November 2021 Print issue by McMahon Group

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

November 2021 • Volume 48 • Number 11

Hernia Mesh and Litigation: Where Things Stand

Nanopore Sequencing Promising for Quick, Accurate Intra-op Cultures Study of Microbial Profiling in Pancreatic Head Resection; Other SSI Applications Possible

By MONICA J. SMITH

rogress invites criticism, and in surgery, innovation often begets litigation, as most every surgeon whose practice involves mesh-reinforced hernia repair can attest. “The ads for hernia mesh lawsuits are everywhere, and if you Google ‘hernia mesh lawsuit,’ you’ll see ad after ad after ad for lawyers. We face it every day in our offices; it’s ubiquitous,” said Guy Voeller MD, at the 2021 virtual Abdominal Wall Reconstruction Conference. Dr. Voeller is a professor of surgery at the University of Tennessee Health Science Center, in Memphis. “But the problem with mesh in hernia repair is that we have to have it; trying to repair many hernias with suture alone is doomed to failure.” Mesh is now the standard of care in hernia repair for its ability to dramatically reduce the rate of recurrence. But it’s also become a target for lawsuits. What started with a smattering of cases in the 2000s has ramped up considerably in the last

By KATE O’ROURKE

n patients undergoing pancreatic head resection, organisms identified from intraoperative bile duct cultures correlate with postoperative infection, which is a major source of morbidity. Data suggest tailored perioperative antimicrobial therapy based on bile duct cultures decreases infection rates; however, standard cultures take days to produce results. New research shows that novel metagenomic techniques using nanopore sequencing can provide robust microbial profile data in just hours. “We can use nanopore sequencing technology to improve our antibiotic stewardship and tailor antibiotic delivery to patients,” said lead study author Jennifer Yonkus, MD, a

Continued on page 14

Surgical Planning in a Crisis: Leaders Share Lessons Learned By KAREN BLUM

Continued on page 13

OPINION

The Path to Surgical Autonomy: A Return to Apprenticeship

The Most Harm

ssessing patients’ priority for surgical care, taking more precise inventory of predicted bed use after surgery, and moving some cases to same-day operations or ambulatory surgery centers are some ways surgical teams can still manage their caseloads during times of disruption, a panel of clinicians said during a recent webinar hosted by Becker’s Healthcare. One of the biggest recent and ongoing disruptors has been the COVID-19 pandemic. Spectrum Health, an integrated health system in western Michigan, introduced seven critical interventions over the past 18 months to continue to deliver surgical care during an overwhelming period, said Adam Post, MSN, MBA,

here has been ongoing concern among the surgical education community about the “autonomy crisis”—residents lacking the requisite operative experience and autonoomy to enter practice. In exploring this crisis, the literature will anecdotally mention the historical training model of Halsted and apprenticem ship; none of the literature, however, Continued on page 18

Continued on page 16

By JEREMY STOLLER, MD, FACS, B and TAHIR JAMIL, MD, FACS

IN THE NEWS

The Surgery of Trauma S URGEONS’ LOUN G E

12 The National Pancreas Foundation Centers Of Excellence OP IN ION

15 Optimizing the Patient for Surgery: The Pre-op Psychological Survey

REVIEW

Oliceridine for the Management of Acute Surgical Pain in High-Risk Patients see PAGE 12

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omeone famous once said: “We do the most harm to the ones we love ve when we do for them the thingss they should do for themselves.” Thee modern system of surgical residentt and subspecialty surgical fellowwship education in America is deeply ply flawed and needs to immediately be made aware of the incredible importance of these timeless words of wisdom. For a variety of reasons, it is now common in our academic programs for senior-level general surgery residents and postgraduate fellows to find themselves standing in our nation’s operating rooms, functioning

Continued on page 20

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IN THE NEWS

NOVEMBER 2021 / GENERAL SURGERY NEWS

Robot Facilitates Less Invasive Approach udy Suggests To More Liver Resections, Study By MONICA J. SMITH

Atlanta—Use of the robotic platform for minor and major liver resections appears to be safe and feasible, and may open minimally invasive hepatectomy to more patients, according to the findings of a recent study. Despite the significant development of minimally invasive surgery over the last few decades, three-fourths of liver resections are still open procedures, mainly due to the complexity of the intrahepatic anatomy, the need for rapid bleeding control and the minimally invasive skills required to perform laparoscopic procedures, said Harel Jacoby, MD, an advanced gastrointestinal and hepatobiliary surgical fellow under Iswanto Sucandy, MD, the director of robotic surgery at Advent Health Tampa, in Florida. “Robotic liver surgery overcomes several limitations of conventional laparoscopy, as it offers 3D visualization, improved articulation, precise vascular dissection, the ability to suture with both hands and better ergonomics,” he said, presenting the research at the 2021 Southeastern Surgical Congress.

Senior Medical Adviser Frederick L. Greene, MD Charlotte, NC

Furthermore, in 2019, the international consensus statement ment on robotic hepatectomy reportported equivalent peri- and postoptoperative outcomes compared with laparoscopy. To investigate the safety ety and feasibility of robotic liverr resection, surgeons at Adventt Health Tampa prospectivelyy followed consecutive patients ts undergoing robotic minor or major hepatectomy for anyy indication between 2016 and d 2020. They defined minor heppatectomy as a liver resection with two or fewer contiguous Couinaud uinaud segments, and major hepatectomy as the resection of three or more. Ultimately, the study included 220 patients, 82 of whom (37%) had minor hepatectomy and 138 (63%) who underwent major hepatectomy. “Demographically, there were no statistically significant differences between major and minor hepatectomy patients; however, it’s worth noting that more than 50% patients had previous abdominal operation, but this didn’t affect our

‘We found minor and major robotic hepatectomy to be safe and feasible, associated with excellent short-term outcomes, and we believe that the robotic approach will play a wider role in hepatopancreato-biliary surgery.’ —Harel Jacoby, MD

MISSION STATEMENT OF GSN It is the mission of General Surgery News to be an independent and reliable source of news and analysis about the current state of surgery. It strives to provide a venue for discussion and opinions, from all viewpoints, on the issues most important to surgeons. Peter K. Kim, MD Bronx, NY

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ability to complete the procedure co using the robotic platform,” Dr. Jacoby ssaid. The most common indications for hepatectomy were colorectal metastasis and co hepatocellular carcinoma. h Patients with hepatocelP lular carcinoma were more lul likely to undergo a major hepatectomy, while patients hep with benign lesions were wi more likely to undergo a mo minor hepatectomy. mi The operative duration tio for minor hepatectomy was about four hours, and five hours for major hepatectomy. Estimated blood loss for minor and major hepatectomy was 100 and 200 mL, respectively. There was one interoperative complication requiring conversion to open in a patient who had a previous right hepatectomy. “However, the postoperative course for this patient went well, and he was able to be discharged home on post-op day 4,” Dr. Jacoby said. The average length of continued on the following page

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OPINION

GENERAL SURGERY NEWS / NOVEMBER 2021

B U LLETI N B O A R D

On Being Grateful By FREDERICK L. GREENE, MD

s we find ourselves once again at this special time when we, in the United States, think of all the good things we are grateful for and ponder on the future year to come, it is hard not to only focus on the truly unpleasant and harmful events that have occurred since we last gave thanks. Our country continues to be fractionated through its politics and the scientific differences created by the ongoing COVID19 pandemic. Even our recent remembrances of the 9/11 attacks, which galvanized us as a nation 20 years ago, are overridden by those who now strive to divide us. Despite these ongoing and disruptive influences: • I am so grateful to live in a country where the majority of our citizens value the principles originally crafted to create our democracy. • I am grateful for the incredible leaders in science and public health who continue to bring us through this pandemic.

• I am so grateful for my brother and sister physicians who risk their lives daily to treat patients infected by the virus and who, simultaneously, minister to those needing surgical and medical care not related to COVID-19. • I am grateful for computer-generated platforms that have kept us together and allowed organizations to maintain engagement. • I am grateful for all those who have received vaccines against the SARS-CoV-2 virus and its mutations. • I am grateful for the few in-person surgical meetings that I have attended in 2021 and appreciate the strict public health measures that have allowed these to occur. • I am grateful for all the bright medical students who have entered into the 2025 classes this fall and who represent the future of medicine. • I am grateful for the opportunity to meet devoted residents and fellows who have worked diligently to both learn and care for patients during these trying times. • I am grateful for the wonderful colleagues whom we lost in the past year and for the enrichment that I have gained from knowing them. • I am grateful for loving family and friends whom I have treasured being with virtually or in real time. Finally, I am grateful for the opportunity to have General Surgery News as a vehicle to transmit our thoughts and for the many readers who acknowledge the benefits of this publication. Happy Thanksgiving! ■ —Dr. Greene is the senior medical advisor for General Surgery News.

Resections continued from the previous page

stay was three days for minor hepatectomy patients and four days for major hepatectomy patients. Nine patients had postoperative complications, most of which were seen, somewhat surprisingly, in the minor hepatectomy group; and two patients died related to cardiopulmonary events. “We were able to maintain excellent oncologic outcomes, as 97% of our patients had an R0 resection; no patients had an R2 resection,” Dr. Jacoby said. “We found minor and major robotic hepatectomy to be safe and feasible, associated with excellent short-term outcomes, and we believe that the robotic approach will play a wider role in hepatopancreato-biliary [HPB] surgery,” he said. The Advent Health group expects to make further data on robotic major hepatectomy available to the scientific public. Laura Enomoto, MD, MSc, a

surgical oncologist and an assistant professor of surgery at the University of Tennessee Medical Center, in Knoxville, applauded the researchers for contributing to the growing body of literature reporting the safety and efficacy of robotic hepatectomy. “Your rate of conversion to open is low, and your complication rate is low as well,” she said. But she questioned why they didn’t compare robotic hepatectomy with laparoscopic or open hepatectomy, which is a more standard study design for investigating new technologies or techniques. “Also, many institutions are just starting their robotic experience. Do you have any advice or lessons learned that you could share?” Dr. Enomoto asked. Dr. Jacoby was unsure about the first question, as his institution switched fully to robotic programs for all but the most minor procedures in recent years. Dr. Sucandy told General Surgery News that in their program, comparisons of robotic, laparoscopic and open procedures

are now being performed using a propensity score matching method. “A prospective randomization is near impossible to achieve, since most patients come specifically for the robotic minimally invasive liver surgery,” he said. But Dr. Jacoby was able to describe the learning curve, which for robotic major hepatectomy is 60 to 80 cases. “We started with minor procedures such as peripheral segmentectomy and gradually reached the most challenging procedures, such as extended hepatectomy and Klatskin tumor resection,” Dr. Jacoby said. Further advice came from Sharona Ross, MD, an advanced foregut and HPB surgeon with Advent Health and a professor of surgery at the University of Central Florida College of Medicine in Tampa, who was also involved in the research. “My suggestion is to start with easy cases that you’re very comfortable with and learn the technology before you apply it to the harder cases; that’s what we did here.” ■

TRENDING Read the five most-viewed articles last month on generalsurgerynews.com.

1 2

Surgery Is a Contact Sport

Clinical Pearls in Hernia Repair: Avoiding Errors

Bile Duct Injury Prevention Debate: Final Thoughts

Malpractice: How to React to a Lawsuit

The History of Robotic-Assisted Surgery ▼

HEARD HERE FIRST “Using the nanopore sequencing technology was significantly faster than standard cultures (eight vs. 165 hours) but came at a higher cost ($165 vs. $38.49). That really is a nominal increase if you consider the cost of one surgical site infection is up to $30,000 or can, even worse, cost a patient their life.” From “Nanopore Sequencing Promising for Quick, Accurate Intra-op Cultures,” page 1.

ONLINE EXCLUSIVE “ERAS Protocol Improves Host of Whipple Outcomes” “A four-year initiative found that a standardized enhanced recovery after surgery protocol was associated with reductions in hospital length of stay, readmission rates, reoperations and surgical site infections/pancreatic leaks.” generalsurgerynews.com/web-only

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IN THE NEWS

FIRST LOOK All Articles by ETHAN COVEY

EMS Efforts May Save Trauma Patients More Than Rush to Hospital Saving lives among patients with noncompressible torso hemorrhage (NCTH) may require advances in on-the-spot emergency services, not simply getting patients to the hospital faster, according to a study presented at the American Association for the Surgery of Trauma 2021 annual meeting (paper 2). “NCTH is the leading cause of potentially preventable death in both military and civilian populations, accounting for 30% to 40% of trauma mortality,” said Juan C. Duchesne, MD, a professor of surgery and the chief of trauma, acute care and critical care surgery at Tulane University School of Medicine, in New Orleans. In these patients, time is of the essence, as studies have shown that many deaths occur within the first 30 minutes after injury (Alarhayem AQ, et al. Am J Surg 2016;212[6]:1101-1105). However, the mortality rate of emergent trauma laparotomy has been relatively unchanged over the past two decades, hovering around 40% (Harvin J, et al. Trauma Acute Care Surg 2017;83[3]:464-468). “It feels like we’re spinning the wheel in this group of patients,” Dr. Duchesne said. To better treat these critically ill hypotensive patients with NCTH, Dr. Duchesne and his colleagues hypothesized that shortening times to surgical intervention for hemorrhage control would decrease mortality. Their AAST-sponsored, multicenter prospective analysis focused on hypotensive patients aged 15 years and older who presented with NCTH from May 2018 through December 2020. A total of 242 patients were included in the analysis, 48.7% of whom had blunt injury and 51.3% had penetrating injury; of this group, 80.1% survived.

