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.
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MISS NEWS NOVEMBER 2021Vol. 8 No. 61 |
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Surgeon Thoughts Today and Tomorrow IntroductionHappy Thanksgiving, MISS Readers! We hope you have a wonderful, peaceful holiday. Over the last few months, thought leaders in surgery and endoscopy have opined frankly in this series about some of the most controversial topics in surgery and endoscopy. These included racial disparity and diversity, surgeon/endoscopist burnout, industry’s role as a partner in surgical education and research, artificial intelligence, mentoring, and the conference of the future. If you missed any of these interviews, they can be accessed here. Happy Thanksgiving and thank you for reading!
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InterviewThe Final Installment of the MISS Seatbelt Series: Candid Takes on Hot Topic Walter Pories, MDFavorite MISS symposium historically and why: The first one because it brought in a wonderful new idea followed by superb programs, not unexpected since these meetings were started by Phil Schauer—one of the major leaders and trend-setters in our discipline. He not only has vision, but manages, against discouraging odds, to make impossible advances happen. Dr. Jaime PonceFavorite MISS symposium historically and why: The early ones because that was the beginning of great open discussions and debates on controversial and new issues lead by Phil Schauer, and of course skiing!
Dr. Michael RosenFavorite MISS symposium historically and why: Heavenly Valley, because we could ski!!!
Dr. Leena KhaitanFavorite MISS symposium historically and why: All of them! I always learn so much practical knowledge from the experts!
Dr. Daniel B. JonesFavorite MISS symposium historically and why: Breckinridge - family ski in afternoon
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MISS E-News Resource Center updateACS Bulletin Brief: New Society of Surgical Ergonomics Launches: AIS Channel: Improving Outcomes in Routine Hernia Repair: SOARD article: 10-year weight loss outcomes after Roux-en-Y gastric bypass and attendance at follow-up visits: A single-center study. JAMA Surgery Original Investigation: Understanding the Meaning of Recovery to Patients Undergoing Abdominal Surgery Surgery article: Factors associated with potentially avoidable interhospital transfers in emergency general surgery–A call for quality improvement efforts: Surgical Endoscopy article: Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis: JACS Article: Is It Time to Revisit Biologic Mesh?:
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MISS NEWS OCTOBER 2021Vol. 8 No. 60 |
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The Final Installment of our Seatbelt Series: KOLS in Surgery/Endoscopy— Training the Endoscopists and Surgeons of Today and Tomorrow IntroductionTighten those seatbelts one last time in 2021 for this final installment of my series with KOLs. Over the last few months, thought leaders in surgery and endoscopy have opined frankly in this series about some of the most controversial topics in surgery and endoscopy. These included racial disparity and diversity, surgeon/endoscopist burnout, industry’s role as a partner in surgical education and research, artificial intelligence, mentoring, and the conference of the future. If you missed any of these interviews, they can be accessed here. Stay safe and thank you for reading!
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InterviewThe Final Installment of the MISS Seatbelt Series: Candid Takes on Hot Topics Is there merit to the concern that while work-hour restrictions and other protections do good, they also may be doing some harm—because residents and fellows may not be developing the level of mental skill and toughness needed to be a surgeon, and some surgeons feel they can’t teach them in ways that are effective for a job that can result daily in life and death outcomes? Dr. Jaime Ponce: I think there are opinions and concerns on both sides. The evidence doesn’t show a strong conclusion. The truth is, maybe the restricted hours are affecting some residents, but not all. We are forgetting that individuals can make a difference, but also there has a been a response from the academic standpoint to address those who have the need, to step into a “transitional" fellowship with some supervision and mentoring and some independence. Like I have stated before, mentoring will make a big difference to alleviate some of those potential deficiencies. Dr. Ajita Prabhu: This is a difficult question to answer. In my mind, mental skill and toughness are innate characteristics that are difficult to acquire, work hour restrictions or not. Generally speaking, people either have it, or they don’t. I think it’s easy to say that the change in work hours is detracting from cultivating so-called “tough” residents. Likely, it’s way more complicated than that. I think that if a resident is driven, they will make the most of their time at work, and will get to the skills lab when they can, absorb as much as they can from conferences, and operate as much as they can. In the OR, they will engage fully and work hard on technical skills, and will never consider second scrubbing a “waste of time.” They will come prepared so they don’t lose out on the educational parts by not knowing the steps of the case. They will learn from their errors and will reflect on opportunities for improvement. I do think that all of that can be accomplished in 80 hours a week, but it’s not a passive process. I think we can train a surgeon to be outstanding in 80 hours a week, and I also think that it’s not a guarantee that one will become outstanding if they don’t fight for it. Dr. Michael Schweitzer: I'm not at all convinced that there is a problem with “the level of mental skill and toughness” after graduating from general surgery residency and fellowship. We can now educate the residents and fellows far better than anything I was exposed to in my residency. Simulator labs and teaching videos of operations available to our students accelerate learning for all involved. The excellent fellowships that are now offered after general surgery residency have, for most residents, helped to overcome the work-hour restrictions that were not in place when I was a resident. Dr. Marina Kurian: I have only been impressed by the level of commitment of the residents to patient care and improving their skill sets, both in the operating room and out. I think time well spent is far more important than time logged. Dr. Tolga Erim: I do hear this from my colleagues from both the medical side and the surgical side of training. They lament that we are training a generation of physicians and surgeons who will not have the same skills in dealing with the stresses they will encounter in practice. Yet, I also see the same physicians and surgeons burn out and disengage from their practice. I think rather than impose the same intolerable strains on the new generation, we should work on ways to make practicing these specialties sustainable. Dr. Guy Voeller: I am old school and believe the touchy-freely approach and work-hour restrictions and the like have destroyed our training programs. The office of equity and diversity at your local university has more power than any department, and more money is spent in that department than any other department in your university. This is the first place some residents go when they want to complain about something that they don’t agree with. Some of the residents today want to tell you how they want to be trained when they have no idea what it takes to be a great surgeon. In certain programs, having a resident on your service can be a risky proposition to your job security because of all these rules and regulations. Dr. Luke Funk: I do not think there is merit to this concern. It's reasonable to continue to monitor the impact of surgery resident work-hour restrictions on patient outcomes and trainee well-being. However, work-hour restrictions have been in place now for at least a decade. We now have multiple cohorts of fully trained residents and fellows going out into practice. Overall, they are well prepared to progress to fellowship or in some cases directly into practice. Some of the chief residents and fellows who have graduated from our programs over the past couple of years are the best trainees I have ever worked with. This idea that today’s trainees are not mentally tough is ridiculous. The trainees I work with are gritty, hardworking, and damn smart. They will be safe, competent surgeons. I think surgeons who feel they cannot teach trainees effectively within an 80-hour work week should re-examine their approach to training.
