The January 2013 Digital Edition of General Surgery News

CONVENTION ISSUE:

Society of Critical Care Medicine

GENERALSURGERYNEWS.COM

January 2013 • Volume 40 • Number 1

The Independent Monthly Newspaper for the General Surgeon

Opinion

65 B Y J ON C. W HITE , MD

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read a statistic the other day that I thought must surely be a misprint. It claimed that two-thirds (approximately 65%) of all people who have ever lived to the age of 65 are alive today. I did some research with the intent of exposing the obvious exaggeration, but instead came up with more disturbing statistics: The number of people who have ever lived on the earth since man first appeared 50,000 years ago can be estimated by mathematical modeling; the total is thought to be 106 billion.

Currently, there are 7 billion people living or about 7% of all who have ever drawn a breath. These extraordinary numbers are a consequence of the exponential nature of population growth.

I also confirmed that an estimated 50% to 70% of people who have lived to age 65 are indeed alive today! The fact that 65% of the planet’s 65-year-olds are living now suggests that there is more than just the growth of the population at work.

There is also a dramatic increase in life expectancy. In short, population growth is in a very sharp incline and these multitudes are living far beyond what they did see POPULATION page 26

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Seasoned Surgeons Find Rewards in Surprising Place: Military Service

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Tracking System Improves Care for Cancer Patients B Y C HRISTINA F RANGOU

B Y M ONICA J. S MITH

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of the previously sacrosanct doctor–patient relationship. The future aligns with those who learn the benefits of self-preservation, gained by an understanding of how medical facilities and physicians will be judged and paid. One important

ancer centers that participated in a performance tracking system significantly improved their adherence to key quality measures in oncologic care, according to a new study. Developed by the Commission on Cancer of the American College of Surgeons (ACS), the system also helps hospitals to track their patients’ information, which prevents medical records from getting lost, the researchers said.

“Cancer care is unique in that it requires extensive coordination with providers across disciplines to ensure patients receive all of their treatments. Patients are not only getting surgical treatment but also chemotherapy, radiation and possibly hormone therapy,” said Erica McNamara, MPH, lead study author and quality improvement analyst at the ACS. “Our system is built to provide an extra layer of support in the coordination of that care.”

Ms. McNamara presented the findings at the American Society of Clinical Oncology’s inaugural Quality Care Symposium in December (abstract 286).

The ACS’ Rapid Quality Reporting System (RQRS) provides feedback to cancer centers on individual patient

see DIAGNOSIS-RELATED GROUPS page 31

see RQRS TRACKING page 12

Surgeon Norris Childs, MD, right, with junior navy medical officer in snow cave they built at cold weather medicine course at Marine Corps Mountain Warfare Training Center in Bridgeport, California. For his and other stories, see page 22.

What Are Diagnosis-Related Groups and Why Should You Care?

B Y L UCIAN N EWMAN III, MD

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s fate would have it, the assembly of accurate information on patient care may have more of an effect on the assessment of a physician’s care than the care itself. I know—this is a disgusting concept.

This represents the encroachment of bureaucracy squarely in the middle

INSIDE In the News

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How They Coped: Docs, Staff Go Extra Mile in Wake of Sandy

Stitches

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(New Column)

Josep Trueta Raspall, Creator of the ClosedPlaster Method for Open Fractures

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Gastric Bypass Patients Often Relapse After Diabetes Remission

Surgeons’ Lounge

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Patient with angle of His gastrocutaneous fistula after sleeve gastrectomy

Opinion Two Rules to Surviving the Affordable Care Act

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GSN Editorial

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Peeling the Onion Frederick L. Greene, MD, FACS Clinical Professor of Surgery UNC School of Medicine Chapel Hill, North Carolina

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ne of the byproducts of the Affordable Care Act (ACA) has been a savings by consumers of $1.5 billion in 2011 as a result of rules that limit what insurance companies can spend on expenses unrelated to medical care. A study by the New York-based Commonwealth Fund suggests that the ACA forced insurers to become more efficient by limiting administrative expenses, a key goal of the 2010 law.

In some cases, insurers passed savings on to consumers in the form of lower premiums and higher spending on medical care. Administrative costs in the individual market dropped in 39 states, while insurers in 37 states spent relatively more of their customers’ premiums on medical care.

The health law requires insurers to spend at least 80 to 85 cents of every dollar they collect in premiums on medical care rather than administrative expenses.

We must continue to look for ways in which we can salvage our health care

system and reduce costs by examining many different aspects of medical care in the United States. As we challenge our insurers to reduce their administrative costs, it occurs to me that there is another group of institutions, our hospitals. that should come under the same scrutiny. Hospitals, regardless of size and complexity, have become like the proverbial onion, having layer upon layer of administrative complexity that drives up cost and leads to inefficiency and waste of time and economy. I would venture that every reader of this column has become frustrated with the exponential addition of administrators at every level of hospital activity.

This complexity has contributed to difficulties in decision making and has heightened frustration for all of us.

As we look for additional ways to reduce costs throughout the entire sphere of medical care, the cost of an everincreasing cadre of administrators should be evaluated and streamlined. This evolution and proliferation of multiple layers of junior vice presidents, senior vice presidents, executive vice presidents and other titles have blossomed and have been essentially unchecked at most institutions.

Every time I turned around there was

Senior Medical Adviser Frederick L. Greene, MD Charlotte, NC General Surgery, Laparoscopy, Surgical Oncology

Editorial Advisory Board Maurice E. Arregui, MD Indianapolis, IN General Surgery, Laparoscopy, Surgical Oncology, Ultrasound, Endoscopy

Kay Ball, RN, CNOR, FAAN Lewis Center, OH Nursing

Philip S. Barie, MD, MBA New York, NY Critical Care/Trauma, Surgical Infection

L.D. Britt, MD, MPH Norfolk, VA General Surgery, Trauma/Critical Care

David Earle, MD Springfield, MA General Surgery, Laparoscopy

James Forrest Calland, MD Philadelphia, PA General Surgery, Trauma Surgery

Edward Felix, MD Fresno, CA General Surgery, Laparoscopy

Robert J. Fitzgibbons Jr., MD Omaha, NE General Surgery, Laparoscopy, Surgical Oncology

David R. Flum, MD, MPH Seattle, WA General Surgery, Outcomes Research

Michael Goldfarb, MD

Leo A. Gordon, MD Los Angeles, CA General Surgery, Laparoscopy, Surgical Education

Gary Hoffman, MD Los Angeles, CA Colorectal Surgery

Namir Katkhouda, MD Los Angeles, CA Laparoscopy

another memo of reorganization and dif- efficiency can be realized. Our hospitals, ferentiation that had added two or three like the onion, continue to be wrapped by more individuals who would continue the multiple layers that frequently obscure the work done formerly by a single person! central core.

We need to continue aggressively to peel Before we criticize insurance comback the onion and the layers of adminis- panies, “Big Pharma,� device makers trative personnel to reduce the overall cost and other entities for adding to the ecoof medical care. nomic burden of health We must always Patients come to the care, we must continue remind our administrative hospital to be cared to look critically at our colleagues that patients own practices and those for by physicians, come to the hospital to of our hospitals. Just as be cared for by physicians, not administrators. the ACA has challenged not administrators. The insurers to become more operating margin of the hospital continues responsible and savvy regarding reduction to erode as more nonmedical personnel in administrative costs, it would have been are brought onboard. Although I certain- nice to witness the same legislation directly understand that our support personnel ed to our hospitals. Unfortunately, all of are of value and necessary to the efficient the regulations regarding the introducworking of our hospitals, the continued tion of the electronic medical record and layering of administrators adds cost and “meaningful use� will miss the mark! eventually contributes to inefficiency. The As physicians caring for patients, we path to accomplishing goals in the hospital must encourage our nonphysician hospisetting is frequently hindered by the maze tal leaders to avoid the continued layering of administrative personnel. It is hard of administrative personnel. I am certainto understand conceptually why it takes ly in favor of having people employed, but more and more individuals with a variety I believe we have come to a significant of intriguing titles to do the job that assur- impasse in our ability to provide efficient edly could be done by a smaller number of care in hospitals because of the number of dedicated individuals. I am sure that with algorithms that we must choose from to some strategic planning a significant num- accomplish our work. Just as peeling an ber of these positions can be consolidated onion may cause a few tears to be shed, and that appropriate economic savings and the final product will be well worth it.

Joseph J. Pietrafitta, MD

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INFECTIOUS DISEASE SPECIAL EDITION

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Chest Injuries Cause More Deaths in Recent U.S. Conflicts Severity of Injuries, Improved Triage and Transport Systems May Explain Rise B Y C HRISTINA F RANGOU CHICAGO—In a finding that illustrates the stark realities of modern warfare, a military trauma study has shown that soldiers who sustained chest injuries in Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom had higher mortality rates than soldiers in Korea, Vietnam and Bosnia.

The finding surprised many surgeons who heard the results presented at the 2012 Clinical Congress of the American College of Surgeons (ACS). The results were, in the words of one surgeon, “counterintuitive.”

The investigators said that the results may be explained by advancements in other areas of battlefield care, namely triage and transport systems. Severely wounded soldiers who would have been killed in action in previous conflicts are more likely to survive in today’s wars and be sent to trauma centers in the United States.

“We feel that these findings are likely a reflection of our ability to get more severely injured soldiers, who otherwise may have died on the battlefield, to a medical facility,” said Capt. Katherine M. Ivey, MD, a resident in general surgery at San Antonio Military Medical Center, who presented the study.

Dr. Ivey and trauma surgeons from the U.S. Army Institute of Surgical Research in Fort Sam Houston, Texas, compared mortality rates from chest injuries in conflicts dating back to the Civil War, when 63% of

such injuries resulted in death compared with 10% in World War II, 2% in Korea and 3% in Vietnam. In the wars in Iraq and Afghanistan, the rate of mortality from chest injuries rose to 8.3%—9.2% in Afghanistan and 6.2% in Iraq.

The investigators said that advances in prehospital care, rapid transport and protective equipment for combat personnel may have resulted in more severely injured patients arriving alive at a field hospital or other medical facility, which contributed to increased mortality after admission.

‘This may serve as a cause to have our military consider blast injuries and take steps to equip our troops to be more protected from them.’

—John S. Ikonomidis, MD, PhD The researchers focused on injuries of the thorax and analyzed data from the Joint Theater Trauma Registry for U.S. soldiers who sustained a chest injury in Iraq and Afghanistan from January 2003 to May 2011. The analysis did not include soldiers killed in action.

Of 2,049 chest injuries analyzed in the two conflicts, 70% occurred in Operation Iraqi Freedom. The most common thoracic injuries were collapsed lung, pulmonary contusions and rib fractures. Most chest injuries were caused by penetrating trauma (61.5%), followed by blunt trauma (26.7%) and blast injuries (11.6%). In just over two-thirds of cases, the injured soldiers died

in the operating theater.

It is impossible to isolate a single cause of the high mortality rates from chest injuries, said John S. Ikonomidis, MD, PhD, Horace G. Smithy Professor and chief of cardiothoracic surgery, Medical University of South Carolina, Charleston. He moderated the ACS session during which the study was presented.

“I find it hard to believe that it was a problem with technology and availability of medical care. But for whatever reason, there has been a bit of a concerning—concerning to me—increase in mortality.

“I have to wonder if there has been a change in the trend of warfare and the trend of artillery that may have contributed to this. Certainly, we can see that these blast injuries are very bad. This may serve as a cause to have our military consider blast injuries and take steps to equip our troops to be more protected from them,” he said.

Helicopters and fixed-wing aircraft have long played a role in evacuating battlefield wounded. But in the Iraq and Afghanistan wars, the army has acquired the ability to move wounded patients to higher-level care centers in the United States “within days or weeks of injury as opposed to weeks or months,” the investigators said.

In all, 1,412 operations were performed at combat support hospitals, which are modern military field hospitals that provide a range of surgical and medical specialties and have ICUs. The study did not analyze specific transport factors that contributed to improved survivability of battlefield wounded. The investigators did not analyze why soldiers fighting in Iraq experienced a higher rate of chest injuries than in other wars.

Observing an Occult Pneumothorax Safe, but No Better Than Chest Tube B Y J AMES E. B ARONE , MD

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autious observation is likely safe but no better than tube thoracostomy for occult pneumothorax found on chest computed tomography (CT) scan, according to results from a randomized trial presented at the 2012 annual meeting of the American Association for the Surgery of Trauma.

With the liberal use of CT scanning for trauma patients, occult pneumothorax (a pneumothorax seen on CT scan but not on plain chest x-ray) is being discovered more frequently. Previous studies have reported conflicting results for the two management strategies.

A randomized multicenter, unblinded trial from four Canadian trauma centers included 52 patients in the observation group and 40 patients in the group treated with chest tubes after discovering their occult pneumothoraces. All patients enrolled in the study were adults.

Baseline characteristics and injury severity scores of patients in both groups were similar. Patients who were randomized to observation were allowed to undergo tube thoracostomy at the discretion of the attending surgeon or for respiratory distress, difficulty weaning or increasing pleural fluid collections.

Andrew W. Kirkpatrick, MD, medical director of trauma services at the University of Calgary and lead author of the study commented by email to General Surgery Newss that it was hard to tell exactly what triggered

the decision to place a tube.

“A conclusion that we are coming to with looking and relooking at all the data is that no patient got into trouble with just an elective operation and an occult pneumothorax, but about 25% of those needing prolonged positive pressure ventilation required a tube for some, often multifactorial reason,” Dr. Kirkpatrick said.

The primary outcome, which was the incidence of respiratory distress, and the secondary outcomes of mortality rate, number of ventilator days, ICU length of stay (LOS) and hospital LOS were not significantly different. Of the patients who were initially treated with chest tubes, 15% had complications related to the tubes and another 15% had tubes that were not optimally placed.

Regarding the malpositioned chest tubes, Dr. Kirkpatrick said, “Several required repositioning but none of these [required] replacement; otherwise, they would have been upgraded to a ‘major’ complication.”

One patient in the observation group suffered a tension pneumothorax that was successfully treated, and 21% of the observed patients eventually required insertion of a chest tube for such problems as progression of

the pneumothorax, increased plural effusion size, pneumonia or acute respiratory distress syndrome.

