December 2021 Print Issue

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

December 2021 • Volume 48 • Number 12

Will CODA Trial Results Change Surgeons’ Approach to Appendicitis?

Study Investigators Suggest Antibiotic Therapy Should Be Part of DecisionMaking Process With Patients

Same-Day Discharge for Lap Colectomy Possible For Selected Patients Study Employs Remote Follow-up and Gives Patients Choice of Discharge or Admission

By CHRISTINA FRANGOU

By CHRISTINA FRANGOU

I

n the largest study of surgery versus antibiotics for appendicitis, almost half of patients who received a single course of antibiotics did not require an appendectomy by four years.

Investigators said the results illustrate a need for surgeons and emergency physicians to change the way they talk to patients about treatment options for appendicitis.

They want patients to be given a choice between surgery and antibiotics, following an individualized discussion of the risks and benefits, and patients’ goals and concerns.

“Surgeons have strong opinions about what is the right amount of

S

ome patients can be safely discharged home on the same day as their laparoscopic colectomy if they are followed remotely by a health care team, according to a study presented at the 2021 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons. Some surgeons and patients, however, say they worry about patients being rushed home before they feel ready.

In a study carried out at two university-affiliated colorectal referral institutions, 79 out of 105 patients, or 75%, were successfully discharged on the day of their surgery. They were eligible for same-day discharge, or SDD, if they had

Continued on page 20

Normothermic Machine Perfusion a ‘Game-Changer’ For Liver Transplants

Continued on page 16

OPINION

OPINION

The Surgical Mindset

Words, Words, Words

Increasing Interest in Mental Skills for Training, Performance Excellence

The Essence of Words

By KATE O’ROURKE

By HENRY BUCHWALD, MD, PhD

I

n a new study, the use of normothermic machine perfusion allowed the transplantation of roughly 70% of livers that were deemed unfit for transplant. The findings, presented at the joint annual meeting of the Central Surgical Association/ Midwest Surgical Association (abstract 20), come from a study of 21 humans livers designated to be discarded.

According to lead study author Cristiano Quintini, MD, Director of the Liver Transplant Program at the Cleveland Clinic in Ohio, this is the first clinical trial in the United States to evaluate normothermic machine perfusion (NMP) for use on discarded livers with the goal of liver transplantation. “There continues to be a huge discrepancy in the organ supply and demand. There are still 15% to 20% of patients that Continued on page 14

IN THE NEWS

4 First Look: The American College of Surgeons Clinical Congress NE W TECHNOLOG Y

8 Device Uses Mechanotransduction

To Treat Small Bowel Syndrome X

IN THE NEWS

19 Drivers of Readmission After Hernia Repair facebook.com/generalsurgerynews

@gensurgnews

By MICHAEL J. ASKEN, PhD, ELIZABETH MORGAN, MLS, and R. SCOTT OWENS, MD

T

he importance of mindset, and the mental skills that comprise it, has been a staple of training in high-expectation, high-risk occupations for some time now. Often evolving from sports psychology, the military, police and firefighters understand the potential benefit of mental skills to elite performance in high-stress situations. This recognition is also suggested to be important in training for medical emergencies and surgery.1-3 Reading this area of the surgical literature Continued on page 8

Polonius: What do you read, my lord? d?

Hamlet: Words, words, words.

—William Shakespeare, Hamlet, Act II, Scene II: 191-194

B

ecause Hamlet wishes to feign madness or simply to disguise what he is reading from Polonius, he implies that whatever the words, they don’t matter. Of all people, however, Shakespeare used words for their explicit and multiple meanings, knowing that specific connotations could determine courses of action. In medical practice, our choice of words can be most critical. They can convey hope or Continued on page 24

FASTER ACTING† Superior INR reduction at 30 minutes after end of infusion vs plasma

FASTER ADMINISTRATION, LOWER VOLUME • Mean infusion time is under 25 minutes • ~85% less volume vs plasma

SUSTAINED INR REDUCTION‡ Statistically significant INR reduction sustained ≤1.3 for up to 8 or 12 hours vs plasma

OPINION

DECEMBER 2021 / GENERAL SURGERY NEWS

Templative Operative Reporting: A Caveat

By FREDERICK L. GREENE, MD

P

robably the earliest recorded “operative report” was that of Paul of Aegina in the 7th century a.d. describing his method of performing a tonsillectomy:

“Wherefore, having seated the patient in the sunlight, and directed him to open his mouth, one assistant holds his head and another presses down the tongue with a tongue depressor. We take a hook and perforate the tonsil with it and drag it

outwards as much as we can without dragging the capsule out along with it, and then we cut it off by the root with the tonsillotome suited to that hand, for there are two such instruments having opposite curvatures. After the excision of one we may operate on the other in the same way.”

From that description, the “art” of archiving operative events evolved significantly over many centuries. Only six years after its founding, the American College of Surgeons proposed a template for the written description of an operative event and

Paul of Aegina, a 7th-century Byzantine physician, is often considered the “Father of Early Medical Writing.”

Source: Wikimedia Commons

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Dose* of Kcentra (units† of Factor IX) / kg body weight

These highlights do not include all the information needed to use Kcentra safely and effectively. See full prescribing information for Kcentra.

WARNING: ARTERIAL AND VENOUS THROMBOEMBOLIC COMPLICATIONS Patients being treated with Vitamin K antagonists (VKA) therapy have underlying disease states that predispose them to thromboembolic events. Potential benefits of reversing VKA should be weighed against the potential risks of thromboembolic events, especially in patients with the history of a thromboembolic event. Resumption of anticoagulation should be carefully considered as soon as the risk of thromboembolic events outweighs the risk of acute bleeding.

• Both fatal and non-fatal arterial and venous thromboembolic complications have been reported with Kcentra in clinical trials and post marketing surveillance. Monitor patients receiving Kcentra for signs and symptoms of thromboembolic events.

• Kcentra was not studied in subjects who had a thromboembolic event, myocardial infarction, disseminated intravascular coagulation, cerebral vascular accident, transient ischemic attack, unstable angina pectoris, or severe peripheral vascular disease within the prior 3 months. Kcentra may not be suitable in patients with thromboembolic events in the prior 3 months.

------------------------------------INDICATIONS AND USAGE---------------------------------Kcentra, Prothrombin Complex Concentrate (Human), is a blood coagulation factor replacement product indicated for the urgent reversal of acquired coagulation factor deficiency induced by Vitamin K antagonist (VKA, e.g., warfarin) therapy in adult patients with: • acute major bleeding or • need for an urgent surgery/invasive procedure.

-----------------------------DOSAGE AND ADMINISTRATION--------------------------------For intravenous use after reconstitution only.

• Kcentra dosing should be individualized based on the patient’s baseline International Normalized Ratio (INR) value, and body weight.

• Administer Vitamin K concurrently to patients receiving Kcentra to maintain factor levels once the effects of Kcentra have diminished.

• The safety and effectiveness of repeat dosing have not been established and it is not recommended.

Maximum Factor IX) *

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Units refer to International Units.

Dose is based on body weight up to but not exceeding 100 kg. For patients weighing more than 100 kg, maximum dose should not be exceeded.

---------------------------------DOSAGE FORMS AND STRENGTHS-------------------------• Kcentra is available as a white or slightly colored lyophilized concentrate in a single-use vial containing coagulation Factors II, VII, IX and X, and antithrombotic Proteins C and S. --------------------------------------CONTRAINDICATIONS -----------------------------------Kcentra is contraindicated in patients with: • Known anaphylactic or severe systemic reactions to Kcentra or any components in Kcentra including heparin, Factors II, VII, IX, X, Proteins C and S, Antithrombin III and human albumin.

• Disseminated intravascular coagulation.

• Known heparin-induced thrombocytopenia. Kcentra contains heparin.

----------------------------------WARNINGS AND PRECAUTIONS---------------------------• Hypersensitivity reactions may occur. If necessary, discontinue administration and institute appropriate treatment.

• Arterial and venous thromboembolic complications have been reported in patients receiving Kcentra. Monitor patients receiving Kcentra for signs and symptoms of thromboembolic events. Kcentra was not studied in subjects who had a thrombotic or thromboembolic (TE) event within the prior 3 months. Kcentra may not be suitable in patients with thromboembolic events in the prior 3 months.

• Kcentra is made from human blood and may carry a risk of transmitting infectious agents, e.g., viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent, and theoretically, the Creutzfeldt-Jakob disease (CJD) agent.

-----------------------------------ADVERSE REACTIONS---------------------------------------• The most common adverse reactions (ARs) (frequency * 2.8%) observed in subjects receiving Kcentra were headache, nausea/vomiting, hypotension, and anemia. (6) • The most serious ARs were thromboembolic events including stroke, pulmonary embolism, and deep vein thrombosis.

To report SUSPECTED ADVERSE REACTIONS, contact CSL Behring at 1-866-9156958 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Revised: October 2018

published it in the January 1919 ACS Bulletin. Some years later, the mostly written format transformed into recorded narrative renderings as dictating equipment and transcription services in hospitals evolved. We all grew up using some form of narrative description, although there was no standardized approach to capture the important elements of the operation. I am also sure that most of us received little in the way of training and direction as to the correct formatting of these notes. It was assumed that most surgical residents who were allowed to dictate after their operative experiences were born with some innate concept of how an operation should be chronicled!

Over the last 10 to 15 years, the notion of the “synoptic” operative template or checklist approach to operative recordings has gained traction, just as this form of reporting endoscopic and physical examinations has gained acceptance. The word synopsis is derived from two ancient Greek words: sún (“with or whole”) and ópsis (“view”). If done correctly, the synoptic approach gives an abbreviated, but overall view of an activity, whether it be an endoscopic event, physical exam or operative report. Multiple articles in the peer-reviewed literature have supported the notion that these templative approaches may actually capture the important elements of an operation better than the traditional narrative formats and, perhaps more importantly, allow for more complete billing!

Recommendations for including use of operative templates especially in resident continued on page 6

3

4

IN THE NEWS

GENERAL SURGERY NEWS / DECEMBER 2021

FIRST LOOK All articles by ETHAN COVEY

Cutting Hospital Stay May Increase Complications

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Focusing on shortening patients’ length of stay (LOS) following surgery may result in increased rates of postdischarge complications, according to a new study.

“LOS has been used as a meaningful outcomes measure and as a potential target for quality improvement,” said Roujia D. Li, MD, of Northwestern University Surgical Outcomes and Quality Improvement Center, in Evanston, Ill. “One way is by introducing accelerated pathways to decrease LOS, such as an enhanced recovery protocol.”

However, Dr. Roujia questioned whether a push toward shorter LOS has resulted in shifting complications to the post-discharge setting.

To answer this question, Dr. Roujia and her colleagues set out to characterize changes in LOS and post-discharge complications over time, and to evaluate risk factors associated with post-discharge complications.

Using data from the ACS National Surgical Quality Improvement Program (or NSQIP) Procedure-Targeted database, patients were identified who underwent colorectal, esophageal, hepato-pancreatico-biliary,

gynecologic and urologic surgery from 2014 to 2019.

Among a total of 538,712 patients, median LOS decreased from three days in 2014 to two days in 2019.

Additionally, overall postoperative complications, readmission rates, median LOS and mortality rates all decreased with time.

In contrast, while rates of postoperative complications often fell, those for post-discharge complications did not. The proportion of postdischarge complications—including surgical site infection/wound dehiscence, infections such as pneumonia, urinary tract infection, sepsis, cardiovascular complications and venous thromboembolism— increased from 44.6% in 2014 to 56.5% during 2019.

Patient characteristics associated with post-discharge complications included age, race/ethnicity, American Society of Anesthesiologists physical status class, functional status, body mass index and other comorbidities.

“It is crucial to develop a patient monitoring program to focus on the early identification and management of post-discharge complications,” Dr. Roujia said.

Method of Communicating Risk Affects Patient Decision Making The way in which information about risks of treatments is communicated to patients can have a significant 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.

IP) ha-

014 tes,

Senior Medical Adviser

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ion

Frederick L. Greene, MD Charlotte, NC

The American College of Surgeons Clinical Congress

Peter K. Kim, MD Bronx, NY

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effect on their perceptions and decision making.

“Surgeons must frequently communicate the probability of various treatment outcomes, complications and chances of cure to their patients to help them make health care decisions,” said Joshua Eli Rosen, MD, of the Surgical Outcomes Research Center at the University of Washington, in Seattle. “Prior studies have shown that how probability information is communicated can impact its interpretation and ultimately decisions that are made with it.”