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Suggested Reading:Article: A simple difficulty scoring system for laparoscopic total mesorectal excision. Krizzuk D, Yellinek S, Wexner S, et al. Tech Coloproctol. 2020 Nov;24(11):1137-1143. doi: 10.1007/s10151-020-02285-8. |
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MISS E-News Resource Center updateUPDATE ACS Bulletin Brief: Top Things to Know from the American College of Surgeons: AIS Channel: Lessons Learned from Asian Academic Surgeons: SOARD article: Are eHealth interventions for adults who are scheduled for or have undergone bariatric surgery as effective as usual care? A systematic review. JAMA Surgery Viewpoint: Bridging the Digital Divide to Avoid Leaving the Most Vulnerable Behind: Surgery article: Differentiating What is hot from what is scientifically sound: Surgical Endoscopy article: SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD): JACS Article: US Medical Licensing Exam Performance and American Board of Surgery Qualifying and Certifying Examinations:
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MISS NEWS AUGUST 2021Vol. 8 No. 59 |
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Seatbelt Series Part 2: KOLS on Industry’s Role in Surgery, Artificial Intelligence in Your Practice, and the Conference of the Future IntroductionSeatbelts on again for this second installment of our three-part series with KOLs, readers! This month and last, I spoke with several thought leaders in surgery and endoscopy about some topics that are hot, timely, and controversial. Last month we tackled racial disparity and diversity and surgeon/endoscopist burnout. If you missed it, that interview can be accessed here. In this Part 2 installment, we address industry’s role as a partner in surgical education and research, artificial intelligence, and the conference of the future. I’d like to thank all of these participants for sharing their thoughts on these critical topics. They include Drs. Jaime Ponce, Tolga Erim, Marina Kurian, Tammy Fouse, Guy Voeller, Michael Schweitzer, Luke Funk, Ajita Prabhu, Leena Khaitan, and Matthew Kroh. We again have the most current best practice resources and educational activities in our MISS E-News Resource Center. Resources include Annals of Surgery, the ACS Bulletin Brief, Surgery, JACS, New England Journal of Medicine and the AIS Channel. Check them out, stay safe and thank you for reading!
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InterviewSeatbelt Series Part 2: Industry’s Role in Surgery, Artificial Intelligence in Your Practice, and the Conference of the Future Colleen: How would you characterize the evolution of industry’s role as a partner in surgical education/research and what it is today? Dr. Erim Tolga: There has been a steady decline in industry support for educational programs over the years. I believe it is going to continue to decrease over time. Dr. Ajita Prabhu: This is always a fraught discussion. It is virtually impossible to separate conflict of interest from education when education is financially driven by industry players. At the same time, education and research have to exist, and there aren't that many reliable alternative avenues (philanthropy, federal or state funding, etc.) by which to accomplish this. I also think industry partners should absolutely contribute to research and education, particularly since they have such great profit margins and also contribute heavily to our US annual healthcare expenditure. In a perfect world, that money from industry partners would be amassed in a non-profit organization to which we could apply for educational and research grants, and we could take the conflict part away completely. As we all know, that's very unlikely to happen, so here we are. I don't think our current relationship will change soon, so the best thing we can all do is manage our conflicts to the best of our abilities. Dr. Matthew Kroh: The surgeon-industry partnership has brought revolutionary change to our practices. This will continue and should be promoted. Disclosures and potential conflicts of interest need to be thoroughly vetted and transparent, but also should not be deemed as a negative. Dr. Guy Voeller: We all know that the relationship between industry and surgery has been key in the development of a huge number of products that have benefited our patients. Unfortunately, today at times this relationship has gotten a bad name due to some behaviors that may have been questionable. The mainstream press loves to try to paint a picture of a constant stream of nefarious doings between surgeons and industry when in fact the majority of time the relationship is very beneficial to the patient. Certainly, there are some bad actors, and they seem to get all of the attention. The good things that result from these relationships between surgeons and industry are rarely publicized. I believe it will be tougher and tougher for these relationships to occur, however, due to the climate that exists today. Dr. Michael Schweitzer: It is a complex equation where “conflict of interest” and ensuring excellent education appear to struggle to cohabitate. However, we are relying on more advanced technology in the OR; therefore, industry will play an important role in education for both residents and attendings. Dr. Tammy Fouse: Industry partners provide meaningful data, insight into emerging technology, surgical outcomes, efficient utilization, safety, etc. However, it is incumbent upon surgeons to analyze evidence-based data to make decisions for their own practice. Industry input should be one source of data to be analyzed, but not the only source. Dr. Leena Khaitan: The partnership with industry is essential for surgery to continue to move forward and evolve. They will always be a part of all of those things. It just will look different with more online options and online communication. Dr. Luke Funk: Technical innovation in surgery requires a partnership between the creators/end users (usually surgeons) and those who can turn ideas into mass-manufactured reality. Industry will continue to be a critical partner in surgical education and research and may even play an increasing role given the highly competitive extramural funding environment and the continual march toward virtual/simulated/artificial intelligence-type technology in surgery. Dr. Marina Kurian: Industry is still a critical partner in surgery. I think innovation needs surgeon partners to validate and improve it. In terms of education, industry help is greatly appreciated and is still needed to meet needs, especially as we return to in-person courses. Colleen: Where are we going with in-person conferences versus virtual post-COVID? Dr. Guy Voeller: I think most of us miss the interpersonal relationships you get at in-person conferences. There certainly are some conveniences to virtual conferences with respect to expense and not having to travel, etc. I think the future will be a kind of hybrid where we can have the best of both worlds and people can pick how they wish to participate based on all the factors involved. Dr. Luke Funk: I suspect that most conferences that are able to return to an in-person format will do so starting in Spring 2022, and in certain cases, in Fall 2021. Surgeons enjoy discussing research findings, socializing with friends and colleagues, and networking in person. Virtual formats are okay for presenting research and having discussions, but they don’t replicate in-person conferences. Dr. Ajita Prabhu: To be honest, I have felt for a while that in-person conferences are diminishing in their value, especially when viewed from a return-on-investment standpoint. Virtual platforms have proven to be very useful for everything from the mundane all the way to important professional meetings. Without question, there is value to meeting in person for certain indications, and