June 2014

CONVENTION ISSUE:

Abdominal Wall Reconstruction

GENERALSURGERYNEWS.COM

June 2014 • Volume 41 • Number 6

The Independent Monthly Newspaper for the General Surgeon

Opinion

Group Takes Cue From Manufacturing To Overcome

The Screening Dilemma B Y F REDERICK L. G REENE , MD

B Y C HRISTINA F RANGOU

I

t is virtually impossible to be exposed to any scientific or quasi-scientific treatise, whether in print media, electronic format, organizational newsletter or nightly news, without being bombarded by the current controversies involving cancer screening.

For those of us who have to recommend screening studies, especially for the secondary prevention (screening) of cancer, the issues raised create angst not only among physicians, but also for our patients and our entire population that is at risk for cancer.

Although we as general surgeons could possibly avoid the ongoing controversy of prostate-specific antigen, or PSA, testing for prostate cancer and Pap smears for cervical cancer, the issues and controversies of mammography and of upper and lower gastrointestinal tract screening are unavoidable because of our interest in breast cancer and gastrointestinal tract cancer.

I have been particularly perplexed by the ongoing dispute that continues

B Y C HRISTINA F RANGOU

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o be successful in commercial manufacturing, a company has to be efficient, speedy, streamlined.

These attributes help surgical practice, too. So when a group of

Cleveland-based endocrine surgeons became frustrated with the number of delays and patient cancellations at their clinic, they turned to experts in see OR DELAYS page 15

The First Surgeon Nobel Prize Winner:

Emil Theodor Kocher, MD

see INSERT AT page 12

I

n 1909, Emil Theodor Kocher, MD, was awarded the Nobel Prize in Physiology or Medicine for his contributions to physiology, pathology and surgery of the thyroid. Dr.

Kocher was the first surgeon ever to receive this honor.

Although the Nobel Prize was his greatest award, it was far from his only

INSIDE In the News

Stitches

Surgeons’ Lounge

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Time for a different approach to critical care in the United States?

Experts Discuss

see STITCH page 18

CORPORATE SPOTLIGHT

B Y V ICTORIA S TERN

Clinical Performance and Economic Analysis of GORE® BIO-A® Tissue Reinforcement

LAS VEGAS—Surgeons can reduce a patient’s risk for developing an incisional hernia after laparotomy by as much as 35% if they use a “small bites” technique to close the fascia, a large randomized trial has shown.

“After this trial, we now recommend suturing the fascia of an abdominal midline incision with a continuous small-bite technique. This merits wide application,” said study co-author Eva Deerenberg, MD, a surgeon at Erasmus University Medical Center in Rottterdam, The Netherlands.

She presented the study results at the 2014 Annual Hernia Repair Meeting.

The STITCH trial was a multicenter, double-blind randomized controlled trial (RCT) designed to evaluate the effect of small stitches on long-term development of incisional hernia after midline laparotomy.

Groundbreaking Work in the Field of Thyroid Surgery

see SCREENING page 5

REPORT

‘Small Bites’ Drop Rate of Incisional Hernias

Women in Surgery: A Profile of Patricia Sylla, MD (first in a series)

Highlights of the 13th Annual Surgery of the Foregut Symposium, Cleveland Clinic Florida

see NOBEL PRIZE page 19

Question: Current clinical evidence affirms that biologic matrices provide a long-term repair in complex AWR?

See page 17

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

Most Benign Right-Sided Colon Polyps Do Not Require Resection B Y D AVID W ILD CHICAGO—Difficult-to-remove colon polyps often are treated with partial colon resection, but a small randomized study presented at the 2014 Digestive Disease Week (DDW) meeting suggests laparoscopic-assisted colonoscopic polypectomy (LACP) requires fewer resources and is just as effective. The 34-patient study showed that LACP took significantly less time to perform than laparoscopic hemicolectomy (LHC), and was associated with a faster recovery, shorter hospital stay and less blood loss.

“Anytime you can find a way to conserve resources while achieving comparable outcomes, that approach is worth studying further,” said Lawrence Friedman, MD, chair of the DDW Council and chair of the Department of Medicine, Newton-Wellesley Hospital, Newton, Mass. “Long-term outcomes will need to be studied, but these data look quite promising,” said Dr. Friedman, who was not involved in the study.

Lead investigator Jonathan Buscaglia, MD, associate professor of medicine and director of interventional endoscopy,

Division of Gastroenterology, Stony Brook University, Stony Brook, N.Y., said that LHC often is used to remove difficult-to-remove colon polyps. To determine whether LACP can be used in place of LHC for this indication, Dr. Buscaglia and his colleagues randomized 34 patients with benign right-sided polyps to undergo either LACP or LHC. The two groups were similar in age and gender distribution, average body mass index, American Society of Anesthesiologists class and history of previous abdominal surgery; polyp morphology, location, size and histology were similar between the two groups.

Dr. Buscaglia reported that physicians were able to remove polyps in 92.9% of patients assigned to LACP, with one patient requiring conversion to LHC. In the group randomized to LHC, four patients required conversion to laparotomy. His team also found that LACP required less time than LHC (95 vs. 179 minutes; P P=0.001) and LACP patients lost less blood (13 vs. 63 mL; P=0.001).

P LACP patients also required less IV fluids (2.1 vs. 3.1 L; P P=0.049), took less time to pass flatus (1.44 vs. 2.88 days; P=0.002), P resumed solid food intake sooner postoperatively (1.69 vs. 3.94 days; P<0.001)

‘The biggest roadblock to performing laparoscopicassisted colonoscopic polypectomy is the ability of a surgeon and gastroenterologist to coordinate their schedules. You need a good relationship between the two departments, and schedules that can accommodate being in the operating room at the same time.’

—Jonathan Buscaglia, MD and were discharged earlier (2.63 vs. 4.94 days; P<0.001).

Rates of postoperative complications, hospital readmissions and reoperations were similar in the two groups.

Although the investigators did not conduct a cost-savings analysis, there could be significant differences in that measure, Dr. Buscaglia noted.

During a press conference where he presented the findings, Dr. Buscaglia said that although LACP has clear benefits, adoption of the procedure has been slow, in part because of a paucity of welldesigned studies.

“Until now, there have been only a handful of published case series on LACP,” he said.

Physicians also may find it more challenging to schedule an LACP, he added.

“The biggest roadblock to performing LACP is the ability of a surgeon and gastroenterologist to coordinate their schedules,” Dr. Buscaglia said. “You need a good relationship between the two departments, and schedules that can accommodate being in the operating room at the same time. It’s not always the easiest thing to do.”

Dr. Buscaglia said patients in the study will undergo surveillance colonoscopies to determine whether there are any differences in their long-term outcomes.

Drs. Buscaglia and Friedman reported no relevant financial conflicts of interest.

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 20144

Critical Question: Experts Discuss the Best Model for ICU B Y C HRISTINA F RANGOU

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s it time for a different approach to critical care in the United States?

At the 2014 Critical Care Congress of the Society of Critical Care Medicine, specialists made the case for a more multidisciplinary approach to the delivery of critical care services and the training of critical care physicians in this country.

During a panel discussion on subspecialty and general ICUs, Andrew J. Patterson, MD, PhD, division chief for critical care medicine in the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, Calif., said years of increasing subspecialization of ICUs have driven up costs but failed to produce measurable advantages for patients.

“If you look at the assessments that have been done, there is a lack of evidence that specialized ICU care is financially beneficial, [with] the possible exceptions being neuro-ICUs and cardiothoracic ICUs. There is also no consistent benefit in terms of length of stay and there is no survival benefit, again, with the exceptions of neuro-ICUs and cardiothoracic ICUs,” Dr. Patterson said.

All speakers stressed that it is difficult to compare subspecialty and general ICUs because of disparities between patient populations, hospital sizes and referral patterns. Moreover, a clear definition of a subspecialty ICU does not exist, making fair comparisons challenging.

As a result, there is a lack of high-quality data examining this issue, said Kenneth Krell, MD, a critical care and internal medicine physician at Eastern Idaho Regional Medical Center, Idaho Falls.

But the available data do not show any significant differences in risk-adjusted mortality between general and subspecialty ICUs for all conditions other than cardiac surgery and intracranial hemorrhage, he said.

“What we’re seeing is that it’s not the specialized unit that’s going to be the most equipped to take care of those patients who have a multitude of comorbidities and who are simply sicker than having one organ failing,” Dr. Krell said.

The Evidence The most notable study to address this question was published five years ago, and it relied on data collected before 2006 ((Am J Respir Crit Care Med 2009;179:676-683). In that study, physicians from the University of Pennsylvania conducted a retrospective review of more than 84,000 patients admitted to 124 ICUs between January 2002 and December 2005. The patients were

classified by admission into a general ICU, a diagnosis-appropriate or “ideal” specialty ICU, or a diagnosis-inappropriate or “non-ideal” specialty ICU. (Patients in the latter group reflect what is known as “boarding,” the practice of admitting patients to a non-ideal specialty ICU because the right ICU is not available or is full.)

The study was limited to patients admitted with one of six specific diagnoses or procedures: abdominal surgery, acute myocardial infarction, cardiac surgery, intracranial hemorrhage, ischemic stroke or pneumonia.

After adjusting for potential confounders, the investigators could not detect any consistent survival advantage for patients admitted to an ideal specialty ICU. Mortality rates in the ideal specialty ICU hovered at a nearly identical rate to those in the general ICU. However, patients admitted to a non-ideal specialty ICU had a significantly greater risk for dying.

‘It may not be the presence of that particular subspecialty unit and that particular subspecialty intensivist that improves outcomes as much as it is the presence of an intensivist in an organized ICU.’ —Kenneth Krell, MD There was one exception: cardiothoracic surgery patients. When specialization was examined as a continuous variable, each 10% increase in specialization was associated with an 18% reduction in the odds of death among cardiothoracic surgery patients (odds ratio, 0.82; 95% confidence interval, 0.76-0.88).

The study had several important limitations beyond the narrow patient population. The investigators could not adjust for key organizational factors, such as intensivist staffing. They used in-hospital mortality as the outcome rather than 28-day mortality, which is a measure less sensitive to variation in discharge practices between hospitals. The investigators advised that their results should be viewed with caution for patients with intracranial hemorrhage, as other studies showed improved outcomes with specialty ICU care in this group. Finally, the investigators did not evaluate other patient-centered outcomes, such as functional status and quality of life.