The invited discussant of the paper, Raul Coimbra, MD, chief of trauma at the University of California San Diego Health System, was not involved with the study.

He told General Surgery Newss that the authors should be applauded for performing a prospective, randomized multi-institutional study.

“This is the right methodology to answer critical questions related to a difficult clinical problem.”

Dr. Coimbra added, “Based on our own data which led to an [American Association for the Surgery of Trauma] multi-institutional study and the data presented in Dr. Kirkpatrick’s manuscript, we use chest tubes selectively.”

Dr. Coimbra feels that a period of observation is safe for patients with occult pneumothorax even when undergoing positive pressure ventilation. “The key here is awareness of the presence of the pneumothorax and close clinical observation and monitoring,” he said.

Dr. Kirkpatrick and his fellow researchers concluded that both treatments have distinct complications and “cautious routine observation with immediate ondemand pleural drainage seems safe but not proven better.”

They plan to continue enrolling patients in the study.

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

How They Coped: Docs, Staff Go Extra Mile in Wake of Sandy B Y M ONICA J. S MITH New York—By the time Hurricane Sandy, the largest Atlantic hurricane ever recorded, was over, the storm had claimed an estimated 200 lives in seven countries, cost tens of billions of dollars through direct damages and business interruptions, and laid waste to hundreds of miles of coastline. In the United States, Sandy swept the east coast from Florida to Maine, traveling inland as far west as Michigan and Wisconsin.

New York City was hit particularly hard when the storm made landfall in the early morning of Oct. 29, with surging waters that flooded tunnels, subway lines and streets. A power outage left most of Manhattan, south of about 40th Street, dark for the better part of a week and crippled mass transit services throughout the region.

Some low-lying neighborhoods—the Rockaways, in Queens, and Coney Island and Red Hook, in Brooklyn—experienced widespread destruction from floods and fires. Staten Island, where floods initially claimed eight lives within an area of about eight blocks, had the highest density of storm-related mortalities in the country. Fuel shortages and lack of power at the majority of service stations in New York City, Long Island and New Jersey resulted in rationing and hours-long lines at the gas stations. The New Jersey coastline was badly battered, with mass devastation crippling coastal towns. Even two weeks after the storm, some areas in the outer boroughs, Long Island and New Jersey remained without power.

Hospitals and medical centers were not immune to the destruction. In New York City, five major medical centers—New York Downtown Hospital, Coney Island Hospital, Bellevue Hospital Center, Manhattan Veterans Affairs Medical Center and New York University (NYU) Langone Medical Center—moved their most vulnerable patients before the storm hit, and were forced to evacuate remaining patients to nearby centers when flooding and other storm-related damages forced them to close. New York Downtown Hospital quickly reopened and Coney Island Hospital offered limited services in the days after the storm. It is now partly functional, but the inpatient department and emergency room are still closed.

NYU Langone Medical Center Hit Hard NYU Langone was able to get most of its ambulatory

NYU Langone Medical Center and neighboring Bellevue Hospital Center, situated along the East River in Manhattan, both suffered unprecedented flooding and were forced to close.

Photo: Cynthia Gordon, PhD

care centers and faculty group practices up and running less than a week after Sandy hit, but the medical center’s main campus, including its emergency department, laboratory testing services and blood bank are still closed.

New York City is no stranger to volatile weather and tropical storms, and NYU’s emergency power system was designed to meet all safety codes.

“We believed we could withstand a surge of approximately 12 feet, which is above the 100-year flood level for New York City,” wrote Christopher Rucas, director of media relations, in an email, noting that the facility did not experience any major damages during Hurricane Irene in 2011. This time, however, the basement of Langone, one of the city’s top academic medical centers, was flooded by the East River, causing damage that resulted in the failure of its emergency electrical systems, which will require extensive resources to repair and rebuild.

“Even though our facility and our faculty and staff were trained and prepared for the storm, this was an unprecedented event,” Mr. Rucas said. “The surge from Hurricane Sandy was recorded at 13.88 feet at Battery Park, which was 2.68 feet higher than the record level in 1821. In our location, we believe the surge from Sandy may have been even higher.”

“You saw whole lives—pictures, beds, televisions, couches—piled up by the side of the road, all the way down the street. People who didn’t have boats had boats sitting on their lawns that just floated into town. Signs from restaurants and stores crossed the river and drifted into people’s yards. It was absolutely shocking,” said Howard Ross, MD, of the devastation in Monmouth County, N.J. Photo: Trevor Higginson

Jacobi Helps Rescue Shuttered Bellevue With the closing of these large, major medical centers, neighboring facilities rose to the challenge to accommodate redirected patients and, in some cases, staff that needed to continue working and residents who needed to continue learning. In one case, Jacobi Medical Center/North Central Bronx Hospital, a member hospital of New York City Health and Hospitals Corporation (NYCHHC), opened up new wings of its facility and mobilized staff to accommodate patients evacuated from Bellevue, also an NYCHHC facility.

“I’ve spoken with some of the patients who were transferred over,” said Peter K. Kim, MD, assistant professor of surgery at Albert Einstein College of Medicine, New York City. “[Bellevue] was without power, and physicians and nurses carried patients down stairs in the dark.

Ambulances waiting out front brought them to all the city hospitals that could provide services.”

Eric Manheimer, MD, former medical director of Bellevue, gave his account of that hospital’s harrowing evacuation in a New England Journal of Medicinee editorial that was published online on Nov. 14 (www.nejm.org/ doi/full/10.1056/NEJMp1213611): “Prisoners, hundreds of psychiatric patients, neonates, new mothers, post-op surgical patients, ICU patients on ventilators—the breadth and depth of an acute care hospital in the flood zone needed to go, stat. The power went, the elevators filled with water, one generator after another failed. Firefighters, EMTs and police officers helped hospital staff walk, carry and slide patients down through darkened stairwells on hard plastic boards to waiting taxis, car services and ambulances. Staff organized bucket brigades to take

water to patient floors and fuel to generators.”

Jacobi Medical Center had preemptively cancelled all elective operations before the storm and discharged patients who could go home in the event that after the storm they might not be able to get home. Still, physicians, surgeons, residents, nurses and staff all worked overtime to provide care for the influx of new patients, many of whom were very ill, in need of surgery or immediate postoperative care.

“It was very busy for the people on call,” Dr. Kim said. “But some people were sort of trapped in the hospital; many live in Manhattan and couldn’t get back, so they slept in the hospital and helped take care of these patients.”

Jacobi did lack some services that it would normally have, such as social workers who were unable to make it to work on the day of the storm and for the two days after. But the medical center picked up some of Bellevue’s nurses and residents, for whom the transition went fairly smoothly, partly because the operating systems between Jacobi and Bellevue are quite similar. “So it’s not like you’re working in a different system,” Dr. Kim said.

Furthermore, Jacobi is well versed in disaster care.

“Last year we were involved with the Bronx bus accident—the worst bus accident in New York City’s history—and we all came together and took care of those patients,” Dr. Kim said. “I think a lot of us who work at Jacobi, a level 1 trauma center, are used to being ready for anything, and being creative.”

In a second New England Journal of Medicine editorial published online on Nov. 14 (www.nejm.org/doi/ full/10.1056/NEJMp1213843), Danielle Ofri, MD, PhD, described the effects of the hurricane on Bellevue: “The 4,000 faculty and staff members, residents and see HURRICANE SANDY PAGE 8

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GEN GE G E N ERA EN EER RA A LSUR L SU LS LSU S RGERYN R GEE RYN RGE R YYN RYNEWS N EW E WS EWS S .CO . CO .C OM M / GEN G EENERA EN ERA A L SURG S URG URGERY E RY ERY R Y NE N E WS W S / JA J NUA A RY 201 2 013 20 01 3

HURRICANE SANDY jContinued from page 7

medical students of Bellevue have been dispersed throughout the five boroughs, taking care of our inpatients, struggling to care for our tens of thousands of outpatients. The generosity of spirit from the hosting hospitals, our peripatetic patients, and our coworkers has been boundless. But without our nexus of Bellevue to knit us together, we feel unmoored. When a hospital is forced to halt, it’s not just the patients who are evacuated.” Bellevue expects to be fully operational by February 2013.

Staff Shortages Pose a Problem At NewYork-Presbyterian NewYork-Presbyterian Hospital/Weill Cornell Medical Center sits on a platform suspended above FDR Drive, which runs alongside the East River in Manhattan. Water lapped up over the drive and caused extensive flooding on the Upper East Side of Manhattan, but did not cause any major damages to the hospital, which also did not lose power.

“Fortunately, there was no damage to critical systems,” said Philip S. Barie, MD, MBA, professor of surgery and public health, at Cornell, and chief of acute care surgery at the hospital.

“We were affected more from a human resources perspective,” he said.

Some could not make it in to work, whereas others were unable to leave. One ICU nurse worked eight days in a row before being able to return to her home in New Jersey, and a clinical pharmacist worked five or six days in a row before she was able to return to her home in

about 40% of its capability to perform surgeries, and had returned to performing limited elective procedures, “depending, it seems kind of silly, but in part on which doctors and patients could get here,” Dr. Barie said. “I did one elective procedure on Wednesday because I was around and my patient lived in the neighborhood and was willing to proceed as scheduled.”

By Thursday, Weill Cornell Medical Center was functioning normally, but had to contend with a substantial increase in demand for trauma care.

Many of the trauma patients arriving at NewYork-Presbyterian after the storm had the same types of injuries as those seen during the blackout of 2003.

“Last year we were involved with the Bronx bus accident— the worst bus accident in New York City’s history—and we all came together and took care of those patients. I think a lot of us who work at Jacobi, a level 1 trauma center, are used to being ready for anything, and being creative.”

Peter K. Kim, MD Queens. The center set up shower facilities, helped match people with temporary roommates nearby and kept everyone fed.

“Everybody pitched in to keep us functional,” Dr. Barie said.

In preparation for the storm, the center activated its disaster plan the Friday evening before Sandy hit, cancelling all elective surgeries and closing the urgent care center to preserve resources for emergencies.

“Because of staff shortages, we were able to operate only two of our 38 operating rooms on Monday. But by Tuesday, we were able to get 11 operating rooms staffed and functional,” Dr. Barie said.

By Wednesday the center had reached

“We saw a lot of head injuries from people falling either on the darkened streets or in their darkened apartments. We saw exactly the same phenomenon when we had the blackout,” Dr. Barie said.

The trauma volume at Bellevue and NewYork-Presbyterian are about equal, so it stands to reason that the latter experienced a 100% increase in emergency room visits and trauma admissions. At one point during the height of the storm and its immediate aftermath, NewYorkPresbyterian had patients on gurneys in the lobby, as its disaster plan calls for.

The emergency department, operating rooms and ICUs were at full capacity.

“The docs are all for it—that’s what we’re here for. But I’m starting to hear

stories that other people who are integral parts of the team are stretched pretty thin. Trauma patients, in particular, are very needy. It’s putting a lot of stress on our physical therapists and social workers,” Dr. Barie said at the time.

As for the rest of the city, two weeks after the storm, the areas that were hit most severely continued to dig out, and some in the outer boroughs were still without power. Most public transportation had been restored, but gasoline rationing was still in effect. The use of sanitation vehicles to clear snow from the streets after a nor’easter blew through town a week after the hurricane added to the somewhat alien, postdisaster effect.

“In New York City, they put plow blades on the garbage trucks, so when there is a snow emergency, they stop collecting garbage,” Dr. Barie said.

Two Jersey Shore Hospitals Survive The Storm Jersey Shore University Medical Center was designed with generators capable of running the entire hospital in the event of power outages, and when Hurricane Sandy hit, the facility was successfully sustained by generator-only power for two days, during which only emergency procedures were performed.

“But after that, they were pretty much full court press,” said Glenn Parker, MD, vice chair of the Department of Surgery.

The administrators set up a command center in the boardroom and designated different areas of the hospital for preoperative care and a holding area to contain overflow from the emergency department.

“They were prepared from the standpoint of administrators, physicians and nurses,” Dr. Parker said. “There was also a tremendous amount of coordination

Above: A decimated boardwalk in Rockaway Beach, Queens, serves as a reminder to residents of the devastating potential of the nearby ocean.

Photo: Cynthia Gordon, PhD

trying to get patients out of the hospital— into a rehabilitative facility or home— before the hurricane hit to allow for accommodation if there were any catastrophic events or multiple injuries.”

As efficient as the hospital was, communications were complicated by the enduring loss of power to Ocean Township.

“The phone service for our office went down because there was no power, so we had to cancel office hours for the week,” Dr. Parker said. “Ultimately, once the phone service was up and running, we were able to rig a number and work around that, so any patient who absolutely had to be seen could reach us through the hospital. The operators would connect the patients to us, and we were usually able to see them in the emergency room.”

The hospital cut back to doing only emergency procedures during the first two days of the storm, but Dr. Parker resumed a nearly full schedule of surgery shortly thereafter.

“I was able to do two colon resections a day without a problem—mostly inhouse patients, but some from the elective schedule,” he said.

There were some, however, on whom they could not operate due to the storm’s effect on their homes.

“They couldn’t go home to a dark place without power or hot water and expect to convalesce; there were a number of cases where we couldn’t operate on patients because their homes were wiped out. They had no place to heal,” Dr. Parker said.

For Howard Ross, MD, director of the Colon and Rectal Oncology Program at

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Meridian Health System, chief of colon and rectal surgery at Riverview Medical Center and clinical associate professor of surgery at University of Medicine and Dentistry, New Jersey, in Red Bank, his hospital literally served as a port in the storm.

“It was the only place to get warm,” Dr. Ross said.

“The hospital was really extraordinary through all of this. It went on generator power, so it always functioned. But what was really awe-inspiring to me was how some of the unsung heroes—custodians, patient transport, cafeteria workers,

the people who don’t get a lot of glamour—hung on in the hospital through the storm and afterward, even though their families were at home.”

The hospital served as a shelter and second home for the people who worked there, most of whom were without power for 12 days.

“We had no heat, no light [at home].

