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VIDEO: Laparoscopy is a safe approach throughout pregnancy, expert says
NATIONAL HARBOR, MD. – Laparoscopy offers advantages over laparotomy when performing nonobstetrical surgery on pregnant women, Yuval Kaufman, MD, said at the AAGL Global Congress.
“When we talk about advantages in referral to the pregnant patient, one of the most important things is early ambulation,” Dr. Kaufman, a gynecologic surgeon at Carmel Medical Center in Haifa, Israel, said in an interview. “These patients are in a hypercoagulable state; they are more likely to have DVT and PE. You need them up and running as soon as possible.”
Laparoscopy also tends to be better in terms of handling of the uterus, offering a field of view so that the uterus doesn’t need to be moved as much. In addition, laparoscopy is associated with a smaller, more easily healed scar, and usually requires fewer analgesics, which is better for the fetus, he said.
The Society of American Gastrointestinal and Endoscopic Surgeons recently issued guidelines for the use of laparoscopy during pregnancy, advising surgeons that these procedures can be safely performed during any trimester when the operation is indicated, he said.
“There was an older misconception that surgery has to be done in the second trimester only,” Dr. Kaufman said. “But they actually contradict that; they show that if you postpone surgery for this reason you might be doing much more damage to the mother and to the fetus.”
Dr. Kaufman reported having no relevant financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @eaztweets
NATIONAL HARBOR, MD. – Laparoscopy offers advantages over laparotomy when performing nonobstetrical surgery on pregnant women, Yuval Kaufman, MD, said at the AAGL Global Congress.
“When we talk about advantages in referral to the pregnant patient, one of the most important things is early ambulation,” Dr. Kaufman, a gynecologic surgeon at Carmel Medical Center in Haifa, Israel, said in an interview. “These patients are in a hypercoagulable state; they are more likely to have DVT and PE. You need them up and running as soon as possible.”
Laparoscopy also tends to be better in terms of handling of the uterus, offering a field of view so that the uterus doesn’t need to be moved as much. In addition, laparoscopy is associated with a smaller, more easily healed scar, and usually requires fewer analgesics, which is better for the fetus, he said.
The Society of American Gastrointestinal and Endoscopic Surgeons recently issued guidelines for the use of laparoscopy during pregnancy, advising surgeons that these procedures can be safely performed during any trimester when the operation is indicated, he said.
“There was an older misconception that surgery has to be done in the second trimester only,” Dr. Kaufman said. “But they actually contradict that; they show that if you postpone surgery for this reason you might be doing much more damage to the mother and to the fetus.”
Dr. Kaufman reported having no relevant financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @eaztweets
NATIONAL HARBOR, MD. – Laparoscopy offers advantages over laparotomy when performing nonobstetrical surgery on pregnant women, Yuval Kaufman, MD, said at the AAGL Global Congress.
“When we talk about advantages in referral to the pregnant patient, one of the most important things is early ambulation,” Dr. Kaufman, a gynecologic surgeon at Carmel Medical Center in Haifa, Israel, said in an interview. “These patients are in a hypercoagulable state; they are more likely to have DVT and PE. You need them up and running as soon as possible.”
Laparoscopy also tends to be better in terms of handling of the uterus, offering a field of view so that the uterus doesn’t need to be moved as much. In addition, laparoscopy is associated with a smaller, more easily healed scar, and usually requires fewer analgesics, which is better for the fetus, he said.
The Society of American Gastrointestinal and Endoscopic Surgeons recently issued guidelines for the use of laparoscopy during pregnancy, advising surgeons that these procedures can be safely performed during any trimester when the operation is indicated, he said.
“There was an older misconception that surgery has to be done in the second trimester only,” Dr. Kaufman said. “But they actually contradict that; they show that if you postpone surgery for this reason you might be doing much more damage to the mother and to the fetus.”
Dr. Kaufman reported having no relevant financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @eaztweets
AT AAGL 2017
In bariatric surgery, leak test may backfire
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
AT WSA 2017
Key clinical point: Use of endoscopy to perform the provocative test may reduce the incidence of anastomotic leaks.
Major finding: The rate of leaks was 0.8% in patients who had the provocative test, compared with 0.4% in patients who didn’t have the test.
Data source: A retrospective analysis of 133,478 procedures.
Disclosures: The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
Living liver donation safety supported in single-center study
SCOTTSDALE, ARIZ. – A single-center analysis of complications following living liver donation found a low rate of severe complications, and a high quality of life among donors. The results are similar to what has been seen in a previous multicenter study in the United States, and the authors hope that the results can help inform potential donors and their physicians.
There is a significant shortage of deceased liver donors, leading to the death of about 3,500 liver transplant hopefuls in 2016, compared with about 2,900 who received a transplant. Living donor transplant was developed and first attempted in 1996 as an attempt to counter this shortage, and for a brief period it was popular, peaking at 500 donor surgeries in 2001. But that year the death of a donor occurred in New York and received widespread publicity.
Overall, though, the study showed relatively few complications, and that donors reported good quality of life. “There was a slight dip in health-related quality of life at 5 years and 10 years, but at all times the donors had significantly better quality of life compared to the standard population,” said Dr. Chinnakotla, clinical director of pediatric transplantation at the University of Minnesota, Minneapolis.
The researchers examined long-term complications and quality of life among 176 liver donors who underwent surgery between 1997 and 2016 at the University of Minnesota. At total of 140 donors underwent a right-lobe hepatectomy without middle hepatic vein, 14 underwent right lobe with middle hepatic vein, 4 underwent left lobe, and 18 underwent left lateral segmentectomy.
The researchers then analyzed complications graded by the Clavien scale. They found that 59.1% of right-lobe donors experienced no complications at all; 5.8% had Clavien scale 1 complications, meaning something abnormal occurred but required no intervention; and 27.3% had a Clavien 2 complication, requiring pharmaceutical treatment, a blood transfusion, or parenteral nutrition. Clavien 3a complications, which required an intervention without general anesthesia, occurred in 1.9% of cases, and Clavien 3b complications, which required anesthesia, occurred in 5.8%.
A total of 81.8% of left-lobe donors experienced no complications, 4.5% had a Clavien 1 complication, and 13.6% a Clavien 2. There were no Clavien 3 or 4 complications in left-lobe donors.
Overall, the incidence of Clavien grade 3 or higher complications was 7%, there were no complications involving organ failure, and there were no deaths.
Quality of life, as measured by the 36-item Short Form Health Survey and an internally designed donor-specific survey, was higher among recipients than in the general population at all time points. The primary long-term complaints were incisional discomfort, which ranged from about 23% to 38% in frequency, and intolerance to fatty meals, which had a frequency of 20%-30%, and is likely attributable to accompanying cholecystectomy, according to Dr. Chinnakotla.
