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Acute cholecystitis: Not always routine
The more we think we know, the less we actually may know. As new techniques develop and their use is closely examined and reported, details about the patient’s disease and the surgeon’s skill and judgment turn out to matter more and more in the decision-making process. So it is with acute cholecystitis.
I have recently been puzzled and intrigued by changing trends in the management of acute cholecystitis that are apparent in the medical literature, discussions in the ACS Communities, and practice in my local community.
When I was a resident, the debate about early cholecystectomy vs antibiotics with interval operation 6 weeks later was just being settled in the literature in favor of early cholecystectomy. The weight of evidence in the surgical literature found that delay made the eventual operation more difficult and costly.
In the following 2 decades, early cholecystectomy became the indicated treatment for acute cholecystitis. In that era, of course, these operations were open, as that was our only option and one which we all learned to perform with confidence during residency. Tube cholecystostomy was a rarity reserved only for the most severely ill and feeble, and done by surgeons, since interventional radiologists had not yet appeared on the scene.
In the rare instance of acute cholecystitis so severe, and anatomic landmarks so obscured, that the gallbladder could not be safely dissected away from the common bile duct, a remnant of the gallbladder might be left behind, the mucosa cauterized, and the right upper quadrant drained.
Fast forward 40 years, and we find a distinctly different landscape. As the Boomer generation reaches geriatric age in expanding numbers, surgeons encounter an increasingly older patient population, often with numerous comorbidities and high surgical risk. Our increased critical care capability to rescue patients from sepsis and organ failure also introduces new challenges in decision-making about whether immediate cholecystectomy or a temporizing option is better for the elderly septic ICU patient before us.
At the same time, our overwhelmingly most common elective biliary procedure has become a laparoscopic cholecystectomy (LC), with which our younger surgeons have become comfortable and facile. Multiple randomized studies also confirm the superiority of early LC for acute cholecystitis, although LC is associated with a higher rate of conversion to open cholecystectomy in acute cholecystitis than in the elective setting. Since it is acknowledged that the mortality and morbidity of an open cholecystectomy is greater than that of its laparoscopic counterpart, especially in the setting of severe inflammation, and the younger surgeons are less confident in performing open cholecystectomy, it is not surprising that they embrace a strategy that allows them to avoid surgical management of acute cholecystitis in the high-risk patient with severe disease.
The ready availability of interventional radiologists in the past 30 years also offers a less invasive option than surgery – the percutaneous tube cholecystostomy (PC). It is no wonder that PC has increasingly become the “go-to” early option when the patient is old and sick or the surgeon lacks confidence in his/her open surgical skills in a potentially hostile, inflamed right upper quadrant. If the increasing number of articles on PC appearing in the literature is any indication, its use has proliferated in the recent past. As yet, no randomized clinical trials or other high-quality evidence have emerged to support its increased use, but a consensus panel of experts has issued the Tokyo Guidelines, recommending PC as primary therapy for stage III acute cholecystitis, the form of disease associated with organ failure, but not citing evidence to support this recommendation (J Hepatobiliary Pancreat Surg. 2007;14[1]:91-7). Although the rate of PC use in Medicare patients with stage III acute cholecystitis has more than doubled in the past 20 years, Tokyo Guidelines have clearly not been uniformly adopted in the U.S., since PC use in patients with stage III acute cholecystitis is only 10% (J Am Coll Surg. 2017;224[4]: 502-14).
Whether the increase in PC use is appropriate or not remains undetermined. Other uncertainties about PC need clarification. When patients have a PC placed for acute cholecystitis, do they always need their gallbladders removed later? The rate of recurrent acute cholecystitis after PC is variable in the literature, although it appears to be more likely in patients with acute calculous than acalculous cholecystitis. The likelihood that the patient will later undergo a cholecystectomy varies from a low of 3% to a high of 57% in various studies.(Surgery. 2014;155[4]:615-22; J Am Coll Surg. 2012; 214[2]:196-201).
The exact rate may not even accurately be known, since some patients may be lost to follow-up or get subsequent care in another facility. The decision to perform cholecystectomy after PC involves assessment of patient risk for surgery and, ultimately, surgeon judgment. Other questions also remain unanswered: What is the role of surgeon experience in the decision to defer surgical therapy for acute cholecystitis? Is the surgeon even the one who is in charge of the decision in all cases, or is that decision being made by an internist, intensivist, or hospitalist, who may judge the patient’s risk differently than a surgeon would? Are we witnessing an evolution in management of severe cholecystitis in the high-risk, septic and elderly patient towards antibiotics and PC unless the patient fails that treatment? This strategy appears to be gaining in popularity, since several studies have shown that the minority of patients who have PC end up having their gallbladders removed. If symptoms recur and nonoperative treatment has clearly failed, should the decision be made to refer to a highly experienced surgeon (by virtue of laparoscopic skills or reputation as a hepatic-pancreatic biliary specialist)? Recent studies show that 46%-86% of elective interval cholecystectomies after successful PC can be performed laparoscopically with low complication rates, although those studies came from institutions with notable laparoscopic expertise (J Am Coll Surg. 2012;214[2]:196-201; J Gastrointest Surg. 2017; 21[5]:761-69).
One of my most revered senior surgical mentors recently opined that the safest strategy for the high-risk patient with severe acute cholecystitis was indeed PC and antibiotics followed by watchful waiting, and reserving cholecystectomy only for those who fail nonoperative therapy. I initially bristled at that concept as being antithetic to the surgical bias in favor of cholecystectomy as the answer to all gallbladder evils. But after reflecting further on the changing landscape of our therapeutic options and our changing surgical training, I’m thinking that his strategy may be reasonable.
After all, it’s about choosing the safest path for the patient. All cholecystectomies are not routine.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
The more we think we know, the less we actually may know. As new techniques develop and their use is closely examined and reported, details about the patient’s disease and the surgeon’s skill and judgment turn out to matter more and more in the decision-making process. So it is with acute cholecystitis.
I have recently been puzzled and intrigued by changing trends in the management of acute cholecystitis that are apparent in the medical literature, discussions in the ACS Communities, and practice in my local community.
When I was a resident, the debate about early cholecystectomy vs antibiotics with interval operation 6 weeks later was just being settled in the literature in favor of early cholecystectomy. The weight of evidence in the surgical literature found that delay made the eventual operation more difficult and costly.
In the following 2 decades, early cholecystectomy became the indicated treatment for acute cholecystitis. In that era, of course, these operations were open, as that was our only option and one which we all learned to perform with confidence during residency. Tube cholecystostomy was a rarity reserved only for the most severely ill and feeble, and done by surgeons, since interventional radiologists had not yet appeared on the scene.
In the rare instance of acute cholecystitis so severe, and anatomic landmarks so obscured, that the gallbladder could not be safely dissected away from the common bile duct, a remnant of the gallbladder might be left behind, the mucosa cauterized, and the right upper quadrant drained.
Fast forward 40 years, and we find a distinctly different landscape. As the Boomer generation reaches geriatric age in expanding numbers, surgeons encounter an increasingly older patient population, often with numerous comorbidities and high surgical risk. Our increased critical care capability to rescue patients from sepsis and organ failure also introduces new challenges in decision-making about whether immediate cholecystectomy or a temporizing option is better for the elderly septic ICU patient before us.
At the same time, our overwhelmingly most common elective biliary procedure has become a laparoscopic cholecystectomy (LC), with which our younger surgeons have become comfortable and facile. Multiple randomized studies also confirm the superiority of early LC for acute cholecystitis, although LC is associated with a higher rate of conversion to open cholecystectomy in acute cholecystitis than in the elective setting. Since it is acknowledged that the mortality and morbidity of an open cholecystectomy is greater than that of its laparoscopic counterpart, especially in the setting of severe inflammation, and the younger surgeons are less confident in performing open cholecystectomy, it is not surprising that they embrace a strategy that allows them to avoid surgical management of acute cholecystitis in the high-risk patient with severe disease.
The ready availability of interventional radiologists in the past 30 years also offers a less invasive option than surgery – the percutaneous tube cholecystostomy (PC). It is no wonder that PC has increasingly become the “go-to” early option when the patient is old and sick or the surgeon lacks confidence in his/her open surgical skills in a potentially hostile, inflamed right upper quadrant. If the increasing number of articles on PC appearing in the literature is any indication, its use has proliferated in the recent past. As yet, no randomized clinical trials or other high-quality evidence have emerged to support its increased use, but a consensus panel of experts has issued the Tokyo Guidelines, recommending PC as primary therapy for stage III acute cholecystitis, the form of disease associated with organ failure, but not citing evidence to support this recommendation (J Hepatobiliary Pancreat Surg. 2007;14[1]:91-7). Although the rate of PC use in Medicare patients with stage III acute cholecystitis has more than doubled in the past 20 years, Tokyo Guidelines have clearly not been uniformly adopted in the U.S., since PC use in patients with stage III acute cholecystitis is only 10% (J Am Coll Surg. 2017;224[4]: 502-14).
