The December 2012 Digital Edition of General Surgery News

40th Anniversary 1972-2012

GENERALSURGERYNEWS.COM

December 2012 • Volume 39 • Number 12

The Independent Monthly Newspaper for the General Surgeon

Opinion

A SCIPpery Slope B Y S TEVEN S. K RON , MD “Essentially, we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring.”

—Atul Gawande, MD, The New Yorker, — r August 11, 2012

I

t began almost imperceptibly with a small regulation here, a comment there.

Slowly at first and then with relentless speed and force it grew, and like a tsunami overwhelms anything in its path. By now, every physician who has practiced for more than a few years has noticed the dramatic shifts in the relationship of doctors to the society in which we practice our profession. From relative independence, we are being forced further into group think.

Hardly a day goes by without some new directive from above instructing what and how to perform a task to benefit our patient. Examples abound: The Surgical Care Improvement Project (SCIP) see SCIPPERY SLOPE page 24

32% of Complications Diagnosed After Discharge From Hospital, Study Shows Findings Come Amid Increased Public Scrutiny; utiny; Seeking Level Playing Field in Reporting

®

Documentation Can Increase Pay For Complex Cases Using Modifier 22 With a Detailed Operative Note Detai B Y C HRISTINA F RANGOU

B Y C HRISTINA F RANGOO U CHICAGO—A new study found d that one in three complications arising from major operations is diagnosed after the patientt leaves the hospital, a finding that adds a new dimension to the health policy debate surrounding public reporting of complications and readmissions.

The study showed that sig-nificant numbers of postoperrative complications occur after the patient is discharged and may acccount for longer, more difficult and d more expensive recoveries, often requiring readmission to the hospital. As a

see COMPLICATIONS page 14

General Surgery Residents Concerned About Duty Limitation

C H I CAG O — S u r g e o n s may be missing out on valuable reimbursement dollars because they fail to accurately document thee complexities of some surgiccal procedures.

In a study presented at the 20122 Clinical Congress of the American College of Surgeons, researrchers showed that detailed d docum mentation is the key to reiimbursement in atyp typically arrduou us cases. Docuumentation can c affect both oth reimbu ursement approoval and th the speed of reimb bursement, the study showeed.

And many surgeeons and residents skim m over details in the operative note, particularly those details that justify the modifier 22 claim.

B Y G EORGE O CHOA Optimizing the Prevention and Management of Postsurgical Adhesions See insert at page 8

Reversal and Recovery From Neuromuscular Blockade: Examining the Science See insert at page 16

T

he majority of general surgery residents are concerned about the 16-hour duty limitation for postgraduate year 1 (PGY-1) residents, according to a study presented at the American College of Surgeons’

see MODIFIER 22 2 pa page 22

annual Clinical Congress in Chicago, and published online on October 5 ((J Am Coll Surgg doi: 10.1016/j. jamcollsurg.2012.08.005).

Implemented by the Accreditation

PROCEDURAL BREAKTHROUGH Advances in Stent Technology for Esophageal Cancer

see DUTY RESTRICTIONS page 5

see page 13

INSIDE In the News

Surgeons’ Lounge

Opinion

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16

27

Technique Choice for Anastomosis and Leakage Rate

Test Your Knowledge With Three Surgeon’s Challenges

Why Do 31% of General Surgery Residents Need Remediation?

In the News

Opinion

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30

Genetic Findings Could Reshape Approach to Breast Cancer

The Day I Knew It Would Be OK To Stop Operating

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GSN Editorial

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

The ‘Availability Heuristic’ and Global Surgical Volunteerism Frederick L. Greene, MD, FACS Clinical Professor of Surgery UNC School of Medicine Chapel Hill, North Carolina

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ecently I had the pleasure to meet with a group of Davidson College students who participated in clinical clerkships at one of the local Charlotte hospitals. After listening to each student’s report of the various clinical experiences, we began a discussion of the 2007 monograph, “How Doctors Think,� authored by Dr. Jerome Groopman.

If you have not included this in your “reading to-do list,� I would heartily encourage it. Dr. Groopman, through a series of clinical scenarios and physician interviews, develops the premise that our ability as physicians to diagnose clinical problems may be predetermined by the strategies, the “heuristics,� that we use to achieve rational and hopefully correct diagnoses.

Although medicine is not an exact science and logic does not always suffice, Dr.

Groopman introduces the concept of the “availability heuristic,� first coined and promulgated by Amos Tversky and the Nobel laureate, Daniel Kahnerman.

The essence of this construct is that we, as physicians, make diagnoses based on the frequency of events that we have had available to us in our careers beginning in medical school and continuing through residency, fellowships and the extent of our clinical lives. We bring our biases as well as factual information to the table as we attempt to make logical deciphering of symptoms, signs and all available data in order to make correct diagnoses, which ultimately translate into proper judgments leading to correct management. Remember your oral board examination? This availability heuristic was the essence of being a success in that process.

Obviously, relevant and repetitive data may only be useful when one is living and working in the same “universe� where available cues rarely change. The young man with periumbilical pain migrating to the right lower quadrant and accompanied by anorexia, nausea and vomiting see HEURISTICS PAGE 4

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

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

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

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

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

David Earle, MD Springfield, MA General Surgery, Laparoscopy

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

Edward Felix, MD Fresno, CA General Surgery, Laparoscopy

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

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

Michael Goldfarb, MD

Remember your oral board examination? This ‘availability heuristic’ was the essence of being a success in that process.

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

Gary Hoffman, MD Los Angeles, CA Colorectal Surgery

Namir Katkhouda, MD Los Angeles, CA Laparoscopy

Joseph J. Pietrafitta, MD

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

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INFECTIOUS DISEASE SPECIAL EDITION

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Technique Choice for Anastomosis in Emergencies May Affect Leakage Rate Emergency Patients Benefited From Hand-Sewn Technique B Y J AMES E. B ARONE , MD

I

n emergency situations, intestinal anastomoses performed with staples were associated with a significantly higher leak rate than those that were hand sewn, according to research by surgeons at Wake Forest University, Winston-Salem, N.C. Lead author Jason P. Farrah, MD, noted to General Surgery Newss by email that this study has changed the way his group manages these patients. “The surgery should be tailored to this population,” he said. Dr. Farrah is a fellow in acute care surgery and assistant instructor in general surgery at Wake Forest Baptist Health.

Although the literature for elective surgery shows that hand-sewn and stapled anastomoses yield similar leak rates, there have been few studies on intestinal resections in emergency patients. Conflicting results have been found in the trauma literature. Edema of the bowel wall resulting from fluid resuscitation and reperfusion injury in emergency and trauma patients have been suggested as possible causes of healing problems with stapled procedures.

The study, presented at the 2012 annual meeting of the American Association for the Surgery of Trauma, in Kauai, Hawaii, in September, retrospectively analyzed outcome data from a single center over a recent 4.5-year period. There were 133 stapled and 100 hand-sewn

anastomoses. Preoperative patient characteristics including age, gender, disease process and laboratory values were similar. Operative durations were significantly shorter by median of 12 minutes in the stapled group.

However, 20 of 133 (15%) of the patients undergoing stapled procedures suffered anastomotic leaks compared with six of 100 (6%) with hand-sewn procedures (P=0.03).

P Mortality rates were 5.3% and 2%, respectively, a difference that was not statistically significant. Hospital length of stay was a median of 13 days for patients with hand-sewn anastomoses versus nine days for the stapled

group (P<0.01). Similar percentages of small bowel-to-small bowel, small bowelto-colon and colon-to-colon anastomoses were performed in both cohorts.

Damage control laparotomy (DCL) was performed in 41 patients who had significantly higher mean preoperative lactic acid levels than the rest of the participants and had anastomotic failure in 24% of cases compared with 8% for non-DCL patients (P=0.01). Leaks occurred at the same rate regardless of whether the anastomosis was done at the time of the initial DCL or during a subsequent operation.

“The impact of utilizing DCL, and

‘Some patients, such as those with small-bowel obstruction, would have had a longer preoperative observation period.

There may have been some bias that these patients were more likely to get hand-sewn anastomosis.’

HEURISTICS

jcontinued from page 3 gives reliable cues that we have appreciated throughout our careers as surgeons and, hopefully, even without the obligate computed tomography scan, we can be reasonably certain of the diagnosis of acute appendicitis and act appropriately. This diagnosis, however, may not be as assured if we meet the same young man in a village clinic in sub-Saharan Africa where the incidence of gastrointestinal parasites, unfamiliar bacteria and colonic volvulus may not be high on our diagnostic calculus.

I recount two examples of this phenomenon from my own experience working in a remote area. During my postgraduate 4 resident-year, I had the wonderful opportunity to work at the Albert Schweitzer Hospital in the Artibonite Valley of Haiti. Although I had taken several years of French, my ability to converse in Creole was limited, requiring me to have an interpreter for all patient encounters. During my first postoperative evaluations, I was impressed that several patients had temperatures in the 38.8°-40°C range. Naturally, coming from my high-tech university hospital in

— Jason P. Farrah, MD

the northeastern United States, I used the appropriate mnemonic, looking for the usual causes of postoperative fever (wound infection, urinary tract infection, atelectasis, thrombophlebitis, pulmonary embolism, etc). It was not until my local mentor pointed out that most of our patients had been previously infected with malaria and that postanesthetic fever was the usual course of the chronic malaria carriers, that I finally was able to add 1+1 and not come up with 3! My available database had an important new entry.

Similarly, during my first few weeks in Haiti, I evaluated several patients who presented with intense abdominal pain of relatively recent onset associated with bloating, abdominal tenderness, rebound and all the signs that I equated with secondary peritonitis from a perforated viscus. My availability heuristic logically told me that with this scenario, a celiotomy was mandatory. To my surprise, during the operative exploration on several of these patients, rather than perforation or abscess, I noted many white nodules on the serosa of the bowel and parietal peritoneum. These were the pathognomonic miliary nodules associated with the dry form (no ascites) of tuberculous peritonitis, a disease that begged to be treated with antituberculous drugs

the effect it has on outcomes in the emergency general surgery population is still to be determined,” said Dr. Farrah.

His group is working to refine criteria for the use of DCL. In addition to the use of staples, intraoperative hypothermia, perioperative corticosteroid use and lower admission serum albumin levels were significantly linked to anastomotic breakdown on univariate analysis. On multivariate analysis, stapled anastomosis, patient age and admission albumin were the only significant risk factors for anastomotic leak.

Regarding the hospital length of stay discrepancy between the hand-sewn and stapled groups, Dr. Farrah said, “Some patients, such as those with small-bowel obstruction, would have had a longer preoperative observation period. There may have been some bias that these patients were more likely to get handsewn anastomosis.”

The investigators concluded that elective patients needing bowel resections are different from emergency patients, and hand-sewn anastomoses are safer in the latter group.

But Dr. Farrah admitted, “This is retrospective data which in the end can really only be used to generate hypotheses for future prospective randomized trials. The type of anastomosis may be one of the most variable and highly biased topics in all of surgery. I think a randomized trial confined to just the emergency general surgery population is ultimately needed.”

and not a long midline incision. That was a hard lesson, but I eventually placed primary (tuberculous) peritonitis high on my differential, managing to avoid subsequent operative assaults on future patients presenting with this disease.

My message in recounting this is to urge colleagues that the availability heuristic changes dramatically when we are functioning outside of our normally familiar medical territory. We cannot unabashedly rely on all the logic and data points that were drilled into us in medical school and throughout our postgraduate experiences. Our thought processes need to be reworked as we undertake voluntary missions to remote areas of the world where history taking and traditional diagnosis may not be a reliable heuristic. As I begin to plan for this global voluntary clinical phase in my life, the mistakes that I made as a resident working in remote regions will be uppermost in my thoughts. All who are planning to participate in the rewarding opportunities to provide global surgical care must remember that we honed our approach to surgical diseases in familiar settings and that our need to rethink our traditional and available cues is mandatory.

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

DUTY RESTRICTIONS jcontinued from page 1

Council for Graduate Medical Education effective July 1, 2011, the duty period limitation was intended to minimize fatigue and decrease the frequency of errors. But overall, 75% of general surgery residents in the study voiced dissatisfaction with this limitation.

“The 16-hour duty restriction was implemented for the PGY-1 class without a whole lot of data supporting its benefits and patient safety,” lead author David Y. Lee, MD, general

surgery resident (PGY-4), Department of Surgery, St. Luke’s-Roosevelt Hospital Center, in New York City, told General Surgery News.

“We wanted to see what general surgery residents have to say about it.” The key finding, he said, was that “most of the residents are very concerned that it will have a negative impact.”

The anonymous web-based survey was distributed via program directors of 233 publicly listed general surgery residency programs across the nation. Only fully completed surveys (N=464) were analyzed.

Eighty-seven percent of all respondents

’Not one metric has been improved by dutyhour limitations. This article addresses the most recent modification, the 16hour duty limitation. It shows a shift in responsibility from interns to senior residents and an increase in handoffs.’