It was almost sensory deprivation, except when you were in the hospital, which was functioning. It made me very proud to be associated with the hospital and medicine during this time that was so hard for the shore.”

Monmouth Hospital Prevails, But Residents Devastated Several days after the storm, Monmouth and Ocean counties resembled a war zone in their devastation. “It’s an absolute tragedy,” Dr. Ross said. “If you’re not from here, it’s hard to understand how badly it was actually hit. These are beach towns and they got absolutely decimated.”

Unable to conduct office hours during the week after the storm, Dr. Ross and other physicians and hospital colleagues set out to help friends and neighbors clean up.

“You saw whole lives—pictures, beds,

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televisions, couches—piled up by the side of the road, all the way down the street.

People who didn’t have boats had boats sitting on their lawns that just floated into town. Signs from restaurants and stores crossed the river and drifted into people’s yards. It was absolutely shocking.”

Even for residents of the two counties who do not live on the water, the beach towns are a focal point of their lives, and the devastation was emotionally wrenching.

“We go to [the towns] not just in summers, but in off seasons. The most special time to be at the beach is in the fall or spring, when it’s only the locals. Now to see the towns where entire storefronts are blown out, no glass, big red Xs meaning they’re uninhabitable. … It’s very sad,” Dr. Ross said.

In the week or so after the storm, during which time Michael A. Goldfarb, MD, chairman/program director of surgery at Monmouth Medical Center, was able to rely on a gas-powered generator to light and heat his home, he and his family helped out those less fortunate.

“We took them in the house. They slept here; we fed them. Friends walked in and showered. It was kind of a revolving door,” he said.

“Most of the people around here left or are staying with friends who have generators at their houses,” he continued. “But that’s small stuff. A lot of people were killed.”

Dr. Goldfarb’s medical center, backed by generators, never lost power and was efficiently managed throughout the crisis. Less than 10 days after the storm, the hospital was running at full steam.

“But the lost revenue for a week in a hospital is unbelievable,” Dr. Goldfarb said. “The residents and nurses and everyone pitched in, but it’s a matter of getting there, too. The roads were blocked with downed trees and wires.”

The hospitals will recover from their financial losses, and the people whose properties were damaged will repair them. But the bigger question is what will become of those who lost their homes entirely?

“Do they rebuild where they were living, raise houses in the air? Do they knock down their houses and collect $250,000 in flood insurance, if they're lucky? I don’t know what people who live in low-lying areas are going to do,” Dr. Goldfarb said.

“This is not a five-mile or one-town problem. This is a 1,000-mile problem.”

If Hurricanes Irene and Sandy, described as once-in-a-lifetime storms yet both occurring within a toddler’s years, are harbingers of emergent weather patterns and storms to come, our days of enjoying the pleasures vast and simple of proximity to oceans, beaches and rivers may indeed be numbered.

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Stitches

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Josep Trueta, Creator of Innovative Method for Open Fractures B Y V ICTORIA S TERN

S

urgeons tend to refer to the same gods of surgery. In 1846, Antonin Jean Desormeaux, often called the “Father of Endoscopy,” performed the first successful operative procedure with an endoscope called “cystoscopy”—a technique that allows surgeons to navigate the urethra and study the urinary bladder—using an alcohol lamp for his

light source. William Morton, another great innovator, was the first to demonstrate anesthesia, also in 1846.

There are, however, innovators in surgery who have made great strides in the field, but whose stories are less well known. General Surgery Newss presents a new column, called Stitches, which illuminates some of these accomplishments.

Take, for example, Josep Trueta Raspall, MD. During the Spanish Civil War, Dr. Trueta’s development of the

closed-plaster method for treatOct. 27, 1897, into a family ing open fractures revolutionized of doctors. Pressure from his orthopedic practice, and saved father prompted Dr. Trueta countless limbs and lives. Before to leave behind his dream of Dr. Trueta devised this technique, becoming a painter. Instead, known as the Trueta Method, serihe studied to be a surgeon, ous fractures were associated with graduating from the Universihigh rates of gas gangrene, amputy of Barcelona as a doctor of tation and death. Before World Josep Trueta medicine in 1921.

War I, the mortality rate from open femWhile traveling through Europe, he oral fractures was more than 70%. met another physician, Lorenz Böhler, Dr. Trueta was born in Barcelona on MD, who has been described as one of the originators—if not the originator—of modern accident surgery. Dr. Böhler was the head of a premier hospital in Vienna dedicated to war causalities and acci® dents, and Dr. Trueta saw firsthand the most advanced treatments of war wounds at that time. Dr. Böhler treated fractures using the open method, which involved encasing a patient’s limb in a non-padded plaster cast fitted with a small window so the wound could be drained and observed. After being repaired, wounds ® often were left exposed to the air.

Inspired by Dr. Böhler’s work, Dr. TruIn cancer surgery, the single most important eta went home to Barcelona and, in 1929, ƉƌĞĚŝĐƚŽƌ ŽĨ ůŽĐĂů ƌĞĐƵƌƌĞŶĐĞ ŝƐ ƚŚĞ ƟƐƐƵĞ ŵĂƌŐŝŶƐ͘1 became chief surgeon at the Caja de Prevision y Socorro, which treated more than 40,000 accident cases per year. At this The Problem time, he began researching wound care Medical research shows discordance rates of and osteomyelitis, a bone infection caused ϯϭй ƚŽ ϱϮй ŝŶ ƚŚĞ ŝĚĞŶƟĮĐĂƟŽŶ ŽĨ ƐƉĞĐŝŵĞŶ by bacteria or other germs, and found the ŵĂƌŐŝŶƐ ďĞƚǁĞĞŶ ƐƵƌŐĞƌLJ͕ ƉĂƚŚŽůŽŐLJ ĂŶĚ ƌĂĚŝŽůŽŐLJ͘2,3 rate of infection remained high when the ZĞͲĞdžĐŝƐŝŽŶ ƌĂƚĞƐ ĞdžĐĞĞĚ ϮϬй ŝŶ ďƌĞĂƐƚ ƐƵƌŐĞƌLJ͘4 open method was used (Proc R Soc Med 1939;33:65-74). dŚĞ ^ŽůƵƟŽŶ͗ DĂƌŐŝŶDĂƌŬĞƌ ĂŶĚ ŽƌƌĞĐƚ ůŝƉƐ In 1936, the Spanish War broke out. sĞĐƚŽƌ ^ƵƌŐŝĐĂů͛Ɛ ƟƐƐƵĞ ŽƌŝĞŶƚĂƟŽŶ ƐLJƐƚĞŵ ƉƌŽǀŝĚĞƐ For three days in March 1938, Italian airƐĞĐƵƌĞ ĂŶĚ ĂĐĐƵƌĂƚĞ ĚĞƐŝŐŶĂƟŽŶ ŽĨ ƐƉĞĐŝŵĞŶ ŵĂƌŐŝŶƐ͕ crafts bombed Barcelona. During this ĐŽŶƚƌŝďƵƟŶŐ ƚŽ͗ time, Dr. Trueta, now a professor and head of the Department of Surgery at the Fewer unnecessary re-excisions Hospital de la Santa Creu i Sant Pau in More accurate re-excisions Barcelona, saw 2,200 casualties and treat Lower cancer recurrence ed 1,073 patients in his clinic. /ŵƉƌŽǀĞĚ KZ ƐĂĨĞƚLJ The devastation that Dr. Trueta witnessed pushed him to develop his revolutionary method for treating fractures, which significantly reduced the rate of infection. The technique involved four stages: performing surgery, cleaning the ® wound, draining and packing the wound, and immobilizing the limb in a cast.

Unlike his contemporaries, he believed that the greatest danger of infection was in the muscle, not in the bone. “Dead muscle tissue is a favorable soil for the www.vectorsurgical.com development of anaerobic infections, and +1 (262) 798-7970 for this reason must be excised meticu Ξ ϮϬϭϮ sĞĐƚŽƌ ^ƵƌŐŝĐĂů >> lously,” he wrote.

Dr. Trueta used a method called debridement, in which he excised all dead, dying, contaminated or damZĞĨĞƌĞŶĐĞƐ͗ ;ϭͿ ŽŽůĞLJ͕ t͘ ĂŶĚ WĂƌŬĞƌ͕ :͘ ͞hŶĚĞƌƐƚĂŶĚŝŶŐ ƚŚĞ DĞĐŚĂŶŝƐŵƐ ƌĞĂƟŶŐ &ĂůƐĞ aged subcutaneous tissue and muscle, WŽƐŝƟǀĞ >ƵŵƉĞĐƚŽŵLJ DĂƌŐŝŶƐ͘͟ American Journal of Surgery ϭϵϬ ;ϮϬϬϱͿ͗ ϲϬϲͲϲϬϴ͘ ;ϮͿ ƌŝƩŽŶ͕ but tried to conserve all healthy skin W͘ ͖͘ ^ŽŶŽĚĂ͕ >͘/͖͘ zĂŵĂŵŽƚŽ͕ ͘<͖͘ <ŽŽ͕ ͖͘ ^ŽŚ͕ ͖͘ ĂŶĚ 'ŽƵĚ͕ ͘ ͞ ƌĞĂƐƚ ^ƵƌŐŝĐĂů ^ƉĞĐŝŵĞŶ ZĂĚŝŽŐƌĂƉŚƐ͗ ,Žǁ ZĞůŝĂďůĞ ƌĞ dŚĞLJ͍͟ European Journal of Radiology ϳϵ ;ϮϬϭϭͿ͗ ϮϰϱͲϮϰϵ͘ ;ϯͿ and bone. Surgery, Dr. Trueta believed, DŽůŝŶĂ͕ D͘ ͖͘ ^ŶĞůů͕ ^͖͘ &ƌĂŶĐĞƐĐŚŝ͕ ͖͘ :ŽƌĚĂ͕ D͖͘ 'ŽŵĞnj͕ ͖͘ DŽīĂƚ͕ &͘>͖͘ WŽǁĞůů͕ :͖͘ ĂŶĚ ǀŝƐĂƌ͕ should be performed within eight ͘ ͞ ƌĞĂƐƚ ^ƉĞĐŝŵĞŶ KƌŝĞŶƚĂƟŽŶ͘͟ Annals of Surgical Oncology ϭϲ ;ϮϬϬϵͿ͗ ϮϴϱͲϮϴϴ͘ ;ϰͿ DĐ ĂŚŝůů͕ >͘ ͖͘ ^ŝŶŐůĞ͕ Z͘D͖͘ ŝĞůůŽ ŽǁůĞƐ͕ ͘:͖͘ &ĞŝŐĞůƐŽŶ͕ ,͘^͖͘ :ĂŵĞƐ͕ d͘ ͖͘ ĂƌŶĞLJ͕ d͖͘ ŶŐĞů͕ :͘D͖͘ ĂŶĚ hours of an accident, although often

D Ù¦®ÄD Ù» Ù® Ä ÊÙÙ ã ½®ÖÝ The New Standard ĨŽƌ dŝƐƐƵĞ KƌŝĞŶƚĂƟŽŶ

KŶŝƟůŽ͕ ͘ ͘ ͞sĂƌŝĂďŝůŝƚLJ ŝŶ ZĞĞdžĐŝƐŝŽŶ &ŽůůŽǁŝŶŐ ƌĞĂƐƚ ŽŶƐĞƌǀĂƟŽŶ ^ƵƌŐĞƌLJ͘͟ Journal of the ŵĞƌŝĐĂŶ DĞĚŝĐĂů ƐƐŽĐŝĂƟŽŶ ϯϬϳ͘ϱ ;ϮϬϭϮͿ͗ ϰϲϳͲϰϳϱ͘

Stitches

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Dr. Trueta performing his closed plaster method on a patient with open fracture of the lower leg.

Source: Actas Urol Esp 2008;32:276-280.

even sooner. “In wounds from shrapnel, and especially those produced by aerial bombs, infection occurs much earlier, often in less than four hours,” Dr. Trueta wrote in Proceedings of the Royal Society of Medicine (1939;33:65-74), where he first described his method.

Dr. Trueta would clean the wound with soap, water and a nailbrush, and apply a solution of iodine to the skin.

He then packed the wound with dry, sterile gauze,

and provided a method of drainage. “Good drainage is essential, for a badly drained cavity allows the collection of fluid, at first consisting of blood, but rapidly changing to pus,” Dr. Trueta wrote.

Finally, to allow the bone to heal, Dr. Trueta immobilized the limb in a cast made of plaster of Paris, considered the “best and least expensive material for splinting fractures because of its ease of application and stability” ((JAMA A 1932;99:158-159). Plaster of Paris, also called gypsum plaster, was molded around the patient’s leg to immobilize it. Dr. Trueta noted, “Immobilization constitutes one of the most effective means of preventing and combating infection. … This protection against movement can only be obtained by enclosing the extremity under a rigid casing which, while preventing all movement, even the most insignificant, permits a good circulation.” He did not advocate using plaster windows to monitor wounds, except in special cases, because they interfered with circulation at the fracture and disturbed the immobilized limb.

Of the 1,073 patients Dr. Trueta treated with his closed-plaster method, he found that 976 (91%) improved significantly; the patients’ limbs were preserved and, with time, healed effectively. Several patients experienced adverse events. Six patients died (0.56%); eight developed cellulitis and lymphangitis

(0.75%), which required removal of the plaster; and one experienced gas gangrene (0.09%).

In 1939, other surgeons employed Trueta’s Method and reported on its success to the Academy of Surgery in Paris. In one report, surgeons observed 800 soldiers wounded in Catalonia, most of whom received Trueta’s closed-plaster method, and found that their wounds healed, with minimal instances of infection and only one case of gas gangrene (Proc R Soc Medd 1939;33:6574). These striking results were the basis of Trueta’s books The Treatment of War Wounds and Fracturess and The Principles and Practice of War Surgery, both published in 1943.

During World War II, Dr. Trueta’s closed treatment of wounds became popular and helped to lower the rate of amputations and gas gangrene from 5% in World War I, with a 28% mortality rate, to 1.5% in World War II, with a 15% mortality rate and 0.08% in the Korean War with no mortality (Mil Medd 2004;169:265-269).

