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Fast-Track EVAR protocol shown safe, effective, and cheaper
LAS VEGAS – A ‘fast-track” stenting method for endovascular abdominal aortic aneurysm repair (EVAR) enabled patients to be treated safely and effectively without general anesthetic or ICU admission, and with next-day discharge, Zvonimir Krajcer, MD, said at the 2016 Vascular Interventional Advances meeting.
Dr. Krajcer discussed the final results of the Prospective LIFE Registry, which followed 250 patients treated with the Ovation Abdominal Stent Graft platform, who had suitable femoral arteries to allow the use of the Perclose ProGlide Suture-Mediated Closure (SMC) System.
For the Fast-Track patients, vascular access, stent graft delivery, and deployment were successful. The Fast-Track EVAR protocol was successfully completed in 216 (87%) of the patients. In comparing the Fast-Track cohort (n = 216) to the non–Fast-Track cohort (n = 34), procedure time was found to be 84 vs. 110 minutes, the use of general anesthesia was 0% vs. 18%, and the need for ICU stay was 0% vs. 32%. Hospital stay for the two groups was 1.2 vs. 1.9 days, respectively.
Quality of life score improvement from baseline to 30 days as assessed via the EQ-5D questionnaire, was significantly greater in the Fast-Track patients, compared with the EVAR controls, said Dr. Krajcer, an interventional cardiologist at Texas Heart Institute and St. Luke’s Hospital, Houston, and a clinical professor of medicine at Baylor College of Medicine.
To determine adverse events, patients were followed through 1 month after treatment. The researchers found no device- or procedure-related major adverse events, abdominal aortic aneurysm (AAA) ruptures, surgical conversions, or AAA-related secondary interventions. One patient in the fast-track group died from acute respiratory failure. Overall, for the Fast-Track and control groups, the freedom from type I/III endoleak was 99% and 100%, respectively.
Dr. Krajcer reported that the 30-day hospital readmission rate in the LIFE study was 1.6%, compared to 8% reported for EVAR from the American College of Surgeons National Surgical Quality Improvement Program.
The economic analysis was performed comparing the Fast-Track patients to a control group, which consisted of a database of 8,306 patients treated with elective infrarenal EVAR at 3,750 U.S. hospitals based on inpatient discharge between 2012 and 2015. The researchers calculated costs related to access, anesthesia, ICU stay, and hospital stay.
The Fast-Track protocol showed $21,000 in perioperative cost savings relative to standard EVAR, largely driven by differences in hospital stay costs, according to Dr. Krajcer.
“Fast-track EVAR using the Ovation Prime stent graft is safe and feasible and lowers perioperative costs,” said Dr. Krajcer. “Our results warrant the establishment of a Fast-Track EVAR protocol in experienced EVAR centers,” he concluded.
Dr. Krajcer had nothing to disclose.
LAS VEGAS – A ‘fast-track” stenting method for endovascular abdominal aortic aneurysm repair (EVAR) enabled patients to be treated safely and effectively without general anesthetic or ICU admission, and with next-day discharge, Zvonimir Krajcer, MD, said at the 2016 Vascular Interventional Advances meeting.
Dr. Krajcer discussed the final results of the Prospective LIFE Registry, which followed 250 patients treated with the Ovation Abdominal Stent Graft platform, who had suitable femoral arteries to allow the use of the Perclose ProGlide Suture-Mediated Closure (SMC) System.
For the Fast-Track patients, vascular access, stent graft delivery, and deployment were successful. The Fast-Track EVAR protocol was successfully completed in 216 (87%) of the patients. In comparing the Fast-Track cohort (n = 216) to the non–Fast-Track cohort (n = 34), procedure time was found to be 84 vs. 110 minutes, the use of general anesthesia was 0% vs. 18%, and the need for ICU stay was 0% vs. 32%. Hospital stay for the two groups was 1.2 vs. 1.9 days, respectively.
Quality of life score improvement from baseline to 30 days as assessed via the EQ-5D questionnaire, was significantly greater in the Fast-Track patients, compared with the EVAR controls, said Dr. Krajcer, an interventional cardiologist at Texas Heart Institute and St. Luke’s Hospital, Houston, and a clinical professor of medicine at Baylor College of Medicine.
To determine adverse events, patients were followed through 1 month after treatment. The researchers found no device- or procedure-related major adverse events, abdominal aortic aneurysm (AAA) ruptures, surgical conversions, or AAA-related secondary interventions. One patient in the fast-track group died from acute respiratory failure. Overall, for the Fast-Track and control groups, the freedom from type I/III endoleak was 99% and 100%, respectively.
Dr. Krajcer reported that the 30-day hospital readmission rate in the LIFE study was 1.6%, compared to 8% reported for EVAR from the American College of Surgeons National Surgical Quality Improvement Program.
The economic analysis was performed comparing the Fast-Track patients to a control group, which consisted of a database of 8,306 patients treated with elective infrarenal EVAR at 3,750 U.S. hospitals based on inpatient discharge between 2012 and 2015. The researchers calculated costs related to access, anesthesia, ICU stay, and hospital stay.
The Fast-Track protocol showed $21,000 in perioperative cost savings relative to standard EVAR, largely driven by differences in hospital stay costs, according to Dr. Krajcer.
“Fast-track EVAR using the Ovation Prime stent graft is safe and feasible and lowers perioperative costs,” said Dr. Krajcer. “Our results warrant the establishment of a Fast-Track EVAR protocol in experienced EVAR centers,” he concluded.
Dr. Krajcer had nothing to disclose.
LAS VEGAS – A ‘fast-track” stenting method for endovascular abdominal aortic aneurysm repair (EVAR) enabled patients to be treated safely and effectively without general anesthetic or ICU admission, and with next-day discharge, Zvonimir Krajcer, MD, said at the 2016 Vascular Interventional Advances meeting.
Dr. Krajcer discussed the final results of the Prospective LIFE Registry, which followed 250 patients treated with the Ovation Abdominal Stent Graft platform, who had suitable femoral arteries to allow the use of the Perclose ProGlide Suture-Mediated Closure (SMC) System.
For the Fast-Track patients, vascular access, stent graft delivery, and deployment were successful. The Fast-Track EVAR protocol was successfully completed in 216 (87%) of the patients. In comparing the Fast-Track cohort (n = 216) to the non–Fast-Track cohort (n = 34), procedure time was found to be 84 vs. 110 minutes, the use of general anesthesia was 0% vs. 18%, and the need for ICU stay was 0% vs. 32%. Hospital stay for the two groups was 1.2 vs. 1.9 days, respectively.
Quality of life score improvement from baseline to 30 days as assessed via the EQ-5D questionnaire, was significantly greater in the Fast-Track patients, compared with the EVAR controls, said Dr. Krajcer, an interventional cardiologist at Texas Heart Institute and St. Luke’s Hospital, Houston, and a clinical professor of medicine at Baylor College of Medicine.
To determine adverse events, patients were followed through 1 month after treatment. The researchers found no device- or procedure-related major adverse events, abdominal aortic aneurysm (AAA) ruptures, surgical conversions, or AAA-related secondary interventions. One patient in the fast-track group died from acute respiratory failure. Overall, for the Fast-Track and control groups, the freedom from type I/III endoleak was 99% and 100%, respectively.
Dr. Krajcer reported that the 30-day hospital readmission rate in the LIFE study was 1.6%, compared to 8% reported for EVAR from the American College of Surgeons National Surgical Quality Improvement Program.
The economic analysis was performed comparing the Fast-Track patients to a control group, which consisted of a database of 8,306 patients treated with elective infrarenal EVAR at 3,750 U.S. hospitals based on inpatient discharge between 2012 and 2015. The researchers calculated costs related to access, anesthesia, ICU stay, and hospital stay.
The Fast-Track protocol showed $21,000 in perioperative cost savings relative to standard EVAR, largely driven by differences in hospital stay costs, according to Dr. Krajcer.
“Fast-track EVAR using the Ovation Prime stent graft is safe and feasible and lowers perioperative costs,” said Dr. Krajcer. “Our results warrant the establishment of a Fast-Track EVAR protocol in experienced EVAR centers,” he concluded.
Dr. Krajcer had nothing to disclose.
AT VIVA16
Key clinical point:
Major finding: Quality of life score improvement from baseline to 30 days was significantly greater in the Fast-Track patients, compared with the EVAR controls.
Data source: The researchers assessed 250 patients in the Prospective LIFE Registry and compared results to more than 8,000 patients in an EVAR database as controls.
Disclosures: Dr. Krajcer had nothing to disclose.
Sarcopenia an effective measure of frailty in elderly patients
WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.
“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).
Traditionally, surgeons use subjective opinion or basic scoring systems such as the American Society of Anesthesiologists (ASA) classification to stratify risk for surgery in elderly patients. “However, the ASA score can be subjective, and there’s inconsistency between evaluators,” Dr. Rangel said. “The Charlson Comorbidity [Index] rates a patient based on the presence or absence of 19 comorbidities, but it doesn’t tell the surgeon anything about the patient’s functional status.” Frailty is a good measure of an elderly patient’s physiologic reserve to withstand an operation, she continued, but is difficult to measure in the acute care setting. One solution is to measure sarcopenia, which predicts postoperative complications, disability, and mortality in elderly elective surgery patients. “The problem is that very few studies have looked at the impact of sarcopenia in the emergency surgery populations, and the ones that exist only look at short-term outcomes, which don’t completely capture the mortality risk,” she said.
In an effort to better understand how sarcopenia affects long-term outcomes after emergency surgery in the elderly, the researchers retrospectively reviewed patients aged 70 years or older who underwent urgent or emergent abdominal surgery at Brigham and Women’s between 2006 and 2011. Patients were stratified by operative severity using the POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) score. Operations considered major included any laparotomy, open cholecystectomy, and bowel resection, while those considered moderate were laparoscopic cholecystectomy, appendectomy, and hernia repairs without bowel compromise. To measure sarcopenia, the researchers used preoperative CT images to calculate the average bilateral psoas muscle cross-sectional area at the L3 level, normalized for height. Primary outcome was 1-year mortality. Secondary outcomes were mortality at 30 days, 90 days, and 180 days.
Dr. Rangel reported results from 297 patients that were evaluated: 222 with no sarcopenia and 75 with sarcopenia. Their mean age was 78 years, 57% were female, and 84% were white. Compared with nonsarcopenic patients, sarcopenic patients did not differ in terms of age, sex, or race. Comorbidities were high in both groups, with 75% of patients having an ASA score of 3 or greater and 31% having a Charlson score of 4 or greater. More than 40% had some sort of underlying malignancy, yet there were no significant differences between the two groups in terms of ASA scores, Charlson scores, or the prevalence of malignancy.
Compared with nonsarcopenic patients, sarcopenic patients had longer hospital length of stay (14 vs. 11 days, respectively; P = .012), were more likely to require ICU care (67% vs. 50%; P = .012), and had higher in-hospital mortality (27% vs. 9%; P less than .01). In addition, sarcopenic patients had higher hazard ratios of mortality, compared with their nonsarcopenic counterparts, at 30 days (hazard ratio, 3.5; P = .01), 90 days (HR, 3.5; P less than .001), 180 days (HR, 2.6; P = .001), and at 1 year (HR, 2.5; P = .001).