—L.D. Britt, MD believed the 16-hour duty limitation had an adverse impact on the learning of the PGY-1 class, and 57% believed it contributed to inadequate patient sign-outs.

Take a skeptical look at surgery.

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Seventy-six percent of residents reported problems caused by inadequate sign-outs, and PGY-1 residents performed more sign-outs than their senior colleagues.

More PGY-2 to PGY-5 residents than PGY-1 residents noted dissatisfaction with the duty limitation and expressed more concern about its educational impact. Eighty-nine percent of PGY-2 to PGY-5 residents believed the duty limitation had shifted more responsibilities to them from the PGY-1 residents; 73% felt more fatigued because of this shift; and 86% detected a decrease in the level of patient ownership.

“There is an increasing body of knowledge that duty-hour limitations are not working,” said L.D. Britt, MD, MPH, FACS, FCCM, Brickhouse Professor and chairman, Department of Surgery, Eastern Virginia Medical School, in Norfolk, who was not associated with the study. “Not one metric has been improved by duty-hour limitations. This article addresses the most recent modification, the 16-hour duty limitation.

It shows a shift in responsibility from interns to senior residents and an increase in handoffs.”

Dr. Lee said the study’s main shortcoming was its survey-based nature. “It doesn’t include objective data on medical error.” Dr. Britt added, “The downside of the article is that less than 10% of the residents responded. There could be a selection bias. However, I do think it reflects broader attitudes.”

Alexey Markelov, MD, chief surgical resident, Easton Hospital, Drexel University College of Medicine, in Easton, Pa., who was not associated with the study, commented by email. “I am particularly concerned about the potential negative impact on surgery residents due to limited time to acquire the necessary surgical proficiency and skills,” Dr. Markelov wrote. “There is also a plausible concern that 16-hour duty limitation profoundly impacts continuity of care. New limitations make it almost impossible for general surgery residents to follow up with a single patient through preoperative evaluation, surgery and postoperative care.”

“Surgery is like an apprenticeship,” said Dr. Britt. “You have to be exposed to patients. It’s hard doing that when you’re at home. … For our specialty, which is surgery, so far the duty-hour limitation doesn’t work.”

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Societies Collaborate on New Guidelines for Geriatric Care B Y C HRISTINA F RANGOU CHICAGO—Comprehensive new guidelines for the preoperative care of the nation’s elderly have been issued by the American College of Surgeons (ACS) and The American Geriatrics Society (AGS). It is the first time the two societies have worked together to develop guidelines for older patients.

The guidelines, which were published

in the October issue of the Journal of the American College of Surgeons, apply to the management of all patients who are aged 65 years and older (J ( Am Coll Surg 215:453-466). An expert panel comprising 14 medical centers, various surgical subspecialties and doctors from urology, anesthesiology and geriatric medicine, developed the document.

“The major objective of these guidelines is to help surgeons and the entire

perioperative care team improve the quality of surgical care for elderly patients,” said Clifford Y. Ko, MD, director of the ACS National Surgical Quality Improvement Program and professor of surgery, University of California, Los Angeles.

“This population is growing in number and we want to emphasize the depth and breadth of care required for them.”

According to the U.S. Census Bureau,

the number of Americans aged 65 years and older will more than double between 2010 and 2015. Surgeons say they can see the changing demographics in their practices.

“Certainly, in my practice, we’re seeing an increased number of geriatric patients and we are not really well equipped as surgeons to manage many problems specific to geriatric patients: problems with cognitive impairment and frailty,” said Zara Cooper, MD, assistant professor of surgery, Harvard Medical School, Boston. The guidelines are “useful, clinically relevant and important,” she said.

Dr. Cooper and her colleagues currently are trying to incorporate the guidelines into their preoperative checklist. “I’m a trauma surgeon, so very few of my patients are elective. It’s going to take some time to incorporate the guidelines into our practice.”

‘This population is growing in number and we want to emphasize the depth and breadth of care required for them.’

—Clifford Y. Ko, MD

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The guidelines address 13 key areas of preoperative care of the elderly: cognitive impairment and dementia; decision-making capacity; postoperative delirium; alcohol and substance abuse; cardiac evaluation; pulmonary evaluation; functional status, mobility and fall risk; frailty; nutritional status; medication management; patient counseling; preoperative testing; and patient-family and social support systems.

All the recommendations are summarized in a checklist that is to be completed during preoperative evaluations.

The checklist is directed specifically at surgeons: Although parts of the checklist may be delegated to other physicians, the surgeon must be “able to interpret the results,” according to the report.

Among the recommendations, the panel calls for patients to be assessed for cognitive impairment using a tool such as the Mini-Cog test and also to be screened for depression. Both depression and cognitive impairment predict worse surgical outcomes.

Patients also should be screened for alcohol and substance abuse and dependence using the modified CAGE questionnaire. CAGE is a four-question survey used for identifying potential alcohol abuse. CAGE stands for the four areas identified: felt need to Cut back, Annoyance by critics, Guilt about

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

drinking, and Eye-opening morning drinking. Patients with alcohol use disorder should receive perioperative daily multivitamins with folic acid and highdose oral or parenteral thiamine.

The panel called on surgeons to identify the patient’s risk factors for developing postoperative delirium and to document these risk factors. For patients at risk, benzodiazepines and antihistamines should be avoided except in certain circumstances, they said.

The guidelines stress that evaluating patients for their perioperative cardiac risk and postoperative pulmonary complication risk are critical steps. Patients should be assessed according to the algorithm for patients undergoing noncardiac surgery set out by the American College of Cardiology and the American Heart Association.

Dr. Ko said the guidelines reflect the need for a multidisciplinary approach to managing cardiac risk. “The surgeon knows how to perform surgery and the cardiologist knows how to take care of the heart. It’s best for everyone to work together.”

Surgeons should document a patient’s functional status, such as any reported deficiencies in vision, hearing or swallowing and any history of falls. The panel recommends using the Timed Up and Go (TUG) test to establish a patient’s risk for falls, where any patient with difficulty rising from a chair or requiring more than 15 seconds to complete the test is considered at high risk. They also recommend that surgeons determine a patient’s baseline frailty score.

The guidelines do fall short when it comes to recommending what actions surgeons should take in “what-if ” scenarios, said Dr. Cooper. “For instance, if a patient has frailty or cognitive impairment, I’d like more guidance on what to do.”

A significant portion of the guidelines is dedicated to medication management.

The panel called on surgeons to review and document patients’ complete medication list and ask about use of nonprescription agents and herbal products.

They suggest minimizing the patient’s risk for adverse drug reactions by identifying medications that should be avoided or discontinued before surgery. At the same time, surgeons should consider any medications that should be started or continued preoperatively to reduce perioperative risks for adverse events. They note that the doses of medication for renal function should be adjusted based on glomerular filtration rate and not on serum creatinine alone.

Patients should be evaluated for nutritional status and preoperative interventions, led by a dietician, should be considered if the patient is at severe nutritional risk, the panel said.

The panel called on surgeons to review and document patients’ complete medication list and ask about use of nonprescription agents and herbal products.

When it comes to preoperative testing, the panel did not recommend routine sets of preoperative screening tests, with the exception of hemoglobin, renal function tests and albumin. Diagnostic tests

should be performed selectively and limited to high-risk patients.

Finally, the panel called for surgeons to determine the patient’s treatment goals and expectations of treatment outcomes and to identify the patient’s family and social support systems. Surgeons should ensure that the patient has an advance directive and a designated surrogate decision maker and this information should be placed in the chart.

Physicians who specialize in palliative medicine applaud the panel’s efforts to highlight the need for frank preoperative discussions. Geoffrey P. Dunn, MD, a

surgeon at UPMC Hamot, Erie, Pa., and chairman of the Surgical Palliative Care Task Force of the ACS, said in an email: “The ACS/AGS guidelines are very consistent with the priorities of the palliative care community.”

The guidelines were developed in response to a performance measure, “The Elderly Surgery Measure,” developed by the ACS and the Centers for Medicare & Medicaid Services. They launched a pilot program in October that gives hospitals the opportunity to publicly and voluntarily report their outcome results for this performance measure.

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Breast Cancer in Younger Women Poses Unique Challenges B Y M ONICA J. S MITH PHOENIX X—Within the population of breast cancer patients, there is a group that is particularly discomfiting to surgeons: women under the age of 40 years, which includes, on rare occasion, women diagnosed with breast cancer while pregnant.

These challenging and poignant cases are few and far between, but “when it happens, it’s really important that people know what to do or know how to get information on what to do,” said Ann H. Partridge, MD, MPH, Dana-Farber Cancer Institute, Boston, who addressed the topic at the American Society of Breast Surgeons’ annual meeting.

Breast cancer in young women is difficult, partly because it is so uncommon, representing only a small proportion of the breast cancers that surgeons see. “It’s more unknown to us, and the stakes are high. Therefore, it becomes problematic in trying to care for them,” Dr. Partridge said.

Surgeons may not meet these patients often, but breast cancer strikes about 12,000 women under the age of 40 every year in the United States, and tens of thousands worldwide, and it is the leading cancer-related cause of death in young women. Things may have changed with the availability of trastuzumab (Herceptin, Genentech) but Surveillance, Epidemiology and End Results [SEER] data published seven years ago (plus recent information provided by the American Cancer Society) showed a significant difference in five-year survival rates between younger breast cancer patients and those aged 40 years or older, at 84% and 90%, respectively. “We all see this clinically, unfortunately,” Dr. Partridge said.

This is due largely to the fact that younger women present at a more advanced stage of the disease. Reliable screening is lacking for this group, as is awareness; diagnosis is difficult in young women who are pregnant; and younger patients are more likely than older patients to have access issues.

Younger women are more likely to have endoplasmic reticulum (ER) disease, lymphovascular invasion and possibly more HER2-positive disease, and 60% to 67% of young women with breast cancer present with high-grade disease, making it more difficult to achieve negative margins and increasing the risk for recurrence. Young black women in particular appear to be more likely to develop aggressive basal-like subtypes of breast cancer than older black women and non-black women in general ((JAMA 2006;295:2492-2502).

“All of these data beg the question: Is this a different disease in young women, or is it a different mix of tumor subtypes?”

Dr. Partridge asked. So far, she said, there is no evidence that it is a different disease.

“If it is, that’s something we could capitalize on. But it’s not clear at this point.”

Although on average, the prognosis is worse for young women, recent studies (that control for known prognostic and predictive variables in tumor subtypes) suggest young age alone does not explain the reason for this. Dr. Partridge’s research team examined data from the HERA trial of women with HER2-positive disease who were randomly selected to receive trastuzumab or no trastuzumab (N Engl J Medd 2005;353:1659-1672) and found no statistically significant difference across age groups (Breast Cancer Res Treatt 2010). “Age was neither a prognostic nor a predictive factor for early recurrence,” she said.

The researcher also examined the National Comprehensive Cancer Network data, and found that young age was not associated with a higher risk for mortality in women with ER disease and HER2-positive disease (Partridge et al, SABCS 2011; poster 010805).

“There’s a lot more workk to do in this area, but I think as we fleesh things out we’ll be thinking a lot m more about tumor subtype related to aage and less age alone over time,”” Dr. Partridge said.

One of the biggest questions cancer care teams face now in the care of young women with breast cancer is whether some patients can forgo chemotherapy.

“Young women can and do get wimpy tumors, so we need to think about whom we can spare from some of the toxicity off additional therapies,” Dr. D Partridge said.

“There are definitely studies that suggest that some young women can do quite well with hormonal therapy only,” she said, noting that doctors can use parameters, such as Oncotype DX, to identify these women. This raises the question of whether ovarian function suppression or oophorectomy is the optimal solution for these patients. A lot of the benefit of heavy chemotherapy for young women stemmed from the chemo-endocrine effect, Dr. Partridge explained. “Especially in older regimens like CMF [cyclophosphamide, methotrexate and 5-fluorouracil (5-FU)], ovaries were shot by the chemotherapy.”

Some research suggests ovarian suppression is beneficial in the metastatic setting ((J Natl Cancer Instt 2000;92:903911) and in the adjuvant setting (N Engl J Medd 2010). Results of the Suppression of Ovarian Function trial [SOFT]— in which women were randomized to tamoxifen alone or tamoxifen plus ovarian suppression, or the aromatase inhibitor exemestane plus ovarian suppression—should answer the question, perhaps in the next year or two. “My personal hunch is that ovarian suppression will add to some degree, and we’ll

AT A GLANCE CE Breast cancer strikes about 12,000 under the age of 40 every year in the United States, and tens of thousands worldwide, and it is the leading cancer-related cause of death in young women.

Data for lymphoma suggest that radiation can be used successfully to treat pregnant patients, without adverse outcomes for the baby.