“The overall results appear to have been excellent,” said William C. Chapman, MD, who was invited by the meeting organizers to review and comment on the study. Dr. Chapman is surgical director of transplant surgery at Washington University in St. Louis.
Dr. Chapman also noted that some studies in Asia have looked at reducing complications in donors, while avoiding a small-for-size graft, by using two left-lobe grafts from separate living donors (Liver Transpl 2015;21[11]1438-48). “We haven’t been brave enough to do that in the United States, but I think that is a strategy we can look forward to in the future,” said Dr. Chinnakotla.
No funding source was disclosed.
SCOTTSDALE, ARIZ. – A single-center analysis of complications following living liver donation found a low rate of severe complications, and a high quality of life among donors. The results are similar to what has been seen in a previous multicenter study in the United States, and the authors hope that the results can help inform potential donors and their physicians.
There is a significant shortage of deceased liver donors, leading to the death of about 3,500 liver transplant hopefuls in 2016, compared with about 2,900 who received a transplant. Living donor transplant was developed and first attempted in 1996 as an attempt to counter this shortage, and for a brief period it was popular, peaking at 500 donor surgeries in 2001. But that year the death of a donor occurred in New York and received widespread publicity.
Overall, though, the study showed relatively few complications, and that donors reported good quality of life. “There was a slight dip in health-related quality of life at 5 years and 10 years, but at all times the donors had significantly better quality of life compared to the standard population,” said Dr. Chinnakotla, clinical director of pediatric transplantation at the University of Minnesota, Minneapolis.
The researchers examined long-term complications and quality of life among 176 liver donors who underwent surgery between 1997 and 2016 at the University of Minnesota. At total of 140 donors underwent a right-lobe hepatectomy without middle hepatic vein, 14 underwent right lobe with middle hepatic vein, 4 underwent left lobe, and 18 underwent left lateral segmentectomy.
The researchers then analyzed complications graded by the Clavien scale. They found that 59.1% of right-lobe donors experienced no complications at all; 5.8% had Clavien scale 1 complications, meaning something abnormal occurred but required no intervention; and 27.3% had a Clavien 2 complication, requiring pharmaceutical treatment, a blood transfusion, or parenteral nutrition. Clavien 3a complications, which required an intervention without general anesthesia, occurred in 1.9% of cases, and Clavien 3b complications, which required anesthesia, occurred in 5.8%.
A total of 81.8% of left-lobe donors experienced no complications, 4.5% had a Clavien 1 complication, and 13.6% a Clavien 2. There were no Clavien 3 or 4 complications in left-lobe donors.
Overall, the incidence of Clavien grade 3 or higher complications was 7%, there were no complications involving organ failure, and there were no deaths.
Quality of life, as measured by the 36-item Short Form Health Survey and an internally designed donor-specific survey, was higher among recipients than in the general population at all time points. The primary long-term complaints were incisional discomfort, which ranged from about 23% to 38% in frequency, and intolerance to fatty meals, which had a frequency of 20%-30%, and is likely attributable to accompanying cholecystectomy, according to Dr. Chinnakotla.
“The overall results appear to have been excellent,” said William C. Chapman, MD, who was invited by the meeting organizers to review and comment on the study. Dr. Chapman is surgical director of transplant surgery at Washington University in St. Louis.
Dr. Chapman also noted that some studies in Asia have looked at reducing complications in donors, while avoiding a small-for-size graft, by using two left-lobe grafts from separate living donors (Liver Transpl 2015;21[11]1438-48). “We haven’t been brave enough to do that in the United States, but I think that is a strategy we can look forward to in the future,” said Dr. Chinnakotla.
No funding source was disclosed.
SCOTTSDALE, ARIZ. – A single-center analysis of complications following living liver donation found a low rate of severe complications, and a high quality of life among donors. The results are similar to what has been seen in a previous multicenter study in the United States, and the authors hope that the results can help inform potential donors and their physicians.
There is a significant shortage of deceased liver donors, leading to the death of about 3,500 liver transplant hopefuls in 2016, compared with about 2,900 who received a transplant. Living donor transplant was developed and first attempted in 1996 as an attempt to counter this shortage, and for a brief period it was popular, peaking at 500 donor surgeries in 2001. But that year the death of a donor occurred in New York and received widespread publicity.
Overall, though, the study showed relatively few complications, and that donors reported good quality of life. “There was a slight dip in health-related quality of life at 5 years and 10 years, but at all times the donors had significantly better quality of life compared to the standard population,” said Dr. Chinnakotla, clinical director of pediatric transplantation at the University of Minnesota, Minneapolis.
The researchers examined long-term complications and quality of life among 176 liver donors who underwent surgery between 1997 and 2016 at the University of Minnesota. At total of 140 donors underwent a right-lobe hepatectomy without middle hepatic vein, 14 underwent right lobe with middle hepatic vein, 4 underwent left lobe, and 18 underwent left lateral segmentectomy.
The researchers then analyzed complications graded by the Clavien scale. They found that 59.1% of right-lobe donors experienced no complications at all; 5.8% had Clavien scale 1 complications, meaning something abnormal occurred but required no intervention; and 27.3% had a Clavien 2 complication, requiring pharmaceutical treatment, a blood transfusion, or parenteral nutrition. Clavien 3a complications, which required an intervention without general anesthesia, occurred in 1.9% of cases, and Clavien 3b complications, which required anesthesia, occurred in 5.8%.
A total of 81.8% of left-lobe donors experienced no complications, 4.5% had a Clavien 1 complication, and 13.6% a Clavien 2. There were no Clavien 3 or 4 complications in left-lobe donors.
Overall, the incidence of Clavien grade 3 or higher complications was 7%, there were no complications involving organ failure, and there were no deaths.
Quality of life, as measured by the 36-item Short Form Health Survey and an internally designed donor-specific survey, was higher among recipients than in the general population at all time points. The primary long-term complaints were incisional discomfort, which ranged from about 23% to 38% in frequency, and intolerance to fatty meals, which had a frequency of 20%-30%, and is likely attributable to accompanying cholecystectomy, according to Dr. Chinnakotla.
“The overall results appear to have been excellent,” said William C. Chapman, MD, who was invited by the meeting organizers to review and comment on the study. Dr. Chapman is surgical director of transplant surgery at Washington University in St. Louis.
Dr. Chapman also noted that some studies in Asia have looked at reducing complications in donors, while avoiding a small-for-size graft, by using two left-lobe grafts from separate living donors (Liver Transpl 2015;21[11]1438-48). “We haven’t been brave enough to do that in the United States, but I think that is a strategy we can look forward to in the future,” said Dr. Chinnakotla.