there will always be pros and cons to both in-person and virtual events. Once we figure out how to block out the space and time for virtual events, I have a feeling that they will be game changers for many physicians, particularly those with families, outside interests, or really any other pursuits that don't involve work. For me, it's becoming harder and harder to justify being away from my family for work travel. Dr. Leena Khaitan: The in-person conferences will be smaller, and folks will always be looking for the opportunity for virtual learning. I miss the in-person aspect and am excited to get back into them next month! The reality is that institutions are also more hesitant for faculty to be away unless absolutely necessary. There will be fewer people in person, I think, who are just going to learn, as many view the remote option to see the same talks as more economical. It also avoids the hassle of travel that is also challenging at the moment. This will also be in a state of flux as COVID is still not gone and as surges change, in-person meetings will, too. Dr. Tammy Fouse: The events of 2020-2021 have provided an opportunity to see what the future could look like. Virtual formats allowed participants to attend conferences and educational events that they may not have had time to attend in the past. While there were certainly technological challenges that were identified, these challenges were beginning to be less and less as time went on. I feel the future will be a blend of in-person and virtual offerings that will allow healthcare providers to tailor their educational and professional development to fit their work and personal schedules. Dr. Marina Kurian: I think in the short term, these will be hybrid conferences. Many people like the fact that they can get more CME per meeting than in person and see more than one session when parallel sessions occur. Dr. Michael Schweitzer: The hybrid model is most likely the future for most large conferences. However, networking on the virtual format is not nearly as good as in person. The virtual format does not make it easy for the audience members to challenge what is being presented, and the chat box just is not the same as a surgeon who is on the floor at the microphone. Dr. Erim Tolga: I believe that we will continue to have good attendance at in-person conferences. We will likely have a virtual component to most conferences for both speakers and attendees. Dr. Matthew Kroh: In-person conferences are important not only for educational content, but for formal and informal networking, liaising to identify job and research opportunities, and face-to-face connection. Virtual access will have a place for those who cannot attend based on time, distance, and finances, but in-person meetings will continue, when appropriate. Colleen: Where do we stand with use of artificial intelligence in your area of practice? Dr. Jaime Ponce: Artificial intelligence will be the next big step in computer technology advancement. We need the surgical tools to teach us and to better assist us. I can see in the future having robots or tools that can follow our “usual” way of doing things, cameras that can move where we want, tools that can expose and assist to identify dangerous structures, etc. Dr. Matthew Kroh: We will be making important clinical inroads soon. Most immediately in endoscopy to identify lesions for resection during screening as well as to understand characteristics of advanced lesions prior to removal. Dr. Leena Khaitan: AI is the future, particularly in many aspects of MIS. It will be used to identify anatomy, to confirm surgical anatomy—after a Nissen for example, to evaluate anatomy in endoscopy or for laparoscopic cholecystectomy. This is one of the most exciting aspects of surgery right now. Dr. Michael Schweitzer: It has a lot of potential to revolutionize how we educate and grade residents. Dr. Marina Kurian: Artificial intelligence that assesses blood flow, and also tension on anastomoses, and that allows visualization of lymph nodes and ureters would be interesting. Dr. Luke Funk: In my clinical areas of bariatric, foregut, and hernia surgery, use of artificial intelligence to change how I do an operation (i.e., computer-augmented operative performance) hasn’t become the norm – yet. Perhaps as more robotic platforms become available, these options will emerge. I think there is tremendous potential to leverage AI not only for intraoperative aspects, but for pre- and post-operative decision-making (e.g., using approaches like artificial neural networks or natural language processing). For example, my research group is working on an artificial intelligence/machine learning approach to weight prediction in the outpatient setting. Dr. Ajita Prabhu: We are likely to see some of this from the surgical robotics industry soon. New technology is always exciting. We will have to see where it goes. Dr. Guy Voeller: I think if the money exists, artificial intelligence will play a big role in surgery. We certainly are only seeing the tip of the iceberg with the most amazing yet to come for sure – if the money allows. Dr. Tammy Fouse: AI’s influence in the surgical realm is in its infancy state and will continue to expand significantly in the coming years. From robotics to pattern recognition in diagnostic and therapeutic data sets, natural language processing in EMR systems, computer vision that provides real-time analysis of laparoscopic cases - the future is exciting! Surgeons are in a unique position to help drive and develop these innovations to optimize patient care and surgeon workflow.
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Resource CenterAnnals of Surgery: Implementation of Enhanced Recovery Pathways in the Real World—Change is Hard: ACS Bulletin Brief: Joint Statement in Support of COVID-19 Vaccine Mandates for All Workers in Health Care and Long-Term Care: Surgery article: What’s new? Addressing novelty in manuscripts: JACS Article: Importance of Practice Continuity: New England Journal of Medicine: Dexamethasone and Surgical-Site Infection AIS Channel: The Rives Stoppa Technique for Incisional Hernias
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MISS NEWS JUNE/JULY 2021Vol. 8 No. 58 |
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Seatbelt Series—Readers! Candid Talk on Hot Topics with KOLS in Surgery/Endoscopy Part 1 IntroductionSeatbelts on for this three-part series with KOLs, readers! This month I spoke with several thought leaders in surgery and endoscopy about some topics that are hot, timely, and some controversial—including racial disparity and diversity and surgeon/endoscopist burnout in this Part 1 installment. The following issues will feature Parts 2 and 3 and will address topics such as mentoring in 2021, artificial intelligence, the conference of the future, and industry’s role as a partner. I’d like to thank all of these participants for sharing their thoughts on these critical topics. They include Drs. Marina Kurian, Tammy Fouse, Guy Voeller, Michael Schweitzer, Luke Funk, Ajita Prabhu, Leena Khaitan, Erim Tolga, and Matthew Kroh. We again include the most current best practice resources and educational activities in our MISS E-News Resource Center. Check them out, and don’t miss this issue’s suggested reading, which is an Annals of Surgery article titled “Semper Prorsus: Anti-racism and American Surgery.” Last month’s issue featured an interview with Drs. Rami Lutfi and Jaime Ponce. We discussed the vertical gastric clip—which both doctors recently traveled to Mexico to witness the implantation of, use of pharmacotherapy in a bariatric program, challenges in career/affiliation changes, the biggest recent debates in bariatric surgery that have been settled—and the most legitimate one that hasn’t, and the role of robotics in bariatrics. If you missed it, that interview can be accessed here.