Yet, despite these concerns, no standard practice exists for how surgeons should communicate such information to their patients.

To further study the effect of different communication approaches, an online survey was conducted that queried respondents on a set of complications associated with surgical and antibiotic treatment of appendicitis.

Risk information was presented either verbally (i.e., “uncommon”), as quantitative point estimates (i.e., 3%), or via quantitative ranges (i.e., 1%-5%). Next, participants were asked to estimate the likelihood of a complication occurring for an average person with appendicitis.

A total of 296 respondents completed the survey, with a mean age of 37 years.

Verbal risk communications were found to result in significantly higher ranges of risk estimates for each surveyed complication, and were found to consistently lead to overestimation of risk. continued on page 6

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IN THE NEWS

GENERAL SURGERY NEWS / DECEMBER 2021

ACS Clinical Congress continued from page 4

“There are many reasons why a surgeon may want to use a verbal descriptor of risk,” Dr. Rosen said. These may include convenience and fluidity of communication, lack of precise numerical estimates, or hesitation to communicate data with greater certainty than they feel is warranted by existing data.

“However,” Dr. Rosen added, “we must recognize that by addressing these concerns with verbal descriptors alone, we are simply passing that uncertainty and variability to the patient in an uncontrollable way that may result in suboptimal decision making.”

Although verbal descriptors of probability resulted in greatly variable and inaccurate interpretations of risk, participants were able to accurately interpret numerical point estimates and ranges.

“This is particularly notable given that many surgeons may be concerned that too much numerical risk information may overwhelm patients,” Dr. Rosen said. “These data may be used to inform how surgeons communicate probability of risks and benefits to their patients.”

Receipts Help Surgical Staff Cut Costs Providing surgical staff with case cost receipts, which detail expenditures for procedures, can lead to sustainable cost-saving procedures.

“Health care costs in the U.S. continue to escalate at a rate outpacing general inflation, and operating room (OR) costs comprise nearly 25% of all inpatient health care costs,” said Bradley S. Kushner, MD, of the Department of Surgery at Washington University in St. Louis, citing data from a Peterson-KFF analysis of Organisation for Economic Co-operation and Development and National Health Expenditure data.

“By directly controlling OR supplies utilized, surgeons play a key role in reducing health care expenditure,” Dr. Kushner added.

Starting in the spring of 2020, Washington University in St. Louis began providing surgical faculty with case supply receipts, delivered immediately through the electronic health record following each surgical case. The receipts detailed total procedure costs, itemized breakdowns of supplies used during the surgery, and provided a comparison of overall costs with institutional peers.

Dr. Kushner and his colleagues conducted a survey to evaluate perceptions of the cost receipts and their effectiveness in enacting individual practice and/or cultural change.

A total of 119 individuals completed the survey.

Response to the case receipts was very strong, with 62% very/extremely interested in the practice, and 74.5% commenting that they reviewed the receipts daily. In addition, 87% noted a feeling of responsibility for lowering costs. Over half reported that viewing the receipts resulted in altering their surgical technique due to cost feedback, 60% changed surgical supplies used, and 80% of the general surgery faculty reported now being aware of how to lower OR costs.

“Next steps include evaluating whether this perceived cultural change has led to actual decreases in OR costs,” Dr. Kushner said.

Is Care From Multisite Surgeons Lacking?

Patients who undergo procedures performed by surgeons who work at multiple sites (MSS) have higher 30-day readmission rates than patients receiving care from single-site surgeons (SSS).

“Integration of hospitals into systems raises concerns about the safety of surgeons operating at multiple sites,” said Ava Ferguson Bryan, MD, a general surgery resident at the University of Chicago, an MPH candidate at the Harvard T.H. Chan School of Public Health, in Boston, and an incoming ACS-MacLean Center Surgical Ethics Fellow at the University of Chicago.

Previous research has shown that surgeons who operate at single and multiple sites have equivalent mortality outcomes, but questions remain about the continuity of care provided by MSS. “The literature currently lacks evaluation of SSS versus MSS surgeons on quality metrics other than mortality,” Dr. Bryan added.

Dr. Bryan and her colleagues analyzed Medicare data from patients who received surgery for hip/knee replacement, prostatectomy, colectomy, pulmonary lobectomy, abdominal aortic aneurysm repair and coronary artery bypass surgery via either SSS or MSS during 2011 to 2016.

Overall, MSS had significantly higher rates of 30-day readmission than SSS (8.78% vs. 8.66%; P<0.01), and the gap in performance of MSS versus SSS widened over time.

When the data were stratified by system status, MSS performed more poorly in-system and not in-system (8.81% vs. 8.74%; P=0.09 and 9.26% vs. 9.06% P=0.05).

While the differences in rates were statistically significant, Dr. Bryan noted that it was unknown whether there were differences clinically, and there may not be major harm related to surgeons operating at multiple sites.

However, the trends may reflect fragmentation of care across sites.

“As health systems continue to expand and consolidate, we need to continue to monitor these trends in surgical quality to ensure consistency of care, whether the operation is performed by a SSS or MSS,” Dr. Bryan said.

Mass Shootings Highest in Areas With Low Levels of Trauma Care Mass shootings occur most often in areas of the United States that have generally low access to trauma centers, resulting in a significant disparity in how communities can react to these events.

“Despite increasing gun violence and mass shooting incidence, advances in pre-hospital care and trauma systems have led to a decline in mortality,” said Kaylin Beiter, PhD, a third-year medical student at Louisiana State University School of Medicine, in Baton Rouge. “However, access to this lifesaving care may not be universal.”

To study this correlation, Dr. Beiter and her colleagues compared the locations of Level 1 and Level 2 trauma centers, extracted from the online registries maintained by the ACS and the Trauma Centers of America, with locations of mass shootings taken from the Gun Violence Archive. Mass shootings were defined as four or more people shot at a single event.

A total of 564 trauma centers and 1,672 mass shooting incidents were included in the analysis.

Overall, states with the greatest discordance between the number of mass shooting events and trauma care centers were generally clustered in the southeastern United States. Median household income was not significantly correlated with the number of trauma centers or the number of mass shootings. In contrast, it was significantly correlated with the ratio of mass shootings to trauma centers.

“These states where there was a high discrepancy in burden of mass shootings relative to need were also the states where there was a really high percentage of the population below the federal poverty limit,” Dr. Beiter said.

“Poverty remains a factor that must be considered when examining these systemic disparities, and overall there may be a need for improvement in hospital infrastructure in states and communities with high levels of poverty, rather than simply allocating resources to communities with obvious high levels of mass shootings,” Dr. Beiter noted.

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Operative Reporting continued from page 3

training also have sent a clear message to all residency training directors.

I am particularly delighted that the new 2020 Standards of the ACS Commission on Cancer introduced the concept of reporting essential elements of a cancer operation using a synoptic template. These standards will be highlighted outside of the traditional narrative or operative templates used. By means of this approach, important components of oncologic procedures will be mandated, and recognition of these standards will be made easier at future accreditation site visits. There are two important

barriers to using information: 1) a significant amount of information is locked in text format, making it difficult to pull from the records; and 2) the textual information in the record is variable in content, accuracy and quality. These two barriers limit the usefulness of information, which becomes particularly evident when attempting to measure and track quality. An ideal future state involves surgeons having an efficient mechanism to document relevant information that allows for automatic extraction for use in front-line clinical care tools and for quality and research purposes.

My main concern, however, as one trained to report using a narrative approach, is that we may find it more

Multiple articles in the peerreviewed literature have supported the notion that these templative approaches may actually capture the important elements of an operation better than the traditional narrative formats and, perhaps more importantly, allow for more complete billing!

difficult to personalize our operative descriptions in the future as we migrate to complete templative reporting. Will the templates allow for archiving all important elements of an operation? Will a template permit describing any unforeseen issues that arise? Will the template give opportunity to describe arcane anatomic variants? We must always realize that not only is the operative record the best source of cataloging and subsequently reviewing an operative event; it is also a formidable medicolegal document.

Will a templative approach satisfy that role? Stay tuned!

■ —Dr. Greene is the senior medical advisor for General Surgery News.

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OPINION

GENERAL SURGERY NEWS / DECEMBER 2021

Mental Skills for Training, Performance Excellence in Surgery continued from page 1

gives a subjective impression of related growth in the number of articles on the value of these skills for the training and practice of surgery. More than 20 years ago, surgeons agreed that mental skills are a large component of performance excellence.4 More recently, this perspective has been reinforced in the surgical literature for performance and procedural preparation.5,6 Mental imagery may be the most frequently cited technique, but critical skills such as emotion regulation, negative thought stopping, affirmations, self-talk, breathing techniques and others are also described, as are individual, group and comprehensive curricular approaches.7,8 A perceived increasing emphasis on training mindset and mental skills suggests an important trend, but this is subjective. In an attempt to objectively document the growing surgical focus on the value of training and use of mental skills through the frequency of relevant publications, we surveyed the surgical literature from 1990 to May 2021 for articles published on this topic.

A search of the literature was conducted in the databases PubMed, Web of Science and Google Scholar. Two thousand articles were retrieved and assessed for specific relevance. Articles on non-surgeon populations were discarded. Furthermore, articles on general aspects of resilience and wellness in surgeons (although important and impacting performance) were also excluded to focus on psychological skills and concepts directly related to enhancing surgical performance.

Our findings are shown in the Figure, which displays the number of publications on mental skills in surgery on a five-year basis from 1990 to 2019.

As can be seen in this figure, there has been steadily increasing growth, with a positively accelerating trend in the past decade, of publications related to mental skills for training and performance in surgery.

Our analysis is limited to articles that focused on psychological performance concepts and skills such as mental training, mental practice, mental skills and mental toughness. This approach was adopted to avoid potential contamination

80 70 60 Number of Articles

8

50

50 40

33 30 20 10 0

7 1

2

3

1990-1994

1995-1999

2000-2004

2005-2009

2010-2014

2015-2019

5-Year Period

Figure. Number of publications on mental performance skills in surgery.

by other similar terms in the surgical literature like “cognitive training” and “nontechnical skills,” which often do refer to psychological skills, although not necessarily or exclusively. However, if articles on these terms are included, the same pattern emerges, just with higher absolute numbers.

A systematic review of the impact of mental practice on surgical performance described benefits from the use of this technique.9 Of note, despite using a different search strategy and focus resulting in higher absolute numbers, an incidental finding of a similar pattern of increasing frequency of publications in this area was reported.

Novel Device Uses Mechanotransduction To Treat Small Bowel Syndrome

By MONICA J. SMITH

A

pplying the concept of mechanotransduction to the small intestine in animal models, researchers have had success in regenerating tissue. They expect to soon begin human trials to treat patients with short bowel syndrome, a rare but debilitating disease with few, usually less than satisfactory, treatment options.

“The basic concept is similar to distraction osteogenesis, which orthopedic surgeons have used for years, applying distraction force to broken bone that will grow up to a millimeter a day,” said Andre Bessette, the CEO and a co-founder of Eclipse Regenesis, Inc., a medical device company in Menlo Park, Calif.

From that point, around 2005, Dr. Dunn devoted himself to documenting his research and proving the science behind it—“the basic science at the cellular level, the stimulation of growth factors, what type of tissue is created: Is it scar tissue? Is it functional? Will it disappear? What he found was that this procedure produces healthy, viable small intestine tissue,” Mr. Bessette said.

How It Works

To regenerate small-bowel tissue, a surgeon inserts the device, which looks like a small, compressed coil, inside the small intestine and secures both ends with plication sutures applied to the outside of the intestine. Over two to three weeks, the device slowly expands to its uncomThis 20-mm diameter device is intended for older and larger pediatric How It Started pressed state, stimulating new Seeing colleagues in orthope- patients; younger patients would tissue growth—ultimately two dic medicine successfully stimulate receive a 10-mm diameter device. to three times the segment’s bone growth, James Dunn, MD, original length, about 4 cm.

PhD, wondered if that concept could be applied to the Once this process is complete, the chromic sutures unmet need he saw in his pediatric patients with short dissolve over about a month, allowing the device to pass bowel syndrome (SBS). through the body to be excreted.

“He literally started off with a screw-and-nut conPreclinical studies have shown successful lengthencept in a rat model and slowly put some distraction on ing (tissue growth), no perforations and no obstructhis intestinal tissue and—lo and behold—it grew new tions, and the newly formed tissue looks and acts like intestinal tissue,” Mr. Bessette said. normal intestinal tissue with regard to metabolic uptake

and contractile function. (These studies are available on Eclipse’s website at www.eclipseregenesis.com/ publications.)

