The August 2012 Digital Edition of General Surgery News

40th Anniversary 1972-2012

GENERALSURGERYNEWS.COM

August 2012 • Volume 39 • Number 8

The Independent Monthly Newspaper for the General Surgeon

Opinion

Ventral Hernia Repairs a Financial Bust for Hospitals?

101 Tips for Surgical Internship

Money Lost on Most Procedures at One Facility

B Y M ARC A. N EFF , MD over 10 years ago, I gradJust uated from surgical residency.

B Y C HRISTINA F RANGOU

Since that time, I’ve accumulated many gray hairs from an unimaginable variety of patients and surgical pathology. Recently, I began the painful process of throwing out some of my study materials left over from that indentured servitude, and, in a

Pick and choose your battles wisely—your reputation and mental health depend on it. box of my old antiquities, I came across a remarkable treasure—my hospital’s “Tips for Surgical Internship.” I spent hours crafting this project with two of my fellow surgical interns. The composition amassed the wealth and depth of our knowledge approximately twothirds of the way through our internship.

Looking at this list now, I’m impressed at how wise I was when I was so young and innocent. I once heard it said that with “wisdom comes bad experience, and that it is best to learn from someone else’s bad experience, than your own.” It see TIPS FOR INTERNSHIP page 23

Principles and Practice of Surgery: With STUDENT CONSULT Online

By O. James Garden see page 27

®

American Society of Breast Surgeons shows that surgeons at one large institution have grown increasingly comfortable applying the Z0011 data to their patients.

In August 2010, the University of Texas MD Anderson Cancer Center, in Houston, assembled a multidisciplinary team of surgeons, radiation oncologists, pathologists and medical

SAN DIEGO—Ventral hernia repairs are one of the most common surgical procedures in the United States. But for the hospital’s ledger book, these procedures add up to a financial loss.

Ventral hernia repair, particularly biologic mesh repair, results in overall financial losses for the hospital, according to a new study presented at the 53rd Annual Meeting of the Society for Surgery of the Alimentary Tract, a part of Digestive Disease Week 2012. Inpatient synthetic mesh repairs were associated with a net profit of $60, meaning they were “essentially budget neutral” for the hospital. All other ventral hernia repairs were associated with net losses, maxing out at a loss of $8,370 per procedure for biologic mesh repair.

“At our facility, the vast majority of open ventral hernia repairs were performed at a financial loss for the hospital,” said lead investigator Drew Reynolds, MD, instructor of surgery and minimally invasive surgery fellow, University of Kentucky, Lexington.

The study did not take into account readmissions, which would have further added to the losses, said experts.

“Dr. Reynolds and his colleagues have presented a disturbing financial profile for ventral hernia repair, which would in fact become even more grim if the cost of readmissions were added,”

see AXILLARY LYMPH NODE page 20

see VENTRAL HERNIA REPAIR page 6

General Surgery Newss is pleased to introduce the work of Chad Hoover. Above is his Ephemera #5,, 48” x 48,” oil on canvas. In his paintings, Mr. Hoover presents the viewer with a surgeon’s point of view. For further description of his work, see page 24.

Surgeons More Comfortable Applying Z0011 Data, Sentinel Lymph Node Biopsy B Y M ONICA S MITH PHOENIX X—After results of the American College of Surgeons Oncology Group’s ACOSOG Z0011 trial were released—first the local recurrence data in 2010 (JAMA ( A 2011;305:569575) and then the survival data in April 2011 at a meeting of the American Surgical Association—it has been unclear how the trial’s findings have influenced practice. Research presented at the annual meeting of the

INSIDE In the News

Opinion

Surgeons’ Lounge

Cheap, Effective Solutions in Trauma Care Are Born in Africa. ............................ 8

The FBI and Health Care Fraud: Tracking a Dishonest Few ............... 12

A patient with espohageal diverticula and a leiomyoma .............. 16

Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Physician Penalties: A Slippery Slope (radiologists, surgeons and primary care Frederick L. Greene, MD, FACS physicians) would be sanctioned for not Clinical Professor of Surgery recommending alternative screening is UNC School of Medicine reprehensible. It is true that most of us Chapel Hill, North Carolina already practice defensive medicine in recommending a variety of testing stratne of my interests over the past egies, but the additional creation of sancseveral decades has been the man- tions in managing certain health risks is agement of breast cancer. This clinical not the answer. involvement not only has included the Several states, including Connecticut, surgical treatment of benign and malig- Texas and Virginia, have notification legnant breast lesions, but also has been islation relating to information that must devoted to counseling women in the pri- be given to women with dense breast tismary and secondary prevention of breast sue. California’s governor, Jerry Brown, cancer. I am sure that all clinicians with recently vetoed similar legislation. a similar interest practice this approach.

In New York, a law requiring notiSo, it was disquieting to hear recent- fication of women by mammograly that both state and congressional leg- phers recently passed the state assembly islation is being considered that would and senate and was signed into law by penalize physician caregivers who do not Gov. Andrew Cuomo. This bill requires counsel patients regarding the risk asso- that women be informed of additional ciated with having dense breast tissue and screening modalities, namely magnetic recommend additional screening. resonance imaging (MRI). If the breast Although it is known that 40% to imager fails to notify women who are 50% of women have dense breast tis- found to have dense breasts on routine sue, possibly increasing their risk for can- mammography, they risk fines of up to cer, and that such tissue may mask early $2,000! malignancy using mammography as a Recently, a Michigan congressman screening tool, the fact that physicians has become the legislative crusader for

O

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

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The additional cost of

one of his constituents who had breast cancer associated with breast screening using MRI dense breast tissue. He has pro- averaging $3,000 per exam posed legislation similar to the approach taken in New York. It for the 40% to 50% of women is uncertain how this legislation with ‘dense breasts’ will will fare in Washington, D.C. Rather than invoke mone- further burden our reeling tary sanctions for physicians who health care system. fail to discuss the role of MRI as a screening tool in the setting of dense breasts, the more ratio- atherosclerotic disease or osteoporosis, nal approach would be to assume that respectively—where does it stop? appropriate patient literature, public serUnfortunately, the specter of sancvice announcements and profession- tions—whether “penalties� or “taxes� al education strategies be developed to as highlighted recently in the Supreme educate both patients and practitioners.

Court discussions of the Affordable If the physician-sanction approach is Care Act—does have a desired effect on allowed to promulgate, where does it stop? behavior. The additional cost of breast Will we see monetary penalties and man- screening using MRI averaging $3,000 datory reporting to the National Practitio- per exam for the 40% to 50% of women ner Data Bank for a variety of “offenses�? with “dense breasts� will further burOr, what about failure to recommend den our reeling health care system. With colonoscopy to patients who reach age all the additional pressures that we face 50 years, failure to discuss the virtues of today in caring for patients, physician SPF 30 sunblock with our blonde and penalties created by legislators and interblue-eyed patients, omitting the “pre- posed in the physician–patient dynamic sumed� benefits of statins or vitamin D are not the answer. for our patients with family histories of

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INFECTIOUS DISEASE SPECIAL EDITION

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Nerve Handling Key to Avoiding Chronic Pain After Hernia Surgery B Y C HRISTINA F RANGOU

end implantation … should be performed,” they said.

At the meeting, the investigators presented their 10-year outcomes data. They had sent a questionnaire to 736 patients, and received responses from 55%. Eight patients in the cohort died over the course of the study.

Among the respondents, 13.6% reported chronic pain 10 years after surgery. Most patients with pain classified it as mild without an effect on

NEW YORK K—One in six patients who reported chronic pain six months after an open inguinal hernia repair still suffers from chronic pain 10 years later, according to a prospective German study reported at the Fifth International Hernia Congress. Others develop late-onset pain, even after five years.

“Patients reporting chronic pain vary with ‘Surgeons are beginning time. This is a very important message,” said lead to understand that they author Wolfgang Reinpold, MD, director of the Department of Surgery of Gross Sand Hospi- have to deprogram their tal and director of the Hernia Center, Hamburg, memory bank and not rely Germany. on teachings of the past.’

The study was initially published in Annals of Surgery in 2011, at which point, only five-year —Paviz K. Amid, MD data were available. At this spring’s international hernia meeting, Dr. Reinpold presented updated results after conducting a 10-year follow-up of the pro- daily activities or quality of life. spective two-phase study. The prospective cohort study However, eight patients (1.8%) followed 736 patients who underwent 781 elective pri- had relevant pain, defined as a mary inguinal hernia operations at the Hernia Centre of score greater than 3 on the visual anaReinbek Hospital, Germany, from April 2000 to April log scale. No patient described the sensa2002. Patients underwent pain assessments on the day tion as very strong. Five of the eight reported of surgery; the first, second and seventh day postsurgery; a slight interference with daily activities. and at six months and five years after surgery.

Among the eight patients with relevant pain, five had The chronic pain rate was 16.4% and sensory disorder undergone a Lichtenstein repair and three had a Shoulrate was 15.9% after six months. At the five-year mark, dice repair. Seven of the eight patients had neurolysis 16.1% of patients reported chronic pain and 20.3% had of the ilioinguinal nerve with preservation of the nerve. sensory disorder of the groin. Independent significant Significant predictors of chronic pain were younger predictors of chronic pain were preoperative pain, chron- than age 50 years, sensory disorder of the groin after ic pain after six months, sensory disorder after five years five years and chronic pain after six months. and ilioinguinal nerve neurolysis in Lichtenstein repair Dr. Reinpold said the 10-year results confirm their due to mobilization of the nerve from its natural bed and earlier recommendations. They called on surgeons to nerve preservation. visualize the nerves and handle with care; to leave the Based on the results of the study, Dr. Reinpold and inguinal nerves untouched in their natural bed or, if this colleagues called on surgeons to avoid ilioinguinal nerve is not possible, to perform a neurectomy and proximal mobilization in the Lichtenstein technique. “The ingui- end implantation; to leave the cremasteric muscle and nal nerves should either be left untouched in their natural spermatic fascia intact; and to avoid mesh suture fixabed or, if this is not possible, a neurectomy and proximal tion to the internal oblique muscle.

The investigators believe that a chronic inflammatory reaction occurs between the conventional polypropylene mesh and mobilized nerve, leading to long-term post-herniorrhaphy chronic pain. Another hypothesis is that chronic scar formation with fibrotic nerve traction leads to chronic pain.

