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MISS eNEWS

Improving Patient Outcomes with Minimally Invasive Surgery

Each month, MISS eNews brings you the latest on novel minimally invasive techniques and findings from around the world.

 

Click here or the button below to sign up to receive monthly issues of MISS eNews.


 

 

MISS NEWS

Vol. 8 No. 14


 

Introduction

This month we feature an interview with Cleveland Clinic fellow Katherine Meister, MD. Dr. Meister is currently serving a fellowship in advanced laparoscopic and bariatric surgery at the Cleveland Clinic in Cleveland, Ohio, and this coming fall she will begin as staff surgeon with TriHealth in Cincinnati, Ohio. This interview focuses on current fellows’ and residents’ mindsets on some critical topics, including pay fellowship criteria, industry and fellow/resident education, women surgeons and academia, mentoring, social media, and more. Dr. Meister’s informed perspective provides candid but balanced insights.
Also, don’t miss the article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. Enjoy!
Colleen Hutchinson

 

Colleen: How did you decide what type of job you wanted (employed, academic, private)? How did you go about finding a job?
Dr. Meister: While a resident, I was recruited by my residency program to return upon completion of my fellowship. I will be hospital-employed, joining a large group of general surgeons, with two other bariatric surgeons. Although my program is not associated with an academic institution, I will still have a teaching role with the residents and rotating medical students. I felt like this was the ideal job for me; I was never really drawn to the research aspect of academia, but feel that it is important to teach and train the next generation.
Colleen: What did you look for in a fellowship?
Dr. Meister: There are the usual things—case logs, number of trainees, clinical expectations, personalities during the interviews, etc. I was looking for the complexity level of the cases and variation in the technical aspects of the cases. Being exposed to different techniques (hand sewn anastomosis, linear stapler, circular stapler) would provide me with options in the future. While I will end up having my preferred approach, it is important to have a back-up plan. I felt that exposure to the complex cases, such as revisions and complications, would best prepare me for future—If I knew and understood how to manage the tough cases, then the rest should be straightforward.

 

Colleen: Do you think fellowships are mandatory prior to entering the workforce?
Dr. Meister: I think that depends on what field you are interested in joining. For many specialized fields, the exposure and experience during residency is not enough to prepare a young surgeon to enter the workforce. However, for residents wanting to pursue a general surgery practice, I believe there are residency programs that more than adequately prepare residents to go directly into the workforce without additional training.

 

Colleen: What are the three most relevant factors that affect the graduating fellow’s decision about career choice?

Dr. Meister:

  1. Location
  2. Scope of practice (how much general surgery versus bariatric; academic versus community)
  3. Experience and availability of partners/mentors

Colleen: What changes you suggest to have the upcoming generation better prepared to be in practice?
Dr. Meister: Focus training on the complete preoperative and postoperative care of a surgical patient. As much as trainees want to be in the operating room, there is more to training than learning how to operate. When you enter the “real world,” you have to be comfortable with all aspects of the preoperative and postoperative management of the patient, and a lot of this decision-making process occurs in office.
Graduated autonomy during training is another suggestion. In the real world, you won’t have an attending/partner there to assist through an entire case. I think that by completion of training, the trainee should be able to perform most cases with little to no help from the attending.
Also, another suggestion is structured mentorship upon entering practice. Even though we are finished with training, we aren’t done learning and we will still have questions. It is important to have someone with more experience that you can rely on to discuss clinical cases, academic advancement, the business of a practice, work/home balance, etc.

 

Colleen: Do you feel comfortable understanding the business aspects of a practice?
Dr. Meister: No. We hear bits and pieces of the business of medicine throughout our training. For the majority of us, there is no formal training in the business of a practice.

 

Colleen: Are you comfortable with the job market available?
Dr. Meister: No. I am very lucky to be in the position I am. Having signed prior to starting fellowship allowed me to focus this year on my education. Unfortunately, I know of a number of fellows who are currently still looking for a job with three months to go until the end of fellowship.

 

Colleen: How many cases (sleeves and bypass) have you done? How many bypasses are enough in fellowship?
Dr. Meister: I am currently three quarters of the way through my 12-month fellowship. I have completed 115 bariatric cases: 64 bypasses, 36 sleeves, and 15 revisional procedures. While there is currently a set number of cases (100) and bypasses or anastomotic procedures (50) required to obtain the fellowship certificate from the ASMBS, I believe that setting a number to determine “competency” is often a misrepresentation of if and when a trainee is ready. I think more formal evaluations from attendings to determine when a trainee is competent or safe with a particular procedure would be a better marker than merely the number of cases a trainee logs. But I think this takes a lot of dedication from the attendings and would definitely be a shift from our current system.

 

Colleen: How would you characterize industry’s role in surgeon and especially fellow education?
Dr. Meister: There is definitely a symbiotic relationship between the surgeon and high tech industry. From a minimally invasive surgery standpoint, the field has been able to develop and flourish because of technology advances from industry. Because of those advances, laparoscopic cases are now the standard of care for many procedures. We wouldn’t be able to perform the procedures that we do if it weren’t for the technology that has allowed the instrumentation for these approaches. As far as industry’s role in fellow education, there have been industry-sponsored courses that give us the opportunity to learn how to use the instruments, energy devices, staplers, etc. on live tissue, in a low-stress educational environment. This is typically in conjunction with lectures on the science behind product development, which is definitely educational for trainees.

 

Colleen: What is the biggest challenge today facing female surgeons who are on an academic path, and how do you feel about the current state of gender salary equity in surgery?
Dr. Meister: There are currently only 16 female chairs of the department of surgery. The Association of Women Surgeons has published a statement on gender salary equality that discusses a lot of the inequality issues. We are still fighting stereotypes in a male dominated field. While there have been improvements, there are still a number of disparities. There are a lot of factors that contribute to the pay disparity, but the inequality is real. I think that it is progress that we are aware and we are discussing this as an issue, but the current rate of change is too slow.

 

Colleen: Do you feel social media is a good tool for surgeon and clinician education, and do you use it?
Dr. Meister: I think the social media is a really hot topic right now. I’ve been to many of conferences recently that feature lectures on how to incorporate social media into your practice. I have never used any form of social media in my personal life, which has probably held me back from getting active from a professional standpoint. I definitely see the value in using social media as a means of education, communication, and collaboration.

Suggested Readings


Foregut

Article: GERD and acid reduction medication use following gastric bypass and sleeve gastrectomy. Barr AC, Frelich MJ, Bosler ME, Goldblatt MI, Gould JC. Surg Endosc. 2016;31(1):410-415.
https://www.ncbi.nlm.nih.gov/pubmed/27287901
Dr. Dmitry Oleynikov: Obesity is often accompanied by GERD. However, the literature is still inconclusive as to whether Roux-en-Y gastric bypass provides better outcomes and esophageal symptoms resolution than sleeve gastrectomy. This study addressed acid reduction medication use in patients at 12 months after bariatric surgery. Patients who underwent Roux-en-Y gastric bypass were found to have less overall use of antireflux medication at 12 months postoperative compared to patients who underwent sleeve gastrectomy.

 

Article: Post-Nissen dysphagia and bloating syndrome: outcomes after conversion to Toupet fundoplication. Schwameis K, Zehetner J, Rona K, et al. J Gastrointest Surg. 2017 Mar;21(3):441-445.
https://www.ncbi.nlm.nih.gov/pubmed/27834011
Dr. Cory Richardson: The reported side effect profile of Nissen fundoplication has made this effective antireflux procedure less attractive to the general public as well as referring physicians. The incidence of persistent symptoms such as dysphagia and bloating is relatively low in experienced hands, and although most symptoms are mild, some patients will report more severe symptoms and a significant decrease in quality of life. The goal of improving the side effect profile while not compromising the efficacy of the antireflux procedure in these patients can be challenging. The authors discuss their success with conversion from Nissen to Toupet in 25 of these patients. Dysphagia resolved in 84% and bloating resolved in 100% of patients reporting those symptoms preoperatively. Two patients developed clinically significant reflux requiring redo Nissen, and no major complications were noted. This appears to be a very effective strategy for patients with postoperative Nissen side effects. The authors point out that most of these patients could have been identified as better candidates for partial fundoplication at their index operation, reminding us of the importance of an individualized and comprehensive preoperative workup.


Endoscopy

Article: Laparoscopic and luminal endoscopic cooperative surgery can be a standard treatment for submucosal tumors of the stomach: a retrospective multicenter study. Matsuda T, Nunobe S, Kosuga T, Society for the Study of Laparoscopy and Endoscopy Cooperative Surgery, et al. Endoscopy. 2017 May;49(5):476-483.
https://www.ncbi.nlm.nih.gov/pubmed/28395384
Dr. Vivek Khumbari: This large retrospective case series of 126 patients from 8 centers in Japan describes how luminal endoscopic cooperative surgery (LECS) can be used to resect gastric GIST tumors between 2 and 5cm in size with minimal gastric resection. LECS utilizes the simultaneous use of the flexible endoscope to expose and free the lesion whilst the laparoscope ensures the security of adequate defect closure and management of bleeding. In this series, 26.2% of tumors were located in the upper stomach or esophagogastric junction. At a median follow-up of nearly 5 years, no local or distant recurrence was detected. The morbidity of the procedure was low at <5%. LECS may be a useful alternative to standard laparoscopic wedge resection of gastric GIST tumors.

Article: Endoluminal vacuum therapy for esophageal and upper intestinal anastomotic leaks. S Leeds, J Burdick, J Fleshman. JAMA Surg. 2016 Jun 1;151(6):573-4.
https://www.ncbi.nlm.nih.gov/pubmed/27074117
Dr. Rees Porta: This innovative concept was devised in Germany but has been accepted and implemented at Baylor University. This article describes the technology and the technique utilized. In short, the authors use a sponge (like what is widely used for negative pressure wound healing systems of the soft tissue) attached to an NGT and placed endoscopically. There are excellent published healing rates of a variety of GI leaks (esophageal, anastomotic, colorectal, etc.) with animal models specifically looking at gastrojejunostomy leaks as well as a retrospective study (by the same group) looking at sleeve gastronomy leaks where all nine patients had resolution of their leak (including 5 that had already failed stenting). Although this technique requires frequent endoscopies with sponge exchange and the associated high costs, it seems to have multiple applications and may be a consideration for anastomotic leaks not responding to traditional treatments.


Hernia

Article: Hidden morbidity of ventral hernia repair with mesh: as concerning as common bile duct injury? Kummerow BK, Huang LC, Faqih A. J Am Coll Surg. 2017 Jan;224(1):35-42.
https://www.ncbi.nlm.nih.gov/pubmed/27725219
Dr. Ajita Prabhu: I like this article because it brings a fresh perspective to the serious nature of placing implantable devices in patients, and the complications that can occur as a result. This is something that we all get comfortable with, and it's easy to forget that the complications can be catastrophic.

Article: Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair? Hernia. 2017 Jun 19. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28631104
Dr. Guy Voeller: While not a randomized trial, this study shows what occurs in the every day surgical world throughout the United States. This study was done in response to the AORN trying to eliminate the traditional surgeons skullcap without any data to support this move. The American College of Surgeons (ACS) actually resisted this move by AORN and this data from the AHSQC supports the ACS resistance.