No funding source was disclosed.
AT WSA 2017
Enhanced recovery protocol applied to liver surgery reduced costs
SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.
“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.
The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.
The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.
The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.
A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.
The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).
ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days
Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).
There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.
The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.
“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.
The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.
The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.
The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.
A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.
The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).
ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days
Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).
There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.
The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.
“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.
The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.
The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.
The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.
A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.
The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).
ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days
Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).
There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.
The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
AT WSA 2017
Key clinical point: An enhanced recovery program reduced hospital costs for livery surgery.
Major finding: The program was associated with a 9% reduction in costs, but only in minor hepatectomy procedures.
Data source: Retrospective analysis of 212 patients.
Disclosures: The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
High-volume centers have lower costs for some pancreatic surgeries
SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.
The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.
In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.
There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.
“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.
The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.
“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.
That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.
The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.
High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).
In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).
In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).
The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).
Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.
The study received no outside support. Dr. Vuong reported having no financial disclosures..
SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.
The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.
In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.
There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.
“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.
The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.
“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.
That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.
The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.
High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).
In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).
In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).
The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).
Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.
The study received no outside support. Dr. Vuong reported having no financial disclosures..
SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.
The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.
In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.
There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.
“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.
The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.
“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.
That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.
The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.
High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).
In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).
In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).
The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).
Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.
The study received no outside support. Dr. Vuong reported having no financial disclosures..
AT WSA 2017
Key clinical point: Surgeons performing five or more pancreaticoduodenectomies annually had lower overall costs.
Major finding: Costs dropped by $3,680, but there was no significant cost difference in distal pancreatectomies.
Data source: Retrospective analysis of 796 surgeries at 14 hospitals.
Disclosures: The study received no outside support. Dr. Vuong reported having no financial disclosures.
Safety-net hospitals would be hurt by hospital-wide 30-day readmission penalties
Considering all readmissions within 30 days of discharge in the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals, based on a study of two years of Medicare claims data from 3,443 hospitals.
“Transition to a hospital-wide measure would require an adjustment in the penalty formula to keep penalties in the same range for most hospitals and without a change in procedures would have a deleterious effect on safety-net hospitals,” according to Rachael B. Zuckerman, PhD, from the Department of Health and Human Services, Washington, and her co-authors.
Analyzing 6,807,899 admissions for hospital-wide readmission measures and 4,392,658 admissions for condition-specific measures, the researchers found that a condition-specific approach would result in 3,238 hospitals being eligible for penalties for at least one condition. A hospital-wide measure of readmissions would result in 76 additional hospitals being eligible for penalties based on one year of admissions data, and 128 additional hospitals based on 3 years of admissions data (NEJM 2017, 377:1551-58. DOI: 10.1056/NEJMsa1701791).
Moving to a hospital-wide measure of readmissions also would significantly increase mean annual penalty rates across all hospitals by 0.89% of base diagnosis-related group (DRG) payments or $393,000; 43% of hospitals would be penalized under this standard.
“Moving to the hospital-wide readmission measure would also substantially increase the disparity between safety-net and other hospitals: the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals,” the authors wrote.
“Since safety-net hospitals tend to perform slightly worse on the hospital-wide measure, they are more likely to receive a penalty, which would increase the disparity in penalties between the two groups.”
The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associate editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
Considering all readmissions within 30 days of discharge in the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals, based on a study of two years of Medicare claims data from 3,443 hospitals.
“Transition to a hospital-wide measure would require an adjustment in the penalty formula to keep penalties in the same range for most hospitals and without a change in procedures would have a deleterious effect on safety-net hospitals,” according to Rachael B. Zuckerman, PhD, from the Department of Health and Human Services, Washington, and her co-authors.
Analyzing 6,807,899 admissions for hospital-wide readmission measures and 4,392,658 admissions for condition-specific measures, the researchers found that a condition-specific approach would result in 3,238 hospitals being eligible for penalties for at least one condition. A hospital-wide measure of readmissions would result in 76 additional hospitals being eligible for penalties based on one year of admissions data, and 128 additional hospitals based on 3 years of admissions data (NEJM 2017, 377:1551-58. DOI: 10.1056/NEJMsa1701791).
Moving to a hospital-wide measure of readmissions also would significantly increase mean annual penalty rates across all hospitals by 0.89% of base diagnosis-related group (DRG) payments or $393,000; 43% of hospitals would be penalized under this standard.
“Moving to the hospital-wide readmission measure would also substantially increase the disparity between safety-net and other hospitals: the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals,” the authors wrote.
“Since safety-net hospitals tend to perform slightly worse on the hospital-wide measure, they are more likely to receive a penalty, which would increase the disparity in penalties between the two groups.”
The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associate editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
Considering all readmissions within 30 days of discharge in the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals, based on a study of two years of Medicare claims data from 3,443 hospitals.
“Transition to a hospital-wide measure would require an adjustment in the penalty formula to keep penalties in the same range for most hospitals and without a change in procedures would have a deleterious effect on safety-net hospitals,” according to Rachael B. Zuckerman, PhD, from the Department of Health and Human Services, Washington, and her co-authors.
Analyzing 6,807,899 admissions for hospital-wide readmission measures and 4,392,658 admissions for condition-specific measures, the researchers found that a condition-specific approach would result in 3,238 hospitals being eligible for penalties for at least one condition. A hospital-wide measure of readmissions would result in 76 additional hospitals being eligible for penalties based on one year of admissions data, and 128 additional hospitals based on 3 years of admissions data (NEJM 2017, 377:1551-58. DOI: 10.1056/NEJMsa1701791).
Moving to a hospital-wide measure of readmissions also would significantly increase mean annual penalty rates across all hospitals by 0.89% of base diagnosis-related group (DRG) payments or $393,000; 43% of hospitals would be penalized under this standard.
“Moving to the hospital-wide readmission measure would also substantially increase the disparity between safety-net and other hospitals: the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals,” the authors wrote.
“Since safety-net hospitals tend to perform slightly worse on the hospital-wide measure, they are more likely to receive a penalty, which would increase the disparity in penalties between the two groups.”
The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associate editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
FROM NEJM
Key clinical point: Adopting a hospital-wide measure of 30-day readmissions for the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals.
Major finding: With a hospital-wide measure of readmissions in the Hospital Readmissions Reduction Program, the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals.
Data source: Analysis of two years of Medicare claims data from 3,443 hospitals.
Disclosures: The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associated editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
Robotic Nissen fundoplication has teaching advantages
Training level affected operative time for laparoscopic Nissen fundoplication, but not for the robotic procedure, according to Maureen D. Moore, MD, and her associates.
