke Wright November 30, 1919 - February 19, 2013

“Work hard, persevere, collaborate with one another, be pioneers in the field, and keep up the good fight.” Historically, Black women have faced systemic barriers and discrimination that have hindered their opportunities for career advancement. In education, they often encounter disparities in socioeconomic resources that obstruct academic progress. Some attribute these injustices to a long, persistent campaign of race and gender prejudices, fostering a perceived inferiority complex, moral depravity, and the enforced subordination of Black women. In the mid-to-late 1900s, these sentiments were reinforced by codified laws and customs. It is without doubt that limited opportunities and resources can have a demoralizing effect on students and future professionals. The impact of bias, prejudice, and discrimination is complex, elusive, and a formidable barrier. Given these challenges, the story of Dr. Jane Wright is all the more remarkable. At a time when the United States was undergoing a transformation to reduce segregation, she pursued her aspirations and ultimately revolutionized clinical care.

Jane Cooke Wright was born in Manhattan, New York, on November 30, 1919, into a dynasty of physicians. Her paternal grandfather was among the first graduates of Meharry Medical College after the Civil War, her step-grandfather was the first African American to graduate from Yale Medical School, and her father was one of Harvard Medical School’s first Black graduates. Dr. Wright grew up with high expectations, yet rather than being burdened by them, she thrived. She followed in the footsteps of her predecessors and exceeded them.

Ironically, Dr. Wright originally aspired to be an artist. Her eventual breakthroughs in chemotherapy could be seen as an artistic application of medical science. She initially pursued art studies at Smith College in Massachusetts, but at her father’s encouragement, she shifted toward medicine. Her decision was facilitated by her natural aptitude for science and the opportunity of a scholarship to New York Medical College. Dr. Wright was an exceptional student, graduating third in her class with honors. She also served as president of the school's honor society, class president, and literary editor of the yearbook. Her commitment to excellence mirrored the influence of her civic-minded father, who, as the first Black doctor at a public hospital in New York City, worked relentlessly to integrate the medical workforce.

After graduating in 1945, Dr. Wright joined her father at the Cancer Research Foundation at Harlem Hospital. While her father focused on basic cancer research, she developed a keen interest in clinical cancer research. When he passed away in 1952, she took over as head of the foundation at just 33 years old. The transition was seamless, as she was widely respected for her work ethic and leadership. Colleagues described her as "cheerful, open, humorous, constructive, and very easy to work with." She was known for her ability to navigate professional relationships without hostility. In 1955, she left Harlem for Bellevue Hospital, later joining her alma mater in 1967 as a professor of surgery.

Dr. Wright's relentless dedication led to groundbreaking discoveries. Her lab is credited with identifying methotrexate as an effective treatment for solid tumors, including certain breast cancers. Her research allowed for the targeted application of anticancer agents based on a patient’s specific cancer type—an innovative approach for her time. In the mid-1900s, chemotherapy was often considered a last resort behind surgery and radiation. Dr. Wright’s foresight in recognizing the potential of personalized chemotherapy was groundbreaking and demonstrated how ahead of her time she was. She went on to develop treatment guidelines and registries to optimize chemotherapy benefits while minimizing adverse effects, applying principles similar to those used in antibiotic treatment and microbial resistance.

A lesser-known but significant contribution from Dr. Wright's research was her development of intra-arterial infusion, a method for delivering high doses of chemotherapy directly to tumors. Before her work, regional chemotherapy infusion was hindered by the need for surgical exposure of the targeted artery. Dr. Wright revolutionized this approach by using fluoroscopic manipulation of the catheter, eliminating the need for invasive surgery. She employed a radiopaque polyethylene catheter connected to a pneumatically powered pump to administer chemotherapy continuously and precisely to a tumor’s blood supply. Her research demonstrated no harmful effects at the cannulation site or in the targeted region—an achievement attributed to her meticulous technique and choice of materials.

Dr. Wright’s contributions did not go unnoticed. In 1964, she was appointed to a commission by President Lyndon Johnson to advise on heart disease, cancer, and stroke. Her efforts played a key role in the establishment of regional cancer centers across the country. That same year, she helped found the American Society of Clinical Oncology (ASCO), which saw substantial growth in membership. As one of ASCO’s seven founding members—and the only Black woman—her mission was to improve cancer clinical care by expanding awareness and knowledge. Dr. Wright retired from academia in 1987 after an illustrious career that included authorship of 135 scientific papers and contributions to nine books.

Dr. Jane C. Wright, a pioneer in oncology, passed away from complications of dementia on February 19, 2013. She was predeceased by her husband, David Jones, a civil rights attorney, and is survived by her two daughters, Jane and Allison. Sources: 1. Changing the Face of Medicine: Celebrating America’s Women Physicians. U.S. National Library of Medicine. 2. Children in Science: Jane C. Wright, a Forgotten Pioneer in Cancer Research. Frontiers in Oncology, 2022. 3. Eulogy in Honor of ASCO Founder Jane C. Wright, MD. ASCO Connection. 4. In Memoriam: ASCO Remembers Founding Member Dr. Jane Cooke Wright. ASCO Connection. 5. Jane Cooke Wright, M.D.: A Forgotten Pioneer in Cancer Research. Journal of Medical Biography. 6. Jane C. Wright: An Icon in Cancer Research. JAMA, vol. 195, no. 6, 1966, pp. 474–475. 7. Revolutionary Cancer Treatments and the Legacy of Jane C. Wright. Clinical Key, 2020. 8. The Contributions of Jane C. Wright to Modern Oncology. Clinical Key, 2021. 9. The Pioneering Work of Dr. Jane C. Wright. PMC Archive, 2014. 10. Wright, Jane C. Cancer Chemotherapy in Clinical Research. PubMed, 1957. FUTURE OPPORTUNITIES & REMINDERS ❖ Will send applications out for lead and CV writers next month. Send us your CV if interested. ❖ Also looking for EDITORS! Need to have a strong writing background. Send CV if interested. ❖ Do you have research you would like showcased? Let us know ❖ Email us at thekeatssurgery@gmail.com for any questions or comments