26 minute read
First Look: Highlights From the Southeastern Surgical Congress
First Look: The Southeastern Surgical Congress
All articles by MONICA J. SMITH
Survey Captures Patient Attitudes On Surgical Resident Involvement
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.
Older Age and ICU Readmission: A Steep Increase in Mortality
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. ■
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How Physician Burnout Differs Outside the U.S.
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Catherine Ronaghan, MD, FACS, a professor and the vice chair of the Department of Surgery at Texas Tech, used the word “revelatory” to describe the restructuring. “I noticed a difference immediately in my focus and energy, which allowed me to have much more meaningful experiences with patients,” she said.
In the United States, a growing body of evidence shows that long days on the job can contribute to physician burnout (J Am Coll Surg 2016;223[3]:440-451; Arch Surg 2011;146[2]:211-217). Most recently, Medscape’s 2021 National Physician Burnout & Suicide Report, which included more than 12,000 physicians, found that 37% of respondents cited hours at work as one of the top four factors leading to burnout. Other key factors highlighted by physicians included bureaucratic tasks (58%); lack of respect from colleagues, administrators and staff (37%); and insufficient compensation or reimbursement (32%).
But what about outside the United States? Do work hours affect surgeons in other countries to a similar degree?
Although data are more limited, several reports indicate that work hours do play an important part in surgeon burnout abroad (Royal Coll Surg Eng 2020;102[6]:401407; Arch Surg 2010;145[10]:1013-1016). An analysis published earlier this year, which surveyed 615 general surgeons in Turkey, reported a prevalence of burnout of 69% and ranked work hours—specifically 60 hours or more per week—as one of the three main contributors to burnout (BMC Health Serv Res 2021;21:39).
The main factors highlighted by Medscape’s 2019 Global Physicians’ Burnout and Lifestyle Comparisons report, which included almost 20,000 physicians spanning the United Kingdom, France, Germany, Portugal and Spain, also largely align with those described in the U.S. survey. Too many hours at work ranked a close second to excessive bureaucratic tasks, especially for physicians in Portugal (51%), Germany (50%), and France (45%). Lack of respect from colleagues, administrators and staff represented the third major stressor, followed by feeling like “a cog in the wheel,” insufficient compensation or reimbursement, and a focus on profits over patients.
However, according to several surgeons who spoke to General Surgery News, long work hours may not actually be a key factor driving surgeon burnout abroad. Using a relatively simple metric like work hours may miss the more complex stressors that surgeons face on the job.
“Burnout has always been multifactorial and, in Europe, there are broader issues at play than work hours, related to how surgeons are remunerated and valued—or not valued—in the health care system,” said Neil Smart, a consultant colorectal surgeon at the Royal Devon & Exeter Hospital, in Exeter, England.
The 2021 analysis from Turkey provides a window into that complexity. The study concluded that the top three contributors were long hours at work, employment at a training and research or state hospital, and minimal time for social activities. But, notably, surgeons’ top 10 suggestions on how to reduce burnout did not match these three major contributors. The three often cited remedies were implementing a fair salary policy (84%), preventing violence against health care workers (78%), and introducing reforms to reduce medical malpractice lawsuits (75%). Regulating work hours appeared on the list but toward the bottom.
“Surgeon burnout is a big problem in Turkey, and my colleagues and I conducted this analysis to highlight the main sources and what can be done,” said the study’s corresponding author Cihangir
—Neil Smart, MD
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Akyol, MD, a colorectal surgeon at Ankara University, in Turkey. “We found that improving work hours is one solution, but it is likely not the most important one.”
Still, Dr. Akyol did not downplay the role that work hours play in surgeon burnout, which he acknowledged may be on par with surgeons’ experience in the United States, especially considering the increased workload and stressors physicians have faced during the COVID-19 pandemic.