“Patients with SBS have lost more than 50% of their small intestine, so they’ll need more than one device applied or more than one procedure,” Mr. Bessette said.

Treatment will vary depending on a patient’s starting point (how much small intestine they have), and their end point (how much new intestine they need) to achieve the clinical benefits of reducing total parenteral nutrition dependence and being able to absorb nutrients from the food they eat.

Michael R. Harrison, MD, the director emeritus of the Fetal Treatment Center at the University of California, San Francisco, is not involved in Dr. Dunn’s research, but has been following the company’s progress for the past decade.

“I like the people, and I really like the technology— the idea of mechanotransduction, that you can push on something a little bit over a long period of time and change biology. We’ve been using this principle for a long time,” Dr. Harrison said.

Eclipse: On the Horizon One of the newest companies to join the acclaimed Fogarty Innovation Accelerator Program, Eclipse Regenesis recently was awarded a National Institutes of Health Small Business Innovation Fast Track grant of $1.7 million to help promote research on the Eclipse XL1 System.

“The Fast Track grant will allow us to fund the final animal studies we need to do for our FDA submission,

NEW TECHNOLOGY

DECEMBER 2021 / GENERAL SURGERY NEWS

Our results suggest there is indeed a growing interest in the value of mental skills for surgical trainees and practitioners. These skills are not a verbal, passive, reflective, existential experience, but active outcome- and performancefocused, empirically driven skills. Applications include both general and specific psychological skills and general and specific surgical techniques.7,10 Given the innovative integration of mental skills training in other disciplines and the encouraging impact of mental skills and such training on surgical performance (and careers), this increasing interest and emphasis is welcome and should be disseminated and encouraged in surgical education and training.9,11 ■

References 1. Asken M, Kochert E, Wyatt A, et al.

Calm amidst storm: psychological skills and mindset training for maximizing performance in medical emergencies.

Resuscitation. 2020;146:32-33.

2. Asken M. Code calm: mental toughness skills for medical emergencies. 2021.

Amazon Kindle.

3. Deshauer S, McQueen S, Mobilio M, et al.

Mental skills in surgery: lessons learned from virtuosos, Olympians and Navy

which will lead to phase 2 funding for the first in-human clinical trials,” Mr. Bessette said.

He and his colleagues expect to start these trials in the first half of 2022, and they have identified two primary investigator sites: Boston Children’s Hospital and Cincinnati Children’s Hospital. Although they intend to eventually extend the procedure to adults, they plan to start with pediatric patients.

“That’s where we see the greatest need and also the greatest benefit. The longer you’re on TPN [total parenteral nutrition], the greater the risk of sepsis from a central-line infection and the higher the risk for liver failure. Getting these young patients off TPN sooner in life will only benefit them,” Mr. Bessette noted.

“We’re excited to be getting close to performing the first-in-human procedure, and we hope to eventually be able to perform this procedure completely endoscopically,” he said.

■ Column Editor: Michael A. Goldfarb, MD, clinical professor of surgery, Rutgers University Medical School, in New Brunswick, NJ.

Seals. Ann Surg. 2021;274(1):195-198.

4. McDonald J, Orlick T, Letts M. Excellence in surgery: psychological considerations. Contemporary Thought in Performance Enhancement. 1994;3:13-32.

and proposed next steps. J Laparoendosc Adv Surg Tech A. 2017;27(5):459-469.

laparoscopic surgery. SurgEndosc.

2010;24(1):179-187.

8. Asken M, Yang H. SIM: The surgeon’s imagery mindset, performance enhancing mental imagery and the optimization of surgical skill. 2021. Amazon Kindle.

11. Anton N, Lebares C, Karapidis T, et al. Mastering stress: mental skills and emotional regulation for surgical performance and life. J Surg Res. 2021;263:A1-A12.

6. Rosenthal R, Rosales A, Menzo E, et al.

Mental Conditioning to Perform Common Operations in General Surgery Training.

Springer; 2020.

9. Snelgrove H, Gabbott B. Critical analysis of evidence about the impacts on surgical teams of “mental practice” in systematic reviews: a systematic rapid evidence assessment. BMC Med Educ.

2020;20:221.

7. Anton N, Bean EA, Hammonds SC, et al. Application of mental skills training in surgery: a review of its effectiveness

10. Arora S, Aggarwal R, Sevdalis N, et al.

Development and validation of mental practice as a training strategy for

—Dr. Asken is the director at Provider Well-Being, UPMC in Central Pa., Harrisburg, Pa. Ms. Morgan is a medical librarian, UPMC in Central Pa., Harrisburg, Pa. Dr. Owens is the chair of the Department of Surgery, UPMC in Central Pa., Harrisburg, Pa.

5. Asken M, Yang H, Aboushi R, et al.

Prepping for surgery: surgeon prepare thyself. Am J Surg. 2020;221(4):775-776.

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GENERAL SURGERY NEWS / DECEMBER 2021

Gastrointestinal Stromal Tumors Associated With Neurofibromatosis Type 1 Syndrome QUESTION for Armando Rosales, MD From Elliot Toy, MD, PGY-1, Advent Health Orlando, and Lisandro Montorfano, MD, PGY-4, Cleveland Clinic Florida, in Weston

Welcome to the December issue of The Surgeons’ Lounge. In this issue, Armando Rosales, MD, a staff surgeon specializing in minimally invasive foregut and hepatobiliary surgery at AdventHealth, in Orlando, Fla., discusses gastrointestinal stromal tumors associated with neurofibromatosis type 1 syndrome.

This issue also looks at the history of the STOP the Bleed campaign.

We look forward to our readers’ questions, comments and interesting cases to present.

Sincerely, Samuel Szomstein, MD, FACS ACS Editor, The Surgeons’ Lounge nge Szomsts@ccf.org

We present the case of a 75-year-old woman with no known history of malignancy who presented with upper abdominal pain and iron deficiency anemia. CT of the abdomen was suggestive of duodenal wall thickening. The patient subsequently underwent an upper endoscopy of the gastrointestinal tract and endoscopic ultrasound that revealed a duodenal ulcer and an underlying 16- by 9-mm hypoechoic oval mass with well-defined borders that involved all the wall layers of the second portion of the duodenum.

Fine needle aspiration (FNA) and an on-site rapid evaluation of the duodenal mass revealed a welldifferentiated neuroendocrine tumor (NET). The permanent cell block revealed nests and clusters of relatively uniform epithelial cells with salt-and-pepper nuclei, eosinophilic cytoplasm, and absence of cytologic atypia. The epithelial cells were positive for synaptophysin, which supported the diagnosis of a well-differentiated NET. Unexpectedly, the cell block also revealed rare fragments of spindle cells set in a collagenous background, which displayed immunopositivity for CD117 and DOG-1, thus supporting the diagnosis of a gastrointestinal stromal tumor (GIST). Because of the unusual cytologic findings in the FNA, the prospect of two separate tumors—NET and GIST—was raised. The patient was subsequently referred to our pancreaticobiliary surgeons for resection of the duodenal mass. Upon further clinical workup, it was found that the patient had a history of neurofibromatosis type 1 (NF1) syndrome.

Clinical examination revealed several cutaneous neurofibromas. Preoperative evaluation with abdominopelvic CT of the pancreas revealed a 2.4-cm ovoid arterially enhancing mass in the proximal third portion of the duodenum with mild to moderate wall thickening (Figure 1). In addition, a 0.7-cm arterially enhancing ovoid lesion was noted. The patient subsequently underwent a pancreaticoduodenectomy, which demonstrated a 2.5- by 2.5- by 2.5-cm solid mass in the duodenum that grossly appeared to consist of two adjacent tumors (Figure 2).

Histologic examination showed two separate neoplasms in close proximity. The superficial tumor infiltrated the duodenal wall and was positive for cytokeratin AE1/AE3 and somatostatin, supporting the diagnosis of a somatostatin-producing, well-differentiated NET. The deeper located tumor was a spindle cell neoplasm that was positive for DOG-1 and CD117, consistent with a GIST. The combination of such cytologic findings has almost exclusively occurred in patients with NF1 syndrome. Hence, the coexistence of a duodenal/periampullary NET and GIST is deemed virtually pathognomonic for NF1 syndrome.

In summary, the current case documents concomitant well-differentiated NET cells and GIST diagnosed in the same FNA from a composite tumor of the periampullary duodenum.

• We know NF1, also known as von Recklinghausen’s disease, is an uncommon genetic disorder associated with the development of benign and malignant tumors. What combination of gastrointestinal tumors is most commonly found in patients with NF1 syndrome?

• What age groups are affected by NF1 syndrome?

• Why do you think this is relevant for your clinical practice?

Figure 1. Preoperative evaluation with abdominopelvic CT of the pancreas revealed a 2.4-cm ovoid arterially enhancing mass in the proximal third portion of the duodenum with mild to moderate wall thickening.

Figure 2. Pancreaticoduodenectomy demonstrated a 2.5- by 2.5- by 2.5-cm solid mass in the duodenum, which grossly appeared to consist of two adjacent tumors.

Dr. Rosales’ RESPONSE In response to your first question, the most common tumors associated with NF1 syndrome are GISTs, followed by NETs and then pheochromocytomas.

Regarding your second question, the age groups predominantly affected by NF1 are children or adolescents. However, it has been seen in the elderly, as described in this case presentation.

To address your last question, the management of patients with NF1 syndrome is based on careful surveillance. When a tumor is found, a multidisciplinary approach is needed. In the case of localized, resectable GISTs, surgical treatment is the mainstay and laparoscopic surgery is a valid option. The rare coexistence of the simultaneous finding of NETs and GISTs in the same FNA should alert the clinician for the possibility of NF1 syndrome, and appropriate workup should be obtained.

Suggested Reading • IJzerman NS, Drabbe C, den Hollander D, et al. Gastrointestinal stromal tumours (GIST) in young adult (18-40 years) patients: a report from the Dutch GIST Registry. Cancers (Basel). 2020;12(3):730.

• Joo M, Lee HK, Kim H, et al. Multiple small intestinal stromal tumors associated with neurofibromatosis-1. Yonsei Med J. 2004;45(3):564-567.

• Kramer K, Hasel C, Aschoff AJ, et al. Multiple gastrointestinal stromal tumors and bilateral pheochromocytoma in neurofibromatosis. World J Gastroenterol. 2007;13(24):3384-3387.

• Makita N, Kayahara M, Kano S, et al. A case of duodenal neuroendocrine tumor accompanied by gastrointestinal stromal tumors in type 1 neurofibromatosis complicated by life-threatening vascular lesions. Am J Case Rep. 2021;22:e927562.

• Park EK, Kim HJ, Lee YH, et al. Synchronous gastrointestinal stromal tumor and ampullary neuroendocrine tumor in association with neurofibromatosis type 1: a report of three cases.

Korean J Gastroenterol. 2019;74(4):227-231.

SURGEONS’ LOUNGE

DECEMBER 2021 / GENERAL SURGERY NEWS

11

STOP the Bleed Campaign

By Narinderjeet Kaur, medical student, Ross University School of Medicine, Miramar, Fla., and Lisandro Montorfano, MD, PGY-4, Cleveland Clinic Florida

A

ccording to the World Health Organization, more than 5 million deaths are caused by traumatic injuries worldwide each year.1 Post-traumatic bleeding resulting in coagulopathy has been the leading cause of preventable death upon presentation to the emergency department. A report published in 2017 found that up to 20% of preventable deaths were related to trauma.2 The report noted the significant improvements in prehospital trauma care leading to preventable deaths in combat made by the U.S. military, and stressed the essentials of effective response from bystanders being an important link in improving trauma system care.2 It has been shown that 30% to 40% of trauma mortality is caused by hemorrhage, and, of these, 33% to 56% occurs during the prehospitalization period with the underlying cause of early mortality being coagulopathy, continued hemorrhage and incomplete resuscitation.3,4 On April 19, 2015, following the fatal mass shooting event at Sandy Hook Elementary School, in Newtown, Conn., the American College of Surgeons convoked the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events, with collaboration from the medical community, federal government representatives, the National Security Council, the U.S. military, the FBI, and governmental and nongovernmental emergency medical response organizations, among others.