“The measurement of sarcopenia is a practical tool that can be used at the bedside,” Dr. Rangel concluded. “It just takes 3 or 4 minutes using a single axial slice of a preoperative CT scan. Since it uses CT imaging that’s obtained for initial diagnostic purposes, it incurs no additional cost. The identification of sarcopenia has immediate applications for care of the geriatric patient. It should trigger the surgeon to set realistic goals of care and frame expectations about survival [and] should prompt processes of care that improve patient outcomes. High-risk patients might benefit from geriatric consultation or specialized geriatric pathways, early palliative care evaluation, and advance care planning.” She reported having no financial disclosures.
WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.
“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).
Traditionally, surgeons use subjective opinion or basic scoring systems such as the American Society of Anesthesiologists (ASA) classification to stratify risk for surgery in elderly patients. “However, the ASA score can be subjective, and there’s inconsistency between evaluators,” Dr. Rangel said. “The Charlson Comorbidity [Index] rates a patient based on the presence or absence of 19 comorbidities, but it doesn’t tell the surgeon anything about the patient’s functional status.” Frailty is a good measure of an elderly patient’s physiologic reserve to withstand an operation, she continued, but is difficult to measure in the acute care setting. One solution is to measure sarcopenia, which predicts postoperative complications, disability, and mortality in elderly elective surgery patients. “The problem is that very few studies have looked at the impact of sarcopenia in the emergency surgery populations, and the ones that exist only look at short-term outcomes, which don’t completely capture the mortality risk,” she said.
In an effort to better understand how sarcopenia affects long-term outcomes after emergency surgery in the elderly, the researchers retrospectively reviewed patients aged 70 years or older who underwent urgent or emergent abdominal surgery at Brigham and Women’s between 2006 and 2011. Patients were stratified by operative severity using the POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) score. Operations considered major included any laparotomy, open cholecystectomy, and bowel resection, while those considered moderate were laparoscopic cholecystectomy, appendectomy, and hernia repairs without bowel compromise. To measure sarcopenia, the researchers used preoperative CT images to calculate the average bilateral psoas muscle cross-sectional area at the L3 level, normalized for height. Primary outcome was 1-year mortality. Secondary outcomes were mortality at 30 days, 90 days, and 180 days.
Dr. Rangel reported results from 297 patients that were evaluated: 222 with no sarcopenia and 75 with sarcopenia. Their mean age was 78 years, 57% were female, and 84% were white. Compared with nonsarcopenic patients, sarcopenic patients did not differ in terms of age, sex, or race. Comorbidities were high in both groups, with 75% of patients having an ASA score of 3 or greater and 31% having a Charlson score of 4 or greater. More than 40% had some sort of underlying malignancy, yet there were no significant differences between the two groups in terms of ASA scores, Charlson scores, or the prevalence of malignancy.
Compared with nonsarcopenic patients, sarcopenic patients had longer hospital length of stay (14 vs. 11 days, respectively; P = .012), were more likely to require ICU care (67% vs. 50%; P = .012), and had higher in-hospital mortality (27% vs. 9%; P less than .01). In addition, sarcopenic patients had higher hazard ratios of mortality, compared with their nonsarcopenic counterparts, at 30 days (hazard ratio, 3.5; P = .01), 90 days (HR, 3.5; P less than .001), 180 days (HR, 2.6; P = .001), and at 1 year (HR, 2.5; P = .001).
“The measurement of sarcopenia is a practical tool that can be used at the bedside,” Dr. Rangel concluded. “It just takes 3 or 4 minutes using a single axial slice of a preoperative CT scan. Since it uses CT imaging that’s obtained for initial diagnostic purposes, it incurs no additional cost. The identification of sarcopenia has immediate applications for care of the geriatric patient. It should trigger the surgeon to set realistic goals of care and frame expectations about survival [and] should prompt processes of care that improve patient outcomes. High-risk patients might benefit from geriatric consultation or specialized geriatric pathways, early palliative care evaluation, and advance care planning.” She reported having no financial disclosures.
WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.
“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).
Traditionally, surgeons use subjective opinion or basic scoring systems such as the American Society of Anesthesiologists (ASA) classification to stratify risk for surgery in elderly patients. “However, the ASA score can be subjective, and there’s inconsistency between evaluators,” Dr. Rangel said. “The Charlson Comorbidity [Index] rates a patient based on the presence or absence of 19 comorbidities, but it doesn’t tell the surgeon anything about the patient’s functional status.” Frailty is a good measure of an elderly patient’s physiologic reserve to withstand an operation, she continued, but is difficult to measure in the acute care setting. One solution is to measure sarcopenia, which predicts postoperative complications, disability, and mortality in elderly elective surgery patients. “The problem is that very few studies have looked at the impact of sarcopenia in the emergency surgery populations, and the ones that exist only look at short-term outcomes, which don’t completely capture the mortality risk,” she said.
In an effort to better understand how sarcopenia affects long-term outcomes after emergency surgery in the elderly, the researchers retrospectively reviewed patients aged 70 years or older who underwent urgent or emergent abdominal surgery at Brigham and Women’s between 2006 and 2011. Patients were stratified by operative severity using the POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) score. Operations considered major included any laparotomy, open cholecystectomy, and bowel resection, while those considered moderate were laparoscopic cholecystectomy, appendectomy, and hernia repairs without bowel compromise. To measure sarcopenia, the researchers used preoperative CT images to calculate the average bilateral psoas muscle cross-sectional area at the L3 level, normalized for height. Primary outcome was 1-year mortality. Secondary outcomes were mortality at 30 days, 90 days, and 180 days.
Dr. Rangel reported results from 297 patients that were evaluated: 222 with no sarcopenia and 75 with sarcopenia. Their mean age was 78 years, 57% were female, and 84% were white. Compared with nonsarcopenic patients, sarcopenic patients did not differ in terms of age, sex, or race. Comorbidities were high in both groups, with 75% of patients having an ASA score of 3 or greater and 31% having a Charlson score of 4 or greater. More than 40% had some sort of underlying malignancy, yet there were no significant differences between the two groups in terms of ASA scores, Charlson scores, or the prevalence of malignancy.
Compared with nonsarcopenic patients, sarcopenic patients had longer hospital length of stay (14 vs. 11 days, respectively; P = .012), were more likely to require ICU care (67% vs. 50%; P = .012), and had higher in-hospital mortality (27% vs. 9%; P less than .01). In addition, sarcopenic patients had higher hazard ratios of mortality, compared with their nonsarcopenic counterparts, at 30 days (hazard ratio, 3.5; P = .01), 90 days (HR, 3.5; P less than .001), 180 days (HR, 2.6; P = .001), and at 1 year (HR, 2.5; P = .001).
“The measurement of sarcopenia is a practical tool that can be used at the bedside,” Dr. Rangel concluded. “It just takes 3 or 4 minutes using a single axial slice of a preoperative CT scan. Since it uses CT imaging that’s obtained for initial diagnostic purposes, it incurs no additional cost. The identification of sarcopenia has immediate applications for care of the geriatric patient. It should trigger the surgeon to set realistic goals of care and frame expectations about survival [and] should prompt processes of care that improve patient outcomes. High-risk patients might benefit from geriatric consultation or specialized geriatric pathways, early palliative care evaluation, and advance care planning.” She reported having no financial disclosures.
Key clinical point:
Major finding: Sarcopenic patients had higher hazard ratios of mortality, compared with their nonsarcopenic counterparts, at 30 days (HR, 3.5), 90 days (HR, 3.5), 180 days (HR, 2.6), and at 1 year (HR, 2.5).
Data source: A retrospective review of 297 patients aged 70 years or older who underwent urgent or emergent abdominal surgery at Brigham and Women’s between 2006 and 2011.
Disclosures: Dr. Rangel reported having no financial disclosures.
Laparoscopic hysterectomy best in morbidly obese uterine cancer patients
BOSTON – Total laparoscopic hysterectomy had fewer complications and a shorter length of stay among morbidly obese women with uterine cancer, compared with an abdominal approach, according to findings presented at the annual Minimally Invasive Surgery Week.
“We wanted to look at current trends and see if we’re doing more the abdominal route or adopting more minimally invasive surgery, but also find out what obesity has to do with it,” Emad Mikhail, MD, of the University of South Florida in Tampa, said in an interview. “Morbidly obese patients are a really vulnerable group of patients; they have a lot of medical comorbidities, and when they need surgery they have an increased risk of having poor perioperative outcomes because of their BMI [body mass index].”
More than half of the cases were total laparoscopic hysterectomy (1,025), a third were total abdominal hysterectomy (672), about 12% were laparoscopic assisted vaginal hysterectomy (248), and less than 3% were total vaginal hysterectomy (57).
Comparing total abdominal and total laparoscopic hysterectomy – the two most commonly performed type of hysterectomy in the study – median operative times were notably higher in total laparoscopic hysterectomy: 171 minutes versus 150 minutes (P less than .05). But the laparoscopic approach had a shorter length of stay, a lower rate of hospital readmissions, and fewer surgical complications.
Within the total laparoscopic hysterectomy cohort, length of stay averaged 1 day. Dr. Mikhail reported that this cohort also had 14 blood transfusions, 13 superficial surgical site infections, 5 deep incisional surgical site infections, and 41 readmissions within 30 days, all of which were significantly lower than in the total abdominal hysterectomy cohort (P less than .05).
Mean BMI was similar in the two groups, with 34.0 in the total abdominal hysterectomy cohort and 33.7 in the total laparoscopic hysterectomy cohort.
“As the BMI goes up, more [minimally invasive surgery] is adopted, which is a great finding,” Dr. Mikhail said. “It actually serves the purpose of vulnerable patients. Instead of having an increase in perioperative morbidity, they should benefit more from a [minimally invasive surgery] approach, which this study is showing.”
Next, Dr. Mikhail said he wants to tease out what types of procedures subspecialists are performing among morbidly obese patients with uterine cancer. This type of data collection would be easier, he added, if minimally invasive gynecologic surgeons had their own taxonomy code.
“Without a code, we cannot pull data and see if being a fellowship-trained, minimally invasive surgeon has a benefit for patients,” he said. “Are those surgeons offering more minimally invasive techniques for morbidly obese patients?”
Dr. Mikhail reported having no relevant financial disclosures. The meeting was held by the Society of Laparoendoscopic Surgeons.
BOSTON – Total laparoscopic hysterectomy had fewer complications and a shorter length of stay among morbidly obese women with uterine cancer, compared with an abdominal approach, according to findings presented at the annual Minimally Invasive Surgery Week.
“We wanted to look at current trends and see if we’re doing more the abdominal route or adopting more minimally invasive surgery, but also find out what obesity has to do with it,” Emad Mikhail, MD, of the University of South Florida in Tampa, said in an interview. “Morbidly obese patients are a really vulnerable group of patients; they have a lot of medical comorbidities, and when they need surgery they have an increased risk of having poor perioperative outcomes because of their BMI [body mass index].”
More than half of the cases were total laparoscopic hysterectomy (1,025), a third were total abdominal hysterectomy (672), about 12% were laparoscopic assisted vaginal hysterectomy (248), and less than 3% were total vaginal hysterectomy (57).
Comparing total abdominal and total laparoscopic hysterectomy – the two most commonly performed type of hysterectomy in the study – median operative times were notably higher in total laparoscopic hysterectomy: 171 minutes versus 150 minutes (P less than .05). But the laparoscopic approach had a shorter length of stay, a lower rate of hospital readmissions, and fewer surgical complications.