Colon

Article: Hand-assisted laparoscopic versus standard laparoscopic colectomy: are outcomes and operative time different? J Gastrointest Surg. 2016 Nov;20(11):1854-1860.
https://www.ncbi.nlm.nih.gov/pubmed/27456018
Dr. Steven Wexner: Since the adoption of laparoscopic colorectal surgery in 1991, it has evolved to theoretically less invasive methods including NOTES, transanal total mesorectal excision, and single port surgery. Interestingly, there has been a divergent pathway to the more invasive hand-assisted surgery. Multiple small single center series have postulated that the significant increase in incision length needed to perform hand-assisted surgery is justifiable due to the alleged improved tactile feedback allowing reduced operative time. Gilmore and coworkers tested this hypothesis through the National Surgical Quality Improvement Program participant data use file. They specifically queried the NSQIP database for patients who underwent either laparoscopic or hand-assisted colectomy between 2012 and 2013. During this time period, 7,865 patients (56.4%) underwent laparoscopic colectomy while 6,084 patients (43.6%) underwent hand-assisted surgery. As compared to patients who underwent laparoscopic colectomy, patients who underwent hand-assisted colectomy had higher rates of postoperative ileus (8.7% vs 6.3% p=0.001), wound complications (8.8% vs 6.3%, p=0.006), and 30-day readmission (7.5% vs 6.0% p = 0.002) without any differences in operating time (156 vs 157 minutes).
When subgroup analysis of patients who underwent segmental colectomy was undertaken as compared to laparoscopy, hand-assisted surgery remained associated with high rates of wound complications (8.6% vs 6.5% p=0.016), postoperative ileus (8.9% vs 6.3% p= 0.001), and 30-day readmissions (7.1% vs 5.9% p=0.041) with a failure to show any reduction in operative times (145 minutes in both groups).
According to the authors, this very well powered large population based analysis demonstrated that the use of hand-assisted surgery in routine colectomy “should be limited.” It will be very interesting to see whether surgeons heed the results of the study or continue to make larger hand-assist incisions thereby, accordingly to these results, increasing the morbidity rates in their patients without actually reducing operative time.
I applaud the authors for this very well analyzed large national data set.


Bariatric

Article: Vitamin D3 loading is superior to conventional supplementation after weight loss surgery in vitamin D-deficient morbidly obese patients: a double-blind randomized placebo-controlled trial. Luger M, Kruschitz R, Kienbacher C, Traussnigg S, et al. Obes Surg. 2017; ;27(5):1196-1207.
https://www.ncbi.nlm.nih.gov/pubmed/27837387
Dr. Marina Kurian: One of the problems we face with or without weight loss surgery is vitamin D deficiency. This is an interesting and successful approach to treating vitamin D deficiency that is currently not utilized by most bariatric practices, including my own. I am glad to have this article featured because it draws attention to an easy change in the postoperative protocol that may help counteract refractory or difficult to treat vitamin D deficiency seen in weight loss surgery patients.

Article: Surgical cure for type 2 diabetes by foregut or hindgut operations: a myth or reality? A systematic review. Goh YM, Toumi Z, Date RS. Surg Endosc. 2017 Jan;31(1):25-37.
https://www.ncbi.nlm.nih.gov/pubmed/27194257
Dr. Akshay Chauha/ Dr. Dmitry Oleynikov: Type 2 diabetes mellitus (T2DM) and morbid obesity are conditions representing increasing public health threats. They are associated with significant morbidity and mortality, and despite lifestyle modifications and medical support, glycemic control remains difficult to achieve in obese diabetic patients. Several mechanisms have been proposed to explain the weight-independent improvement and remission of diabetes after bariatric and metabolic surgery. The authors challenge the foregut and hindgut theory, which is based on regulation of incretins. In their systematic review of outcomes of foregut and hindgut weight loss surgeries, they conclude superiority of sleeve gastrectomy in resolution of T2DM, thereby questioning the validity of adding more complex anastomotic procedures in addition to sleeve gastrectomy. This raises the question of whether bariatric surgeons are adding complex and morbid anastomosis when objective outcomes can be achieved with a straight forward less complex sleeve gastrectomy. The authors give an opportunity to look back and reexamine the validation of foregut and hindgut theory for metabolic surgery outcomes.

 

MISS NEWS

Vol. 8 No. 13

MISS E-News:

MISS Q&A Interview with Rees Porta, M.D.


 

Introduction

This month I asked several colleagues to form questions for an interview with military surgeon Dr. Rees Porta, who agreed to address major aspects of military surgery practice for MISS eNews. Dr. Porta is a staff surgeon who has completed two combat tours and currently works at William Beaumont Army Medical Center in El Paso, TX (Fort Bliss). The majority of Dr. Porta’s practice is advanced laparoscopy (foregut and bariatrics), but he also performs endoscopy and acute care general surgery. I want to thank my colleagues for their astute and informed questions posed to Dr. Porta, and I’d especially like to extend a very warm thank you to Dr. Porta for taking the time to share his insights and experience with us in this interview, and of course for his service and dedication.
I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. A new contributor this month is Dr. Vivek Kumbhari, who oversees the endoscopy program at Johns Hopkins and the bariatric endoscopy program at Johns Hopkins Bayview. Thank you to Dr. Khumbari and all of this month’s contributors!  –Colleen Hutchinson

Dr. Steven Wexner: What are your most useful educational resources to remain in contact with MIS while deployed, and how we can improve such access for you and your colleagues during your tours of duty?
Dr. Rees Porta: Fortunately, most of the resources I utilize while stateside are online and the military does a good job of maintaining Internet access for soldiers, even in rather austere environments. However, Internet speeds can be very slow (think dial-up), so allowing files to be downloaded in advance (i.e. something downloaded and stored prior to leaving the U.S.) and/or avoiding large non-compressed videos is helpful. Understanding that correspondence may be delayed due to lack of connectivity and/or significant time zone differences is also appreciated.

 

Dr. Guy Voeller: How long does a tour last?
Dr. Rees Porta: They used to be 6 to 12 months, with some tours as long as 15. Currently they are usually 4.5 or 9 months with some exceptions. ACGME program directors deploy for 3 months.
Because of the shorter duration, we now deploy more frequently. This was all done as a balance to fulfill the US Army mission as well as to minimize skill degradation.

 

Dr. Ajita Prabhu: I would like to know if there have been any advances in portable surgical ops for military use to care for injured soldiers in the field. Robotics was developed as a federal initiative initially, but then quickly moved into the private space when the technology was too unwieldy for military use. Now that robotics has evolved over the past 20 years, do you anticipate mobile robotic units for surgery in the field arriving at last? Is the military continuing to work on this?
Dr. Rees Porta: Great question. This is definitely a field the military is still investigating. Currently, robotics (re: Da Vinci type platforms) is not being utilized in combat. The theory is awesome, but the applicability is challenging. Really, the rate-limiting factor (besides the logistics of delivery and maintenance) is the bandwidth necessary to remotely control the device. As I mentioned earlier, Internet speeds in Iraq and Afghanistan are usually in the range of dial-up and the bandwidth necessary to remotely control these robots is difficult to obtain even in the US. We do utilize telemedicine frequently using mobile units with audio/video streaming (even including a stethoscope) to help deployed providers with complex clinical issues. They can instantly link up to an expert at a major US medical center 24/7.

 

Dr. Guy Voeller: How much does your MIS training come into play when you are deployed, and how often are you operating on local national soldiers?
Dr. Rees Porta: Advanced laparoscopic/robotic skills are not specifically utilized while deployed (as you might imagine), but familiarity with the anatomy certainly helps. Only a few of the bases in the Middle East have laparoscopic or endoscopic capabilities. None have robotics. Very frequently I have the skills to perform an MIS operation, but not the assets available, and then clinical judgment is required to decide if transfer or an open operation is in the soldier’s best interest.
Those of us deployed to Iraq, Afghanistan, Egypt, Syria, etc. operate on local national soldiers frequently (>50% of the trauma cases) to prevent loss of life, limb, or eyesight. Humanitarian elective cases are performed, but that is variable and highly dependent on the command, the hospital capabilities, and the combat climate. During the invasion years, early in the war, a higher proportion of the combat casualties were US soldiers, but now that we have transitioned to more of a stabilization and support role, the majority of the acute trauma patients we care for are from the host country.

 

Dr. Daniel B. Jones: How can societies like SAGES help the MIS military surgeon?
Dr. Rees Porta: Societies like SAGES, ASMBS, ACS, etc. have been incredibly understanding and accommodating to the military surgeon. Understanding that deadlines may need to be extended to the deployed surgeon and that case volumes may need to be adjusted due to the frequent deployments and military training obligations are probably the biggest areas that we appreciate. Additionally, reduced meeting fees and societal dues helps a lot as there is no compensation or assistance from our hospital with that. Overall, the support from our surgical organizations has been overwhelming.

 

Dr. Guy Voeller: What do you do when you’re not doing a tour?
Dr. Rees Porta: When stateside, we function very much like civilian surgeons with some extra military training added in (physical fitness tests, shooting at the range, and other various training). I cover trauma and acute care surgery call, operate two days a week (with a focus on foregut and bariatrics), see clinic, and perform therapeutic and screening endoscopy.

 

Dr. Raul Rosenthal: Did you get involved in the newly established ASMBS military committee (https://asmbs.org/committees/military-committee)?
Dr. Rees Porta: Yes, I work with Dr. Eric Ahnfeldt, who was one of the pioneers of the committee’s initiation. Not only did it help with representation, but it also unifies the MIS military surgeons for collaboration on clinical issues, research, MBSAQIP, etc.  

 

Dr. Guy Voeller: Do you perform all aspects of general surgery when you are on a tour?
Dr. Rees Porta: Unless you are at a major center (Combat Support Hospital [CSH]), your entire focus is open trauma care. The CSHs can have laparoscopy and may perform more semi-urgent type cases (laparoscopic cholecystectomy, appendectomy, and herniorrhaphy). Endoscopy is also sometimes available at the CSH. If assigned to a smaller unit (Forward Surgical Team [FST]), you may also find yourself being the only doctor around and thus become the de facto primary care / emergency / and gynecologic physician.

 

Dr. Guy Voeller: How much of your time is spent operating versus doing other duties?
Dr. Rees Porta: While stateside, I would estimate that about half a day each week is dedicated to some unique military duty that I wouldn’t be doing in a civilian practice. This is highly variable, however, depending on the surgeon, the hospital, the military unit, etc.

 

Dr. Raul Rosenthal: Does the military support your CME and attendance to national conferences?
Dr. Rees Porta: Yes, athough this has varied over time (waxes and wanes) and with the individual local command at each hospital. It requires a lot of paperwork to be filled out just right (think DMV), but overall the military does currently support research, conference attendance, and CME. Getting funding for attendance from the Department of Defense (DoD) is even more difficult (hence the appreciated cost reductions stated earlier).

 

Dr. Guy Voeller: Do you have access to all the equipment in the MIS armamentarium—robots? Spy technology? 4K? 
Dr. Rees Porta: While deployed, we usually only have an ultra-sound and X-ray at the FST, with computed tomography (CT), endoscopy, and laparoscopy at the CSH. When not deployed, I work at a large tertiary Army Medical Center and we have all the toys. Those surgeons at the smaller U.S. community-based medical treatment facilities typically don’t have those advanced technologies (named above), but the Army doesn’t typically send fellowship-trained surgeons to those locations.

 

Dr. Guy Voeller: Do you use an EMR?
Dr. Rees Porta: Yes, we are fully electronic. Although maybe not the most user-friendly EMR, it is nice to have worldwide access to a patient’s medical information 24/7. Even while deployed, the EMR is utilized at the CSH, but most FSTs operating in damage control mode utilize a paper chart.

 

Dr. Raul Rosenthal: What are your capabilities to complete online CME?
Dr. Rees Porta: While deployed, internet speeds usually allow completion of CME. Loading videos and large files can sometimes be difficult, however.

 

Dr. Guy Voeller: Do military surgeons have malpractice insurance?
Dr. Rees Porta: Military surgeons practicing at a DoD center are covered under the tort reform and do not need separate insurance. Those of us that moonlight find coverage through the locums company or via private insurance.

 

Dr. Rees Porta: I want to thank the interviewers not only for the excellent questions, but also for the interest in the military surgeon and in how we can better incorporate into MIS/ASMBS/SAGES. I am humbled to have the opportunity to share this information with the MIS community.

