Behind The Knife: The Surgery Podcast

For decades, a tight carotid stenosis felt like a ticking time bomb — a plaque waiting to throw an embolus and cause the next stroke. We were taught that severe narrowing meant surgery, and trials like ACAS and ACST-1 seemed to prove it. But medicine has changed. Statins, antiplatelets, tighter blood pressure control, even PCSK9 and GLP-1 therapies have quietly slashed stroke risk, and now newer data from CREST-2 suggest that for many asymptomatic patients, the knife — or the stent — may not add much at all. So if modern medical therapy works better than ever… who actually benefits from intervention anymore? Today, we unpack the evidence, the controversies, and how to counsel the patient who feels perfectly fine but has high-grade stenosis.
Hosts: Carolyn Judge, Andrew Huang, Luciano Delbono, Frank Davis, Robert Beaulieu
Institution: University of Michigan, Department of Surgery, Section of Vascular Surgery
Learning objectives:

Describe how modern intensive medical therapy has transformed the natural history of asymptomatic carotid stenosis and explain why contemporary patients experience substantially lower annual stroke risk than those in earlier eras.

Interpret and compare the results of landmark trials—including ACAS, ACST-1, and CREST-2—to assess the relative benefits of medical therapy, endarterectomy, and stenting.

Apply current evidence and guideline recommendations to patient care by selecting which asymptomatic patients are most likely to benefit from carotid revascularization versus optimized medical therapy alone.

References:
SVS Guidelines:
Brook, R. D., et al. (2022). Society for Vascular Surgery clinical practice guidelines for management of extracranial carotid artery disease. Journal of Vascular Surgery, 75(1), e1–e67. https://doi.org/10.1016/j.jvs.2021.09.031

CREST (1)
Brott, T. G., Hobson, R. W., Howard, G., et al. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine, 363(1), 11–23. https://doi.org/10.1056/NEJMoa0912321

CREST-2
Brott, T. G., Howard, G., Fong, P., et al. (2024). Randomized trial of carotid artery stenting or carotid endarterectomy vs best medical therapy for asymptomatic carotid stenosis: CREST-2 results. [Manuscript in preparation]. ClinicalTrials.gov Identifier: NCT02089217. Retrieved from https://clinicaltrials.gov/ct2/show/NCT02089217

ACST-1
Halliday, A., Mansfield, A., Marro, J., et al. (2004). Randomised trial of carotid artery surgery for asymptomatic stenosis. Lancet, 363(9420), 1491–1502. https://doi.org/10.1016/S0140-6736(04)16153-1

ACST-2
Halliday, A., Bulbulia, R., Bonati, L. H., et al. (2021). Carotid artery stenting versus carotid endarterectomy in patients with asymptomatic carotid stenosis (ACST-2): A randomised trial. Lancet, 398(10291), 1065–1073. https://doi.org/10.1016/S0140-6736(21)01980-1

ACAS
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. (1995). Endarterectomy for asymptomatic carotid stenosis. JAMA, 273(18), 1421–1428. https://doi.org/10.1001/jama.1995.03520420033036