Within the total laparoscopic hysterectomy cohort, length of stay averaged 1 day. Dr. Mikhail reported that this cohort also had 14 blood transfusions, 13 superficial surgical site infections, 5 deep incisional surgical site infections, and 41 readmissions within 30 days, all of which were significantly lower than in the total abdominal hysterectomy cohort (P less than .05).
Mean BMI was similar in the two groups, with 34.0 in the total abdominal hysterectomy cohort and 33.7 in the total laparoscopic hysterectomy cohort.
“As the BMI goes up, more [minimally invasive surgery] is adopted, which is a great finding,” Dr. Mikhail said. “It actually serves the purpose of vulnerable patients. Instead of having an increase in perioperative morbidity, they should benefit more from a [minimally invasive surgery] approach, which this study is showing.”
Next, Dr. Mikhail said he wants to tease out what types of procedures subspecialists are performing among morbidly obese patients with uterine cancer. This type of data collection would be easier, he added, if minimally invasive gynecologic surgeons had their own taxonomy code.
“Without a code, we cannot pull data and see if being a fellowship-trained, minimally invasive surgeon has a benefit for patients,” he said. “Are those surgeons offering more minimally invasive techniques for morbidly obese patients?”
Dr. Mikhail reported having no relevant financial disclosures. The meeting was held by the Society of Laparoendoscopic Surgeons.
BOSTON – Total laparoscopic hysterectomy had fewer complications and a shorter length of stay among morbidly obese women with uterine cancer, compared with an abdominal approach, according to findings presented at the annual Minimally Invasive Surgery Week.
“We wanted to look at current trends and see if we’re doing more the abdominal route or adopting more minimally invasive surgery, but also find out what obesity has to do with it,” Emad Mikhail, MD, of the University of South Florida in Tampa, said in an interview. “Morbidly obese patients are a really vulnerable group of patients; they have a lot of medical comorbidities, and when they need surgery they have an increased risk of having poor perioperative outcomes because of their BMI [body mass index].”
More than half of the cases were total laparoscopic hysterectomy (1,025), a third were total abdominal hysterectomy (672), about 12% were laparoscopic assisted vaginal hysterectomy (248), and less than 3% were total vaginal hysterectomy (57).
Comparing total abdominal and total laparoscopic hysterectomy – the two most commonly performed type of hysterectomy in the study – median operative times were notably higher in total laparoscopic hysterectomy: 171 minutes versus 150 minutes (P less than .05). But the laparoscopic approach had a shorter length of stay, a lower rate of hospital readmissions, and fewer surgical complications.
Within the total laparoscopic hysterectomy cohort, length of stay averaged 1 day. Dr. Mikhail reported that this cohort also had 14 blood transfusions, 13 superficial surgical site infections, 5 deep incisional surgical site infections, and 41 readmissions within 30 days, all of which were significantly lower than in the total abdominal hysterectomy cohort (P less than .05).
Mean BMI was similar in the two groups, with 34.0 in the total abdominal hysterectomy cohort and 33.7 in the total laparoscopic hysterectomy cohort.
“As the BMI goes up, more [minimally invasive surgery] is adopted, which is a great finding,” Dr. Mikhail said. “It actually serves the purpose of vulnerable patients. Instead of having an increase in perioperative morbidity, they should benefit more from a [minimally invasive surgery] approach, which this study is showing.”
Next, Dr. Mikhail said he wants to tease out what types of procedures subspecialists are performing among morbidly obese patients with uterine cancer. This type of data collection would be easier, he added, if minimally invasive gynecologic surgeons had their own taxonomy code.
“Without a code, we cannot pull data and see if being a fellowship-trained, minimally invasive surgeon has a benefit for patients,” he said. “Are those surgeons offering more minimally invasive techniques for morbidly obese patients?”
Dr. Mikhail reported having no relevant financial disclosures. The meeting was held by the Society of Laparoendoscopic Surgeons.
Key clinical point:
Major finding: Total laparoscopic hysterectomy had shorter length of stay, fewer transfusions, fewer surgical site infections, and fewer readmissions, compared with total abdominal hysterectomy (P less than .05).
Data source: Retrospective review of data on 2,002 morbidly obese patients with uterine cancer in the ACS-NSQIP database.
Disclosures: Dr. Mikhail reported having no relevant financial disclosures.
ACS should make firearm injury prevention a priority, COT member survey says
WAIKOLOA, HAWAII – Nearly 90% of American College of Surgeons Committee on Trauma members believe that the ACS should give the highest or a high priority to reducing firearm-related injuries, according to results from a national survey.
“In the United States, we value personal liberty and personal safety highly,” Deborah A. Kuhls, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. “However, that sometimes leads to a polarized view on firearms. Some view it as a freedom in personal safety. Others view it as a limitation of freedom and [as promotion of] violence.”
In an effort to evaluate ACS COT member attitudes about firearm ownership, freedom, responsibility, physician/patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development, Dr. Kuhls and the COT Injury Prevention and Control Committee developed a 32-item anonymous survey that was sent to 254 COT members between December 2015 and February 2016. Results were extracted by ACS staff.
Of 254 COT members who received the survey, 237 completed the survey, for a response rate of 93%. Their mean age was 52 years, and 88% were male, 88% were married, 85% were white, and 58% had children in the home. More than one-quarter (29%) had military experience, 88% practiced acute care, trauma, general surgery, or pediatric surgery; 43% had firearms in the home, and 33% had personal experience with a family or friend injured or killed from firearm injury. A significantly higher proportion of respondents with military experience had firearms in the home, compared with those who had no military experience (56% vs. 37%, respectively; P less than .01). By Centers for Disease Control and Prevention demographic region, the percentage of members who have firearms in their home was lowest in the Northeast (14%), followed by the West (38%), the Midwest (48%), and the South (56%).
Dr. Kuhls also reported that 88% of respondents indicated that they think the ACS should give a high or the highest level of priority to firearm injury prevention. When asked about private ownership of firearms, about 53% thought that gun ownership is generally beneficial/an important personal liberty, while 30% believed that gun ownership is generally harmful and limits personal liberty. The remaining 17% had no opinion on the issue.
The majority of respondents (95%) said that health care professionals should be allowed to counsel patients (or parents of patients) about how to prevent gun-related injuries, while 96% felt that the CDC and other federal agencies should fund research on the epidemiology and prevention of gun-related injuries.
Survey respondents were then asked to rate their opinion on the ACS initiating efforts to advocate for or support legislation on 15 possible initiatives to prevent firearm violence, ranging from “improve mental health screening and treatment to reduce suicides and gun violence” to increase penalties when guns [are] provided to others illegally including dealers” to “require safety features, including child-proof locks and ‘smart gun’ technology,” and “identify and implement evidence-based injury prevention programs.”
The greatest consensus was reached in the advocacy area titled “improve mental health screening and treatment to reduce suicides and gun violence” (ranging from 89% to 93%), while the least consensus was in the advocacy area titled “require firearms owners to be 21 years of age or older” (ranging from 41% to 71%).
The most common themes that emerged on qualitative analysis were concern that the topic is too political, as well as calls to improve existing data “to understand what role we can play in injury prevention,” and that “surgeons should be involved in solving the problem,” Dr. Kuhls said. “There were also a lot of comments on responsible ownership.” She noted that more than 90% of respondents support 7 out of 15 proposed initiatives, 80%-90% support an additional 3 initiatives, and 70%-80% support an additional 4 proposed initiatives.
The invited discussant, Ernest E. Moore, MD, FACS, a surgeon in Denver, described the effort to develop firearm injury prevention policy as laudable. However, “this process carries a risk of merely supporting the bandwagons already in motion,” Dr. Moore said. “In that light I would like to focus on the conspicuous areas of disagreement, specifically civilian access to assault rifles. The fundamental issue is the magazine capacity of rifles – housing 30 or more bullets, enabling rapid shooting. Mass shootings, defined as greater than or equal to five victims, are currently an epidemic in our country. The volatile issues are eliminating assault rifles to reduce mass shootings [and] the interpretation of the Second Amendment to keep and bear arms. I do not believe a randomized prospective trial is necessary to establish the fact that mass shootings are only feasible because irresponsible individuals have access to these weapons. The urgency in this issue is heightened by the reality that mass shootings are increasingly inspired by terrorist activity, beyond individuals traditionally considered mentally ill.”
Dr. Kuhls described the current survey as “the initial step” in an effort to develop firearm injury prevention policy. “We are just about to receive results from a survey of the Board of Governors for the ACS,” she said. “We plan to develop short- and long-term plans to address this public health challenge that leverages survey consensus findings in four ACS pillars: advocacy, quality, systems, and education. We need to continue this conversation.” She expressed gratitude to the COT Executive Committee and liaison members from the ACS Board of Regents in addition to members of the COT Injury Prevention and Control Committee. She reported having no financial disclosures.
WAIKOLOA, HAWAII – Nearly 90% of American College of Surgeons Committee on Trauma members believe that the ACS should give the highest or a high priority to reducing firearm-related injuries, according to results from a national survey.
“In the United States, we value personal liberty and personal safety highly,” Deborah A. Kuhls, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. “However, that sometimes leads to a polarized view on firearms. Some view it as a freedom in personal safety. Others view it as a limitation of freedom and [as promotion of] violence.”
In an effort to evaluate ACS COT member attitudes about firearm ownership, freedom, responsibility, physician/patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development, Dr. Kuhls and the COT Injury Prevention and Control Committee developed a 32-item anonymous survey that was sent to 254 COT members between December 2015 and February 2016. Results were extracted by ACS staff.
Of 254 COT members who received the survey, 237 completed the survey, for a response rate of 93%. Their mean age was 52 years, and 88% were male, 88% were married, 85% were white, and 58% had children in the home. More than one-quarter (29%) had military experience, 88% practiced acute care, trauma, general surgery, or pediatric surgery; 43% had firearms in the home, and 33% had personal experience with a family or friend injured or killed from firearm injury. A significantly higher proportion of respondents with military experience had firearms in the home, compared with those who had no military experience (56% vs. 37%, respectively; P less than .01). By Centers for Disease Control and Prevention demographic region, the percentage of members who have firearms in their home was lowest in the Northeast (14%), followed by the West (38%), the Midwest (48%), and the South (56%).
Dr. Kuhls also reported that 88% of respondents indicated that they think the ACS should give a high or the highest level of priority to firearm injury prevention. When asked about private ownership of firearms, about 53% thought that gun ownership is generally beneficial/an important personal liberty, while 30% believed that gun ownership is generally harmful and limits personal liberty. The remaining 17% had no opinion on the issue.
The majority of respondents (95%) said that health care professionals should be allowed to counsel patients (or parents of patients) about how to prevent gun-related injuries, while 96% felt that the CDC and other federal agencies should fund research on the epidemiology and prevention of gun-related injuries.
Survey respondents were then asked to rate their opinion on the ACS initiating efforts to advocate for or support legislation on 15 possible initiatives to prevent firearm violence, ranging from “improve mental health screening and treatment to reduce suicides and gun violence” to increase penalties when guns [are] provided to others illegally including dealers” to “require safety features, including child-proof locks and ‘smart gun’ technology,” and “identify and implement evidence-based injury prevention programs.”
The greatest consensus was reached in the advocacy area titled “improve mental health screening and treatment to reduce suicides and gun violence” (ranging from 89% to 93%), while the least consensus was in the advocacy area titled “require firearms owners to be 21 years of age or older” (ranging from 41% to 71%).