Even so, they concluded: “Our study suggests that investments (such as

di idi dividing a generall ICU into i specialty i l ICUs or building a hospital with several specialty ICUs) should not take place with the expectation of improved patient outcomes.”

Dr. Krell said it was unclear why specialized ICUs do not translate into significantly improved survival. One possibility, he suggested, may be that critical illness syndromes are common among all ICU patients. “Perhaps ICU patients, regardless of the organ that’s failing, are more alike than different.”

Other studies have shown that some patients treated in subspecialized ICUs do benefit. In a retrospective review of more than 2,600 trauma patients at a Level I trauma center in Virginia, patients admitted to the surgical trauma ICU were sicker yet had similar outcomes to patients treated in non-trauma ICUs ((J Emerg Trauma Shock 2008;1:74-77).

“Our study supports the concept of specialized ICU care, appropriately triaged between trauma and non-trauma ICUs,” concluded authors Therese M. Duane, MD, and her colleagues from Virginia Commonwealth University Health System, in Richmond.

The researchers argued that the most severely injured patients should be preferentially placed in specialized trauma ICUs, where the staff possesses years of experience in the “complex trauma care that only a surgery/trauma ICU can provide.”

ICU specialization may not be as important for less severely injured patients as long as the management of these patients is guided by an ICU team with a surgical intensivist and dedicated, experienced nursing personnel, they

noted. d Similar findings were reported in patients with intracerebral hemorrhage treated in specialized neuro-critical care units ((J Neurosurg Anesthesiol 2001;13:8392). Patients cared for in a new neuroscience ICU (NSICU) had higher rates of survival and improved disposition at discharge than those treated two years earlier in a general ICU. Patients treated in the NSICU also had shorter hospital stays and lower total costs of care than national benchmarks. This initial study was confirmed by later studies.

Importantly, both the trauma study and the neuro-critical care studies stress that the presence of a full-time intensivist on the unit is as important as ICU subspecialization.

“It may not be the presence of that particular subspecialty unit and that particular subspecialty intensivist that improves outcomes as much as it is the presence of an intensivist in an organized ICU,” Dr. Krell said.

(One well-known study involving more than 100,000 critically ill adults and 123 ICUs showed higher mortality rates among patients managed by critical care physicians than those who were not [[Ann Intern Med 2008;148:801-809].

The authors cautioned that, despite efforts to adjust for illness severity, some markers may have been unaccounted for and confounded the results.)

Other organizational factors, too, have been shown to significantly affect patient outcomes, said Dennis A. Taylor, DNP, chair of the research and evidence-based practice council at Carolinas Medical Center, Charlotte, N.C. Things like coordination of care,

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

‘Closing an ICU to a particular patient cohort based on diagnosis or admitting service does not affect outcome, and may actually increase cost by creating redundancy and decreasing the overall ICU bed availability.’

—Wendy Greene, MD

protocols and pr specialty trained nurses lower the odds of mortality and failure to rescue, he said.

The debate over specialty an nd general ICU care is becomin ng more important against the baackdrop of the enormous cost of heealth care in the United States, Dr. Patterson said. Today, critical D caare accounts for more than $180 biillion in health care costs. It is im mpossible to tease out what perceentage of that figure is attributab ble to subspecialty critical care.

What is clear, however, is that th he up-front expenses associated d with i h a specialty ICU are higher but without a proven financial benefit in the long term, Dr. Patterson said.

He noted that some data support financial benefit of neuro-critical care units and cardiac surgery or cardiovascular specialty units. “But otherwise, what we know is that there is some reason to believe that some ICUs that are specialized may be financially disadvantaged.”

Financial models suggest that a costeffective option for critical care may be intensivist staffing in the ICU. A 2006 analysis of the Leapfrog group looked at the costs associated with having a dedicated intensivist present during daytime hours and available by pager at night (Crit Care Med 2006;34:S18-S24). Cost savings ranged from $510,000 to $3.3 million for six- to 18-bed ICUs. The best-case scenario demonstrated savings of $4.2 million to $13 million. In a worst-case scenario, there was a net cost of $890,000 to $1.3 million.

A detailed report on the economics of ICU organization, published in 2012,

SCREENING

jContinued from page 1 to be reignited surrounding the benefit of screening mammography for early breast cancer. As one who has taken a great interest in breast cancer over many years in my own practice, I have generally followed the guidelines that reasonable-risk women should begin having screening mammograms at the age of 40 and should have mammograms repeated on an annual basis. Several years

showed that certain aspects of ICU organization, such as the inclusion of a staff pharmacist on a multidisciplinary ICU team, can be financially and clinically beneficial (Crit Care Clin 28:25-37).

The authors noted that few studies have examined the economics of the ICU, and even fewer acknowledge the competing economic interests of patient, hospital, payor and society.

In an interview, Wendy Greene, MD, associate professor of surgery and associate director of trauma and critical care, Howard University College of Medicine, Washington, D.C., said the clinical and financial implications of various ICU structures are still being debated. At present, she said, data suggest that it is intensivist-directed high-intensity staffing and a closed ICU that improve outcomes and shorten stays.

High-intensity staffing was shown to reduce the length of stay in 10 of 13 studies examining hospital length of stay and in 14 of 18 studies addressing ICU length of stay, she said. “No study found increased length of stay with high-intensity staffing after case mix adjustment.”

Dr. Greene pointed to a growing body of evidence suggesting that a closed ICU format is a more favorable setting to minimize the effects of high-risk surgery. In an open ICU, patients can be admitted by their physician and receive care directed by that physician with or without consultation from an intensivist. In a closed ICU, the patient’s care is transferred to an intensive care physician who is trained in critical care medicine and who has no clinical responsibilities outside the ICU. In one study of highrisk surgical patients, mortality of ICU patients was 25.7% in the open-format group and 15.8% in the closed-format group (P=0.01) P (BMC Surg 2011;11:18).

“Closing an ICU to a particular patient

ago, the U.S. Preventive Services Task Force recommended that women should begin screening at the age of 50 and that screening should be done no more frequently than every two years in appropriate low-risk populations. This, of course, was met with great consternation by many organizations and support groups that deal with breast cancer, and the controversy has continued to the present day.

Now, however, there has been a significant escalation because of the publication of the Canadian National

cohort based on diagnosis or admitting service does not affect outcome, and may actually increase cost by creating redundancy and decreasing the overall ICU bed availability,” she said in an email.

Current Trends in ICU Care Today, approximately one-third of the 6,000-plus ICUs in the United States are subspecialty units, most often catering to patients with neurologic, respiratory, cardiac, surgical and trauma diagnoses. That’s an increase from 2006, when 25% of ICUs were classified as subspecialty ICUs. Critical care training, too, has become increasingly specialized, Dr. Krell said.

In 2010, the majority of diplomates in critical care represented specialties such as cardiac, surgical or neuro-critical care.

This shift occurred as a response to the growing burden of critically ill patients in the United States. Since 1991, patients with many serious conditions present more frequently in hospitals, a trend attributed in part to the aging patient population. Between 2000 and 2005, the number of ICU beds in the country increased by 7% while total hospital beds decreased 4% (Crit Care Medd 2010,38:65-71). As ICUs expanded and technologies improved, so did the demand for highly trained specialists and staff to look after severely ill patients.

Proponents of specialty ICUs point to multiple benefits of these units. They are managed by staff with expertise in caring for very sick patients. Subspecialty units are more likely to use set protocols and possess specialized technology befitting their patient population. Other benefits include physician convenience, reduction of diagnoses and treatment variability, increased nurse expertise and education and focused training for

If we find an invasive cancer and are able to recommend reasonable therapy for a population, it seems terribly shortsighted to even use the concept of “overdiagnosis” as an argument against routine screening.

fellows (Crit Caree 2009;13:314).

Today, the majority of ICU patients in the United States are treated in smaller hospitals that lack the number of beds that would justify fragmented ICUs, Terence O’Keeffe, MD, associate professor of surgery and medical director of the surgical ICU at the University of Arizona, in Tucson, said in an interview.

“The size of the hospital is key. Once you’re in a larger hospital, subspecialty care makes more sense. If you’re in a small hospital, you’re much better off having a multidisciplinary ICU with a specialized intensivist available in-house during the day and then 24/7 from home,” Dr. O’Keeffe said.

Finding intensivists to provide coverage is one of the biggest issues in critical care today. The United States is experiencing a well-documented shortage of intensivists, a shortfall driven by numerous factors, including low compensation rates and poor work–life balance for intensivists (Crit Care Med 2013;41:2754-2761).

Dr. O’Keeffe suggested that an option for critical care in the United States is to follow a more European-style model, which is heavily dependent on multidisciplinary care. The European Society of Intensive Care Medicine has emphasized multidisciplinary training in critical care so intensivists across Europe could move from one country to another. This model has been picked up by countries such as Argentina, Australia, New Zealand and Uruguay, and in the United States, at the University of Pittsburgh.

Dr. Krell believed that the multidisciplinary model may help draw more specialists to the field and improve overall quality of care in ICUs. “I would suggest we need to look beyond our individual fiefdoms and our silos in academic ICUs and academic training to what the needs are out there in the community. I would suggest they are much more in the areas of multidisciplinary ICUs with well-trained, general multidisciplinary intensivists who can take care of this load of critically ill patients,” Dr. Krell said.

Breast Screening Study (CNBSS) (BMJ 2014;348:g366 doi:10.1136/bmj.g366), which concluded that for the majority of women, mammograms not only should be avoided routinely, but lead to unnecessary and costly procedures based on false-positive studies and “overdiagnosis” of cancer.

Once again, the clinical breast community, especially our breast imagers, have gotten into the fray and have see SCREENING PAGE 6

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Opinion SCREENING

jContinued from page 5 pointed out significant flaws in this study and in other trials that have been done in the past to answer the question of whether routine mammographic screening should be performed using current guidelines for most women. The problem is what is a clinician to do? Which studies should we use as guidelines and benchmarks? How should we counsel our patients and their caregivers regarding the issue of routine breast imaging? How can we avoid contributing to increased health

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

care costs in this country and still recommend appropriate secondary prevention for our patient population?

