ACS Surgery News

To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession. 

The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS.  Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director.  Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee. 

Applications are due no later than April 1.  Contact [email protected] with any questions. 

To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession. 

The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS.  Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director.  Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee. 

Applications are due no later than April 1.  Contact [email protected] with any questions. 

To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession. 

The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS.  Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director.  Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee. 

Applications are due no later than April 1.  Contact [email protected] with any questions. 

LAS VEGAS – Minimally invasive techniques have clear benefits for colectomy, including reduced hospital length of stay, less pain, faster return to work, and reduced incidence of adhesive small bowel obstructions. But the methods are underutilized, in part because they can be challenging to learn.

There are some tools and methods that can help surgeons perform surgeries laparoscopically, including hand-assisted laparoscopy and the use of single-incision laparoscopic colectomy (SILC). These methods were the subject of a talk at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Between 2009 and 2012, a little over 30% of colon cancer cases in the United States and about half of diverticulitis cases were performed laparoscopically. The percentage of laparoscopic procedures ticked up slightly from 2009 to 2012, but only by a few percentage points. “The fact is, we’re just not doing [minimally invasive procedures],” Ian M. Paquette, MD, FACS, associate professor of surgery at the University of Cincinnati, said during his talk.

When a laparoscopic procedure proves challenging, one option is the hand-assist technique. The literature hasn’t been very supportive of the method, with one study of data from the American College of Surgeons National Surgical Quality Improvement Program showing that it offers no improvement in operation time, compared with standard laparoscopy, and that it has slightly higher complication rates (J Gastrointest Surg. 2016 Nov;20[11]:1854-60). “They say you should do everything laparoscopically,” said Dr. Paquette.

copyright monkeybusinessimages/Thinkstock

LAS VEGAS – Minimally invasive techniques have clear benefits for colectomy, including reduced hospital length of stay, less pain, faster return to work, and reduced incidence of adhesive small bowel obstructions. But the methods are underutilized, in part because they can be challenging to learn.

There are some tools and methods that can help surgeons perform surgeries laparoscopically, including hand-assisted laparoscopy and the use of single-incision laparoscopic colectomy (SILC). These methods were the subject of a talk at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Between 2009 and 2012, a little over 30% of colon cancer cases in the United States and about half of diverticulitis cases were performed laparoscopically. The percentage of laparoscopic procedures ticked up slightly from 2009 to 2012, but only by a few percentage points. “The fact is, we’re just not doing [minimally invasive procedures],” Ian M. Paquette, MD, FACS, associate professor of surgery at the University of Cincinnati, said during his talk.

When a laparoscopic procedure proves challenging, one option is the hand-assist technique. The literature hasn’t been very supportive of the method, with one study of data from the American College of Surgeons National Surgical Quality Improvement Program showing that it offers no improvement in operation time, compared with standard laparoscopy, and that it has slightly higher complication rates (J Gastrointest Surg. 2016 Nov;20[11]:1854-60). “They say you should do everything laparoscopically,” said Dr. Paquette.

copyright monkeybusinessimages/Thinkstock

LAS VEGAS – Minimally invasive techniques have clear benefits for colectomy, including reduced hospital length of stay, less pain, faster return to work, and reduced incidence of adhesive small bowel obstructions. But the methods are underutilized, in part because they can be challenging to learn.

There are some tools and methods that can help surgeons perform surgeries laparoscopically, including hand-assisted laparoscopy and the use of single-incision laparoscopic colectomy (SILC). These methods were the subject of a talk at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Between 2009 and 2012, a little over 30% of colon cancer cases in the United States and about half of diverticulitis cases were performed laparoscopically. The percentage of laparoscopic procedures ticked up slightly from 2009 to 2012, but only by a few percentage points. “The fact is, we’re just not doing [minimally invasive procedures],” Ian M. Paquette, MD, FACS, associate professor of surgery at the University of Cincinnati, said during his talk.

When a laparoscopic procedure proves challenging, one option is the hand-assist technique. The literature hasn’t been very supportive of the method, with one study of data from the American College of Surgeons National Surgical Quality Improvement Program showing that it offers no improvement in operation time, compared with standard laparoscopy, and that it has slightly higher complication rates (J Gastrointest Surg. 2016 Nov;20[11]:1854-60). “They say you should do everything laparoscopically,” said Dr. Paquette.

copyright monkeybusinessimages/Thinkstock

ORLANDO – Treating patients who developed myocardial injury after noncardiac surgery with the anticoagulant dabigatran significantly cut the rate of subsequent major vascular complications in a randomized, multicenter trial with 1,754 patients, a result that gives surgeons and physicians the first evidence-based intervention for treating a common postsurgical condition.

“Because we have not systematically followed noncardiac surgery patients, it’s easy to presume that everyone is okay, but all the epidemiology data show that these patients [who develop myocardial injury after noncardiac surgery] don’t do okay. We need to be aggressive with secondary prophylaxis,” P.J. Devereaux, MD, said at the annual meeting of the American College of Cardiology. “The unfortunate thing is that right now, we don’t do much for these patients,” said Dr. Devereaux, professor of medicine and director of cardiology at McMaster University in Hamilton, Ont.

Results from prior epidemiology studies have shown that, among the roughly 200 million patients who undergo noncardiac surgery worldwide each year, 8% will develop MINS (myocardial injury after noncardiac surgery) (Anesthesiology. 2014 March;120[3]:564-78). The myocardial injury that defines MINS is identified by either an overt MI that meets the universal definition, or an otherwise unexplained rise in serum troponin levels from baseline in the first couple of days after surgery. In the new study, Dr. Devereaux and his associates identified 80% of MINS by a troponin rise and 20% by a diagnosed MI.

The challenge in diagnosing MINS and then administering dabigatran will be implementation of this strategy into routine practice, commented Erin A. Bohula May, MD, a cardiologist at Brigham and Women’s Hospital in Boston. “The problem is, troponin is not routinely measured in postoperative patients. It will be hard to change practice,” she noted.

Dr. Devereaux agreed that a significant barrier is convincing clinicians, especially surgeons, to routinely measure a patient’s troponin levels just before and immediately after surgery. “People are lulled into a false sense of security because patients [who develop MINS] usually don’t have chest pain,” he said in a video interview. “When we first showed that patients with MINS have bad outcomes, that convinced some [surgeons] to measure troponin after surgery. “Showing we can do something about it” is another important step toward fostering more awareness of and interest in diagnosing and treating MINS.

The Management of Myocardial Injury After Noncardiac Surgery Trial (MANAGE) enrolled 1,754 patients at 82 centers in 19 countries. Researchers randomized patients to treatment with either 110 mg dabigatran b.i.d. or placebo. A majority of patients in both arms also received aspirin and a statin, treatments that Dr. Devereaux should be used along with dabigatran in routine practice, based on observational findings, although the efficacy of these drugs for MINS patients has not been tested in randomized studies. The study’s primary endpoint was the incidence of major vascular complications, a composite that included vascular mortality, nonfatal MI, nonfatal and nonhemorrhagic stroke, peripheral arterial thrombosis, amputation, or symptomatic venous thromboembolism.

After an average follow-up of 16 months, the primary endpoint occurred in 11% of the dabigatran-treated patients and in 15% of controls, which represented a 28% risk reduction that was statistically significant. The study’s primary safety endpoint was a composite of life-threatening, major, and critical organ bleeds, which occurred in 3% of the dabigatran-treated patients and in 4% of controls, a nonsignificant difference. The dabigatran-treated patients showed a significant excess of both minor bleeds – 15% compared with 10% in controls – and “nonsignificant” lower gastrointestinal bleeds, 4% with dabigatran and 1% in the controls. The dabigatran-treated patients also had a significantly higher incidence of dyspepsia.

