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No increased complication risk with delaying resection for LARC
CHICAGO – Delaying surgery after neoadjuvant therapy for locally advanced rectal cancer for up to 12 weeks does not seem to impact complication rates compared to surgery at 8 weeks or earlier, findings that run counter to results from a major European clinical trial reported in 2016, investigators reported at the Society of Surgical Oncology Annual Cancer Symposium.
“There’s an increasing trend toward delayed surgery beyond eight to 12 weeks after neoadjuvant therapy (NT) for locally advanced rectal cancer (LARC),” said Campbell Roxburgh, FRCS, PhD, of the University of Glasgow in Scotland. “Although we saw an increase in all complications in patients who had surgery beyond 12 weeks, there were no increases in surgical site complications, grade 3-5 complications, or anastomotic leaks. Before 12 weeks we did not observe increases in any type of complication where surgery was performed prior to or after 8 weeks.”
The study involved 798 patients who had received NT for LARC from June 2009 to March 2014 at Memorial Sloan Kettering Cancer Center in New York. The vast majority – 76% (607) – had rectal resection within 16 weeks of completing NT. Among them, 52% (317) had surgery 5-8 weeks after NT, 38% (229) had surgery at 8-12 weeks post-NT, and 10% (61) had surgery 12-16 weeks after completing NT. Those who had surgery beyond 16 weeks mostly had it deferred because they were undergoing nonoperative management in the case of complete clinical response to treatment or had a comorbidity that prevented earlier surgery, Dr. Roxburgh said.
The complication rate was 42.3% among the patients who had surgery up to 16 weeks after NT, Dr. Roxburgh said. The most common complication was surgical site infection (SSI) in 16.6% (101), followed by a grade 3-5 complication in 10.5% (64) and anastomotic leak in 6.4% (39). Overall complication rates among the two groups that had surgery within 12 weeks were not statistically different from the overall complication rate, Dr. Roxburgh said: 42.5% (138) in the 5- to 8-week group; and 36.7% (84) in the 8- to 12-week group. The 12- to16-week group had a complication rate of 56% (34, P = .022).
Dr. Roxburgh noted that the idea of delaying surgery beyond 8 weeks after NT has been a subject of debate, and that these findings run counter to those reported in the GRECCAR-6 trial (J Clin Oncol. 2016;34:3773-80). That study compared groups that had surgery for rectal cancer at 7 and 11 weeks after neoadjuvant radiochemotherapy and found that those in the 11-week group had higher rates of complications.
Dr. Roxburgh also reported on an analysis of the 12- to 16-week subgroup that found the highest complication rates were among those who had low anterior resection (53% vs. 41% in the 5- to 8-week group and 31% in the 8- to 12-week population), and patients who had a poor treatment response (no T-downstaging, 66% vs. 44% and 33%, respectively). Age, pretreatment and posttreatment TNM stages, surgical approach (open or minimally invasive), and year of treatment did not factor in complication rates in the subgroup analysis, Dr. Roxburgh noted.
The univariate regression analysis determined a trend toward increased rates of all complications in the 12- to 16-week group (P = .081). But the multivariate analysis did not find timing of surgery to be an independent risk factor for all complications, Dr. Roxburgh said. “We believe other factors, including tumor location, the type of NT, operative approach, and treatment response, however, were more important on multivariate analysis,” he said. For example, open surgery had an odds ratio of 1.7 (P = .004).
During the discussion, Dr. Roxburgh was asked what would be the optimal timing for resection after NT in LARC. “I would recommend posttreatment assessment with MRI and proctoscopy between 8 to 12 weeks and in the case of residual tumor or incomplete response to treatment, scheduling surgery at that time,” he said.
Dr. Roxburgh and coauthors reported having no financial disclosures.
SOURCE: Roxburgh C, et al. Society of Surgical Oncology Annual Cancer Symposium Abstract No. 3.
CHICAGO – Delaying surgery after neoadjuvant therapy for locally advanced rectal cancer for up to 12 weeks does not seem to impact complication rates compared to surgery at 8 weeks or earlier, findings that run counter to results from a major European clinical trial reported in 2016, investigators reported at the Society of Surgical Oncology Annual Cancer Symposium.
“There’s an increasing trend toward delayed surgery beyond eight to 12 weeks after neoadjuvant therapy (NT) for locally advanced rectal cancer (LARC),” said Campbell Roxburgh, FRCS, PhD, of the University of Glasgow in Scotland. “Although we saw an increase in all complications in patients who had surgery beyond 12 weeks, there were no increases in surgical site complications, grade 3-5 complications, or anastomotic leaks. Before 12 weeks we did not observe increases in any type of complication where surgery was performed prior to or after 8 weeks.”
The study involved 798 patients who had received NT for LARC from June 2009 to March 2014 at Memorial Sloan Kettering Cancer Center in New York. The vast majority – 76% (607) – had rectal resection within 16 weeks of completing NT. Among them, 52% (317) had surgery 5-8 weeks after NT, 38% (229) had surgery at 8-12 weeks post-NT, and 10% (61) had surgery 12-16 weeks after completing NT. Those who had surgery beyond 16 weeks mostly had it deferred because they were undergoing nonoperative management in the case of complete clinical response to treatment or had a comorbidity that prevented earlier surgery, Dr. Roxburgh said.
The complication rate was 42.3% among the patients who had surgery up to 16 weeks after NT, Dr. Roxburgh said. The most common complication was surgical site infection (SSI) in 16.6% (101), followed by a grade 3-5 complication in 10.5% (64) and anastomotic leak in 6.4% (39). Overall complication rates among the two groups that had surgery within 12 weeks were not statistically different from the overall complication rate, Dr. Roxburgh said: 42.5% (138) in the 5- to 8-week group; and 36.7% (84) in the 8- to 12-week group. The 12- to16-week group had a complication rate of 56% (34, P = .022).
Dr. Roxburgh noted that the idea of delaying surgery beyond 8 weeks after NT has been a subject of debate, and that these findings run counter to those reported in the GRECCAR-6 trial (J Clin Oncol. 2016;34:3773-80). That study compared groups that had surgery for rectal cancer at 7 and 11 weeks after neoadjuvant radiochemotherapy and found that those in the 11-week group had higher rates of complications.
Dr. Roxburgh also reported on an analysis of the 12- to 16-week subgroup that found the highest complication rates were among those who had low anterior resection (53% vs. 41% in the 5- to 8-week group and 31% in the 8- to 12-week population), and patients who had a poor treatment response (no T-downstaging, 66% vs. 44% and 33%, respectively). Age, pretreatment and posttreatment TNM stages, surgical approach (open or minimally invasive), and year of treatment did not factor in complication rates in the subgroup analysis, Dr. Roxburgh noted.
The univariate regression analysis determined a trend toward increased rates of all complications in the 12- to 16-week group (P = .081). But the multivariate analysis did not find timing of surgery to be an independent risk factor for all complications, Dr. Roxburgh said. “We believe other factors, including tumor location, the type of NT, operative approach, and treatment response, however, were more important on multivariate analysis,” he said. For example, open surgery had an odds ratio of 1.7 (P = .004).
During the discussion, Dr. Roxburgh was asked what would be the optimal timing for resection after NT in LARC. “I would recommend posttreatment assessment with MRI and proctoscopy between 8 to 12 weeks and in the case of residual tumor or incomplete response to treatment, scheduling surgery at that time,” he said.
Dr. Roxburgh and coauthors reported having no financial disclosures.
SOURCE: Roxburgh C, et al. Society of Surgical Oncology Annual Cancer Symposium Abstract No. 3.
CHICAGO – Delaying surgery after neoadjuvant therapy for locally advanced rectal cancer for up to 12 weeks does not seem to impact complication rates compared to surgery at 8 weeks or earlier, findings that run counter to results from a major European clinical trial reported in 2016, investigators reported at the Society of Surgical Oncology Annual Cancer Symposium.
“There’s an increasing trend toward delayed surgery beyond eight to 12 weeks after neoadjuvant therapy (NT) for locally advanced rectal cancer (LARC),” said Campbell Roxburgh, FRCS, PhD, of the University of Glasgow in Scotland. “Although we saw an increase in all complications in patients who had surgery beyond 12 weeks, there were no increases in surgical site complications, grade 3-5 complications, or anastomotic leaks. Before 12 weeks we did not observe increases in any type of complication where surgery was performed prior to or after 8 weeks.”
The study involved 798 patients who had received NT for LARC from June 2009 to March 2014 at Memorial Sloan Kettering Cancer Center in New York. The vast majority – 76% (607) – had rectal resection within 16 weeks of completing NT. Among them, 52% (317) had surgery 5-8 weeks after NT, 38% (229) had surgery at 8-12 weeks post-NT, and 10% (61) had surgery 12-16 weeks after completing NT. Those who had surgery beyond 16 weeks mostly had it deferred because they were undergoing nonoperative management in the case of complete clinical response to treatment or had a comorbidity that prevented earlier surgery, Dr. Roxburgh said.
The complication rate was 42.3% among the patients who had surgery up to 16 weeks after NT, Dr. Roxburgh said. The most common complication was surgical site infection (SSI) in 16.6% (101), followed by a grade 3-5 complication in 10.5% (64) and anastomotic leak in 6.4% (39). Overall complication rates among the two groups that had surgery within 12 weeks were not statistically different from the overall complication rate, Dr. Roxburgh said: 42.5% (138) in the 5- to 8-week group; and 36.7% (84) in the 8- to 12-week group. The 12- to16-week group had a complication rate of 56% (34, P = .022).
Dr. Roxburgh noted that the idea of delaying surgery beyond 8 weeks after NT has been a subject of debate, and that these findings run counter to those reported in the GRECCAR-6 trial (J Clin Oncol. 2016;34:3773-80). That study compared groups that had surgery for rectal cancer at 7 and 11 weeks after neoadjuvant radiochemotherapy and found that those in the 11-week group had higher rates of complications.
Dr. Roxburgh also reported on an analysis of the 12- to 16-week subgroup that found the highest complication rates were among those who had low anterior resection (53% vs. 41% in the 5- to 8-week group and 31% in the 8- to 12-week population), and patients who had a poor treatment response (no T-downstaging, 66% vs. 44% and 33%, respectively). Age, pretreatment and posttreatment TNM stages, surgical approach (open or minimally invasive), and year of treatment did not factor in complication rates in the subgroup analysis, Dr. Roxburgh noted.
The univariate regression analysis determined a trend toward increased rates of all complications in the 12- to 16-week group (P = .081). But the multivariate analysis did not find timing of surgery to be an independent risk factor for all complications, Dr. Roxburgh said. “We believe other factors, including tumor location, the type of NT, operative approach, and treatment response, however, were more important on multivariate analysis,” he said. For example, open surgery had an odds ratio of 1.7 (P = .004).
During the discussion, Dr. Roxburgh was asked what would be the optimal timing for resection after NT in LARC. “I would recommend posttreatment assessment with MRI and proctoscopy between 8 to 12 weeks and in the case of residual tumor or incomplete response to treatment, scheduling surgery at that time,” he said.
Dr. Roxburgh and coauthors reported having no financial disclosures.
SOURCE: Roxburgh C, et al. Society of Surgical Oncology Annual Cancer Symposium Abstract No. 3.
REPORTING FROM SSO 2018
Key clinical point: Timing of surgery for rectal cancer within 12 weeks of neoadjuvant therapy does not influence complications.
Major finding: Complication rates in early and later surgery groups were 44% and 38%.
Study details: Institutional cohort of 607 patients who had rectal resection within 16 weeks of completing NT between June 2009 and March 2015.
Disclosure: Dr. Roxburgh and coauthors reported having no financial disclosures.
Source: Roxburgh C, et al. Society of Surgical Oncology Annual Cancer Symposium Abstract No. 3.
