General Surgery News (May 2020) by McMahon Group

7 Tips for Managing Stress, Burnout During the COVID-19 Crisis

See page 4

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

May 2020 • Volume 47 • Number 5

Preserving the Health and Safety of Surgical Teams

Return to Elective Surgery: A Road Map Societies Collaborate to Address Safe Resumption of Operations

Updated Recommendations For Preventing Transmission

By CHRISTINA FRANGOU

our leading American medical organizations for OR personnel have issued a joint road map for when and how hospitals across the United States can safely resume elective surgery, as several governors announced plans to lift the pause on nonessential care in their states. In a statement, the American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses and American Hospital Association outlined the key steps that should guide health care providers and organizations in returning to elective surgery after cases of COVID-19 peak in their area. “When the first wave of this pandemic is behind us, the pentup patient demand for surgical and procedural care may be immense, and health care organizations, physicians and nurses

By CHASE DOYLE

hese days, misinformation about COVID-19 can be as virulent as the virus itself. Thankfully, several medical and professional associations have published living documents that provide physicians with up-to-date and accurate information on the novel coronavirus and its treatment. In this roundup, we cover the latest recommendations for preventing transmission so surgeons can continue to protect themselves while treating patients with COVID-19.

Continued on page 18

Continued on page 5

Study Data Favor Earlier Operations For Rib Fractures

Gastric Bypass Bests Sleeve Gastrectomy for Weight Loss, Remission

By MONICA J. SMITH

By CHRISTINA FRANGOU

New Orleans—Surgical rib fixation has grown in popularity in recent decades, with some research showing benefits in terms of pain, ventilator days, pneumonia risk, hospital length of stay (LOS) and mortality. One recent study has found late fixation to be inferior to nonoperative management, lending support to the argument for early surgical intervention. “There has been an increase in the number of publications on this topic, as well as an increase in the number of patients sustaining rib fractures who undergo operative intervention across all corners of the country,” said Kevin Harrell, MD, a surgery

COVID-19 Reduces Surgeons’ Business, But Relief Is Available An Overview of Financial Aid for Surgeons

n a multicenter study of more than 9,700 patients in the United States who underwent bariatric surgery, those who were treated with a Roux-en-Y gastric bypass (RYGB) experienced greater weight loss, a higher diabetes remission rate, less weight regain and better long-term glycemic control than patients who had a sleeve gastrectomy (SG).

Continued on page 20

IN THE NEWS

10 Reports from the Southeastern ern Surgical Congress T H E SURGICAL PA U SE

14 Issues in Palliative Care OP IN ION

22 Top 10 Things I Wish I Knew In Residency . facebook.com/generalsurgerynews

@gensurgnews

Continued on page 27

By KAREN BLUM

Roux-en-Y gastric bypass

s a solo practitioner in rural El Centro, Calif., surgeon Seung Gwon, MD, FACS, usually has a booming business performing hernia, gallbladder, breast cancer, colon cancer, bowel and other operations. Then the COVID-19 pandemic hit, and her hospital’s capacity for elective operations was cut by almost 95%. The financial impact on Dr. Gwon and other surgeons in private practice from COVID-19—and the resulting indefinite Continued on page 16

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Philip R. Schauer, MD (Co-Director) John B. Dixon, MBBS, PhD, FRACGP, FRCP, Edin (Co-Director) Cheguevara Afaneh, MD Ali Aminian, MD Eric J. DeMaria, MD Neil Floch, MD

Michel Gagner, MD Daniel B. Jones, MD, MS Lee M. Kaplan, MD, PhD Tammy Lyn Kindel, MD, PhD Kenneth G. MacDonald, Jr., MD Corrigan McBride, MD John Morton, MD, MPH

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OPINION

MAY 2020 / GENERAL SURGERY NEWS

How Cellphones Can Help Tame COVID-19 and Save the World Apple and Google Preparing a Contact Tracing System By PAUL ALAN WETTER, MD, FACS, FACOG

ithin the next week or so, Apple and Google will be distributing new software that will fill an urgent and vital need to track our movements and allow people to know whether they have come in close contact of someone who later tests positive for COVID-19. Most people who know of me know I’m a surgeon who has been working in the fields of robotics, laparoscopy and education. But my involvement with computers dates before my time in medical school, in the late 1960s when, in a previous career in banking, IBM mainframes where showing up in large banking institutions and filling an entire climate-controlled room for the sole purpose of adding and subtracting large columns of numbers. This was previously done by humans with pencil and ledger cards in paper spreadsheets. So, in parallel with my medical career, I’ve been peripherally involved with circuits and programs ever since then, and was among the first app developers for Apple, a group that has now grown to more than 12 million people. The cellphones that most people carry in their pockets are the equivalent of what were called supercomputers just a few years ago, with more than 8 billion transistors in each new device. The nanotechnology that we hear about at medical science meetings is already

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present in these devices with sensors and micro-communications. We, as physicians, know that two things that are urgently needed to get COVID-19 under control: universal testing and universal tracking. Both of these seem like monumental tasks that might involve millions of medical and social workers to accomplish. The good news is that the technology is already available, and it’s very possible to assist in tracking.

Wouldn’t we all like to know if we came near someone who has tested positive? The good news is that the technology is already available. Apple and Google recently announced their joint effort to create a platform to allow health care authorities to track spread. From what I know from years of working on Apple devices and programs, that’s great news, because it can be implemented rapidly, rolled out and scaled quickly, and has the promise of filling the need for tracking and controlling spread—two things that are desperately needed to gain control over the

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virus. The system will work by using near-field Bluetooth radio signals in the Bluetooth low-energy beacon system that is found in all modern phones. This allows the computer chips in our phones to securely communicate with each other, and track and record the other phones (people) who have come within a few feet of us. The final program may not log locations using the GPS signals our phones receive from satellites, only proximity to people who later test positive. The record of proximity contacts would be encrypted, and therefore secure, for a period of weeks or more. Because the records are encrypted and constantly changing, they cannot be used to work back to a person’s identity, thus ensuring privacy. Wouldn’t we all like to know if we came near someone who has tested positive? Yes, we would, but it’s not just for us, but for the people who we come into close contact with after that encounter. It’s for tracking and stopping the spread of this very contagious virus. People can then be notified, stay in quarantine, and get tested. Also, the codes you collect only reside on your phone, so there is no list of who is having interactions with whom. There is greater complexity here than this simple overview, but the system has great promise and is one of the best things to happen in our fight against this virus. This type of protocol will help testing, too, as there will not be enough tests to test everyone, but there could be enough to test those most likely to be exposed. continued on the following page

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OPINION

GENERAL SURGERY NEWS / MAY 2020

7 Tips for Managing Stress, Burnout During the COVID-19 Crisis By DAWN E. SHEDRICK, LCSWR

e are navigating uncharted waters in the COVID-19 pandemic. Health care professionals face increased risk for compounded stress and burnout in the wake of this global crisis. Although information about the novel coronavirus develops at a rapid pace daily, the need to monitor and manage stress remains paramount. The health and well-being of all health care professionals is integral to ensuring health care systems can keep up with the needs of COVID-19 patients. Burnout is defined as a syndrome of emotional exhaustion, depersonalization of others and a feeling of reduced personal accomplishment. A 2009 study of members of the American College of Surgeons found that 40% of surgeons experienced burnout. It appears safe to assume that many surgeons working on the front lines of the COVID-19 pandemic were at high risk for burnout before the beginning of the outbreak. Signs of burnout include sadness, depression, irritability, frustration, isolation, poor hygiene, social isolation, feelings of hopelessness and low job satisfaction. Health care professionals working in this pandemic are also at higher risk for secondary traumatic stress. Secondary traumatic stress is stress reactions resulting from exposure to another person’s traumatic experiences, rather than from direct exposure to a traumatic event. Signs of secondary traumatic stress mimic those of post-traumatic stress disorder, but the most common are excessive fear or worry, startle response, ruminations about the traumatic event, and sleep disturbance. Self-care can be challenging for health care workers, many of whom are conditioned to prioritize the needs and care of patients over their own. It is important to keep personal well-being in mind and manage stress to prevent physical, mental and emotional exhaustion. Here are seven tips for managing stress and fostering emotional resilience to prevent burnout while providing critical health services during the pandemic.

1. Know that what you’re feeling is a normal stress response. Health care professionals are encountering stressors that may include direct exposure to COVID-19 while treating patients, loss of patients to death, deciding how to allocate sparse resources, working longer hours, and extended periods away from loved ones. As a result, physicians are experiencing an increased frequency of stress responses throughout the course of a day. Exercise self-compassion and give yourself grace, as all medical professionals working during this crisis are experiencing distress. 2. Engage in consistent self-reflection to identify the emotional and mental signs of stress. Take a few moments at different points throughout the day for a personal mental health check-in. It may feel as if there’s no time to spare, but this is a critical aspect of managing stress. Some emotional signs of stress include the persistence of fear, irritability, anger, deep sadness and overwhelmed feeling. Mental signs include loss of concentration, local memory loss, inability to make decisions, disorientation and confusion. Stress arousal occurs as physical, mental and emotional reactions to stressors. Try incorporating breathing exercises in your daily self-care routine to help calm the body’s reactions to the stressors you encounter throughout the day. 3. Prioritize your basic needs. In times of crisis, we tend to ignore our basic needs, including food, water, exercise and sleep. To reduce stress and prevent burnout, try as best as possible to eat at least three balanced meals every day while avoiding inflammatory ingredients such as sugar, trans fats, saturated fats and alcohol. Drink water throughout the day to stay hydrated. Exercise or take walks for at least a few minutes daily to maximize the release of endorphins. As

Cellphones & COVID continued from page 3

The current time line for agencies to receive a release of the software is mid-May, and this may come just in time as the first wave will be waning, and people will begin going off quarantines and thus become more exposed. Based on the way things are playing out politically, you may first see this distributed by state governments a few weeks later, but there are plans to have these programs as part of regular software updates in Android and iOS. As with other apps, it will still require the

far as possible, set a routine time for bed to gain the benefits of quality sleep. 4. Take brief mental breaks throughout the day. Health care professionals often urge patients to prioritize self-care while dismissing the need for their own. It’s important to take scheduled breaks to rest your mind and reset. Find a quiet space during your work breaks or at home when offduty. It’s important to be mindful of any internal chatter that may try to convince you that you don’t have enough time for a break or don’t deserve it. Ignore the chatter and take a break anyway.

It’s important to be mindful of any internal chatter that may try to convince you that you don’t have enough time for a break or don’t deserve it. Ignore the chatter and take a break anyway. 5. Incorporate sensory-soothing techniques to facilitate calm and relaxation. Research supports the effectiveness of embracing sensory-soothing activities to calm the nervous system and promote healing from trauma. Be intentional in taking time throughout the day to engage in sensory-soothing techniques, such as listening to your favorite calming music, visualizing the places where you tend to feel at peace, and imagining your favorite culinary aromas that trigger meaningful memories. 6. Create and nurture supportive connections with your colleagues. Check in with your colleagues and remain open to receiving support in return. Talk to them about your feelings, experiences and accomplishments each day. The validation will help normalize your experiences and prevent feelings of isolation and moral distress. Consistent focus on

user’s permission. As with other apps, there are potential downsides, but with both Apple and Google working together with the system I have described, those will be minimal, and no different from the occasional issues that arise with our phone apps now. We have been so busy dealing with hospital beds, ventilators and personal protective equipment that there has not been time to create the much-needed tracking system by other means. I can’t emphasize enough how important this could be for us to defeat this highly contagious virus and the potential for this to do the job better than anything that has existed in the past.

the harsh realities of the pandemic can often overshadow the bright side, such as patient recovery and discharge and reductions in new COVID-19 diagnoses on a given day. Be sure to talk about the positive things occurring within your facility and personally during this crisis. 7. Seek professional support to cope with moral distress and grief. Many health care professionals are encountering unprecedented circumstances that may cause moral injury. Decisions such as which patient is placed on a ventilator or prioritizing the treatment of COVID-19 over other chronic illnesses can result in moral distress. Symptoms of moral distress include self-criticism and excessive feelings of shame, guilt and regret. This moral distress and anticipatory grief can be difficult to cope with, and additional support is needed to address their harmful effects. Early support is key for addressing trauma from moral distress. Seek peer, supervisory and external professional support to cope with moral distress. If you have access to an employee assistance program through your employer, you can receive confidential support and referrals to help you cope with moral distress. You can also contact your health insurance provider for referrals to mental health professionals who provide video and audio teletherapy. ■ Suggested Reading A list of references and resources for this article can be found in the online version at www.generalsurgerynews.com

—Dawn Shedrick, LCSW-R, is the founder and CEO of JenTex Training & Consulting, a professional development company for social workers and health care professionals. She is a licensed clinical social worker, trainer, consultant and certified life/business coach, and a lecturer at the Columbia University School of Social Work in New York City, and St. Joseph’s College Department of Human Services in Patchogue, N.Y.

There is even more good news on the horizon. Look for micro-temperature sensors among other sensors in future devices. Just imagine how those small additions will revolutionize medical care. The computing power is there, just waiting. ■ —Dr. Wetter is chairman emeritus, Society of Laparoscopic and Robotic Surgeons; professor emeritus, the University of Miami Miller School of Medicine; steering committee member, International Society for Medical Innovation and Technology; and member, WHO Global Initiative for Emergency and Essential Surgical Care committee.

MAY 2020 / GENERAL SURGERY NEWS

Return to Elective Surgery continued from page 1

must be prepared to meet this demand,” the medical groups said. Readiness to resume elective surgery will vary by geographic location depending on the rate of COVID-19 cases locally and the availability of trained staff and supplies, the groups said. They called for a sustained reduction in the rate of new COVID-19 cases in the geographic area for at least 14 days before elective surgery begins. In addition, they said every facility should have an appropriate number of ICU and non-ICU beds, personal protective equipment (PPE), ventilators and trained staff to treat all non‒elective surgery patients without resorting to a crisis standard of care. Among other recommendations, facilities should do the following: • Implement a policy for testing staff and patients for COVID-19, accounting for accuracy and availability of testing and response when a staff member or patient tests positive. • Form a committee with representatives from surgery, anesthesiology and nursing to develop a prioritization policy for surgeries. • Develop policies addressing care issues specific to COVID-19 and the postponement of surgical scheduling, including a reevaluation if patients have had COVID-19‒related illness. All surgical patients should undergo a recent history and physical examination within 30 days of surgery to confirm no interim change in a patient’s health status. • Social distancing measures should remain in place for staff, patients and visitors in nonrestricted areas in anticipation of a second wave of COVID-19 activity. Health care facilities should reevaluate and reassess procedures frequently, based on COVID-19‒related data, resources, testing and other clinical information. In the joint statement, the medical organizations did not specify that all patients should be tested prior to surgery but said if testing is not available, hospitals and surgery centers should consider a policy that addresses evidence-based infection prevention techniques, access control, workflow and distancing processes to create a safe environment in which elective surgery can occur. “If there is uncertainty about patients’ COVID-19 status, PPE appropriate for the clinical tasks should be provided for the surgical team,” the groups said. Several governors, including Oklahoma Gov. Kevin Stitt and Texas Gov. Greg Abbott, announced plans to allow hospitals to resume some elective procedures. On April 19, the Centers for

Medicare & Medicaid Services (CMS) issued the first in a series of recommendations for allowing elective procedures to resume. The CMS plan requires states or regions to meet specific gating criteria before phasing in elective procedures. The agency also called for a downward trajectory of COVID-19 cases for a 14-day period before resumption of services. Mary Dale Peterson, MD, the president of the American Society of Anesthesiologists, said the number of postponed elective procedures across the United States is unknown but dramatic. Countless patients continued on the following page

IN THE NEWS

Elective Surgery continued from page 5

are waiting for surgical procedures, even though some may lose their insurance as job losses mount. “We are estimating that 70% of surgeries have been canceled,” said Dr. Peterson, the executive vice president and chief operating officer of Driscoll Health System and emeritus staff at Driscoll Children’s Hospital, in Corpus Christi, Texas. “We need to take appropriate precautions, but we do need to start opening up.”