The study confirmed that the majority of deaths among these patients occurred in the initial 30 minutes following arrival of emergency medical services on the scene. However, there was no difference between transport time to the hospital among survivors and nonsurvivors. Once arriving at the emergency department, nonsurvivors actually moved seven minutes faster through the system than patients who survived. This trend increased

GENERAL SURGERY NEWS / NOVEMBER 2021

The American Association for the Surgery Of Trauma sas patients progressed through the hospital, with nonsurvivors arriving to the OR 30 minutes earlier than survivors. Generally, the analysis found it took 74 to 88 minutes to get a hypotensive NCTH patient from the scene of the injury to the OR. “Interestingly, in our model, shorter time from emergency department arrival to OR start was not associat-sne ed with improved survival,” Dr. Duchesne said. Dr. Duchesne noted that a limitation of the study was that times were tracked from EMS arrival upon the scene of the injury and do not account for the elapsed time between the injury and EMS arrival. However, he noted the study adds credence to the idea that saving lives among these patients may depend on efforts conducted by EMS teams prior to hospital arrival, a shift to a “scoop and control” approach versus the traditional emergency services approach of “scoop and run.” “We need to start thinking outside the box if we want to move the pendulum of care and outcomes in this group of patients,” Dr. Duchesne said. “The continuum of care starts with the first contact with the patient. It does not start when the patient arrives at the trauma center.”

“The biggest takeaway of the study is how little we feed our critically ill patients in the SICU,” Dr. Stolarski said. “We are feeding our trauma patients on average less than 600 calories per day in the first week post-injury.” Even with the introduction of parenteral AA, only half of recommended d daily caloric intake is being met. Protein levels were also low, although they approached the threshold in the EMS group. Upon assessing urea nitrogen change and nitrogen balance, the study found that patients in the EMS group who had been given supplemental protein still had a day 5 nitrogen balance of –16.3, compared with –5.3 in the SOC group.

Metabolic Support for Trauma Patients May Provide Benefits Providing early metabolic support may help critically ill patients who are hospitalized following trauma, according to a study presented at the American Association for the Surgery of Trauma 2021 annual meeting (paper 7). “The role of nutritional support, and its benefit to patient outcomes, is really well established for patients who present with malnutrition or at a high risk of developing malnutrition throughout their hospital course after surgery,” said Allan E. Stolarski, MD, a general surgery resident at Boston Medical Center. “However, there is a lack of consensus regarding the optimal timing and components of nutritional support, particularly for critically ill patients after significant trauma.” The pilot randomized controlled trial looked at all adult trauma patients aged 18 to 65 years admitted to the surgical ICU at Boston Medical Center with an expected survival of at least three days and hospital stay of at least one week. Eligible patients were randomized within the first 24 hours of ICU admission into an early metabolic support (EMS) group or standard of care (SOC). A total of 42 patients were enrolled: 21 in the SOC group and 21 in the EMS group. In the SOC group, enteral nutrition was initiated as soon as determined to be feasible by the surgical ICU (SICU) team. And parenteral feeds were initiated only if/when enteral feeds failed after seven days. Among the EMS group, parenteral amino acid (AA) infusions were initiated within 24 hours of admission to the SICU. Across the board, the study found that trauma patients are being underfed and can likely benefit from increased caloric and protein intake.

“Our interpretation of this is that the overwhelming response to injury is so great at driving catabolic effect that regardless of what substrate we add upstream, we cannot undo that overwhelming catabolism,” Dr. Stolarski said. “All the AA we deliver early on during the post-injury period are oxidized through traditional pathways and end up downstream in the urine.” In conclusion, the study found that EMS with AA is safe, modifies protein metabolism, alters the body’s stress response and may downregulate the inflammatory state associated with significant trauma.

Systemwide Approaches Needed to Address Errors In Trauma Care Interventions are needed to cut down on errors made during the care of trauma patients. However, it’s likely that systemwide approaches will be most successful long term, even if they require additional implementation effort. “Humans will inevitably make mistakes,” said Doulia M. Hamad, MD, a general surgery resident at the University of Toronto, and an author of the study presented at the American Association for the Surgery of Trauma 2021 annual meeting (paper 17). “The way to make health care safer is not to focus on individuals being perfect, rather to turn to systems and develop solutions at that level.” Dr. Hamad and her colleagues reviewed a total of 395 cases from the American College of Surgeons Trauma Quality Improvement Mortality Reporting System to assess what types of errors occur during trauma care,

IN THE NEWS

NOVEMBER 2021 / GENERAL SURGERY NEWS

and how trauma centers learn from and prevent recurrent harm. Of the identified cases, 66.3% were anticipated deaths and 33.7% unanticipated. A significant number of both anticipated (10.7%) and unanticipated (36.1%) deaths were reported to have failure to rescue, or death following a treatable complication. The most common causes of death were traumatic brain injury (46.3%), bleeding (34.4%), cardiac events (22%) and multisystem organ failure (20.1%). Errors most frequently occurred in the ICU, followed by the trauma bay and patient ward, and most often involved an active staff physician or resident. The top types of errors were human failure (61%); management issues, such as questionable tracking and follow-up (50.9%); communication, such as lack of adequate handover (56.2%); and clinical performance, such as untimely procedures (54.7%). “The most frequent response based upon this data would be to provide education to the emergency department provider and nurse, and possibly place a hospitalist on performance review,” Dr. Hamad said. Yet, she noted that many other interventions exist that may provide the necessary improvements. These include reviewing trauma team activation criteria, updating admission guidelines, improving communication logistics and providing education to all hospital staff. Also, individual interventions, while the simplest to conduct, will likely not have the same level of long-term impact as larger systemwide changes. “There are many complex causes contributing to deaths with an opportunity for improvement,” Dr. Hamad said. “We know the care of trauma patients is complex, and despite our best efforts, we haven’t improved the safety of this care in decades.”

Metal Plates Outperform Resorbable Plates in Study of Rib Fractures Metal plates used in the stabilization of rib fractures resulted in better alignment with less displacement upon discharge and at three- to six-month follow-up, according to a study presented at the American Association for the Surgery of Trauma 2021 annual meeting (paper 59). “Surgical options for the management of rib fractures have increased over the last decade,” said Dennis W. Ashley, MD, a professor of surgery at the Mercer University School of Medicine, in Macon, Ga. “There are many systems now available to the acute care surgeon who wishes to perform surgical stabilization.” Although plates constructed of polymers—which are resorbed by the body

over the course of 18 to 24 months— are frequently used in procedures such as chest wall reconstruction, there is limited experience using them for the surgical stabilization of rib fractures. Dr. Ashley and his colleagues conducted a study among adult patients with rib fractures treated at a Level I trauma center who were randomized to receive either metal or resorbable plates. The study focused on whether the two types of plates would provide similar fracture alignment, pain control and quality-oflife scores. Assessment of rib displacement was conducted on the day of

discharge, and outpatient follow-up was conducted between three and six months. A total of 29 patients were included in the study: 14 in the titanium group and 15 in the resorbable plate group. Demographics and mechanism of injury were similar for both groups, and motor vehicle crash was the most common mechanism of injury for all patients. Nine patients had displacement upon discharge, all of whom were in the resorbable group. Twenty-two specific ribs had displacement upon discharge, all of which were also in the resorbable group.

The trend continued. During the follow-up period, three patients experienced additional displacement in the resorbable cohort. Similarly, 10 ribs with displacement at follow-up were found in the resorbable group. Pain scores, opioid use and quality-oflife scores were similar in both groups at all periods. Dr. Ashley noted that the study was limited by its single-center design. However, he said since chest radiography was used in place of CT for displacement, follow-up displacement rates were likely ■ conservative.

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IN THE NEWS

GENERAL SURGERY NEWS / NOVEMBER 2021

Study Examines Factors in Early Readmissions After Bariatric Surgery like a leak or bleed, while public insurance and a younger age predicted nonurgent reasons such as dehydration,” Dr. Noria said. “However, given that this study was too small to detect differences in race/ethnicity, we sought to extend our previous work by examining the readmissions, stratified by urgency, u in a national sample.” To T shed light on the issue, the researchers analyzed ana the Metabolic and Bariatric Surgery Accreditation Ac and Quality Improvement Project ec (MBSAQIP) database between 2015 and 2018. 2 “In determining our patient cohort, given medically and surgically complicatg ed patients have issues that can drive reade missions and confound results, we wanted to m examine patients that would be considered a exa low surgical risk, to better understand differences in readmissions by urgency. As such we created an ‘ideal’ cohort characterized by basic crea obesity-related comorbidities, who underob went the most common laparoscopic procew dures, with a smooth perioperative course,” d Dr. Noria said. “We even went so far as to D also exclude any ideal patient who had a drain al placed, despite that being common pracpl tice prior to 2017, to avoid the possibility of including patients that had a complicated course. includ While this ensured an ideal cohort, it decreased our th

By KATE O’ROURKE

eadmissions following bariatric surgery rgery are decreasing over time, but racial and nd ethnic disparities persist, according to new research. The findings were present-ed at the 2021 annual meeting of the American Society for Metabolic and Bariatric Surgery by Sean O’Neill, MD, D, PhD, a fellow in the Advanced MIS/Bariatric ric Fellowship Program at The Ohio State Universiniversiniversi ty Wexner Medical Center, in Columbus. bus. According to Sabrena Noria, MD, D, PhD, the surgical director of the Comprehensive hensive Weight Management, Metabolic/Barriatric Surgery Program at The Ohio State University Wexner Medical Center, and principal investigator of the he study, while bariatric surgery is safe and nd effective, postoperative readmissions persist,, rangrang ing from 1% to 13%, and disproportionately onately affect patients from underrepresented backgrounds and/or a lower socioeconomic bracket. “Our previous institutional-level analysis alysis demonstrated several predictors of overrall readmissions, including prolonged length of stay, public insurance and younger age. However, when we strat-ified readmissions by urgency, length gth of stay predicted urgent reasons for readmission, dmission,

Table. Characteristics of Readmitted Bariatric Patients Readmitted

Not Readmitted

P Value

(n=8,046)

(n=284,501)

Sleeve gastrectomy

5,071 (63)

220,366 (77)

<0.001

Roux-en-Y gastric bypass

2,975 (37)

64,135 (23)

<0.001

Age, years (SD)

42.7 (12)

43.3 (11.7)

<0.001

BMI, kg/m2 (SD)

45.2 (6.8)

44.9 (6.6)

<0.001

Female sex, n (%)

6,763 (84)

230,122 (81)

<0.001

Obstructive sleep apnea, n (%)

2,830 (35)

97,458 (34)

0.087

GERD, n (%)

2,680 (33)

78,107 (27)

<0.001

Hypertension, n (%)

3,658 (45)

123,270 (43)

<0.001

719 (9)

16,903 (6)

<0.001

1,315 (16)

47,271 (17)

0.518

White

4,578 (57)

176,024 (62)

<0.001

Black

1,778 (22)

49,122 (17)

<0.001

Hispanic

1,177 (15)

40,127 (14)

0.183

49 (1)

1,643 (1)

0.713

29 (>1))

1,377 (>1))

0.114

435 (5)

16,208 (6)

0.267

Procedure, n (%)

Patient Characteristics

Insulin-dependent diabetes, n (%) Non–insulin-dependent diabetes, n (%)

Race/Ethnicity, n (%)