Accuracy of colon cancer lymph node sampling influenced by location
CHICAGO – Clinical guidelines recommend , but those guidelines may need to be revised to take into account which side the cancer is on to accurately stage a subset of patients with colon cancer, according to results of a prospective, multicenter clinical trial presented at the Society of Surgical Oncology Annual Cancer Symposium.
Ahmed Dehal, MD, of John Wayne Canter Institute in Santa Monica, Calif., presented results of the trial that compared nodal staging in right-sided vs. left-sided colon cancer in two cohorts with T3N0 colon cancer who had at least one lymph node examined: a group of 370 patients from the randomized, multicenter prospective trial; and a sampling of 153,945 patients in the National Cancer Database (NCDB). The latter was used to validate findings in the trial group.
The probability of achieving true nodal negativity when 12 lymph nodes were examined was 64% for left and 68% for right colon cancer in the trial group and 72% and 77% in the NCDB cohort, Dr. Dehal said.
The analysis also examined how many nodes would need to be sampled to achieve probabilities of 85%, 90% and 95% true nodal negativity. This analysis found the numbers were consistently lower for right- vs. left-sided disease, Dr. Dehal said. For example, in the trial cohort, 27 lymph nodes would need be sampled in right-sided disease to achieve 85% probability vs. 31 in left-sided. In the NCDB cohort, those numbers were 21 and 25, respectively.
“The current threshold for adequate nodal sampling does not reliably predict the true nodal negativity in this subgroup of patients,” Dr. Dehal said. “In both cohorts – the trial and NCDB – more lymph nodes are needed to predict the true nodal negativity in patients with left compared to right colon cancer.”
These findings may help to inform revisions to existing clinical guidelines, Dr. Dehal said.
“Current guidelines regarding the minimum number of nodes needed to accurately stage patients with node-negative T3 colon cancer may need to be reevaluated given that the decision to give those patients chemotherapy is largely based on the nodal status,” he said. “More studies are needed to improve our understanding of the impact of sidedness on nodal staging in the colon cancer.”
Dr. Dehal and his coauthors reported having no financial disclosures.
SOURCE: Dehal A et al. Society of Surgical Oncology Annual Cancer Symposium. Abstract #23: Accuracy of nodal staging is influenced by sidedness in colon cancer: Results of a multicenter prospective trial.
*CORRECTION, 4/4/2018; a previous version of this story misidentified the cancer type
CHICAGO – Clinical guidelines recommend , but those guidelines may need to be revised to take into account which side the cancer is on to accurately stage a subset of patients with colon cancer, according to results of a prospective, multicenter clinical trial presented at the Society of Surgical Oncology Annual Cancer Symposium.
Ahmed Dehal, MD, of John Wayne Canter Institute in Santa Monica, Calif., presented results of the trial that compared nodal staging in right-sided vs. left-sided colon cancer in two cohorts with T3N0 colon cancer who had at least one lymph node examined: a group of 370 patients from the randomized, multicenter prospective trial; and a sampling of 153,945 patients in the National Cancer Database (NCDB). The latter was used to validate findings in the trial group.
The probability of achieving true nodal negativity when 12 lymph nodes were examined was 64% for left and 68% for right colon cancer in the trial group and 72% and 77% in the NCDB cohort, Dr. Dehal said.
The analysis also examined how many nodes would need to be sampled to achieve probabilities of 85%, 90% and 95% true nodal negativity. This analysis found the numbers were consistently lower for right- vs. left-sided disease, Dr. Dehal said. For example, in the trial cohort, 27 lymph nodes would need be sampled in right-sided disease to achieve 85% probability vs. 31 in left-sided. In the NCDB cohort, those numbers were 21 and 25, respectively.
“The current threshold for adequate nodal sampling does not reliably predict the true nodal negativity in this subgroup of patients,” Dr. Dehal said. “In both cohorts – the trial and NCDB – more lymph nodes are needed to predict the true nodal negativity in patients with left compared to right colon cancer.”
These findings may help to inform revisions to existing clinical guidelines, Dr. Dehal said.
“Current guidelines regarding the minimum number of nodes needed to accurately stage patients with node-negative T3 colon cancer may need to be reevaluated given that the decision to give those patients chemotherapy is largely based on the nodal status,” he said. “More studies are needed to improve our understanding of the impact of sidedness on nodal staging in the colon cancer.”
Dr. Dehal and his coauthors reported having no financial disclosures.
SOURCE: Dehal A et al. Society of Surgical Oncology Annual Cancer Symposium. Abstract #23: Accuracy of nodal staging is influenced by sidedness in colon cancer: Results of a multicenter prospective trial.
*CORRECTION, 4/4/2018; a previous version of this story misidentified the cancer type
CHICAGO – Clinical guidelines recommend , but those guidelines may need to be revised to take into account which side the cancer is on to accurately stage a subset of patients with colon cancer, according to results of a prospective, multicenter clinical trial presented at the Society of Surgical Oncology Annual Cancer Symposium.
Ahmed Dehal, MD, of John Wayne Canter Institute in Santa Monica, Calif., presented results of the trial that compared nodal staging in right-sided vs. left-sided colon cancer in two cohorts with T3N0 colon cancer who had at least one lymph node examined: a group of 370 patients from the randomized, multicenter prospective trial; and a sampling of 153,945 patients in the National Cancer Database (NCDB). The latter was used to validate findings in the trial group.
The probability of achieving true nodal negativity when 12 lymph nodes were examined was 64% for left and 68% for right colon cancer in the trial group and 72% and 77% in the NCDB cohort, Dr. Dehal said.
The analysis also examined how many nodes would need to be sampled to achieve probabilities of 85%, 90% and 95% true nodal negativity. This analysis found the numbers were consistently lower for right- vs. left-sided disease, Dr. Dehal said. For example, in the trial cohort, 27 lymph nodes would need be sampled in right-sided disease to achieve 85% probability vs. 31 in left-sided. In the NCDB cohort, those numbers were 21 and 25, respectively.
“The current threshold for adequate nodal sampling does not reliably predict the true nodal negativity in this subgroup of patients,” Dr. Dehal said. “In both cohorts – the trial and NCDB – more lymph nodes are needed to predict the true nodal negativity in patients with left compared to right colon cancer.”
These findings may help to inform revisions to existing clinical guidelines, Dr. Dehal said.
“Current guidelines regarding the minimum number of nodes needed to accurately stage patients with node-negative T3 colon cancer may need to be reevaluated given that the decision to give those patients chemotherapy is largely based on the nodal status,” he said. “More studies are needed to improve our understanding of the impact of sidedness on nodal staging in the colon cancer.”
Dr. Dehal and his coauthors reported having no financial disclosures.
SOURCE: Dehal A et al. Society of Surgical Oncology Annual Cancer Symposium. Abstract #23: Accuracy of nodal staging is influenced by sidedness in colon cancer: Results of a multicenter prospective trial.
*CORRECTION, 4/4/2018; a previous version of this story misidentified the cancer type
REPORTING FROM SSO 2018
Key clinical point: Sidedness influences the number of lymph nodes needed to predict true nodal negativity in colon cancer.
Major finding: Probability of true nodal negativity when 12 lymph nodes were examined was 64% for left and 68% for right colon cancer.
Study details: Randomized, multicenter trial of ultrastaging in colon cancer in 370 patients and National Cancer Database sampling of 153,945 patients.
Disclosures: Dr. Dehal and his coauthors report having no financial disclosures.
Source: Dehal A et al. Society of Surgical Oncology Annual Cancer Symposium, Abstract 23: Accuracy of nodal staging is influenced by sidedness in colon cancer: Results of a multicenter prospective trial.
Transgender trauma patients: What surgeons need to know
The likelihood that a is increasing every year.
The number of patients who self-identify as transgender and who have undergone both medical and/or surgical gender-affirming treatment is on the rise. The trend has accelerated since private insurers, Medicare, and Medicaid are now covering some of the costs (JAMA Surg. 2018 Feb 28. doi: 10.1001/jamasurg.2017.6231).
Lead author Samuel Mandell, MD, FACS, a trauma surgeon at the University of Washington Harborview Medical Center, Seattle, and his colleagues quote an estimate of 1 million transgender people in the United States. These individuals, many of whom have experienced gender dysphoria, in addition to stigma and negative psychosocial sequelae, may or may not have sought medical treatment. Medical interventions range from hormonal treatments to craniofacial plastic surgery and/or genital surgery.
“As transgender patients are more likely to be victims of assault and intimate partner violence or suicide, they are at increased risk for traumatic injury,” Dr. Mandell and coauthors said. More than 60% of the transgender population has been subjected to assault and more than 40% have attempted suicide. A recent study found that 42% of transgender individuals had a history on nonsuicidal self-injury (Psychiatr Clin North Am. 2017;40:41-50). The research team based their recommendations on managing transgender trauma patients on their own experience, and suggest some topics for future research
The authors searched the MEDLINE database for articles with the key words “trauma” or “injury” and “transgender/transsexual,” in addition to “surgery” and “transgender.” While the search yielded 388 articles, only 6 were relevant to acute care surgery or physical trauma/injury in the transgender population. “No articles were identified that addressed trauma/injury from the perspective of caring for the injured transgender patient,” Dr. Mandell and coauthors said.
The researchers recommend that the trauma surgeon begin if possible by working to establish patient-provider trust. “During surgical consultation, it is important to be aware that any transgender patient may have limited or negative interactions with general health care providers due to the significant discrimination this population faces,” the investigators wrote. Among the steps they suggest for the initial encounter with transgender patients are respectful questions about gender identity, asking what name they prefer, as well as what pronoun should be used.
Privacy concerns can be of particular sensitivity. “Care must be taken to maintain privacy for the patient, as others outside of the hospital may not know they are transgender. Consultation with the patient’s primary care provider may be beneficial to determine the extent of gender-affirmation and the patient’s disclosure to family and friends,” the investigator advised. In addition, the clinician needs to establish which if any nonmedical interventions the transgender patients has had. These may include nonprescription hormone therapy and silicone injections.
The encounter should include an evaluation for injury to genitalia. “Transgender patients may have significant dysphoria associated with their preoperative genitals,” Dr. Mandell and his coauthors said. In these cases, “involvement of providers experienced with examination of transgender patients should be sought, if possible.” These patients should be screened for potential abuse by a companion or self-injury, the investigators suggested.
Dr. Mandell and his coauthors also discussed some of the nuances of trauma care for this population. For example, transgender women may need a smaller endotracheal tube for establishing an airway as intubation to avoid damaging surgically altered vocal chords. Other craniofacial alterations can get in the way of establishing an airway. Clinicians also should keep in mind the increased likelihood of a venous thromboembolism from estrogen hormone therapy in immobilized transgender patients in the trauma setting. Implants and surgical alterations can add a layer of complexity to reading images. Anatomical rearrangement can make catheterization challenging.
Dr. Mandell and his coauthors concluded, “Further research is needed on the appropriate management of cross-gender hormones, dosing of medications and nutrition, and the special considerations for injury patterns and risks in transgender patients. Development of a system for quickly determining the state of gender-affirmation of the patient in regards to hormone therapy, surgeries, and social aspects may prove beneficial to providers in the setting of trauma, but involvement of the transgender population in the development of any such system is crucial.”
Eileen M. Bulger, MD, FACS, Chair ACS Committee on Trauma and one of the coauthors of the study, views the findings as potentially useful to meet the training deficit on transgender trauma issues. “As trauma surgeons, we strive to provide optimal care by attending to the physical, psychological, and social needs of our patients. This review raises awareness of critical issues to consider when caring for transgender patients and should be included in our educational programs for trauma fellowship training and used as a resource to raise awareness in our trauma centers.”
Dr. Mandell and his coauthors reported having no financial disclosures.