One major conclusion of the CNBSS was that mammography did not reduce deaths for women aged 40 to 59 years.

I find this particularly problematic since other randomized controlled studies have shown a 30% decline in mortality for women who are screened. Obviously one of the byproducts of improved screening technology, especially in the digital mammographic era, is the ability to discern smaller and smaller breast cancers that may not become clinically apparent

during a personâ&#x20AC;&#x2122;s lifetime. This seems to be a major negative point stressed by most advocates who are recommending against routine mammography. In my view, it is very problematic to predict who might develop metastatic breast cancer from ductal carcinoma in situ or a T1a or T1b invasive cancer, and who, indeed, may live well into their 90s without any indication of clinical disease. This is the same argument that has been made for PSA testing for early prostate cancer, but may be more relevant in men over the age of 65 or 70 years.

Another criticism of the Canadian

study is that state-of-the-art equipment that is currently used by our breast imagers in the United States was generally not being used for the majority of patients reported from the Canadian sites. We are obviously aware that women with dense breasts will have small cancers obscured even on modern mammographic equipment. For this reason, a number of states have legislated that radiologists must inform and educate women regarding the issues of breast density, and that perhaps even magnetic resonance imaging should be employed in this population. If one uses outdated and reduced-quality mammographic equipment, the likelihood of finding lesions in women with dense breasts becomes even more problematic.

Additional issues are apparent when one reviews the Canadian study, including the inappropriate randomization that placed a significant increased number of already palpable tumors into the mammographic arm of the study that obviously would lead to an increased incidence of mortality from the disease. The authors of the CNBSS ultimately state that routine screening mammography was associated with substantial â&#x20AC;&#x153;overdiagnosisâ&#x20AC;? of breast cancer. This is probably the most problematic statement for me, because if we find an invasive cancer and are able to recommend reasonable therapy for a population, it seems terribly shortsighted to even use the concept of â&#x20AC;&#x153;overdiagnosisâ&#x20AC;? as an argument against routine screening.

The mammographic screening controversy is not limited to the United States or North America. The Swiss Medical Board, based on some of the concerns raised in the CNBSS, has recommended that no new breast cancer screening programs be introduced in their country (N Engl J Medd April 16, 2014; doi:10.1056/ NEJMp1401875). They state that â&#x20AC;&#x153;from an ethical perspective, a public health program that does not clearly produce more benefits than harms is hard to justify.â&#x20AC;?

For those of us who care for women with breast disease as a significant portion of our clinical practice, the mammographic screening issues are all important.

Our patients also have been bombarded through print and electronic media, and are as confused and concerned as many of us with the current dialogue. Secondary prevention of breast cancer is not going away. Our goal is to use the best, most reliable data and to educate ourselves about the pros and cons, so that we may counsel our patients appropriately and wisely. â&#x20AC;&#x201D;Dr. Greenee is Clinical Professor of Surâ&#x20AC;&#x201D; gery, UNC School of Medicine, Chapel Hill, North Carolina.

khorty@mcmahonmed.com.

Stitches

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

Women in Surgery: A Profile of Patricia Sylla, MD P

atricia Syllaâ&#x20AC;&#x2122;s passion for medicine was ignited during her childhood growing up in Abidjan, a port city in Ivory Coast, West Africa. Unlike most young girls, Dr. Sylla had the opportunity to help her mother, a French-American, collect medical supplies for French medical missions.

In exchange, the doctors performed medical procedures free of charge.

During one mission, physicians came to Abidjan to repair cleft palates in local children. â&#x20AC;&#x153;These kids were essentially outcasts because of their defects,â&#x20AC;? Dr. Sylla said. â&#x20AC;&#x153;They were usually begging in the streets. But these doctors from France spent a week fixing their cleft palates so they could lead a normal life. I was really struck by that.â&#x20AC;?

After this experience, at just 12 years old, Dr. Sylla knew she wanted to become a doctor. Throughout her schooling, Dr. Sylla focused on science and medicine.

In college, she majored in biology, and in 1996, she moved to New York City, to attend Weill Cornell College of Medicine of Cornell University.

When she entered medical school, Dr. Sylla gravitated toward ENT surgery, ultimately planning to focus on plastic reconstruction. But after completing a project in her first year, she became disheartened by surgery. Her supervisor â&#x20AC;&#x153;was the opposite of a good mentor,â&#x20AC;? she recalled. She would scrub in with him for 15-hour procedures and he wouldnâ&#x20AC;&#x2122;t say a word to her. â&#x20AC;&#x153;After the project, I felt uninspired.

Surgery was no longer a priority,â&#x20AC;? she said.

Two years of medical school passed and Dr. Sylla did not set foot in an operating room (OR).

The turning point came during her third-year rotation. Her first case was in general surgery. â&#x20AC;&#x153;That moment I walked into the OR was like coming home,â&#x20AC;? she said. â&#x20AC;&#x153;Although I had convinced myself I hated surgery, in that instant I knew I belonged in the OR.â&#x20AC;?

Feeling encouraged, Dr. Sylla carefully planned out her long road ahead in surgery, making sure to surround herself with better mentors and expose herself to a variety of specialties. When she landed a month-long rotation in colorectal surgery at Mount Sinai Hospital that year, she knew she had found the right place. â&#x20AC;&#x153;I ended up, completely by luck, on a team with expert colorectal surgeons, doing things I had never seen before,â&#x20AC;? she said. â&#x20AC;&#x153;For one month, I became completely immersed in minimally invasive colorectal surgery.â&#x20AC;?

But this time, Dr. Sylla knew the importance of surrounding herself with

better mentors. During her rotation, Dr. Sylla met Randolph Steinhagen, MD, chief of the Division of Colon and Rectal Surgery, who was very impressed by her. â&#x20AC;&#x153;She was obviously very bright and mature, and had a great grasp of surgical fundamentals,â&#x20AC;?

Dr. Steinhagen said. â&#x20AC;&#x153;I

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tried to recruit her to choose Mount Sinai for her residency training.â&#x20AC;?

But after graduating from Cornell University in 2000, Dr. Sylla decided to do her residency at ColumbiaPresbyterian Hospital (now NewYork-Presbyterian Hospital), working closely with Richard Whelan, MD, the see PATRICIA SYLLA PAGE 8

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PATRICIA SYLLA

Evolution: A NOTES Takeover

former chief of the Division of Colon and Rectal Surgery, and Kenneth Forde, MD, a prestigious colorectal surgeon and former president of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Dr. Forde became a key mentor early in Dr. Sylla’s surgical career, helping her solidify her interest in colorectal surgery, endoscopy and minimally invasive surgery (MIS).

After Dr. Sylla’s residency, Dr. Steinhagen continued to recruit her, and in 2006, she circled back to Mount Sinai Hospital for a year-long fellowship in MIS colorectal surgery.

“I was thrilled when those efforts were successful,” he said. “It was an extremely positive year for both of us.

She worked very hard and was very productive, both clinically and academically, authoring several papers with us and presenting her work at the colon and rectal surgery meetings.”

The mentorship has continued to the present day. “I am looking forward to many more years of a close professional relationship,” Dr. Steinhagen said. “She has been doing great work, and I am very proud to have contributed to her training.”

In late 2007, Dr. Sylla moved to Boston with her husband, Paul Cohen, MD, PhD. The two had met and fallen in love while in medical school together, and were married in 2005. Despite demanding careers in different specialties, they worked as a unit. So when Dr. Cohen landed his dream cardiology fellowship at Brigham and Women’s Hospital, Dr. Sylla decided to apply for fellowships in Boston, focusing on MIS and colorectal surgery. She was matched at Massachusetts General Hospital, and soon began working with David Rattner, MD, the chief of the Division of Gastrointestinal and General Surgery.

During this time, worldwide interest in natural orifice transluminal endoscopic surgery (NOTES) had exploded, and Dr. Rattner was at the forefront of the developments.

“I was very impressed by Dr. Rattner’s program, the breadth and spectrum of the cases, and especially thrilled about the opportunity to be at the epicenter of NOTES,” Dr. Sylla said. “Dr. Rattner had a thriving NOTES lab, and was an exceptional mentor. Given my interest in MIS, I couldn’t wait to be involved.”

At a 2007 NOSCAR [Natural Orifice Surgery Consortium for Assessment

jContinued from page 7

‘I’m thrilled to contribute to making NOTES better and more widespread. But it’s seeing patients going back to life after surviving cancer that drives me and makes me excited about the future.’

—Patricia Sylla, MD and Research] conference in Boston, Dr. Sylla became particularly intrigued by the possibilities that NOTES offered. She had just come out of a session by Lee Swanstrom, MD, and Mark Whiteford, MD, FACS, FASCRS, on transanal radical sigmoid colectomy in human cadavers using transanal endoscopic microsurgery (TEM) (Surg Endoscc 2007;21:18701874). “In that moment, I saw NOTES was the way of the future,” she said.

After that, Drs. Sylla and Rattner investigated transanal rectosigmoid resection using TEM in pigs and later human cadavers, and found that their approach was feasible in both (J ( Gastrointest Surgg 2008;12:1717-1723; Surg Endosc 2013;27:74-80).

“Pigs are not the best models, so

working on human cadavers was key to perfecting the technique and preparing for what the procedure would be like in humans,” Dr. Sylla said. “We continued to tweak the technique to make sure we could standardize it and that there were no complications.”

At the end of 2009, Dr. Sylla was presented with the opportunity of a lifetime.

At a SAGES meeting, Antonio M. de Lacy, MD, approached Dr. Sylla to ask if she would join him on a novel case: the first NOTES transanal rectal cancer resection on a patient. Dr. de Lacy, chief of gastrointestinal surgery and MIS at the Hospital Clínic/Barnaclinic in Barcelona, already had secured approval from his hospital’s ethics committee and had his first patient lined up, a 76-year-old woman with a malignant rectal tumor.

“I had read Dr. Sylla’s papers in cadavers and wanted her to join me on the surgery,” Dr. de Lacy said.

The only hitch for Dr. Sylla was that by early November 2009, she was 34 weeks pregnant with her first child. But after some convincing, Dr. Sylla’s obstetrician gave her permission to travel overseas.