Native American Asian Unknown BMI, body mass index; GERD, gastroesophageal reflux disease

examined population from 46% to 39% of all patients in the database.” Specifically, the researchers only included patients with the most common weight-related comorbidities, a body mass index of 35 to 70 kg/m2, ages 18 to 79 years, who underwent primary laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass without having a drain placed, who had no perioperative complications, and a hospital length of stay of two days or less. The researchers identified 28 specific urgent reasons for readmission, six nonurgent reasons and an “other” category for unrelated etiologies. The analyses included bivariate comparisons and multivariate logistic regression to identify predictors of overall, urgent and nonurgent readmissions. The sample included 292,547 patients. Roughly 75% of the patients underwent sleeve gastrectomy and the majority were white (62%) and female (81%). Of the total, 23% had diabetes and 43% had hypertension. The overall readmission rate in this low-risk cohort was 2.75%, with 1.27% due to nonurgent reasons and 1.06% due to urgent reasons. The two most common reasons for readmission overall were in the nonurgent category, with 46% of all readmissions caused by nausea; vomiting; fluid, electrolyte or nutritional depletion; or abdominal pain without a specific diagnosis. Between 2015 and 2018, overall readmissions decreased from 3.0% to 2.63%, driven by a reduction in nonurgent readmissions (1.4%-1.2%) with no change in urgent readmissions. Bivariate analysis demonstrated that surgically ideal patients readmitted after bariatric surgery were more likely to be female; identify as Black; have a higher BMI, gastroesophageal reflux disease (GERD), hypertension or insulin-dependent diabetes; and undergo a Roux-en-Y gastric bypass (Table). Using multivariate analysis to determine predictors of readmission, Roux-en-Y gastric bypass, identification as Black or Hispanic, female sex, GERD, hypertension and insulin-dependent diabetes independently predicted an increased likelihood of readmission. Stratifying by urgency, predictors of nonurgent readmissions paralleled those of overall readmissions, whereas urgent readmissions differed according to demographic/comorbidities variables. Specifically, while Roux-en-Y gastric bypass, identification as Black or Hispanic, and GERD all remained significant, for urgent readmissions a higher baseline BMI and obstructive sleep apnea were also predictive. “Overall, the study suggests that while there is a decline in readmissions, driven by nonurgent causes, there continues to be a disparity in terms of race, despite the fact that all patients examined were the ideal bariatric candidate,” Dr. Noria said. “Whether you look at overall readmissions or stratify them by urgency, patients who identify as Black or Hispanic were more likely to return to hospital within 30 days of surgery—patients who presumably were at low risk for complications. The question now is, why? Ultimately, this study underscores the need to move beyond large data sets, which by their very construction only collect de-identified clinical data, and examine these disparate outcomes in the context of social determinants of health.” “I thought that this study was really interesting,” said Monique Hassan, MD, a bariatric surgeon at Baylor Scott and White Medical Center in Temple, Texas, who served as the discussant of the study. She said some of the results ■ of the paper are limited by its retrospective design.

IN THE NEWS

NOVEMBER 2021 / GENERAL SURGERY NEWS

Bariatric Surgery Reduces Insulin Use in Obese Patients With Type 1 Diabetes By KATE O’ROURKE

n patients with severe obesity and type 1 diabetes, bariatric surgery decreases insulin utilization and reduces the cost burden, according to results from a new study. The study findings were presented at the 2021 annual meeting of the American Society for Metabolic and Bariatric Surgery (abstract A006). According to Brian Dessify, DO, a bariatric fellow at Geisinger Medical Center in Danville, Pa., who presented the study, approximately 50% of patients with type 1 diabetes are overweight or obese, and being obese further complicates patient care, as it leads to insulin insensitivity. Dr. Dessify and his colleagues evaluated two-year outcomes of insulin and hyperglycemic medication requirements in obese type 1 diabetic patients after bariatric surgery. To conduct their study, the researchers performed a retrospective chart review at Geisinger Health System from 2002 to 2019 of patients undergoing bariatric surgery. They identified 38 patients with type 1 diabetes. The researchers collected data on insulin type used, total dose of

insulin, non–insulin-related diabetes medications, total number of diabetes medications and demographic data such as age, race, ethnicity, sex and body mass index. Thirty-three of the 38 patients underwent laparoscopic Roux-en-Y gastric bypass surgery, and the remainder underwent laparoscopic sleeve gastrectomy. The researchers utilized paired t tests to evaluate insulin dose per day from baseline to one and two years postoperatively. They used the Bowker’s test of symmetry to evaluate changes in the number of diabetes medications required at baseline versus one and two years after surgery. The researchers found that two years after surgery, insulin requirements decreased from 118.3 to 60.3 units (P=0.0033). The number of hyperglycemic medications decreased from 66% on greater than one medication preoperatively to only 53% and 52% of patients being on greater than one medication at one and two years, respectively. The mean

‘This study … raises the question if the benefit of bariatric surgery in type 1 diabetes may be subclassified into a group of patients called double diabetics, which are your type 1 diabetic patients who have features of type 2 diabetes.’ —Brian Dessify, DO age was 41 years, 87% were women, 97% were white and 3% were Black, and the mean BMI was 43.0 kg/m2. “This study does provide good evidence for bariatric surgery in obese type 1 diabetic patients. The decreased utilization of insulin within these patients does help with the significant cost burden that comes with purchasing insulin for these patients,” Dr. Dessify said. “This study also raises the question if the benefit of bariatric surgery in type 1 diabetes may be subclassified into a group of patients called double diabetics, which

are your type 1 diabetic patients who have features of type 2 diabetes.” Dr. Dessify said the limitations of the study include that it is a retrospective chart review, and it was conducted in a very small patient population with limited demographic data. “This is a really important study. We don’t operate on patients with type 1 diabetes primarily for their diabetes,” said Ali Aminian, MD, the director of the Bariatric and Metabolic Institute at Cleveland Clinic, who served as the discussant for the study. ■

How Best to Manage the Crura During Sleeve Gastrectomy? Study Finds No Impact on Hiatal Hernia Development With Three Different Approaches By MONICA J. SMITH

Atlanta—For patients undergoing sleeve gastrectomy, different approaches to managing the crura had an impact on short-term complications, but not on the development of a hiatal hernia in the long term, according to new research presented at the 2021 Southeastern Surgical Congress. Hiatal hernia, which has been reported in up to 50% of obese patients, remains a vexing problem for bariatric surgeons among whom there are no formal consensus on how best to manage the crura at the time of sleeve gastrectomy. To shed some light on this situation, Edward C. Tobin, MD, a general surgery resident at the University of West Virginia, in Charleston, and his colleagues performed a retrospective review of patients undergoing sleeve gastrectomy at their institution between 2007 and 2014. “One clarifying point I’d like to make is a distinction between crural management and hiatal hernia repair, which is sometimes used

interchangeably,” Dr. Tobin said. “However, it’s important to remember that in patients who have undergone lap sleeve gastrectomy, there is not a formal hiatal repair, as there cannot be any fundoplication.” The procedures, all performed by the same surgeon, included three strategies for managing the crura: no crural closure, primary closure of the crura and primary closure with mesh reinforcement. The primary end point of the study was the presence of a hiatal hernia within five years of surgery. Secondary end points included dysphagia, reflux, nausea and vomiting. Based on esophagogastroduodenoscopy

“We found the lowest rates of dysphagia, reflux and overall complications in the group that had no crural closure, and the highest rates were seen in the group that had crural closure with mesh reinforcement.” —Edward C. Tobin, MD

and imaging findings, patient symptoms and subsequent hiatal hernia repair, Dr. Tobin and his colleagues determined that hiatal hernias had occurred in 15 of 154 patients with no crural closure (9.7%), 23 of 164 patients with primary crural closure (14%) and seven of 43 patients with mesh-enforced closure (16.3%), differences that did not reach statistical significance (P=0.37). In regard to the short-term complications, however, while there was no difference across the board for nausea or vomiting, crural management was associated with the presence of dysphagia and reflux. Dysphagia was experienced by 2.2%, 7.4% and 14.3% of patients with no crural closure, primary closure and mesh-enforced closure, respectively; and reflux was seen in 6.5%, 17% and 19%. “We found the lowest rates of dysphagia, reflux and overall complications in the group that had no crural closure, and the highest rates were seen in the group that had crural closure with mesh reinforcement,” Dr. Tobin said. He was surprised by the findings. One explanation that he offered for not seeing a difference in hiatal hernia presence despite attempts to reduce it with crural closure with or without mesh reinforcement was that none of the patients could undergo fundoplication. “Also, our mesh group had only 43 patients and the other two had more than 150; it could be that if we’d had a larger sample size and longer follow-up, we might have found a difference.” ■

IN THE NEWS

GENERAL SURGERY NEWS / NOVEMBER 2021

Learning Curves: The Importance of Practice, Goals and Feedback Washington University also started a master’s suturing and knot-tying program for PGY-1 residents. “We have some of the most highly motivated individuals in any field among our students and residents. They clearly have the ability to reach proficiency targets early on, but that won’t happen unless we are directed about it, that we give instructions about using the proper techniques and also provide feedback and assessment,” Dr. Brunt said. A randomized trial comparing fourth-year medical students who underwent summer proficiency training and those who took the traditional boot camp program in the spring revealed that the summer intervention group performed significantly better on all suturing and knot-tying tasks and were comparable to both surgical interns and end of PGY-2 surgical residents (Surgery 2013;154[4]:823-830; 2015;158:962-971).

By KATE O’ROURKE

t the joint annual meeting of the Central Surgical Association and Midwest Surgical Association, L. Michael Brunt, MD, the president of the Central Surgical Association and a surgeon in the Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine in St. Louis, devoted part of his presidential address to learning curves. He focused on three aspects of learning curves: learning it while you’re young; practice makes permanent and perfect practice makes perfect; and stop, pause and look.

Learn It While You’re Young The first aspect is learn it while you’re young. “The reason that I became very interested in this was my observation that some of our most junior residents didn’t have strong enough basic skill sets that would allow them to progress as quickly as they should,” Dr. Brunt said. He noted that this is true for many reasons, some of which are due to the way health care is delivered now, some are related to societal expectations, and some are from not taking much call and not being around in the evenings when opportunities to build skills more commonly arise. To address this gap, Washington University started an accelerated skills preparation course for senior medical students that was focused on technical skills development and coupled with an assessment program.

Practice Makes Permanent; Perfect Practice Makes Perfect

L. Michael Brunt, MD, delivers his presidential address at the 2021 joint annual meeting of the Central Surgical Association and Midwest Surgical Association.

The second aspect Dr. Brunt discussed regarding learning curves was that practice makes permanent and perfect practice makes perfect. He admitted he is not the first person to say this. As an example, he said one of the best-ever performers in the residency program in suturing and knot tying said he got so good by practicing 15 to 20 minutes each day. “It takes that kind of regular practice on a consistent basis to develop and hone those skills,” Dr. Brunt said. “Suturing and knot tying is

Keynote Talk Targets Physician, Patient Wellness 18 Months Into Pandemic By CHRISTINA FRANGOU

urgical organizations put a new focus on physician wellness and address racism—key mandates that have emerged so far in the COVID-19 pandemic, said surgeons speaking during one of the first in-person meetings held by a national surgical society since March 2020. “We are not at the point now where we can truly debrief about what happened,” said Patricia Sylla, MD, an associate professor of surgery at the Mount Sinai Hospital, in New York City, during a keynote address at the 2021 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, or SAGES. “But I think as we stand here today, we can all agree unanimously that we have learned a tremendous amount from this experience,” she added. She spoke during what was an unusual setup for a keynote talk, reflecting the unusual nature of the conference: Dr. Sylla and John Mellinger, MD, the J. Roland Folse, MD Endowed Chair in Surgery at Southern Illinois University in Springfield, interviewed each other about their experiences over the past 18 months. They highlighted several key steps that surgical organizations must take moving forward, including prioritizing surgeons’

mental and physical health; adapting surgical education to virtual platforms; adopting anti-racist policies; and providing care to patients who’ve been disproportionately harmed during the pandemic. “We need to be very sharp focused not only on our members and their wellbeing as they return to clinical practice but also on our trainees, and especially on our vulnerable patients,” Dr. Sylla said. “Many of our patients have been disenfranchised during the pandemic. And it’s going to be very important to be laser focused on their needs as we move forward.” COVID-19 hit Dr. Sylla’s New York City hospital hard early in the pandemic. Surgical wards were turned into COVID-19 wards, and she was redeployed to care for patients with the virus. At the time, little was known about how to care for patients infected with the SARS-CoV-2 virus, and personal protective equipment was in short supply. The most frustrating part “was the utter sense of not being able to help and not being able to really do anything to reverse what was happening,” she said. Dr. Sylla said she and her colleagues struggled with isolation. Many, like her, decided to separate from their families to reduce the risk for bringing COVID19 home. She said she was aided by

colleagues from around the country who supported her through virtual visits and online meetings arranged by organizations like SAGES. Surgeons were sharing information as they were learning about how to care for patients with this novel virus while health systems were under intense pressure. “It was really these weekly calls—putting information together and generating that discussion—that really kept me grounded,” she said.

‘Never lose hope that in the end, we’ll prevail. I think that’s something we learned in this past year.’ —John Mellinger, MD Health care workers are still struggling with the aftermath of the firstwave surge in New York City, she said. “We’ve seen a massive exodus of medical people away from the city looking for a fresh start. And many of us still struggle with various phases of grief.” The pandemic has forced physicians to reflect on their values, she noted. “We’ve had to prioritize our health, our family and definitely our wellness,” she said.