In Turkey, an ongoing threat of physical violence and malpractice accusations from patients, in particular, carry significant weight for surgeons. For instance, a piece published in January 2020 in the outlet Inside Turkey reported a physician exodus to countries in the European Union (EU) given the harsh working conditions in Turkey—the threat of mass layoffs, mandatory security checks, and ongoing problems including “verbal and physical violence against health care professionals.” According to the Turkish Medical Association, data from the Ministry of Health revealed that about “40 cases of violence are reported daily at healthcare institutions” and in 2018, “more than 15,000 such cases were reported.”
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“These risks to our personal and professional safety make the job especially challenging,” Dr. Akyol said.
In the United Kingdom, Dr. Smart cited elements of the job that create the most stress for him: the changing nature of the work itself and the lack of respect for physicians.
“Time at work is not just about the total number of hours; it’s also about the structure and substance of the work,” Dr. Smart said. “For one, the endless problems and time spent with EMRs [electronic medical records] contribute to feelings of burnout.”
The nature of surgical training has changed with the introduction of shift work in the early 2000s. When the EU’s Working Time Directive capped workweeks at 48 hours including overtime, “the hierarchical mentorship structure and sense of teamwork among trainees and senior surgeons largely went away,” he said.
Regarding professional respect, Dr. Smart has witnessed the rise of the uninformed expert, especially during the coronavirus pandemic. “We saw demonstrations in London recently where an anti-vaxxer compared doctors and nurses to Nazi war criminals,” he said. “That’s a moment when you ask yourself, ‘Why am I doing all this hard work?’”
For Gregorio Maldini, MD, a hepatobiliary surgeon who began his career in Rome and now practices at Straub Medical Center, in Honolulu, burnout in Italy is largely fueled by low pay as well as too much bureaucracy and paperwork. In other words, “when your effort is not correlated to your rewards is when people feel the pain”—what he calls work that is “not morally and financially compensated.”
Although the individual factors contributing to burnout will vary from country to country, the underlying issue remains the same. Whether chronic work-related stress arises from too many hours on the job or with the EMR, a pay structure that does not fairly compensate years of training and level of expertise, or a lack of personal and professional safety and respect, these issues reflect the ways in which health systems around the world do not adequately protect physicians.
Identifying the risk factors and their variations that exist across countries, institutions and individuals will go a long way toward mitigating their impact. But solving such a complex problem will also take considerable time and likely require an overhaul of health care systems. Dr. Akyol was cautiously optimistic that the landscape for surgeons can improve, but he saw a long road ahead.
“I’m currently 45 years old and will likely work 20 more years before I retire, and I’m not sure I’ll see the burnout problem change in that time. But the more we talk about this issue and study it, the better equipped health care workers will be to solve it,” Dr. Akyol said. ■
Breast Surgeon Finds Insights From the Patient’s Perspective
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the 2021 virtual meeting of the American Society of Breast Surgeons.
Before her diagnosis, Dr. O’Riordan’s focus was largely on outcomes—leaving undetectable scars and minimizing complications as much as possible—a mindset that is not uncommon among physicians.
“We are trained and taught to focus on outcomes, and sometimes, because we know a particular treatment has the best outcome, we tend to glaze over possible side effects,” said Jill Dietz, MD, the director of Breast Growth and Strategy and chief transformation officer at Allegheny Health Network Cancer Institute, in Pittsburgh. “But true shared decision making is where you go over the outcomes of a particular intervention and then discuss the most common side effects and the cost, as well as other treatment options to decide together what’s best for that particular patient.”
The lump that Dr. O’Riordan initially suspected was a benign cyst was in fact a large, mixed ductal and lobular, estrogen receptor (ER)-positive, HER2-negative cancer that put her through some of the most invasive and extensive treatments breast cancer patients endure. She underwent neoadjuvant chemotherapy, mastectomy with reconstruction (a subpectoral implant she later had removed), and radiotherapy. Three years later, she had a locoregional recurrence that required more surgery and radiotherapy. A side effect of the latter—reduced range of motion in her left arm—forced Dr. O’Riordan to retire from surgery at the age of 43.
What she learned since that initial diagnosis made Dr. O’Riordan rethink what quality care really looks like, and what patients need beyond good outcomes to maintain a satisfactory quality of life.