The most common themes that emerged on qualitative analysis were concern that the topic is too political, as well as calls to improve existing data “to understand what role we can play in injury prevention,” and that “surgeons should be involved in solving the problem,” Dr. Kuhls said. “There were also a lot of comments on responsible ownership.” She noted that more than 90% of respondents support 7 out of 15 proposed initiatives, 80%-90% support an additional 3 initiatives, and 70%-80% support an additional 4 proposed initiatives.
The invited discussant, Ernest E. Moore, MD, FACS, a surgeon in Denver, described the effort to develop firearm injury prevention policy as laudable. However, “this process carries a risk of merely supporting the bandwagons already in motion,” Dr. Moore said. “In that light I would like to focus on the conspicuous areas of disagreement, specifically civilian access to assault rifles. The fundamental issue is the magazine capacity of rifles – housing 30 or more bullets, enabling rapid shooting. Mass shootings, defined as greater than or equal to five victims, are currently an epidemic in our country. The volatile issues are eliminating assault rifles to reduce mass shootings [and] the interpretation of the Second Amendment to keep and bear arms. I do not believe a randomized prospective trial is necessary to establish the fact that mass shootings are only feasible because irresponsible individuals have access to these weapons. The urgency in this issue is heightened by the reality that mass shootings are increasingly inspired by terrorist activity, beyond individuals traditionally considered mentally ill.”
Dr. Kuhls described the current survey as “the initial step” in an effort to develop firearm injury prevention policy. “We are just about to receive results from a survey of the Board of Governors for the ACS,” she said. “We plan to develop short- and long-term plans to address this public health challenge that leverages survey consensus findings in four ACS pillars: advocacy, quality, systems, and education. We need to continue this conversation.” She expressed gratitude to the COT Executive Committee and liaison members from the ACS Board of Regents in addition to members of the COT Injury Prevention and Control Committee. She reported having no financial disclosures.
WAIKOLOA, HAWAII – Nearly 90% of American College of Surgeons Committee on Trauma members believe that the ACS should give the highest or a high priority to reducing firearm-related injuries, according to results from a national survey.
“In the United States, we value personal liberty and personal safety highly,” Deborah A. Kuhls, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. “However, that sometimes leads to a polarized view on firearms. Some view it as a freedom in personal safety. Others view it as a limitation of freedom and [as promotion of] violence.”
In an effort to evaluate ACS COT member attitudes about firearm ownership, freedom, responsibility, physician/patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development, Dr. Kuhls and the COT Injury Prevention and Control Committee developed a 32-item anonymous survey that was sent to 254 COT members between December 2015 and February 2016. Results were extracted by ACS staff.
Of 254 COT members who received the survey, 237 completed the survey, for a response rate of 93%. Their mean age was 52 years, and 88% were male, 88% were married, 85% were white, and 58% had children in the home. More than one-quarter (29%) had military experience, 88% practiced acute care, trauma, general surgery, or pediatric surgery; 43% had firearms in the home, and 33% had personal experience with a family or friend injured or killed from firearm injury. A significantly higher proportion of respondents with military experience had firearms in the home, compared with those who had no military experience (56% vs. 37%, respectively; P less than .01). By Centers for Disease Control and Prevention demographic region, the percentage of members who have firearms in their home was lowest in the Northeast (14%), followed by the West (38%), the Midwest (48%), and the South (56%).
Dr. Kuhls also reported that 88% of respondents indicated that they think the ACS should give a high or the highest level of priority to firearm injury prevention. When asked about private ownership of firearms, about 53% thought that gun ownership is generally beneficial/an important personal liberty, while 30% believed that gun ownership is generally harmful and limits personal liberty. The remaining 17% had no opinion on the issue.
The majority of respondents (95%) said that health care professionals should be allowed to counsel patients (or parents of patients) about how to prevent gun-related injuries, while 96% felt that the CDC and other federal agencies should fund research on the epidemiology and prevention of gun-related injuries.
Survey respondents were then asked to rate their opinion on the ACS initiating efforts to advocate for or support legislation on 15 possible initiatives to prevent firearm violence, ranging from “improve mental health screening and treatment to reduce suicides and gun violence” to increase penalties when guns [are] provided to others illegally including dealers” to “require safety features, including child-proof locks and ‘smart gun’ technology,” and “identify and implement evidence-based injury prevention programs.”
The greatest consensus was reached in the advocacy area titled “improve mental health screening and treatment to reduce suicides and gun violence” (ranging from 89% to 93%), while the least consensus was in the advocacy area titled “require firearms owners to be 21 years of age or older” (ranging from 41% to 71%).
The most common themes that emerged on qualitative analysis were concern that the topic is too political, as well as calls to improve existing data “to understand what role we can play in injury prevention,” and that “surgeons should be involved in solving the problem,” Dr. Kuhls said. “There were also a lot of comments on responsible ownership.” She noted that more than 90% of respondents support 7 out of 15 proposed initiatives, 80%-90% support an additional 3 initiatives, and 70%-80% support an additional 4 proposed initiatives.
The invited discussant, Ernest E. Moore, MD, FACS, a surgeon in Denver, described the effort to develop firearm injury prevention policy as laudable. However, “this process carries a risk of merely supporting the bandwagons already in motion,” Dr. Moore said. “In that light I would like to focus on the conspicuous areas of disagreement, specifically civilian access to assault rifles. The fundamental issue is the magazine capacity of rifles – housing 30 or more bullets, enabling rapid shooting. Mass shootings, defined as greater than or equal to five victims, are currently an epidemic in our country. The volatile issues are eliminating assault rifles to reduce mass shootings [and] the interpretation of the Second Amendment to keep and bear arms. I do not believe a randomized prospective trial is necessary to establish the fact that mass shootings are only feasible because irresponsible individuals have access to these weapons. The urgency in this issue is heightened by the reality that mass shootings are increasingly inspired by terrorist activity, beyond individuals traditionally considered mentally ill.”
Dr. Kuhls described the current survey as “the initial step” in an effort to develop firearm injury prevention policy. “We are just about to receive results from a survey of the Board of Governors for the ACS,” she said. “We plan to develop short- and long-term plans to address this public health challenge that leverages survey consensus findings in four ACS pillars: advocacy, quality, systems, and education. We need to continue this conversation.” She expressed gratitude to the COT Executive Committee and liaison members from the ACS Board of Regents in addition to members of the COT Injury Prevention and Control Committee. She reported having no financial disclosures.
Key clinical point:
Major finding: A majority of respondents (88%) indicated that they think the ACS should give a high or the highest level of priority to firearm injury prevention.
Data source: Responses to 32-item anonymous survey that was completed by 237 members of the ACS COT between December 2015 and February 2016.
Disclosures: Dr. Kuhls reported having no financial disclosures.
Trauma operative training declining for general surgery residents
WAIKOLOA, HAWAII – Trauma training for general surgery residents has significantly declined in recent years, results from an analysis of the Accreditation Council for Graduate Medical Education data registry on surgical education showed.
Aaron Strumwasser, MD, an attending trauma surgeon and surgical intensivist at the Los Angeles County/University of Southern California Medical Center, characterized the decline in trauma training as “sobering.” In an effort to test their hypothesis that trauma training for general surgery residents is on the decline since the inception of the 80-hour workweek, Dr. Strumwasser and his associates set out to compare the operative caseloads before and after the inception of the 80-hour workweek; to note trends in specific operative domains and determine if deficiencies exist and to determine whether subspecialty training (specifically, vascular fellowship and integrated vascular surgery residency) has altered general surgery resident operative volume. They extracted data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015. Only those cases logged as primary surgery were included. The researchers subdivided trauma cases into five domains: head and neck, thoracic, abdomen, solid organ, and extremity. Resident trauma experience (operative caseload) was compared, based on before the inception of the 80-hour workweek (1999-2002) and after (2003-present).
Solutions to the current situation seem to fall into one of three categories, Dr. Strumwasser said: advanced simulation training such as Advanced Surgical Skills Exposure in Trauma and Advanced Trauma Operative Management; extending or changing the structure of general surgery training and promoting trauma and Acute Care Surgery fellowships.
“Subspecialization has clearly narrowed the scope of general surgery and trauma surgery practice. As a result, we now treat many complex injuries with a team-based approach. So unless societal trends reverse, it is highly unlikely that we will do more open operations in the future, since many nonoperative and noninvasive options work just as well or even better, said Dr. Malangoni. “It’s easy to blame these changes on duty hours requirements and the corresponding reduction in call, and decreasing exposure to trauma and emergent conditions. However, it’s important to recognize that there are 10% more residencies as well as 15% more resident graduates in 2015, compared to 15 years ago, which further magnifies the effect of the overall decline in trauma operative volume. So how do we meet the challenge of teaching residents to perform operations uncommonly done not only during but also after residency, while maintaining quality care for our patients? This is a challenge shared by nearly every surgical specialty due to a general decline in open operations overall.”
Dr. Strumwasser reported having no financial disclosures.
WAIKOLOA, HAWAII – Trauma training for general surgery residents has significantly declined in recent years, results from an analysis of the Accreditation Council for Graduate Medical Education data registry on surgical education showed.
Aaron Strumwasser, MD, an attending trauma surgeon and surgical intensivist at the Los Angeles County/University of Southern California Medical Center, characterized the decline in trauma training as “sobering.” In an effort to test their hypothesis that trauma training for general surgery residents is on the decline since the inception of the 80-hour workweek, Dr. Strumwasser and his associates set out to compare the operative caseloads before and after the inception of the 80-hour workweek; to note trends in specific operative domains and determine if deficiencies exist and to determine whether subspecialty training (specifically, vascular fellowship and integrated vascular surgery residency) has altered general surgery resident operative volume. They extracted data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015. Only those cases logged as primary surgery were included. The researchers subdivided trauma cases into five domains: head and neck, thoracic, abdomen, solid organ, and extremity. Resident trauma experience (operative caseload) was compared, based on before the inception of the 80-hour workweek (1999-2002) and after (2003-present).
Solutions to the current situation seem to fall into one of three categories, Dr. Strumwasser said: advanced simulation training such as Advanced Surgical Skills Exposure in Trauma and Advanced Trauma Operative Management; extending or changing the structure of general surgery training and promoting trauma and Acute Care Surgery fellowships.
“Subspecialization has clearly narrowed the scope of general surgery and trauma surgery practice. As a result, we now treat many complex injuries with a team-based approach. So unless societal trends reverse, it is highly unlikely that we will do more open operations in the future, since many nonoperative and noninvasive options work just as well or even better, said Dr. Malangoni. “It’s easy to blame these changes on duty hours requirements and the corresponding reduction in call, and decreasing exposure to trauma and emergent conditions. However, it’s important to recognize that there are 10% more residencies as well as 15% more resident graduates in 2015, compared to 15 years ago, which further magnifies the effect of the overall decline in trauma operative volume. So how do we meet the challenge of teaching residents to perform operations uncommonly done not only during but also after residency, while maintaining quality care for our patients? This is a challenge shared by nearly every surgical specialty due to a general decline in open operations overall.”
Dr. Strumwasser reported having no financial disclosures.
WAIKOLOA, HAWAII – Trauma training for general surgery residents has significantly declined in recent years, results from an analysis of the Accreditation Council for Graduate Medical Education data registry on surgical education showed.
