Highlights From the SAGES 2022 Annual Meeting

FIRST LOOK

The Society of American Gastrointestinal And Endoscopic Surgeons

All Articles by CHRISTINA FRANGOU

Living Donor Robotic Kidney Transplant

DENVER—Surgeons from the Lahey Clinic presented a technique for a living donor robotic kidney transplant, an approach that leads to a speedier recovery for patients and lower wound complication rates.

“We have noted excellent wound healing, lower narcotic pain usage and shorter length of hospital stays following our early cohort of robotic kidney transplantation recipients,” said Caroline J. Simon, MD, the senior staff surgeon and fellowship program director at the Lahey Hospital and Medical Center in Burlington, Mass.

Graft function after robotic transplantation is similar to that for conventional kidney transplantation, she said. o At SAGES, Dr. Simon showed a video of a robotic kidney transplant performed on a 53-year-old female patient who received a living donor kidney graft from her daughter.

To perform the operation, surgeons made five incisions for four robotic ports and two laparoscopic ports, with one GelPort (Applied Medical) used as both a laparoscopic and robotic port.

Robotic dissection was used to prepare the iliac vessels for implantation, while waiting for the living donor nephrectomy procurement. The graft was then inserted via the GelPort in the umbilicus, and the robot was used to perform all anastomoses. Total warm ischemia time is around 40 minutes, she said.

The technique was first reported in 2010 by Italian surgeons who performed a robotic kidney transplant in a morbidly obese patient, for whom conventional laparoscopic instruments were unsuitable (Am J Transplant 2010;10[6]:1478-1482).

Dr. Simon and her colleagues performed their first robotic kidney transplant in January 2020, after adapting the technique from surgeons at Henry Ford Hospital, in Detroit.

Since then, they’ve operated on eight patients using the robotic approach. They expect to increase uptake in the next year after early delays due to the COVID-19 pandemic, she said.

“We are hoping to have a fairly rapid expansion, as we have seen good preliminary results,” Dr. Simon said.

Open kidney transplantation, first performed in 1954, is associated with high rates of incisional hernias, as well as wound dehiscence and surgical site infections. The first laparoscopic kidney transplant was reported by Spanish surgeons in 2010 (Eur Urol 2010;57[1]:164-167).

Surgeons at SAGES said the total robotic approach is promising. “I think there’ll be wound benefits, potentially decreased hernia rates. There’s a lot of potential benefits from converting this to a robotic procedure,” said Jacob Greenberg, MD, a professor of surgery at Augusta University, in Georgia. hospital hospital kide

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Pre-op Bowel Stimulation Reduces Post-op Ileus

reduced rates of postoperative ileus in patients undergoing elective loop ileostomy closure, according to results from a multicenter, single-blind randomized trial.

In the study of 97 patients, only 6% of those who received repeat bowel stimulation in the three weeks before surgery developed postoperative ileus—down from 24.5% of patients in the control arm.

“The relative risk reduction with this intervention makes it quite attractive and appealing,” said study co-author Richard Garfinkle, MD, a PGY-4 resident in general surgery at Montreal’s McGill University, during his presentation at SAGES. Investigators recruited adult patients from five hospitals in Canada, one in the United States and another in New Zealand. All patients previously had a segmental colectomy or proctectomy with a diverting loop ileostomy and were randomly assigned to the control or stimulation arm.

Patients in the stimulation arm received up to 10 episodes of bowel stimulation performed in an outpatient clinic over the three weeks prior to ileostomy closure. During each session, an 18 Fr Foley catheter was used to intubate the distal limb of the loop of the ostomy, which was infused with a solution of 500 cc of normal saline combined with 30 g of thickening agent.

Nearly 80% of patients completed all 10 sessions, 17% completed seven to nine and 4% completed less than seven sessions. Each stimulation lasted an average of 25 minutes, and about 25% of patients reported abdominal cramping. However, only four out of 410 sessions were terminated early due to poor tolerance. There were no major adverse events.

Forty-seven percent of patients in the intervention arm had a return of flatus by postoperative day 1, compared with 22.4% in the control arm (P=0.022). Their postoperative length of stay fell to three days, down from four in the control arm (P=0.003).