Brief Summary (For full prescribing information refer to package insert) INDICATIONS AND USAGE EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Limitation of Use: Safety and efficacy has not been established in other nerve blocks. CONTRAINDICATIONS EXPAREL is contraindicated in obstetrical paracervical block anesthesia. While EXPAREL has not been tested with this technique, the use of bupivacaine HCl with this technique has resulted in fetal bradycardia and death. WARNINGS AND PRECAUTIONS Warnings and Precautions Specific for EXPAREL As there is a potential risk of severe life-threatening adverse effects associated with the administration of bupivacaine, EXPAREL should be administered in a setting where trained personnel and equipment are available to promptly treat patients who show evidence of neurological or cardiac toxicity. Caution should be taken to avoid accidental intravascular injection of EXPAREL. Convulsions and cardiac arrest have occurred following accidental intravascular injection of bupivacaine and other amide-containing products. Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL. EXPAREL has not been evaluated for the following uses and, therefore, is not recommended for these types of analgesia or routes of administration. • epidural • intrathecal • regional nerve blocks other than interscalene brachial plexus nerve block • intravascular or intra-articular use EXPAREL has not been evaluated for use in the following patient population and, therefore, it is not recommended for administration to these groups. • patients younger than 18 years old • pregnant patients The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days as seen in clinical trials. ADVERSE REACTIONS Clinical Trial Experience Adverse Reactions Reported in Local Infiltration Clinical Studies The safety of EXPAREL was evaluated in 10 randomized, double-blind, local administration into the surgical site clinical studies involving 823 patients undergoing various surgical procedures. Patients were administered a dose ranging from 66 to 532 mg of EXPAREL. In these studies, the most common adverse reactions (incidence greater than or equal to 10%) following EXPAREL administration were nausea, constipation, and vomiting. The common adverse reactions (incidence greater than or equal to 2% to less than 10%) following EXPAREL administration were pyrexia, dizziness, edema peripheral, anemia, hypotension, pruritus, tachycardia, headache, insomnia, anemia postoperative, muscle spasms, hemorrhagic anemia, back pain, somnolence, and procedural pain. Adverse Reactions Reported in Nerve Block Clinical Studies The safety of EXPAREL was evaluated in four randomized, double-blind, placebocontrolled nerve block clinical studies involving 469 patients undergoing various surgical procedures. Patients were administered a dose of either 133 or 266 mg of EXPAREL. In these studies, the most common adverse reactions (incidence greater than or equal to 10%) following EXPAREL administration were nausea, pyrexia, and constipation. The common adverse reactions (incidence greater than or equal to 2% to less than 10%) following EXPAREL administration as a nerve block were muscle twitching, dysgeusia, urinary retention, fatigue, headache, confusional state, hypotension, hypertension, hypoesthesia oral, pruritus generalized, hyperhidrosis, tachycardia, sinus tachycardia, anxiety, fall, body temperature increased, edema peripheral, sensory loss, hepatic enzyme increased, hiccups, hypoxia, post-procedural hematoma. Postmarketing Experience These adverse reactions are consistent with those observed in clinical studies and most commonly involve the following system organ classes (SOCs): Injury, Poisoning, and Procedural Complications (e.g., drug-drug interaction, procedural pain), Nervous System Disorders (e.g., palsy, seizure), General Disorders And Administration Site Conditions (e.g., lack of efficacy, pain), Skin and Subcutaneous Tissue Disorders (e.g., erythema, rash), and Cardiac Disorders (e.g., bradycardia, cardiac arrest). DRUG INTERACTIONS The toxic effects of local anesthetics are additive and their co-administration should be used with caution including monitoring for neurologic and cardiovascular effects related to local anesthetic systemic toxicity. Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL. Patients who are administered local anesthetics may be at increased risk of developing methemoglobinemia when concurrently exposed to the following drugs, which could include other local anesthetics: Examples of Drugs Associated with Methemoglobinemia: Class Examples Nitrates/Nitrites nitric oxide, nitroglycerin, nitroprusside, nitrous oxide Local anesthetics articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, tetracaine Antineoplastic cyclophosphamide, flutamide, hydroxyurea, ifosfamide, agents rasburicase Antibiotics dapsone, nitrofurantoin, para-aminosalicylic acid, sulfonamides Antimalarials chloroquine, primaquine Anticonvulsants Phenobarbital, phenytoin, sodium valproate Other drugs acetaminophen, metoclopramide, quinine, sulfasalazine Bupivacaine Bupivacaine HCl administered together with EXPAREL may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. Therefore, bupivacaine HCl and EXPAREL may be administered simultaneously in the same syringe, and bupivacaine HCl may be injected immediately before EXPAREL as long as the ratio of the milligram dose of bupivacaine HCl solution to EXPAREL does not exceed 1:2. Non-bupivacaine Local Anesthetics EXPAREL should not be admixed with local anesthetics other than bupivacaine. Nonbupivacaine based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. There are no data to support administration of other local anesthetics prior to administration of EXPAREL.

GENERAL SURGERY NEWS / MAY 2020

The medical organizations said institutions need to weigh several factors in deciding which cases will take priority once operating rooms are reopened. These include: • previously canceled and postponed cases;

• objective priority scoring; • specialty prioritization for cancer, organ transplantation, cardiac surgery and trauma surgery; • a strategy for allotting daytime OR/ procedural time; • identification of essential health care professionals and medical device representatives per procedure; and

Other than bupivacaine as noted above, EXPAREL should not be admixed with other drugs prior to administration. Water and Hypotonic Agents Do not dilute EXPAREL with water or other hypotonic agents, as it will result in disruption of the liposomal particles USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary There are no studies conducted with EXPAREL in pregnant women. In animal reproduction studies, embryo-fetal deaths were observed with subcutaneous administration of bupivacaine to rabbits during organogenesis at a dose equivalent to 1.6 times the maximum recommended human dose (MRHD) of 266 mg. Subcutaneous administration of bupivacaine to rats from implantation through weaning produced decreased pup survival at a dose equivalent to 1.5 times the MRHD [see Data]. Based on animal data, advise pregnant women of the potential risks to a fetus. The background risk of major birth defects and miscarriage for the indicated population is unknown. However, the background risk in the U.S. general population of major birth defects is 2-4% and of miscarriage is 15-20% of clinically recognized pregnancies. Clinical Considerations Labor or Delivery Bupivacaine is contraindicated for obstetrical paracervical block anesthesia. While EXPAREL has not been studied with this technique, the use of bupivacaine for obstetrical paracervical block anesthesia has resulted in fetal bradycardia and death. Bupivacaine can rapidly cross the placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity. The incidence and degree of toxicity depend upon the procedure performed, the type, and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus, and neonate involve alterations of the central nervous system, peripheral vascular tone, and cardiac function. Data Animal Data Bupivacaine hydrochloride was administered subcutaneously to rats and rabbits during the period of organogenesis (implantation to closure of the hard plate). Rat doses were 4.4, 13.3, and 40 mg/kg/day (equivalent to 0.2, 0.5 and 1.5 times the MRHD, respectively, based on the BSA comparisons and a 60 kg human weight) and rabbit doses were 1.3, 5.8, and 22.2 mg/kg/day (equivalent to 0.1, 0.4 and 1.6 times the MRHD, respectively, based on the BSA comparisons and a 60 kg human weight). No embryo-fetal effects were observed in rats at the doses tested with the high dose causing increased maternal lethality. An increase in embryo-fetal deaths was observed in rabbits at the high dose in the absence of maternal toxicity. Decreased pup survival was noted at 1.5 times the MRHD in a rat pre- and post-natal development study when pregnant animals were administered subcutaneous doses of 4.4, 13.3, and 40 mg/kg/day buprenorphine hydrochloride (equivalent to 0.2, 0.5 and 1.5 times the MRHD, respectively, based on the BSA comparisons and a 60 kg human weight) from implantation through weaning (during pregnancy and lactation). Lactation Risk Summary Limited published literature reports that bupivacaine and its metabolite, pipecoloxylidide, are present in human milk at low levels. There is no available information on effects of the drug in the breastfed infant or effects of the drug on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for EXPAREL and any potential adverse effects on the breastfed infant from EXPAREL or from the underlying maternal condition. Pediatric Use Safety and effectiveness in pediatric patients have not been established. Geriatric Use Of the total number of patients in the EXPAREL local infiltration clinical studies (N=823), 171 patients were greater than or equal to 65 years of age and 47 patients were greater than or equal to 75 years of age. Of the total number of patients in the EXPAREL nerve block clinical studies (N=531), 241 patients were greater than or equal to 65 years of age and 60 patients were greater than or equal to 75 years of age. No overall differences in safety or effectiveness were observed between these patients and younger patients. Clinical experience with EXPAREL has not identified differences in efficacy or safety between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Hepatic Impairment Amide-type local anesthetics, such as bupivacaine, are metabolized by the liver. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations, and potentially local anesthetic systemic toxicity. Therefore, consider increased monitoring for local anesthetic systemic toxicity in subjects with moderate to severe hepatic disease. Renal Impairment Bupivacaine is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. This should be considered when performing dose selection of EXPAREL. OVERDOSAGE Clinical Presentation Acute emergencies from local anesthetics are generally related to high plasma concentrations encountered during therapeutic use of local anesthetics or to unintended intravascular injection of local anesthetic solution. Signs and symptoms of overdose include CNS symptoms (perioral paresthesia, dizziness, dysarthria, confusion, mental obtundation, sensory and visual disturbances and eventually convulsions) and cardiovascular effects (that range from hypertension and tachycardia to myocardial depression, hypotension, bradycardia and asystole). Plasma levels of bupivacaine associated with toxicity can vary. Although concentrations of 2,500 to 4,000 ng/mL have been reported to elicit early subjective CNS symptoms of bupivacaine toxicity, symptoms of toxicity have been reported at levels as low as 800 ng/mL. Management of Local Anesthetic Overdose At the first sign of change, oxygen should be administered. The first step in the management of convulsions, as well as underventilation or apnea, consists of immediate attention to the maintenance of a patent airway and assisted or controlled ventilation with oxygen and a delivery system capable of permitting immediate positive airway pressure by mask. Immediately after the institution of these ventilatory measures, the adequacy of the circulation should be evaluated, keeping in mind that drugs used to treat convulsions sometimes depress the circulation when administered intravenously. Should convulsions persist despite adequate respiratory support, and if the status of the circulation permits, small increments of an ultra-short acting barbiturate (such as thiopental or thiamylal) or a benzodiazepine (such as diazepam) may be administered intravenously. The clinician should be familiar, prior to the use of anesthetics, with these anticonvulsant drugs. Supportive treatment of

• phased opening of ORs and issues associated with increased OR/procedural volume. The ACS also issued a separate, more detailed guidance for resumption of elective surgery, including a 10-page checklist for facilities. The ACS statement highlights the need to track local capabilities and constraints, while monitoring for potential subsequent waves of COVID-19. The ACS checklist is separated into four categories: awareness, preparedness, patient issues and delivery of safe highquality surgery.

circulatory depression may require administration of intravenous fluids and, when appropriate, a vasopressor dictated by the clinical situation (such as ephedrine to enhance myocardial contractile force). If not treated immediately, both convulsions and cardiovascular depression can result in hypoxia, acidosis, bradycardia, arrhythmias and cardiac arrest. If cardiac arrest should occur, standard cardiopulmonary resuscitative measures should be instituted. Endotracheal intubation, employing drugs and techniques familiar to the clinician, maybe indicated, after initial administration of oxygen by mask, if difficulty is encountered in the maintenance of a patent airway or if prolonged ventilatory support (assisted or controlled) is indicated. DOSAGE AND ADMINISTRATION Important Dosage and Administration Information • EXPAREL is intended for single-dose administration only. • Different formulations of bupivacaine are not bioequivalent even if the milligram strength is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL. • DO NOT dilute EXPAREL with water for injection or other hypotonic agents, as it will result in disruption of the liposomal particles. • Use suspensions of EXPAREL diluted with preservative-free normal (0.9%) saline for injection or lactated Ringer’s solution within 4 hours of preparation in a syringe. • Do not administer EXPAREL if it is suspected that the vial has been frozen or exposed to high temperature (greater than 40°C or 104°F) for an extended period. • Inspect EXPAREL visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not administer EXPAREL if the product is discolored. Recommended Dosing in Adults Local Analgesia via Infiltration The recommended dose of EXPAREL for local infiltration in adults is up to a maximum dose of 266mg (20 mL), and is based on the following factors: • Size of the surgical site • Volume required to cover the area • Individual patient factors that may impact the safety of an amide local anesthetic As general guidance in selecting the proper dosing, two examples of infiltration dosing are provided: • In patients undergoing bunionectomy, a total of 106 mg (8 mL) of EXPAREL was administered with 7 mL infiltrated into the tissues surrounding the osteotomy, and 1 mL infiltrated into the subcutaneous tissue. • In patients undergoing hemorrhoidectomy, a total of 266 mg (20 mL) of EXPAREL was diluted with 10 mL of saline, for a total of 30 mL, divided into six 5 mL aliquots, injected by visualizing the anal sphincter as a clock face and slowly infiltrating one aliquot to each of the even numbers to produce a field block. Regional Analgesia via Interscalene Brachial Plexus Nerve Block The recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults is 133 mg (10 mL), and is based upon one study of patients undergoing either total shoulder arthroplasty or rotator cuff repair. Compatibility Considerations Admixing EXPAREL with drugs other than bupivacaine HCl prior to administration is not recommended. • Non-bupivacaine based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. • Bupivacaine HCl administered together with EXPAREL may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. Therefore, bupivacaine HCl and EXPAREL may be administered simultaneously in the same syringe, and bupivacaine HCl may be injected immediately before EXPAREL as long as the ratio of the milligram dose of bupivacaine HCl solution to EXPAREL does not exceed 1:2. The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to local anesthetic systemic toxicity. • When a topical antiseptic such as povidone iodine (e.g., Betadine®) is applied, the site should be allowed to dry before EXPAREL is administered into the surgical site. EXPAREL should not be allowed to come into contact with antiseptics such as povidone iodine in solution. Studies conducted with EXPAREL demonstrated that the most common implantable materials (polypropylene, PTFE, silicone, stainless steel, and titanium) are not affected by the presence of EXPAREL any more than they are by saline. None of the materials studied had an adverse effect on EXPAREL. Non-Interchangeability with Other Formulations of Bupivacaine Different formulations of bupivacaine are not bioequivalent even if the milligram dosage is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL and vice versa. Liposomal encapsulation or incorporation in a lipid complex can substantially affect a drug’s functional properties relative to those of the unencapsulated or nonlipid-associated drug. In addition, different liposomal or lipid-complexed products with a common active ingredient may vary from one another in the chemical composition and physical form of the lipid component. Such differences may affect functional properties of these drug products. Do not substitute. CLINICAL PHARMACOLOGY Pharmacokinetics Administration of EXPAREL results in significant systemic plasma levels of bupivacaine which can persist for 96 hours after local infiltration and 120 hours after interscalene brachial plexus nerve block. In general, peripheral nerve blocks have shown systemic plasma levels of bupivacaine for extended duration when compared to local infiltration. Systemic plasma levels of bupivacaine following administration of EXPAREL are not correlated with local efficacy. PATIENT COUNSELING Inform patients that use of local anesthetics may cause methemoglobinemia, a serious condition that must be treated promptly. Advise patients or caregivers to seek immediate medical attention if they or someone in their care experience the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath; lightheadedness; or fatigue.

