August 2013 by McMahon Group

GENERALSURGERYNEWS.COM

August 2013 • Volume 40 • Number 8

The Independent Monthly Newspaper for the General Surgeon

Opinion

The Constitution And the ACA B Y J ON C. W HITE , MD

hen people mention the Constitution and the Affordable Care Act (ACA) in the same sentence, they are usually commenting on the legality of the ACA and whether its methods are consistent with laws either contained or derived by the Constitution. This commentary usually comes in the form of a tribute to the legislative genius behind the ACA or a vitriolic denunciation of the scoundrels who trampled the U.S. Constitution. This editorial is neither. Rather, it is a reflection on how these two documents have historical similarities, suggesting that the ACA will ultimately be accepted and fine-tuned like the Constitution. On the other hand, their dissimilarities point out certain critical weaknesses of Obamacare.

Prehospital Aspiration Puts Patients at Higher Risk For Developing Pneumonia Health Care–Associated Pneumonia in Trauma Patients Greatly Affected By Events Before Arrival at Hospital B Y C HRISTINA F RANGOU

ne of the deadliest typees of hospital-acquired infection ns in adult trauma patients is set in motion long before patients arrive at the hospital, according to a study reported at the 2013 meeting of the Surgical Infection Society. A study involving surgeons and paramedics showed that trauma patients who aspirate before they get to the hospital have a fourfold increased risk for developing health care–associated pneumonia (HCAP) and a more than threeefold increased risk for ventilator-associated pneumonia (VAP).

see PNEUMONIA page 18

How the ACA Is Like the Constitution The U.S. Constitution was negotiated and written over the course of four months by the Second Constitutional Convention. It was based on the core principles of natural rights, espoused by

Study Suggests Gastric Bypass Causes Glucose Spikes, Crashes

see CONSTITUTION page 21

FROM THE BENCH TO THE BEDSIDE Collaboration Between the Anesthesia and Surgical Teams In the Perioperative Setting see page 8

More Overlap Means Fewer Hernia Recurrences Size and Placement of Mesh Key to Success B Y C HRISTINA F RANGOU ORLANDO, FLA A.—When Karl LeBlanc, MD, MBA A, FACS, a private practice general surgeon in Baton Rouge, La., p performed the world’s first lap paroscopic ventral hernia rrepair in 1991, he aimed for a mesh overlap of about 1 cm. Tw wenty years later, he shaakes his head at the notion off a 1-cm overlap. A growing body of evidence suggests that a larger mesh overlap, along with symmetrical placement of the mesh, result in far fewer hernia recurrencees, Dr. LeBlanc said at the 15th Annual Hernia Repair Meeting. “Increasingly, we’re looking at the more overlap, the better, when it comes to recurrence,” said Dr. LeBlanc, who has amassed one of the largest volumes of see MESH OVERLAP page 22

B Y M ONICA S MITH

espite its reputation as the gold standard for weight loss, gastric bypass surgery may result in a post-meal glucose spike followed by a blood sugar crash that causes between-meal hunger, according to a new study. The research

examined the effects of different bariatric procedures on post-meal glucose reactions. Mitchell S. Roslin, MD, FACS, Lenox Hill Hospital, New York City, and his colleagues first became

INSIDE In the News

Surgeons’ Lounge

In the News

Experts Discuss a Controversial Topic: Local Excision or Nonoperative Management for Rectal Cancer

Single-Incision Laparoscopic Cholecystectomy Linked to Higher Hernia Rates in Published Study

A case of a patient with a pseudocyst; the use of fluorescenceguided surgery.

see GASTRIC BYPASS page 15

REPORT Clinical Perspectives on Using Advanced Vessel-Sealing Technology: Experience With the Multifunctional THUNDERBEAT TM Device See insert at page 12

In Memoriam

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

GSN N Remembers: Dr. Spencer R. McLean, FRCSC (1977-2013) [It is with much sadness that we at GSN announce the loss of Dr. Spencer McLean, husband of Senior Reporter, Christina Frangou. This is Christina’s tribute to her husband.] Dr. Spencer R. McLean passed away peacefully on June 24, 2013, surrounded by his family after a short but courageous battle with cancer. He is deeply missed by his soul mate and wife Christina (Frangou), his parents Roy and Charlotte, his brother Brendan and wife Kim, and the Frangou family, Panayiotis, Josephine, Nicole, Martin, Evan, Jen and Sarah. Uncle Spencer will always be adored by his nephews, Lukas and Noel, to whom he was completely devoted. No one gave better airplane rides or knew more about helicopters than Uncle Spencer. Spencer was raised in Fernie, British Columbia, Canada. He spent much of his childhood skiing, biking and camping with his family. These activities remained fundamental to his happiness throughout his life. As he often said, “you can take the boy out of Fernie but you can’t take Fernie out of the boy.”

Spencer moved to Calgary in 1996 to study at the University of Calgary, where he completed a Bachelor of Science in Kinesiology, a Master of Science in Exercise Physiology, medical school and residency in orthopaedic surgery. Two months before the end of his residency, Spencer was diagnosed with stage

Spencer McLean operating in Haiti in early 2013.

IV renal cell carcinoma. Despite his illness, he wrote and excelled in his board exams for the Royal College of Surgeons. On June 13, 2013, he achieved his dream of becoming a Fellow of the Royal College of Physicians and Surgeons of Canada. Spencer was known for his kindness, wit, sense of humor, his athleticism and his devotion to family and work. This year, he gave up his vacation time to save lives in Haiti with Team Broken Earth (http:// www.theglobeandmail.com/news/world/ life-and-death-in-haiti-a-doctors-diary/article8711178/?page=all). He always knew the names of everyone he worked with, his patients and their families. Even at his sickest moments, Spencer took time to teach nursing students or greet with a smile those who were caring for him. He inspired every physician, nurse and staff member who came in contact with him. Above all else, he was a devoted husband. He was married nearly three happy

years to his wife Christina. For both, their marriage was their greatest accomplishment. His life, while short, was a life well lived. The family extends a grateful thank-you to the staff of Foothills Medical Center and Unit 46, Dr. Daniel Heng and Dr. Michel Henin for the care and compassion shown to Spencer and his family during these two difficult months. A special thank-you to his mentors Dr. Geoff Seagram, Dr. Paul Duffy, Dr. Norman Schachar, Dr. Richard Buckley, Dr. Jim Powell, Dr. Robert Korley, Dr. Shannon Puloski, Dr. Ian Le and the many others who helped Spencer achieve his dreams. Thank you to his friends Dr. Prism Schneider, Dr. Paul Cantle, Dr. Gerald Cole and Dr. Jeremy LaMothe for everything along the way. Memorial tributes in Spencer’s name may be made to Team Broken Earth (http://www.brokenearth.ca/calgary. html) or to Kidney Cancer Canada.

Mission Statement It is the mission of General Surgery Newss to be an independent and reliable source of news and analysis about the current state of surgery. It strives to provide a venue for discussion and opinions, from all viewpoints, on the issues most important to surgeons.

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Editorial Advisory Board Maurice E. Arregui, MD Indianapolis, IN

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INFECTIOUS DISEASE SPECIAL EDITION

GSN Editorial

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

A ‘Feel Good’ Economy Frederick L. Greene, MD, FACS Clinical Professor of Surgery UNC School of Medicine Chapel Hill, North Carolina

Because I travel with some frequency, I find myself spending a significant amount of time at airports mainly because of my own compulsion to get through security early. I sometimes use this extra time to experience the pleasure of getting a good shoeshine. Over the years I have become recognizable at my local airport to the very expert shoeshine mavens, who until recently told me exactly how much I owed them after a shine. It was always a reasonable amount and, of course, was enhanced by a generous gratuity to acknowledge their expertise and effort. As we all know, tipping has become rather expected, and frequently does not really represent the true feeling of the giver. In my case, however, I always felt that a tip was in order. Recently, after I got the typical great shine, I asked the usual question, “How much do I owe you,” even

though I knew the answer. To my utter amazement, the response was, “Whatever makes you feel good.” As I made my calculations regarding the difference between the usual and customary fee and my emotional state after having a good shine, I overheard other members of the shoeshine group give the same response to all their customers. I know for a fact that I paid more that day based on the “whatever makes you feel good” directive. I have been thinking about this experience and wondering what would be the implication if our entire economic system were based on the premise that our emotional state was the ultimate benchmark driving the economy. What if the electrician, the plumber, our car mechanic, my barber or anyone involved in the service industry said “please pay me based on whatever makes you feel good”? What would be the implication for our own profession or for health care reimbursement on a global basis if patients decided on compensation based on “whatever made them feel good”? This would be the ultimate utilization of patient

What would be the implication for our own profession or for health care reimbursement on a global basis if patients decided on compensation based on ‘whatever made them feel good’? satisfaction benchmarks. Patients would be encouraged to approach their insurers and to relate their emotional wellbeing as the basis of reimbursement for their medical care. This might actually work to our benefit because reimbursement could be directly tied into a feeling of well-being from both patient and insurer. Of course, the obverse is always a possibility! I know that I feel better when I reimburse those who do a good job and perform well. In the case of my entrepreneurial friends at the airport, there is no doubt in my mind that they have benefitted financially from this new

reimbursement example. I have made a habit of watching faces as money is exchanged, and, in my view, no one seems unhappy with this new business model. I personally think that this “feel good” approach may become more widespread, and I am surprised that it has not permeated our economy more fully. In the past, physicians were sometimes reimbursed based on a barter system when patients could only give what they either could afford or what they had in material goods. Perhaps everyone felt better about reimbursement in those bygone days. I really don’t know what would happen if this “feel good” economy actually permeated the service industry. Perhaps this would lead to hyperinflation, driving cost for services to astronomical heights because everyone ultimately wants to feel good. Yes, I think we still need parameters and guidelines in our economic lives. For other things, however, I think this type of approach may be the answer. If you enjoyed this editorial, let me hear from you, especially if it “makes you feel good.”