In Dr. Trueta’s obituary, published in the British edition of the Journal of Bone and Joint Surgeryy (1977;59B:243-245), Sir Herbert John Seddon called Dr. Trueta’s arrival in England “a godsend; after a short-lived display of characteristic British skepticism, we converted to the ‘closed-plaster’ regimen.” Another admirer wrote, “As an orthopedic thinker he will probably be judged by posterity as one of the most outstanding in his generation.”

Even 80 years after Dr. Trueta first introduced his method for managing wounds and fractures, surgeons continue to employ similar tactics, building on his original schema with advances in antibiotics and surgical equipment, to treat these injuries.

11

In the News jcontinued from page 1

care while the patient is still undergoing oncologic treatment.

Accredited cancer centers submit data about their current breast or colorectal cancer cases on a monthly or quarterly basis. The RQRS system tracks the data for adherence to five quality measures for breast and colon cancer that are endorsed by the National Quality Forum, a not-for-profit organization whose mission is to “improve the quality of American health care.”

These measures, which are considered the standard of care, include radiation therapy following breast-conserving surgery; multiadjuvant chemotherapy for hormone receptor–negative breast cancer patients; hormone therapy for hormone receptor–positive breast cancer patients; adjuvant therapy for lymph node–positive colon cancer patients; and the removal and pathologic examination of at least 12 regional lymph nodes for resected cancer.

The RQRS system will send an alert to the cancer center when patients are scheduled to enter the next stage of treatment. Physicians, cancer registrars and cancer program administrators have access to the feedback. For example, a hospital will receive a color-coded alert to indicate that staff should check on a patient’s treatment status when the RQRS does not receive a timely report confirming that a treatment decision or adjuvant therapy has been completed.

Furthermore, the RQRS system provides performance rates and comparisons to other centers, based on current patients and clinical practice.

Study researchers examined data from 64,129 breast and colorectal cancer patients treated between 2006 and 2010 at 64 RQRS-participating cancer programs nationally. The investigators assessed how well the cancer programs adhered to the five quality measures before and after participation in the program.

Analysis of the data showed that all five compliance rates rose considerably after hospitals joined RQRS. The greatest increase was in the number of patients who received hormone therapy for breast cancer, which grew from 47% in 2006 to 85% to 2010. Delivery of adjuvant chemotherapy for colon cancer increased 18%, from 68% to 86%, and the percentage of patients from whom 12 or more lymph nodes were retrieved rose from 70% to 90%.

“This study is really noteworthy in that the development of this database significantly improved cancer care within a very short period of time,” said Jyoti Patel, MD, a thoracic oncologist and associate professor of medicine, Feinberg School of Medicine of Northwestern University,

Chicago. “This sort of innovative feedback can provide real-time improvement in care, so it’s very exciting.”

Investigators also reported that performance rates differed by patient age, race and payer status (private insurance versus Medicare), but the relative number and size of the disparities were reduced in participating programs two years after implementing the RQRS system.

“The results from this analysis suggest that those differences may actually have been more of a reflection of incomplete data and information in the registries than a reflection of differences

in care delivery to subpopulations of patients,” said Andrew Stewart, MA, study coauthor and National Cancer Database senior manager at the ACS. These measures have been the focus of significant public awareness campaigns, led by professional organizations and the National Quality Forum, and they frequently are discussed at surgical and oncologic meetings.

Officials familiar with RQRS said that the system boosts compliance with quality measures because

Participants in the program said that they regularly “catch” patients who otherwise would have been missed, when the system issues an alert that the patient should have received adjuvant therapy.

Less pain. Less opioids.

OFIRMEV® provides significant fi pain relief1

OFIRMEV re educes opioid consu umption1

Mean pain relief scores after initial dose1

Reduction in morphine consumption1

(Total hip or knee replacement surgery)

(Total hip or knee replacement surgery) 60

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50

P P<0.05 1.2

OFIRMEV 1 g (q6h) + PCA morphine p (n=49) Placebo

–33%

+ PCA morphine (n=52)

Significant improvement over placebo + PCA morphine

Morphine (mg)

RQRS TRACKING

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Pain relief

12

0.6

40 30

–46%

20 10

17.8 mg .0

9.7 mg

57.4 mg

38.3 mg

0 0 .25.50.75 1

2

3

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Time (h) Sinattra et al (Pain Study 1) Randomized, double-blind, placebo-controlled, single- and repeated-dose 24-h study (n=101). Patients received OFIRMEV 1 g (q6h) + PCA morphine or placebo + PCA morphine the morning following total hip or knee replacement surgery.

Primary endpoint: pain relief measured on a 5-point verbal scale over 6 h. Morphine rescue was administered as needed. PP<0.05 at every time point.

Over 6 h P<0 <0.01 01

Over 24 h P<0 <0.01 01

Sinatra et al (Pain Study 1) Randomized, double-blind, placebo-controlled, single- and repeated-dose 24-h study (n=101). Patients received OFIRMEV 1 g (q6h) + PCA morphine or placebo + PCA morphine the morning following total hip or knee replacement surgery.

Primary endpoint: pain relief measured on a 5-point verbal scale over 6 h. Morphine rescue was administered as needed.

• The clinical benefit of reduced opioid consumption was not demonstrated

Indication OFIRMEV is indicated for the management of mild to moderate pain; the management of moderate to severe pain with adjunctive opioid analgesics; and the reduction of fever.

Important Safety Information OFIRMEV is contraindicated in patients with severe hepatic impairment, severe active liver disease or with known hypersensitivity to acetaminophen or to any of the excipients in the formulation. Acetaminophen should be used with caution in patients with the following conditions: hepatic impairment or active hepatic disease, alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment.

Do not exceed the maximum recommended daily dose of acetaminophen. Administration of acetaminophen by any route in doses higher than recommended may result in hepatic injury, including the risk of severe hepatotoxicity and death.

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Discontinue OFIRMEV immediately if symptoms associated with allergy or hypersensitivity occur.

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The antipyretic effects of OFIRMEV may mask fever in patients treated for postsurgical pain.

To report SUSPECTED ADVERSE REACTIONS, contact Cadence Pharmaceuticals, Inc. at 1-877-647-2239 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.com.

Please see Brief Summary of Prescribing Information on adjacent page or full Prescribing Information at OFIRMEV.com.

Reference: 1. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER, Groudine SB, Payen-Champenois C. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. y 2005;102:822-831.

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

it improves the coordination of evidence-based care among different disciplines, and it requires more complete reporting of adjuvant therapy data.

Participants in the program said that they regularly â&#x20AC;&#x153;catchâ&#x20AC;? patients who otherwise would have been missed, when the system issues an alert that the patient should have received adjuvant therapy. â&#x20AC;&#x153;We find that after about six to nine months of using RQRS, one-third of program participants report that they have prevented

RQRS patients from slipping through the cracks or not receiving timely adjuvant care,â&#x20AC;? Ms. McNamara said.

An anonymous RQRS participant said, â&#x20AC;&#x153;We have prevented at least two patients from slipping through the cracks. The oncology providers now ask for the reports to be given to them monthly so that they can review the yellow and orange alert cases and prevent any red alerts.â&#x20AC;?

The RQRS system is the only known disease-specific treatment monitoring system in the country. The program was launched nationally in September

From the start.

Administer OFIRMEV pre-op, then sched dule q6h CONTINUE WITH OFIRMEV IF:

Schedule hed d l OFIRMEV RM q6h for or first 24 hours

â&#x20AC;˘ Parenteral analgesia is clinically warranted â&#x20AC;˘ Coompromised GI absorption or inability to take oral analgesiccs â&#x20AC;˘ 1000% bioavailability desired

TRANSITION TO PO ANALGESIA WHEN: â&#x20AC;˘ PPatient ti t can ttake k andd absorb b b orall analgesics l i

Visit OFIRMEV.com to watch educational videos, download clinical case studies, register for live webinars, and much more

Š2012 Cadence Pharmaceuticals, Inc. All rights reserved.

OFIRMEV and the OFIRMEV dot design are trademarks of Cadence Pharmaceuticals, Inc.

OFV1132A1112

OFIRMEV.com

2011, in 66 test sites that are accredited by the Commission on Cancer. Currently, there are about 400 centers using the system.

The researchers are developing additional clinical measures to expand the use of RQRS to encompass adherence to quality measures for lung, stomach and esophagus cancers.

khorty@mcmahonmed.com.

13

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Gastric Bypass Patients Often Relapse After Diabetes Remission B Y G EORGE O CHOA

S

tudies have shown that gastric bypass surgery can achieve diabetes remission, but a new, large, long-term study suggests the remission may not always be permanent.

In the current study of patients who initially had complete remission, 35.1% redeveloped diabetes within five years.

When the patients who never remitted

and those who relapsed were added together, more than half of the patients (56%) did not have durable remission of diabetes (Obes Surgg 2012 Nov 18; doi 10.1007/ s11695-012-0802-1). However, there was evidence that patients who received earlier surgical intervention for their diabetes might have better outcomes.

“What’s new and different [about this trial] is that we focused on relapse of diabetes after patients have remitted,” David E. Arterburn, MD, associate investigator,

Group Health Research Institute, Seattle, and lead researcher on the study, told General Surgery News. “We followed them longer—beyond their initial remission—and found that by five years, 35% of patients had redeveloped diabetes. No prior studies have examined this question on this scale.”

Motivated by recent literature indicating the benefits, at least short term, of bariatric surgery for diabetes control, the researchers conducted a retrospective

‘We involved patients in real-world health care systems, not academic medical centers with highly specialized surgical teams.

Our study is a look at what happens to the average patient in routine clinical care.’

—David E. Arterburn, MD cohort study of adults with type 2 diabetes who received Roux-en-Y gastric bypass from 1995 to 2008 in three integrated health care delivery systems, one in Minnesota and two in California.

“We involved patients in real-world health care systems, not academic medical centers with highly specialized surgical teams,” Dr. Arterburn said. “Our study is a look at what happens to the average patient in routine clinical care.”

The study included 4,434 adults. Overall, 68.2% (95% confidence interval [CI], 66%-70%) had complete diabetes remission within five years postsurgery. Among these, 35.1% (95% CI, 32%-38%) redeveloped diabetes within five years. The median duration of remission was 8.3 years (3,019 days; 95% CI, 2,507-3,281 days). Factors significantly associated with higher relapse rate included longer diabetes duration, insulin use and poor preoperative glycemic control (hemoglobin [Hb]A1c ≥6.5%).

In secondary analyses, weight trajectories after surgery differed significantly among never remitters, relapsers and durable remitters (P=0.03).

P Patients who never remitted had slightly less weight loss and greater weight regain than those who remitted. Those who relapsed had similar if not slightly superior body mass index (BMI) maintenance after surgery than those with durable remission. Preoperative BMI values did not differ significantly (P=0.93) P among the three groups.

“For most patients with type 2 diabetes, gastric bypass is not a cure,” said Dr. Arterburn.

Dr. Arterburn and his colleagues identified three factors that they believe most strongly affect durable remission of diabetes after bariatric surgery: 1. How long did the patient have diabetes at the time of surgery? The longer the period, the less likely they were to have a remission and the more likely to relapse.

2. Was the patient on insulin therapy?

Patients were less likely to remit and more likely to relapse if they were on

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

insulin at the time of surgery.

Was the patient’s blood sugar controlled at the time of surgery? If blood sugar was poorly controlled at the time of surgery, the patient was less likely to remit and more likely to relapse.

“These are all markers of how severe one’s diabetes is. We concluded that patients with more severe diabetes are likely to benefit less than patients with less severe diabetes. Patients with early diabetes appear to benefit more,” Dr. Arterburn said.

“The biggest message is early intervention in diabetic patients with obesity,” said Jaime Ponce, MD, FACS, FASMBS, president, American Society for Metabolic & Bariatric Surgery, Gainesville, Fla. “Evaluate them for bariatric surgery at BMI of 35 [kg/m2] and at 30 to 35 with diabetes requiring more medications.”

“Because patients who had earlier disease achieved a higher percentage of longterm remission, physicians and patients should consider earlier intervention”— within five to 10 years of diagnosis, said Philip Schauer, MD, director, Bariatric and Metabolic Institute, Cleveland Clinic, in Ohio. “If they wait until their diabetes is more advanced, they’ll have less of a chance for long-term remission.”

Of the new research, Dr. Schauer said, “This study supports what other studies have shown: Not all patients will have a long-term remission.” However, he noted, “a lot of patients who are so-called relapsing are still in good blood sugar control. If their HbA1cc is 6% to 7% compared with higher than 7% before surgery, their control is relatively good.”

The potential benefits of a period of remission for patients who relapsed 3.

remain unclear, according to Dr. Ponce.

“We still don’t know, in patients who got their diabetes back, whether they got a benefit in the years diabetes was in remission,” he said. “Out-of-control diabetes can increase the risk for retinopathy, nephropathy and liver damage, and cause vascular changes and cardiac damage.

They didn’t study the benefit out of those years. We need a longer study with a longer follow-up. Even a few years of benefit would be valuable.”

“We do believe and hope to confirm with a future study that even a short period of diabetes remission [in patients who

eventually relapse] will have long-lasting benefits compared with those who didn’t have remission or didn’t get surgery,” Dr. Arterburn said.

Limitations of the study noted by Dr. Ponce included not looking at results per variations in technique of bypass, and not having sufficient data to analyze differences in outcomes by race or ethnicity. Dr. Schauer noted the low five-year retention rate of 67.8%. “They’re missing a lot of patients at the five-year mark,” he said. “We would like to see retention rates of 80% to 90%.”

Dr. Schauer stated that a definitive

multicenter randomized controlled trial comparing medical and surgical treatment is needed to determine the true effects of bariatric surgery on patients with diabetes. “[The study] should evaluate not just blood sugar control but occurrence of diabetic complications. Some might interpret this study as ‘surgery doesn’t cure everybody,’ which is true. But the real value of surgery is not just in achieving remission in some patients, which is remarkable, but its ability to substantially improve even those patients who don’t achieve remission.”

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AT A GLANCE In a study of 4,434 adults, 68.2% of patients who had gastric bypass had complete diabetes remission within five years postsurgery.