Further, in laparoscopic and robotic procedures, junior and senior assistant cohorts had similar outcome measures for estimated blood loss, length of stay, postoperative complications, and 30-day readmission rate.
“The robotic technique offers unique advantages as an educational platform and potentially allows for increased trainee participation without compromising perioperative outcomes,” researchers concluded.
They evaluated surgical times and outcomes for 105 patients; junior assistants (postgraduate year-3 surgery residents) were present in 29 laparoscopic and 44 robotic procedures and senior assistants (minimally invasive surgery fellows) assisted in 18 laparoscopic and 14 robotic procedures.
Median operative time was significantly shorter for the laparoscopic procedures, 112 minutes vs. 157 minutes for the robotic procedures (P less than 0.001). Plus, the median operative time was significantly lower when senior assistants were involved in the laparoscopic procedures, 85 minutes vs. 129 minutes for the junior assistants (P = 0.02).
For the robotic procedures, the median operative times were not significantly different based on the assistant’s level of training, 154 minutes vs. 158 minutes.
Read the full study in the Journal of Surgical Research (doi: 10.1016/j.jss.2017.05.127).
Training level affected operative time for laparoscopic Nissen fundoplication, but not for the robotic procedure, according to Maureen D. Moore, MD, and her associates.
Further, in laparoscopic and robotic procedures, junior and senior assistant cohorts had similar outcome measures for estimated blood loss, length of stay, postoperative complications, and 30-day readmission rate.
“The robotic technique offers unique advantages as an educational platform and potentially allows for increased trainee participation without compromising perioperative outcomes,” researchers concluded.
They evaluated surgical times and outcomes for 105 patients; junior assistants (postgraduate year-3 surgery residents) were present in 29 laparoscopic and 44 robotic procedures and senior assistants (minimally invasive surgery fellows) assisted in 18 laparoscopic and 14 robotic procedures.
Median operative time was significantly shorter for the laparoscopic procedures, 112 minutes vs. 157 minutes for the robotic procedures (P less than 0.001). Plus, the median operative time was significantly lower when senior assistants were involved in the laparoscopic procedures, 85 minutes vs. 129 minutes for the junior assistants (P = 0.02).
For the robotic procedures, the median operative times were not significantly different based on the assistant’s level of training, 154 minutes vs. 158 minutes.
Read the full study in the Journal of Surgical Research (doi: 10.1016/j.jss.2017.05.127).
Training level affected operative time for laparoscopic Nissen fundoplication, but not for the robotic procedure, according to Maureen D. Moore, MD, and her associates.
Further, in laparoscopic and robotic procedures, junior and senior assistant cohorts had similar outcome measures for estimated blood loss, length of stay, postoperative complications, and 30-day readmission rate.
“The robotic technique offers unique advantages as an educational platform and potentially allows for increased trainee participation without compromising perioperative outcomes,” researchers concluded.
They evaluated surgical times and outcomes for 105 patients; junior assistants (postgraduate year-3 surgery residents) were present in 29 laparoscopic and 44 robotic procedures and senior assistants (minimally invasive surgery fellows) assisted in 18 laparoscopic and 14 robotic procedures.
Median operative time was significantly shorter for the laparoscopic procedures, 112 minutes vs. 157 minutes for the robotic procedures (P less than 0.001). Plus, the median operative time was significantly lower when senior assistants were involved in the laparoscopic procedures, 85 minutes vs. 129 minutes for the junior assistants (P = 0.02).
For the robotic procedures, the median operative times were not significantly different based on the assistant’s level of training, 154 minutes vs. 158 minutes.
Read the full study in the Journal of Surgical Research (doi: 10.1016/j.jss.2017.05.127).
FROM THE JOURNAL OF SURGICAL RESEARCH
Restrictive transfusion strategy safe in cardiac surgery
ANAHEIM, CALIF. – Waiting to transfuse heart surgery patients until their hemoglobin drops below 7.5 g/dL is just as safe as transfusing them when their hemoglobin drops below 9.5 g/dL, and it saves a lot of blood, according to the TRICS III randomized, noninferiority trial of nearly 5,000 patients undergoing cardiac surgery with cardiopulmonary bypass.
Cardiac surgeons have been moving to more restrictive transfusion policies following reports of worse postoperative survival when patients are transfused. However, there are concerns about safety and uncertainty over whether it’s the transfusions themselves that are problematic or whether transfused patients do worse because they are sicker to begin with. The Transfusion Requirements in Cardiac Surgery (TRICS) III trial removes some of the doubt: “A restrictive transfusion strategy is as effective and safe as a liberal strategy in patients undergoing cardiac surgery,” said lead investigator C. David Mazer, MD, a professor in the department of anesthesia at the University of Toronto.
Overall, 11.4% in the restrictive-threshold group and 12.5% in the liberal-threshold group met the study’s composite primary outcome of death from any cause, MI, stroke, and new-onset renal failure with dialysis (P less than .001 for noninferiority). There were no statistically significant between-group differences in the individual components of the composite outcome. Mortality was 3% in the restrictive group and 3.6% in the liberal group, a 15% reduction for the restrictive group.
About 52% of the patients in the restrictive arm, compared with 72.6% in the liberal arm, were transfused. When transfused, patients in the restrictive arm received a median of 2 units of red cells; liberal-arm patients received a median of 3 units. The overall cost difference was roughly $3 million, Dr. Mazer said at the American Heart Association scientific sessions.
There were no statistically significant differences in secondary outcomes. Restrictive patients were on mechanical ventilation for a median of 0.38 days and in the ICU for a median of 2.1 days; patients in the liberal arm were ventilated for a median of 0.36 days and in the ICU for a median of 1.9 days. The median hospital stay was 8 days in both groups.
Unexpectedly, patients 75 years and older did better with the restrictive transfusion strategy, with a 30% lower risk of the composite outcome. “Many people think the older you are, the higher your hemoglobin should be, and the more liberal you should be with transfusions. We didn’t find that. [It] challenges current beliefs and may be considered to be hypothesis generating; at a minimum, it highlights that a restrictive transfusion strategy appears to be safe in elderly patients,” Dr. Mazer said.
The participants were a mean of 72 years old, and 35% were women. The majority in both arms underwent coronary artery bypass surgery, valve surgery, or both. Heart transplants were excluded from the study. The trial was conducted in 19 countries, including China and India, but “the results were remarkably consistent independent of where the sites were,” he said.
Results of the TRICS III trial were published simultaneously with Dr. Mazer’s presentation (N Engl J Med. 2017 Nov 12. doi: 10.1056/NEJMoa1711818).
The trial was funded by the Canadian Institutes of Health Research, among others. Dr. Mazer reported personal fees from Amgen, Boehringer Ingelheim, Octapharma, and Pharmascience, as well as grants and personal fees from Fresenius Kabi.