Education on the care of transgender and gender nonbinary population is lacking in both medical schools as well as surgical residencies, and it is often left to individual surgeons to seek out their own training. Unfortunately, this leaves many uncertain how to ask a patient about his/her/their history without making the patient uncomfortable. If we don’t ask the right questions, some patients may not disclose information that could be very detrimental to their care. Documentation in EHRs can be made difficult if the software doesn’t include transgender female, transgender male, and gender nonbinary options in addition to the binary choice of female or male. This can contribute to the misgendering and distress of the patient.
Asking which pronouns a transgender individual uses can be a big first step because it allows that person know that you are being respectful. Be prepared for pronouns you may not be used to: Some may use she/her or he/his, and some may use they/their, ze/hir, ze/zir or xe/xyr. It is important to have appropriate registration forms, gender neutral bathrooms, and respect and discretion from every individual provider for all of our patients. Providers should seek out education and training so that the patients aren’t forced to do the educating themselves. As trauma and acute care surgeons, we are used to caring for a diverse patient population with many unique needs. However, we don’t know enough about the trauma and surgery risks in the transgender and gender nonbinary population as only a limited research has been done. Studies such as this by Dr. Mandell et al. are encouraging and hopefully more will follow.
Andrea Long, MD, is an acute care surgeon and an assistant clinical professor at University of San Francisco, Fresno.
Education on the care of transgender and gender nonbinary population is lacking in both medical schools as well as surgical residencies, and it is often left to individual surgeons to seek out their own training. Unfortunately, this leaves many uncertain how to ask a patient about his/her/their history without making the patient uncomfortable. If we don’t ask the right questions, some patients may not disclose information that could be very detrimental to their care. Documentation in EHRs can be made difficult if the software doesn’t include transgender female, transgender male, and gender nonbinary options in addition to the binary choice of female or male. This can contribute to the misgendering and distress of the patient.
Asking which pronouns a transgender individual uses can be a big first step because it allows that person know that you are being respectful. Be prepared for pronouns you may not be used to: Some may use she/her or he/his, and some may use they/their, ze/hir, ze/zir or xe/xyr. It is important to have appropriate registration forms, gender neutral bathrooms, and respect and discretion from every individual provider for all of our patients. Providers should seek out education and training so that the patients aren’t forced to do the educating themselves. As trauma and acute care surgeons, we are used to caring for a diverse patient population with many unique needs. However, we don’t know enough about the trauma and surgery risks in the transgender and gender nonbinary population as only a limited research has been done. Studies such as this by Dr. Mandell et al. are encouraging and hopefully more will follow.
Andrea Long, MD, is an acute care surgeon and an assistant clinical professor at University of San Francisco, Fresno.
Education on the care of transgender and gender nonbinary population is lacking in both medical schools as well as surgical residencies, and it is often left to individual surgeons to seek out their own training. Unfortunately, this leaves many uncertain how to ask a patient about his/her/their history without making the patient uncomfortable. If we don’t ask the right questions, some patients may not disclose information that could be very detrimental to their care. Documentation in EHRs can be made difficult if the software doesn’t include transgender female, transgender male, and gender nonbinary options in addition to the binary choice of female or male. This can contribute to the misgendering and distress of the patient.
Asking which pronouns a transgender individual uses can be a big first step because it allows that person know that you are being respectful. Be prepared for pronouns you may not be used to: Some may use she/her or he/his, and some may use they/their, ze/hir, ze/zir or xe/xyr. It is important to have appropriate registration forms, gender neutral bathrooms, and respect and discretion from every individual provider for all of our patients. Providers should seek out education and training so that the patients aren’t forced to do the educating themselves. As trauma and acute care surgeons, we are used to caring for a diverse patient population with many unique needs. However, we don’t know enough about the trauma and surgery risks in the transgender and gender nonbinary population as only a limited research has been done. Studies such as this by Dr. Mandell et al. are encouraging and hopefully more will follow.
Andrea Long, MD, is an acute care surgeon and an assistant clinical professor at University of San Francisco, Fresno.
The likelihood that a is increasing every year.
The number of patients who self-identify as transgender and who have undergone both medical and/or surgical gender-affirming treatment is on the rise. The trend has accelerated since private insurers, Medicare, and Medicaid are now covering some of the costs (JAMA Surg. 2018 Feb 28. doi: 10.1001/jamasurg.2017.6231).
Lead author Samuel Mandell, MD, FACS, a trauma surgeon at the University of Washington Harborview Medical Center, Seattle, and his colleagues quote an estimate of 1 million transgender people in the United States. These individuals, many of whom have experienced gender dysphoria, in addition to stigma and negative psychosocial sequelae, may or may not have sought medical treatment. Medical interventions range from hormonal treatments to craniofacial plastic surgery and/or genital surgery.
“As transgender patients are more likely to be victims of assault and intimate partner violence or suicide, they are at increased risk for traumatic injury,” Dr. Mandell and coauthors said. More than 60% of the transgender population has been subjected to assault and more than 40% have attempted suicide. A recent study found that 42% of transgender individuals had a history on nonsuicidal self-injury (Psychiatr Clin North Am. 2017;40:41-50). The research team based their recommendations on managing transgender trauma patients on their own experience, and suggest some topics for future research
The authors searched the MEDLINE database for articles with the key words “trauma” or “injury” and “transgender/transsexual,” in addition to “surgery” and “transgender.” While the search yielded 388 articles, only 6 were relevant to acute care surgery or physical trauma/injury in the transgender population. “No articles were identified that addressed trauma/injury from the perspective of caring for the injured transgender patient,” Dr. Mandell and coauthors said.
The researchers recommend that the trauma surgeon begin if possible by working to establish patient-provider trust. “During surgical consultation, it is important to be aware that any transgender patient may have limited or negative interactions with general health care providers due to the significant discrimination this population faces,” the investigators wrote. Among the steps they suggest for the initial encounter with transgender patients are respectful questions about gender identity, asking what name they prefer, as well as what pronoun should be used.
Privacy concerns can be of particular sensitivity. “Care must be taken to maintain privacy for the patient, as others outside of the hospital may not know they are transgender. Consultation with the patient’s primary care provider may be beneficial to determine the extent of gender-affirmation and the patient’s disclosure to family and friends,” the investigator advised. In addition, the clinician needs to establish which if any nonmedical interventions the transgender patients has had. These may include nonprescription hormone therapy and silicone injections.
The encounter should include an evaluation for injury to genitalia. “Transgender patients may have significant dysphoria associated with their preoperative genitals,” Dr. Mandell and his coauthors said. In these cases, “involvement of providers experienced with examination of transgender patients should be sought, if possible.” These patients should be screened for potential abuse by a companion or self-injury, the investigators suggested.
Dr. Mandell and his coauthors also discussed some of the nuances of trauma care for this population. For example, transgender women may need a smaller endotracheal tube for establishing an airway as intubation to avoid damaging surgically altered vocal chords. Other craniofacial alterations can get in the way of establishing an airway. Clinicians also should keep in mind the increased likelihood of a venous thromboembolism from estrogen hormone therapy in immobilized transgender patients in the trauma setting. Implants and surgical alterations can add a layer of complexity to reading images. Anatomical rearrangement can make catheterization challenging.
Dr. Mandell and his coauthors concluded, “Further research is needed on the appropriate management of cross-gender hormones, dosing of medications and nutrition, and the special considerations for injury patterns and risks in transgender patients. Development of a system for quickly determining the state of gender-affirmation of the patient in regards to hormone therapy, surgeries, and social aspects may prove beneficial to providers in the setting of trauma, but involvement of the transgender population in the development of any such system is crucial.”
Eileen M. Bulger, MD, FACS, Chair ACS Committee on Trauma and one of the coauthors of the study, views the findings as potentially useful to meet the training deficit on transgender trauma issues. “As trauma surgeons, we strive to provide optimal care by attending to the physical, psychological, and social needs of our patients. This review raises awareness of critical issues to consider when caring for transgender patients and should be included in our educational programs for trauma fellowship training and used as a resource to raise awareness in our trauma centers.”
Dr. Mandell and his coauthors reported having no financial disclosures.
The likelihood that a is increasing every year.
The number of patients who self-identify as transgender and who have undergone both medical and/or surgical gender-affirming treatment is on the rise. The trend has accelerated since private insurers, Medicare, and Medicaid are now covering some of the costs (JAMA Surg. 2018 Feb 28. doi: 10.1001/jamasurg.2017.6231).
Lead author Samuel Mandell, MD, FACS, a trauma surgeon at the University of Washington Harborview Medical Center, Seattle, and his colleagues quote an estimate of 1 million transgender people in the United States. These individuals, many of whom have experienced gender dysphoria, in addition to stigma and negative psychosocial sequelae, may or may not have sought medical treatment. Medical interventions range from hormonal treatments to craniofacial plastic surgery and/or genital surgery.
“As transgender patients are more likely to be victims of assault and intimate partner violence or suicide, they are at increased risk for traumatic injury,” Dr. Mandell and coauthors said. More than 60% of the transgender population has been subjected to assault and more than 40% have attempted suicide. A recent study found that 42% of transgender individuals had a history on nonsuicidal self-injury (Psychiatr Clin North Am. 2017;40:41-50). The research team based their recommendations on managing transgender trauma patients on their own experience, and suggest some topics for future research
The authors searched the MEDLINE database for articles with the key words “trauma” or “injury” and “transgender/transsexual,” in addition to “surgery” and “transgender.” While the search yielded 388 articles, only 6 were relevant to acute care surgery or physical trauma/injury in the transgender population. “No articles were identified that addressed trauma/injury from the perspective of caring for the injured transgender patient,” Dr. Mandell and coauthors said.
The researchers recommend that the trauma surgeon begin if possible by working to establish patient-provider trust. “During surgical consultation, it is important to be aware that any transgender patient may have limited or negative interactions with general health care providers due to the significant discrimination this population faces,” the investigators wrote. Among the steps they suggest for the initial encounter with transgender patients are respectful questions about gender identity, asking what name they prefer, as well as what pronoun should be used.
Privacy concerns can be of particular sensitivity. “Care must be taken to maintain privacy for the patient, as others outside of the hospital may not know they are transgender. Consultation with the patient’s primary care provider may be beneficial to determine the extent of gender-affirmation and the patient’s disclosure to family and friends,” the investigator advised. In addition, the clinician needs to establish which if any nonmedical interventions the transgender patients has had. These may include nonprescription hormone therapy and silicone injections.
The encounter should include an evaluation for injury to genitalia. “Transgender patients may have significant dysphoria associated with their preoperative genitals,” Dr. Mandell and his coauthors said. In these cases, “involvement of providers experienced with examination of transgender patients should be sought, if possible.” These patients should be screened for potential abuse by a companion or self-injury, the investigators suggested.
Dr. Mandell and his coauthors also discussed some of the nuances of trauma care for this population. For example, transgender women may need a smaller endotracheal tube for establishing an airway as intubation to avoid damaging surgically altered vocal chords. Other craniofacial alterations can get in the way of establishing an airway. Clinicians also should keep in mind the increased likelihood of a venous thromboembolism from estrogen hormone therapy in immobilized transgender patients in the trauma setting. Implants and surgical alterations can add a layer of complexity to reading images. Anatomical rearrangement can make catheterization challenging.
Dr. Mandell and his coauthors concluded, “Further research is needed on the appropriate management of cross-gender hormones, dosing of medications and nutrition, and the special considerations for injury patterns and risks in transgender patients. Development of a system for quickly determining the state of gender-affirmation of the patient in regards to hormone therapy, surgeries, and social aspects may prove beneficial to providers in the setting of trauma, but involvement of the transgender population in the development of any such system is crucial.”
