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Official Newspaper of the American College of Surgeons
Single-port laparoscopy has few complications but BMI matters
NATIONAL HARBOR, MD. – Single-port laparoscopy is both safe and feasible, and has the potential to decrease surgical complications and increase efficiency, according to findings presented at the AAGL Global Congress.
Ahmed N. Al-Niaimi, MD, of the University of Wisconsin–Madison, and his colleagues, conducted a retrospective cohort study analyzing 587 consecutive patients who underwent single-port laparoscopy from March 2012 to December 2016. Of the 587 patients, there were 27 clinically-relevant complications among 18 patients (3%). The complications included intensive care unit admission, reoperation, end organ damage, organ space surgical site infection, and readmission. 
“Those factors leading to those complications are similar to the factors that cause complications in any other surgery,” Dr. Al-Niaimi said in an interview before the meeting.
Body mass index was found to be a primary contributor to surgical complications. Patients with a BMI of more than 30 kg/m2 experienced a 1% increase in the risk of surgical complications per unit value increase of BMI. This is significant because the median BMI of the patient population in the study was 33.9 kg/m2 and 57% of the study participants were considered obese or morbidly obese.
“The heavier the patient, the higher the complication rate,” Dr. Al-Niaimi said.
Surgeons who are learning single-port laparoscopy should choose patients with lower BMIs to gain efficiency in using the new technique, Dr. Al-Niaimi suggested. This will allow patients to decrease their risk of surgical complications while allowing surgeons to hone their abilities in a new surgical technique, he said.
The other prime contributor to surgical complications is the length of surgical time. The average time of surgery during the study was 156 minutes. Dr. Al-Niaimi and his colleagues found that for each 10-minute increase in surgical time, the risk of complications increased by 2%.
While the results of the study demonstrate safety in the single-port approach, Dr. Al-Niaimi said a randomized controlled trial is needed to validate the findings and determine whether single-port laparoscopy is more effective than multi-port laparoscopy.
Dr. Al-Niaimi reported having no financial disclosures.
NATIONAL HARBOR, MD. – Single-port laparoscopy is both safe and feasible, and has the potential to decrease surgical complications and increase efficiency, according to findings presented at the AAGL Global Congress.
Ahmed N. Al-Niaimi, MD, of the University of Wisconsin–Madison, and his colleagues, conducted a retrospective cohort study analyzing 587 consecutive patients who underwent single-port laparoscopy from March 2012 to December 2016. Of the 587 patients, there were 27 clinically-relevant complications among 18 patients (3%). The complications included intensive care unit admission, reoperation, end organ damage, organ space surgical site infection, and readmission.
“Those factors leading to those complications are similar to the factors that cause complications in any other surgery,” Dr. Al-Niaimi said in an interview before the meeting.
Body mass index was found to be a primary contributor to surgical complications. Patients with a BMI of more than 30 kg/m2 experienced a 1% increase in the risk of surgical complications per unit value increase of BMI. This is significant because the median BMI of the patient population in the study was 33.9 kg/m2 and 57% of the study participants were considered obese or morbidly obese.
“The heavier the patient, the higher the complication rate,” Dr. Al-Niaimi said.
Surgeons who are learning single-port laparoscopy should choose patients with lower BMIs to gain efficiency in using the new technique, Dr. Al-Niaimi suggested. This will allow patients to decrease their risk of surgical complications while allowing surgeons to hone their abilities in a new surgical technique, he said.
The other prime contributor to surgical complications is the length of surgical time. The average time of surgery during the study was 156 minutes. Dr. Al-Niaimi and his colleagues found that for each 10-minute increase in surgical time, the risk of complications increased by 2%.
While the results of the study demonstrate safety in the single-port approach, Dr. Al-Niaimi said a randomized controlled trial is needed to validate the findings and determine whether single-port laparoscopy is more effective than multi-port laparoscopy.
Dr. Al-Niaimi reported having no financial disclosures.
NATIONAL HARBOR, MD. – Single-port laparoscopy is both safe and feasible, and has the potential to decrease surgical complications and increase efficiency, according to findings presented at the AAGL Global Congress.
Ahmed N. Al-Niaimi, MD, of the University of Wisconsin–Madison, and his colleagues, conducted a retrospective cohort study analyzing 587 consecutive patients who underwent single-port laparoscopy from March 2012 to December 2016. Of the 587 patients, there were 27 clinically-relevant complications among 18 patients (3%). The complications included intensive care unit admission, reoperation, end organ damage, organ space surgical site infection, and readmission.
“Those factors leading to those complications are similar to the factors that cause complications in any other surgery,” Dr. Al-Niaimi said in an interview before the meeting.
Body mass index was found to be a primary contributor to surgical complications. Patients with a BMI of more than 30 kg/m2 experienced a 1% increase in the risk of surgical complications per unit value increase of BMI. This is significant because the median BMI of the patient population in the study was 33.9 kg/m2 and 57% of the study participants were considered obese or morbidly obese.
“The heavier the patient, the higher the complication rate,” Dr. Al-Niaimi said.
Surgeons who are learning single-port laparoscopy should choose patients with lower BMIs to gain efficiency in using the new technique, Dr. Al-Niaimi suggested. This will allow patients to decrease their risk of surgical complications while allowing surgeons to hone their abilities in a new surgical technique, he said.
The other prime contributor to surgical complications is the length of surgical time. The average time of surgery during the study was 156 minutes. Dr. Al-Niaimi and his colleagues found that for each 10-minute increase in surgical time, the risk of complications increased by 2%.
While the results of the study demonstrate safety in the single-port approach, Dr. Al-Niaimi said a randomized controlled trial is needed to validate the findings and determine whether single-port laparoscopy is more effective than multi-port laparoscopy.
Dr. Al-Niaimi reported having no financial disclosures.
AT AAGL 2017
Key clinical point:
Major finding: Obese patients experienced a 1% increase in risk of surgical complications per unit value increase of BMI.
Data source: Retrospective cohort study of 587 consecutive patients undergoing single-port laparoscopy at a single academic institution.
Disclosures: Dr. Al-Niaimi reported having no financial disclosures.
Direct oral anticoagulants okay during AF device placement
ANAHEIM, CALIF. – Whether direct oral anticoagulants are continued or interrupted for device placement in atrial fibrillation patients, the risk of device pocket hematoma or stroke is very low, based on results of the BRUISE CONTROL–2 trial in more than 600 subjects.
Either strategy is reasonable depending on the clinical scenario, coprincipal investigator David Birnie, MD, said in presenting the results at the American Heart Association scientific sessions.
When atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) present for device surgery, there’s concern that keeping them on the drugs will increase the bleeding risk, but that taking them off will increase the stroke risk. “We sought to resolve this dilemma,” said Dr. Birnie, an electrophysiologist and director of the arrhythmia service at the University of Ottawa Heart Institute.
The subjects were on dabigatran, rivaroxaban, or apixaban, about a third in each group; 328 were randomized to continue their daily dosing, including on the day of surgery. The other 334 were randomized to interrupted treatment. For rivaroxaban and apixaban, that meant taking their last dose 2 days before surgery. Dabigatran patients discontinued the drug 1-2 days beforehand, depending on glomerular filtration rate. Patients resumed treatment about 24 hours after surgery. CHA2DS2-VASc scores were a mean of 3.9 in both arms, and at least 2 in all participants.
The rate of clinically significant hematoma – the primary outcome in the study, defined as a hematoma requiring prolonged hospitalization, interrupted postoperative anticoagulation, or reoperation to evacuate – was identical in both arms, 2.1% (seven patients each). There were two ischemic strokes, one in each arm. There was one delayed cardiac tamponade in the continuation arm and one pericardial effusion in the interrupted arm. The three deaths in the trial were not related to device placement.