The committee was led by trauma surgeon Lenworth M. Jacobs, MD, MPH, FACS, FWACS, a professor of surgery and traumatology and emergency medicine at the University of Connecticut School of Medicine, in Farmington. The committee reported their recommendations in the “Hartford Consensus,” which consists of four reports. The principle of the Hartford Consensus is that, “in case of intentional mass casualty and active shooter events, no one should die from uncontrollable bleeding.”5 The Hartford Consensus III: Implementation of Bleeding Control was presented at the White House roundtable forum in April 2015.

Subsequently, in October 2015, former President Barack Obama launched the STOP the Bleed campaign as part of the National Preparedness System.6 In 2013, a group of military medical providers collaborated on a Facebook page called Next Generation Combat Medic (NGCM), with the aim of sharing Free Open Access Meducation (FOAMed) resources with military and prehospital medics. The Tourniquet

Project (TTP) had similar objectives of sharing medical education regarding basic hemorrhage control techniques to save lives. While NGCM had a large military group following, the TTP following was civilian-based.2 While the administrators of NGCM and TTP contemplated on how to best fill the gaps of the STOP the Bleed campaign’s goal of training 200 million

Americans, another mass shooting took place in Las Vegas on Oct. 1, 2017.

Within 12 hours of the Last Vegas shooting, the STOP the Bleed campaign was launched. The campaign leveraged social media to establish a network of regional coordinators who would work together to raise public awareness and be directed to nearby bleeding control courses. An arbitrary date of March 31,

2018, was chosen as the National STOP the Bleed Day (NSTBD), which was later expanded to two weeks (March 26 to April 7, 2018) due to potential conflicts of national sporting events and religious holidays. The lessons learned in FOAMed, initiated by TTP, NGCM and special operations National Medical Association’s Scientific Assembly, continued on page 12

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12

THE SURGICAL PAUSE

GENERAL SURGERY NEWS / DECEMBER 2021

The Fifth Annual Symposium for Research in Surgical Palliative Care

By MELISSA RED HOFFMAN, MD

T

his year’s symposium coincided with the 20th anniversary of the first meeting of the Surgical Palliative Care Task Force (the precursor to the Committee on Surgical Palliative Care), which first convened in Chicago, on Sept. 10, 2001. Since the initial meeting, the field of surgical palliative care, defined by Geoffrey P. Dunn, MD, FACS, as “the attention to suffering in all of its manifestations of the patient and the family under surgical care,” has continued to develop and mature.

According to the American Board of Surgery, there are currently 75 surgeons board certified in hospice and palliative medicine, with several more enrolled in a oneyear fellowship, and several enrolled in the fellowship application process. There are also many surgeons who routinely integrate palliative medicine principles into their surgical practice.

The following are the presentations from the meeting: 1. Joseph A. Lin, MD, presented his abstract titled “Development of a Primary Palliative Care Vertical Curriculum for Surgery Residents.” The curriculum spans all five years of residency and is modeled after surgical training, with graduated complexity that includes learning both basic and advanced palliative care skills and then eventually learning how to teach these skills to junior residents.

2. Halle Ellison, MD, FACS, discussed her abstract, “Undergraduate and Graduate Medical Learners’ Reflections on a Palliative Care Rotation” and reflected upon five themes—empathy, humanism, challenge, meaning and transformation—that emerged through written narratives provided by the learners. Dr. Ellison concluded that “a palliative

STOP the Bleed continued from page 11

were applied in NSTBD to optimize viewership and interaction across social media platforms using the hashtag #NSTBD18 to empower people to become a part of NSTBD to making a difference. NSTBD included 43 states and 18 countries, with a total of 1,884 registered courses at bleedingcontrol.org with training of 34,699 students during the two-week period.2 The goal of the STOP the Bleed campaign emerged as a public health initiative to raise awareness and educate lay civilians to act as immediate responders to help victims of traumatic events by stopping or slowing life-threatening hemorrhages until primary responders, such as emergency medical services (EMS) or other medical professional help, arrive.

EMS is not allowed to enter and provide medical assistance until the identified threats have been mitigated by specially trained police due to historically being victims of secondary threats of

care rotation helped learners to become better communicators and more fully connect with patients and their families” and postulated that the rotation “may help to counter the decline in empathy that often occurs during medical education.”

3. Erin A. Strong, MD, MBA, MPH, presented “Palliative Care Specialty Consultation in Patients with Peritoneal Carcinomatosis undergoing CRS/ HIPEC with Palliative Intent.” The purpose of the study was to evaluate the incidence and timing of palliative care consultation in patients undergoing palliative cytoreductive surgery and/ or hyperthermic intraperitoneal chemotherapy, and concluded that “the ideal timing for palliative care consultation at a tertiary cancer center would be at the time of referral or immediately after the first specialty oncology visit.” Dr. Strong also suggested that “high-risk anesthesia consults could serve as a trigger event if a palliative care consultation has not already occurred.”

4. Caitlin Hodge, MD, MPH, presented “Association Between Cancer Diagnosis and End of Life Wishes,” a pilot project using the Five Wishes document and patient interviews to compare end-of-life wishes between patients with cancer receiving treatment for cure, patients with metastatic disease undergoing treatment and patients who are no longer receiving treatment.

5. Lastly, Hiren V. Patel, MD, PhD, discussed “Factors Associated with Palliative Intervention Utilization in Metastatic Renal Cell Carcinoma.”

The symposium concluded with a brief tribute to Robert A. Milch, MD, FACS, who died this year on June 4. Dr. Milch was a general and vascular surgeon

explosive devices and additional shooters.

The window of opportunity to save a life from a major arterial bleed is less than five minutes, making bystanders’ training essential to saving lives due to mass casualties from active shooters.

STOP the Bleed classes are composed of a one-hour didactic lecture and two skill training stations consisting of tourniquet application and wound packing with hemostatic gauze.7 The acronym STOP stands for: Searching the patient at risk of coagulopathic bleeding, Treating the coagulopathies as soon as they develop, Observing the response to interventions Preventing secondary bleeding coagulopathies.5,8 STOP the Bleed also recommends installation of bleeding control kits in plain view at public places, such as airports, federal buildings, heavily populated public places, malls and sports arenas, next to automated external defibrillators

Issues in Surgical Palliative Care who co-founded Hospice Buffalo in 1978, and eventually became the hospice medical director. Along with Dr. Dunn, he was the co-chair of the Surgical Palliative Care Task Force and worked closely with Dr. Olga Jonassen to promote the principles of palliative medicine throughout the College. He also served as a consultant for multiple countries, including Hungary, Slovenia and Croatia, as they started their national hospice programs.

The symposium, which was sponsored by the American College of Surgeons’ Committee on Surgical Palliative Care, was held virtually on Nov. 4, 2021. Anne Mosenthal, MD, FACS, the chair of the committee, kicked off the event, which was organized by Ana Berlin, MD, MPH, FACS, Susan D. McCammon, MD, FACS, and Vanessa P. Ho, MD, FACS. ■ For more information about the field of surgical palliative care, follow @surgpallcare on Twitter and consider joining the recently launched Surgical Palliative Care Society (www.spcsociety.org).

—Dr. Hoffman is an acute care surgeon and hospice attending in Asheville, N.C., and the host of The Surgical Palliative Care Podcast. To learn more about her, visit her website at www.redhoffmanmd.com. She is a member of the editorial advisory board of General Surgery News.

for public access.7 Over the years, the use of tourniquets has been controversial due to the complication of resultant tissue ischemia leading to amputation.7 The use of tourniquets in controlling extremity hemorrhage dates back to the 17th century but was strongly discouraged during World War I after military personnel reported complications of nerve damage and limb loss. The continued debate during World War II, the Korean War and the Vietnam War halted after the conflicts in Afghanistan and Iraq yielded more data regarding tourniquet use in a significant number of peripheral arterial injuries as a result of explosive devices. A prospective study at a combat support hospital in Baghdad in 2006 by Kragh and colleagues showed that the morbidity risk was low, and there was a survival benefit when tourniquets were used correctly.9 The University of Texas San Antonio Office of Medical Directors conducted a study to determine the curriculum of hemorrhagic control education to assess a layperson’s willingness to respond to a

traumatic medical emergency and their ability to use a tourniquet. Individuals with medical health certificates were excluded from this study. Pre-event questionnaires were used to assess participants’ knowledge and comfort level with tourniquet use followed by a 20-minute didactic instruction on hemorrhagic control techniques and hands-on training with tourniquet placement on adult and child mannequins. Of the 218 participants, 64.2% responded “yes” to using a tourniquet in real life before training, and 95.6% responding “yes” to using a tourniquet in real life after training, showing a significant improvement in the participants’ comfort level of using the tourniquet in real life.10 In addition, a randomized clinical trial performed by Goralnick showed that a one-hour in-person training course is efficacious in retaining the proper tourniquet skills for three to nine months, and suggests a refresher training courses in individuals aged 18 to 55 years.11 ■ References can be found online at generalsurgerynews.com

IN THE NEWS

DECEMBER 2021 / GENERAL SURGERY NEWS

13

Data Show Benefits of Early Testing for Small Bowel Obstructions

By MONICA J. SMITH

Atlanta—The availability of gastrografin small bowel follow-through (G-SBFT) shifted small bowel obstruction from a condition treated surgically to one of watchful waiting. Although optimal timing for G-SBFT has been unclear, new research indicates ordering the procedure early offers clear benefits and no disadvantages.

“Some data shows that a significant proportion of small bowel obstructions will resolve after 48 hours, suggesting that we should observe these patients longer in an attempt to avoid an operation,” said Andrew Licata, MD, a surgical resident at Eastern Virginia Medical School, in Norfolk. He presented the research at the 2021 Southeastern Surgical Congress (SESC).

“But there is also data that suggests delaying surgery more than 48 hours in patients who will inevitably require an operation is associated with an increase in their overall morbidity,” Dr. Licata said.

“So when should we be performing the test? That’s what we sought to discover.”

To do so, Dr. Licata and his colleagues retrospectively reviewed data on patients ages 18 to 89 years who were admitted to any of 13 Sentara facilities with a diagnosis of small bowel obstruction between 2012 and 2019. They divided the patients into two categories: those with a SBFT within 48 hours and those whose SBFT was ordered later than 48 hours.

The primary outcomes were hospital length of stay and total hospital costs.

Secondary outcomes were operative intervention, 30-day mortality and 30-day readmission.

548 patients who met the inclusion criteria, 391 (71%) fell into the early category and 157 (28%) into the later group.

The average hospital stay was five days, average cost was $20,000 and about 24% of patients ultimately required surgery.

“When we split our patients into the early and late categories, we found those in the early group had a significantly shorter hospital stay—four days versus eight,” Dr. Licata said. Costs were significantly less in the early G-SBFT group, averaging $17,000 compared with about $33,000 in the late group, and patients in the early group were less likely to undergo surgery than those in the late group, at 20% and 31%, respectively.

“Looking specifically at those patients who had an operation, those in the early group spent less than the later group for their hospital stay, $50,000 compared with $80,000, and had a shorter hospital stay, nine days compared to 15,” Dr. Licata said.

These differences were also seen in patients who did not require surgery.

Patients with an earlier SBFT cost less

‘Looking specifically at those patients who had an operation, those in the early group spent less than the later group for their hospital stay, $50,000 compared with $80,000, and had a shorter hospital stay, nine days compared to 15.’

—Andrew Licata, MD

for care and had a shorter hospital stay than those whose SBFT happened later.

Based on these findings, Dr. Licata and his colleagues concluded that ordering a SBFT within 48 hours can decrease length of stay, cost and rate of operative intervention without increasing readmission rates or mortality.

“We feel that delaying SBFT really only delays an operative intervention.

Delaying that SBFT did not give patients continued on page 15

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IN THE NEWS

GENERAL SURGERY NEWS / DECEMBER 2021

Normothermic Machine Perfusion a ‘Game-Changer’ for Liver Transplants continued from page 1

are on the liver transplant waitlist that will never be offered an organ and will die on the waiting list,” said Dr. Quintini. “Normothermic machine perfusion is a game-changer in the field of organ transplantation.”

NMP is a method of organ preservation that provides oxygen and nutrition during organ preservation and allows aerobic metabolism. “The machine allows livers to be kept outside of the body in near-physiological conditions, similar to those found in the body, with oxygenated blood that is pumped at body temperature through the organ,” said Dr. Quintini. “I tell the patient that we maintain the organ alive, for lack of a better term, during the preservation time, as opposed to maintaining the organ on ice and cooling it down to near freezing temperatures [as is usually done in transplants].”

In the study, conducted at Cleveland Clinic, 21 human livers declined for transplantation were enrolled for assessment with NMP. Reasons for discard included long warm ischemia time in donors after circulatory death, high degree of steatosis, hypernatremia, hyperbilirubinemia and severe hypertransaminasemia.