Eileen M. Bulger, MD, FACS, Chair ACS Committee on Trauma and one of the coauthors of the study, views the findings as potentially useful to meet the training deficit on transgender trauma issues. “As trauma surgeons, we strive to provide optimal care by attending to the physical, psychological, and social needs of our patients. This review raises awareness of critical issues to consider when caring for transgender patients and should be included in our educational programs for trauma fellowship training and used as a resource to raise awareness in our trauma centers.”
Dr. Mandell and his coauthors reported having no financial disclosures.
FROM THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
Over one-third report financial burden from breast cancer treatment
CHICAGO – Women who have treatment for breast cancer seldom talk about the costs of care with their medical team, but a study out of Duke University has found that more than one-third reported having a financial burden from their breast cancer treatment, even among women with health insurance, according to a report presented at the Society of Surgical Oncology Annual Cancer Symposium.
“The financial harm associated with cancer treatment is now known as ‘financial toxicity,’ ” Rachel A. Greenup, MD, MPH, said in reporting the results of an 88-item survey completed by 654 adult women who had treatment for breast cancer. The women were recruited through the Army of Women of the Dr. Susan Love Research Foundation and The Sister’s Network of North Carolina, an African-American breast cancer survivors’ organization.
Overall, 69% of survey respondents had private insurance and 26% had Medicare. Of the patients surveyed, 94% had breast cancer surgery: 40.6% lumpectomy, 23.7% mastectomy, and 29.7% bilateral mastectomy; 34% also had breast reconstruction. Among those surveyed, 43% reported considering costs in their treatment decision. Of these, 29% considered costs when making surgical treatment decisions, including 14% who reported that costs were “extremely” important.
Despite the high levels of insurance coverage, 35% of the study participants reported a financial burden resulting from cancer treatment, ranging from “somewhat” burdensome to “catastrophic.” The median out-of-pocket cost for the study participants was $4,000, and 5% exceeded $40,000 in such costs, Dr. Greenup said. “The risk of financial harm and increased out-of-pocket costs to patients differed by surgery type,” with higher financial burdens seen in women who underwent bilateral mastectomy.
Cost was one of many factors survey participants reported considering when making surgical treatment decisions, but the most important factors were the opinions and advice of the medical team and the individual patient’s fear of recurrence. However, in lower-income women, cost factored more significantly in decision making. “In a subset of women who reported an annual income of $45,000 a year or less, cost of treatment gained importance and, interestingly, became more important than many variables we routinely discuss – for example, appearance of the breast, sexuality, avoiding radiation, and breast preservation,” Dr. Greenup said. “An income of $74,000 a year was the tipping point at which women reported incorporating costs into their cancer treatment decisions.”
She added that younger, minority women who did not have Medicare coverage were more likely to consider costs in breast cancer treatment decisions.
Most women surveyed (79%) said they preferred to know their out-of-pocket costs before they begin treatment, Dr. Greenup said, “and 40% believed that we as physicians should be considering out-of-pocket costs while making medical decisions.” However, 78% of those surveyed said they never discussed costs with their cancer team – despite American Society of Clinical Oncologists guidelines, she pointed out – and 35% said their treatment costs were higher than expected.
Dr. Greenup described the study population as “well engaged … with good insurance and strong educational background that likely does not reflect the general population.” The results may not be generalizable. “We expect that in a general cohort of women, our findings would be even more exaggerated,” she said.
The study points out the need to better understand how cost transparency may affect breast cancer treatment decisions, Dr. Greenup said. “As eligible women with breast cancer choose between surgical options, it’s important that we consider the potential risk of financial harm as we guide them through these difficult treatment decisions,” she said.
Dr. Greenup and her study coauthors reported having no financial disclosures.
SOURCE: Greenup RA. SSO 2018, Abstract No. 24.
CHICAGO – Women who have treatment for breast cancer seldom talk about the costs of care with their medical team, but a study out of Duke University has found that more than one-third reported having a financial burden from their breast cancer treatment, even among women with health insurance, according to a report presented at the Society of Surgical Oncology Annual Cancer Symposium.
“The financial harm associated with cancer treatment is now known as ‘financial toxicity,’ ” Rachel A. Greenup, MD, MPH, said in reporting the results of an 88-item survey completed by 654 adult women who had treatment for breast cancer. The women were recruited through the Army of Women of the Dr. Susan Love Research Foundation and The Sister’s Network of North Carolina, an African-American breast cancer survivors’ organization.
Overall, 69% of survey respondents had private insurance and 26% had Medicare. Of the patients surveyed, 94% had breast cancer surgery: 40.6% lumpectomy, 23.7% mastectomy, and 29.7% bilateral mastectomy; 34% also had breast reconstruction. Among those surveyed, 43% reported considering costs in their treatment decision. Of these, 29% considered costs when making surgical treatment decisions, including 14% who reported that costs were “extremely” important.
Despite the high levels of insurance coverage, 35% of the study participants reported a financial burden resulting from cancer treatment, ranging from “somewhat” burdensome to “catastrophic.” The median out-of-pocket cost for the study participants was $4,000, and 5% exceeded $40,000 in such costs, Dr. Greenup said. “The risk of financial harm and increased out-of-pocket costs to patients differed by surgery type,” with higher financial burdens seen in women who underwent bilateral mastectomy.
Cost was one of many factors survey participants reported considering when making surgical treatment decisions, but the most important factors were the opinions and advice of the medical team and the individual patient’s fear of recurrence. However, in lower-income women, cost factored more significantly in decision making. “In a subset of women who reported an annual income of $45,000 a year or less, cost of treatment gained importance and, interestingly, became more important than many variables we routinely discuss – for example, appearance of the breast, sexuality, avoiding radiation, and breast preservation,” Dr. Greenup said. “An income of $74,000 a year was the tipping point at which women reported incorporating costs into their cancer treatment decisions.”
She added that younger, minority women who did not have Medicare coverage were more likely to consider costs in breast cancer treatment decisions.
Most women surveyed (79%) said they preferred to know their out-of-pocket costs before they begin treatment, Dr. Greenup said, “and 40% believed that we as physicians should be considering out-of-pocket costs while making medical decisions.” However, 78% of those surveyed said they never discussed costs with their cancer team – despite American Society of Clinical Oncologists guidelines, she pointed out – and 35% said their treatment costs were higher than expected.
Dr. Greenup described the study population as “well engaged … with good insurance and strong educational background that likely does not reflect the general population.” The results may not be generalizable. “We expect that in a general cohort of women, our findings would be even more exaggerated,” she said.
The study points out the need to better understand how cost transparency may affect breast cancer treatment decisions, Dr. Greenup said. “As eligible women with breast cancer choose between surgical options, it’s important that we consider the potential risk of financial harm as we guide them through these difficult treatment decisions,” she said.
Dr. Greenup and her study coauthors reported having no financial disclosures.
SOURCE: Greenup RA. SSO 2018, Abstract No. 24.
CHICAGO – Women who have treatment for breast cancer seldom talk about the costs of care with their medical team, but a study out of Duke University has found that more than one-third reported having a financial burden from their breast cancer treatment, even among women with health insurance, according to a report presented at the Society of Surgical Oncology Annual Cancer Symposium.
“The financial harm associated with cancer treatment is now known as ‘financial toxicity,’ ” Rachel A. Greenup, MD, MPH, said in reporting the results of an 88-item survey completed by 654 adult women who had treatment for breast cancer. The women were recruited through the Army of Women of the Dr. Susan Love Research Foundation and The Sister’s Network of North Carolina, an African-American breast cancer survivors’ organization.
Overall, 69% of survey respondents had private insurance and 26% had Medicare. Of the patients surveyed, 94% had breast cancer surgery: 40.6% lumpectomy, 23.7% mastectomy, and 29.7% bilateral mastectomy; 34% also had breast reconstruction. Among those surveyed, 43% reported considering costs in their treatment decision. Of these, 29% considered costs when making surgical treatment decisions, including 14% who reported that costs were “extremely” important.
Despite the high levels of insurance coverage, 35% of the study participants reported a financial burden resulting from cancer treatment, ranging from “somewhat” burdensome to “catastrophic.” The median out-of-pocket cost for the study participants was $4,000, and 5% exceeded $40,000 in such costs, Dr. Greenup said. “The risk of financial harm and increased out-of-pocket costs to patients differed by surgery type,” with higher financial burdens seen in women who underwent bilateral mastectomy.
Cost was one of many factors survey participants reported considering when making surgical treatment decisions, but the most important factors were the opinions and advice of the medical team and the individual patient’s fear of recurrence. However, in lower-income women, cost factored more significantly in decision making. “In a subset of women who reported an annual income of $45,000 a year or less, cost of treatment gained importance and, interestingly, became more important than many variables we routinely discuss – for example, appearance of the breast, sexuality, avoiding radiation, and breast preservation,” Dr. Greenup said. “An income of $74,000 a year was the tipping point at which women reported incorporating costs into their cancer treatment decisions.”
She added that younger, minority women who did not have Medicare coverage were more likely to consider costs in breast cancer treatment decisions.
Most women surveyed (79%) said they preferred to know their out-of-pocket costs before they begin treatment, Dr. Greenup said, “and 40% believed that we as physicians should be considering out-of-pocket costs while making medical decisions.” However, 78% of those surveyed said they never discussed costs with their cancer team – despite American Society of Clinical Oncologists guidelines, she pointed out – and 35% said their treatment costs were higher than expected.
Dr. Greenup described the study population as “well engaged … with good insurance and strong educational background that likely does not reflect the general population.” The results may not be generalizable. “We expect that in a general cohort of women, our findings would be even more exaggerated,” she said.
The study points out the need to better understand how cost transparency may affect breast cancer treatment decisions, Dr. Greenup said. “As eligible women with breast cancer choose between surgical options, it’s important that we consider the potential risk of financial harm as we guide them through these difficult treatment decisions,” she said.
Dr. Greenup and her study coauthors reported having no financial disclosures.
SOURCE: Greenup RA. SSO 2018, Abstract No. 24.
REPORTING FROM SSO 2018
Key clinical point: Treatment costs are important to many women with breast cancer, although most report not having cost discussions with their physicians.
Major finding: Despite the high levels of insurance coverage, 35% of study participants reported a financial burden resulting from cancer treatment, ranging from “somewhat” burdensome to “catastrophic.”
Study details: An 88-item survey completed by 654 adult women who had treatment for breast cancer.
Disclosures: Dr. Greenup and her coauthors reported having no financial disclosures.
Source: Greenup RA. SSO 2018, Abstract No. 24.
Bile spillage during lap cholecystectomy comes with a price
Bile spillage that happens during laparoscopic gallbladder removal is a known problem, but a large study has put some numbers to quantify the risks to patients.
A research team at Massachusetts General Hospital, Boston, conducted a prospective study of 1,001 such operations to look at the impact of bile spillage. They found that wound infection rates in cases involving bile spillage were almost three times higher than were those without spillage and resulting hospital stays were 50% longer, according to an article in the Journal of the American College of Surgeons.
The study involved adults who had laparoscopic and laparoscopic converted to open cholecystectomy at the academic hospital during May 2010-March 2017. The latter category accounted for 95 patients, a 9.5% conversion rate. Overall, bile was spilled in 591 patients (59%), with empyema in 86 (8.6%), hydrops in 62 (6.2%), and clear bile spillage in the remainder. Bile spillage along with gallstone spillage occurred in 202 patients (20.2%), with recovery of all spilled gallstones in 145 (71.8%) of those cases.
Overall, the surgical site infection (SSI) rate was 2.4% (n = 8) in patients with no bile spillage vs. 7.1% (n = 30) for those with bile spillage. Median hospital length of stay was 2 days for the nonspillage patients vs. 3 days for those with spillage. The 30-day readmission rates were 5.9% for the nonspillage group vs. 9.6% for the spillage group.