So, what to do depends on the clinical scenario, Dr. Birnie said in an interview. If someone needs urgent placement and there’s no time to wait for DOAC washout, “it’s quite reasonable to go ahead.” Also, “if somebody is at extremely high risk for stroke, then it’s very reasonable to continue the drug.”
On the other hand, “if someone has a much lower stroke risk, then the risk-benefit ratio is probably in the opposite direction, so temporarily discontinuing the drug is the right thing to do,” he said.
Dr. Birnie cautioned that although continued DOAC may reduce the risk of thromboembolism, “this study was not designed with power to answer this.”
“We are already putting these findings into practice” in Ottawa, he said. “Our protocol” – as in many places – “ was always to stop anticoagulation for 2 or 3 days, but now, for very high-risk patients – high-risk AF, unstable temporary pacing, that type of thing – we are very comfortable continuing it,” he said. The study follows up a previous randomized trial by Dr. Birnie and his colleagues that pitted continued warfarin against heparin bridging for AF device placement. There were far fewer device pocket hematomas with uninterrupted warfarin (N Engl J Med. 2013 May 30;368[22]:2084-93).
The team wanted to repeat the study using DOACs, since their use has grown substantially, with the majority of AF patients now on them.
The arms in BRUISE CONTROL–2 (Strategy of Continued Versus Interrupted Novel Oral Anticoagulant at Time of Device Surgery in Patients With Moderate to High Risk of Arterial Thromboembolic Events) were well matched, with a mean age of about 74 years; men made up more than 70% of the subjects in both arms. About 17% of the participants were on chronic aspirin therapy and about 4% were on clopidogrel, in each arm. The uninterrupted DOAC group went about 14 hours between their last preop and first postop DOAC dose. The interrupted group went about 72 hours.
BRUISE CONTROL–2 was funded by the Heart and Stroke Foundation of Canada, Boehringer Ingelheim, Bayer, Pfizer, and Bristol-Myers Squibb, among others. Dr. Birnie had no relevant financial disclosures.
ANAHEIM, CALIF. – Whether direct oral anticoagulants are continued or interrupted for device placement in atrial fibrillation patients, the risk of device pocket hematoma or stroke is very low, based on results of the BRUISE CONTROL–2 trial in more than 600 subjects.
Either strategy is reasonable depending on the clinical scenario, coprincipal investigator David Birnie, MD, said in presenting the results at the American Heart Association scientific sessions.
When atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) present for device surgery, there’s concern that keeping them on the drugs will increase the bleeding risk, but that taking them off will increase the stroke risk. “We sought to resolve this dilemma,” said Dr. Birnie, an electrophysiologist and director of the arrhythmia service at the University of Ottawa Heart Institute.
The subjects were on dabigatran, rivaroxaban, or apixaban, about a third in each group; 328 were randomized to continue their daily dosing, including on the day of surgery. The other 334 were randomized to interrupted treatment. For rivaroxaban and apixaban, that meant taking their last dose 2 days before surgery. Dabigatran patients discontinued the drug 1-2 days beforehand, depending on glomerular filtration rate. Patients resumed treatment about 24 hours after surgery. CHA2DS2-VASc scores were a mean of 3.9 in both arms, and at least 2 in all participants.
The rate of clinically significant hematoma – the primary outcome in the study, defined as a hematoma requiring prolonged hospitalization, interrupted postoperative anticoagulation, or reoperation to evacuate – was identical in both arms, 2.1% (seven patients each). There were two ischemic strokes, one in each arm. There was one delayed cardiac tamponade in the continuation arm and one pericardial effusion in the interrupted arm. The three deaths in the trial were not related to device placement.
So, what to do depends on the clinical scenario, Dr. Birnie said in an interview. If someone needs urgent placement and there’s no time to wait for DOAC washout, “it’s quite reasonable to go ahead.” Also, “if somebody is at extremely high risk for stroke, then it’s very reasonable to continue the drug.”
On the other hand, “if someone has a much lower stroke risk, then the risk-benefit ratio is probably in the opposite direction, so temporarily discontinuing the drug is the right thing to do,” he said.
Dr. Birnie cautioned that although continued DOAC may reduce the risk of thromboembolism, “this study was not designed with power to answer this.”
“We are already putting these findings into practice” in Ottawa, he said. “Our protocol” – as in many places – “ was always to stop anticoagulation for 2 or 3 days, but now, for very high-risk patients – high-risk AF, unstable temporary pacing, that type of thing – we are very comfortable continuing it,” he said. The study follows up a previous randomized trial by Dr. Birnie and his colleagues that pitted continued warfarin against heparin bridging for AF device placement. There were far fewer device pocket hematomas with uninterrupted warfarin (N Engl J Med. 2013 May 30;368[22]:2084-93).
The team wanted to repeat the study using DOACs, since their use has grown substantially, with the majority of AF patients now on them.
The arms in BRUISE CONTROL–2 (Strategy of Continued Versus Interrupted Novel Oral Anticoagulant at Time of Device Surgery in Patients With Moderate to High Risk of Arterial Thromboembolic Events) were well matched, with a mean age of about 74 years; men made up more than 70% of the subjects in both arms. About 17% of the participants were on chronic aspirin therapy and about 4% were on clopidogrel, in each arm. The uninterrupted DOAC group went about 14 hours between their last preop and first postop DOAC dose. The interrupted group went about 72 hours.
BRUISE CONTROL–2 was funded by the Heart and Stroke Foundation of Canada, Boehringer Ingelheim, Bayer, Pfizer, and Bristol-Myers Squibb, among others. Dr. Birnie had no relevant financial disclosures.
ANAHEIM, CALIF. – Whether direct oral anticoagulants are continued or interrupted for device placement in atrial fibrillation patients, the risk of device pocket hematoma or stroke is very low, based on results of the BRUISE CONTROL–2 trial in more than 600 subjects.
Either strategy is reasonable depending on the clinical scenario, coprincipal investigator David Birnie, MD, said in presenting the results at the American Heart Association scientific sessions.
When atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) present for device surgery, there’s concern that keeping them on the drugs will increase the bleeding risk, but that taking them off will increase the stroke risk. “We sought to resolve this dilemma,” said Dr. Birnie, an electrophysiologist and director of the arrhythmia service at the University of Ottawa Heart Institute.
The subjects were on dabigatran, rivaroxaban, or apixaban, about a third in each group; 328 were randomized to continue their daily dosing, including on the day of surgery. The other 334 were randomized to interrupted treatment. For rivaroxaban and apixaban, that meant taking their last dose 2 days before surgery. Dabigatran patients discontinued the drug 1-2 days beforehand, depending on glomerular filtration rate. Patients resumed treatment about 24 hours after surgery. CHA2DS2-VASc scores were a mean of 3.9 in both arms, and at least 2 in all participants.
The rate of clinically significant hematoma – the primary outcome in the study, defined as a hematoma requiring prolonged hospitalization, interrupted postoperative anticoagulation, or reoperation to evacuate – was identical in both arms, 2.1% (seven patients each). There were two ischemic strokes, one in each arm. There was one delayed cardiac tamponade in the continuation arm and one pericardial effusion in the interrupted arm. The three deaths in the trial were not related to device placement.
So, what to do depends on the clinical scenario, Dr. Birnie said in an interview. If someone needs urgent placement and there’s no time to wait for DOAC washout, “it’s quite reasonable to go ahead.” Also, “if somebody is at extremely high risk for stroke, then it’s very reasonable to continue the drug.”