Of the 68.2% of patients who were in remission five years after gastric bypass surgery, 35% then redeveloped diabetes within five years.

Factors significantly associated with higher relapse rate included longer diabetes duration, insulin use and poor preoperative glycemic control.

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Dear Readers,

Surgeon’s Challenge No. 1 From December 2012 Issue

Welcome to the January issue off The Surgeons’ Lounge, and Haappy New Year to all our readers! I hope everyone had a happy and safe holidaay and is ready for another year oof timely and interesting topics, discussions, challenges, historical facts, international updates, tor and of course, our readers’ feedback.

In this first issue of 2013, Dr. Manoel Galvao Neto, MD, scientific coordinator of Gastro-Obeso Center, in Sao Paulo, Brazil, discusses the case of a patient with post-laparoscopic sleeve gastrectomy with an Angle of His gastrocutaneous fistula.

The answer to one of the three challenges from the December issue is provided here. Stay tuned for

the other two! The next issue will feature Ann M. Rogers, MD, FACS, director, Penn State Surgical Weight Loss Program and associate professor of surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pa. I look forward to your questions, comments and feedback.

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

Answer

Collaborators: Boris Hristov, MS, Florida International University, Herbert Wertheim College of Medicine, Miami, and Hira Ahmad, MD (PGY-1), Cleveland Clinic Florida Surgery Residency Program, Weston he patient is a previously healthy 38-year-old man.

His past medical history is negative. He has no allergies and is not taking any medications. He initially presented to his primary care physician with complaints of an extremely painful small lump on his upper right abdomen. He stated that the pain was severe and affecting his quality of life. On physical examination, he had a very small, difficult-to-palpate and exquisitely tender subcutaneous nodule, approximately 1 cm, that was soft and mobile. There were no associated symptoms such as erythema, fever or chills. The rest of his physical exam was benign. Due to the atypical symptoms for such a small barely palpable nodule, a computed tomography (CT) scan of the abdomen was performed and showed an opacity in the subcutaneous fat (Figure 1). Lab results (complete blood cell count and comprehensive metabolic rate) were within normal ranges. The patient was diagnosed with a possible symptomatic lipoma.

What would you do for this barely palpable but very tender “mass”?

The patient’s surgery to remove the abdominal mass was performed approximately three months after his initial visit to his primary care physician. Once the initial skin incision was made, the mass was no longer palpable. Good marking of the zone was done preoperatively in the holding area.

What would you do now?

Although the mass was no longer palpable or evident, the subcutaneous fat in the area of the mass was widely excised, based on the CT scan findings.

The gross appearance of the specimen was not distinguishable from normal adipose tissue and the removed specimen was sent to pathology.

What would you tell the patient?

The pathology report was completed one week later and the mass was identified as a CD34-positive dermatofibrosarcoma protuberans (DFSP).

What would you do now?

T

Figure 1. A computed tomography [CT] scan of the abdomen showing an opacity in the subcutaneous fat.

The patient subsequently was scheduled for a wider excision. During the second operation, the abdominal fascia below the original specimen was excised through an elliptical excision and the specimen was sent to pathology, which ultimately was positive for DFSP with clear margins. The patient’s only postoperative complication was hematoma, which was evacuated on the same day. The patient was scheduled for monitoring by an oncologist for any subsequent recurrence.

DFSP is an exceedingly rare skin tumor—its incidence rate is about one case per million per year— and is classified as a cutaneous soft tissue sarcoma.

The tumor usually occurs in adults between 20 and 50 years old and is as frequent in men as it is in women.

Clinically, the tumor appears as an indurated plaque or nodule that may be violaceous, reddish brown or flesh-colored. These lesions occur on the torso in 50% to 60% of cases, with less common involvement of the proximal extremities, the head and the neck. The tumor usually is attached to the overlying skin and sometimes to the fascia below as well. It metastasizes at a low rate of 2% to 5%, but it is locally aggressive if not completely excised. Mohs surgery with 2- to 4-cm margins is the current standard of care for DFSP, according to guidelines set by the National

Dr. Szomstein n is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.

Comprehensive Cancer Network (NCCN). Usually, Mohs surgery with negative margins is curative.

The NCCN’s non-melanoma guidelines (basal cell and squamous cell skin cancer) include: Category 1. Based on high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2A. Based on lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2B. Based on lower-level evidence, there is NCCN consensus that the intervention is appropriate.

Category 3. Based on any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

All recommendations are category 2A unless otherwise noted.1 Radiation therapy is sometimes used as an adjunct to surgery, especially when the excision margins are not clear. DFSP recurs if it is not excised completely. Additionally, there is some research on control of DFSP proliferation with platelet-derived growth factor antagonists, which can induce apoptosis in the tumor cells.

DFSP has a low rate of metastasis but it is locally aggressive, with a recurrence rate between 49% and 80%. The five-year survival rate for this patient’s condition is estimated at 99.2% based on average survival rates, and most likely he will make a full recovery.

With a 2- to 3-cm wide excision margin, the recurrence rate is about 20%. However, if Mohs surgery is chosen, the recurrence rate is as low as 1%.

This case is relevant not only as a presentation of a rare sarcoma, but as an illustration of the need for vigilance in patients who often present with seemingly benign conditions but may instead have a serious underlying disease. In this case, the patient had a barely palpable mass of less than 1 cm at presentation that was assumed to be a lipoma. However, in retrospect, the severe pain that the patient complained of was not consistent with a typical lipoma presentation.

It should be noted that the initial reading of the CT scan of the patient’s abdomen was negative, despite the presence of a small but distinct opacity in the subcutaneous fat. This should raise suspicion because lipomas usually show up as isodense on CT scans. DFSP

Surgeons’ Lounge

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Question for Dr. Galvao Neto Lyz Bezerra, MD

Question:

•

We are thinking of converting the sleeve to a gastric bypass. Do you think there is anything further to be done endoscopically for this patient before converting to a gastric bypass?

Recife, Pernambuco, Brazil

43-year-old woman presented with post-laparoscopic sleeve gastrectomy with an Angle of His gastrocutaneous fistula. Six months before, the patient had the surgery for morbid obesity. She had a body mass index of 42 kg/m2, hypertension and sleep apnea.

The procedure was uneventful and the patient was discharged on postoperative day 2. Nine days later, the patient started to complain of fever and shoulder pain and was admitted to the emergency department with tachycardia, tachypnea and a temperature of 39 C (102 F).

A computed tomography (CT) scan showed perigastric fluid. The patient underwent exploratory laparoscopy, which revealed an abdominal abscess and a 1-cm opening of the staple line at the level of the Angle of His. The abdominal cavity was washed; the opening was sutured; drains were placed; and a nasoenteric tube was inserted to deliver nutrition. On follow-up, sepsis was resolved but the patient developed a gastrocutaneous fistula that persisted for six months, despite three endoscopic attempts to close it with clips and glue.

The fistula also led to prolonged total parenteral nutrition.

A

has a distinct lobular or nodular structure that typically is hypervascular. In this particular case, the structure of the mass was difficult to evaluate due to its small size.

This patient had only two clues that his abdominal mass was not a lipoma: his severe pain and the abnormal appearance of the CT scan. Both findings easily could have been missed or dismissed without proper vigilance.

Furthermore, during the initial excision, it was noted that the removed mass was virtually indistinguishable from the subcutaneous fat in both appearance and texture. This case illustrates the importance of a good excision technique for suspicious masses to ensure that even if the mass cannot be excised entirely, the specimen is large enough for pathologic evaluation.

References 1. NCCN Clinical Practice Guidelines in Oncology. Categories of evidence and consensus for dermatofibrosarcoma protuberans. http://www.nccn.org/ professionals/physician_gls/f_guidelines.asp.

Dr. Galvao Neto’s

Reply

The sleeve gastrectomy has gained popularity as the primary treatment for patients with morbid obesity because it is a less complex procedure with good outcomes. However, the associated complications, specifically stenosis and leaks, now are being better understood in that their clinical outcomes are more likely to become chronic and their treatment to be more complex, compared with the gastric bypass or gastric band.

Leaks that occur after gastric bypass and sleeve gastrectomy are among the worst, and possibly the most feared, complications in bariatric surgery. From the perspective of healing, it appears that the two procedures have different outcomes in terms of leakage. The gastric bypass has a well-established and known endoscopic approach, whereas leaks that occur after the sleeve gastrectomy point in another direction, especially at the Angle of His and when performed with a primary bariatric intention using thinner French bougies (32 to 36 Fr).

Unlike a fistula that occurs after gastric bypass and tends to heal with a conservative approach, the Angle of His fistula (the most frequent one) after sleeve gastrectomy tends to become chronic, and demands an alternative endoscopic approach divided into early (up to 40 days) and late-occurring treatments. The medical literature is sparse in addressing this complication: Common practice among medical centers that deal with these types of complications is the traditional endoscopic approach of “closing the hole,” which does not achieve satisfactory healing rates. The Angle of His leak has specific conditions that have a unique and unusual pattern: • poor irrigation • absence of the remnant stomach to block or patch the leak • physiologic obstruction of the pylorus • severe narrowing at the level of the incisura angularis • body–antrum axis deviation and the “corkscrew” or “nutcracker” sleeve possibilities • the longest staple line in bariatric surgery

the leak is so “high” that it is under negative pressure from the thorax • the sleeve gastrectomy is a highpressure “closed” system instead of a “drainage” procedure like the bypass.

Despite these characteristics, for sleeve gastrectomy leaks, our first approach for early leaks is to use stents, and for late leaks (after 40 days), endoscopy with pneumatic dilation and associated septomy. Both approaches release the pressure on the lumen by dilating the pylorus, incisura and gastric body, as well as correct the body–antrum axis deviation.

Early Treatment After treating the sepsis, stents are the first-line endoscopic treatment for early leaks. A correctly positioned stent must pass the incisura angularis to

achieve two of the most important aims in the endoscopic treatment of fistula: release of pressure and correction of the axis of the gastric tube to ensure that the lumen will stay open and a lowering of the pressure to ensure the flow is maintained.

The stents we currently use were designed to provide temporary release of significant obstructions. There are no specific or ideal stents for treating leaks.

Stents made of silicone tend to dislodge more often, and those made from nitinol, single-covered, are difficult to remove if implanted at the correct size as they become strongly attached to the adjacent tissue. These stents also are available in nonoptimal sizes and lengths, which sometimes leads to the need to implant a second stent. This problem has resulted in a push for the medical device industry to design tailored stents.

It is important to note that the use of stent placement sometimes results in a patient complaining of symptoms such as pain, reflux, nausea and salivation; however, due to a consistent healing rate of 80%, as reported in the literature, this method is worth attempting. The mean stent implant duration is approximately four weeks, and periodic rechecks are strongly recommended (Figures 1 and 2).

Late Treatment Figure 1. Modified double-covered stent (note the external marks) covering the leak site. Most important: getting ahead of the incisura angularis, ensuring a proper lumen and correcting any axis deviation.

If the patient is referred for endoscopic treatment after four weeks, or if stent therapy fails, we recommend the use of pneumatic dilation (Figures 3-5) with endoscopic septomy (Figures 6 and 7), because we very often see a division

Figure 2. A malpositioned silicone stent that does not pass through the incisura and therefore does not release the pressure or ensure good flow that would allow the fistula to heal.

Figure 3. Deflated pneumatic balloon assumes the shape of the sleeve gastrectomy, highlighting the body–antrum axis deviation. see SURGEONS‘ LOUNGE page 18

17

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Surgeons’ Lounge jcontinued from page 17 of the septum at the leak site (at a higher level) from the gastric lumen, which impairs healing. Specifically, we perform the endoscopic septomy with a needle knife or an It-Knife, followed by balloon dilation. This maneuver will reshape the fistula site in a way that is similar to endoscopically treating a Zencker’s diverticulum, thus improving healing. Of note, endoscopic treatment can, and usually will, be repeated in consecutive sessions before healing will occur.

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

If endoscopic treatment fails after six months, a surgical approach should be considered. In our practice, this strategy was successfully used to treat more than 50 patients with leaks: Only one patient was referred for surgical treatment after four months of failed endoscopic attempts.

Therefore, for the current case, it is recommended that the chronic Angle of His leak following sleeve gastrectomy be treated by pneumatic dilation sessions with septomy, before considering surgery.

Figure 4. Once the pneumatic balloon is inflated (from 10 to 25 psi), it dilates the entire sleeve, correcting the lumen narrowing and axis deviation, and releasing the pressure at the leak site.

Figure 5. Endoscopic image of a fully inflated pneumatic dilation balloon, where proper dilation of the gastric body and incisura are visible.

Suggested Reading Campos JM, et al. Endoscopia em cirurgia bariátrica Diretriz SOBED. Sociedade Brasileira de Endoscopia Digestiva, 2008. http://www.sobed. org.br/pdf/diretrizes/Endoscopia_e_ cirurgia_bariatrica_Pernambuco.pdf.

Campos JM, et al. Endoscopia em cirurgia da obesidade–reference e book. 1st ed. São Paulo: Santos; 2008.

Campos JM, et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg.

2011;211:520-529.

Neto MP, et al. Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases. Surg Obes Relat Dis. 2010;6: 423-427.

Rosenthal RJ, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8:8-19.

Zundel N, et al. Strictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech.

2010;20:154-158.

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Figure 6. Sequence of septomy. On the left side of the image, the leak site is located between 9 and 11 o’clock and the lumen can be seen at 4 o’clock. On the right side of the image, between the leak and the lumen is the septum being cut using cautery.

Meta-Analysis: IV Analgesic Reduces PONV When Given Early I

ntravenous acetaminophen prevents postoperative nausea and vomiting (PONV), but only if given prophylactically, a new meta-analysis has found.

The study, by researchers at the University of California, San Francisco School of Medicine, showed that IV acetaminophen—marketed in the United States as Ofirmev by Cadence Pharmaceuticals and as Perfalgan by BristolMyers Squibb abroad—had antiemetic effects as long as patients received the drug before, during or immediately after surgery. It did not appear to help ease nausea or vomiting in patients who had already begun experiencing pain during recovery. The researchers presented their study at the 2012 annual meeting of the American Society of Anesthesiologists (abstract 1314).