Dr. Mellinger, who served as the chair of the American Board of Surgery’s Board of Directors in 2020-2021, said the pandemic shone a light on the depth of racism in society and how it affects marginalized and underrepresented groups, driving many of the disparities in surgical care and outcomes. In July 2020, the ABS experienced “probably our biggest public relations disaster” in history when a qualifying exam failed over a virtual platform. After the exam, the ABS planned to devote its fall retreat to the theme of future examinations. But the ABS board decided that the more pressing need was to address racism in surgery and surgeons’ role as caregivers in their communities. All surgical organizations must lean into anti-racism and “think about it and how to do it, not just as a fringe or frame on our operations but to change the very fabric of how we [go] about our business,” Dr. Mellinger said. The ABS—led by surgeons Paris D. Butler, MD, MPH, an assistant professor of surgery at the University of Pennsylvania, in Philadelphia, and John H. Stewart IV, MD, MBA, the founding director of the LSU-LCMC Cancer Center, in New Orleans—issued a statement after the retreat, which was published in the Annals of Surgery (2021;273[4]:619-622).

IN THE NEWS

NOVEMBER 2021 / GENERAL SURGERY NEWS

fundamental to everything we do in surgery, and I think learning that is critical to accelerate your learning pathway.” Dr. Brunt said to be maximally effective, practice should be accompanied by feedback, coaching and remediation. “When we instituted what we termed a master’s suturing and knot-tying program for our residency, we found that all PGY-1 trainees reached proficiency targets, but not until 10.4 months of internship and after 2.4 remediation and assessment sessions,” Dr. Brunt noted. “This highlights the importance of goals.”

‘In the operating room, there are certain moments in time where you need to slow down and take pause. You don’t see as much if you are moving all the time.’ —L. Michael Brunt, MD were approaching a critical juncture or something with enhanced risk, ‘Take your time, you can’t take back time,’” Dr. Brunt said. “I frequently repeat that mantra in the operating room to our trainees. You have to slow down and be more aware of your surroundings. In the middle of an operation, you can get so locked in that you may not realize that there is critical

anatomy nearby that maybe you haven’t seen because you are so focused on exactly what you are doing at that moment.” Dr. Brunt said surgeons should be sure to frequently ask trainees to verbalize what they are seeing and thinking. “One of my favorite quotes is from John Wooden, UCLA basketball coach from 1959 to 1975, whose teams won the NCAA

championship 10 times over 12 years. ‘Be quick but don’t hurry—if you hurry, you are more likely to make mistakes, but if you aren’t quick, you won’t get much. When you hurry, your mind gets ahead of your body, and errors are more likely to occur.’” This principle, according to Dr. Brunt, is part of why in the safe cholecystectomy program they have pushed the concept of a momentary pause or stop point before clipping or cutting the ductal structures to verify the anatomy to reduce the risk for biliary injury. “A momentary operative pause or time-out could easily apply to other realms of surgery as well,” he said. ■

Stop, Pause and Look The final aspect of learning curves that Dr. Brunt discussed was stop, pause and look. “I think this applies to many things that we do in life; we are often under time constraints and pushed to get things done,” he said. “In the operating room, there are certain moments in time where you need to slow down and take pause. You don’t see as much if you are moving all the time.” Surgeons need to periodically take a step back and look beyond the view of where they are working at a given moment in time, he said. “Twenty years ago, I got into mountain climbing, and one of the guides I would climb with would say when we

It sets a framework for the ABS to address racism in surgery. In the statement, the ABS acknowledged that “cultural, institutional, ideological and interpersonal racism have harmed the profession and the public.” Both surgeons praised the Coronavirus Global Surgical Collaborative, an initiative set up by SAGES in March 2020, in collaboration with three international surgical societies. The collaborative consisted of surgical leaders from COVID-19–affected countries sharing information on what they were learning during redeployment. Dr. Mellinger said one of the pandemic’s lessons is the value of collective intelligence, meaning that organizations work better when individuals share their knowledge and experience for consensus decision making. “Never lose hope that in the end, we’ll prevail,” he said, citing Vice Adm. James Stockdale, a highly decorated Navy pilot who rallied fellow prisoners of war during the Vietnam War. “I think that’s something we learned in this past year,” he said. Approximately 1,400 surgeons registered to attend the meeting in person, down from 2,900 in 2019. SAGES did not provide figures on how many surgeons attended. Another 1,000 surgeons registered to attend virtually. ■

Digestive Disease & Surgery Institute presents…

4TH ANNUAL

Updates in General Surgery February 4–7, 2022 Vail Marriott Mountain Resort, Vail, Colorado

ACTIVITY DIRECTOR Michael Rosen, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine Director, Comprehensive Hernia Center Department of General Surgery Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, OH

EDUCATIONAL OBJECTIVES After completing this educational activity, the participant will be able to do the following: • Describe the management of common general surgery emergency cases • Describe the indications and contraindications for managing various cases of ventral and inguinal hernia repairs. • Rationalize patient management and treatment options for patients with breast and skin disease. • Discuss evidence-based and cost-effective diagnostic approach for patients with common benign and malignant colorectal cases. • Review and provide update on current enhanced recovery protocols.

COURSE DESCRIPTION Technology for general surgery is constantly evolving. This course will provide an interactive and comprehensive experience focusing on management and treatment options from a general surgical perspective. The goal of the Cleveland Clinic presents Updates in General Surgery is to provide an atmosphere to foster collaboration, innovation and sharing a cost-effective diagnostic approach for patients with complex general surgery cases involving hernia, colorectal and trauma surgery. Surgical oncology topics will also be discussed, along with a variety of topics affecting the rural/ community surgeon. We will cover what is new in enhanced recovery protocols and offer interactive sessions consisting of cases and questions and answers. American Board of Surgery (ABS) Maintenance of &HUWLÀFDWLRQ 02& VHOI DVVHVVPHQW FUHGLWV ZLOO EH RIIHUHG Great refresher course for ABSITE training exam.

TARGET AUDIENCE This interactive, comprehensive event is designed for general surgeons, fellows, residents and other medical professionals.

EARLY REGISTRATION encouraged. Register online at ccfcme.org/UpdateGENSUR

GENERAL SURGERY NEWS / NOVEMBER 2021

Better Outcomes in Pancreatic Cancer The National Pancreas Foundation Centers of Excellence Program Dr. Lisandro Montorfano, a PGY-4 surgical resident at Cleveland Clinic Florida, Weston, interviews hepatobiliary surgeon Dr. Mayank Roy, and medical oncologist Dr. Arun Nagarajan.

Welcome to the November issue of The Surgeons’ Lounge. We dedicate this issue to the National Pancreas Foundation (NPF) Centers of Excellence program that uses a multidisciplinary team approach to achieve better outcomes for patients with pancreatic cancer. Mayank Roy, MD, a hepatobiliary surgeon, and Arun Nagarajan, MD, a medical oncologist, both at Cleveland Clinic Florida, in Weston, provide up-todate answers to the most common questions regarding the NPF Centers of Excellence for pancreatic cancer. Also in this issue, you will find another installment of “The Instrument, the Name,” featuring the Thompson Retractor. We look forward to our readers’ questions, comments and interesting cases to present. Sincerely, Samuel Szomstein, MD, FACS ACS Editor, The Surgeons’ Lounge Szomsts@ccf.org

Pancreatic centers of excellence can act as a guide for these patients, where they can get high-quality care for pancreatic cancer without traveling long distances. —Mayank Roy, MD and Arun Nagarajan, MD

Dr. Montorfano: What are some wide geographic distances create a challenge. From a new advances in pancreatic cancer patient’s perspective, they often do not want to travel long treatment? distances for their treatment. Pancreatic Centers of ExcelDrs. Roy and Nagarajan: More than 60,000 peolence can act as a guide for these patients, where they ple will be diagnosed with pancreatic cancer, and can get high-quality care for pancreatic cancer withmore than 48,000 people will die from the disease out traveling long distances. in the United States in 2021. Traditionally, surWhat is the reaction of your patients when gical resection has been the cornerstone of treatyou explain to them what the NPF program ment for resectable pancreatic cancer. However, entails? Dr. Mayank Roy the prognosis remains poor. The addition of chemotherapy, and in some cases, radiation, Drs. Roy and Nagarajan: From a patient’s improves survival. Recent trials have looked at perspective, they may not understand the concept the sequence of treatment to compare adjuvant of Centers of Excellence. Although we cannot and neoadjuvant therapy. In addition, in the last provide solid evidence of better outcomes solely decade, genetic analysis and immune therapy based on the programs themselves, the fact that the have been the topics of interest for researchfundamentals of these programs are based on Dr. Mayank Roy ers and clinicians. While immune therapy high volume, expertise and a multidisciplinary on its own has not shown improved survivapproach allows patients to feel satisfied with al in pancreatic cancer because of a very resistant tumor and confident in their treatment. microenvironment, it has shown some promising results in Are pancreatic cancer outcomes improving nationwide combination treatment. since the program has been implemented? What is the National Pancreas Foundation (NPF) Drs. Roy and Nagarajan: Outcomes in the form of Centers of Excellence program for pancreatic cancer? complications and survival for pancreatic cancer have Drs. Roy and Nagarajan: The NPF Centers of Excel- been shown to be better in high-volume centers. Some of lence program is a charitable organization set up in 1997, the criteria for Centers of Excellence for pancreatic canto provide resources to patients and their families affect- cer involve volume and expertise (e.g., a minimum of >100 ed by pancreatic disease. The Centers of Excellence pro- ERCPs, >100 endoscopic ultrasound procedures and >12 gram provides research funds, advocates for new therapies, pancreticodudoenectomies a year, and a gastroenterologist and provides education for patients and physicians, and is and surgeon with >5 years of experience). Although the one of the pillars of the NPF. Centers of excellence are Centers of Excellence concept is still a relatively new conpremier health facilities located throughout the Unit- cept with minimal data, the fundamentals on which it is ed States. These centers can provide pancreatic cancer based will translate into better outcomes. patients with specialists to help with the diagnosis and treatment, including surgery. In addition, they can help Are similar Centers of Excellence program guidelines patients with overall management, including pain, nutri- being implemented in the rest of the world? tion and psychosocial support. Drs. Roy and Nagarajan: The NPF gives accreditation to centers located in the United States. As mentioned earHow is the program structured? What specialties does lier, most European models have already shifted toward it involve? How do hospitals become members of this centralization of care for pancreatic cancer. prestigious program? Drs. Roy and Nagarajan: Centers of Excellence for Are the standards of the NPF program reproducible in pancreatic cancer are selected based on the criteria devel- rural and community hospitals? oped by experts in the field, with a high-level focus on Drs. Roy and Nagarajan: Presumably, if rural and commultidisciplinary treatment of pancreatic cancer. This munity hospitals can meet all of the requirements and criteinvolves active participation of pancreatic surgeons, gas- ria deemed essential by NPF experts, then they can provide troenterologists, medical oncologists, endocrinologists, the same high standard of quality care to pancreatic cancer radiation oncologists, pathologists, radiologists and genet- patients, similar to other Centers of Excellence. ■ ics specialists through a biweekly multidisciplinary gastroenterology tumor board. The program should be able Suggested Reading to support next-generation sequencing and molecular and Fogel EL, Shahda S, Sandrasegaran K, et al. A multidisciplinary approach to pancreas cancer in 2016: a review. Am J Gastroenterol. genomic profiling. In addition, nutritional support, pal- 2017;112(4):537-554. liative care and psychosocial support should be available. Oba A, Ho F, Bao QR, et al. Neoadjuvant treatment in pancreatic cancer. Hospitals can apply if they meet all these criteria through Front Oncol. 202;10:245. a yearly application. Parekh HD, Starr J, George TJ Jr. The multidisciplinary approach What is the benefit of implementing the NPF Centers of Excellence program for pancreatic cancer? Drs. Roy and Nagarajan: Most European models have moved toward centralizing pancreatic cancer care around state-of-the art referral centers where a multidisciplinary approach is used to manage the patients. Although we are slowly adopting these changes in the United States model,

to localized pancreatic adenocarcinoma. Curr Treat Options Oncol. 2017;18(12):73. Roth MT, Cardin DB, Berlin JD. Recent advances in the treatment of pancreatic cancer. 2020;9:F1000 Faculty Rev-131. Prades J, Arnold D, Brunner T, et al. Bratislava Statement: consensus recommendations for improving pancreatic cancer care. ESMO Open. 2020;5(6):e001051. www.cancer.org/cancer/pancreatic-cancer/about/key-statistics.html www.pancreasfoundation.org/npf-centers-info/