Additional information about the struggle we face with sustaining combat trauma support while also maintaining advanced surgical skills and caseload can be found here:
http://www.journalacs.org/article/S1072-7515(16)30034-5/abstract

More information about the Army roles (echelons) of care (re: FST, CSH, etc) can be found here:
http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=1a73495d-1176-4638-9011-9e7f3c6017d8

Data on humanitarian efforts by deployed general surgeons can be found here:
http://www.americanjournalofsurgery.com/article/S0002-9610(14)00096-8/abstract


Foregut

Article: Laparoscopic surgery for adhesive small bowel obstruction is associated with a higher risk of bowel injury: A population-based analysis of 8,584 patients. Behman R, Nathans A, Byrne J, Mason S, Look Hong N, Karanicolas P. Ann Surg. 2017 Jun 27. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28657949
Dr. Ajita Prabhu: This article is interesting because it represents an opportunity to find some balance in what we do. As surgeons, we are constantly pushing to use technology to minimize the impact of the operations we do on the recovery and wellbeing of patients. In this article, the authors take a look at what happens when we near the limits of what we should be doing routinely. It is always necessary to push until we find the boundaries, and as we all know in surgery, that is frequently what informs our practices in the long run. I look at this article as a way to say, "OK, there are probably some patients that benefit from minimally invasive approaches to SBO; however, there are other patients that may be harmed by it. Now we need to figure out which patients are the best candidates for this approach, and which ones we should steer clear of."

 

Article: The model for end-stage liver disease predicts outcomes in patients undergoing cholecystectomy. Dolejs SC, Beane JD, Kays JK, Ceppa EP, Zarzaur BL. Surg Endosc. 2017 May 10. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28493164
Dr. Michael Schweitzer: The authors examined MELD score as a predictor for morbidity and mortality after cholecystectomy using the NSQIP database from 2005 to 2013. Patients were excluded if they had choledocholithiasis or preoperative dialysis. A 30-day mortality of 6% and morbidity of 23% was seen if the MELD score was over 20 and the case was accomplished laparoscopically; however, if the case had to be completed open, the rates were 18% and 58%, respectively. If the patients had ascites and a MELD over 20 then the mortality went to 33.3% laparoscopic and 48.5% open cholecystectomy. For those of us taking emergency general surgery call, this paper helps define risks to our cirrhotic patients and those taking care of them. It also supports the laparoscopic approach, if possible, even in high MELD score cirrhotic patients.


Bariatric

Article: Endoscopic sleeve gastroplasty significantly reduces body mass index and metabolic complications in obese patients. Sharaiha RZ, Kumta NA, Saumoy M, Aronne LJ, et al. Clin Gastroenterol Hepatol. 2017 Apr;15(4):504-510.
https://www.ncbi.nlm.nih.gov/pubmed/28017845
Dr. Vivek Kumbari: This prospective single center US study of 91 consecutive patients undergoing endoscopic sleeve gastroplasty (ESG) evaluates its medium term effectiveness and safety. ESG is performed by endoscopically placating the stomach to reduce its volume by approximately 70%. There was follow-up data at 6 months (73 patients) and 12 months (53 patients) with limited data at 24 months (12 patients). Total body weight loss was excellent at 14% at 6 months and 18% at 12 months. Furthermore, the mean waist circumference decreased by more than 25cm per patient. The adverse event rate was extremely low at 1%. Therefore, this procedure is effective and safe as a weight loss procedure. From a metabolic perspective, despite the dramatic reduction in weight and waist circumference, only modest metabolic benefits were noted.

 

Article: Five-year outcomes after vertical sleeve gastrectomy for severe obesity: a prospective cohort study. Flølo TN, Andersen JR, Kolotkin RL, et al. Obes Surg. 2017 Feb 21. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28224471
Kurian: Many long-term studies are showing poor follow-up at five years. This study gives us 5-year results with 82% follow-up and provides valuable data. Remission of type 2 diabetes mellitus reduced over five years but was still fairly high, GERD increased, and there was a low rate of reoperation for weight regain with primary sleeve.


Colon

Article: Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multi-center cohort. Burgess NG, Hourigan LF, Zanati SA, et al. Gastroenterology. 2017 Jun 2.
https://www.ncbi.nlm.nih.gov/pubmed/28583826
Dr. Vivek Kumbari: This large prospective cohort study of over 2000 patients with large colorectal sessile polyps (All >20mm in size) from Australia attempts to decipher which polyps are best suited to resection with endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) or surgery. Submucosal invasive cancer was seen in 171 lesions (7.6%). The factors associated with submucosal invasive cancer were if the polyp: a) surface had an amorphous or nonstructural surface pattern, b) had a depressed component, c) was in the rectosigmoid location, d) was elevated >2mm from the surrounding colonic mucosa, e) had a non-granular surface morphology and f) was of a larger size. The implications of these findings may help stratify patients to ESD or surgery as opposed to EMR if multiple risk factors for submucosal invasive cancer are apparent.


Endoscopy

Article: Treatment of leaks following sleeve gastrectomy by endoscopic internal drainage (EID).
Donatelli G, Dumont JL, Cereatti F, Ferretti S, Vergeau BM, Tuszynski T, et al.
Obes Surg. 2015 Jul;25(7):1293-301.
https://www.ncbi.nlm.nih.gov/pubmed/25913755
Dr. Matthew Kroh: Laparoscopic sleeve gastrectomy is currently the most common bariatric surgery performed in the United States. With time and experience, as well as a better understanding of the pertinent anatomy, complication rates have decreased. Technical considerations including appropriate bougie sizing, staple line reinforcement, identification and repair of hiatal hernia, and the importance of avoiding narrowing at the incisura have all resulted in improved outcomes. Even with low rates of leakage ranging from 0.2% to 3% in recent studies, staple line dehiscence remains a source of morbidity. Endoscopic therapies for leakage and stenosis, including stent placement, through-the-scope balloon and pneumatic dilation, septotomy, and vacuum-assisted closure, have all been reported on in the literature. Donatelli at all described their experience treating leak after sleeve gastrectomy by internal drainage from the extraluminal cavity.
In this study, 67 patients underwent endoscopic internal drainage for treatment for leak after sleeve gastrectomy by means of deployment of a double pigtail biliary stent across the defect. Technical success of the procedure was high at greater than 98%. 50 of the 67 patients eventually had successful endoscopic therapy, at a mean time of 57.5 days. Over the course of this time, the 3.1 endoscopic sessions were required for stent removal and exchange, which was performed every 4 to 6 weeks.
This study relays important information on an evolving endoscopic technique in a large number of patients. The high success rate the authors demonstrate for this complex problem should give increased attention to this procedure. In this study, however, there is no mention of the anatomic configuration of the sleeve. This is an important consideration as leakage after sleeve gastrectomy often is due to obstruction at the incisura. Treatment of the obstruction at the incisura is necessary for successful healing of a proximal staple line dehiscence. Successful treatment of leakage after sleeve gastrectomy may require multimodal endoscopic and/or surgical intervention to treat successfully. This study demonstrates that endoscopic internal drainage with biliary stent may fit into an appropriate treatment algorithm.
 

Article: Endoscopic sleeve gastroplasty for obesity: a multicenter study of 248 patients with 24 months follow-up.
Lopez-Nava G, Sharaiha RZ, Vargas EJ, Bazerbachi F, Manoel GN, Bautista-Castaño I, et al. Obes Surg. 2017 Apr 27. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/28451929
Dr. Matthew Kroh: Endoluminal therapies to treat obesity and weight-related diseases show promise. There is a significant number of patients who meet criteria for bariatric surgery to treat weight-related diseases but do not get therapy, for a multitude of reasons ranging from lack of access to surgical care to a desire to not undergo surgery. This group of patients has a significant disease burden, and endoluminal intervention may offer new treatments.
Endoscopic sleeve gastroplasty is an evolving technique that produces plication of the stomach with resultant decreased gastric volume. The technical conduct and devices used vary among practitioners. In this article, Lopez-Nava et al report on a multicenter study of more than 200 patients with two-year follow-up. At baseline, the BMI of this group was 38 and follow-up after the procedure is reported at 6 and 24 months, yielding results of percent total body weight loss of 15.2% and 18.6% at the respective intervals. Importantly, at 24 months on a per-protocol analysis and intention-to-treat analysis, the percent of patients achieving greater than or equal to 10% total body weight loss was 84% and 53%, respectively.
This multi-center study of a relatively large cohort of patients demonstrated acceptable weight loss in a moderately obese group of patients. Endoluminal therapies, including endoscopic sleeve gastroplasty, need to be monitored and the results reported so that appropriate and effective therapies are available to patients who cannot, or choose not to, undergo surgery, and those that have not been treated effectively by medical treatment. More widespread and longer-term data are important to accurately assess efficacy and durability of this procedure.


Hernia

Article: Onlay with adhesive use compared with sublay mesh placement in ventral hernia repair: Was Chevrel right? An Americas Hernia Society Quality Collaborative Analysis. Haskins IN, Voeller GR, Stoikes NF, Webb DL, Chandler RG, Phillips S, Poulose BK, Rosen MJ. J Am Coll Surg. 2017 May;224(5):962-970.
https://www.ncbi.nlm.nih.gov/pubmed/28161483
Dr. Guy Voeller: Chevrel came up with his onlay repair for ventral/incisional hernia at the same time Rives came up with his sublay repair. He was a forgotten man due to the laparoscopic revolution but this article does a nice job in showing that there is a place for his repair in our armamentarium for ventral/incisional hernia.

 

Article: Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial.
Jairam AP, Nieuwenhuizen, Jeroen et al. Lancet 2017 [Epub ahead of print]
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31332-6/abstract
Dr. Guy Voeller: This is a multicenter randomized prospective trial showing a significant reduction in the incidence of Incisional Hernia following midline laparotomy with the use of prophylactic mesh compared to no mesh in high risk patients. The authors feel onlay mesh had the potential to become standard of care for high-risk patients.

 

MISS NEWS

Vol. 8 No. 12

MISS E-News:

Interview with Jaime Sanchez, M.D., USF Physicians Group, Division of Colon and Rectal Surgery at USF Health


 

Introduction

Happy summer! This month we include an interview with Jaime Sanchez, MD. This interview touches on various topics surrounding colorectal surgery practice, new developments in technologies and techniques, 2017 MISS, and challenges that residents and fellow face. His informed perspectives on these topics are candid and insightful.

I hope you also enjoy the article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. Thank you!  –Colleen Hutchinson

 

What were some of the most critical topics in colon surgery discussed at MISS 2017 in Las Vegas?

Dr. Sanchez: From the perspective of advanced minimally invasive colorectal surgery at MISS, the presentations regarding transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) techniques for me were some of the most important. These were critical as they exemplify the forefront of treatments now available to provide patients quality operations that reduce morbidity while maintaining quality outcomes.

 

How would you characterize the MISS meeting versus other meetings that are out there for CME?

Dr. Sanchez: MISS really has a leg up on providing attendees with CME content that is highly relevant to surgeons now and is useful in daily clinical practice. The material is never esoteric and never misses a beat in terms of providing attendees with what’s cutting edge that they need to know; it’s all relevant information that helps surgeons stay ahead and informed in terms of new techniques and procedures.

 

What are the biggest challenges the up and coming colorectal surgeon faces?

Dr. Sanchez: For most of us it seems to be the challenge of balancing time and effort between clinical practice and the increasing need to perform administrative duties including onerous documentation.

 

What are some of the most exciting new developments in colorectal surgery research and innovation that you’ve directly benefited from in your practice?

Dr. Sanchez: I would definitely have to say that again the advances we have seen in transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) techniques. These are innovative techniques that can either spare a more radical resection such as protectomy or alternatively provide an improved approach that appears to provide good quality outcomes.

 

How would you characterize benefits and drawbacks of the EMR in your experience?