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InterviewSeatbelts on for this one, Readers!—Candid Takes on Hot Topics with KOLS in Surgery/Endoscopy: Part 1 Colleen: What are your thoughts on racial disparity in academic medicine and leadership roles (in institutions and in associations)? Dr. Guy Voeller: I don’t care whether you’re brown, black, blue, yellow, white, purple, have a penis, have a vagina, or have both, as long as you are the best one for the position. No one should be selected for a position based on race, color, creed, or anything else—or more importantly not be selected based on these criteria. Pick the best person for the position. Unfortunately, this does not occur today. I am tired of it. Dr. Ajita Prabhu: Diversity and inclusivity committees have exploded onto the scene recently, much of it fueled by current events in our country. I am often asked to sit on or chair a committee about this, and it continues to surprise me that this is the approach. The unintended consequence of these requests is essentially dumping the work onto those who have already been affected by the lack of diversity thus far in their careers. While it is trendy to have these committees to demonstrate that we are socially responsible, the elephant in the room remains: If we truly believe that we haven't done enough to build diversity, then why isn't everyone doing the work? I would challenge anyone who is trying to start up this type of initiative to be thoughtful about it. Be courageous enough to have your well-represented colleagues get involved and truly participate. If they aren't willing, perhaps there is a bigger problem. The attitude of "this doesn't affect me" or "this doesn't apply to me, so I can't help" is what got us here to begin with. Asking women (or any other underrepresented demographic) surgeons to mentor women (or any other underrepresented demographic) medical students or residents doesn't move the needle whatsoever in my opinion; it is something most of us were already doing long before this conversation became en vogue. And besides, mentoring is something that should occur organically and isn't matchy-matchy in that way, generally speaking. We need to change the construct of our educational and training processes to create better opportunities for underrepresented in medicine persons entirely. We need to open the door for them to come see what we do, but beyond that, they need to be visible to those in leadership positions so that we can cultivate further opportunities for training, education, speaking, committee work, or whatever their goals may be. Everyone has a part to play in this. In absence of that acknowledgment and effort, the committees are only performative. Dr. Erim Tolga: This exists in academic medicine, but even more glaringly in leadership roles. We have to remove implicit and unconscious bias from the workplace. Dr. Leena Khaitan: Awareness of this is at an all-time high. Surgical associations have all created diversity committees and actively working to make sure they have less disparity particularly in leadership and at conferences. Some associations are better than others. There are still a lot of "manels". But this is getting better. Institutions are also making efforts, but I think this is slower at many sites. This will take time. At least awareness is there, and this is driving change. Dr. Michael Schweitzer: Clearly, we need to continue to work on increasing the opportunities to have a more diverse staff at academic institutions. Dr. Marina Kurian: This is a problem that is being addressed now and we are headed in the right direction. It will take time to ensure that our implicit bias is recognized, addressed, and redressed. Dr. Luke Funk: Dr. Fiemu Nwariaku, a Past-President of the Association for Academic Surgery, published an excellent editorial on this topic in the Annals of Surgery in May 2021 (“Semper Prorsus: Anti-racism and American Surgery”). I will quote him: “In 2014–2015, Black [adults] represented 12.4% of the U.S. population, but only 2% of full professors’ of surgery...Even fewer African Americans are in academic surgical leadership. Academic surgeons have an obligation, if not an imperative to lead the way in changing policies that exclude any racial or ethnic group from achieving their full potential. I believe that the time has come to shift the conversation toward developing systems, policies, and processes to seek and fully integrate the input from all our colleagues in the decision-making ecosystem within our institutions.” Dr. Nwariaku subsequently outlined how surgical journals, surgical organizations, surgical boards, academic surgical departments, and health systems could help make this happen. His suggestions represent a blueprint for moving things forward not only for Black surgeons, but also other non-white surgeons (e.g., Asian American Pacific Islander and Hispanic surgeons). Dr. Matthew Kroh: This requires intentional equity and action. We need to address disparities based on race and sex so that our profession better reflects who we are and those we serve. This includes immediate focus on promotion, compensation, leadership positions, and also on the next generation of students and residents. Colleen: Surgeon burnout—education, awareness and prevention—where are we? And are associations doing enough? Dr. Guy Voeller: I don’t know exactly what surgeon burnout is. If it means you hate what you do and you don’t want to go to work, then maybe you should not be a surgeon. This all goes back to creating expectations. Today we tell young applicants that you can have it all. You can’t. If you want to be an excellent surgeon something else has to be sacrificed. It’s that simple. If you’re not willing to do that, then become a pathologist or radiologist or a dermatologist. We are talking about life and death decisions every day of your career. If that is something you cannot handle, then don’t become a surgeon. I am 68 and do 13,000 RVUs per year, have been married for 43 years, and love what I do. I guess I should be burnt out according to the “experts.” Dr. Marina Kurian: There’s still burnout. The first step to decrease it comes from the institutions and not the associations. Societies can offer help in how to deal with it, improve it or decrease it to the individual but the institutions need to have a plan for prevention. Dr. Matthew Kroh: This is a real problem, and the answers aren’t easy and there’s no universal solution. Burnout threatens our profession and our personal lives. We need to be creative and humane. It’s not always about resilience and grit. There is a middle path that can be forged from the standard surgical practice with fluidity to accommodate diverse and changing needs. Dr. Michael Schweitzer: We are not doing enough. The healthcare system is stressed, our patients are now even more stressed due to the recent pandemic, and of course healthcare providers are stressed. We need to discuss this at our meetings and fight for change. Dr. Tammy Fouse: The successful healthcare models will recognize the grave cost of surgeon burnout. Why are surgeons expected to be superhuman? While our teammates in the surgical suite are held to strict work-hour regulations, why is it “ok” for a surgeon to work all night on an emergency case and still be expected to perform at top condition in the OR the following day? Why are we not held to