During NMP, the researchers evaluated the viability of the livers for transplant by assessing bile production rate, perfusate lactate clearance rate, hemodynamics and liver morphology. The researchers discarded six livers after NMP because of insufficient lactate clearance, limited bile production, or moderate macrosteatosis, leaving 15 deemed suitable for transplant.

The livers deemed suitable for transplant included seven donors after circulatory death with 13 to 46 minutes of donor warm ischemia time and cold ischemia time that ranged from three hours and 41 minutes to seven hours and 42 minutes. NMP duration ranged from three hours and 49 minutes to 10 hours and 29 minutes without technical problems or adverse events. MELD score before transplantation ranged from 15 to 23.

Patients experienced good graft and transplant outcomes. There were no intraoperative or major early postoperative complications in any of the recipients of the liver transplants, and no primary non-function occurred after transplantation. Seven livers had early allograft dysfunction with fast recovery and one patient developed ischemic cholangiopathy after four months, which was treated with biliary stents. With a follow-up that ranged from five to 17 months, all other patients had good liver function.

“Our hope is that we can salvage and rescue many organs that are deemed untransplantable,” said Dr. Quintini. “Currently, about 20% of the livers are discarded in the United States.

‘Currently, about 20% of the livers are discarded in the United States.

Assuming that we can salvage approximately 70% of these organs, we can potentially increase the number of liver transplants every year by 14%, which is approximately 1,200 patients per year.’

—Cristiano Quintini, MD

Assuming that we can salvage approximately 70% of these organs, we can potentially increase the number of liver transplants every year by 14%, which is approximately 1,200 patients per year.”

Parsia Vagefi, MD, chief of the Division of Surgical Transplantation at UT Southwestern Medical Center, in Dallas, also believes that NMP is a gamechanger for liver transplants. In a recent study (Ann Surg 2020;272[3]:397-401), Dr. Vagefi and colleagues queried the

United Network for Organ Sharing database to identify deceased donor livers procured from 2016 to 2019. Donor livers were divided by preservation method, either standard cold-static preservation (n=30,368) or NMP (n=228). The NMP group had a 3.5% discard rate versus 13.3% in the cold-static preservation group (P<0.0001), and this was despite NMP donors being older, more frequently donated after cardiac death, and having a greater donor risk index.

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Indication: Byfavo is a benzodiazepine indicated for the induction and maintenance of procedural sedation in adults undergoing procedures lasting 30 minutes or less.

Important Safety Information WARNING: PERSONNEL AND EQUIPMENT FOR MONITORING AND RESUSCITATION AND RISKS FROM CONCOMITANT USE WITH OPIOID ANALGESICS AND OTHER SEDATIVE-HYPNOTICS • Only personnel trained in the administration of procedural sedation, and not involved in the conduct of the diagnostic or therapeutic procedure, should administer Byfavo.

• Administering personnel must be trained in the detection and management of airway obstruction, hypoventilation, and apnea, including the maintenance of a patent airway, supportive ventilation, and cardiovascular resuscitation.

• Byfavo has been associated with hypoxia, bradycardia, and hypotension.

Continuously monitor vital signs during sedation and through the recovery period.

• Resuscitative drugs, and age- and size-appropriate equipment for bag/ valve/mask assisted ventilation must be immediately available during administration of Byfavo.

• Concomitant use of benzodiazepines with opioid analgesics may result in profound sedation, respiratory depression, coma, and death.

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Byfavo is contraindicated in patients with a history of severe hypersensitivity reaction to dextran 40 or products containing dextran 40.

Neonatal Sedation: Use of benzodiazepines during the later stages of pregnancy can result in sedation (respiratory depression, lethargy, hypotonia) in the neonate. Observe newborns for signs of sedation and manage accordingly.

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IN THE NEWS

DECEMBER 2021 / GENERAL SURGERY NEWS

Small Bowel continued from page 13

Dr. Vagefi was also a co-author on the PROTECT trial presented at the 2021 American Transplant Congress (abstract 297). In this trial, NMP was pitted against ischemic cold storage for liver transplants and was found to reduce early allograft dysfunction (17.3% vs. 30.5%; P=0.009) and ischemic biliary complications at six (1.3% vs. 8.5%; P=0.004) and 12 months (2.6% vs. 9.9%; P=0.010).

“I think [NMP] is going to change a lot of how we practice,” said Dr. Vagefi. ■

more time to resolve their obstruction; in fact, these patients had a higher rate of operative intervention,” Dr. Licata said.

“Ordering the SBFT early simply allows us to decide whether or not they need surgery more quickly, and to get them the treatment they need to get them out of the hospital with less expense.”

Dr. Licata said that to the best of his knowledge, this is the largest multicenter study to date showing the benefits of SBFT. He also noted that a similar

study published shortly after his abstract was submitted to the SESC had similar findings using an even earlier cutoff for early intervention: 12 hours.

Deborah Martin, MD, an acute care surgeon with Northside Hospital in Atlanta, commented that the paper is timely because small bowel obstruction is commonly seen by general surgeons. ”In patients who present with a closed loop obstruction or complete obstruction, ischemia, necrosis, perforation— the management is straightforward—we take them right to the OR. The remaining patients are the ones who present

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age in humans. Anesthetic and sedation drugs are a necessary part of the care of children needing surgery, other procedures, or tests that cannot be delayed, DQG QR VSHFLƓF PHGLFDWLRQV KDYH EHHQ VKRZQ WR EH VDIHU WKDQ DQ\ RWKHU Decisions regarding the timing of any elective procedures requiring anesthesia VKRXOG WDNH LQWR FRQVLGHUDWLRQ WKH EHQHƓWV RI WKH SURFHGXUH ZHLJKHG DJDLQVW the potential risks.

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8VH LQ 6SHFLƓF 3RSXODWLRQV Pregnancyŋ7KHUH DUH QR GDWD RQ WKH VSHFLƓF effects of Byfavo on pregnancy. Benzodiazepines cross the placenta and may produce respiratory depression and sedation in neonates. Monitor neonates exposed to benzodiazepines during pregnancy and labor for signs of sedation and respiratory depression. Lactation—Monitor infants exposed to Byfavo through breast milk for sedation, respiratory depression, and feeding problems.

A lactating woman may consider interrupting breastfeeding and pumping and discarding breast milk during treatment and for 5 hours after Byfavo administration. Pediatric Use—Safety and effectiveness in pediatric patients have not been established. Byfavo should not be used in patients less than \HDUV RI DJH Geriatric Use—No overall differences in safety or effectiveness were observed between these subjects and younger subjects. However, there is a potential for greater sensitivity (eg, faster onset, oversedation, confusion) in some older individuals. Administer supplemental doses of Byfavo slowly to achieve the level of sedation required and monitor all patients closely for cardiorespiratory complications. Hepatic Impairment—In patients with

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severe hepatic impairment, the dose of Byfavo should be carefully titrated to effect. Depending on the overall status of the patient, lower frequency of supplemental doses may be needed to achieve the level of sedation required for the procedure. All patients should be monitored for sedation-related cardiorespiratory complications.

Abuse and Dependence: Byfavo is a federally controlled substance (CIV) because it contains remimazolam which has the potential for abuse and physical dependence. %<) +&3 ,6,

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the challenge, so in this setting, gastrografin SBFT has been a wonderful tool to help us with our surgical decision making,” she said.

But Dr. Martin did ask if there are potential complications associated with SBFT that would be reasons not to order one.

Dr. Licata said there are potential complications and SBFT is not something that should be ordered blindly. “Especially in older patients, it may not be a good idea to order an SBFT in the middle of the night with less staff because there’s certainly a risk of aspiration.”

■

15

16

IN THE NEWS

GENERAL SURGERY NEWS / DECEMBER 2021

Same-Day Discharge for Lap Colectomy Safe in Select Patients continued from page 1

no significant comorbidities, lived within 30 minutes of the hospital and did not require creation of a new ileostomy.

Patients were asked if they preferred to go home or be admitted.

All patients underwent remote followup with a mobile health app or daily telephone call from their surgeon.

Two patients returned to the emergency department within 72 hours of discharge—one for urinary retention and the other with an anastomotic leak,

which was managed conservatively.

“Same-day discharge can be done safely with either an mHealth phone app or telephone calls for remote follow-ups, which significantly reduces the resource burden but with the same results,” said lead author Lawrence Lee, MD, PhD, an assistant professor of surgery, McGill University Health Centre, in Montreal, in an email to General Surgery News.

Co-investigator Jules Eustache, MD, a general surgery resident at McGill

University, presented the study at SAGES. Overall, 10 patients, or 12.7%, returned to hospital within one month of surgery, consistent with previously published studies of colorectal surgery, said the investigators.

The study started before the pandemic but picked up new urgency as COVID-19 put pressure on hospital systems. In the first wave, many patients were afraid to stay in the hospital, and Quebec’s ministry of health

&VMIJ 7YQQEV] SJ 4VIWGVMFMRK -RJSVQEXMSR for Byfavo© VIQMQE^SPEQ JSV -RNIGXMSR 7II TEGOEKI MRWIVX TVMSV XS YWMRK &]JEZS ;%62-2+ 4)67322)0 %2( )59-41)28 *36 132-836-2+ %2( 6)797'-8%8-32 %2( 6-7/7 *631 '32'31-8%28 97) ;-8, 34-3-( %2%0+)7-'7 %2( 38,)6 7)(%8-:) ,=4238-'7 4IVWSRRIP ERH )UYMTQIRX JSV 1SRMXSVMRK ERH 6IWYWGMXEXMSR • Only personnel trained in the administration of procedural sedation, and not involved in the conduct of the diagnostic or therapeutic procedure, should administer Byfavo.

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• Byfavo has been associated with hypoxia, bradycardia, and hypotension. Continuously monitor vital signs during sedation and during the recovery period.

• Resuscitative drugs, and age- and size-appropriate equipment for bag-valve-mask–assisted ventilation must be immediately available during administration of Byfavo.

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asked hospital staff to reserve capacity for patients with illnesses related to the virus, said Dr. Lee. As a result, SDD enabled more patients to have surgery that they otherwise would have waited for, said Dr. Lee. “It is not an exaggeration to say that a good proportion of our SDD patients would not have had their surgery done in a timely manner if the SDD hadn’t existed,” he said.

The investigators set out to study SDD

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IN THE NEWS

‘It just takes one patient having a major complication at home where they cannot get through to their provider or get fast-tracked through the emergency department, and that morbidity becomes a preventable mortality for this concept to go up in flames, so it is critical that implementation is appropriate.’

—Deborah S. Keller, MD

because McGill’s experience with an enhanced recovery after surgery protocol, or ERAS, showed that most of the patients remained in hospital after a laparoscopic colectomy only to pass gas. But research from other institutions demonstrated that patients could be safely discharged before their GI function returned.

The development of mHealth apps around the same time made remote post-discharge monitoring possible, said Dr. Lee. The investigators felt the combination of these principles suggested that SDD in these patients could be safe, he added.

Patients underwent laparoscopic colectomy, using a Pfannenstiel incision when extraction was necessary. After surgery, patients spent four to six hours in the recovery room. To be discharged, they had to be able to tolerate a liquid diet, have continued on the following page

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18

IN THE NEWS

GENERAL SURGERY NEWS / DECEMBER 2021

Creating Better Surgeons Through Better Learning

By KATE O’ROURKE

A

t the joint annual meeting of the Central Surgical Association and Midwest Surgical Association, David Farley, MD, president of the Midwest Surgical Association and an emeritus professor of surgery and former general surgery program director at the Mayo Clinic in Rochester, Minnesota, devoted part of his presidential address to how to get learners to efficiently acquire knowledge and skill, and ultimately perform surgery better.

Dr. Farley provided four background points.

• First, a learner needs an experience and then must code that memory with the brain’s neural pathways; memories can be consolidated and refined and ultimately retrieved. “The emphasis must be on assisting the learner in creating their own neural pathways and practicing to retrieve those memories,” said Dr. Farley.

• The second background point is that teachers can offer a variety of experiences but learners must engage in the experience, code the memory, consolidate it and retrieve it for learning to occur.

• The third background point is that a test creates a stronger memory that eventually will be easier to retrieve over time. A test forces a learner to go back into their mind and retrieve data, skill or information, and the effort it takes to go back and generate this memory is key to burning that fact or skill into the working memory (neural pathways) and something ready to use on demand.