Whether the increase in PC use is appropriate or not remains undetermined. Other uncertainties about PC need clarification. When patients have a PC placed for acute cholecystitis, do they always need their gallbladders removed later? The rate of recurrent acute cholecystitis after PC is variable in the literature, although it appears to be more likely in patients with acute calculous than acalculous cholecystitis. The likelihood that the patient will later undergo a cholecystectomy varies from a low of 3% to a high of 57% in various studies.(Surgery. 2014;155[4]:615-22; J Am Coll Surg. 2012; 214[2]:196-201).
The exact rate may not even accurately be known, since some patients may be lost to follow-up or get subsequent care in another facility. The decision to perform cholecystectomy after PC involves assessment of patient risk for surgery and, ultimately, surgeon judgment. Other questions also remain unanswered: What is the role of surgeon experience in the decision to defer surgical therapy for acute cholecystitis? Is the surgeon even the one who is in charge of the decision in all cases, or is that decision being made by an internist, intensivist, or hospitalist, who may judge the patient’s risk differently than a surgeon would? Are we witnessing an evolution in management of severe cholecystitis in the high-risk, septic and elderly patient towards antibiotics and PC unless the patient fails that treatment? This strategy appears to be gaining in popularity, since several studies have shown that the minority of patients who have PC end up having their gallbladders removed. If symptoms recur and nonoperative treatment has clearly failed, should the decision be made to refer to a highly experienced surgeon (by virtue of laparoscopic skills or reputation as a hepatic-pancreatic biliary specialist)? Recent studies show that 46%-86% of elective interval cholecystectomies after successful PC can be performed laparoscopically with low complication rates, although those studies came from institutions with notable laparoscopic expertise (J Am Coll Surg. 2012;214[2]:196-201; J Gastrointest Surg. 2017; 21[5]:761-69).
One of my most revered senior surgical mentors recently opined that the safest strategy for the high-risk patient with severe acute cholecystitis was indeed PC and antibiotics followed by watchful waiting, and reserving cholecystectomy only for those who fail nonoperative therapy. I initially bristled at that concept as being antithetic to the surgical bias in favor of cholecystectomy as the answer to all gallbladder evils. But after reflecting further on the changing landscape of our therapeutic options and our changing surgical training, I’m thinking that his strategy may be reasonable.
After all, it’s about choosing the safest path for the patient. All cholecystectomies are not routine.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
The more we think we know, the less we actually may know. As new techniques develop and their use is closely examined and reported, details about the patient’s disease and the surgeon’s skill and judgment turn out to matter more and more in the decision-making process. So it is with acute cholecystitis.
I have recently been puzzled and intrigued by changing trends in the management of acute cholecystitis that are apparent in the medical literature, discussions in the ACS Communities, and practice in my local community.
When I was a resident, the debate about early cholecystectomy vs antibiotics with interval operation 6 weeks later was just being settled in the literature in favor of early cholecystectomy. The weight of evidence in the surgical literature found that delay made the eventual operation more difficult and costly.
In the following 2 decades, early cholecystectomy became the indicated treatment for acute cholecystitis. In that era, of course, these operations were open, as that was our only option and one which we all learned to perform with confidence during residency. Tube cholecystostomy was a rarity reserved only for the most severely ill and feeble, and done by surgeons, since interventional radiologists had not yet appeared on the scene.
In the rare instance of acute cholecystitis so severe, and anatomic landmarks so obscured, that the gallbladder could not be safely dissected away from the common bile duct, a remnant of the gallbladder might be left behind, the mucosa cauterized, and the right upper quadrant drained.
Fast forward 40 years, and we find a distinctly different landscape. As the Boomer generation reaches geriatric age in expanding numbers, surgeons encounter an increasingly older patient population, often with numerous comorbidities and high surgical risk. Our increased critical care capability to rescue patients from sepsis and organ failure also introduces new challenges in decision-making about whether immediate cholecystectomy or a temporizing option is better for the elderly septic ICU patient before us.
At the same time, our overwhelmingly most common elective biliary procedure has become a laparoscopic cholecystectomy (LC), with which our younger surgeons have become comfortable and facile. Multiple randomized studies also confirm the superiority of early LC for acute cholecystitis, although LC is associated with a higher rate of conversion to open cholecystectomy in acute cholecystitis than in the elective setting. Since it is acknowledged that the mortality and morbidity of an open cholecystectomy is greater than that of its laparoscopic counterpart, especially in the setting of severe inflammation, and the younger surgeons are less confident in performing open cholecystectomy, it is not surprising that they embrace a strategy that allows them to avoid surgical management of acute cholecystitis in the high-risk patient with severe disease.
The ready availability of interventional radiologists in the past 30 years also offers a less invasive option than surgery – the percutaneous tube cholecystostomy (PC). It is no wonder that PC has increasingly become the “go-to” early option when the patient is old and sick or the surgeon lacks confidence in his/her open surgical skills in a potentially hostile, inflamed right upper quadrant. If the increasing number of articles on PC appearing in the literature is any indication, its use has proliferated in the recent past. As yet, no randomized clinical trials or other high-quality evidence have emerged to support its increased use, but a consensus panel of experts has issued the Tokyo Guidelines, recommending PC as primary therapy for stage III acute cholecystitis, the form of disease associated with organ failure, but not citing evidence to support this recommendation (J Hepatobiliary Pancreat Surg. 2007;14[1]:91-7). Although the rate of PC use in Medicare patients with stage III acute cholecystitis has more than doubled in the past 20 years, Tokyo Guidelines have clearly not been uniformly adopted in the U.S., since PC use in patients with stage III acute cholecystitis is only 10% (J Am Coll Surg. 2017;224[4]: 502-14).
Whether the increase in PC use is appropriate or not remains undetermined. Other uncertainties about PC need clarification. When patients have a PC placed for acute cholecystitis, do they always need their gallbladders removed later? The rate of recurrent acute cholecystitis after PC is variable in the literature, although it appears to be more likely in patients with acute calculous than acalculous cholecystitis. The likelihood that the patient will later undergo a cholecystectomy varies from a low of 3% to a high of 57% in various studies.(Surgery. 2014;155[4]:615-22; J Am Coll Surg. 2012; 214[2]:196-201).
The exact rate may not even accurately be known, since some patients may be lost to follow-up or get subsequent care in another facility. The decision to perform cholecystectomy after PC involves assessment of patient risk for surgery and, ultimately, surgeon judgment. Other questions also remain unanswered: What is the role of surgeon experience in the decision to defer surgical therapy for acute cholecystitis? Is the surgeon even the one who is in charge of the decision in all cases, or is that decision being made by an internist, intensivist, or hospitalist, who may judge the patient’s risk differently than a surgeon would? Are we witnessing an evolution in management of severe cholecystitis in the high-risk, septic and elderly patient towards antibiotics and PC unless the patient fails that treatment? This strategy appears to be gaining in popularity, since several studies have shown that the minority of patients who have PC end up having their gallbladders removed. If symptoms recur and nonoperative treatment has clearly failed, should the decision be made to refer to a highly experienced surgeon (by virtue of laparoscopic skills or reputation as a hepatic-pancreatic biliary specialist)? Recent studies show that 46%-86% of elective interval cholecystectomies after successful PC can be performed laparoscopically with low complication rates, although those studies came from institutions with notable laparoscopic expertise (J Am Coll Surg. 2012;214[2]:196-201; J Gastrointest Surg. 2017; 21[5]:761-69).
One of my most revered senior surgical mentors recently opined that the safest strategy for the high-risk patient with severe acute cholecystitis was indeed PC and antibiotics followed by watchful waiting, and reserving cholecystectomy only for those who fail nonoperative therapy. I initially bristled at that concept as being antithetic to the surgical bias in favor of cholecystectomy as the answer to all gallbladder evils. But after reflecting further on the changing landscape of our therapeutic options and our changing surgical training, I’m thinking that his strategy may be reasonable.
After all, it’s about choosing the safest path for the patient. All cholecystectomies are not routine.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
An Act of Service, an Act of Love
Since its foundation in 1913 as the premier surgical professional organization in the United States, and one of the most influential in the world, the American College of Surgeons has shaped the policies and molded the education of numerous generations of surgeons. All young surgeons should aspire to be invested as Fellows some day as the highest honor in their career.