Pacira Pharmaceuticals, Inc. San Diego, CA 92121 USA Patent Numbers: 6,132,766 5,891,467 5,766,627 8,182,835 Trademark of Pacira Pharmaceuticals, Inc. For additional information call 1-855-RX-EXPAREL (1-855-793-9727) Rx only November 2018

‘It’s going to be a challenge, obviously, to restart elective surgery and get caught up, but we’ll get there.’ —David Hoyt, MD, Executive Director, ACS The ACS asked surgeons to know their community’s COVID-19 numbers, including prevalence, incidence and isolation mandates. It also is imperative that surgeons know the local COVID19 testing availability, and policies for patients and health care workers. The organization called on surgeons to get involved in setting policies at their institution. “Surgeons should be involved in institutional policymaking since the risk to the patient and the staff varies with the type of procedure, the patient’s condition, local circumstances and over time. Some surgeon discretion is necessary and should be permitted,” the ACS said. The surgical organization cautioned that testing availability might decrease as community testing demands increase. The ACS also highlighted the need for retesting of patients, noting false-negative results have been reported to be as high as 30%. “It’s going to be a challenge, obviously, to restart elective surgery and get caught up, but we’ll get there,” said David Hoyt, MD, the executive director of the ACS. The ACS has been involved in disaster planning for four decades, particularly in the area of trauma and mass casualty events. But the pandemic required an approach on an unprecedented scale with the number of cities and countries affected. “What we experienced is really the exhaustion of resources,” Dr. Hoyt said. “I personally could not be prouder of the way surgeons and hospitals and nurses and everybody pulled together to do what’s right for our patients.” The ACS has developed a COVID-19 registry, available to all hospitals. The registry, which was developed by experts currently treating COVID-19 patients, will collect data on COVID-19 patients who undergo surgery and those who did not. All surgeons who are interested in participating are asked to contact COVID19registry@facs.org or Amy Sachs, the senior manager, ACS Program and Registry Operations, for more information. The Ambulatory Surgery Center Association issued a statement to support lifting the pause in elective, nonurgent surgery: “The reality is that regions across the nation are impacted by COVID-19 to varying degrees. There are some communities that are ready for a strategic restart of deferred healthcare at this time, while continuing to focus on ■ limiting COVID-19 spread.”

IN THE NEWS

MAY 2020 / GENERAL SURGERY NEWS

Breast Surgery During COVID-19: A Stratified Approach By MONICA J. SMITH

he coronavirus pandemic has placed unprecedented demands on doctors across the United States, not only in caring for the legions ill with COVID-19, but in making care decisions for their usual patient population, of whom cancer patients pose a unique challenge. To help the multidisciplinary teams that care for breast cancer patients, five medical societies recently released recommendations to help these care teams navigate this uncertain time. â&#x20AC;&#x153;The idea was to provide guidance for triaging patients, looking at the benefits and risks of not just delaying treatment but also the possibility of exposure to COVID-19, and the community risks of using up personal protective equipment and other resources,â&#x20AC;? said Jill Dietz, MD, the director of breast operations at University Hospital of Cleveland in Ohio, president of the American Society of Breast Surgeons (ASBrS) and lead author of the recommendations. The joint commission, composed of the ASBrS, the National Accreditation Program for Breast Centers, the Commission on Cancer, the American College of Radiology and the National Comprehensive Cancer Network, stratified patients into three priority levels across the disciplines of surgical oncology, medical oncology and radiation oncology depending on the urgency of their situation. â&#x20AC;˘ Priority A patients are those with immediately life-threatening or symptomatic illnesses requiring urgent treatmentâ&#x20AC;&#x201D;for example, a hemodynamically unstable patient with an expanding hematoma. â&#x20AC;˘ Priority B patients, who comprise the majority, are those who can delay treatment for the time being (although not indefinitely)â&#x20AC;&#x201D;for example, a patient who is finishing or progressing with neoadjuvant treatment. â&#x20AC;˘ Priority C patients are those whose treatment can safely wait until the pandemic has concludedâ&#x20AC;&#x201D;for example, a patient with ER-positive ductal carcinoma in situ. â&#x20AC;&#x153;You canâ&#x20AC;&#x2122;t predict every single scenario, but there is some tiered generality in these priority classifications. If the patientâ&#x20AC;&#x2122;s situation falls outside of the classification, you use your best judgment as to which priority is the closest match,â&#x20AC;? Dr. Dietz said. Her team and others are using the recommendations during their multidisciplinary tumor boards, going over each patientâ&#x20AC;&#x2122;s situation and discussing both the standard recommendation and the COVID-19 era alternative. â&#x20AC;&#x153;For example, the standard

recommendation for a patient with a 1.5cm, ER [estrogen receptor]/PR [progesterone receptor]-positive, HER2-negative, clinically node-negative tumor would be lumpectomy, sentinel lymph node (SLN) biopsy, hormonal therapy and postoperative radiation,â&#x20AC;? Dr. Dietz said. â&#x20AC;&#x153;The COVID-19 recommendation would be hormone therapy and, when the pandemic is over, lumpectomy, SLN and radiation.â&#x20AC;? For this patient, who would fall into

the C priority category, strong evidence indicates there is no difference in survival whether they undergo surgery early or delay it while on a regimen of hormone therapy. The trickier decisions will involve certain B priority patients who are at higher risk for poorer outcomes if surgery is delayed. â&#x20AC;&#x153;We always want to do standard of care in those situations, but if the institution does not have the resources, or if the patient is exposed to COVID-19 and

develops it, we havenâ&#x20AC;&#x2122;t done that patient any favors,â&#x20AC;? Dr. Dietz said. The recommendations note that physicians will need to take into account local conditions when determining patient priority categories. â&#x20AC;&#x153;This is kind of like being hit by a tsunami,â&#x20AC;? said Benjamin O. Anderson, MD, a professor of surgery at the University of Washington in Seattle, and a co-author of the recommendations. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s amazing how much change continued on page 14

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IN THE NEWS

Ventral Hernia Repair in Obese Patients: Risks and Benefits Approaching a Bariatric Patient With an Unexpected Hernia By MONICA J. SMITH

New York—As much as 60% of the 350,000 patients who undergo ventral hernia repair every year meet the criteria for obesity. Despite the frequency with which surgeons see such patients, there is little consensus on how to treat them: Laparoscopic or open? Primary repair or mesh-enforced? Concomitant with bariatric surgery or delayed? “We see a lot of obese patients with ventral hernias, and most of the time we don’t know what to do,” said Pablo Omelanczuk, MD, the director of the Mendoza Obesity and Surgery Center, in Argentina. “With a body mass index (BMI) of more than 50, the risk of any complication in any kind of surgery is more than 20%; you always have to think of the risks and benefits of doing a repair in these patients.” At the 2019 Controversies, Problems and Techniques in Surgery meeting, Dr. Omelanczuk described the link between obesity and hernia formation, the risks of surgery in this patient population, and an algorithm for guiding treatment in bariatric patients with ventral hernias.

Obesity and Ventral Hernia Risk: A Matter of Biology? The correlation between obesity and ventral hernia has long been known, but the understanding behind what drives this correlation has become more sophisticated in recent years. It is not only a mechanical problem. A 2015 paper evaluating biopsies from the rectus sheath of bariatric and nonbariatric patients found a decrease of both type I and type III collagen in the former, possibly due to changes in messenger RNA (J Surg Res 2015;195[2]:475-480). “The same thing has been found with elastin,” Dr. Omelanczuk said. “These alterations in connective tissue can be causes of the tissue pathology of the hernia.” Obesity also has an impact on OR resources. In a database evaluation of nearly 190,000 patients undergoing 14 types of procedures, the authors noted a stepwise increase in procedure time by BMI category for all procedures. Nonoperative OR time also was drawn out (World J Surg 2018;42[10]:3125-3133). “Obese patients require additional time for any kind of surgery,” Dr. Omelanczuk

COVID-19 Blogs

Flattening the Curve Brought to You by Your Friendly Neighborhood Health Care Heroes By Maria Baimas-George, MD

‘If the hernia needs to be taken down at the time of the bariatric operation, it should be fixed. Whether primarily or with mesh depends on the size of the hernia and location, and whether synthetic or biologic mesh is used depends on the amount of contamination.’

—Emanuele Lo Menzo, MD, PhD

said, noting that of the three types of procedures most affected by obesity, ventral hernia repair was No. 1, followed by laminectomy and hysterectomy.

Risks of Surgery in Obese Patients Although there is a range of outcomes reported in the literature, obesity is generally associated with a higher risk for recurrence, complications and infection; longer procedural time; and greater length of stay in patients undergoing hernia repair. Patients with metabolic syndrome (MetS) may be at an especially high risk for poorer outcomes. A review of 39,118 patients with or without MetS undergoing ventral hernia repair found the former more likely to have an ASA physical status of III or higher, more likely to require emergency surgery, required longer operative times, had a longer length of stay, and had more complications related to the wound (Surg Obes Relat Dis 2018;14[2]:206-213). “They also had more readmissions, more reoperations and a higher risk of death,” Dr. Omelanczuk said. Not surprisingly, he takes MetS into consideration while making treatment decisions when bariatric patients present with a ventral hernia in need of repair, and there are a lot of treatment decisions to consider.

Hernia Repair in Bariatric Patients

This cartoon and other surgeon-authored COVID-19 blogs can be found at www.generalsurgerynews.com.

“When we find an unexpected ventral hernia during bariatric surgery, or when we already know the patient has a ventral hernia, we can do nothing and leave the omentum in place; we can close the defect laparoscopically with no mesh according to the size of the defect; we can repair the hernia with a synthetic mesh, close the defect with a biological mesh, or close the defect with a bioabsorbable mesh,” Dr. Omelanczuk said.

The algorithm that he and his colleagues use considers both patient and hernia characteristics (body habitus, hernia size and location, weight, body wall thickness) and the presence or absence of hernia-related symptoms. “If the patient has favorable anatomy (gynecoid body habitus, centrally located hernia <8 cm, a BMI under 50, body wall thickness <4 cm) and is symptomatic, we can do a laparoscopic ventral hernia repair (LVHR) first and delay the bariatric surgery; if the patient is asymptomatic, we can do the LVHR and bariatric procedure at the same time.” If the patient has unfavorable anatomy (android body habitus, peripherally located hernia >8 cm, body wall thickness >4 cm) and is symptomatic, they try nonsurgical weight loss before LVHR followed by bariatric surgery, reversing the order of procedures if the patient is asymptomatic. “We always prefer to do the bariatric surgery first, then repair the hernia,” Dr. Omelanczuk said. Emanuele Lo Menzo, MD, PhD, the director of the Department of Clinical Research and an associate professor of surgery at Cleveland Clinic Florida, in Weston, also prefers to do hernia repair after patients have lost some weight after bariatric surgery. “But if the hernia needs to be taken down at the time of the bariatric operation, it should be fixed. Whether primarily or with mesh depends on the size of the hernia and location, and whether synthetic or biologic mesh is used depends on the amount of contamination.” The type of bariatric procedure being performed may influence mesh decision. Although both Roux-en-Y gastric bypass and sleeve gastrectomy are considered clean–contaminated cases, this may not be entirely true for sleeve gastrectomy. “There is evidence, including from our group, that certain procedures, such as the sleeve gastrectomy, do not seem to have contamination,” Dr. Lo Menzo said. “We’ve found there is no bacterial contamination in the abdominal cavity, ■ as opposed to a gastric bypass.”

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FIRST LOOK

GENERAL SURGERY NEWS / MAY 2020

Southeastern Surgical Congress 2020 A First Look at Research Presented at the Annual Meeting All Articles by MONICA J. SMITH

ERAS Surprise: Protocol Falls Short on Outcomes, Cost for Colon Resection on New Orleans—Enhanced recovery after surgery pro- 498 between implementation and 2017. Before impletocols are associated with reduced hospital length of mentation, the most frequently performed surgery was right colectomy; after implementation, sigstay, fewer complications and lower costs, moidectomy was most commonly perbut one institution found no improvep formed. (Less commonly performed were ment in outcomes and higher her left colectomy, transverse colectomy and costs after implementing an n low anterior resection). ERAS protocol. They found a general cost increase that was “ERAS has been wide-statistically significant for every site of resection ly studied and accepted; except transverse colectomy. “That did have a however, more recent more than $2,000 increase, but with the low data have contradicnumber of procedures, it failed to reach statory findings, calltistical significance,” Dr. Landry said. ing into question the There was a smaller difference in the cost true impact of the proincrease with the frequenttocol’s benefit,” said ly performed right colectomy Miles Landry, MBBS, Length of stay improved and sigmoidectomy procethe academic chief resin the laparoscopic initially l dures, “which suggests we’re ident at the University of gaining some level of efficienTennessee Medical Center, in surgery cohort, but then cy from doing those more Knoxville. “We wanted to look at returned to average. regularly,” Dr. Landry said. the impact on outcomes and cost, and to furHospital length of stay, ther investigate if site of resection had an averaging 4.5 days for open procedures and 3.5 days influence on these results.” Dr. Landry and his colleagues evaluated data on 598 for minimally invasive procedures prior to the protocol, patients undergoing elective colon resection, 100 before improved initially in the laparoscopic surgery cohort, the implementation of an ERAS protocol in 2014, and but then returned to average.

“Is this a worthwhile thing to do? I think if we can truly establish the preoperative and perioperative factors that identify patients who would be in the hospital for five to seven days rather than two to three, we’ll be able to see the real benefit of the ERAS protocol,” Dr. Landry said. He presented his study at the 2020 Southeastern Surgical Congress (abstract 67). Russell Farmer, MD, an assistant professor of colon and rectal surgery at the University of Louisville, in Kentucky, congratulated the authors for examining a topic that is becoming a standard of care in minimally invasive colectomy. “Many accrediting bodies outside the [United States] include ERAS protocol components as a mandatory part of their board examination,” he said. Dr. Farmer asked if the shift from right colectomy to sigmoidectomy might have affected the researchers’ findings. “I do think that hints at the idea that the expected outcomes for patients would have been different as we included more difficult patients, but we didn’t design the database that way. That’s a key component that we’ll include in future evaluations,” Dr. Landry said. “I do think there is a population that will benefit from this protocol; being able to customize our medical care is a goal of this process,” he added.

Geriatric Patients See Similar Outcomes After Lap Hernia Repair New Orleans—Geriatric patients who undergo laparoscopic ventral hernia repair tend to have more comorbidities and larger hernias than younger patients, but their outcomes and quality of life may be similar to those of younger patients, according to new research. “Laparoscopy has been shown to improve morbidity and postoperative recovery in many patient populations. Furthermore, laparoscopic ventral hernia repair [LVHR] has been shown to decrease wound complications and shorten length of stay [LOS]. But there’s minimal data for LVHR in the geriatric population,” said Sharbel Elhage, MD, a general surgery resident physician at Atrium Health’s Carolinas Medical Center in Charlotte, N.C. To evaluate postoperative outcomes and QOL after LVHR in geriatric patients, Dr. Elhage and his colleagues queried their institution’s prospectively enrolled database for all patients undergoing LVHR and divided them into three groups: patients under 40 years of age, patients between 40 and 64, and patients 65 and older. They used the Carolinas Comfort Scale to measure QOL, choosing a score of 2 (mild but bothersome) as

indicative of nonideal to QOL. Nearly 1,200 patients met the inclusion criteria. “As expected, the geriatric group had higher rates of nearly all comorbidities, including pulmonary, cardiac and diabetes; body mass index was higher in the younger population,” Dr. Elhage said. The older population also had larger defects, but their number of prior recurrences was similar to that of the younger cohorts.

The hernia-specific outcomes were similar among the three cohorts, with the exception of seroma requiring intervention, which was slightly higher in the geriatric group. Recurrence, too, was similar among all groups, at 5.7% with a mean follow-up of 44 months. The team assessed pain, mesh sensation, activity limitation and overall QOL at two weeks, one month, six months and

‘Pain was lower in the geriatric group at two weeks and 12 months, but similar at one month and six months.’ —Sharbel Elhage, MD

12 months. They found mesh sensation similar among the three groups. “Interestingly, pain was lower in the geriatric group at two weeks and 12 months, but similar at one month and six months,” Dr. Elhage said. Activity limitation and overall QOL were also better in the geriatric group at two weeks, but equivalent to the other age cohorts at all other time points. Dr. Elhage presented his research at the 2020 Southeastern Surgical Congress. Stephen McNatt, MD, an associate professor of surgery at Wake Forest School of Medicine, in Winston-Salem, N.C., said, “This gives us great insight into how this operation affects people.” But he questioned the paradoxical relationship between QOL and LOS, which was five days in the geriatric population, compared with about three and four days in the other age cohorts. “I think the greater LOS may have to do with their comorbidities, not necessarily hernia-related complications but urinary retention and postoperative ileus, plus just general recovery in the older population; good pain control could explain the QOL,” Dr. Elhage said.