Dr. Sanchez: One significant benefit is the early access it provides to a patient’s entire medical record from any location. But in terms of drawbacks, there are several. They include the fact that unfortunately, the amount of administrative time it takes to deal with an EMR has made it burdensome. Also, errors to the EMR seem to propagate, and at times are difficult to correct. Allergies are an example of a typical error I see within EMRs, and that’s an important error to correct, especially for surgeons.

 

Since being a fellow/resident yourself in 2011, what do you see as the most significant changes since then for residents and fellows?

Dr. Sanchez: The most significant change I’ve seen since being a resident and fellow has been the incredible increase in exposure to minimally invasive procedures that trainees are receiving. From robotics and advances laparoscopic approaches to transanal and endoscopic procedures, the advancements in MIS colorectal surgery that residents and fellows now learn are impressive. On the other hand, exposure to open operations has declined. However, I don’t think this will become as critical an issue as others may believe as newer generations of surgeons become better equipped to handle more complex problems and complications with that same MIS skill set.

 

What are some of the best ways for up and coming colorectal surgeons to become educated on latest technologies?

Dr. Sanchez: A very effective way to become and stay educated on latest technologies is to become engaged with societies such as SAGES that are innovative and dedicated to helping their members keep abreast of new technologies, techniques and general developments in our field of colorectal surgery. An example of this is SAGES Tech Alerts, which are provided by the technology and value assessments committee and are just what they are called—alerts that go out as FYIs to members regarding any FDA approvals or other relevant advances in the field.

Secondarily, while I have not use social media in my personal life, I have found that it can be a great tool professionally; specifically, the social media platform that helps me keep current on advances in colorectal surgery is Twitter. It’s a great way to keep up on what respected members in the colorectal surgery community are thinking and find interesting. Conor Delaney and Steven Wexner are excellent examples of thought leaders who use Twitter very effectively to disseminate information that other colorectal surgeons would likely find compelling and in many instances also share.


Suggested Readings

HERNIA

Article: Development of a Disease-based Hernia Program and the Impact on Cost for a Hospital System. Krpata DM, Haskins IN, Rosenblatt S, Grundfest S, Prabhu A, Rosen MJ. Ann Surg. 2016 Nov 30. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/27906759

Dr. Michael Rosen: Krpata et al from the Cleveland Clinic Comprehensive Hernia Program recently published a manuscript in Annals of Surgery evaluating the potential for developing a system wide disease based hernia program on reducing cost for the hospital system. These authors detail their approach to developing a hernia program that included key highlights of transparency with physicians on cost of mesh, engagement and collaboration with physicians, administration and purchasing departments to set goals of quality outcomes and cost containment. They also detailed their approach to developing a reasonable approach to mesh utilization guidelines. In developing these guidelines the authors noted that surgeons felt that they needed access to expensive biologic mesh and absorbable synthetic mesh in certain cases, but were willing to avoid over utilization of these materials in cases deemed unnecessary by the group. The group also participated in real time quality improvement utilizing data captured from the Americas Hernia Society Quality Collaborative. They evaluated the effect of developing this program on hospital cost comparing a year prior to the development of the hernia program to a year after the development. The collaborative efforts of the hernia program resulted in a system wide savings of over 500,000 dollars by reducing utilization of expensive meshes in cases outside of the Cleveland Clinic mesh protocol. They authors note that they will continue to engage this program for cost savings opportunities in mechanical fixation and synthetic mesh choices. Importantly, utilizing outcomes from the AHSQC the authors will be able to evaluate how these cost savings measures impact the value equation.

 

Article: Biologic mesh for repair of ventral hernias in contaminated fields: long-term clinical and patient-reported outcomes. Madani A, Niculiseanu P, Marini W, et al. Surg Endosc. 2017 Feb;31(2):861-871. https://www.ncbi.nlm.nih.gov/pubmed/27334966

Dr. Ed Felix: Here is an article on biological mesh for contaminated ventral hernias that really sheds light on the use of biological mesh use. Bio was supposed to be the savior of contaminated repairs, but this paper really demonstrates the contrary. Therefore an important paper.


BARIATRIC

Article: Management of gastric leaks after sleeve gastrectomy with endoluminal vacuum (E-Vac) therapy. Leeds SG, Burdick JS. Surg Obes Relat Dis. 2016 Aug;12(7):1278-1285.  https://www.ncbi.nlm.nih.gov/pubmed/27178614

Dr. Edward Felix: As sleeve gastrectomy has grown in popularity and become the most prevalent bariatric procedure worldwide, it has become evident that leaks after sleeve are not the same as after gastric bypass (RYGB). The refractory nature of this complication and etiology are quite different than we saw with RYGB in the past. The treatment of leak after sleeve remains controversial and varies widely from center to center, as does the success of different treatment modalities. This paper presents a new and novel approach that is less invasive and may be worth considering to treat this difficult problem.

 

Article: Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study. Varban OA, Sheetz KH, Cassidy RB, Stricklen A, Carlin AM, Dimick JB, Finks JF. Surgery for Obesity and Related Diseases. 2017;3(4):560-567. http://www.soard.org/article/S1550-7289(16)30847-4/abstract

Michael Schweitzer: In this case-control study from the Michigan Bariatric Surgery Collaborative on leaks after laparoscopic sleeve gastrectomy, leaks were found to be less likely if the surgeon oversewed the staple line when compared to the use of buttress material. Overall leak rate of 0.38% over the study period was found by the researchers. On multivariate analysis, the operative technique of “oversewing” reduced leaks; however, “oversewing” was not standardized and surgeons with more experienced were found to be more likely to oversew but were also found to have less complications.  Interestingly, bougie size and stapler manufacture did not make a statistical difference on multivariate analysis.


FOREGUT

Article: Who should get extended thrombophylaxis after bariatric surgery? A risk assessment tool to guide indications for post-discharge pharmacoprophylaxis. A Aminian, A Andalib, Z Zhorgami, et al. Ann Surg 2017;265:143–150.  http://journals.lww.com/annalsofsurgery/Citation/2017/01000/Who_Should_Get_Extended_Thromboprophylaxis_After.24.aspx

Rees Porta: Although VTE is a relatively rare event (0.29%) after bariatric surgery, more than 70-80% of cases occur post discharge. The authors at the Cleveland Clinic have used the NSQIP data from 2007 - 2012 to analyze over ninety-thousand bariatric surgery patients and have identified several risk factors associated with VTE. They subsequently validated their findings using the 2013 NSQIP data and created a free online calculator to help providers estimate a patient's risk of VTE using the 10 identified risk factors. There are still several unanswered questions - specifically at what threshold risk is extended prophylaxis warranted (based largely on cost and bleeding risk), as well as the optimal dosing, medication, and duration. Additionally, several important factors are not captured in the NSQIP database and thus not included in this calculation (previous DVT, congenital hypercoagulable disorders, OCP usage, etc). That being said, this is a major step forward and the authors should be commended for analyzing such a large database and publishing a free online calculator to assist surgeons in making a very complex decision.


COLON

Article: Oral and parenteral versus parenteral antibiotic prophylaxis in elective laparoscopic colorectal surgery: a phase 3, multicenter, open-label, randomized trial. Hata H, Yamaguchi T, Hasegawa S, et al. Ann Surg 2016;263(6):1085-1091. https://www.ncbi.nlm.nih.gov/pubmed/26756752

Dr. Sean Langenfeld: There are few topics in modern surgery that possess as much emotion and controversy as bowel preparation for colorectal surgery. Recent retrospective studies have shown that what is old is new again, with the pendulum swinging back from the complete omission of bowel prep to the reintroduction of oral antibiotics into a combined oral mechanical prep.  This is a randomized trial from Japan which focuses on patients undergoing elective laparoscopic colorectal surgery. This study reported a reduced surgical site infection (SSI) rate for patients with a combined oral/mechanical prep when compared to mechanical prep only (7.3% vs. 12.8%, p=0.028). The study has several important limitations including a non-blinded treatment team, slow accrual, and unclear control for several other factors that impact SSI such as skin prep, extraction site, and normothermia. Still, it is well-designed overall, and is one of only a few recent studies on the topic with a prospective design.


ENDOSCOPY

Article: Natural orifice specimen extraction with single stapling colorectal anastomosis for laparoscopic low anterior resection: feasibility, outcomes, and technical considerations. Saurabh B, Chang SC, Ke TW, et al. Dis Colon Rectum 2017;60:43-50. https://www.ncbi.nlm.nih.gov/m/pubmed/27926556/

Dr. Sean Langenfeld: Extraction of the specimen through the rectum itself is not a new technique, being first described by Dr. Morris Franklin over 20 years ago. This is a nice case series of 82 patients with sigmoid or upper rectal cancers who underwent transrectal specimen extraction with the help of a transrectal wound protector or a TEO port (Storz). When compared to 106 patients in the same institution who underwent transumbilical extraction, the natural orifice group had less narcotic requirements, quicker return of bowel function, and a shorter length of stay, all while maintaining similar specimen quality and similar rates of anastomotic leak and other complications.  It should be noted that patient anatomy was likely quite favorable overall, with a mean BMI of 24.4, but this demonstrates a safe and effective method of specimen extraction in a highly-selected group of patients.

Article: Gastric per-oral endoscopic myotomy (POEM) for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video). Khashab MA, Ngamruengphong S, Carr-Locke D, et al. Gastrointest Endosc. 2016. 2017;85(1):123-128.

https://jhu.pure.elsevier.com/en/publications/gastric-per-oral-endoscopic-myotomy-for-refractory-gastroparesis-

Dr. Matthew Kroh: Advances in endoluminal surgery have allowed for increasingly complex procedures to be performed more commonly. For example, per oral esophageal myotomy (POEM) for achalasia is routinely performed in specialized centers with excellent results. Endoscopic intra-mural surgical techniques have been applied elsewhere, too, including resection of submucosal lesions and division of the pylorus as a treatment for gastroparesis.

MISS NEWS

Vol. 8 No. 11

 
TOP NEWS
Introduction


Welcome to the March issue of MISS E-News! I hope you find this month’s interview with Dr. Stephanie B. Jones valuable; she shares with us some critical aspects of enhanced recovery after surgery from an anesthesiologist’s perspective. Attendees of this month’s MISS Meeting were fortunate to hear Dr. Jones share her expertise on fluids and pain management during the MISS Enhanced Recovery after Surgery Program. (Couldn’t make this year’s MISS meeting? Save the date for next year: March 6-9, 2018.)

We have some new contributors of selected readings this month, including Robert Lim and Jonathan Thompson, who have imparted their thoughts on critical current articles in minimally invasive surgery. I hope you enjoy this month’s edition and please feel free to contact us with any feedback!

— Colleen Hutchinson

 

Enhanced Recovery Interview

Could you please tell us about enhanced recovery and its development?

Dr. Jones: The concept of enhanced recovery after surgery was first promoted in the late 1990s by Danish surgeon Henrik Kehlet in his work on fast-track colorectal surgery. Enhanced recovery uses protocol-driven, multimodal pathways with the aim of reducing the surgical stress response and speeding recovery. Many of the components of the enhanced recovery pathways were revolutionary at the time–eliminating nasogastric tubes and postoperative drains, for example–but as the positive evidence has accumulated over the years, these practices have become more widely accepted. Enhanced recovery starts as early as preadmission with patient education and optimization, and contains specific elements for pre-, intra-, and postoperative care.

What kind of anesthesia is the most favorable to enhance the enhanced recovery protocol?

 

Dr. Jones: The type of maintenance anesthetic (intravenous versus inhalational) is less important than achieving the overall goals of enhanced recovery. For the anesthesiologist, these include use of non-opioid or opioid-sparing multimodal pain strategies, postoperative nausea and vomiting (PONV) prophylaxis, and "zero balance" fluid management, avoiding both hyper- and hypovolemia. Some do advocate use of propofol-based total intravenous anesthesia in patients at high risk for PONV as inhalational anesthetics can contribute to PONV. For most patients, use of multiple prophylactic antiemetics will suffice. Dexamethasone and ondansetron are common choices. Reducing or avoiding opioids altogether will also help reduce the incidence of PONV.