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

Biologic Mesh Fails To Reduce Rate of Parastomal Hernias in Trial Surprisingly Few Hernias in Control Group; Benefit of Mesh Can’t Be Ruled Out, Expert Says B Y C HRISTINA F RANGOU

arastomal reinforcement with a biologic mesh failed to reduce the incidence of hernia formation in a large, prospective, randomized study. The study, which was presented at the 2013 annual meeting of the American Society of Colon and Rectal Surgeons, demonstrated no difference in hernia occurrence or quality of life when Strattice reconstructive tissue matrix (LifeCell) was placed in the rectus sheath in patients undergoing surgery for permanent abdominal wall ostomy. “Reinforcement of stomas with Strattice was safe but did not statistically reduce the incidence of parastomal hernia formation,” said lead author David E. Beck, MD, professor and chair of colon and rectal surgery, Oschner Clinic, New Orleans.

reported studies. In this study, only 12% of patients without mesh reinforcement developed a hernia within two years of surgery. This rate was almost identical to the 11% hernia occurrence in patients who had tissue reinforcement with a biologic mesh. The study was conducted at 22 centers throughout the United States. In all, 113 patients who were expected to have a stoma for more than one year were prospectively randomized to undergo

standard end stomal construction or placement of a 6 cm × 6 cm square of Strattice tissue matrix reinforcement at the time of stomal construction. The mesh was inserted through the stomal skin opening and placed in the space between the posterior sheath/ peritoneum and rectus muscle. Patients were evaluated at three, six, 12 and 24 months for parastomal hernia occurrence by clinical exam. They also were asked to complete the Stomal Quality of Life

questionnaire. Clinical suspicions were confirmed with an abdominal computed tomography scan. At the 24-month follow-up, there were no differences in adverse events, stoma-related adverse events or deaths between the two groups of patients. Scores on quality of life were also similar. The investigators are conducting subgroup analyses. Follow-up studies could explain the low hernia occurrence rate see REINFORCEMENT page 6

Introducing

Patients who do not have mesh reinforcement during surgery for a permanent abdominal wall ostomy are typically expected to have about a 30% chance of hernia occurrence, based on previously reported studies. In this study, only 12% of patients without mesh reinforcement developed a hernia within two years of surgery. Experts caution that the study results were confounded by a lower-than-average incidence of parastomal hernia formation among patients without mesh reinforcement. More investigations are needed before biologic mesh can be ruled out as beneficial in this population. “The real shock of this study is that there weren’t more hernias in the control group. You can’t say from this that there’s no benefit to reinforcement with a biologic. You can say, however, that we need more studies and need this study to be followed longer,” said Peter W. Marcello, MD, chair of colon and rectal surgery at the Lahey Clinic Medical Center, Burlington, Mass. Dr. Marcello was not involved in the study. Patients who do not have mesh reinforcement during surgery for a permanent abdominal wall ostomy are typically expected to have about a 30% chance of hernia occurrence, based on previously

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

jcontinued from page 5

among patients without mesh reinforcement, Dr. Beck said. “Potential reasons might include inclusions of ileostomies versus colostomies; use of laparoscopy; the fact that all cases were elective; [and] all were placed in the rectus sheath and were performed by experienced surgeons.” Dr. Beck said he believed that highrisk patients, such as those with colostomies, people with weaker abdominal walls or those who engage in heavy lifting or manual labor, benefit from mesh reinforcement. Although biologics are expensive, he said the benefits justify the cost for some patients. Dr. Marcello said the results should not be construed as parastomal hernias rarely occurring after a stoma.

“Parastomal hernias are still a major concern for us, and remain the leading surgical complication after a stoma construction. Despite the encouraging results in the control group of this study, we believe that longer follow-up of this study and future studies will determine the role of prophylactic mesh in the prevention of parastomal hernias.” “Long-term avoidance of this specific complication—one that is very hard to treat—would dramatically improve the quality of life of the ostomy patient,” Dr. Marcello added. Dr. Beck disclosed that he received research funding and honoraria from LifeCell, the maker of Strattice. He also received support for research, honoraria and consulting fees from Helsin, Ethicon and Pacira. Dr. Marcello disclosed that he has been a consultant for Baxter and Covidien.

‘Despite the encouraging results in the control group of this study, we believe that longer follow-up of this study and future studies will determine the role of prophylactic mesh in the prevention of parastomal hernias.’ —Peter W. Marcello, MD

REINFORCEMENT

From Dr. Maa:

“I met with President Obama twice recently. At the first meeting in April, we discussed projects in health care, and I suggested that my friend Capt. Sully Sullenberger be appointed to a Presidential Commission focused on patient safety. At the second meeting in June in Palo Alto, Calif., when this photo was taken, it was my honor and privilege to reintroduce Capt. Sullenberger to President Obama. The two had not seen each other since the Presidential Inauguration in January 2009, in the days after ‘The Miracle on the Hudson.’ The president and I spoke about health care projects once again, and I focused on the need to appoint a neurosurgeon to the Presidential Brain Mapping Commission. There has been much progress since that conversation in that regard.”

John Maa, MD, a member of the General Surgery Newss advisory board, with President Obama in Palo Alto, Calif. Dr. Maa is president of the Northern California Chapter of the American College of Surgeons.

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

Single-Incision Laparoscopic Cholecystectomy Linked to Higher Hernia Rates B Y G EORGE O CHOA

n a head-to-head comparison, patients undergoing single-incision laparoscopic cholecystectomy had a significantly higher rate of hernia formation at oneyear follow-up than those having standard four-port laparoscopy. Only one of 81 patients who received standard laparoscopy developed a hernia (1.2%) versus 10 of 119 patients (8.4%) who underwent the single-incision procedure (P=0.03). P “I was somewhat surprised by the results,” the study’s lead author, Jeffrey M. Marks, MD, FACS, FASGE, told General Surgery News. “But as you make incisions larger, there is a greater consequence of hernia.” Dr. Marks is professor of surgery at University Hospitals Case Medical Center, Cleveland. Steven Schwaitzberg, MD, FACS, chief of surgery, Cambridge Health Alliance, and associate professor, Harvard Medical School, Boston, who was not involved in the study, said in an interview: “In many ways, this is a landmark paper because it’s going to drive clinical practice.” The study, published in the Journal of the American College of Surgeons (2013;216:1037-1047) was sponsored by Covidien, manufacturer of the SILS Port, a device used in single-incision laparoscopic cholecystectomy. According to Dr. Marks, Covidien was “fully transparent, and above all wanted to assure that they didn’t influence the study.” In an invited commentary accompanying the study, David W. Rattner, MD, FACS, wrote, “Covidien Inc., and the authors are to be congratulated both for performing the study properly and publishing results that were not necessarily what the corporate sponsor might have hoped for.” In the prospective, multicenter, singleblinded, controlled trial, 200 patients were randomized to single-incision (n=119) or standard (n=81) laparoscopic cholecystectomy. All patients at the 10 sites had biliary colic with documented gallstones or polyps, or had biliary dyskinesia. The primary end points were feasibility and safety. Follow-up at 12 months was completed by 100 patients (84%) in the single-incision group and 64 (79%) in the standard laparoscopy group. Adverse events and severe adverse events did not differ significantly between the two groups. Four wound-related complications were reported in the standard laparoscopy group (4.9%) and 14 were reported in the single-incision group (11.7%), but the difference was not statistically significant (P=0.13). P Pain scores were higher in the single-incision group

than for standard laparoscopy at nearly all measured points, but the difference in most cases was not statistically significant. Cosmesis scores favored single-incision over standard laparoscopy at all time points (P<0.0004). Physical quality-of-life scores favored standard laparoscopy over single-incision laparoscopy at some time points (day 3, P=0.01; one week, P=0.03; P one month, P P=0.03), but were equivalent at all other time points. The two groups did not differ with respect to mental

quality-of-life scores. At all time points, more than 92% of patients preferred single-incision laparoscopy if they needed a cholecystectomy again (P<0.0001). Although the study is now closed, Dr. Marks, who is also director of surgical endoscopy and program director, Case Medical Center, said, “It would be nice to reassess the patients in three and five years, and see if the difference in hernia formation is greater or if it has equilibrated.” For now, Dr. Schwaitzberg, who is also

past president, Society of American Gastrointestinal and Endoscopic Surgeons, said, “The data support the continued use of multiport surgery for cholecystectomy since the hernia rate is lower.” Dr. Marks noted, “Cosmesis was improved for the single-port group. That is one of our goals with any surgery, but an effective surgery with minimal complications is the greater goal.” Drs. Marks and Schwaitzberg reported no relevant financial conflicts of interest.

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Collaboration Between the Anesthesia and Surgical Teams In the Perioperative Setting Merck Consultants Roy G. Soto, MD Professor Oakland University William Beaumont School of Medicine Residency Program Director Department of Anesthesiology Royal Oak, Michigan

David E. Stein, MD Associate Professor and Chief Division of Colorectal Surgery Drexel University College of Medicine Philadelphia, Pennsylvania

Medical Writer Oren Traub, MD, PhD This article was written with significant input, direction, and editorial review by Merck.

(35.7%), unresolved issues (24%), and communication events when key individuals were excluded (20.9%).1 Dr. Soto, who has practiced for more than 10 years, noted that the size of certain medical centers may contribute to communication problems. “At my center alone, there are 87 different locations where anesthesia might be administered,” Dr. Soto said. “That means that you’re working with people every day who you’ve never met before and haven’t yet established a common language for good communication.”

Perspectives of the Anesthesia Provider And the Surgeon A recent survey conducted with surgeons, anesthesiologists, and certified registered nurse anesthetists (CRNAs) from one institution suggests that the level and quality of communication often is perceived differently by team members.2 Awad et al used a validated Likert-scale survey with questions aimed at communication in the operating room (OR) to establish the baseline of communication among surgeons, anesthesiologists, and CRNAs prior to participating in

medical team training. A study objective was to determine if OR communication could be improved through training.2 The study found that anesthesiologists perceived overall communication to be “poor”; nurses viewed communication as “adequate”; and surgeons found communication among OR staff was “good.” The study found that medical team training could improve communication in the OR.2 Similarly, Sexton et al sought to survey operating theatre and intensive care unit staff about attitudes concerning stress, error, and teamwork.3 Using 4 questionnaires that contained a core set of questions whose responses could match across disciplines and countries, researchers evaluated responses from 1,033 doctors, residents, fellows, and nurses from 12 urban hospitals in Italy, Germany, Switzerland, Israel, and the United States.3 Results showed that 62% of surgical staff reported high levels of teamwork with anesthesia staff. Among anesthesia staff, 41% (106 out of 250) reported high levels of teamwork with surgical staff.3 Also, less than 30% of anesthesia residents, anesthesia nurses, and surgical nurses (10%, 26%, and 28%, respectively), and

Introduction Active coordination by different members of the health care team (eg, surgeons, anesthesiologists, and nurse anesthetists) is important during the perioperative period; investigational and anecdotal observations suggest that poor communication among anesthesia professionals, surgeons, and other surgical staff may exist during this period. Lingard et al observed 48 selected surgical procedures at a Canadian hospital center over 3 months in 2003 in order to describe the content and effects of communication events as well as identify common communication failures.1 The authors identified 421 communication events—defined as a verbal or non-verbal exchange between 2 or more surgical team members—and categorized 129 of these events as communication failures in that content of the communication was directed at the wrong team member, had the incorrect goal or intent for the current situation, or was miscommunicated or not communicated due to the physical or temporal situation at the time (eg, a request was inaudible because of an alarm) (Table 1).1 In separate interviews conducted for this article, David E. Stein, MD, associate professor and chief of the Division of Colorectal Surgery at Drexel University College of Medicine in Philadelphia, Pennsylvania, and Roy G. Soto, MD, professor of anesthesiology and director of the residency program at Oakland University William Beaumont School of Medicine in Royal Oak, Michigan, discussed their experience regarding communication among the health care team. “In my experience, one of the things that gets pushed aside during the perioperative period is communication,” said Dr. Stein, who has practiced since 2003. “It’s important to take a step back and communicate with your team members.” In the aforementioned study by Lingard et al, incidents of communication failure (30.6% of the 421 total number of events) were divided into several categories: poor timing (45.7%), missing or inaccurate information communicated

GENERAL SURGERY NEWS • AUGUST 2013

Table 1. Definitions of Types of Communication Failure With Illustrative Examples and Notes Occasion Failures

Definition

Illustrative Example and Analytical Note (In Italics)

Content failures

Problems in the situation The staff surgeon asks the anesthesiologist whether the antibiotics or context of the comhave been administered. At the point of this question, the procedure munication event has been under way for >1 h. As antibiotics are optimally given within 30 min of incision, the timing of this inquiry is ineffective both as a prompt and as a safety redundancy measure.