Aaron Strumwasser, MD, an attending trauma surgeon and surgical intensivist at the Los Angeles County/University of Southern California Medical Center, characterized the decline in trauma training as “sobering.” In an effort to test their hypothesis that trauma training for general surgery residents is on the decline since the inception of the 80-hour workweek, Dr. Strumwasser and his associates set out to compare the operative caseloads before and after the inception of the 80-hour workweek; to note trends in specific operative domains and determine if deficiencies exist and to determine whether subspecialty training (specifically, vascular fellowship and integrated vascular surgery residency) has altered general surgery resident operative volume. They extracted data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015. Only those cases logged as primary surgery were included. The researchers subdivided trauma cases into five domains: head and neck, thoracic, abdomen, solid organ, and extremity. Resident trauma experience (operative caseload) was compared, based on before the inception of the 80-hour workweek (1999-2002) and after (2003-present).
Solutions to the current situation seem to fall into one of three categories, Dr. Strumwasser said: advanced simulation training such as Advanced Surgical Skills Exposure in Trauma and Advanced Trauma Operative Management; extending or changing the structure of general surgery training and promoting trauma and Acute Care Surgery fellowships.
“Subspecialization has clearly narrowed the scope of general surgery and trauma surgery practice. As a result, we now treat many complex injuries with a team-based approach. So unless societal trends reverse, it is highly unlikely that we will do more open operations in the future, since many nonoperative and noninvasive options work just as well or even better, said Dr. Malangoni. “It’s easy to blame these changes on duty hours requirements and the corresponding reduction in call, and decreasing exposure to trauma and emergent conditions. However, it’s important to recognize that there are 10% more residencies as well as 15% more resident graduates in 2015, compared to 15 years ago, which further magnifies the effect of the overall decline in trauma operative volume. So how do we meet the challenge of teaching residents to perform operations uncommonly done not only during but also after residency, while maintaining quality care for our patients? This is a challenge shared by nearly every surgical specialty due to a general decline in open operations overall.”
Dr. Strumwasser reported having no financial disclosures.
Key clinical point:
Major finding: A trend toward decreased operative trauma for general surgery residents was observed in the time periods before and after implementation of the 80-hour workweek (a mean of 39,252 vs. 36,065 cases, respectively; P = .07).
Data source: An analysis of data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015.
Disclosures: Dr. Strumwasser reported having no financial disclosures.
Absorbable suture performs well in sacrocolpopexy with mesh
DENVER – Using absorbable polydioxanone suture during laparoscopic sacrocolpopexy was associated with a mesh erosion rate of just 1.6%, according to a single-center, 1-year prospective study of 64 patients.
That is substantially less than typical erosion rates of about 5% when permanent suture is used, Danielle Taylor, DO, of Akron (Ohio ) General Medical Center said at Pelvic Floor Disorders Week sponsored by the American Urogynecologic Society.
The researchers observed no anatomic failures or suture extrusions, and patients reported significant postoperative improvements on several validated measures of quality of life.
“Larger samples and longer follow-up may be needed,” said Dr. Taylor. “But our study suggests that permanent, nondissolving suture material may not be necessary for sacrocolpopexy.”
Sacrocolpopexy with mesh usually involves using nonabsorbable suture to attach its anterior and posterior arms to the vaginal mucosa. Instead, Dr. Taylor and colleagues used 90-day delayed absorbable 2.0 V-Loc (Covidien) suture during laparoscopic sacrocolpopexy for patients with baseline Pelvic Organ Prolapse Quantification (POP-Q) scores of at least 2 and symptomatic uterovaginal prolapse.
Two permanent Gore-Tex sutures were also placed at the apex of the cervix in each of the 64 patients, said Dr. Taylor, a urogynecology fellow at the University of Massachusetts, Worcester, who worked on the study as a resident at the Cleveland Clinic Akron General, in Ohio. She and her colleagues rechecked patients at postoperative weeks 2 and 6, and at months 6 and 12. They lost two patients to follow-up, both after week 2.
At baseline, 37 patients (58%) were in stage II pelvic organ prolapse, 27% were in stage III, and 14% were in stage IV. At 6 months after surgery, 85% had no detectable prolapse, 8% had stage I, and 6% had stage II. At 1 year, 82% remained in pelvic organ prolapse stage 0 and the rest were in stage I or II. All stage II patients remained asymptomatic, Dr. Taylor said.
At baseline, the median value for POP-Q point C was -3 (range, –8 to +6). At 6 months and 1 year later, the median value had improved to –8, and patients ranged between –10 and –8.
Quality of life surveys of 54 patients reflected these outcomes, Dr. Taylor said. A year after surgery, average scores on the Pelvic Floor Distress Index (PFDI) dropped by 67 points, from 103 to 35 (P less than .0001). Likewise, average scores on the Pelvic Floor Impact Questionnaire (PFIQ) dropped by 29 points (P less than .0001), and scores on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) indicated a significant decrease in the effects of pelvic organ prolapse on sexual functioning (P = .008).
In addition to a single case of mesh erosion, one patient developed postoperative ileus and one experienced small bowel obstruction, both of which resolved, Dr. Taylor reported. The researchers aim to continue the study with longer follow-up intervals and detailed analyses of postoperative pain.
Dr. Taylor reported no funding sources and had no disclosures. One coauthor disclosed ties to Coloplast Corp.
DENVER – Using absorbable polydioxanone suture during laparoscopic sacrocolpopexy was associated with a mesh erosion rate of just 1.6%, according to a single-center, 1-year prospective study of 64 patients.
That is substantially less than typical erosion rates of about 5% when permanent suture is used, Danielle Taylor, DO, of Akron (Ohio ) General Medical Center said at Pelvic Floor Disorders Week sponsored by the American Urogynecologic Society.
The researchers observed no anatomic failures or suture extrusions, and patients reported significant postoperative improvements on several validated measures of quality of life.
“Larger samples and longer follow-up may be needed,” said Dr. Taylor. “But our study suggests that permanent, nondissolving suture material may not be necessary for sacrocolpopexy.”
Sacrocolpopexy with mesh usually involves using nonabsorbable suture to attach its anterior and posterior arms to the vaginal mucosa. Instead, Dr. Taylor and colleagues used 90-day delayed absorbable 2.0 V-Loc (Covidien) suture during laparoscopic sacrocolpopexy for patients with baseline Pelvic Organ Prolapse Quantification (POP-Q) scores of at least 2 and symptomatic uterovaginal prolapse.
Two permanent Gore-Tex sutures were also placed at the apex of the cervix in each of the 64 patients, said Dr. Taylor, a urogynecology fellow at the University of Massachusetts, Worcester, who worked on the study as a resident at the Cleveland Clinic Akron General, in Ohio. She and her colleagues rechecked patients at postoperative weeks 2 and 6, and at months 6 and 12. They lost two patients to follow-up, both after week 2.
At baseline, 37 patients (58%) were in stage II pelvic organ prolapse, 27% were in stage III, and 14% were in stage IV. At 6 months after surgery, 85% had no detectable prolapse, 8% had stage I, and 6% had stage II. At 1 year, 82% remained in pelvic organ prolapse stage 0 and the rest were in stage I or II. All stage II patients remained asymptomatic, Dr. Taylor said.
At baseline, the median value for POP-Q point C was -3 (range, –8 to +6). At 6 months and 1 year later, the median value had improved to –8, and patients ranged between –10 and –8.
Quality of life surveys of 54 patients reflected these outcomes, Dr. Taylor said. A year after surgery, average scores on the Pelvic Floor Distress Index (PFDI) dropped by 67 points, from 103 to 35 (P less than .0001). Likewise, average scores on the Pelvic Floor Impact Questionnaire (PFIQ) dropped by 29 points (P less than .0001), and scores on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) indicated a significant decrease in the effects of pelvic organ prolapse on sexual functioning (P = .008).
In addition to a single case of mesh erosion, one patient developed postoperative ileus and one experienced small bowel obstruction, both of which resolved, Dr. Taylor reported. The researchers aim to continue the study with longer follow-up intervals and detailed analyses of postoperative pain.
Dr. Taylor reported no funding sources and had no disclosures. One coauthor disclosed ties to Coloplast Corp.
DENVER – Using absorbable polydioxanone suture during laparoscopic sacrocolpopexy was associated with a mesh erosion rate of just 1.6%, according to a single-center, 1-year prospective study of 64 patients.
That is substantially less than typical erosion rates of about 5% when permanent suture is used, Danielle Taylor, DO, of Akron (Ohio ) General Medical Center said at Pelvic Floor Disorders Week sponsored by the American Urogynecologic Society.
The researchers observed no anatomic failures or suture extrusions, and patients reported significant postoperative improvements on several validated measures of quality of life.
“Larger samples and longer follow-up may be needed,” said Dr. Taylor. “But our study suggests that permanent, nondissolving suture material may not be necessary for sacrocolpopexy.”
Sacrocolpopexy with mesh usually involves using nonabsorbable suture to attach its anterior and posterior arms to the vaginal mucosa. Instead, Dr. Taylor and colleagues used 90-day delayed absorbable 2.0 V-Loc (Covidien) suture during laparoscopic sacrocolpopexy for patients with baseline Pelvic Organ Prolapse Quantification (POP-Q) scores of at least 2 and symptomatic uterovaginal prolapse.
Two permanent Gore-Tex sutures were also placed at the apex of the cervix in each of the 64 patients, said Dr. Taylor, a urogynecology fellow at the University of Massachusetts, Worcester, who worked on the study as a resident at the Cleveland Clinic Akron General, in Ohio. She and her colleagues rechecked patients at postoperative weeks 2 and 6, and at months 6 and 12. They lost two patients to follow-up, both after week 2.
At baseline, 37 patients (58%) were in stage II pelvic organ prolapse, 27% were in stage III, and 14% were in stage IV. At 6 months after surgery, 85% had no detectable prolapse, 8% had stage I, and 6% had stage II. At 1 year, 82% remained in pelvic organ prolapse stage 0 and the rest were in stage I or II. All stage II patients remained asymptomatic, Dr. Taylor said.
At baseline, the median value for POP-Q point C was -3 (range, –8 to +6). At 6 months and 1 year later, the median value had improved to –8, and patients ranged between –10 and –8.
Quality of life surveys of 54 patients reflected these outcomes, Dr. Taylor said. A year after surgery, average scores on the Pelvic Floor Distress Index (PFDI) dropped by 67 points, from 103 to 35 (P less than .0001). Likewise, average scores on the Pelvic Floor Impact Questionnaire (PFIQ) dropped by 29 points (P less than .0001), and scores on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) indicated a significant decrease in the effects of pelvic organ prolapse on sexual functioning (P = .008).
In addition to a single case of mesh erosion, one patient developed postoperative ileus and one experienced small bowel obstruction, both of which resolved, Dr. Taylor reported. The researchers aim to continue the study with longer follow-up intervals and detailed analyses of postoperative pain.
Dr. Taylor reported no funding sources and had no disclosures. One coauthor disclosed ties to Coloplast Corp.
Key clinical point:
Major finding: When 90-day delayed absorbable polydioxanone suture was used, the mesh erosion rate was 1.6%. There were no anatomic failures or cases of suture extrusion.
Data source: A single-center prospective case series of 64 patients.
Disclosures: Dr. Taylor reported having no financial disclosures. One coauthor reported ties to Coloplast Corp.
ATA’s risk assessment guidelines for thyroid nodules using sonography patterns validated
DENVER – The malignancy risk of thyroid nodules can be assessed with reassuring accuracy using ultrasound and the guidelines developed by the American Thyroid Association.
Ultrasound assessment is the first step of the evaluation of any patient with one or more thyroid nodules. “Maybe it shouldn’t be, but, for now, it is,” noted David L. Steward, MD, at the annual meeting of the American Thyroid Association.