Research shows that young age was not associated with a higher risk for mortality in women with endoplasmic reticulum [ER] disease and HER2-positive disease.

spend the next decade or so figuring out for whom it adds and whether it’s worth it,” Dr. Partridge said.

SOFT is also collecting a lot of data on tolerability, quality of life and other issues that are important when deciding whether small benefits are worth it, she added, noting that the late and longterm effects of diagnosis and treatment are much different for younger women than for older ones. The ramifications of very premature menopause, the potential for second cancers, the ongoing pursuit of genetic issues—all lead to a heavy psychosocial burden at diagnosis and at follow-up.

“It’s the stress of having a higher-risk disease, the tendency to receive more aggressive chemotherapy, and [being at] a time in their lives where their role at home or at work may be less replaceable,” Dr. Partridge said. “They are worried more than older women in general about beauty and attractiveness, sexual functioning, fertility, family planning— these things are of paramount importance to the younger set.”

This stress is compounded by the fact that there is less information and less support for younger women. “They’re the youngest young woman in the room in breast-onlly clinics. In support groups, the otherr women are worried about seeing th heir grandchildren grow up while young women are worried abou ut even getting a date with no breast,” Dr. Partridge said.

“T The good news is that a lot oof groups now are focusing on the unique needs of young women.”

Breast cancer in pregnant women is exceptionally rare, estimated to occur in about oone in 3,000 women per year in n the United States. Over the coourse of a career, a surgeon migght encounter only a few of thesee patients for whom the cancer poses “aan ethical dilemma; an existential threatt to two human beings—the patient wiith the cancer and her unborn child,” said d Richard Theriault, MD, proffessor, Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston. “The psychosocial dynamics around that make it a particularly poignant and difficult clinical management process, and it is a process.”

At his institution, management of these patients involves a multidisciplinary team of maternal–fetal medicine specialists, surgeons, medical oncologists and often a geneticist, who work together to evaluate the patient’s pregnancy and

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the state of her disease before deciding on a course of action.

Patients who have been advised to terminate the pregnancy need to be assured that it may not be necessary; available data do not suggest it improves patient outcomes.

“The decision to terminate must be made by the woman who has been informed of the risks, harms, burdens and potential benefits of treatments for herself, and potential fetal risks, with cancer treatment or no treatment,” Dr. Theriault said. “It’s an ethical, moral, religious, philosophical decision and it’s not the doctor’s to make. The major indications for considering termination would be fetal malformation and mother’s choice.”

If the patient decides to maintain the pregnancy, evaluation of the patient and the extent of her disease does not differ much from that of a nonpregnant patient.

“We conduct an evaluation with mammography and ultrasound of the breast and nodal basins; a chest radiograph; and an ultrasound of the liver, which can be done concomitantly with ultrasound of the fetus,” Dr. Theriault said. If the medical team suspects bone abnormalities that might affect the pregnancy, they will look at a screening noncontrast magnetic resonance imaging of the spine.

Biopsy can and should be done as soon as possible, as these patients are likely to have had a lump for months and to have

‘It’s the stress of having a higherrisk disease, the tendency to receive more aggressive chemotherapy, and [being at] a time in their lives where their role at home or at work may be less replaceable.’

—Dr. Partridge, MD been told that it’s just a plugged milk duct or a cyst. “If it’s been there more than two or three weeks, it needs to be evaluated; we can easily do core biopsies or fine-needle aspirations,” Dr. Theriault said, noting that the latter may be more problematic for the pathologist to interpret due to pregnancy’s effect on the breast, whereas core biopsy provides more information.

Treatment is guided by the extent of the disease. The options are similar to those for any breast cancer patient: surgery, radiation and systemic therapy, although radiation is best suspended until after the birth of the child. Surgery can be performed at any point during the pregnancy. Mastectomy is not associated with an increased risk for fetal abnormality, “but if you’re going to do surgery after week 25 of gestation, I would recommend you have obstetricians available

in case there is a precipitous delivery,” Dr. Theriault said.

Breast-conserving surgery is technically feasible, but does require radiation, which Dr. Theriault prefers to avoid until the patient is postpartum, although it is not clear whether radiation is contraindicated in pregnancy: Data for lymphoma suggest that radiation can be used successfully during pregnancy without adverse outcomes for the baby. “You can ask your medical physicists to calculate the fetal dosimetry and give a risk assessment if you feel that it’s absolutely necessary to do radiation,” Dr. Theriault said.

For localization in sentinel lymph node biopsy, Dr. Theriault uses technetium-99m, and one of his colleagues assessed the fetal radiation dose to be less than the 5 cGy exposure that is problematic to the National Council on Radiation Protection and Measurements.

Dr. Theriault’s team does not use isosulfan blue dye because, similar to chemotherapy, it is teratogenic, but some regimens are less toxic than others. When the proper agent is restricted to the second and third trimesters, the risk for fetal malformation is about 1.3%, similar to that seen in the general population.

“Most of the case series look at anthracycline-based therapies, and supporting

experiences with chemotherapy regimens including AC [adriamycin and cyclophosphamide], FAC [5-FU, doxorubicin and cyclophosphamide] and FEC [5-FU, epirubicin and cyclophosphamide] during the second and third trimesters. There are limited data on dose-dense anthracycline safety and tolerance, but theoretically it is just as safe as the others,” Dr. Theriault said. Dosage is based on the patient’s weight and body surface area. “The practical aspect of that is, as the pregnancy progresses, most women gain weight, and the dose of chemotherapy goes up. Some people get a little bit frightened by that.”

Endocrine therapy is reserved for postdelivery. “We don’t want to interfere with the hormonal milieu of the pregnancy by fiddling around with estrogen receptors,” Dr. Theriault said.

Monitoring the pregnancy throughout treatment is crucial. At MD Anderson, pregnant patients consult with a maternal–fetal medicine specialist the day before each cycle of chemotherapy. “If everything looks normal, we proceed with our next cycle of chemotherapy; we don’t want to give chemotherapy if the baby appears to be in extremis,” Dr. Theriault said. If there is evidence of oligohydramnios or intrauterine growth retardation, suspending systemic treatment until after the delivery can be arranged.

Breast Ultrasound Best for Women 30 to 39 Years Old, Study Suggests B Y G EORGE O CHOA

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ltrasound should be the primary imaging modality in women aged 30 to 39 years with focal breast signs or symptoms, according to a large study ((Am J Roentgenoll 2012;199:1169-1177).

Adjunct mammography adds little value and should be reserved for certain highrisk cases, such as patients with a highly suspicious lesion on ultrasound, a known gene mutation or a strong family history, the authors wrote.

“We studied women under [the age of ] 40 with palpable breast lumps to see how best to diagnose cancer. This hasn’t been studied carefully,” said lead author Constance D. Lehman, MD, PhD, FACR, professor and vice chair, radiology and section head, breast imaging, University of Washington, and director of imaging, Seattle Cancer Care Alliance. “This is the largest study to date, of breast ultrasound and adjunct mammography in women 30 to 39 years of age, who present with focal breast signs or symptoms of cancer in the United States.”

In the retrospective, single-center study, the researchers identified all

women aged between 30 and 39 years who underwent ultrasound examination with corresponding mammography for focal breast signs or symptoms, between Jan. 1, 2002, and Aug. 31, 2006. The number of cases identified was 1,208 in 954 patients (mean age, 35 years; age range, 30-39 years). Outcomes were benign in 1,185 (98.1%) cases and malignant in 23 (1.9%). Ultrasound discovered 22 of the 23 cancers, whereas mammography discovered only 14 of 23. Breast ultrasound proved to have 95.7% sensitivity for cancer detection at the site of focal breast concern (89.2% specificity; 99.9% negative predictive value [NPV]; and 13.2% positive predictive value [PPV]). Mammography had a sensitivity of 60.9%, (specificity 94.4%; NPV 99.2%; and PPV 18.4%). Mammography also detected one additional malignancy in an asymptomatic area in one patient who was subsequently found to have a breast cancer type 2 susceptibility protein (BRCA2) gene mutation.

“Before our study, in the United States we were doing mammography first in women aged 30 to 39,” said Dr. Lehman. “We found that best practice is to start with ultrasound. Ultrasound is the

better primary tool for these women.”

The current American College of Radiology (ACR) Appropriateness Criteria, for women aged 30 years or older with a palpable breast mass, recommends using mammography as the first imaging modality, followed by ultrasound.

Dr. Lehman said the criteria should be revised: “ACR is reviewing our data and other available evidence, and considering changes to their guidelines.”

Andrew D. Seidman, MD, attending physician, Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, and professor of medicine, Weill Cornell Medical College, New York City, who is not associated with the paper, commented by email: “It is an important study because it represents the largest analysis of the utility of ultrasonography and diagnostic mammography in patients between 30 to 39 years of age who present with breast signs or symptoms. It suggests that a change in guidelines and practice is warranted, specifically that ultrasound should be the first ‘go-to’ radiologic examination, and that mammography might be largely abandoned for patients in this age group, in this specific clinical scenario.”

Of the study’s limitations, Dr. Lehman said, “It’s a single-site study. And the ultrasound was performed by radiologists specialized in the use of breast ultrasound.”

Additional limitations observed by Dr. Seidman include the retrospective nature of the study and its insufficient “special handling” of patient subgroups at higher baseline risk for breast cancer or ductal carcinoma in situ.

Dr. Seidman did not agree that the current ACR Appropriateness Criteria should be revised on the strength of this study. “While it would appear that mammography may indeed add very little to ultrasonography for the woman aged 30 to 39 who presents with breast signs or symptoms, it is hard for me to imagine that, under such circumstances, patients and their physicians will forgo mammography. The time of breast pain, or a lump, is an anxious moment for most women, and a retrospective, single-institution study, no matter how robust, does not seem sufficient to either change guidelines nor dissuade patients and their physicians from proceeding with mammography, or even MRI [magnetic resonance imaging], for that matter.”

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Genetic Findings Could Reshape Approach to Breast Cancer Four Distinct Subtypes Found; Genetic Makeup of Tumors More Important Than Location; Research Brings Promise, and More Questions B Y C HRISTINA F RANGOU

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n a finding that is expected to revolutionize future approaches to the treatment of breast cancer, researchers have confirmed the presence of four distinct subtypes of breast cancer, each with a unique heterogeneous mix of genetic and molecular abnormalities.

The findings, published online Sept.

23 in Nature, add to the growing body of evidence suggesting that tumors should be catalogued and treated based on the genes that are disrupted, rather than the tumor location in the body.

As well, the researchers reported a breakthrough finding about triple-negative breast cancers: These breast cancers more closely resemble ovarian cancer than other breast cancers.

Basal-like breast tumors and ovarian tumors could potentially be treated with the same therapeutic approaches, said the investigators.

“With this study, we’re one giant step closer to understanding the genetic origins of the four major subtypes of breast cancer,” said Matthew J. Ellis, MD, PhD, Anheuser-Busch Chair in Medical Oncology, Washington University School of Medicine, St. Louis, in a statement.

“Now, we can investigate which drugs work best for patients based on the genetic profiles of their tumors. For basal-like breast tumors, it’s clear they are genetically more similar to ovarian tumors than to other breast cancers. Whether they can be treated the same way is an intriguing possibility that needs to be explored.”

Surgeons, oncologists and other physicians who treat patients with breast cancer say the study adds significantly to knowledge of breast cancer, and will shift from the traditional way of thinking about cancer, in which tumors are classified by body part, to a more modern system that relies on a tumor’s genetic signature.

“I believe that this study is highly significant because it confirms what many of us have predicted for some time: Our current breast cancer phenotypes are far more complex than the current classification system suggests, and the genetic abnormalities extend to primary tumors in other organ systems,” said Richard J. Bleicher, MD, director of the Breast Fellowship Program and associate professor of surgical oncology, Fox Chase Cancer Center, Philadelphia.

“Data of this type will be what reshapes our understanding of cancer, how we classify it and how we tailor therapy.”

The new research is part of The Cancer Genome Atlas Project, which brings together the country’s leading genetic sequencing centers to identify and catalogue mutations involved in many common cancers. The effort is funded by the National Institutes of Health.

A nationwide consortium of researchers analyzed tumors from 825 women with breast cancer. The scientists used six different technologies to examine subsets of the tumors for defects in DNA, RNA and proteins. (In comparison, most other studies use one, perhaps two techniques to perform genetic analysis of cancer tumors.) The techniques included Agilent mRNA expression microarrays, Illumina Infinium DNA methylation chips, Affymetrix 6.0 single-nucleotide polymorphism arrays, miRNA sequencing, whole-exome sequencing and reverse-phase protein array data. Nearly 350 tumors were analyzed using all six techniques.

By integrating information across platforms, researchers gained key insights into previously defined gene expression subtypes and confirmed the existence of four main breast cancer classes: luminal A, luminal B, HER2-enriched and basal-like.