MANAGE was funded by the Population Health Research Institute and had no commercial funding. Dr. Devereaux has received research support from Abbott Diagnostics, Boehringer Ingelheim, Philips Healthcare, and Roche Diagnostics. Dr. May has been a consultant to Daiichi Sankyo, Merck, and Servier and has received research funding from Eisai.

[email protected]

SOURCE: Devereaux P et al. ACC 18.

ORLANDO – Treating patients who developed myocardial injury after noncardiac surgery with the anticoagulant dabigatran significantly cut the rate of subsequent major vascular complications in a randomized, multicenter trial with 1,754 patients, a result that gives surgeons and physicians the first evidence-based intervention for treating a common postsurgical condition.

“Because we have not systematically followed noncardiac surgery patients, it’s easy to presume that everyone is okay, but all the epidemiology data show that these patients [who develop myocardial injury after noncardiac surgery] don’t do okay. We need to be aggressive with secondary prophylaxis,” P.J. Devereaux, MD, said at the annual meeting of the American College of Cardiology. “The unfortunate thing is that right now, we don’t do much for these patients,” said Dr. Devereaux, professor of medicine and director of cardiology at McMaster University in Hamilton, Ont.

Results from prior epidemiology studies have shown that, among the roughly 200 million patients who undergo noncardiac surgery worldwide each year, 8% will develop MINS (myocardial injury after noncardiac surgery) (Anesthesiology. 2014 March;120[3]:564-78). The myocardial injury that defines MINS is identified by either an overt MI that meets the universal definition, or an otherwise unexplained rise in serum troponin levels from baseline in the first couple of days after surgery. In the new study, Dr. Devereaux and his associates identified 80% of MINS by a troponin rise and 20% by a diagnosed MI.

The challenge in diagnosing MINS and then administering dabigatran will be implementation of this strategy into routine practice, commented Erin A. Bohula May, MD, a cardiologist at Brigham and Women’s Hospital in Boston. “The problem is, troponin is not routinely measured in postoperative patients. It will be hard to change practice,” she noted.

Dr. Devereaux agreed that a significant barrier is convincing clinicians, especially surgeons, to routinely measure a patient’s troponin levels just before and immediately after surgery. “People are lulled into a false sense of security because patients [who develop MINS] usually don’t have chest pain,” he said in a video interview. “When we first showed that patients with MINS have bad outcomes, that convinced some [surgeons] to measure troponin after surgery. “Showing we can do something about it” is another important step toward fostering more awareness of and interest in diagnosing and treating MINS.

The Management of Myocardial Injury After Noncardiac Surgery Trial (MANAGE) enrolled 1,754 patients at 82 centers in 19 countries. Researchers randomized patients to treatment with either 110 mg dabigatran b.i.d. or placebo. A majority of patients in both arms also received aspirin and a statin, treatments that Dr. Devereaux should be used along with dabigatran in routine practice, based on observational findings, although the efficacy of these drugs for MINS patients has not been tested in randomized studies. The study’s primary endpoint was the incidence of major vascular complications, a composite that included vascular mortality, nonfatal MI, nonfatal and nonhemorrhagic stroke, peripheral arterial thrombosis, amputation, or symptomatic venous thromboembolism.

After an average follow-up of 16 months, the primary endpoint occurred in 11% of the dabigatran-treated patients and in 15% of controls, which represented a 28% risk reduction that was statistically significant. The study’s primary safety endpoint was a composite of life-threatening, major, and critical organ bleeds, which occurred in 3% of the dabigatran-treated patients and in 4% of controls, a nonsignificant difference. The dabigatran-treated patients showed a significant excess of both minor bleeds – 15% compared with 10% in controls – and “nonsignificant” lower gastrointestinal bleeds, 4% with dabigatran and 1% in the controls. The dabigatran-treated patients also had a significantly higher incidence of dyspepsia.

MANAGE was funded by the Population Health Research Institute and had no commercial funding. Dr. Devereaux has received research support from Abbott Diagnostics, Boehringer Ingelheim, Philips Healthcare, and Roche Diagnostics. Dr. May has been a consultant to Daiichi Sankyo, Merck, and Servier and has received research funding from Eisai.

[email protected]

SOURCE: Devereaux P et al. ACC 18.

ORLANDO – Treating patients who developed myocardial injury after noncardiac surgery with the anticoagulant dabigatran significantly cut the rate of subsequent major vascular complications in a randomized, multicenter trial with 1,754 patients, a result that gives surgeons and physicians the first evidence-based intervention for treating a common postsurgical condition.

“Because we have not systematically followed noncardiac surgery patients, it’s easy to presume that everyone is okay, but all the epidemiology data show that these patients [who develop myocardial injury after noncardiac surgery] don’t do okay. We need to be aggressive with secondary prophylaxis,” P.J. Devereaux, MD, said at the annual meeting of the American College of Cardiology. “The unfortunate thing is that right now, we don’t do much for these patients,” said Dr. Devereaux, professor of medicine and director of cardiology at McMaster University in Hamilton, Ont.

Results from prior epidemiology studies have shown that, among the roughly 200 million patients who undergo noncardiac surgery worldwide each year, 8% will develop MINS (myocardial injury after noncardiac surgery) (Anesthesiology. 2014 March;120[3]:564-78). The myocardial injury that defines MINS is identified by either an overt MI that meets the universal definition, or an otherwise unexplained rise in serum troponin levels from baseline in the first couple of days after surgery. In the new study, Dr. Devereaux and his associates identified 80% of MINS by a troponin rise and 20% by a diagnosed MI.

The challenge in diagnosing MINS and then administering dabigatran will be implementation of this strategy into routine practice, commented Erin A. Bohula May, MD, a cardiologist at Brigham and Women’s Hospital in Boston. “The problem is, troponin is not routinely measured in postoperative patients. It will be hard to change practice,” she noted.

Dr. Devereaux agreed that a significant barrier is convincing clinicians, especially surgeons, to routinely measure a patient’s troponin levels just before and immediately after surgery. “People are lulled into a false sense of security because patients [who develop MINS] usually don’t have chest pain,” he said in a video interview. “When we first showed that patients with MINS have bad outcomes, that convinced some [surgeons] to measure troponin after surgery. “Showing we can do something about it” is another important step toward fostering more awareness of and interest in diagnosing and treating MINS.

The Management of Myocardial Injury After Noncardiac Surgery Trial (MANAGE) enrolled 1,754 patients at 82 centers in 19 countries. Researchers randomized patients to treatment with either 110 mg dabigatran b.i.d. or placebo. A majority of patients in both arms also received aspirin and a statin, treatments that Dr. Devereaux should be used along with dabigatran in routine practice, based on observational findings, although the efficacy of these drugs for MINS patients has not been tested in randomized studies. The study’s primary endpoint was the incidence of major vascular complications, a composite that included vascular mortality, nonfatal MI, nonfatal and nonhemorrhagic stroke, peripheral arterial thrombosis, amputation, or symptomatic venous thromboembolism.