The ATA guidelines categorize thyroid nodules on the basis of their ultrasound patterns, with the high risk of malignancy being in nodules that are taller than they are wide and /or have microcalcifications, irregular margins, hypoechoic areas, extrathyroidal extension, interrupted rim calcification with soft tissue extrusion, and suspicious lymph nodes. Between 70% and 90% of thyroids with such patterns will contain malignancy, according to the ATA guidelines. Lesions with an intermediate risk of malignancy have such sonographic findings as hypoechoic solid tissue and regular margins; between 10% and 20% of these are malignant. The third category in the ATA’s guidelines are those that are of low suspicion, with hyperechoic solid tissue, isoechoic solid tissue, partially cystic with eccentric solid area, and regular margins; 5%-10% of these are malignant. Thyroid nodules with a very-low risk of malignancy (less than 3%) are spongiform or partially cystic with no suspicious findings. Finally, benign nodules, of which less than 1% contain malignancy, are cysts, he said.
“We found that the size of the nodule on ultrasound that underwent fine needle aspiration was inversely correlated with malignancy risk: The lower risk nodules were larger,” he said.
Using the ATA’s system, 9 (4%) of the nodules were high risk, 64 (31%) were intermediate risk, 79 (38%) were low risk, 54 (26%) were very-low risk, and none were benign. Five of the nodules were not included in the results presented.
There was good correlation between the Bethesda and ATA classification systems. Of the lesions that were malignant or suspicious for malignancy in the Bethesda system, 77% were very-high risk for malignancy on ultrasound according to the ATA. Of the lesions that were atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), 22% were very high risk according to the ATA. Neither of the systems classified as malignant any of the lesions as follicular/Hurthle cell cancer, benign, or nondiagnostic.
The AUS/FLUS nodules “tend to be all over the map,” he noted. Looking at just the AUS/FLUS nodules, malignancy was found on pathology in 100% classified by the ATA system as being high risk; in 21% of those called intermediate risk; in 17% of those called low risk; and in 12% of the very-low risk group.
The study was funded by the University of Cincinnati. Dr. Steward said his only disclosure is that he was a member of the ATA committee that wrote the guidelines under evaluation in this study.
DENVER – The malignancy risk of thyroid nodules can be assessed with reassuring accuracy using ultrasound and the guidelines developed by the American Thyroid Association.
Ultrasound assessment is the first step of the evaluation of any patient with one or more thyroid nodules. “Maybe it shouldn’t be, but, for now, it is,” noted David L. Steward, MD, at the annual meeting of the American Thyroid Association.
The ATA guidelines categorize thyroid nodules on the basis of their ultrasound patterns, with the high risk of malignancy being in nodules that are taller than they are wide and /or have microcalcifications, irregular margins, hypoechoic areas, extrathyroidal extension, interrupted rim calcification with soft tissue extrusion, and suspicious lymph nodes. Between 70% and 90% of thyroids with such patterns will contain malignancy, according to the ATA guidelines. Lesions with an intermediate risk of malignancy have such sonographic findings as hypoechoic solid tissue and regular margins; between 10% and 20% of these are malignant. The third category in the ATA’s guidelines are those that are of low suspicion, with hyperechoic solid tissue, isoechoic solid tissue, partially cystic with eccentric solid area, and regular margins; 5%-10% of these are malignant. Thyroid nodules with a very-low risk of malignancy (less than 3%) are spongiform or partially cystic with no suspicious findings. Finally, benign nodules, of which less than 1% contain malignancy, are cysts, he said.
“We found that the size of the nodule on ultrasound that underwent fine needle aspiration was inversely correlated with malignancy risk: The lower risk nodules were larger,” he said.
Using the ATA’s system, 9 (4%) of the nodules were high risk, 64 (31%) were intermediate risk, 79 (38%) were low risk, 54 (26%) were very-low risk, and none were benign. Five of the nodules were not included in the results presented.
There was good correlation between the Bethesda and ATA classification systems. Of the lesions that were malignant or suspicious for malignancy in the Bethesda system, 77% were very-high risk for malignancy on ultrasound according to the ATA. Of the lesions that were atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), 22% were very high risk according to the ATA. Neither of the systems classified as malignant any of the lesions as follicular/Hurthle cell cancer, benign, or nondiagnostic.
The AUS/FLUS nodules “tend to be all over the map,” he noted. Looking at just the AUS/FLUS nodules, malignancy was found on pathology in 100% classified by the ATA system as being high risk; in 21% of those called intermediate risk; in 17% of those called low risk; and in 12% of the very-low risk group.
The study was funded by the University of Cincinnati. Dr. Steward said his only disclosure is that he was a member of the ATA committee that wrote the guidelines under evaluation in this study.
DENVER – The malignancy risk of thyroid nodules can be assessed with reassuring accuracy using ultrasound and the guidelines developed by the American Thyroid Association.
Ultrasound assessment is the first step of the evaluation of any patient with one or more thyroid nodules. “Maybe it shouldn’t be, but, for now, it is,” noted David L. Steward, MD, at the annual meeting of the American Thyroid Association.
The ATA guidelines categorize thyroid nodules on the basis of their ultrasound patterns, with the high risk of malignancy being in nodules that are taller than they are wide and /or have microcalcifications, irregular margins, hypoechoic areas, extrathyroidal extension, interrupted rim calcification with soft tissue extrusion, and suspicious lymph nodes. Between 70% and 90% of thyroids with such patterns will contain malignancy, according to the ATA guidelines. Lesions with an intermediate risk of malignancy have such sonographic findings as hypoechoic solid tissue and regular margins; between 10% and 20% of these are malignant. The third category in the ATA’s guidelines are those that are of low suspicion, with hyperechoic solid tissue, isoechoic solid tissue, partially cystic with eccentric solid area, and regular margins; 5%-10% of these are malignant. Thyroid nodules with a very-low risk of malignancy (less than 3%) are spongiform or partially cystic with no suspicious findings. Finally, benign nodules, of which less than 1% contain malignancy, are cysts, he said.
“We found that the size of the nodule on ultrasound that underwent fine needle aspiration was inversely correlated with malignancy risk: The lower risk nodules were larger,” he said.
Using the ATA’s system, 9 (4%) of the nodules were high risk, 64 (31%) were intermediate risk, 79 (38%) were low risk, 54 (26%) were very-low risk, and none were benign. Five of the nodules were not included in the results presented.
There was good correlation between the Bethesda and ATA classification systems. Of the lesions that were malignant or suspicious for malignancy in the Bethesda system, 77% were very-high risk for malignancy on ultrasound according to the ATA. Of the lesions that were atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), 22% were very high risk according to the ATA. Neither of the systems classified as malignant any of the lesions as follicular/Hurthle cell cancer, benign, or nondiagnostic.
The AUS/FLUS nodules “tend to be all over the map,” he noted. Looking at just the AUS/FLUS nodules, malignancy was found on pathology in 100% classified by the ATA system as being high risk; in 21% of those called intermediate risk; in 17% of those called low risk; and in 12% of the very-low risk group.
The study was funded by the University of Cincinnati. Dr. Steward said his only disclosure is that he was a member of the ATA committee that wrote the guidelines under evaluation in this study.
Key clinical point:
Major finding: Of the lesions that were malignant or suspicious for malignancy in the Bethesda system, 77% were very-high risk for malignancy on ultrasound, according to the ATA.
Data source: Prospective validation of the ATA’s ultrasound risk assessment guidelines on 211 thyroid nodules excised from 199 patients.
Disclosures: The study was funded by the University of Cincinnati. Dr. Steward said his only disclosure is that he was a member of the ATA committee that wrote the guidelines under evaluation in this study.
Robotic surgery boasts fewer postoperative complications in radical hysterectomy
BOSTON – Robot-assisted radical hysterectomy is just as safe, or perhaps safer, than open surgery, according to a new study that examined perioperative and postoperative outcomes with long-term follow-ups for both types of procedures.
“Robotic surgery has been expanding for the last 20 years, but still the recurrence rate with cancer patients is missing data because very few studies are published; they don’t have long-term oncologic outcomes, and if [the technology] works properly we have to put it into the literature,” M. Bilal Sert, MD, of Oslo University, said at the annual Minimally Invasive Surgery Week.
Dr. Sert and his coinvestigators identified 215 women who underwent either open or robot-assisted radical hysterectomy between November 2005 and December 2012. All of the procedures were elective and the robot-assisted operations were performed using the da Vinci robotic surgical platform. After excluding neoadjuvant cases, which totaled 19, the researchers looked at data on 196 patients (122 open radical hysterectomy cases and 74 robot-assisted radical hysterectomy cases).
On average, operating time for open radical hysterectomy was 171 minutes, versus 263 minutes for robot-assisted radical hysterectomy. However, the robotic surgery arm had lower mean estimated blood loss than the open surgery cohort: 80 milliliters versus 468 milliliters, respectively (P = .003). Follow-up time frames were shorter in the robotic surgery cohort by 6 months: 46 months reported for robotic surgery, compared with a 52-month average experienced by those in the open surgery cohort.
Both groups experienced recurrences, including 12 patients in the open surgery cohort (9.8%) and 9 patients in the robotic surgery cohort (12.1%) (P = .3), indicating a statistically insignificant difference. Similarly, rates of perioperative complications were 8% for open surgery and 11% for robotic surgery (P = .3), which was not significantly different.
However, rates of postoperative complications were 36% for open surgery and 12% for robotic surgery (P = .001), which was statistically significant.
“Based on our data, I can say that [robot-assisted radical hysterectomy] is safe, and in fact I prefer to use the robot,” Dr. Sert said at the meeting, which was held by the Society of Laparoendoscopic Surgeons. “Of course, robot-assisted surgery will not automatically make you a better surgeon, but on more complicated radical hysterectomy patients, it will help make the surgeon more precise.”
No funding source was disclosed for this study. Dr. Sert reported having no relevant financial disclosures.
BOSTON – Robot-assisted radical hysterectomy is just as safe, or perhaps safer, than open surgery, according to a new study that examined perioperative and postoperative outcomes with long-term follow-ups for both types of procedures.
“Robotic surgery has been expanding for the last 20 years, but still the recurrence rate with cancer patients is missing data because very few studies are published; they don’t have long-term oncologic outcomes, and if [the technology] works properly we have to put it into the literature,” M. Bilal Sert, MD, of Oslo University, said at the annual Minimally Invasive Surgery Week.
Dr. Sert and his coinvestigators identified 215 women who underwent either open or robot-assisted radical hysterectomy between November 2005 and December 2012. All of the procedures were elective and the robot-assisted operations were performed using the da Vinci robotic surgical platform. After excluding neoadjuvant cases, which totaled 19, the researchers looked at data on 196 patients (122 open radical hysterectomy cases and 74 robot-assisted radical hysterectomy cases).
On average, operating time for open radical hysterectomy was 171 minutes, versus 263 minutes for robot-assisted radical hysterectomy. However, the robotic surgery arm had lower mean estimated blood loss than the open surgery cohort: 80 milliliters versus 468 milliliters, respectively (P = .003). Follow-up time frames were shorter in the robotic surgery cohort by 6 months: 46 months reported for robotic surgery, compared with a 52-month average experienced by those in the open surgery cohort.
Both groups experienced recurrences, including 12 patients in the open surgery cohort (9.8%) and 9 patients in the robotic surgery cohort (12.1%) (P = .3), indicating a statistically insignificant difference. Similarly, rates of perioperative complications were 8% for open surgery and 11% for robotic surgery (P = .3), which was not significantly different.