the same physical and mental constraints as other healthcare providers? The paradigm needs to change. Our surgical societies can take the lead in beginning the dialogue in recognition and thoughts for prevention and treatment. Dr. Ajita Prabhu: By now, I'm pretty sure the education and awareness part is fairly well established. Prevention and management of burnout are the two areas that we have a long way to go, in my opinion. The majority of the message to surgeons is related to how we should manage our own burnout by maximizing the quality of our personal time. No offense to anyone who believes that this is a reasonable solution, but we are physicians, so I'd say most of us are smart enough to work that part out on our own. Although we have identified what is definitely a major problem, we haven't truly scratched the surface of fixing it. I think the major contributor to burnout is the huge volume of non-compensated work that occurs around our practices and the daily running of our hospital businesses and practices. During non-business hours, work emails, phone calls/texts/pages about non-urgent clinical care, committee meetings, etc, need to become a thing of the past. Physicians need to be able to say no to professional obligations within reason, and without fear of losing their jobs. I'm not really familiar with what professional societies are doing about this. This problem isn't going to be resolved by just talking about it, though. It will need to be a concerted effort including administrators and physicians alike. Dr. Leena Khaitan: This is real. But really so challenging. Associations are raising awareness. Local institutions need to do more to help their docs. There is pressure to be productive and stay on top of clerical EMR work and the amount of paperwork seems to be increasing rather than being more efficient. Most are aware of it. The prevention still has a long way to go. The pressures within medicine that do not involve patient care but are more the finances, EMR, etc., need to improve. That is the only way this will change. Dr. Luke Funk: Surgeon burnout is really common, with some reports estimating that nearly half of surgeons meet criteria for burnout. According to a systematic review published in 2020 (Galaiya, et al. Ann R Coll Surg Engl), each of these factors was associated with a lower risk of surgeon burnout: a supportive work environment, mentorship, physical activity, emotional intelligence/grit/mindfulness, extraversion, academic work, less concern over income/finances, and having kids. Areas such as optimizing the work environment (fewer mandatory credentialing modules anyone?) and providing strong mentorship seems like excellent targets for associations and health systems. They are doing some of this work, but they can do much more.
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Suggested ReadingsArticle: Semper Prorsus: Anti-racism and American Surgery. Nwariaku, Fiemu MD, FACS. Annals of Surgery: May 2021 - Volume 273 - Issue 5 - p e162-e163
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Resource CenterACS Bulletin Brief: Clinical Update—Update from Board of Governors Health Policy and Advocacy Workgroup: Administrative Burden Definitions and Implications: AIS Channel: Optimizing Surgical Outcomes through Fluorescence Imaging: 4th International Bariatric Club Symposium at the Argentinian Society of Bariatric Surgery (SACO) Annual Congress Surgery article: Evolution of gastrectomy for cancer over 30-years: Changes in presentation, management, and outcomes: JACS Article: Upgrading Your Surgical Skills Through Preceptorship:
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MISS NEWS MAY 2021Vol. 8 No. 57 |
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An Interview with Dr. Jaime Ponce and Dr. Rami Lutfi: Recent Experience in Bariatrics Introduction This month I spoke with Jaime Ponce, MD, FACS, FASMBS, Medical Director, CHI Memorial Weight Management Center, in Chattanooga, Tennessee, and Rami E. Lutfi, MD, FACS, FASMBS, Clinical Associate Professor of Surgery, University of Illinois at Chicago. We discuss several hot topics—including the vertical gastric clip—which both doctors recently traveled to Mexico to witness the implantation of, use of pharmacotherapy in a bariatric program, challenges in their recent career/affiliation changes, and some of the biggest recent debates in bariatric surgery that have been settled—and the most legitimate one that hasn’t, and the role of robotics in bariatrics. I’d like to thank Dr. Ponce and Dr. Lutfi for sharing their thoughts on these critical topics. We again include the most current best practice resources and educational activities in our MISS E-News Resource Center. Check them out, and especially don’t miss the AIS Channel and IBC TV latest offerings! Also check out Dr. Ponce’s article recommendations on the gastric clip to become updated on the procedure. Last month’s issue featured an interview with Dr. Sean Langenfeld. We discussed that Twitter chatter about negative surgical stereotypes we’ve all recently seen, some recent debates in colon surgery that have been settled—and the most legitimate debate in colon surgery that is not, and the evolution of robotics in colon surgery. If you missed it, that interview can be accessed here. Stay safe and thank you for reading!
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InterviewJaime Ponce, MD, FACS, FASMBS, is Medical Director, CHI Memorial Weight Management Center, in Chattanooga, Tennessee. Colleen: What is the gastric clip and how did the first procedure in Mexico go? Dr. Lutfi: The gastric clip, or vertical gastric clip, is a removable device to be placed on the stomach parallel to the lesser curvature. It aims to "compartmentalize" the stomach into two compartments, and force the food to go through a narrow channel separated by the clip from the remaining storage space of the gastric body and the fundus. Colleen: Who will the gastric clip best target/help? Dr. Lutfi: Of course, who would benefit the most is yet to be determined by data. As for population to target, I see the gastric clip attracting the high number of patients who are worried about having "more aggressive" surgery that may not be reversed. This could finally drive up surgical procedure numbers. Colleen: Where are we in R&D with it, as it relates internationally and in the US? Colleen: What other new technologies do you think are most groundbreaking/useful? Colleen: How are you using pharmacotherapy in your patient treatment algorithm? Dr. Lutfi: Medications should be offered as part of the treatment options by every bariatric program. They should be offered for low BMI, partial responders, weight recidivism, and to those who are high risk. Colleen: Both of you have had career/affiliation moves in the last couple years that are significant. What is a challenge you faced and conquered, and what is the biggest improvement you’ve experienced with the move? Dr. Lutfi: For me (and everyone in private practice), COVID was the biggest challenge. This was in addition to the closure of my main hospital where I serve as Chief of Surgery. I was able to not only survive but grew the business. This was achieved by:
Colleen: What is one of the most legitimate debates in bariatric surgery that is not settled? Colleen: What is one of the biggest recent debates in bariatric surgery that has been settled?