Audience failures

Insufficiency or inaccuracy apparent in the information being transferred

As the case is set up, the anesthesia fellow asks the staff surgeon if the patient has an ICU bed. The staff surgeon replies that the “bed is probably not needed, and there isn’t likely one available anyway, so we’ll just go ahead.” Relevant information is missing and questions are left unresolved: Has an ICU bed been requested, and what will be the plan if the patient does need critical care and an ICU bed is not available? [Note: classified as a content and purpose failure.]

Purpose failures

Gaps in the composition The nurses and the anesthesiologist discuss how the patient should of the group engaged in be positioned for surgery without the participation of a surgical the communication representative. Surgeons have particular positioning needs so they should be participants in this discussion. Decisions made in their absence occasionally lead to renewed discussions and repositioning upon their arrival.

Failure

Communication events in which the purpose is unclear, not achieved, or inappropriate

During a living donor liver resection, the nurses discuss whether ice is needed in the basin they are preparing for the liver. Neither knows. No further discussion ensues. The purpose of this communication—to find out if ice is required—is not achieved. No plan to achieve it is articulated.

Reprinted with permission from Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-334.

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39% of anesthesia consultants reported high levels of teamwork with consultant surgeons overall.3 In another study, 16 Canadian clinicians (11 anesthesiologists and 5 surgeons) were interviewed in order for researchers to identify beliefs about preoperative testing practices.4 The content of the physicians’ statements was analyzed and separated into relevant conceptual domains. Results found that surgeons and anesthesiologists differed as to who was responsible for ordering tests and how many and which tests should be ordered.4 Also, results showed that surgeons may order tests based on what they perceive relevant for the anesthesiologist, as opposed to directly communicating with the anesthesiologist about which tests would be most relevant.4 This problem can be compounded by the absence of a formalized communications system or an integrated electronic medical records system across different groups. “If I see the patient in my clinic and ordered all the preoperative tests, the results may be sitting on my desk. I have to remember to transmit those results to the anesthesiologist so that they are available when that practitioner evaluates the patient,” Dr. Stein said. “Having those results might prompt the anesthesiologist to order other tests that I didn’t even consider. It doesn’t do any good if we’re not sharing the information we know.”

Improving Communication in the Perioperative Setting In an effort to improve the level and quality of communication, one model often employed by experts is crew resource management or the use of aviation techniques. Principles of this strategy as applied to the perioperative setting include using a preoperative briefing with all surgical staff. In the past 10 years, following the adoption of crew resource management techniques, the aviation industry has experienced a marked decrease in communication-related mistakes.5 Dr. Soto explained that the recent integration of aviation crew resource management techniques into surgical workflow at his institution is helping communication: “In addition to empowering each member of the surgical and anesthesia staff to speak up when they see something during the case, these aviation management techniques also involve immediate review of cases. This enables us to evaluate the case and use that knowledge for our future cases,” he said. “More and more centers are using a formalized preoperative huddle where they explicitly discuss the case, the positioning, and the procedural details and time,” Dr. Stein said. “Knowledge is power: Having this information can help both surgeons and anesthesiologists navigate their intraoperative approach to the patient.” Dr. Soto also described the usefulness of preoperative meetings. “The anesthesiologist may want to obtain more information to prepare an appropriate anesthetic management plan,” he said. “There’s where the ‘preoperative huddle’ may help.”

Physicians also have indicated that documentation and/ or notes derived from a template sometimes can provide further aid in assuring that all the vital information has been obtained and documented.6,7 Finally, several groups of investigators have studied the effect of formalized processes that incorporate these system improvements. For example, Awad et al instituted a dedicated training session (eg, didactic instruction, interactive participation, role-play sessions, training films, and clinical vignettes) for the entire surgical service using crew resource management principles and principles of change management. Additionally, researchers established formal preoperative briefings (Table 2) conducted among the surgeon, the anesthesiologist, and the surgical nurse.2 Four months after conducting the training session and initiation of the preoperative briefing protocol, investigators found briefings occurred preoperatively for all patients, and there was a significant increase in the perceived communication score among anesthesiologists and surgeons (score increase among OR nursing staff was not statistically significant).2 Lingard et al performed a 13-month prospective study of a short team briefing structured by a checklist in order to assess whether these briefings could improve OR communication. Participants included 11 general surgeons, 24 surgical trainees, 41 OR nurses, 28 anesthesiologists, and 24 anesthesia trainees from a Canadian academic tertiary care hospital.8 The primary outcome measure was the total number of communication failures per surgical procedure. During the structured briefings, led by the surgeon, team members were to share their knowledge of the case and resolve knowledge gaps as to how the procedure would proceed.8 Study researchers reported that the mean number of communication failures per procedure declined from 3.95 before the briefing intervention was introduced to 1.31 failures per procedure following the intervention period (P<0.001).8

Conclusion Overall, Dr. Stein noted that the success of these types of interventions begins with the staff members themselves. “Everybody has to check their egos at the door. The days of having a central person saying ‘I know best’ and ‘you should do what I say’ are well past,” he said. “It’s best to have a team that is communicating well with one another.”

References 1. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-334. 2. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5): 770-774. 3. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237):745-749. 4. Patey AM, Islam R, Francis JJ, et al. Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk patients:

Table 2. Preoperative Briefing Guide Category

Components

Time out

Patient name Procedure Site verification Laterality

Roll call

Staff surgeon Anesthesiologist Nurse

Anticipated problems Documentation

Consent History and physical within 30 d Staff preoperative note

Case discussion

Anesthesia plans/concerns Allergies IV antibiotics Position Sequential compression device Required instrumentation Special equipment Blood Length of procedure Postoperative disposition Precautions Consensus on plan and site

Reprinted with permission from Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-774.

application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests. Implement Sci. 2012;7:52. 5. Rivers RM, Swain D, Nixon WR. Using aviation safety measures to enhance patient outcomes. AORN J. 2003;77(1):158-162. 6. Lubarsky D, Candiotti K. Giving anesthesiologists what they want: how to write a useful preoperative consult. Cleve Clin J Med. 2009; 76(suppl 4):S32-S36. 7. Bader AM, Sweitzer B, Kumar A. Nuts and bolts of preoperative clinics: the view from three institutions. Cleve Clin J Med. 2009; 76(suppl 4):S104-S111. 8. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12-17; discussion 18.

Disclosures Both Drs. Soto and Stein were paid by Merck for their contributions to this article. Dr. Soto reported receiving grant/ research support from Merck. Dr. Stein reported receiving speaker fees from Cubist, Ethicon Endo-Surgery, and Merck.

BB1322

Disclaimer: This monograph is designed to be a summary of information. While it is detailed, it is not an exhaustive clinical review. McMahon Publishing, Merck, and the authors neither affirm nor deny the accuracy of the information contained herein. No liability will be assumed for the use of this monograph, and the absence of typographical errors is not guaranteed. Readers are strongly urged to consult any relevant primary literature. Copyright © 2013, McMahon Publishing, 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form. ANES-1081276-0001 06/13

GENERAL SURGERY NEWS • AUGUST 2013

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New Colonoscope Offers Sweeping, 330-Degree Views of the Colon B Y A UDREY A NDREWS ORLANDO, FLA.—A new colonoscope that provides three simultaneous fullspectrum images of the colon detected significantly more adenomas—and missed significantly fewer—in findings presented at the 2013 Digestive Disease Week (DDW) meeting. Ian M. Gralnek, MD, MSHS, associate professor of medicine/gastroenterology at

the Rappaport Family Faculty of Medicine Technion-Israel Institute of Technology in Haifa, Israel, presented data on the Fuse Full Spectrum Endoscopy (Fuse) system in a study that compared the new technology with traditional, forwardviewing (TFV) colonoscopy in a tandem endoscopy study design. “Compared with TFV colonoscopy, Fuse found significantly more adenomas, had a significantly lower adenoma

miss rate and impacted colonoscopy surveillance recommendations,” Dr. Gralnek said. “Our results are very compelling. We believe that Fuse is an advance in colonoscopy technology.” At a press briefing, Dr. Gralnek indicated that interest in the technology at the meeting had been “huge.” Dr. Gralnek said, “We are all becoming aware that we miss adenomas. We need to do a better job at finding them, and we

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need better technology for this.” The Fuse system, developed by EndoChoice, shares similar technical features of standard colonoscopes but allows a 330-degree view of the colon, much broader than the 170-degree viewing angle of traditional colonoscopes. The Fuse colonoscope employs multiple imagers and projects the expanded view on three corresponding screens, instead of the one display used with TFV. With TFV, up to 31% of adenomas can be missed, primarily due to inadequate visualization of the proximal side of colonic folds and anatomic flexures within the colon (World J Gastroenteroll 2012;18:3400-3408). The Fuse system fulfills the need for technology that will expand visualization, Dr. Gralnek said. In the randomized, multicenter trial, investigators followed a tandem colonoscopy design in which same-day, back-toback colonoscopies using Fuse and TFV were performed by the same endoscopist. Dr. Gralnek presented results on 185 patients, whose indications for colonoscopy included screening (55.7%), surveillance (19.5%) and diagnostic evaluation (24.8%). Among 88 patients who received TFV as their initial colonoscopy followed by Fuse, 28 adenomas/cancers were detected on the first pass with TFV, and an additional 20 adenomas/cancers were detected on the second pass using Fuse. “This amounted to a 71.4% increase in the number of adenomas found with Fuse,” Dr. Gralnek reported. In contrast, among 97 patients initially scoped with Fuse, 61 adenomas/cancers were found on the first pass with Fuse, and only five additional adenomas were seen on the second pass with TFV, for an 8.2% increase in adenoma detection via the conventional approach. The difference in this comparison was statistically significant (P<0.0001). Significant differences also were observed in rates of missed adenomas and false-negatives. Additionally, the adenoma detection rate (ADR) per colonoscopy type at first colonoscopy was numerically, but not significantly, improved with Fuse. Dr. Gralnek noted that the study was powered as a per-lesion analysis and not as a per-patient analysis; therefore, perpatient ADRs could not be statistically evaluated. More than 1,000 patients would need to be studied to evaluate ADR as an end point on a per-patient basis, he explained. Most of the 20 adenomas that were initially missed by TFV in the study were sessile lesions in the right colon, primarily tubular adenomas, 1 to 5 mm. The five adenomas missed by Fuse on the initial