On the other hand, “if someone has a much lower stroke risk, then the risk-benefit ratio is probably in the opposite direction, so temporarily discontinuing the drug is the right thing to do,” he said.
Dr. Birnie cautioned that although continued DOAC may reduce the risk of thromboembolism, “this study was not designed with power to answer this.”
“We are already putting these findings into practice” in Ottawa, he said. “Our protocol” – as in many places – “ was always to stop anticoagulation for 2 or 3 days, but now, for very high-risk patients – high-risk AF, unstable temporary pacing, that type of thing – we are very comfortable continuing it,” he said. The study follows up a previous randomized trial by Dr. Birnie and his colleagues that pitted continued warfarin against heparin bridging for AF device placement. There were far fewer device pocket hematomas with uninterrupted warfarin (N Engl J Med. 2013 May 30;368[22]:2084-93).
The team wanted to repeat the study using DOACs, since their use has grown substantially, with the majority of AF patients now on them.
The arms in BRUISE CONTROL–2 (Strategy of Continued Versus Interrupted Novel Oral Anticoagulant at Time of Device Surgery in Patients With Moderate to High Risk of Arterial Thromboembolic Events) were well matched, with a mean age of about 74 years; men made up more than 70% of the subjects in both arms. About 17% of the participants were on chronic aspirin therapy and about 4% were on clopidogrel, in each arm. The uninterrupted DOAC group went about 14 hours between their last preop and first postop DOAC dose. The interrupted group went about 72 hours.
BRUISE CONTROL–2 was funded by the Heart and Stroke Foundation of Canada, Boehringer Ingelheim, Bayer, Pfizer, and Bristol-Myers Squibb, among others. Dr. Birnie had no relevant financial disclosures.
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: The rate of clinically significant hematoma was identical in both arms, at 2.1% (seven patients each).
Data source: BRUISE CONTROL-2, a randomized trial with more than 600 subjects.
Disclosures: The work was funded by the Heart and Stroke Foundation of Canada, Boehringer Ingelheim, Bayer, Pfizer, and Bristol-Myers Squibb, among others. The presenter had no relevant financial disclosures.
Shorter hospital stays with robotic thoracic surgery
Robotic thoracic surgery is associated with shorter hospital stays, shorter duration of chest tube usage, and lower postoperative pain intensity than open thoracotomy, new data suggests.
In a paper published in Surgical Endoscopy, researchers reported the results of a retrospective study comparing the outcomes from 38 individuals who underwent robotic thoracic surgery using the da Vinci System with those of 38 patients who underwent open thoracic surgery.
They saw significantly shorter hospital stays associated with robotic surgery, compared with open surgery (6.9 days vs. 8.0 days, respectively; P = .02), as well as a shorter duration of chest tube use (2.9 plus or minus 2.0 days vs. 4.9 plus or minus 2.2 days; P less than .001).
While robotic surgery did not result in significant reductions in postoperative pain intensity when patients coughed, pain intensity for patients at rest on days 4 and 5 after surgery was significantly lower among those who had undergone robotic surgery than among those who had undergone open surgery (Surg Endosc. 2017. doi: 10.1007/s00464-017-5464-6). On day 4, those who had undergone robotic surgery reported a mean pain score of 0.5 on a scale of 1-10, while those who underwent open surgery had a mean pain score of 1.1 (P = .04). On day 5, the mean pain scores were 0.7 in the robotic-surgery group and 1.6 in the open-surgery group (P = .003).
However, there was no difference in postoperative opioid use between the two groups. The robotic-surgery group showed a trend toward more postoperative nausea, but this did not reach statistical significance.
Most of the surgeries in the study were performed to remove malignant or benign tumors. Among both groups, 68% of patients received epidural analgesia, and 32% received systemic opioid-based postoperative analgesia.
“Current evidence shows that more than 70% of stage I lung cancers are still being performed by open technique,” wrote Christopher Darr, from the West German Lung Center at University Hospital Essen (Germany), and his coauthors. “However, the safety and the feasibility of robotic anatomic lung resection have been shown in several case series. Robotic thoracic surgery is gaining popularity as benefits can be suggested, such as improved ergonomics, three-dimensional optics, and simplifying operative procedure.”
One author declared financial support for meetings and presentations from Intuitive Surgical, the company that developed the da Vinci System. No other conflicts of interest were declared.
Robotic thoracic surgery is associated with shorter hospital stays, shorter duration of chest tube usage, and lower postoperative pain intensity than open thoracotomy, new data suggests.
In a paper published in Surgical Endoscopy, researchers reported the results of a retrospective study comparing the outcomes from 38 individuals who underwent robotic thoracic surgery using the da Vinci System with those of 38 patients who underwent open thoracic surgery.
They saw significantly shorter hospital stays associated with robotic surgery, compared with open surgery (6.9 days vs. 8.0 days, respectively; P = .02), as well as a shorter duration of chest tube use (2.9 plus or minus 2.0 days vs. 4.9 plus or minus 2.2 days; P less than .001).
While robotic surgery did not result in significant reductions in postoperative pain intensity when patients coughed, pain intensity for patients at rest on days 4 and 5 after surgery was significantly lower among those who had undergone robotic surgery than among those who had undergone open surgery (Surg Endosc. 2017. doi: 10.1007/s00464-017-5464-6). On day 4, those who had undergone robotic surgery reported a mean pain score of 0.5 on a scale of 1-10, while those who underwent open surgery had a mean pain score of 1.1 (P = .04). On day 5, the mean pain scores were 0.7 in the robotic-surgery group and 1.6 in the open-surgery group (P = .003).
However, there was no difference in postoperative opioid use between the two groups. The robotic-surgery group showed a trend toward more postoperative nausea, but this did not reach statistical significance.
Most of the surgeries in the study were performed to remove malignant or benign tumors. Among both groups, 68% of patients received epidural analgesia, and 32% received systemic opioid-based postoperative analgesia.
“Current evidence shows that more than 70% of stage I lung cancers are still being performed by open technique,” wrote Christopher Darr, from the West German Lung Center at University Hospital Essen (Germany), and his coauthors. “However, the safety and the feasibility of robotic anatomic lung resection have been shown in several case series. Robotic thoracic surgery is gaining popularity as benefits can be suggested, such as improved ergonomics, three-dimensional optics, and simplifying operative procedure.”
One author declared financial support for meetings and presentations from Intuitive Surgical, the company that developed the da Vinci System. No other conflicts of interest were declared.
Robotic thoracic surgery is associated with shorter hospital stays, shorter duration of chest tube usage, and lower postoperative pain intensity than open thoracotomy, new data suggests.
In a paper published in Surgical Endoscopy, researchers reported the results of a retrospective study comparing the outcomes from 38 individuals who underwent robotic thoracic surgery using the da Vinci System with those of 38 patients who underwent open thoracic surgery.
They saw significantly shorter hospital stays associated with robotic surgery, compared with open surgery (6.9 days vs. 8.0 days, respectively; P = .02), as well as a shorter duration of chest tube use (2.9 plus or minus 2.0 days vs. 4.9 plus or minus 2.2 days; P less than .001).
While robotic surgery did not result in significant reductions in postoperative pain intensity when patients coughed, pain intensity for patients at rest on days 4 and 5 after surgery was significantly lower among those who had undergone robotic surgery than among those who had undergone open surgery (Surg Endosc. 2017. doi: 10.1007/s00464-017-5464-6). On day 4, those who had undergone robotic surgery reported a mean pain score of 0.5 on a scale of 1-10, while those who underwent open surgery had a mean pain score of 1.1 (P = .04). On day 5, the mean pain scores were 0.7 in the robotic-surgery group and 1.6 in the open-surgery group (P = .003).