FIRST LOOK

MAY 2020 / GENERAL SURGERY NEWS

Oral, IV Acetaminophen Equally Effective for Rib Fracture in Elderly New Orleans—Elderly trauma patients, an ever-increasing population, may experience just as much pain control from oral medication as from IV acetaminophen, according to new research. “Rib fractures are the most common chest injuries in patients over the age of 65, and pain is the most common symptom after rib fracture. We wanted to see if oral acetaminophen was as effective at controlling pain as IV acetaminophen,” said Andrew C. Antill, MD, a thirdyear general surgery resident at the University of Tennessee Medical Center, in Knoxville.

due to the high cost of IV acetaminophen,” Dr. Antill said, noting that the cost difference is significant. According to numbers he pulled from the company’s website, a single dose of IV acetaminophen is $180.00 and a single dose of oral acetaminophen is $0.45, a difference of about 400-fold. Dr. Antill presented his research at the 2020 Southeastern Surgical Congress. Philip Ramsay, MD, a general and trauma surgeon in Atlanta, affiliated with Wellstar Atlanta Medical Center,

called the paper important and relevant given the aging population. “We are seeing more elderly trauma patients; we’re trying to decrease the use of opiates; and we are expected to provide excellent health care while decreasing health care costs,” Dr. Ramsay said. He observed, however, that nearly 35% of patients were excluded due to missed doses of medication and documentation of doses given; he questioned the accuracy of the pain scores. “We had specific documentation

marking every dose of medication and documenting pain scores, so I would think they were pretty accurate,” Dr. Antill said. One limitation is that the study reached only 30% of required power. It was performed over a three-year period, after which it ran out of funding. “But it was clear by then that there wasn’t a difference,” Dr. Antill said. “There is an opportunity here for further research in a generalized trauma study in a multi■ center setting.”

In High-risk Breast Cancer a Single dose of oral acetaminophen:

Neoadjuvant Therapy Surgery Together

$0.45

Single dose of IV acetaminophen:

$180.00

Difference:

400-fold

Preoperative systemic therapy PD\ EHQHˋW FHUWDLQ KLJK ULVN breast cancer patients1,2,a

Considerations and Potential Concerns Associated With Neoadjuvant Treatment

Potential preoperative benefits include3,b:

• Consider the potential concerns associated with neoadjuvant treatment for early breast cancer3,5

• Downstaging the tumor • Breast conservation • Assessment of tumor response to systemic therapy

– Risk of disease progression during preoperative systemic therapy • Reduced window of opportunity for fertility preservation5

Potential long-term benefits To do so, Dr. Antill and his colleagues randomized patients aged 65 years and older with at least one rib fracture to either IV acetaminophen plus oral placebo or IV placebo plus oral acetaminophen. Their primary end point was a mean reduction in pain score at 24 hours; they also evaluated opioid use, ICU and hospital length of stay, use of adjunctive pain control, and development of pneumonia. Ultimately 138 patients were included in the final analysis, with 63 in the IV drug and oral placebo group, and 75 in the oral acetaminophen and IV placebo group. There was no statistically significant difference in the reduction of pain; at 24 hours, both groups reported a mean pain score reduction of 1 point. There was also no statistically significant difference in the secondary end points. “Oral acetaminophen should be the drug of choice whenever possible

in neoadjuvant patients who achieved a pCR (vs those who did not) include3,b: • Favorable event-free survival • Favorable overall survival Patients with more aggressive subtypes have been shown to have an increased likelihood of achieving a pCR.2

• Accurate clinical staging at baseline is essential before initiating neoadjuvant treatment3,5 – There is a risk of overtreatment with systemic therapy if patient’s clinical stage is overestimated – There is a risk of undertreatment with certain therapies if patient’s clinical stage is underestimated

Consider Neoadjuvant Therapy for high-risk patients, such as stage II and III TNBC and HER2+ breast cancer patients1,3,a Learn more at WhyNeoadjuvant.com “High-risk” defined as early stage breast cancer patients who have a high risk of distant disease recurrence and death despite use of optimal modern local and systemic adjuvant therapy.4

CTNeoBC pooled analysis: 12 international trials of 11,955 patients with breast cancer treated with preoperative chemotherapy followed by surgery, with available data for EFS, OS, and pCR; pCR was not the primary end point for evaluation. Three most commonly used definitions of pCR were evaluated for their association with EFS or OS. Patients who attained pCR demonstrated improved EFS and OS vs those who had residual disease. The prognostic value was greatest in aggressive tumor subtypes, particularly TNBC and HER2+.2

CTNeoBC = Collaborative Trials in Neoadjuvant Breast Cancer; EFS = event-free survival; HER2 = human epidermal growth factor receptor 2; OS = overall survival; pCR = pathological complete response; TNBC = triple-negative breast cancer.

References: 1. Wirapati P, Sotiriou C, Kunkel S, et al. Meta-analysis of gene expression profiles in breast cancer: toward a unified understanding of breast cancer subtyping and prognosis signatures. Breast Cancer Res. 2008;10(4):R65. doi:10.1186/bcr2124. 2. Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet. 2014;384(9938):164–172. 3. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer V.1.2019. © National Comprehensive Cancer Network, Inc. 2019. All rights reserved. Accessed April 11, 2019. To view the most recent and complete version of the guidelines, go online to NCCN.org. 4. US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research (CDER). Guidance for industry. Pathological complete response in neoadjuvant treatment of high-risk early-stage breast cancer: use as an endpoint to support accelerated approval. www.fda.gov/downloads/drugs/ guidances/ucm305501.pdf. Published October 2014. Accessed April 16, 2019. 5. Cain H, Macpherson IR, Beresford M, et al. Neoadjuvant therapy in early breast cancer: treatment considerations and common debates in practice. Clin Oncol. 2017;29(10):642–652.

OPINION

GENERAL SURGERY NEWS / MAY 2020

Conquering Fear in Times of Epidemics By PAULA MU TO, MD, FACS

he past few weeks have been unprecedented in my career as a surgeon. The sweeping response to this global COVID-19 pandemic—to mobilize resources, restrict social behaviors and curtail businesses—is far beyond any previous modern health threat. What makes this particularly frightening is how many of my colleagues on the front lines have contracted the virus, become critically ill or even died. But this isn’t the only contagious disease in recent history. As a medical student in New York in the late 1980s, another deadly illness was wreaking havoc on all ages including newborns, and also posed a threat to doctors—surgeons in particular. As medical students across the country are graduating early to help staff hospitals, I am reminded how their future in medicine will be shaped by their experience today. I remember how excited we were to start our third year of medical school. After two years of sitting in a lecture hall and memorizing endless amounts of information, we would finally have a chance to put on a white coat and take care of patients. I was assigned to three months of internal medicine at Lincoln Hospital in the South Bronx, a rotation known for being fast paced and where a medical student “could do a lot.” It was also one of many hospitals in New York City at the time that was overwhelmed with patients suffering from AIDS and AIDS-related complex. Looking back, it all seems a little surreal, given the way we were thrown into the thick of things with little to no preparation. Compared with today’s standards, there was no training in HIPAA compliance or diagnosis coding. Instead, at the start of every rotation they threatened us with $10,000 fines if we failed to dispose of medical waste or sharp objects properly. We didn’t need much convincing as medical waste washing up on local shore lines was a frequent story on the nightly news. Either way, we were fearful enough that a bloody needle, under the right circumstances, could turn into a weapon of mass destruction. My very first patient was a 35-year-old woman with a history of IV drug abuse, who was admitted to the hospital with fever and pneumonia. She was cachectic, with a hollow expression that over time would become an instantly recognizable measure of months spent suffering from the effects of an immune system under attack by a relentless enemy. She was cooperative and patient, allowing me to “practice” drawing blood and placing an IV. Her X-ray showed a familiar pattern

of patchy infiltration. She was started on antibiotic therapy with a presumptive diagnosis of Pneumocystis pneumonia (PCP), one of the opportunistic infections that turned someone who was HIV-positive into a full-blown AIDS patient. This was a question that an eager medical student was expected to answer correctly on teaching rounds, not having to acknowledge its grim meaning for the patient. The sheer number of patients suffering from HIV at the time was almost

hard to believe. It seemed nearly every admission was yet another form of a disease that had barely even made it into our textbooks. Toxoplasmosis, Kaposi’s sarcoma and cryptococcal meningitis were routine diagnoses, and yet there were many patients without obvious infection but tested positive for HIV. Because patients could spread the disease through bodily fluids, all patients were considered risky, so we adopted a policy of universal precautions. The HIV

epidemic defined all patient interactions. We learned how to take care of contagious disease, how to protect ourselves and others, and how to temper our fears with knowledge and common sense. We also followed the lead of our mentors: in my case, my father, a thoracic surgeon and an inventor who developed a disposable catheter to diagnose PCP without the need for a surgical procedure. He was at the side of any patient who needed him, well trained and skillful. He had

L I

OPINION

My hope is that our students will learn, as we did, not to run away from a patient’s bedside, but be guided by an understanding of the risks—real, not imagined.

a healthy respect for infectious pulmonary diseases and understood the risks for transmission, but did not allow fear to prevent him from doing his best for a patient. My patient recovered and was discharged, only to be readmitted at the end of my rotation. Once again, she was kind enough to allow me to place her IV and draw her blood. I was much more adept at it by now. I stopped by her room on my way home one evening, listened to her lungs, quickly palpated her abdomen, and then found myself sitting by her side with my hand resting

reassuringly on her arm. All of a sudden one of my attendings pulled me by the arm, yanked me off the bed and out of the room, as if he were saving me from viral contamination. I often think of that moment. Even at the time, we knew sitting next to or holding the hand of an AIDS patient would not spread the disease, and yet my attending, motivated by fear or protective instinct, wanted me to be cautious. Given what we know about COVID-19, I suppose I could have unknowingly carried a pathogen to another patient’s room. But being a good doctor requires you to be both reasonable and compassionate, knowing how to differentiate what is possible from what is likely, and proceed accordingly without significant anxiety. The key is understanding the science; and with current technology, like artificial intelligence, we can process and share data exponentially faster than we could 30 years ago. In the case of COVID-19, I imagine this generation of students will learn a whole new set of ways to prevent airborne illness, and more importantly how not to spread it to themselves or others. In fact, better handwashing techniques should lead to a drop in other nosocomial infections that cause significant morbidity and mortality, such as methiciliin-resistant Staphylococcus aureus and Clostridioides difficile, much like the proper disposal of sharps decreased the risk for hepatitis from needlesticks. Best practices are often derived from a response to a crisis or when existing practice fails to solve the problem. The sheer number of patients will make these inexperienced doctors experts in the diagnosis and management of viral pneumonia. Although COVID-19 is not as deadly as AIDS was, its rapid onset, casual transmission and potential for serious respiratory failure makes it a much more tangible threat. My hope is that our students will learn, as we did, not to run away from a patient’s bedside, but be guided by an understanding of the risks—real, not imagined. Despite starting my career at a time of a deadly epidemic, I faced my fears, became a surgeon, and have safely operated on many patients over the years with HIV and other equally threatening diseases. I learned from my father that good training and experience mitigate fear, and allow you to do your best. I have no doubt that for those students working on the front lines, their future will be shaped by the events of today, and what ■ an exciting future it will be. —Dr. Muto is a vascular and general surgeon in solo practice. She is the founder and CEO of UBERDOC and the director of Vein Center at Mutosurgical, in North Andover, Mass.

THE SURGICAL PAUSE

GENERAL SURGERY NEWS / MAY 2020

Feet Firmly on the Ground: COVID-19 By MELISSA RED HOFFMAN, MD, ND

awoke with a jolt and fumbled around for my phone to check the time: 1:45 a.m. I was once again wide awake, four hours past falling into yet another restless, exhausted sleep and three hours from my morning alarm. The past few days were all the same: exercise, go to work, return home exhausted (both mentally and physically), succumb to an angry sleep, wake in the middle of the night, lie in bed while my mind wrestled with (and mostly lost to) anxiety and fear, repeat. Every night, the same questions haunted me: How in the hell was I truly going to avoid getting infected? What limits would I really be willing to place upon the care I received? And ultimately, would I die from this disease? I willed myself to return my phone to my night table, to not fall down the rabbit hole of Twitter, Facebook and The New York Times. Instead, my mind wandered from proning, PEEP and PPE to a decidedly simpler time in my life when I studied naturopathic medicine and yoga in Portland, Ore. My teacher would regale us with poetry by Mary Oliver as we drifted off to sleep during savasana [corpse pose].

defeated. “What?” he hollered when I asked him how he was feeling. “I can’t hear you! I lost my hearing aid!” After a series of hand motions and a lot more yelling between us, I finally located his hearing aid lying under the bed. “So, tell me,” I asked once the hearing aid was in place. “How are you feeling?” “I’m scared, Doc. I was a medic in Vietnam. Did I tell you that?” I began to assure him that yes, he had told me that yesterday, as well as two days before, but he kept talking. “And I was scared then. But I’m scared now, way more scared. What if this kills me?” I had no easy answers. Instead, I cleaned off his bedside table, arranged his breakfast and handed him an opened carton of milk. We called his son on speakerphone so I could provide an update. He shared stories of battling cancer and again declared, “I’ve never been so scared.”

You do not have to be good Yes, the past few days had all been the same, but they were remarkably more different than anything I experienced in my two decades in medicine. As I walked into the hospital that morning, I was greeted by a line of coworkers waiting to be queried about fever, cough, sore throat and potentially unprotected exposures. After passing the brief screen, I grabbed a mask and then was scolded for not slathering my hands with sanitizer. As I walked to my office, I wavered between feeling immensely grateful that my hospital had PPE and immensely annoyed that I was treated (and reacted) like a petulant child. I had gotten into the habit of seeing the few patients under investigation on my list first. As I trudged up the stairs to the COVID-19 rule-out ward, I wavered again, this time between feeling exceedingly grateful that the majority of my patients were not suspected to have COVID-19 and exceedingly guilty that I was hesitant to round on the few patients who were potentially infected. How could I justify my fear while colleagues just 700 miles north were rushing between rooms with no PPE, rounding on patients who were all presumed to be positive? Tell me about your despair, and I will tell you of mine I donned a mask, face shield, gown and gloves and entered John’s room. He was lying cattywampus across the bed, fumbling with his sheets and looking utterly

Breast Cancer continued from page 7

has taken place, but it’s not synchronous. Each institution has to adapt to their own resources when the wave hits.” The recommendations also acknowledge that an intervention in one specialty will have an effect on others, for example, deferring surgery places a heavier burden on medical oncologists. “This does add significantly to patient visits. We’re

My next three patients were similar to John—elderly, disoriented and frightened. In between asking about symptoms and examining wounds, I made certain to do all of the tasks I often rely on families to perform: I straightened sheets, opened milk cartons and wiped crumbs from gowns. I called each family with an update and was met with a mixture of anger, fear, sadness and relief. Of all the palliative care skills that I’ve learned over the years, the one that seems to come most naturally to me is empathetic presence, the ability to hold space for all the feelings. And so as I called each family, I did one of the few things I could do: I listened. When silence didn’t seem appropriate, I acknowledged that with “Yes, this is a frightening time.” I asked, “Please tell me more about your loved one.” And I encouraged: “Keep talking. I am here for you.” Meanwhile the world goes on Next, I headed downstairs to round on the rest of my list. One patient recounted, in painstaking detail, his memories of his entire ICU admission, including days of intubation, deep suctioning and painful dressing changes. Another patient had a wound infection that was going to require conscious sedation and a bedside debridement. A

managing this, but it’s an issue we are aware of,” Dr. Anderson said. He advises cancer care teams to be proactive in preparing for a potential surge of COVID-19 patients in their state, and to plan ahead as well as possible. “You don’t want to be making this up as you go along; you need to have standard protocols everyone can agree to.” Convincing patients about their care, too, may be more effective as a group effort. “They are understandably fearful. It

Issues in Surgical Palliative Care third had just ripped out both his IVs and his nasogastric tube, and was vomiting into his lap. None had COVID19 but all were suffering, both physically and emotionally. Whoever you are, no matter how lonely, The world offers itself to your imagination … On my way to the OR for an emergent laparotomy, I took a quick detour outside. I peeled my mask away from my nose and mouth and turned my face toward the sun. As my black jacket absorbed the heat, I reveled in the utterly delicious feeling of being warmed from the outside in. Two purple Eastern Redbud trees bloomed against a shockingly blue sky and, beyond that, the Blue Ridge Mountains showcased their splendid mirage. I sat down and, as I have been prone to do these past few weeks, started to cry. “Red, are you okay?” asked a familiar voice. I turned around and realized I had walked past a favorite work friend sitting on a nearby bench. Just as I had done for the patients and their families, she offered me several precious moments of empathetic presence. Few words were exchanged and, as has become our collective custom, no hugs were given. But as I walked into the OR, I felt more grounded and more connected than I had in days. … Announcing your place In the family of things As I donned another mask, face shield, gown and gloves, I had no new answers about avoiding infection. As I paused for a timeout, I had no greater understanding of my personal health care preferences. And as my scalpel slid through skin, I had no less anxiety about dying from this awful disease. But for the moment, my feet were firmly planted on the OR floor, my mind was firmly focused on the patient in front of me, and my heart felt firmly connected to all of those in health care ■ who do what we do. [Excerpts from the poem “Wild Things” (1994) by Mary Oliver are indicated in bold text throughout article.] —Dr. Hoffman is an acute care surgeon and hospice attending in Asheville, N.C. You can listen to her podcast, The Surgical Palliative Care Podcast, at https://apple.co/33H6s5w.

may help if you communicate to them that the decision to delay surgery wasn’t one surgeon’s decision, but a decision made by the whole group and applied consistently across the panel,” Dr. Anderson said. Although it is always important, “the doctor–patient relationship is especially critical at this time to help patients understand the risks of treatment versus the benefits,” Dr. Dietz said. Dr. Anderson is hopeful that lessons learned during the pandemic might

ultimately change medicine for the better. “If you’d asked me last December if we could use telemedicine to do postoperative visits and maybe some pre-op, I’d have said, ‘yeah, maybe in 2030.’ But now we’re learning to do things that could improve patient care that we would otherwise have been slow to adopt.” The recommendations are available on each of the five societies’ websites, and will be published in Breast Cancer Research ■ and Treatment.