Charles Perou, MD, co-author of the paper and the May Goldman Shaw Distinguished Professor of Molecular Oncology, University of North Carolina School of Medicine, said researchers were able to collect “the most complete picture of breast cancer diversity ever.”

“This study has now provided a near complete framework for the genetic causes of breast cancer, which will significantly impact clinical medicine in the coming years as these genetic markers are evaluated as possible markers of therapeutic responsiveness.”

‘This study has now provided a near complete framework for the genetic causes of breast cancer, which will significantly impact clinical medicine in the coming years as these genetic markers are evaluated as possible markers of therapeutic responsiveness.’

—Charles Perou, MD

‘Now, we’re much closer to understanding the true origins of the different types of breast cancer.’

— Matthew J. Ellis, MD, PhD

Across the four subtypes, mutations in only three genes—TP53, PIK3CA A and GATA3—occurred in more than 10% of patients’ tumors. But the scientists found unique genetic and molecular signatures within each of the subtypes.

Compared with other subtypes, basallike and HER2 tumors had the highest mutation rates but the shortest list of significantly mutated genes. These genes are thought to be the major drivers of cancer progression. Eighty percent of basallike tumors had mutations in the TP53 gene, a known marker for more aggressive disease and poorer overall survival.

About 20% of the tumors also had inherited mutations in the BRCA1 or BRCA2 genes, which are known to increase the risk for breast and ovarian cancer.

“This suggests that it only takes a few hits to key genes that drive cancer growth,” said co-author Elaine Mardis, PhD, co-director of The Genome Institute at Washington University.

Overall, the genetic profiles of basallike and ovarian tumors were strikingly similar, with widespread genomic instability and mutations occurring at similar frequencies and in similar genes.

Among the similarities, both tumors have BRCA1 inactivation, RB1 loss and cyclin E1 amplification, high expression of AKT3, MYC C amplification and high expression, along with the high frequency of TP53 mutations.

“The common findings of TP53, RB1 and BRCA1 loss, with MYC C amplification, strongly suggest that these are shared driving events for basal-like and serious ovarian carcinogenesis,” the authors reported.

“This suggests that common therapeutic approaches should be considered, which is supported by the activity of platinum analogues and taxanes in breast basal-like and serous ovarian cancers.”

Finding new drug targets for this group is critical, said the authors. Basal-like tumors account for about 10% of all breast cancers and disproportionately affect younger women and those who are black.

Another previous study from Dr. Ellis’ group showed that women with basallike tumors do not benefit from anthracycline-based chemotherapy, commonly used to treat breast cancers (Clin Cancer Res 2012;18:2402-2412). The new

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data indicate that clinical trials should be designed to avoid the use of these drugs in basal-like tumors.

Instead, patients with mutations in the BRCA A genes may benefit from poly (ADP-ribose) polymerase inhibitors or platinum-based chemotherapy, which already are used to treat breast cancer.

“It’s particularly exciting when research delivers important findings with an immediate impact on treatment,” said Marisa C. Weiss, director of breast radiation oncology at Lankenau Hospital in Philadelphia, and founder of the nonprofit information website breastcancer.org.

The study showed that luminal cancers had the lowest mutation frequencies and longer lists of significantly mutated genes, suggesting that defects in multiple genetic pathways lead to the development of luminal breast cancers.

Luminal A tumors are the most common form of breast cancer in the United States and the primary cause of breast cancer deaths, accounting for 40%. The study helps provide a much better picture of the genetic causes of this subtype.

The most common mutation in luminal A tumors occurred in PIK3CA, and was present in 45% of these tumors. TP53 mutations occurred only in 12%.

Patients with luminal B tumors generally do well after treatment but many

’Although this is interesting and fascinating research, it does not really change how we manage the patient with breast or ovarian cancer who is diagnosed today.’

—Deanna Attai, MD experience recurrence years after treatment. The study showed that the most common mutations in these tumors occurred in TP53 and PIK3CA, which may explain the disparate results seen in patients with this subtype.

“Now, we’re much closer to understanding the true origins of the different types of breast cancer,” said Dr. Ellis.

“With this information, physicians and scientists can look at their own samples to correlate patients’ tumor profiles with treatment response and overall outcomes.

That’s the challenge for the future: translating a patient’s genetic profile into new treatment strategies.”

For now, experts say that the findings are not changing clinical practice.

“Although this is interesting and fascinating research, it does not really change how we manage the patient with breast or ovarian cancer who is diagnosed

today,” said Deanna Attai, MD, a breast surgeon at the Center for Breast Care, Burbank, Calif.

“We are able to get more information than ever before on the genetic makeup and biological behavior of an individual patient’s cancer, but we still are not at the point where we can offer truly individualized treatment. And the more we learn, the more questions remain.”

The study offers “lots of promise and potential for future treatment, but no real changes today in how surgeons and medical oncologists approach patients with breast or ovarian cancer,” Dr. Attai said.

But, physicians can use the report to help patients understand the complexity of breast cancer and the need for a multidisciplinary response, said Dr. Weiss.

“The message here is quite clear: The constitution of a cancer is complex, heterogeneous; the cells are not all identical,” she said.

“Each woman’s individual cancer is unique. It’s made up of a range of different cells that work in different ways. In order to get rid of them, you need to use different treatments that address different vulnerabilities of that cancer.”

Drs. Ellis and Perou are inventors on patent filing for PAM50 and have equity interest in Bioclassifier LLC.

AT A GLANCE Physicians who treat patients with breast cancer say the study will shift the way they think about cancer.

Triple-negative breast cancers more closely resemble ovarian cancer than other breast cancers.

The new research is part of The Cancer Genome Atlas Project which brings together leading genetic sequencing centers to identify and catalogue mutations involved in many common cancers.

The researchers gained key insights into previously defined gene expression subtypes and confirmed the existence of four main breast cancer classes.

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Nearly 30% of ICU Deaths Have Missed Diagnoses B Y D AVID W ILD

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s many as 28% of adult patients in intensive care each year die with a misdiagnosis, and up to 8% die with a potentially fatal “major missed diagnosis,” such as pulmonary embolism or myocardial infarction, researchers have found.

The findings, from a meta-analysis of 31 autopsy-based studies (BMJ Qual Saf 2012; doi:10.1136/bmjqs-2012-000803), may even understate the rate of missed diagnoses, said Bradford Winters, MD, PhD, associate professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, in Baltimore, who led the research.

“Since we did not include non–autopsy-based studies in our analysis, we did not evaluate misdiagnoses that did not result in death, but that are likely associated with increased morbidity health care costs,” Dr. Winters told General Surgery News.

The 31 studies—which were observational, mostly retrospective studies and largely based in the United States— included information from 5,863 autopsied adults who had died in an intensive care unit (ICU). The papers were published between 1966 and 2011. The analysis excluded publications that examined the rate of disease-specific misdiagnoses and studies that did not include original data. A median of 43% of ICU deaths that occurred during the study period were autopsied.

The investigators turned to the Goldman Classification, widely used for autopsy findings, to group the misdiagnoses they identified. The criteria define class I errors as “missed major misdiagnoses with potential adverse impact on survival and that would have changed management”; class II errors as missed major diagnoses that would not have affected survival or altered the course of care; and class III and class IV errors as misdiagnoses related to the terminal disease but not related to death or unrelated to both disease and death, respectively.

The rate of misdiagnoses detected during autopsy ranged from 5.5% to 100%, with a 28% overall rate (1,632 of 5,863), the researchers found. Class I and class II errors accounted for 8% and 15% of misdiagnoses, respectively; class III and class IV errors accounted for 15% and 21%, respectively. Dr. Winters noted that some studies reported only the total number of misdiagnoses and class I or class II errors, leaving the specific misdiagnoses of the remaining 41% unclear.

The most common class I and class II misdiagnoses reported in the studies were vascular events and infections.

The 8% rate of major and potentially lethal ICU misdiagnoses is higher than the 5% rate of lethal misdiagnoses documented in the general hospital population in a previous study (JAMA ( 2003;289:2849-2856).

The difference, Dr. Winters explained, can be attributed to ICU-specific factors such as the inability of patients to communicate

their medical history during the workup process and limited staff resources leading to “competition for care.” Factors not specific to the ICU, including an overload of information and cognitive errors that lead to a biased interpretation of patient data, also may play a role.

Richard Dutton, MD, executive director of the Anesthesia Quality Institute, in Park Ridge, Ill., who specializes in trauma, said several limitations may undermine the generalizability of the findings.

“Most autopsied patients have some level of diagnostic uncertainty to begin with, which makes the population in this meta-analysis not completely representative of the general ICU population,” said Dr. Dutton, who was not involved in the research.

Some of the studies included in the meta-analysis were conducted before the introduction of more accurate and advanced imaging-based diagnostics, Dr. Dutton noted. And he questioned the effect that missed class I or class II diagnoses would have had on patient outcomes had they been identified. “If a patient is dying of septic shock, secondary events like myocardial infarction and pulmonary embolism, which are common during the immediate premortem period, may not have affected their survival.”

Dr. Winters has received fees for expert testimony from several defense and plaintiff law firms, as well as honoraria from 3M and various health systems.

Study Shows Dramatic Rise in Hospital Visits for C. difficile B Y G EORGE O CHOA

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espite efforts by the U.S. Department of Health and Human Services and antimicrobial stewardship programs to combat Clostridium difficilee infections (CDIs), the national rate of hospitalizations related to these infections is projected to more than double from 2001 to 2012, according to a report from the Agency for Healthcare Research and Quality (AHRQ).

“It has been known that C. difficilee hospitalizations are increasing,” said the report’s lead author, Claudia Steiner, MD, MPH, senior research physician at AHRQ, in Rockville, Md. “One thing our report adds is data that projects out to 2011 and 2012. Often health care data is behind by a couple of years.”

From 2001 to 2010, the national rate of C. difficile hospitalizations per 1,000 nonmaternal adult discharges rose from about 5.6 to 11.5. The projected rate climbed to 12.5 in 2011 and is projected to climb to 12.8 in 2012.

Results were obtained not only for the nation overall but also for the nine census divisions, which showed variation. New England states had the highest rate of

C. difficile hospitalizations both in 2001 (average, 7.7) and 2010 (average, 13.7), whereas the West South Central states (Arkansas, Louisiana, Oklahoma and Texas) had the lowest rate in 2001 (average, 4.5) and 2010 (average, 9.1).

Dr. Steiner said the reasons for the regional differences were unclear. “It could be differences in use of antibiotics, in diagnosing and coding of C. difff or in the threshold to admit a patient. ... Our report shows the [rate in the] Northeast is flattening—does this mean hospitals have changed something in their approach or that the health care community is intervening?”

Debra Goff, PharmD, an infectious disease pharmacist at The Ohio State University Medical Center, in Columbus, who was not involved with the report, said it was “a wake-up call to hospitals to get an action plan in place now—because the consequence to patients can be death. C. difff infection is a disease for which CMS [Centers for Medicare & Medicaid Services] will require public reporting in 2013.”

Acknowledging that the report had limitations, Dr. Steiner said, “Our report shows burden of illness rather than incidence or causation. Because some patients may

have been readmitted, the number of hospitalizations may represent fewer patients.”

Dr. Goff said the analysis “excluded large hospitals and teaching hospitals. It’s representative of small community hospitals, which the lion’s share of C. diff patients aren’t in. Possibly it underestimates rates of C. difff hospitalization.” Even so, she said, the report gives practicing pharmacists “a benchmark to compare your own rates of C. difff to other hospitals nationally.

“I’d like to think stewardship programs are the reasonfor the plateaus seen in some areas of the country,” Dr. Goff added.

She stressed, however, that “until all health care facilities make prevention of C. difficile infection a priority, lower rates may not be realized for some time. Publicly reporting CDI rates and reducing hospital reimbursement for preventable diseases [such as CDI] will expedite putting CDI on the radar screen of health care facilities.

Pharmacists can help empower patients through education and increased awareness of how to prevent CDI. Patients are the reason we do stewardship.”

Drs. Goff and Steiner reported no relevant financial conflicts of interest.

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Advances in Stent Technology for Esophageal Cancer Rafael S. Andrade, MD Associate Professor Section of Thoracic and Foregut Surgery University of Minnesota Medical Center, Fairview Minneapolis, Minnesota

Introduction Esophageal stricture and tracheoesophageal fistula in the setting of advanced esophageal cancer can have a devastating effect on quality of life due to severe dysphagia, aspiration pneumonia, and the inability to sustain nutrition or enjoy meals. .BOBHFment of dysphagia is indicated for palliative purposes in patients with unresectable esophageal cancer and in order to optimize nutrition prior to surgery in the neoadjuvant setting.