• Fourth, sequential learning sessions coupled with frequent tests, quizzes, challenges, or self-reflection is not only useful, it enhances learning, memory retrieval, and, ultimately, performance.

Dr. Farley said based on the four background points and education research over the last few decades, he suggests that surgeons and educators spend serious time on three things: praising learner effort, offering detailed individualized feedback, and repeatedly challenging learners.

In terms of praising effort, Dr. Farley said that today in 2021, we know that intelligence, talent and ability is not fixed. If learners understand that effort is necessary and mandatory to make gains in surgery, said Dr. Farley,

Colectomy continued from page 17

their pain controlled with oral analgesia, and could ambulate and void independently after removal of any catheters.

Patients were only discharged on the same day if they preferred to go home.

The main reason for admission was patient preference, followed by intraoperative complications that required monitoring, nausea, poorly controlled pain and urinary retention.

Patient Perspectives Should Be Considered By video at SAGES, Sue Blackwell, a patient working with the patient relations

they will understand that the sky is the limit if they put forth effort. Educators, he said, should praise effort, not talent or skill.

“Praising the learning process and effort they put into improving is positive feedback without the burden of perfection,” said Dr. Farley. “Praising effort gives positive feedback and subtly asks learners to continue to challenge themselves. … Moving more learners into a growth mindset where perfection is not expected and mistakes are known to happen will allow most learners to accelerate forward and challenge themselves to get better.”

‘Many attending surgeons are reluctant to speak up in the OR— R— either afraid to come across ass too tough or harassing, or they simply mply are fixated on the task at hand. d.

This is unfortunate, given thatt feedback is critical to any learner trying to improve.’

—David Farley, MD Dr. Farley said that in 15 years as a general surgery program director at the Mayo Clinic-Rochester, the number one complaint students, residents and fellows gave him of the attending surgeon was not enough feedback provided in the operating room. “Many attending surgeons are reluctant to speak up in the OR—either afraid to come across as too tough or harassing, or they simply are fixated on the task at hand,” said Dr. Farley.

This is unfortunate, given that feedback is critical to any learner trying to improve.

“Using detailed feedback within focused practice sessions, coaches effectively improve their players’ performance in crucial areas and skills where they are underperforming,” said Dr. Farley. “Deliberate practice offering detailed feedback to learners in surgical simulation labs, cadaver labs, M&M conferences etc. can offer repeated attempts at correcting flaws, gaining fluency and finesse, and honing in on better judgment and decision-making.”

group of the Association of Coloproctology of Great Britain and Ireland, said patients want to stay in hospital until they felt ready to go home—“not when clinicians felt they were ready. If that was day 3, then great, but if it was day 10, then also great.”

Deborah S. Keller, MD, an assistant professor of surgery at the University of California Davis Medical Center, said patients need to be asked if they are comfortable going home on the same day as their surgery. They often feel rushed by ERAS and SDD policies, she said.

Dr. Keller said patients being discharged on the same day need in-depth communication with their surgeon and

Dr. Farley said that individualized and focused feedback is memorable, and offering that feedback with multiple practice repetitions in a sequential fashion creates an optimal learning environment. “Surgeons must learn and simply be willing to offer better feedback in the OR. Somehow. Someway,” said Dr. Farley. He said feedback works best when it is intermittent and not always immediately after an action. “With more ready access to recording video in our operating rooms, having learners view their own efforts is useful,” said Dr. Farley. “Better yet, asking the learner to edit out a few clips from the procedure for the staff surgeon to review with them or voice over is effective use of surgeon ti time and offers the learner superb feedback— back—available 24/7 at minimal cost.”

Th The third tip that Dr. Farley provided was to ch challenge learners. “Considering distributive learning offers trainees greater long term memory m acquisition and better retrieval al, it makes sense to challenge our learners with multiple repetitions spread out over time,” said Dr. Farley. He said as long as students understand that repeated challenges or quizzes or questions are offered as part of a learning strategy, and that no one expects perfection, learners greatly respect staff that are taking the time and effort to help them improve.

“The next time you are in your chief conference, or your M&M conference or your basic science conference: make your point,” said Dr. Farley. “And if it is a great point or an important point or if it might save somebody’s life, make that point again—in the form of a question or quiz or fill-in-the-blank comment at the next conference two days later. Make your point, and your test, two weeks later at some other conference or walking down a hallway with a student.” Ultimately, said Dr. Farley, the surgical coach needs to teach learners how to quiz and challenge themselves.

Dr. Farley said educators should ask learners at least a question or two each day. “Make it a fill-in-the-blank or open-ended question to force them to generate and retrieve that memory in their brain,” said Dr. Farley.

“Multiple choice questions and true/false questions do not mandate generational type recall.”

Repetition is the mother of learning, said Dr. Farley. ■

wearables that are actively monitored and addressed in timely fashion, and they must be given well-defined pathways to contact health care providers with questions.

“There are few places where all these are currently feasible, but they are necessary for SDD to be safe,” she said.

“It just takes one patient having a major complication at home where they cannot get through to their provider or get fast-tracked through the emergency department, and that morbidity becomes a preventable mortality for this concept to go up in flames, so it is critical that implementation is appropriate,” she said.

Findings Similar to French Experience The McGill results are similar to those published by French surgeons in 2019 (Ann Surg 2019; 270[2]:317-321). The French team used a more resource-intensive follow-up after patients were discharged.

Trained nurses spoke with patients daily for the first five days and visited them at home throughout the first week. Patients also underwent regular blood tests.

This approach is probably not feasible in North America, said Dr. Lee. The McGill team did not measure the burden of the interventions on the health care team and did not assess whether patients preferred the mobile app or telephone.

■

IN THE NEWS

DECEMBER 2021 / GENERAL SURGERY NEWS

Study Finds Main Drivers of Readmission After Hernia Repair

By CHRISTINA FRANGOU

A

person’s socioeconomic status predicts their likelihood of readmission and complications after ventral and inguinal hernia repairs, according to the first nationwide study to examine this issue.

“Socioeconomic status will have an effect on patients’ outcomes despite the type of procedure,” said study co-author James Feimster, MD, who performed the research as chief resident at Southern Illinois University, in Springfield.

Dr. Feimster, now a MIS/bariatric fellow at Atrium Health in Charlotte, N.C., presented the study at SAGES 2021 annual meeting.

The data also suggest there is more that surgeons could do to counter the harmful effects of low socioeconomic status, he said.

Patients who had laparoscopic surgery or underwent elective repairs were readmitted at significantly lower rates— meaning surgeons may be able to improve outcomes in at-risk populations by trying to get more minimally invasive procedures to lower-income communities and operating earlier in a patient’s disease course, said Dr. Feimster.

“Increasing the amount of minimally invasive techniques as the first line for ventral and inguinal hernia repairs and improving access to patients with lower socioeconomic status, so that they can undergo elective repair, can theoretically improve overall hernia outcomes,” he said.

He and his colleagues performed a retrospective analysis of laparoscopic and open ventral and inguinal hernia repairs using the nationwide readmissions database from 2016 to 2017.

Patients were selected from the database using ICD-10 codes; 1:1 propensity score matching was conducted between patients who were readmitted and those who were not. A multivariate logistic regression analysis was performed including confounding variables like hospital setting, comorbidities, urgency of repair, socioeconomic status and payor status.

Among more than 214,000 hernia repairs with 30-day follow-up data, 24,329 patients, or 11.6%, were readmitted within one month. The most significant predictor of readmission was having open surgery; patients who received laparoscopic surgery were less likely to be readmitted, with an odds ratio of 0.65 (95% CI, 0.63-0.69).

Medicaid patients were more likely to be readmitted within 30 days, with an odds ratio of 1.25 (95% CI, 1.201.30). Medicaid patients were more likely to require emergent repairs compared to other patients, at 56.3% versus 49.2% (P<0.0001).

Patients who were in the bottom half of income were more likely to be readmitted than upper-income earners.

Patients treated in rural hospitals, those treated in hospitals with a large bed size and patients admitted on weekends were also more likely to be readmitted.

Factors affecting 90-day readmission were similar.

Patients who were in the bottom half of income were more likely to be readmitted than upper-income earners.

It takes trust to advance together

Overall, 17.9% of 175,253 hernia repair patients were readmitted within 90 days. Patients were less likely to be readmitted if they underwent laparoscopic surgery, and more likely if they were Medicaid patients, were among lower income earners, admitted on a weekend or for emergent surgery, or treated at rural hospitals or continued on page 21

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19

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IN THE NEWS

GENERAL SURGERY NEWS / DECEMBER 2021

Will CODA Trial Results Change Surgeons’ Approach to Appendicitis? continued from page 1

risk and have not been too open about asking questions effectively get information about their diagnosis and Dr. Davidson said. “They’re thinking about what goes about how patients conceptualize the risk of ‘failure,’” clinical outcomes and help facilitate treatment discus- into having to cope with needing an urgent or emergent said lead investigator David Flum, MD, MPH, a profes- sions between patients and their surgeons,” Dr. David- operation at this moment in their life.” sor and the associate chair of surgery at the University of son said.

Patients also are concerned about finances related to Washington School of Medicine, in Seattle, referring to The online tool is the first stage of part of a planned surgery or time off work. Many patients would prefer the risk that a patient will need surgery after antibiotics. national program, led partly by the ACS, which will to avoid surgery if they don’t have insurance coverage “But there’s the other side of it, which is to ask include training support for clinicians and a protocol to or have a high deductible, Dr. Flum said. patients, ‘What else is going on in your life right now?’” standardize appendicitis treatment.

Appendicolith and Appendiceal Diameter he said. “And it’s remarkable how little, or not, that was Patients and Surgeons Differ Over Associated With Appendectomy part of our training as surgeons to ask these questions.”

Acceptable Failure Rate Dr. Flum and his co-investigators presented the Patients with an appendicolith who received antiresults, which are the latest data from the CODA At least one study suggests that many patients are biotics were more likely to require an appendectomy (Comparison of Outcomes of antibiotic Drugs and interested in trying antibiotics first, even if they are like- within 48 hours of diagnosis, but this heightened risk Appendectomy) trial at the American College of Sur- ly to require an appendectomy at some point. did not extend over weeks and months. The hazard geons virtual Clinical Congress 2021. The study was In a report published in the British Journal of Surgery, ratio for appendectomy among patients with an appenpublished simultaneously in The New England Journal over 70% of people surveyed said they were willing to dicolith compared with those without was 2.9 within 48 of Medicine (2020;383[20]:1907-1919). try antibiotics if it gave them a 60% chance of avoiding hours (95% CI, 1.9-4.4), but fell to 1.4 from 48 hours to Researchers randomized 1,552 patients with appen- surgery. The study came from a survey of 1,257 Amer- 30 days (95% CI, 0.8-2.4) and 1.1 from 31 days to two dicitis to surgery or antibiotics, which were delivered ican adults who were asked about their willingness to years (95% CI, 0.8-1.6). intravenously for 24 hours and then orally for 10 days. accept the risk for treatment failure (Br J Surg 2021 When asked whether they would still offer antibiThe noninferiority trial included patients with perfora- Aug 17. doi:10.1093/bjs/znab280). Dr. Flum was a co- otics to patients with an appendicolith, panelists said tion and those with appendicoliths, groups historically author of the study. they would outline the risks but would not rule out considered too at risk to be part of a ranantibiotics. domized trial of antibiotics.

“I don’t think it’s completely off the Analysis showed that 31% of patients table to offer these folks a trial of antibiwho had antibiotics as a first-line treatment otics if they are well aware of their risks underwent an appendectomy by 90 days, being higher with that appendicolith,” said 40% by one year and 49% by four years. co-investigator Callie Thompson, MD, an Although most patients underwent an assistant professor of surgery at University appendectomy for recurrence, 4.5% had of Utah Health, in Salt Lake City. surgery for nonclinical reasons such as travIn an unexpected finding, patients el; 14% did not have a known reason. with an appendiceal diameter of at least 10 mm were also more likely to have There were no deaths related to appenrequired surgery after receiving antidicitis or its treatment in the study. biotics. This is the first study to report Based partly on the early CODA results that wider appendiceal diameter may be and other studies, the ACS changed its a factor contributing to recurrence. guidance for appendicitis treatment in tri- ‘We believe patients with appendicitis, including those with an Lillian Kao, MD, MS, a professor and age guidelines issued for the COVID-19 appendicolith, should be appropriately informed about both the division chief of acute care surgery at pandemic last December, calling antibiotics McGovern Medical School at The Uni“an acceptable first-line treatment” for most treatment options as part of a shared decision-making process.’ versity of Texas Health Science Center patients with appendicitis.