However, there was no difference in postoperative opioid use between the two groups. The robotic-surgery group showed a trend toward more postoperative nausea, but this did not reach statistical significance.
Most of the surgeries in the study were performed to remove malignant or benign tumors. Among both groups, 68% of patients received epidural analgesia, and 32% received systemic opioid-based postoperative analgesia.
“Current evidence shows that more than 70% of stage I lung cancers are still being performed by open technique,” wrote Christopher Darr, from the West German Lung Center at University Hospital Essen (Germany), and his coauthors. “However, the safety and the feasibility of robotic anatomic lung resection have been shown in several case series. Robotic thoracic surgery is gaining popularity as benefits can be suggested, such as improved ergonomics, three-dimensional optics, and simplifying operative procedure.”
One author declared financial support for meetings and presentations from Intuitive Surgical, the company that developed the da Vinci System. No other conflicts of interest were declared.
FROM SURGICAL ENDOSCOPY
Key clinical point: Robotic thoracic surgery is associated with shorter hospital stays and shorter duration of chest tube use, compared with open surgery.
Major finding: Patients who underwent robotic thoracic surgery had a mean hospital stay of 6.9 days, compared with 8 days for those who underwent open thoracic surgery.
Data source: Retrospective study of 38 patients who underwent robotic thoracic surgery and 38 who underwent open thoracic surgery.
Disclosures: One investigator declared financial support from Intuitive Surgical, the company that developed the da Vinci System, for meetings and presentations. No other conflicts of interest were declared.
Robotic guide hits the mark in abdominal surgeries
More than 90% of the image-based movements of a new robotic camera steering device were accurate in a study of 66 procedures sponsored by the device maker. The findings were published online in Surgical Endoscopy.
“A robotic laparoscopic positioner can perform the task of the surgical assistant and enables the surgeon to control camera movements personally,” wrote Paul J. M. Wijsman, MD, of Meander Medical Center, Amersfoort, the Netherlands, and colleagues (Surg. Endosc 2017. doi: 10.1007/s00464-017-5957-3).
To assess the accuracy of an image-guided robotic control system (AutoLap, MST, Israel), the researchers conducted a multicenter study of patients scheduled for abdominal surgeries including hernia repair and gallbladder removal. The primary outcomes were the number of successful movements and adverse events. The average age of the patients was 49 years, and approximately 75% were women.
“A movement is deemed successful if the laparoscope reached the desired position, which was verbally verified with the surgeon after each movement,” the researchers wrote. An average of 99 joystick movements and 12.8 “follow-me” movements were made during a procedure. The nine surgeons who participated in the study reported an average satisfaction of 4 on a scale of 1-5. Overall, no adverse events related to the procedures were reported.
The operational times using the robotic device were consistent with previous studies, the researchers said. The average time to set up the system was 4 minutes.
The findings were limited by several factors, including the limitations of the system and possible bias of the participants; factors affecting image quality included fogging and blurring of the lens, the researchers said. However, the results suggest that a robotic system such as AutoLap may have economic value by reducing the number of surgical team members needed for a procedure, and more research is needed to determine both economic and ergonomic benefits, they noted.
The study was sponsored by MST – Medical Surgery Technologies. Dr. Wijsman is a clinical field engineer for the company.
More than 90% of the image-based movements of a new robotic camera steering device were accurate in a study of 66 procedures sponsored by the device maker. The findings were published online in Surgical Endoscopy.
“A robotic laparoscopic positioner can perform the task of the surgical assistant and enables the surgeon to control camera movements personally,” wrote Paul J. M. Wijsman, MD, of Meander Medical Center, Amersfoort, the Netherlands, and colleagues (Surg. Endosc 2017. doi: 10.1007/s00464-017-5957-3).
To assess the accuracy of an image-guided robotic control system (AutoLap, MST, Israel), the researchers conducted a multicenter study of patients scheduled for abdominal surgeries including hernia repair and gallbladder removal. The primary outcomes were the number of successful movements and adverse events. The average age of the patients was 49 years, and approximately 75% were women.
“A movement is deemed successful if the laparoscope reached the desired position, which was verbally verified with the surgeon after each movement,” the researchers wrote. An average of 99 joystick movements and 12.8 “follow-me” movements were made during a procedure. The nine surgeons who participated in the study reported an average satisfaction of 4 on a scale of 1-5. Overall, no adverse events related to the procedures were reported.
The operational times using the robotic device were consistent with previous studies, the researchers said. The average time to set up the system was 4 minutes.
The findings were limited by several factors, including the limitations of the system and possible bias of the participants; factors affecting image quality included fogging and blurring of the lens, the researchers said. However, the results suggest that a robotic system such as AutoLap may have economic value by reducing the number of surgical team members needed for a procedure, and more research is needed to determine both economic and ergonomic benefits, they noted.
The study was sponsored by MST – Medical Surgery Technologies. Dr. Wijsman is a clinical field engineer for the company.
More than 90% of the image-based movements of a new robotic camera steering device were accurate in a study of 66 procedures sponsored by the device maker. The findings were published online in Surgical Endoscopy.
“A robotic laparoscopic positioner can perform the task of the surgical assistant and enables the surgeon to control camera movements personally,” wrote Paul J. M. Wijsman, MD, of Meander Medical Center, Amersfoort, the Netherlands, and colleagues (Surg. Endosc 2017. doi: 10.1007/s00464-017-5957-3).
To assess the accuracy of an image-guided robotic control system (AutoLap, MST, Israel), the researchers conducted a multicenter study of patients scheduled for abdominal surgeries including hernia repair and gallbladder removal. The primary outcomes were the number of successful movements and adverse events. The average age of the patients was 49 years, and approximately 75% were women.
“A movement is deemed successful if the laparoscope reached the desired position, which was verbally verified with the surgeon after each movement,” the researchers wrote. An average of 99 joystick movements and 12.8 “follow-me” movements were made during a procedure. The nine surgeons who participated in the study reported an average satisfaction of 4 on a scale of 1-5. Overall, no adverse events related to the procedures were reported.
The operational times using the robotic device were consistent with previous studies, the researchers said. The average time to set up the system was 4 minutes.
The findings were limited by several factors, including the limitations of the system and possible bias of the participants; factors affecting image quality included fogging and blurring of the lens, the researchers said. However, the results suggest that a robotic system such as AutoLap may have economic value by reducing the number of surgical team members needed for a procedure, and more research is needed to determine both economic and ergonomic benefits, they noted.
The study was sponsored by MST – Medical Surgery Technologies. Dr. Wijsman is a clinical field engineer for the company.
FROM SURGICAL ENDOSCOPY
Key clinical point: The Autolap system was a safe and effective way to manage a robotic camera during a range of abdominal surgical procedures.
Major finding: An image-based steering device for a robotic camera was accurate more than 90% of the time when used to guide surgeons.
Data source: The data come from a review of 66 abdominal surgeries in adults.
Disclosures: The study was sponsored by MST – Medical Surgery Technologies – maker of the device. Dr. Wijsman is a clinical field engineer for the company.
DAPT produces better CABG outcomes than aspirin alone
ANAHEIM, CALIF. – Treatment with dual-antiplatelet therapy following coronary artery bypass grafting with a saphenous vein maintained vein-graft patency better than aspirin alone in a randomized, multicenter trial with 500 patients.