After an average follow-up of 16 months, the primary endpoint occurred in 11% of the dabigatran-treated patients and in 15% of controls, which represented a 28% risk reduction that was statistically significant. The study’s primary safety endpoint was a composite of life-threatening, major, and critical organ bleeds, which occurred in 3% of the dabigatran-treated patients and in 4% of controls, a nonsignificant difference. The dabigatran-treated patients showed a significant excess of both minor bleeds – 15% compared with 10% in controls – and “nonsignificant” lower gastrointestinal bleeds, 4% with dabigatran and 1% in the controls. The dabigatran-treated patients also had a significantly higher incidence of dyspepsia.

MANAGE was funded by the Population Health Research Institute and had no commercial funding. Dr. Devereaux has received research support from Abbott Diagnostics, Boehringer Ingelheim, Philips Healthcare, and Roche Diagnostics. Dr. May has been a consultant to Daiichi Sankyo, Merck, and Servier and has received research funding from Eisai.

[email protected]

SOURCE: Devereaux P et al. ACC 18.

The American Board of Surgery (ABS) has unveiled a shorter, more flexible assessment to take the place of the dreaded 10-year, pass-fail exam to maintain certification.

The new test, required every other year, consists of a 40-question, open-book assessment that surgeons can take on their own computers within the assessment time frame, according to a March 5 announcement. The previous 10-year exam consisted of nearly 250 questions and had to be completed at a highly secure testing center.

The assessment shift was made to address diplomates’ concerns that the prior exam was burdensome, stressful, and challenging to complete because of its rigid design and location requirements, ABS Chair Mary E. Klingensmith, MD, FACS, said in an interview.

“This new method, which allows a take-from-home or office format, is much less stressful, as both the setting, and the ability to choose the content area, give diplomates much more control,” Dr. Klingensmith said. “Additionally, the testing concepts and references will be provided in advance, should a diplomate desire to know these aspects.”

On March 11, the American College of Surgeons released a statement regarding the new assessment and suggested that, while the new approach is welcomed by the ACS, some details of the process are of concern to surgeons. “The American College of Surgeons (ACS) leadership has heard your concerns both through personal conversations with many of you and through your posts on ACS Communities. In fact, many in leadership share these concerns. We have been in discussions with ABS leadership and can tell you that they are also listening. They want to get this right.”

Of the 40 questions on the new exam, 20 questions will cover core surgical principles, while the other 20 will cover a practice-related area of the diplomate’s choosing. For 2018, diplomates can select from four practice-related areas: general surgery, abdomen, alimentary tract, or breast. More areas are planned based on future feedback from diplomates and surgical societies. Other aspects of the new exam include:

• Topics and references for the various areas will be published in advance on the ABS website.
• Diplomates will be provided with immediate feedback, and will have two opportunities to answer a question correctly.
• A final score of 80% correct will be required to pass.
• Once the assessment is started, diplomates will have 2 weeks to complete the test, with the ability to save and continue when convenient.

The purpose of the new assessment is to provide practicing surgeons with a timely, relevant, and accessible method to stay current with surgical practice knowledge,” Dr. Klingensmith said.

“By selecting a practice-specific area of their own choosing, surgeons will no longer have to study for and be tested upon the entire breadth of general surgery; instead they can focus on those areas that most reflect their practice,” she said. “By submitting to a learning exercise every 2 years, which is focused in the areas of an individual surgeon’s practice, I expect important aspects of knowledge will be transmitted and integrated into a surgeon’s practice. This new program will provide practicing surgeons with an accessible method for keeping up with the constantly changing landscape of surgical practice.”

The new exam is part of an ongoing effort by ABS to revamp its maintenance of certification requirements after widespread criticism that its past provisions were burdensome and irrelevant. In July, ABS announced that it was extending its continuing medical education reporting cycle from 3 to 5 years and reducing the number of required self-assessment by a third. Surgeons now have to report 150 credits over 5 years, 50 from self-assessment CMEs. Under the old system, it was 90 credits over 3 years, 60 of which had to include self-assessment.

After the July announcement, ABS sent surveys to all diplomates to gather feedback about alternatives to the 10-year exam. Nearly 10,000 surgeons responded, according to an ABS summary. The majority of respondents said they wanted more frequent, lower-stakes, open-book assessments that would be required no frequently than every 2 years. Most surgeons were also in favor of being tested on both surgery concepts and practice-specific content.

For 2019 and beyond, the ABS’ Component Boards – Vascular, Pediatric Surgery, Surgical, and Critical Care – will develop their continuous certification processes, Dr. Klingensmith said. Additional areas for the surgery exam also will be developed in collaboration with specialty societies.

In the meantime, registration for the new general surgery assessment opens Aug. 1. The assessment will be available from Sept. 7 to Nov. 5, during which time diplomates can take the assessment at their convenience.

For more information, go to the continuous certification section on the ABS website.

[email protected]

The American Board of Surgery (ABS) has unveiled a shorter, more flexible assessment to take the place of the dreaded 10-year, pass-fail exam to maintain certification.

The new test, required every other year, consists of a 40-question, open-book assessment that surgeons can take on their own computers within the assessment time frame, according to a March 5 announcement. The previous 10-year exam consisted of nearly 250 questions and had to be completed at a highly secure testing center.

The assessment shift was made to address diplomates’ concerns that the prior exam was burdensome, stressful, and challenging to complete because of its rigid design and location requirements, ABS Chair Mary E. Klingensmith, MD, FACS, said in an interview.

“This new method, which allows a take-from-home or office format, is much less stressful, as both the setting, and the ability to choose the content area, give diplomates much more control,” Dr. Klingensmith said. “Additionally, the testing concepts and references will be provided in advance, should a diplomate desire to know these aspects.”

On March 11, the American College of Surgeons released a statement regarding the new assessment and suggested that, while the new approach is welcomed by the ACS, some details of the process are of concern to surgeons. “The American College of Surgeons (ACS) leadership has heard your concerns both through personal conversations with many of you and through your posts on ACS Communities. In fact, many in leadership share these concerns. We have been in discussions with ABS leadership and can tell you that they are also listening. They want to get this right.”

Of the 40 questions on the new exam, 20 questions will cover core surgical principles, while the other 20 will cover a practice-related area of the diplomate’s choosing. For 2018, diplomates can select from four practice-related areas: general surgery, abdomen, alimentary tract, or breast. More areas are planned based on future feedback from diplomates and surgical societies. Other aspects of the new exam include:

• Topics and references for the various areas will be published in advance on the ABS website.
• Diplomates will be provided with immediate feedback, and will have two opportunities to answer a question correctly.
• A final score of 80% correct will be required to pass.
• Once the assessment is started, diplomates will have 2 weeks to complete the test, with the ability to save and continue when convenient.

The purpose of the new assessment is to provide practicing surgeons with a timely, relevant, and accessible method to stay current with surgical practice knowledge,” Dr. Klingensmith said.

“By selecting a practice-specific area of their own choosing, surgeons will no longer have to study for and be tested upon the entire breadth of general surgery; instead they can focus on those areas that most reflect their practice,” she said. “By submitting to a learning exercise every 2 years, which is focused in the areas of an individual surgeon’s practice, I expect important aspects of knowledge will be transmitted and integrated into a surgeon’s practice. This new program will provide practicing surgeons with an accessible method for keeping up with the constantly changing landscape of surgical practice.”