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Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  
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Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-review
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In this episode, our expert panel dives into the critical, historically debated topic of early burn wound excision using a real-world case of a patient with massive surface area burns. We explore the dramatic shift from the pre-1970s "wait and watch" approach to the modern standard of early source control, backed by landmark literature showing reduced mortality and shorter hospital stays. The discussion also highlights the nuances of this timeline, covering specific scenarios where delaying surgery is actually safer due to physiologic instability, uncertain burn depths, or mass casualty events. Tune in to hear the evidence behind these clinical decisions and learn why modern burn surgeons believe that removing necrotic eschar early is the best way to dominate the day!
Hosts: 
- Kathleen Romanowski – University of California Davis Hospital, Shriners Hospital Sacramento
- Laura Johnson – Grady Memorial Hospital
- Lauren Nosanov – Grady Memorial Hospital
-  Victoria Miles – Louisiana State University Health Science Center, University Medical Center New Orleans
Learning Objectives:
- Review the historical development of early burn excision and understand how these studies shaped modern burn surgical practice.
-  Evaluate contemporary evidence on the timing of burn excision.
- Apply current evidence and clinical principles to operative decision-making, identifying key patient and injury factors that influence the timing of excision and grafting in patients with major thermal injury.
References:
- Thompson P, Herndon DN, Abston S, Rutan T. Effect of early excision on patients with major thermal injury. J Trauma. 1987 Feb;27(2):205-7. doi: 10.1097/00005373-198702000-00019. PMID: 3820353. https://pubmed.ncbi.nlm.nih.gov/3820353/
-  Gray DT, Pine RW, Harnar TJ, Marvin JA, Engrav LH, Heimbach DM. Early surgical excision versus conventional therapy in patients with 20 to 40 percent burns. A comparative study. Am J Surg. 1982 Jul;144(1):76-80. doi: 10.1016/0002-9610(82)90605-5. PMID: 7046487. https://pubmed.ncbi.nlm.nih.gov/7046487/
- De La Tejera G, Corona K, Efejuku T, Keys P, Joglar A, Villarreal E, Gotewal S, Wermine K, Huang L, Golovko G, El Ayadi A, Palackic A, Wolf SE, Song J. Early wound excision within three days decreases risks of wound infection and death in burned patients. Burns. 2023 Dec;49(8):1816-1822. doi: 10.1016/j.burns.2023.06.003. Epub 2023 Jun 15. PMID: 37369613; PMCID: PMC10721718. https://pubmed.ncbi.nlm.nih.gov/37369613/
- Ramsey WA, O'Neil CF Jr, Corona AM, Cohen BL, Lyons NB, Meece MS, Saberi RA, Gilna GP, Satahoo SS, Kaufman JI, Schulman CI, Namias N, Proctor KG, Pizano LR. Burn excision within 48 hours portends better outcomes than standard management: A nationwide analysis. J Trauma Acute Care Surg. 2023 Jul 1;95(1):111-115. doi: 10.1097/TA.0000000000003951. Epub 2023 Apr 11. PMID: 37038260. https://pubmed.ncbi.nlm.nih.gov/37038260/
- Hayashi K, Sasabuchi Y, Matsui H, Nakajima M, Otawara M, Ohbe H, Fushimi K, Ono K, Yasunaga H. Does early excision or skin grafting of severe burns improve prognosis? A retrospective cohort study. Burns. 2023 May;49(3):554-561. doi: 10.1016/j.burns.2023.01.013. Epub 2023 Feb 3. PMID: 36774244. https://pubmed.ncbi.nlm.nih.gov/36774244/
- Janzekovic Z. Once upon a time ... how west discovered east. J Plast Reconstr Aesthet Surg. 2008;61(3):240-4. doi: 10.1016/j.bjps.2008.01.001. Epub 2008 Feb 1. PMID: 18243082. https://pubmed.ncbi.nlm.nih.gov/18243082/

This episode includes a full, sample cardiothoracic scenario pulled directly from our Cardiothoracic Surgery Oral Board Review Course. Listen in and test your clinical pathways in real-time as we walk through the perfect answers and provide high-yield commentary to help you pass the "hot seat."
About our Cardiothoracic Surgery Oral Board Review Course:

43 High-Yield Scenarios

Dual-Format Learning: Each case includes "Part A" (a straight run-through of the perfect exam response) and "Part B" (the same scenario packed with expert tips, tricks, and commentary).

Free Simulator Access: Every purchase of the course includes access to our new AI-powered Oral Board Simulator, allowing you to practice your verbal responses under pressure.

Resources:

Cardiothoracic Surgery Oral Board Review Course: https://app.behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-review

Oral Board Simulator: https://app.behindtheknife.org/oral-board-simulator

Download the BTK App on iOS and Android for on-the-go studying.

DOMINATE THE DAY!

This mini-series on Behind the Knife delves into the technical aspects of the Operative Standards for Cancer Surgery, developed through the American College of Surgeons Cancer Research Program and Cancer Surgery Standards Program. This episode highlights sentinel lymph node biopsy for breast cancer.
Hosts:
- Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a Surgical Oncology fellow at MD Anderson Cancer Center.
- Lauren Postlewait, MD, FACS, is an Associate Professor of Surgery at Emory University School of Medicine and is the Medical Director of the Breast Center at Grady Memorial Hospital in Atlanta, GA.
- Chantal Reyna, MD, FACS (@kprgrl3) is a Breast surgical oncologist at Loyola University Medical Center in Chicago, IL and serves as the oncology clinical lead for the breast service line.
Guest:
- Susan E. Pories, MD, FACS (@SusanPoriesMD) is a professor of surgery, vice chair for quality and safety, and director of the Rutger’s Breast Center at the University hospital. 
Learning Objectives: 
-       Understand the definition and identification of axillary sentinel lymph node. 
-       Understand the technique for injecting tracer or dye to perform sentinel lymph node biopsy. 
-       Understand the importance of preincision drainage evaluation and transcutaneous localization.
-       Understand techniques to minimize seroma formation.
Links to Papers Referenced in this Episode
Operative Standards for Cancer Surgery, Volume 1: Breast, Lung, Pancreas, Colon
https://www.facs.org/quality-programs/cancer-programs/cancer-surgery-standards-program/operative-standards-for-cancer-surgery/purchase/