“It’s not just clinical effectiveness, safety, doing the right thing to the right person at the right time. There is also the patient experience,” Dr. O’Riordan said. “My practice changed so much in the year between my diagnoses, and I want to share the lessons I’ve learned that may be able to help you improve the already impressive care you give your patients.”
Sudden Menopause: Its Side Effects and Impact on Sex
Natural menopause is problematic for many women, but the medically or surgically induced overnight change of life by can be particularly cruel.
“I used to tell my patients, ‘you’ll be fine, the odd hot flash.’ I had no idea how devastating it could be, especially for younger women,” Dr. O’Riordan said.
No one on her care team discussed the management of menopause symptoms, which for Dr. O’Riordan included hot flashes, weight gain, sleep-disrupting night sweats and distressing gynecologic discomfort. She had no idea what to do until a friend suggested she try clonidine, which can improve hot flashes, or venlafaxine, which has been shown effective in improving menopause-related quality-of-life issues.
“Wouldn’t it be great if, in addition to telling our patients what the side effects of their treatments are, we tell them how to manage these side effects,” Dr. O’Riordan noted.
Another rarely discussed topic is the effect of medical or surgical menopause on a woman’s sex life. “I never talked about it as a consulting surgeon, and I rarely heard my colleagues talk about it. But it’s awful when you’re young to suddenly have no libido, or find that sex can be so painful you never want to do it,” Dr. O’Riordan said. “You need to make sure someone on your team is talking to patients about the impact menopause can have on their sex life, and what they can do about it.”
Like other menopausal symptoms, gynecologic dryness, pain and irritation can be managed by those who know what options are out there: dilators, lubricant and vaginal estrogen. Breast cancer care physicians might be leery about the last one, but it’s worth a discussion.
“I was very wary of this, and didn’t want to give anyone with ER-positive disease extra estrogen. But we know breast cancer comes back in a third of our patients despite full treatment, and a tiny dose of absorbed vaginal estrogen is not going to have a big impact. However, the impact it will have on a patient’s quality of life is huge, and it should be her choice,” Dr. O’Riordan said.
—Elizabeth O’Riordan, MD
The Importance of Exercise
Just as no one on her care team discussed management of menopausal side effects, no one suggested to Dr. O’Riordan that she should continue to exercise. But she wanted to. Inspired by an extremely active woman with metastatic breast cancer she discovered on Twitter, Dr. O’Riordan kept on exercising—she completed a sprint triathlon halfway through chemotherapy.
“I was one of the slowest people to finish, but the sense of achievement was amazing. For a few hours, I was no longer Liz the cancer patient; I was just Liz,” she said.
She credits exercise with mitigating some of the physical and mental side effects of chemotherapy, and the year she spent lifting weights at home during lockdown returned Dr. O’Riordan to a body she feels comfortable in.
And there’s this boon: Exercise may reduce the risk for recurrence by 50%.
“That’s five-zero. Exercise halves the risk of recurrence and it’s something patients can do for themselves that helps them feel in control,” she said.
Guidelines from a multidisciplinary roundtable recommend 30 minutes of aerobic exercise three times per week and 30 minutes of resistance training twice weekly for cancer survivors (Med Sci Sport Ex 2019;51[11]:2375-2390). Dr. O’Riordan suspects resistance training may be even more important than aerobic exercise.
“Chemotherapy can cause muscle fatigue and wasting, and if you can get your patients doing gentle exercises at home—squats while they’re brushing their teeth, push-ups against a kitchen counter five minutes here and there will do them so much good.
“Promise me one person on your team will tell every patient to exercise,” Dr. O’Riordan said.
Looking for What No One Wants to Find
Breast cancer comes back in one-third of these patients, but some are in the dark about this possibility. “You’d be amazed how many women think they’re cured; they don’t know what to look for,” Dr. O’Riordan said.
Recurrence is something she didn’t discuss at length with her patients. “I don’t think I ever told patients what the signs for recurrence are; it was a leaflet tucked into a pile of other leaflets I hoped they would read. But if they don’t know what the signs are, and if their primary care physicians don’t know the warning flags, we’re doing our patients a disservice,” Dr. O’Riordan said.