Service is an important factor in the decision to become a surgeon. As a Fellow of the ACS, the young surgeon will find many opportunities for service. Active participation as a Fellow is an act of service and can be an act of love for our patients, our colleagues, and our profession. And, with it, comes loyalty, a spirit of dedication, and a sense of unity. In addition, by joining the College we contribute to influencing our society in a positive way to protect our patients and our profession.
Becoming an active participant in the College means serving on committees, attending the Clinical Congress as frequently as feasible, and encouraging colleagues to aspire to become a Fellow.
In the end, being a part of our College and contributing to its growth and legacy is an act of service and, for many, an act of love.
Dr. Oviedo is with Capital Regional Surgical Associates, Tallahassee, Fla., and is Assistant Professor of Surgery, Florida State University College of Medicine. He serves as the ACS Young Fellow Association Liaison.
Since its foundation in 1913 as the premier surgical professional organization in the United States, and one of the most influential in the world, the American College of Surgeons has shaped the policies and molded the education of numerous generations of surgeons. All young surgeons should aspire to be invested as Fellows some day as the highest honor in their career.
Service is an important factor in the decision to become a surgeon. As a Fellow of the ACS, the young surgeon will find many opportunities for service. Active participation as a Fellow is an act of service and can be an act of love for our patients, our colleagues, and our profession. And, with it, comes loyalty, a spirit of dedication, and a sense of unity. In addition, by joining the College we contribute to influencing our society in a positive way to protect our patients and our profession.
Becoming an active participant in the College means serving on committees, attending the Clinical Congress as frequently as feasible, and encouraging colleagues to aspire to become a Fellow.
In the end, being a part of our College and contributing to its growth and legacy is an act of service and, for many, an act of love.
Dr. Oviedo is with Capital Regional Surgical Associates, Tallahassee, Fla., and is Assistant Professor of Surgery, Florida State University College of Medicine. He serves as the ACS Young Fellow Association Liaison.
Since its foundation in 1913 as the premier surgical professional organization in the United States, and one of the most influential in the world, the American College of Surgeons has shaped the policies and molded the education of numerous generations of surgeons. All young surgeons should aspire to be invested as Fellows some day as the highest honor in their career.
Service is an important factor in the decision to become a surgeon. As a Fellow of the ACS, the young surgeon will find many opportunities for service. Active participation as a Fellow is an act of service and can be an act of love for our patients, our colleagues, and our profession. And, with it, comes loyalty, a spirit of dedication, and a sense of unity. In addition, by joining the College we contribute to influencing our society in a positive way to protect our patients and our profession.
Becoming an active participant in the College means serving on committees, attending the Clinical Congress as frequently as feasible, and encouraging colleagues to aspire to become a Fellow.
In the end, being a part of our College and contributing to its growth and legacy is an act of service and, for many, an act of love.
Dr. Oviedo is with Capital Regional Surgical Associates, Tallahassee, Fla., and is Assistant Professor of Surgery, Florida State University College of Medicine. He serves as the ACS Young Fellow Association Liaison.
New ACS Resources in Surgical Education Online Now
The American College of Surgeons (ACS) Division of Education’s new Resources in Surgical Education (RISE) recently debuted on the ACS website. RISE is headed by Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education. The RISE web page is available at www.facs.org/education/division-of-education/publications/rise/current.
The inaugural article, “Create a Surgical Faculty Compensation Plan that Supports the Educational Mission,” by David A. Rogers, MD, MHPE, FACS, FAAP, is now available at www.facs.org/education/division-of-education/publications/rise/current. Future articles will be posted every six to eight weeks.
For additional information, contact Krashina Hudson at [email protected] or at 312-202-5335.
The American College of Surgeons (ACS) Division of Education’s new Resources in Surgical Education (RISE) recently debuted on the ACS website. RISE is headed by Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education. The RISE web page is available at www.facs.org/education/division-of-education/publications/rise/current.
The inaugural article, “Create a Surgical Faculty Compensation Plan that Supports the Educational Mission,” by David A. Rogers, MD, MHPE, FACS, FAAP, is now available at www.facs.org/education/division-of-education/publications/rise/current. Future articles will be posted every six to eight weeks.
For additional information, contact Krashina Hudson at [email protected] or at 312-202-5335.
The American College of Surgeons (ACS) Division of Education’s new Resources in Surgical Education (RISE) recently debuted on the ACS website. RISE is headed by Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education. The RISE web page is available at www.facs.org/education/division-of-education/publications/rise/current.
The inaugural article, “Create a Surgical Faculty Compensation Plan that Supports the Educational Mission,” by David A. Rogers, MD, MHPE, FACS, FAAP, is now available at www.facs.org/education/division-of-education/publications/rise/current. Future articles will be posted every six to eight weeks.
For additional information, contact Krashina Hudson at [email protected] or at 312-202-5335.
Surgeons learn about leading, influencing policy at 2017 ACS Leadership & Advocacy Summit
The 2017 American College of Surgeons (ACS) Leadership & Advocacy Summit, May 6–9 in Washington, DC, was a well-attended conference that brought together surgeons from across the U.S. to enhance their leadership skills and to learn about how they can advocate for the advancement of issues important to the field of surgery.
Leadership Summit
More than 450 surgeons and residents participated in the ACS Leadership Summit held May 6–7. The Leadership portion of the Leadership & Advocacy Summit included a series of presentations that provided practical, take-home tips on how to be a better leader. Presentations covered such diverse leadership topics as how to handle difficult conversations, manage difficult people, and lead from behind; how it’s not all about you, and leading by example; volunteering in your own backyard; avoiding burnout and promoting resilience; preparing for leadership positions in medicine; and successfully addressing critical situations in the operating room. PowerPoint presentations shown at the 2017 Leadership Summit are available at facs.org/advocacy/participate/summit/2017-presentations.
In addition, ACS chapter leaders shared success stories. Representatives of the Connecticut Chapter focused on resident engagement, representatives of the North Texas Chapter and South Texas Chapter explained the positive results that can be realized by holding joint chapter meetings, and members of the Georgia Society of the ACS discussed their Stop the Bleed® effort. Participants then convened in state breakout sessions during the lunch hour to identify new strategies and initiatives for implementation at the chapter level. ACS Executive Director David B. Hoyt, MD, FACS, provided an update on ACS activities.
Advocacy Summit
More than 300 surgeons and residents participated in the ACS Advocacy Summit, May 7−9. Participants in the Advocacy Summit portion of the ACS Leadership & Advocacy Summit came to Washington primarily to meet with lawmakers and congressional staff to educate them about key ACS legislative priorities that affect surgical patients, including ensuring an adequate surgical workforce in underserved areas; advancing childhood cancer research and surveillance and providing resources for pediatric cancer survivors; allocating funding for the Children’s Health Insurance Program, which provides health care coverage to uninsured children from low-income families; improving liability protections for trauma care providers; and providing greater flexibility for providers during implementation of the Merit-based Incentive Payment System (MIPS). The issue briefs presented during the Advocacy Summit are available on the ACS Professional Association website at web4.facs.org/eBusiness/login.aspx?ReturnURL=~/SAML/SSOService.aspx?r=1.
In addition, health care reform was discussed during a few panel sessions. Just days before the Advocacy Summit, the House of Representatives had passed the American Health Care Act by a vote of 217-213. Summit attendees were educated about the College’s concerns with the legislation and were advised that the Senate bill likely would be dramatically different. The College continues to work to ensure that ACS health care reform principles—patient safety and quality, patient access to surgical care, reduction of health care costs and medical liability reform—are included in a revised Senate bill. The full ACS 2017 statement on health care reform was published in the May issue of the Bulletin and is available at bulletin.facs.org/2017/05/american-college-of-surgeons-2017-statement-on-health-care-reform/.
The 2017 American College of Surgeons (ACS) Leadership & Advocacy Summit, May 6–9 in Washington, DC, was a well-attended conference that brought together surgeons from across the U.S. to enhance their leadership skills and to learn about how they can advocate for the advancement of issues important to the field of surgery.
Leadership Summit
More than 450 surgeons and residents participated in the ACS Leadership Summit held May 6–7. The Leadership portion of the Leadership & Advocacy Summit included a series of presentations that provided practical, take-home tips on how to be a better leader. Presentations covered such diverse leadership topics as how to handle difficult conversations, manage difficult people, and lead from behind; how it’s not all about you, and leading by example; volunteering in your own backyard; avoiding burnout and promoting resilience; preparing for leadership positions in medicine; and successfully addressing critical situations in the operating room. PowerPoint presentations shown at the 2017 Leadership Summit are available at facs.org/advocacy/participate/summit/2017-presentations.