The bile spillage rate in this study was considerably higher than previous studies had reported, the researchers noted. A retrospective study of 1,127 patients reported a spillage rate of 11.6% (World J Surg. 1999;23:1186-90). “One needs to notice that a retrospective review of medical records almost certainly underappreciates the rate of bile spillage,” the investigators wrote. A Mayo Clinic study reported a bile spillage rate of 29% and an increased risk of intra-abdominal abscesses (J Gastrointest Surg. 1997;1:85-90). The complex and acute nature of the cases at Mass General may explain their higher spillage rates, the researchers suggested.
This study identifies bile spillage, along with conversion to open surgery and patient ASA class 2 or higher as the only independent predictors of SSI. The study also found no link between empyema and hydrops with SSI, although the small number of cases may preclude an representative sample.
Nonetheless, surgeons must face the question of how to decrease SSI in laparoscopic cholecystectomy with bile spillage, study authors wrote. “First, surgeons should acknowledge that gallbladder perforations and bile spillage come at a price,” they said, “and thus should be cautious and try to avoid them.”
When bile is spilled, liberal peritoneal irrigation may be futile; this study showed similar SSI rates after bile spillage, regardless of peritoneal irrigation. “We could consider modifying perioperative antibiotic coverage,” the investigators wrote, but they acknowledged a need for more research to validate its benefit.
The investigators reported having no financial disclosures.
SOURCE: Peponis T et al. J Am Coll Surg. 2018 Mar 1. doi: 10.1016/j.jamcollsurg.2017.11.025.
Bile spillage that happens during laparoscopic gallbladder removal is a known problem, but a large study has put some numbers to quantify the risks to patients.
A research team at Massachusetts General Hospital, Boston, conducted a prospective study of 1,001 such operations to look at the impact of bile spillage. They found that wound infection rates in cases involving bile spillage were almost three times higher than were those without spillage and resulting hospital stays were 50% longer, according to an article in the Journal of the American College of Surgeons.
The study involved adults who had laparoscopic and laparoscopic converted to open cholecystectomy at the academic hospital during May 2010-March 2017. The latter category accounted for 95 patients, a 9.5% conversion rate. Overall, bile was spilled in 591 patients (59%), with empyema in 86 (8.6%), hydrops in 62 (6.2%), and clear bile spillage in the remainder. Bile spillage along with gallstone spillage occurred in 202 patients (20.2%), with recovery of all spilled gallstones in 145 (71.8%) of those cases.
Overall, the surgical site infection (SSI) rate was 2.4% (n = 8) in patients with no bile spillage vs. 7.1% (n = 30) for those with bile spillage. Median hospital length of stay was 2 days for the nonspillage patients vs. 3 days for those with spillage. The 30-day readmission rates were 5.9% for the nonspillage group vs. 9.6% for the spillage group.
The bile spillage rate in this study was considerably higher than previous studies had reported, the researchers noted. A retrospective study of 1,127 patients reported a spillage rate of 11.6% (World J Surg. 1999;23:1186-90). “One needs to notice that a retrospective review of medical records almost certainly underappreciates the rate of bile spillage,” the investigators wrote. A Mayo Clinic study reported a bile spillage rate of 29% and an increased risk of intra-abdominal abscesses (J Gastrointest Surg. 1997;1:85-90). The complex and acute nature of the cases at Mass General may explain their higher spillage rates, the researchers suggested.
This study identifies bile spillage, along with conversion to open surgery and patient ASA class 2 or higher as the only independent predictors of SSI. The study also found no link between empyema and hydrops with SSI, although the small number of cases may preclude an representative sample.
Nonetheless, surgeons must face the question of how to decrease SSI in laparoscopic cholecystectomy with bile spillage, study authors wrote. “First, surgeons should acknowledge that gallbladder perforations and bile spillage come at a price,” they said, “and thus should be cautious and try to avoid them.”
When bile is spilled, liberal peritoneal irrigation may be futile; this study showed similar SSI rates after bile spillage, regardless of peritoneal irrigation. “We could consider modifying perioperative antibiotic coverage,” the investigators wrote, but they acknowledged a need for more research to validate its benefit.
The investigators reported having no financial disclosures.
SOURCE: Peponis T et al. J Am Coll Surg. 2018 Mar 1. doi: 10.1016/j.jamcollsurg.2017.11.025.
Bile spillage that happens during laparoscopic gallbladder removal is a known problem, but a large study has put some numbers to quantify the risks to patients.
A research team at Massachusetts General Hospital, Boston, conducted a prospective study of 1,001 such operations to look at the impact of bile spillage. They found that wound infection rates in cases involving bile spillage were almost three times higher than were those without spillage and resulting hospital stays were 50% longer, according to an article in the Journal of the American College of Surgeons.
The study involved adults who had laparoscopic and laparoscopic converted to open cholecystectomy at the academic hospital during May 2010-March 2017. The latter category accounted for 95 patients, a 9.5% conversion rate. Overall, bile was spilled in 591 patients (59%), with empyema in 86 (8.6%), hydrops in 62 (6.2%), and clear bile spillage in the remainder. Bile spillage along with gallstone spillage occurred in 202 patients (20.2%), with recovery of all spilled gallstones in 145 (71.8%) of those cases.
Overall, the surgical site infection (SSI) rate was 2.4% (n = 8) in patients with no bile spillage vs. 7.1% (n = 30) for those with bile spillage. Median hospital length of stay was 2 days for the nonspillage patients vs. 3 days for those with spillage. The 30-day readmission rates were 5.9% for the nonspillage group vs. 9.6% for the spillage group.
The bile spillage rate in this study was considerably higher than previous studies had reported, the researchers noted. A retrospective study of 1,127 patients reported a spillage rate of 11.6% (World J Surg. 1999;23:1186-90). “One needs to notice that a retrospective review of medical records almost certainly underappreciates the rate of bile spillage,” the investigators wrote. A Mayo Clinic study reported a bile spillage rate of 29% and an increased risk of intra-abdominal abscesses (J Gastrointest Surg. 1997;1:85-90). The complex and acute nature of the cases at Mass General may explain their higher spillage rates, the researchers suggested.
This study identifies bile spillage, along with conversion to open surgery and patient ASA class 2 or higher as the only independent predictors of SSI. The study also found no link between empyema and hydrops with SSI, although the small number of cases may preclude an representative sample.
Nonetheless, surgeons must face the question of how to decrease SSI in laparoscopic cholecystectomy with bile spillage, study authors wrote. “First, surgeons should acknowledge that gallbladder perforations and bile spillage come at a price,” they said, “and thus should be cautious and try to avoid them.”
When bile is spilled, liberal peritoneal irrigation may be futile; this study showed similar SSI rates after bile spillage, regardless of peritoneal irrigation. “We could consider modifying perioperative antibiotic coverage,” the investigators wrote, but they acknowledged a need for more research to validate its benefit.
The investigators reported having no financial disclosures.
SOURCE: Peponis T et al. J Am Coll Surg. 2018 Mar 1. doi: 10.1016/j.jamcollsurg.2017.11.025.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: Bile spillage during laparoscopic cholecystectomy increases the patient’s risk for surgical site infection.
Major finding: Surgical site infection rates were 7.1% in cases in which bile spillage occurred vs. 2.4% in cases that had no bile spillage.
Data source: Prospective analysis of 1,001 laparoscopic or laparoscopic converted to open operations in adults during May 2010-March 2017.
Disclosures: Dr. Velmahos and coauthors reported having no financial disclosures.
Source: Peponis T et al. J Am Coll Surg. 2018 Mar 1. doi: 10.1016/j.jamcollsurg.2017.11.025.
Defining incisional hernia risk in IBD surgery
Open surgery for inflammatory bowel disease (IBD) has been known to carry a high risk of incisional hernia, but the risk factors have not been well understood.
A review of 1,000 operations performed over nearly 40 years at a high-volume, nationally recognized center has identified five patient factors that can raise the risk of incisional hernia in these operations by 50% or more, according to a study published in the Annals of Surgery.
The study followed the patients for an average of 8 years after their operations, which were performed between January 1976 and December 2014 at Mount Sinai Medical Center in New York. The overall incidence of incisional hernia was 20%-21% for patients with ulcerative colitis and 20% for those with Crohn’s disease.
Half of these patients developed an incisional hernia less than 2 years after the index surgery and 75% in less than 4 years.
The researchers identified the following statistically significant risk factors for incisional hernia: wound infection (hazard ratio, 3.66; P less than .001); hypoalbuminemia (HR, 2.02; P = .002); previous bowel resection (HR, 1.6; P = .003); ileostomy created at time of procedure (HR, 1.53; P = .01); and a history of smoking (HR, 1.52; P less than .013). Other risk factors to lesser degrees are body mass index at time of surgery (HR, 1.036; P = .009); age at time of surgery (HR, 1.021; P less than .001), and age at disease onset (HR, 1.018; P less than .001).
Lead author Tomas Heimann, MD, and his coauthors pointed out that this study population had severe levels of disease. Almost half of the patients had severe intractable disease that had resisted medical treatment. More than a quarter of these patients had received preoperative steroid therapy within 6 weeks, and 15% had received recent immunosuppressive therapy. Almost 80% were either anemic or had hypoalbuminemia or both. The average duration of disease was 12 years. More than half had undergone previous bowel surgery – “often lengthy and difficult” – with many patients suffering from fistulae, abscesses, and dense adhesions. “These factors were more likely to predispose patients to develop wound infections and delayed healing resulting in incisional hernia in one-fifth of our patients,” Dr. Heimann and his coauthors noted.
A somewhat unexpected finding was that immunosuppressive therapy and steroids were not linked to incisional hernia in these patients.
Prophylactic mesh placement in patients with IBD is impractical because of the risk of infection it carries, Dr. Heimann and his coauthors said.
Dr. Heimann and his coauthors reported having no financial disclosures.
SOURCE: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
Open surgery for inflammatory bowel disease (IBD) has been known to carry a high risk of incisional hernia, but the risk factors have not been well understood.
A review of 1,000 operations performed over nearly 40 years at a high-volume, nationally recognized center has identified five patient factors that can raise the risk of incisional hernia in these operations by 50% or more, according to a study published in the Annals of Surgery.
The study followed the patients for an average of 8 years after their operations, which were performed between January 1976 and December 2014 at Mount Sinai Medical Center in New York. The overall incidence of incisional hernia was 20%-21% for patients with ulcerative colitis and 20% for those with Crohn’s disease.
Half of these patients developed an incisional hernia less than 2 years after the index surgery and 75% in less than 4 years.
The researchers identified the following statistically significant risk factors for incisional hernia: wound infection (hazard ratio, 3.66; P less than .001); hypoalbuminemia (HR, 2.02; P = .002); previous bowel resection (HR, 1.6; P = .003); ileostomy created at time of procedure (HR, 1.53; P = .01); and a history of smoking (HR, 1.52; P less than .013). Other risk factors to lesser degrees are body mass index at time of surgery (HR, 1.036; P = .009); age at time of surgery (HR, 1.021; P less than .001), and age at disease onset (HR, 1.018; P less than .001).
Lead author Tomas Heimann, MD, and his coauthors pointed out that this study population had severe levels of disease. Almost half of the patients had severe intractable disease that had resisted medical treatment. More than a quarter of these patients had received preoperative steroid therapy within 6 weeks, and 15% had received recent immunosuppressive therapy. Almost 80% were either anemic or had hypoalbuminemia or both. The average duration of disease was 12 years. More than half had undergone previous bowel surgery – “often lengthy and difficult” – with many patients suffering from fistulae, abscesses, and dense adhesions. “These factors were more likely to predispose patients to develop wound infections and delayed healing resulting in incisional hernia in one-fifth of our patients,” Dr. Heimann and his coauthors noted.
A somewhat unexpected finding was that immunosuppressive therapy and steroids were not linked to incisional hernia in these patients.