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Suggested ReadingsArticle: A vertically placed clip for weight loss: a 39-month pilot study. Jacobs M, Zundel N, Plasencia G. Obes Surg 2017;27:1174-81. Article: Laparoscopic vertical clip gastroplasty – quality of life. Noel P, Nedelcu AM, Eddbali I, Zundel N. Surg Obes Relat Dis. 2018;14:1587–93. Dr. Ponce: As mentioned above, the gastric clip is not available for use as of yet in the US. These are two studies that give some background and data on the device. The procedure is being performed in Europe, Mexico, Chile, United Arab Emirates, and Mexico. The first article is a pilot study that led to European Union approval, and the second article also gives good background. Overall, we need more studies. In the US, we will need an FDA approval study—likely a randomized controlled trial.
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Resource CenterACS Bulletin Brief: Clinical Update—Update from Board of Governors Health Policy and Advocacy Workgroup: Administrative Burden Definitions and Implications: AIS Channel: Surgical Options for Rectal Prolapse: IBC Hot Topics in Surgery Free Webinar: SASI Technique, Single Anastomosis Ileal Bypass Surgery article: Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: A systematic review and meta-analysis: JACS Article: State-Level Examination of Clinical Outcomes and Costs for Robotic and Laparoscopic Approach to Diaphragmatic Hernia Repair:
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MISS NEWS MARCH 2021Vol. 8 No. 56 |
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Interview with Sean J. Langenfeld, MD, FACS, FASCRS Introduction This month I speak with Dr. Sean Langenfeld, who heads up colon and rectal surgery at the University of Nebraska Medical Center. We discuss several hot topics—that Twitter chatter about negative surgical stereotypes we’ve all recently seen, what some of the biggest recent debates in colon surgery that have been settled are—and the most legitimate debate in colon surgery that is not settled, and the evolution of robotics in colon surgery. I’d like to thank Dr. Langenfeld for sharing his thoughts on these critical topics and events. We again include the most current best practice resources and educational activities in our MISS E-News Resource Center. Check them out, and especially don’t miss Call to Action: Surgeons Can and Should Aid in Administering COVID-19 Vaccinations. I hope you also enjoy Dr. Langenfeld’s article recommendations on the latest research from the Michigan Surgical Quality Collaborative on opioid consumption after open and MIS colectomy, and the largest study to date on laparoscopic colectomy versus laparoscopic complete mesocolic excision (CME). Last month’s issue featured an interview with our MISS Director Phil Schauer. We discussed Virtual MISS2021 and its critical success in the new world of virtual conferences, and what to expect for MISS moving forward. If you missed it, that interview can be accessed here. Stay safe and thank you for reading!
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InterviewSean J. Langenfeld, MD, FACS, FASCRS is Chief, Colon and Rectal Surgery and Associate Professor of Surgery at the University of Nebraska Medical Center Colleen: There has been recent discussion on Twitter about negative surgical stereotypes. You were outspoken in how much you felt this stereotype was a deviation from reality. Please explain. Colleen: What is one of the most legitimate debates in colon surgery that is not settled? Colleen: What is one of the biggest recent debates in colon surgery that has been settled?
Colleen: How would you characterize the evolution of robotics in colon surgery to date versus in general surgery use?
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Suggested ReadingsArticle: Post-discharge Opioid Consumption After Minimally Invasive and Open Colectomy: Does Operative Approach Matter? Vu J, Cleary RK, Englesbe MJ, Brummett CM, Waljee JF, Suwanabol PA.Ann Surg. 2020 Jul 9. Online ahead of print. Article: Laparoscopic Colectomy vs Laparoscopic CME: A Retrospective Study of Two Hospitals with Comparable Laparoscopic Experience. Rinne JK, Ehrlich A, Ward J, Väyrynen V, Laine M, Kellokumpu IH, Kairaluoma M, Hyöty MK, Kössi JA. J Gastrointest Surg. 2020 Feb;25(2):475-483.
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Resource CenterCall to Action: Surgeons Can and Should Aid in Administering COVID-19 Vaccinations: General Surgery News Article: On the Spot: Wound Care—The Wild, Wild West? (Part 2) AIS Channel: Surgical Virtual Broadcast Event | Technical Steps to Perform a Gastric Bypass. March 18, 2021 @10am: American College of Surgeons Bulletin Brief: Women's History Month: Honoring Dr. Kathryn Anderson, First Woman President of the ACS: IBC Hot Topics in Surgery Free Webinar: Reflux Revisited—Watch here: Surgery article: A narrative celebrating the recent contributions of women to colorectal surgery:
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MISS NEWSVol. 8 No. 55 |
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IntroductionThis month’s issue features an interview with our MISS Director Phil Schauer. We discuss this past year’s Virtual MISS2020 and its critical success in the new world of virtual conferences, and we talk about what to expect for Virtual MISS2021. We discussed the question of whether the pandemic has stifled or helped grow innovation in surgery, the demand for in-person versus virtual meetings and conferences, and how COVID has shed light on the devastating comorbid effects of obesity—as evidenced by the particular vulnerability of patients with obesity during this pandemic. Next issue I will speak with Dr. Francesco Rubino, expert on both the pathophysiology of diabetes and obesity and the anti-diabetes effect of bariatric procedures. We will discuss his recent groundbreaking Lancet publication (Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial), which assessed 10-year follow-up after metabolic surgery compared with medical therapy for the treatment of type 2 diabetes. We will touch on the study’s most important findings, how the findings will change patient care, and whether we need a large multicenter randomized controlled trial for metabolic surgery. We again include for you the most current resources and educational activities in our MISS E-News Resource Center. Check them out, and especially don’t miss the IFSO Position Statement on single anastomosis duodenal-ileal bypass with sleeve gastrectomy/one anastomosis duodenal switch and the NEJM Perspective article that examines whether surgical staff have fallen from favor during COVID. Stay safe and thank you for reading!
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Colleen: Let’s talk about MISS2021. Remarkably, MISS 2020 ended up being one of the most successful surgical meetings of 2020, mainly due to adept pivoting and reallocation of resources to a virtual platform. With record registration and attendance, Virtual MISS2020 actually flourished. What will the next MISS look like? And how will it answer the unique current needs of surgeons? Colleen: That said, the general feeling among surgeons seems to be that there is still a place for in-person meetings—although many may forego that option moving forward based on recent positive virtual meeting experience, as well as time away from work and cost. What are your thoughts, given that our audience of general surgeons comprises surgeons from many different circumstances, practice structures, and needs? Colleen: Do you think the pandemic has stifled or helped grow innovation in surgery? Colleen: You remarked recently that COVID has shed a light on the devastating comorbid effects of obesity as a disease and is evidenced by the particular vulnerability of patients with obesity during this pandemic. In what way?