Dr. Reinpold’s study comes on the heels of international guidelines published in 2011. Both reports stress what some specialists have argued for years: A mesh repair is not the same as a traditional tissue repair with the addition of mesh.

Mesh repairs are a completely different operation and the nerves need to be treated carefully, left in their natural beds and not exposed to contact with the mesh.

“Mesh repair has its own principles that have to be followed. For many years, surgeons had a mindset that was otherwise,” said Parviz K. Amid, MD, clinical professor of surgery, David Geffen School of Medicine at University of California, Los Angeles and director of the Lichtenstein Amid Hernia Clinic.

Dr. Amid said surgeons persistently hung onto three “cardinal mistakes from the past”: removing the ilioinguinal nerve from its natural bed, roughly mobilizing the spermatic cord by finger instead of doing it gently under direct vision and removing the cremasteric layers that protect the genital branch of the genitofemoral nerve and the vas deferens.

Based on the current evidence, the rate of chronic pain can be reduced to less than 1% by careful nerve handling, Dr. Amid said, and surgeons are growing more cognizant of nerve management. “Surgeons are beginning to understand that they have to deprogram their memory bank and not rely on teachings of the past,” said Dr. Amid.

Surgery Should Be Primary Treatment for Achalasia, Say Surgeon Investigators B Y J OHN S CHIESZER

AND

V ICTORIA S TERN

SAN DIEGO—Surgery should be the primary treatment for patients with achalasia, despite higher morbidity than observed with endoscopy, according to a new study presented at Digestive Disease Week 2012.

Investigators found that although surgery appears to increase morbidity for patients with achalasia, it also reduces patients’ risk for repeat interventions and relieves symptoms more effectively compared with endoscopy.

“Surgery is more efficacious than endoscopy alone because there is better resolution of achalasia and maybe even better treatment of the reflux,” said study investigator Michael Ujiki, MD, clinical assistant

professor of surgery at the University of Chicago. “If you look at this issue overall, the endoscopic surgeries end up costing more because of all the subsequent repeat interventions that may be required.”

Dr. Ujiki and his colleagues conducted a retrospective study between Jan. 1, 2000 and Aug. 9, 2011, in which they analyzed electronic medical records from patients with achalasia to determine the efficacy of endoscopic versus surgical treatments.

The investigators noted no statistically significant differences between the demographics, except that patients in the surgical cohort were significantly younger (56.3 vs. 72.7 years; P<0.001).

In the surgical group, 72 patients underwent surgical myotomy with or without a full or partial fundoplication. Eight of those patients (11%) had

more than one surgical admission, and 23 patients (32%) had undergone prior endoscopic treatment. In the endoscopic group, 76 patients underwent only endoscopic treatments, which included balloon dilation, botulinum injection or both; 53 of those patients (70%) had more than one treatment, which came to 174 endoscopic interventions total.

Overall, the researchers found that the average time between the first and second surgery was almost seven times longer than that for endoscopic procedures (16.3 vs. 2.5 years, respectively; P<0.05).

The investigators found that patients in the endoscopic group underwent a mean of three interventions and had significantly more dysphagia and gastroesophageal reflux disease (GERD)-related symptoms than the surgical group (42.1%

vs. 16.7%, respectively, for dysphagia, P<0.005; 72.6% vs. 15.3%, respectively, for GERD-related symptoms, P<0.005).

Patients in the endoscopy and surgery groups had similar follow-up periods (7.2 vs. 7.3 years, respectively).

The 30-day morbidity rate in the surgical group was more than four times greater than that in the endoscopy group (6.9% vs. 1.3% patients, respectively). Deaths did not occur in either group.

P. Marco Fisichella, MD, assistant professor of surgery at Loyola University Medical Center, Maywood, Ill., said this research is notable because it confirms previously published findings, and does so with a large number of patients and a longer follow-up. “There are very few studies with this kind of follow-up,” Dr. Fisichella said.

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Pre-op Chemotherapy Safely Treats Colorectal Liver Metastases B Y J OHN S CHIESZER

AND

V ICTORIA S TERN

SAN DIEGO—Preoperative chemotherapy may be administered safely without increasing postoperative complications in patients with colorectal cancer (CRC) and multifocal metastatic disease in the liver, according to a new study presented at Digestive Disease Week 2012.

“I believe that preoperative chemotherapy prior to liver resection should become a standard in the patients with negative prognostic factors,” said study author Ilia Gur, MD, hepatobiliary fellow and clinical instructor in the Division of Surgical Oncology at Oregon Health & Science University (OHSU), Portland.

Dr. Gur added, “There has been concern that the use of chemotherapy before liver resection may decrease the liver’s ability to recover and lead to postoperative comp plicati ions, but our study [eases those concerns].

Wee didn’t see increased rates of liver cancer– reelated complications in the patients who had chemotherapy.” h Although preoperative chemotherapy has the potential to increase the number of surgical candidates by downsizing b leesions, postoperative safety and survival hav ave not been clearly delineated in patients who undergo this treatment. In the only prospective randomized trial to date that compares preoperative chemotherapy with no chemotherapy, investigators found disease-free survival (DFS) improved

VENTRAL HERNIA REPAIR jcontinued from page 1

said Daniel J. Deziel, MD, professor of surgery, Rush University Medical Center, Chicago.

In the first known study to look at the effect of ventral hernia repair on hospital finances at a major academic medical center, the investigators studied cost data on all consecutive open ventral hernia repairs (current procedural terminology [CPT] codes 49560, 49562, 49565 and 49566) performed between July 1, 2008 and May 31, 2011, at a tertiary care referral facility associated with the University of Kentucky.

Patients who underwent tracheostomies and liver transplants were excluded. Investigators looked at the effect of all direct costs (costs directly attributed to a patient’s care) and indirect costs (which included overhead depreciation, goods and services, and personnel).

During the study period, 415 patients underwent ventral hernia repair, including 353 as inpatients and 62 as outpatients. For 42% of the cohort, the hernia repair was performed as a primary procedure.

The results showed that mesh drove up direct costs associated with hernia repair. Median direct costs for cases

modestly in the preoperative chemotherapy group; however, oveerall survival (OS) did not differ signiificantly between the two groupss (Lancett 2008;371:1007-1016).

Dr. Gur and his colleagues performed a retrospective review of all patients who had d liver resections for metastatiic CRC between 2003 and 2011 at OHSU to help clarify the usefu ulness of preoperative chemotherapy. The he investigators analyzed data from 157 patients who had a total of 168 liver resections. Median length of follow-up from a first liver resection was 22.3 months. The data showed 114 patients (72%) underwent chemotherapy before liver resection, most frequently with FOLFOX (oxaliplatin, 5-fluorouracil [5-FU], leucovorin; 68%) or FOLFIRI (folinic acid, 5-FU, irinotecan; 12%) protocols. The mean size of lesions in the preoperative chemotherapy group was 3 cm compared with 4 cm in the no-chemotherapy preoperative group.

After undergoing a liver resection, patients’ OS was 89% at one year, 57% at three years and 27% at five years, and DFS was 61% at one year, 30% at three years and 23% at five years. There was no significant difference in overall complications nor in those related to the liver between patients who received preoperative chemotherapy and those who did not. After a multivariate analysis, Dr. Gur’s team found that the presence of

three or more lesions as well as age older than 70 0 years were significant predictors of poor ssurvival. Additionally, the presence of several variables—such as older age and multiplicity and synchronicity of liver lesions—pointed to a subset of patients with a particularly high risk for recurrence. The presence of these variables “justified the decision to recommend use of chemotherapy [in these patients],” Dr. Gurr said.

Dr. G Gur’s team concluded that even with chemotherapy and aggressive resections, only a subset of patients remains free of disease after five years and that preoperative chemotherapy should be considered strongly in patients with risk factors.

“Although there was no disease-free or overall survival advantage in the preoperative chemotherapy group, [this may be explained by] the fact that the chemotherapy group had more risk factors and that the study was not powered enough nor were the groups randomized to detect a difference,” Dr. Gur added.

P. Marco Fisichella, MD, assistant professor of surgery at Loyola University Medical Center, Maywood, Ill., noted that this is an important study with significant clinical ramifications. “This [study] is clinically relevant and has the potential to change the way we do things,” Dr. Fisichella told General Surgery News. “This study offers evidence to support chemotherapy before resection.”

performed without mesh were $5,432. net revenue was higher for hernia repairs Costs rose to $7,590 when synthetic done as a secondary procedure than mesh was used, and more than tripled repairs performed as a primary proceto $16,970 in cases with biologic mesh dure ($17,310 vs. $10,360, respectively; (P<0.01).

P<0.01). However, net losses, too, were Investigators cautioned that it is dif- greater for hernia repairs done as a secficult to pinpoint the actual cost of each ondary procedure ($3,430 vs. $1,700, mesh due to changing hospital con- respectively; P<0.01). tracts over the study period. Broadly, Use of inpatient mesh increased over the cost for synthetic mesh was as high the course of the study, but was not as $2,200 and for biologic mesh ranged employed uniformly as of 2011. In 2001, between $8,000 and $10,000. only 80% of repairs were performed Despite the price with mesh despite evi‘There are certain of the mesh, inpatient dence available long synthetic mesh repairs before 2011 showing clinical scenarios were the most finanthat mesh use decreases in which the patient hernia recurrence. cially viable of all ventral hernia repairs. The Although the study is is best served with investigators observed focused on a single tera biologic graft for tiary center, other cena median net profit of $60 for synthetters serving complex abdominal wall ic mesh–based repairs, patients likely experireconstruction, whereas repairs withence a “similar financial out mesh were associ- especially in a tertiary plight,” Dr. Reynolds ated with a $500 net said. “Patients underenvironment.’ loss. Repairs involvgoing open ventral ing a biologic mesh —Drew Reynolds, MD hernia repair at a terresulted in a meditiary referral center are an net financial loss of often a more compli$8,370, and a negative median contri- cated patient population, both from a bution margin (a measure of the hospi- technical standpoint and in terms of tal’s net revenue minus the direct cost) medical comorbidities. Our data demof $4,060. onstrate the current fiscal insolvency The study also showed that median involved in caring for these patients.”