That November, Dr. Sylla flew to Barcelona to assist Dr. de Lacy on this groundbreaking procedure.

“Although it was nerve-wracking to be

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performing a new procedure, Dr. de Lacy worked with incredible confidence and calm,” Dr. Sylla recalled. “For me, this was the best experience. We followed the same steps we had so many times in the lab, and the procedure went smoothly.”

The surgeons created a 5-mm port through which they gained a visual and could mobilize the tumor site. They transected the tumor transanally, and sewed the coloanal anastomosis by hand. The operation took less than 4.5 hours, and the patient left the hospital after four days with no postoperative complications and a small scar on her belly (Surg Endosc 2010;24:1205-1210).

Dr. Sylla recalls being well taken care of during the procedure. “The nurses were amazing, making sure I was doing OK and that I could sit down with my fat belly.”

Dr. Sylla flew home the next day, and delivered a healthy baby at 41 weeks of pregnancy.

The Future of NOTES Dr. Sylla’s work with Dr. de Lacy endured. “She is a very generous woman, and has become a good friend and important collaborator,” Dr. de Lacy said.

In recent years, Drs. Sylla, de Lacy and Rattner have conducted trials of laparoscopic-assisted transanal NOTES using TEM in patients with rectal cancer (Surg Endoscc 2013;27:339-346; Surg Endosc 2013;27:3165-3172; Surg Endosc 2013;27:3396-3340), finding additional evidence that the procedure is safe and feasible.

“I’m thrilled to contribute to making NOTES better and more widespread,” Dr. Sylla said. “But it’s seeing patients going back to life after surviving cancer that drives me and makes me excited about the future.”

However, Dr. Sylla noted, there is still a long way to go before NOTES becomes mainstream. The major hurdles are educating surgeons and developing better technology and instrumentation.

“There is still a training and technical skill gap among surgeons,” Dr. Sylla said. “Every piece of data is coming from centers of expertise, and we need to make sure that the technique is feasible for the majority of surgeons to absorb and perform safely.”

Dr. Sylla said it’s now a matter of sitting down with colorectal societies to iron out a plan to introduce NOTES training, and to collect data on a wider scale.

Additionally, industry remains reluctant to invest millions of dollars in NOTES technology that might not pay off, so NOTES is moving forward but on a smaller scale, Dr. Sylla said. “However, if we can recapture the attention of industry, I’m optimistic we will get better instruments that will allow us to do NOTES procedures on a routine basis.”

Reflections: Women in Surgery Although surgery is still a field dominated by men, it has evolved dramatically over the past few decades. In particular, Dr. Sylla noted, having an annual Women in Surgery conference is an excellent way to meet other female medical students, residents and professionals, to hear the inspiring stories of how women achieved full professorships or became chair of their department, and to discuss obstacles that women tend to encounter.

“There are still sex-related discrepancies and issues women have to tackle,

such as disproportionate salaries, but we’re in a much more women-friendly world,” Dr. Sylla said. “I certainly didn’t feel picked on or that I had a harder time.”

Part of the key for Dr. Sylla was that she chose New York City for her training. “I was less conscious of being female or a minority because in New York City, you completely blend in,” she said. “You become a mirror image of the population you serve. I wanted my patients to be able to identify with me.”

Perhaps the greatest difficulty was

balancing family goals with professional ambitions. “Being female, issues of family and sacrifice do enter your mind more often,” she said. “But when going into surgery, there’s no mystery of how demanding the training will be. You have to be 100% committed, whether you’re male or female.”

The key to a successful career, Dr. Sylla said, is going with your passion.

“I found myself in a fortunate position, having the right mentors and collaborators at the right time. But it was so important for me to follow my instinct and not give up.”

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Coverage From the 13th Annual Surgery of the Foregut Symposium Held February 15-19, 2014, in Coral Gables, Florida All articles by Mayank Roy, MD, MRCS, general surgery resident, Cleveland Clinic Florida, Weston

Introduction From Symposium Director It is my pleasure to share a few highlights from the 13th Annual Surgery of the Foregut Symposium, held at the Biltmore Hotel in Coral Gables, Florida.

John Fung, MD, PhD, a pioneer and world leader in organ transplantation, delivered the third Annual Robert E. Hermann Lecture. Dr. Fung presented an overview on the evolution of organ transplantation in parallel with the understanding and implementation of new immunosuppressive drugs.

Fernando Dip, MD, reviewed the routine use of fluorescent cholangiography, and what I believe will become the new standard in imaging when performing laparoscopic cholecystectomy.

The last featured speaker was Almino Ramos, MD, current president of the Brazilian Society of Bariatric Surgeons and secretary-treasurer of the International Federation for the Surgery of Obesity and Metabolic Disorders. Dr. Ramos analyzed the current incidence and treatment modalities of staple-line disruption after sleeve gastrectomy.

I hope our readers will enjoy these briefly summarized discussions, and I look forward to welcoming everyone to the 14th Annual Surgery of the Foregut Symposium, in February 2015.

Long-Term Survival After Liver Transplantation A Triumph of Surgery and Immunosuppression John J. Fung, MD, PhD, from the Cleveland Clinic, in Ohio, delivered the Annual Robert E. Hermann Keynote Lecture on the successful history of liver transplantation surgery (LTS) and an insight into the future of the procedure.

Although experimental, LTS dates back to 1952, after which Thomas Starzl, MD, performed the first human liver transplant in 1963, with the longest surviving patient living for 22 days. Dr. Starzl and others subsequently performed the first successful LTS, and in 1982 published long-term survival data of liver transplant patients, showing that five-year survival had doubled since 1978 to 40% (Hepatologyy 1982;2:614-636).

These data led to approval of LTS as a therapeutic modality by the National Institutes of Health (NIH) in 1983. Over the next 20 years, liver transplant centers worldwide increased dramatically, leading to a donor shortage and the need for partial-graft transplantations.

In the 1980s, Henry Bismuth, MD, pioneered the first reduced-size orthotopic liver transplant (Surgeryy 1984;95:367370), and Strong and Lynch performed the first successful living donor liver transplantation from mother to child (N Engl J Med 1990;322:1505-1507). This ushered in adult-toadult living donor liver transplantation.

Despite an initial rise in living related donor (LRD) use between 2000 and 2002, stringent regulations requiring high levels of resources and concerns related to donor risk and

Sincerely, Raul J. Rosenthal, MD Chair, General Surgery Bariatric and Metabolic Institute Cleveland Clinic Florida, Weston

Figure 1. Changes in medication use for liver transplantation.

recipient complications resulted in a decline in LRD. Dr. Fung reported that mortality rates for right- and left-lobe liver donors are approximately 0.5% and 0.1%, respectively.

Dr. Fung went on to explain that success in LTS would not have been possible without advances in immunosuppressant medications. Development of 6-mercaptopurine in 1951, followed by azathioprine in 1957, led the way for chemical immunosuppression. By 1960, azathioprine was being used by several centers in clinical transplantation, and then in 1972, the immunosuppressive properties of cyclosporine were identified. Cyclosporine was found to be effective in clinical transplant trials and was approved by the FDA in 1983, the same year it approved LTS as a therapeutic modality, thus setting the stage for dramatic improvements in LTS. The next big breakthrough in immunosuppression came with the development of tacrolimus, in 1989, at the University of Pittsburgh. The FDA approved tacrolimus for clinical use in 1994. From 1998 to 2007, the use of tacrolimus and mycophenolate mofetil steadily increased, while the use of cyclosporine and steroids steadily decreased. The use of the mammalian target of rapamycin (mTOR) inhibitor sirolimus remained relatively low during this time (Figure 1).

Dr. Fung noted that the incidence of acute rejection after liver transplant decreased from 85% to less than 10% with the combined use of tacrolimus, mycophenolatemofetil and steroids. The highest mortality rate after LTS is within the first year, Dr. Fung said. The most common cause of late mortality after LTS is complications secondary to immunosuppressant use; other causes include disease recurrence and cardiovascular complications.

Risk for renal failure associated with immunosuppression in LTS gradually increases over the years after transplantation.

Dr. Fung reported one retrospective analysis showing that patients who were more than 10 years postorthotopic liver transplant developed chronic renal failure and endstage renal disease at a high rate secondary to the use of calcineurin inhibitor (Figure 2). Data such as these prompted the need to develop new strategies for long-term immunosuppression as a means to decrease this complication. Sirolimus and everolimus (mTOR inhibitors)

2008 Organ Procurement and Transplantation Network/ Scientific Registry of Transplant Recipients annual report

continued on page 12

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continued from page 11

appear to lack nephrotoxicity. Dr. Fung discussed the results of a recent multiinstitutional trial that showed early initiation of everolimus facilitated early minimization of tacrolimus, with comparable efficacy and superior renal function.

Dr. Fung concluded that despite the numerous advances in LTS, many issues remain that challenge the wider application, improved survival and enhancement in quality of life for these patients. Dr. Fung proposed that

organ preservation at body temperature, and treating unhealthy livers and transplanting them at a later stage are innovations that could change the face of transplant surgery in the future.

Although the modern history of LTS spans only five decades, great achievements have been made.

Advances in surgery, anesthesia, critical care and pharmacologic therapies have all contributed to improvements in patient and graft survival.

20 18

CRF + ESRD ESRD KTX

16

Morbidity, %

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Figure 3. When prints and other fluorescent trace are illuminated with green (or blue) light, the fluorescence is easy to distinguish from scattered light using an orange filter.

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Illumination source: Coherent Trace Laser.

10 8 6 4 2 0 0

2

4

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Years from Liver Transplantation Figure 2. Renal disease and failure after liver transplantation.

CRF, chronic renal failure; ESRD, end-stage renal disease; KTX, kidney transplantation.

Source: Transplantationn 2001;72:1934.

Intraoperative Incisionless Fluorescent Cholangiography A New Standard in Surgery of the Biliary Tract?

Fernando Dip, MD, visiting professor at Cleveland Clinic Florida from Hospital de Clinicas Buenos Aires, Argentina, discussed fluorescenceguided surgery as a newly emerging technology and the role of intraoperative incisionless fluorescent cholangiography (IOFC) in biliary tract surgery.

Eric Muhe, MD, performed the first laparoscopic cholecystectomy in 1985, and this approach has rapidly become the gold standard for symptomatic gallbladder disease (Langenbecks Arch Chir Suppl Kongressbdd 1991:416-423).