—Giana H. Davidson, MD, MPH at Houston, called the finding “hypothThe investigators said the evidence supesis-generating.” It will be explored in ports antibiotics as a first-line option for Some surgeons have said a recurrence rate of even further analyses, she said. patients, even after the pandemic has ended.

“While some clinicians may find these rates of appen- 25% is difficult to justify.

In August, Irish surgeons reported results of a ran- Patients in Both Arms Reported Positive dectomy unacceptable, there are conditions where it’s common for patients to select less invasive treatments, domized controlled trial, known as COMMA, of Perceptions even if there’s a probability that surgery may ultimate- 186 patients who received antibiotics or surgery Feelings of dissatisfaction and regret were rare, but ly be needed,” said co-investigator Giana H. David- as a first-line approach to appendicitis (Ann Surg more common among patients in the antibiotic arm, son, MD, MPH, an associate professor of surgery at the 2021;274[2]:240-247). particularly those who eventually required surgery.

Within a year, one-fourth of patients in the antibiotic University of Washington School of Medicine.

Patients who had surgery initially or those who even“We believe patients with appendicitis, including arm experienced a recurrence. Patients treated with anti- tually needed surgery after antibiotics were more likethose with an appendicolith, should be appropriate- biotics also had a reduced quality of life compared with ly to experience prolonged time off work. Overall, most ly informed about both treatment options as part of a those treated with surgery, the investigators reported. patients returned to usual activities within 30 days and They concluded: “Without a test to exclude patients missed less than two weeks of work. shared decision-making process.” at high risk of recurrence, it is difficult to justify how Patients reported their health status as measured by Tool Available to Help Patients and antibiotic-only treatment can be routinely recommend- the EQ-5D. The EQ-5D survey asks questions in five Physicians ed for patients with acute uncomplicated appendicitis.” dimensions related to mobility, self-care, usual activiCODA investigators have developed an online deciBut CODA investigators said surgeons need to con- ties, pain/discomfort and anxiety/depression. However, sion-making tool, available at www.appyornot.org. sider that patients may be reluctant to undergo surgery. outcomes data from the CODA trial are mostly short Available in English and Spanish, the video provides Patients’ decisions about treatment are influenced by term: Surveys were available for 97% of patients after information about treatment risks and benefits, and factors other than long-term surgery risk, they said. one year, 10% at three years and only 5% at four years. asks users questions about personal preferences, pri“When we have patients that come in and say, ‘I have Dr. Thompson said no single factor can predict the orities and resources to help them choose a treatment kids at home. I don’t have any other caretaker to take success or failure of either antibiotic or surgical treatbased on their individual situation. care of them,’ or ‘I have a test on Friday and I have ment for all patients. “It means tailoring treatment rec“Our hope is that a standardized tool that can be eas- to be able to get to that test,’ they’re not thinking just ommendations and plans based on an individual patient’s ily disseminated across health systems can help patients in terms of ‘Will I need an eventual appendectomy?’” goals and values, which change over time,” she said.

IN THE NEWS

DECEMBER 2021 / GENERAL SURGERY NEWS

Barriers to Implementation Dr. Davidson pointed out that the current payment system disincentivizes surgeons to engage in-depth discussions with patients about the risks and benefits of the two approaches. These conversations might take longer than the operation itself, she said.

The investigators also addressed concerns about missed neoplasms in patients who receive antibiotics rather than surgery. In the study, appendiceal neoplasms were identified in nine participants: seven in the appendectomy group and four in the antibiotics group who underwent appendectomy, including two that were discovered since the first report was published in 2020.

Dr. Kao said surgeons need to tell patients that there’s a potential risk for a missed neoplasm when they don’t have surgery.

“You have to arm patients with the best available information, which is what CODA is supplying, and let them judge for themselves,” she said. “But I think it’s a very low rate, and that should not be the primary driver of decision making unless there’s some family history or other concern.”

She said surgeons should consider whether patients have timely access to return to the ER if antibiotic therapy fails. Hospitals will need to put policies in place so patients can receive appropriate care if they return to the hospital in need of surgery, she said.

If a patient has to “sit in the emergency room for six hours again, that’s not improving access,” Dr. Kao said.

Study’s Limitations and Strengths Many elements of care were not standardized. Surgeons could choose laparoscopic or open surgery, and imaging in the emergency department could be ultrasound or CT. The study did not include patients who had sepsis, recurrent appendicitis, evidence of severe phlegmon on imaging, had free air or abscesses, or were pregnant or immunocompromised. Women were underrecruited in the study.

However, CODA was a pragmatic trial, taking advantage of the way care is delivered in the United States and the effects on normal treatment patterns.

It’s the only major trial of surgery versus antibiotics for appendicitis in adults that reflects real-world practice in the United States, Dr. Flum said.

The second-largest trial to date of surgery versus appendectomy, known as the APPAC trial, took place in Europe and did not include high-risk patients.

The failure rate for antibiotic therapy among 257 patients was 39.1% over five years, or 100 patients (JAMA 2018;320[12]:1259-1265).

■

Hernia Repair continued from page 19

hospitals with a large number of beds.

Analysis showed that streptococcal sepsis and sepsis from other sources were the main diagnoses associated with readmission, indicating that wound infection was a common cause of readmission, said Dr. Feimster.

However, the database provides limited information on reasons for readmission and further details were not available, he pointed out.

The study was limited by lack of

detailed data, particularly patient-level information about, for instance, why patients underwent laparoscopic or open repair, or the size of the hernia defect, he said. Confounding variables were not examined in the study, including race, ethnicity, educational level and smoking status.

Commenting on the paper during the session, Dana Telem, MD, MPH, the section head of general surgery and associate chair for quality and patient safety at the University of Michigan, in Ann Arbor, said the findings illustrate the importance of social determinants

21

of health in surgical outcomes.

“I think we’re starting to recognize this more and more, and really understanding that where we live is probably more predictive of how we do than the complexity of our disease,” she said.

Previous studies have shown that socioeconomic disparities are associated with differences in anesthesia during hernia repair, hernia recurrence rates and postoperative complications. But the association of socioeconomic status with readmission rates after hernia repair has not been well studied in the United States.

■

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response

Getting Back to the Old Normal, or Not

By LINDA WONG, MD

W

hen the COVID19 pandemic began, we were all in a panic.

No more conferences. No meetings. Less elective surgery. Human contact was just a big nidus for infection, and the less contact we had, the better. Although surgeons tried to be understanding, there was inner outrage as elective cases were

canceled, office visits were postponed, and the fast-paced life of meetings, collaborations, research and clinical duties stopped. How would we make a living?

We all worked 60 to 80 hours every week, and now what were we going to do? It was like driving a Porsche down a deadend street, as life came to a grinding halt.

Pandemic life was new and scary, but we adapted to the new normal. Twenty months later, as cases decrease and we prepare to emerge from this pandemic,

we have all become very comfortable with this “new normal.” So, are we ready to go back to the “old normal”?

The New Normal Is Not So Bad … I Think In a way, the new normal is easier. I’m not sure about the rest of you, but I am frequently parked in my office chair at these virtual meetings, and if I turn off the camera, no one knows what I am doing. In the old days, human contact

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and peer pressure kept me attentive. No one wanted to be that geezer snoring in the conference hall. With these virtual meetings, nothing is forcing you to pay attention. If you had an attention-deficit disorder before, it has likely progressed to a Ritalin (methylphenidate)-resistant form. During these virtual conferences, I am simultaneously doing patient notes, answering emails, and in a stream of internet consciousness from reading the news, checking the number of COVID-19 cases, adding to my Amazon shopping cart, doing online banking, searching for the latest K-pop video and Googling for updates on my friends.

I have attended these virtual meetings while walking on the beach, on an elliptical machine, lying on my sofa and baking cookies. On a good day, I am in my office at these meetings, but I am nursing a large Diet Coke and a desk full of snacks. The most important thing I do at these meetings is hit the mute button, so the other attendees do not hear me crunching on chips and nuts.

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We have all stopped really caring what we look like. For women, there is no need for makeup or lipstick, thanks to the masks and face shields. I have attended some virtual meetings where most of the physicians on the call were in their home offices and wearing T-shirts. Hair care is optional because you can turn off the camera. The key is to have a nice still picture of yourself so people remember you are there. Virtual telehealth visits distort how we really look, and a nice background picture can cover up the mess in your office. There is no need to wear fancy clothes, and in fact, with Zoom, you really do not even need to wear pants. I find that I can sit comfortably on this desk chair with my feet up and shoes off, and as long as I have a white coat on, the patients still think that I look professional.

Unintended Consequences Of the New Normal, and the Old Normal Isn’t Looking So Bad Anymore Patients also seem uninterested in their medical care. Elderly patients who cannot figure out the telehealth visits have chosen to delay care or just forgo medical care until an emergency. Cancers

response

have been detected in later stages, as routine screening procedures have been postponed. Telehealth visits no longer seem like sacred visits with physicians, as I have had visits with patients who are driving, waiting in their car in a parking lot, at a shopping mall and even at Disneyland. How will they remember any advice that I have given them when I was just part of the drive home?

The trainees may be affected as well.

Medical students were sequestered for a while, and their clinical experience has likely been limited. This probably resulted in the new interns being particularly green and having to catch up on clinical skills. While the residents have been working, there were fewer elective cases, fewer blunt traumatic injuries, canceled didactics and less research enrollment.

Both residents and students adjusted their schedules to reduce potential COVID19 exposure. True, we had to protect the health of our trainees, but did this affect their experience? Will we be able to get them energized again after this hiatus?

Have we all become too comfortable with this less hectic life? Millions of Americans have quit their jobs or retired in what has been called “The Great Resignation.” Perhaps some of them are looking for new opportunities or reinventing themselves. Many Americans have been resting at home and collecting unemployment. Others have been working remotely because if you can still get a paycheck while never leaving your house and never getting out of pajamas, then why go back?

Many health care workers are burned out from this pandemic and are quitting their jobs. For those near retirement, now seems like the right time. We are reevaluating our priorities and deciding if we should continue. Perhaps one can quit his/her job and hope for a better one, but how long is this plan going to work? Someone else will take your old job in no time, and you might be left unemployed. No one is irreplaceable.

We are all sitting around saying “poor me,” but at some point, we need to snap out of it and get back to work.

We Need the Old Normal, and We Need It Now COVID-19 affected millions and took the lives of hundreds of thousands. It decimated businesses and jobs and changed

life as we know it. However, while we have all been on the sidelines waiting for the virus to go away, we have all lost our momentum. The pandemic made us lazy, and we seem to just be going through the motions. For starters, patients need to come back to the office. As convenient as virtual visits are, this is just not good surgical care. We need to palpate masses, reduce hernias, debride wounds and drain pus. Readjusting the camera to try to see things better is just not the same. The fact that patients drove over, found a parking space and waited for their appointment will make the time spent with you

far more meaningful, and they will be more likely to remember your advice. We also need in-person conferences because human contact, social networking and peer pressure will make us better surgeons and far better individuals.

Yeah, it’s a pain and it’s hard work, but it’s hard for a reason. It elevates us. Physicians and surgeons are respected. People look up to us and want to emulate us. So, let’s get our butts off the office chairs and back to conferences. Go back to work and back to the way it used to be. Take that trip to the hairdresser to get your haircut. Go back to the gym. Attend

23

in-person conferences. Get the patients back to the office.

So, let’s lead by example and maybe ■ society will follow our lead.

—Dr. Wong is a professor of surgery, University of Hawaii, in Honolulu.

Column editor: Gary H. Hoffman, MD, is surgical director at Los Angeles Colon and Rectal Surgical Associates (www. lacolon.com), attending surgeon at CedarsSinai Medical Center, and instructor in the Cedars-Sinai colon and rectal surgical fellowship, in Los Angeles.

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OPINION

GENERAL SURGERY NEWS / DECEMBER 2021

The Essence of Words continued from page 1

despair, progress or inertia, life or death. In this column, I am concerned with the language that we, as physicians, speak to each other and to, or not to, our patients.

Several hundred years ago, physicians spoke in Latin to each other to discuss a case secretly and in order to have patients admire them for their wisdom. Doctors also found it convenient to obfuscate diagnoses by naming afflictions in Latin. Thus, a reddish rash of unknown origin was not called “a reddish rash” but designated as roseola; chest pain was angina pectoris. Certain words for incurable afflictions of the time were spoken only to close relatives or persons of authority, but hidden from the patient. In the last century, and in some circles, even today, the diagnosis of cancer is kept from the patient.