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pass were all sessile lesions, tubular subtype and 1 to 5 mm in diameter; two were located in the right colon, and three were in the left colon. Discussing the Fuse system at the DDW press briefing, Dr. Gralnek described the “feel” of the new device, specifically the three-screen viewing system. “I have done about 75 cases myself, and I became comfortable using Fuse after about five cases. I focus on the center video monitor, and my peripheral vision picks up polyps that appear on the side monitors. It’s very intuitive.” The findings could theoretically change surveillance recommendations for some patients. Of the 15 patients who had the 20 missed adenomas with TFV, the use of Fuse changed their colonoscopy surveillance schedule—the interval for follow-up colonoscopy was shortened for 53.3% of those patients. David Lieberman, MD, professor of medicine and chief of the Department of Gastroenterology and Hepatology at Oregon Health & Science University, in Portland, called the Fuse system a “very exciting technology.” Dr. Lieberman drew an analogy between using the Fuse system and driving a car: “You look out your front window, but you can also see things out of the side windows, too, such as a pedestrian standing on the curb,” he explained. “That could be a polyp, and you can see what angle you need to have in order to make your turn.” He said the findings from the comparison study “suggest that you may see more polyps” using Fuse. Frank Sinicrope, MD, professor of medicine and oncology at Mayo Clinic, Rochester, Minn., also acknowledged the advantages of the device over TFV. “It is acknowledged that a major limitation of our current forward-viewing colonoscopes is that they do not allow visualization behind mucosal folds, which can result in missed polyps, or even cancers. This limitation is an important factor that reduces the effectiveness of colonoscopy for cancer prevention,” he noted. The study by Dr. Gralnek showed Fuse to be superior to TFV for the detection of adenomas, with significantly fewer missed adenomas, Dr. Sinicrope added. Because ADR is a key quality metric, these are “important data,” he said. However, more information is needed regarding the risk features of these adenomas, he said. It is also important to determine if Fuse can increase the detection of flat polyps because these lesions may lead to interval cancers and contribute to the observed reduction in efficacy of TFV in the right versus the left side of the colon. “This will be important to demonstrate in future studies, he said.

He added that although Fuse could represent a true advance, it also might detect more adenomas and polyps that are simply harmless. “Detecting more polyps and adenomas does not necessarily indicate that a reduction in cancer risk or mortality will result. Many small adenomas may never develop into cancers, whereas the detection and removal of advanced adenomas is expected to translate into the prevention of future cancers. However, better adenoma detection and complete removal are necessary steps for colorectal cancer prevention.

“Despite these issues,” he said, “the Fuse colonoscope represents an important advance in endoscopic technology that improves ADR, and thereby the efficacy of colonoscopy.” Colleen M. Schmitt, MD, of Galen Gastroenterology in Chattanooga, Tenn., who moderated the DDW press conference, noted that the miss rate in the control group was “at the top of the reported range,” which could exaggerate the differences between the two approaches. However, she added, a difference of even half of what was reported would be “important.” Dr. Schmitt, who is president-elect

of the ASGE, said that the findings should be replicated in a community setting, pointing out that the 71% increase in the number of adenomas found was achieved “by expert hands.” Studies are needed, she said, to determine the ADR with Fuse “in the hands of general practitioners,” although she predicted the outcomes “will probably be better than what we are achieving now.” Dr. Gralnek has served on an advisory committee or review panel for Given Imaging and Motus GI, and has served as a consultant for AstraZeneca, Given Imaging and PeerMedical.

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Dear Readers, Welcome to the August issue of the Surgeons’ Lounge. I hope all of our readers enjoyed the stories relating to current issues in colorectal surgery and surgery of the foregut from our three previous issues. We are interested in receiving stories and updates regarding all areas of surgery, and welcome our readers’ suggestions for future issues of Surgeons’ Lounge. In this issue, our guest expert is Eduardo A. Souchon, MD, FACS, professor of surgery, Department of Surgery at The University of Texas Medical School at Houston, discusses the cas e of a patient with a pseudocyst. We also present “The Latin Quarter” section this month with guest expert, Fernando Dip, MD, chief of research surgery, Surgical Oncology, Hospital de Clinicas Jose de San Martín in Buenos Aires, who discusses the use of fluorescence-guided surgery. Our next guest expert will be Andreas G. Tzakis, MD, PhD, director, Transplant Center at Cleveland Clinic Florida, in Weston. Finally, our Surgeon’s Challenge presents a case of a 44-year-old woman with a symptomatic ventral hernia. I look forward to your questions, comments and feedback. Sincerely Samuel Szomstein, MD, FACS Editor, The Surgeons’ Lounge Szomsts@ccf.org

Question for Dr. Souchon Dhivya Reghunathan, MD PGY-3, UT Health, The University of Texas Medical School at Houston

55-year-old man with a history of alcoholism and recurrent pancreatitis was admitted for acute-onset abdominal pain and nausea. He had multiple previous workups for upper gastrointestinal (GI) bleeding that showed no gastric or duodenal source. At this admission, he was found to have an infected pancreatic pseudocyst. A computed tomography (CT) scan showed a large,multiloculated pseudocyst with complex fluid (Figures 1 and 2). An endoscopic retrograde cholangiopancreatography (ERCP) and a stented minor papilla did not alleviate the symptoms. Via interventional radiology, a drain was placed in the pseudocyst and the patient was given antibiotics based on fluid culture results. One week later, the patient’s hemoglobin had significantly dropped and he was found to have active extravasation from the gastroduodenal artery (Figure 3). He underwent angiography with interventional radiology and a stent was placed across the hepatic artery proper (Figures 4 and 5). The patient became hemodynamically stable, but still had greater than a 500 cc daily output from the pseudocyst, despite the pancreatic stent.

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

Question 1. Given the history of multiple episodes of upper GI bleeding, with no source, in the setting of a pseudocyst and chronic pancreatitis, do you think earlier angiography would have been warranted? Question 2. Would you consider a surgical drainage procedure for management of this pseudocyst in the acute setting? How long after resolution of the hemorrhage would you wait? Question 3. Is there any additional workup you would have recommended early in this patient’s care?

Dr. Souchon’s

Question 1. Yes. Given that the patient had multiple recurrent episodes of upper GI bleeding with no source noted on endoscopy, angiography would have been indicated in this specific patient. With pancreatic pseudocysts— especially when they are large and in close proximity to major vessels—erosions and hemorrhage may occur. Such complications from pancreatitis are well published, and usually involve the gastroduodenal artery, splenic artery or inferior pancreaticoduodenal artery. Although acute hemorrhage requires immediate surgical intervention, angiography has become widely available and should be used in both an acute and

nonacute setting and if possible, treatment via embolization or stenting also should be used.1 Question 2. I would nott recommend a surgical drainage procedure in the acute setting. Assuming the hemorrhage has been dealt with, the psuedocyst is likely filled with hard, clotted blood and would not be easy to isolate and operate on. Although a cystenterostomy is indicated in a staged manner, it would be most prudent to wait for the clot to soften, and most importantly, for the pseudocyst wall to mature. It is important to keep in mind that a pseudocyst is so named because it is an inflammatory reaction. I would recommend waiting, rescanning the patient, and confirming that the pseudocyst has matured with a wall thickness of 4 to 5 mm before attempting a surgical drainage procedure. It also is key to isolate which organ is in closest proximity to the cyst in order to plan the appropriate anastomosis. Of note, newer modalities, including endoscopic ultrasound (EUS), have been used to drain and treat pancreatic pseudocysts.2 However, the negatives include a failure rate of almost 25% and complications such as perforation that require emergent surgery. Although EUS drainage may be criticized as a shortterm solution, current case reviews show near resolution in a clear majority of the patients.3,4 In a high-risk surgical patient, or one in whom isolating the pseudocyst or the anastomosis would be difficult, EUS-guided treatment should be considered as a viable option.

2 Figures 1 and 2: CT scan showed a large, multiloculated pseudocyst with complex fluid Question 3. The specific description of this pseudocyst included multiple loculations with different fluid densities. This should always trigger a workup for pancreatic malignancy, specifically

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The Latin Quarter I would like to thank Dr. Szomstein for the invitation to participate as guest expert in this edition of “The Latin Quarter.” I am happy to present the initial work we did in Argentina on fluorescence-guided surgery, a new minimally invasive technology. Currently, we are developing several projects in association with the Cleveland Clinic Florida in this new and exciting field. I hope you enjoy reading about this exciting new work and that you provide us with your feedback. —Fernando Dip, MD

The Use of Fluorescence-Guided Surgery When performing surgery, accurate recognition of the anatomy is essential. New technologies have been developing to facilitate the dissection and identification of structures. Fluorescence-guided surgery is a new and promising method. Using adequate fluorescent dye and appropriate laparoscopic equipment, the specific tissue can be illuminated. We focus our discussion here on the application of this new technology in laparoscopic cholecystectomy. Minimally invasive surgery has become the procedure of choice for cholecystectomies.1 It is essential to have a thorough knowledge of the anatomy of the biliary ducts including the multiple variations of the biliary tree.2,3 Experience is essential, but not sufficient to protect surgeons and patients from biliary injury.4 Bile duct injuries are estimated to occur at a rate of 0.5%.5 The rate of injury remains stable but the frequency has increased because of the rising numbers of cholecystectomies performed. Injury occurs mainly from the misidentification of ducts. Inexperience, inflammation and aberrant anatomy are key risk factors.6