However, the rate of bile duct injury increased from 0.2% with the open approach to 0.4% with the laparoscopic approach, Dr. Dip reported.

Approximately 750,000 cholecystectomies are performed in the United States every year, with more than 300 reported bile duct injuries (Surg Endosc

2013;27:1051-1054). Most patients can be managed by endoscopic retrograde cholangiopancreatography and/or percutaneous drainage. However, some patients will require multiple interventions, which is associated with increased morbidity, mortality and litigation, Dr. Dip said.

It has been reported that bile duct injury is the most common source of litigation ((Ann Surgg 2010;251:682685). The learning curve, lack of tactile feedback, visual perception from two-dimensional images and anatomic variation are reasons suggested for bile duct injury with laparoscopic cholecystectomy, Dr. Dip said ((Ann Surgg 2003;237:460-469; Br J Surgg 1996;83:171175; J Am Coll Surgg 1995;180:101-125; Surg Today 2010;40:507-513; J Am Coll Surgg 2010;211:132-138).

Intraoperative cholangiography (IOC) has been proposed to avoid bile duct injury during laparoscopic cholecystectomy. However, published studies have

Figure 4. Calot’s triangle under xenon light.

not shown any robust evidence to support or abandon the use of IOC to prevent bile duct injury, Dr. Dip noted. Moreover, there is much variation in the use of IOC among surgeons and hospitals ((J Am Coll Surg 2012;214:668-679). Dr. Dip noted that although IOC does not necessarily prevent injury, it may reduce the severity of the lesion if recognized intraoperatively (Br J Surgg 2012;99:160-167).

There is currently a need for a technique that will improve the surgeon’s visual field during laparoscopic cholecystectomy, said Dr. Dip. The technique should add value to the existing options, be financially viable and be easily adopted by any surgeon. Fluorescence image-guided surgery has emerged as a new surgical revolution.

Fluorescence is the emission of light by a substance that has absorbed light of another electromagnetic radiation, Dr. Dip explained (Figure 3). Chemically,

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fluorescence is brought about by absorption of photons in the singlet-ground state promoted to a singlet-excited state. The spin of the electron is still paired with the ground-state electron. As the excited molecule returns to ground state, it involves the emission of a photon of longer wavelength and lower energy than the absorbed photon.

One of the first reports of illumination of the biliary tract with fluorescent bile acid in rabbits came from Switzerland in 2001. Indocyanine green (ICG) is a dye excreted by the liver that becomes fluorescent near-infrared (NIR) light.

In 1959, the FDA approved ICG for use in humans for various medical purposes such as measurement of hepatic function, cardiac output, Figure 5. Calot’s triangle under infrared light. renal perfusion and angiography. In 2010, Ishizawa and colleagues, from the University of Tokyo, published their results of IOFC using Dr. Dip discussed the results of a prospective ICG. The authors reported that they were able to study of IOFC during laparoscopic cholecystectomy identify the cystic and common hepatic duct sin conducted at Cleveland Clinic Florida, which is 100% of the cases ((J Am Coll Surgg 2009;208:e1-e4). pending publication. Routine IOC was performed The technique of IOFC during laparoscopic in every patient to compare and confirm the results. cholecystectomy involves a xenon light (Karl Storz IOFC was performed in all 45 patients, whereas Endoskope, Germany) source and a laparoscope with a IOC could be performed in 42 of the 45 patients charge-coupled device that filters out light wavelengths (93%) (P<0.078, χ2 test). Individual median cost of below 830 nm with a specific 780-nm infrared light performing IOFC was lower than IOC ($13.97±4.3 source. During the procedure, alternate exposure from vs. $778.43±0.4 per xenon and infrared light (by pressing a pedal) is used to patient; P P=0.0001) identify extrahepatic biliary structures before and after and IOFC was faster the dissection. Biliary structures are then visualized than IOC (0.71±0.26 under the NIR light (780-830 nm) with fluorescent vs. 7.15±3.76 minutes; light (Figures 4 and 5).

P<0.0001). The cystic

duct was identified by IOFC in 44 of 45 patients (97.77%). All third- and fourth-year surgical residents were able to easily identify the extrahepatic structures including the bile duct in the 45 cases using IOFC, without any direction from the attending surgeon. No surgical complications that might have been related to the use of IOFC were noted. Also, no allergic or adverse reactions secondary to the injection of the dye were noted.

Dr. Dip concluded that IOFC is a useful tool in the laparoscopic surgeon’s armamentarium.

Dr. Dip proposed that IOFC should be routinely performed during laparoscopic cholecystectomy as it is safe, feasible, fast and inexpensive; avoids radiation exposure; and provides the surgeon with the ability to directly visualize the biliary anatomy and provide tactile perception. Most importantly, Dr. Dip noted, IOFC can be used in real-time surgery, guiding the surgeon during dissection, transection and resection around the biliary anatomy.

Although IOFC has proven quite useful, Dr. Dip did not suggest it is intended to replace IOC. Instead, he proposed IOFC as a complementary method, with its main goal being to visualize bile duct structures when visualization is not possible with xenon light.

20 Years of Experience in Laparoscopic Fundoplication Bernard Dallemagne, MD, from the University Hospital Strasbourg, France, discussed the principles and controversies in laparoscopic antireflux surgery.

Over the past two decades, laparoscopic antireflux surgery has proven to be safer than and as effective as the open technique, Dr. Dallemagne said. Diagnostic work-up is crucial to the selection of appropriate patients.

Dr. Dallemagne discussed the broad principles of laparoscopic antireflux surgery, namely: 1) restoring the length of abdominal esophagus, 2) permanently augmenting the resting distal esophageal sphincter pressure, 3) using only the fundus of the stomach to construct the fundoplication, and 4) ensuring that the resistance of the reconstructed valve matches the propulsive power of the esophagus.

Failures and complications continue to present challenges to antireflux surgery. Wrap herniation (39%) and slippage (35%) remain the most common causes of failure after laparoscopic

fundoplication (Figure 6); in all, 3% to 6% of these patients require reoperation, Dr. Dallemagne reported.

Six technical aspects of antireflux surgery include trocar placement, dissection of the gastroesophageal junction, ensuring appropriate length of the esophagus, crural repair, fundic mobilization (with special attention to short gastric vessels) and architecture of the fundoplication.

Dr. Dallemagne emphasized the importance of ensuring appropriate length of the esophagus to minimize axial tension, a potential Achilles heel even after a technically good fundoplication operation. Dysfunction of the lower esophageal sphincter leads to acid/alkaline regurgitation, causing an inflammatory response. Repetition of this injurious cycle can lead to fibrosis of deeper muscular layers and esophageal shortening, and this occurs in 5% to 10% of patients.

Most patients can be appropriately continued on page 14

Figure 6. Wrap herniation and slippage.

Source: Am J Surg g 2004;188:195-199. Reprinted with permission.

Figure 7. Collis gastroplasty.

Source: Am J Surg g 2004;188:195-199. Reprinted with permission.

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managed with extensive mediastinal mobilization of the esophagus; 20% of patients, however, will require an aggressive surgical approach in the form of Collis gastroplasty (Figure 7, page 13). With experience gained from sleeve gastrectomy, gastroplasty should be used when in doubt to decrease the risk for tension.

Dr. Dallemagne mentioned the importance of a good crural repair. In his own technique, he mobilizes the gastric fundus after dividing the short gastric vessels to prevent torsion. The

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

fundoplication should not be too tight because that also can increase the tension, he advised.

Dr. Dallemagne also discussed controversies surrounding the use of mesh to prevent recurrence. Studies have reported recurrence rates of zero to 8% and 22% to 24% with or without the use of polytetrafluoroethylene mesh, respectively (Arch ( Surgg 2002;137:649652; J Am Coll Surgg 2011;213:461468). However, studies have shown no difference in recurrence between using mesh and not using mesh after a follow-up of 58 months (54% vs. 59%)

((J Am Coll Surgg 2011;213:461-468). Dr. Dallemagne said he was aware of the associated risk for mesh erosion in the stomach and esophagus. He shared some of his personal experiences, including the need to remove eroded mesh endoscopically from the stomach.

Dr. Dallemagne concluded by addressing developments such as the assessment of functional diameter and geometric reconstruction of the esophagogastric junction using the functional lumen impedance probe.

ANNOUNCING POSTGRADUATE COURSE IFSO 2014 Montreal

Fifth International Conference on Sleeve Gastrectomy TUES AUG 26, 2014 - WED AUG 27, 2014 – 0800-1800 HRS MONTREAL CONVENTION CENTRE – PALAIS DE CONGRÈS - Montreal, Canada

A Comprehensive 2 day Course FULL DAY OF LIVE SURGERY The 5th ICSG will include one full day of live surgeries, followed by a day of oral and video presentations and debates, as well as panel discussions.

At the end of the conference, the surgeons will be able to: • Describe indications, contraindications and surgical guidelines for LSG as a primary or secondary operation • Identify steps of laparoscopic sleeve gastrectomy to avoid complications • Discuss postoperative care and nutritional support options for LSG patients • Describe strategies to avoid or treat common complications following this operation • Comprehend revision and conversion strategies Co-Directors and Moderators: Dr Camilo Boza, Dr Michel Gagner, Dr David Nocca, Dr Raul Rosenthal

Find more details at www.ifso2014.com/postgraduate

Gastrectomy for Chronic Leak After Lap Sleeve Gastrectomy Almino Ramos, MD, from Brazil, discussed the management of leak after laparoscopic sleeve gastrectomy (LSG).

Laparoscopic sleeve gastrectomy has increased exponentially over the past decade. Chronic leak after LSG remains a challenging complication to manage for most bariatric surgeons. Dr. Ramos discussed the management of chronic leak and shared some of his experiences with performing gastrectomy for resistant cases.

Sleeve gastrectomy creates a perfect storm for development of a fistula at the angle of His. Physiologic obstruction due to the pylorus and mechanical obstruction from the “L” shape of the sleeve causes increased pressure inside the sleeve.

The negative pressure inside the thorax compounds this process. Complete resection of the angle of His is desirable to achieve maximum weight loss. However, this might cause a leak due to the loss of blood supply in the surrounding area, leading to ischemic changes.