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Financial Aid for Surgeons: Relief Is Available continued from page 1

postponement of elective procedures— “has been devastating,” she said. “In a typical day, I would see anywhere from 20 to 30 patients. Right now, I’m seeing two. In a typical week, I would do probably at least 10 surgeries and 10 additional procedures. In the last two weeks, I did zero surgeries, and next week I’ll be doing two.” Dr. Gwon, like others, has moved largely to telehealth appointments. She furloughed half her staff and moved the rest

to half-time work. The few patients still coming to the office for postoperative care are seen one at a time, while she and her staff wear masks and sanitize the room and waiting area as soon as they leave. “I’m wondering how many of us are going to be able to survive this,” Dr. Gwon told General Surgery News. She and others working in rural communities at least get paid to take call, which is enough to keep her “limping along so that I don’t think I’ll have to close,” she said.

“For doctors who have purely elective practices, who don’t take call or have an alternate way to generate income, this is going to be a really tough time for them,” she said. “The longer this goes on, the worse it’s going to be for that specific category of physician.” Dr. Gwon is not alone. Marina Kurian, MD, who has her own bariatric surgery practice in New York City, usually sees 60 to 80 patients a week. She last performed surgery in early March. Dr. Kurian has

In complex hernia repair, patient risk factors and postoperative wound complications can contribute to the peril of hernia recurrence

In a recent retrospective evaluation of biologic meshes,

S T R A T T I C E™ R T M,

A 100% BIOLOGIC MESH, IS A DURABLE SOLUTION for abdominal wall reconstruction based on the long-term outcomes of low hernia recurrence rates across multiple published clinical studies1-5

91.7%

of patients were

RECURRENCE-FREE AT

7 YEARS post-op1,*

*Includes porcine and bovine acellular dermal matrices (ADMs) (n = 157) 5 . Bridged repair and human ADM were excluded from the study group.

TO LEARN MORE ABOUT STRATTICE™ RTM, SPEAK TO YOUR ALLERGAN REPRESENTATIVE INDICATIONS STRATTICE™ Reconstructive Tissue Matrix (RTM), STRATTICE™ RTM Perforated, STRATTICE™ RTM Extra Thick, and STRATTICE™ RTM Laparoscopic are intended for use as soft tissue patches to reinforce soft tissue where weakness exists and for the surgical repair of damaged or ruptured soft tissue membranes. Indications for use of these products include the repair of hernias and/or body wall defects which require the use of reinforcing or bridging material to obtain the desired surgical outcome. STRATTICE™ RTM Laparoscopic is indicated for such uses in open or laparoscopic procedures. These products are supplied sterile and are intended for single patient one-time use only. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS These products should not be used in patients with a known sensitivity to porcine material and/or Polysorbate 20. WARNINGS Do not resterilize. Discard all open and unused portions of these devices. Do not use if the package is opened or damaged. Do not use if seal is broken or compromised. After use, handle and dispose of all unused product and packaging in accordance with accepted medical practice and applicable local, state, and federal laws and regulations. Do not reuse once the surgical mesh has been removed from the packaging and/or is in contact with a patient.

This increases risk of patient-to-patient contamination and subsequent infection. For STRATTICE™ RTM Extra Thick, do not use if the temperature monitoring device does not display “OK.” PRECAUTIONS Discard these products if mishandling has caused possible damage or contamination, or the products are past their expiration date. Ensure these products are placed in a sterile basin and covered with room temperature sterile saline or room temperature sterile lactated Ringer’s solution for a minimum of 2 minutes prior to implantation in the body. Place these products in maximum possible contact with healthy, well-vascularized tissue to promote cell ingrowth and tissue remodeling. These products should be hydrated and moist when the package is opened. If the surgical mesh is dry, do not use. Certain considerations should be used when performing surgical procedures using a surgical mesh product. Consider the risk/ benefit balance of use in patients with significant co-morbidities; including but not limited to, obesity, smoking, diabetes, immunosuppression, malnourishment, poor tissue oxygenation (such as COPD), and pre- or post-operative radiation. Bioburden-reducing techniques should be utilized in significantly contaminated or infected cases to minimize

contamination levels at the surgical site, including, but not limited to, appropriate drainage, debridement, negative pressure therapy, and/or antimicrobial therapy prior and in addition to implantation of the surgical mesh. In large abdominal wall defect cases where midline fascial closure cannot be obtained, with or without separation of components techniques, utilization of the surgical mesh in a bridged fashion is associated with a higher risk of hernia recurrence than when used to reinforce fascial closure. For STRATTICE™ RTM Perforated, if a tissue punch-out piece is visible, remove using aseptic technique before implantation. For STRATTICE™ RTM Laparoscopic, refrain from using excessive force if inserting the mesh through the trocar. STRATTICE™ RTM, STRATTICE™ RTM Perforated, STRATTICE™ RTM Extra Thick, and STRATTICE™ RTM Laparoscopic are available by prescription only. For more information, please see the Instructions for Use (IFU) for all STRATTICE™ RTM products available at www.allergan.com/StratticeIFU or call 1.800.678.1605. To report an adverse reaction, please call Allergan at 1.800.367.5737. For more information, please call Allergan Customer Service at 1.800.367.5737, or visit www.StratticeTissueMatrix.com/hcp.

References: 1. Garvey PB, Giordano SA, Baumann DP, Liu J, Butler CE. Long-term outcomes after abdominal wall reconstruction with acellular dermal matrix. J Am Coll Surg. 2017;224(3):341-350. 2. Golla D, Russo CC. Outcomes following placement of non-cross-linked porcine-derived acellular dermal matrix in complex ventral hernia repair. Int Surg. 2014;99(3):235-240. 3. Liang MK, Berger RL, Nguyen MT, Hicks SC, Li LT, Leong M. Outcomes with porcine acellular dermal matrix versus synthetic mesh and suture in complicated open ventral hernia repair. Surg Infect (Larchmt). 2014;15(5):506-512. 4. Booth JH, Garvey PB, Baumann DP, et al. Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg. 2013;217(6):999-1009. 5. Richmond B, Ubert A, Judhan R, et al. Component separation with porcine acellular dermal reinforcement is superior to traditional bridged mesh repairs in the open repair of signiﬁcant midline ventral hernia defects. Am Surg. 2014;80(8):725-731. Allergan® and its design are trademarks of Allergan, Inc. STRATTICE™ and its design are trademarks of LifeCell Corporation, an Allergan afﬁliate. © 2020 Allergan. All rights reserved. STM134734 03/20

been able to maintain caring for patients postoperatively through phone or telehealth appointments, and participated in webinars, but hasn’t evaluated any new patients since the pandemic hit. “It’s a problem because I need to keep the pipeline going,” she said. So far, Dr. Kurian hasn’t had to lay off staff, but she’s relying on her billing company to try to recoup any outstanding claims, and also trying to reduce costs. “The biggest concern is how long is this going to last, how much will it affect us, and how much of a loan can you take out,” Dr. Kurian said. “At some point you’re borrowing money now, but you still have to pay it back. You want to be sure that the patient stream is there, which I think it will be, but this is really going to hurt us more than some of the employed people. This is not like we’re on hiatus for a couple of days; this is a disaster of epic proportions, not being able to operate.” David Earle, MD, FACS, the founder of the New England Hernia Center, in North Chelmsford, Mass., said he last operated on March 13. “I usually see 12 patients in a day,” he said, “and now it’s three, on the telephone. I do not get any income right now unless I do elective surgical cases, which are banned. Unfortunately, my professional liability insurance premium isn’t banned, my rent isn’t banned and my utilities aren’t banned.” The curtailment of elective surgery “is causing a significant amount of distress and concern” for surgeons, said Patrick Bailey, MD, MLS, FACS, the medical director of advocacy for the American College of Surgeons (ACS). Fortunately, there are funds available to help. The ACS has information on its website about financial resources to assist surgeons during the pandemic (www. facs.org/covid-19). Dr. Bailey said these consist of four main areas: 1. On April 10, the Department of Health and Human Services began delivering the first $30 billion of the $100 billion Public Health and Social Services Emergency Fund allocated to hospitals and providers, including surgeons, as part of the Coronavirus Aid, Relief and Economic Security (CARES) Act. All disbursements were done automatically, Dr. Bailey said, without people having to apply. A second disbursement of $20 billion was being distributed as of April 24.

IN THE NEWS

2. Surgeons who derive a large portion of income from Medicare and/or who need to receive funds quickly can take advantage of the Medicare Advance Payments Program, which allows a request for up to 90 days’ advance payments. These payments are considered a loan against future Medicare claims. Applicants who receive payments continue to bill and receive payments normally for 120 days, after which time all billed claims are automatically used to offset advance payments. The balance must be repaid within 210 days. To apply, contact your Medicare administrative contractor. CMS approved more than 21,000 applications for Part A providers and almost 24,000 applications for Part B suppliers, totaling about $100 billion. The agency announced on April 26 that it was suspending its Advance Payment Program to Part B suppliers. 3. The Paycheck Protection Program is intended for small businesses to maintain operations and keep staff on the payroll. If you use the loan for specified purposes such as payroll and to pay mortgage interest, rent or utilities, up to the full amount may be forgiven. Congress initially set aside $349 billion for this program. To apply, contact your local bank or Small Business Administration (SBA)-approved lending authority. The application is complicated, Dr. Bailey said, and involves requests for data you may not have at your fingertips. Ask your professional tax advisor or accountant for assistance. He advises applying as soon as possible, as funds may run out. SBA relaunched the PPP April 27 with $320 billion in new funding after the initial pool of money was exhausted on April 16. 4. In addition, the SBA has an Economic Injury Disaster Loan (EIDL) program, which provides small businesses with loans of up to $10,000 to help overcome a loss of revenue. The loans have favorable terms but are not forgiven, Dr. Bailey said. This program was on hold, but with additional funding the SBA will resume processing applications already in their queue on a first-come, first-served basis. More information on the availability of EIDL loans for new applications will be provided by the agency as soon as possible. Additionally, the SBA offers express bridge loans. These are for small businesses who currently have a business relationship with an SBA Express Lender to access up to $25,000 quickly, and can be used to bridge

the gap while applying for an EID loan. The SBA also has a debt relief program through which the agency will automatically pay six months of principal, interest and any associated fees borrowers owe for any current 7(a), 504 and microloans in regular servicing status, as well as new 7(a), 504 and microloans disbursed prior to Sept. 27, 2020. This is not available for PPP or EID loans. For more information, see the Small Business Administration's website at www.sba.gov. It’s a tough time for a lot of businesses, Dr. Gwon said. She applied for the SBA

loan the morning it became available, and was about the 300,000th person to do so. A colleague who applied the next day was No. 600,000. “I don’t think anyone realized how many people were going to be affected,” she said. There are other avenues surgeons can pursue, too. Some states and cities have grants available to help boost small businesses, Drs. Gwon and Kurian said. In addition, check with your landlord or malpractice carrier to see if they will permit extra time to make payments. If you are leasing equipment, ask if the manufacturer will allow you to defer payments.

The ACS has formed a Practice Protection Committee that has additional resources on items to discuss with your tax advisor or how to bill for telehealth appointments, Dr. Bailey said. “I’m amazed right now at how everybody is trying to be very accommodating,” he said. “I’m hearing reports of medical malpractice providers delaying when payments are due and landlords understanding about rents. … I encourage surgeons to have those conversations and hopefully, we will continue to hear of the same kind of willingness to ■ be flexible.”

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IN THE NEWS

GENERAL SURGERY NEWS / MAY 2020

COVID Safety Guidelines: Preserving the Health of Surgical Teams continued from page 1

Rationing of Services In a recent webinar hosted by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Jonathan Dort, MD, noted that the first step in preserving the health and safety of surgical teams during the pandemic is to postpone all elective and surgical endoscopy cases. This places a significant financial burden on every hospital and surgery center, but rationing of services will protect patients and staff from unnecessary exposure, minimize unnecessary use of valuable personal protective equipment (PPE), and keep rooms open for only the truly emergent cases. The difficulty, however, is defining what constitutes an elective case versus an emergent one. “With operating rooms being converted to ICUs at an increasing rate, an appendicitis or cholecystitis may have to be treated nonoperatively with antibiotics,” Dr.

‘All outpatient clinics should be converted to video or audio visits, and only patients with urgent issues that require a physical exam should be seen in the office. The same goes for nonessential activities, including surgical education.’ —Kevin Wasco, MD Dort said. “Similarly, with hernia repairs and other elective procedures, pain alone may have to mandate a postponement.” As such, the Society of Surgical Oncology has released a brief guidance on surgery for cancer for several different tumor types (www.surgonc.org/resources/covid-19-resources/), and other organizations have started to do the same. “This is not a time to be teaching techniques or to have students or other nonessential learners present in the room,” Dr. Dort said. “In-person surgical consultation should be performed by decision makers only, and repetitive visits by multiple providers should be avoided in the pre-op area.” Ideally, all patients should be tested for COVID19 prior to entering the OR, but quick and reliable testing has been scarce, he added. To be abundantly cautious, providers should consider all patients with unknown status to be positive for the virus and capable of transmission. “A lack of symptoms in no way rules out the presence of this virus, and the stakes of being wrong are just way too high,” Dr. Dort said.

Minimally Invasive or Open Procedure? Regarding the SARS-CoV-2 virus, Dr. Dort cautioned that the available evidence is still too limited to make strong recommendations or establish standards of practice in a surgical environment. However, because COVID-19 is mainly a respiratory disease, data from previous studies that have demonstrated the presence of viral particles in surgical smoke should be taken into account. “Although these are different viruses that have distinct modes of transmission and cause other diseases, we must assume that the novel coronavirus has similar properties and make subsequent precautions based on that assumption in order to minimize the possibility of transmission,” Dr. Dort said.

Even with the assumption that the virus can live in surgical smoke and be transmitted through that mode, he emphasized the difficulty of deciding whether to offer minimally invasive surgery. “Surgical smoke and a pressurized pneumoperitoneum certainly would increase the risk for transmission with its uncontrolled release into the room under velocity,” Dr. Dort said. “However, an equal argument could be made that the sealed abdomen allows better control of the smoke with utilization of evacuation considerations.” In addition, he said, if a minimally invasive procedure turns a one-week hospital stay into a one-day stay, the decreased length of stay and resource utilization should be factored into the decision. According to Dr. Dort, SAGES recommends minimally invasive surgery procedures under the right clinical conditions, but only if proper precautions for smoke evacuation have been taken.