In addition, ACS chapter leaders shared success stories. Representatives of the Connecticut Chapter focused on resident engagement, representatives of the North Texas Chapter and South Texas Chapter explained the positive results that can be realized by holding joint chapter meetings, and members of the Georgia Society of the ACS discussed their Stop the Bleed® effort. Participants then convened in state breakout sessions during the lunch hour to identify new strategies and initiatives for implementation at the chapter level. ACS Executive Director David B. Hoyt, MD, FACS, provided an update on ACS activities.
Advocacy Summit
More than 300 surgeons and residents participated in the ACS Advocacy Summit, May 7−9. Participants in the Advocacy Summit portion of the ACS Leadership & Advocacy Summit came to Washington primarily to meet with lawmakers and congressional staff to educate them about key ACS legislative priorities that affect surgical patients, including ensuring an adequate surgical workforce in underserved areas; advancing childhood cancer research and surveillance and providing resources for pediatric cancer survivors; allocating funding for the Children’s Health Insurance Program, which provides health care coverage to uninsured children from low-income families; improving liability protections for trauma care providers; and providing greater flexibility for providers during implementation of the Merit-based Incentive Payment System (MIPS). The issue briefs presented during the Advocacy Summit are available on the ACS Professional Association website at web4.facs.org/eBusiness/login.aspx?ReturnURL=~/SAML/SSOService.aspx?r=1.
In addition, health care reform was discussed during a few panel sessions. Just days before the Advocacy Summit, the House of Representatives had passed the American Health Care Act by a vote of 217-213. Summit attendees were educated about the College’s concerns with the legislation and were advised that the Senate bill likely would be dramatically different. The College continues to work to ensure that ACS health care reform principles—patient safety and quality, patient access to surgical care, reduction of health care costs and medical liability reform—are included in a revised Senate bill. The full ACS 2017 statement on health care reform was published in the May issue of the Bulletin and is available at bulletin.facs.org/2017/05/american-college-of-surgeons-2017-statement-on-health-care-reform/.
The 2017 American College of Surgeons (ACS) Leadership & Advocacy Summit, May 6–9 in Washington, DC, was a well-attended conference that brought together surgeons from across the U.S. to enhance their leadership skills and to learn about how they can advocate for the advancement of issues important to the field of surgery.
Leadership Summit
More than 450 surgeons and residents participated in the ACS Leadership Summit held May 6–7. The Leadership portion of the Leadership & Advocacy Summit included a series of presentations that provided practical, take-home tips on how to be a better leader. Presentations covered such diverse leadership topics as how to handle difficult conversations, manage difficult people, and lead from behind; how it’s not all about you, and leading by example; volunteering in your own backyard; avoiding burnout and promoting resilience; preparing for leadership positions in medicine; and successfully addressing critical situations in the operating room. PowerPoint presentations shown at the 2017 Leadership Summit are available at facs.org/advocacy/participate/summit/2017-presentations.
In addition, ACS chapter leaders shared success stories. Representatives of the Connecticut Chapter focused on resident engagement, representatives of the North Texas Chapter and South Texas Chapter explained the positive results that can be realized by holding joint chapter meetings, and members of the Georgia Society of the ACS discussed their Stop the Bleed® effort. Participants then convened in state breakout sessions during the lunch hour to identify new strategies and initiatives for implementation at the chapter level. ACS Executive Director David B. Hoyt, MD, FACS, provided an update on ACS activities.
Advocacy Summit
More than 300 surgeons and residents participated in the ACS Advocacy Summit, May 7−9. Participants in the Advocacy Summit portion of the ACS Leadership & Advocacy Summit came to Washington primarily to meet with lawmakers and congressional staff to educate them about key ACS legislative priorities that affect surgical patients, including ensuring an adequate surgical workforce in underserved areas; advancing childhood cancer research and surveillance and providing resources for pediatric cancer survivors; allocating funding for the Children’s Health Insurance Program, which provides health care coverage to uninsured children from low-income families; improving liability protections for trauma care providers; and providing greater flexibility for providers during implementation of the Merit-based Incentive Payment System (MIPS). The issue briefs presented during the Advocacy Summit are available on the ACS Professional Association website at web4.facs.org/eBusiness/login.aspx?ReturnURL=~/SAML/SSOService.aspx?r=1.
In addition, health care reform was discussed during a few panel sessions. Just days before the Advocacy Summit, the House of Representatives had passed the American Health Care Act by a vote of 217-213. Summit attendees were educated about the College’s concerns with the legislation and were advised that the Senate bill likely would be dramatically different. The College continues to work to ensure that ACS health care reform principles—patient safety and quality, patient access to surgical care, reduction of health care costs and medical liability reform—are included in a revised Senate bill. The full ACS 2017 statement on health care reform was published in the May issue of the Bulletin and is available at bulletin.facs.org/2017/05/american-college-of-surgeons-2017-statement-on-health-care-reform/.
ACS-AEI Forum to Address Early-Career Simulation Training and Assessment
The American College of Surgeons Accredited Education Institutes (ACS-AEI) will host a forum June 12 that seeks to mobilize stakeholders to identify best practices and key considerations in simulation training and to build the case for more standardized implementation of simulation training and assessment in early-career surgical education. The forum, called “Training the Next Generation of Surgeons: Making It Stick, Making It Real, Making It Together,” will take place at the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Institute of Simulation in Healthcare (WISH) at the University of Washington (UW), Seattle. The ultimate goal of the forum will be to begin formulating principles and standards that will maximize the value of simulation and ultimately improve surgeon performance.
Hosting the forum are David B. Hoyt, MD, FACS, ACS Executive Director; Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education; Robert Sweet, MD, FACS, professor of urology, UW, medical director, UW Medicine Kidney Stone Center at Northwest Hospital, and executive director, WISH and Center for Research in Education and Simulation Technologies, UW Medicine; and Carlos A. Pellegrini, MD, FACS, chief medical officer, UW Medicine, vice-president for medical affairs, UW, and Past-President of the ACS.
The forum will include opening remarks from ACS and UW leadership and panel sessions on key topics, including model simulation programs, advances in simulation technologies and tools, and best practices for broadly applying simulation training and assessment. A keynote address centered on the cognitive learning process behind skills acquisition and expert performance, WISH simulation lab tours, and a workshop session on team training will round out the program. To learn more about the forum and to register, visit the ACS-AEI event page at www.facs.org/education/accreditation/aei/next-generation.
The American College of Surgeons Accredited Education Institutes (ACS-AEI) will host a forum June 12 that seeks to mobilize stakeholders to identify best practices and key considerations in simulation training and to build the case for more standardized implementation of simulation training and assessment in early-career surgical education. The forum, called “Training the Next Generation of Surgeons: Making It Stick, Making It Real, Making It Together,” will take place at the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Institute of Simulation in Healthcare (WISH) at the University of Washington (UW), Seattle. The ultimate goal of the forum will be to begin formulating principles and standards that will maximize the value of simulation and ultimately improve surgeon performance.
Hosting the forum are David B. Hoyt, MD, FACS, ACS Executive Director; Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education; Robert Sweet, MD, FACS, professor of urology, UW, medical director, UW Medicine Kidney Stone Center at Northwest Hospital, and executive director, WISH and Center for Research in Education and Simulation Technologies, UW Medicine; and Carlos A. Pellegrini, MD, FACS, chief medical officer, UW Medicine, vice-president for medical affairs, UW, and Past-President of the ACS.
The forum will include opening remarks from ACS and UW leadership and panel sessions on key topics, including model simulation programs, advances in simulation technologies and tools, and best practices for broadly applying simulation training and assessment. A keynote address centered on the cognitive learning process behind skills acquisition and expert performance, WISH simulation lab tours, and a workshop session on team training will round out the program. To learn more about the forum and to register, visit the ACS-AEI event page at www.facs.org/education/accreditation/aei/next-generation.
The American College of Surgeons Accredited Education Institutes (ACS-AEI) will host a forum June 12 that seeks to mobilize stakeholders to identify best practices and key considerations in simulation training and to build the case for more standardized implementation of simulation training and assessment in early-career surgical education. The forum, called “Training the Next Generation of Surgeons: Making It Stick, Making It Real, Making It Together,” will take place at the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Institute of Simulation in Healthcare (WISH) at the University of Washington (UW), Seattle. The ultimate goal of the forum will be to begin formulating principles and standards that will maximize the value of simulation and ultimately improve surgeon performance.
Hosting the forum are David B. Hoyt, MD, FACS, ACS Executive Director; Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education; Robert Sweet, MD, FACS, professor of urology, UW, medical director, UW Medicine Kidney Stone Center at Northwest Hospital, and executive director, WISH and Center for Research in Education and Simulation Technologies, UW Medicine; and Carlos A. Pellegrini, MD, FACS, chief medical officer, UW Medicine, vice-president for medical affairs, UW, and Past-President of the ACS.