After 1 year of dual-antiplatelet therapy (DAPT) with ticagrelor (Brilinta) and aspirin, 89% of saphenous-vein grafts remained patent, compared with a 77% patency rate in saphenous-vein grafts in patients treated with aspirin alone, a statistically significant difference for the study’s primary endpoint, Qiang Zhao, MD, said at the American Hart Association scientific sessions. The data, collected at six Chinese centers, also showed a nominal decrease in the combined rate of cardiovascular death, MI, and stroke: 2% with DAPT and 5% with aspirin alone. It further showed an increase in major or bypass-related bleeds: 2% with DAPT and none with aspirin alone, reported Dr. Zhao, professor and director of cardiac surgery at Ruijin Hospital in Shanghai, China.
“If this result were repeated in a larger study it would be important,” John H. Alexander, MD, professor of medicine at Duke University in Durham, N.C., commented in a video interview.
The Compare the Efficacy of Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Graft Surgery (DACAB) trial randomized patients who underwent coronary artery bypass grafting (CABG). They averaged about 64 years of age, and received an average of nearly four grafts each including an average of nearly three saphenous vein grafts. The study assigned patients to one of three treatment arms starting within 24 hours after surgery: 168 received ticagrelor 90 mg twice daily plus aspirin 100 mg once daily, 166 got ticagrelor alone, and 166 received aspirin alone. Treatment continued for 1 year.
“Some surgeons and physicians currently prescribe DAPT to CABG patients, but there is not much evidence of its benefit. The DACAB trial is useful, but you need to show that it does not just improve patency but that patients also have better outcomes. The excess of major bleeds is a big deal. It gives one pause about adopting DAPT as standard treatment,” Dr. Gardner said.
DACAB received no commercial funding. Dr. Zhao has been a speaker on behalf of and has received research funding from AstraZeneca, the company that markets ticagrelor (Brilinta). He has also been a speaker for Johnson & Johnson and Medtronic and has received research funding from Bayer, Novartis, and Sanofi. Dr. Gardner had no disclosures.
[email protected]
On Twitter @mitchelzoler
Results from the DACAB trial showed that using aspirin and ticagrelor improved vein-graft patency, compared with using aspirin alone. It was a compelling result, but for the intermediate, imaging-based outcome of graft patency at 1 year after surgery. This finding is conclusive evidence that dual-antiplatelet therapy has some benefit.
But the findings from this trial, modestly sized with 500 patients, failed to prove that the clinical benefit from dual-antiplatelet therapy was worth the adverse effect of an increase in the rate of major and bypass-related bleeding. The study was underpowered to prove that dual-antiplatelet therapy had a clear beneficial impact on clinical outcomes such as cardiovascular death, MI, and stroke, although this combined rate went in the right direction with dual therapy, compared with aspirin alone. We need to see proof of a benefit for these clinical outcomes to justify using a treatment that causes an increase in major bleeds.
The DACAB results alone are not enough to justify a change in practice. It would be an important finding if the results could be replicated in a larger study. And if dual-antiplatelet therapy was proven to have a net clinical benefit for patients, we would still want to target it to patients with a higher ischemic risk and, in general, avoid using it in patients with a high bleeding risk.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
John H. Alexander, MD , is a cardiologist and professor of medicine at Duke University in Durham, N.C. He has been a consultant to and has received research funding from several companies, including AstraZeneca, the company that markets ticagrelor (Brilinta). He made these comments as designated discussant for the DACAB study and in a video interview .
Results from the DACAB trial showed that using aspirin and ticagrelor improved vein-graft patency, compared with using aspirin alone. It was a compelling result, but for the intermediate, imaging-based outcome of graft patency at 1 year after surgery. This finding is conclusive evidence that dual-antiplatelet therapy has some benefit.
But the findings from this trial, modestly sized with 500 patients, failed to prove that the clinical benefit from dual-antiplatelet therapy was worth the adverse effect of an increase in the rate of major and bypass-related bleeding. The study was underpowered to prove that dual-antiplatelet therapy had a clear beneficial impact on clinical outcomes such as cardiovascular death, MI, and stroke, although this combined rate went in the right direction with dual therapy, compared with aspirin alone. We need to see proof of a benefit for these clinical outcomes to justify using a treatment that causes an increase in major bleeds.
The DACAB results alone are not enough to justify a change in practice. It would be an important finding if the results could be replicated in a larger study. And if dual-antiplatelet therapy was proven to have a net clinical benefit for patients, we would still want to target it to patients with a higher ischemic risk and, in general, avoid using it in patients with a high bleeding risk.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
John H. Alexander, MD , is a cardiologist and professor of medicine at Duke University in Durham, N.C. He has been a consultant to and has received research funding from several companies, including AstraZeneca, the company that markets ticagrelor (Brilinta). He made these comments as designated discussant for the DACAB study and in a video interview .
Results from the DACAB trial showed that using aspirin and ticagrelor improved vein-graft patency, compared with using aspirin alone. It was a compelling result, but for the intermediate, imaging-based outcome of graft patency at 1 year after surgery. This finding is conclusive evidence that dual-antiplatelet therapy has some benefit.
But the findings from this trial, modestly sized with 500 patients, failed to prove that the clinical benefit from dual-antiplatelet therapy was worth the adverse effect of an increase in the rate of major and bypass-related bleeding. The study was underpowered to prove that dual-antiplatelet therapy had a clear beneficial impact on clinical outcomes such as cardiovascular death, MI, and stroke, although this combined rate went in the right direction with dual therapy, compared with aspirin alone. We need to see proof of a benefit for these clinical outcomes to justify using a treatment that causes an increase in major bleeds.
The DACAB results alone are not enough to justify a change in practice. It would be an important finding if the results could be replicated in a larger study. And if dual-antiplatelet therapy was proven to have a net clinical benefit for patients, we would still want to target it to patients with a higher ischemic risk and, in general, avoid using it in patients with a high bleeding risk.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
John H. Alexander, MD , is a cardiologist and professor of medicine at Duke University in Durham, N.C. He has been a consultant to and has received research funding from several companies, including AstraZeneca, the company that markets ticagrelor (Brilinta). He made these comments as designated discussant for the DACAB study and in a video interview .
ANAHEIM, CALIF. – Treatment with dual-antiplatelet therapy following coronary artery bypass grafting with a saphenous vein maintained vein-graft patency better than aspirin alone in a randomized, multicenter trial with 500 patients.
After 1 year of dual-antiplatelet therapy (DAPT) with ticagrelor (Brilinta) and aspirin, 89% of saphenous-vein grafts remained patent, compared with a 77% patency rate in saphenous-vein grafts in patients treated with aspirin alone, a statistically significant difference for the study’s primary endpoint, Qiang Zhao, MD, said at the American Hart Association scientific sessions. The data, collected at six Chinese centers, also showed a nominal decrease in the combined rate of cardiovascular death, MI, and stroke: 2% with DAPT and 5% with aspirin alone. It further showed an increase in major or bypass-related bleeds: 2% with DAPT and none with aspirin alone, reported Dr. Zhao, professor and director of cardiac surgery at Ruijin Hospital in Shanghai, China.
“If this result were repeated in a larger study it would be important,” John H. Alexander, MD, professor of medicine at Duke University in Durham, N.C., commented in a video interview.
The Compare the Efficacy of Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Graft Surgery (DACAB) trial randomized patients who underwent coronary artery bypass grafting (CABG). They averaged about 64 years of age, and received an average of nearly four grafts each including an average of nearly three saphenous vein grafts. The study assigned patients to one of three treatment arms starting within 24 hours after surgery: 168 received ticagrelor 90 mg twice daily plus aspirin 100 mg once daily, 166 got ticagrelor alone, and 166 received aspirin alone. Treatment continued for 1 year.