 

Does preemptive analgesia help with enhanced recovery protocols?

 

Dr. Jones: I hesitate to use the term preemptive analgesia as the evidence for this in humans has never really materialized. However, the administration of non-opioid adjuncts preoperatively, in order to achieve therapeutic levels of drug intraoperatively, is a key component of enhanced recovery. Oral acetaminophen is widely used, and gabapentinoids (gabapentin and pregabalin) are becoming increasingly popular as part of opioid-sparing strategies that then are extended into the postoperative period.

 

Should epidural analgesia be part of enhanced recovery?

 

Dr. Jones: Thoracic epidural analgesia (TEA) has shown benefit in patients undergoing open abdominal surgery. TEA provides improved pain relief, reduces respiratory and cardiac morbidity, and speeds gastrointestinal (GI) recovery. But there are also risks, including hypotension, motor block, and urinary retention. For laparoscopic procedures, where postoperative pain is less intense, many have abandoned TEA in favor of less invasive procedures such as TAP blocks. However, TEA may still be advantageous for laparoscopic colorectal procedures, due to improved GI motility.

 

 



 

 

Suggested Readings:

Foregut

Article: A nomogram to predict disease-free survival after surgical resection of GIST. Bischof D, Kim Y, Behman R, et al. J Gastrointestinal Surgery 2014;18(12):2123-2129.
https://www.ncbi.nlm.nih.gov/pubmed/25245766
Dr. Robert Lim: The risk of recurrence of a GIST malignancy remains undefined and surgery remains the mainstay of therapy for such tumors. There are several nomograms used to predict disease recurrence. The nomogram presented by the authors seems to be more inclusive and a better predictor of recurrence and thus the need for adjuvant therapy. This paper also highlights the need for routine KIT mutational analysis testing as it may identify more patients who would benefit from adjuvant imatinib therapy.

Article: Efficacy of transoral incisionless fundoplication (TIF) for the treatment of GERD: a systematic review with meta-analysis. Huang, Xiaoquan, Shiyao Chen, Hetong Zhao, Xiaoqing Zeng, Jingjing Lian, Yujen Tseng, and Jie Chen. Surgical Endoscopy (2016): 1-13.

https://www.ncbi.nlm.nih.gov/pubmed/27495332

Dr. Bill Richards: Meta-analysis of the transoral incision-less fundoplication (TIF) from 5 randomized controlled trials and 13 prospective observational studies were pooled to evaluate the results after TIF. The study shows the pooled results of the TIF 1.0 and TIF 2.0 are an alternative in carefully selected GERD patients, but that efficacy declines over time and satisfaction at 6 months is 69.15%.

 



 

Colon

Article: Impact of the specific extraction-site location on the risk of incisional hernia after laparoscopic colorectal resection. Benlice C, Stocchi L, Costedio MM, Gorgun E, Kessler H. Dis Colon Rectum. 2016 Aug;59(8):743-50.
https://www.ncbi.nlm.nih.gov/pubmed/27384092
Dr. Sean Langenfeld: For reasons both technical and patient-specific, rates of incisional hernia after laparoscopic colorectal surgery remain high, typically occurring at the extraction site rather than the smaller port sites. Recent literature has suggested that transverse, muscle-splitting incisions for specimen extraction are associated with lower hernia rates (e.g. Surg Endosc 2011;25:1031-1036 and Am J Surg 2013;205:264-267). This is a retrospective, single-center database review of 11 years of laparoscopic colorectal surgeries at the Cleveland Clinic. While the overall hernia rate was only 7.2% at a mean followup of 6 years in this cohort, suggesting that the database did not capture all hernias, the authors did discover that periumbilical midline incisions had a much higher rate of hernia than Pfannenstiel incisions (HR=12.7). For left-sided resections, a low-transverse extraction site is therefore preferred. For right-sided resections, this becomes more difficult, but a transverse incision in the midline or right upper quadrant should be considered.

Article: Natural orifice specimen extraction with single stapling colorectal anastomosis for laparoscopic anterior resection: feasibility, outcomes, and technical considerations. Saurabh B, Chang SC, Ke TW, Huang YC, Kato T, Wang HM, Tzu-Liang Chen W, Fingerhut A. Dis Colon Rectum. 2017 Jan;60(1):43-50.

https://www.ncbi.nlm.nih.gov/pubmed/27926556
Dr. Steven Wexner: Numerous recent studies have confirmed the dangers of applying multiple staple firings across the distal rectal remnant prior to construction of distal colorectal or coloanal anastomosis. In order to help avoid this problem, the authors described natural orifice specimen extraction with single stapling in the February 2017 issue of Diseases of the Colon and Rectum. In order to perform this technique, this distal resection margin was identified and the rectum lumen included occluded with an intracorporeal free tie #1 silk suture proximal to the proposed line of rectal division to prevent contamination. After irrigation, the rectum was divided and prior to extraction a transanal endoscopic operation port (TEO® Transanal Endoscopic Operations, Karl Storz Endoscopy America, El Segundo, California) or an Alexis® wound retractor (Applied Medical, Rancho Santa Margarita, California) was placed. An intracorporeal purse-string was then created. After specimen extraction, the anastomosis was performed in the usual fashion. The authors compared 82 patients in whom the single stapled technique was employed with 106 patients who underwent double stapling. The single stapling group required less Meperidine, had more rapid return of bowel function, and shorter hospital stay–without any differences in the rates of anastomotic leak. The authors concluded that the transanal endoscopic operating platform can be a useful alternative to permit transanal purse-string placement in cases of longer rectal stumps and that the Applied Medical platform was useful in patients with shorter stumps. These techniques help us continue to evolve in our quest to decrease the trauma and the morbidity of surgery and especially the hazards of multiple distal stapler applications.

 

 



 

Bariatric

Article: The impact of different surgical techniques on outcomes in laparoscopic sleeve gastrectomies: the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Berger E, Clements R, Morton J, Huffman K, Wolfe B, Nguyen, N, Ko C and Hutter M. Annals of Surgery 2016 September; 264(3): 464-473.
https://www.ncbi.nlm.nih.gov/pubmed/27433904
Dr. Jonathan Thompson: This is the first publication from the MBSAQIP registry, representing 189,477 sleeve gastrectomy cases performed by 1634 surgeons from 2012 to 2014. The authors analyzed sleeve gastrectomy technique variants and associations with 30-day morbidity and 1-year effectiveness outcomes.

There are many factors that are not measured in MBSAQIP, such as distance of the staple line from the incisura angularis, distance of the staple line from the gastroesophageal junction, type of buttress material used and where it was used, oversewing technique employed, type of stapler and cartridge selection, reattaching the omentum to the greater curve of the sleeve and the technique employed, hiatal hernia repair and technique employed, resultant volume of the sleeve under a distension pressure, and the use of fibrin sealant. There are also many factors that are unmeasurable, such as the amount of tension/stretch placed on the stomach during stapling, degree of bougie ’hugging’ during stapling, and presence of zig-zags, twists, or spirals in the staple line.

Despite the limitations of the data set, we are a bit closer to answering a few important questions: What is ideal sleeve gastrectomy anatomy and what adjuncts are useful when creating it? The findings tell us a couple of things regarding the anatomy of a sleeve: 1) it provides evidence that a larger sleeve is probably safer and more effective for weight loss (assuming bougie size approximates sleeve size; bougie size ≥ 38 had fewer leaks; bougie size ≥ 40 had better 1 year BMI reduction); and 2) it provides evidence that antral preservation (distance from pylorus ≥ 6) is associated with greater weight loss at one year. Many surgeons use staple line reinforcement to protect against leak, so finding that staple line reinforcement was associated with a higher leak rate in the largest sleeve gastrectomy data set analyzed to date may cause some surgeons to question its utility in their practice. This study and the analyses that will follow the release of the MBSAQIP Participant Use File will hopefully give surgeons the confidence to change their practice if a change is necessary.

 

Article: Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Kumar N, Thompson CC. Gastrointestinal Endoscopy 2016 Apr;83(4):776-9.

https://www.ncbi.nlm.nih.gov/pubmed/26344204
Dr. Manoel Galvao Neto: The Endolumenal Roux-en-Y gastric bypass revision is gaining momentum with the use of full-thickness suture devices that allow for a more durable procedure than previous ones. The duration of the procedure was always the Achilles tendon. Among revisional bariatric procedures, the endoluminal procedures each had at least one prospective randomized trial published, pointing to its efficacy over a control group, but only at 1 year and using a non-full-thickness suturing device.

In the current paper, durability is proven at 3 years follow-up. As usual, caution should be taken in translating this paper to clinical practice as it is a single reference center report and needs to be reproducible.

As bariatric surgery has become a mature field, its blessings and failures have become known as well. For RYGB, there is an expected 15-20% weight loss failure rate; some of those patients can be considered for a revisional procedure, especially the ones who lost their "ideal” proximal bariatric anatomy, having its pouch and anastomoses enlarged; the growing numbers of endolumenal revision have a good safety profile with results similar to revisional surgery. This may be establishing a trend on at least trying to revise endolumenally first.

 


 

Endoscopy

Article: Outcome of peroral endoscopic myotomy (POEM) for treating achalasia compared with laparoscopic Heller myotomy (LHM). Peng L, Tian S, Lu L, et al. Surg Laparosc Endosc Percutan Tech 2017; 27:60-64.

https://www.ncbi.nlm.nih.gov/pubmed/28145968
Dr. Rees Porta: Clinical use of POEM was reported back in 2010, yet there is no data published with any patient followup greater than one year. Dr. Peng and colleagues published their experience comparing outcomes between POEM and LHM with followup in both groups well over 3 years. This was a non-randomized retrospective trial in which the authors state they primarily selected patients for POEM; however, patient characteristics (age, gender, previous treatments, duration and severity of symptoms) were not statistically significant between the groups. Of note, the authors did not use manometry (HRM) before or after treatment and their population seemed to have less GERD (7%) and shorter myotomes (7cm) than other publications. Outcomes were based on Eckardt, GerdQ, and SF-36 QOL scores. Although this study has its limitations, it shows that POEM outcomes are durable and comparable to the LHM at 3 to 4 years followup. Randomized trials incorporating HRM and longer-term followup are needed, but these preliminary studies are encouraging that POEM will prove to be an effective long-term treatment option for achalasia.

Article: Skrobić, Ognjan, Aleksandar Simić, et al. Significance of Nissen fundoplication after endoscopic radiofrequency ablation of Barrett’s esophagus. Surg Endosc 2016;30(9):3802-3807.
https://www.ncbi.nlm.nih.gov/pubmed/26659238
Dr. Bill Richards: This was a review of the prospective clinical database on patients with Barrett’s esophagus (BE) who underwent radiofrequency ablation (RFA) of BE and then were either treated with daily proton pump inhibitors (PPI) or underwent laparoscopic Nissen fundoplication (LNF). The authors found that in the patients with the BE length greater than 4 cm who treated with RFA and LNF had a much lower recurrence rate (25%) than patients who underwent RFA and PPI treatment (100% recurrence). The authors concluded that patients undergoing RFA ablation of BE with long segments of BE and who have hiatal hernias > 3 cm should undergo LNF as a first line treatment after successful RFA to prevent recurrence of the BE.

 

Hernia

Article: Long-term incidence of contralateral primary hernia repair following unilateral inguinal hernia repair in a cohort of 32,834 patients.

Zheng R, Altieri MS, Yang J, Chen H, Pryor AD, Bates A, Talamini MA, Telem DA. Surg Endosc. 2017 Feb;31(2):817-822.

https://www.ncbi.nlm.nih.gov/pubmed/27369285
Dr. Ajita Prabhu: I like this article because when we do laparoscopic inguinal hernia repair, sometimes we may see a small hernia on the other side. This article addresses the issue of what to do with a contralateral inguinal hernia, and suggests that there may be certain patient populations that can benefit from repair of that incidentally identified inguinal hernia.