Every patient should be informed that their cancer can come back. They need to know what to look out for, and who to see for the appropriate scan to determine whether or not it is a recurrence.
Finally, find out what your patients think about and what they need. “Eric Topol, a cardiologist in the U.S., says, ‘The patient is the single most unused person in health care,’ and I think he’s right,” Dr. O’Riordan said.
“Every once in a while, go read a patient forum, go read a blog. Find out what it’s like to be in our shoes so you can provide the best quality care.” ■
White Light Imaging
Firefly imaging is not visible in white light imaging mode.
Standard Firefly Mode
In Standard mode, the image is displayed as a fluorescent green overlay on a black and white background view. The closer the endoscope is to the tissue, the stronger (more intense green) the signal appears.
Sensitive Firefly Mode
In Sensitive mode, the system attempts to automatically adjust the signal intensity and brightness to be consistent, whether the endoscope is moved closer or farther away from the tissue.
Note: Sensitive Firefly mode is only available with Endoscope Plus.
Scan to learn more about the evolution of surgery
Images above show porcine pelvic vasculature using the da Vinci Xi Endoscope Plus.
*Total da Vinci Practice refers to the transferable value of da Vinci surgery across procedures in surgeon’s minimally invasive surgery (MIS) practice. It is at the surgeon’s discretion to determine when a patient is a candidate for
MIS surgery and whether da Vinci surgery is an option.
Adjust Your Perspectice Using the da Vinci Firefly Imaging System
The da Vinci Xi® and da Vinci X™ surgical systems with integrated fluorescence imaging capability provide you with real-time endoscopic visible and near-infrared fluorescence imaging. This fluorescence imaging capability provides you with the opportunity for visual assessment of at least one of the major extra-hepatic bile ducts, as well as the cystic artery during cholecystectomy procedures performed using the da Vinci® system. It can also be used to assess vessels, blood flow, and related tissue perfusion during cases across your da Vinci Total Practice* when indicated.
Firefly Fluorescence Imaging
The da Vinci fluorescence imaging vision system (Firefly® fluorescence imaging) is intended to provide real-time endoscopic visible and near-infrared fluorescence imaging. The da Vinci fluorescence Imaging vision system enables surgeons to perform minimally invasive surgery using standard endoscopic visible light as well as visual assessment of vessels, blood flow, and related tissue perfusion, and at least one of the major extra-hepatic bile ducts (cystic duct, common bile duct and common hepatic duct), using near infrared imaging.
Fluorescence imaging of biliary ducts with the da Vinci fluorescence imaging vision system is intended for adjunctive use only, in conjunction with standard of care white light and when indicated, with intraoperative cholangiography. The device is not intended for standalone use for biliary duct visualization.
Intuitive’s ICG packs are available for sale in the U.S. ONLY. Intuitive’s ICG packs are cleared for commercial distribution in the U.S. for use in combination with the fluorescence-capable da Vinci HD vision system and Firefly integrated hardware. Intuitive-distributed ICG contains necessary directions for use of ICG with Firefly fluorescence imaging. Using generic ICG with Firefly fluorescence imaging is considered off-label and is not recommended. Anaphylactic deaths have been reported following ICG injection during cardiac catheterization. Total ICG dosage should not exceed 2 mg/kg per patient. Anaphylactic or urticarial reactions have been reported in patients with or without histories of allergy to iodides.
Important safety information
For Important Safety Information, indications for use, risks, full cautions and warnings, please refer to www.intuitive.com/safety.
Da Vinci Xi/X system precaution statement
The demonstration of safety and effectiveness for the specific procedure(s) discussed in this material was based on evaluation of the device as a surgical tool and did not include evaluation of outcomes related to the treatment of cancer (overall survival, disease-free survival, local recurrence) or treatment of the patient’s underlying disease/condition. Device usage in all surgical procedures should be guided by the clinical judgment of an adequately trained surgeon.
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