The forum will include opening remarks from ACS and UW leadership and panel sessions on key topics, including model simulation programs, advances in simulation technologies and tools, and best practices for broadly applying simulation training and assessment. A keynote address centered on the cognitive learning process behind skills acquisition and expert performance, WISH simulation lab tours, and a workshop session on team training will round out the program. To learn more about the forum and to register, visit the ACS-AEI event page at www.facs.org/education/accreditation/aei/next-generation.
New ACS surgical practice guidelines now include patient education
The American College of Surgeons (ACS) Evidence-Based Decisions in Surgery (EBDS) and Patient Education programs have collaborated to offer established surgical practice guidelines that surgeons can use at the point of care. The modules, which are viewable on all digital platforms, now include relevant patient education information to aid in high-quality care for surgical patients.
The EBDS modules provide peer-reviewed recommendations for surgeons based on clinical practice guidelines promulgated by national and international professional organizations and government agencies. The surgical recommendations are presented along with the strength of the evidence that supports the recommendations. Grading of the evidence is done with the understanding that the contribution of surgical judgment in developing effective and safe treatment strategies is essential for effective care of individual surgical patients. As such, the modules are intended to guide surgical practice but should always take into consideration the needs and preferences of individual patients.
Each EBDS module has a section labeled “Suggested Talking Points for Patient Education,” which covers topics such as who developed the guidelines, recommended actions for patients and physicians, and potential benefits and harms associated with these recommendations. Where applicable, links will now be included in the modules that will lead the user directly to the patient education material that supports the particular topic. For example, the EBDS module for Hemodialysis Access has a link to the Patient Education section of the Central Lines Home Skills Kit. The home page for the Central Lines Home Skills Kit provides a host of information, ranging from a welcome video, to a Central Lines Home Skills booklet, to an evaluation.
At present, 13 EBDS modules have links to patient education material from the ACS. As more modules and patient education materials are developed, more comprehensive offerings will be available to surgeon members. Brochures for patients provide all pre-, peri-, and postoperative information to help patients make informed decisions and fully participate in all aspects of their care for many common surgical procedures. The Home Skills Kit series uses a multimedia approach to explain, demonstrate, and provide directed learning experiences and practice opportunities for patients requiring a lung procedure, an ostomy, feeding tube, central line placement, or complex wound care.
ACS Patient Education resources are based on contemporary principles of evidence-based medicine tailored to the individual patient’s needs, with a focus on health literacy. Patients who are trained to actively participate in their care show improved treatment compliance, decreased complications, and enhanced outcomes and satisfaction.*
With outpatient operations representing a growing share (65 percent, 17.3 million) of all procedures performed in the U.S., patient preparation is essential to the delivery of high-value, safe surgical care.
To learn more and view the modules, go to ebds.facs.org. After logging in with ACS credentials, click on the Topics tab and take note of the modules with a tag labeled “Updated” to find modules that have ACS Patient Education information included. This can be found in the Suggested Talking Points for Patient Education section with links directly to the content available.
Ms. Dalal is Senior Manager, Evidence-Based Decisions in Surgery, ACS Division of Education, Chicago, IL.
Ms. Strand is Manager, ACS Patient Education Program, Division of Education.
The American College of Surgeons (ACS) Evidence-Based Decisions in Surgery (EBDS) and Patient Education programs have collaborated to offer established surgical practice guidelines that surgeons can use at the point of care. The modules, which are viewable on all digital platforms, now include relevant patient education information to aid in high-quality care for surgical patients.
The EBDS modules provide peer-reviewed recommendations for surgeons based on clinical practice guidelines promulgated by national and international professional organizations and government agencies. The surgical recommendations are presented along with the strength of the evidence that supports the recommendations. Grading of the evidence is done with the understanding that the contribution of surgical judgment in developing effective and safe treatment strategies is essential for effective care of individual surgical patients. As such, the modules are intended to guide surgical practice but should always take into consideration the needs and preferences of individual patients.
Each EBDS module has a section labeled “Suggested Talking Points for Patient Education,” which covers topics such as who developed the guidelines, recommended actions for patients and physicians, and potential benefits and harms associated with these recommendations. Where applicable, links will now be included in the modules that will lead the user directly to the patient education material that supports the particular topic. For example, the EBDS module for Hemodialysis Access has a link to the Patient Education section of the Central Lines Home Skills Kit. The home page for the Central Lines Home Skills Kit provides a host of information, ranging from a welcome video, to a Central Lines Home Skills booklet, to an evaluation.
At present, 13 EBDS modules have links to patient education material from the ACS. As more modules and patient education materials are developed, more comprehensive offerings will be available to surgeon members. Brochures for patients provide all pre-, peri-, and postoperative information to help patients make informed decisions and fully participate in all aspects of their care for many common surgical procedures. The Home Skills Kit series uses a multimedia approach to explain, demonstrate, and provide directed learning experiences and practice opportunities for patients requiring a lung procedure, an ostomy, feeding tube, central line placement, or complex wound care.
ACS Patient Education resources are based on contemporary principles of evidence-based medicine tailored to the individual patient’s needs, with a focus on health literacy. Patients who are trained to actively participate in their care show improved treatment compliance, decreased complications, and enhanced outcomes and satisfaction.*
With outpatient operations representing a growing share (65 percent, 17.3 million) of all procedures performed in the U.S., patient preparation is essential to the delivery of high-value, safe surgical care.
To learn more and view the modules, go to ebds.facs.org. After logging in with ACS credentials, click on the Topics tab and take note of the modules with a tag labeled “Updated” to find modules that have ACS Patient Education information included. This can be found in the Suggested Talking Points for Patient Education section with links directly to the content available.
Ms. Dalal is Senior Manager, Evidence-Based Decisions in Surgery, ACS Division of Education, Chicago, IL.
Ms. Strand is Manager, ACS Patient Education Program, Division of Education.
The American College of Surgeons (ACS) Evidence-Based Decisions in Surgery (EBDS) and Patient Education programs have collaborated to offer established surgical practice guidelines that surgeons can use at the point of care. The modules, which are viewable on all digital platforms, now include relevant patient education information to aid in high-quality care for surgical patients.
The EBDS modules provide peer-reviewed recommendations for surgeons based on clinical practice guidelines promulgated by national and international professional organizations and government agencies. The surgical recommendations are presented along with the strength of the evidence that supports the recommendations. Grading of the evidence is done with the understanding that the contribution of surgical judgment in developing effective and safe treatment strategies is essential for effective care of individual surgical patients. As such, the modules are intended to guide surgical practice but should always take into consideration the needs and preferences of individual patients.
Each EBDS module has a section labeled “Suggested Talking Points for Patient Education,” which covers topics such as who developed the guidelines, recommended actions for patients and physicians, and potential benefits and harms associated with these recommendations. Where applicable, links will now be included in the modules that will lead the user directly to the patient education material that supports the particular topic. For example, the EBDS module for Hemodialysis Access has a link to the Patient Education section of the Central Lines Home Skills Kit. The home page for the Central Lines Home Skills Kit provides a host of information, ranging from a welcome video, to a Central Lines Home Skills booklet, to an evaluation.
At present, 13 EBDS modules have links to patient education material from the ACS. As more modules and patient education materials are developed, more comprehensive offerings will be available to surgeon members. Brochures for patients provide all pre-, peri-, and postoperative information to help patients make informed decisions and fully participate in all aspects of their care for many common surgical procedures. The Home Skills Kit series uses a multimedia approach to explain, demonstrate, and provide directed learning experiences and practice opportunities for patients requiring a lung procedure, an ostomy, feeding tube, central line placement, or complex wound care.
ACS Patient Education resources are based on contemporary principles of evidence-based medicine tailored to the individual patient’s needs, with a focus on health literacy. Patients who are trained to actively participate in their care show improved treatment compliance, decreased complications, and enhanced outcomes and satisfaction.*
With outpatient operations representing a growing share (65 percent, 17.3 million) of all procedures performed in the U.S., patient preparation is essential to the delivery of high-value, safe surgical care.
To learn more and view the modules, go to ebds.facs.org. After logging in with ACS credentials, click on the Topics tab and take note of the modules with a tag labeled “Updated” to find modules that have ACS Patient Education information included. This can be found in the Suggested Talking Points for Patient Education section with links directly to the content available.
Ms. Dalal is Senior Manager, Evidence-Based Decisions in Surgery, ACS Division of Education, Chicago, IL.
Ms. Strand is Manager, ACS Patient Education Program, Division of Education.
Dr. Bowyer to Receive Robert Danis Prize from ISS/SIC
Mark W. Bowyer, MD, FACS, Chair of the American College of Surgeons Committee on Trauma’s Surgical Skills Committee, has been named the 2017 recipient of the Robert Danis Prize.