However, rates of postoperative complications were 36% for open surgery and 12% for robotic surgery (P = .001), which was statistically significant.
“Based on our data, I can say that [robot-assisted radical hysterectomy] is safe, and in fact I prefer to use the robot,” Dr. Sert said at the meeting, which was held by the Society of Laparoendoscopic Surgeons. “Of course, robot-assisted surgery will not automatically make you a better surgeon, but on more complicated radical hysterectomy patients, it will help make the surgeon more precise.”
No funding source was disclosed for this study. Dr. Sert reported having no relevant financial disclosures.
BOSTON – Robot-assisted radical hysterectomy is just as safe, or perhaps safer, than open surgery, according to a new study that examined perioperative and postoperative outcomes with long-term follow-ups for both types of procedures.
“Robotic surgery has been expanding for the last 20 years, but still the recurrence rate with cancer patients is missing data because very few studies are published; they don’t have long-term oncologic outcomes, and if [the technology] works properly we have to put it into the literature,” M. Bilal Sert, MD, of Oslo University, said at the annual Minimally Invasive Surgery Week.
Dr. Sert and his coinvestigators identified 215 women who underwent either open or robot-assisted radical hysterectomy between November 2005 and December 2012. All of the procedures were elective and the robot-assisted operations were performed using the da Vinci robotic surgical platform. After excluding neoadjuvant cases, which totaled 19, the researchers looked at data on 196 patients (122 open radical hysterectomy cases and 74 robot-assisted radical hysterectomy cases).
On average, operating time for open radical hysterectomy was 171 minutes, versus 263 minutes for robot-assisted radical hysterectomy. However, the robotic surgery arm had lower mean estimated blood loss than the open surgery cohort: 80 milliliters versus 468 milliliters, respectively (P = .003). Follow-up time frames were shorter in the robotic surgery cohort by 6 months: 46 months reported for robotic surgery, compared with a 52-month average experienced by those in the open surgery cohort.
Both groups experienced recurrences, including 12 patients in the open surgery cohort (9.8%) and 9 patients in the robotic surgery cohort (12.1%) (P = .3), indicating a statistically insignificant difference. Similarly, rates of perioperative complications were 8% for open surgery and 11% for robotic surgery (P = .3), which was not significantly different.
However, rates of postoperative complications were 36% for open surgery and 12% for robotic surgery (P = .001), which was statistically significant.
“Based on our data, I can say that [robot-assisted radical hysterectomy] is safe, and in fact I prefer to use the robot,” Dr. Sert said at the meeting, which was held by the Society of Laparoendoscopic Surgeons. “Of course, robot-assisted surgery will not automatically make you a better surgeon, but on more complicated radical hysterectomy patients, it will help make the surgeon more precise.”
No funding source was disclosed for this study. Dr. Sert reported having no relevant financial disclosures.
Key clinical point:
Major finding: Postoperative complications were 36% for patients who underwent open radical hysterectomy, compared with 12% for those undergoing robot-assisted radical hysterectomy (P = .001).
Data source: Retrospective review of data on 215 patients who underwent open or robot-assisted radical hysterectomy between November 2005 and December 2012.
Disclosures: Dr. Sert reported having no relevant financial disclosures.
Seven days of antibiotics sufficient for most hospital-acquired pneumonia
A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology of the infection, according to an updated Clinical Practice Guidelines for managing adults with these disorders.
In addition, every hospital should develop its own antibiogram to align clinicians’ choice of treatments with the local distribution of likely pathogens and their antimicrobial susceptibilities. Both of these recommendations, as well as others that are also new to the updated guidelines, are intended to minimize patient exposure to unnecessary antibiotics and reduce antibiotic resistance, said Andre C. Kalil, MD, and Mark L. Metersky, MD, cochairs of the guidelines panel of 18 experts in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, pharmacology, and guideline methodology.
The guidelines, an update of the last version issued in 2005 and developed jointly by representatives of the Infectious Disease Society of America (including Dr. Kalil) and the American Thoracic Society (including Dr. Metersky), are intended for use by all clinicians who care for patients at risk for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP), including surgeons, anesthesiologists, and hospitalists as well as specialists in infectious diseases, pulmonary diseases, and critical care. The guidelines no longer use the concept of health care–associated pneumonia (HCAP), chiefly because new evidence shows that designation is too general: HCAP patients are not at high risk for multidrug-resistant organisms simply because of their contact with the health care system, the guidelines panel wrote (Clin Infect Dis. 2016 Sep 1;63[5]:e61-e111).
The IDSA/ATS Guidelines strongly recommend short-course (1-week) antibiotic therapy instead of longer courses for both HAP and VAP and assert that antibiotic doses should be de-escalated rather than fixed. It advises that serum procalcitonin level plus clinical criteria, not just clinical criteria alone, should be used to guide antibiotic discontinuation, and suggests that the Clinical Pulmonary Infection Score not be used to guide discontinuation.
The guidelines also address empiric treatments when MRSA is suspected and give detailed guidance for selecting antibiotics once the causative organism is identified, including Pseudomonas aeruginosa, extended-spectrum beta-lactamase–producing gram-negative bacilli, Acinetobacter species, and pathogens resistant to carbapenem.
The guidelines include numerous other recommendations concerning the diagnosis of HAP and VAP, the optimal initial treatments, the pharmacokinetic and pharmacodynamic optimization of antibiotic therapies, and the use of inhaled antibiotics. All the recommendations “are a compromise between the competing goals of providing early appropriate antibiotic coverage and avoiding superfluous treatment that may lead to adverse drug effects, Clostridium difficile infections, antibiotic resistance, and increased costs,” the guidelines panel noted.
The full-text guidelines, including details about the panel’s methodology in reviewing the current literature and the summaries of evidence that support each recommendation, is available free on the Clinical Infectious Diseases website.
The Infectious Diseases Society of America and the American Thoracic Society provided financial and administrative support to develop the guidelines. No industry funding was permitted. Dr. Kalil reported having no potential conflicts of interest; Dr. Metersky reported ties to Aradigm, Gilead, Pfizer, Bayer, and their associates reported ties to numerous industry sources.
A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology of the infection, according to an updated Clinical Practice Guidelines for managing adults with these disorders.
In addition, every hospital should develop its own antibiogram to align clinicians’ choice of treatments with the local distribution of likely pathogens and their antimicrobial susceptibilities. Both of these recommendations, as well as others that are also new to the updated guidelines, are intended to minimize patient exposure to unnecessary antibiotics and reduce antibiotic resistance, said Andre C. Kalil, MD, and Mark L. Metersky, MD, cochairs of the guidelines panel of 18 experts in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, pharmacology, and guideline methodology.
The guidelines, an update of the last version issued in 2005 and developed jointly by representatives of the Infectious Disease Society of America (including Dr. Kalil) and the American Thoracic Society (including Dr. Metersky), are intended for use by all clinicians who care for patients at risk for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP), including surgeons, anesthesiologists, and hospitalists as well as specialists in infectious diseases, pulmonary diseases, and critical care. The guidelines no longer use the concept of health care–associated pneumonia (HCAP), chiefly because new evidence shows that designation is too general: HCAP patients are not at high risk for multidrug-resistant organisms simply because of their contact with the health care system, the guidelines panel wrote (Clin Infect Dis. 2016 Sep 1;63[5]:e61-e111).
The IDSA/ATS Guidelines strongly recommend short-course (1-week) antibiotic therapy instead of longer courses for both HAP and VAP and assert that antibiotic doses should be de-escalated rather than fixed. It advises that serum procalcitonin level plus clinical criteria, not just clinical criteria alone, should be used to guide antibiotic discontinuation, and suggests that the Clinical Pulmonary Infection Score not be used to guide discontinuation.
The guidelines also address empiric treatments when MRSA is suspected and give detailed guidance for selecting antibiotics once the causative organism is identified, including Pseudomonas aeruginosa, extended-spectrum beta-lactamase–producing gram-negative bacilli, Acinetobacter species, and pathogens resistant to carbapenem.
The guidelines include numerous other recommendations concerning the diagnosis of HAP and VAP, the optimal initial treatments, the pharmacokinetic and pharmacodynamic optimization of antibiotic therapies, and the use of inhaled antibiotics. All the recommendations “are a compromise between the competing goals of providing early appropriate antibiotic coverage and avoiding superfluous treatment that may lead to adverse drug effects, Clostridium difficile infections, antibiotic resistance, and increased costs,” the guidelines panel noted.
The full-text guidelines, including details about the panel’s methodology in reviewing the current literature and the summaries of evidence that support each recommendation, is available free on the Clinical Infectious Diseases website.
The Infectious Diseases Society of America and the American Thoracic Society provided financial and administrative support to develop the guidelines. No industry funding was permitted. Dr. Kalil reported having no potential conflicts of interest; Dr. Metersky reported ties to Aradigm, Gilead, Pfizer, Bayer, and their associates reported ties to numerous industry sources.
A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology of the infection, according to an updated Clinical Practice Guidelines for managing adults with these disorders.
In addition, every hospital should develop its own antibiogram to align clinicians’ choice of treatments with the local distribution of likely pathogens and their antimicrobial susceptibilities. Both of these recommendations, as well as others that are also new to the updated guidelines, are intended to minimize patient exposure to unnecessary antibiotics and reduce antibiotic resistance, said Andre C. Kalil, MD, and Mark L. Metersky, MD, cochairs of the guidelines panel of 18 experts in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, pharmacology, and guideline methodology.
The guidelines, an update of the last version issued in 2005 and developed jointly by representatives of the Infectious Disease Society of America (including Dr. Kalil) and the American Thoracic Society (including Dr. Metersky), are intended for use by all clinicians who care for patients at risk for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP), including surgeons, anesthesiologists, and hospitalists as well as specialists in infectious diseases, pulmonary diseases, and critical care. The guidelines no longer use the concept of health care–associated pneumonia (HCAP), chiefly because new evidence shows that designation is too general: HCAP patients are not at high risk for multidrug-resistant organisms simply because of their contact with the health care system, the guidelines panel wrote (Clin Infect Dis. 2016 Sep 1;63[5]:e61-e111).
The IDSA/ATS Guidelines strongly recommend short-course (1-week) antibiotic therapy instead of longer courses for both HAP and VAP and assert that antibiotic doses should be de-escalated rather than fixed. It advises that serum procalcitonin level plus clinical criteria, not just clinical criteria alone, should be used to guide antibiotic discontinuation, and suggests that the Clinical Pulmonary Infection Score not be used to guide discontinuation.
The guidelines also address empiric treatments when MRSA is suspected and give detailed guidance for selecting antibiotics once the causative organism is identified, including Pseudomonas aeruginosa, extended-spectrum beta-lactamase–producing gram-negative bacilli, Acinetobacter species, and pathogens resistant to carbapenem.
The guidelines include numerous other recommendations concerning the diagnosis of HAP and VAP, the optimal initial treatments, the pharmacokinetic and pharmacodynamic optimization of antibiotic therapies, and the use of inhaled antibiotics. All the recommendations “are a compromise between the competing goals of providing early appropriate antibiotic coverage and avoiding superfluous treatment that may lead to adverse drug effects, Clostridium difficile infections, antibiotic resistance, and increased costs,” the guidelines panel noted.
The full-text guidelines, including details about the panel’s methodology in reviewing the current literature and the summaries of evidence that support each recommendation, is available free on the Clinical Infectious Diseases website.