Dr. Reynolds said that operating room supply costs, including biologic mesh materials, account for a significant component of the net financial losses observed. He added, however, that mesh has significant value in decreasing hernia recurrence. “This is under-appreciated in current reimbursement strategies,” he said.

Even biologics, although expensive, have a role, he said. “There are certain clinical scenarios in which the patient is best served with a biologic graft for abdominal wall reconstruction, especially in a tertiary environment.”

Dr. Reynolds called for more costeffective strategies to manage these complex patients, especially as the numbers of these patients, and the costs associated with their care, appear to be rising. “There is significant need for reevaluation of reimbursement, more appropriate adjustment of preoperative risk factors and operative complexity.”

Dr. Reynolds said the study suggests there may be a role in the future for specialized hernia centers, which could minimize losses by optimizing outcomes. Additionally, developing a nationwide hernia registry could contribute to better standardization in herniorrhaphy and better outcomes in the future, he said.

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Scalp Melanomas Carry Worse Survival Prognosis Than Other Melanomas B Y C HRISTINA F RANGOU ORLANDO, FLA.—Scalp melanomas are associated with worse disease-free survival (DFS) and overall survival (OS) than other melanomas, including those of the face and neck, according to the largest reported series of scalp melanomas to date.

“Compared with melanomas of the face and neck, the trunk and extremities,

scalp melanomas have a poor overall prognosis,” said lead author Junko OzaoChoy, MD, surgical oncology fellow, John Wayne Cancer Institute, Santa Monica, Calif., who presented the results at the 65th Annual Cancer Symposium of the Society of Surgical Oncology.

The current research is the second large study to show that scalp melanomas are more lethal than other melanomas.

One nationwide study found that people with scalp or neck melanomas die at

nearly twice the rate of people with melanomas elsewhere on the body, based on data from the Surveillance, Epidemiology and End Results (SEER) registries ((Arch Dermatoll 2008;144:515-521). That study, however, lumped scalp and neck melanomas together.

In the latest investigation, researchers differentiated between scalp and neck melanomas and found that scalp melanomas have the worst prognosis. Less than half of patients with scalp melanomas (46.9%)

had five-year DFS after their diagnosis, the lowest of all melanomas studied. Fiveyear DFS was 62.7% for patients with face, neck and ear melanomas; 66.5% for trunk melanomas; and 68.6% for melanomas located on the extremities. Scalp melanomas also had significantly more local recurrence (P<0.0001) and distant metastases (P<0.0001) compared with other melanomas.

The results are based on a review of the John Wayne Cancer Center’s melanoma database for the years 1971 to 2010.

Investigators reviewed the records of all patients diagnosed with primary cutaneous melanoma (ranging in size from 1.00 to 1.99 mm), which included 799 patients with melanomas located on the scalp, 1,249 on the face/neck/ear, 6,236 on the trunk and 3,112 on the extremities.

‘This contributes to our understanding of something we’ve suspected for a while.’

—Nancy Thomas, MD, PhD

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On multivariate analysis, scalp location was an independent predictor of melanoma-specific survival (hazard ratio, 1.52; 95% confidence interval, 1.221.91; P<0.0003). Five-year OS rate was 58%, 72%, 74% and 77% for scalp, face/ neck, trunk, and extremity melanomas, respectively.

Nancy Thomas, MD, PhD, professor of dermatology at the University of North Carolina, Chapel Hill and senior author of the original study based on SEER data, said that together, the two studies suggest there is a “robust” effect. “This contributes to our understanding of something we’ve suspected for a while,” said Dr. Thomas, who added that clinicians should include the scalp as part of a full skin examination.

In the past, experts have speculated that scalp melanoma may be more lethal because it’s diagnosed later than other melanomas; however, there’s a growing belief that biology, not location, contributes to the worse prognosis.

“There may be a biologically different mechanism driving scalp melanomas to have a worse prognosis,” said Dr. OzaoChoy. “This may be due to the biology of the melanoma itself or the biology of the environment of the scalp. For example, the scalp is very well vascularized and the lymphatic drainage is varied and complex in this area.”

Investigators said further studies are needed to ascertain whether biology or anatomy contributes to the worse clinical course associated with scalp melanomas.

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Cheap, Effective Solutions in Trauma Care Born in Africa B Y C HRISTINA F RANGOU SAN FRANCISCO—Surgical trauma care, by definition, is about managing the unanticipated.

So, if you want to improve trauma care, start in unexpected places, said Doruk Ozgediz, MD, a pediatric surgeon at the University of Buffalo, in Buffalo, N.Y., and cofounder of Global Partners in Anesthesia and Surgery (GPAS), an international group that seeks to improve quality of perioperative care in the developing world.

That’s what happened in Uganda, where a pivotal change in trauma care over the past three years evolved in the backseats of police cars and taxis. Uganda lacks a designated ambulance service. For years, police cars and taxis have served as the de facto ambulance service to get trauma victims to the hospital in the capital city of Kampala. Onlookers would load an injured person into the back of a taxi or police car and the driver would careen off to the hospital with the victim. Many patients lost their airways en route or had an uncontrolled hemorrhage, significantly increasing their risk for dying before they got to a trauma center.

“We thought that we could improve the situation by training the first responders—the non-medics, police, taxi drivers. Basically, it’s a modified scoop-and-run,” said Dr. Ozgediz.

Three years ago, GPAS, in collaboration with other providers, launched a program to train these first responders to transport injured individuals more safely and offer first aid. Following the course, trainees’ scores in basic first-aid knowledge nearly doubled from 45.3% to 86% (World J Surg 2009;33:2512-2521). Figures from GPAS suggest the program would cost about 12 centss per capita if this were rolled out across the city, and woulld result in approximately $25 to $150 per life-year saved..

This is just one example of the way that surrgery and trauma care is changing in Africa, said Dr. Ozgediz, speaking at a special session at the American College of Surgeons Clinical Congress, which focussed on extreme affordability in surgery. Similarr programs have been successful in conflict settings in Iraq, Cambodia and Ghana. The ideaa is to build on existing, informal mechanisms rather than introduce new systems that mayy not fit the local context.

For years, surgery has not been on the radarr in global public health efforts. Compared with h HIV, tuberculosis and malaria, surgery pales in terms of funding and public awareness in developing countries. Surgical services are perceived ed as too expensive, too high-tech and too unique too be practical in countries where people die from lack ck of basic nourishment.

Yet, the poorest regions of the world havee the largest surgical-disease burden on earth, mostly from injuries. Injuries account for an estimated 38% of the disease burden attributed to surgical conditions. That’s’ followed by malignancies at 19%, obstetric complicatioons at 9%, and congenital anomalies, cataracts and glaucoma, c and perinatal conditions at 6%, 5% and 4%, reespectively, according to figures from the World Health Organization (WHO).

Now, a growing movement is calling for a larger role for surgery in poorer regions of the world. Advocates A argue that funds dedicated to improving surrgical care are dollars well spent. Additionally, an emergin ng body of

evidence indicates that funding for basic surgical services is more cost-effective than other broadly supported health projects. For instance, the Disease Control Priorities in Developing Countries Project found surgery is more cost-effective than distributing antiretroviral drugs in countries with a high prevalence of HIV. Surgery costs an estimated $7 to $200 per disability-adjusted life-year (DALY) averted. (DALY is a single measure of disease burden, commonly used by the WHO.) In comparison, antiretroviral drugs cost about $300 to $500 per DALY averted; the measles vaccine costs about $1 to $5 (Lancet 2006;367:1193-1208).

Other research has shown that inguinal hernia repair is cost-effective compared with no treatment when repairs are done with inexpensive mosquito netting. Researchers found an incremental cost-effectiveness ratio of $12.88 per DALY averted, as described in the book Global Surgery and Public Health.

Many problems contribute to the lack of surgical care in low-income countries: a shortage of surgeons and anesthesiologists (in Uganda, an estimated 100 surgeons look after a population of about 25 million), a lack of basic equipment and training, and inadequate infrastructure, such as a transportation system to get patients to

‘We thought that we could improve the situation by training the first responders—the non-medics, police, taxi drivers. Basically, it’s a modified scoop-and-run.’

—Doruk Ozgediz, MD

hospital.

But the problems are not insurmountable, said Dr. Ozgediz. He believes that surgeons in the United States can help. For one, they can help train surgical health care providers, said Dr. Ozgediz.

His team has taught a version of advanced trauma care in Uganda for about $500 total. “We didn’t fly in any people. We helped the

Ugandans do their own course. What we did was organize it.”

This venture marks a change in thinking about health care delivery in the developing world. In the past, many North American and European surgeons traveled overseas to train physicians and treat populations in the developing world, said Philip L. Glick, MD, MBA, vice chairman of surgery, University of Buffalo. “These trips don’t make sense because when you leave, there’s no one there to take care of the population anymore. I think we’re shifting to a belief that our best management of resources is to teach Third-World health care workers how to take care of their own people in a resource-constrained way.”

Dr. Ozgediz also advocates training nonsurgical personnel to provide surgical services. In many countries, health care practitioners and nonphysicians do surgery, he said. Former fistula patients now treat fistulas in Addis Ababa, Ethiopia. In Mozambique, Malawi and Tanzania, governments have explicit policies to train non-surgeons to perform surgery. The health care workers live and work in rural areas and are trained over a shorter period of time than a typical surgeon.

A new study under way in Malawi and Zambia will look at surgical training in these countries. In a clusterrandomized trial, the research aims to produce a new cadre of surgically trained health care professionals who are likely to remain in Africa, particularly rural areas.

American-based surgeons along with non-governmental organizations also can set up scholarships for surgeons abroad. For example, it costs about $1,500 per year to become a specialist surgeon in East Africa by training through a three-year postgraduate program, such h as that h offered ff d iin Uganda.

U d GPAS has been setting up scholarsh hips for four years, h said Dr. Ozgediz. “We’ve had a sigggnificant increase, over fourfold, in the number of train nees in anesthesia n and surgery.”

Even if poorer countries train eenough surgeons, surgery can’t happen without aanesthesia. Anesthesiologists, anesthetic equip pm ment and drugs are in short supply. Many cooountries still rely on Epstein-Macintosh-Oxfordd ether anesthesia, which dates back 50 years, oor spinal anesthesia. Some groups try to com mbat the anesthem sia problem by bringing in n equipment from other counttries. r Oftentimes, equipment aarrives that is useless or not compatible with the environmeeent.