After the presentation, Dimitrios Stefanidis, MD, a professor of surgery at Indiana University School of Medicine, in Indianapolis, called the findings “extremely convincing.”

But it’s unclear how many patients would be eligible for this kind of bowel stimulation. The intervention used in the study is time-consuming for both patients and providers and may not be realistic for all patients, Dr. Garfinkle said.

As such, he and his colleagues are looking at the potential for patients to perform stimulation at home with the help of community nurses, on their own or with family members, he said.

The investigators initially planned to recruit 166 patients, based on sample size calculations indicating that 83 participants would be required in each arm to show a significant effect of bowel stimulation. However, the pandemic affected patient recruitment and study logistics. The investigators performed an interim analysis after 101 patients were randomized.

Although the study was stopped early, this remains the largest trial to explore bowel stimulation in these patients and is the first multicenter trial to do so. A 2014 single-center Spanish trial of 70 patients found ileus fell to 3% from 20% after preoperative bowel stimulation (Dis Colon Rectum 2014;57[12]:1391-1396).

The findings are only applicable to patients with residual colon, and not to patients with ileal pouch–anal anastomosis, according to the authors.

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U.K.-Based Liver Surgery Scoring System Correlates With U.S. Outcomes

DENVER—The Halls/Southampton Laparoscopic Liver Difficulty Score—a model that predicts the risk for intraoperative complications during minimally invasive liver resections—correlates with operative outcomes in North American patients, including estimated blood loss, operative time and length of stay, according to data from eight centers participating in the Americas Minimally Invasive Liver Resection (AMILES) registry.

In comparison, the IWATE scoring system did not correlate with operative outcomes or postoperative complication rate in these patients.

This may reflect differences in populations in the East and West, the authors said. The IWATE system was developed and revised in Japan where resection for hepatocellular carcinoma is common. The United States, however, has higher rates of resection for colorectal liver metastases, said study co-author Yasmin Essaji, MD, a fellow in hepatobiliary surgery at Virginia Mason Medical Center, in Seattle.

The study is based on a retrospective analysis of 1,051 patients in the AMILES registry who underwent a minimally invasive hepatic resection. Patients were scored based on the Halls/Southampton and IWATE scoring systems.

The Halls/Southampton score, which was developed in the United Kingdom, categorizes patients in groupings ranging from low, moderate to high. Analysis showed these groupings correlated with estimated blood loss (343, 499 and 681 mL; P<0.001); operative time (116, 225 and 265 minutes; P<0.001) and length of stay (3.53, 6.30 and 7.05 days; P<0.05), respectively. However, there was no statistically significant difference in need for conversion to open and postoperative complication rate.

Analysis revealed no significant correlation with IWATE scores and operative or clinical outcomes.

Investigators said more research will be needed using a prospective database to better delineate the predictive potential for these scoring systems. But difficulty scoring systems will help surgeons as they develop their skills, Dr. Essaji said.

“It really helps to judge the difficulty of minimally invasive liver surgery and resections, and can help surgeons better identify cases where they feel comfortable so that they can start on the lower-difficulty procedures,” she said.

Several surgical scoring systems have been proposed, but none are routinely used in practice.

A third scoring system developed in France— the Institut Mutualiste Montsouris classification, or IMM—is not as widely validated or accepted as the IWATE and Halls/Southampton scoring systems, and was excluded from this study.

The investigators did not differentiate between laparoscopic and robotic-assisted surgery in this analysis, but plan to assess those differences as more centers, especially those with robotic expertise, join the AMILES registry. ■

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SBO Surgical

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“We wanted to know if surgical services should be admitting patients who are, at least initially, being managed nonoperatively,” said Christopher Thacker, MD, a thirdyear surgical resident at Geisinger Medical Center, in Danville, Pa., who spoke at the 2022 Southeastern Surgical Congress.

Dr. Thacker and his colleagues conducted a multicenter, retrospective study of all patients 18 years of age and older, admitted to their health system for SBO from June 2007 to June 2019. They included only patients who did not require any surgical procedure during their admission, and excluded patients admitted initially to the ICU or hematology/ oncology services.

The primary outcomes were mortality, length of stay (LOS) and readmission rate.