SARS-CoV-2 and Filtration Although no evidence of COVID-19 aerosolization currently exists, according to Dean Mikami, MD,

the use of devices to filter released carbon dioxide for aerosolized particles should be strongly considered. Dr. Mikami, an associate professor of surgery and the division chief of general surgery at the University of Hawaii at Manoa, reported that SARS-CoV-2 has been found in the nasopharynx, upper respiratory tract and lower respiratory tract, the entire gastrointestinal tract from the mouth to the rectum, saliva, sputum, throat and nasal swabs, blood, bile and feces. Filtration may be an effective means of protection from the release of the virus during minimally invasive surgery and endoscopy, he said. Although N95 respirators are designed to filter out 95% of particles that are 0.3 microns and larger, highefficiency particulate air filters have a minimum 99.97% efficiency rating for removing particles of the same size. Furthermore, ultra-low particulate air filters have a minimum 99.999% efficiency rating for removing particles 0.12 microns or larger in diameter. Dr. Mikami said the current best practice for mitigating possible infectious transmission during open laparoscopic and endoscopic procedures is to use a multifaceted

Table. Guidance for Health Care Workers Regarding Exposure to COVID-19 Epidemiologic risk classification for asymptomatic health care personnel (HCP) after exposure to patients with COVID-19 in the health care setting, and their associated monitoring and work restriction recommendations. Both high- and medium-risk exposures place health care workers (HCW) at more than low risk for developing infection; therefore, the recommendations for active monitoring and work restrictions are the same for these exposures. However, these risk categories were created to align with risk categories described in the “Interim US Guidance for Risk Assessment and Public Health Management of Persons With Potential Coronavirus Disease (COVID-19) Exposure in Travel-Associated or Community Settings,” which outlines criteria for quarantine and travel restrictions specific to high-risk exposures. Use that interim guidance for information about the movement, public activity and travel restrictions that apply to the HCW included here. The highest risk exposure category that applies to each person should be used to guide monitoring and work restrictions. Note: Respirators provide a higher level of protection than face masks and are recommended when caring for patients with COVID-19, but face masks still confer some level of protection to HCW, which was factored into our assessment for risk.

Epidemiological Risk Factors

Exposure Category

Recommended Monitoring For COVID-19 (until 14 days Work Restrictions for after last potential exposure) Asymptomatic HCP

Prolonged close contact with a COVID-19 patient who was wearing a face mask (i.e., source control) HCP PPE: None

Medium

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing a face mask or respirator

Medium

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing eye protection

Low

Self with delegated supervision

None

HCP PPE: Not wearing gown or glovesa

Low

Self with delegated supervision

None

HCP PPE: Wearing all recommended PPE (except wearing a face mask instead of a respirator)

Low

Self with delegated supervision

None

Prolonged close contact with a COVID-19 patient who was not wearing a face mask (i.e., source control) HCP PPE: None

High

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing a face mask or respirator

High

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing eye protectionb

Medium

Active

Exclude from work for 14 days after last exposure

HCP PPE: Not wearing gown or glovesa,b Low

Self with delegated supervision

None

HCP PPE: Wearing all recommended PPE (except wearing a face mask instead of a respirator)b

Self with delegated supervision

None

Source: CDC

Low

IN THE NEWS

MAY 2020 / GENERAL SURGERY NEWS

approach, which includes proper room filtration and ventilation, appropriate PPE, and smoke evacuation devices with a suction and filtration system, as available.

Algorithm for Surgical Care During COVID-19 Emergency

N95 Mask Use, Reuse, Decontamination Due to the shortage of PPE around the world, much effort has been made to extend the life of N95 masks (www.sages.org/n-95-reuse-instructions). Viola Huang, MD, a general surgery specialist in Stony Brook, N.Y., noted that surgical N95s are designed for onetime use, but the CDC has approved “extended use,” meaning they can be used with several patients and for up to eight hours. Per the CDC, expired N95s meeting the following criteria are acceptable to reuse: • not exposed to aerosolizing procedures; • no extended contact with a COVID-19‒positive patient; • stored properly (breathable container, allowed to fully dry); • not soiled (no bodily fluids); • fit is still intact (perform user seal check before each use); and • consider wearing face shield and surgical mask over it. Additionally, Dr. Huang said providers who reuse N95s should have a mask rotation strategy and allow each one to dry for at least 72 hours before re-donning. With this strategy, CDC recommends that N95s be extended up to five days maximum. Dr. Huang also advised caution when implementing decontamination because each version of N95 differs in appropriate decontamination method. “Decontamination will always be inferior to obtaining a new mask because of many variables that are difficult to control,” she explained. “Sweat, saliva, makeup, etc., can impact the efficacy of decontamination, and the viral load on the mask will differ based on your work conditions.” As Dr. Huang reported, the FDA has now approved at least two systems for sterilization of N95 masks that will “likely be of significant impact while we wait for a larger production of new masks.” Both systems use vaporized hydrogen peroxide. In contrast, the use of microwaves, autoclaves, soapy water, alcohol, bleach immersion and storage for less than 72 hours are not approved by the FDA, she added.

A Role for Telemedicine Kevin Wasco, MD, a general surgery specialist in Neenah, Wis., reported that use of telehealth services has been facilitated by recent policy changes related to the COVID-19 pandemic. “Medicare will now pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, and patients can receive telehealth services in all areas of the country and at any point of service including home,” said Dr. Wasco, who noted that the list of eligible services is not necessarily the same for all state or private insurance plans. According to Dr. Wasco, since transmission is all about exposure, nonessential staff which can include administrative staff, research staff, education staff, quality staff and clerical staff, should be allowed and encouraged to telework from home. However, the review of how best to utilize manpower with telehealth visits should be done by each department and each hospital. Some hospitals rotate teams between inpatient and outpatient services to allow breaks from the constant intensity of the inpatient service, while other hospitals factor the age or medical conditions of health care providers into deployment decisions. Dr. Wasco said all outpatient clinics should be converted to video or audio visits, and only patients with urgent issues that require a physical exam should be seen in the office. The same goes for nonessential activities, including surgical education. Many academic programs have successfully changed the didactic sessions to a virtual format, and many organizations and groups offer online education through webinars, videos and social media platforms. Multidisciplinary meetings also should be transitioned to a virtual format, he concluded. ■

Urgent

Droplet (gown, gloves, eye protection) and fitted N-95 **If unable to symptom screen or perform RT-PCR, treat as emergency

High-risk procedure

Low-risk procedure

Symptom screen

Consider surgical delay. If unable to delay, then RT-PCR test

–

RT-PCR

HIGHEST risk • Approval by anesthesia chair, surgical chair and CMD • Droplet + fitted N-95 • Follow COVID+ protocol

–

Consider surgical delay. If unable to delay, then RT-PCR test

STANDARD risk Proceed with standard surgical attire

–

STANDARD risk Proceed with standard surgical attire

– HIGHER risk • Approval by anesthesia and surgical chair • Droplet + fitted N-95 • Follow COVID+ protocol

CMO, chief medical officer; RT-PCR, reverse transcription polymerase chain reaction. Source: J Am Coll Surg 2020. https://doi.org/10.1016/j.jamcollsurg.2020.03.030

n easy-to-follow algorithm could help protect surgical teams during the COVID-19 pandemic while conserving valuable personal protective equipment (PPE). Developed by researchers from the Department of Surgery at Stanford University, the new scoring system is based on the urgency of operation, the likelihood that a patient could be infected with COVID-19, and the risk of the surgical procedure itself. “Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision tree algorithm, we can maintain our capacity to provide surgical care in a way that’s safe for both patients and providers,” said Joseph D. Forrester, MD, an assistant professor of surgery at Stanford University, in California. “This algorithm represents a conceptual framework on how to provide surgical care in the time of a pandemic by breaking down the overall risk of a surgery into a few key components and ensuring rational use of PPE in a resource-constrained setting.” A task force of hospital and medical school leaders from interventional suites at Stanford developed the scoring system by considering the following criteria: • health care worker safety; • patient safety; • risk for procedure to transmit virus from infected patient to health care worker; • anticipated PPE stock, surge in burn rate, and opportunity for resupply; • risk for patient having COVID-19; and • institutional access to laboratory testing. Task force members reviewed current data describing COVID-19 transmission and relied on decision-making algorithms developed during outbreaks associated with severe acute respiratory syndrome and Ebola virus disease. The algorithm was then vetted by experts from infection control and infectious disease. According to the algorithm, patients are first triaged by severity of illness into urgent and emergency procedures. Urgent cases are stratified into high- and low-risk procedures depending on the anticipated viral burden at the surgical site and the likelihood that a procedure would aerosolize virus. All aerosol-generating procedures, including endoscopy, open or laparoscopic surgery on the bowel with gross contamination, and procedures of the aerodigestive tract, are classified as high risk. Patients are then stratified according to their risk for having active infection, which is based on symptomatology and the ability to perform reverse transcriptase–polymerase chain reaction (RT-PCR) to determine infection status. The Stanford guideline assumes that every patient is potentially infected with COVID-19 until proven otherwise. Given the availability of in-house testing at Stanford, RT-PCR testing of symptomatic patients is mandatory, provided it can be done in 24 hours. However, the authors noted that these guidelines may need to be adjusted to reflect local testing availability. When operating on an infected patient, Dr. Forrester said all members of the OR team are required to wear N95 masks with droplet attire. Standard surgical clothing is only permitted when an RT-PCR test is negative for COVID-19. “We wanted to come up with an algorithm that would allow rational allocation of PPE,” Dr. Forrester explained. “It’s not often in the United States that we’re forced to operate in a resource-constrained setting, but in a pandemic, it’s important to utilize appropriate PPE when needed while also recognizing those situations that call for more traditional PPE use.”

CODE OF THE MONTH

GENERAL SURGERY NEWS / MAY 2020

B97.29—What in the World? COVID-19 Coding for Surgeons By LUCIAN NEWMAN III, MD

e are living through an unprecedented time in society today. It has been discussed for years with many predicting cataclysmic results. SARS-CoV-2 has seemingly stopped the world from spinning. There are many resources available describing individual responses to the crisis; however, I will discuss this from a general surgery perspective. The coding aspects are as follows: The vast majority of morbidity related to COVID-19 is respiratory: • Pneumonia, J12.89 • Bronchitis, J20.8 • Lower respiratory, J22 • Acute respiratory distress syndrome, J80 When a relationship to COVID-19 is known, B97.29 is attached. The following also may be documented: • Cough, R05 • Shortness of breath, R06.02 • Fever, R50.9 “Possible” and known exposure have separate, distinct codes: • Possible exposure, Z03.818 • Known exposure, Z20.828 The point of coding is to be as specific as possible, and, in these trying times, it is critical to be able to track, test and treat this scourge. Surgeons become involved for a number of reasons, namely critical care support,

Rib Fixation continued from page 1

resident at the University of Tennessee College of Medicine, in Chattanooga. Studies have suggested a benefit associated with surgical intervention within one day of admission, but few have matched patient outcome data or investigated optimal surgical timing, he noted. To compare operative rib fixation with nonoperative management of rib fractures, Dr. Harrell and his colleagues identified 95 patients with rib fractures at a Level I trauma center who underwent surgical treatment between 2007 and 2018, and matched them to 190 patients who had nonoperative treatment. The investigators included only surgical patients whose surgery was performed at the time of the initial hospitalization, and all operations were performed exclusively by trauma surgeons. There were no statistically significant differences in patient age, sex, injury severity score, abbreviated injury score of head or chest, body mass index or medical comorbidities. “There was, however, a higher rate of history of smoking in the surgical group, at 52% compared with 35% in the nonsurgical group (P=0.009),” Dr. Harrell said.

but the diseases that we routinely treat do not disappear in deference to the coronavirus. The practice of surgery, as for many other medical professions, has become severely curtailed, limited to urgent and emergent treatment at most facilities. Shortages of personal protective equipment (PPE), fear of surface contact where known cases exist, and exposure of the already limited staff are just a few of the reasons for the curtailment. For many employed surgeons, who are paid a regular salary plus productivity incentives, the financial damage may be limited. For private practice surgery, the impact is substantial. Although many laypeople may not accept the fact that physician offices are not always flush with cash, it is the hard truth. At my office, we are applying for small business relief to be able to continue paying our employees. Likely there will be weeks and even months ahead in which the physicians will get no paychecks at all. Just as in health care facilities, there are limitations on PPE used in daily care in our offices. Surgeons are accustomed to judging conditions that are potentially life-threatening, so scheduling now forces that behavior. Stay-at-home orders are in place. One strategy being employed with increasing frequency

The most common indication for surgical intervention was flail chest, typically diagnosed radiologically but in conjunction with clinical factors. Other indications included respiratory failure, pain and significant rib displacement. “Looking at trauma data, the surgical group had a significantly higher rate of chest tube placement on their initial presentation, a higher number of rib fractures at 9.5 compared with 6.4 in the nonsurgical group, as well as higher rates of pulmonary contusion and flail chest,” Dr. Harrell reported. Most patients were operated on between hospitalization day 3 and day 6; eight patients underwent surgery within two days of hospitalization; and 22 patients underwent surgery six or more days after hospitalization. The average number of ribs plated was 3.4 and the average time to discharge after surgery was 9.8 days. In the surgical group, hospital LOS was greater in patients who underwent later surgery.

is telehealth, or telemedicine, to conduct patient appointments. The restrictions for billing during the national emergency are relaxed at this point. We are using Skype or FaceTime in our office to accomplish off-site visits in which the direct physical exam is not performed. If, despite best efforts, the patient simply cannot participate by videoconferencing, and the surgeon documents this clearly, a phone conversation may be billable as a visit. Obviously, the current crisis is the perfect storm to work out the particulars of televisits. Our society has been exposed to virus exposures presumably since the beginning of time. Notables include the Spanish flu of 1918 in which 50 million people perished, flaviviruses, West Nile and Zika, and coronaviruses SARS and MERS. Approximately 34 million people contracted influenza A last year with more than 34,000 deaths. The speed with which this one spreads and the fear of outstripping our ability to treat the consequences has made this episode particularly vexing. If nothing else, the current crisis has taught everyone to respect what the medical world has feared viral pandemics can do. Stay safe. ■ —Dr. Newman is a general and vascular surgeon in Gadsden, Ala. He is a chief medical information officer of Nuance Surgical CAPD (Nuance.com).

“Similarly, patients operated on between days 3 and 4 and greater than six days had a longer ICU LOS, and those undergoing surgery between days 3 and 4 had more ventilator days and higher rates of hospital-acquired pneumonia,” Dr. Harrell said. Comparing surgical and nonsurgical groups, hospital LOS was significantly greater across all day-of-surgery categories except the earliest group. “While there was clearly a difference, it did not reach statistical significance, which is likely a type II error given the small sample size,” Dr. Harrell said. He acknowledged other limitations inherent to a retrospective study, and also the fact that the operative group had a greater number of rib fractures, more flail chest and pulmonary contusion. “We recognize that this limits the quality of our comparison to the control group.” Despite these limitations, patients who underwent surgical rib fixation had worse outcomes across the board, including LOS in the hospital and ICU, Dr. Harrell said. “These results have shifted our practice pat‘What are the long-term terns toward earlier surgical intervention and away consequences of rigidly fixing from later fixation after fractures? Are we improving a failure of nonoperative short-term outcomes at management.” Dr. Harrell presented the the expense of subsequent study findings at the Southunmeasured morbidity?’ eastern Surgical Congress —Surresh Agarwal, MD 2020 (abstract 19).