To change th his, the WHO has h issued health caree equipment donation guidelines, avaiiilable online. The goal is to reduce donaations t that do not achieve their intended objjjectives or further burden the recipient health caaare system.

Dr. Ozgediz called for glooobal standards for equity in surgery to help reeeduce the disparities between caaare in the United States and in n the developing world. “We sh hould advocate to h level global su urgical disparities. u We need to measure disparities and we need d to come up with solutions.”

More informattion on GPAS is available at www.globalpas.org.

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Mild Surgical Complications Increase When Residents Participate But Increase May Not be Clinically Relevant B Y C HRISTINA F RANGOU

R

esident involvement in surgical cases is associated with a small increase in mild surgical complications, mostly caused by superficial wound infections, according to a new study that included more than 60,000 procedures.

The risk for mild surgical complications increases if the residents are in their later years of residency when they take on a greater role in the operating room, the study showed; however, the investigators stressed that the risk remains very small and may not be clinically relevant.

“Resident involvement in surgical procedures is safe. There is a small overall increase in mild surgical complications but we are unsure if it is clinically relevant. The difference may be marginal,” said lead author Ravi P. Kiran, MD, staff surgeon and head of the research section of colorectal surgery, Cleveland Clinic, Ohio, who presented the study at the 132nd Annual Meeting of the American Surgical Association (abstract 9).

The study is the largest and strongest to date to measure the effect of surgical trainees on patient outcomes. An earlier study showed that resident intraoperative participation is associated with slightly higher morbidity rates but slightly decreased mortality rates across a variety of procedures, which is minimized further after taking into account hospitallevel variation ((JACS 2011;212:889-898).

All studies prior to this one were restricted to the experiences of a single hospital or geographic region.

Dr. Kiran and colleagues studied data collected by National Surgical Quality Improvement Program between 2005 and 2007. They performed a matched comparative study comparing outcomes for 40,474 patients who underwent surgery with resident participation and 20,237 whose operations did not involve resident participation.

Analysis showed that resident involvement did not affect 30-day mortality, severe complications or medical complications. But overall complications did increase from 6.7% to 7.5%, surgical complications rose from 6.2% to 7.0% and mild complications went up from 3.5% to 4.4% when residents participated in an

operative case (P<0.001).

The increase stems from a spike in superficial surgical site infections (SSI).

Superficial SSIs rose from 2.2% in cases without residents to 3.0% when residents participated. Surgical SSIs were the only surgical complication associated with a statistically significant increase when residents were involved. Deep SSIs, wound disruptions, peripheral nerve injuries, bleeds requiring transfusion, graft failures and reoperations remained the same regardless of resident participation. Surgical trainees did prolong operative time, with the mean procedure time lasting 122 minutes compared with 97 for cases without residents. Length of surgical and hospital stay was unaffected.

There are likely multiple reasons for the spike in SSIs, but a major driver appears to be prolonged operative time, said investigators. Operative time is a known factor associated with SSIs. Investigators said they could not confirm whether resident involvement led to the increased infections or if sicker patients with increased complexity underwent surgery at teaching hospitals with resident participation.

“Resident participation may by itself

be a surrogate for complexity and disease severity despite any attempts at controlling for all potential patient-, disease- and operation-related factors in a matched study,” said Dr. Kiran.

The study also showed an association between year of training and rate of complications. Complication rates rose incrementally with year of training.

When postgraduate year (PGY) 1 and 2 residents participated in care, 5.9% of patients developed complications. That number rose to 8.2% for PGY 3, 4 and 5 residents and, again, to 8.7% for PGY 6 residents. The investigators suggested that enhanced supervision of residents in PGY 3 or beyond might improve their surgical skills and promote patient outcomes.

“The overarching issue seems to be how we might achieve high-quality patient care (and outcomes) in the context of training, and how we might do both well,” said Clifford Y. Ko, MD, professor of surgery and health services at the David Geffen School of Medicine at the University of California, Los Angeles. “With increasingly used metrics, high-quality care and training remain the responsibility of every surgical training program.”

Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Things That Puzzle Me About Surgical Education B Y S KEPTICAL S CALPEL

W

hen I was a surgical residency program director, I often wondered what the establishment, you know those guys who ran surgical education, were thinking. Some may remember the rule that a resident had to see at least 50% of the patients he or she operated on in clinic or the private surgeon’s office in order to claim credit for having done the case.

Why can’t residents learn advanced laparoscopy during a five-year surgical residency? Are they too busy memorizing the Glasgow Coma Scale?

There was the emphasis that still exists today on making sure every resident did research. At last, some are questioning the value of this for the average clinical surgeon. Contrary to the prevailing wisdom, there is no evidence that a resident who is dragged kicking and screaming through a clinical research project or who spent a year in someone’s lab really learns anything about research or how to read and understand a research paper.

Then, there is the obsession with a transplant rotation, recently noted in a published paper to be a waste of time in the opinion of surgical residency program directors (Am ( J Surgg 2011;202:618-622).

And what’s with all the emphasis on basic science? Shouldn’t residents have learned all the basic science they need (and more) in medical school? Why are residents forced to relearn basic science that they will not ever use in practice? When you stand at the bedside of a sick patient do you ask yourself, “What is the Cori cycle doing right now?” or do you simply order a lactic acid level?

Why do we teach surgery the same way we did 40 years ago? Instead of teaching residents how to think, we still force them to memorize large volumes of information that they can carry in their smartphones.

I am also wondering what is going on with clinical training. A recent paper found that residents are concerned that their operative skills are inadequate (J ( Am Coll Surgg 2012;214:53-60). Last year in a blog reviewing that paper, I wrote, “A significant number of all residents surveyed worried that they would not feel confident to perform surgery by themselves when they finished training. A similar number were not satisfied with their operative experience.”

Many graduates of residency take

fellowships to gain extra experience. Especially interesting is the proliferation of so-called “advanced” laparoscopic fellowships. There was a time when we taught residents all they needed to know in five years. Why can’t residents learn advanced laparoscopy during a five-year surgical residency? Are they too busy memorizing the Glasgow Coma Scale?

I recently heard of a new proposal. Get this: There may be a plan to offer “open surgery” fellowships. Details are sketchy,

but the idea would be to train surgeons to do old-fashioned laparotomies. It’s not yet clear which of the surgical disciplines (such as vascular, colorectal, hepatobiliary) would be involved or which hospitals have enough volume of open surgery to support such a fellowship.

Maybe we should skip most of general surgery residency altogether and just let them go to

their fellowships after a year or two of basic training.

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical subspecialty and has recertified in both several times. For two years, he has been blogging at SkepticalScalpel.blogspot. com and tweeting as @SkepticScalpel.

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12

Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Health Care Fraud and the FBI Tracking a Small Minority of Providers Who Cost the System Billions B Y T HAD T ROUSDALE [Editorâ&#x20AC;&#x2122;s note: The following article was originally published in Missouri Medicine (March/ April 2012. 109:2:102-105). Mr. Trousdale is a staff operations specialist from the FBI, Kansas City Division. The opinions expressed in this article are those of the author and not the FBI.]

T

he FBI is the primary agency for exposing and conviction of offenders, the FBI provides assistance to investigating health care fraud, with jurisdiction various regulatory and state agencies, which may seek over federal and private insurance programs as well as exclusion of convicted medical providers from further non-insurance health care fraud matters. The FBI uses participation in the Medicare and Medicaid health care its analytic expertise to identify key trends and tap systems. into its investigative partnership with federal, state and Currently, the FBI is working on more than 2,600 local agencies, as well as our relationships with national pending health care fraud investigations. During fiscal groups and associations, to uncover fraud. year (FY) 2010, cooperative efforts with its law enforceHealth care fraud investigations are among the high- ment partners led to charges against approximately 930 est priority investigations within the FBIâ&#x20AC;&#x2122;s White-Collar individuals and convictions of close to 750 subjects.

Crime Program, ranking behind only public corruption Additionally, the investigations led to the dismantling and corporate fraud. The FBI works closely with its fed- of dozens of criminal enterprises engaged in widespread eral, state and local law enforcement partners, the Cen- health care fraud. In FY 2009, FBI investigations resultters for Medicare & Medicaid Services (CMS) and other ed in $1.6 billion in restitutions, $853 million in recovergovernment and privately sponsored program partici- ies, $68 million in fines and $54 million in seized assets. pants to address vulnerabilities, fraud and abuse in the The FBI remains committed to working additionhealth care system. al health care fraud investigations with its partners at The FBIâ&#x20AC;&#x2122;s 56 field offices proactively target fraud the Department of Health and Human Services (HHS) through coordinated initiatives, task forces, strike teams Office of Inspector General, individual state Medicare and undercover operations. Throughout the country, FBI fraud offices and Special Investigative Units from private field offices participate in Health Care Fraud Working insurance companies. The FBI also works jointly with Groups that involve law enforcement agencies, prose- the Drug Enforcement Administration, the FDA and cutors, regulatory agencies and health insurance indus- the Department of Homeland Security to address drug try professionals to identify the various crime problems diversion, Internet pharmacy fraud, prescription drug involving health care fraud. FBI offices establish state abuse and other health care fraud threats. and local initiatives to meet the needs of the community.

Those seeking to perpetrate health care fraud take In the United States, various field offices have con- advantage of the confidence that the public, and ducted their own initiatives targeting clinics, pharmacies, especially their patients, places in health care sysdurable medical equipment providers, home health agen- tem professionals. All health plans heavily rely on cies and other possible sources of fraud that are a concern the fundamental premise that providers are, for the within communities. nities. The FBI also develops national most part part, honest h honest. R Relatively l i l few f claims l i are ever and local initiatives ti when large-scale fraud is detected; reviewed by a human or subthis may involvee participation by several FBI field offic- jected to electronic quales and other law aw enforcement agencies. One example ity assurance audits. In of these initiativves is the Department of Justice/Department ar of Health and In fiscal year 2009, FBI Human Services es Health Care Fraud Prevention and d Enforcement Action investigations resulted in Team (HEAT), which now operates $1.6 billion in restitutions, in seven cities across c the country.