Historically, management of malignant dysphagia consisted of radiation therapy with or without systemic chemotherapy, endoscopic tumor ablation, stricture dilation or enteral feeding.4,5 Although radiation therapy provides excellent palliation, its effect is delayed by weeks.6,7

Esophageal Stenting Endoscopically placed stents are being used for immediate palliation of dysphagia as well as tracheoesophageal fistulae. The 4*3&$ 4UFOU PS *OUSBMVNJOBM 3BEJPUIFSBQZ GPS *OPQFSBCMF &TPQIBHFBM $BODFS TUVEZ found that newer stents produced more immediate relief of dysphagia than radiation therapy,8 although the latter offers a more durable result for patients with more than NPOUIT MJGF FYQFDUBODZ 8 Thus, the paradigm of esophageal stenting for immediate relief followed by radiation therapy may be the most effective way to palliate dysphagia in patients with malignant dysphagia and a MJGF FYQFDUBODZ PG BU MFBTU NPOUIT The WallFlexÂŽ #PTUPO 4DJFOUJGJD GVMMZ PS partially covered esophageal stent, constructed of multiple braided radiopaque nitinol wires, is indicated for the maintenance of esophageal luminal patency in malignant esophageal strictures or for the occlusion of concurrent esophageal fistulae.9

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stricture is so tight that we cannot pass the deployment system. We usually select the NN EJBNFUFS TUFOU UP SFMJFWF TPMJE GPPE EZTQIBHJB *O JOTUBODFT XIFO UIF TUSJDUVSF JT OPU BT UJHIU XF XJMM QMBDF B NN EJBNeter stent. We tend to put in longer stents if we have to stent across the gastroesophageal junction due to tumor involvement since we believe they help address higher migration rates in these instances. We admit the patient for overnight observation and obtain a chest x-ray the following morning to confirm proper stent position.

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Figure. Esophageal tumor before and after placement of the WallFlexÂŽ stent.

for this procedure, under which conditions they use general anesthesia and fluoroscopy, and how they ensure proper positioning, and make note of technical pearls.

References

4IBSNB 1 ,P[BSFLL 3 1SBDUJDF 1BSBNFUFST $PNNJUUFF PGG "NFSJDBO $PMMFHF PG (BTUSPenterology. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol

1FMMFO .( 4BCSJ 4 3B[BDLL " (JMBOJ 42 +BJO 1, 4BGFUZ BOE FGGJDBDZ PG TFMG FYQBOEJOH removable metal esophageal stents during neoadjuvant chemotherapy for resectable esophageal cancer. Dis Esophagus.

% $VOIB + 3VFUI /. (SPUI 44 .BEEBVT ." "OESBEF 34 &TPQIBHFBM TUFOUT GPS anastomotic leaks and perforations. J Thorac Cardiovasc Surg

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(BTQFS 8+ +BNTIJEJ 3 5IFPEPSF 13 1BMMJBtion of thoracic malignancies. Surg Oncol.

5.

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6.

#PXO 4( 1BMMJBUJPO PG NBMJHOBOU EZTQIBHJB 4VSHFSZ SBEJPUIFSBQZ MBTFS JOUVbation alone or in combination? Gut.

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1BMMJBUJPO PG NBMJHOBOU EZTQIBHJB GSPN PFTPQIBHFBM DBODFS 3PUUFSEBN 0FTPQIBgeal Tumour Study Group. Scand J Gastroenterol Suppl

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)PNT .: : 4UFZFSCFSH &8 &JKLFOCPPN 8. et al. Single-dose brachytherapy versus metal stent placement for the palliation PG EZTQIBHJB GSPN PFTPQIBHFBM DBODFS multicentre randomised trial. Lancet.

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WBO #PFDLFM 1( 4JFSTFNB 1% 4UVSHFTT 3 et al. A new partially covered metal stent GPS QBMMJBUJPO PG NBMJHOBOU EZTQIBHJB B prospective follow-up study. Gastrointest Endosc

#PTUPO 4DJFOUJGJD *OD 8BMM'MFYÂŽ Fully BOE 1BSUJBMMZ $PWFSFE &TPQIBHFBM 4UFOUT IUUQ XXX CPTUPOTDJFOUJGJD DPN %FWJDF CTDJ QBHF )$1@0WFSWJFX OBW3FM*E NFUIPE %FW%FUBJM)$1 JE QBHF%JTDMBJNFS %JTDMBJNFS "DDFTTFE 0DUPCFS

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In the News COMPLICATIONS jcontinued from page 1

result, hospitals and surgeons need to track and monitor postoperative complications closely, even when they occur after a patient is discharged from the hospital, said investigators.

“If hospitals only look at what happens during the index hospital stay, they’re missing a big part of the picture,” said study co-author Mary T. Hawn, MD, MPH, professor and chief of gastrointestinal (GI) surgery, University of Alabama at Birmingham, and a staff surgeon at Birmingham VA Medical Center.

Senior author Melanie S. Morris, MD, assistant professor of surgery at the University of Alabama at Birmingham and also a staff surgeon at the Birmingham VA, presented the findings at the 2012 Clinical Congress of the American College of Surgeons.

The investigators analyzed 59,464 surgical procedures performed at 112 VA hospitals in four surgical specialties— orthopedics, GI, vascular and gynecology—from 2005 to 2009.

Overall, one in seven cases (14.7%) resulted in a complication within 30 days of surgery. Of these, 32.15% were diagnosed after the patient was discharged from the hospital.

Surgical site infections (SSIs) accounted for 56% of the complications identified after patients were discharged. In turn, SSIs significantly increased the likelihood that a patient would require readmission to the hospital. Of the 1,775 patients who had a post-discharge SSI, 57.3% were readmitted. Only 19.4% of patients with an SSI diagnosed in the hospital later required readmission.

Readmissions add up to billions of health care dollars per year. A 2009 study in The New England Journal of Medicine found that nearly 20% of Medicare beneficiaries who had been discharged from the hospital were rehospitalized within 30 days, costing Medicare $17.4 billion annually in additional hospital bills (360:1418-1428).

To make a dent in SSI-related readmission rates, post-discharge SSIs need to be tracked and monitored, a move that should result in cost savings while improving the quality of care delivered to surgical patients, said investigators.

At the same time, hospitals and ambulatory surgical centers need to adhere to a standard for tracking and reporting post-discharge SSIs, said the authors.

Otherwise, the hospitals that do a more thorough job of tracking and reporting these infections will appear to have higher infection rates.

“Public reporting of SSI rates is here but we need to ensure a level playing field so patients and payers have accurate data,” said Dr. Morris.

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Factors associated with post-discharge SSI were shorter hospital length of stay (LOS; odds ratio [OR], 0.79; 95% confidence interval [CI], 0.77-0.81), non-GI procedures (OR, 5.18; 95% CI, 4.186.43), dependent functional status (OR, 1.62; 95% CI, 1.12-2.35) and American Society of Anesthesiologists physical status class (OR, 1.90; 95% CI, 1.46-2.49).

The study showed each type of surgery is associated with a distinct pattern of complications. Nearly one in five patients who underwent vascular procedures developed a complication and of these, 40% were diagnosed after discharge. Nearly half of the complications reported in vascular patients were SSIs

pre- or post-discharge complications influenced readmission rates. Their work showed that postoperative complications were the most significant driver of readmissions, associated with a nearly fivefold increase (hazard ratio [HR], 4.81; 95% CI, 4.56-5.07). No other variable was nearly as predictive. A preoperative history of congestive heart failure, the second most potent factor influencing readmission, was associated with an approximately 40% increase (HR, 1.41; 95% CI, 1.18-1.69).

“We should be able to keep more of these patients from being readmitted now that we have begun to realize patients who have complications diag-

‘If we know what those high-risk operations are, what the high-risk complications are, we can begin to intervene preoperatively to minimize risks as much as possible.’ —John F. Sweeney, MD (8.4%), followed by respiratory complications at 6.7%. Among patients who had GI procedures, 27% developed complications and 23% of these were diagnosed after patients were released from the hospital. Approximately 11% of these patients developed an SSI, making it the highest rate of SSIs among surgical specialties. However, GI surgery also had the lowest rate of complications that arose or were diagnosed after patients were released from the hospital.

Orthopedic and gynecologic surgeries had overall complication rates of 7% and SSI rates hovering around 2%, but gynecology had a much higher rate of postdischarge complications at 81% versus 39.4% for orthopedic surgery. Dr. Morris attributed this variation to the typically shorter hospital LOS for gynecologic procedures, many of which have sameday discharge.

Investigators also studied whether

nosed during their index stay are very much at higher risk,” said Elizabeth C. Wick, MD, assistant professor of surgery, Johns Hopkins University, Baltimore.

The study comes at a time of increased public scrutiny of hospital readmission and complication rates. Mandatory reporting of complications by hospitals is now required and the Affordable Care Act requires hospitals to report readmission rates as a quality indicator. As of late this year, payments are linked to readmission rates as part of a broad strategic plan for quality care improvement.

With increasing pressure to track and report complications, it’s important that policymakers, physicians and researchers are capturing all the important data points, said investigators.

“In health care, we’re all focused on quality care,” said Dr. Morris. “It’s important to know we are actually capturing the data points that we are going

to be held accountable for.”

John F. Sweeney, MD, chief of general and GI surgery at Emory University School of Medicine, Atlanta, said postoperative surgical complications and the resultant readmissions can and must be decreased. The nature of surgery itself lets surgeons and hospital staff prepare for complications, he pointed out.

Surgical patients differ from medical patients because the surgical procedure, in and of itself, places them at risk for readmission.

“That’s a planned event. And if we know what those high-risk operations are, what the high-risk complications are, we can begin to intervene preoperatively to minimize risks as much as possible. We can plan for the events that can happen after surgery and be ready if it does happen.”

Dr. Sweeney led a large study, published in the Journal of the American College of Surgeons in September (215:322-330), which came to similar conclusions as the VA study. In a retrospective review of 1,442 general surgery patients treated at hospitals enrolled in the American College of Surgeons National Surgical Quality Improvement Program, postoperative complications were the most significant independent risk factor leading to 30-day hospital readmissions.

The more postoperative complications a patient experienced, the more likely the risk for readmission. And when a complication developed after the patient left the hospital, the risk for readmission was higher than among patients who experienced complications in the hospital.

“We need to do our best to minimize this as much as possible,” said Dr. Sweeney.

He said a “high sense of urgency” now surrounds the issue of readmissions. “It’s coming from two places: one, American health care costs are unsustainable and readmissions are a small part of that puzzle, and two, because of the enormous upset to patients who go through a big operation and only to end up back in the hospital.”

Experts say more research is needed to investigate the links among patient risk, complications and readmissions.

For now, they recommend surgeons educate their patients about the risk for post-discharge complications, especially SSIs, and explain to patients how they should seek care early in the course of a complication.

“This education starts at the preoperative visit, continues during hospitalization, involves clear discharge instructions and ends with follow-up visits. This will enable patients to be active participants in their care,” said Dr. Morris.

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16

Surgeons’ Lounge

Dear Readers, Welcome to the December issue of The Surgeons’ Lounge.

We have been honored throughout the year by having had the opportunity to feature experts in their respective fields who provided thought-provoking and timely insight, in response to our readers’ questions and comments. In this last issue for 2012, we will not include a guest expert, but instead we will challenge our readers and present threee Surgeon’s Challenges!

This month, the “History and Other Facts” column features Emil Theodor Kocher, MD, Swiss physician and Nobel laureate (1841-1917).

The January 2013 issue will kick off with our guest expert, Manoel Galvao Neto, MD, scientific coordinator of Gastro-Obeso Center, in Sao Paulo, Brazil.

Surgeon’s Challenge No. 1 Collaborators: Boris Hristov, MS, Florida International University; Herbert Wertheim College of Medicine, Miami, and Hira Ahmad, MD (PGY-1), Cleveland Clinic Florida Surgery Residency Program, Weston. he patient is a previously healthy, 38-year-old white man. His past medical history is negative.

He has no allergies and is not taking any medications. He initially presented to his primary care physician with complaints of an extremely painful small lump on his upper right abdomen. He stated that the pain was severe and affecting his quality of life.

On physical examination, he had a very small, difficult-to-palpate and exquisitely tender subcutaneous nodule, approximately 1 cm, that was soft and mobile. There were no associated symptoms such as erythema, fever or chills. The rest of his physical exam was benign. Due to the atypical symptoms for such a small, barely palpable nodule, a computed tomography [CT] scan of the abdomen was performed and showed an opacity in the subcutaneous fat (Figure 1).

T

Figure 1.

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

On behalf of the Surgeons’ Loungee team, we wish all our readers happy and safe holidays, and look forward to your comments and questions in the new year.

Sincerely, Samuel Szomstein, MD, FACS Editor, The Surgeons’ Lounge Szomsts@ccf.org Dr. Szomstein n is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.

Surgeon’s Challenge No. 2 Collaborator: Yaniv Cosacov, MD, University of Debrecen Medical and Health Science Center, Debrecen, Hungary.

45-year-old women presented for a Roux-enY gastric bypass procedure. Her weight was 390 pounds and her body mass index [BMI] was 66.9 kg/m2.