The investigators identified 3,278 patients, of whom 933 (28%) were admitted to surgical services and 2,345 (72%) were admitted to medical services. Of the group, the vast majority was sent to hospitalist services.

“Demographically, there were some significant differences, including [scores on] the Charleston Comorbidity Index,” Dr. Thacker said.

Patients admitted to medical services tended to be older (58 vs. 55 years; P<0.001), and were more likely to have diabetes (24% vs. 20%; P<0.015), congestive heart failure (6% vs. 3%; P<0.002) and acute kidney injury (30% vs. 17%; P<0.001). Patients admitted to surgical services were more likely to have cancer (19% vs. 14%; P<0.001) and more likely to have had surgery in the past 30 days.

“The only major comorbidity that did not reach statistical significance was hypertension,” Dr. Thacker said.

On univariate analysis, patients admitted to surgical services had lower mortality at their index admission (0.1% vs. 2%; P<0.001), 30 days (1% vs. 7%; P<0.001) and 180 days; The mortality rate was 4.9% in those admitted to surgical services and 13.4% of those admitted to medical services. They also had fewer readmissions at 30 days (8% vs. 12%; P<0.001) and an overall shorter mean LOS, at three versus four days (P<0.001).

“We then performed a multivariable analysis controlling for Charleston Comorbidity Index, age, sex and race, as well as all of the individual comorbidities,” Dr. Thacker said.

Controlling for all of those variables, patients admitted to surgical services still had a lower odds ratio for admission and 30- and 180-day mortality, and experienced fewer readmissions and a shorter LOS.

Dr. Thacker acknowledged some limitations of the study, such as its retrospective design and the fact that practice patterns vary among institutions. Ultimately, however, the findings showed admission to a surgical service decreases index admission mortality and readmission for nonoperative patients, even after controlling for comorbidities.

“Hopefully in the future, we’ll be looking at the impact of surgical consult in patients who are admitted to medical services,” Dr. Thacker said.

Deborah Martin, MD, an acute care surgeon at Northside Hospital, in Cumming, Ga., who reviewed the study, pointed out that patients admitted to medical services may be healthier, “and we’re getting them in and out because we don’t do surgery. I’m not sure that means we should admit them all, especially those who have significant medical comorbidities.

“But I do think if they’re admitted to the medical service, surgeons need to be consulted in a timely manner and see the patient so that they can decide, as a team, the treatment plan. Both services need to be there,” Dr. Martin said. ■

Social Media Can Be a Boon for Surgeons, When Used Responsibly

By KAREN BLUM

Social media platforms have grown tremendously in popularity among the general public and medical community, but surgeons and other healthcare professionals need to use it responsibly to avoid lawsuits, disciplinary actions and other woes, a panel of surgeons said during the 2021 virtual American College of Surgeons Clinical Congress.

“We are clearly living in a post-or-perish era,” said Brian Jacob, MD, FACS, a private practice surgeon in New York City. However, surgeons need to think critically about what they post, he added: “We need to be a little careful about what we do online, because anything you post can and may be used against you at some point.”

Social media usage has been exploding, from just under 1 billion users in 2010 to a projected 3.4 billion users in 2023, said Steven Wexner, MD, PhD, FACS, the director of the Digestive Disease Center and chair of the Department of Colorectal Surgery at Cleveland Clinic Florida, in Weston. Physicians and surgeons most commonly use blogs to express their opinions and thoughts, followed by Twitter and Facebook (BMD Med Inform Decis Mak 2016;16:91), whereas the general population is more likely to use Facebook, followed by YouTube and WhatsApp, Dr. Wexner said.

The use of social media varies by specialties, he added. Some 82% to 85% of plastic surgeons use social media, versus 28% of academic radiologists, according to a 2017 study that he led (Colorectal Dis 2017;19[2]:105-114). The journal Surgery, under his editorial leadership, launched its digital media efforts about a year and a half ago and now features a digital media and innovations editorial board. The group can now tell authors about alternative metrics, such as how often their article was referenced on Google or LinkedIn or how many blogs mentioned it.