Mark W. Bowyer, MD, FACS, Chair of the American College of Surgeons Committee on Trauma’s Surgical Skills Committee, has been named the 2017 recipient of the Robert Danis Prize awarded by the International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC). This award is presented to a surgeon who has made important contributions to the fields of trauma, burns, or critical care. Dr. Bowyer was selected for his lifelong commitment and broad contributions to the field of trauma and surgical simulation.
Dr. Bowyer, the Ben Eiseman Professor of Surgery and surgical director of simulation, division of trauma and combat surgery, department of surgery, Uniformed Services University of the Health Sciences (USUHS)–Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, spent more than 22 years as an Air Force trauma and combat surgeon. He has taught trauma skills to thousands of medical students and physicians around the world in the last three decades and is one of the chief architects of the Advanced Surgical Skills for Exposures in Trauma course, which has been presented in more than 100 course sites in 11 countries in the last six years. Dr. Bowyer served as the Air Force’s “trauma czar” while serving Iraq, where he directed and coordinated all care provided to combat trauma patients.
In addition, he is the surgical director of the USUHS Val G. Hemming Simulation Center, where he has been on the forefront of using simulators to teach advanced trauma and acute care surgical skills and where he works to develop and validate augmented and virtual reality, as well as trauma, laparoscopic, acute care surgical, triage, and critical care-based simulators. At present, Dr. Bowyer is working on simulation projects to improve patient safety.
Dr. Bowyer will receive the Danis Prize during the ISS/SIC 2017 World Congress of Surgery, August 13−17 in Basel, Switzerland. (Read more about the World Congress of Surgery at www.wcs2017.org/.) Read more about Dr. Bowyer at bit.ly/2qcpETa.
Mark W. Bowyer, MD, FACS, Chair of the American College of Surgeons Committee on Trauma’s Surgical Skills Committee, has been named the 2017 recipient of the Robert Danis Prize.
Mark W. Bowyer, MD, FACS, Chair of the American College of Surgeons Committee on Trauma’s Surgical Skills Committee, has been named the 2017 recipient of the Robert Danis Prize awarded by the International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC). This award is presented to a surgeon who has made important contributions to the fields of trauma, burns, or critical care. Dr. Bowyer was selected for his lifelong commitment and broad contributions to the field of trauma and surgical simulation.
Dr. Bowyer, the Ben Eiseman Professor of Surgery and surgical director of simulation, division of trauma and combat surgery, department of surgery, Uniformed Services University of the Health Sciences (USUHS)–Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, spent more than 22 years as an Air Force trauma and combat surgeon. He has taught trauma skills to thousands of medical students and physicians around the world in the last three decades and is one of the chief architects of the Advanced Surgical Skills for Exposures in Trauma course, which has been presented in more than 100 course sites in 11 countries in the last six years. Dr. Bowyer served as the Air Force’s “trauma czar” while serving Iraq, where he directed and coordinated all care provided to combat trauma patients.
In addition, he is the surgical director of the USUHS Val G. Hemming Simulation Center, where he has been on the forefront of using simulators to teach advanced trauma and acute care surgical skills and where he works to develop and validate augmented and virtual reality, as well as trauma, laparoscopic, acute care surgical, triage, and critical care-based simulators. At present, Dr. Bowyer is working on simulation projects to improve patient safety.
Dr. Bowyer will receive the Danis Prize during the ISS/SIC 2017 World Congress of Surgery, August 13−17 in Basel, Switzerland. (Read more about the World Congress of Surgery at www.wcs2017.org/.) Read more about Dr. Bowyer at bit.ly/2qcpETa.
Mark W. Bowyer, MD, FACS, Chair of the American College of Surgeons Committee on Trauma’s Surgical Skills Committee, has been named the 2017 recipient of the Robert Danis Prize.
Mark W. Bowyer, MD, FACS, Chair of the American College of Surgeons Committee on Trauma’s Surgical Skills Committee, has been named the 2017 recipient of the Robert Danis Prize awarded by the International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC). This award is presented to a surgeon who has made important contributions to the fields of trauma, burns, or critical care. Dr. Bowyer was selected for his lifelong commitment and broad contributions to the field of trauma and surgical simulation.
Dr. Bowyer, the Ben Eiseman Professor of Surgery and surgical director of simulation, division of trauma and combat surgery, department of surgery, Uniformed Services University of the Health Sciences (USUHS)–Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, spent more than 22 years as an Air Force trauma and combat surgeon. He has taught trauma skills to thousands of medical students and physicians around the world in the last three decades and is one of the chief architects of the Advanced Surgical Skills for Exposures in Trauma course, which has been presented in more than 100 course sites in 11 countries in the last six years. Dr. Bowyer served as the Air Force’s “trauma czar” while serving Iraq, where he directed and coordinated all care provided to combat trauma patients.
In addition, he is the surgical director of the USUHS Val G. Hemming Simulation Center, where he has been on the forefront of using simulators to teach advanced trauma and acute care surgical skills and where he works to develop and validate augmented and virtual reality, as well as trauma, laparoscopic, acute care surgical, triage, and critical care-based simulators. At present, Dr. Bowyer is working on simulation projects to improve patient safety.
Dr. Bowyer will receive the Danis Prize during the ISS/SIC 2017 World Congress of Surgery, August 13−17 in Basel, Switzerland. (Read more about the World Congress of Surgery at www.wcs2017.org/.) Read more about Dr. Bowyer at bit.ly/2qcpETa.
OSA in pregnancy linked to congenital anomalies
BOSTON – Newborns exposed to obstructive sleep apnea (OSA) in utero are at a higher risk of being diagnosed with congenital anomalies, according to a new study presented at the annual meeting of the Associated Professional Sleep Societies.
The researchers’ analysis covered data from more than 1.4 million births during 2010-2014. Circulatory, musculoskeletal, and central nervous systems were among the types of anomalies they saw in the 17.3% of babies born to mothers who had OSA during pregnancy. These babies were also more likely to require intensive care at birth, compared with those born to mothers who had not been diagnosed with OSA.
Additionally, the investigators found that the 0.1% of women who had a diagnosis of OSA were 2.76 times more likely to have babies that required some kind of resuscitative effort at birth. Specifically, 0.5% of the newborns of the mothers with OSA required resuscitation, compared with 0.1% of the other group’s babies. The newborns of women with OSA were also 2.25 times more likely to have a longer hospital stay.
Mothers with OSA were older and more likely to be non-Hispanic black and have a diagnosis of obesity, tobacco use, and drug use but not alcohol use.
“We can’t say for sure that sleep apnea is causing these outcomes,” said abstract presenter and principal investigator Ghada Bourjeily, MD, of Brown University and Miriam Hospital, both in Providence, R.I., in an interview.
“We know that women who have sleep apnea also often have other morbidities, so we don’t know what might have contributed to the congenital outcomes,” said Dr. Bourjeily. “We also don’t know if treating sleep apnea can reverse or prevent birth complications or even maternal complications, like preeclampsia or gestational diabetes.”
Ongoing studies are looking at maternal continuous positive airway pressure therapy use and neonatal outcomes, but “they are nothing to write home about yet,” she said.
“This is an underdiagnosed condition and it’s probably undercoded too, but we know from another study that the prevalence of OSA in the first trimester in an all-comers population that was screened for the condition is 4%,” said Dr. Bourjeily. “If another 3% of [the study participants] actually had OSA, then all of these findings are potentially underestimated.”
The majority of OSA in pregnant women that has been identified in prospective studies is mild and not necessarily something that most physicians would treat, she noted. “In our study, the ones who were diagnosed were those who probably went to their doctors and complained of sleepiness or loud snoring.”
The researchers also determined that the newborns of mothers with sleep apnea were more likely to be admitted to an intensive care unit (25.3% vs. 8.1%) or a special care nursery (34.9% vs. 13.6%).
A diagnosis of OSA was established when a diagnosis code for OSA was present on the delivery discharge record. Maternal and infant outcomes were collected for ICD-9 and procedural codes.
Dr. Bourjeily received research equipment support from Respironics.
BOSTON – Newborns exposed to obstructive sleep apnea (OSA) in utero are at a higher risk of being diagnosed with congenital anomalies, according to a new study presented at the annual meeting of the Associated Professional Sleep Societies.
The researchers’ analysis covered data from more than 1.4 million births during 2010-2014. Circulatory, musculoskeletal, and central nervous systems were among the types of anomalies they saw in the 17.3% of babies born to mothers who had OSA during pregnancy. These babies were also more likely to require intensive care at birth, compared with those born to mothers who had not been diagnosed with OSA.