In my youth, polio was a word often only whispered, as in prior centuries was the verdict of syphilis.

But what about the words we use today in common conversation with other health care professionals and with our patients: words with double entendres, words with subtle interpretations, words of subterfuge, words with lethal connotations, words of expectations good and bad, words of joy, and words of sorrow.

For certain of the thoughts expressed in this column, I am indebted to my colleague of many years, Mary E. Knatterud, PhD, who has written extensively on the impact of language in medical practice. A word Dr. Knatterud and I greatly dislike is “elderly.” “Elder” means a person advanced in age, and has, in the past, been a sign of respect. The specific starting age for this designation is not defined. “Elderly” has become almost the opposite of “elder,” implying infirmity of body and/ or mind. Other dictionary synonyms for elderly are venerable, aged, declining, hoary, long in tooth, no spring chicken, over the hill. In general, these synonyms are neither favorable nor laudatory; they imply that the elderly are no longer in the vigorous fullness of life and that somehow this is a transgression warranting a loss of respect. In another column with the title “Live Fast, Die Young” [GSN, May 2017, page 1], I emphasized that ageism is the formative basis for age discrimination. I reminded the young among us that if they are lucky, they, too, will one day be old.

I do not wish to imply that age is irrelevant in medical and surgical practice. A person’s age may be a critical factor in determining a diagnosis or therapy. For example, a person with significant changes in motor function at age 65 is unlikely to be exhibiting the onset of cerebral palsy and is more likely to be developing Parkinson’s disease. Women with the onset of breast cancer at age 25 versus ages 55 on to 85 require a different constellation of therapeutic considerations. However, a woman at age 85 should not be denied the appropriate range of therapy because of her age.

In my career, I have seen being designated as elderly used as justification for passive euthanasia. I have witnessed care conference decisions for withdrawal of active therapy and maintenance of comfort care only until death, based on the patient’s being called “elderly.”

I have seen surgeons I respected deny therapy based on the patient being elderly or old. I once did a Whipple procedure for a carcinoma of the head of the pancreas on a 90-year-old and was severely criticized; however, happily, the patient lived an active life into her late 90s.

Another term Dr. Knatterud and I find alien in taking care of patients is “manage.” Dr. Knatterud in the AMWA Journal (2020;35[3]:129-130) wrote, “I find it imprecise and disrespectful to posit patients as

The most important words spoken to patients take place in the examining room in an atmosphere that should be imbued with courtesy toward the patient. A smile, a post-COVID handshake or a touch of the shoulder, and certainly greeting a patient by name, should start an interaction with a patient. inanimate things or unruly kids or hapless subordinates to be managed by the powers-that-be.” Patients are to be cared for as fellow sentient humans, with dignity and compassion, with respect, courtesy and regard, with the empathy they are entitled to by their offer of faith in us, their physicians.

Two of the darkest words in the medical lexicon are “terminal” and “incurable.” A physician, a person of knowledge, who speaks those words to a patient is pronouncing a death sentence. Though we must at times make that pronouncement, we must do so with the greatest compassion, recognizing that life per se is terminal and that someday all of us will face the pronouncement of terminality. We must emphasize the time remaining and help the patient live the best life possible with the knowledge that we, as their doctor, will be there for them.

Incurable is less an expression of knowledge, than an apology for helplessness. Syphilis was incurable; diabetes was incurable; certain cancers were incurable. There was no surgery for congenital heart disease, obesity and its attributes. These afflictions are now curable, yet today, the list of incurable diseases is just as long and just as dramatic. We can’t cure the multitude of neurocognitive functional impairments; or Crohn’s disease, ulcerative colitis, or irritable bowel syndrome; and the many causes of deafness and blindness; or the huge spectrum of autoimmune diseases; and so on.

If we must tell a patient that his illness is incurable, we need to add the word “today.” We can recite to the patient diseases that were once incurable but that today are not. We can offer visions of cure as more effective therapy in their lifetime is developed, possibly fairly imminently. We need to portray hope not defeat; providing patients with the best palliative therapy available and the belief that better is to come.

Recently, a 17-year-old I know was introduced to living with type 1 diabetes after a frightening episode of hypokalemic ketoacidosis that required emergency

hospitalization. Her excellent diabetologists talked to her about lifelong glucose monitoring, insulin administration, and avoidance of diabetic complications. I talked to her about the future: islet cell transplantation free of the disadvantages of immunosuppression therapy by treated xenografts, organic polymer encapsulation, and islet cell transformation of her own polypotential embryonic cells. I told her that these “cures” will likely be available in her future.

Within the realm of medical research, the word “incurable” should be followed by the word “yet.” It should represent not a barrier, but a challenge. A plethora of incurable infections, from strep throat to leprosy are now curable. Once polio and today malaria were incurable, but the polio vaccine now prevents the former and, recently, the first malaria vaccine has been produced and is about to be introduced.

Finally, I want to call attention to the term “idiopathic,” derived from Greek roots. Idios means “one’s own,” and pathos is a “disease.” So, idiopathic is, “a disease of its own,” or a disease with no identifiable cause. We certainly have many of those! In using this term in a discussion with a patient, most physicians hide behind the word and pronounce it as if it portrayed some universal knowledge rather than universal ignorance. Would it not be more honest to say, “I don’t know why you have atrial fibrillation,” rather than “you have idiopathic atrial fibrillation”? The same is true for pulmonary fibrosis without determinable cause, and so many other diseases currently labeled idiopathic.

Comparable terms that hide ignorance and attempt to portray wisdom are “essential” and “primary.” What is the purpose, other than obfuscation, of diagnosing “essential hypertension” or “primary immunodeficiency disease?” These terms are themselves nearly as harmful to the mental perspective of physicians as are terminal or incurable. They convey complacency and acceptance of the status quo rather than dissatisfaction with the lack continued on page 26

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26

GENERAL SURGERY NEWS / DECEMBER 2021

The Scientific Greats: A Series of Drawings

By MOISES MENENDEZ, MD, FACS

Alexis Carrel (1873-1944) Alexis Carrel was a French American surgeon who was awarded the Nobel Prize in Physiology or Medicine in 1912 for pioneering vascular suturing techniques and organ transplantation.

After completing a medical degree at the Lyon Faculty of Medicine in 1893, Dr. Carrel spent several years as a surgical intern. In June 1894, the former president of France, Francois Carnot, was assassinated while visiting Lyon. He was stabbed in his torso, and the doctors who gathered to attend the moribund president stated that major blood vessels had been punctured and he could not be saved. Even if a laparotomy were performed, no one, so far, had been able to suture an internal blood vessel.

The entire episode was shocking to young Carrel, and, according to his autobiography, he then dedicated his future career in mending blood vessels and organ transplantation. As early as 1902, he published a paper in the Lyon Médical on a technique for the end-to-end anastomosis of blood vessels. And in 1910, he demonstrated that blood vessels could be kept for long periods in cold storage before they were used as transplants in surgery.

The technique of triangulation, using three stay sutures for traction in order to minimize damage and blood spillage, was inspired by sewing lessons he took from a seamstress.

Despite his innovative research, he failed to impress the surgical hierarchy in France and instead traveled to the United States, where, in 1904, he took up a position at the University of Chicago. In 1906, he joined the Rockefeller Institute in New York under the direction of Dr. Simon Flexner. Dr. Carrel carried out most of the experiments in that institution for several years. In this country, he attracted important scientists and surgeons.

With the support of William Halsted, Harvey Cushing and Simon Flexner, Dr. Carrel’s work on vascular anastomoses and organ transplantation became nationally recognized, and he was awarded the Nobel Prize in Medicine in 1912.

During World War I, Dr. Carrel served as a major in

Words continued from page 24

of knowledge professed. We require the inquisitiveness to learn, explore, research, to abolish words of concealment and replace them with words of knowledge.

The most important words spoken to patients take place in the examining room in an atmosphere that should be imbued with courtesy toward the patient. A smile, a post-COVID handshake or a touch of the shoulder, and certainly greeting a patient by name, should start an interaction with a patient. Talking to the patient is ever so preferable to talking about the patient to associates in the room. Personally eliciting a patient’s history and performing a physical examination establish rapport.

Above all, concentrating one’s communication on the computer in the room

the French Army Medical Corps, and at this time, he helped to devise the well-known Carrel-Dakin method of treating war wounds, which was widely used. By way of the Carrel-Dakin method, the pair developed Dakin’s solution (i.e., Dakin’s fluid or Carrel-Dakin fluid).

Dakin’s solution is a dilute solution of sodium hypochlorite (0.4%-0.25%) traditionally used as an antiseptic. This solution is still in use today for wound care, especially for heavily infected wounds.

In 1935, Dr. Carrel collaborated with Charles Lindbergh, the famous aviator, to devise an improved perfusion pump, but it required modifications. Lindbergh was adept at mechanical devices. The glass pump they created was used to preserve animal organs outside the body by pushing “artificial blood” through the pump and into the organ by way of a tube connected to the organ’s artery, keeping the organ viable for weeks.

Between 1935 and 1939, nearly 900 perfusion experiments were carried out using ovaries, spleens, kidneys and adrenal glands from cats, dogs and birds. Cat hearts would continue to beat for up to 12 hours.

Lindbergh’s device became an object of wonder, having been exhibited before large crowds at the 1939 World’s Fair in New York City. The Lindbergh-Carrel perfusion pump led to the development of the heart– lung machine and the feasibility of stopping the heart for open-heart surgery.

During World War II, Dr. Carrel was accused of being a Nazi collaborator. While it was likely that he was to be charged with being an enemy collaborator, it is by no means obvious that he would have been convicted, and in time, his philosophical views may have been forgiven.

In 1943, Dr. Carrel suffered a myocardial infarction from which he recovered only to suffer a further episode ■ in 1944, which resulted in his death.

—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.

rather than the patient is a poor substitute for care, for doing the job of a physician. The doctor–patient relationship is a unique bond whose tone and boundaries the doctor establishes.

Words are among our best tools in establishing empathy between doctor and patient. In a health care world under the control of administrators, a world of robots and frustrating receptionists, designated hours, prescribed patient management, loss of physician independence, the doctor (not employee) is left in control only of the few moments allowed for patient interaction. In this minimal timespan, the patient should not be treated as a client to be managed. These are the few moments for words to tell the patient that his/her problem, though serious, does not preclude a rewarding lifetime remaining, whatever its length.

These are the few moments to explain

Alexis Carrel (1873-1944) Work was done on Archer paper, 20×17, using charcoal pencils.

2018 Artist: Moises Menendez, MD, FACS

Sources • Benveniste GL. Alexis Carrel: the good, the bad, the ugly.

ANZ J Surgery. Published online April 26, 2013. doi. org/10.1111/ans.12167 • Hansson N, Jones DS, Schlich T. Defining ‘cuttingedge’ excellence: awarding Nobel Prizes (or not) to surgeons. In: Attributing Excellence in Medicine: The History of the Nobel Prize. Brill; 2019:122-142. doi. org/10.1163/9789004406421_008 • Navis AR. Alexis Carrel (1873-1944). Embryo Project Encyclopedia. Published February 29, 2008. https:// embryo.asu.edu/pages/alexis-carrel-1873-1944 • Van de Laar A. Under the Knife. A History of Surgery in 28 Remarkable Operations. St. Martin’s Press; 2018:197-272.

that though the etiology of the problem is as yet unknown, you, as their doctor, will do your best to ascertain and overcome their affliction. These are the few moments for empathy. Only by empathy for the patient does the physician warrant the patient’s trust in return, and the designation of being—a healer. The right words matter.

■ —Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis. His articles appear every other month.

Editor’s note: Opinions in General Surgery News belong to the author(s) and do not necessarily reflect those of the publication.

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ID

Near-Infrared Fluorescence 4K Imaging See more than ever before with new image modes for customizable white light color augmentation, 4 times the number of pixels as HD, a multi-sensory camera design, 10-bit precision color reproduction, and direct LED integration. Using endoscopic imaging, the SynergyID™ UHD 4K system offers dynamic range and depth of light for unrivaled contrast and depth of field for optimal sharpness.

At the touch of a button, new visualization options include standard visible light imaging with nearinfrared (NIR) overlay, grayscale visible light imaging with NIR overlay, or NIR imaging-only modes.

This valuable modularity provides immediate access to critical features with flexibility to scale investment in the system to meet future needs.

4 Chips. 4 Modes. 4K.

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