IN THE NEWS

NOVEMBER 2021 / GENERAL SURGERY NEWS

THE INSTRUMENT, THE NAME: THE THOMPSON RETRACTOR By Lisandro Montorfano, MD

A “retractor” is defined as a device used by surgeons to separate the ends of a surgical incision. Although retractors are very popular and have been used for centuries, not many surgeons know the origins of the different retractors they use. The developer of the Thompson Retractor (Figure), Richard C. Thompson, MD, studied medicine at the Stanford Medical School, in California, and practiced anesthesia for more than 30 years. It was during this time that he developed the first table-mounted retractor. It all started in 1959, while Dr. Thompson was observing tonsillectomies. He noticed the McIvor mouth gag depressed the children’s chest wall with every inspiration as the weight of the retractor rested on their chest. During one of these tonsillectomies, Dr. Thompson observed a colleague secure the McIvor mouth gag to a towel with a Kelly clamp to free his hands and perform other tasks in the OR. Dr. Thompson also witnessed a nurse adjusting stirrups and recognized that the universal joint on the operating table allowed them to be adjusted in nearly any position. He decided to integrate these two ideas, and designed a McIvor mouth gag that could be secured by a steel rod to the operating table using a universal joint. Colleagues in vascular surgery showed interest in this new system and requested Dr. Thompson to develop a new table-mounted retractor system that could replace handheld retractors. The first table-mounted retractor system was born. Dr. Thompson patented his retractor in 1965, but the first prototype did not function efficiently due to mechanical problems. To address this, he contacted the chief metallurgical engineer of the Lockheed Aircraft Corporation, who was an old acquaintance. The engineer suggested Dr. Thompson use a particular type of stainless steel and a particular heat treatment, both of which were used in aircraft landing gear. After heeding the engineer’s advice, the table-mounted retractor became efficient and ultimately successful. While observing various surgical procedures, Dr. Thompson came up with different versions of his retractor system. In the 1980s, Dr. Thompson was approached by Dan Farley, an industrial designer and the son of the neurosurgeon Dr. Albert W. Farley Jr., with a new table-mounted, self-retaining retractor prototype for neurosurgery. Dr. Thompson was very impressed with both the new prototype and Mr. Farley, and suggested that he take over his company and use it as a stepping-stone to further develop and market his retractor systems. The Thompson retractor has become increasingly popular and is still one of the most frequently used table-mounted, self-retaining retractors in the United States. These retractor systems have continued to lead the way in providing the visibility that surgeons need and has become synonymous with open surgery. Suggested Reading Powell JL. The Thompson retractor system. J Pelvic Surg. 1999;5(4):242-243. Rousou JA, Engelman RM, Flack JE, et al. Cardiac retractor for coronary bypass operations. Ann Thorac Surg. 1991;52(4):877-878. Thompson RC. Self-retaining retractor support. New applications. Calif Med. 1964;101(4):277-279. The Thompson Retractor Surgical Atlas. Thompson Surgical Instruments, Inc., USA. 2010.

Nanopore Sequencing continued from page 1

general surgery resident at Mayo Clinic in Rochester, Minn. Researchers collected bile duct fluid from 41 patients undergoing pancreatic head resection and sent it for both standard culture and nanopore sequencing for microbial profiling. The results were presented at the 2021 joint annual meeting of the Central Surgical Association/Midwest Surgical Association (abstract 22). “The nanopore sequencing involves extraction of the total DNA from a sample and then you deplete the host DNA and amplify the microbial DNA,” Dr. Yonkus explained. “You then take that microbial DNA and you sequence it on a nanopore sequencer. Then you take all those genes and you compare it back to a genomic library, which allows you to identify a wide variety of pathogenic bacterial organisms and their anticipated antibiotic sensitivity or resistance.” De-identified results of both tests were provided to a surgical clinical pharmacist and an infectious disease physician for antibiotic recommendations. Time to results was defined as time from sample acquisition to either final standard culture or nanopore sequencing results. Roughly half (52%) of the samples from patients came back as positive in standard cultures, and all patients (100%) had organisms detected using nanopore sequencing. On average, nanopore sequencing detected twice as many bacterial species compared with standard culture (10.5 vs. 4.4; P<0.05). Resistance genes were screened using nanopore sequencing in the 22 positive samples, with a mean of 6.4 genes being detected. The predicted resistance phenotypes were significantly greater from nanopore sequencing than using standard cultures (10.3 vs. 2.7; P<0.05). Antimicrobial recommendations for nanopore sequencing provided coverage for standard culture results in 61% of samples. Using the nanopore sequencing technology was significantly faster than standard cultures (median time to results, eight vs. 165 hours) but came at a higher cost ($165 vs. $38.49). “That really is a nominal increase if you consider the cost of one surgical site infection is up to $30,000 or can, even worse, cost a patient their life,” Dr. Yonkus said. Nanopore sequencing also provided a perfect negative predictive value. “In all patients who had no growth on standard cultures, they also had no growth detected using nanopore sequencing,” she said. “So, all of those patients, about half, could have discontinued their prolonged course of antibiotic prophylaxis

on postoperative day 1. That makes up for the additional cost of the assay, the extra days of unnecessary antibiotics, and it also prevents the known complications associated with prolonged antibiotic administration.” The researchers say because microbiome metagenomics may prove to be applicable to all body fluid samples (blood, urine, etc.), nanopore sequencing may have a major impact on diagnosis and treatment of all surgical site infections. Dr. Yonkus and her colleagues are in the process of planning a randomized controlled trial of

Nanopore sequencer. Image courtesy of BioRender.com.

the nanopore sequencing for patients undergoing pancreatic head resection. Asked to comment on the study, Nicholas Zyromski, MD, a professor of surgery at Indiana University School of Medicine, in Indianapolis, said it’s significant. “Bacteria in the biliary system is very important in pancreatic and biliary surgery. What we know is that when the bile duct undergoes instrumentation, which it almost always does for patients who have cancers in the head of the pancreas or cancers that are blocking the bile duct, the bile that needs to be instrumented is contaminated with bacteria typically from the intestinal system. What that leads to when we operate is an increased incidence of infection. “So, the ability to diagnose the type of bacteria quickly would be a major advantage. When we suspect an infection, we typically prescribe a broadspectrum antibiotic, and when the bacteria is isolated, we can narrow the spectrum of antibiotics. This technology allows the narrowing of the bacteria coverage quite a bit earlier and potentially cuts down the development of resistant bacteria.” Dr. Zyromski said the study was potentially practice-shifting methodology to diagnose infections, but the technology was not yet widely available. “The study was done in the bile ducts, but this could be potentially used in a number of other body systems,” he ■ added.

IN THE NEWS

GENERAL SURGERY NEWS / NOVEMBER 2021

Hernia Mesh and Litigation: Where Things Stand continued from page 1

five years, so much so that many of them are being tried as multi-district litigation (MDL). “MDL is a creature of the federal court system; typically, you’ll bring a number of cases that have been filed in a variety of districts around the country under one umbrella,” said Todd R. Bartos, Esq., an attorney with The Bartos Group LLC, in Lancaster, Pa. “The MDL is basically an efficient way to consolidate common portions of cases and reduce the risk of inconsistent results. MDLs also encourage the quick resolution of these cases by trying one case, the bellwether case,” Mr. Bartos said. “Generally, as goes the bellwether case, so goes the entire group of cases.”

What Are All These Lawsuits About? The complaints against inguinal and incisional hernia repair with mesh have some similarities, but not entirely; legal issues in inguinal hernia repair revolve mainly around chronic groin pain. In 2013, a commentary by Josef Fischer in “Fischer’s Mastery of Surgery” argued that mesh is responsible for inguinodynia and that surgeons should stop using it; this provoked a counterargument by Arthur Gilbert that autologous repair, along with its higher recurrence rate, also causes chronic groin pain, Dr. Voeller said. “Dr. Gilbert’s position was that the pain is due to the absence of technique, not the technique itself.” Thus, paper after paper examined recurrence rates and pain with or without mesh; in sum, the clinical data find mesh-based laparoscopic inguinal repairs less associated with chronic groin pain than any other type of repair, Dr. Voeller said. “Mesh in and of itself is not a major cause of chronic groin pain.” This is not to imply that mesh is benign; take the case of mesh in transvaginal pelvic organ prolapse (TV-POP), which was FDA approved for this indication in 2001 as a 510(k) clearance. “But we had no short- or long-term safety data regarding this use due to the 510(k) approval process not requiring clinical trials; as more surgeons started using mesh, we saw more complications at a rate up to 50% for erosion, pain, infection, dyspareunia and GU [genitourinary] issues,” Dr. Voeller said. Ultimately, the FDA required all companies to withdraw mesh for TV-POP in 2018. Soon, lawsuits around mesh use in that procedure were big news and big money. “In 2019, The New York Times reported that seven manufacturers paid nearly $8 billion to resolve more than 100,000

Although many cases were suspended in 2020 due to the coronavirus pandemic, these cases are now working their way through the multi-district litigation system.

claims. The law firms got a lot of money; having profited from these claims, they decided to look at mesh in inguinal and incisional hernia,” Dr. Voeller said. Complaints against mesh use in incisional repair are similar to those in TVPOP: pain, erosion, recurrence, bowel obstruction, seroma, infection and death—“all the complications we see with complex reconstruction of the abdominal wall,” Dr. Voeller said. “In these lawsuits, the material is accused of tearing or breaking, the coatings don’t prevent adhesions, the pore size isn’t right—the complaints go on and on.” Plaintiffs’ counsels are not just motivated by money, Mr. Bartos said. “Many are truly in it to protect patients and prevent avoidable harm. Where we get into disputes is whether something is ‘avoidable’ or simply a known risk of using a foreign material to repair a fascial defect. Many times, there are issues of what a manufacturer knew and when it knew it regarding risk profiles. But there is no arguing that it is a lucrative business, and there are some who invest heavily in ads to generate a larger group of plaintiffs.”

Where We Stand Now

Tips for Surgeons Using Mesh Have detailed, documented conversations with patients. “Explain why mesh is necessary, the pros and cons of different types of mesh, and whether there’s an alternative,” said Todd R. Bartos, Esq., an attorney with The Bartos Group LLC, in Lancaster, Pa. “Also, explain post-op instructions. Tell them why it’s important not to lift that 40-pound bag of dog food for the next six weeks.”

Take clear operative notes. “The op note is the critical piece to keep surgeons out of the hot seat. It’s one thing for mesh manufacturers to bear the risk of litigation of a failed product, but you want to make sure that you’re minimizing your chances that a failed product will be argued to have also been improperly applied,” Mr. Bartos said.

Maximize patients’ preoperative condition and manage expectations. “We have to let patients know that abdominal wall reconstruction is a very complex surgery w with complex issues and the potential for w significant complications,” said Guy Voeller, MD, a professor of surgery at the University of Tennessee Health Science Center, in Memphis, at the 2021 virtual Abdominal Wall Reconstruction Conference.

At this point, many of the manufacturers of mesh used in hernia repair are involved in MDLs. Although many cases were suspended in 2020 due to the coronavirus pandemic, these cases are now working their way through the MDL system; the case against Bard and its Ventralight ST mesh rebooted in August 2021. “The use of MDL and bellwether cases gives a sense of where a jury would go in each of the other tens of thousands of potential cases. That allows a reasoned risk calculation for both sides,” Mr. Bartos said. If there is a loss at trial, that is not the end of it. “If Bard loses and there is a damages award, typically the MDL parties would get together to discuss a global settlement, but Bard could appeal a bellwether case defeat,” Mr. Bartos said. ■

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OPINION

NOVEMBER 2021 / GENERAL SURGERY NEWS

Optimizing the Patient for Surgery: The Pre-op Psychological Survey BY MICHAEL J. ASKEN, PHD, AND DANIELLE E. LADIE, MD, MPH, FACS B

t is obvious that optimizing the patient prior to surgery is essential for maximizing desirable outcomes. While these efforts typically focus on managing comorbidities and assessing physiologic parameters, “comprehensive” optimization is achieved by including attention to the psychological status of the surgical patient. With evolving specialization in surgery and increasing sophistication of procedures, psychological evaluations have become integral in the evaluation of patients for certain operations, such as bariatric, transplant and pain-related orthopedic surgeries.1,2 The benefits of psychological “preparation” of surgical patients has been proposed as an important consideration.3,4 Less developed, in contrast to specialized psychological evaluations, is a simple and broad approach to assessing every patient’s psychological state in a manner appropriate for use by the surgeon involved in the case. Psychological preparation of the patient requires a first step of evaluation through a preoperative psychological survey (POPS). While not an in-depth, diagnostic or psychopathology-oriented evaluation (hence the term “survey”), the qualitative POPS addresses a variety of areas of patient functioning that can bear directly on the quality and satisfaction of the surgical experience for both the patient and surgical team. A more specific and comprehensive evaluation may become indicated as a result of information elicited from such a general psychological inquiry. There are two reasons why an assessment like the POPS is indicated: Surgery is a psychological, as well as physical, experience and psychological factors affect the surgical course, outcome and recovery.5-10 Although the POPS could be delegated to another member of the surgeon’s team, we strongly suggest the surgeon engage the patient. We describe the POPS as a “discussion” with the patient that provides direct and useful information to the surgeon, illuminating issues that the surgeon will want to ensure are addressed. Perhaps, as importantly, this interaction can convey the sincerity of the surgeon’s concern for the patient’s overall well-being, enhance the perception of a positive bedside manner and bolster the quality of the surgeon‒patient relationship. When engaging the patient, the following items should be considered:

3. Discuss the patient’s understanding of their condition and need for the procedure. The patient should have a substantial understanding of their condition, how the surgery will affect their condition and, consequently, a positive acceptance (if not enthusiasm) of the surgery. The reality is that patients do not always fully comprehend, or may be confused about, aspects of their condition and care. 4. Discuss the patient’s understanding of the procedure itself. This is where you want the patient to tell you what they understand about their situation. What you told them is crucial, but what they heard, retained and understand is essential. 5. Discuss the patient’s short-term expectations. Explore what the patient understands will happen going into the procedure, immediately after and in the ensuing 24 to 48 hours. Is there a realistic expectation of hospital length of stay, pain levels and fatigue? Discussion of postoperative sensations, such as stitches pulling, itching, numbness or oozing can be valuable. When these events occur unexpectedly, there is a tendency to interpret them in a negative manner (“my wound is tearing open!”). 6. Discuss the patient’s long-term expectations. Ultimately, you want to hear that the patient has an accurate and reasonable expectation of time and any postoperative rehabilitation that is required. You want to listen for their understanding of what the procedure will accomplish and perhaps what it will not. Unrealistic expectations lead to a difficult postoperative course, strained interactions, disappointment and anger.6 7. Discuss current life stresses. Stress is common, but a burned-out, dejected, pessimistic patient is not in an optimal state for surgery. While the acute need for surgery may preclude immediate intervention for stresses, their acknowledgment, especially with a commitment to help with follow-up postoperatively, can provide a sense of relief and a more optimistic outlook for the patient.