Christian Apfel, MD, PhD, and his colleagues analyzed 30 studies, involving 2,364 patients, of whom 1,223 had received IV acetaminophen during the perioperative period. Dr. Apfel’s group found that patients who received IV acetaminophen were about 40% less likely to experience PONV, but those who got the analgesic at the first sign of pain during recovery had no reduction in risk.

“Prophylactically administered IV acetaminophen reduces postoperative nausea and postoperative vomiting,” the researchers wrote. “The effect size measured on a relative risk scale to reduce PONV is comparable with that of antiemetics used for the prevention of PONV.” —Adam Marcus

19

Figure 7. After the septomy, on the left side of the image, pneumatic dilation is performed to stretch the muscular layer, ensuring remodeling of the leak site. On the right side of the image, the healed leak site is visible between 9 and 11 o’clock.

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Prolonged Hypotension In Surgery Linked to Poor Outcomes

BY MICHAEL VLESSIDES WASHINGTON—The total time patients in surgery spend with low blood pressure may be a stronger predictor of serious postoperative complications than the depth of the hypotensive troughs they hit during the procedure, researchers have found.

The researchers, from the Cleveland Clinic in Ohio, have used their analysis

to create an algorithm to guide the management of blood pressure in the operating room.

“This research attempted to address a seemingly simple question, yet one many of us might find difficult to answer: What really constitutes hypotension, especially when it comes to long-term outcomes?” said Wolf H. Stapelfeldt, MD, chair of general anesthesiology and vice chair of surgical operations at Cleveland Clinic, who led the study. “From a practical

point of view, we all have to draw the line somewhere. We’ve chosen to start out with drawing the line at a mean arterial pressure [MAP] of 60 mm Hg, but what does that mean? When should we start worrying? After two minutes? Five minutes? Fifteen minutes? Quite frankly, we don’t know, and this prompted our current study.”

The Cleveland Clinic team is now in the process of validating the algorithm, including, it hopes, by comparing its data

21st International Congress of the EAES Vienna, Austria 19 - 22 June 2013 HOFBURG

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Vienna Convention Centre

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Congress President: Prof. Selman Uranues

Program Committee Chair: Prof. Nicola di Lorenzo

Postgraduate courses Hands-on training New technologies “How I do it” video session Challenges in colorectal surgery

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Deadlines: Abstract submission deadline: 15 January 2013 Early registration deadline: 15 April 2013

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to those from Mayo Clinic and Vanderbilt University Medical Center, in Nashville, Tenn.

“Depending upon the results of these validation steps, we anticipate an evolutionary practice change assuming that not all, but many patients’ outcomes might be improved by minimizing hypotensive exposures,” Dr. Stapelfeldt said. “Depending upon the magnitude of the impact on patient outcome, the [decision support system] is principally designed to allow any such algorithm to either be pushed to every provider as a mandatory alert— i.e., a matter of departmental or institutional policy—versus functionality that is made available to individual providers via subscription at their discretion.” Any alert, whether global or individual, may be disregarded by the anesthesia care team using its best judgment, he added.

Dr. Stapelfeldt and his colleagues examined the institution’s registry for adult patients undergoing non-cardiac surgery between Jan. 1, 2009 and Sept. 30, 2010.

They analyzed minute-to-minute MAP readings from more than 35,000 patient records for periods of time spent below hypotensive thresholds ranging from 75 to 45 mm Hg. Patients were considered to have dropped below a certain threshold if they spent at least one minute below that level. The investigators used logistic regression to determine the relationship between cumulative time spent below the various thresholds and 30-day mortality.

As Dr. Stapelfeldt reported at the 2012 annual meeting of the American Society of Anesthesiologists (abstract 074), spending any amount of time below a certain threshold was common, decreased in incidence with progressively lower hypotensive thresholds and was associated with increased 30-day mortality (Figure 1).

Several factors independently affected patient outcomes after surgery. These included patient age, Charlson comorbidity index and cumulative blood loss.

“There was a 20% increase in mortality for each additional comorbidity,” Dr. Stapelfeldt said. “And every additional 20 years of age more than doubled a patient’s risk for dying within 30 days of surgery.”

But the most striking finding involved the cumulative amount of time spent below various blood pressure thresholds, he continued. “We found that as patients started spending even just a few minutes below an MAP of 55, there was a sharp increase in the odds ratio for mortality [Figure 2]. More importantly, similar increases in mortality were seen whenever patients exceeded other, longer exposure limits for time spent below any of the less severely hypotensive MAP thresholds.”

Indeed, as each additional exposure limit was exceeded, there was an

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Figure 1. Incidence, distribution of cumulative time spent and 30-day mortality for patients dropping below blood pressure thresholds.

Figure 2. Percentage increase in the odds ratio for 30-day mortality depending on the duration of hypotension below certain thresholds.

(Figures courtesy of Wolf H. Stapelfeldt, MD.)

incremental 4% to 7% increase in the risk for 30-day mortality. “What’s most disconcerting is that many of our patients routinely exceeded a large number of these exposure limits by spending substantial amounts of time below their respective MAP thresholds, on the order of half an hour or longer in many instances.”

These results suggest that long-term outcome may not only be affected by periods of severe hypotension, but also by extended periods spent at seemingly adequate intraoperative blood pressure levels.

“Unlike conventional vital sign monitors—which alert only to blood pressure dropping below a certain threshold level—decision support systems can alert to a certain level of risk attributable to significant cumulative hypotensive exposure, something apparently very critical yet difficult for humans to keep track of, unlike the detection of any sudden changes in blood pressure.

“This information would be most useful if it is provided in real time, which decision support is now able to do,” Dr. Stapelfeldt said. “The idea is that once the anesthesia care team receives any first alerts to excessive hypotensive exposure, it might be able to adjust the anesthetic in such a way that the patient’s mean arterial pressure trends higher. One can choose how aggressive one wants to be with minimizing hypotension according to what level of attributable risk one might want to attempt to mitigate.”

Christian Apfel, MD, PhD, adjunct associate professor of anesthesia, perioperative care, epidemiology and biostatistics at the University of California, San Francisco, called the research fascinating and rigorous. “We still have procedures where surgeons are asking for ‘controlled’ hypotension,” Dr. Apfel said. “And that is actually something I’ve always been uncomfortable with.

“Dr. John Drummond from the University of California, San Diego is always warning against this kind of controlled hypotension,” Dr. Apfel continued. “And until now, we only had anecdotal evidence.

This decision support system might help us in those kinds of situations.”

21

SAGES 2013 scientific session & postgraduate courses April 17 - 20, 2013 · Baltimore, MD Held in conjunction with ISLCRS – the 8th International Congress of Laparoscopic Colorectal Surgery

Surgical Spring Week – Innovating the Present for the Future Early Housing & Registration Deadline: March 15, 2013

Wednesday, April 17

Friday, April 19

Half-Day Postgraduate Course: Foregut Half-Day Postgraduate Course: Bariatric SAGES/ISLCRS Half-Day Postgraduate Course: MIS Colorectal SAGES Foundation Awards Lunch Postgraduate Course: Joint SAGES/AAES session - MIS Endocrine Postgraduate Course: Optimizing Outcomes of Ventral & Inguinal Hernia Repairs Half-Day Hands-On Course: Bariatric Half-Day Hands-On Course: Colorectal SAGES/AHPBA Panel: Minimally Invasive HPB Panel: Pre-, Intra-, Post-Operative Management of CBD Stones Panel: SAGES/JSES – Endoscopic Management of GEJ Disease Dysplasia & Barrett’s Session: Complications Exhibits Opening Welcome Reception 5:30pm - 7:30pm

Exhibits/Posters/Learning Center

Thursday, April 18

Panel: Multidisciplinary Future of Surgery

SAGES Scientific Sessions Exhibits/Posters/Learning Center open 9:30am - 3:30pm Half-Day Postgraduate Course: Endolumenal Treatments - GERD and POEM Half-Day Postgraduate Course: Ventral Hernia Panel: SAGES/ISLCRS – IBD Panel: SAGES/ISLCRS – Colorectal Potpourri Symposium: SAGES/ALACE – Surgery South of the Border; What’s New? Educator’s Lunch: Do Quality Initiatives Change Surgery Residency Training?

Half-Day Hands-on Course: Endolumenal Treatments Half-Day Hands-on Course: Ventral Hernia Symposium: SAGES/ISLCRS/ASCRS – Optimizing Outcomes in Rectal Cancer Panel: Reoperative Foregut Surgery Panel: SAGES/ASMBS – Innovative Bariatric Procedures Panel: Humanitarianism Panel: NOTES Videos

open 9:30am - 3:30pm

Panel: SAGES Town Hall on Healthcare Reform Presidential Address – W. Scott Melvin, MD Gerald Marks Lecture – E. Christopher Ellison, MD Debates: Presidential Debate Panel: SAGES/SSAT – Update on Bile Duct Injuries Session: Simulation Panel: MIS Pregnancy Fellowship Council Lunch Panel: Bariatric and Pediatric Emergencies for the non-Bariatric, non-Pediatric Surgeon Session: Emerging Technology Panel: Pancreas – Current Controversies in Minimally Invasive Pancreatic Surgery Panel: Foregut – Myth Meets Reality Panel: Acute Care Laparoscopy Panel: SAGES/ISLCRS Colorectal Robotics SAGES/CAGS Session: Ultimate SAGES Main Event & International Sing-Off

Saturday, April 20 SAGES Scientific Sessions Exhibits/Posters/Learning Center

open 10:00am - 1:00pm

Session: Career Development Session: Advancements in Military Surgery Karl Storz Lecture – Lee L. Swanstrom, MD FREE Lunch in Exhibit Hall for all SAGES Meeting Attendees

12:00pm - 1:00pm

Panel: Management of GIST Tumors Symposium: Essentials of Robotic Surgery Session: SAGES/AORN – Patient Safety Checklist – Time Out and Huddle

Who Should Attend: The SAGES Annual Meeting has elements that have been specifically designed to meet the needs of practicing surgeons, surgeons-in-training, GI assistants, nurses and other allied health professionals who are interested in minimally invasive surgery and gastrointestinal endoscopy. Thorough coverage of traditional topics and presentations of “cutting edge” material can be found in this program. The SAGES Program Committee recommends that participants design their own attendance schedule based on their own personal educational objectives.

Hosted By Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 11300 W. Olympic Blvd., Suite 600, Los Angeles, CA 90064 | Phone: 310-437-0544 | Fax: 310-437-0585 | Email: sagesweb@sages.org web: www.sages.org | Twitter: @SAGES_Updates | Register on-line at www.sages.org/registration/ | Email: registration@sages.org

22

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

COVER STORY: FINDING REWARDS IN MILITARY SERVICE

T

he majority of physicians who pursue a career in military medicine set their sights on that goal before they even begin medical school as they seek eligibility to participate in the Health Professions Scholarship Program (HPSP), which funds students’ education in exchange for required periods of duty in the U.S. Army, Navy or Air Force.

The benefits of this approach are clear: The scholarship covers most or all of their education and training, books and materials, as well as provides a monthly stipend and military pay. In return, doctors serve one year for each year of the military’s support, with a minimum commitment of two years. They begin their careers free of medical school debt, and if they choose to continue in the military, which about two-thirds of HPSP participants do, they can look forward to retiring relatively young with a healthy benefits package.

But there is a small proportion of military physicians who enter through direct accession later in life, sometimes after years or even decades in civilian practice, occasionally beginning their military career at the point when an HPSP recipient would be retiring. The common thread that unites these late joiners is a desire to serve their country and take care of those who defend it.

When U.S. Navy Capt. (ret) Norris Childs, MD, finished his residency, he set out to pursue his surgical career as a solo practitioner in Philadelphia. He regularly received letters from the armed services spelling out the perks and benefits of joining, letters that he ignored.

But a letter that he received in 1988, simply stating a desperate need for physicians, touched a chord.

“There were no promises of money, adventure, allure or anything like that. Just ‘we need doctors badly,’ and that appealed to me,” Dr. Childs said.

Rear Adm. Michael Baker, MD, chairman of surgery at John Muir Hospital, in Walnut Creek, Calif., who spent 30 years in uniform, did everything he could think of to avoidd the military while attending college and medical school during the Vietnam War.

‘I had this fantasy that in the military I might find a more appreciative audience for my trauma care. I’d say in the 22 years I served, the military has not disappointed me in that regard at all.’ —Norris Childs, MD “I even went into U.S. Public Health Services for a while,” he said. But as his residency came to a close, he felt so grateful to have had the chance to get the education and training to become a surgeon that he no longer had qualms about service.

“By that time, the Vietnam War was nearly over, but I decided that no matter what the politics were, I could put on a uniform and take care of those who had served our country,” Dr. Baker said.

Maj. Paula Oliver, MD, FACS, spent 20 years in a single-specialty practice when her involvement with an army officer exposed her to the acute shortage of general surgeons in the military, and she felt her own call to duty.

At the same time, she was feeling increasingly frustrated with practice in the civilian setting, and this is another common thread among physicians who enter the military

Above: Norris Childs, MD, with members of the Advanced Trauma Life Support training class in Malindi, Kenya; Right: Maj. Paula Oliver, MD, FACS, spent 20 years in a single-specialty practice when her involvement with an army officer exposed her to the acute shortage of general surgeons in the military, and she felt her own call to duty. later in life: Medical practice isn’t what they’d expected, or a once-satisfying career is beginning to turn sour.

“I often see that there is a general dissatisfaction with life in the civilian surgical world, a feeling that there is no higher sense of purpose in what they are doing,” said Col. Tommy Brown, MD, general surgery consultant to the Surgeon General.

At the time that Dr. Childs decided to join, part of his practice was taking care of nonpaying, inner-city trauma patients. “Occasionally I’d come across a person who was totally unappreciative. I knew I’d never get paid for taking care of that patient, and there was a high risk of being sued for unhappy results,” he said. “I had this fantasy that in the military I might find a more appreciative audience for my trauma care. I’d say in the 22 years I served, the military has not disappointed me in that regard at all.”