The Infectious Diseases Society of America and the American Thoracic Society provided financial and administrative support to develop the guidelines. No industry funding was permitted. Dr. Kalil reported having no potential conflicts of interest; Dr. Metersky reported ties to Aradigm, Gilead, Pfizer, Bayer, and their associates reported ties to numerous industry sources.
Key clinical point: A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology.
Major finding: The joint IDSA/ATS Guidelines include 25 recommendations regarding diagnosis, empiric therapy, and pathogen-targeted antibiotics for HAP and VAP.
Data source: An update to the 2005 Clinical Practice Guidelines for managing adults with HAP or VAP.
Disclosures: The Infectious Diseases Society of America and the American Thoracic Society provided financial and administrative support to develop the guidelines. No industry funding was permitted. Dr. Kalil reported having no potential conflicts of interest; Dr. Metersky reported ties to Aradigm, Gilead, Pfizer, Bayer, and their associates reported ties to numerous industry sources.
GAO report calls out HHS for misdirecting ACA reinsurance funds
The Health and Human Services department is failing to properly administer a reinsurance program under the Affordable Care Act by unlawfully diverting funds intended for the U.S. Treasury, according to a nonpartisan watchdog report.
The Government Accountability Office (GAO) report, released Sept. 29, finds that HHS is breaking ACA regulations that require a portion of funds collected under its Transitional Reinsurance Program to go to the Treasury. Instead, the agency has redirected $5 billion so far to pay health insurers that enroll high-cost patients under the program.
“In light of the foregoing analysis, we conclude that HHS lacks authority to ignore the statute’s directive to deposit amounts from collections under the Transitional Reinsurance Program to the Treasury and instead make deposits in the Treasury only if its collections reach the amounts for reinsurance payments specified in section 1341,” Susan A. Poling, GAO general counsel, wrote in a legal opinion. “The agency is not authorized to prioritize collections in this manner.”
Republican lawmakers, including Sen. John Barrasso III (Wyo.), chair of the Senate Republican Policy Committee, praised the legal opinion, saying it shows the Obama administration is bending the rules when it comes to rolling out the ACA.
“This is a major victory for the American people who are suffering with higher premiums and fewer choices because of this failed law,” said Sen. Barrasso, who with several fellow Republican legislators requested the GAO investigation. “The administration should end this illegal scheme immediately, and focus on providing relief from the burdens of this law.”
At press time, neither the White House nor HHS had responded to request for comment on the report.
The Transitional Reinsurance Program is a 3-year initiative under the ACA that collects fees from employers and other private health insurance plans and directs the funds to health plans that face large claims for patients with high-cost medical conditions. The ACA specifies that between 2014 and 2016, HHS would collect $25 billion in fees, of which $5 billion would go into the Treasury.
But when HHS was unable to collect the full amount over the 3 years, it did not distribute funds into the Treasury, but instead used it pay the health plans. To justify that decision, HHS officials announced that the department would allocate all collections first for reinsurance payments until collections totaled the target amount set forth for reinsurance payments under the law, and that any remaining collections would go toward to administrative expenses and the Treasury, according to the GAO report.
But the GAO argues that HHS falling short of the projected collections does not alter the meaning of the statute.
“Specifically, where actual funding has fallen short of an agency’s original expectations, courts have directed the agency to distribute available funds to approximate the allocation plan Congress designed in anticipation of full funding,” Ms. Poling wrote. The HHS “assertion that the statute is silent with respect to allocation of collections overlooks the fact that section 1341 expressly directs HHS to collect amounts for the Treasury and prohibits the use of these amounts for any purpose other than deposit in the Treasury. HHS’s analysis focuses on words and phrases in the statute in isolation rather than in their appropriate context.”
While the GAO cannot force HHS to act with the opinion, lawmakers could use the report to craft legislation forcing HHS to repay the Treasury.
“This issue has been brewing for a while, and is another example of a series of attempts to challenge or limit payments being made to carriers under the ACA,” Katherine Hempstead, senior adviser to vice president at the Robert Wood Johnson Foundation, said in an interview. “It’s no mystery why making these payments is a pretty high priority for the [Centers for Medicare & Medicaid Services] right now, given the losses sustained by many market participants. My guess is that the can will probably be kicked down the road on this and a number of other issues for the next administration and Congress to resolve.”
The reinsurance program was one of three programs intended to protect against the negative impacts of adverse selection and risk selection, while working to stabilize premiums during the initial years of the health law’s implementation. The program aims to protect against premium increases in the individual market by offsetting expenses of high-cost patients.
On Twitter @legal_med
The Health and Human Services department is failing to properly administer a reinsurance program under the Affordable Care Act by unlawfully diverting funds intended for the U.S. Treasury, according to a nonpartisan watchdog report.
The Government Accountability Office (GAO) report, released Sept. 29, finds that HHS is breaking ACA regulations that require a portion of funds collected under its Transitional Reinsurance Program to go to the Treasury. Instead, the agency has redirected $5 billion so far to pay health insurers that enroll high-cost patients under the program.
“In light of the foregoing analysis, we conclude that HHS lacks authority to ignore the statute’s directive to deposit amounts from collections under the Transitional Reinsurance Program to the Treasury and instead make deposits in the Treasury only if its collections reach the amounts for reinsurance payments specified in section 1341,” Susan A. Poling, GAO general counsel, wrote in a legal opinion. “The agency is not authorized to prioritize collections in this manner.”
Republican lawmakers, including Sen. John Barrasso III (Wyo.), chair of the Senate Republican Policy Committee, praised the legal opinion, saying it shows the Obama administration is bending the rules when it comes to rolling out the ACA.
“This is a major victory for the American people who are suffering with higher premiums and fewer choices because of this failed law,” said Sen. Barrasso, who with several fellow Republican legislators requested the GAO investigation. “The administration should end this illegal scheme immediately, and focus on providing relief from the burdens of this law.”
At press time, neither the White House nor HHS had responded to request for comment on the report.
The Transitional Reinsurance Program is a 3-year initiative under the ACA that collects fees from employers and other private health insurance plans and directs the funds to health plans that face large claims for patients with high-cost medical conditions. The ACA specifies that between 2014 and 2016, HHS would collect $25 billion in fees, of which $5 billion would go into the Treasury.
But when HHS was unable to collect the full amount over the 3 years, it did not distribute funds into the Treasury, but instead used it pay the health plans. To justify that decision, HHS officials announced that the department would allocate all collections first for reinsurance payments until collections totaled the target amount set forth for reinsurance payments under the law, and that any remaining collections would go toward to administrative expenses and the Treasury, according to the GAO report.
But the GAO argues that HHS falling short of the projected collections does not alter the meaning of the statute.
“Specifically, where actual funding has fallen short of an agency’s original expectations, courts have directed the agency to distribute available funds to approximate the allocation plan Congress designed in anticipation of full funding,” Ms. Poling wrote. The HHS “assertion that the statute is silent with respect to allocation of collections overlooks the fact that section 1341 expressly directs HHS to collect amounts for the Treasury and prohibits the use of these amounts for any purpose other than deposit in the Treasury. HHS’s analysis focuses on words and phrases in the statute in isolation rather than in their appropriate context.”
While the GAO cannot force HHS to act with the opinion, lawmakers could use the report to craft legislation forcing HHS to repay the Treasury.
“This issue has been brewing for a while, and is another example of a series of attempts to challenge or limit payments being made to carriers under the ACA,” Katherine Hempstead, senior adviser to vice president at the Robert Wood Johnson Foundation, said in an interview. “It’s no mystery why making these payments is a pretty high priority for the [Centers for Medicare & Medicaid Services] right now, given the losses sustained by many market participants. My guess is that the can will probably be kicked down the road on this and a number of other issues for the next administration and Congress to resolve.”
The reinsurance program was one of three programs intended to protect against the negative impacts of adverse selection and risk selection, while working to stabilize premiums during the initial years of the health law’s implementation. The program aims to protect against premium increases in the individual market by offsetting expenses of high-cost patients.
On Twitter @legal_med
The Health and Human Services department is failing to properly administer a reinsurance program under the Affordable Care Act by unlawfully diverting funds intended for the U.S. Treasury, according to a nonpartisan watchdog report.
The Government Accountability Office (GAO) report, released Sept. 29, finds that HHS is breaking ACA regulations that require a portion of funds collected under its Transitional Reinsurance Program to go to the Treasury. Instead, the agency has redirected $5 billion so far to pay health insurers that enroll high-cost patients under the program.
“In light of the foregoing analysis, we conclude that HHS lacks authority to ignore the statute’s directive to deposit amounts from collections under the Transitional Reinsurance Program to the Treasury and instead make deposits in the Treasury only if its collections reach the amounts for reinsurance payments specified in section 1341,” Susan A. Poling, GAO general counsel, wrote in a legal opinion. “The agency is not authorized to prioritize collections in this manner.”
Republican lawmakers, including Sen. John Barrasso III (Wyo.), chair of the Senate Republican Policy Committee, praised the legal opinion, saying it shows the Obama administration is bending the rules when it comes to rolling out the ACA.
“This is a major victory for the American people who are suffering with higher premiums and fewer choices because of this failed law,” said Sen. Barrasso, who with several fellow Republican legislators requested the GAO investigation. “The administration should end this illegal scheme immediately, and focus on providing relief from the burdens of this law.”
At press time, neither the White House nor HHS had responded to request for comment on the report.
The Transitional Reinsurance Program is a 3-year initiative under the ACA that collects fees from employers and other private health insurance plans and directs the funds to health plans that face large claims for patients with high-cost medical conditions. The ACA specifies that between 2014 and 2016, HHS would collect $25 billion in fees, of which $5 billion would go into the Treasury.
But when HHS was unable to collect the full amount over the 3 years, it did not distribute funds into the Treasury, but instead used it pay the health plans. To justify that decision, HHS officials announced that the department would allocate all collections first for reinsurance payments until collections totaled the target amount set forth for reinsurance payments under the law, and that any remaining collections would go toward to administrative expenses and the Treasury, according to the GAO report.
But the GAO argues that HHS falling short of the projected collections does not alter the meaning of the statute.
“Specifically, where actual funding has fallen short of an agency’s original expectations, courts have directed the agency to distribute available funds to approximate the allocation plan Congress designed in anticipation of full funding,” Ms. Poling wrote. The HHS “assertion that the statute is silent with respect to allocation of collections overlooks the fact that section 1341 expressly directs HHS to collect amounts for the Treasury and prohibits the use of these amounts for any purpose other than deposit in the Treasury. HHS’s analysis focuses on words and phrases in the statute in isolation rather than in their appropriate context.”
While the GAO cannot force HHS to act with the opinion, lawmakers could use the report to craft legislation forcing HHS to repay the Treasury.
“This issue has been brewing for a while, and is another example of a series of attempts to challenge or limit payments being made to carriers under the ACA,” Katherine Hempstead, senior adviser to vice president at the Robert Wood Johnson Foundation, said in an interview. “It’s no mystery why making these payments is a pretty high priority for the [Centers for Medicare & Medicaid Services] right now, given the losses sustained by many market participants. My guess is that the can will probably be kicked down the road on this and a number of other issues for the next administration and Congress to resolve.”
The reinsurance program was one of three programs intended to protect against the negative impacts of adverse selection and risk selection, while working to stabilize premiums during the initial years of the health law’s implementation. The program aims to protect against premium increases in the individual market by offsetting expenses of high-cost patients.
On Twitter @legal_med