10. Discuss current/past counseling history and assess mental status. Discussion of these last areas often is the most difficult and sensitive for both the surgeon and patient. Generalizing problems with the term “stress” (everyone has it!) can reduce intrusiveness. Asking “how are you doing” is an effective way to start and listen for current, acute or ongoing anxiety or depressive thinking. Surgeon discomfort here should not be a rationale for avoiding this assessment. It is often extremely valuable as a baseline in the face of postoperative concerns like delirium and other cognitive changes. The preoperative psychological assessment has the potential to provide important information to the surgeon for optimizing patient readiness for surgery. Obviously when concerns are revealed, addressing them in some manner from reassurance to psychiatric/psychological consultation is indicated. The ability, interest and comfort of surgeons to engage productively in such discussions will vary greatly. We are not suggesting a prescription for how to evaluate a patient psychologically, but rather the value of generally increasing awareness of the patient’s psychological state and needs. Again, we differentiate POPS from in-depth psychological, neuropsychological or psychiatric evaluations that are essential in certain surgical scenarios and clinical situations. What is suggested is a thoughtful discussion with the patient. The content and extent are to be determined by each individual surgeon and situation. Some patients (with an avoidant coping style) will be reluctant to engage fully and they should not be pressed.3 However, completing a POPS through discussion allows an opportunity for unique concerns to emerge while cultivating the relationship. ■

References

1. Discuss the patient’s perceptions of past surgical experiences. The goal here is to illuminate psychological and emotional residuals (both positive and negative) that might still linger from those experiences. Did all go smoothly and as expected? Were there aspects that were uncomfortable, frustrating, angering or anxiety-arousing? What views of surgery—trust or fear—did past experiences create for the patient?

8. Discuss the patient’s usual way of coping with challenges. A gentle, but effective way to approach this is by discussing how the patient usually deals with challenges and stressors. You might hope to hear approaches such as “I read up on things,” “I lean on my friends” and “My faith sustains me.” While usual perioperative support is still important here, such statements are a good foundation for the response to surgery. Responses like “I don’t know” and “I get pretty down” suggest a psychological infrastructure that would probably benefit from greater professional support.

2. Discuss the patient’s view of others’ experiences with the same or similar procedures. What has the patient heard from friends or relatives about the pending surgery? Are these stories exaggerated, especially in a negative way? The plethora of television medical dramas, social media commentary and internet (mis)information can influence a patient’s perception of their situation.

9. Discuss current care and relationships with medical/nursing staff. Despite best efforts, and for many reasons, patients don’t always perceive that they received the kind of care they expected. While never acceptable, frustration, anger, anxiety or fear of returning to a floor or team’s care is especially concerning going into surgery. A deteriorating relationship with staff is a risk for psychological morbidity.11

1. Block A, Sarwer D, eds. Pre-surgical Psychological Screening: Understanding Patients, Improving Outcomes. American Psychological Association; 2012. 2. Kumnig M, Jowsey-Gregoire S. Pre-operative psychological evaluation of transplant patients: challenges and solutions. Transplant Res Risk Manage. 2015;7:35-43. 3. Johnston M, Vogele C. Benefits of psychological preparation for surgery: a meta-analysis. Ann Behav Med. 1993;15(4):245-256. 4. Salzmann S, Salzmann-Djufri M, Wilhelm M, et al. Psychological preparation for cardiac surgery. Curr Cardiol Rep. 2020;22:172. 5. Burton D, King A, Bartley J, et al. The surgical anxiety questionnaire: development and validation. Psychol Health. 2019;34(2):129-146. 6. Cody EA, Mancuso CA, Burket JC, et al. Patient factors associated with higher expectations for foot and ankle surgery. Foot Ankle Int. 2017;38(5):472-478. 7. Orri M, Boleslawski E, Regimbeau JM, et al. Influence of depression on recovery after major noncardiac continued on page 17

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The Most Harm continued from page 1

as observers, while the teaching attending does all the critical parts of even the most routine operations, often delegating only administrative and assistant tasks to the trainee. Residents and fellows are forced to watch politely, month after month, as a parade of faculty surgeons feeds them a standardized litany of academic excuses for why they won’t be allowed to perform the operation that day: “ Watch this one and you can do the next case”—which never comes. “ The schedule is very busy today, so let me get this case done real quick.” “ This case is a little complicated, so let me get things going.” Perhaps worst of all is the unforgivable professor who has become so comfortable and cold-blooded with “stealing” cases from his residents and fellows that they simply walk into and out of the OR, saying nothing about the fact that they are performing the entire case, and never acknowledging or expressing any consideration or regret for the fact that the individual they are solemnly charged with teaching has gained neither confidence nor competency from that operative experience. Let us be very clear about a basic point regarding the education of surgical residents and fellows: Delaying legitimate, challenging, independent, operative technical and decision-making experience to senior surgical residents and fellows is an absurd, if not criminal, idea. It indicates there is either a failure of adequate exposure, education and preparation during the junior resident years, or there has been a systemwide decision made to completely abandon the idea of ever graduating competent, confident, independent surgeons and fellows from our training programs. I am certain that 26-year-old doctors who recently graduated from medical school are fully physically, neurologically and psychosocially developed. There is no logic to the idea of delaying their immersion in the inevitable challenging intellectual and technical OR demands of the surgeon while awaiting some type of miraculous delayed future biological maturation to occur. In fact, it is clear to me that the progress and development of young surgeons are determined solely by how quickly they are granted the increased and intense demands in technical skills and decision making that occur only during the course of operative procedures. As such, one has to ask: Why are we delaying when our residents and fellows are finally getting these critical experiences? There are no explanations

for this question other than satisfying the comfort, convenience and ego of the academic attending and bowing to the organizational demands of administrators. In our South Florida community, over the past decade, we have seen several young general surgeons, and just as many cardiac and thoracic surgeons, arrive unprepared for the routine work of an independent, well-trained surgeon. The consequences have been devastating to the patients in our community and the careers of these young colleagues. All these surgeons eventually had to leave the community—discouraged, disgraced, embarrassed and lacking any semblance of confidence after being fired and harshly disciplined by their groups, the hospi-

the same time are thinly staffed by faculty who often are unprepared or unwilling to provide adequate, high-level academic instruction and mentorship and a diverse interesting caseload to their young surgical trainees. Add to this grave situation the constant negative pressure placed on surgical training by the fatal combination of resident work-hour restrictions and the inescapable dilution in exposure to complex advanced general, vascular and oncologic cases that results from an unlimited number of subspecialty fellows who parasitize these experiences from senior residents, and we find ourselves as educators in the midst of a grave crisis. The reports I get on a near-daily basis regarding the independent operative experiences in fellowship programs from the recent graduates of the two general surgery residencies with which I am

well in the community if they have no independent operative experience? Department heads and division chiefs like to boast proudly at cocktail receptions about “their fellows” and “their residents” as if they are talking about their Rolex watches and Mercedes-Benz cars—pieces of highly prized property that give credibility to their lofty status in academics, that they think they own and can use as they wish. They then use the fellows and residents in the hospital as glorified nurse practitioners or physician assistants to run their services, do their dictations and answer their calls at night. Once in a rare while, they throw them a bone in the OR, temporarily lifting their hopes that they actually might be ready to get a chance to learn how to operate. The idea of graduating residents and fellows without giving them ample

To take away our students’ ability to independently suffer, and thus learn, through difficult cases as they search for both confidence and competency is an unforgivable violation of our treasured role as professors and mentors.

tal medical executive committees and the state medical boards, while often simultaneously facing the stress of malpractice lawsuits. It is heartbreaking to watch these young surgeons tremble as they face the unimaginable impending collapse of the careers they dreamed of their entire lives and worked so terribly hard to earn. These types of stories are common around our country and only those of us who are charged with the education of the nation’s new surgeons are to blame! I fear that the dilemma of inadequate surgical resident and fellow education is doomed to only worsen as we see an explosion in the number of general surgery residency and fellowship programs around the country. Many of these government-subsidized programs are highly profitable for hospital systems, but at

involved is nothing short of depressing. A talented surgeon who as a fourth- and fifth-year general surgery resident was independently performing successful, safe colectomies as a “teaching” resident recently admitted to me that they were never—not once—the actual surgeon on a colon operation during an entire one-year colorectal surgery fellowship at a prestigious Ivy League medical center. Their role was always as a first assistant. How is that possible? I have former residents who are now vascular surgery fellows who say we let them do more independent open and endovascular procedures as third-year residents than they are granted as second-year vascular fellows. What is going on? How are our young subspecialist and general surgeons going to function safely and compete

opportunities to struggle independently in the OR is as absurd as having a student prepare for a chemistry or physics final exam by only watching an experienced tutor solve problems on a blackboard and never actually battling through endless difficult problems in a library study session by themselves. Acquiring new knowledge and skills has been recognized since antiquity by thoughtful educators as one of the most difficult challenges that humans face. Aeschylus said: “He who learns must suffer. And even in our sleep, pain that cannot forget falls drop by drop upon the heart, and in our own despair, against our will, comes wisdom to us by the awful grace of God.” We must not take away, for the sake of our own convenience or the misguided rules of our administrative class, our

OPINION

NOVEMBER 2021 / GENERAL SURGERY NEWS

residents’ and fellows’ ability to work and struggle autonomously in search of surgical wisdom as they learn to solve the complex intellectual and technical puzzles that the surgeon faces every day while trying to find remedies for the unlimited array of derangements of human anatomy and physiology. To take away our students’ ability to independently suffer, and thus learn, through difficult cases as they search for both confidence and competency is an unforgivable violation of our treasured role as professors and mentors. I have had the great privilege to participate in the training of dozens of fine young surgeons. I suffer daily watching them make procedures that are now simple reflexes for me, look incredibly hard and take an eternity to complete. Yet, I also find incredible satisfaction and pride in noting how quickly they learn and improve when they are forced to work through a difficult case alone or with a junior resident. I try to make sure our residents graduate with substantial experience and confidence by making sure they have “suffered” as residents while I was available to help so they (and their patients) eventually do not have to suffer as much when they are finally out alone in the terrifying world of surgery. If you are a resident or fellow who is watching your opportunities to learn being squandered on a daily basis by selfish faculty or absurd policies and rules, then you need to speak up loudly and plead your case to your program director and mentors regarding the absolute necessity of having an adequate independent operative experience during your internship, residency and fellowship years. The safety of your future patients and the success of your entire career depend on it! If, by the same token, you are an academic surgeon who simply cannot tolerate the delays, setbacks, risk, inconveniences and stress of watching your young student surgeons operate independently, then you need to find yourself an experienced, efficient physician assistant and get out of surgical education, because every day you walk into the OR and steal your resident’s or fellow’s case, you are unforgivably causing far more harm than good to the careers of our bright young colleagues. Finally, I ask you to imagine how you, as a surgeon, would feel if your own son or daughter was a surgical resident or fellow, and every week they relayed to you hopeless dissatisfaction with the operative training they were getting and terror from the fact that they might finish their training as an incompetent surgeon. How would you feel about that? Allowing my residents to feel this way is anathema to me. I love and treat my residents as if they were my own children, and I worry constantly about how they will do alone in the real world. That is why, every day,

I remember: “We do the most harm to the ones we love when we do for them the things they should do for themselves.” ■ —Dr. Lopez-Viego is a vascular and general surgeon, and clinical professor of surgery at Charles E. Schmidt College of Medicine, Florida Atlantic University and University of Miami Miller School of Medicine.