For Dr. Oliver, currently deployed, dissatisfaction with civilian practice evolved in recent years, with “the change in private practice clientele, new laws and restrictions, change in new partner behavior—more detail here is just too negative,” she wrote in an email.

Dr. Brown’s perception of the majority of physicians who choose to serve as military doctors is that they are deeply satisfied with that decision. “Most people are pretty happy with the change,” he said. “As a surgical oncologist, I take care of a lot of cancer patients, which is a very appreciative group. But when you go downrange and take care of these young kids who are in combat, it really is just you pulling them out of these life-and-death situations. It’s extremely professionally rewarding.”

Soul Searching For those with little or no exposure to the military, enlisting with the armed services, even to do the work of a physician, can feel like an alien endeavor. For some, it requires a suspension of disbelief and willingness to examine long-held opinions and beliefs, especially if they

grew up in a culture ambivalent about or hostile toward the military.

Christopher Dillon, MD, a colonel in the Medical Corps, U.S. Army, Adolescent Medicine Specialist/Physician Recruiting and Accessions Liaison, HPSP, realized early in medical school that his expectations about the costs were unrealistic, so he entered the program, which covered his remaining three and a half years of training.

“I thought I’d made a deal with the devil to pay for medical school because I was really going into the unknown. I had no comfort level with the military, but I was not going to go into that kind of debt,” he said.

As a physician recruiter, Dr. Dillon finds one of the hardest problems in reaching potential military physicians is overcoming myths and preconceived notions.

“I’ve seen people whose families say, ‘we’ll mortgage the house, whatever it takes,’” he said. “But we’re physicians.

We’re noncombatants. We are expected to be as safe as possible to take care of our people, plus anybody else.” see MILITARY MEDICINE page 24

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call to duty when it comes.

“The price you pay is that … when the U.S. government decides to go to war with Iraq, they call you up and say, ‘your unit has been mobilized, you need to show and be ready to go to Saudi Arabia.’ And that’s what happened to me,” Dr. Childs said.

“Within 15 months of joining the Navy, I got my wish, got to go to war and see what all these evil people were like.”

What he found was that the vast majority of his colleagues were committed to doing the right thing for their country. “They felt it was their duty to put themselves in harm’s way, to protect the things we stand for in this country, and

MILITARY MEDICINE jcontinued from page 22

Dr. Baker’s perceptions of the military were largely informed by television and movies, and his decision to join came as quite a surprise to his entire family. “Even by the time I got to the rank of admiral, my own mother couldn’t understand what I was doing in uniform,” he said.

For Dr. Childs, joining the military was anathema to his spiritual beliefs and practices. Although his grandfather and father had both served in the military, Dr. Childs was raised a Quaker.

“Quakers are pacifists and have a definite antiwar sentiment and an antimilitary bent, so this weighed on my mind.

But the Quaker educational tradition [dictates that] you should seek out independent inquiry and not just take other people’s word about how things are,” he said. “It was in keeping with this tradition to explore the real truth, to find out if these people were as evil as they were made out to be, to find out what the military was really like.”

‘When you go downrange and take care of these young kids who are in combat, it really is just you pulling them out of these life-anddeath situations. ’ —Tommy Brown, MD

Qualifying, Committing, Deploying To qualify for active duty, a physician is required to be a U.S. citizen, and for the reserves, a legal resident. Physicians going into the military through direct accession are required to be board-certified in their specialty and to have an active license to practice medicine. The military is not a solution for physicians who are faring poorly in civilian practice.

“We look closely at people. If we see that someone has had a lot of litigation, that’s questionable. Especially if someone has something still hanging, that’s not acceptable,” Dr. Dillon said. “For general surgeons, the entire CV packet … is sent to the general surgery consultant who

‘I thought I’d made a deal with the devil to pay for medical school ... I had no comfort level with the military, but I was not going to go into that kind of debt.’

—Christopher Dillon, MD contacts the surgeon and gives a thumbs up or thumbs down.”

Although physicians do not go through the type of boot camp training that a new recruit would experience, there are physical standards they must meet. “The physical exam trips up a lot of people,” Dr. Dillon said. Pre-existing conditions, including eczema, can disqualify a candidate. “Usually that waives, but it is a process. The Army is very stringent about making sure people are physically fit to serve, and that standard is the same

Top: Dr. Norris Childs on the deck of a landing ship dock at fleet week in San Francisco, Sept. 2011, with surgical Mentee, CDR Tuan Hoang, USN. Bottom: Col. Christopher Dillon, MD, right, in a bazaar in Bagram, Afghanistan in 2009.

With him, a local resident with his camel, ”Joe.” whether you’re talking about a private or a more senior officer.”

Full-time military physicians on active duty receive a compensation package that includes health care for themselves and their families, malpractice insurance, a retirement fund, a relatively good salary that in some specialties is higher than they would earn in civilian practice and a paid vacation plan rarely experienced by other workers: 30 days that, if not taken, roll over into the next year.

“You get time with your family,” Dr. Dillon said. “One of the reasons the military sets it up that way is that you’re part of a security force and you can potentially be deployed, but life when you’re here is very, very good.”

For the past 11 years or so, most Army surgeons have deployed to combat theater every one or two years. “Generally you have a one- to two-year dwell time on the ground in the U.S. before you go downrange again,” Dr. Brown said.

Dr. Oliver was deployed eight months after she joined, and she was warned during her interview of this possibility. But she was ready for it. “I can’t imagine volunteering for the military and being surprised that you have to deploy, although I’ve heard others were surprised by this scenario,” she wrote.

Reservists serve one weekend per month and one two-week commitment each year, usually at a reserve center near their home. “The goal of this is primarily to provide some relevant training to what your mission will be if you’re called up and deployed,” Dr. Baker explained.

“This might mean you go to Bethesda Naval Hospital for two weeks, work there in your specialty and learn the ways of military life in the hospital.”

Reservists are paid for these periods of employment, and can retire after 20 years with a pension that starts at age 60 and enduring military health coverage. In exchange, they are obligated to answer the

that everybody had a pretty good vision of what the right thing was,” Dr. Childs said.

But he also found, during his first deployment, that war is hell. “You can say you won the war, and we won that war.

But everyone in my unit lost the war,” he said. “They lost their job, they lost their wife. Some of them lost kids.”

The day that Dr. Childs was called up, his middle son broke his neck in a wrestling accident and was paralyzed from the neck down. “It was the most devastating day of my life, yet here I was committed to going overseas, leaving my wife alone with this injured kid. It made me think a lot about why we sacrifice to do these things. Everyone pays the price in the long term. It made me even more of an antiwar person.”

Professional and Personal Rewards His son received prompt and excellent care after his accident, and was able to stand, move his hands and feed himself by the time Dr. Childs left for the Gulf.

“I knew in my heart that he was going to get better, and I thought, this is why I’m going to Saudi Arabia—so I can take care of some kid like him and get him back to his mom or his wife or girlfriend.”

That rationale is unarguably noble, but Dr. Childs is honest about the fact that serving his country as a military physician also allowed him to indulge his sense of adventure. “Staying in the military was a way for me to do things I would never have gotten to do in a civilian practice.

I’ve been to places I would not have been allowed to go.”

For Dr. Baker, every tour of duty presented an opportunity to learn or do

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

‘I learned lessons about leadership, teamwork and taking care of your people that I use every day in my civilian practice and in the operating room.’

—Michael Baker, MD something new, such that his career as a physician took a more military bent than he possibly could have anticipated. After his second tour, the Navy reserves offered him a position as a general medical officer with a Navy Special Warfare Unit.

“That turned out to be a magnificent assignment because there was so much to do. I had to learn how to be a Navy officer instead of just a doctor who is in the Navy uniform,” he said.

He became a river warfare–qualified officer for patrol boats, which got him heavily involved in day-to-day proceedings. “I was leading people and learning how to captain a small boat, reading maps and calling in helicopter support. I was heavily involved in the planning and execution of real missions, which was a quantum leap from what I was doing as a doctor and surgeon,” Dr. Baker said.

“I learned lessons about leadership, teamwork and taking care of your people that I use every day in my civilian practice and in the operating room,” he said.

to hope that you’ve groomed good people to move up and provide leadership.”

Post-retirement, he stays connected with the military by teaching abroad two or three times per year in Korea as part of a conference of U.S. and Korean medical personnel called the 38th Parallel Medical Society, and in Germany. “All the casualties coming out of Iraq and Afghanistan go there to be reoperated and restaged, so I’ve gone a number of times as a mentor to train young trauma surgeons,” he said. “It’s a very rewarding experience, although emotionally difficult. But I learn as much as I teach.”

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After Service Following his stint in the first Gulf War, Dr. Childs spent about 10 years in the reserves before being mobilized again in spring 2005. He spent a full year on active duty, including six months in Portsmouth, Va., where he was required to repeat his trauma training course.

“At the end of the course, they said they’d detected I had instructor potential.

So they sent me to a training course in Fort Sam Houston, Texas, and I became an instructor,” he said. Even now as a retiree, Dr. Childs returns to Fort Sam Houston five or six times per year to teach young military doctors how to take care of trauma patients.

“It’s always a thrill to go there because they’re young and enthusiastic to do the right thing for soldiers, sailors and Marines, and it always energizes me when I go and teach these kids,” he said.

Dr. Baker retired from the Navy in 2005, and although he is deeply satisfied with his civilian practice, there’s a part of him that still wants to be involved as current events unfold. “Particularly when my brothers and sisters in arms are conducting combat operations somewhere, it’s pretty hard to sit on the sidelines,” he said.

“But the reality is that it’s time for younger and faster people to take your place, and

25

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Opinion POPULATION

jcontinued from page 1 in the past. There are sobering consequences to these numbers.

Food for Thought In the early 1800s, Thomas Malthus introduced the notion that the world’s increasing population would result in a food supply crisis. Fortunately, bet better agricultural techniq ques were introduced toward the end of the century and famine was avert-ed. In the 1970s, anoth-er population scientistt, Paul Ehrlich, opined th hat the disaster was not averted but only delayed un ntil the 1980s. This time the “Green Revolution” intervened d with ih improved farming techniques such as fertilizers based on petrochemicals and genetically engineered crops. The agricultural yields increased even further and, again, we avoided world food shortages and mass starvation. Both Malthus and Ehrlich are usually associated with global food supplies but their chief concern was more than food; it was overpopulation.

They both understood that the population numbers are relentless and, although

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

neither one had the dates right, it just seems to be a matter of time before we have a problem on our hands and again will need to be rescued by another scientific advance.

I manage to stay optimistic about the future of our planet, however, and the source of my optimism can be best explained by a computation done by the two-time Pulitzer prize-winning entomologist, E.O. W Wilson. He estimated that if you takee all 7 billion people in the

This time, the problem is too big and we cannot temporize by manipulating the details. As the expression goes, just do the numbers. And you can start with 65. world and stack them like logs they h would ld form a cube one mile on each side. You could hide this cube in the Grand Canyon, which is one mile deep and 18 miles wide. If you then look at earth from space the biomass representing all humanity becomes a vanishingly small speck that is all but invisible. The great swaths of green, representing plant life, and blue, which is the water, make up most of the surface of our planet. It seems improbable that this enormous globe with its considerable plant and water resources

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is not enough to sustain this microscopic speck of biomass hidden in the Grand Canyon. But if the exponential growth of the population is relentless, you may still postulate that this insignificant speck of humanity will eventually outgrow even the earth’s tremendous resources. I like to think not, so again I should explain the source of my optimism. It is estimated that by the year 2050, the earth’s population will be 9 billion and after that some estimates have it declining. At some

MN125

point, the rate of growth, which has been slowing, will go to zero and will then start to reverse. When the earth’s fertility rate, which has been continuously decreasing, falls below 2.33 children per family, the population will start to shrink and we will stay forever small enough to be hidden in the Grand Canyon.

So, I am confident that a combination of decreased fertility rates and our scientific ingenuity can and will prevent the earth from running out of resources to support its multitudes, but how about our own microcosm, the United States of America?

I’m afraid that our national populationrelated problems will be more difficult to solve than those of global resources. The greatest threat for us is not our food supply but our health care system.

U.S. Health Care There are many problems that will be caused by our expanding and aging population, but none is as severe or as imminent as its effect on our already over-burdened health care system. Of course the sheer numbers are daunting. Both the population and the percentage of people who are older and require more expensive care are growing at alarming rates. We recently have closed a few more gaps in the safety net, which should add about 30 million to the rolls of people with health care coverage. The financial effect of this to the nation has not yet been felt, but most health care economists predict that it will be significant. By 2050, it is estimated that there will be another 117 million people in the country. A larger percentage of these people will be older than age 65, nonworking dependents with more expensive health care needs. At the same time, the number of physicians and nurses as a percentage of the population will shrink.

As a nation, we are the victims of better public sanitation and an effective health care system. People are living longer and it is more expensive to care for them as they age. Not only do they have more health problems, but their chronic illnesses and

debilities are more expensive than acute illnesses. The Department of Health and Human Services reports that 90% of health care expenses go to treating chronic conditions and 77% of people over the age of 65 years have two or more chronic conditions.

The notion that keeping people healthy will save money is an attractive theory, but unfortunately it is incorrect. It has been shown that healthy people who live longer will spend more money for health care over their lifetimes than unhealthy people. Several studies, including one

by Boston College’s Center for Retirement Research, have calculated individual health care spending over a lifetime and have concluded that healthier people should save more for future healthrelated expenses. Someone who has an unhealthy lifestyle might die of complications of obesity, hypertension or diabetes in his or her 60s, whereas a healthy person is more likely to survive into his or her 90s and require years of care at the end of life to manage dementia, arthritis, fractured hips, pneumonia and other medical consequences of aging.

Does this mean we should not promote healthy lifestyles? Absolutely not. As a profession, we should promote practices that lead to longer lives but we should realize that we are proposing the more expensive alternative and healthy living is not going to solve our financial problems.

The global food shortage problem noted above seems to have an easy solution, but I’m not quite so sanguine about our national health care problem. The dual realities of our expanding and aging population are going to make many things progressively more difficult and health care delivery and financing will be our biggest and most immediate problem.