The new exam is part of an ongoing effort by ABS to revamp its maintenance of certification requirements after widespread criticism that its past provisions were burdensome and irrelevant. In July, ABS announced that it was extending its continuing medical education reporting cycle from 3 to 5 years and reducing the number of required self-assessment by a third. Surgeons now have to report 150 credits over 5 years, 50 from self-assessment CMEs. Under the old system, it was 90 credits over 3 years, 60 of which had to include self-assessment.

After the July announcement, ABS sent surveys to all diplomates to gather feedback about alternatives to the 10-year exam. Nearly 10,000 surgeons responded, according to an ABS summary. The majority of respondents said they wanted more frequent, lower-stakes, open-book assessments that would be required no frequently than every 2 years. Most surgeons were also in favor of being tested on both surgery concepts and practice-specific content.

For 2019 and beyond, the ABS’ Component Boards – Vascular, Pediatric Surgery, Surgical, and Critical Care – will develop their continuous certification processes, Dr. Klingensmith said. Additional areas for the surgery exam also will be developed in collaboration with specialty societies.

In the meantime, registration for the new general surgery assessment opens Aug. 1. The assessment will be available from Sept. 7 to Nov. 5, during which time diplomates can take the assessment at their convenience.

For more information, go to the continuous certification section on the ABS website.

[email protected]

The American Board of Surgery (ABS) has unveiled a shorter, more flexible assessment to take the place of the dreaded 10-year, pass-fail exam to maintain certification.

The new test, required every other year, consists of a 40-question, open-book assessment that surgeons can take on their own computers within the assessment time frame, according to a March 5 announcement. The previous 10-year exam consisted of nearly 250 questions and had to be completed at a highly secure testing center.

The assessment shift was made to address diplomates’ concerns that the prior exam was burdensome, stressful, and challenging to complete because of its rigid design and location requirements, ABS Chair Mary E. Klingensmith, MD, FACS, said in an interview.

“This new method, which allows a take-from-home or office format, is much less stressful, as both the setting, and the ability to choose the content area, give diplomates much more control,” Dr. Klingensmith said. “Additionally, the testing concepts and references will be provided in advance, should a diplomate desire to know these aspects.”

On March 11, the American College of Surgeons released a statement regarding the new assessment and suggested that, while the new approach is welcomed by the ACS, some details of the process are of concern to surgeons. “The American College of Surgeons (ACS) leadership has heard your concerns both through personal conversations with many of you and through your posts on ACS Communities. In fact, many in leadership share these concerns. We have been in discussions with ABS leadership and can tell you that they are also listening. They want to get this right.”

Of the 40 questions on the new exam, 20 questions will cover core surgical principles, while the other 20 will cover a practice-related area of the diplomate’s choosing. For 2018, diplomates can select from four practice-related areas: general surgery, abdomen, alimentary tract, or breast. More areas are planned based on future feedback from diplomates and surgical societies. Other aspects of the new exam include:

• Topics and references for the various areas will be published in advance on the ABS website.
• Diplomates will be provided with immediate feedback, and will have two opportunities to answer a question correctly.
• A final score of 80% correct will be required to pass.
• Once the assessment is started, diplomates will have 2 weeks to complete the test, with the ability to save and continue when convenient.

The purpose of the new assessment is to provide practicing surgeons with a timely, relevant, and accessible method to stay current with surgical practice knowledge,” Dr. Klingensmith said.

“By selecting a practice-specific area of their own choosing, surgeons will no longer have to study for and be tested upon the entire breadth of general surgery; instead they can focus on those areas that most reflect their practice,” she said. “By submitting to a learning exercise every 2 years, which is focused in the areas of an individual surgeon’s practice, I expect important aspects of knowledge will be transmitted and integrated into a surgeon’s practice. This new program will provide practicing surgeons with an accessible method for keeping up with the constantly changing landscape of surgical practice.”

The new exam is part of an ongoing effort by ABS to revamp its maintenance of certification requirements after widespread criticism that its past provisions were burdensome and irrelevant. In July, ABS announced that it was extending its continuing medical education reporting cycle from 3 to 5 years and reducing the number of required self-assessment by a third. Surgeons now have to report 150 credits over 5 years, 50 from self-assessment CMEs. Under the old system, it was 90 credits over 3 years, 60 of which had to include self-assessment.

After the July announcement, ABS sent surveys to all diplomates to gather feedback about alternatives to the 10-year exam. Nearly 10,000 surgeons responded, according to an ABS summary. The majority of respondents said they wanted more frequent, lower-stakes, open-book assessments that would be required no frequently than every 2 years. Most surgeons were also in favor of being tested on both surgery concepts and practice-specific content.

For 2019 and beyond, the ABS’ Component Boards – Vascular, Pediatric Surgery, Surgical, and Critical Care – will develop their continuous certification processes, Dr. Klingensmith said. Additional areas for the surgery exam also will be developed in collaboration with specialty societies.

In the meantime, registration for the new general surgery assessment opens Aug. 1. The assessment will be available from Sept. 7 to Nov. 5, during which time diplomates can take the assessment at their convenience.

For more information, go to the continuous certification section on the ABS website.

[email protected]

The Food and Drug Administration on March 9 issued warning letters to all three duodenoscope manufacturers for failing to comply with the requirements of federal law under which they were ordered to conduct postmarket surveillance studies to assess the effectiveness of reprocessing the devices.

The warning is part of an ongoing effort to prevent patient infections associated with the transmission of bacteria from contaminated duodenoscopes. The three manufacturers – Olympus, Fujifilm, and Pentax – are required to conduct studies to sample and culture reprocessed duodenoscopes that are in clinical use to learn more about issues that contribute to contamination, and to study human factors to determine how hospital staff who have had training are following the reprocessing instructions. In 2015, the FDA ordered the companies to conduct a postmarket surveillance study to determine whether health care facilities were able to properly clean and disinfect the devices.

Currently, the Olympus manufacturer has failed to start data collection, while both Pentax and Fujifilm have failed to provide sufficient data required for their respective studies to sample and culture reprocessed duodenoscopes that are in clinical use. In addition, Olympus and Pentax have not complied with requirements to assess how well staff members have followed the reprocessing instructions after the human factors studies and Fujifilm has been meeting its requirements for its human factors study only.

“The FDA has taken important steps to improve the reprocessing of duodenoscopes, and we’ve seen a reduction in reports of patient infections, but we need the required postmarket studies to determine whether these measures are being properly implemented in real-world clinical settings and whether we need to take additional action to further improve the safety of these devices,” said Jeff Shuren, MD, director of the FDA’s Center for Devices and Radiological Health in a press release. “We expect these device manufacturers to meet their study obligations to ensure patient safety.”

The companies have until March 24 to submit a plan that outlines how study milestones will be achieved. If the companies fail to respond to the warning letter, the FDA states that they may take additional action, such as seizure, injunction, and civil monetary penalties.

Read the full press release on the FDA’s website.

[email protected]

The Food and Drug Administration on March 9 issued warning letters to all three duodenoscope manufacturers for failing to comply with the requirements of federal law under which they were ordered to conduct postmarket surveillance studies to assess the effectiveness of reprocessing the devices.

The warning is part of an ongoing effort to prevent patient infections associated with the transmission of bacteria from contaminated duodenoscopes. The three manufacturers – Olympus, Fujifilm, and Pentax – are required to conduct studies to sample and culture reprocessed duodenoscopes that are in clinical use to learn more about issues that contribute to contamination, and to study human factors to determine how hospital staff who have had training are following the reprocessing instructions. In 2015, the FDA ordered the companies to conduct a postmarket surveillance study to determine whether health care facilities were able to properly clean and disinfect the devices.