Surresh Agarwal, MD, a trauma and critical care surgeon at Duke University Hospital in Durham, N.C., said surgical rib fixation remains controversial and the true beneficiaries and optimal operation time have yet to be defined. “What are the long-term consequences of rigidly fixing fractures? Are we improving short-term outcomes at the expense of subsequent unmeasured morbidity?” Dr. Agarwal drew attention to the small sample in the early operative group, noting that his own trauma patients are usually recovering from significant extrathoracic injuries. “If a patient is unable to have a procedure early due to instability from separate injury, would you recommend they not have the procedure performed if you had to wait more than four days?” Dr. Harrell said significant injury was one reason for the delay in surgery, but the attitude toward surgical rib fixation at his institution also played a role. “We have tended to see it as an operation of convenience rather than early and aggressive operative therapy, and this is something we’re working to change. “There are, of course, situations where patients are unable to undergo early surgery. We have to be careful about patient selection to maximize the benefits this operation offers, looking specifically at respiratory function, pain control and ■ their ability for mobilization.”

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OPINION

GENERAL SURGERY NEWS / MAY 2020

You Are Not Alone The Top 10 Things I Wish I Knew When en I Was a Resident By JENNIFER F. TSENG, MD, MPH

or the first two years of medical cal school, I was sure I was headed for a career as a primary care provider, or maybe I would be an obstetrician-gynenecologist or a medical oncologist. Then en during my third year, I was thunderstruck by the realalization that I really enjoyed surgery! I resisted this for quite some time, and even requested residency program am applications for both medicine and surgery. With some me trepidation, I picked surgery. It has been a great ride, de, culminating in my current dream job at Boston Medidical Center and Boston University—and largely, I have ave never looked back. The 10 years I spent in residency and fellowship were ere some of the best years of my life. Despite the intensity ity of training both in the clinical and research years, life ife kept moving forward! Among other things, I got mararried and became pregnant with the first of my two chilil dren. Of course, looking in the rearview mirror, there are a number of things I wish I had known then. In no particular order, I offer my top 10.

1. You’re adequate. You have to fight hard against impostor syndrome. It is critical to recognize that no one is killing it across the board, because you just cannot do everything simultaneously at an A+ level. None of us is perfect, and everyone has feelings of inadequacy. Imposter syndrome, left unchecked, is a pernicious infection that leads to insecurity, failure and a cementing of the status quo. I remember worrying that I was out of my league while looking around a room at Memorial Sloan Kettering, where surgical oncology fellowship candidates like myself were nervously waiting after their interviews during the faculty rank meeting. We had some time to kill, and one of the other candidates—a woman who was clearly an outstanding, impressive future surgical oncologist—asked me if I wanted to go for a walk. This simple gesture shifted the dynamic from competition to camaraderie, and off we went walking at a very rapid surgical pace—of course—through Central Park. That person, Sandra Wong, MD, now the chair of the Department of Surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and I are friends and occasional meeting roommates to this day, and she recently gave a great surgical grand rounds here at my institution on making sure rural patients receive excellent cancer care.

2. Take care of your health. It is never easy to carve out time for yourself, but it’s easier now than it used to be because of workweek restrictions. Take advantage of post-call days. Go to your primary care doctor, go to your OB-GYN, and perhaps most of all, go to the dentist! I remember putting off this last “chore,” to my detriment. By the time I finally made it there, what was once a small cavity now required a root canal. Exercise when you can; get your screening tests; and try to eat as healthily as you can, the majority of the time.

3. Take care of your finances. Pay off your student loans, don’t amass credit card

debt, and start saving for retirement “now.” I am told that Suze Orman says this, but I received this advice from a junior resident in the ER, and he was right. Yes, you feel poor now. You have loans hanging over your head, and you spend all your money each month. But if you automatically save a little money every month in your institution’s 403(b), you won’t even notice it. In other words, you will feel just as poor, not more, and you will be making incremental progress toward your goals instead of just putting it off! If you have leftover money after paying the rent and bills, use it to take care of the things listed above.

4. If you wear nice clothes and a white coat, people don’t think you’re a nurse. During residency, I was universally assumed to be a nurse during the early years. I want to emphasize that I have the utmost respect for nurses and all the other individuals who provide complete care of our patients. But it’s also important for patients to know when they are talking to the doctor. It gives them reassurance, and also teaches everyone that surgeons and doctors are diverse. During my residency at Massachusetts General Hospital, doctors, including attending surgeons, wore short white coats. I wore scrubs every single day of the first three years of residency, and unlike my similarly attired male peers, I was always taken to be a nurse, or sometimes a respiratory therapist. One day after the lab years, I wore a dress and heels under that short white coat on the day we had an important visiting professor giving grand rounds. Afterward, while doing routine work, for the first time I was spontaneously addressed as “doctor” on the wards. People have unconscious biases that shouldn’t be your job to correct, but nonetheless remain in your own interest to counteract. A black resident friend, wearing scrubs, was invariably assumed to be an orderly in the OR. More alarmingly, a different black male surgical resident (wearing scrubs and a cloth OR hat) was routinely stopped by law enforcement while jogging into the hospital. As unfair as it is, people make rapid judgments based on externals. You have some control over how you’re perceived. That said, for your sake, I recommend that you be the best version of yourself.

5. All is forgivable. We all commit what we perceive as unforgivable medical sins. As an intern, I mistakenly pulled the drain on postoperative day 1 from a patient on whom the future president of the American College of Surgeons, Andrew Warshaw, MD, had just performed a Whipple procedure. After realizing my error, I was mortified and thought I was already an abject failure at the very beginning of my surgical training. After a good deal of agonizing, and with encouragement from the then chief resident Bryan Meyers, MD (now of Washington University in St. Louis), I mustered the courage to apologize. I stood on a stand during an operation and waited for what seemed like an eternity until I was finally called on. Dr. Warshaw went on to have a major influence on my career, and I hope and pray that he does not remember that incident at all, but I certainly do.

6. One thing at a time. Multitasking isn’t real. A person can only truly focus on one major endeavor at a time; the most you can do with the other myriad activities competing for your attention is to keep them organized and potentially make gradual progress in the background. I like to cook, and an analogy I like to use is making Thanksgiving dinner. You have numerous dishes to prepare and get on the table for the feast. You need a game plan for the big tasks that will take multiple hours—say, making stuffing and getting the turkey in the oven and making the pies, because without a careful strategy, no one will be eating until late in the evening. Once the pie crust is made and the turkey is in the oven, these big-ticket items don’t require much attention, other than tinkering and listening for the timer. You can then concentrate on the sides and what needs to be prepared on the stove. One burner, say for the mashed potatoes, has a pot that’s boiling and has to be watched or it will boil over. That pot is the priority and has your attention, but you’ve got to keep all the rest at a simmer, the other items roasting or resting in the oven until it’s time to concentrate on them in turn—just like life. It may not be absolutely picture-perfect as you envisioned it a priori, but it will be delicious.

OPINION

MAY 2020 / GENERAL SURGERY NEWS

7. No one gets rich m moonlighting. This pearl is related to No. 3 (finances) and No. 6 (focus). Most surgical residents moonlight moon at one time or another. It’s partic particularly tempting to do a lot of moonlighting mo if you’re working in th the lab, but resist the temptation to overdo it. Inevitably, your research or your personal life, re or both, will suffer as a result. Two shifts per month, in my mind, is the most someone ccan do and still be focused and productive in the laboratory. I have produ met many m residents who used their moonlighting money, and more, moo and ended up poorer than before because of the desire to splurge, beca and besides that, they were not academically productive. Use more academ than half h of any money from moonlighting for productive purposli es—paying off student loans and supporting your family—and make sure to put some away for your retirement.

8. Don’t leave dead mice in the freezer. Especially in the research years, realize that you need to end projects. It all comes down to aspirations and good intentions. Submit all your projects as papers, or thoroughly sign them out to someone else before you leave a lab to return to clinical work. Surgeons are just naturally

optimistic. You think you will be able to finish all your projects; they just require “a little more” work. That work will grow exponentially as you rapidly forget exactly how you designed the project, how you programmed the statistics, and just where those numbers in the abstract you presented last year came from. You have every intention of coming back in the evenings or on weekends to finish a research project, so you leave the “materials” in the freezer, or on the computer server, or on your bench. In my case, after years of trying to finish basic science research while working as a clinical PGY-4 and PGY-5 across town, finally, someone else got stuck cleaning up the remnants of the various research projects I had started. It’s better to be a second author on a paper that gets published instead of first author on a paper that will never exist.

9. Don’t over-plan. Surgeons are doers. I will overgeneralize and say that women, especially, have a tendency to map out their goals and life plan in a very specific way and to worry about “failing” various future tasks. The problem with having strict benchmarks and to-do lists is that it may lead to crossing off viable variations in plan—alternative options that will inevitably come your way. God laughs at people who make plans. My well-thought-out life plan mandated living in the Bay Area, where I was born and raised and my family still resides. But one thing leads to another. One door closes, another one opens. I have made a life near the bay, but this one is in Massachusetts, “the Bay State,” where I have been lucky enough to establish a family and a career over the past 25 years. Be flexible. Life takes twists and turns, and you cannot see all the moves ahead of you. Who could have predicted just last year the

effect of COVID-19 on surgery and residency training? It’s an illusion that those who succeed do so thanks to perfect planning and ideal execution. As Emerson so eloquently said, “Life is a journey, not a destination.”

10. You are not alone. No one has it all figured out. Although it may not seem like it when you look around, everyone is juggling life as fast as they can. Every one of us carries within us a feeling that at some level we don’t quite belong. Use that feeling of exclusion to make someone else feel included. Sharing your experiences, including mistakes, and building a sense of community are so important. We have a lot to learn from one another. Reach out to others, and lend them a hand. If you are feeling troubled, ask for help. This is a wonderful, stressful, crazy life we have chosen. What would I change? A million little things, every day. Big picture? Not much. A surgeon’s life is filled with so many challenges and so many rewards. What we do is important and worthwhile, and often really fun. Be kind to yourself along the way. My oldest child, with whom I was pregnant when I was finishing training, will soon be graduating from a very New England middle school. Despite all my planning, his now-virtual “graduation” will look very different than I expected. Nonetheless, I still quite like its motto: “Our best today, better tomorrow.” What more can anyone ask? ■ —Dr. Tseng is the surgeon-in-chief at Boston Medical Center and James Utley Professor and Chair of Surgery at Boston University School of Medicine.

OPINION

GENERAL SURGERY NEWS / MAY 2020

For More Prepared Residents, Incentivize the Master Teachers By JESSE WRIGHT, MD

recently stumbled upon a heated debate on a popular social media platform: Are graduating general surgery residents able to operate safely and independently upon completion of their training? Responses from a variety of veteran surgeons were thoughtful, honest and thorough, but mostly disheartening.

Many noted “that’s what fellowship is for,” “they’ll get that once they are out there on their own,” or a crowd favorite, “back in my day.” Although a minority of responders were optimistic and proud of their institution’s end product, the general consensus was clear: Many veteran surgeons do not see this generation of graduates as being as prepared as it could (or should) be. As a recent chief resident and current fellow, I have been a part of many

late-night, self-reflecting debates with my peers about our own experience and progress. What had we learned? Were we ready to move on? Were we as prepared or as skilled as the chiefs we idolized when we were interns or junior residents? What could we change? Arguably one of the most critical pillars of effective surgical education is the strong presence of invested and effective clinical teaching from the surgical faculty. Many surgeons can list, with ease, the

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Faculty Curtis Choice, MD (Chair) Assistant Professor Department of Anesthesiology Albert Einstein College of Medicine Director, Division of Ambulatory Anesthesia Director of Anesthesiology Monteﬁore Hutch Ambulatory Surgery Center Clinical Director, Preoperative Services for Hutch Tower II PAT Clinic Monteﬁore Medical Center Bronx, New York

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names of the most influential and devoted surgical teachers during their training— those who inspired, helped navigate career paths, offered mentorship, invested the time to teaching technique and clinical pearls, and provided honest, personalized feedback. The teaching (and learning) occurred not only in the OR, but continued during rounds, in the ICU or trauma bay during physiologic crises, in the emergency department with new consults or readmissions, and in the lounge over a cup of coffee. These teachers aren’t required to have gray hair, prestigious training pedigrees, or an alphabet soup of initials, titles and degrees following their name. They don’t have to be the most verbose or opinionated voices at teaching conference(s), textbook authors, or the chairs of departments or divisions. These teachers have a certain je ne sais quoi: They spend the extra effort and the extra time—time to explain, to demonstrate, to assist and to repeat, day in and day out, year after year. Most importantly, they make the effort to relinquish—relinquish the knife and clinical decision making in a controlled and graduated manner to provide appropriate autonomy for the advancing trainee. Why, then, are these master teachers so few and far between, only making up a minority of the available faculty and staff? How can we increase this yield of master teachers, and how would such an increase affect the product of trainees and the overall learning environment? In the current era of subspecialization and niche-based clinical and surgical practices, the teaching of fundamentals in surgical principles and perioperative clinical management can often be overlooked, assumed or even ignored. This can have significant unintended consequences for trainees. Often overstretched, it is not infrequent that a surgeon may prefer the assistance of a more efficient and seasoned senior resident or fellow instead of a junior resident or intern. There are undoubtedly index cases that are too complex or rare and require a more senior trainee for assistance. However, upgrading of resident coverage can potentiate an unfortunate negative feedback cycle of performance expectations wherein junior residents are increasingly perceived, with or without just cause, to be less skilled than previous generations of junior residents, and thus aren’t the preferred choice for assistance, resulting in less exposure and experience and repeating the problem as junior residents become senior residents. This upward shift of responsibility and autonomy can cause junior residents to miss key level-appropriate learning opportunities and, as result, they can be

OPINION

such, departmental leadership should find ways to appropriately incentivize or tenure those faculty members who excel at teaching at all levels and help encourage a more robust teaching paradigm. Faculty members could perhaps then focus more time on creating and tailoring specialtyspecific curricula, and ensure that goals and objectives of each rotation are met. More time could be spent on rounds or in clinic promoting “the art of surgery” and patient interaction, and more time could be invested in the OR reviewing technique, mobilization, relevant anatomy and common pitfalls.

If the burden of academic productivity and responsibility could be shifted to teaching, and surgical educators could be appropriately recognized, supported and incentivized, residents at all levels would benefit. Perhaps then the current trend of responsibility inflation may be minimized as junior and future senior surgical trainees become stronger, preparing them for confident, safe and independent practice as they move forward. ■ —Dr. Wright is a clinical fellow in colorectal surgery at AdventHealth, Orlando, Fla.

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underprepared as they rise to more senior training levels. Thus, it is paramount that surgical training be focused on keeping appropriate level patient care and operative experiences for all levels of residents to thwart this trend. The aforementioned master teachers find ways to be that best teacher to all levels of trainees and tailor their instruction and approach to the situation at hand. There is just as much to be taught during a routine wide local excision, central line placement or umbilical hernia repair for the junior trainee levels as there is in a pancreatectomy, liver transplant or complex rectal resection for senior trainees. Aside from annual teaching awards, usually bestowed at a graduation banquet (or similar forum), there is often little recognition for those educators who have had the most meaningful impact on surgical trainees. In a modern academic surgical practice, faculty members are pulled in numerous directions by their varied clinical, administrative and research responsibilities. There is no doubt that the demand and pressure for productivity can limit time available to be involved with even the basics of surgical education (intraoperative critiques and lessons, skills and simulation workshops, career development, teaching sessions, mock oral boards and so forth). As deadlines abound, inpatient and outpatient censuses grow, and administrative duties increase in addition to full surgical schedules, it is not surprising that there is little incentive to devote any additional time or effort to education. It can be argued that the master teacher can offer more value to the future of surgery than any highly funded surgeonscientist or surgical administrator. As

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Resident Writing Contest TOPIC You have the ability to instantly change one aspect of surgical education as it is currently implemented. What would you change and why?