Kindle edition:
https://www.amazon.com/Operative-Standards-Cancer-Surgery-Section-ebook/dp/B07MWSNFSB

Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial Lancet Oncol. 2010 Oct;11(10):927-33.
https://pubmed.ncbi.nlm.nih.gov/20863759/

Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection J Clin Oncol. 2016 Apr 1;34(10):1072-8.
https://pubmed.ncbi.nlm.nih.gov/26811528/

The false-negative rate of sentinel node biopsy in patients with breast cancer: a meta-analysis World J Surg. 2012 Sep;36(9):2239-51. 
https://pubmed.ncbi.nlm.nih.gov/22569745/

Effect of lymphoscintigraphy drainage patterns on sentinel lymph node biopsy in patients with breast cancer Am J Surg. 2005 Oct;190(4):557-62.
https://pubmed.ncbi.nlm.nih.gov/16164919/

Sentinel Lymph Node Biopsy vs No Axillary Surgery in Patients With Small Breast Cancer and Negative Results on Ultrasonography of Axillary Lymph Nodes: The SOUND Randomized Clinical Trial JAMA Oncol. 2023 Nov 1;9(11):1557-1564.
https://pubmed.ncbi.nlm.nih.gov/37733364/

Choosing Wisely Guidelines
Society of Surgical Oncology. Released 2016 July 12; last updated 2020 November 13. Choosing Wisely: Five Things Physicians and Patients Should Question.
https://surgonc.org/wp-content/uploads/2020/11/SSO-5things-List_2020-Updates-11-2020.pdf

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  
If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen
Behind the Knife Premium:
General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-review
Oral Board Simulator: https://app.behindtheknife.org/oral-board-simulator
Trauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlas
Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-audio-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-audio-review
Cardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-review
Download our App:
Apple App Store: https://apps.apple.com/us/app/behind-the-knife/id1672420049
Android/Google Play: https://play.google.com/store/apps/details?id=com.btk.app&hl=en_US

This episode includes two full, sample vascular scenarios pulled directly from our Vascular Surgery Oral Board Review Course. Listen in and test your clinical pathways in real-time as we walk through the perfect answers and provide high-yield commentary to help you pass the "hot seat."
Sample Scenarios Included in This Episode:

Case 22: Aortoenteric Fistula (AEF). A 78-year-old woman presents to the ER with a massive upper GI bleed and a history of an open AAA repair 10 years ago. We walk you through the immediate stabilization, CTA evaluation, and the definitive operative management—including axillobifemoral bypass, aortic stump closure, and duodenal repair.

Case 27: Acute Mesenteric Ischemia. A 79-year-old woman with a history of atrial fibrillation presents with abdominal pain out of proportion to her physical exam. Test your decision-making on systemic heparinization, SMA embolectomy versus stenting (ROMS), and how to appropriately evaluate bowel viability with a second-look laparotomy.

About our Vascular Surgery Oral Board Review Course:

72 High-Yield Scenarios: Covering everything from carotid stump syndrome to a AAA with a horseshoe kidney.

Dual-Format Learning: Each case includes "Part A" (a straight run-through of the perfect exam response) and "Part B" (the same scenario packed with expert tips, tricks, and commentary).

Free Simulator Access: Every purchase of the course includes access to our new AI-powered Oral Board Simulator, allowing you to practice your verbal responses under pressure.

Resources:

Vascular Surgery Oral Board Review Course: https://app.behindtheknife.org/premium/vascular-surgery-oral-board-audio-review

Oral Board Simulator: https://app.behindtheknife.org/oral-board-simulator

Download the BTK App on iOS and Android for on-the-go studying.

DOMINATE THE DAY!