As part of it its strategy to address $853 million in recoveries, health care fraud, ud the FBI cooperates $68 million in fines and $54 with the Department r of Justice and U.S. Attorney Offices throughout the million in seized assets. country to pursue s offenders through parallel criminal al and civil remedies.

These cases typically target large-scale medical providers, e such as hospitals and corporations, ns that engage in criminal activity to commit fr fraud against the government that underminess the credibility of the health care system. Ass a result, much emphasis is placed on recovering the illegal proceeds through ro seizure and forfeiture proceedings, e as well as substantial ci civil settlements. Upon successful uc

fact, 95% of all claims are processed electronically, and as long as the patient is eligible and the diagnosis is not inconsistent with the service billed, the claim is paid.

Most insurers seek to make it as convenient as possible for providers to bill the plan and keep documentation to minimum levels. Consequently, fraudulent claims frequently look exactly like legitimate claims and are easily concealed among the billions of claims, bills and cost reports filed by over a million providers. Some contractors are required to process claims within a specified time limit, increasing the likelihood that a claim initially will be paid, only to be found to be fraudulent after the fact. The actual amount of money lost to fraud is unknown, but it is estimated that anywhere between 3% and 10% of all health care expenditures, both public and private, can be attributed to fraud.

One of the most significant and troubling trends observed in recent fraud cases is the willingness of medical professionals to risk patient harm in their schemes.

FBI investigations in several offices are focusing on subjects who conduct unnecessary operations, prescribe dangerous drugs without medical necessity and engage in abusive or substandard care practices, such as withholding necessary treatment or medication to cause patients to qualify for a higher level of home health care or hospice care.

Recent trends also suggest that advances in technology and electronic medical data have caused fraud schemes to evolve. The FBI has developed expertise in investigating technical schemes involving medical data theft and other fraud schemes facilitated f through the use of computers. Of course, frraud a schemes continue to consist of traditional schemees that involve fraudulent billing, such as billing for serr vvices not rendered and deliberate upcoding of charges for services provided.

Some of the common types of h health care fraud occur in the areas of home health carrre, hospice care, durable medical equipment, Internett pharmacies and infusion therapy.

One of the predominan nt emerging areas of health care fraud is in the area of home health care. Hom me Healthcare Agenm cies (HHAs) make a up approximately $15.1 billion off the health care market and HHA As continue to grow.

A This rapidly eexpanding market is a good targett for perpetrators who are seekin ng to acquire illicit proceeds b by exploiting expensive HHA services. In the moost common HHA frraud scheme, dishonest providers inflate HHA diabetic episodes to create outlier payments that are in excess of the

Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

national 60-day episode payments. This scheme alone is projected to cost Medicare more than $1 billion a year.

Other HHA fraud schemes include billing for services not rendered, billing for medically unnecessary services, kickbacks to physicians to sign plans of care or to patients for their participation, forging physician signatures in order to bill Medicare, billing for unqualified patients, fabricating or altering visit notes and billing for housekeeping and unskilled services as skilled nursing care. The March 2009 Government Accountability Office (GAO) Medicare report stated that at least part of the 44% increase in home health care spending between 2002 and 2006 could be attributed to fraud. With so much at risk to patients, legitimate health care providers and the health care system, the federal crime of health care fraud is enforced with serious penalties. The basic crime carries a federal prison term of up to 10 years in addition to large financial penalties (18 USC, Section 1347). The federal law also provides that if a perpetrator’s fraud results in injury to a patient, that prison term can double up to 20 years; and if the fraud results in the patient’s death, an individual can be sentenced to life in federal prison.

In addition to criminal penalties, health care fraud perpetrators also may be subject to civil penalties under the federal False Claims Act (FCA). The FCA imposes civil liability on persons who knowingly submit a false or fraudulent claim or engage in various types of misconduct involving federal government money or property. Penalties under the FCA include treble damages, plus an additional penalty of up to $11,000 for each false claim filed. In order to assist physicians in better protecting their practices from the potential for erroneous or fraudulent conduct, the HHS, Office of Inspector General has published a list of recommendations designed to help physicians create a voluntary compliance program. The following summarizes those recommendations: 1. Conduct internal monitoring and auditing through the performance of periodic audits.

2. Implement compliance and practice standards through the development of written standards and procedures.

3. Designate a compliance officer to monitor compliance efforts and enforce practice standards.

4. Conduct staff training on practice standards and procedures.

5. Respond appropriately to detect violations by investigating allegations and the disclosure of incidents to appropriate government entities.

6. Develop open lines of communication, such as discussions at staff

7.

meetings on how to avoid erroneous or fraudulent conduct and the use of community bulletin boards to keep employees updated on compliance.

Enforce disciplinary standards through well-publicized guidelines.

For more information about compliance program guidelines from the HHS, visit www.hhs.oig.gov/oig.

The FBI and its law enforcement partners recognize that patient care is the first priority of any physician’s practice and that the majority of health care

FBI investigations in several offices are focusing on subjects who conduct unnecessary operations, prescribe dangerous drugs without medical necessity and engage in abusive or substandard care practices.

fraud is committed by a small minority of dishonest providers. Unfortunately, the fraud perpetrated by these individuals ultimately serves to tarnish the reputation of the most trusted and respected members of our society, our physicians.

Keeping America’s health care system free from fraud requires active participation from each of us. Those who have knowledge of possible health care fraud schemes are encouraged to contact their local FBI field office, state’s Medicare Fraud Office or the HHS, Office of Inspector General.

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13

14

On the Spot

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Gut Reaction: Colorectal Surgery

(See July issue, page 4 for On the Spot: Watch and Wait for Rectal Cancer?)

Contributor

My nightmare case

In the colorectal cancer case, the colorectal surgeon should be

In the colorectal In the colorectal cancer case, the cancer case, the oncologist patient should be should be

In the colorectal cancer case, the pathologist should be

TEM is

Radical rectal resection is

Fellowships are

Gerald Marks, MD Wynnewood, Pa.

The patient with a frozen post-radiated pelvis with recurrent cancer

Stouthearted, determined and technically well prepared

An integrated team player

Optimistic and spiritually supported by the surgical team

Dedicated and attentive to the finest details

A monumental innovation; Gerhard Buess’ wonderful legacy

A challenge in surgical expertise

The true path to excellence

Rodrigo Perez, MD Sao Paulo, Brazil

Anterior rectal cancer, obese male patient with unfavorable response to CRT

Radical

Unnecessary

Thin and healthy

Meticulous

Alternative

Standard

Absolutely necessary

Conor Delaney, MD Cleveland, Ohio

Breast surgery

Technically and judgmentally perfect

Selective about who to treat

Asking questions about the physician’s experience

Using standard templates and standardized assessment

Good for selected cases

Good for selected cases as well

Important for maximizing training and skills

John Marks, MD Wynnewood, Pa.

Recurrent cancer in the obese male pelvis

Aggressive, careful and technically excellent

Optimistic, openminded and well read

Hoping for the best and preparing for the worst

Focused on fine details

The ultimate in minimally invasive surgery

The gold standard

A luxury for the resident surgeon pursuing excellence

Brad Champagne, MD Cleveland, Ohio

Unexpectedly find- Compulsive ing carcinomatosis

Both evidencebased and pragmatic

Part of the team

Useful for selected rectal lesions

The most effective oncologic approach

Actually called colorectal residencies

Richard Goldberg, MD Columbus, Ohio

Involves local wound complications from postoperative infection

Constantly attentive to the nuances of individual cases

Working as a team

Fully informed of options and their relative risks and benefits

Compulsive in looking for nodes

An emerging option for T1 tumor management

Still a standard of care for >T2 and N-positive disease

Critical to optimal training

Theodore Saclarides, MD Chicago, Ill.

Recurrent rectal cancer following radiation, chemotherapy and previous surgery

Involved when the diagnosis is first made

Compassionate, caring and available

Compassionate, caring and available

Compassionate, caring and available

More likely to obtain negative margins and produce an intact specimen compared with conventional transanal surgery

Required for the major- Necessary in order to proity of rectal cancers vide surgeons capable of producing the best outcomes

Albert DeNittis, MD Wynnewood, Pa.

A recurrence in the previously irradiated pelvis that is unresectable, in need of radiation surrounded by loops of bowel

Open-minded, fearless, thickskinned and always handsome

Knowledgeable, weary of old dogma, part of a team

Hopeful, and part of the decision making

Someone who knows what the team is looking for

The future

Useful in appropriately selected patients

Critical to the viability of our nation’s health care

Tim Nguyen, MD Weston, Fla.

Profuse rectal bleeding or bowel obstruction

Skillful, aggressive, fearless

Thoughtful, think Resilient, demand Knowledgeable, outside the box, the best care, yet be descriptive and but careful not to patient thorough cause more harm than good

Here to stay, especially for frail patients

More advanced tumors

Rite of passage

Hutchinson’s Picks

Delaney

DeNittis for sure

G Marks

Nguyen

J Marks

Saclarides

Champagne

Perez

APR, abdominoperineal resection; CME, continuing medical education; CRT, chemoradiotherapy; OR, operating room; TEM, transanal endoscopic microsurgery

O nthe

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Spot

15 with Colleen Hutchinson

Robotics in colorectal surgery

Neoadjuvant therapy is

Association membership and attendee fees

Centers of excellence

Industry-driven science?