Currently, the Olympus manufacturer has failed to start data collection, while both Pentax and Fujifilm have failed to provide sufficient data required for their respective studies to sample and culture reprocessed duodenoscopes that are in clinical use. In addition, Olympus and Pentax have not complied with requirements to assess how well staff members have followed the reprocessing instructions after the human factors studies and Fujifilm has been meeting its requirements for its human factors study only.

“The FDA has taken important steps to improve the reprocessing of duodenoscopes, and we’ve seen a reduction in reports of patient infections, but we need the required postmarket studies to determine whether these measures are being properly implemented in real-world clinical settings and whether we need to take additional action to further improve the safety of these devices,” said Jeff Shuren, MD, director of the FDA’s Center for Devices and Radiological Health in a press release. “We expect these device manufacturers to meet their study obligations to ensure patient safety.”

The companies have until March 24 to submit a plan that outlines how study milestones will be achieved. If the companies fail to respond to the warning letter, the FDA states that they may take additional action, such as seizure, injunction, and civil monetary penalties.

Read the full press release on the FDA’s website.

[email protected]

The Food and Drug Administration on March 9 issued warning letters to all three duodenoscope manufacturers for failing to comply with the requirements of federal law under which they were ordered to conduct postmarket surveillance studies to assess the effectiveness of reprocessing the devices.

The warning is part of an ongoing effort to prevent patient infections associated with the transmission of bacteria from contaminated duodenoscopes. The three manufacturers – Olympus, Fujifilm, and Pentax – are required to conduct studies to sample and culture reprocessed duodenoscopes that are in clinical use to learn more about issues that contribute to contamination, and to study human factors to determine how hospital staff who have had training are following the reprocessing instructions. In 2015, the FDA ordered the companies to conduct a postmarket surveillance study to determine whether health care facilities were able to properly clean and disinfect the devices.

Currently, the Olympus manufacturer has failed to start data collection, while both Pentax and Fujifilm have failed to provide sufficient data required for their respective studies to sample and culture reprocessed duodenoscopes that are in clinical use. In addition, Olympus and Pentax have not complied with requirements to assess how well staff members have followed the reprocessing instructions after the human factors studies and Fujifilm has been meeting its requirements for its human factors study only.

“The FDA has taken important steps to improve the reprocessing of duodenoscopes, and we’ve seen a reduction in reports of patient infections, but we need the required postmarket studies to determine whether these measures are being properly implemented in real-world clinical settings and whether we need to take additional action to further improve the safety of these devices,” said Jeff Shuren, MD, director of the FDA’s Center for Devices and Radiological Health in a press release. “We expect these device manufacturers to meet their study obligations to ensure patient safety.”

The companies have until March 24 to submit a plan that outlines how study milestones will be achieved. If the companies fail to respond to the warning letter, the FDA states that they may take additional action, such as seizure, injunction, and civil monetary penalties.

Read the full press release on the FDA’s website.

[email protected]

LAS VEGAS – Patients with inflammatory bowel disease who are in need of a surgical intervention can pose a special challenge to surgeons who encounter these patients only occasionally.

The question of whether to perform surgery or refer a patient to a higher-volume specialty center can depend on proximity. In some cases, a specialty center isn’t close, or the patient can’t tolerate the required travel. In fact, a recent study showed that 85.8% of IBD patients are treated surgically in hospitals that treat fewer than 50 patients per year (Am J Gastroenterol. 2008;103:2789-98).

In a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education, Larry Whelan, MD, FACS, discussed some of the challenges these patients pose and offered guidance on which cases are best referred to high-volume centers, and the best way to proceed in emergencies.

IBD patients at high-volume centers have lower mortality than do those in low-volume centers, but patients treated at lower-volume centers tend to be sicker, and studies have shown no significant difference in complication rate. This suggests that surgeons shouldn’t be afraid to tackle these cases, according to Dr. Whelan, chief of colorectal surgery at Mount Sinai West, New York.

Dr. Whelan disclosed financial relationships with Ethicon Endosurgery and Olympus Corporation. Global Academy for Medical Education and this news organization are owned by the same parent company.”

LAS VEGAS – Patients with inflammatory bowel disease who are in need of a surgical intervention can pose a special challenge to surgeons who encounter these patients only occasionally.

The question of whether to perform surgery or refer a patient to a higher-volume specialty center can depend on proximity. In some cases, a specialty center isn’t close, or the patient can’t tolerate the required travel. In fact, a recent study showed that 85.8% of IBD patients are treated surgically in hospitals that treat fewer than 50 patients per year (Am J Gastroenterol. 2008;103:2789-98).

In a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education, Larry Whelan, MD, FACS, discussed some of the challenges these patients pose and offered guidance on which cases are best referred to high-volume centers, and the best way to proceed in emergencies.

IBD patients at high-volume centers have lower mortality than do those in low-volume centers, but patients treated at lower-volume centers tend to be sicker, and studies have shown no significant difference in complication rate. This suggests that surgeons shouldn’t be afraid to tackle these cases, according to Dr. Whelan, chief of colorectal surgery at Mount Sinai West, New York.

Dr. Whelan disclosed financial relationships with Ethicon Endosurgery and Olympus Corporation. Global Academy for Medical Education and this news organization are owned by the same parent company.”

LAS VEGAS – Patients with inflammatory bowel disease who are in need of a surgical intervention can pose a special challenge to surgeons who encounter these patients only occasionally.

The question of whether to perform surgery or refer a patient to a higher-volume specialty center can depend on proximity. In some cases, a specialty center isn’t close, or the patient can’t tolerate the required travel. In fact, a recent study showed that 85.8% of IBD patients are treated surgically in hospitals that treat fewer than 50 patients per year (Am J Gastroenterol. 2008;103:2789-98).

In a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education, Larry Whelan, MD, FACS, discussed some of the challenges these patients pose and offered guidance on which cases are best referred to high-volume centers, and the best way to proceed in emergencies.

IBD patients at high-volume centers have lower mortality than do those in low-volume centers, but patients treated at lower-volume centers tend to be sicker, and studies have shown no significant difference in complication rate. This suggests that surgeons shouldn’t be afraid to tackle these cases, according to Dr. Whelan, chief of colorectal surgery at Mount Sinai West, New York.

Dr. Whelan disclosed financial relationships with Ethicon Endosurgery and Olympus Corporation. Global Academy for Medical Education and this news organization are owned by the same parent company.”

As President Donald Trump and congressional Republicans tirelessly try to dismantle the Affordable Care Act, a number of states are scrambling to enact laws that safeguard its central provisions.

The GOP tax plan approved by Congress in the last days of 2017 repealed the ACA penalty for people who fail to carry health insurance, a provision called the “individual mandate.” On Jan. 30, in Trump’s first State of the Union address, he claimed victory in killing off this part of the health law, saying Obamacare was effectively dead without it.

But before that federal action kicks in next year, some states are enacting measures to preserve the effects of the mandate by creating their own versions of it.

Maryland is on the cutting edge with legislation moving through both chambers of the Statehouse.

“We’ve been just struggling since Trump became president with how to protect the ACA in our state,” said Vincent DeMarco, president of the Maryland Citizens’ Health Initiative, a nonprofit organization that has been instrumental in pushing the measure.

Maryland’s take on the individual mandate

Maryland’s effort began last April when the state legislature created the Maryland Health Insurance Coverage Protection Commission “both in response to and in anticipation of efforts at the federal level to repeal and replace the ACA,” according to a report by the state’s legislative services department and the commission itself.