“Some surgeons and physicians currently prescribe DAPT to CABG patients, but there is not much evidence of its benefit. The DACAB trial is useful, but you need to show that it does not just improve patency but that patients also have better outcomes. The excess of major bleeds is a big deal. It gives one pause about adopting DAPT as standard treatment,” Dr. Gardner said.
DACAB received no commercial funding. Dr. Zhao has been a speaker on behalf of and has received research funding from AstraZeneca, the company that markets ticagrelor (Brilinta). He has also been a speaker for Johnson & Johnson and Medtronic and has received research funding from Bayer, Novartis, and Sanofi. Dr. Gardner had no disclosures.
[email protected]
On Twitter @mitchelzoler
ANAHEIM, CALIF. – Treatment with dual-antiplatelet therapy following coronary artery bypass grafting with a saphenous vein maintained vein-graft patency better than aspirin alone in a randomized, multicenter trial with 500 patients.
After 1 year of dual-antiplatelet therapy (DAPT) with ticagrelor (Brilinta) and aspirin, 89% of saphenous-vein grafts remained patent, compared with a 77% patency rate in saphenous-vein grafts in patients treated with aspirin alone, a statistically significant difference for the study’s primary endpoint, Qiang Zhao, MD, said at the American Hart Association scientific sessions. The data, collected at six Chinese centers, also showed a nominal decrease in the combined rate of cardiovascular death, MI, and stroke: 2% with DAPT and 5% with aspirin alone. It further showed an increase in major or bypass-related bleeds: 2% with DAPT and none with aspirin alone, reported Dr. Zhao, professor and director of cardiac surgery at Ruijin Hospital in Shanghai, China.
“If this result were repeated in a larger study it would be important,” John H. Alexander, MD, professor of medicine at Duke University in Durham, N.C., commented in a video interview.
The Compare the Efficacy of Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Graft Surgery (DACAB) trial randomized patients who underwent coronary artery bypass grafting (CABG). They averaged about 64 years of age, and received an average of nearly four grafts each including an average of nearly three saphenous vein grafts. The study assigned patients to one of three treatment arms starting within 24 hours after surgery: 168 received ticagrelor 90 mg twice daily plus aspirin 100 mg once daily, 166 got ticagrelor alone, and 166 received aspirin alone. Treatment continued for 1 year.
“Some surgeons and physicians currently prescribe DAPT to CABG patients, but there is not much evidence of its benefit. The DACAB trial is useful, but you need to show that it does not just improve patency but that patients also have better outcomes. The excess of major bleeds is a big deal. It gives one pause about adopting DAPT as standard treatment,” Dr. Gardner said.
DACAB received no commercial funding. Dr. Zhao has been a speaker on behalf of and has received research funding from AstraZeneca, the company that markets ticagrelor (Brilinta). He has also been a speaker for Johnson & Johnson and Medtronic and has received research funding from Bayer, Novartis, and Sanofi. Dr. Gardner had no disclosures.
[email protected]
On Twitter @mitchelzoler
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: The 1-year saphenous-vein graft patency rate was 89% with DAPT treatment and 77% with aspirin alone. Data source: DACAB, a multicenter, randomized trial with 500 Chinese patients.
Disclosures: DACAB received no commercial funding. Dr. Zhao has been a speaker on behalf of and has received research funding from AstraZeneca, the company that markets ticagrelor (Brilinta). He has also been a speaker for Johnson & Johnson and Medtronic and has received research funding from Bayer, Novartis, and Sanofi.
Former pharma exec nominated for top HHS post
Alex M. Azar II, a former pharmaceutical executive and member of the George W. Bush administration, has been selected by President Donald Trump to lead the Department of Health & Human Services.
Mr. Azar served as president of Eli Lilly in the United States for 5 years from 2012 to 2017, after joining the company in 2007. Prior to that, he served President Bush at HHS from 2001 to 2007, serving first as general counsel and later as deputy secretary under Secretary Michael O. Leavitt.
“The challenges plaguing the American health care system are serious. For too long, hardworking, middle-class families have been forced to bear the brunt of Obamacare’s failures in the form of higher premiums and fewer choices,” Senate Finance Committee Chairman Orrin Hatch (R-Utah) said in a statement. “The leader of HHS will be at the tip of the spear, working to not only right the wrongs of this deeply flawed law but also ensure the long-term sustainability of both Medicare and Medicaid.”
The Senate Finance Committee must first approve the nomination before it is considered by the full chamber.
“We commend President Trump for nominating Alex Azar for secretary of Health & Human Services,” House Energy & Commerce Committee Chairman Greg Walden (R-Ore.) and Health Subcommittee Chairman Michael Burgess, MD, (R-Texas) said in a joint statement. “He is a veteran of HHS, bringing with him a wealth of institutional knowledge that will be instrumental in delivering patient-centered health care and combating the opioid crisis. We look forward to working with Mr. Azar on these critical issues and many others in the future.”
The Campaign for Sustainable Rx Pricing, a coalition of physicians and other stakeholders across the health care industry, was more measured in its reaction to the news.
“We sincerely hope that Secretary-nominee Azar will follow through on the President’s commitment to achieve lower drug prices for all Americans,” according to a statement from CSRxP. “We look forward to working with him, once confirmed, to end anticompetitive practices that artificially inflate drug prices, restore a functioning prescription drug market, and rein in the exorbitant price hikes that harm patients, job creators, and taxpayers alike.”
The nomination process could be bumpy, as Mr. Azar has made statements in the news in the past that were in support the dismantling of the Affordable Care Act. But keeping him from the post will be difficult, as he would only need a simple majority vote in the Senate to gain approval. With Republicans holding 52 seats, it would only require three dissenting GOP senators, assuming the Democrats vote against the appointment. If two crossed the aisle, Vice President Mike Pence would cast the deciding vote.
Finance Committee Democrats boycotted the committee vote on Mr. Azar’s predecessor, Secretary Tom Price, MD, forcing committee Chairman Hatch to suspend rules in order to move the appointment to the full chamber for consideration.
Alex M. Azar II, a former pharmaceutical executive and member of the George W. Bush administration, has been selected by President Donald Trump to lead the Department of Health & Human Services.
Mr. Azar served as president of Eli Lilly in the United States for 5 years from 2012 to 2017, after joining the company in 2007. Prior to that, he served President Bush at HHS from 2001 to 2007, serving first as general counsel and later as deputy secretary under Secretary Michael O. Leavitt.
“The challenges plaguing the American health care system are serious. For too long, hardworking, middle-class families have been forced to bear the brunt of Obamacare’s failures in the form of higher premiums and fewer choices,” Senate Finance Committee Chairman Orrin Hatch (R-Utah) said in a statement. “The leader of HHS will be at the tip of the spear, working to not only right the wrongs of this deeply flawed law but also ensure the long-term sustainability of both Medicare and Medicaid.”
The Senate Finance Committee must first approve the nomination before it is considered by the full chamber.
“We commend President Trump for nominating Alex Azar for secretary of Health & Human Services,” House Energy & Commerce Committee Chairman Greg Walden (R-Ore.) and Health Subcommittee Chairman Michael Burgess, MD, (R-Texas) said in a joint statement. “He is a veteran of HHS, bringing with him a wealth of institutional knowledge that will be instrumental in delivering patient-centered health care and combating the opioid crisis. We look forward to working with Mr. Azar on these critical issues and many others in the future.”
The Campaign for Sustainable Rx Pricing, a coalition of physicians and other stakeholders across the health care industry, was more measured in its reaction to the news.