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Suggested ReadingsArticle: Association of Bariatric Surgery with Clinical Outcomes of SARS-CoV-2 Infection: A Systematic Review and Meta-analysis in the Initial Phase of COVID-19 Pandemic. Aminian A, Tu C. Obes Surg. 2021 Jan 8:1–7. doi: 10.1007/s11695-020-05213-9. Epub ahead of print. PMID: 33420671; PMCID: PMC7792914.
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Resource CenterIFSO Position Statement: Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) American College of Surgeons Bulletin Brief: ACS Endorses Resuming Cancer Screening and Treatment as COVID-19 Pandemic Continues General Surgery News Article: On the Spot: Wound Care: The ‘Wild Wild West’? ASMBS Guidelines/Statements: Safer through surgery: American Society for Metabolic and Bariatric Surgery statement regarding metabolic and bariatric surgery during the COVID-19 pandemic IBC Hot Topics in Surgery Webinar: The Acute Sleeve Leak - An Evidence-based Management Strategy—Watch here: New England Journal of Medicine Perspective: Have surgical staff fallen from favor in the pandemic-time demand for ER physicians, pulmonologists, and intensivists? |
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MISS NEWSVol. 8 No. 54 |
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IntroductionHello 2021 and goodbye 2020! In this final MISS E-News of this remarkable and challenging year, I speak with several thought leaders who we heard from this year. I would like to extend a big thank you to these surgeons for taking the time to discuss experiences, opinions, and perspectives regarding 2020, as well as their thoughts on best applications of robotics in their disciplines, the continuing paradigm shift of virtual meetings and conferences, and more. **If you haven’t done so this year, you can still link to the Virtual MISS 2020 Symposium here.** Happy New Year from all of us at MISS and Medscape! Stay safe and thank you for reading!
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An Exit Interview with Our Thought Leaders… Colleen: What has been one of the most positive things you’ve seen occur within your profession over the past year? What is one of the worst? Dr. Ajita Prabhu: Within our profession, it has been very inspiring to see that our colleagues have been able to pivot to fill in the gaps wherever care has been needed, often redeploying to be placed in harm's way, but always with the patients first in mind. Outside of that, surgeons have continued on in research and professional society endeavors, transitioning onto virtual platforms, and keeping connected in nontraditional ways. One of the worst things I have seen is an appalling lack of decorum from surgical colleagues regarding academic publications, and the loss of true intellectual discourse in favor of sarcasm, vitriol, and generalized lack of respect for each other's work. While some may attribute this behavior to conflict of interest, I think that may be only a small contributor to the issue. I think the problem is fueled in part by the dehumanizing effect of social media platforms, and fueled in equal part by some of the same divisive sentiments that seem to have overtaken our country in the past few years. Generally speaking, I have never felt that we have to agree with or support each other's findings; however, the inability to have professional, balanced discourse and disagree with each other in a respectful manner is unfortunate and only does a disservice to our profession in my opinion. Dr. Jaime Ponce: For my specialty of bariatric surgery, there has been more evidence of the obesity risk and the benefit of bariatric surgery in the context of COVID. There was also a significant impact from the shutdown of elective surgery at the beginning of the pandemic, but that allowed opportunities to communicate that bariatric surgery is not necessarily elective, but needed, for certain patients. Dr. Guy Voeller: I think the most positive thing this year is the response of the entire health care profession to the COVID pandemic. This is what the profession is all about, caring for the sick and everyone involved—from housekeeping to physicians to nurses and everyone in between—who were and are tremendous in what they have done. The development of the vaccines also is included in my answer. What a tremendous accomplishment in a such a short amount of time. Dr. Bradley Davis: This year has certainly been extraordinary and the challenges we have and are facing continue to strain our systems to the limit. Throughout it has never been clearer how dedicated my teammates are to each other and to their patients. The “can do” attitude and the selflessness has been incredible to be part of. Dr. Phil Schauer: Best - COVID has brightened the spotlight on obesity as a killer disease, and patients and referring doctors are beginning to take action by seeking obesity treatment. Worst - Many have died from COVID—mostly people with obesity and diabetes. Colleen: What are the best-case scenarios for utilization of robotics in general surgery in your discipline? Dr. Ajita Prabhu: I think we are still sorting this out. As I have said before, I am not sure the robot truly adds any major advantage to straightforward operations. The better application of the touted benefits (improved visualization, wristed motion, etc.) would seem to me to be with more complex operations such as abdominal wall reconstruction, recurrent inguinal hernia repair, etc. I think it's fine to utilize the platform in straightforward applications as a precursor to more challenging cases as surgeons are gaining skills and comfort on the robot, but I'm not sure I would call that best-case scenario for utilization of robotics as a routine and ongoing practice. Dr. Phil Schauer: It may keep older surgeons with physical limitations working longer. Dr. Jaime Ponce: Probably in difficult complex cases where there is difficult dissection or suturing on difficult narrow spaces, and expected longer cases. Another potential benefit is the improvement on ergonomics, especially for some surgeons who are already suffering from musculoskeletal difficulties. Dr. Bradley Davis: For colorectal, I suspect that robotics will become the preferred platform for left-sided and rectal resections/pelvic surgery. In my opinion, the benefits for right colectomies are not as clear for MIS surgeons that can perform a total intracorporeal anastomosis laparoscopically. For those who cannot, the robotic platforms may offer an advantage for right-sided resections as well. Dr. Guy Voeller: I think the best-case scenario for the use of robotic laparoscopy is when the surgeon does not have the ability to properly do an MIS procedure with straight sticks laparoscopy (that has distinct advantages for the patient when done in an MIS fashion), and the robot allows the surgeon to safely and properly perform that procedure. I have yet to find this scenario myself in my MIS practice, which includes foregut, colon, solid organ, bariatric and hernia, but I believe it is because I was lucky enough to be there at the beginning of laparoscopy. Dr. Bradley Davis: This is really just what I mentioned above – some great advances in virtual care, but problems with access will continue to be an issue until we have emerged from the pandemic. Dr. Jaime Ponce: The COVID pandemic has enabled new ways of communicating with our patients, using more telehealth. There has been an increased use of virtual technology to prepare patients for surgery and/or perform follow-up. I think some of these features will remain in place for the long run. Dr. Ajita Prabhu: Well, I think COVID has certainly had a negative impact on many aspects of life, including those you mentioned here. As far as patient treatment goes, I would like to think that we all provide the same caliber of care to our patients despite the ongoing pandemic, and I am sure we do. That said, many of us have been affected by temporary shutdowns of nonessential surgery, which of course can serve as an area of frustration for both patients and surgeons when inevitable delays in care occur. Overall, I think we are all doing the best we can, and patients generally seem to understand this. Dr. Guy Voeller: The impact of COVID on meetings and conferences has been huge, but tele-learning is better than nothing and has some advantages for both the teachers and the students. Face-to-face meetings will come roaring back once this pandemic is under control because that one-on-one personal contact is important to surgical training. Dr. Phil Schauer: The COVID crisis sped up telemedicine, which will continue to expand after COVID is gone. COVID accelerated expansion of web-based meetings and conferences, which will now have a permanent place in future education, but will not replace live face-face meetings like MISS!