Her past medical history consisted of multiple medical problems including asthma, hypertension and osteoarthritis, which were treated with bronchodilators and anti-inflammatory drugs (valsartan and hydrocodone/acetaminophen, respectively). Due to poor exercise tolerance and chronic shortness of breath, the patient was essentially bound to her wheelchair (obstructive sleep apnea [OSA] evaluation was negative). She also was diagnosed with dysthymic and anxiety disorders, for which she was treated with several antidepressants and anxiolytics (citalopram, amitriptyline, bupropion and

A

Lab results (complete blood cell count [CBC] and comprehensive metabolic rate [CMR]) were within normal ranges. The patient was diagnosed with a possible symptomatic lipoma.

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

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

What would you do now?

buspirone). She previously had undergone ankle, knee and back surgery, as well as tonsillectomy and sinus surgery.

The patient appeared well and a review of systems and physical examination were all within normal limits. All preoperative lab results and radiological tests were within normal limits. Once access was gained to the peritoneal cavity, the liver appeared enlarged and cirrhotic with multiple, white patchy lesions in all lobes (Figure 2).

What would you do?

Figure 22.

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

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

What would you tell the patient?

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

What would you do now?

Surgeons’ Lounge

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Surgeon’s Challenge No. 3 t following weekend to treat three epithe sodes of melena. An upper gastroenterologist was then consulted for a double balloon endoscopy, which showed no significant pathology in the jejunal loop and healing of the ulcer. There also was a ring-like dark object seen penetrating the gastric mucosa of the remnant stomach above the pylorus and two ulcers at the points where this object made contact with the gastric mucosa. These findings led to the diagnosis of an eroded gastric ring to remnant.

What would you do if endoscopic removal of this ring was not feasible?

Collaborator:: Nicholas L. Cukingnan Lee, MD, Sydney, Australia.

The patient is a 50-year-old woman who presented to the clinic for a second opinion regarding her epigastric pain, nausea and vomiting that she had had for the past two years. She had undergone a Roux-en-Y gastric bypass with silastic ring (Figure 3) 10 years earlier at an outside facility. Her proton pump inhibitor [PPI] dose was increased and the patient noted improvement of symptoms. One month later, another esophagogastroduodenoscopy [EGD] was performed at our facility, which showed a small ulcer in the jejunum. The patient was admitted Figure 3.

3

History and Other Facts About …

Emil Theodor Kocher, MD (1841-1917)

By Yaniv Cosacov, MD, University of Debrecen Medical and Health Science Center, Debrecen, Hungary.

Emil Theodor Kocher was born and did his life’s work in Bern, Switzerland. Upon his death, an obituary was published in the journal Annals of Surgery, which declared that Emil Kocher “the world’s best surgeon has died.”

In Vienna, Kocher studied under Theodor Billroth, considered to be the father of modern abdominal surgery. During that time, a case came along in which a patient, who had a dislocated shoulder for a long time, was brought into Billroth’s theater where Kocher was part of the audience. Every known method was tried to reduce the dislocated shoulder, but none succeeded.

Just as efforts were being abandoned, Kocher asked if he could try a technique he had recently developed.

Billroth agreed and Kocher succeeded in reducing the shoulder. His technique is still used today.

On Jan. 8, 1874, Kocher performed a total thyroidectomy on an 11-year-old patient, Maria Richsel.

In those days, thyroid goiters were operated on only when they were life-threatening: if the thyroid gland closed on the trachea and breathing became impossible. In a preoperative photograph, Maria was taller than her younger sister. Nine years after the operation, another photograph shows her as the shorter of the two siblings. This came to Kocher’s attention, along with the fact that, since the operation, Maria had undergone personality changes, and had become cretinoid in appearance. This prompted Kocher to investigate other of his thyroidectomy patients and he invited them for a checkup at his clinic. This is one

of the earliest, if not the first, example of a follow-up study. What he found was a high incidence of myxoedema (named cachexia strumiprivia), especially in children. During the late 1870s, textbooks deemed the thyroid gland a complete mystery in terms of its function and necessity. But with Kocher’s findings, for the first time, a great clue had been found and the mystery of the thyroid gland was unlocked.

Kocher performed a second study in which he operated on goiters, but this time, instead of doing a total thyroidectomy, he left a small piece of tissue intact. This tissue was enough to compensate, not only for normal physiology, but also in times of increased demand, such as pregnancy and childhood. This small, keen observation has changed the lives of millions of people for more than 100 years. By 1917, at the time of Kocher’s death, more than 7,000 patients had undergone operations at his clinic, three-fourths of whom he operated on personally.

Kocher was one of the first surgeons to espouse asepsis, and he adopted Joseph Lister’s principles of complete asepsis in surgery. He collaborated with Tavel, whose bacteriologic studies on infective processes he sought to advance. From this work came the second edition of Vorlesungen über chirurgische Infektionskrankheiten (lectures on surgical infectious diseases) (Kocher and Tavel, Basel, Switzerland 1892, and Jena, 1900). Kocher published his statistics religiously: In 1884, the mortality rate was 14%; by 1889, it was 2.4%; and by 1898, it was 0.18%. In his acceptance speech for the Nobel Prize in Physiology or Medicine in 1909, he claimed to have performed more than 300 consecutive thyroid operations without a single death.

These statistics made a worldwide impact, and many of the renowned surgeons of that period came to Kocher’s clinic to learn and disseminate this knowledge to their apprentices and colleagues.

Above are the photographs that Kocher published at the time of his discovery of the effects of thyroidectomy. Left: Maria Richsel is taller than her younger sister.

Right: nine years after Kocher removed Maria’s thyroid gland, her sister grew taller but Maria remained about the same height.

Studies of perioperative anxiety states show that lower anxiety yields better wound healing results (especially of the skin), in both pre- and postoperative periods. Kocher believed this to be true, and claimed that the physician should calm the patient both before and after surgery. He did so in such a way that the patient eventually was looking forward to the operation—a status that all of us would like to achieve with our patients!

Perhaps Kocher is less relevant today in the area of treatment methods and surgical techniques, and his work is being regarded and referred to less frequently.

However, with his pioneering techniques, he should be regarded more as a source of inspiration rather than a source of information.

Kocher received the Nobel Prize in Physiology or Medicine on Dec.10, 1909, for his work on the physiology, pathology and surgery of the thyroid gland.

17

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In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Genetic Analysis Inches Closer to Role in Inflammatory Bowel Disease Will Sharpen Surgical and Medical Decision Making; How Soon Is Debatable B Y C HRISTINA F RANGOU CHICAGO—Surgeons consider plenty of factors when deciding whether to operate on a patient with inflammatory bowel disease (IBD). What is the patient’s response to prednisone or

immunomodulators? Is he or she suffering frequent flare-ups? Are they developing life-threatening complications?

And soon, surgeons will factor in one more element into their decision making: a patient’s genetic makeup.

“How close are we to using genetics in IBD? Close. We’re pretty close. Soon, we will be doing surgical decision making using genes just like we do now for cancer,” said Walter A. Koltun, MD, professor of surgery and Peter and Marsha

Carlino Chair in IBD, Penn State Hershey Medical Center, Hershey, Pa. In a presentation at the 2012 Clinical Congress of the American College of Surgeons, Dr. Koltun said that scientific understanding of genes has progressed so far that genetic analysis will soon be used to subclassify and diagnose patients with IBD, similar to the way genetic testing is integral in diagnosis and management of patients with colorectal cancer.

Researchers have now identified many of the genes and gene mutations that come into play in IBD, said Dr. Koltun.

Now, the focus is on understanding how those genes influence outcomes in the disease. Once those studies are completed, genetic analysis can shift out of the research lab and into physicians’ offices and hospitals.

In the surgical field, the information gleaned from gene expression profiles will help surgeons and patients decide if a patient should have surgery early in the course of their disease and how aggressive clinicians should be in medical management pre- and postoperatively, said experts.

“Genetic analysis in IBD will happen but when depends on how you define ‘very soon.’ I think we’ll start applying it in clinical trials and experimental approaches in the next two decades,” said Alessandro Fichera, MD, professor of surgery, University of Washington Medical Center, Seattle.

What the research from Penn State, as well as other institutions, has shown is that the role of genes isn’t as simple as ‘one gene, one disease.’

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But moving personalized medicine out of the laboratories and into clinical practice is still some time away, he added.

“As far as genetic-directed approaches to therapy, I think it’s going to take a little longer before it is ready for prime time.”

Over the past two decades, researchers have come a long way in understanding genes and disease. Significant advancements came as the human genome project progressed. When it was completed in 2003, scientists had mapped out approximately 20,000 to 25,000 genes. With that accomplished, research efforts zeroed in on identifying links between specific genes and disease.

To figure out gene–disease associations, scientists carry out genome-wide association studies. Researchers compare a group of healthy patients with a group of patients with a particular disease and look at hundreds of thousands of single nucleotide polymorphisms (SNPs) to find correlations with specific disease types.

Researchers and surgeons at Penn State Hershey Medical Center have led the way in using genetic abnormalities that relate to IBD and surgical outcomes.

In 1998, physicians and researchers at Penn State established the area’s first IBD-dedicated BioBank, consisting of

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

three components: an IBD patient registry that characterizes the clinical factors that define subcategories of IBD, a DNA bank derived from patient leukocytes and an IBD tissue library, harvested at the time of surgery. Today, investigators have entered information collected from nearly 1,400 patients, some with three generations of family members in the registry.

The program is unique in that surgeons’ participation is front and center, said Dr. Fichera. “That means they can look at surgical outcomes in addition to medical. Because they started so long ago, they’re way ahead of the curve.”

What the research from Penn State, as well as other institutions, has shown is that the role of genes isn’t as simple as “one gene, one disease,” said Dr. Koltun. Instead, it’s a very complex process whereby numerous genes and predisposing factors interact with numerous environmental factors. The end result is a unique phenotype for patients with IBD. To date, about 300 SNPs and 100 genes have been shown to have an association with IBD. Some genes are affiliated with Crohn’s disease (CD), some with ulcerative colitis (UC) and some with both.

To date, the most important genes identified in IBD include IL23 pathway genes, which contribute to the immune responses that play a role defending against microbial infection and intestinal inflammation; TNFSF15, an immune regulatory gene associated with severe pouchitis and medication-refractory UC; and the NOD2/CARD15 5 gene.

In 2001, two groups independently identified NOD2, also known as CARD15, as the first susceptibility gene for CD (Naturee 2001;411:599-603, Nature 2001;411:603-606). The gene’s role in IBD is still somewhat murky. But there is no question the genetic mutation is strongly associated with ileal disease, stricturing disease and earlier-onset disease. (Interestingly, no role for NOD2 has been demonstrated in UC.) In almost every month of the past year, researchers have published studies looking at NOD2 and IBD and, most often, link the gene to poor outcomes. A study this summer reported that NOD2 mutations are an independent risk factor for surgery in patients with CD ((J Clin Gastroenterol 2012 [Epub ahead of print]). Another study, a single series of 185 patients, showed that a higher percentage of CD patients with NOD2 mutation carrier status were steroid refractory but could be treated well with other immunosuppressants (Dig Dis Sci 2012;57:879-886).

But none of this information has clear clinical implications as yet. Researchers hope that it will one day help provide patients with a personalized prognosis, especially regarding the natural history of the disease, said Dr. Koltun.

The potential benefits of “knowing genetically what the future of a young IBD patient will be is tremendous,” said Dr. Fichera.

A genetic approach to IBD could help direct therapy over a lifetime for patients with CD, who are usually diagnosed in their 20s or 30s. “We don’t know what their outcomes will be so, today, we subject them all—and I would add blindly subject them all—to very standard medical approaches and surgical treatment without knowing, in reality, who will benefit from them. We don’t know who needs a more aggressive approach, who

needs surgery right away or, for that matter, who we are overtreating.

“Imagine being able to let a 19-yearold girl, who has her entire life ahead of her, know if she needs aggressive therapy or an early surgery that could spare her years of treatment with the associated well-known side effects. That benefit is huge.”

One study published last winter clearly demonstrates that genetic analysis is getting closer to shaping surgical decision making in CD. Dr. Koltun and his colleagues studied the genetics associated with

ileocolectomy in patients with CD (Dis Colon Rectum 2012;55:115-121). They retrospectively reviewed results for 66 patients (30 male) with ileocolonic CD who previously underwent ileocolectomy and examined each patient for the 83 SNPs associated with IBD. Results showed that patients carrying the SNP rs4958847 in the IRGM M gene underwent surgery once every 6.87 years (±1.33 years). That’s nearly five years sooner than patients with the wild type genotype who average one operation every 11.43 years (±1.21 years; P=0.001).

P see IBD AND GENETICS PAGE 22

21

22

In the News MODIFIER 22 jcontinued from page 1

The study showed that, of all cases where modifier 22 was eventually applied at a community teaching hospital, only 23% initially included sufficient documentation on the original operative note. In all other cases, the hospital’s coding review specialists requested additional documentation from surgeons and residents before proceeding with the code.