Initial management of leak at the angle of His remains nasoenteral feeding and drainage. Stent placement by endoscopy is one of the conventional methods used for fistula treatment. However, the anatomic position of the angle of His poses a challenge. Endoscopy has also been used for fibrin glue, mesh placement or clips. Some surgeons have proposed conversion of the sleeve into a Roux-en-Y gastric bypass.

Dr. Ramos discussed his experience with performing laparoscopic total gastrectomy for resistant cases of leak in 12 patients who already had at least one attempt with conventional treatment. Dr. Ramos concluded that, in his experience, laparoscopic total gastrectomy could be the only alternative in some cases of resistant leak and can be performed safely. These patients should wait at least three months and should initially undergo conventional methods of leak management. Surgeons should consider this procedure only after they have acquired substantial experience in bariatric and minimally invasive surgery procedures.

We would like your opinion.

Please send letters to: khorty@mcmahonmed.com.

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

OR DELAYS

jContinued from page 1 commercial manufacturing for assistance.

The results?

Increased patient throughput, reduced wait time for consults and quicker scheduling of surgical procedures. With these improvements, patient cancellations also dropped significantly.

“The entire process hums along much more efficiently now, so we can handle an increased number of patients and in a lower overall time,” said senior study author Allan Siperstein, MD, chair of the Department of Endocrine Surgery, Cleveland Clinic, in Ohio.

“It’s a better system for everyone.”

David Reznick, MD, a surgical outcomes fellow at Cleveland Clinic, presented the study at the 2014 annual meeting of the Central Surgical Association.

In the past decade, a number of health care organizations, including Cleveland Clinic, adapted techniques from industry.

Published reports describe how hospitals use “process improvement methodologies” from manufacturing industries to reduce operating room (OR) time, turnover time and postanesthesia care unit time, and improve office efficiency.

This is the first report of commercial manufacturing processes put to use in a surgical clinic.

The program started in 2012, when Dr. Siperstein and his partners called on process engineers from Cleveland Clinic to work with their surgical clinic. Engineers arranged a meeting with staff members involved at every point of patient care, including the secretarial service, scheduling service, nursing staff and surgeons. At that meeting, attendees described their duties and outlined their frustrations with the system.

“It was a real eye-opener to everybody as we learned how complex the system was, how many redundancies there were,” Dr. Siperstein said.

Based on that meeting, a list of inefficiencies was created. That list led to several major but simple changes.

Now, when a patient first calls the office, the secretarial service uses a script to categorize the patient’s disease, determine what labs and studies are needed, and assess the patient’s likelihood of needing surgery. Patients receive online health information and risk assessment forms that stratify them for surgery. The first appointment is scheduled during that phone call.

As a result, patients experience fewer delays in the process of getting to surgery, and more patients are seen in the clinic each month. Since the changes were put in place, the number of days from the initial call to scheduling of a patient’s first appointment decreased

from 14 to 0.8±0.3 (P<0.01). The percentage of patients who cancelled their appointments fell from 27.9% to 17.3%.

The group also altered their system for patients waiting for surgery after an initial consult. Low-risk patients are scheduled for surgery within a two-week period. Surgeons no longer have set OR and clinic days per week. Instead, their schedules are flexible, ensuring that OR blocks do not go unfilled because someone is out of town.

Wait times from the initial consult to surgery fell from 39.9 to 33.9 days for the overall practice and to 15 days for

Since the changes were put in place, the number of days from the initial call to scheduling of a patient’s first appointment decreased from 14 to 0.8±0.3. The percentage of patients who cancelled their appointments fell from 27.9% to 17.3%.

low-risk patients. Today, the clinic bustles with an increased patient flow, from 30.9 to 53.1 consults per month.

The results should stimulate surgeons around the country to look for novel ways to reorganize their clinics, said L. Michael Brunt, MD, professor of surgery and co-director of the Washington University Institute for Minimally Invasive Surgery, St. Louis.

“This was an interesting and novel approach, and I like the fact that the authors took a business model to problems that are fairly universal in surgery: see OR DELAYS page 18

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Another synthetic mesh removal.

And considering the average $31k cost of explantation, there goes our upfront cost savings.1

Why would you use anything other than Strattice™ Reconstructive Tissue Matrix in your Complex AWR patients?

Fact is, postoperative infection occurs in 26% of Complex AWR patients with a synthetic mesh,1 and removal of infected mesh has been shown to be 65% more costly than the average VHR admission.1,2 This can put a tremendous burden on the surgeon, the patient and the healthcare system at large.3

Strattice™ Tissue Matrix is clinically differentiated from other repair types in Complex AWR: t Can decrease downstream complications 5-fold in Complex AWR patients, and costs by 2-fold1 t Studied in more than 1,100 Complex AWR patients in 50 peer-reviewed articles 4 t <1% incidence of explantation reported in all peer-reviewed articles t Provides for a long-term repair4 1 LifeCell data on file based on a longitudinal analysis of private and public insurance claims from the Truven MarketScan® Database. Patients were followed from their initial procedure in 2007 for 18 months. (n=740).

2 Reynolds D, Davenport DL, Korosec RL, Roth JS. Financial implications of ventral hernia repair: a hospital cost analysis. J Gastrointest Surg.2013 Jan;17(1):159-66.

3 Poulose BK, Beck WC, Phillips SE, et al. The Chosen Few: Disproportionate Resource Use in Ventral Hernia Repair. Am Surg. 2013 Aug; 79(8):815-8..

4 Searches performed on PubMed, Google, Google Scholar and ScienceDirect® in September 2013. Each study was considered independent during calculation.

Studies may contain overlapping patient populations.

Before use, physicians should review all risk information, which can be found in the Instructions for Use attached to the packaging of each LifeCell™ Tissue Matrix graft. © 2014 LifeCell Corporation. All rights reserved. Strattice™ is a trademark of LifeCell Corporation. MLC4001/3898/4-2014

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17

Corporate Spotlight

Question: Current clinical evidence affirms that biologic matrices provide a long-term repair in complex AWR? Dr. Garvey, Plastic Surgeon, MD Anderson Cancer Center

Dr. Liang, General Surgeon, University of Texas

Agree, particularly when the AWR with biologic matrix utilizes optimal surgical practices such as primary fascial closure and perforator-sparing techniques to optimize skin perfusion.

When choosing a mesh, our group takes into account both the patient and defect characteristics. We have a low tolerance for avoidable complications in our clinical practice and believe that long-term data should guide surgical decision-making. In that vein, we recently published our centerâ&#x20AC;&#x2122;s experience in over 220 consecutive AWRs using bioprosthetic mesh with a mean follow-up of more than 31 months (JACS, 2013). Our data suggested that the most significant predictor of hernia recurrence was the creation of a bridged fascial repair (n = 25, 56% recurrence rate). The patients with bioprosthetic reconstructions that achieved fascial closure (n = 195), typically with component separation, experienced only an 8% recurrence rate, and no patients required mesh explantation due to infection. This represents the largest study to date, with the longest follow-up, of complex AWR using bioprosthetic mesh and speaks to the safety and efficacy of bioprosthetic mesh for AWR. So to answer the question of whether bioprosthetic mesh provides a durable AWR, the answer is that it depends.

If the repair is performed in a way that adheres to optimal surgical techniques and principles, the answer is yes.

On the fence, the level of evidence to support prosthetic material selection in CAWR is low, and therefore, we must base clinical practice on the highest level of evidence currently available. From the available literature, we know that heavy-weight permanent synthetic mesh should not be used in cases at high risk for developing surgical site infection.

In addition, lightweight synthetic mesh may not be strong enough for AWR and the ability of lightweight mesh to clear bacterial contamination is overstated. Regarding the performance of biologics, our institution conducted a risk-adjusted (through case matching) retrospective study (level III) to compare forty (40) PADM repairs versus forty (40) synthetic mesh repairs in a moderately complex patient population. We reported a non-statistically significant trend towards a lower incidence of mesh explantation (5% vs. 15%) and hernia recurrence (7% vs 22%) at a median follow-up of 61 months. This trend may indicate that a biologic offers a long-term repair in this patient group (in press, Surgical Infections). A long-term prospective randomized controlled trial is necessary to provide a definitive scientific answer to the durability and complications associated with various repair materials. However, based upon current best evidence along with biologic plausibility, in patients at high risk for developing surgical site infection, biologic mesh is the treatment of choice.

Dr. Martindale, General Surgeon, OHSU Agree, when used in the correct setting. When biologics are used in the right patient with ability to get the approximation of well vascularized fascial tissue over the matrix they serve as an excellent repair with long term durability. Iâ&#x20AC;&#x2122;ve used a PADM in well over 400 patients, including going back on patients more than three years out, and found that when placed with good approximation and healthy vascularized tissue, PADM, placed in an underlay position delivers good results. Possibly even more importantly, with biologics you rarely have to reoperate for explantation of mesh. When I have cut through the PADM at the midline it is often hard to tell what is fascia and what is the biologic. It looks like host fascia.

In my experience, durability is largely dependent on surgeon technique and patient factors.

Dr. Sbitany, Plastic Surgeon, University of California San Francisco Agree. A robust and growing body of evidence supports use of a biologic in many abdominal wall reconstruction cases, especially when you consider the risk for developing infection and reoperation that can occur in a co-morbid patient population. In my practice, the only instance where I am hesitant to use a biologic is for very large defects where primary fascias closure cannot be achieved.

Our data has shown that even followed out to greater than 24 months, recurrence rates with a PADM reinforced repair were less than 10% when used in a non-bridged repair.

Dr.Garvey, Dr. Martindale, Dr.Liang and Dr. Sbitany are paid consultants for LifeCell. The above represents each surgeonâ&#x20AC;&#x2122;s own opinion and is based on his own clinical experience and research. Š 2014 LifeCell Corporation. All rights reserved. MLC3994/3888/5-2014

Scan the QR code or visit us at www.lifecell.com to learn more.

18

In the News STITCH

jContinued from page 1 In recent years, support has grown among surgeons for the “small bites” concept, particularly in Europe.

Still, this approach is not commonly used.