For many years, intraoperative cholangiography (IOC) was used to define the biliary anatomy and also to mitigate the severity of bile duct injury. Recently, the routine use of IOC has become controversial.7 Radiation exposure, high cost and prolonged operative time are disadvantages of the procedure.8,9 The development of new imaging methods is necessary because standard cholangiography requires incision of the cystic duct before definitive identification of the biliary structures. Fluorescent cholangiography is a new technique that creates illumination of the biliary structures using a fluorescent dye that is injected intravenously, and a special light source.10 The fluorescent imaging system consists of a light source and a filter that emits infrared and xenon light. This system is incorporated into the charge-coupled device, camera and scope that can filter out light with wavelengths below 810 and above 800 nm (Figure 1a). The light of the laparoscope can easily be changed to the infrared view using a pedal. Indocyanine green is a fluorescent dye that has been approved for multiple clinical purposes. It is used in cardiac, hepatic and ophthalmic angiography.11 When illuminated by infrared light, the dye manifests fluorescence. The dye has 0.003% toxicity level in a dose of 0.5 mg/kg. The main pathway for excretion is hepatic. The procedure begins with administration of a single dose of 0.05 mg/kg of indocyanine green dye one hour before surgery. A Storz® xenon light source and a laparoscope with a charge-coupled device that filters out light wavelengths (except 830 nm with a specific 780 nm infrared light source), are used intraoperatively. Abdominal inspection with standard trocar placement is performed while the dye is excreted through the liver (Figures 1b and 1c). The fluorescence system is then easily activated using a pedal, thus creating luminance

from the biliary structures. The fluorescence provides visualization of the trajectory of a cystic duct. Localization of the hepatic ducts or accessory ducts also is possible. Fluorescent cholangiography is a novel technique that does not require further training. A pedal conveniently activates the fluorescent system, therefore making it easy for the surgeon to switch between the standard and the fluorescent view. The dye can be administered in a shorter time frame before surgery although it is preferable that the dye is injected one hour preoperatively. In the case of symptomatic cholelithiasis, the dye can even be administered during anesthesia induction. The fluorescent dye is still visible two hours after the time of injection. The degree of fluorescent illumination of biliary structures varies due to different tissue types and the extent of tissue inflammation. When the depth of the tissue is increased, such as in acute or chronic cholecystitis, the quality of luminance is lowered. However, the fluorescence would continue to guide further dissection. Fluorescence from the liver illuminates the abdominal cavity to show the movements of the laparoscopic instruments during dissection. The cost and the risk for radiation exposure of the procedure are lessened because fluoroscopic imaging is unnecessary. In some cases where the cystic and choledochal junction are not visible (as with a long and parallel cystic duct), compression of the main bile duct with a grasper can show reflux of the dye to the gallbladder, thereby delineating the structures. In another maneuver, lifting the liver enhances the appearance of the hepatic duct bifurcation. Injuries related to the cannulation of biliary structures are avoided because no invasive maneuvers are performed with fluorescent cholangiography. Data were obtained from 65 patients who underwent laparoscopic

Figure 1a. Wavelength Spectrum. Figure 1b. ICG excretion; Xenon light. Figure 1c. Infrared light.

Figure 2a. Main bile duct. Figure 2b. Cystic duct parallel to main bile duct. Figure 2c. Cystic duct main bile duct. cholecystectomy with fluorescent cholangiography. During the procedure, alternate exposure from xenon to infrared lights was used to identify the biliary structures before and after dissection (Figures 2a, 2b and 2c). Standard cholangiography was performed in all cases. A questionnaire to assess the surgeon’s visibility with and without fluorescentguided identification of extrahepatic bile ducts was distributed. Continued ON PAGE 14

cystadenocarcinoma of the pancreas. Fluid and cyst wall cytology and pathology should be reviewed. Although the history of alcoholism and chronic pancreatitis suggests a pseudocyst, one should always rule out malignancy where appropriate.

References 1. 2.

3 Figure 3: Active extravasation from the patient’s gastroduodenal artery

4 Figures 4 and 5: Angiography with IR and a stent across the hepatic artery proper

3. 4.

J Endovasc Ther. 2002;9:38-47. Diag Ther Endoscop. http://dx.doi. org/10.1155/2013/924291. J Gastroenterol Hepatol. 2012;27:722-727. Vosoghi M, Sial S, Garrett B, et al. EUS-guided pancreatic pseudocyst drainage: review and experience at Harbor-UCLA Medical Center. MedGenMed. 2002;4:2.

Surgeons‘ Lounge jContinued from page 13 In the study cohort, 42 patients were diagnosed with symptomatic cholelithiasis: 15 with acute cholecystitis and 12 with chronic cholecystitis. Fluorescence alone, without any dissection, identified the cystic duct in 47 cases. In all cases, the surgeons confirmed biliary anatomy with fluorescence before catheterization and transection of the cystic duct. Results from the questionnaire showed that surgeons found the technique convenient relative to traditional cholangiography and without a significant increase in length of

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

operation time (estimated increase was two minutes). Fluorescent cholangiography with indocyanine green appears to be a viable method for real-time detection of the extrahepatic structures without catheterization of the bile duct. An international group dedicated to the study and implementation of fluorescent imaging techniques in surgery was recently formed. The International Study Group of Fluorescence Imaging in Surgery was created in association with Cleveland Clinic Florida, Hospital de Clinicas Buenos Aires and University of Tokyo. The group’s

main objective is to share knowledge and experience, and to bring surgeons together from around the globe who are working on fluorescence imaging or are interested in learning more about its application. Our readers are invited to join this group.

References 1. 2. 3. 4. 5.

World J Surg. 2011;35:1422-1427. J Chir. 1989;126:147-154. Nippon Rinsho. 1998;56:2918-2922. Surg Endosc. 2006;20:1654-1658. Ann Surg. 2001;234:549-558; discussion 558-559.

J Hepatobiliary Pancreat Surg. 2002; 9(5): 543-547.

Read the #1 general surgery publication in the country anywhere, anytime.

7. 8. 9. 10. 11.

J Am Coll Surg. 2012;214:668–679. Surg Endosc. 1996;10:798-800. Br J Surg. 2012;99:160-167. Br J Surg. 2010;97:1369-1377. Int J Biomed Imaging. 2012; 1155/2012/940585.

doi:

10.

Surgeon’s Challenge Submitted by MS-IV medical students: Jessica Landau, University of Miami, Florida, and Jenna M. Jun, Ross University School of Medicine, Dominica A 44-year-old woman with a past medical history of idiopathic thrombocytopenic purpura had a symptomatic ventral hernia from a previous midline incision. She underwent a partial hysterectomy and a concomitant ventral hernia repair with synthetic mesh in January 2012. Her postoperative recovery was complicated by severe bleeding for which she needed a blood transfusion. She developed a seroma and had 1.3 L of serosanguineous fluid percutaneously drained in March 2012, and another 600 mL percutaneously drained in April 2012. In December 2012, she was found to have leukocytosis of 20 K and an abdominal computed tomography (CT) showed that the hernias had recurred, and also confirmed an inflammatory process. She was taken to the operating room and the synthetic mesh was replaced by a biological mesh. She was discharged with multiple drains. After the drains were removed, the seroma recurred. A subsequent CT scan in April 2013 showed that the seroma was now loculated and only 400 mL of fluid was removed percutaneously (Figures 1 and 2). Challenge question: What is the best course of action at this time?

1 Figure 1. CT abdomen, sagittal view, showing largest extent of seroma

2 Figure 2. CT abdomen showing transverse view of abdominal wall and seroma.

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GASTRIC BYPASS jcontinued from page 1

interested in glucose tolerance testing after noticing that many of their patients who regained weight after gastric bypass surgery complained of inter-meal hunger, especially following meals rich in simple carbohydrates. “Consistent with that is the fact that there are new conditions—nesidioblastosis, noninsulinoma pancreatogenous hypoglycemia syndrome, hyperinsulinemia and hypoglycemia—[that are] becoming more common after gastric bypass,” Dr. Roslin said. “These are entities surgeons rarely encountered previous to this [era in bariatric surgery].” The research was presented at the 2013 meeting of the Society of American Gastrointestinal and Endoscopic Surgeons; the study was sponsored by Covidien. Dr. Roslin and his team decided to compare glucose metabolism among patients who had undergone gastric bypass, sleeve gastrectomy or duodenal switch (DS), in which a common channel of at least 125 cm was preserved. “This type of model gives us the ability to compare two operations that preserve the pyloric valve, as well as two operations that have an intestinal bypass component,” he said. In the prospective, nonrandomized study, 13 patients received gastric bypass, 12 received sleeve gastrectomy, and 13 underwent DS. All completed an oral glucose tolerance test (GTT) at baseline and six, nine and 12 months. The nine-month GTT comprised a solid mixed-meal muffin. The only significant, preoperative difference among the patients was greater body mass index in the DS group. There were no significant differences in their glucose homeostasis parameters, fasting glucose or insulin. At 12 months, the DS patients lost significantly more weight than the other two groups, although those also experienced good weight loss. All of the operations reduced fasting blood glucose levels as well. But after GTT, the gastric bypass group had much higher levels of one-hour glucose than the DS group, and the sleeve gastrectomy group had intermediate levels. The gastric bypass group also had higher one-hour insulin levels, higher even than their preoperative level, whereas insulin was suppressed in the DS group. “When you have high insulin, glucose falls, and we know that hypoglycemia causes hunger,” Dr. Roslin said. “Looking at the one- to two-hour glucose ratio, the gastric bypass patients have the highest one-hour sugar [levels] and the lowest two-hour sugar [levels], and I think this begins to explain why we have intermeal hunger with gastric bypass.” All of the operations resulted in

significant weight loss and other positive outcomes, but compared with gastric bypass patients, DS patients had a much smaller rise in one-hour glucose and insulin levels. “The sleeve behaves intermediately to the bypass and DS, meaning that preserving the pylorus may be part of the explanation, but not the whole story,” Dr. Roslin said. “Obviously, controlled trials between gastric bypass and DS are needed to determine the real long-term significance, but I think we should all be cautious before we label gastric bypass the gold standard operation,” he said.

‘These are entities surgeons rarely encountered previous to this [era of bariatric surgery].’ —Mitchell Roslin, MD

Kevin M. Reavis, MD, FACS, esophageal and foregut surgery, Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, said that improved assays are allowing for

a more rapid and better understanding of the true complexity of the physiologic changes that contribute to the results seen with each of the bariatric procedures. “This study highlights aspects of glucose metabolism that have previously been underappreciated.” “Although it is a relatively small study, it illustrates that with gastric bypass, sleeve gastrectomy and duodenal switch, there are substantial metabolic changes we are just beginning to understand and must investigate on a larger scale in order to optimize clinical outcomes,” Dr. Reavis said.