Our health care system lacks

Colorectal oncology is

Our surgical unit has most need for

Our most underrated staff member is

Open surgery in colorectal

Interesting

A total game changer for rectal cancer; truly transformative

Too high

A tricky topic requiring exceptional standards and scrupulous assessment based on results and not reputation

Industry-partnered science is what I support. Industry should be a major provider of the resources for education and research

Proper leadership at the top

Demanding and where openminded attention to details is necessary

Team concept at all levels

The OR team leader

Basic

The immediate future

Beneficial

Painful but necessary

Few but required

A word of caution

Many things

Very interesting

More efficient and time-saving documentation

Anesthesiologist

Still needs to be taught

Are unnecessary if you are trained in laparoscopy

Good for selected cases

Should be able to provide all required components of care in an efficient manner

Can be useful source of funding when done in a carefully controlled manner

Efficiency and cost control

Evidence-based when practiced properly

Nothing at present

An area for exploration

A tremendous advance when well done

A necessary evil, that’s risen too high

Both opportunity for excellence and impediment to progress

Bad. Industry funded =fine

Ability to measure and reward quality

A growing and exciting field

Outcomes data

OR tech Greg Paisley

Hopefully a vanishing art form

Are rarely useful in experienced hands

Essential for most rectal cancer cases

Should be paid by hospital administration

Are difficult to establish for colorectal disease

Necessary in this economy

Patient accountability, tort reform, double mandate

Always evolving

Hard-working anesthesiologists

The administrative assistant or secretary

Will always have its place

Is an emerging technology with considerable promise but no comparative data exist regarding open or laparoscopic management

The standard of care to optimize local recurrence rates and minimize the need for APRs

Provide the funding for intellectual discourse and CME

Provide for optimal outcomes

Should be tempered by input from academic partners

Adequate resources for the uninsured and underinsured

Making impressive progress in recent years

More ORs

Ostomy nurses

Will be done less frequently in the future

Unnecessary

Necessary for rectal cancers that demonstrate fixity, transmural penetration and/ or have enlarged adenopathy on imaging studies

Are a necessity

Provide the best outcomes

Should be viewed with caution

Nothing; it’s the best in the world

A multidisciplinary entity; the surgeon cannot play in the sandbox alone

Physician extenders

The nurses

Is here to stay

N/A

The standard of care; saves lives.

Overrated

Should be based on the physicians and not reputation.

Always, always Google your doctor.

Sell your soul for the money? As long as it’s doctor-driven

The guts to make the tough calls

Fascinating

N/A

Our physics staff

Elementary school

A neat toy

Integral part of treatment

Expensive, but worth the price

Many, Cleveland Clinic Florida is not bad

Not an evil empire, can work well together with academic-driven science

Universal health coverage

Easy if it was not for rectal cancer

More dedicated surgical oncologists

Research staff and office coordinators

Unlikely to go away

Goldberg

DeNittis

Perez

G Marks

Delaney

Champagne

Saclarides

J Marks

Goldberg

Champagne

Only necessary for reoperative cases, some emergencies and particularly complex cases

16

Surgeons’ Lounge

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Dear Readers, Welcome to the August issue of The Surgeons’ Lounge. This issue features David S. Tichansky, MD, FACS, associate professor of surgery and director of Minimally Invasive and Bariatric Surgery at Thomas Jefferson University, in Philadelphia, who discusses a case of distal esophageal diverticulum with an associated mass suspicious for a leiomyoma. On the topic of diverticulum, we offer some interesting facts about Zenker’s diveriticulum in our “History and Other Facts” section.

Our next guest expert is Rami E. Lutfi, MD, FACS, clinical assistant professor of surgery, University of Illinois at Chicago, and director of The Chicago Institute of Advanced Bariatrics, Saint Joseph Hospital. We greatly value our readers’ opinions and encourage all feedback.

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

Question for Dr. Tichansky

By Kathleen Lamb, MD

A

30-year-old woman presented to our office with a 38-lb weight loss over the past few months, progressive dysphasia and regurgitation of liquids and solids. Her preoperative workup, including upper gastrointestinal study, revealed a distal esophageal diverticulum with an

associated mass suspicious for a leiomyoma, along with diffuse esophageal spasm.

We are now trying to plan for surgical resection of this diverticulum and mass. Would you pursue a thoracoscopic or laparoscopic surgical approach? Additionally, would you recommend performing an antireflux procedure, such as a fundoplication? How frequently are esophageal diverticula associated with leiomyoma and is diverticulum development influenced by the presence of a leiomyoma?

Dr. Tichansky

Reply

The patient described above possesses a very rare diagnosis, mostly because it is the combination of two relatively uncommon diagnoses. Let’s look at the two disorders separately first, and try to find treatment commonality.

Leiomyomas are one of the more common benign tumors of the esophagus, but much less common than esophageal carcinoma. The incidence is

generally accepted to be between less than 1% and up to about 5%. However, these lesions usually are discovered when symptoms develop, once the mass reaches a certain size. Many smaller lesions may be present, but asymptomatic. The majority of these lesions are in the lower esophagus, with less in the mid-esophagus and only rare occurrences in the proximal esophagus.

These lesions often are diagnosed if an upper gastrointestinal x-ray finds a filling defect, followed by endoscopic visualization of normal mucosa covering a presumably intramural mass. Chest computed tomography (CT) and/or endoscopic ultrasound could better

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

define the lesion in the esophageal wall.

It is generally accepted that the treatment for symptomatic esophageal leiomyomas is surgical resection regardless of size. Asymptomatic lesions smaller than 3 to 5 cm may be followed radiographically. However, concerns about occult malignancy and/or more challenging resection later, after the mass has grown, often will lead to resection of these smaller lesions. The approach to these lesions has traditionally been through a thoracotomy or thoracoscopically, depending on their location.

For lesions in the upper two-thirds of the esophagus, approach through the right chest is standard. Lesions in the lower third, as is the case in this patient, can be approached by multiple routes, which I discuss briefly below.

Distal esophageal diverticula are typically pulsion diverticula, often associated with a motility disorder or a hypertensive lower esophageal sphincter. Although symptoms of dysphasia often prompt workup and discovery of these lesions, dysphagia often is related to the motility disorder and not necessarily the presence of the diverticulum.

Asymptomatic patients often are not offered surgical management. Treatment of the underlying motility issue

should be addressed first, either by medical (i.e., Botulinum toxin) or surgical treatment (i.e., Heller myotomy). If surgery is offered to these patients, the standard treatment is diverticulectomy.

We prefer the relatively straightforward and reliable stapled diverticulectomy with a linear cutting stapler.

There has been debate over closure of the muscular defect following diverticulectomy. Due to the propensity for relatively high leak rates from the staple line, many surgeons will close the muscle over the staple line and perform a longitudinal myotomy 180 degrees away from the staple line on the esophagus. This myotomy is extended onto the stomach a minimum of 2 cm. Some surgeons also have advocated simply extending the existing myotomy down onto the stomach. Both methods are probably acceptable if the staple line is uncomplicated through healthy tissue.

Addition of an antireflux procedure also has been debated with many surgeons performing a partial wrap in this instance, such as a Dor fundoplication.

The question of whether the leiomyoma in this specific patient actually is causing a traction component of the diverticulum is uncertain and likely will never be answered. In this

see SURGEONS’ LOUNGE page 18

18

Surgeons’ Lounge jcontinued from page 16 rare instance, with its associated uncertainty, I would lean toward the more extensive treatment regimen of a pulsion diverticulum (diverticulectomy and myotomy). Access to these lesions historically has been through the left chest.

However, the transabdominal/transhiatal laparoscopic approach has gained significant momentum in recent years, which brings us to your first question.

I think the fact that both of your approach choices include “-scopic” is good. Minimally invasive techniques to access to the lower third of the esophagus, either through the left chest or the abdomen, have become a well-established standard in many institutions. Exposure and mobilization on the lower third of the esophagus through the esophageal hiatus from the abdomen is feasible, although sometimes challenging. The benefit of the abdominal approach is that contact with the ribs and subcostal nerves, which can sometimes cause pain, can be avoided. Additionally, by avoiding the lung and pleural cavity, a chest tube (which also can cause pain) is not required. The learning curve to perform the transhiatal technique is long and stressful, however. Care must be taken to avoid injury to the esophagus itself while extensively manipulating it and simultaneously avoiding the pleural cavity on both sides as well as the named blood vessels. However, relative comfort with this exposure can come with experience.

Ultimately, it is this comfort level that should dictate the appropriate approach. All the members of my group are comfortable with the laparoscopic transhiatal approach to mobilize the lower esophagus, thus this is the approach I would use in this patient.

The treatment commonality of these two diseases is that they both require surgical resection in the symptomatic patient. As this patient is symptomatic, the plan for surgical resection is the most appropriate course. Once exposure of the esophagus above the lesion is obtained, it is safe to assume that the leiomyoma can be enucleated.

Given its intimate association with the diverticulum, this enucleation may reveal the diverticulum through a common myotomy. The leiomyoma should be excised either with or without the diverticulum, depending on which choice is less likely to cause breach of the mucosa. All attempts should be made to maintain the mucosal integrity. The diverticulum should then be bluntly dissected with judicious use of energy down to its neck. Once the neck is exposed, a laparoscopic linear cutting stapler can be applied across the neck of the diverticulum taking care not to incorporate the muscle. At that point, the surgeon is obliged to either extend the myotomy down onto the stomach, or close the muscle and create a new myotomy on the other side of the esophagus down onto the stomach.

Regarding the addition of an antireflux procedure, my preference is to perform a fundoplication of some sort with any myotomy. In this instance, a Dor fundoplication would work well without concern for creating any significant restriction below the staple line. Theoretically, because distal restriction could occur if a Nissen fundoplication is wrapped too tightly, avoiding a Nissen fundoplication is recommended.

Finally, this patient’s diagnosis is extremely rare. Our group recently presented a video at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) annual meeting of this exact case, which is available for viewing online at the SAGES Web site. To my knowledge, there are only scattered case reports, including this recent one, with little data-driven speculation on true incidence or whether the leiomyoma influences the pathogenesis of the diverticulum.

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

History and Other Facts About Zenker’s Diverticulum Background • Friedrich Albert von Zenker (1825-1898), a pathologist and physician, was born in Dresden, Germany.

• Dr. Zenker is credited with discovering trichinosis. In 1860, he discovered trichinosis in Dresden Hospital. He demonstrated that trichinis was capable of producing severe and even deadly diseases. Trichinosis is a disease derived from eating raw or undercooked pork or other wild game infected with the larvae of a roundworm called the trichina worm.

• Zenker’s diverticulum is named after Dr. Zenker. His report on Zenker’s diverticulum included five personal cases and 22 cases collected from information in the medical literature.

• The first Zenker’s diverticulum successfully resected took place in Dublin in 1887 at the hands of William Ireland de Courcy Wheeler, MD. • A diverticulum is a pouch or sac that is created by herniation of the muscle wall.

• Zenker’s diverticulum is a diverticulum of the mucosa in the pharynx above the upper sphincter of the esophagus and often occurs in the left side of the neck in an area called the Killian triangle. It is rare and mostly affects older men.