Surgeons post information to social media platforms primarily for a status update, or for educational purposes, to enhance awareness of what’s going on in the surgical field, Dr. Jacob said. However, “the intent to egotistically boast about one’s accomplishments is easily distinguishable from a genuine intent to educate or disseminate to a global audience useful information that might optimize patient outcomes,” he said. Poor judgment when it comes to postings can result in actions such as being fired, having a license suspended or being subject to lawsuits—not to mention damage to your reputation.

There are two main areas of concern when it comes to this, he said. One is committing an act that constitutes potential malpractice. The other is the impact of social media use on a potential or pending malpractice proceeding.

“If you post a tweet about how nervous you are for an upcoming robotic colon or upcoming hernia case, and that case goes on to have a complication, and the legal team discovers your posts, those posts can be used against you in some form,” Dr. Jacob cautioned.

Posting information within private Facebook groups generally is considered safe, he added. However, screen sharing is very commonplace, and those screenshots also could be used by a legal team during the discovery period. A 2019 white paper that he co-authored provides additional information about sharing information in such groups (Surg Endosc 2019;33[1]:1-7).

When used responsibly in the surgery realm, social media posts and tweets can provide a newer means of connecting researchers for shared projects or papers, finding mentors or mentees, and finding participants for clinical trials or studies, Dr. Wexner said.

“It’s not only where the future is, it’s where the present is, and it’s where our patients are,” he said. “But we have to be very careful with it and follow the rules.”

Know that anything posted to social media, even if you hit delete, leaves a footprint in cyberspace that you cannot take back. Never post or send anything until you’re 100% sure you want to do it, he said. You also must be HIPAA-compliant. Do not reveal any information that would potentially reveal any confidential aspect of your physician–patient relationships.

Here are some best practices for using social media, from the Icahn School of Medicine at Mount Sinai, in New York City. For more, see bit.ly/3om1vdT. • Take responsibility and use good judgment. You are responsible for what you post. Be courteous, respectful and thoughtful about how others may perceive or be affected by the postings. • Think before you post. Anything you post is highly likely to be permanently connected to you and your reputation. • Protect patient privacy. Disclosing information about patients without written permission is prohibited at Mount Sinai—and likely other employers. • Use a disclaimer. Make it clear you are speaking for yourself and not on behalf of your employer. • Respect copyright and fair use laws. ■

isclosing information about permission inai—and clear self and ployer. r use laws.

Know that anything posted to osted to social media, even if you hit ou hit delete, leaves a footprint rint in cyberspace that you u cannot take back. Never er post or send anything until you’re 100% sure you want to do it.

Surgeons Call for More Support for Residents During Pregnancy ncy

By CHRISTINA FRANGOU

From the pages of medical journals to the virtual podium at online surgical meetings, surgeons are sounding the alarm over a high rate of pregnancy complications in their profession and calling for widespread changes to support surgeons’ maternal health during pregnancy.

Writing in the Annals of Surgery in January, surgeons from the University of Michigan issued a call to action for surgery chairs and program directors.

They want residency programs to provide better support to residents who choose to have children during training (Ann Surg 2022;275[1]:e1-e2). “There’s been some progress, but the work has not finished when it comes to creating places where women who desire motherhood and working moms are playing on an even field [with other surgeons],” lead author Michaela Bamdad, MD, MHS, a resident in general surgery and mother of two, told General Surgery News in an interview.

She and her co-authors wrote that programs need to create healthy environments for residents who are pregnant. Many policies currently focus on the period after a child is born—primarily by providing better leave policies for new parents—but improvements to support residents during pregnancy are lacking.

“Instead of viewing pregnancy during training as a handicap or a hassle, we must view it as promising evidence that the face of surgery is changing,” the authors wrote. “That’s a good thing.”

Dr. Bamdad said surgical programs have improved since she had her first child in residency five years ago. But “it’s not happening fast enough or in as much of [an] organized fashion as it should,” she said. Instead of a national organized effort, “it feels like a grassroots de novo sort of operation at each program.”

Those concerns were echoed by authors of a study presented at the 2021 Clinical Congress of the American College of Surgeons. They found that female surgeons experience far more pregnancy complications than female partners of their male surgeon colleagues, and these complications have a ripple effect on career satisfaction.

Large-scale changes are needed to support surgeons through pregnancy, the authors concluded.