 

Article: Long-term recurrence and complications associated with elective incisional hernia repair. Kokotovic D, Bisgaard T, Helgstrand F. JAMA. 2016 Oct 18;316(15):1575-1582.

https://www.ncbi.nlm.nih.gov/pubmed/27750295
Dr. Dana Telem: This is an interesting article investigating the long-term recurrence and mesh-related complications in a registry-based nationwide cohort study. The study found that while primary repair of incisional hernia is associated with a higher risk of recurrence and reoperation in 5 years, this benefit is offset by mesh-related complications. This represents important data for use when counseling patients regarding hernia repair.

 

 

MISS NEWS

Vol. 8 No. 10

 
TOP NEWS
Introduction


Welcome to the February issue of MISS E-News! It’s an exciting month for us because this is the month of the MISS Symposium in Las Vegas. With more than 40 faculty, and presentations that range from clinical practice research and guidance to debate panels on the latest procedural advances in surgery, this Symposium promises to be the most current educational meeting of the year.

 

The 2017 MISS will also feature two keynote addresses, one from Dr. Daniel B. Jones, the incoming President of SAGES whose interview was featured in last month’s E-News, and a second keynote address with Dr. Kevin Hall.

 

Dr. Hall is the tenured Senior Investigator at the National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), one of the National Institutes of Health (NIH). His research interests are the regulation of food intake, macronutrient metabolism, energy balance, and body weight, and his laboratory performs experiments in humans and rodents and develops mathematical models and computer simulations to help design, predict, and interpret the experimental data. Dr. Hall is the recipient of the NIH Director’s Award, the NIDDK Director’s Award, the E.V. McCullum Award from the American Society for Nutrition, the Lilly Scientific Achievement Award from The Obesity Society, and the Guyton Award for Excellence in Integrative Physiology from the American Society of Physiology. His award-winning Body Weight Planner has been used by millions of people to help predict how diet and physical activity dynamically interact to affect human body weight.

 

His keynote will address some critical biological findings he has discovered in his long-term research on past participants of the reality television show, The Biggest Loser. I hope you enjoy my short interview with Dr. Hall, as well as the critical article recommendations that follow it from some of the most talented clinicians in surgery. New contributor faces include Michael Schweitzer, Rees Porta, Sean Langenfeld, and Dmitry Oleynikov.

 

See you in Vegas at MISS! — Colleen Hutchinson

 

 

Colleen: If participants of the television program The Biggest Loser now have slower metabolisms today and burn fewer calories at rest than before the show began, patients who suffer from obesity might feel afraid to undergo the lifestyle and dietary changes seen in the show, because they also might risk ending up in a worse place metabolically than their current status. Given what you have found in the long-term research of show participants, as well as other efforts in which you are involved, what would you say to these patients–and their doctors–in terms of how they should view the potential for long-term weight loss success?

 

Dr. Hall: The Biggest Loser intervention was extreme in terms of both the quantity of exercise and the degree of calorie restriction, and resulted in a slowing of metabolic rate that amounted to several hundred calories per day. I wouldn’t recommend that kind of weight loss program to anyone since it is clearly unsustainable. People undertaking more realistic lifestyle and diet changes will not experience such large changes in metabolism and should not be discouraged from engaging in sustainable, healthy changes in diet and lifestyle. Success should be determined based on long-term maintenance of the healthy diet and lifestyle changes regardless of the degree of weight loss achieved. I worry that focusing on large amounts of weight loss as the sole measure of success may lead people to abandon changes that improve their health.

 

Colleen: Do you see more potential for success with current and emerging endoscopic, surgical and/or pharmacological therapies than you have seen with the dietary and lifestyle modifications to which the The Biggest Loser participants adhered?

 

Dr. Hall: I’m neither a surgeon nor a physician, so I won’t pretend to understand the subtleties of the various procedures or pharmacotherapies. However, we did a study in 2014 where we retrospectively pair-matched 13 patients undergoing Roux en-Y gastric bypass surgery (RYGB) to Biggest Loser contestants who had lost similar amounts of weight. The RYGB surgery patients lost weight more slowly than the Biggest Loser contestants, and their metabolic rates fell by a similar amount 6 months after surgery. However, 1 year after the surgery, the RYGB patients had metabolic rates that were appropriate for their new body size, whereas 6 years after the competition, the Biggest Loser contestants regained most of their lost weight and continued to experience reduced metabolic rates. We don’t know if these disparate results were because of something special about the surgery, something damaging about the Biggest Loser competition, or both. (Article: Metabolic adaptation following massive weight loss is related to the degree of energy imbalance and changes in circulating leptin. Obesity (Silver Spring). 2014 Dec; 22(12): 2563–2569.)

 

Colleen: There are ongoing global efforts to solve this puzzle and its various components—research focusing on the mechanisms of action in metabolic and bariatric surgery, research such as yours focusing on resting metabolism and basic biology of the body, endocrine research surrounding the role of hormones such as ghrelin and leptin–as well as the development and remission of type two diabetes with certain therapies, and pharmacological research into approaches that have met with success and failure. With all of this research in play against the disease of obesity, do you feel this is a solvable puzzle?

 

Dr. Hall: Obesity research is progressing at a rapid pace and we are learning more and more each day about its biological, social, and environmental drivers. I am highly optimistic that this research will lead to better interventions that improve the lives of people with obesity.

 

Colleen: Thanks for your time, Dr. Hall!

 

 



 

 

Article Recommendations

Colon

Article: Clinical practice guideline for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Vogel J, Johnson E, Steele S, et al. Dis Colon Rectum. 2016; 59: 1117-1133.
https://www.ncbi.nlm.nih.gov/pubmed/27824697
Dr. Rees Porta: From the American Society of Colon and Rectal Surgeons comes these updated practice guidelines for the management of anorectal abscess and the subsequent fistula(s) that will be present in up to 70% of cases. The authors give us GRADE-system recommendations based on the most up-to-date evidence. Notable changes since the prior publication in 2011 includes what appears to be a shift toward the endoanal advancement flap and the LIFT procedure, and away from the fibrin glue and fistula plug for the treatment of complex fistula-in-ano. Also, now included in this guideline is a section on rectovaginal fistula. These societal recommendations, which are evidence-based and easy to follow, are an invaluable tool for the general surgeon managing this complex but common disease.

Article: Diagnostic accuracy of procalcitonin and C-reactive protein for the early diagnosis of intra-abdominal infection after elective colorectal surgery: a meta-analysis. Cousin F, Ortega-Deballon P, Bourredjem A, et al. Ann Surg 2016;264(2):252-256.
https://www.ncbi.nlm.nih.gov/pubmed/27049766
Dr. Sean Langenfeld: Enhanced recovery pathways for colorectal surgery offer many advantages to patients and surgeons alike. However, concern exists that earlier dismissal from the hospital may hinder the surgeon’s ability to promptly identify and treat postoperative complications such as anastomotic leak. Several studies have focused on the inflammatory markers C-reactive protein and procalcitonin as routine tests on postoperative Days 3 and 4 to determine whether or not it is safe to discharge patients home. This well-designed meta-analysis concludes that both CRP and procalcitonin are useful in detecting postoperative intra-abdominal infection, and that a serum CRP less than 130 mg/L on postoperative Day 3 has a negative predictive value of 96.7%, indicating it is safe to discharge the patient without concern for leak. Of course, this is specific to patients doing well after surgery, and should not replace clinical judgment when there is adequate suspicion for leak.

 



 

Foregut

Article: Clinical outcomes of reoperation for failed antireflux operations. Wilshire CL, Louie BE, Shultz D, Jutric Z, Farivar AS, Aye RW. Ann Thorac Surg. 2016 Apr;101(4):1290-6.
https://www.ncbi.nlm.nih.gov/pubmed/26706754
Dr. Dmitry Oleynikov: Anti-reflux surgery has proven to be feasible and effective in the control of esophageal symptoms. However, symptom recurrence has been reported in 33% of patients who undergo this procedure. This study addressed perioperative outcomes, esophageal symptom resolution, and quality of life of patients who underwent revision anti-reflux surgery. The authors compared the differences in outcomes between patients who had their first revision versus a second or greater revision, and concluded that the last group is associated with less improvement of quality of life. Therefore, patients who need a second or greater revision should be considered for other procedures, such as short colon interposition or Roux-en-Y gastric bypass.

Article: Functional and anatomic esophagogastric junction outflow obstruction: manometry, timed barium esophagram findings, and treatment outcomes. Clayton SB, Rupal Patel R, Richter J. Clin Gastroenterol Hepatol. 2016 Jun;14(6):907-11.
https://www.ncbi.nlm.nih.gov/pubmed/26792374
Dr. Bill Richards: The authors describe the clinical features and treatment outcomes from a group of 49 patients diagnosed with esophagogastric junction outflow obstruction (EGJOO). They first separate into mechanical etiologies (strictures and hiatal hernia) or functional EGJOO. Botox injection and endoscopic dilation were used in some cases, but many required laparoscopic antireflux surgery with repair of the large hiatal hernia.

 

 



 

Hernia

Article: Development of a disease-based hernia program and the impact on cost for a hospital system. Krpata DM, Haskins IN, Rosenblatt S, Grundfest S, Prabhu A, Rosen MJ. Ann Surg. 2016 Nov 30. [Epub ahead of print]

https://www.ncbi.nlm.nih.gov/pubmed/27906759
Dr. Michael Schweitzer: The Hernia Program at the Cleveland Clinic Foundation developed guidelines for the use of mesh based on CDC wound classification at their institution. They developed a protocol that minimized the use of expensive biologic mesh and instead used synthetic mesh with and without component separation. The cost savings for the institution was over $500,000 with a reduction of biologic mesh over 50% in class 1-3 wounds and 47% reduction in dirty class 4 wounds.

 

Article: Long-term recurrence and complications associated with elective incisional hernia repair. Kokotovic D, Bisgaard T, Helgstrand F. JAMA. 2016 Oct 18; 316(15): 1575-1582.
https://www.ncbi.nlm.nih.gov/pubmed/27750295
Dr. Rees Porta: Using the Danish Hernia Database, 5-year data is now available on 3,242 incisional hernia patients. Although this is a non-randomized cohort design (and subsequently subject to selection bias), it is a very large study with phenomenal long-term follow-up rates (reported 100% capture rate). The entire spectrum of repair types were included (primary vs. mesh, open vs. laparoscopic, as well as multiple varieties of mesh material and fixation techniques). The conclusion of the study is no major surprise; primary repair alone is associated with higher rates of recurrence when compared to mesh reinforcement. However, with long-term follow-up, the benefits attributable to mesh are offset somewhat by mesh related complications (4.5% mesh-related complication requiring surgery within 5 years – the risk increasing with mesh size). There is a paucity of available literature with long-term follow-up so it is important when choosing mesh reinforcement to be mindful that 1) the median time to mesh complication in this study was 11 and 24 months (open and laparoscopic respectively) and 2) the risk of mesh related complications increased with time.

 


 

Endoscopy

Article: Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Hungness E, Sternbach J, Teitelbaum E, et al. Ann Surg 2016 Sep;264(3):508-17.
https://www.ncbi.nlm.nih.gov/pubmed/27513156
Dr. Bill Richards: This is a prospective study of 115 patients with achalasia who underwent POEM after each surgeon had completed 15 patients so that the results are after the learning curve was established. They found POEM to be a safe and effective treatment for achalasia but 45% of their patients had objective evidence of pathologic esophageal acid exposure post-POEM procedure. Overall, 92% of the patients reported success of the procedure. The authors acknowledge that patients with obesity and hiatal hernias should be offered Heller myotomy and laparoscopic gastric bypass and they noted that normal weight patients with hiatal hernias had a higher rate of pathologic GERD after POEM than those who did not.