This is an extremely important study. There have been multiple other trials, and, unfortunately, results have been quite equivocal. It’s incumbent upon us to figure out the best transfusion strategy, especially in cardiac surgery, since it is associated with a large amount of blood utilization. Also, there’ve been projections for a significant lack of blood supply in the future.
While the overall results showed no significant difference in outcomes between the groups, there was a numerical benefit evident in the restrictive group for the composite outcome, as well as all components of the main primary outcome except MI. This is not entirely unexpected, but we are really looking at the short-term effects here. I’m hoping that the longer-term outcomes will be evaluated, because they are extremely important.
Frank Sellke, MD , is chief of cardiothoracic surgery at Brown University in Providence, R.I. He made his comments after the study was presented at the American Heart Association scientific sessions. He was not involved with the work.
This is an extremely important study. There have been multiple other trials, and, unfortunately, results have been quite equivocal. It’s incumbent upon us to figure out the best transfusion strategy, especially in cardiac surgery, since it is associated with a large amount of blood utilization. Also, there’ve been projections for a significant lack of blood supply in the future.
While the overall results showed no significant difference in outcomes between the groups, there was a numerical benefit evident in the restrictive group for the composite outcome, as well as all components of the main primary outcome except MI. This is not entirely unexpected, but we are really looking at the short-term effects here. I’m hoping that the longer-term outcomes will be evaluated, because they are extremely important.
Frank Sellke, MD , is chief of cardiothoracic surgery at Brown University in Providence, R.I. He made his comments after the study was presented at the American Heart Association scientific sessions. He was not involved with the work.
This is an extremely important study. There have been multiple other trials, and, unfortunately, results have been quite equivocal. It’s incumbent upon us to figure out the best transfusion strategy, especially in cardiac surgery, since it is associated with a large amount of blood utilization. Also, there’ve been projections for a significant lack of blood supply in the future.
While the overall results showed no significant difference in outcomes between the groups, there was a numerical benefit evident in the restrictive group for the composite outcome, as well as all components of the main primary outcome except MI. This is not entirely unexpected, but we are really looking at the short-term effects here. I’m hoping that the longer-term outcomes will be evaluated, because they are extremely important.
Frank Sellke, MD , is chief of cardiothoracic surgery at Brown University in Providence, R.I. He made his comments after the study was presented at the American Heart Association scientific sessions. He was not involved with the work.
ANAHEIM, CALIF. – Waiting to transfuse heart surgery patients until their hemoglobin drops below 7.5 g/dL is just as safe as transfusing them when their hemoglobin drops below 9.5 g/dL, and it saves a lot of blood, according to the TRICS III randomized, noninferiority trial of nearly 5,000 patients undergoing cardiac surgery with cardiopulmonary bypass.
Cardiac surgeons have been moving to more restrictive transfusion policies following reports of worse postoperative survival when patients are transfused. However, there are concerns about safety and uncertainty over whether it’s the transfusions themselves that are problematic or whether transfused patients do worse because they are sicker to begin with. The Transfusion Requirements in Cardiac Surgery (TRICS) III trial removes some of the doubt: “A restrictive transfusion strategy is as effective and safe as a liberal strategy in patients undergoing cardiac surgery,” said lead investigator C. David Mazer, MD, a professor in the department of anesthesia at the University of Toronto.
Overall, 11.4% in the restrictive-threshold group and 12.5% in the liberal-threshold group met the study’s composite primary outcome of death from any cause, MI, stroke, and new-onset renal failure with dialysis (P less than .001 for noninferiority). There were no statistically significant between-group differences in the individual components of the composite outcome. Mortality was 3% in the restrictive group and 3.6% in the liberal group, a 15% reduction for the restrictive group.
About 52% of the patients in the restrictive arm, compared with 72.6% in the liberal arm, were transfused. When transfused, patients in the restrictive arm received a median of 2 units of red cells; liberal-arm patients received a median of 3 units. The overall cost difference was roughly $3 million, Dr. Mazer said at the American Heart Association scientific sessions.
There were no statistically significant differences in secondary outcomes. Restrictive patients were on mechanical ventilation for a median of 0.38 days and in the ICU for a median of 2.1 days; patients in the liberal arm were ventilated for a median of 0.36 days and in the ICU for a median of 1.9 days. The median hospital stay was 8 days in both groups.
Unexpectedly, patients 75 years and older did better with the restrictive transfusion strategy, with a 30% lower risk of the composite outcome. “Many people think the older you are, the higher your hemoglobin should be, and the more liberal you should be with transfusions. We didn’t find that. [It] challenges current beliefs and may be considered to be hypothesis generating; at a minimum, it highlights that a restrictive transfusion strategy appears to be safe in elderly patients,” Dr. Mazer said.
The participants were a mean of 72 years old, and 35% were women. The majority in both arms underwent coronary artery bypass surgery, valve surgery, or both. Heart transplants were excluded from the study. The trial was conducted in 19 countries, including China and India, but “the results were remarkably consistent independent of where the sites were,” he said.
Results of the TRICS III trial were published simultaneously with Dr. Mazer’s presentation (N Engl J Med. 2017 Nov 12. doi: 10.1056/NEJMoa1711818).
The trial was funded by the Canadian Institutes of Health Research, among others. Dr. Mazer reported personal fees from Amgen, Boehringer Ingelheim, Octapharma, and Pharmascience, as well as grants and personal fees from Fresenius Kabi.
ANAHEIM, CALIF. – Waiting to transfuse heart surgery patients until their hemoglobin drops below 7.5 g/dL is just as safe as transfusing them when their hemoglobin drops below 9.5 g/dL, and it saves a lot of blood, according to the TRICS III randomized, noninferiority trial of nearly 5,000 patients undergoing cardiac surgery with cardiopulmonary bypass.
Cardiac surgeons have been moving to more restrictive transfusion policies following reports of worse postoperative survival when patients are transfused. However, there are concerns about safety and uncertainty over whether it’s the transfusions themselves that are problematic or whether transfused patients do worse because they are sicker to begin with. The Transfusion Requirements in Cardiac Surgery (TRICS) III trial removes some of the doubt: “A restrictive transfusion strategy is as effective and safe as a liberal strategy in patients undergoing cardiac surgery,” said lead investigator C. David Mazer, MD, a professor in the department of anesthesia at the University of Toronto.
Overall, 11.4% in the restrictive-threshold group and 12.5% in the liberal-threshold group met the study’s composite primary outcome of death from any cause, MI, stroke, and new-onset renal failure with dialysis (P less than .001 for noninferiority). There were no statistically significant between-group differences in the individual components of the composite outcome. Mortality was 3% in the restrictive group and 3.6% in the liberal group, a 15% reduction for the restrictive group.
