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IN THE NEWS
GENERAL SURGERY NEWS / OCTOBER 2021
First Look: The Southeastern Surgical Congress All articles by MONICA J. SMITH
Survey Captures Patient Attitudes On Surgical Resident Involvement
Older Age and ICU Readmission: A Steep Increase in Mortality
They may not be entirely certain what residents are, but most of the patients of a community general surgery practice support resident involvement in their care, according to the results of a recent survey. “We wanted to gauge patient understanding of the role of a resident in their care, and use this data to better incorporate resident involvement in the practice,” said James Chambers, MD, PhD, a staff general surgeon with the Northeast Georgia Health System in Braselton. To do so, Dr. Chambers, who is part of a four-surgeon group serving a 177bed hospital, administered surveys to patients between January and June 2020. Because many of his patients do not have home internet access, the 26-question surveys were distributed in office. “We thought we’d be able to capture more people that way,” said Dr. Chambers, presenting his research at the 2021 Southeastern Surgical Congress. By the end of the study period, 172 patients (73% female) completed the survey. Most were either employed (42%) or retired (30%); education levels were about 28% for high school graduate, some college and college graduate; about 50% had private insurance; and about 30% were covered by Medicare. The vast majority, 75%, thought residents were medical students. “That was an interesting aspect, because we actually gave them a bit of a crib sheet before the survey that defined what a resident is,” Dr. Chambers said. In any case, all but seven patients understood that a resident is a doctor in training, and 78% said they would like a resident involved in their care. “The ones who answered ‘yes’ to that question indicated that they thought it was important that they participate and help train future surgeons,” Dr. Chambers said. “They thought it would add value to our health system.” Of the 23% who indicated they did not want a resident involved in their care, most noted that they wanted only a doctor involved in their care. “But I thought this was really important: When we asked if they think a resident will be doing procedures and caring for patients without direct supervision, 91% responded ‘no,’” Dr. Chambers said. He noted that the research has some limitations; it includes only one practice, and some surveys were incomplete. Nonetheless, although the resident program is relatively new and patients had little prior exposure to residents, the response rate was high (89%). “In the future, we want to add more patients, internal and external; do a cross-table analysis of the demographic data to see if we can isolate people who may be more receptive to residents’ involvement in their care; and to keep residents involved in the practice,” Dr. Chambers said.
With ICU beds at a premium, efforts are often made to transfer patients out of the ICU as soon as possible, but this could be particularly detrimental for older patients in whom readmission to the ICU is associated with a steep increase in mortality, according to a recent study. Although geriatric patients comprise about one-fourth of all trauma admissions, geriatric ICU readmission has not been thoroughly studied. To get a better grasp of outcomes in this vulnerable population, Lindsey L. Perea, DO, and her colleagues conducted a retrospective study of all patients aged 40 years and older admitted to accredited Pennsylvania trauma centers between 2003 and 2018. “We hypothesized that older patients with ICU bounce back (ICUBB) would have greater mortality rates than their younger counterparts. We also hypothesized that older age would lead to higher mortality,” said Dr. Perea, a trauma and acute care surgeon with Penn Medicine Lancaster General Health, in Lancaster, Pa., who presented the study at the 2021 Southeastern Surgical Congress. Of all patients aged 40 years and older admitted to trauma centers during the 16-year study period, 3,896 (1.1%) met the inclusion criteria for ICUBB (i.e., being transferred to the ICU, then readmitted to the ICU during the same hospital stay). The ICUBB group was older, had a higher injury severity score and had a significantly longer hospital stay than the non-ICUBB population, at 12 and four days, respectively. The ICUBB group also underwent intubation more frequently, and had a higher incidence of mortality, 12.6%, compared with 5% for non-ICUBB patients. The risk for mortality increased with each decade of age and was most significant in the oldest patients. “When comparing the bounce-back and non–bounce-back groups, we found alarmingly high increased odds of mortality in our octogenarians and nonagenarians, with an odds ratio of 11.31 in the 80 to 89 group and 35 in the 90-plus group,” compared with those aged 40 to 49 years, Dr. Perea said. In contrast, the odds ratio of mortality in ICUBB patients 50 to 59 was 1.02 compared with those 40 to 49. Of note, although ICUBB was associated with severe injuries to the head, neck, abdomen and chest, on multivariate analysis the injuries themselves were not associated with increased mortality. “That raises the question of whether these patients were ready to leave the ICU initially,” Dr. Perea said. She acknowledged limitations of the paper: Being limited to a single-state database, it may not be generalizable to the greater population, and the researchers were not able to discern the temporal nature of ICU admission. “But given the profound increase in mortality in our aging trauma patients, it’s imperative to introduce initiatives to address the underlying causes of unplanned ICU readmissions to identify and mitigate risk in this vulnerable geriatric population,” Dr. Perea said.
New Nomogram May Outdo Older Pancreatic Fistula Risk Scores Researchers have developed a new nomogram that may be more accurate than prior fistula risk scores at assessing patient risk for a clinically relevant postoperative pancreatic fistula (CR-POPF). Although there are a few fistula risk scores available to help surgeons assess patients undergoing pancreatectomy, some have certain drawbacks, such as being based on a small patient population or lacking external validation. “Currently, there is no universal measure used to predict a CR-POPF,” said Abdimajid Mohamed, a fourthyear Maine Track medical student at Tufts University School of Medicine/Maine Medical Center, in Boston, presenting his research at the 2021 Southeastern Surgical Congress. “Our project aimed to improve upon those predictive models and to create a tool to increase surgeons’ ability to utilize preoperative care and postoperative assessment.” To do so, Mr. Mohamed and his colleagues used ACS National Surgical Quality Improvement Program (NSQIP) data on 5,965 pancreaticoduodenectomy
patients, 1,018 of whom had CR-POPF, to compare the original Fistula Risk Score (FRS), Alternative FRS and Samsung Medical Center nomogram, and performed a logistic regression analysis on variable factors from those risk scores. For example, the Alternative FRS identified body mass index, gland texture and duct size as variables associated with CR-POPF. “What we determined within our NSQIP database is that obese patients are 1.6 times more likely to have a CR-POPF,” Mr. Mohamed said. Soft gland texture, too, increased risk—by 3.18 times— whereas duct sizes of 3 to 6 mm were protective. Adding variables from the Samsung nomogram, they found that male patients were 1.59 times more likely to have a clinically relevant fistula, but American Society of Anesthesiologists classification and preoperative albumin had no statistically significant impact on risk. Ultimately, their multivariate analysis identified male sex, obesity and soft gland texture as variables associated with an increased odds of a CR-POPF; duct size of 6 mm or more, pancreatic adenocarcinoma pathology and
neoadjuvant chemotherapy all appeared to be protective. Using this information, Mr. Mohamed and his colleagues created the Portland FRS to assess and predict risk. “Imagine an obese male patient with soft gland texture, pathology other than pancreatic adenocarcinoma, a duct size less than 3 mm and no neoadjuvant chemotherapy; those variables add up to a total point score of 240, which would correlate with a 40% CR-POPF risk,” he said. With an area under the curve (AUC) of 0.72, the Portland nomogram appears to be stronger than the Alternative FRS and Samsung nomogram, which have AUCs of 0.70 and 0.64, respectively. Andrew Page, MD, the director of surgical oncology and hepato-pancreato-biliary surgery at Piedmont Healthcare in Atlanta, reviewed the study and was intrigued by the finding that neoadjuvant chemotherapy correlated with decreased CR-POPF. “There is no doubt that the role of neoadjuvant treatment as a risk factor for post-pancreatectomy fistula will continue to be a controversial subject,” Dr. Page said. ■