“We sincerely hope that Secretary-nominee Azar will follow through on the President’s commitment to achieve lower drug prices for all Americans,” according to a statement from CSRxP. “We look forward to working with him, once confirmed, to end anticompetitive practices that artificially inflate drug prices, restore a functioning prescription drug market, and rein in the exorbitant price hikes that harm patients, job creators, and taxpayers alike.”
The nomination process could be bumpy, as Mr. Azar has made statements in the news in the past that were in support the dismantling of the Affordable Care Act. But keeping him from the post will be difficult, as he would only need a simple majority vote in the Senate to gain approval. With Republicans holding 52 seats, it would only require three dissenting GOP senators, assuming the Democrats vote against the appointment. If two crossed the aisle, Vice President Mike Pence would cast the deciding vote.
Finance Committee Democrats boycotted the committee vote on Mr. Azar’s predecessor, Secretary Tom Price, MD, forcing committee Chairman Hatch to suspend rules in order to move the appointment to the full chamber for consideration.
Alex M. Azar II, a former pharmaceutical executive and member of the George W. Bush administration, has been selected by President Donald Trump to lead the Department of Health & Human Services.
Mr. Azar served as president of Eli Lilly in the United States for 5 years from 2012 to 2017, after joining the company in 2007. Prior to that, he served President Bush at HHS from 2001 to 2007, serving first as general counsel and later as deputy secretary under Secretary Michael O. Leavitt.
“The challenges plaguing the American health care system are serious. For too long, hardworking, middle-class families have been forced to bear the brunt of Obamacare’s failures in the form of higher premiums and fewer choices,” Senate Finance Committee Chairman Orrin Hatch (R-Utah) said in a statement. “The leader of HHS will be at the tip of the spear, working to not only right the wrongs of this deeply flawed law but also ensure the long-term sustainability of both Medicare and Medicaid.”
The Senate Finance Committee must first approve the nomination before it is considered by the full chamber.
“We commend President Trump for nominating Alex Azar for secretary of Health & Human Services,” House Energy & Commerce Committee Chairman Greg Walden (R-Ore.) and Health Subcommittee Chairman Michael Burgess, MD, (R-Texas) said in a joint statement. “He is a veteran of HHS, bringing with him a wealth of institutional knowledge that will be instrumental in delivering patient-centered health care and combating the opioid crisis. We look forward to working with Mr. Azar on these critical issues and many others in the future.”
The Campaign for Sustainable Rx Pricing, a coalition of physicians and other stakeholders across the health care industry, was more measured in its reaction to the news.
“We sincerely hope that Secretary-nominee Azar will follow through on the President’s commitment to achieve lower drug prices for all Americans,” according to a statement from CSRxP. “We look forward to working with him, once confirmed, to end anticompetitive practices that artificially inflate drug prices, restore a functioning prescription drug market, and rein in the exorbitant price hikes that harm patients, job creators, and taxpayers alike.”
The nomination process could be bumpy, as Mr. Azar has made statements in the news in the past that were in support the dismantling of the Affordable Care Act. But keeping him from the post will be difficult, as he would only need a simple majority vote in the Senate to gain approval. With Republicans holding 52 seats, it would only require three dissenting GOP senators, assuming the Democrats vote against the appointment. If two crossed the aisle, Vice President Mike Pence would cast the deciding vote.
Finance Committee Democrats boycotted the committee vote on Mr. Azar’s predecessor, Secretary Tom Price, MD, forcing committee Chairman Hatch to suspend rules in order to move the appointment to the full chamber for consideration.
Frailty, not age, predicted complications after ambulatory surgery
Frailty was associated with a significant increase in 30-day complications after ambulatory hernia repair or ambulatory surgery of the breast, thyroid, or parathyroid, according to the results of a large retrospective cohort study.
The findings reinforce prior work indicating that frailty, not chronologic age, should be a primary factor when deciding about and preparing for surgery, Carolyn D. Seib, MD, and her associates at the University of California, San Francisco, wrote in JAMA Surgery. “Informed consent should be adjusted based on frailty to ensure that patients have an accurate assessment of their risk when making decisions about whether to undergo surgery,” the researchers said.
To test the hypothesis that frailty predicts morbidity and mortality after ambulatory general surgery, the researchers studied 140,828 patients older than 40 years from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program (JAMA Surg. 2017 Oct 11. doi: 10.1001/jamasurg.2017.4007). Nearly 2,500 (1.7%) patients experienced perioperative complications, and 0.7% had serious complications, the researchers said. After controlling for age sex, race or ethnicity, smoking, type of anesthesia, and corticosteroid use, patients with an intermediate (0.18-0.35) frailty score had a 70% higher odds of any complication (odds ratio, 1.7; 95% confidence interval, 1.5-1.9) and a 100% higher odds of serious complications (OR, 2.0; 95% CI, 1.7-2.3), compared with patients with a low frailty score.
An intermediate score reflected the presence of two to three frailty traits, such as impaired functional status, history of diabetes, pneumonia, chronic cardiovascular or lung disease, or impaired sensorium, the investigators noted. Notably, having a high modified frailty index (four or more frailty traits) was associated with 3.3-fold higher odds of any complication and with nearly 4-fold higher odds of serious complications, even after controlling for potential confounders.
Among modifiable risk factors, only the use of local and monitored anesthesia was associated with a significant decrease in the likelihood of serious 30-day complications (adjusted OR, 0.66; 95% CI, 0.53-0.81). Single-center studies of elderly patients undergoing inguinal hernia repair have reported similar findings, the researchers said. “For frail patients who choose to undergo hernia repair, local and monitored anesthesia care should be used whenever possible,” they wrote. “The use of local with monitored anesthesia care may be challenging in complex surgical procedures for breast cancer, such as modified radical mastectomy or axillary dissection, but it should be considered for patients with increased anesthesia risk who are undergoing ambulatory breast surgery.”
The National Institute on Aging provided partial funding. The investigators reported having no conflicts of interest.
Frailty was associated with a significant increase in 30-day complications after ambulatory hernia repair or ambulatory surgery of the breast, thyroid, or parathyroid, according to the results of a large retrospective cohort study.
The findings reinforce prior work indicating that frailty, not chronologic age, should be a primary factor when deciding about and preparing for surgery, Carolyn D. Seib, MD, and her associates at the University of California, San Francisco, wrote in JAMA Surgery. “Informed consent should be adjusted based on frailty to ensure that patients have an accurate assessment of their risk when making decisions about whether to undergo surgery,” the researchers said.
To test the hypothesis that frailty predicts morbidity and mortality after ambulatory general surgery, the researchers studied 140,828 patients older than 40 years from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program (JAMA Surg. 2017 Oct 11. doi: 10.1001/jamasurg.2017.4007). Nearly 2,500 (1.7%) patients experienced perioperative complications, and 0.7% had serious complications, the researchers said. After controlling for age sex, race or ethnicity, smoking, type of anesthesia, and corticosteroid use, patients with an intermediate (0.18-0.35) frailty score had a 70% higher odds of any complication (odds ratio, 1.7; 95% confidence interval, 1.5-1.9) and a 100% higher odds of serious complications (OR, 2.0; 95% CI, 1.7-2.3), compared with patients with a low frailty score.
An intermediate score reflected the presence of two to three frailty traits, such as impaired functional status, history of diabetes, pneumonia, chronic cardiovascular or lung disease, or impaired sensorium, the investigators noted. Notably, having a high modified frailty index (four or more frailty traits) was associated with 3.3-fold higher odds of any complication and with nearly 4-fold higher odds of serious complications, even after controlling for potential confounders.