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REPORT July 2013

Improving Outcomes in Open Colorectal and Gynecologic Procedures Using the LigaSure Impact™ Instrument Faculty: Robert E. Bristow, MD, MBA Professor and Director Division of Gynecologic Oncology Department of OB/GYN UC Irvine Medical Center Orange, California Warner Huh, MD Professor Margaret Cameron Spain Endowed Chair in Obstetrics/Gynecology Division of Gynecology Department of OB/GYN University of Alabama at Birmingham Birmingham, Alabama Raffaele Bruno, MD Assistant Clinical Professor in OB/GYN Boston University School of Medicine Boston, Massachusetts Director of Section of General Gynecology and Reconstructive Pelvic Surgery Department of Gynecology Lahey Clinic Foundation, Inc. Burlington, Massachusetts Laurence Sands, MD Professor of Clinical Surgery University of Miami Miller School of Medicine Miami, Florida Eduardo Garcia-Granero, MD Professor of Surgery Head of Section Coloproctology Unit Hospital la Fe University of Valencia Valencia, Spain Paris Tekkis, MBBS, FRCS Professor of Colorectal Surgery Imperial College of London The Royal Marsden Hospital London, United Kingdom Aneel Bhangu, MBChB, MRCS Imperial College of London The Royal Marsden Hospital London, United Kingdom

Introduction Recent advances in open and laparoscopic surgery have enabled surgeons to perform complicated procedures across surgical specialties, including gynecology and gastroenterology, with improved efficiency while optimizing clinical outcomes.1,2 Although a variety of conventional techniques, including clips, sutures, staples, and energy-sealing devices, have been used for vessel ligation in gynecologic and colorectal procedures,3,4 these methods may present a number of challenges including prolonged operating time, increased risk for blood loss, and increased costs. For example, the use of sutures can be time-consuming given the need to clamp, cut, and ligate the vessel.5 For gynecologic surgeons, procedures, including hysterectomies, are optimized by using surgical instruments that enhance access and visibility when ligating vessels, while minimizing blood loss.4 Raffaele Bruno, MD, assistant clinical professor in obstetrics and gynecology at Boston University School of Medicine, whose practice comprises mainly pelvic organ prolapse and uro-gynecology, indicated that when he was in training, vessel ligation was limited to clamps and suture ties, and basic bipolar instrumentation. Warner Huh, MD, professor in the Division of Gynecologic Oncology at the University of Alabama at Birmingham,

recognized the challenges when performing gynecologic procedures and expressed the need for instrumentation that could help him perform the cytoreductive procedures that make up a substantial proportion of his work. “In ovarian cancer, where women have advanced disease, we’re trying to remove as much disease as possible,” he said. For surgeons performing colorectal procedures, such as a laparoscopic colectomy, mobilization and devascularization of the colon and its mesentery are key parts.3 In the past, Laurence Sands, MD, professor of clinical surgery at the University of Miami Miller School of Medicine in Florida and a practicing colorectal surgeon, had used clips and stapler devices, which were found to be cumbersome and more expensive, respectively. Paris Tekkis, MBBS, professor of colorectal surgery at the Imperial College of London, considered scissors, suture ties, and suture ligation the gold standard for attaining hemostatic control in open colorectal surgery; however, he noted that these methods have some serious drawbacks. “They can be timeconsuming and involve leaving foreign material inside the body, which can be a source of infection,” he said. In addition to potentially introducing foreign particles, most of the mechanical methods can be costly for patients and institutions.4 Gynecologic and colorectal surgeons

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

Rectal Cancer Debate: Local Excision or Nonoperative Management beam radiotherapy, do so by eight months variable T stage, nodal stage and size after initiation of radiation treatment and (Table). “Smaller tumors are going to 60% by four months (Int J Radiat Oncol have a higher CR rate, but even larger WASHINGTON—At the 2013 annual Biol Physs 1995;312:255). Disappearance tumors can melt away,” said Dr. Paty. meeting of the Society of Surgical Oncol- of the tumor is necessary for cure and Dr. Paty pointed out that when manogy, two surgeons discussed the following evolves over time. “If you are going to aged nonoperatively, the vast majority of controversial topic: In patients with rectal practice nonoperative management, you cCR patients will avoid rectal resection cancer who receive neoadjuvant chemora- have to wait,” said Dr. Paty. “You have to within the first five years. “Local failure diotherapy, when is local excision or non- allow time for the tumor to regress fully rates range from 10% to 25% and most operative management most appropriate? after radiotherapy.” occur early, within the first 18 months So, what are the criteria for determin- after radiotherapy,” he said. Nearly all of Nonoperative Management ing a cCR? “If you can reach the tumor the local failures can be salvaged with R0 Philip Paty, MD, attending surgeon with your finger, it should be a complete- [curative] resections. in the Colorectal Surgery Service at ly flat mucosa, no nodularity, no Memorial Sloan-Kettering Cancer Cen- mass,” said Dr. Paty. “It’s okay if ‘You have to allow time ter in New York City, discussed nonop- there is a scar with some smooth for the tumor to regress erative management of patients with T3/ induration, but it has to have a T4 rectal lesions after a clinical com- very benign feel to it.” Visual- fully after radiotherapy.’ plete response (cCR) from neoadjuvant ly, he said, there should be nor- —Philip Paty, MD chemoradiotherapy. mal, flat mucosa, with or without Studies have demonstrated that after a pale scar, and there can be telanneoadjuvant chemoradiotherapy, 10% to gioalatsia. “What is not clear is whether In a study from the Netherlands, 45% of patients with rectal cancer have a a small ulcer is an exclusion criteria,” said only one of the 21 nonoperatively treatpathologic complete response (pCR), and Dr. Paty. “For me, it is.” ed patients had a local recurrence and when this occurs, 95% of these patients Dr. Paty highlighted data from four had surgery as salvage ((J Clin Onc are cured (Ann ( Surg Oncoll 2012;19:384- published series of patients who under- 2011;29:4633-4640). In a consecutive 391; Lancet Oncoll 2010;11:835-844). went nonoperative treatment of T2/T4 series of 49 patients receiving neoadjuvant A 1995 study demonstrated that in rectal lesions after achieving a cCR from chemoradiotherapy in the United Kingrectal adenocarcinoma, nearly all patients neoadjuvant chemotherapy. Patient char- dom, 12% demonstrated a cCR and had who achieve a cCR after primary external acteristics were “all over the map” with been managed without surgery (Colorectal Diss 2012;14:567-571). In a Brazilian study, patients with stage 0 distal rectal cancer, who were nonoperatively managed after achieving a cCR, were matched to patients who received surgery and achieved a pCR. Five-year overall survival (OS) rates (100% vs. 88%) and disease-free survival (DFS) rates (92% vs. 83%) favored the nonoperatively managed patients (Ann ( Surg 2004;240:711-717). An update from this study highlighted the need for long-term follow-up. “The local recurrences seen in the rectum at 5% had a mean time interval of over four years, so there is a long tail to the recurrence curve. This is the most concerning aspect,” said Dr. Paty. “Do we really know what the late failure rates are? There [aren’t] enough data in the literature to assess this accurately.” In a Memorial Sloan-Kettering Cancer Center study, 32 patients with stage I to III rectal cancer were treated nonoperatively after achieving a cCR after chemoradiation; these patients were compared with a control group of 57 patients who underwent rectal resection and had Optimizing the Prevention and Management a pCR ((Ann Surgg 2012;256:965-972). MN125 The two-year distant DFS (88% vs. 98%; of Postsurgical Adhesions P=0.27) and OS (96% vs. 100%; P=0.56) P P December 1, 2013 were similar for the nonoperative group and the control group. Rectal resection was successfully avoided in 81% of the patients who were treated nonoperatively. Assessment of cCR in the four studies was variable, including time to assessment, B Y K ATE O’R OURKE

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which ranged from two to 12 months. In the Brazilian study, clinicians waited a full year before declaring sustained clinical responses ((Ann Surgg 2004;240:711-717). Other issues in assessing a cCR include the role of biopsy; the role of imaging; assessment of lymph-node metastases; trigger to operate (any mass, viable cancer on biopsy, lack of regression and local tumor progression); and the role of local (suspicious scar), small residual cancer. Clinical assessment with proctoscopy is essential, but other practice patterns vary. “There is really no standardization in imaging, but MRI is emerging as the test of choice,” said Dr. Paty. “There are too many false-positives on PET scans, and CT scans are not sensitive enough to detect small residual tumors.” Biopsies are not always reliable and can miss disease. “Most viable tumors are actually deep in the surface rather than at the surface,” he said. One critical question is whether clinicians should be looking for the complete disappearance of a tumor or simply for its regression. For anal cancers, deferring surgery as long as patients aren’t progressing is reasonable, he said, but clinicians should look for continued regression for an adenocarcinoma. While nonoperative management is controversial in itself, Dr. Paty said, there are other reasons surgeons aren’t likely to jump on board soon. “You have to follow patients, you are at medical-legal risk, and it is a lot more work. It is much easier to operate,” he said. He examines his nonoperative patients every three months in the first year, every four months the second year, and then every six months up to five years.

Local Excision Heidi Nelson, MD, professor of surgery, Mayo Clinic, Rochester, Minn., discussed local excision with T1/T2 rectal lesions. She highlighted the case of a a 37-year-old man with no family history of rectal cancer who presented with an 6.5-cm rectal lesion that was soft, flat, 1.5 cm from the top of the anal canal, and negative for microsatellite instability. The colonoscopy was negative for other lesions, and a biopsy revealed an invasive grade 2 carcinoma with mucinous features. Metastatic workup was negative; both MRI and ultrasound suggested a T1N0 anterior lesion. “Based on the size of the lesion, his young age and the mucinous features and histopathology, we chose to go ahead with an ultra lower anterior resection. It turned out to be T1N1, stage III disease,” said Dr. Nelson. “This shows the challenge of these cases.” Candidates suitable for local excision

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

Number Achieving cCR

T Stage

N Stage

Tumor Size, cm

Brazil

265

T2-T4

N0-N1

0-7

Netherlands

T1-T4

N0-N2

0-10

United Kingdom

T2-T4

N0-N2

<12

MSKCC

T2-T3

N0-N1

1-12

cCR, clinical complete response; MSKCC, Memorial Sloan-Kettering Cancer Center

%2 34

. 352

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Sources: Ann Surg g 2004;240:711-7; J Clin Onc c 2011;29:4633-4640; Colorectal Diss 2012;14:567-571; Ann Surg g 2012;256:965-972.

researchers identified a difference in disease-specific survival (DSS), favoring standard resection (97% vs. 93%; P P=0.004), but no difference in OS. Patients should be educated about expected results for T1 lesions treated with local excision and then individualized treatment. â&#x20AC;&#x153;If [patients] are more concerned with cancer recurrence risks, they will likely prefer standard resection, but if they are concerned with having a permanent stoma, then they may opt for local excision,â&#x20AC;? said Dr. Nelson. Selection criteria, however, need to be much more restrictive for T2 lesions. An NCDB analysis identified a survival advantage for standard resection (77% vs. 68%; P P=0.01) and although DSS was not statistically different between the two groups, one-fourth of patients who had local excision had a local failure. â&#x20AC;&#x153;The survival data and local failure data should really bring caution to us,â&#x20AC;? Dr. Nelson said.