Additionally, the investigators found that the 0.1% of women who had a diagnosis of OSA were 2.76 times more likely to have babies that required some kind of resuscitative effort at birth. Specifically, 0.5% of the newborns of the mothers with OSA required resuscitation, compared with 0.1% of the other group’s babies. The newborns of women with OSA were also 2.25 times more likely to have a longer hospital stay.
Mothers with OSA were older and more likely to be non-Hispanic black and have a diagnosis of obesity, tobacco use, and drug use but not alcohol use.
“We can’t say for sure that sleep apnea is causing these outcomes,” said abstract presenter and principal investigator Ghada Bourjeily, MD, of Brown University and Miriam Hospital, both in Providence, R.I., in an interview.
“We know that women who have sleep apnea also often have other morbidities, so we don’t know what might have contributed to the congenital outcomes,” said Dr. Bourjeily. “We also don’t know if treating sleep apnea can reverse or prevent birth complications or even maternal complications, like preeclampsia or gestational diabetes.”
Ongoing studies are looking at maternal continuous positive airway pressure therapy use and neonatal outcomes, but “they are nothing to write home about yet,” she said.
“This is an underdiagnosed condition and it’s probably undercoded too, but we know from another study that the prevalence of OSA in the first trimester in an all-comers population that was screened for the condition is 4%,” said Dr. Bourjeily. “If another 3% of [the study participants] actually had OSA, then all of these findings are potentially underestimated.”
The majority of OSA in pregnant women that has been identified in prospective studies is mild and not necessarily something that most physicians would treat, she noted. “In our study, the ones who were diagnosed were those who probably went to their doctors and complained of sleepiness or loud snoring.”
The researchers also determined that the newborns of mothers with sleep apnea were more likely to be admitted to an intensive care unit (25.3% vs. 8.1%) or a special care nursery (34.9% vs. 13.6%).
A diagnosis of OSA was established when a diagnosis code for OSA was present on the delivery discharge record. Maternal and infant outcomes were collected for ICD-9 and procedural codes.
Dr. Bourjeily received research equipment support from Respironics.
BOSTON – Newborns exposed to obstructive sleep apnea (OSA) in utero are at a higher risk of being diagnosed with congenital anomalies, according to a new study presented at the annual meeting of the Associated Professional Sleep Societies.
The researchers’ analysis covered data from more than 1.4 million births during 2010-2014. Circulatory, musculoskeletal, and central nervous systems were among the types of anomalies they saw in the 17.3% of babies born to mothers who had OSA during pregnancy. These babies were also more likely to require intensive care at birth, compared with those born to mothers who had not been diagnosed with OSA.
Additionally, the investigators found that the 0.1% of women who had a diagnosis of OSA were 2.76 times more likely to have babies that required some kind of resuscitative effort at birth. Specifically, 0.5% of the newborns of the mothers with OSA required resuscitation, compared with 0.1% of the other group’s babies. The newborns of women with OSA were also 2.25 times more likely to have a longer hospital stay.
Mothers with OSA were older and more likely to be non-Hispanic black and have a diagnosis of obesity, tobacco use, and drug use but not alcohol use.
“We can’t say for sure that sleep apnea is causing these outcomes,” said abstract presenter and principal investigator Ghada Bourjeily, MD, of Brown University and Miriam Hospital, both in Providence, R.I., in an interview.
“We know that women who have sleep apnea also often have other morbidities, so we don’t know what might have contributed to the congenital outcomes,” said Dr. Bourjeily. “We also don’t know if treating sleep apnea can reverse or prevent birth complications or even maternal complications, like preeclampsia or gestational diabetes.”
Ongoing studies are looking at maternal continuous positive airway pressure therapy use and neonatal outcomes, but “they are nothing to write home about yet,” she said.
“This is an underdiagnosed condition and it’s probably undercoded too, but we know from another study that the prevalence of OSA in the first trimester in an all-comers population that was screened for the condition is 4%,” said Dr. Bourjeily. “If another 3% of [the study participants] actually had OSA, then all of these findings are potentially underestimated.”
The majority of OSA in pregnant women that has been identified in prospective studies is mild and not necessarily something that most physicians would treat, she noted. “In our study, the ones who were diagnosed were those who probably went to their doctors and complained of sleepiness or loud snoring.”
The researchers also determined that the newborns of mothers with sleep apnea were more likely to be admitted to an intensive care unit (25.3% vs. 8.1%) or a special care nursery (34.9% vs. 13.6%).
A diagnosis of OSA was established when a diagnosis code for OSA was present on the delivery discharge record. Maternal and infant outcomes were collected for ICD-9 and procedural codes.
Dr. Bourjeily received research equipment support from Respironics.
AT SLEEP 2017
Key clinical point: This large cohort study is the first study to show an increased risk of congenital anomalies and resuscitation at birth in newborns born to mothers with diagnosed obstructive sleep apnea (OSA).
Major finding: Of babies born to a mother with OSA, 17.3% had a congenital anomaly, compared with 10.6% of those born to mothers without OSA (P less than .001). This difference remained significant after adjusting for potential confounders.
Data source: A national cohort study including more than 1.4 million linked maternal and newborn records with a delivery hospitalization during 2010-2014.
Disclosures: Dr. Bourjeily received research equipment support from Respironics.
Laparoscopic colectomy cost savings linked to surgeon experience
Laparoscopic colectomy is less expensive than open colectomy only when it is performed by surgeons experienced with the laparoscopic approach, according to a study published in the Annals of Surgery.
Many studies have demonstrated that compared with the open surgery, the laparoscopic approach reduces the cost of major abdominal operations including colectomy by as much as 50%. These savings are attributed to the shorter length of stay and lower complication rate associated with laparoscopic surgery.
“The present study underscores and clarifies the complex relationship between surgeon experience, postoperative complications, and healthcare payments. It builds on prior analyses of surgical cohorts that demonstrate an association of higher complication rates with significantly increased total episode payments,” the investigators wrote.
To assess payments for laparoscopic vs. open colectomy, they performed a population-based analysis of information in a national Medicare database regarding 182,852 procedures done in 2010-2012. They included payments for complications, readmissions, and postacute care as well as for the surgery and hospital stay.
To examine any possible effects of the surgeons’ experience on the resulting costs, the data were divided into quartiles of experience with laparoscopy. The investigators then compared surgeons with the least experience (the lowest quartile), the most experience (the highest quartile), and intermediate experience (the two middle quartiles).
Among the surgeons with the least experience in laparoscopy, Medicare payments were actually higher for laparoscopic ($26,915) than for open colectomy ($23,312). In contrast, among surgeons with the most experience, payments were substantially lower for laparoscopic ($20,476) than for open colectomy ($23,793).
This difference was attributed to the less experienced surgeons’ higher complication rates; higher readmission rates; and greater need for postacute care services, such as discharging the patient to a skilled nursing facility rather than home, the investigators said (Ann Surg. 2017 May 25. doi: 10.1097/SLA.0000000000002312).
These findings demonstrate that “the financial benefits of laparoscopy are only realized when the surgeon has appropriate experience or proficiency.” They have important implications, highlighting the need for more rigorous credentialing standards for individual surgeons and for improving continuing medical education through more extensive proctoring or coaching to enhance surgical skills, Dr. Sheetz and his associates said.
The study results also “make a business case for investing in the training and retraining of surgeons in practice,” they added
“New procedures are continually introduced into practice, and surgeons need to take the time to learn them safely. Taking time to learn new procedures is expensive. Increasing the number of surgeons at a given hospital who are, however, proficient with complex laparoscopy has an important beneficial impact on the financial bottom line for hospitals and health care payers,” the investigators noted.
This study was supported by The National Institutes of Health. Dr. Sheetz and his associates reported having no relevant financial disclosures.
Laparoscopic colectomy is less expensive than open colectomy only when it is performed by surgeons experienced with the laparoscopic approach, according to a study published in the Annals of Surgery.
Many studies have demonstrated that compared with the open surgery, the laparoscopic approach reduces the cost of major abdominal operations including colectomy by as much as 50%. These savings are attributed to the shorter length of stay and lower complication rate associated with laparoscopic surgery.
“The present study underscores and clarifies the complex relationship between surgeon experience, postoperative complications, and healthcare payments. It builds on prior analyses of surgical cohorts that demonstrate an association of higher complication rates with significantly increased total episode payments,” the investigators wrote.
To assess payments for laparoscopic vs. open colectomy, they performed a population-based analysis of information in a national Medicare database regarding 182,852 procedures done in 2010-2012. They included payments for complications, readmissions, and postacute care as well as for the surgery and hospital stay.
To examine any possible effects of the surgeons’ experience on the resulting costs, the data were divided into quartiles of experience with laparoscopy. The investigators then compared surgeons with the least experience (the lowest quartile), the most experience (the highest quartile), and intermediate experience (the two middle quartiles).