Among modifiable risk factors, only the use of local and monitored anesthesia was associated with a significant decrease in the likelihood of serious 30-day complications (adjusted OR, 0.66; 95% CI, 0.53-0.81). Single-center studies of elderly patients undergoing inguinal hernia repair have reported similar findings, the researchers said. “For frail patients who choose to undergo hernia repair, local and monitored anesthesia care should be used whenever possible,” they wrote. “The use of local with monitored anesthesia care may be challenging in complex surgical procedures for breast cancer, such as modified radical mastectomy or axillary dissection, but it should be considered for patients with increased anesthesia risk who are undergoing ambulatory breast surgery.”
The National Institute on Aging provided partial funding. The investigators reported having no conflicts of interest.
Frailty was associated with a significant increase in 30-day complications after ambulatory hernia repair or ambulatory surgery of the breast, thyroid, or parathyroid, according to the results of a large retrospective cohort study.
The findings reinforce prior work indicating that frailty, not chronologic age, should be a primary factor when deciding about and preparing for surgery, Carolyn D. Seib, MD, and her associates at the University of California, San Francisco, wrote in JAMA Surgery. “Informed consent should be adjusted based on frailty to ensure that patients have an accurate assessment of their risk when making decisions about whether to undergo surgery,” the researchers said.
To test the hypothesis that frailty predicts morbidity and mortality after ambulatory general surgery, the researchers studied 140,828 patients older than 40 years from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program (JAMA Surg. 2017 Oct 11. doi: 10.1001/jamasurg.2017.4007). Nearly 2,500 (1.7%) patients experienced perioperative complications, and 0.7% had serious complications, the researchers said. After controlling for age sex, race or ethnicity, smoking, type of anesthesia, and corticosteroid use, patients with an intermediate (0.18-0.35) frailty score had a 70% higher odds of any complication (odds ratio, 1.7; 95% confidence interval, 1.5-1.9) and a 100% higher odds of serious complications (OR, 2.0; 95% CI, 1.7-2.3), compared with patients with a low frailty score.
An intermediate score reflected the presence of two to three frailty traits, such as impaired functional status, history of diabetes, pneumonia, chronic cardiovascular or lung disease, or impaired sensorium, the investigators noted. Notably, having a high modified frailty index (four or more frailty traits) was associated with 3.3-fold higher odds of any complication and with nearly 4-fold higher odds of serious complications, even after controlling for potential confounders.
Among modifiable risk factors, only the use of local and monitored anesthesia was associated with a significant decrease in the likelihood of serious 30-day complications (adjusted OR, 0.66; 95% CI, 0.53-0.81). Single-center studies of elderly patients undergoing inguinal hernia repair have reported similar findings, the researchers said. “For frail patients who choose to undergo hernia repair, local and monitored anesthesia care should be used whenever possible,” they wrote. “The use of local with monitored anesthesia care may be challenging in complex surgical procedures for breast cancer, such as modified radical mastectomy or axillary dissection, but it should be considered for patients with increased anesthesia risk who are undergoing ambulatory breast surgery.”
The National Institute on Aging provided partial funding. The investigators reported having no conflicts of interest.
FROM JAMA SURGERY
Key clinical point: Frailty was an independent risk factor for 30-day complications of ambulatory surgery, independent of age and other correlates.
Major finding: Having an intermediate (0.18-0.35) frailty score increased the odds of any complication by 70% (OR, 1.7).
Data source: A single-center retrospective cohort study of 140,828 patients older than 40 years from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program.
Disclosures: The investigators had no disclosures.
MACRA Monday: Documenting current medications
If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.
Under the Pick Your Pace approach being offered this year, Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.
Consider this measure:
Measure #130: Documentation of Current Medications in the Medical Record
This measure is aimed at capturing the percentage of patients aged 18 years and older who had their current medications documented in the medical record, including nonprescription drugs, vitamins, and supplements.
What you need to do: Review and update the patient’s list of current medications, being sure to document all known prescriptions, over-the-counter medications, herbals, and vitamin/mineral/dietary supplements. This list must include the name, dosages, frequency, and route of administration for each drug.
Eligible cases include patients aged 18 years and older on the date of the encounter and a patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439.
To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, G8427 indicates that the patient’s medical record was updated with the current medications. Use exception code G8430 if you documented in the medical record that the patient is not eligible for a current list of medications being obtained and reviewed.
CMS has a full list of measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.
Certain clinicians are exempt from reporting and do not face a penalty under MIPS:
- Those who enrolled in Medicare for the first time during a performance period.
- Those who have Medicare Part B allowed charges of $30,000 or less.
- Those who have 100 or fewer Medicare Part B patients.
- Those who are significantly participating in an Advanced Alternative Payment Model (APM).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.
Under the Pick Your Pace approach being offered this year, Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.
Consider this measure:
Measure #130: Documentation of Current Medications in the Medical Record
This measure is aimed at capturing the percentage of patients aged 18 years and older who had their current medications documented in the medical record, including nonprescription drugs, vitamins, and supplements.
What you need to do: Review and update the patient’s list of current medications, being sure to document all known prescriptions, over-the-counter medications, herbals, and vitamin/mineral/dietary supplements. This list must include the name, dosages, frequency, and route of administration for each drug.
Eligible cases include patients aged 18 years and older on the date of the encounter and a patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439.
To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, G8427 indicates that the patient’s medical record was updated with the current medications. Use exception code G8430 if you documented in the medical record that the patient is not eligible for a current list of medications being obtained and reviewed.
CMS has a full list of measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.
Certain clinicians are exempt from reporting and do not face a penalty under MIPS:
- Those who enrolled in Medicare for the first time during a performance period.
- Those who have Medicare Part B allowed charges of $30,000 or less.
- Those who have 100 or fewer Medicare Part B patients.
- Those who are significantly participating in an Advanced Alternative Payment Model (APM).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.
Under the Pick Your Pace approach being offered this year, Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.
Consider this measure:
Measure #130: Documentation of Current Medications in the Medical Record
This measure is aimed at capturing the percentage of patients aged 18 years and older who had their current medications documented in the medical record, including nonprescription drugs, vitamins, and supplements.
What you need to do: Review and update the patient’s list of current medications, being sure to document all known prescriptions, over-the-counter medications, herbals, and vitamin/mineral/dietary supplements. This list must include the name, dosages, frequency, and route of administration for each drug.
Eligible cases include patients aged 18 years and older on the date of the encounter and a patient encounter during the performance period. Applicable codes include (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439.
To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, G8427 indicates that the patient’s medical record was updated with the current medications. Use exception code G8430 if you documented in the medical record that the patient is not eligible for a current list of medications being obtained and reviewed.
CMS has a full list of measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.
Certain clinicians are exempt from reporting and do not face a penalty under MIPS:
- Those who enrolled in Medicare for the first time during a performance period.
- Those who have Medicare Part B allowed charges of $30,000 or less.
- Those who have 100 or fewer Medicare Part B patients.
- Those who are significantly participating in an Advanced Alternative Payment Model (APM).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
VIDEO: ERAS for minimally invasive surgery
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
TAP an alternative to epidural for colorectal surgery
SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.
There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.
Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.
“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.
The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.
His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.
The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).
In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).
The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.
SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.
There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.
Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.
“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.
The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.
His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.
The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).
In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).
The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.
SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.
There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.
Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.
“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.
The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.
His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.
The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).
In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).
The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.
AT WSA 2017
Key clinical point: In appropriately selected patients, TAP may be a good alternative to epidural.
Major finding: TAP block was associated with a 0.5-day shorter hospital stay than epidurals.
Data source: Randomized, controlled trial (n = 78).
Disclosures: The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.