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Optimize Patient continued from page 15

surgery: a prospective cohort study. Ann Surg. 2015;262(5):882-889. 8. Rasouli M, Menendez M, Sayadipour A, et al. Direct cost and complications associated with total joint arthroplasty in patients with pre-operative anxiety and depression. J Arthroplasty. 2016;31(2):533-536. 9. Ghoneim M, O’Hara M. Depression and post-operative complications: an overview. BMC Surg. 2016;16(5). doi:10.1186/s12893-016-0120-y 10. Nixon D, Schafer K, Cusworth B,

et al. Preoperative anxiety effects on patient-reported outcomes following foot and ankle surgery. Foot Ankle Int. 2019;40(9):1007-1011. 11. Williams H, Jajja M, Baer W, et al. Perioperative anxiety and depression in patients undergoing abdominal surgery for malignant disease. J Surg Oncol. 2019;120:389-396.

—Dr. Asken is the director at Provider Well-Being, UPMC Central PA Region, Harrisburg, Pa. Dr. Ladie is a transplant surgeon and the vice chair, Department of Surgery, UPMC Central PA Region, Harrisburg, Pa.

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OPINION

GENERAL SURGERY NEWS / NOVEMBER 2021

The Path to Surgical Autonomy: Apprenticeship continued from page 1

actually defines “apprenticeship.” The purpose of this essay is to demonstrate that apprenticeship remains the predominant paradigm of resident training within the operating room and is the ultimate path to solving the autonomy crisis. Apprenticeship “is a process through which a more experienced person assists a less experienced one, providing support and examples, so the less experienced person gains new knowledge and skills. … Often larger skills are broken into smaller ones, and supports are provided so that tasks that are given to the apprenticing learner are within the reach of the learner’s current ability level.”1 This process of learning has also been described as “legitimate peripheral participation.”2 Within this framework, the learner is accepted into a community of practitioners, but the starting place is at the periphery. While at the periphery, the learner begins a process of enculturation into a particular community of practice, learning the language and skills within the work environment through a context of “clear expectations and learning goals.”3 This is the starting place for observing holistic processes of work. Expert practitioners demonstrate to those at the periphery the skills that “are integrated into patterns of expertise and their efficacy and value” when applied to realistic problems.3 “Once the big picture is understood, participation can shift from peripheral to active, with the learner completing smaller, component parts of the larger task while receiving iterations of feedback from someone who is more experienced. At this point, the learner is no longer a legitimate peripheral participant, but instead is inbound, beginning to identify more with insiders of the community’s practice.”1 Furthermore, “by advancing in skill, apprentices are increasing their participation in the community, becoming expert practitioners in their own right.”3

How does this progression happen? The key principle is the teacher who intentionally makes tacit processes visible to the learner.1,4 This has been described classically in the concepts of modeling (expert demonstration), coaching (guidance), scaffolding (fading), articulation, reflection and exploration.3 In brief, the expert demonstrates the task in its entirety and also in its component parts. The learner then works at mastering each component, starting with simpler portions first. Throughout this process, the teacher provides feedback (coaching, mentoring) and support (scaffolding), but then eventually fades into the background as the learner begins to independently master each component and finally the entire task as a whole. This brief survey of apprenticeship has just described contemporary surgical residency training within the OR. The Zwisch scale,5 which recently has been advocated for more effective intraoperative training, is simply putting into different words what has just been said about apprenticeship. The attending models and demonstrates the operation (“show and tell”); then, the attending provides scaffolding and support to the resident as the resident begins to master the operation, with the attending slowly fading into the background (“active help,” then “passive help”); finally, the attending only supervises as the resident has become empowered to complete the entire operation independently. This process is what surgical resident training has always been and what has happened organically in the OR between the resident and attending since the time of Halsted. Halsted’s principles of surgical training also describe apprenticeship: 1. The resident must have intensive and repetitive opportunities to take care of surgical patients under the supervision of a skilled surgical teacher.

2. The resident must acquire an understanding of the scientific basis of surgical disease. 3. The resident must acquire skills in patient management and technical operations of increasing complexity with graded enhanced responsibility and independence.6 This is what forms the backbone of surgical resident training and learning how to operate independently—it is, in fact, our current paradigm of training. Finally, a key aspect of apprenticeship that is often assumed, but not mentioned, is the relationship between the attending and resident. As long as a resident operates with an experienced surgeon, you will have to deal with the social interaction and training relationship between the two. Those exploring entrustable professional activities have realized that without trust, the experienced surgeon will not transfer more responsibility and autonomy to the resident.7 However, trust develops through relationship, which relies upon time, dependability, intellectualism and proximity. This is vital to consider because it is clearly evident that the current medical system severely limits the time and proximity (not to mention the dependability and intellectualism) to develop trust between the attending and resident. The high-throughput work culture with its pressure on surgeons to be productive, defensive medicine and litigation, the patient as consumer, concerns about patient safety, overall increasing regulation, new technologies, increasing specialization, demands for service work over actual learning, shortened rotations due to pressures to gain exposure to a wide variety of specialties, and a rigid application of duty hours have created a context that is malignant to effective apprenticeship and thus development of autonomy.

The solution to the autonomy crisis, therefore, is a reclaiming of Halsted’s apprenticeship model, freshly understood within practices that are able to foster trust in the current context of the overall medical system. Thankfully, there are many ongoing efforts to do this within the surgical education community, such as simulation, longitudinal rotations, development of entrustable professional activities, more effective tools for resident evaluation,8 novel approaches to picking the appropriate applicant for residency/fellowship,9 and discussions for earlier specialization with residents. As long as residents train under experienced surgeons in the OR, we will have to acknowledge the training paradigm of apprenticeship. For the foreseeable future, it is apprenticeship that will form the backbone of developing resident autonomy in the OR. Reflections on how to preserve, adapt and improve trust within the apprenticeship relationship between the attending and resident amid the current medical system and learning environment will ultimately solve the autonomy crisis. ■

References 1. Dennen VP, Burner KJ. The cognitive apprenticeship model in educational practice. In: Spector JM, Merrill MD, Van Merriënboer J, et al, eds. Handbook of Research on Educational Communications and Technology. Routledge; 2007. 2. Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge University Press; 1991. 3. Collins A, Brown JS, Newman SE. Cognitive apprenticeship: teaching the craft of reading, writing and mathematics (Technical Report No. 403). BBN Laboratories, Cambridge, MA. Centre for the Study of Reading, University of Illinois. January 1987. 4. Collins A, Brown JS, Holum A. Cognitive apprenticeship: making thinking visible. American Educator. 1991;15(3):6-11, 38-39. 5. DaRosa DA, Zwischenberger JB, Meyerson SL, et al. A theory-based model for teaching and assessing residents in the operating room. J Surg Educ. 2013;70(1):24-30. 6. Polavarapu HV, Kulaylat AN, Sun S, et al. 100 years of surgical education: the past, present, and future. Bull Am Coll Surg. 2013;98(7):22-27.

The solution to the ‘autonomy crisis’ is a reclaiming of Halsted’s apprenticeship model, freshly understood within practices that are able to foster trust in the current context of the overall medical system.

7. Hauer KE, Ten Cate O, Boscardin C, et al. Understanding trust as an essential element of trainee supervision and learning in the workplace. Adv Health Sci Educ Theory Pract. 2014;19(3):435-456. 8. Torres MB, Quinones PM, Sudarshan M. Assessing resident autonomy: what tools are available? Bull Am Coll Surg. 2018;103(8):46-52. 9. Gardner AK, Dunkin BJ. Evaluation of validity evidence for personality, emotional intelligence, and situational judgment tests to identify successful residents. JAMA Surg. 2018;153(5):409-416.

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OPINION

NOVEMBER 2021 / GENERAL SURGERY NEWS

Science for the Real World By B BRUCE RAMSHAW, MD

n December 2003, Gordon Smith and JJill Pell published an article in BMJ title titled “Parachute Use to Prevent Death and Major Trauma Related to Gravitational Challenge: Systemic Review of Randomised Controlled Trials” (2003;327[7429]:1459-1461). It was a tongue-in-cheek demonstration of the lack of common sense sometimes exhibited when groups attempt to apply reductionist science tools, like prospective, randomized controlled trials (PRCTs), to health care. It’s ironic that the study they described, testing the benefits of using a parachute when jumping out of an airplane, is actually a much better application for the use of a PRCT than most of the treatments and tests we have subjected PRCTs in our complex health care system. Such trials are designed to test a hypothesis in an isolated setting. Ideally, all important variables are controlled so that the intervention can be tested against a separate group under similar circumstances. For the parachute study described in the BMJ article, this could be done fairly well: The height and speed of the plane, as well as the landing surface, could all be reasonably well controlled. Other factors, often important in other medical studies, such as DNA variation, body mass index, medications, age, etc., will not likely affect the outcome of this trial. A 65-year-old woman with diabetes on chemotherapy will probably have the same result as a healthy 30-year-old man. Unfortunately, most of our health care treatments are not so simple, and the more complex the problem is, the less useful it is to apply a reductionist scientific tool like a PRCT. The outcome of the parachute study would likely be clear and generalizable: Wearing a parachute when jumping out of a plane would not be wasteful, would be less harmful than jumping out of the plane without a parachute, and would save lives. Treatments and tests in health care are different; they are complex and have different affects on different patient sub-populations. There is another scientific paradigm available for us that can address complex problems in health care and our world. The systems science paradigm accommodates constant change and uncontrollable biological variability. The tools from systems science are about measurement and improvement. Instead of one static hypothesis, there are feedback loops informing a clinical team so that measurements are improved and outcomes that are measured are also improved. In the reductionist scientific paradigm, there is an accepted phenomenon called the placebo effect. It’s like magic and just accepted by reductionist scientists. But systems scientists know there is no such thing as a placebo effect. It is just a lack of measurement. There are factors that are affecting outcomes that have yet to be measured.

Football Injuries To demonstrate a comparison between the reductionist science and systems science paradigms, each paradigm’s research tools could be applied to the problem of National Football League (NFL) injuries. Using the reductionist paradigm, a hypothesis would be defined based on observations of the problem and knowledge of potential solutions. A primary investigator

Through systems science, we can achieve a global health care system where costs go down and outcomes improve over time, and value-based innovation and improvement can become the norm in our society. It’s time to take a bold, courageous—yes, uncomfortable— step into the unknown, uncertainty and, yes, the real world. might identify a newly available helmet technology that potentially provides more stable cushioning. A study could be designed to prove or disprove the hypothesis that the new helmet technology would reduce the incidence and severity of concussions. Because this study method requires human subjects research protection, it must be submitted for review and approval to an institutional review board (IRB). There would also need to be research agreements executed for all NFL teams and consent from all the players. This will take at least one entire season to complete, and so the study would not begin until the next NFL season. Before this second season, the teams would be randomized so that half would use the standard helmets while half would use the new helmet technology. The data would be collected, and the results at the end of the season might show that the new helmet technology has led to a one-third decrease in the incidence and severity of concussions. However, by this time, almost two years after the study was designed, there might be other new helmet technologies available, and there is no way to know whether they are better than the helmet technology tested in this study. On the other hand, applying tools from systems science would not attempt to prove anything; there would be no hypothesis. The goal would be to measure and improve outcomes by identifying and measuring factors that might affect those outcomes. Then, by gaining insight through the use of various analytical tools, attempts could be made to improve the outcomes measured, in this case, all types of injuries. Because there is no attempt to randomize teams or control variables, there is no requirement for an IRB submission. To determine what data should be collected from observing the games, a small team with diverse expertise and perspectives would be assembled. They would propose how best to measure the incidence and severity of all injuries and factors the group thinks are potentially significant and may contribute to the incidence and severity of injuries. The group might suggest measuring the preseason training regimens, the weather during each game, the altitude of the stadium, the type of helmet used by each team, the quarter in which the

injury occurred, the position of the injured player, etc. At the end of the season, an analysis would be performed that generates weighted correlations to determine which factors and combinations of factors are most highly correlated with injuries. Based on this insight, highly correlated factors (potentially modifiable) could be addressed. Changes could be implemented that would likely lessen the incidence and severity of injuries in the next season. For example, the analysis might reveal that three factors were highly correlated with an increase in the incidence and severity of injuries – high and low extremes of temperature and artificial turf. With that knowledge, the artificial turf could be replaced, and heating and cooling technologies could be developed to be used in the next season. Data would then be collected to measure the impact of these improvement attempts. The analysis of this data might demonstrate a decrease in the incidence and severity of all types of injuries. Now what if health care applied the systems science tools to all patients with all types of diseases to measure and improve the value of care provided in our global health care system? How quickly could we achieve a sustainable system where costs are lowered and outcomes improved over time? The kicker in this example is that this systems science project to attempt to improve the incidence and severity of NFL injuries was my seventh grade science fair project in 1975. Over the next 25 years, the NFL replaced artificial turf and developed heating and cooling technologies for games played in extreme temperatures. Through systems science, we can achieve a global health care system where costs go down and outcomes improve over time, and value-based innovation and improvement can become the norm in our society. It’s time to take a bold, courageous—yes, uncomfortable—step into the unknown, uncertainty and, yes, the real world. A newer ■ scientific paradigm is just waiting for us. —Dr. Ramshaw is a general surgeon and data scientist from Knoxville, Tenn., and a managing partner at CQInsights. He is a member of the editorial advisory board of General Surgery News.