Long-time proponent Leif Israelsson, MD, a Swedish surgeon, led the most significant trial of the smallbites technique and published the results in 2009 in Archives of Surgery (144:1056-1059). In this single-center RCT, incisional hernia rates decreased by 70%—from 18% to 5.6%—when shorter stitch lengths were used (P<0.001). Short stitches also were associated with a 50% reduction in wound infections.

In interpreting these outcomes, it should be noted that the study was conducted at a single center where surgeons had long advocated this approach. Dr. Deerenberg and her colleagues set out to confirm the results, using a larger and more rigorous study design.

Between 2009 and 2012, the researchers randomized 560 patients from nine hospitals to the smallbites technique or the conventional mass closure suture technique. All surgeons and residents involved in the study were trained in standardized techniques.

In the small-bites arm, surgeons applied sutures at 0.5-cm intervals with bite widths of 0.5 cm, with a 2-0 PDS plus II suture using a 31-mm needle. In the control arm, sutures were applied every 1 cm with bite widths of 1 cm, with the use of a looped 0-0 PDS plus II suture using a 48-mm needle.

In both arms, surgeons used a suture length to wound length ratio of at least 4:1. Suturing was initiated at the ends of the incision and moved to the middle where an overlap of at least 2 cm was created.

One year after surgery, 23% of patients in the conventional closure group had an incisional hernia. In contrast, 14% of patients in the small-bites group were found to have an incisional hernia.

In the small-bites group, the fascia was sutured with more stitches (45 vs. 25); there was a greater ratio of suture length to wound length (5.03 vs. 4.37); and

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

closing required more time (14 vs. 10 minutes). Shortterm postoperative complications, such as surgical site infection, burst abdomen and hospital length of stay, did not differ by surgical technique.

Surgeons who heard the study at the meeting said they were unsure if the small-bites technique would be as successful in the United States as in Europe, due to the higher prevalence of obesity in this country. The average body mass index of patients in both arms of the study was 24 kg/m2, significantly lower than the

AT A GLANCE In the Dutch study, researchers randomized 560 patients from nine hospitals to the small-bites technique or conventional mass closure suture technique for closing the fascia.

One year after surgery, 23% of patients in the conventional closure group had an incisional hernia. In contrast, 14% of patients in the small-bites group had an incisional hernia.

Short-term postoperative complications, such as surgical site infection, burst abdomen and hospital length of stay, did not differ by surgical technique.

Surgeons who heard the study said they were unsure if the small-bites technique would be as successful in the United States as Europe, due to the higher prevalence of obesity in this country.

American population average of 28.8 kg/m2.

Dr. Deerenberg said they operated on obese patients using the new technique, but not on those who would be classified as super-obese. “I think the small-bites technique is better in obese patients, but we cannot say for super-obese,” Dr. Deerenberg said.

Alfredo Carbonell, DO, associate professor of surgery and co-director of the Hernia Center at the Greenville Health System, Greenville, S.C., advocates the small-bites approach for both obese and normalweight patients, and said it’s supported by high-quality data. “It’s good science. It’s legitimate, and it works.

Now, it’s been shown in a multicenter trial.”

Small sutures reduce tension on the suture line, which is particularly valuable in obese patients whose increased abdominal pressure adds to the risk for wound complications and hernia development, he said.

He equated the difference in techniques to the differences between a zipper and buttons on a piece of clothing. “It’s the same thing with an abdominal wall closure: Multiple small bites, like multiple small teeth on a zipper, will provide much stronger closure than a few large buttons.”

In the STITCH trial, patients were followed for at least one year after surgery and underwent radiological and clinical evaluation for incisional hernias. Radiological exams were far more sensitive in diagnosing incisional hernia, identifying 40% of hernias missed by clinical exam.

“Radiological examination is essential in diagnosing incisional hernia; otherwise, underestimation of the incidence will occur,” Dr. Deerenberg said.

She and her colleagues previously published a report describing the study design (BMC Surgg 2011;11:2). In the paper, they said incisional hernia remains the most common complication after median laparotomy, with an incidence as high as 30% to 35% among obese and aortic aneurysm patients.

OR DELAYS

jContinued from page 15 maintaining efficiency in our clinic visit process, case scheduling and management.”

After reviewing the study, Dr. Brunt said he and his colleagues plan to revamp their own system of OR scheduling to better coordinate surgeons’ schedules and optimize OR time.

Cleveland Clinic’s approach was set up for a high-volume tertiary care center with a highly specialized practice, Dr. Brunt noted. Smaller, general practices may need to adjust some of the processes.

“Still,” he said, “this kind of approach could work in many places where we need to minimize unused OR time.”

Teamwork and commitment from management are essential for the program to succeed, Dr. Siperstein said. Everyone contributed to brainstorming ideas and identifying previously unknown areas of duplication.

“By working together, duplicate steps were eliminated, and steps that were overlooked could be addressed and reworked efficiently into the system,” he said.

‘It was a real eye-opener to everybody as we learned how complex the system was, how many redundancies there were.’

— Allan Siperstein, MD

Stitches

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

NOBEL PRIZE

jContinued from page 1 one. During his lifetime, Dr. Kocher was given 35 honorary memberships to societies all over the world, the first of which was the Medical Society of London, in 1889.

Dr. Kocher’s drive for recognition, consuming quest for knowledge and precise operative technique made him stand out among his peers and helped propel him to fame.

“Dr. Kocher certainly wanted to achieve something,” said Ulrich Tröhler, MD, PhD, former director of the Institute for the History of Medicine at the University of Freiburg, and author of a book-length biography of Dr. Kocher. “He was persistent, diligent and single-minded when it came to surgery.”

Dr. Emil Theodor Kocher Photo courtesy of Wikipedia

Dr. Kocher was born in Bern, Switzerland, on Aug. 25, 1841, to Jakob Alexander Kocher and Maria Kocher. His father, an industrious railway engineer, and his deeply religious mother had profound influences on the man he became.

A precocious and ambitious child, Dr. Kocher excelled in school and by age 17, chose to study medicine at the University of Bern. Shortly after graduating summa cum laude, he toured medical institutions in Germany, England and France in order to rub elbows with some of the surgical legends of his day. For instance, while in London, he visited Sir Thomas Spencer Wells, who had designed hemostatic clamps and forceps to control bleeding during surgery and developed a hygienic method of surgery.

“Dr. Kocher was impressed that Dr. Wells operated so cleanly,” Dr. Tröhler said. “He washed his hands and instruments, which is the reason he operated with such success. In contrast, Dr. Kocher was disgusted by surgeons in Paris, who operated in filthy conditions, wearing aprons clotted with blood.”

After his travels, Dr. Kocher worked as the assistant of George Albert Lücke,

MD, full professor of surgery and chair at the University of Bern. In 1869, he married Marie Witschi-Courant, a pious woman with whom he had three sons.

In 1872, at only 31 years old, Dr. Kocher became professor of clinical surgery at the University of Bern, a position he kept for the next 45 years. That same year, he performed his first thyroidectomy. At the time, thyroid surgery was considered extremely dangerous, with some estimates putting the mortality rate as high as 75% ((Acta Otorhinolaryngol Ital 2009;29:289). Dr. Kocher wrote to Joseph Lister, who in 1867 had pioneered the

Despite the negative reactions, Dr. Kocher propelled his research forward. His first step was to declare that he would never again perform total thyroidectomies. In future cases, he always left a small piece of thyroid tissue intact.

antiseptic treatment of wounds, in order to reinstitute the technique in his clinic (it had been abandoned because of cost). This was an important move that helped elevate Dr. Kocher’s clinic to a leading surgical center.

Dr. Kocher became known, in particular, for enhancing the safety of thyroid surgery by developing his own technique that combined the use of general anesthesia, antisepsis and hemostasis. He developed instruments called Kocher clamps (which he essentially copied from Dr. Wells), but perhaps most notably, in his see NOBEL PRIZE PAGE 20

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Stitches NOBEL PRIZE

jContinued from page 19 quest to perfect thyroid surgery, he introduced a precise, slow technique that allowed him to avoid infection and selectively remove all diseased thyroid tissue, or in some cases, the entire gland.

Over the next few decades, he performed more than 6,000 thyroid operations and reduced the mortality rate of the procedure to less than 0.5% ((J Clin Neurosci 2009;16:1552-1554).

“His slow and careful operating style astonished visitors from all over

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

the world,” Dr. Tröhler said. He became a sought-after surgeon. Wealthy people throughout Europe, as well as Russian and Polish nobility, traveled to see Dr. Kocher. Even politician Vladimir Lenin brought his wife to Bern for an operation.

Dr. Kocher’s profound volume of operations was possible, in part, because he operated simultaneously on two tables.

After enucleating the goiter, Dr. Kocher would operate on a patient on an adjacent table while his eldest son, Albert, was left to close the wounds.

“This was a painstaking process for his son, who had to remove 20 to 30 Kocher

clamps and tie off each vessel by hand,” Dr. Tröhler said.

In 1883, Dr. Kocher’s obsessiveness brought him close to unraveling a medical mystery that had baffled researchers for decades. His efforts to do so highlight one of his most influential cases, which ultimately changed the way researchers investigate and analyze patient outcomes.

By the late 1800s, some surgeons had been performing thyroid surgery for goiter, but no one yet understood how the gland worked. Several experts expressed suspicions that damage to the thyroid might cause hypothyroidism, known

NE VADA

SEPTEMBER 10 - 13

2014

Preliminary Listing of Participating Organizations Society of Laparoendoscopic Surgeons (SLS) American Institute of Minimally Invasive Surgery (AIMIS) Chinese Journal of Minimally Invasive Surgery (CJMIS) International Pelvic Pain Society (IPPS) International Society of Gynecological Endoscopy (ISGE) New European Surgical Academy (NESA) Society for Medical Innovation and Technology (SMIT) Clinical Robotic Surgery Association (CRSA) Robotic Assisted Microsurgical & Endoscopy Society (RAMSES)

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14

LAS VEGAS

True to his nature, Dr. Kocher was working almost right up until his death, performing his last surgery just four days before he passed away on July 27, 1917, at the age of 76. then as myxedema (Trans Clin Soc Lond 1874;7:180-185), while others, including Dr. Kocher, thought that the thyroid gland had no function at all.