• Zenker’s diverticulum is considered a false diverticulum because it does not include all the layers of the esophageal wall.

Theories To Explain Cause of Zenker’s Diverticulum • Abnormal timing during swallowing, loss of elasticity and incomplete relaxation in and of the cricopharyngeal muscle • Central nervous system injury • Abnormalities in the upper esophageal sphincter

Symptoms of Zenker’s Diverticulum • Dysphagia • Regurgitation of undigested food after hours of consumption • Feeling food sticking in the throat • Coughing excessively • Aspiration of food or liquid in the esophagus into the airways (most dangerous symptom)

Diagnosis • Diagnostic tools for Zenker’s diverticulum include a barium swallow and x-ray observation.

• Endoscopy is not used for diagnosis due to the risk for perforation of the diverticulum.

Treatment • If small and asymptomatic, no treatment is needed.

• If large and symptomatic, neck surgery is necessary in order to remove diverticulum.

• Recently, nonsurgical endoscopic techniques have been adopted due to faster recovery in patients. The use of endoscopic stapling is emerging as a viable option.

Meeting Announcement — Joint International Oncology Congress 5th Symposium on Cancer Metastasis and the Lymphovascular System and the 8th International Sentinel Node Society Congress Thursday, Nov. 29 – Saturday, Dec. 1, 2012 Hyatt Regency Century Plaza, Los Angeles, Calif.

Updates by an internationally renowned faculty on the following: • Our understanding of cancer metastases, especially sentinel lymph node biopsy concepts and technology, the cancer microenvironment, and the molecular mechanisms involved in the progression of cancer cells to metastasis • New developments in biomarker research and their diagnostic and prognostic applications in metastatic disease • New targeted therapy against cancer biomarkers

Co-Chairs Armando E. Giuliano, MD, FACS President, International Sentinel Node Society Executive Vice Chair, Surgery Associate Director, Surgical Oncology Cedars-Sinai Medical Center Los Angeles, California Stanley P.L. Leong, MD, FACS President, Sentinel Node Oncology Foundation Chief of Cutaneous Oncology California Pacific Medical Center and Sutter Pacific Medical Foundation San Francisco, California For more information, visit www.sn-cancermets.org Email: sn-cancermets@pardigmmc.com Phone: (845) 398-5100

Next stop: Your Grand Central Station for all the latest news, opinions and analysis in surgery.

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oncologists to determine how to use the Z0011 findings, that showed no difference in local recurrence or survival between selected patients with positive sentinel lymph nodes (SLN) who omitted axillary lymph node dissection (ALND) and patients who underwent ALND. “We discussed the results of the trial and the relevant literature and came up p with a group consensus on how to apply this data in our clinical practice,” said Abigail S. Caudle, MD, assistant professor of surgical oncology at MD Anderson Cancer Center.

Subsequently, Dr. Caudle and colleagues sought to determine the impact of Z0011 on surgeon practice patterns, and to see which patients’ surgeons seemed most comfortable applying the data. The retrospective review involved 17 surgeons and two cohorts of patients: those seen in the year before the release of Z0011 and those seen in a 12-month period after their interdisciplinary conference. The investigators used only patients who met eligibility criteria for Z0011, excluding those who had neoadjuvant chemotherapy, those who underwent mastectomy and those with tumors larger than 5 cm on surgical pathology.

The investigators included 658 patients: 335 in the pre-Z0011 results group, of whom 62 (19%) were SLNpositive, and 323 in the post-Z0011 results group, of whom 42 (13%) were SLN-positive. In the pre-Z0011 cohort, 85% of SLN-positive patients underwent ALND, compared with 24% of those in the post-Z0011 cohort. Given that the proportion of post-Z0011 patients undergoing ALND dropped from 28% in the first six months of the post-Z0011 time frame to 18% in the subsequent six months suggests that surgeons became more comfortable applying the Z0011 data over time.

One purpose of this study was to determine if there were patient groups to which surgeons were not applying Z0011 data, and how they were distinguishing those patients. “In the pre-Z0011 group, the decision to omit ALND appears to be driven by SLN characteristics, while in the post-Z0011 group, the decision to perform ALND appears to be driven by primary tumor features,” Dr. Caudle said.

In the post-Z0011 cohort, surgeons

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

‘This was definitely a wellreceived paper. I think it’s always important for people to hear that the big institutions have accepted and altered their practice based on the findings.’

—Judy Boughey, MD

were more likely to perform ALND on patients who had larger tumors, lobular histology, fewer SLNs retrieved, larger SLN metastasis, evidence of extranodal extension, and those in whom a validated nomogram predicted a higher probability of positive non-SLNs. The researchers also examined the impact of Z0011 on adjuvant therapy and found that the radiation oncologists at MD Anderson had been adjusting radiation fields to add high tangents for those who do not undergo ALND. “In the pre-Z0011 cohort, 10% had high tangents versus 43% in the postZ011 cohort,” Dr. Caudle said. “We feel that this is a reflection of changing surgical practices, since only 2% of patients who underwent ALND had high tangents compared with 88% who did not have an ALND.” They also found that surgeons were less likely to perform intraoperative nodal assessment in the post-Z0011 cohort; assessment fell from 69% in the preZ0011 cohort to 26% in the post-Z0011 group. This change led to a decrease in operative time, from a median of 92 down to 79 minutes.

“This was definitely a well-received paper,” said Judy Boughey, MD, associate professor of surgery, Mayo Clinic, in Rochester, Minn. “I think it’s always important for people to hear that the big institutions have accepted and altered their practice based on the findings. In particular, people are interested in how

surgeons and institutions have incorporated the study findings into their everyday clinical practice.

“One of the critical things this abstract showed was that it is still a limited proportion of patients you see who fit the exact criteria for Z0011. Surgeons are more likely to do dissections for patients with larger tumors, fewer SLN removed or larger lymph node metastasis—the more worrisome cases,” Dr. Boughey added. “It is also important to note that the findings are not being extrapolated to women undergoing mastectomy, or receiving partial breast radiation or neoadjuvant chemotherapy.”

Dr. Boughey also noted the inclusion of intraoperative nodal assessment and its impact on operating time. “In this day and age, people are more in tune with trying to cut down on unnecessary additive costs if it doesn’t benefit the patient or alter the patient’s treatment; decreased intraoperative assessment lowers cost and allows shorter operating time for the patient.”

In her practice, Dr. Boughey said she and her colleagues still perform frozen section analyses on all SLNs. In particular, it remains important for surgeons to perform intraoperative analysis of SLNs when they encounter a node that they are

concerned will be positive by palpation because it’s more likely that there will be several additional positive nodes.

“But, in nodes you think will be negative, I think it’s reasonable not to do intraoperative nodal assessment in those cases where the patient meets Z0011 criteria, is undergoing breast conservation, doesn’t have a very large tumor and didn’t have neoadjuvant chemotherapy, if you plan not to do a dissection in node-positive cases,” she said.

Drs. Boughey and Caudle had no relevant disclosures.

21

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To the Editor: I agree with all of Dr. [ Jon] Whiteâ&#x20AC;&#x2122;s opinions in â&#x20AC;&#x153;A Keynesian View of Health Careâ&#x20AC;? [ June 2012, page 1].

Although the outcomes he describes [for our health care system] are inevitable, I donâ&#x20AC;&#x2122;t expect that they will occur in the foreseeable future.

There are too many big lobbies that benefit from the current arrangement, Big Pharma, hospitals, insurance companies and trial lawyers, to name a few, and they have the money to bribe the lawmakers to continue the current mess. A politicianâ&#x20AC;&#x2122;s job is to get re-elected and that costs so much that they are addicted to the lobbyistâ&#x20AC;&#x2122;s money. No politician can step up to a podium and tell the public the truth: â&#x20AC;&#x153;My fellow Americans, youâ&#x20AC;&#x2122;re all going to die and the United States cannot afford to try to keep you alive for as long as you would like.â&#x20AC;? Until I hear a politician say something like that, I have no optimism that Dr. Whiteâ&#x20AC;&#x2122;s utopia will actually happen.

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

Lap Choleâ&#x20AC;&#x201C;ERCP Combo To the Editor: I was intrigued by the article on combining laparoscopic cholecystectomy with ERCP [endoscopic retrograde cholangiopancreatogram] for treatment of obstructing common duct stones. There is a huge disparity in the skill of GI [gastroenterologists] doctors who are coming out of training when it comes to performing ERCP. This is related to volume, and most gastroenterologists who plan to do ERCPs are now doing a year of fellowship to get the volume needed for development of those skills. I think it a stretch to think that general surgeons could get enough procedures during their training to be skilled at that highly technical procedure. That is not to say that they cannot be achieved by a few, but I think it impractical to try to make that a core privilege.

Developing a good working relationship with a trained GI doctor who has those skills is a more practical solution for all but a few very technically adept surgeons who have found a good working relationship with their GI department during training and developed skills that would provide success without complications.

Paul H. Robinson, MD, FACS Medical Director, American Fork Hospital American Fork, Utah

www.CMEZone.com Your premier source for practical, relevant and timely continuing medical and pharmacy education

Selected comments on Skeptical Scalpelâ&#x20AC;&#x2122;s blog â&#x20AC;&#x153;Why is the Attrition Rate of General Surgery Residents so High?â&#x20AC;? posted June 13, 2012 From a board-certified general surgeon in practice 21 years: The problem is indicative of the descent of our culture at large, unfortunately. In order to protect general surgical residents from any discomfort, and to protect society from any harm, â&#x20AC;&#x153;protectiveâ&#x20AC;? limits are imposed on students and residents, and we get weak students and residents who canâ&#x20AC;&#x2122;t take it! If we told students up front that general surgery residency was tough, and if we could tell the ACGME [Accreditation Council for Graduate Medical Education] to butt out, we would get residents who knew up front that it was tough, and the residents we get would be more likely to stay in the program. As it is now, who will take care of us in 20 years? These weak and weakly trained surgeons of tomorrow?

Posted on 6/19/2012

If you want to be good at what you do, then experience and time is the only way.

I did not enjoy working every night/day/ week/year but I understood what experience means. These kids today just donâ&#x20AC;&#x2122;t want to work. To them it is just a job, but thatâ&#x20AC;&#x2122;s another story.