Among the surgeons with the least experience in laparoscopy, Medicare payments were actually higher for laparoscopic ($26,915) than for open colectomy ($23,312). In contrast, among surgeons with the most experience, payments were substantially lower for laparoscopic ($20,476) than for open colectomy ($23,793).
This difference was attributed to the less experienced surgeons’ higher complication rates; higher readmission rates; and greater need for postacute care services, such as discharging the patient to a skilled nursing facility rather than home, the investigators said (Ann Surg. 2017 May 25. doi: 10.1097/SLA.0000000000002312).
These findings demonstrate that “the financial benefits of laparoscopy are only realized when the surgeon has appropriate experience or proficiency.” They have important implications, highlighting the need for more rigorous credentialing standards for individual surgeons and for improving continuing medical education through more extensive proctoring or coaching to enhance surgical skills, Dr. Sheetz and his associates said.
The study results also “make a business case for investing in the training and retraining of surgeons in practice,” they added
“New procedures are continually introduced into practice, and surgeons need to take the time to learn them safely. Taking time to learn new procedures is expensive. Increasing the number of surgeons at a given hospital who are, however, proficient with complex laparoscopy has an important beneficial impact on the financial bottom line for hospitals and health care payers,” the investigators noted.
This study was supported by The National Institutes of Health. Dr. Sheetz and his associates reported having no relevant financial disclosures.
Laparoscopic colectomy is less expensive than open colectomy only when it is performed by surgeons experienced with the laparoscopic approach, according to a study published in the Annals of Surgery.
Many studies have demonstrated that compared with the open surgery, the laparoscopic approach reduces the cost of major abdominal operations including colectomy by as much as 50%. These savings are attributed to the shorter length of stay and lower complication rate associated with laparoscopic surgery.
“The present study underscores and clarifies the complex relationship between surgeon experience, postoperative complications, and healthcare payments. It builds on prior analyses of surgical cohorts that demonstrate an association of higher complication rates with significantly increased total episode payments,” the investigators wrote.
To assess payments for laparoscopic vs. open colectomy, they performed a population-based analysis of information in a national Medicare database regarding 182,852 procedures done in 2010-2012. They included payments for complications, readmissions, and postacute care as well as for the surgery and hospital stay.
To examine any possible effects of the surgeons’ experience on the resulting costs, the data were divided into quartiles of experience with laparoscopy. The investigators then compared surgeons with the least experience (the lowest quartile), the most experience (the highest quartile), and intermediate experience (the two middle quartiles).
Among the surgeons with the least experience in laparoscopy, Medicare payments were actually higher for laparoscopic ($26,915) than for open colectomy ($23,312). In contrast, among surgeons with the most experience, payments were substantially lower for laparoscopic ($20,476) than for open colectomy ($23,793).
This difference was attributed to the less experienced surgeons’ higher complication rates; higher readmission rates; and greater need for postacute care services, such as discharging the patient to a skilled nursing facility rather than home, the investigators said (Ann Surg. 2017 May 25. doi: 10.1097/SLA.0000000000002312).
These findings demonstrate that “the financial benefits of laparoscopy are only realized when the surgeon has appropriate experience or proficiency.” They have important implications, highlighting the need for more rigorous credentialing standards for individual surgeons and for improving continuing medical education through more extensive proctoring or coaching to enhance surgical skills, Dr. Sheetz and his associates said.
The study results also “make a business case for investing in the training and retraining of surgeons in practice,” they added
“New procedures are continually introduced into practice, and surgeons need to take the time to learn them safely. Taking time to learn new procedures is expensive. Increasing the number of surgeons at a given hospital who are, however, proficient with complex laparoscopy has an important beneficial impact on the financial bottom line for hospitals and health care payers,” the investigators noted.
This study was supported by The National Institutes of Health. Dr. Sheetz and his associates reported having no relevant financial disclosures.
FROM THE ANNALS OF SURGERY
Key clinical point: Laparoscopic colectomy is less expensive than open colectomy only when it is performed by surgeons experienced with the laparoscopic approach.
Major finding: Among the surgeons with the least experience in laparoscopy, Medicare payments were actually higher for laparoscopic ($26,915) than for open colectomy ($23,312).
Data source: An analysis of Medicare payment data for 182,852 patients who had laparoscopic or open colectomy in 2010-2012.
Disclosures: This study was supported by The National Institutes of Health. Dr. Sheetz and his associates reported having no relevant financial disclosures.
Commentary—Promising Results Should Prompt Further Study
During the past 20 years, mindfulness-based training has become an increasingly popular treatment for many conditions, including migraine. In the February online issue of the Journal of Headache and Pain, Dr. Grazzi addresses medication overuse chronic migraine (CM-MO) and provides initial evidence for the consideration of mindfulness training to help reduce headache symptoms.
However, the reader should take seriously the authors’ caution that “although our findings are encouraging and suggestive of the independent value of mindfulness for headache care, certain design limitations preclude us [from] making unequivocal claims.”
Since the goal of a noninferiority trial is to assess whether a new therapy is at least as beneficial as standard treatment, extra caution is necessary when interpreting findings from an underpowered feasibility study. In general, a useful approach to noninferiority is to determine whether the confidence intervals include effect sizes that one might consider clinically meaningful. Instead of focusing on whether the mindfulness-based training group performed the same as the comparison group, we should accept the valuable information that is presented. The take away message from this pilot study is threefold. Mindfulness-based training is potentially acceptable to patients with CM-MO. Patients with CM-MO might be amenable to participating in a fully powered randomized controlled trial of mindfulness-based training. Finally, it is possible that mindfulness-based training may show improvement similar in magnitude to pharmaceuticals. Overall, Grazzi et al have laid the groundwork for a fully powered, randomized version of their study.
—Alice R. Pressman, PhD
Director of Analytics and Evaluation
Sutter Health
Walnut Creek, California
During the past 20 years, mindfulness-based training has become an increasingly popular treatment for many conditions, including migraine. In the February online issue of the Journal of Headache and Pain, Dr. Grazzi addresses medication overuse chronic migraine (CM-MO) and provides initial evidence for the consideration of mindfulness training to help reduce headache symptoms.
However, the reader should take seriously the authors’ caution that “although our findings are encouraging and suggestive of the independent value of mindfulness for headache care, certain design limitations preclude us [from] making unequivocal claims.”
Since the goal of a noninferiority trial is to assess whether a new therapy is at least as beneficial as standard treatment, extra caution is necessary when interpreting findings from an underpowered feasibility study. In general, a useful approach to noninferiority is to determine whether the confidence intervals include effect sizes that one might consider clinically meaningful. Instead of focusing on whether the mindfulness-based training group performed the same as the comparison group, we should accept the valuable information that is presented. The take away message from this pilot study is threefold. Mindfulness-based training is potentially acceptable to patients with CM-MO. Patients with CM-MO might be amenable to participating in a fully powered randomized controlled trial of mindfulness-based training. Finally, it is possible that mindfulness-based training may show improvement similar in magnitude to pharmaceuticals. Overall, Grazzi et al have laid the groundwork for a fully powered, randomized version of their study.
—Alice R. Pressman, PhD
Director of Analytics and Evaluation
Sutter Health
Walnut Creek, California
During the past 20 years, mindfulness-based training has become an increasingly popular treatment for many conditions, including migraine. In the February online issue of the Journal of Headache and Pain, Dr. Grazzi addresses medication overuse chronic migraine (CM-MO) and provides initial evidence for the consideration of mindfulness training to help reduce headache symptoms.
However, the reader should take seriously the authors’ caution that “although our findings are encouraging and suggestive of the independent value of mindfulness for headache care, certain design limitations preclude us [from] making unequivocal claims.”
Since the goal of a noninferiority trial is to assess whether a new therapy is at least as beneficial as standard treatment, extra caution is necessary when interpreting findings from an underpowered feasibility study. In general, a useful approach to noninferiority is to determine whether the confidence intervals include effect sizes that one might consider clinically meaningful. Instead of focusing on whether the mindfulness-based training group performed the same as the comparison group, we should accept the valuable information that is presented. The take away message from this pilot study is threefold. Mindfulness-based training is potentially acceptable to patients with CM-MO. Patients with CM-MO might be amenable to participating in a fully powered randomized controlled trial of mindfulness-based training. Finally, it is possible that mindfulness-based training may show improvement similar in magnitude to pharmaceuticals. Overall, Grazzi et al have laid the groundwork for a fully powered, randomized version of their study.
—Alice R. Pressman, PhD
Director of Analytics and Evaluation
Sutter Health
Walnut Creek, California