About 52% of the patients in the restrictive arm, compared with 72.6% in the liberal arm, were transfused. When transfused, patients in the restrictive arm received a median of 2 units of red cells; liberal-arm patients received a median of 3 units. The overall cost difference was roughly $3 million, Dr. Mazer said at the American Heart Association scientific sessions.
There were no statistically significant differences in secondary outcomes. Restrictive patients were on mechanical ventilation for a median of 0.38 days and in the ICU for a median of 2.1 days; patients in the liberal arm were ventilated for a median of 0.36 days and in the ICU for a median of 1.9 days. The median hospital stay was 8 days in both groups.
Unexpectedly, patients 75 years and older did better with the restrictive transfusion strategy, with a 30% lower risk of the composite outcome. “Many people think the older you are, the higher your hemoglobin should be, and the more liberal you should be with transfusions. We didn’t find that. [It] challenges current beliefs and may be considered to be hypothesis generating; at a minimum, it highlights that a restrictive transfusion strategy appears to be safe in elderly patients,” Dr. Mazer said.
The participants were a mean of 72 years old, and 35% were women. The majority in both arms underwent coronary artery bypass surgery, valve surgery, or both. Heart transplants were excluded from the study. The trial was conducted in 19 countries, including China and India, but “the results were remarkably consistent independent of where the sites were,” he said.
Results of the TRICS III trial were published simultaneously with Dr. Mazer’s presentation (N Engl J Med. 2017 Nov 12. doi: 10.1056/NEJMoa1711818).
The trial was funded by the Canadian Institutes of Health Research, among others. Dr. Mazer reported personal fees from Amgen, Boehringer Ingelheim, Octapharma, and Pharmascience, as well as grants and personal fees from Fresenius Kabi.
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: Overall, 11.4% in the restrictive-threshold group, versus 12.5% in the liberal-threshold group, met the study’s composite primary outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis.
Data source: TRICS III, a randomized, noninferiority trial with almost 5,000 participants
Disclosures: TRICS III was funded by the Canadian Institutes of Health Research, among others. The lead investigator reported personal fees from Amgen, Boehringer Ingelheim, Octapharma, and Pharmascience, as well as grants and personal fees from Fresenius Kabi.
Preop endocervical sampling pathology can guide trachelectomy planning
NATIONAL HARBOR, MD. – Pathologic findings from preoperative endocervical sampling were fairly consistent with the underlying pathologies identified at trachelectomy, based on a single-center, retrospective chart review presented at the AAGL Global Congress.
“Preoperative endocervical sampling can be performed safely and adequately with results consistent with final trachelectomy pathology,” said Sarah Krantz, MD, of Vanderbilt University, Nashville, Tenn. Importantly, performing preoperative sampling may identify a missed diagnosis of cancer and allows for subsequent appropriate preoperative planning, she added.
Dr. Krantz and her colleagues included 47 women who had a supracervical hysterectomy and subsequently underwent trachelectomy at Vanderbilt from April 1999 to April 2015. Indications for surgery included vaginal bleeding (24), abnormal pap smears (7), pain (16), prolapse (13), and cancer (2). If patients had a prior diagnosis of gynecologic malignancy, they were excluded from the study.
Endocervical sampling was performed in 18 of the 47 women by a gynecologist. Samples were collected by way of various methods, including Pap smear, endocervical brushings and curettage, and endometrial pipelle. The pathologic findings in endocervical samples coincided with the final surgical pathology in 9 of 10 patients with benign findings, 1 of 6 patients with dysplasia, and 2 of 2 patients with cancer.
Among the 29 women who did not undergo preoperative endocervical sampling, one was diagnosed with cervical cancer at final surgical pathology.
In the 24 women with vaginal bleeding, cervicitis was identified in 1 of 10 patients who underwent preoperative endocervical sampling and was found on final pathology in 12 of 24 patients.Given the high incidence of cervicitis in women who report vaginal bleeding, consideration should be given for medical management prior to surgical excision, Dr. Krantz said.
Dr. Krantz reported having no relevant financial disclosures.
NATIONAL HARBOR, MD. – Pathologic findings from preoperative endocervical sampling were fairly consistent with the underlying pathologies identified at trachelectomy, based on a single-center, retrospective chart review presented at the AAGL Global Congress.
“Preoperative endocervical sampling can be performed safely and adequately with results consistent with final trachelectomy pathology,” said Sarah Krantz, MD, of Vanderbilt University, Nashville, Tenn. Importantly, performing preoperative sampling may identify a missed diagnosis of cancer and allows for subsequent appropriate preoperative planning, she added.
Dr. Krantz and her colleagues included 47 women who had a supracervical hysterectomy and subsequently underwent trachelectomy at Vanderbilt from April 1999 to April 2015. Indications for surgery included vaginal bleeding (24), abnormal pap smears (7), pain (16), prolapse (13), and cancer (2). If patients had a prior diagnosis of gynecologic malignancy, they were excluded from the study.
Endocervical sampling was performed in 18 of the 47 women by a gynecologist. Samples were collected by way of various methods, including Pap smear, endocervical brushings and curettage, and endometrial pipelle. The pathologic findings in endocervical samples coincided with the final surgical pathology in 9 of 10 patients with benign findings, 1 of 6 patients with dysplasia, and 2 of 2 patients with cancer.
Among the 29 women who did not undergo preoperative endocervical sampling, one was diagnosed with cervical cancer at final surgical pathology.
In the 24 women with vaginal bleeding, cervicitis was identified in 1 of 10 patients who underwent preoperative endocervical sampling and was found on final pathology in 12 of 24 patients.Given the high incidence of cervicitis in women who report vaginal bleeding, consideration should be given for medical management prior to surgical excision, Dr. Krantz said.
Dr. Krantz reported having no relevant financial disclosures.
NATIONAL HARBOR, MD. – Pathologic findings from preoperative endocervical sampling were fairly consistent with the underlying pathologies identified at trachelectomy, based on a single-center, retrospective chart review presented at the AAGL Global Congress.
“Preoperative endocervical sampling can be performed safely and adequately with results consistent with final trachelectomy pathology,” said Sarah Krantz, MD, of Vanderbilt University, Nashville, Tenn. Importantly, performing preoperative sampling may identify a missed diagnosis of cancer and allows for subsequent appropriate preoperative planning, she added.
Dr. Krantz and her colleagues included 47 women who had a supracervical hysterectomy and subsequently underwent trachelectomy at Vanderbilt from April 1999 to April 2015. Indications for surgery included vaginal bleeding (24), abnormal pap smears (7), pain (16), prolapse (13), and cancer (2). If patients had a prior diagnosis of gynecologic malignancy, they were excluded from the study.