Serving Time: Let’s Move to a Competency-Based Training Model incapable of reproducing a sublimely elegant and simple operation in a way that is safe and efficient. Conversely, her colleague might demonstrate a manual dexterity urgical training is, and will forever remain, that surpasses that of her classmates. Ultimately, being in a never-ending metamorphosis. This is a surgeon requires an excellence of the craft in a strictthe beauty and the exasperation of a field ly proficient and perfectionistic manner. Unlike any that continuously challenges the standard other specialty, a millimeter, the hesitation of a gesture, and pushes its own boundaries. Our roots a tremor, an ever-so-slightly overly pressured touch, are those of barbers, gifted with the precan delineate life from death. Creating the surgeons of cise sharpness of the knife, the unshakable the future requires attention to the individual as much steadiness of our hands, and the couras it does to the group. Some residents are inherentage of trailblazers. Yet, we hold inside ly talented and should be rewarded with shorter trainthe tender thirst for knowledge and a passion for the ing that allows them to advance to the next steps and intricacies of the human body. Indeed, our roots belong grow beyond the basic requirements. Others need more equally to the first Egyptian surgeons in 1800 B.C. support and time to achieve the much-needed skillfulwho documented their practices on papyrus; to Leonness of the craft. ardo DaVinci and his beautifully insightful outlines of Competency-based training in surgical residenhuman anatomy; to John Hunter and his methodical cy should not be a feared utopia. Quite the contrary, it descriptions of organ systems; and to William Halsted, would be an objectively based incessant and real-time whose confidence and leadership have defined the surevaluation of each trainee, with the ultimate goal of nurgical field we know today. turing each talent and addressing each weakness indiThe societal fascination with the essence of surgeons vidually. If the objective of graduate surgical training is has continued fervently even to this day, where despite to create the absolute best surgeon that one is capable of being acknowledged as talented physicians, we are equalbecoming, then we ought to refrain from aggregating all ly separated by our title of “surgeon” and “physician.” Old residents within the same artificial time constraints, and proverbs describe us as bestowed upon with “an eagle’s instead focus on raising each one of them upward from eye, a lion’s heart and a lady’s hand,” and a myriad of their starting level. The practicality of assessing each resbooks have been written in an attempt to understand ident would not be burdensome or complex given the how modern-day surgeons have defied the status quo existing technology, virtual reality and simulation-based and evolved over the centuries. Despite being grounded platforms that already exist, as well as the data regarding in the pursuit of medicine and treating disease through inter-grader consistency of operative evaluations. surgery, the field has remained in a state of flux: always In simplest terms, when a resident and the program eager to incorporate new knowledge, to adopt innovative faculty agree that a certain level of competency has been technologies, and to push the limits of what is humanachieved, then providing the board with several videos ly possible. It is not surprising that the field of surgical of operations performed by the resident might be all education is equally in a constant state of transformation that is necessary to ensure qualification to graduate. and self-renewal, as it tries to breathlessUltimately, the bell curve will prevail, and ly catch up with the existing needs, relinwhile some trainees will finish sooner, othIf the objective of graduate surgical training is to create the quish antiquated practices, and eagerly ers will train for longer. The extrinsic motiabsolute best surgeon that one is capable of becoming, then vation to improve and excel will never be anticipate the future. It would be equally naive and arrogant to insinuate that surgiwe ought to refrain from aggregating all residents within the stronger, which in turn will act to increase cal education will ever achieve a final state competency. While the temporary perceived same artificial time constraints, and instead focus on raising of being. discrimination based on duration of training Despite the seemingly constant refinewill come into question, this will be ephemeach one of them upward from their starting level. ments from year to year, the training of eral as the end result will fundamentally surgeons will forever need to be improved ensure an equal minimal competency of all upon in order to respond to the necessigraduating surgeons. ties of the field. Operations that were once The current state of training is such that routine have now become obsolete. Techthe heterogeneity of trainees and training niques that were once standard maneuprograms is perpetuated by a lack of stanvers have now been forgotten and replaced dardization of operative competency. In by modern tools. Living in a paradox that other words, the current requirement of cherishes tradition while embracing cuttime and case numbers, without a standardting-edge technology, surgeons are defined ized assessment of abilities, produces a much at their core by “versatility.” My mentors more discriminatory and heterogeneous pool have traversed an earth-shattering revoluof practicing surgeons. By contrast, competion of operative techniques from the introtency training would allow surgical educaduction of electrical devices to improve tion to homogenize excellence, to continue coagulation of the tissue, to laparoscoto flow smoothly, and adapt to the ever■ py, endovascular and now robotic surgery. changing field of surgery.

By IOANA BAIU, MD, MPH Stanford University, Palo Alto, Calif.

Traction-countertraction, an elegantly simple and fundamental principle of surgery, mirrors the parallel growth of the field of surgery with the field of surgical education that inevitably must respond with an equal and opposite force. The past decades have in some ways remained frozen in time. While we have successfully removed ourselves from the Halstedian mentality of training, we have entered in many ways another extreme—that of serving time. Whether pushed by practical convenience or by tradition, the idea that a certain number of years must be spent in training has remained a rigid standard across the nation. What seems apparent, however, is that surgeons are as heterogeneous as the patients they treat. Despite attempts at standardizing their competency at the end of training, the current system does not allow for any flexibility in adjusting duration of training to address the infinitely variegated abilities of residents. Training for five clinical years ensures nothing more than a physician body inhouse or across the table, but speaks nothing as to the talent and expertise of that surgeon to be. Admission to a surgical residency does not include a test of manual dexterity, for example. As such, there is an unavoidable mix of surgical residents who struggle and some who excel. Pretending that fine dissection required in laparoscopy while watching a screen should be as second nature or equally challenging for every resident is presumptuous at best. If the field of surgical education is in need for one change today, it is that of competency-based training. The 850 cases required by the Accreditation Council for Graduate Medical Education to graduate surgical residency are regrettably arbitrary, as it does not ensure any quality of the work. A resident may log enough numbers, but nevertheless be

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IN THE NEWS

MAY 2020 / GENERAL SURGERY NEWS

Bariatric Surgery continued from page 1

Within five years, the estimated adjusted cumulative diabetes remission rate was 86.1% for RYGB patients and 83.5% for SG—far higher than that reported for any intensive lifestyle intervention. However, a considerable number of patients also experienced a relapse after a good outcome, particularly if they had a sleeve gastrectomy. After five years, an estimated 41.6% of sleeve gastrectomy patients relapsed compared with 33.1% of RYGB patients, for a hazard ratio of 0.75 (95% CI, 0.67-0.84). “Overall, these results indicate that RYGB is associated with better longterm T2DM [type 2 diabetes mellitus] and weight outcomes than sleeve gastrectomy in real-world clinical settings,” the authors wrote in JAMA Surgery. The findings may be helpful to patients and physicians considering different options for bariatric surgery. In this study, people were less likely to improve if they had more severe diabetes according to the DiaRem score, a validated scoring system that predicts the probability of remission based on age, insulin use, hemoglobin A1c and type of antidiabetic drugs used. Patients with a lower probability of diabetes remission in the DiaRem scoring system may be more likely to achieve sustainable remission with RYGB than a sleeve gastrectomy, said Anita Courcoulas, MD, a study co-author and bariatric and general surgeon at Magee-Womens Hospital at the University of Pittsburgh. “People with more advanced diabetes at the time of surgery, for whom remission of their diabetes would be more difficult to achieve because of factors such as older age, insulin use and poor glycemic control, may expect larger improvements in their diabetes with gastric bypass,” Dr. Courcoulas said. This finding is at odds with recent randomized clinical trials that found no significant differences in diabetes outcomes after RYGB and sleeve gastrectomy (Ann Surg 2019. [Epub ahead of print]. doi: 10.1097/SLA.0000000000003671; Obes Surg 2020;30[2]:664-672). Those trials had longer follow-up but smaller sample sizes, which may limit their power to detect differences, the authors noted. The study was conducted at 34 U.S. health system sites in the National Patient-Centered Clinical Research Network Bariatric Study, and included 9,710 patients who underwent RYGB or sleeve gastrectomy between 2005 and 2015. Remission was defined as any postoperative hemoglobin A1C value less than 6.5% in a patient without a diabetes medication prescription for at least six months. Any occurrence of hemoglobin A1C greater than 6.5% or a diabetes medication order after remission was considered a relapse.

In the United States, less than 1% of patients with class 2 and 3 obesity undergo bariatric surgery. Even fewer patients with class 1 obesity access this surgery due to insurance approval restrictions. Overall, approximately half of RYGB and one-third of sleeve gastrectomy patients had well-controlled hemoglobin A1C levels five years after surgery. Both groups of patients experienced considerable weight loss, but patients treated with RYGB lost more weight and had more sustained weight loss than patients who had a sleeve gastrectomy.

Limitations in the study included possible inaccuracies in electronic health record diagnostic and medication codes. In an accompanying commentary in JAMA Surgery, Natalie Liu, MD, and Luke M. Funk, MD, MPH, of the University of Wisconsin School of Medicine and Public Health, in Madison, said Americans need improved access to

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

bariatric surgery as a treatment for diabetes, even in cases of less severe obesity. In the United States, less than 1% of patients with class 2 and 3 obesity undergo bariatric surgery. Even fewer patients with class 1 obesity access this surgery because they do not meet the body mass index criteria for insurance approval. “Continued advocacy for bariatric surgery coverage, including expansion for patients with T2DM and class 1 obesity, will be critical. All patients deserve access to the most effective, evidencebased obesity and diabetes treatments,” the authors concluded. ■

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MAY 2020

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The incoming Chief of Surgery will have oversight of the delivery of care by CHA’s general surgery and subspecialized surgical services across two hospital campuses in Cambridge and Everett, MA. Incoming Chief will also provide clinical and administrative leadership for our existing surgical teams, which are comprised of more than 20 surgeons and 20 surgical physician assistants. Ideal candidates will have at least 5 years of progressive leadership experience including a successful track record of recruitment, retention, professional development and mentoring of junior staff, medical students and residents. Demonstrated ability to implement department wide protocols, identify clinical process improvement areas and opportunities for quality initiatives are essential. Candidates must have understanding of and/or experience with ACO/PCMH strategies, and previous interdisciplinary collaboration and strategic planning experience is a must. Qualified candidates will also possess a strong commitment to CHA’s underserved, multi-cultural patient population. Previous employment in an academic, safety net system is a plus. Qualified candidates may apply confidentially at www.chaproviders.org. Alternately, CV and cover letter may be confidentially submitted for consideration via email to ProviderRecruitment@challiance.org. CHA’s Department of Provider Recruitment may be reached by phone at (617) 665-3555 or by fax at (617) 665-3553. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.

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OPINION

GENERAL SURGERY NEWS / MAY 2020

Remembering the Berry Plan By FREDERICK L. GREENE, MD

What was the Berry Plan and what do we know of its founder? Born in Dorchester, Mass., Dr. Frank B. Berry received his undergraduate and medical degrees from Harvard. He initially trained as a pathologist at Brigham and Women’s Hospital, in Boston, but his career was interrupted by service as an Army pathologist with the American Expeditionary Forces in France in World War I. He ultimately decided that he really wanted to be a surgeon and I was a “Berry Planner” cruising in the completed his surgical training at Bellevue Hospital, in New York City, where Mediterranean Sea on board the USS Nimitz and, eventually he served as the director of on that very day, was probably living the dream in our OR. one of the surgical services at Bellevue and on the clinical faculty at Columbia University. In 1953, he was appointed Assistant The USS Nimitz (CVN-68) in 1994. Source: Wikimedia Commons. Secretary of Defense for Health and Medicine by former President Dwight D. Eisenhower. By his own account, all, including the medical schools, the the opportunity to return to my clinical he related that he took that position hospitals, and the greater organizations rotations the following year. because of an increasing tremor in his which were objecting to the drafting of Now here is where serendipity or, left hand that caused him to ques- doctors-the American Medical Asso- alternatively, “beshert” (a Yiddish term) tion his ability to continue as a practic- ciation, the Association of American comes into play! I had started out planing surgeon. Shortly after assuming his Medical Colleges, and the American ning to train as a cardiac surgeon after post, Dr Berry thought that “we might Hospital Association” (Berry FB. The my general surgery residency. The lab devise a doctors’ draft with fairness to Story of the “Berry Plan.” Bull NY Acad year offered by my chairman was supMed 1976;52:278-282). ported by the American Cancer Society The “plan” offered three choices. and would involve research in gastroinThose physicians who desired to serve testinal malignancy. That experience— LETTER TO THE in the military must first choose a ser- working at St. Marks Hospital in EDITOR vice (I chose the Navy) and could: 1) London and learning how to perform a serve immediately after internship, 2) colonoscopy—completely refocused me To the Editor: serve after one year of residency fol- toward surgical oncology, a decision that The resident writing contest essays [in the March lowing internship (PGY-2s), or 3) were I have never regretted. It was the exigenand April issues] are well written, but disappointing. I allowed to complete full residency train- cies of the Berry Plan that gave me that finished a five-year surgical residency at an academic ing. Each of these choices was followed opportunity. program in 2002. It was the last class without any duty by two years of obligated active duty serMy time on the USS Nimitz as its hour restrictions. I immediately joined a surgical pracvice. Although it was felt by Berry and surgeon was one of the highlights of my tice. Fortunately, the rigors of surgical residency prehis colleagues that the second choice life. During those eight months at sea, I pared me for the unpredictability and long hours of a would be most desirable, it turned out learned what it meant to be on a floatgeneral surgeon. to be the least popular of the three. The ing city with almost 6,000 men. Women As surgeons, the judgment of our own ability to most attractive option was the privilege were allowed to serve on carriers only continue to work (or not work) while sleep-deprived of a full deferment for residency training years later. After my year on Nimitz, I is something we must determine before we are out on in a civilian hospital. Unfortunately, we completed the second year of my Berry our own. Work–life balance does not exist for a surwere generally not given a choice. Plan obligation at the Naval Medical geon who, by definition, cares for critical emergencies and disease processes that canAs it turned out, I was offered the sec- Center, Portsmouth, Va. Many of my felnot be scheduled and compartmentalized. I feel the 20% trainee attrition rate quoted ond option initially and prepared to leave low surgeons accompanied me to these in the articles is not necessarily something to be avoided [April 2020, page 30]. Do my academic training program after two academic military training facilities. It we want surgeons who have unrealistic work–life balance expectations? Do we real- years of training. As luck would have it, was at Portsmouth Naval that I honed ly want surgeons who have never been subjected to the stresses of life as a surgeon? in the spring of my PGY-2 year, I was my thoughts as to what a well-run acaAre we doing our residents a disservice by shielding them from the demands of sur- notified by the Navy that I would not demic surgical training program should gery? Isn’t it better to realize that life as a surgeon is not for you as soon as possible? be needed at that time and, instead, was look like. The Berry Plan experience has I now specialize in breast surgery, but I learned great surgical technique from given a full deferment for training in stayed with me and has shaped every doing vascular cases and so forth. It is important to continue training our surgeons general surgery. The unfortunate part of facet of my surgical career. in diverse surgical techniques because it makes one a better surgeon. I disagree with this story was that I had already given up Dr. Berry died at the age of 84 in Provthe statement that “aortic aneurysm cases will no longer be wasted on future breast my residency position in anticipation of idence, R.I., on Oct. 14, 1976. I was a surgeons” [April 2020, page 26]. If there is such a shortage of surgical case experi- my military service. We had a traditional “Berry Planner” cruising in the Mediterence, then the solution is more hours taking care of patients, not depriving residents pyramid program at Yale, and, therefore, ranean Sea on board the USS Nimitz and, of learning experiences. Patients take priority, and they deserve the best. I was without a position beginning in on that very day, was probably living the ■ July of that year. Thankfully, my surgical dream in our OR. —Elaine Tanaka, MD, FACS chairman offered me a one-year laboraFounder, Compassion Breast, San Diego tory appointment as an alternative with —Dr. Greene is a surgeon in Charlotte, N.C.

ur younger readers may not be familiar with the Berry Plan and the importance that it played in the lives of many surgeons like myself who trained in the 1970s prior to the conclusion of the Vietnam War. Memories of my personal involvement in Navy Medicine have been stimulated by the COVID-19 pandemic involving the Nimitz-class nuclear aircraft carrier, USS Theodore Roosevelt (CVN-71). The ramifications of this story, as only one of many pandemic-related vignettes, are many and far-reaching. Not only does it highlight the dangers shared by people living in extremely close quarters, but also emphasizes the fallout when an individual, who means well, goes outside the “chain of command” to seek help. As one of the last Berry Plan surgeons in the Navy, I read this story with greater interest than the casual observer. As a newly trained general surgeon in July 1976, my first duty orders directed me to serve as the surgeon for the first deployment of a Nimitz-class nuclear carrier, USS Nimitz (CVN-68)

Are We Shielding Residents From the Demands of Surgery?

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