Prophylactic mesh placement in patients with IBD is impractical because of the risk of infection it carries, Dr. Heimann and his coauthors said.
Dr. Heimann and his coauthors reported having no financial disclosures.
SOURCE: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
Open surgery for inflammatory bowel disease (IBD) has been known to carry a high risk of incisional hernia, but the risk factors have not been well understood.
A review of 1,000 operations performed over nearly 40 years at a high-volume, nationally recognized center has identified five patient factors that can raise the risk of incisional hernia in these operations by 50% or more, according to a study published in the Annals of Surgery.
The study followed the patients for an average of 8 years after their operations, which were performed between January 1976 and December 2014 at Mount Sinai Medical Center in New York. The overall incidence of incisional hernia was 20%-21% for patients with ulcerative colitis and 20% for those with Crohn’s disease.
Half of these patients developed an incisional hernia less than 2 years after the index surgery and 75% in less than 4 years.
The researchers identified the following statistically significant risk factors for incisional hernia: wound infection (hazard ratio, 3.66; P less than .001); hypoalbuminemia (HR, 2.02; P = .002); previous bowel resection (HR, 1.6; P = .003); ileostomy created at time of procedure (HR, 1.53; P = .01); and a history of smoking (HR, 1.52; P less than .013). Other risk factors to lesser degrees are body mass index at time of surgery (HR, 1.036; P = .009); age at time of surgery (HR, 1.021; P less than .001), and age at disease onset (HR, 1.018; P less than .001).
Lead author Tomas Heimann, MD, and his coauthors pointed out that this study population had severe levels of disease. Almost half of the patients had severe intractable disease that had resisted medical treatment. More than a quarter of these patients had received preoperative steroid therapy within 6 weeks, and 15% had received recent immunosuppressive therapy. Almost 80% were either anemic or had hypoalbuminemia or both. The average duration of disease was 12 years. More than half had undergone previous bowel surgery – “often lengthy and difficult” – with many patients suffering from fistulae, abscesses, and dense adhesions. “These factors were more likely to predispose patients to develop wound infections and delayed healing resulting in incisional hernia in one-fifth of our patients,” Dr. Heimann and his coauthors noted.
A somewhat unexpected finding was that immunosuppressive therapy and steroids were not linked to incisional hernia in these patients.
Prophylactic mesh placement in patients with IBD is impractical because of the risk of infection it carries, Dr. Heimann and his coauthors said.
Dr. Heimann and his coauthors reported having no financial disclosures.
SOURCE: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
FROM ANNALS OF SURGERY
Key clinical point: Patients with IBD have a high incidence of incisional hernia after open bowel resection.
Major finding: The overall incidence of incisional hernia after open bowel resection was 20%.
Data source: One thousand patients who had undergone open bowel surgery for IBD at Mount Sinai Medical Center, New York, between January 1976 and December 2014.
Disclosures: Dr. Heimann and his coauthors reported having no financial disclosures.
Source: Heimann T et al. Ann Surg. 2018 Mar;267(3):532-6.
Parental leave not available to all academic surgeons
Paid parental leave policies have been unevenly adopted among academic medical centers, according to a study published in the Journal of Surgical Research. These policies, or their lack, may have important ramifications for recruiting and specialty selection by surgeons, and for women of child-rearing age in particular.
Parental leave for surgeons has been championed by the American College of Surgeons, among other professional societies, in formal statements and supportive policies in recent years.
Dina S. Itum, MD, a fifth-year resident in the department of surgery, University of Texas Southwestern Medical Center, Houston, and a research team looked into how widespread parental leave is for surgeons in US medical centers. Their sample was the 91 top-ranked academic medical centers identified by U.S. News & World Report in 2016. The method used by U.S. News & World Report for ranking medical centers is based on student selectivity, dean and residency directors’ peer assessment of national institutions, faculty to student ratio, and the dollar amount in NIH research grants received.
“Parental leave” was defined by the research team as any leave dedicated to new mothers, fathers and/or primary caregivers after childbirth or adoption. “Paid leave” was defined as some protected leave with salary without mandated use of sick leave or vacation leave.
The study found that among the top-ranked 91 institutions, 48 (53%) offered some form of paid parental leave to faculty surgeons. The higher the rating, the more likely the institution offered paid parental leave: 77% of those in the top third of rankings vs. 53% in the middle third and 29% in the bottom third. Private institutions were more likely to offer paid leave of 6 weeks or longer; 67% vs. 33% of public institutions.
The investigators posed a question: Did these institutions implement the policy to attract the top talent, or did the policy improve faculty morale and productivity leading to a higher ranking? The study does not answer the question, but the investigators consider it an important issue for further study.
The investigators also suggested that surgeons of child-rearing age use parental leave information their in their own employment negotiations. “As physicians, we are aware of the health care benefits associated with parental leave, and as leaders within our communities, we should be at the forefront of supporting further advancement of this benefit,” the investigators wrote.
The investigators reported having no financial disclosures.
SOURCE: Itum DS et al. J Surg Res. 2018 Feb 3. doi. org/10.1016/j.jss.2018.01.001.
Paid parental leave policies have been unevenly adopted among academic medical centers, according to a study published in the Journal of Surgical Research. These policies, or their lack, may have important ramifications for recruiting and specialty selection by surgeons, and for women of child-rearing age in particular.
Parental leave for surgeons has been championed by the American College of Surgeons, among other professional societies, in formal statements and supportive policies in recent years.
Dina S. Itum, MD, a fifth-year resident in the department of surgery, University of Texas Southwestern Medical Center, Houston, and a research team looked into how widespread parental leave is for surgeons in US medical centers. Their sample was the 91 top-ranked academic medical centers identified by U.S. News & World Report in 2016. The method used by U.S. News & World Report for ranking medical centers is based on student selectivity, dean and residency directors’ peer assessment of national institutions, faculty to student ratio, and the dollar amount in NIH research grants received.
“Parental leave” was defined by the research team as any leave dedicated to new mothers, fathers and/or primary caregivers after childbirth or adoption. “Paid leave” was defined as some protected leave with salary without mandated use of sick leave or vacation leave.
The study found that among the top-ranked 91 institutions, 48 (53%) offered some form of paid parental leave to faculty surgeons. The higher the rating, the more likely the institution offered paid parental leave: 77% of those in the top third of rankings vs. 53% in the middle third and 29% in the bottom third. Private institutions were more likely to offer paid leave of 6 weeks or longer; 67% vs. 33% of public institutions.
The investigators posed a question: Did these institutions implement the policy to attract the top talent, or did the policy improve faculty morale and productivity leading to a higher ranking? The study does not answer the question, but the investigators consider it an important issue for further study.
The investigators also suggested that surgeons of child-rearing age use parental leave information their in their own employment negotiations. “As physicians, we are aware of the health care benefits associated with parental leave, and as leaders within our communities, we should be at the forefront of supporting further advancement of this benefit,” the investigators wrote.
The investigators reported having no financial disclosures.
SOURCE: Itum DS et al. J Surg Res. 2018 Feb 3. doi. org/10.1016/j.jss.2018.01.001.
Paid parental leave policies have been unevenly adopted among academic medical centers, according to a study published in the Journal of Surgical Research. These policies, or their lack, may have important ramifications for recruiting and specialty selection by surgeons, and for women of child-rearing age in particular.
Parental leave for surgeons has been championed by the American College of Surgeons, among other professional societies, in formal statements and supportive policies in recent years.
Dina S. Itum, MD, a fifth-year resident in the department of surgery, University of Texas Southwestern Medical Center, Houston, and a research team looked into how widespread parental leave is for surgeons in US medical centers. Their sample was the 91 top-ranked academic medical centers identified by U.S. News & World Report in 2016. The method used by U.S. News & World Report for ranking medical centers is based on student selectivity, dean and residency directors’ peer assessment of national institutions, faculty to student ratio, and the dollar amount in NIH research grants received.
“Parental leave” was defined by the research team as any leave dedicated to new mothers, fathers and/or primary caregivers after childbirth or adoption. “Paid leave” was defined as some protected leave with salary without mandated use of sick leave or vacation leave.
The study found that among the top-ranked 91 institutions, 48 (53%) offered some form of paid parental leave to faculty surgeons. The higher the rating, the more likely the institution offered paid parental leave: 77% of those in the top third of rankings vs. 53% in the middle third and 29% in the bottom third. Private institutions were more likely to offer paid leave of 6 weeks or longer; 67% vs. 33% of public institutions.
The investigators posed a question: Did these institutions implement the policy to attract the top talent, or did the policy improve faculty morale and productivity leading to a higher ranking? The study does not answer the question, but the investigators consider it an important issue for further study.
The investigators also suggested that surgeons of child-rearing age use parental leave information their in their own employment negotiations. “As physicians, we are aware of the health care benefits associated with parental leave, and as leaders within our communities, we should be at the forefront of supporting further advancement of this benefit,” the investigators wrote.
The investigators reported having no financial disclosures.
SOURCE: Itum DS et al. J Surg Res. 2018 Feb 3. doi. org/10.1016/j.jss.2018.01.001.
FROM THE JOURNAL OF SURGICAL RESEARCH
Key clinical point: Parental leave policies have been unevenly adopted by U.S. medical schools.
Major finding: Among the top 91 ranked medical schools, 53% offer paid parental leave.
Data source: Survey of 91 top academic medical centers identified in U.S. News & World Report 2016 listing.
Disclosures: The investigators reported having no financial disclosures.
SOURCE: Itum DS et al. J Surg Res. 2018 Feb 3. doi. org/10.1016/j.jss.2018.01.001.
How real is resident burnout?
JACKSONVILLE, FLA. – Burnout is commonly ascribed to surgical residents, but reliable estimates of the numbers involved and a clear, comparable definition of burnout remain elusive.
A large study of general surgery residents has found that almost one in four have at least one symptom of burnout daily and more than two in five report poor psychiatric well-being, according to results of a survey reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Twenty-two percent of general surgery residents report at least one symptom of burnout daily,” said Daniel “Brock” Hewitt, MD, a research fellow in the Surgical Outcomes and Quality Improvement Center in the department of surgery, Feinberg School of Medicine, Northwestern University, Chicago. “Poor resident wellness is associated with more duty-hour violations, feeling unprepared for residency, and an increase in self-reported medical errors. However, burnout is not associated with worse surgical outcomes.”
The study, undertaken with grant support from The American Board of Surgery, Accreditation of Graduate Medical Education, American College of Surgeons and Agency for Healthcare Research and Quality, provided three significant insights into resident wellness, Dr. Hewitt said. “When measuring the level of burnout, careful consideration should be given to how burnout is defined,” he said. “Secondly, wellness interventions with attention to preparedness for residency and duty-hour restrictions may help alleviate burnout. And finally, with the significant impact it does have on the individual physician, we believe that burnout needs to be addressed regardless of its impact on patient outcomes.”
The study drew on a questionnaire given to residents immediately following the 2017 American Board of Surgery In-Training Examination (ABSITE), which 3,789 general surgery residents from 115 general surgery programs completed. The survey had a 99.3% response rate. The survey evaluated two factors associated with resident wellness: burnout and poor psychiatric well-being. “Poor wellness is prevalent among physicians and trainees and is associated with depression, suicidal ideation, attrition, and absenteeism,” Dr. Hewitt said.
But to measure burnout, the researchers had to first define it. The instrument Dr. Hewitt and coauthors used is the Maslach Burnout Inventory, named for University of California at Berkley psychology professor Christina Maslach, PhD. It quantifies three different factors for burnout: emotional exhaustion; depersonalization or cynicism; and a low sense of personal accomplishment. This study defined “burnout” as having feelings of both emotional exhaustion and depersonalization, and dismissed the third measure of burnout because physicians rarely posses a low sense of personal accomplishment.