Endocervical sampling was performed in 18 of the 47 women by a gynecologist. Samples were collected by way of various methods, including Pap smear, endocervical brushings and curettage, and endometrial pipelle. The pathologic findings in endocervical samples coincided with the final surgical pathology in 9 of 10 patients with benign findings, 1 of 6 patients with dysplasia, and 2 of 2 patients with cancer.
Among the 29 women who did not undergo preoperative endocervical sampling, one was diagnosed with cervical cancer at final surgical pathology.
In the 24 women with vaginal bleeding, cervicitis was identified in 1 of 10 patients who underwent preoperative endocervical sampling and was found on final pathology in 12 of 24 patients.Given the high incidence of cervicitis in women who report vaginal bleeding, consideration should be given for medical management prior to surgical excision, Dr. Krantz said.
Dr. Krantz reported having no relevant financial disclosures.
AT AAGL 2017
Key clinical point:
Major finding: Among 18 women who had preoperative endocervical sampling, the pathology results matched those of the final surgical pathology in 9 of 10 patients with benign disorders, 1 of 6 patients with dysplasia, and 2 of 2 patients with cancer.
Data source: A retrospective chart review of 47 women who underwent trachelectomy at a single academic medical center from April 1999-April 2015.
Disclosures: Dr. Krantz reported having no relevant financial disclosures.
From the Editors: How about that!
For all those who say that the surgeon in the trenches doesn’t have a voice in the world of organized surgery, I have a story or two for you.
About 10 or more years ago, I was at a lovely old hotel in Cooperstown, N.Y., listening to a group of elder rural surgery colleagues hold forth about feeling ignored by the American College of Surgeons and how we should all band together to form a new society of rural surgeons. Like most crowds, they were getting pretty worked up. They were pretty sure such a revolution would solve our problems and we would quit being the Rodney Dangerfields of surgery (not getting any respect, as the great comic used to say).
It took a while – a few years – for the rural surgeons and ACS leadership to get to know each other better. We did, however, get there. An Advisory Council was created with the help of some very heavy hitters not often regarded as rural champions, most of whom had roots in the rural world that helped them understand what this group of surgeons wanted and needed.
Not too much removed from this event, many surgeons were feeling isolated in general due to the many challenges of rural practice familiar to so many of us. ACS leadership sensed that surgeons needed to be connected and with considerable effort they formed listservs and found that they were successful to some degree. So, under Dr. David Hoyt’s guidance a better technology was found, resources were committed, and the ACS Communities was launched. A new era in surgeon-to-surgeon and surgeon-to-leadership communication was born. It was as if we had developed talk radio for surgeons. Some stations were loud, others came in rather softly, but all were on the air. The pulse of the Fellows became audible.
Almost simultaneously, dissatisfaction with Maintenance of Certification grew as surgeons in practice began reaching their second and third recertification and the practice of surgery became ever more specialized. Many surgeons believed that nothing would ever change, that the front-line surgeon didn’t have a chance to affect change, and that the big dogs wouldn’t listen. But the College leadership heard the voices of concern and took steps to support a new approach to certification.
So here we are in 2017, coming off a very successful Clinical Congress. The formerly obscure rural surgeon contingent had several panels on the program. Surgeons practicing in towns as small as 3,000 moderated sessions. Some of those sessions were standing room only. The College assisted (and had for a few years) those rural surgeons in organizing a Rural Surgery Dinner, which filled a restaurant full of surgeons delighted to meet in person surgeons from small communities all over the country. They shared their common experiences and planned for a better tomorrow. Later in the week, the 2nd Vice President-Elect was announced. He is a surgeon from Keokuk, IA, and one of the leaders of the rural surgeon movement within the College, Philip Caropreso, MD, FACS. A new Regent was announced: Gary Timmerman, MD, FACS. Dr. Timmerman started his career in Watertown, S.D., and now runs a rural-based surgery training program.
The Clinical Congress program included many topics and issues that Fellows from every branch of surgery had posted about on the ACS Communities. The American Board of Surgery announced sweeping coming changes to help surgeons move on from an MOC system no one was really happy with to one that has great hope of making ongoing certification more than a hoop to jump through, but instead, a real value to the Diplomate. Sitting on the main committee for the American Board of Surgery’s sprint team on certification is a surgeon from Crockett, Texas, Pat Walker, MD, FACS, who practiced surgery “on the ground” in a small community setting for three decades.
Most of us would agree that rural surgeons are facing truly daunting professional headwinds, despite their critical work in serving rural patients. Yet I have been gladdened at the response and respect that the College leadership has given to rural surgeons in recent years. The outreach by the College to support rural surgeons is part of a broader effort to hear every Fellow and make the College more relevant in the life of hard-working surgeons of every type. Changes in how we retain and improve our certification process in some significant ways came out of College efforts to listen and respond to the concerns of Fellows in the College. These and other initiatives by the College leadership show a degree of farsightedness and caring that should be gratifying to all Fellows.
When Lindsay Fox, MD, FACS, a young rural surgeon in private practice with an 8-week-old baby, receives an award for excellence, moderates her panel at the Clinical Congress to a standing-room-only crowd, and then shares her experience through the Communities, I’d say the American College of Surgeons has done an amazing job in a short period of time to make our organization reflect all of us. As Mel Allen, the voice of the Yankees in their heyday, would say, “How about that!”
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
For all those who say that the surgeon in the trenches doesn’t have a voice in the world of organized surgery, I have a story or two for you.
About 10 or more years ago, I was at a lovely old hotel in Cooperstown, N.Y., listening to a group of elder rural surgery colleagues hold forth about feeling ignored by the American College of Surgeons and how we should all band together to form a new society of rural surgeons. Like most crowds, they were getting pretty worked up. They were pretty sure such a revolution would solve our problems and we would quit being the Rodney Dangerfields of surgery (not getting any respect, as the great comic used to say).
It took a while – a few years – for the rural surgeons and ACS leadership to get to know each other better. We did, however, get there. An Advisory Council was created with the help of some very heavy hitters not often regarded as rural champions, most of whom had roots in the rural world that helped them understand what this group of surgeons wanted and needed.
Not too much removed from this event, many surgeons were feeling isolated in general due to the many challenges of rural practice familiar to so many of us. ACS leadership sensed that surgeons needed to be connected and with considerable effort they formed listservs and found that they were successful to some degree. So, under Dr. David Hoyt’s guidance a better technology was found, resources were committed, and the ACS Communities was launched. A new era in surgeon-to-surgeon and surgeon-to-leadership communication was born. It was as if we had developed talk radio for surgeons. Some stations were loud, others came in rather softly, but all were on the air. The pulse of the Fellows became audible.