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Table. Patient Characteristics and Disease Outcomes

are elderly patients who have a limited life expectancy or a serious medical condition. Tumors should be located below the peritoneal reflection, less than 2 or 3 cm in size, not amenable to lower anterior resection or coloanal, amenable to full-thickness excision and have confirmed negative margins. If a tumor has features of lymphovascular invasion, mucinous features or signet ring features, clinicians should be cognizant that local excision is not the best choice in most cases. Most patients prefer local excision, but at what price? A study in the journal Cancerr (1989;637:1421-1429) examined the relationship between depth of tumor and influence of lymph nodes and showed that local excision will most likely miss lymphatic disease. In 2000, researchers at the University of Minnesota, Minneapolis, published data on 108 patients with early rectal cancer. The study analyzed local failures with local excision compared with standard resection (Dis Colon Rectum 2000;43:1064-1071). Local recurrence rates were higher in the local excision group overall (28% vs. 4%) and for T1 lesions (18% vs. 0). OS also was worse for those receiving local excision (69% vs. 82%), but slightly less so with T1 lesions (72% vs. 80%). This helped spur a National Cancer Database (NCDB) analysis of 35,179 rectal cancer patients between 1989 and 2003. In a subanalysis of 2,000 patients,

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

Ras Mutations Predict Lung Recurrence in Patients With Colorectal Liver Mets B Y C HRISTINA F RANGOU

new study shows that Rass gene mutations in patients with colorectal liver metastases predict a lung-specific recurrence pattern, as well as worse survival. This is the first study of surgical patients to link Ras status with lung recurrence. Patients with a Rass mutation experienced a worse pathologic response to chemotherapy and had a twofold risk for a lung recurrence after liver resection, according to an analysis of 193 patients treated with single-regimen modern chemotherapy before hepatic resection. Their three-year overall survival (OS) rates were only about 60% of that of patients with wild-type Ras. Lead author Jean-Nicolas Vauthey, MD, professor of surgery, the University of Texas MD Anderson Cancer Center, Houston, said the findings indicate Rass status is as important, and possibly more important, than the widely accepted prognostic factors such as the size and number of liver metastases and the presence of affected lymph nodes. “Before, we used an aggregate of clinical and pathological findings for prognosis but now we are getting to the real

biological factor that’s driving the prognosis,” said Dr. Vauthey. He presented the findings at the 133rd annual meeting of the American Surgical Association. The study was based on a series of patients who underwent preoperative chemotherapy and curative resection of colorectal liver metastases between 1997 and 2011. All patients underwent an extensive analysis of gene mutations using Sequenom Technology. Sequenom, which is not approved for use by the FDA, tests for 159 cancer mutations in 33 genes including all K-rass and N-ras mutations known to be associated with aggressive colorectal cancer biology.

confidence interval [CI], 1.13-4.50; P=0.002). Pathologic response to cheP motherapy was the only other significant predictor of OS (HR, 2.1; 95% CI, 1.113.96; P=0.022). P Ras-mutant patients also had a higher risk for early lung recurrence after liver resection. Three-year recurrence for lung metastases reached 59.3% among patients with Ras mutations compared with 34.6% among patients with wildtype Ras. Liver recurrence rates did not appear to be influenced by Ras status (43.8% for wild-type Rass vs. 50.2% for RAS mutation; P=0.181). P Experts in the field said the study

‘The future of cancer care is in individualized targeted treatment and this study provides further evidence that perhaps “one size does not fit all.’”— Anton Bilchik, MD Analysis identified 34 patients (17.6%) with Rass mutations. These patients had a 13.5% three-year recurrence-free survival compared with 34% among patients with wild-type Rass (P P=0.001). OS was 52.2% in Ras-mutant patients and 81% in patients with wild-type Rass (P=0.002). P In multivariate analysis, wild-type Ras was the most important predictor of OS with a hazard ratio (HR) of 2.26 (95%

PNEUMONIA

jContinued from page 1 In many cases, patients aspirate prior to interventions by paramedics, suggesting that a key event leading to HCAP occurs before patients are treated by paramedics or hospital staff, said lead author Vanessa Fawcett, MD, MPH, a fellow in trauma and surgical critical care, Harborview Medical Center, Seattle. “Health care– and ventilator-associated pneumonias, as the names imply, indicate conditions that are iatrogenic. However, given that many patients are aspirating around the time of injury, complications associated with such aspiration may need to be relabeled,” she said. These pneumonias may be part of “the spectrum of traumatic injury, attributable to patient disease rather than health care interventions.” The finding has significant implications for clinical care, said Robert Sawyer, MD, professor of surgery and chief of acute care surgery at the University of Virginia, Charlottesville. “I will be more likely to start antibiotics earlier on patients with witnessed aspiration in the field than signs and symptoms of [an HCAP],” Dr. Sawyer wrote in an email to General Surgery News. Aspiration is common, difficult to diagnose and relatively subjective, he said. “Other objective measures of aspiration, such as airway

could change how surgeons select patients for surgery or follow patients after treatment. The study identifies patients who are at higher risk for recurrence and “may, therefore, require closer monitoring and improving the selection of chemotherapy or biological therapy,” said Anton Bilchik, MD, assistant director of surgical oncology and director of gastrointestinal

glucose or pepsin levels, might be more precise.” He added that health care regulatory organizations should take note of the study. HCAP is followed closely by these organizations as a potential measure of quality of care. But the study shows clearly that HCAP is greatly affected by prehospital events. These events should be accounted for when measuring outcomes in different centers, Dr. Sawyer said. The findings come from an ongoing research project in Seattle. Paramedics in the city work closely with local hospitals and undergo rigorous training in emergency airway techniques. In an effort to further improve the quality of trauma care, surgeons and paramedics put together a study to examine rates of prehospital aspiration and intubation in the field, and any association with hospital-acquired pneumonias. The researchers asked medics to document when adult trauma patients aspirated in the field, and whether they noted blood, emesis or other fluids in the patient’s oropharynx or airway at three points: prior to intubation, during intubation or confirmed via the endotracheal tu tube. Paramedics’ reports were compared with Pa patieents’ pneumonia and mortality outcomes, acccording to the hospital trauma registry. The diagnosis of pneumonia was made clinically using criteria of the Centers for Disease Control and Prevention or microbiologically with bronchoalveolar m llavage. The study differentiated between HCAP, which occurs at least 48 hours after hospitalization, and VAP, which

research at the John Wayne Cancer Institute in Santa Monica, Calif. He said prospective studies are needed before surgeons and oncologists change practice patterns. Still, it’s one more step toward individualizing cancer care for patients. “The future of cancer care is in individualized targeted treatment and this study provides further evidence that perhaps ‘one size does not fit all.’” Dr. Vauthey said the study findings might encourage some surgeons to be more aggressive in patients who are considered borderline resectable but have no Ras mutation. “The decision to be aggressive or not in these patients is sometimes difficult,” said Dr. Vauthey. He added that he would not use Ras status to deny surgery to patients with colorectal metastases because resections have become safer. However, “we now have to decide if we can expand our resection criteria and propose more complex sequential resections in some patients.” He recommends that patients with Ras mutations be considered for computed tomography of the chest before and after resection to fully evaluate the extent of metastatic disease.

appears at least 48 hours after intubation. All adult trauma patients intubated in the field and admitted to a Harborview ICU were studied. Of 228 patients who met the study criteria, 89 (39%) aspirated before being brought to the hospital. They were similar in age, sex and comorbidities, but had more severe injuries and more severe traumatic brain injuries than patients who did not aspirate. Patients aspirated most often before intubation. Ninety-five percent of patients who aspirated blood and 77% of those who aspirated emesis did so before intubation was attempted. Nearly half of these patients aspirated again during intubation. Analysis revealed 15.7% of patients who aspirated went on to develop HCAP compared with 3.6% of patients who did not aspirate (P=0.02). P There was a trend toward increased VAP among patients who aspirated, but the difference was not significant (11.2% vs. 2.9%). The investigators said current practices to reduce pneumonia, such as ventilator bundles, should be reconsidered in light of the study findings. “The effectiveness of such measures is recently being called into question in trauma patients, and perhaps intervention is required at an earlier stage,” Dr. Fawcett said. It is unknown whether prophylactic antibiotics can reduce the incidence of pneumonias in patients who aspirate in the field. “At this point, we would not recommend it, but it may be worth studying in the future,” Dr. Fawcett said. The authors are currently conducting a follow-up study of outcomes, in which paramedics will decontaminate patients’ oral cavities prior to intubation.

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CONSTITUTION jcontinued from page 1

the English philosopher John Locke, and republicanism, championed by the French philosopher Montesquieu. Although the convention had drafted a constitution by fall 1787, it did not become the law of the land until 1789 when the required nine states had ratified it. The final state to ratify, Rhode Island, took three years to elect delegates who at first rejected but finally accepted the Constitution. For many, it was the first time they had experienced the concept of bending to the will of the people and not to the will of a capricious and arbitrary monarch. Does this all sound familiar? The ACA also was negotiated and written over the course of months and, like the Constitution, it is based on a core principle; this time it is universal or nearuniversal health care coverage. It gained enough support by 2010 that it became law of the land, but three years later it is still being debated and challenged in courts. Only about half of the states are fully on board with some of its basic strategies such as Medicaid restructuring. There are many in the country who have not yet signed on and are bending to the will of the people. After 200 years, however, the will of the people is not a novel concept and has become an important part of the democratic process. As the Constitution was being ratified, there were two factions at work: the federalists who believed in a strong central government and supported the Constitution and the anti-federalists who were suspicious of an over-reaching government and were concerned about the potential for tyranny by a central authority. After circulation of early drafts of the Constitution, articles began to show up in the most widely circulated newspapers of the day that were critical of its powerful central authority. James Madison, Alexander Hamilton and John Jay launched a counteroffensive in the form of the Federalist Papers, a series of skillfully written essays explaining and defending both federalism and the Constitution. These essays, also circulated by the lay press, are now considered some of the most astute political writings ever published. Today, members of the Democratic Party, who support a strong central government, might be considered modernday Federalists. Republicans, on the other hand, are suspicious of “big government” and in this regard are more like the antiFederalists. The media outlets these days regularly air these dissenting points of view regarding the ACA. Unfortunately, this is one area where the current debate falls short of the Constitutional debate. The philosophical depth and erudition

of the Federalist Papers puts to shame the caterwauling on TV and in the press today that passes for intelligent discussion about health care.

Why the ACA Is Not Like the Constitution When the U.S. Constitution was finally completed, it was three pages long and the Bill of Rights added a fourth. It could be read in half an hour and both its underlying principles and intent were clear. It created the process by which we are governed, how decisions are made and how our body of laws could be added to and amended. Using its formulas, our laws have been greatly expanded and are recorded as the U.S. Code of Laws, which is published every two years and currently contains 200,000 pages.

republicanism. The architects of the Constitution were not new to this task. Each of the 13 colonies had already drawn up its own version of a constitution after independence and those who framed the U.S. Constitution had been engaged in similar efforts for more than 10 years. Starting with only philosophical principles and theories of political science, they presented their arguments, debated and ultimately arrived at compromises. The end product was a document that has created the longest-standing and most successful democracy in the modern world. By contrast, the ACA was intended to make small adjustments to the existing system rather than consider a new vision. In my view, this is its greatest fault. Our health care system is functioning at present but headed for a precipice. A minor adjustment will not change its course

TTh he phhil ilosophhiical depth and eruddiition of the Federalist Papers puts to shame the caterwauling on TV and in the press today that passes for intelligent discussion about health care.

The ACA, at 1,900 pages, is almost unreadable, and its true intent is still opaque. House Speaker Nancy Pelosi’s comment that we will have to pass it to see what is in it has turned out to be prophetic. In its three-year history, we are witnessing not a gradual accretion of functionality as we have with the Constitution, but a systematic deconstruction of its content. I think that part of the confusion lies in its poorly chosen title. Most of its strategies are designed to increase coverage although its title seems to suggest that it addresses affordability. Affordability is the weakest argument for the ACA, and whether it will be more or less expensive is largely unknown and much debated. Its proponents should cling to the reality that it insures more people rather than try to convince a skeptical public that it is less expensive. There is another point that distinguishes the ACA from the Constitution. When the Constitutional Convention was proposed, most proponents agreed that the purpose of the convention should not be to amend or fix the Articles of Confederation, but to create an entirely new government based on the philosophical principles of democracy and

quickly or sharply enough. At this moment we should be thinking along the lines of the Constitutional Convention. We could start with core principles such as universal coverage, competition, personal financial incentives, promotion of prevention, and so on, and create a new health care system that would be the longest-standing and most successful in the world.