The commission, chartered for 3 years, is charged with studying how federal action could affect the state’s health insurance market and Medicaid program and offering recommendations to mitigate any negative impacts. The panel began meeting months before the Maryland General Assembly started its 90-day session in January.

Based on the commission’s initial recommendations, Sen. Brian Feldman and House Del. Joseline Peña-Melnyk introduced the Protect Maryland Health Care Act of 2018, which lays out a framework for preserving an individual mandate in the state.

The federal individual mandate was put in place to make sure that younger, healthier people joined the insurance risk pool, helping to stabilize the market. The idea is that those relatively healthy customers help cover the insurers’ costs for sicker customers’ care, which keeps premium costs manageable for everyone.

Politics and policy on the ground

Maryland is fertile ground for such health care experiments. The ACA remains popular within the state. Polling commissioned by Mr. DeMarco’s group puts the law’s support at 62%.

In addition, about 52% of Marylanders favored a state-based individual mandate, to make up for the federal provision that was repealed.

Democrats control the general assembly, but Gov. Larry Hogan, a Republican, has not offered a specific position on the issue – rather, he alluded to health reform efforts in his State of the State address. “Let’s develop bipartisan solutions to stabilize [health insurance] rates,” he said.

Ed Haislmaier, a senior research fellow at the Heritage Foundation, expressed skepticism about whether this approach will make a difference. The people who are targeted, he argued, are younger, healthier, and generally lower income. They don’t have insurance because they don’t want it, he suggested.

He pointed to Connecticut as an example. It has two bills pending in its legislature – one that closely mirrors the federal mandate, but with slightly lower fines, and another in which the fines would be deposited into health savings accounts for the individuals.

In New Jersey, a Senate panel advanced a two-bill approach on March 5 that would collect a fee from residents who opt against buying health insurance. These fines would then be used to help pay the health care claims of people who are catastrophically ill.

In the District of Columbia, a health care working group recommended an individual mandate nearly identical to the federal one. The plan would require City Council and congressional approval to become law.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

As President Donald Trump and congressional Republicans tirelessly try to dismantle the Affordable Care Act, a number of states are scrambling to enact laws that safeguard its central provisions.

The GOP tax plan approved by Congress in the last days of 2017 repealed the ACA penalty for people who fail to carry health insurance, a provision called the “individual mandate.” On Jan. 30, in Trump’s first State of the Union address, he claimed victory in killing off this part of the health law, saying Obamacare was effectively dead without it.

But before that federal action kicks in next year, some states are enacting measures to preserve the effects of the mandate by creating their own versions of it.

Maryland is on the cutting edge with legislation moving through both chambers of the Statehouse.

“We’ve been just struggling since Trump became president with how to protect the ACA in our state,” said Vincent DeMarco, president of the Maryland Citizens’ Health Initiative, a nonprofit organization that has been instrumental in pushing the measure.

Maryland’s take on the individual mandate

Maryland’s effort began last April when the state legislature created the Maryland Health Insurance Coverage Protection Commission “both in response to and in anticipation of efforts at the federal level to repeal and replace the ACA,” according to a report by the state’s legislative services department and the commission itself.

The commission, chartered for 3 years, is charged with studying how federal action could affect the state’s health insurance market and Medicaid program and offering recommendations to mitigate any negative impacts. The panel began meeting months before the Maryland General Assembly started its 90-day session in January.

Based on the commission’s initial recommendations, Sen. Brian Feldman and House Del. Joseline Peña-Melnyk introduced the Protect Maryland Health Care Act of 2018, which lays out a framework for preserving an individual mandate in the state.

The federal individual mandate was put in place to make sure that younger, healthier people joined the insurance risk pool, helping to stabilize the market. The idea is that those relatively healthy customers help cover the insurers’ costs for sicker customers’ care, which keeps premium costs manageable for everyone.

Politics and policy on the ground

Maryland is fertile ground for such health care experiments. The ACA remains popular within the state. Polling commissioned by Mr. DeMarco’s group puts the law’s support at 62%.

In addition, about 52% of Marylanders favored a state-based individual mandate, to make up for the federal provision that was repealed.

Democrats control the general assembly, but Gov. Larry Hogan, a Republican, has not offered a specific position on the issue – rather, he alluded to health reform efforts in his State of the State address. “Let’s develop bipartisan solutions to stabilize [health insurance] rates,” he said.

Ed Haislmaier, a senior research fellow at the Heritage Foundation, expressed skepticism about whether this approach will make a difference. The people who are targeted, he argued, are younger, healthier, and generally lower income. They don’t have insurance because they don’t want it, he suggested.

He pointed to Connecticut as an example. It has two bills pending in its legislature – one that closely mirrors the federal mandate, but with slightly lower fines, and another in which the fines would be deposited into health savings accounts for the individuals.

In New Jersey, a Senate panel advanced a two-bill approach on March 5 that would collect a fee from residents who opt against buying health insurance. These fines would then be used to help pay the health care claims of people who are catastrophically ill.

In the District of Columbia, a health care working group recommended an individual mandate nearly identical to the federal one. The plan would require City Council and congressional approval to become law.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

As President Donald Trump and congressional Republicans tirelessly try to dismantle the Affordable Care Act, a number of states are scrambling to enact laws that safeguard its central provisions.

The GOP tax plan approved by Congress in the last days of 2017 repealed the ACA penalty for people who fail to carry health insurance, a provision called the “individual mandate.” On Jan. 30, in Trump’s first State of the Union address, he claimed victory in killing off this part of the health law, saying Obamacare was effectively dead without it.

But before that federal action kicks in next year, some states are enacting measures to preserve the effects of the mandate by creating their own versions of it.

Maryland is on the cutting edge with legislation moving through both chambers of the Statehouse.

“We’ve been just struggling since Trump became president with how to protect the ACA in our state,” said Vincent DeMarco, president of the Maryland Citizens’ Health Initiative, a nonprofit organization that has been instrumental in pushing the measure.

Maryland’s take on the individual mandate

Maryland’s effort began last April when the state legislature created the Maryland Health Insurance Coverage Protection Commission “both in response to and in anticipation of efforts at the federal level to repeal and replace the ACA,” according to a report by the state’s legislative services department and the commission itself.

The commission, chartered for 3 years, is charged with studying how federal action could affect the state’s health insurance market and Medicaid program and offering recommendations to mitigate any negative impacts. The panel began meeting months before the Maryland General Assembly started its 90-day session in January.

Based on the commission’s initial recommendations, Sen. Brian Feldman and House Del. Joseline Peña-Melnyk introduced the Protect Maryland Health Care Act of 2018, which lays out a framework for preserving an individual mandate in the state.

The federal individual mandate was put in place to make sure that younger, healthier people joined the insurance risk pool, helping to stabilize the market. The idea is that those relatively healthy customers help cover the insurers’ costs for sicker customers’ care, which keeps premium costs manageable for everyone.

Politics and policy on the ground

Maryland is fertile ground for such health care experiments. The ACA remains popular within the state. Polling commissioned by Mr. DeMarco’s group puts the law’s support at 62%.

In addition, about 52% of Marylanders favored a state-based individual mandate, to make up for the federal provision that was repealed.

Democrats control the general assembly, but Gov. Larry Hogan, a Republican, has not offered a specific position on the issue – rather, he alluded to health reform efforts in his State of the State address. “Let’s develop bipartisan solutions to stabilize [health insurance] rates,” he said.