Almost simultaneously, dissatisfaction with Maintenance of Certification grew as surgeons in practice began reaching their second and third recertification and the practice of surgery became ever more specialized. Many surgeons believed that nothing would ever change, that the front-line surgeon didn’t have a chance to affect change, and that the big dogs wouldn’t listen. But the College leadership heard the voices of concern and took steps to support a new approach to certification.
So here we are in 2017, coming off a very successful Clinical Congress. The formerly obscure rural surgeon contingent had several panels on the program. Surgeons practicing in towns as small as 3,000 moderated sessions. Some of those sessions were standing room only. The College assisted (and had for a few years) those rural surgeons in organizing a Rural Surgery Dinner, which filled a restaurant full of surgeons delighted to meet in person surgeons from small communities all over the country. They shared their common experiences and planned for a better tomorrow. Later in the week, the 2nd Vice President-Elect was announced. He is a surgeon from Keokuk, IA, and one of the leaders of the rural surgeon movement within the College, Philip Caropreso, MD, FACS. A new Regent was announced: Gary Timmerman, MD, FACS. Dr. Timmerman started his career in Watertown, S.D., and now runs a rural-based surgery training program.
The Clinical Congress program included many topics and issues that Fellows from every branch of surgery had posted about on the ACS Communities. The American Board of Surgery announced sweeping coming changes to help surgeons move on from an MOC system no one was really happy with to one that has great hope of making ongoing certification more than a hoop to jump through, but instead, a real value to the Diplomate. Sitting on the main committee for the American Board of Surgery’s sprint team on certification is a surgeon from Crockett, Texas, Pat Walker, MD, FACS, who practiced surgery “on the ground” in a small community setting for three decades.
Most of us would agree that rural surgeons are facing truly daunting professional headwinds, despite their critical work in serving rural patients. Yet I have been gladdened at the response and respect that the College leadership has given to rural surgeons in recent years. The outreach by the College to support rural surgeons is part of a broader effort to hear every Fellow and make the College more relevant in the life of hard-working surgeons of every type. Changes in how we retain and improve our certification process in some significant ways came out of College efforts to listen and respond to the concerns of Fellows in the College. These and other initiatives by the College leadership show a degree of farsightedness and caring that should be gratifying to all Fellows.
When Lindsay Fox, MD, FACS, a young rural surgeon in private practice with an 8-week-old baby, receives an award for excellence, moderates her panel at the Clinical Congress to a standing-room-only crowd, and then shares her experience through the Communities, I’d say the American College of Surgeons has done an amazing job in a short period of time to make our organization reflect all of us. As Mel Allen, the voice of the Yankees in their heyday, would say, “How about that!”
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
For all those who say that the surgeon in the trenches doesn’t have a voice in the world of organized surgery, I have a story or two for you.
About 10 or more years ago, I was at a lovely old hotel in Cooperstown, N.Y., listening to a group of elder rural surgery colleagues hold forth about feeling ignored by the American College of Surgeons and how we should all band together to form a new society of rural surgeons. Like most crowds, they were getting pretty worked up. They were pretty sure such a revolution would solve our problems and we would quit being the Rodney Dangerfields of surgery (not getting any respect, as the great comic used to say).
It took a while – a few years – for the rural surgeons and ACS leadership to get to know each other better. We did, however, get there. An Advisory Council was created with the help of some very heavy hitters not often regarded as rural champions, most of whom had roots in the rural world that helped them understand what this group of surgeons wanted and needed.
Not too much removed from this event, many surgeons were feeling isolated in general due to the many challenges of rural practice familiar to so many of us. ACS leadership sensed that surgeons needed to be connected and with considerable effort they formed listservs and found that they were successful to some degree. So, under Dr. David Hoyt’s guidance a better technology was found, resources were committed, and the ACS Communities was launched. A new era in surgeon-to-surgeon and surgeon-to-leadership communication was born. It was as if we had developed talk radio for surgeons. Some stations were loud, others came in rather softly, but all were on the air. The pulse of the Fellows became audible.
Almost simultaneously, dissatisfaction with Maintenance of Certification grew as surgeons in practice began reaching their second and third recertification and the practice of surgery became ever more specialized. Many surgeons believed that nothing would ever change, that the front-line surgeon didn’t have a chance to affect change, and that the big dogs wouldn’t listen. But the College leadership heard the voices of concern and took steps to support a new approach to certification.
So here we are in 2017, coming off a very successful Clinical Congress. The formerly obscure rural surgeon contingent had several panels on the program. Surgeons practicing in towns as small as 3,000 moderated sessions. Some of those sessions were standing room only. The College assisted (and had for a few years) those rural surgeons in organizing a Rural Surgery Dinner, which filled a restaurant full of surgeons delighted to meet in person surgeons from small communities all over the country. They shared their common experiences and planned for a better tomorrow. Later in the week, the 2nd Vice President-Elect was announced. He is a surgeon from Keokuk, IA, and one of the leaders of the rural surgeon movement within the College, Philip Caropreso, MD, FACS. A new Regent was announced: Gary Timmerman, MD, FACS. Dr. Timmerman started his career in Watertown, S.D., and now runs a rural-based surgery training program.
The Clinical Congress program included many topics and issues that Fellows from every branch of surgery had posted about on the ACS Communities. The American Board of Surgery announced sweeping coming changes to help surgeons move on from an MOC system no one was really happy with to one that has great hope of making ongoing certification more than a hoop to jump through, but instead, a real value to the Diplomate. Sitting on the main committee for the American Board of Surgery’s sprint team on certification is a surgeon from Crockett, Texas, Pat Walker, MD, FACS, who practiced surgery “on the ground” in a small community setting for three decades.
Most of us would agree that rural surgeons are facing truly daunting professional headwinds, despite their critical work in serving rural patients. Yet I have been gladdened at the response and respect that the College leadership has given to rural surgeons in recent years. The outreach by the College to support rural surgeons is part of a broader effort to hear every Fellow and make the College more relevant in the life of hard-working surgeons of every type. Changes in how we retain and improve our certification process in some significant ways came out of College efforts to listen and respond to the concerns of Fellows in the College. These and other initiatives by the College leadership show a degree of farsightedness and caring that should be gratifying to all Fellows.
When Lindsay Fox, MD, FACS, a young rural surgeon in private practice with an 8-week-old baby, receives an award for excellence, moderates her panel at the Clinical Congress to a standing-room-only crowd, and then shares her experience through the Communities, I’d say the American College of Surgeons has done an amazing job in a short period of time to make our organization reflect all of us. As Mel Allen, the voice of the Yankees in their heyday, would say, “How about that!”
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.