“To retain our future workforce, structural changes in training and practice are warranted to optimize maternal health during pregnancy and to provide workplace support to surgeons facing difficult pregnancies,” said the study’s lead author Manuel Castillo-Angeles, MD, a postdoctoral research fellow at Brigham and Women’s Hospital, in Boston, during his presentation.

The findings come from a survey of 692 female surgeons and 158 male surgeons. Surgeons were recruited through five national surgical organizations and social media platforms between November 2020 and February 2021. Another 325 surgeons completed the survey but were excluded from the analysis, mostly because they or their partner had not been pregnant.

Nearly half of female surgeons—45%— had experienced major pregnancy complications, a rate that is far higher than the 27% reported by male surgeons of their childbearing partner.

In an unadjusted analysis, participants who experienced major pregnancy complications were significantly more likely to report burnout (40% vs. 28%; P<0.001) and to have a low quality of life (53% vs. 40%; P<0.001).

Surgeons who had gone through major pregnancy complications were significantly less likely to recommend a surgical career to their own child (56% vs. 63%; P=0.015). However, most surgeons, whether 001). d gone gnanwere ikea

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they had experienced complications or not, still felt surgery was a career they would be happy to see their children pursue.

More than any other variable, being a female surgeon was independently associated with burnout, with a hazard ratio of 2.08 (95% CI, 1.34-3.22; P=0.001). The only other significant independent factor for burnout was having a major pregnancy complication, with a hazard ratio of 1.55 (95% CI, 1.15-2.08, P=0.004).

Surgeons were more likely to report a low quality of life if they were female, worked in an academic setting or had experienced a major pregnancy complication.

These patterns may deter women from surgery or cause them to leave the profession prematurely, Dr. Castillo-Angeles said.

In the past few years, surgical training programs have taken small steps to support surgical residents during pregnancy or after childbirth. The Accreditation Council for Graduate Medical Education (ACGME) requires programs to provide residents with lactation facilities. Last October, the American Board of Surgery announced a more flexible family leave policy for general and vascular surgery trainees, allowing six weeks of leave for significant life events.

However, these advances do not address health-related issues during pregnancy, Dr. Bamdad said.

She and her colleagues set out a guideline to support the well-being of surgical resident parents. It calls for the following: • prenatal health maintenance and access to prenatal visits without stigma or pushback; • support for health and well-being while operating; • special considerations for work hours and rotation schedules; and • support for non-birthing parents and a culture of support and equity.

They also said the ACGME should require programs to directly address the health and safety of pregnant trainees and the American Board of Surgery should comprehensively update their requirements to allow for additional flexibility during training for pregnancy and peripartum periods.

“It is time for the traditional surgery training model to change to assure all trainees can flourish,” they concluded. ■

$22,700-$48,500; P<0.001) compared with the control group.

The study authors were not surprised by these findings.

“The observed associations between postoperative undertriage and morbidity and mortality were not unexpected from a clinical intuition perspective,” Dr. Loftus noted.

“Undertriage, by definition, implies these patients are sicker and at higher risk for complications than what was assumed preoperatively. Unfortunately but expectedly, these patients suffered higher rates of complications,” Dr. Balch said. “The vast majority (about 90%) of preoperative decision making was appropriate, implying that surgeons are generally good at predicting where their patients should end up.”

From these data, the researchers concluded that while surgeons generally perform accurate postsurgical triage, there remains an opportunity to improve patient evaluation. The authors also noted the importance of the opposite phenomenon: postoperative overtriage of low-risk patients.

“The flip side is overtriage, which we have also analyzed and found to be around 5%. I had assumed this would be higher than the undertriage rate, but it appears, at least at our institution, that postoperative triage decisions err on the optimistic side,” Dr. Balch said.

Ultimately, postoperative triage presents an important opportunity to improve surgical decision making.

“Right now, surgeons can be mindful of the importance of postoperative triage decision making, and critically evaluate their practice patterns and associated outcomes to determine whether there is an opportunity to minimize postoperative undertriage and associated mortality and morbidity,” Dr. Loftus said. ■

Undertriage

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Dr. Loftus reported research support from the National Institute of General Medical Sciences of the National Institutes of Health, under Award No. K23 GM140268.