“The study demonstrates that there is a need for residents and surgeons to better document when the modifier 22 should be applied,” said lead author Benjamin Jarman, MD, general surgery residency program director at Gundersen Lutheran Medical Foundation, La Crosse, Wis. Modifier 22 is added to current procedural terminology (CPT) codes to reflect the increased complexity beyond what is expected of a particular surgical case. It is the only way that a surgeon can obtain additional reimbursement for his or her time and energy in the operating room during unusually arduous cases.

Dr. Jarman and his colleagues reviewed billing and coding data, along with operative records for all patients who underwent one of six common general surgery operations between January 2006 and December 2010 at a community teaching hospital.

Over the study period, 1,610 patients met inclusion criteria for the six procedures selected: laparoscopic cholecystectomy, ostomy takedown, lysis of adhesions, small-bowel resection, ileocolectomy and mastectomy.

In all, modifier 22 was applied in 163 cases, or 10.1% of the general surgery cases, and resulted in a 20% to 33% increase in the total reimbursement.

The increase varied per procedure, ranging from an average increase of $834.60 for laparoscopic cholecystectomy to $1,802.15 for small-bowel resection.

The study also showed that modifier 22 was associated with a delay in payment, which often is a deterrent for surgeons considering using the modifier. Payments arrived between one and 29 days later than usual when the code was used in five of the six procedures studied.

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Unexpectedly, reimbursement for mastectomy arrived two days earlier when n modifier 22 was applied.

The speedy reimbursement foor mastectomy likely reflects the instiitution’s increased experience in append ding for modifier 22 in these cases, said investigators. At the hospital where th he study took place, surgeons use staandardized operative notes for tissu ue-sparing cases where modifier 22 freq quently is used.

The investigators said they did not find the delays to reimbursement “un nreasonable.” They originally planned th he study to examine if modifier 22 delayed d reimbursement enough to negate any benefit of increased reimbursement.

As a result of their study, the hospital has launched a program to improve education for modifier 22 use, particularly for residents and attending surgeons.

The CPT rules state that modifier 22 should be used only when additional work factors requiring the physician’s technical skill involve significantly increased work, time and complexity compared with a typical case. The additional work and time must be clearly documented for the code to be approved.

Coding experts say it is not enough to simply state that the procedure was a reoperation or a revision, or to outline a patient’s comorbidities.

Medicare and the American College of Surgeons recommend that providers intending to submit a claim with modifier 22 prepare a written statement outlining what made the service unusual. They suggest placing a separate paragraph in the operative note with a heading “Unusual Procedure” that briefly describes why the service was unusual.

“If you’re going to code for it, the physician has to document for it right here in the [operative] report. Sometimes surgeons get on automatic pilot and they don’t detail why a case was difficult. But when a case is a lot more work, [they should] describe exactly what that work was,” said Betsy Nicoletti, author

AT A GLANCE Modifier 22 is a code used for atypically arduous cases, and when applied correctly, can result in higher reimbursement for surgeons.

In a study at one hospital, applying the modifier 22 code resulted in a 20% to 33% increase in pay in general surgery procedures.

Researchers found that detailed documentation is the key: Surgeons should not assume that applying modifier 22 will automatically result in increased reimbursement.

It is not enough to simply state that the procedure was a reoperation or a revision, or to outline a patient’s comorbidities.

Medicare and the American College of Surgeons recommend preparing a written statement outlining what made the service unusual.

IBD AND GENETICS jContinued from page 21

“The presence of this IRGM M SNP [rs4958847] may be a marker for disease severity and/or early recurrence after ileocolectomy and may assist in surgical and medical decision making,” the investigators concluded.

The results of the study might help identify patients who can be spared expensive biologic therapies after surgery, said Dr. Koltun. Most patients who undergo ileocolectomy eventually require a second procedure for recurrent disease. However, about one-fourth of patients

will go 15 or 20 years before they experience a recurrence. “That subset would be helpful to identify because those patients probably don’t need expensive and dangerous drugs like TNF [tumor necrosis factor] antagonists or immunosuppressants. Those patients can get a very good response from surgery alone,” Dr. Koltun said.

Patients with UC, too, stand to benefit tremendously from a personalized approach to surgical management, said experts. A genetic analysis could be used to help predict the likelihood of complications such as fistuli or severe pouchitis following an ileal pouch. If their probability is high, then “you might not decide to do the

‘Sometimes surgeons get on automatic pilot and they don’t detail why a case was difficult. But when a case is a lot more work, [they should] describe exactly what that work was.’

—Betsy Nicoletti, coding expert of The Field Guide to Physician Coding.

“Say why and how it was more difficult than a typical case.”

Madhavi Perumpalath, a certified professional coder with the health care accounting and consulting firm PYA GatesMoore, Atlanta, urged surgeons to request additional reimbursement when appropriate.

“Please don’t assume the payer will increase reimbursement because they see modifier 22. As part of your cover letter, recommend an appropriate payment. … If you don’t ask, you could end up with the standard payment only.”

She added that surgeons should use simple medical explanations and terminology in their request. “It must be clear to a lay person.”

Dr. Jarman cautioned that modifier 22 should not be overused. “We applied the M22 in less than 11% of the procedures reviewed. We think that it is very appropriate to seek additional reimbursement for time and effort when appropriate.”

In this study, cases with modifier 22 applied were associated with a longer hospital length of stay, higher body mass index and, for laparoscopic cholecystectomy, a higher American Society of Anesthesiologists physical status classification.

operation,” said Dr. Koltun.

Or, it could be used to detect a patient’s risk for cancer.

“We could potentially save them from yearly colonoscopies, multiple biopsies, or the risk for missing a cancer,” said Dr. Fichera.

Experts say they expect IBD will follow the paradigm of cancer care where personalized medicine is becoming a standard. “I think this is not that different than colorectal cancer. I believe the use of genetic analysis probably will be a paradigm for care for all our patients in the future as we approach this personalized medicine concept,” said Dr. Koltun.

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Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

SCIPPERY SLOPE jcontinued from page 1

commands us to give a β-blocker and an antibiotic.

Woe to the anesthesiologist who misses the magic hour before incision or without explanation holds metoprolol in a bradycardic patient.

Then there is the mandatory computer-based education that instructs us to be caring, do the right thing and dump garbage in the appropriate color-coded bins— followed by a test. Why bother with medical school and residency? You can’t make this stuff up!

Some centuries ago, Alexis de Tocqueville (or was it Machiavelli) explained how control of a population can be simply achieved by forcing compliance with many relatively small and innocuous requirements. Sounds a lot like the multiplicity of rules and expected behaviors coming down daily from the hospital, insurers, the government and even our own colleagues. A doctor could once choose from multiple diagnostic and therapeutic pathways, like a driver motoring down a wide interstate picking a lane. Now that same physician must navigate a narrowing European cobblestone alley.

In a recent issue of The New Yorkerr magazine, Atul Gawande, a Harvard surgeon, wrote about the efficiencies, quality and cost control of the Cheesecake Factory restaurant chain as a model for improvements in medical care delivery. Airline pilots no longer, our new role models deliver crab cakes and teriyaki chicken … but, oh so efficiently.

vogue in the 1970s. These ideas subsequently penetrated state universities and community colleges, became part of the standard curriculum and spread mimetically throughout the culture. Today art, architecture, critical theory, science, medicine, psychiatry and in many ways life in general are viewed through the postmodern lens.

A cornerstone concept of postmodern philosophy is the importance of the collective over the individual.

(Incidentally, this is curious since postmodernism developed out of existentialism, in which individual responsibility was paramount). As reported by Roger Kimball in his book, “Tenured Radicals: How Politics Has Corrupted Our Higher Education” (Ivan R. Dee), a 1984 Stanford University conference of “formidable scholars”

essentially declared the death of the concept of the indivvidual as defined by classic liberal Enlightenment thinking, the American Declaration of Ind dependence and the U.S. Constitution. In n its place was an ill-defined “reconstructed post-culturral entity,” whatever that means. m The postmodern generation iss obsessed with the idea that w we are all in this together. This is sso obvious a truism as to be banal, but do they take it too far? Does this approach translate to remote control of medical decision making by anonymous experts, far removed from a particular doctor–patient interaction? In Dr. Gawande’s view, at least, such a system deserves a chance—indeed, he argues, it’s the future for many hospitals.

Our leaders may not deliberately have decided to deconstruct Marcus Welby, M.D. and his weekly TV struggles against medical conformity. But trapped in their postmodern Weltanschauung, they simply could not help themselves.

—Dr. Kron is a semiretired anesthesiologist in Hartford, Conn.

A Postmodern Infection We have all heard about the advantages of replacing the individualistic physician making clinical decisions based on his judgment, education and experience with uniform algorithm-driven medicine. Minimizing variation and increasing predictability, we are told, will improve care and decrease costs. But, in addition to those practical reasons, I believe deep structural changes must have occurred to allow this viewpoint, unthinkable a generation ago, to become an everyday reality.

I believe the answer lies in the migration of postmodern continental philosophy to the elite bastions of American education. Today’s medico-political-educational opinion leaders, Boomers and Gen Xers, alumni of Ivy League schools—the best of the “best of the best”—came of age in an atmosphere steeped in the words of Derrida, Lyotard, Foucault, Baudrillard and other intellectuals whose thoughts and writings were in

GSN is now on

follow us @gensurgnews Chad Hoover, Ephemera #11, oil on canvas. For more information on the artist and this series, visit www.chadhooverart.com.

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

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Radiofrequency Ablation for Barrett’s Esophagus Appears Safe for Older Patients B Y T ED B OSWORTH SAN DIEGO—Radiofrequency ablation (RFA) has become the dominant therapy for treating dysplasia related to Barrett’s esophagus (BE), a disease that becomes more prevalent with age.

Although RFA is known to be effective and reasonably safe overall, it has only recently been studied as a treatment for older patients.

“Younger patients appear to achieve higher rates of complete eradication of intestinal metaplasia and to do so in a shorter time frame, but older subjects appear to tolerate RFA as well as younger subjects,” said Milli Gupta, MD, Mayo Clinic, Rochester, Minn., one of the authors of a study comparing the efficacy and safety of RFA in older versus younger patients. Dr. Gupta, who conducted the study with senior author, Prasad G. Iyer, MD, also at Mayo Clinic, noted that the rates of recurrence did not appear to be accelerated in older patients and that the data do not support different patterns of surveillance for BE after RFA, based on age. Dr. Gupta provided the results of this multicenter retrospective study at the 2012 Digestive Disease Week (DDW) meeting.

The study included 529 patients treated with RFA over an eight-year period at three participating centers involved in BE research. Eighty-three percent of patients were younger than age 75 years and 17% were older than age 75 years. The mean follow-up after RFA was approximately two years for both groups. There were no significant differences in baseline characteristics, such as length of BE in centimeters and presence of diaphragmatic hernia. The exception was a greater proportion of older patients had high-grade dysplasia (38% vs. 32%; P<0.0068).

The difference in the mean time to complete eradication of intestinal metaplasia (1.21 vs. 1.37 years; P<0.0033) and the proportion who achieved this eradication (44% vs. 27%; P<0.0034) favored younger patients, but none of the complications, including bleeding (0.68% vs. 0%) hospitalization (0.68% vs. 0%) or esophageal tears (0.22% vs.

1.1%) were statistically significant when the groups were compared.

These data are useful because they encourage the use of RFA even in older individuals, who may have more complications if their lesions progress to

cancer, said Julian Abrams, MD, MPH, assistant professor of medicine, Columbia College of Physicians and Surgeons, New York City.

“The average age of [patients with] esophageal cancer is over 70 years of age and older patients are frequently poor candidates for surgical resection. As such, we often end up performing endoscopic

therapy for Barrett’s esophagus with high-grade dysplasia or intramucosal carcinoma in older patients,” said Dr. Abrams, who was not involved in the study. “It is therefore very reassuring to see that RFA has a comparable safety profile in an older population compared with younger patients.”

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Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Looking at the Mountain, Instead of Your Smartphone B Y P ETER J. P APADAKOS , MD

G

rowing up in New York City with its high pulse and 24/7 lifestyle, I always looked forward to the family tradition of summers in the idyllic Adirondack Mountains. The tranquility of looking out from the deck at the mist over Mirror Lake and at the mountains with their many changing colors of the seasons has always cleared my soul. As my professional life has become more complex with constant patient care issues, administrative duties and academic deadlines, I have always looked forward to the distraction-free cocoon of nature. I have always returned feeling cleansed, rested and ready to pick up the many pressures and challenges of modern medical practice.

But lately I have noticed an unsettling—and ironic—change. In the past few years, my research and teaching has concentrated on the topic of electronic distraction in professional practice, and in particular how personal electronic

devices have weakened our ability to focus on patient care. In my view, the proliferation of digital technology in the hospital has done tangible and significant damage to the way physicians interact with patients.

