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IN THE NEWS
FIRST LOOK
GENERAL SURGERY NEWS / APRIL 2022
The Southeastern Surgical Congress All Articles by MONICA J. SMITH
Lower-Pressure Pneumoperitoneum Decreases Post-op Pain
When Fragmentation of Care May Be Better: Treating Pancreatic Cancer
NASHVILLE, Tenn.—The carbon dioxide insufflation used in laparoscopic surgery to create pneumoperitoneum is associated with some challenging metabolic changes and can cause pain. New research suggests low-pressure pneumoperitoneum reduces postoperative pain, with other positive outcomes. As part of a quality improvement program at the University of South Alabama Medical Center, in Mobile, researchers who had been performing laparoscopic procedures with standard pressure, at 15 mm Hg, wanted to find out if they could complete cases at a lower pressure of 8 to 12 mm Hg. g. “Our cases varied from genereral surgery and foregut surgery;; our primary outcomes included post-op pain scores and morphine milligram equivalents (MMEs) at discharge or 24 hours after surgery, whichever came first,” said John Paul Saway, a second-year medical stu-dent presenting on behalf of his co-authors at the 2022 Southeastern Surgical Congress. The investigators’ secondary outcomes included operating times, intraoperative peak inspiratory pressure, end-tidal carbon dioxide (EtCO2) and the need to convert to standard pressure. The results showed that “there was significantly less consumption of MMEs in the low-pressure group, at 11.7 compared with 17.4 in the high-pressure group. In addition, we see that many of the low-pressure patients had an MME score of zero,” Mr. Saway said. In addition, a significantly decreased peak inspiratory pressure value was observed in the low-pressure group, at 24.7 compared with 31.4 in the high-pressure group, and EtCO2 levels also were lower in the low-pressure group. “The question then becomes what factors contribute to completing cases at 8 mm Hg?” Mr. Saway said. He noted that his institution uses two different insufflation systems—constant mode and demand mode— both of which are available in all operating rooms. All of the cases using low pressure and constant mode were able to be completed at 8 to 12 mm Hg, whereas 17% of the low-pressure cases using demand mode needed to be increased to standard pressure. “Looking at the 8-mm Hg group alone, 58% of cases were able to be completed in constant mode compared with only a third of demand mode cases at 8 mm Hg,” Mr. Saway said. In addition, with demand mode, surgeons needed to increase the pressure with heavier patients, but constant mode was able to handle a wider range in body mass index, up to 60 kg/m2, with no patients needing to be converted to 15 mm Hg. “Overall, we saw that the constant insufflation system improves visualization throughout the procedure and increases the ability to perform more procedures at 8 mm Hg,” Mr. Saway said.
NASHVILLE, Tenn.—Fragmentation of care is often associated with disadvantaged populations and poorer healthcare outcomes. Paradoxically, a recent study found better survival in pancreatic cancer patients who sought treatment at multiple institutions. “The care of pancreatic cancer patients involves coordination of specialized multidisciplinary providers and involves multimodal therapy, including surgical resection and chemotherapy,” said Victoria Bouillon, MD, a general surgery resident at the University of South Alabama Medical Center, in Mobile, at the 2022 Southeastern Surgical Congress. easter But surgeons who have the expertise to provide tthese operations are not everywhere, requiring patients to travel for adequate surgical resections. Dr. Bouillon and her colleagues conducted a study to identify patient factors predictive of fragmentation of care, and to assess how this fragmentation affects overall survival in pancreatic cancer. Using the National Cancer Database, they identified 20,013 patients diagnosed with noniden metastatic pancreatic ductal adenocarcinoma between 2005 and 2016. Of those, 4,822 (24%) received fragmented care, while 15,191 (75%) underwent all of their oncologic care at a single institution. “We saw a statistically significant increased rate of fragmented care amongst younger patients (under 80), amongst nonminority white patients and amongst patients in the Northeast and Midwest,” Dr. Bouillon said, noting also a statistically increased rate of fragmented care in patients with fewer comorbidities, higher socioeconomic status and private insurance. “We also saw a statistically significant increased rate of fragmentation amongst patients who had advanced stage disease, amongst those who received care at academic centers, and amongst those who received care at high-volume centers,” she said. A multivariable analysis showed most of those associations remained independent associations—less fragmentation among older and minority patients, and more fragmentation in patients in the Northeast and Midwest. Looking at 30-day, 90-day and overall survival, Dr. Bouillon and her colleagues found decreased mortality at 30 and 90 days and a 10% improvement in overall survival in patients who received fragmented care. The study was done on a national level, but Dr. Bouillon scaled it down to the state level, showing how fragmentation may come about. In Alabama, although medical oncologists are distributed evenly throughout the state, only three counties have surgeons trained to perform the types of resections needed to treat pancreatic ductal adenocarcinoma. “So, patients likely have to travel farther distances for their pancreatic resections while they have the option to receive chemotherapy at home,” she said. Dr. Bouillon acknowledged the study’s limitations: using only the National Cancer Database, which accepts data on patients only from Commission on
Cancer–accredited centers, and having no data on travel or recurrence rates. But their study suggests that fragmented care in pancreatic cancer may indicate higher access to care and confer a protective effect.
Obesity Ups Survival in Esophageal Cancer Patients Undergoing Robotic Surgery NASHVILLE, Tenn.—Obese patients who undergo robotic transhiatal esophagectomy for esophageal adenocarcinoma have longer operating times, but their weight appears to have no impact on other surgical variables and they have longer survival than underweight patients, according to the results of a new study. “Esophagectomy is the cornerstone treatment for patients with esophageal adenocarcinoma, and there have been conflicting results regarding the association between body mass index and postoperative outcomes. The impact of BMI after robotic esophagectomy has hardly been studied,” said Harel Jacoby, MD, a surgical fellow at the AdventHealth Digestive Health Institute Tampa, in Florida, with Sharona Ross, MD; Iswanto Sucandy, MD; and Alex Rosemurgy, MD. To investigate the impact of BMI on postoperative outcomes in patients undergoing robotic transhiatal esophagectomy (THE) and determine the relationship between BMI and long-term survival, Dr. Jacoby and his colleagues prospectively reviewed patients undergoing the procedure between 2012 and 2020. The study included 71 patients with a mean BMI of 27+4.9 kg/m2; most patients (72%) received neoadjuvant chemoradiation. The operations in overweight and obese patients took longer than those in normal-weight and underweight patients (five to six hours compared with four to five hours), but there was no difference in conversion to open, lymph node harvest, tumor size, stage or blood loss. Twelve patients experienced major postoperative complications; five died in the hospital; the median length of stay was seven days; and the readmission rate was 18%. But again, none of these variables were associated with BMI. Dr. Jacoby noted that three of the five deaths occurred in heavy smokers with severe chronic obstructive pulmonary disease. “Looking only at 30-day mortality, two patients died, or 2.7%, which is similar to what we see in the literature. Also, mortality was more common early on, reflecting the learning curve,” Dr. Jacoby said. Median survival was not reached (the probability of survival is 67% at 97 months), but the five-year survival rate for obese patients was 93% compared with 33% of underweight patients (P=0.05). “Obesity does not affect short-term outcomes following robotic THE, but favorably affects long-term survival. The robotic platform is a great way to handle complex abdominal procedures, and we believe it will take a greater role in the near future,” Dr. Jacoby said. ■
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