Overall, 22.3% reported one sign or symptom of burnout daily, and 56.5% did so on a weekly basis, Dr. Hewitt said.
However, Dr. Hewitt noted, burnout measurement thresholds can vary “because burnout itself is not an actual diagnosis.” Studies have calculated the burnout rate among surgeons at 28% to 69% (J Am Coll Surg. 2016:222:1230-9). A recent systematic review found up to eight different cutoffs used to define “high burnout” (Cogent Med. 2016 7 Oct; doi.org/10.1080/2331205X.2016.1237605; J Am Coll Surg, 2016:223:440-51)
How studies of physician burnout establish cutoffs and which Maslach Burnout Inventory subscales they measure has an impact on the rates of burnout they report, Dr. Hewitt said. For this study, the researchers used the Maslach scores in the top quartile in both emotional exhaustion and depersonalization to define burnout. “Burnout is probably best defined as a continuum from engagement on the one end and burnout on the other, so there’s some combination of the [Maslach] subscales that lead to burnout,” he said.
Among survey respondents, 19.5% reported high Maslach scores for emotional exhaustion and 9% of depersonalization on a daily basis (6.2% reported both)--22.3% reported at least one daily. On a weekly basis, 54.2% reported high scores for emotional exhaustion and 25.6% high scores for depersonalization, with 56.5% reporting at least one and 22.4% reporting both.
To evaluate residents’ sense of psychiatric well-being, the study used the General Health Questionnaire (Psychol Med. 1998;28:915-21). Among survey respondents, 43% met criteria for poor psychiatric well-being.
Burnout rates among men and women were identical, but a significantly higher percentage of women had poor psychiatric well-being: 48.4% to 39.7% of men.
Burnout and psychiatric well-being scores also varied depending on post-graduate year. Second- and third-year residents were significantly more likely to report burnout, compared to first-year residents, Dr. Hewitt said. Rates of poor psychiatric well-being were lowest for fourth- and fifth-year residents.
Most pronounced was the impact of 80-hour duty week violations had on residents’ sense of burnout and poor psychiatric well-being. Burnout rates were 8.4% for those who reported no monthly duty-hour violations, but doubled and quadrupled with more frequent monthly duty-hour violations: 16.1% for those who reported one to four violations a month; and 35% for those who reported five or more. Dr. Hewitt also noted wellness rates for those in the standard and flexible policy groups in Flexibility In duty hour Requirements for Surgical Trainees Trial (FIRST Trial) programs were similar.
Another factor that contributed to burnout and poor psychiatric well-being was a sense of unpreparedness for residency, Dr. Hewitt said. Burnout rates for those who felt prepared were 8.9% vs. 19.1% for those who didn’t feel prepared. The disparity was less drastic, but nonetheless significant, for poor psychiatric well-being: 37.5% for those who felt prepared and 52.1% for those who didn’t.
With regard to outcomes, Dr. Hewitt said, “Residents in the highest quartile of burnout and the highest quartile of poor psychiatric well-being were significantly more likely to report a near miss or harmful medical error.” Among the burnout group, highest quartile rates were 39.3% for a near miss and 14.4% for a harmful medical error vs. 11.1% and 2.4%, respectively, for the lowest quartile. Among surgical residents who reported poor psychiatric well-being, highest quartile rates were 31.9% for a near miss and 13.2% for a harmful medical error vs. 12.5% and 2.1%, respectively, for those in the lowest quartile.
The study also analyzed outcomes for 134,877 surgical patients and found no association of overall morbidity and death or serious morbidity with resident wellness. “However,” Dr. Hewitt said, “when we look at mortality and failure to rescue, we can see an association with burnout, specifically in programs that have high levels of burnout; these patients have significantly lower odds of mortality and failure to rescue.” Each has an adjusted odds ratios of 0.81.
Among the study limitations Dr. Hewitt noted were its cross-sectional nature that led to inferences of association, not identification of causation; residents completing the survey after the ABSITE may have influenced their answers; and the fact it did not account for certain intermediate factors such as physician or nursing burnout or institutional quality measures.
The American Board of Surgery, Accreditation of Graduate Medical Education, American College of Surgeons and Agency for Healthcare Research and Quality provided grants to support the research.
SOURCE: Hewitt B et al. abstract 21.01
JACKSONVILLE, FLA. – Burnout is commonly ascribed to surgical residents, but reliable estimates of the numbers involved and a clear, comparable definition of burnout remain elusive.
A large study of general surgery residents has found that almost one in four have at least one symptom of burnout daily and more than two in five report poor psychiatric well-being, according to results of a survey reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Twenty-two percent of general surgery residents report at least one symptom of burnout daily,” said Daniel “Brock” Hewitt, MD, a research fellow in the Surgical Outcomes and Quality Improvement Center in the department of surgery, Feinberg School of Medicine, Northwestern University, Chicago. “Poor resident wellness is associated with more duty-hour violations, feeling unprepared for residency, and an increase in self-reported medical errors. However, burnout is not associated with worse surgical outcomes.”
The study, undertaken with grant support from The American Board of Surgery, Accreditation of Graduate Medical Education, American College of Surgeons and Agency for Healthcare Research and Quality, provided three significant insights into resident wellness, Dr. Hewitt said. “When measuring the level of burnout, careful consideration should be given to how burnout is defined,” he said. “Secondly, wellness interventions with attention to preparedness for residency and duty-hour restrictions may help alleviate burnout. And finally, with the significant impact it does have on the individual physician, we believe that burnout needs to be addressed regardless of its impact on patient outcomes.”
The study drew on a questionnaire given to residents immediately following the 2017 American Board of Surgery In-Training Examination (ABSITE), which 3,789 general surgery residents from 115 general surgery programs completed. The survey had a 99.3% response rate. The survey evaluated two factors associated with resident wellness: burnout and poor psychiatric well-being. “Poor wellness is prevalent among physicians and trainees and is associated with depression, suicidal ideation, attrition, and absenteeism,” Dr. Hewitt said.
But to measure burnout, the researchers had to first define it. The instrument Dr. Hewitt and coauthors used is the Maslach Burnout Inventory, named for University of California at Berkley psychology professor Christina Maslach, PhD. It quantifies three different factors for burnout: emotional exhaustion; depersonalization or cynicism; and a low sense of personal accomplishment. This study defined “burnout” as having feelings of both emotional exhaustion and depersonalization, and dismissed the third measure of burnout because physicians rarely posses a low sense of personal accomplishment.
Overall, 22.3% reported one sign or symptom of burnout daily, and 56.5% did so on a weekly basis, Dr. Hewitt said.
However, Dr. Hewitt noted, burnout measurement thresholds can vary “because burnout itself is not an actual diagnosis.” Studies have calculated the burnout rate among surgeons at 28% to 69% (J Am Coll Surg. 2016:222:1230-9). A recent systematic review found up to eight different cutoffs used to define “high burnout” (Cogent Med. 2016 7 Oct; doi.org/10.1080/2331205X.2016.1237605; J Am Coll Surg, 2016:223:440-51)
How studies of physician burnout establish cutoffs and which Maslach Burnout Inventory subscales they measure has an impact on the rates of burnout they report, Dr. Hewitt said. For this study, the researchers used the Maslach scores in the top quartile in both emotional exhaustion and depersonalization to define burnout. “Burnout is probably best defined as a continuum from engagement on the one end and burnout on the other, so there’s some combination of the [Maslach] subscales that lead to burnout,” he said.
Among survey respondents, 19.5% reported high Maslach scores for emotional exhaustion and 9% of depersonalization on a daily basis (6.2% reported both)--22.3% reported at least one daily. On a weekly basis, 54.2% reported high scores for emotional exhaustion and 25.6% high scores for depersonalization, with 56.5% reporting at least one and 22.4% reporting both.
To evaluate residents’ sense of psychiatric well-being, the study used the General Health Questionnaire (Psychol Med. 1998;28:915-21). Among survey respondents, 43% met criteria for poor psychiatric well-being.
Burnout rates among men and women were identical, but a significantly higher percentage of women had poor psychiatric well-being: 48.4% to 39.7% of men.
Burnout and psychiatric well-being scores also varied depending on post-graduate year. Second- and third-year residents were significantly more likely to report burnout, compared to first-year residents, Dr. Hewitt said. Rates of poor psychiatric well-being were lowest for fourth- and fifth-year residents.
Most pronounced was the impact of 80-hour duty week violations had on residents’ sense of burnout and poor psychiatric well-being. Burnout rates were 8.4% for those who reported no monthly duty-hour violations, but doubled and quadrupled with more frequent monthly duty-hour violations: 16.1% for those who reported one to four violations a month; and 35% for those who reported five or more. Dr. Hewitt also noted wellness rates for those in the standard and flexible policy groups in Flexibility In duty hour Requirements for Surgical Trainees Trial (FIRST Trial) programs were similar.
Another factor that contributed to burnout and poor psychiatric well-being was a sense of unpreparedness for residency, Dr. Hewitt said. Burnout rates for those who felt prepared were 8.9% vs. 19.1% for those who didn’t feel prepared. The disparity was less drastic, but nonetheless significant, for poor psychiatric well-being: 37.5% for those who felt prepared and 52.1% for those who didn’t.
With regard to outcomes, Dr. Hewitt said, “Residents in the highest quartile of burnout and the highest quartile of poor psychiatric well-being were significantly more likely to report a near miss or harmful medical error.” Among the burnout group, highest quartile rates were 39.3% for a near miss and 14.4% for a harmful medical error vs. 11.1% and 2.4%, respectively, for the lowest quartile. Among surgical residents who reported poor psychiatric well-being, highest quartile rates were 31.9% for a near miss and 13.2% for a harmful medical error vs. 12.5% and 2.1%, respectively, for those in the lowest quartile.
The study also analyzed outcomes for 134,877 surgical patients and found no association of overall morbidity and death or serious morbidity with resident wellness. “However,” Dr. Hewitt said, “when we look at mortality and failure to rescue, we can see an association with burnout, specifically in programs that have high levels of burnout; these patients have significantly lower odds of mortality and failure to rescue.” Each has an adjusted odds ratios of 0.81.
Among the study limitations Dr. Hewitt noted were its cross-sectional nature that led to inferences of association, not identification of causation; residents completing the survey after the ABSITE may have influenced their answers; and the fact it did not account for certain intermediate factors such as physician or nursing burnout or institutional quality measures.
The American Board of Surgery, Accreditation of Graduate Medical Education, American College of Surgeons and Agency for Healthcare Research and Quality provided grants to support the research.
SOURCE: Hewitt B et al. abstract 21.01
JACKSONVILLE, FLA. – Burnout is commonly ascribed to surgical residents, but reliable estimates of the numbers involved and a clear, comparable definition of burnout remain elusive.
A large study of general surgery residents has found that almost one in four have at least one symptom of burnout daily and more than two in five report poor psychiatric well-being, according to results of a survey reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Twenty-two percent of general surgery residents report at least one symptom of burnout daily,” said Daniel “Brock” Hewitt, MD, a research fellow in the Surgical Outcomes and Quality Improvement Center in the department of surgery, Feinberg School of Medicine, Northwestern University, Chicago. “Poor resident wellness is associated with more duty-hour violations, feeling unprepared for residency, and an increase in self-reported medical errors. However, burnout is not associated with worse surgical outcomes.”
The study, undertaken with grant support from The American Board of Surgery, Accreditation of Graduate Medical Education, American College of Surgeons and Agency for Healthcare Research and Quality, provided three significant insights into resident wellness, Dr. Hewitt said. “When measuring the level of burnout, careful consideration should be given to how burnout is defined,” he said. “Secondly, wellness interventions with attention to preparedness for residency and duty-hour restrictions may help alleviate burnout. And finally, with the significant impact it does have on the individual physician, we believe that burnout needs to be addressed regardless of its impact on patient outcomes.”