Now, it seems, the focus of my professional life is threatening to consume my time away from the office. This summer while on the family holiday in Lake Placid, I received more than 1,000 workrelated emails and texts. My co-workers and colleagues throughout the world evidently were unable to understand the message on my email system, “Dr. Papadakos is on vacation in the Adirondacks and has limited Internet access.” The majority of people and organizations in my life for some reason needed an immediate response. Many of them sent follow-up emails asking me to respond at once. Some called to verify that I had received their all-important email about a meeting two months in the future. The hyper-social need for responses is now pervasive in all forms of communication.

This obsession that we need to be “in touch” and work without rest, troubles me deeply. Many of us remember the

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Constant emailing and texting is not a replacement for real human interaction.

At the same time, neither is it unobtrusive or, to co-opt a term from the operating room, noninvasive. endless debates in the lay press about the work hours of residents. Back then, physicians needed rest! This debate predates the technology-filled world of smartphones and tablets. What do we do in our new technological world that we and our residents are required to respond to emails, check electronic medical records for lab results and reports, and field texted questions? The business literature is increasingly populated with articles demonstrating that pressure to work “around the clock,” and on days off, leads not to corporate nirvana but to fatigue and lower productivity. There is no reason to believe that health care professionals, whose lives are at least as stressful, if not more so, than those of their colleagues in the business world, would be any less prone to burnout.

This constant electronic work also will affect the dynamics of the work force and may push senior staff to the pointt of quitting or substantially scaling backk their workload.

The never-ending fatigue also mayy lead to irritability—a well-documented phenomenon in the business world—and a lack of focus that may affect both social interactions and patient safety.

Constant emailing and texting is not a replacement for real human interaction.

At the same time, neither is it unobtrusive or, to co-opt a term from the operating room, noninvasive. As professionals,

we need to recognize that we all need time away from our many work-related duties. Many industries have already decreased off-hour and vacation communications with staff. We in health care must educate our hospitals and departments to follow this lead and limit emails and communications after hours and on holidays. Staff should be removed from automated email deliveries when on vacation. We all need time away to sit and look at the mountains. So turn off your phone, refrain from checking email and read a good book on the shore of your own Mirror Lake. You and your family are on vacation.

—Dr. Papadakos is professor of — anesthesiology, surgery and neurosurgery at the University of Rochester, in Rochester, N.Y.

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Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Why Do 31% of General Surgery Residents Need Remediation?

B Y S KEPTICAL S CALPEL [The following editorial was originally posted as a blog on Oct. 22, 2012. You can read this entry as well as comments to this blog at www.generalsurgerynews.com and search under the blog section in the upper right.]

A

recent paper in Archives of Surgeryy looked at the rate of resident remediation over a decade or so at six general surgery programs in California (2012;147:829-833). The authors reviewed the records of 348 categorical general surgery residents and found that 107 (31%) required remediation with knowledge deficits the primary reason in 74%. Other issues, such as interpersonal and communication skills, patient care and professionalism, were cited far less often.

I understand that those accepted to medical school are smart, but how is it that two-thirds of the class can achieve honors in surgery?

The need for remediation did not correlate with attrition. Remediated residents left programs at a rate of 20% compared with 15% of non-remediated residents (P=0.40).

P On multivariate analysis, only two factors were associated with the need for remediation. One was United States Medical Licensing Examination step 1 scores, which were lower in the remediated group. But the median difference in scores between remediated and nonremediated residents was only several points, with wide and overlapping interquartile ranges, and both median scores were above the average for all medical students over the years of the study.

The other factor was quite remarkable.

Remediated residents were significantly more likely to have received a grade of “honors” for their medical school clerkship and surgery. How can this be?

The authors speculated: “One thought is that medical students start residency underprepared for the rigors of surgical residency.” Now where have I heard that before?

I have previously blogged on General Surgery Newss at www.generalsurgerynews. com about the unrealistic third-year experiences of medical students on surgical rotations. Although I agree that they likely are not ready for the workload, I’m not sure what it has to do with the primary reason for their poor performance— a perceived knowledge deficit. Does hard

work cause them to forget everythingg they’ve learned or are they taught the wrong stuff in medical school?

I think not. The real reason may be found in the way medical studentss are graded. A group from Harvard loooked at medical school grading systems and found that honors grades in third--year surgery clerkships are given to an aveerage of about 30% of students ranging from f m a low of 7% to a mind-boggling high of 67% (Acad ( Medd 2012;87:1070-1076). I

un understand that those accepted to medical school are smart, but how is it that two-thirds of the class can achieve honors in surggery? Could it be that some of the hoonors grades given to residents who eveentually needed remediation were not warranted?

Iff you would like to read more about grades in medical school, you can read grade a summary on my personal blog at skepticalscalpel.blogspot.com.

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical subspecialty and has recertified in both several times. For the past two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 300,000 page views, and he has in excess of 3,700 followers on Twitter.

Take a skeptical look at surgery.

The Skeptical Scalpel posts a weekly blog on issues most relevant to surgical practice. Join the conversation at GeneralSurgeryNews.com by clicking on the “Blogs” tab at the upper righ right.

27

GSN Bulletin Board The Division of General Surgery at the University of Washington School of Medicine is seeking applications for a full-time, non-tenured faculty position in the Urgent Care Surgery section at the rank of Acting Instructor, Assistant Professor, or Associate Professor, depending upon the applicant’s credentials. This position will be on a service with three other attending surgeons and will be based primarily at the University of Washington Medical Center. The main responsibilities are to develop a general surgery practice, with a focus on urgent surgical consults and referrals, and to participate in the teaching of surgical residents, medical students, and division fellows. The successful candidate will be expected to develop an area of scholarly expertise, as expected of every faculty member, in consultation with the Division and Section Chief. The University of Washington Medical Center is a nationally recognized academic medical center offering outstanding specialty and primary care. UW faculty engage in teaching, research, and service. The candidates must have an MD (or equivalent) and be board certified or board eligible (or equivalent) in surgery. In order to be eligible for University sponsorship for an H-1B visa, graduates of foreign (non-U.S.) medical schools must show successful completion of all three steps of the U.S. Medical Licensing Exam (USMLE), or equivalent as determined by the Secretary of Health and Human Services.

The University of Washington is an affirmative action, equal opportunity employer. Applicants should submit their curriculum vitae, a cover letter, and references to: Brant K. Oelschlager, MD Byers Endowed Professor in Esophageal Research Department of Surgery, General Surgery Division University of Washington 1959 NE Pacific Street, Box 356410 Seattle, Washington 98195-6410 Email: brant@uw.edu

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

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

Inpatient Surgical Positions Hospital-based Surgical positions with excellent earning potential available in Northeast Ohio areas.

• Paid malpractice • Flexible scheduling and • No On-Call.

John S. Martin at Physician Staffing 30680 Bainbridge Rd, Cleveland, OH 44139 Phone: 440-542-5000 Fax: 440-542-5005 E-mail: jobs@physicianstaffing.com

We’re in a

position

is part of the LifeBridge Health System. There are opportunities within Wound Care and HBOT. Bariatric Surgery is also offered but should not be the primary focus for this position. This is really a position for a Bread and Butter General Surgeon. You will join an established and busy practice which enjoys an excellent reputation in the community. The practice has multiple locations allowing for a wide catchment area for the candidate to work from. Excellent compensation and benefits is offered.

Please contact Margie Quinlan, Lawlor and Associates, 800-238-7150 or 610-251-6852; fax 610-431-4092; email: margie@lawlorsearch.com

to fill your

position

GSN-12-003

For classified advertising: contact Alina Dasgupta 212-957-5300 x338 adasgupta@mcmahonmed.com

GSN-1108-001

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GSN Bulletin Board

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GSN-1212-002

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Opinion

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / DECEMBER 2012

The Day I Knew It Would Be OK To Stop Operating B Y C. R ICHARD P ATTERSON , MD [The following was originally posted as a blog on Oct. 11, 2012, at www.generalsurgerynews.com under “Once a Surgeon” in the blog section at the upper right.]

S

he was in her late 30s when her medical oncologist asked me to see her.

Five years before, one of our community surgeons had removed part of her colon for cancer. She also had a recognized, single metastatic tumor in her liver at the time of that original surgery.

The contemporary standard of practice was to treat for a prescribed period of time with chemotherapy and then re-evaluate for the appearance of other tumors. If there were none, the patient would be a candidate for surgical removal of the liver metastasis.

She completed the chemotherapy protocol, and she had no further lesions. But she was deemed not to be a candidate for liver surgery, because the metastatic tumor had invaded the right hepatic vein and the inferior vena cava, just below the junction of the vena cava and the right heart. At the time, that judgment was current and correct.

Surgically stymied, her oncologist continued to treat her with chemotherapy, and in those five years, her metastatic tumor neither grew nor shrank, and no other tumors appeared. Her surgeon had retired in the interim, and her oncologist, knowing my interest in liver surgery, asked me to evaluate her.

Timing is everything. Two months or so before I met her, I read a report by a French surgical group on “total hepatic vascular exclusion” (THVE) as a technique for safely removing tumors like hers. THVE entailed controlling all blood vessels leading into and out of the liver, and I had managed all the elements of the procedure multiple times, with the exception of the junction of the vena cava and the heart and the partial removal and repair of the vena cava.

I had the good fortune to serve on the surgery faculty for several years, and during that time I worked with a man from his medical school days through his general surgery and cardiothoracic surgery residencies. I knew him to be a talented surgeon, but more importantly a judicious one, one to whom I would entrust my family and myself. We discussed the patient’s circumstances and THVE. When I met the patient, I explained the anatomy and the technique, the risks and the fact that my co-surgeon and I had never combined all the elements of THVE for the removal of a tumor like hers. She understood and asked that we perform the operation.

We collaborated with the anesthesia team on potential consequences of and remedies for the sudden interruption of blood return from the lower body to the heart.

The day came for the procedure, and it went perfectly.

She was stable throughout, even during the cessation of vena cava flow to the heart. We achieved a clean removal of the tumor, along with the right liver and a section of the vena cava. The latter was reconstructed by my cosurgeon with a more than sufficient residual caliber. She recovered rapidly and completely, and she continued to do well during follow-up.

It is no small matter for a surgeon to stop operating. Despite all the very wise advice against being

I came to appreciate that improving the systems and processes of patient care was just as valuable as providing the hands-on care, and I knew that at some point I would devote more and more of my time to the former rather than the latter.

defined by your work, surgery is an absorbing passion and becomes in large part what you are rather than merely what you do.

When I was a young surgeon, I saw too many fine surgeons continue beyond the limits imposed by age.

What would have been admirable careers were tainted by their staying too long, and I vowed that I would stop operating [when] at my best.

I don’t really know what “best” is. You might even convince me with little effort that there is no such thing.

I do know this, though: Throughout my career I always had the sensation of getting better, more able and more knowledgeable. The operation we performed for that young woman was not the most difficult, demanding or dangerous one in my career, not by a very long shot.

In its aftermath, however, I realized that the years of study, repetition, teaching and discipline had produced a moment in which we were able to offer her something valuable and novel. I also realized that I had hit a plateau, much like that experienced by runners. Unlike a runner, I saw no way to change my training regimen and resume an ascendant arc. The effort I had always put into improving my capacity would now be consumed in maintaining it, with the inevitable and ultimate slide downward.

Quitting the operating room was probably less difficult for me than for most of my peers. For one thing, I always felt a bit odd during training. I never experienced the obvious zeal my co-residents had when the

chief resident assigned them a case (“Oh man, I’ve got a gallbladder tomorrow!”).

Surgery attracted me for its emphasis on defining the problem, devising the solution, and then making the solution a reality through technical proficiency. It was not the surgical act alone that compelled me me. I therefore could not miss the adrenaline rush that I had never known.

Early in my career, I also was very fortunate in becoming involved in management of the scarce resources we had to care for patients in our safety-net hospital.

I came to appreciate that improving the systems and processes of patient care was just as valuable as providing the hands-on care, and I knew that at some point I would devote more and more of my time to the former rather than the latter. I was emotionally and mentally prepared, therefore, to make the move when given the opportunity to be the first chief medical officer for my hospital. This new work is challenging and rewarding, and I have never regretted my decision, although I do miss the intimacy of the patient–doctor relationship.

There is one shadow on the matter: Many people and many resources contributed to making me a surgeon, and I had more than several years of useful service left in me when I made the transition to nonclinical work.

Should I have stayed the course to more fully repay those investments, and was my decision overly selfish?

I can only reconcile the debt by leveraging all I learned as a surgeon and all I am learning as an administrator to help advance the ball.

—Dr. Patterson is a surgeon and chief medical officer in — South Carolina. His blogs can be found at www.dailydudley.com as well as at www.generalsurgerynews.com.

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