Although I appreciate that there are a lot of concerned and earnest people engaged in important issues such as donut holes, the sustainable growth rate formula, the constitutionality of mandated health care and so on, there is a much larger, more serious problem on the immediate horizon. That problem is how are we going to continue to pay for what we are doing.

Some look at problems and say that the devil is in the details and solutions will be found merely by attending to these details.

This time, however, the problem is too big and we cannot temporize by manipulating the details. As the expression goes, just do the numbers. And you can start with 65.

I have concluded that the numbers tell us that we need bold ideas, a radical departure from what we are doing now and full commitment to changing how we deliver and finance health care in this country.

Although I consider most of my columns to be opinion pieces, most of what I have written here is not my personal philosophy or politics; it is arithmetic. There are legitimate differences of opinion about

Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

the role of the government, the participation of the private sector, the responsibilities of health care recipients, rationing, tort reform and other issues raised by the health care debate. You undoubtedly have opinions about all of them. The numbers, however, are different. They cannot be interpreted, spun or manipulated. We know where they are headed and beyond that I donâ&#x20AC;&#x2122;t think itâ&#x20AC;&#x2122;s much of a stretch to conclude that health care is headed for a difficult future.

In this column I am not offering any easy solutions because there are none. There are only difficult ones that require compromises with features that will be difficult to digest for almost everyone. The first step in finding a solution is to recognize the magnitude of this problem as well as its inevitability. There will be some pain for all. As physicians, as citizens and as advocates for our patients, we will be called on to participate in the solution. We canâ&#x20AC;&#x2122;t afford to stand on the sidelines. â&#x20AC;&#x201D;Dr. White is professor of surgery, George Washington University, Chief of Surgical Services, Veterans Affairs Medical Center, Washington, DC. The General Surgery News team in their offices in New York City. From left: Deanna Cosme, Michael Enright, Kate Carmody, Diane Lodise, Maureen Sullivan and Kevin Horty. The GSN N staff would like to send an extra special thank you to our editorial board members and our writers for all their work in 2012, and weâ&#x20AC;&#x2DC;d like to wish all of our readers a very happy new year.

GSN Bulletin Board

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Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

Two Rules for Surviving the Affordable Care Act B Y R OBERT E. J OHNSTONE , MD

H

ealth care regulators need our help. They are churning out rules and demonstration projects as the Affordable Care Act (ACA) authorizes, but some of these new provisions are increasing payments to hospitals and physicians. This situation is undesired and awkward, an embarrassment to reformers, whose goal is to reduce such outlays to physicians.

Reformers speak of improving the efficiency and quality of health care while reducing waste and costs, which regulators generally understand are code phrases for paying less. As Ezekiel Emmanuel, an influential reformer, recently explained, “With one-third of total health care expenditures spent on hospital care and about 20% spent on physician services and specialists each year, this is where the big money is—and where it can be saved. … Controlling costs can do more than simply save money, it can also improve the quality of medical care” (NY Times, Nov. 16, 2011). Improving care simply by cutting payments—the philosophy behind bundled payment projects—makes perfect sense to the regulatory royalty of Alice’s wonderland.

This mindset is why Kathleen Sebelius, secretary of the Department of Health and Human Services (HHS) and regulation churner chief, was off-with-their-heads mad when she discovered recently that hospitals adopting her newly required electronic records were getting paid more. “There are troubling indications that some providers are using this (newly required) technology to … obtain payments,” Ms. Sebelius observed.

She described better documentation as possible “upcoding” and “fraud” and vowed to crack down on doctors and hospitals that benefit financially from health care reform (NY Times, Sept. 24, 2012:B1). After all, if the government pays too much to physicians and hospitals, it might not be able to afford its growing legion of workers, an important government effort to improve the economy. Employment at HHS grew from 64,750 workers in 2008 to 83,745 in 2011, but further growth could stall if its bureaucrats cannot master the complexities of payment-reduction regulation writing.

Anesthesiologists and surgeons can help. They work at the intersection of patients, technology, administrators and regulations. They have learned to deal with non-clinical staff, practice revisionists and forced inefficiencies. Locked anesthesia drug carts, checklists of checklists and labeling of spinal kit drug syringes are daily fare. Hospital administrators, institutional accreditors and state inspectors frequently force physicians to cope with complex policies, unintended consequences and less money.

Since regulation churning is difficult work, and real regulators are distracted trying to figure out what an accountable care organization is and how to bundle all health care payments into one check, anesthesiologists have something to offer. Here are two free proposals for regulators to improve anesthesia care while growing their own ranks and avoiding unintentional increases in physician payments. Other physicians, I’m sure, can suggest many more.

1. More bells and whistles. Surgical suites have busy corridors, packed with stored equipment. Patients

and personnel use these corridors to travel to and from operating rooms (ORs), risking stretcher collisions and trauma. For corridor safety, surgical personnel could blow whistles before each corner, just as trains do when approaching intersections. Backup horns on patient stretchers, like those mandated by the Occupational Safety and Health Administration, could also prevent retrograde collisions when backing into ORs. Since everyone is already familiar with the pleasant sound of these back-up horns, implementation of this retrograde program would be easy. To win public support, regulators could announce their whistle-and-horn program as extraordinarily sound, and government agencies could promote harmonized policies.

2. SPAWN (Staying Power: Acronyms Work Nicer).

Most government agencies that have survived from one federal budget to the next have used acronyms to enhance their staying power. Review any list of money-sucking military projects or efficiency-disrupting postal programs and you will find impressive strings of capital letters. Hospitals and anesthesiologists

have been slow to use acronyms and govspeak, still referring to surgical suites as “surgical suites” and Departments of Anesthesiology as “Departments of Anesthesiology.” HHS should require all departments of anesthesiology to form Acronym Adoption Committees (ACADCOMs) to generate Properly Identified Government Titles (PIG-Ts). Departments of anesthesiology could then have the killer title, DOA, populated with physicians known as SLPRDOCS. One potential downside is HHS might mistakenly send larger payments to the DOAs, over-valuing their importance.

Everyone can help write regulations. Just forward your proposals to the HHSCMMI—the Center for Medicare and Medicaid Innovation. Be careful, though, about unintended consequences. I proposed one new project myself, the Center for Revising Anesthesia Programs, until I discovered its unintended acronym.

—Dr. Johnstone is professor of anesthesiology at West Virginia University. This commentary expresses his personal opinions.

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A Companion to Aphorisms & Quotations for the Surgeon

M. Schein, MD, FACS, FCS (SA) March 1, 2008 This book has found its place in surgeons’ personal and public libraries.

Surgeons are using the book to decorate their lectures or manuscripts with relevant smart or entertaining entries; some like to quote from the book during teaching rounds or conferences; many simply enjoy it for its collective and eternal surgical wisdom and wit.

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ACS Multimedia Atlas of Surgery: Hernia Volume Steven D. Schwaitzberg, MD, FACS; Horacio J. Asbun, MD, FACS

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The American College of Surgeons Division of Education and Ciné-Med have developed the interactive Multimedia Atlas of Surgery. Each volume presents a comprehensive list of surgical procedures.

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Atlas of Advanced Operative Surgery: Expert Consult—Online and Print

Vijay P. Khatri November 9, 2012 Advance your surgical expertise with Atlas of Advanced Operative Surgery! This new resource picks up where other surgical references leave off, providing highly visual, step-by-step guidance on more than 100 advanced and complex procedures in both general and subspecialty areas.

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Doctor’s Eyes Only: Exclusive Financial Strategies for Today’s Doctors and Dentists

Thomas Martin; Paul Larson; Jeffrey Larson March 13, 2012 This book is the missing financial guide that physicians need as a supplement to their ongoing professional training. These pages include basic financial wisdom that could end up saving them millions of dollars t oug out their throughout t e medical ed ca careers. ca ee s

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Essentials of Bowel Anastomosis Ahmad M. Zarour; Kimball I. Maull

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This book is a comprehensive yet concise reference work covering modern techniques of bowel surgery. It covers the entire spectrum of gastrointestinal anastomosis, including anatomy, indications and basic surgical principles and techniques through detailed instruction in both hand-sewn and stapled anastomoses, making it unique in its coverage of how to deal with both simple and complex gastrointestinal conditions.

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Evidence-Based Approach to Minimally Invasive Surgery

Kenric Murayama May 27, 2012 This book comprises a review of the scientific literature in the field of minimally invasive surgery. Each chapter includes a summary of the current management strategy for the disease process, review of published literature on the topic and a summary of potential changes in the treatment algorithm.

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Open Wound: The Tragic Obsession of Dr. William Beaumont

Jason Karlawish August 30, 2011 Within this excellent historical novel is something profound—a dark and gripping morality play about friendship, ambition and the very essence of what it means to be a doctor. This should be required reading in med-ical schools.

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Textbook of Simulation: Skills & Team Training

Shawn Tsuda, Daniel J. Scott; Daniel B. Jones March 15, 2012 This book is a resource that provides information on the types of simulation technology available, the role of simulators in surgical education, and establishing skills-training centers. The book also provides back-g ground on the ACS/APDS / Surgical g Skills Curriculum for Residents.

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Code of the Month

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

DIAGNOSIS-RELATED GROUPS jContinued from page 1

TABLE 1. MS-DRG Assignment: Appendectomy Without Complicated Principal Diagnosis Without CC or MC

With CC

With MCC

428

Congestive heart failure

428.1

Left heart failure

428.33

Acute on chronic diastolic heart failure

250

Diabetes mellitus

253x

Diabetes, uncontrolled

250.22

Diabetes with hyperosmolarity, type 2

285.9

Anemia

285.1

Acute posthemorrhagic anemia

785.59

Hemorrhagic shock due to disease

278.0

Obesity

278.01

Morbid obesity 2.21

1.31

0.93

MS-DRG 341

MS-DRG 342

MS-DRG 343 $4,700

$6,500

$11,000

MS-DRG, Medicare Severity Diagnosis-Related Group; CC, comorbid condition; MCC, major comorbid condition

TABLE 2. MS-DRG Assignment: Appendectomy With Peritoneal Abscess Without CC or MCC

With CC

With MCC

250

Diabetes mellitus

253.x

Diabetes, uncontrolled

428.33

Acute on chronic diastolic heart failure

285.9

Anemia

285.1

Acute posthemorrhagic anemia

250.22

Diabetes with hyperosmolarity, type 2

278.0

Obesity

278.01

Morbid obesity

785.59

Hemorrhagic shock due to disease

1.21

1.21

1.21

MS-DRG 340

MS-DRG 340

MS-DRG 340

$6,000

$6,000

$6,000

TABLE 3. MS-DRG Assignment: Major Small and Large Bowel Procedures Without CC or MCC

With CC

With MCC

585

Chronic kidney disease

585.4

Chronic kidney disease, stage IV

428.21

End-stage renal failure

250

Diabetes mellitus

253.x

Diabetes, uncontrolled

250.22

Diabetes with hyperosmolarity, type 2

285.9

Anemia

285.1

Acute posthemorrhagic anemia

785.59

Hemorrhagic shock due to disease

278.0

Obesity

278.01

Morbid obesity

1.59

2.49

5.14

$8,000

$12,500

$26,000

Code of the Month

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2013

subject to investigate is Diagnosis-Related Groups (DRGs).

DRGs are a means of classifying a patient under a particular group where those assigned are likely to need a similar level of hospital resources for their care. This allows hospital administrators to more accurately determine the type of resources needed to treat a particular group and to predict more closely, the cost of that treatment.

The system was developed in 1982

by Robert B. Fetter, PhD, Yale School of Management, and John D. Thompson, MPH, Yale School of Public Health, both in New Haven, Conn., in an effort to quantify hospital care. The system was to be used to help hospital administrators control physician behavior. Cost-based care, which was used before this, was arbitrary and unpredictable. By assigning patients to a specific DRG, the onus is on facilities to work within a more predictable and structured reimbursement system.

The DRG system, comprising approximately 500 groups, takes account of all patients admitted to acute care in the hospital. Each DRG has a payment weight assigned to it, allowing the hospital to determine how much it can charge for its services. Weighting is based on a hospital’s geographic location; whether or not it is a teaching hospital; the percentage of low-income patients in the group; and whether a particular case is more expensive than usual.

By its nature, the DRG system creates more opportunity for medical facilities to benefit financially from maintaining accurate documentation.

Deciding on the most appropriate DRG level to assign a patient is determined by several factors including the International Classification of Diseases (ICD) code or codes recorded during hospital admission. There are generally three levels for major disease categories, with a higher weight given for more serious illnesses. ICD diagnoses are assigned to one of three categories: neutral, comorbid condition (CC), or major comorbid condition (MCC). Documentation of an MCC condition will trigger the highest DRG level for that condition. For example, if when performing an appendectomy, a physician simply records the diagnosis as “appendicitis,” the lowest or neutral DRG category will be applied.

Recording the condition as “acute appendicitis,” means that the CC category will be applied. An abscess or peritonitis falls under the MCC category, the highest level of DRG assignment.

The difference in reimbursement to the medical facility can double or triple based on simple and accurate documentation (Tables 1 and 2) and the numbers grow considerably larger for major bowel procedures (Table 3). However, physicians are not trained coding professionals

Physicians who maintain more accurate documentation procedures will fare better than those who may provide equal quality of care but do not document as well. and many openly state that having to focus on such specifics detracts from actual patient care.

The same system is being used to judge

the quality of care that a physician delivers. Because each admission or procedure is attributed to an individual physician, physicians are given a score based on the severity of a patient’s documented illness.

If the documentation is nonspecific, this forms the assumption that a patient has fewer morbidities, costs less to care for and requires a shorter hospital length of stay.

Physicians who maintain more accurate documentation procedures will fare better than those who may provide equal quality of care but do not document as well.

This information can be used to paint a picture of a physician’s behavior. It could

be extrapolated that the billions of dollars spent by the health care industry to advertise hospital excellence, will potentially be trumped by actual discharge data. Safety and quality assessments also are affected by accurate documentation.

Surgeons everywhere—whether in private practice or employed—should invest the time required to properly maintain patient records. By doing so, the appropriate DRG will be assigned and both medical facility and physician will benefit.

—Dr. Newman is a general surgeon in — Gadsden, Alabama, and founder and CMO of ComplyMD.

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