Ed Haislmaier, a senior research fellow at the Heritage Foundation, expressed skepticism about whether this approach will make a difference. The people who are targeted, he argued, are younger, healthier, and generally lower income. They don’t have insurance because they don’t want it, he suggested.

He pointed to Connecticut as an example. It has two bills pending in its legislature – one that closely mirrors the federal mandate, but with slightly lower fines, and another in which the fines would be deposited into health savings accounts for the individuals.

In New Jersey, a Senate panel advanced a two-bill approach on March 5 that would collect a fee from residents who opt against buying health insurance. These fines would then be used to help pay the health care claims of people who are catastrophically ill.

In the District of Columbia, a health care working group recommended an individual mandate nearly identical to the federal one. The plan would require City Council and congressional approval to become law.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.

These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.

“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”

Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.

While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.

Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.

Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.

“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”

The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.

Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.

“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”

There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.

Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.

These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.

“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”

Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.

While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.

Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.

Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.

“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”

The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.

Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.

“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”

There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.

Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.

These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.

“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”

Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.

While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.

Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.

Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.

“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”

The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.

Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.

“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”

There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.

DALLAS – No clear winner emerged in a first-ever randomized controlled trial comparing Pfannenstiel with vertical incisions for women with obesity having cesarean delivery, though enrollment difficulties limited study numbers, with almost two-thirds of eligible women declining to participate in the surgical trial.

At 6 weeks postdelivery, 21.1% of women who had a vertical incision experienced wound complications, compared with 18.6% of those who had a Pfannenstiel incision, a nonsignificant difference. This was a smaller difference than was seen at 2 weeks postpartum, when 20% of the vertical incision group had wound complications, compared with 10.4% of those who had a Pfannenstiel, also a nonsignificant difference. Maternal and fetal outcomes didn’t differ significantly with the two surgical approaches.

[email protected]

SOURCE: Marrs CC et al. Am J Obstet Gynecol. 2018 Jan;218:S29.
 

DALLAS – No clear winner emerged in a first-ever randomized controlled trial comparing Pfannenstiel with vertical incisions for women with obesity having cesarean delivery, though enrollment difficulties limited study numbers, with almost two-thirds of eligible women declining to participate in the surgical trial.

At 6 weeks postdelivery, 21.1% of women who had a vertical incision experienced wound complications, compared with 18.6% of those who had a Pfannenstiel incision, a nonsignificant difference. This was a smaller difference than was seen at 2 weeks postpartum, when 20% of the vertical incision group had wound complications, compared with 10.4% of those who had a Pfannenstiel, also a nonsignificant difference. Maternal and fetal outcomes didn’t differ significantly with the two surgical approaches.

[email protected]

SOURCE: Marrs CC et al. Am J Obstet Gynecol. 2018 Jan;218:S29.
 

DALLAS – No clear winner emerged in a first-ever randomized controlled trial comparing Pfannenstiel with vertical incisions for women with obesity having cesarean delivery, though enrollment difficulties limited study numbers, with almost two-thirds of eligible women declining to participate in the surgical trial.

At 6 weeks postdelivery, 21.1% of women who had a vertical incision experienced wound complications, compared with 18.6% of those who had a Pfannenstiel incision, a nonsignificant difference. This was a smaller difference than was seen at 2 weeks postpartum, when 20% of the vertical incision group had wound complications, compared with 10.4% of those who had a Pfannenstiel, also a nonsignificant difference. Maternal and fetal outcomes didn’t differ significantly with the two surgical approaches.

[email protected]

SOURCE: Marrs CC et al. Am J Obstet Gynecol. 2018 Jan;218:S29.
 

LAS VEGAS – Colorectal surgery is rife with potential complications, but there are steps that surgeons can take to improve outcomes, and factors to consider to reduce complications. These strategies and considerations were the focus of a talk by Matthew G. Mutch, MD, at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Prehabilitation

The approach to improve outcomes can begin with prehabilitation – preparing the patient for the difficult process of surgery. “If somebody is going to fight a 15-round heavyweight bout, they train for 6 or 8 weeks before a fight. Why not bring that concept to surgery?” said Dr. Mutch, chief of colon and rectal surgery at the Washington University, St. Louis.

Prehabilitation can include lifestyle changes, such as quitting smoking, but can also incorporate aerobic and/or resistance exercise, dietary counseling and protein supplementation, anxiety reduction, and medical education to prepare the patient for the challenges ahead. “Preoperatively, we try to identify factors to see if we can make meaningful lifestyle changes, because that’s really the grassroots level where a lot of this [improvement in outcomes] is going to occur,” said Dr. Mutch.
 

Frailty

Frailty is a factor driving complications in colorectal surgery. A meta-analysis of 20 studies showed that frailty and prefrailty were associated with worse all-cause mortality during follow-up among older cancer patients. More striking, it showed that frail patients were nearly five times more likely to be intolerant of cancer treatment (odds ratio, 4.86) and more likely to experience postoperative complications (30-day hazard ratio, 3.19) (Ann Oncol. 2015;26[6]:1091-1101).

Hemoglobin A_1c

Dr. Mutch went on to discuss hemoglobin A_1c (HbA_1c) levels as a risk factor in colorectal surgery. HbA_1c levels higher than 6 are associated with worse outcomes, but tight postoperative control is associated with hypoglycemia. “What you want to do is set that patient up before surgery. HbA_1c has a half-life of about a month, so if you start modifying their risk factors 4-6 weeks before you get them into surgery, by 1 month you can see a 50% reduction, and at 2 months a 75% reduction. If you do these things in a preoperative setting it makes a difference,” said Dr. Mutch.

Smoking cessation

Smoking cessation is another key strategy. Two weeks of cessation should lead to a decline in coughing, but a minimum of 4 weeks is needed to significantly reduce overall complications. Lifestyle changes need to be long term. “These are not measures that you’re going to do over a short period of time, and then when surgery is over throw it out the window,” said Dr. Mutch.

Anastomotic leak

Another factor is the detection of anastomotic leak, which can be challenging because its definitions vary significantly, and its causes can be multifactorial. Studies show that predictions of anastomotic leak are not especially successful, Dr. Mutch said, but routine leak testing improves outcomes. In a study of left-side anastomoses in Washington State, hospitals that performed leak tests had lower leak rates at least 90% of the time (OR, 0.23), and hospitals that later implemented leak tests experienced a significant reduction (Arch Surg. 2012:147[4]:345-51).

Venous thromboembolic events

Venous thromboembolic events (VTE), are the leading cause of operative mortality in colorectal surgery patients. This complication can be greatly reduced with prophylaxis, but requires screening for risk factors. Major surgery raises the risk of deep vein thrombosis in 20% of all hospitalized patients to 40%-80%, depending on the surgery type. “We have a lot of room to improve,” said Dr. Mutch.

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Timing

One factor that may have an impact on complications appears to be timing of surgery, at least at Washington University, where Dr. Mutch practices. The institution found that patients who had surgery the same day they were admitted had a 2.5% VTE risk, compared with 11% in patients who had surgery 5 or more days after admission.

Postop ambulation

Postsurgical ambulation was another critical complication factor. Dr. Mutch cited a study showing that ambulation on the day after surgery was associated with a 1% VTE risk, compared to 6.9% in patients who waited until day 2.