The study drew on a questionnaire given to residents immediately following the 2017 American Board of Surgery In-Training Examination (ABSITE), which 3,789 general surgery residents from 115 general surgery programs completed. The survey had a 99.3% response rate. The survey evaluated two factors associated with resident wellness: burnout and poor psychiatric well-being. “Poor wellness is prevalent among physicians and trainees and is associated with depression, suicidal ideation, attrition, and absenteeism,” Dr. Hewitt said.
But to measure burnout, the researchers had to first define it. The instrument Dr. Hewitt and coauthors used is the Maslach Burnout Inventory, named for University of California at Berkley psychology professor Christina Maslach, PhD. It quantifies three different factors for burnout: emotional exhaustion; depersonalization or cynicism; and a low sense of personal accomplishment. This study defined “burnout” as having feelings of both emotional exhaustion and depersonalization, and dismissed the third measure of burnout because physicians rarely posses a low sense of personal accomplishment.
Overall, 22.3% reported one sign or symptom of burnout daily, and 56.5% did so on a weekly basis, Dr. Hewitt said.
However, Dr. Hewitt noted, burnout measurement thresholds can vary “because burnout itself is not an actual diagnosis.” Studies have calculated the burnout rate among surgeons at 28% to 69% (J Am Coll Surg. 2016:222:1230-9). A recent systematic review found up to eight different cutoffs used to define “high burnout” (Cogent Med. 2016 7 Oct; doi.org/10.1080/2331205X.2016.1237605; J Am Coll Surg, 2016:223:440-51)
How studies of physician burnout establish cutoffs and which Maslach Burnout Inventory subscales they measure has an impact on the rates of burnout they report, Dr. Hewitt said. For this study, the researchers used the Maslach scores in the top quartile in both emotional exhaustion and depersonalization to define burnout. “Burnout is probably best defined as a continuum from engagement on the one end and burnout on the other, so there’s some combination of the [Maslach] subscales that lead to burnout,” he said.
Among survey respondents, 19.5% reported high Maslach scores for emotional exhaustion and 9% of depersonalization on a daily basis (6.2% reported both)--22.3% reported at least one daily. On a weekly basis, 54.2% reported high scores for emotional exhaustion and 25.6% high scores for depersonalization, with 56.5% reporting at least one and 22.4% reporting both.
To evaluate residents’ sense of psychiatric well-being, the study used the General Health Questionnaire (Psychol Med. 1998;28:915-21). Among survey respondents, 43% met criteria for poor psychiatric well-being.
Burnout rates among men and women were identical, but a significantly higher percentage of women had poor psychiatric well-being: 48.4% to 39.7% of men.
Burnout and psychiatric well-being scores also varied depending on post-graduate year. Second- and third-year residents were significantly more likely to report burnout, compared to first-year residents, Dr. Hewitt said. Rates of poor psychiatric well-being were lowest for fourth- and fifth-year residents.
Most pronounced was the impact of 80-hour duty week violations had on residents’ sense of burnout and poor psychiatric well-being. Burnout rates were 8.4% for those who reported no monthly duty-hour violations, but doubled and quadrupled with more frequent monthly duty-hour violations: 16.1% for those who reported one to four violations a month; and 35% for those who reported five or more. Dr. Hewitt also noted wellness rates for those in the standard and flexible policy groups in Flexibility In duty hour Requirements for Surgical Trainees Trial (FIRST Trial) programs were similar.
Another factor that contributed to burnout and poor psychiatric well-being was a sense of unpreparedness for residency, Dr. Hewitt said. Burnout rates for those who felt prepared were 8.9% vs. 19.1% for those who didn’t feel prepared. The disparity was less drastic, but nonetheless significant, for poor psychiatric well-being: 37.5% for those who felt prepared and 52.1% for those who didn’t.
With regard to outcomes, Dr. Hewitt said, “Residents in the highest quartile of burnout and the highest quartile of poor psychiatric well-being were significantly more likely to report a near miss or harmful medical error.” Among the burnout group, highest quartile rates were 39.3% for a near miss and 14.4% for a harmful medical error vs. 11.1% and 2.4%, respectively, for the lowest quartile. Among surgical residents who reported poor psychiatric well-being, highest quartile rates were 31.9% for a near miss and 13.2% for a harmful medical error vs. 12.5% and 2.1%, respectively, for those in the lowest quartile.
The study also analyzed outcomes for 134,877 surgical patients and found no association of overall morbidity and death or serious morbidity with resident wellness. “However,” Dr. Hewitt said, “when we look at mortality and failure to rescue, we can see an association with burnout, specifically in programs that have high levels of burnout; these patients have significantly lower odds of mortality and failure to rescue.” Each has an adjusted odds ratios of 0.81.
Among the study limitations Dr. Hewitt noted were its cross-sectional nature that led to inferences of association, not identification of causation; residents completing the survey after the ABSITE may have influenced their answers; and the fact it did not account for certain intermediate factors such as physician or nursing burnout or institutional quality measures.
The American Board of Surgery, Accreditation of Graduate Medical Education, American College of Surgeons and Agency for Healthcare Research and Quality provided grants to support the research.
SOURCE: Hewitt B et al. abstract 21.01
AT THE ANNUAL ACADEMIC SURGICAL CONGRESS
Key clinical point: Almost one in four surgical residents manifest a daily symptom of burnout.
Major finding: Overall 22.8% of daily and 44.3% had poor psychiatric well-being scores.
Study details: Surveys completed by 3,789 general surgery residents during the American Board of Surgery In-Training Examination in January 2017.
Disclosures: The American Board of Surgery, Accreditation of Graduate Medical Education, American College of Surgeons and Agency for Healthcare Research and Quality provided grants to support the research.
Source: Hewitt B et al. abstract 21.01
Study pinpoints link between ERAS and acute kidney injury
JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.
The rate of acute kidney injury (AKI) before ERAS was 7.1% ,compared with 13.6% after ERAS (P less than .01). After researchers adjusted for significant covariates, “ERAS patients were 2.3 times more likely to develop postoperative acute kidney injury,” Mr. Wiener said (P less than .01). That led the researchers to conclude that the ERAS protocol was independently associated with AKI following colorectal surgery. Average hospital stays for the ERAS group were less than half of those for the non-ERAS group, Wiener said: 3 days for the former vs. 7 days for the latter (P less than .01).
He noted that when UAB implemented ERAS for colorectal surgery, it also adopted the PDSA – Plan, Do, Study, Act – a cyclical quality improvement tool. “So we had done the study,” he said. “How do we act?”
Further investigation revealed the surgeons were using a stacked dosing of ketorolac with one dose at the end of the case and the next dose with initiation of the postoperative order set. “We eliminated the last intraoperative ketorolac dose to avoid the stacked dosing,” Wiener said. “Furthermore, we educated our residents to use ERAS as a guideline, but to always remember to treat the patient individually first.”
After that change, the subsequent semiannual ACS NSQIP report showed that UAB’s outcomes had improved. “We were able to go from the 10th decile for kidney failure after colorectal surgery to the first decile,” Wiener said.
“Moving forward, we will continue to monitor protocol outcomes in our ERAS patients and customize a pathway based on individual preoperative risk,” he said. That includes identifying optimal perioperative IV fluid management and refining multimodal pain management.
Mr. Wiener and coauthors had no financial relationships to disclose.
SOURCE: Wiener JG et al. Abstract 76.03
JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.
The rate of acute kidney injury (AKI) before ERAS was 7.1% ,compared with 13.6% after ERAS (P less than .01). After researchers adjusted for significant covariates, “ERAS patients were 2.3 times more likely to develop postoperative acute kidney injury,” Mr. Wiener said (P less than .01). That led the researchers to conclude that the ERAS protocol was independently associated with AKI following colorectal surgery. Average hospital stays for the ERAS group were less than half of those for the non-ERAS group, Wiener said: 3 days for the former vs. 7 days for the latter (P less than .01).
He noted that when UAB implemented ERAS for colorectal surgery, it also adopted the PDSA – Plan, Do, Study, Act – a cyclical quality improvement tool. “So we had done the study,” he said. “How do we act?”
Further investigation revealed the surgeons were using a stacked dosing of ketorolac with one dose at the end of the case and the next dose with initiation of the postoperative order set. “We eliminated the last intraoperative ketorolac dose to avoid the stacked dosing,” Wiener said. “Furthermore, we educated our residents to use ERAS as a guideline, but to always remember to treat the patient individually first.”
After that change, the subsequent semiannual ACS NSQIP report showed that UAB’s outcomes had improved. “We were able to go from the 10th decile for kidney failure after colorectal surgery to the first decile,” Wiener said.
“Moving forward, we will continue to monitor protocol outcomes in our ERAS patients and customize a pathway based on individual preoperative risk,” he said. That includes identifying optimal perioperative IV fluid management and refining multimodal pain management.
Mr. Wiener and coauthors had no financial relationships to disclose.
SOURCE: Wiener JG et al. Abstract 76.03
JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.
The rate of acute kidney injury (AKI) before ERAS was 7.1% ,compared with 13.6% after ERAS (P less than .01). After researchers adjusted for significant covariates, “ERAS patients were 2.3 times more likely to develop postoperative acute kidney injury,” Mr. Wiener said (P less than .01). That led the researchers to conclude that the ERAS protocol was independently associated with AKI following colorectal surgery. Average hospital stays for the ERAS group were less than half of those for the non-ERAS group, Wiener said: 3 days for the former vs. 7 days for the latter (P less than .01).
He noted that when UAB implemented ERAS for colorectal surgery, it also adopted the PDSA – Plan, Do, Study, Act – a cyclical quality improvement tool. “So we had done the study,” he said. “How do we act?”
Further investigation revealed the surgeons were using a stacked dosing of ketorolac with one dose at the end of the case and the next dose with initiation of the postoperative order set. “We eliminated the last intraoperative ketorolac dose to avoid the stacked dosing,” Wiener said. “Furthermore, we educated our residents to use ERAS as a guideline, but to always remember to treat the patient individually first.”
After that change, the subsequent semiannual ACS NSQIP report showed that UAB’s outcomes had improved. “We were able to go from the 10th decile for kidney failure after colorectal surgery to the first decile,” Wiener said.
“Moving forward, we will continue to monitor protocol outcomes in our ERAS patients and customize a pathway based on individual preoperative risk,” he said. That includes identifying optimal perioperative IV fluid management and refining multimodal pain management.
Mr. Wiener and coauthors had no financial relationships to disclose.
SOURCE: Wiener JG et al. Abstract 76.03
REPORTING FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Implementation of the ERAS protocol for colorectal surgery was independently associated with acute kidney injury.
Major finding: After elective colorectal surgery, 13.6% of those in the ERAS protocol had acute kidney failure vs. 7.1 % of those who had surgery preprotocol (P less than .01).
Study details: Single-institution retrospective study of a prospectively maintained database containing 480 patients in the pre-ERAS group and 572 in the ERAS group.
Disclosures: The investigators reported having no financial disclosures.
Source: Wiener JG et al. Abstract 76.03.
Morbid, super obesity raises laparoscopic VHR risk
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
REPORTING FROM THE ANNUAL ACADEMIC SURGICAL CONGRESS
Key clinical point: Laparoscopic ventral hernia repair is associated with a significantly increased risk of complications in the morbidly and super obese.
Major finding: Individuals with a body mass index in the overweight range (BMI 25 to 29.99 kg/m2) had a complication rate of 3% vs. 6.9% for those with BMI greater than or equal to 50 kg/m2.
Story details: A retrospective analysis of 57,957 patients in the NSQIP database who had laparoscopic ventral hernia repair between 2005 and 2015.
Disclosures: Dr. Swendiman and coauthors reported having no financial disclosures.
Source: Academic Surgical Congress. Abstract 50.02.