IN THE NEWS

GENERAL SURGERY NEWS / NOVEMBER 2021

Surgical Planning in a Crisis: Leaders Share Lessons Learned continued from page 1

the system’s senior director of business operations for radiology and surgery. In March 2020, the health system opened a command center in response to COVID-19 to offer a systemwide approach to coordinate clinical activities and any incident-related communications. A few days later, the surgical services division launched a “surgery camp” to support all COVID-19 operations, consisting of surgeons, project specialists and business intelligence analysts. Mr. Post and his colleagues first realized they needed a way to prioritize surgical cases. While they had never leveled patients by need before, the team introduced and built into the electronic health record a prompt for surgeons to assign patients a priority level of 1 to 4 based on surgeons’ professional assessments, patients’ acuity and projected length of stay; LACE+ index scores and American Society of Anesthesiologists physical status; and preoperative diagnoses. Level 1 cases were considered urgent/emergent and level 4 were those that could be deferred. They began deferring surgeries for level 4 patients, then for level 3 patients, but as time progressed and more safety protocols were put in place, the system was able to bring in many of those patients for surgery. “We took the performing providers’ assessment and level assignment very seriously in our process, and had surgeon leaders reviewing assigned leveling and assuring adherence to our criteria,” Mr. Post said. As the pandemic wore on, by August 2020, the team wanted to better understand patients’ postoperative destination. Some surgeons who previously were uncomfortable with the idea of safe, same-day discharges for procedures soon became followers, to continue to deliver much-needed care to their patients. “Everything we did was of course rooted in what was best and most safe for each patient,” he said. “As of today, we haven’t seen any uptick in clinical outcomes,

‘From flooding, to heating, ventilation and air conditioning failures, to full-blown hurricanes, I think we’re going to have better plans and better response strategies, and quicker response times. I think our patient outcomes and our operational effectiveness will be enhanced as a result.’ —Lee Ausmus such as ED [emergency department] visits or readmissions.” Along with the transition to outpatient care and same-day discharges, the team wanted to better predict their volume of available surgical beds. Some providers were scheduling patients as admissions when they planned to discharge the same day, while others were scheduling patients as outpatient if they required a bed. The team added a post-procedure destination field in the electronic health record to coordinate planned surgical admission volume. It was so helpful— a “game changer for predictive analytics,” Mr. Post said—that the team plans to keep the procedure in place even after the pandemic recedes. Next, by the end of 2020, the team created a deferral dashboard to track all deferred cases. “We treated every deferral like the precious surgical patients that they were, and wanted to assure that when we were able, that their care would be delivered,” he said. The team worked hard to understand where each patient was in the surgical process, either waiting to be scheduled or rescheduled, and whether their procedure was completed or no longer needed because it was completed elsewhere or the patient was no

longer interested. Finally, in April 2021, the team introduced daily deferral calls with representatives from incident command as well as the physician on call, inpatient nursing director, staffing office, bed planning and surgery operations to understand what deferrals, if any, need to be made each day based on the current situation. All together, these methods allowed the team to predict their census for a 1,000-bedplus hospital system within 0.5%. Some Fortune 500 companies like IBM use the “what if ” philosophy to plan for crises, said Lee Ausmus, the administrator of St. Michael’s Ambulatory Surgery Center in Clearwater, Fla. “I think that’s really key to our ability for quick responses to disruptions or unexpected components,” he said. Organizations like the Federal Emergency Management Agency, as well as first responders, are tuned in to vulnerability assessments, Mr. Ausmus said. “As health care leaders, if we can have ongoing readiness, that potentially allows us to conduct the ‘what if ’ with tremendous frequency,” he said. “From flooding, to heating, ventilation and air conditioning failures, to full-blown hurricanes, I think we’re going to have

better plans and better response strategies, and quicker response times. I think our patient outcomes and our operational effectiveness will be enhanced as a result. All health care organizations have been working hard over the last 18 months to be nimble and resilient, Mr. Post said. He has used three common words with his team to summarize: • React. React to the unexpected change and begin to brainstorm countermeasures to fill gaps. • Evolve. Take everything that has been instituted as a response to surgical care in this pandemic and continue to make it better. In a crisis, don’t let perfection get in the way of launching a new process. You can tweak details along the way. • Mature. Through the evolution process, teams can mature to a whole new level. “We capitalize on every opportunity to strive for better, and it really shows,” he said. “That’s how our teams have become incredibly nimble in our situation, and continue to be nimble going forward.” ■

Can Infection Prevention Go Green? By ALISON McCOOK

ndoscopes are dirty—and not just from the standpoint of infection. They’re dirty because of how much their use and reprocessing contribute to hospitals’ waste and carbon footprints. Each endoscopy bed generates nearly 7 pounds (3.09 kg) of waste every day, putting it in the top three of all hospital departments (Lancet Gastroenterol Hepatol 2020;5[7]:636-638). It’s easy to see where the waste comes from: disposable tools and protective gear,

high-throughput caseloads, and use of large amounts of water and disinfectants during reprocessing. Some experts fear the waste problem in endoscopy could worsen, as the field moves more toward disposable products to reduce the risk for infection. The trend toward disposables is creating some tension between infection control and environmental protection, where emphasizing one may put the other at risk, said Nitin K. Ahuja, MD, an assistant professor of clinical medicine

and the co-director of the program in neurogastroenterology and motility at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia. “I’m sympathetic to the thinking of people concerned with infection control, but it’s hard for those of us who are concerned about waste,” Dr. Ahuja said. “Is the disposable duodenoscope just another thing that’s going to end up in the ocean?” continued on page 22

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IN THE NEWS

GENERAL SURGERY NEWS / NOVEMBER 2021

The Scientific Greats: A Series of Drawings By MOISES MENENDEZ, MD, FACS

Javier Arias-Stella, MD (1924-2020) In surgery, the frozen section is one of the most valuable intraoperative tools the surgeon has while working with a surgical pathologist. The relationship between the surgeon and pathologist began at the turn of the 19th century when surgery became a common procedure, and pathology was vital when malignancy was in question. Distinction between benign and malignant tissue is critical, even for permanent sections. Therefore, the work of the surgical pathologist is deeply intertwined with the surgeon, and the pathologist is a vital part of any patient’s care team. And yet, the pathologist may be largely invisible to the patient. By the same token, eponyms are a long-standing tradition in surgery. Eponyms usually involve honoring a prominent physician-scientist who played a major role in the identification of the disease. Under the right circumstances, a disease or condition becomes well known through the name of this individual. In that consideration, a name that epitomized the spirit of hard work, persistence and teamwork was Javier Arias-Stella, MD. Dr. Arias-Stella was a Peruvian pathologist, academic and lecturer who variously served as the minister of Public Health of Peru, minister of Foreign Affairs of Peru and president of the United Nations Security Council. He also traveled as a visiting professor to many universities in the United States. Dr. Arias-Stella found that a reaction previously thought of as a cancer in the endometrium was rather a normal reaction of hormones from placental tissue. His quest started when he finished medical school in Lima, Peru, in 1951. He found two cases in which the pathologic findings could not distinguish the difference between malignant and benign features in an endometrial curettage after hyperstimulation of the endometrium by chorionic hormones, he hypothesized. Consulting with other pathologists and a review of the current literature at that time were unfruitful. Fortunately, Dr. Arias-Stella received a grant to travel to the United States, and spent three years at Memorial Sloan Kettering Cancer Center (MSKCC), in New York City. In that institution, Dr. Fred Stewart was the chief pathologist and considered a world authority in surgical pathology. During his fellowship at this

Infection Prevention continued from page 20

Flying Blind When he first heard about the disposable duodenoscope, Bu’Hussain Hayee, MBBS, PhD, a consultant gastroenterologist at King’s College Hospital London, was very concerned. “A hospital like King’s, where I work, performs 1,000 procedures using duodenoscopes per year. This is a huge demand for disposable equipment, which I just cannot see being realistic,” he said. “I have also yet to hear a convincing argument that this is sustainable at all.” However, there’s no way of knowing whether the alternative—reusable scopes that need reprocessing— has any less environmental impact because of the lack of data comparing the footprint of reusable and disposable tools, Dr. Hayee said. Cleaning one endoscope uses between 90 and 100 L (22 gallons) of water, filtered using reverse osmosis to ensure purity, which consumes

institution, Dr. Arias-Stella gathered more information about this unknown phenomenon. Dr. Stewart himself could not make a diagnosis, and so he encouraged him to pursue his work for an answer. Dr. Arias-Stella was facing a pathologic change not yet described. In August 1954, after extensive research and working after hours, Dr. Arias-Stella published a paper in which he described atypical endometrial changes associated with the presence of chorionic tissue. In 1956, two papers described the atypical endometrium associated with hormonal hypersecretion, and one paper, from Denmark, called these changes the Arias-Stella phenomenon for the first time. Years later while working as the chairman and a professor of pathology at the Universidad Peruana Cayetano Heredia in Lima, he did experimental studies in animals that proved his initial hypothesis. The distinction of the Arias-Stella reaction from clear cell carcinoma of the endometrium is usually straightforward; however, this differential diagnosis can be difficult when the Arias-Stella reaction occurs outside the setting of pregnancy or in older patients. The fascinating story is the recognition of Dr. AriasStella for his persistent work in distinguishing this phenomenon that carries his name. Surgical pathology is now enriched with the addition of another eponym: the Arias-Stella reaction. In 1991, he received the Fred Stewart Award at MSKCC. Each year, this award honors a pathologist who has made outstanding contributions in advancing our knowledge of human cancer. Later in his life, Dr. Arias-Stella became involved in researching how altitude changes in the Andes affected anatomy and histology in human beings, specifically men. Dr. Arias-Stella’s research showed that “hypoxiainduced thickening of the pulmonary arteriolar walls” was the main cause for hypertension. Dr. Arias-Stella died on Feb. 25, 2020, in Lima. His son and grandson followed his path, as they currently ■ practice pathology medicine. —Dr. Menendez is a general surgeon and self-taught portrait artist in Magnolia, Ark. Since 2012, he has completed a series of portraits of historical figures, particularly well-known physicians and surgeons.

a lot of energy, he said. “Obviously, single-use scopes do not need water to reprocess them, so there is that. But we can only incinerate used scopes; they can’t be recycled, so the impact is high.” The bottom line, Dr. Ahuja said, is there needs to be more research about the environmental impact of the waste associated with endoscopy: disposable materials such as packaging, single-use instruments and personal protective equipment versus the water, detergents and decontamination used during reprocessing of reusable instruments. “Certainly, more could be done to understand what percentage of resources in any given endoscopy is contributing to the global carbon footprint.”

Ideas for Reducing Waste Dr. Ahuja recommends that providers think deliberately about their use of accessories during procedures, such as using only one for a small and large polyp in the same colon, so there are fewer things to throw away or

Javier Arias-Stella, MD Work was done on gray paper, 12×16, using charcoal pencil and white chalk 2020; Artist: Moises Menendez, MD, FACS

Sources Arias-Stella J. Atypical endometrial changes associated with the presence of chorionic tissue. AMA Arch Pathol. 1954;58:112-128. Elleson LH, Young RH. A new historical feature for the journal: eponyms and entities. Int J Gynecol Pathol. 2015;34(4):313-313. Fienberg R, Lloyd HE. The Arias-Stella reaction in early normal pregnancy—an involutional phenomenon: the ovary-placenta changeover as a possible cause. Human Pathol. 1974;5(2):183-190. Luks S, Simon RA, Lawrence WD. Arias-Stella reaction of the cervix: the enduring diagnostic challenge. Am J Case Rep. 2012;13:271-275. Rosai J, Young RH. Eponyms and entities. Javier Arias-Stella and his famous reaction. Int J Gynecol Pathol. 2015;34(4):314-322.

reprocess. Dr. Hayee’s practice has installed energy-efficient light bulbs and infrared faucets to control water flow in sinks and started emailing reports and digitizing information, instead of using paper. They also are recycling all noncontaminated waste, and using thermal compaction machines to deal with personal protective equipment and aprons that otherwise would be incinerated, creating an inert plastic “flock” that can be sold to plastic manufacturers for reuse. The biggest step providers can take is to simply cut back on unnecessary procedures, Dr. Ahuja said—a particular problem for practices in which doctors are paid according to the number of procedures they perform. “Substantive change with regard to the carbon footprint of medicine at large would probably entail moving away from productivity as a primary incentive and toward outcomes instead. We would need to include environmental outcomes as part of the shared set of things we all care about as a professional community.” ■

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