Article: Rectal indomethacin reduces pancreatitis in high- and low-risk patients undergoing endoscopic retrograde cholangiopancreatography. Thiruvengadam NR, Forde KA, Ma GK, et al. Gastroenterology. 2016 Aug;151(2):288-297.e4.
https://www.ncbi.nlm.nih.gov/pubmed/27215656

Dr. Douglas Adler: This is a large retrospective study from UPENN on rectal NSAID for the prevention of post-ERCP pancreatitis. It is well done and conflicts with some other important studies on the topic, highlighting the lack of consensus on this critical issue. I wrote the accompanying editorial on this paper for Gastroenterology, highlighting the fact that the exact role of these agents in preventing post-ERCP pancreatitis remains unknown, and that whether or not they need to be used universally remains unclear, despite the fact that many (most?) doctors use these drugs in this manner.

 



 

Bariatric

Article: Management of gastric leaks after sleeve gastrectomy with endoluminal vacuum (E-Vac) therapy. Leeds SG, Burdick JS. Surg Obes Relat Dis. 2016 Aug;12(7):1278-1285. Epub 2016 Jan 21.
https://www.ncbi.nlm.nih.gov/pubmed/27178614
Recommendation 1
Dr. Matthew Kroh: Sleeve gastrectomy is the most commonly performed bariatric procedure in the United States. Changes in technique and a better understanding of the pathophysiology of sleeve gastrectomy have resulted in improved outcomes and lessened complication rates. Despite this, leak after sleeve gastrectomy imparts significant morbidity. Therapies for sleeve leaks include a focus on source control of sepsis and treatment of systemic manifestations. Endoscopic therapies including stents, clips, and suturing have demonstrated varying degrees of success in treatment of this complication. This article introduces a new concept in endoluminal treatment of sleeve complications, the endoluminal vacuum (E-Vac).

E-Vac is an endoluminal technique of placing a sponge attached to a nasogastric tube into the cavity at the site of leakage. Negative pressure through the tube results in healing by secondary intention, and obliteration of the defect.

Leeds and Burdick describe a series of 9 patients treated by E-Vac therapy. All patients developed a leak after sleeve gastrectomy and initiated therapy at a mean of 61 days after surgery. Each patient underwent a mean of 10.3 endoscopic procedures over the course of an average 50 days of therapy. All patients eventually had resolution of the leak confirmed radiographically.

This small series describes another endoscopic method for treating a morbid complication after sleeve gastrectomy. Treatment time and number of interventions is quite intensive. However, as an adjunct to, or in lieu of, other procedures, E-Vac may be an option for a select group of patients, and the providers capable of treating this challenging problem.

 

Recommendation 2
Dr. Michael Schweitzer: This is a well written article describing one of the newer ways to manage a leak after sleeve gastrectomy where an endoluminal vacuum sponge is placed on a nasogastric tube and then transoral endoscopically guided through the leak opening into the abscess cavity. While their series is small, this is one possible way to treat a difficult leak after sleeve gastrectomy that may help to avoid reoperation or in some cases when reoperation fails and the leak reoccurs.

 

 

MISS NEWS

Vol. 8 No. 9

 
TOP NEWS
Introduction


Welcome back and Happy New Year! It is my pleasure this month to feature an interview with two of my favorite people in surgery, MISS Conference Hernia Program Co-Director Dr. Guy Voeller and Dr. Michael Rosen. This article focuses on the Americas Hernia Society Quality Collaborative (AHSQC), which is a quality collaborative for hernia surgeons that is free to join. These two phenomenal hernia surgeons are not only at the forefront of hernia surgery research and advancement, but have also been involved in and developed recent healthcare initiatives that aim to improve several aspects of hernia care: the position of surgeons in the current healthcare environment, hernia surgery education, patient outcomes, hernia care processes, real world research efforts, and product development. I learned about the AHSQC last year and found the concept intriguing because participation seemed to be such a win-win for all relevant stakeholders in surgery—including surgeons, hospitals, patients, insurance companies, and product developers. Each group stands to benefit from the creation and success of the AHSQC, and the existing and potential future benefits of it are tremendous. Delving more into it, I found out that the AHSQC is a 501c3 supported by unrestricted industry grants. Currently there are three levels of supporters, which are Platinum (Intuitive Surgical); Gold (Bard, LifeCell, and Medtronic); and Silver (W. L. Gore).

Read on for some insights from Drs. Voeller and Rosen on this exciting effort. If you don’t know much about the AHSQC but practice hernia surgery, this interview is a must-read for you.

Enjoy the first article recommendations of 2017 from some thought leaders in minimally invasive surgery, and we hope to see you in Las Vegas for MISS next month!

—Colleen Hutchinson

 

AHSQC Interview

What is the AHSQC?

 

Dr. Voeller: The definition of the AHSQC (www.ahsqc.org) is contained in its initials–Americas Hernia Society Quality Collaborative. It is a quality collaborative. That may sound simple but its purpose is to improve the quality of hernia repair by collaboration amongst surgeons. This is what Benjamin Poulose and Michael Rosen had in mind when they came up with the idea of the AHSQC. As we are trying to switch from a quantity-based healthcare system to a quality-based one, it is important that surgeons are the ones who determine what is true quality. Hospitals, insurance companies, and entities are judging us on their quality metrics, and these groups are the least likely to know what true quality is or is not. The AHSQC enables surgeons to determine quality. In addition, another purpose of the AHSQC is to help those surgeons who may be having trouble and/or are on the lower end of the bell curve to improve their quality in a non-confrontational or punitive environment.

What does it entail on an individual surgeon/program level in terms of process and cost?

 

Dr. Voeller: Membership in the AHSQC is free. Any surgeon who wishes to join must be a member of the Americas Hernia Society (AHS), which costs $160 per year. There is no other associated cost with joining and actively being part of the Collaborative. Once a surgeon joins, the surgeon’s hospital will then enter into an agreement with the AHSQC regarding sharing and entering of patient data. This can turn out to be one of the more lengthy parts of the process and probably is the most significant hurdle for an institution that wants to participate in the quality collaborative. Lawyers are involved and, as always, this can take some time to work through the various systems. Once everything is approved, the individual surgeon will have to enter the hernia data on a case-by-case basis into the software of the collaborative. Normally when a surgeon finishes an operation, he or she has to speak with family, enter postoperative orders, and dictate an operative report. But it is best to enter this case data into the AHSQC database when the case is first completed. While this will add 3 to 10 minutes per case (typically 5 or less if you enter the data right after the case and closer to 10 if you are doing it at a later time when one must go back and find all the answers), and can be difficult for a busy surgeon to accomplish day in and day out, it is well worth the time in the long run.

It is important to note that maintaining the AHSQC as a free resource for surgeons really depends on participation; the more surgeons participate, the higher chance this will be able to remain free.

So to recap, in terms of cost, total cost is free if you are an AHS member, and cost of time is a couple minutes of time for data entry after each case.

 

Where are you now in terms of development?

 

Dr. Voeller: I know that Ben and Mike want to increase surgeon and institution numbers because that is the key to the success of the collaborative. Presently there are almost 200 surgeons with a total of almost 14,000 patients entered. There are about 400 new patients entered every month. This number will increase significantly when inguinal hernia becomes part of the collaborative this month.

 

 

What are the advantages for surgeons in joining the AHSQC, especially with Value Based Purchasing being enforced January 2017?
Dr. Rosen: There are many advantages to surgeons who join the AHSQC. First, you are actually able to track your own outcomes and compare yourself to a larger group in real time. This allows you to see what you are doing well, and what you might want to improve on in the future. This is often the first time many of our surgeons are able to actually see how they are doing amongst their peers, and it is very powerful.

Second, you are able to have real time data analytics to show your institution the exact value that you as an individual surgeon provide to their enterprise in the care of hernia patients. With the growing need to measure and report quality outcomes, it is critical for surgeons to control their own destiny by being involved in the data collection and outcome measures on which they are being judged. Waiting and hoping that your institution will do this for you in a fair and balanced means is often met with disappointment. Third, with value based payment adjustments starting this month, many surgeons are going to feel the 2% payment cut for Medicare patients if they are not deemed high quality surgeons. The AHSQC has been extremely proactive in this regard, and is now recognized by CMS as a qualified clinical data registry (QCDR), which basically means that your data in the AHSQC can be used to avoid these severe payment cuts. Fourth, we have a world class coaching system where collaborative-nominated surgical coaches are available to coach other surgeons via a cloud-based system to improve their outcomes and streamline their care processes.

Finally, it is an amazing experience to be part of a collaborative. For many surgeons out in practice, it can be very lonely and isolating. Being part of something that is much bigger than just one surgeon is a special experience, and every surgeon in our collaborative makes a difference.

What are the global benefits of the Collaborative?

 

Dr. Voeller: The global benefits to the Collaborative have the potential to be tremendous. First, and most importantly, it will allow us to find out what techniques, meshes, methods of mesh fixation and other issues in hernia repair work or don»t work. Also, part of the Collaborative is a mentoring and teaching function that will help educate surgeons on improving their techniques for hernia repair. Surgeons can look at their data and have access to other data on the Collaborative to help not only in education, but improvement in outcomes. In addition, research can be and has been done using the data on the Collaborative. It is well known that randomized prospective trials can leave many more questions unanswered than answered due to the difficulty in controlling variables. The Collaborative allows ready access to a tremendous amount of data to analyze what»s going on in the real world. The research potential is huge. Lastly, the companies are very interested because the FDA has said if data gathered on the Collaborative shows a product can be used safely in an instance where it may not have approval, the FDA may approve the new indication solely based on the data from the Collaborative. That is a totally new paradigm that helps patients, hospitals, and new product developers.

 

Speaking of data, what happens to members’ individual data and how is the data being used on a national level to help surgeons?

Dr. Rosen: The real power of our quality collaborative is that an individual surgeon can make a tremendous difference and their outcomes and experience counts. By pooling data from all practice patterns, and all levels of experience, we are able to see what is actually happening in the real world. As Guy mentions, all too often the peer review publications come from centers with high volumes and specialized practices, and this often doesn’t represent data that is relevant to most surgeons that are fixing hernias. In participating in this endeavor, surgeons are able to level the playing field and let their experience count.

In practice, each surgeon has access to their own data through our export function and can see their own results compared to the collaborative real time. Their data is also used as an aggregate analysis on the collaborative level. We have a publications committee that reviews protocols from any surgeon that wishes to analyze and perform research on our data and is a member of the AHSQC. This allows all of our collaborative surgeons to also have access to the larger data set to answer key questions in hernia surgery. In a few short years, we have been able to answer critical questions about the effectiveness of epidural analgesia after ventral hernia repairs, utilization of chlorhexadine scrubs prior to ventral hernia repairs, and outcomes of patients receiving bowel preparation before ventral hernia repairs, and have developed a validated readmission reduction tool for institutions to implement to reduce costly readmissions.

We are excited to report that participation in this collaborative is now recognized by the American Board of Surgery as acceptable for fulfilling the Maintenance of Certification Part IV requirement. As mentioned, we have also been recognized by CMS as a QCDR, which is critical in the quality payment program of CMS that started this month.

 

What are some of the major barriers to joining the AHSQC?

Dr. Rosen: There are a few barriers to joining the AHSQC, some of which are perceived and some are real and due to the fact that the system in which we practice medicine is not really ready for us to work together on a large scale to improve the care of our patients. It’s worth going into detail about some of these issues to provide surgeons a better understanding of what it takes to become a part of a collaborative.

Perhaps the most important barrier to discuss is the surgeons themselves. We simply were not taught to collaborate with our fellow surgeons. In fact, we were taught to compete against the fellow surgeon at all costs. This bitter competition has led to distrust in collaboration. It is so unfortunate, because while we do not work together as a group, many others are coming together and they are organized, and often don’t have the surgeon’s or patient’s best interest in mind. No one has a closer bond with their patients than a surgeon, and we need to be at the table when important decisions are being made. Surgeons must move past this discomfort with collaboration in order to be successful in today’s healthcare climate.