History Will Be the Judge The principles of the Constitution have remained intact for more than 200 years. The details of how these principles are applied have been amended, added to and sometimes subtracted from and have resulted in the U.S. Code of Laws. I think that the underlying principle of the ACA, near-universal coverage, will be preserved. We will not go back to having 15% of the population uninsured and, in this regard, the ACA has been a great accomplishment. The particulars of how we do it, such as government subsidies, tax incentives, insurance exchanges, changes in Medicare coverage and mandatory participation are being debated. They are being challenged in state courts, the Supreme Court and in the court of

public opinion. Some of these details will be retained, some will be altered and others will be abandoned. It is, simply put, democracy at work. On the other hand, I think that the ACA is a band-aid approach to a much larger problem. Opinion is divided as to whether it will increase or decrease the expense of our health care system. Opinion is less divided on whether it will solve our main problem, which is the approaching insolvency of our health care industry and the government that it will drag down with it. Most people recognize that it does not address the fact that we spend twice the percentage of gross domestic product on health care than most Organization for Economic Cooperation and Development (OECD) countries and achieve no better health care results. Fortunately, the ACA is like the Constitution in some regards but, regrettably, it is not in others. Both documents were written in response to significant national problems. In the 1780s, the Articles of Confederation had not created a central government with the authority to negotiate international treaties, establish a national military or even levy taxes to pay for its minimal role. People were suspicious of central authority, however, because they had just fought for their independence from a colonial power that they considered tyrannical. The Constitution had to address these two competing problems. In the same way, the ACA was written to address two competing problems: the lack of access to the health care system by an increasing percentage of the population and the unsustainable cost of this less-than-adequate coverage. The Constitution solved its dilemma with negotiated strategies such as separation of powers and checks and balances. The ACA does not seem to have struck such a successful balance. Although it does increase coverage to almost all of the population, its effect on health care spending and the economy is unknown. Some argue it will slow health care inflation, whereas others insist it will make the economy worse. Regardless of which argument is correct, the small way in which the ACA affects health care spending will not come close to solving the problem of its unsustainable economics. We can’t just amend our current system. We should get our best minds together in a room in Philadelphia for another four months. This time they can come up with an entirely new plan that incorporates centuries-old economic and political philosophies as well as the realities of our rapidly changing health care demographics. That kind of a health care plan would truly be constitutional. —Dr. Whitee is Professor of Surgery, — George Washington University, Chief of Surgical Services, VAMC, Washington, DC.

In the News MESH OVERLAP jcontinued from page 1

laparoscopic ventral and incisional hernia repairs in the world, with a total of more than 1,200 cases. At the meeting, Dr. LeBlanc said that currently, he believes that an overlap of 5 cm or more is optimal. He extends the overlap to as much as 8 cm in patients who are obese, who have several prior recurrences or who have hernias unusually high or low in the abdominal cavity. “The algorithm I have in my head is the bigger the defect and the more comorbidities, the more overlap you need,” he said. Over the past decade, it has become standard practice for surgeons to recommend a mesh overlap of at least 3 to 5 cm on all sides surrounding the defect. However, sparse robust data exist to back this up, so Dr. LeBlanc set out to evaluate this recommendation along with other technical factors that may affect the outcome of laparoscopic incisional and ventral hernia repairs. He reviewed the PubMed and Cochrane Library scientific databases for the years 1992 to 2012, looking at all technical failures leading to hernia recurrence. Overall, the review found little highquality evidence that focused on technical reasons for repair failures. Of 111 articles that addressed technical issues in hernia

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2013

repairs, the vast majority overlooked the question: Only 16 of them adequately assessed the effect of mesh overlap. In these studies, recurrence rates ranged from 9% to 14.3% when mesh overlapped by 2 to 3 cm. Recurrences dropped substantially to between 0% and 7% with mesh overlap of at least 3 to 5 cm. The studies included about 3,500 patients with an average of 25.5 months of follow-up and a mesh overlap of 2 to 5 cm. In one of the largest reported series, an overlap of between 2 and 2.25 cm was associated with a recurrence rate of 9%. Recurrences dropped to 2% with an overlap of 4 cm or greater (JSLS ( 2008;12:51-57). “What we’re seeing is that increasing the overlap of the fascial defect to between 3 and 6 cm results in decreasing the recurrence rate by at least half,” Dr. LeBlanc said. Asymmetrical placement of the mesh was another contributing factor to recurrences, according to the literature review. Two studies linked failed repairs to inaccurate centering of the mesh or inadequate overlap on one side. Experts noted that the quality of the published studies in hernia surgery is

‘What we’re seeing is that increasing the overlap of the fascial defect to between 3 and 6 cm results in decreasing the recurrence rate by at least half.’ —Karl LeBlanc, MD, MBA “notably weak,” with a lack of grade A evidence and little uniformity across the published studies. Maciej Smietanski, MD, PhD, a hernia surgeon at the Medical University of Gdansk in Poland, said the report underscores a very important issue in hernia surgery, “that mesh overlap and the right positioning are the key factors for success.” Dr. LeBlanc offered surgeons some technical tips to improve mesh placement in laparoscopic hernia repair. Surgeons must carefully measure both the defect and the mesh prior to surgery, and they should dissect any fat that could come in contact with the mesh. Dr. LeBlanc also recommended that surgeons place a camera on both sides of the abdomen to assess both sides of the mesh. He said that he places sutures on two axes of the mesh prior to placement in order to help with mesh placement. “You put the mesh in, then pull one side of the suture up and then the other suture up so you know it’s centered

superiorly and inferiorly,” Dr. LeBlanc said. He also said new mesh-positioning devices such as the Echo PS™ by Davol Inc., and AccuMesh™ Positioning System by Covidien, can help with accurate placement. The conclusions of the review were similar to those in a retrospective study published last year in the Journal of Surgical Researchh (2012;177:e7-e13). Investigators from Baylor College of Medicine reviewed the outcomes of 201 patients who underwent laparoscopic ventral hernia repair between 2000 and 2010. They said potential solutions to the problem of mesh shift include increasing mesh overlap to 6 cm or greater, transcutaneous closure of central defect, securing transfascial sutures before tacking, placing operative side tacks first, and possible placement of contralateral ports to secure the mesh. Dr. LeBlanc is a speaker/consultant for Covidien, Davol Inc., and W.L.Gore & Associates. He also has received a research grant from Cousin Biotech Inc.,/Medline and is a shareholder in Via Surgical Ltd.

Single-Port Surgery for Early Gastric Cancer Appears Safe, Feasible B Y V ICTORIA S TERN

educed-port laparoscopic distal gastrectomy to treat early gastric cancer is a feasible and safe procedure that provides improved cosmesis and fewer port-related complications, according to a study presented at the recent International Congress of the European Association for Endoscopic Surgery (EAES) S in Vienna, Austria. “Laparoscopic gastrectomy is still classified as an investigational treatment because there is no level 1 evidence of long-term oncologic outcome even in early gastric cancer,” said Hyung-Ho Kim, MD, PhD, chairman of the Department of Surgery, Seoul National University Bundang Hospital, in Korea, and president of the Korean Laparoscopic Gastrointestinal Surgery Study Group, who was not involved in the current research. In the United States, most gastric cancers are clinically advanced when diagnosed, but in Asian countries, many of these cancers are detected early. This means minimally invasive approaches could benefit patients in countries with robust early detection methods, said lead author Hiroyuki Kashiwagi, MD, Department of Surgery, Shonai Amarume Hospital, Yamagata, Japan. Recently, laparoscopic approaches to treating early gastric cancer have started to gain momentum in East Asia, especially in Korea and Japan, with reports showing better early postoperative outcomes compared with open surgery. But only a handful of reports exist due to the technical difficulty and lack of tools designed specifically

for such procedures. For instance, three studies detailing surgeons’ initial clinical experiences with singleincision laparoscopic distal gastrectomy for early gastric cancers have all required the use of one or two assistant ports (Surg Endoscc 2011;25:2400-2404; Surg Laparosc Endosc Percutan Techh 2012;22:e214-e216; Surg Endosc 2012;26:1490-1494). Now, the availability of multichannel ports, such as the single-incision laparoscopic surgery (SILS) port (Covidien, Japan), has made reduced-port laparoscopic distal gastrectomy more technically viable, allowing surgeons to insert up to three instruments through one port. In the current study, Dr. Kashiwagi and his colleagues performed a laparoscopic distal gastrectomy on 10 patients (six men, four women) diagnosed with early stage gastric cancer between December 2010 and December 2012. The team employed a dual-port method, using Covidien’s SILS-port, a 5-mm flexible scope (Olympus, Japan) and surgical nylon with straight needles (Ethicon, Japan). Patients’ mean age was 68.1 years (range, 52-87 years) and body mass index was 21.4s4.5 kg/m2. Average operative time was 266.9s38.3 minutes and blood loss was 37.8s56.8 mL. Patients recovered well and experienced no complications postsurgery. All patients could tolerate soft meals on postoperative day 1 and had an average hospital length of stay (LOS) of eight days. Additionally, the authors reported no differences between the current SILS dual-port approach and the laparoscopic multiport method they performed on

nine patients between 2008 and 2010, in terms of mean operative time (266.9±38.3 vs. 255.3±68.5 min., respectively), blood loss (37.8±56.8 vs. 55.4±57.1 mL, respectively) and retrieved lymph nodes (16.1±8.9 vs. 14.9±7.2, respectively). Postoperative hospital LOS, however, was significantly longer in the conventional multiport group (17.3±7.4 vs. 8.1±1.5 days; P<0.0001), and three patients in the conventional multiport group experienced complications (one case of postoperative pneumonia and two cases of gastric stasis). There were no complications in the dual-port group. In addition to cosmetic benefits, Dr. Kashiwagi said that a single-port approach to early gastric cancers may result in less postoperative pain and a shorter hospital LOS as well as a reduced chance of tissue trauma and complications associated with multiple ports, such as organ damage, bleeding, wound infection and hernias. According to Dr. Kashiwagi, more research is needed to make reduced-port surgery a standard approach in countries with high rates of early detection of gastric cancers. “We need to perform larger studies to confirm the advantages of this operation,” he said. Dr. Kim agreed, adding that advancing the single-port technique will involve further development of smart, articulated instruments and perhaps also robotic technology. Although still early, Dr. Kashiwagi believes that eventually “reduced-port surgery will become a standard therapy for early stage gastric cancer, although not for advanced cancer.”

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