On the subject, Dr. Kocher wrote: “Unfortunately the physiologists know next to nothing about the physiological significance of the thyroid gland, and this may have been the main reason for surgeons tacitly assuming that the thyroid gland had no function at all” (Archiv ( für Klinische Chirurgiee 1883;29:254-337).

In 1874, Dr. Kocher removed the thyroid of an 11-year-old girl, Maria Bichsel. Six months after the operation, Ms. Bichsel’s physician, August Fetscherin, MD, contacted Dr. Kocher to inform him that the girl had changed dramatically after surgery (Schweiz Med Wochenschrr 1970;100:721-727). In a letter to Dr. Kocher, Dr. Fetscherin wrote that she had always been a lively and intelligent girl, but had now become overweight and lazy. At the time, Dr. Kocher did not heed these comments. “He didn’t care, he was just interested in improving his operative technique,” Dr. Tröhler said.

It wasn’t until eight years later, in 1882, while attending an international meeting in Geneva, that Dr. Kocher realized the significance of Dr. Fetscherin’s remarks.

During a conversation, his colleague Jacques Louis Reverdin asked Dr. Kocher if he had noticed certain symptoms in patients who had had their entire thyroid removed, specifically delays in physical and intellectual development (Revue Médicale de la Suisse Romandee 1883;3:169198, 233-278, 309-364).

The inquiry prompted Dr. Kocher to reconsider what Dr. Fetscherin had reported years earlier. He tracked down Ms. Bichsel, and found that the girl had indeed undergone a striking transformation. Once mistaken for her younger sister, she was now physically stunted and her extremities and body had swelled. Dr. Kocher noted that she exhibited impaired cognitive function, writing that she “exhibits the ugly looks of a semi-idiot.”

In February 1883, Dr. Kocher invited 77 of 102 of his former thyroidectomy patients for a follow-up. He was only able to reexamine 34 patients but received written reports from 26 patients. The 28 patients who had undergone partial thyroidectomies were in good health, but the 34 with total thyroidectomies had not see NOBEL PRIZE PAGE 22

GSN Bulletin Board

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We’re in a Harvard Medical School BETH ISRAEL DEACONESS MEDICAL CENTER DEPARTMENT OF SURGERY General/MIS Surgeons: The Division of General Surgery at Beth Israel Deaconess Medical Center invites applications and nominations for positions that will be available in the 2013-2015 academic years for general surgeons. Candidates must be Board-certified or Board-eligible in General Surgery. Candidates with fellowship training or special qualifications in advanced laparoscopy are preferred. Candidates must have a record of academic accomplishment in basic or clinical research, systems management, surgical education and/or simulation. The surgeon will have a primary responsibility of developing a network of community general surgical care in the state of the art BIDH-Needham affiliated Hospital, which is currently undergoing a major operating room expansion, located just miles west of Boston in the suburb of Needham. Secondary responsibilities may include teaching, clinical and/or basic research and patient care. Academic appointment at Harvard Medical School will be commensurate with experience and qualifications. The Beth Israel Deaconess Medical Center, a 600-bed tertiary and quaternary care hospital, is a member of BIDCO, LLC, a value-based physician and hospital network and an Accountable Care Organization (ACO). Beth Israel Deaconess Medical Center and Harvard Medical School are Equal Opportunity/Affirmative Action Employers. Women and minorities are particularly encouraged to apply. Inquiries, nominations, and applications should be directed in confidence, together with a current curriculum vitae and the names of at least four individuals from whom letters of reference may be solicited to: Mark P. Callery, M.D., FACS Chief, Division of General Surgery Beth Israel Deaconess Medical Center 330 Brookline Avenue, ST-928 Boston, MA 02215 Email: mcallery@bidmc.harvard.edu

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Stitches NOBEL PRIZE

jContinued from page 20 fared so well; five had died, one had thyroid cancer, and 16 of the 18 whom Dr. Kocher reexamined in person exhibited distinct mental and physical deterioration.

Dr. Kocher now understood that the thyroid’s function was essential. In an 1883 lecture to the German Congress of Surgery, Dr. Kocher defined a new disease called “cachexia strumipriva” (or severe hypothyroidism, in modern terminology), caused by removing the whole thyroid ((Archiv für Klinische Chirurgie

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JUNE 2014

1883;29:254-337). Dr. Kocher went on to describe his meticulous methods to unravel the effects of completely removing the thyroid, publishing his copious patient records along with notes from 134 additional cases performed by colleagues.

He concluded by discussing several theories about the thyroid’s role in the body, including his own erroneous hypothesis that the gland regulated blood flow to the brain as well as respiration.

Dr. Kocher’s careful investigation of former patients represented an early example of a follow-up study, and his focus on thorough scientific documentation and

analysis marked an important legacy of his work.

Reactions to his lecture were mixed, however. Although some colleagues praised Dr. Kocher for his innovative ideas, most criticized him for his operative lust. Critics also stated that cachexia strumipriva was not a new condition, but rather represented the late stages of cretinism, which had been defined earlier by Sir William Gull and others.

Dr. Kocher had indeed failed to acknowledge the contributions of his colleagues, Dr. Tröhler noted, behavior that became a pattern for him. Even

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in his Nobel Prize acceptance speech, he did not give Dr. Reverdin credit for being the first to discover that removing the entire thyroid causes severe physical and mental damage ((J Royal Soc Med 2011;104:129-132).

Despite the negative reactions, Dr. Kocher propelled his research forward.

His first step was to declare that he would never again perform total thyroidectomies. In future cases, he always left a small piece of thyroid tissue intact.

“He realized what he had done, and being a deeply religious man, felt that he had sinned,” Dr. Tröhler said. “This desire to repent for his sin motivated him to try to rectify his error by performing the first organ transplant.”

By July 1883, Dr. Kocher began transplanting thyroid tissue, first under the skin, then locally and finally into the bone marrow of patients who had undergone total thyroidectomies, hoping to reverse the adverse effects of the surgery.

Dr. Kocher often operated on two tables simultaneously so that he could take fresh thyroid from one patient and transplant it into the other. He also prescribed fresh thyroid sandwiches, and later tablets of dried thyroid for patients to consume.

“Dr. Kocher saw some transient improvements when transplanting pieces of organs, but basic science was not developed enough at the time for him to understand the immune reactions that might occur,” Dr. Tröhler said. “In fact, it’s incredible that patients survived these transplants. This speaks to Dr. Kocher’s excellent operative technique.”

Dr. Kocher’s endeavors in thyroid transplantation became a prototype for future organ transplants and a jumpingoff point for research on transplantation.

Although best known for his work on the thyroid, Dr. Kocher’s interests also extended to neurosurgery, cancer surgery and abdominal surgery. Dr. Kocher performed one of the earliest cholecystectomies, devised a technique to reduce a dislocated shoulder, and developed his famous Kocher clamp. Dr. Kocher also conducted extensive research on wound ballistics to treat battle wounds and infections (Surg Gyn Obstett 1991;172:153-160).

True to his nature, Dr. Kocher was working almost right up until his death, performing his last surgery just four days before he passed away on July 27, 1917, at the age of 76.

On his personality and skill, Dr. Tröhler said, “Dr. Kocher was only interested in surgery. He developed a carefulness in operating, which we might call a physiologic style. This was quite extraordinary in his time, set new standards and is in some sense still with us today.”

—The editors thank Leo Gordon, MD for suggesting the idea for this column.

The McMahon Group Celebrates the Best of Its Outstanding Employees

2013

Once a year the McMahon Group takes time to look back at the previous year and acknowledge the exxtraordinary talents and persistence of its employees. The 43--year-old company publishes best-read medical newsspapers and websites, creates custom media for medical industry firms and hospital systems and produces certified medical education platforms for clinicians.

Here is a review of the winners of the 2013 employee awards: MANAGEMENT/SUPPORT/IT/FINANCE/PRODUCTION

MANAGEMENT/SUPPORT/IT/FINANCE/PRODUCTION

Employees are asked to select two outstandding members from these diverse departments. The first winner was ROSA DIMICCO, whose challenging work in Finance includes overseeing accounts payyable.

The seconnd winner was YUMI VELIZ, who as part of the IT Department manages requests for IT assistance and maintains all servers and the infrastructture of the McMahon network.

MOST IMPROVED SALESPERSON OF THE YEAR

SALES ACHIEVEMENT AWARD OF THE YEAR

MATTHEW SPOTO,, whose work on Gastroenterology & Endoscopy News has brrought in new clients and maintained steady relationships with existinng clients, clients resulting in a record year.

DAVID KA APLAN, publication director of Pharmacy Practice Newss as well as Speciallty Pharmacy Continuum, received this award for, among other accomplisshments, hments spearheading new pharmacy publications. publications

ASSOCIATE/SENIOR/PROJECTS EDITOR OF THE YEAR

MANAGING EDITOR/COPYEDITOR OF THE YEAR

This award was given to Associate Projects Editor CARLOS PERKINS JR., whose job includes working closely with sponsoring companies to create great medical education programs that are delivered on time.

This year, Copy Editor ELIZABETH ZHONG won the award for her efforts in fine-tuning all the editorial material that is assigned to her. Her work helps ensure acccuracy in all of our publications, medical education programs and sponsoredd custom media.

MAX GRAPHICS PERSON OF THE YEAR

SALESPERSON OF THE YEAR

Longtime staffer FRANK TAGARELLO, who manages the Graphics Department, received the award for his inveentive design work on such publications as Clinical Oncology News and Pharmacy Practice News and a variety of medical education projects.

For the eigghth year in a row, RICHARD TUORTO, the senior group publicatioon director of both Anesthesiology News and Pain Medicine News, won the award for bringing in the most revenue in the calendar year.

MCMAHON GROUP PERSON OF THE YEAR

PARTNERS’ AWARD

The winner of this year’s award was HYONG KWON, manager of the company’s IT development team, who oversaw innumerable projects, including updating our websites, creating tablet and digital versions of our publications, and managing the IT staff, to name just a few. There is a constant stream of IT requests that land on his desk and, somehow, Hyongg is able to continually perfect our digital presence.

From time to time, CEO and Managing Partner Ray McMahon extends a special award to an individual whose efforts over many years have madee a fundamental difference in the well-being of the company. This year that award went to his son, MATTHEW MCMAHON, whose position as thhe company’s general manager puts him front and center for major decisioons involving policy, finance and overall governance.