The second barrier to joining a collaborative is the HIPPA laws that currently make sharing of data extremely difficult amongst different surgeons in different institutions. Depending on what your practice type is, a contract lawyer from your institution must sign off on the agreement to allow us to share data. Despite over 200 institutions across the country already signing that contract, we have found that many hospitals also resist joining this endeavor simply because they are not equipped to share data for the greater good of their patients, and instead fear public reporting, or misuse of their data. It is unfortunate, because so many groups with much less accurate administrative data are already publically reporting on all of us, for which we have no say, validation, or basic risk adjustment to control the accuracy of what is being released.

Hopefully as the quality collaborative movement grows, the inappropriate resistance that many institutions put forth will be eliminated. It is also important that surgeon champions be ready to fight for their right to know their own risk adjusted outcomes, which is a very powerful position to be in when negotiating with your institution.

The final barrier is the perceived amount of time that is required to participate in this effort. It is important to point out that half of our membership is composed of private practice surgeons. You do not need a fleet of data abstractors to complete the data entry. This is surgeon-entered data and takes roughly 3-10 minutes per case. This is well worth the effort as we can now answer key questions that have plagued hernia surgeons for years, and have a seat at many tables to begin to shape some of the policy decisions involved in the practice of surgery.

 

 


 

 

Suggested Readings:

Bariatric

Article: Bariatric Surgery Outcomes in US Accredited vs. Non-Accredited Centers: A Systematic Review. Azagury D, Morton JM. J Am Coll Surg 2016;223(3):469-77.

https://www.ncbi.nlm.nih.gov/pubmed/27423398

Dr. Shanu Kothari: The authors have provided an excellent history of accreditation within the American Society for Metabolic and Bariatric Surgery (ASMBS) in the introduction of their article. They reviewed the baseline requirements for accreditation that goes far beyond a minimum volume requirement. They reviewed 13 papers on the topic for a total of 1.5 million patients, and compared the outcomes at accredited centers vs. non-accredited centers. Ten of the 13 papers demonstrated a considerable benefit at accredited centers for risk-adjusted outcomes. Specifically, 6 of 8 papers showed a reduction in mortality at accredited versus non-accredited centers and 8 of 11 showed reductions (albeit small) for morbidity at accredited centers. Moderate improvements in morbidity but significant improvements in mortality imply that accredited centers have the appropriate personnel and resources to treat patients in a timely fashion without letting them succumb to what is deemed "failure to rescue" in the literature. All of the studies reviewed were retrospective, large cohort studies that used a variety of databases (Centers for Medicare & Medicaid Services database, Nationwide Inpatient Sample database, University Health System Consortium database, etc.), each of which have inherent limitations. Hopefully, a day will come when the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) will be the definitive accrediting body and all third-party payers will honor that designation when it comes to reimbursement.

Article: The Role of Metabolic Surgery on Blood Pressure Control. Schiavon, CA, Drager LF, Bortolotto LA, et al. Curr Atheroscler Rep 2016:18(8):50.

https://www.ncbi.nlm.nih.gov/pubmed/27324638

 

Dr. Ricardo Cohen: Metabolic surgery is not only about diabetes. This interesting review approaches the benefits of bariatric/metabolic surgery on blood pressure (BP). So far, most published trials did not pay attention to hypertension, examining it only as a secondary endpoint. The observational series report diverse outcomes, with some reporting BP remission, BP control, or BP unchanged, while some randomized controlled trials (RCT) showed good outcomes with reduction of medication as easier control. This non-glycemic endpoint is important to be taken into account, because the main goal of metabolic surgery is to reduce cardiovascular risk. This group of authors are running the first RCT to address this important question, comparing the Roux-en-Y versus the medical treatment gastric bypass to treat obese patients with steady hypertension (the GATEWAY study). This is another interesting effect of metabolic/bariatric surgery that, combined with other outcomes (glycemic and lipids), is responsible for the long-term decreased all cause and cardiovascular mortality after surgery.

 



 

Colon

Article: Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial. Fleshman J, Branda M, Sargent DJ, et al. JAMA 2015; 314(13):1346-55.
https://www.ncbi.nlm.nih.gov/pubmed/26441179

Article: Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial.

Stevenson AR, Solomon MJ, Lumley JW, et al. JAMA 2015; 314(13):1356-63.

https://www.ncbi.nlm.nih.gov/pubmed/26441180

 

Dr. David Etzioni: These two studies, published in the same issue of the Journal of the American Medical Association (JAMA), randomized patients with stage II/III rectal cancer to laparoscopic versus open rectal cancer surgery. The endpoint for both of the studies was a composite endpoint–successful resection–which included: 1) a macroscopically complete mesorectal specimen; 2) a negative (≥ 1 mm) circumferential radial margin; and 3) a negative (≥ 1 mm) distal resection margin. Sample size accrual was sufficient in each of these studies (462 in the ACOSOG study and 402 in the ALaCaRT study) to achieve the a priori goals. The statistical endpoint was non-inferiority, with non-inferiority margins set at -6% in the ACOSOG study and -8% in the ALaCaRT study. Non-inferiority is met if the confidence intervals for the endpoint (successful resection) do not encompass these margins. In both of these studies, there was a failure to establish non-inferiority of the laparoscopic technique compared with open surgery (successful resection in ACOSOG = 81.7% for lap, 86.9% for open; ALaCaRT = 82% for lap, 89% for open). The implication is that the laparoscopic approach is oncologically inferior to the open approach.

Assimilating these results into appropriate changes in practice will challenge the field of colorectal surgery. Should the minimally invasive approach to rectal cancer care be abandoned? Doing so would be throwing out the baby with the bathwater. There may, however, be a greater role for stratifying the surgical approach for patients with rectal cancer. Patients with cancers that are more technically challenging may be better served with an open approach. A detailed paradigm to determine this is impossible to develop because of the significant differences in the skill sets available to particular surgeons. Long-term results of each of these studies will characterize the relationship between elements of successful resection and long-term outcomes. For now, the decision to use minimally invasive techniques in patients with rectal cancer should be made cautiously, and with a deep appreciation of the importance of appropriate oncologic principles.

 

 



 

Foregut

Article: Outcomes for trainees vs. experienced surgeons undertaking laparoscopic antireflux surgery - is equipoise achieved? Brown C, Smith L, Watson D, Devitt P, Thompson S, Jamieson G. J Gastrointestinal Surg 2013;17(7):1173–1180.

https://www.ncbi.nlm.nih.gov/pubmed/23653375

Dr. Robert Lim: We continue in an era where surgical quality is marked by long-term surgical outcomes, and this paper highlights how experience may play a factor in these outcomes. There is some uncertainty as to whether or not laparoscopic antireflux surgery, which would constitute both GERD and hiatal hernias, should be considered among the basic surgical skills of the general surgeon. This paper highlights that the short–term outcomes are equivalent, but long–term ones benefit from more experience. Other than reoperative patents, there is no distinction in the study between complicated and uncomplicated patients, and sub–groups were too small to make definitive conclusions about outcomes. However, there was significant advantage in reoperation rates, need for dilation, and patient satisfaction in the more experienced group. Consequently, I believe that the complex patient would benefit from more experience and the uncomplicated ones would have high quality outcomes regardless of the experience of the surgeon.

 

Article: Long–term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. Ganz RA, Edmundowicz SA, Taiganides PA, et al. Clin Gastroenterol Hepatol. 2016;14(5): 671–677.

https://www.ncbi.nlm.nih.gov/pubmed/27760265

 

Dr. Bill Richards: This is a five–year safety and efficacy study on 100 patients who underwent magnetic sphincter augmentation (MSA) for treatment of severe GERD. There were no device erosions, migrations, or malfunctions and the median preoperative GERD–HRQL of 27 fell to 4 after 5 years of implantation. The authors conclude that the MSA procedure is safe and effective after 5 years of follow–up.

 



 

Hernia

Article: Standard laparoscopic versus robotic retromuscular ventral hernia repair.

Warren JA, Cobb WS, Ewing JA, Carbonell AM. Surg Endosc. 2017 Jan;31(1):324-332.

https://www.ncbi.nlm.nih.gov/pubmed/27287903

Dr. Ajita Prabhu: Hernia repair is the fastest growing market for the currently available robotic platform. While several other articles have been published on this topic, this article is the first of its kind to compare the robotic approach with laparoscopy in terms of postoperative narcotics requirements, operative time, wound morbidity, length of stay, and cost. This is important because, while it is still early, there is some indication that at least for certain populations there may be some advantage to robotic retromuscular ventral hernia repair. It is also important to interpret these early results with caution, as we certainly have a long way to go with demonstrating that this is a reproducible and generalizable technology, and also that it makes sense from a cost standpoint.

Article: Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias. Rona K, Reynolds J, Schwameis K, et al. Surg Endosc 2016:1-7.
https://www.ncbi.nlm.nih.gov/pubmed/27553803
 

Dr. Bill Richards: This is a study of 192 patients who underwent magnetic sphincter augmentation (MSA) at one institution comparing the results of after MSA with hiatal hernia repair in patients with hiatal hernias greater than 3 cm in size to MSA in patients with hiatal hernias smaller than 3 cm. Patients who had larger hiatal hernias repaired and MSA had better outcomes than the MSA without Hiatal hernia repair. These short-term results suggest MSA may be a good option even in patients with larger hiatal hernias.

 



 

Endoscopy

Article: Endoscopic sleeve gastroplasty with 1-year follow-up: factors predictive of success. Lopez-Nava G, Galvao M, Bautista-Castaño I, Fernandez-Corbelle JP, Trell M. Endosc Int Open. 2016;4(2):E222-7.

https://www.ncbi.nlm.nih.gov/pubmed/26878054

 

Dr. Marina Kurian: The endoscopic sleeve gastroplasty is a new procedure that is being taught worldwide. This is very good early data from a premier center and early adopter. It is clear that this is a procedure for a different group of patients—those who don’t qualify for surgery based on BMI and comorbidity but have obesity and would benefit from weight loss.

 

Article: Gastric per-oral endoscopic myotomy (POEM) for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video). Khashab MA, Ngamruengphong S, Carr-Locke D, et al. Gastrointest Endosc. 2016.
https://www.ncbi.nlm.nih.gov/pubmed/27354102

Dr. Matthew Kroh: Advances in endoluminal surgery have allowed for increasingly complex procedures to be performed more commonly. For example, per oral esophageal myotomy (POEM) for achalasia is routinely performed in specialized centers with excellent results. Endoscopic intra-mural surgical techniques have been applied elsewhere, too, including resection of submucosal lesions and division of the pylorus as a treatment for gastroparesis.

With a spectrum of causes including diabetes, post-surgical dysfunction, and idiopathic etiologies, gastroparesis is a rare but an increasingly frequent disease. Medical therapies exist with varying success rates, and surgical treatments include gastric electrical stimulation (GES), gastrectomy, and pyloroplasty. In this study, Khashab et al describe their experience with gastric per-oral myotomy (G-POEM), a new intramural technique for treatment of gastroparesis. In this endoscopic procedure, the pyloric sphincter is divided to allow for better gastric emptying without transabdominal surgical access.

This multi-center study reports on 30 patients with refractory gastroparesis.

The technical success rate was 100% with a mean procedural time of 72 minutes. Mean myotomy length was 2.6 cm. Adverse events were rare. Objective postoperative evaluation was documented by gastric emptying studies, which were improved or normalized in 82% of patients.

Gastroparesis is a challenging disease process and, based partly on studies such as this, G-POEM may provide a less invasive, intra-mural technique for treatment. Further studies need to focus on the long-term durability of the procedure and quality of life metrics.

 

 
 

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