Posted on 6/19/2012 I have a somewhat different take on the article. As a retired general surgeon who practiced for 30 years, I think that the evolution of surgery as video games in the operating room is a big factor. Were I to be choosing a specialty now, I would not choose surgery.

Today you canâ&#x20AC;&#x2122;t touch tissue, you canâ&#x20AC;&#x2122;t make incisions longer than 1 cm, and it really doesnâ&#x20AC;&#x2122;t feel like surgery.

Posted on 6/19/2012

Check out Skeptical Scalpelâ&#x20AC;&#x2122;s blog at www.generalsurgerynews.com.

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years.

He delves into a varietty of subject matters, including the sttate of surgical residency programs and the importance (or lack thereof) of single-incision laparoscopic surgery.

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Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

TIPS

FOR INTERNSHIP

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24. is to that end that I share with you now the pearls from that time.

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Tips for Surgical Internship 1.

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First do no harm (Primum non nocere) The chief is always right Your residency is like a family … never dishonor the family Always do your best Resident safety before patient safety before patient comfort Call for backup Shield your attending and your chiefs from extra work but keep them informed There is no completely benign intervention (even a nasogastric tubee can kill) Not every patient needs an operation before they die (credit … Alfred Blaylock) Be honest with yourself: Do not attempt solo tasks above your ability Check the operating room (OR) schedule before leaving the hospital each day Read about cases night before day in OR in Surgical Atlas and Surgical Text Notify upper-level residents about complex cases and they will return the favor regarding simpler ones Speak up when you don’t know something or you may hurt someone when you intended to help Always remember that you are on the same side as the nurses, respiratory therapists … and treat them with the same amount of respect that you expect Eat when you can, go to the bathroom when you can, sleep when you can, read when you can and always call your significant other when on call Call the cafeteria to set food aside if you are running late—-don’t let your patients suffer because of your appetite Write all your notes in the morning before you go to the OR or a.m. conferences Everyone should have an assessment and plan in legible handwriting Memorize the beeper numbers of the surgical residents and the phone numbers for each surgical floor Be kind to the medicine and family practice interns because they will refer you cases and be a source of information for you about cases that encompass their specialty Pick and choose your battles wisely—your reputation and mental health depend on it Read an hour of general surgery a day

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in addition to whatever other reading you have to do to care for your patients Take one night completely off each week Don’t wait until the night before to do any presentations, and always practice Exercise at least three times a week Fresh fruit and vitamins never hurt a surgical resident Sign out difficult patients to residents on call Always inform the chief-in-house about patients seen in the emergency

Don’t get cocky until you have completed your residency … somebody always knows or has seen more department (ED), patients going to the OR or crashing patients when on call (even surgical subspecialty patients) 30. See your patients twice a day to see what consults have been written, and be sure that they will live

through the night 31. Never let them see you sweat 32. Your program director’s word should be regarded as law 33. Never turn down an invitation from an attending for dinner or a research project 34. Be eager and ask questions in the OR and on rounds. It lets the attending know that you are interested and thinking 35. Don’t order a test unless it is absolutely necessary and be ready to justify ordering it—they are often costly see TIPS FOR INTERNSHIP page 24

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Opinion TIPS

FOR INTERNSHIPS

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and uncomfortable for sick patients (the Pandelidis Principle).

Surgery is not a spectator sport—you sometimes need to be aggressive and ask to do things Doctor means teacher so don’t pass up an opportunity to teach a medical student, nurse or other health care provider because it will earn you their respect and confidence Being tired is not an excuse for being cranky Medical students deserve your attention in return for their hard work Don’t make a mess of your on-call quarters or lounge because you will make an enemy of your roommate and housekeeping Leaving notes on problem patients on call is a way of letting people know where you were and what you were thinking Anticipating the complications of any procedure you do will help you identify problems when they happen Respect your patients’ privacy and feelings—let them pull up their own gowns, don’t rip off bandages, apologize when appropriate and pull curtains shut before examinations Don’t go out drinking pre-call On days when you aren’t going to the OR, dress like a doctor Keep a clean shirt/pants/blouse/underwear in your call room Only keep in your pockets what you absolutely need Be regular about cleaning your apartment, paying your bills, doing laundry, checking mailboxes and completing charts in medical records Being a surgeon means being an internist who can operate Clinic is not a chore—it is the closest thing to a resident’s own office Arrive early to the OR, read the chart and prep the patient whenever possible on general surgery procedures Be prompt to lectures and meetings It is wise to keep some deodorant in your surgical locker Don’t bring your beeper into the OR unless cleared with the attending surgeon Always carry an extra beeper battery with you Don’t change the schedule without the permission of the chief of the day Sign up for vacations early Simple audiovisuals help with complex morbidity and mortality presentations Swallowing your pride, and not burping, is part of being an intern Try to read the abstracts from a surgical/medical journal whenever possible Don’t dump on your colleagues because revenge is sweet Don’t fall behind on your OR logs or you will never catch up Teaching yourself and your peers is part of adult learning No matter how bad things get, remember that you have the one thing your sick patients don’t have, your health Treat all patients as if they were your mother, father, sister, brother or child, and you will never go wrong

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

66. Don’t put off to tomorrow what you can do today because tomorrow can always be worse 67. It is more work to avoid work than to just do it and get it over with 68. Call in all of your own consults and your consultants will know what you are consulting them for 69. Labs and diagnostic tests are never a substitute for a complete history and physical 70. It is not so important which book you buy, as it is to read the books you have already bought 71. An acute abdomen does not always equal an operation 72. Even Cope’s Early Diagnosis of the Acute Abdomen believes that surgical patients merit appropriate analgesia after evaluation by a surgeon 73. Wash your hands between patients unless you enjoy putting your patients on methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus/enterococci contact precautions 74. Not putting a blue pad on the patient’s bed before a procedure is a great way to make an enemy of a nurse 75. If your attending has to write orders or add more than his signature to your note, you are not being complete enough 76. Getting up and rounding early will give you the time you need for unexpected problems and to eat breakfast 77. It is a bad career move to embarrass a colleague or attending at a lecture unless you are ready to go into private practice 78. Don’t forget your hobbies because they will help keep you sane 79. Not writing discharge instructions legibly is a great way to ensure that your patient will contact you immediately after discharge 80. Before acting on a critical lab value or vital sign, think about whether it needs to be repeated or confirmed 81. Know everything about appendectomies; they are likely to be the first case you will get to do 82. Unless you like being awakened repeatedly throughout the night, make sure your post-op orders include orders for pain, nausea, fever and diet 83. Avoid abandoning your attending and call team when your attending’s cases run past 5 p.m.

84. Check out the other surgical clinics like ortho or plastics to find easy cases that you may otherwise not be exposed to 85. The earlier you arrive, the emptier the parking lot 86. Don’t be afraid to call the attending but don’t call until you get your sh_t together 87. They’re really not yourr patients; this is why you sometimes/frequently get overruled 88. Never leave the hospital without checking all the labs and x-rays you have ordered

Never tell one attending, “This is not how Dr. ___ does it.”

89. Always show the films to a radiologist. Your attending will ask you to and the radiologist will teach you something 90. Starting off sentences with, “Do you have a moment?” will win you more friends with nurses and attending than simply interrupting what they are doing 91. If you develop any conflicts, discuss them privately 92. Bringing food to nursing floors on call is similar to bringing a peace offering and will help make your night more pleasant 93. Learn the nurses' names ASAP 94. Always try to educate your patients about their disease so that they can make informed decisions 95. There are those who are great surgeons only in the OR and there are those who are great surgeons even outside of the OR … you can learn from both 96. Don’t get cocky until you have completed your residency … somebody always knows or has seen more 97. A practical joke once in a while will keep you and your colleagues sane. You should enjoy your chosen profession 98. Be careful what you say and address your colleagues as “Doctor…” over voice pagers and in front of patients 99. Every attending has their own little quirks—-keep track of them 100. Never tell one attending, “This is not how Dr. ___ does it.”

101. Your reputation will form by the end of the first week, people will recognize you by the end of the first month, so be extra vigilant in the beginning If you follow even half of these as you move through your surgical residency, you will be well ahead of the curve. A heartfelt and special thanks go to my fellow interns, Nick Cottrell and Sridhar Chalasani, who helped me with this comprehensive list and helped me survive that grueling year.

—Dr. Nefff is medical director of the Kennedy — University Hospital Bariatric Surgery Program, Cherry Hill, N.J.

Ephemera # 5 Chad Hoover, 48” x 48”, oil on canvas The Ephemera Series comments on humankind’s struggle against mortality. Becoming more than a record of history, Hoover’s work places the viewer into the visual vantage point of a surgeon. The anonymous identity of the patient, the surgeon, and assistants invites the viewer to participate in roleplay, where they are directly confronted with the borderline of life. In the coming months, General Surgery News will feature Mr. Hoovers work from the Ephemera Series.

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

GSN Bulletin Board

25

GENERAL SURGERY: SUBURBAN BALTIMORE We are seeking a General Surgeon to join and be employed by our client in Randallstown, MD. You will “hit the ground running” in this very busy surgical enterprise in a community hospital setting.

Northwest Hospital is part of the LifeBridge Health System. There As a phy h sician, yo y u hav a e a wide range of options, so why h not talk with a team that can off ffer a wide range of opportunities. Community t Health Sy Systems has grown into one of the nation’s leading operators of general acute care hospitals.

Our aff ffiliates operate more than 130 hospitals in 29 states. These locations can provide ideal env n ironments fo f r personal and profe f ssional success.

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is also offered but should not be the primary focus for this position.

You will join an established and busy practice which enjoys an excellent reputation in the community. The practice has multiple locations allowing for a wide catchment area for the candidate to work from. Excellent compensation and benefits is offered. Please contact Margie Quinlan, Lawlor and Associates, 800-238-7150 or 610-2516852; fax 610-431-4092; email: margie@lawlorsearch.com g

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For more info f rmation visit: www. w chs.net/ t/dcs c Email: docj c obs@chs.net or Call: 800-367-6813

are opportunities within Wound Care and HBOT. Bariatric Surgery

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GSN Bulletin Board

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

GENERAL AND TRAUMA SURGEONS JOIN OUR TEAM!

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