Dr. Mutch had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

LAS VEGAS – Colorectal surgery is rife with potential complications, but there are steps that surgeons can take to improve outcomes, and factors to consider to reduce complications. These strategies and considerations were the focus of a talk by Matthew G. Mutch, MD, at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Prehabilitation

The approach to improve outcomes can begin with prehabilitation – preparing the patient for the difficult process of surgery. “If somebody is going to fight a 15-round heavyweight bout, they train for 6 or 8 weeks before a fight. Why not bring that concept to surgery?” said Dr. Mutch, chief of colon and rectal surgery at the Washington University, St. Louis.

Prehabilitation can include lifestyle changes, such as quitting smoking, but can also incorporate aerobic and/or resistance exercise, dietary counseling and protein supplementation, anxiety reduction, and medical education to prepare the patient for the challenges ahead. “Preoperatively, we try to identify factors to see if we can make meaningful lifestyle changes, because that’s really the grassroots level where a lot of this [improvement in outcomes] is going to occur,” said Dr. Mutch.
 

Frailty

Frailty is a factor driving complications in colorectal surgery. A meta-analysis of 20 studies showed that frailty and prefrailty were associated with worse all-cause mortality during follow-up among older cancer patients. More striking, it showed that frail patients were nearly five times more likely to be intolerant of cancer treatment (odds ratio, 4.86) and more likely to experience postoperative complications (30-day hazard ratio, 3.19) (Ann Oncol. 2015;26[6]:1091-1101).

Hemoglobin A_1c

Dr. Mutch went on to discuss hemoglobin A_1c (HbA_1c) levels as a risk factor in colorectal surgery. HbA_1c levels higher than 6 are associated with worse outcomes, but tight postoperative control is associated with hypoglycemia. “What you want to do is set that patient up before surgery. HbA_1c has a half-life of about a month, so if you start modifying their risk factors 4-6 weeks before you get them into surgery, by 1 month you can see a 50% reduction, and at 2 months a 75% reduction. If you do these things in a preoperative setting it makes a difference,” said Dr. Mutch.

Smoking cessation

Smoking cessation is another key strategy. Two weeks of cessation should lead to a decline in coughing, but a minimum of 4 weeks is needed to significantly reduce overall complications. Lifestyle changes need to be long term. “These are not measures that you’re going to do over a short period of time, and then when surgery is over throw it out the window,” said Dr. Mutch.

Anastomotic leak

Another factor is the detection of anastomotic leak, which can be challenging because its definitions vary significantly, and its causes can be multifactorial. Studies show that predictions of anastomotic leak are not especially successful, Dr. Mutch said, but routine leak testing improves outcomes. In a study of left-side anastomoses in Washington State, hospitals that performed leak tests had lower leak rates at least 90% of the time (OR, 0.23), and hospitals that later implemented leak tests experienced a significant reduction (Arch Surg. 2012:147[4]:345-51).

Venous thromboembolic events

Venous thromboembolic events (VTE), are the leading cause of operative mortality in colorectal surgery patients. This complication can be greatly reduced with prophylaxis, but requires screening for risk factors. Major surgery raises the risk of deep vein thrombosis in 20% of all hospitalized patients to 40%-80%, depending on the surgery type. “We have a lot of room to improve,” said Dr. Mutch.

copyright monkeybusinessimages/Thinkstock

Timing

One factor that may have an impact on complications appears to be timing of surgery, at least at Washington University, where Dr. Mutch practices. The institution found that patients who had surgery the same day they were admitted had a 2.5% VTE risk, compared with 11% in patients who had surgery 5 or more days after admission.

Postop ambulation

Postsurgical ambulation was another critical complication factor. Dr. Mutch cited a study showing that ambulation on the day after surgery was associated with a 1% VTE risk, compared to 6.9% in patients who waited until day 2.

Dr. Mutch had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

LAS VEGAS – Colorectal surgery is rife with potential complications, but there are steps that surgeons can take to improve outcomes, and factors to consider to reduce complications. These strategies and considerations were the focus of a talk by Matthew G. Mutch, MD, at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Prehabilitation

The approach to improve outcomes can begin with prehabilitation – preparing the patient for the difficult process of surgery. “If somebody is going to fight a 15-round heavyweight bout, they train for 6 or 8 weeks before a fight. Why not bring that concept to surgery?” said Dr. Mutch, chief of colon and rectal surgery at the Washington University, St. Louis.

Prehabilitation can include lifestyle changes, such as quitting smoking, but can also incorporate aerobic and/or resistance exercise, dietary counseling and protein supplementation, anxiety reduction, and medical education to prepare the patient for the challenges ahead. “Preoperatively, we try to identify factors to see if we can make meaningful lifestyle changes, because that’s really the grassroots level where a lot of this [improvement in outcomes] is going to occur,” said Dr. Mutch.
 

Frailty

Frailty is a factor driving complications in colorectal surgery. A meta-analysis of 20 studies showed that frailty and prefrailty were associated with worse all-cause mortality during follow-up among older cancer patients. More striking, it showed that frail patients were nearly five times more likely to be intolerant of cancer treatment (odds ratio, 4.86) and more likely to experience postoperative complications (30-day hazard ratio, 3.19) (Ann Oncol. 2015;26[6]:1091-1101).

Hemoglobin A_1c

Dr. Mutch went on to discuss hemoglobin A_1c (HbA_1c) levels as a risk factor in colorectal surgery. HbA_1c levels higher than 6 are associated with worse outcomes, but tight postoperative control is associated with hypoglycemia. “What you want to do is set that patient up before surgery. HbA_1c has a half-life of about a month, so if you start modifying their risk factors 4-6 weeks before you get them into surgery, by 1 month you can see a 50% reduction, and at 2 months a 75% reduction. If you do these things in a preoperative setting it makes a difference,” said Dr. Mutch.

Smoking cessation

Smoking cessation is another key strategy. Two weeks of cessation should lead to a decline in coughing, but a minimum of 4 weeks is needed to significantly reduce overall complications. Lifestyle changes need to be long term. “These are not measures that you’re going to do over a short period of time, and then when surgery is over throw it out the window,” said Dr. Mutch.

Anastomotic leak

Another factor is the detection of anastomotic leak, which can be challenging because its definitions vary significantly, and its causes can be multifactorial. Studies show that predictions of anastomotic leak are not especially successful, Dr. Mutch said, but routine leak testing improves outcomes. In a study of left-side anastomoses in Washington State, hospitals that performed leak tests had lower leak rates at least 90% of the time (OR, 0.23), and hospitals that later implemented leak tests experienced a significant reduction (Arch Surg. 2012:147[4]:345-51).

Venous thromboembolic events

Venous thromboembolic events (VTE), are the leading cause of operative mortality in colorectal surgery patients. This complication can be greatly reduced with prophylaxis, but requires screening for risk factors. Major surgery raises the risk of deep vein thrombosis in 20% of all hospitalized patients to 40%-80%, depending on the surgery type. “We have a lot of room to improve,” said Dr. Mutch.

copyright monkeybusinessimages/Thinkstock

Timing

One factor that may have an impact on complications appears to be timing of surgery, at least at Washington University, where Dr. Mutch practices. The institution found that patients who had surgery the same day they were admitted had a 2.5% VTE risk, compared with 11% in patients who had surgery 5 or more days after admission.

Postop ambulation

Postsurgical ambulation was another critical complication factor. Dr. Mutch cited a study showing that ambulation on the day after surgery was associated with a 1% VTE risk, compared to 6.9% in patients who waited until day 2.

Dr. Mutch had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.