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IN THE NEWS
GENERAL SURGERY NEWS / JULY 2021
First Look: The American Society of Colon and Rectal Surgeons All Articles by CHRISTINA FRANGOU
The American Society of Colon and Rectal Surgeons (ASCRS) held its 2021 meeting virtually this spring. Here, General Surgery News presents some of the top papers from the meeting.
The TINGLE Trial: TAP Block With Liposomal Bupivacaine Not Supported A liposomal bupivacaine block does not provide superior or extended analgesia for minimally invasive colorectal surgery, according to results from the first randomized trial comparing liposomal bupivacaine with bupivacaine plus epinephrine and dexamethasone for transversus abdominis plane blocks. “While the ideal TAP block medication isn’t known, the very expensive liposomal bupivacaine [Exparel, Pacira] doesn’t seem to offer any benefits above our recommended mixture of bupivacaine, epinephrine and dexamethasone, which is highly effective, cheap and readily available,” said author Adam Truong, MD, the chief surgical resident at Cedars-Sinai Medical Center, in Los Angeles. The study is published in Diseases of the Colon & Rectum (2021;64[7]:888-898). In the single-center trial, 102 adult patients undergoing minimally invasive colorectal surgery were randomized 1:1 to receive a laparoscopic TAP block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone. There was no difference in the primary end point of total oral morphine equivalents administered within 48 hours after surgery. Patients received 69 mg in the liposomal bupivacaine group and 47 mg in the group with bupivacaine plus epinephrine and dexamethasone (difference
in median 95% CI, –17 to 49 mg; P=0.60). Emily Carter Paulson, MD, an associate professor of clinical surgery at the University of Pennsylvania, in Philadelphia, noted that the difference in postoperative morphine use could be clinically significant, even though it was not statistically significant. “It seems that a 50% difference in opioid usage is pretty significant,” she said. The study had 84% power to detect a 15-mg mean difference in 48-hour morphine requirement, Dr. Truong said. There were no significant differences in pain scores, time to ambulation, time to diet tolerance or bowel movement, length of stay, overall complications or readmission rates between the two groups. The average wholesale price of liposomal bupivacaine is $336.22 compared with $5.47 for a TAP block with bupivacaine plus epinephrine and dexamethasone. Dr. Truong said the study could not be conducted in a double-blind fashion, as the investigators were required to document the administered TAP block medication into the medication administration record. In order to conceal the treatment assignment, the team performed several methods, such as employing a single investigator who was not part of the treatment team to manage randomization and handling of medications. The paper was first presented at the ASCRS in 2020 and received the New England Society of Colon & Rectal Surgeons Award. It was presented this spring as part of the “best of 2020” session.
Gender Differences In Remuneration in Colorectal Surgery Male surgeons perform more highly remunerated procedures in colorectal surgery than their female counterparts, contributing to a gender wage gap in colorectal surgery, according to an analysis of Medicare claims data. Investigators examined nearly 63,000 Medicare claims submitted by board-certified colorectal surgeons between 2013 and 2017. Of these, only 16.9% were from female surgeons—a rate that increased annually, reaching 22.7% in 2017. Analysis showed that, every year, male surgeons submitted more claims, submitted more highly reimbursed claims and used a greater number of procedural codes than female surgeons. Men and women were remunerated the same amount for performing the same procedures, but mean submitted charges per female surgeon in 2017 were $2,562 less than that for male surgeons ($16,614 vs. $19,176; P<0.0001). The same year, the average reimbursement for female surgeons was $4,193 compared with $4,962 for male surgeons, for a difference of $1,105 (P<0.0001). At $689 per procedure, therapeutic endoscopy was the highest remunerated claim. Half of male surgeons who submitted Medicare claims performed therapeutic endoscopies, compared with only one-third of female surgeons (P<0.001). In 2017, male surgeons submitted claims
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for 675 polypectomies, the most commonly performed therapeutic endoscopic procedure; female surgeons submitted 107. In comparison, 41.8% of female surgeons obtained the majority of their income from outpatient clinic procedures. These are the lowest remunerated procedures at $189. The study also showed that male surgeons utilize a higher proportion of procedural codes compared with female surgeons (98% vs. 46%; P<0.0001). Of the 147 unique codes used in 2017, 77 were used only by male surgeons compared with three that were used only by female surgeons. The study did not look at private practice wage contributions, rank, and seniority of surgeons or academic and educational pursuits. Lead author Nathalie Sela, MD, an abdominal transplant surgery fellow at the University of Nebraska Medical Center, in Omaha, said the study could not account for factors driving this wage gap. Other studies have shown that female surgeons receive fewer referrals and are quicker to lose referrals after a single negative outcome. They’re also more likely to have smaller clinical networks (Am J Surg 2020;220[1]:69-75). “Understanding this unique gender equity will allow current surgeons to offer greater support and mentorship for future generations,” Dr. Sela said.
High-Risk Features in Stage II Colon Cancer Portend Worse Survival Than Stage III Disease A new analysis suggests that patients with multiple high-risk features in the presence of stage II colon cancer have worse survival than patients with stage III disease. High-risk features “have a cumulative effect in stage II colon cancer,” said study author Brian Herritt, MD, a fifthyear resident in general surgery at Louisiana State University Health Sciences Center New Orleans. These features include T4 lesions, perineural invasion, poor lymph node sampling of 12 nodes or fewer, and poor histologic differentiation. Using the SEER*Stat database, Dr. Herritt and his colleagues compared the