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MISS E-News COVID Resource Center: Link to these!IBC Hot Topics in Surgery Webinar: Laparoscopic Surgical Stapling Technology under the Microscope—Watch here: The New England Journal of Medicine Audio Interview: A Look at Covid-19 Prevention and Care in 2020—Listen here: American College of Surgeons Communication Pulse—An Interview: General Surgery News Article: Financial Security: Lessons Not Taught in Medical School:
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Suggested ReadingsColonArticle: Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery. Surg Endosc. 2020 May 26. doi: 10.1007/s00464-020-07662-w. Online ahead of print. Dr. Steven Wexner: A diverting loop ileostomy is a commonly performed procedure. As laparoscopy has become more widespread in its implementation, we were able to compare outcomes of ileostomy closure in groups of patients who underwent their index operation either as a laparoscopic or an open operation. Along with Drs. Shlomo Yellinek, Dimitri Krizzuk, Hayim Gilshtein, Teresa Moreno Djadou, Cesar Augusto Barros de Sousa, and Sana Qureshi, we were able to identify 516 patients who underwent ileostomy creation during a laparoscopic procedure and an additional 279 patients who underwent loop ileostomy construction during a laparotomy. Multivariate regression analysis revealed that laparoscopy as the first operation offered significant benefits in terms of morbidity and length of stay following ileostomy closure. This publication should serve as yet another compelling reason to offer laparoscopy rather than laparotomy to patients undergoing an operation in which a loop ileostomy is planned.
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GeneralArticle: Consensus Conference Statement on the General Use of Near-Infrared Fluorescence Imaging and Indocyanine Green Guided Surgery: Results of a Modified Delphi Study. Ann Surg. 2020 Nov 17. doi: 10.1097/SLA.0000000000004412. Online ahead of print. Dr. Steven Wexner: The International Society for Fluorescence Guided Surgery undertook a consensus conference that included a Delphi analysis of 41 statements regarding the use of indocyanine green near-infrared imaging to improve surgical safety and outcomes. This panel of 19 international experts concluded that fluorescence imaging with or without ICG is highly effective and very safe in a myriad of clinical situations. This high-level consensus was published in the Annals of Surgery under the direct leadership of Drs. Fernando Dip and Raul Rosenthal from Cleveland Clinic Florida. |
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MISS NEWSVol. 8 No. 53 |
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IntroductionWe are back in your inbox this month with a new MISS E-News! **Don’t forget to link to the Virtual MISS 2020 Symposium here.** Happy Thanksgiving from all of us at MISS and Medscape! Stay safe and thank you for reading!
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Colleen: What were your biggest goals for this past year as Americas Hernia Society (AHS) President and how did the society fare regarding them? Colleen: What has been the biggest challenge of your AHS President tenure? Colleen: What are the strengths that the newly elected officers bring to the table and how do you foresee their impact? Colleen: What is exciting on the horizon for the newly elected officers?
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MISS E-News COVID Resource Center: Link to these!IBC Hot Topics in Surgery Webinar: Battle of the Balloons—Watch here: The New England Journal of Medicine Article: Esophageal Motility Disorders and Gastroesophageal Reflux Disease American College of Surgeons Bulletin Brief—November 10 Issue: General Surgery News Article: The Surgeon of the Future The Fight Continues: Contact Congress to Support Legislation Preventing Medicare Cuts! —Write to Congress here:
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Suggested ReadingsHerniaArticle: Abdominal Core Health-A Needed Field in Surgery. Benjamin K Poulose, Gina L Adrales, Jeffrey E Janis. JAMA 2020 Mar 1;155(3):185-186. doi: 10.1001/jamasurg.2019. Dr. Benjamin Poulose: We thought carefully about the concept of Abdominal Core Health, how it might enhance our identity, and how it could open up new avenues not available to us as hernia surgeons.
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GeneralArticle: In Defense of Peer Review. Surg Innov. 2020 Apr;27(2):133-135. doi: 10.1177/1553350620902349. Epub 2020 Feb 1. Prabhu A. Dr. Benjamin Poulose: Peer review is a critical part of our scientific validation process. That said, unhealthy competition can also play out in peer review-especially when the reviewer is typically blinded. I believe that peer reviewed work can coexist with the many other means of information dissemination coming online.
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MISS NEWSVol. 8 No. 52 |
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IntroductionThis month’s issue features an interview with our MISS 2020 Faculty Robin Blackstone, Guy Voeller, Leena Khaitan, and Jaime Ponce. These thought leaders discuss various topics involving education—including the most effective tools in teaching and training our residents on multiple platforms—and whether surgical associations have adapted and grown accordingly, the biggest challenges in training residents, and social media as a tool or a weapon in teaching. Happy Halloween from all of us at MISS!
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What are the most effective tools in teaching and training in your area of surgery today, in a climate and environment where there are multiple surgical approaches to learn, and what role does simulation play? Dr. Ponce: I think today it is more important than ever that new trainees get exposed to different approaches and techniques. If accessible, direct exposure to experts in those different methods is the best way of learning and adopting them. If experts are not readily available, certainly external rotations or simulators are the other options. I think the simulators’ capabilities nowadays are very real and very useful to shorten the learning curve for operating in real patients. Dr. Voeller: Please note that the answers to all these questions are the same. Training for all medical personnel has suffered. Nurses are getting their “doctorates” online and telemedicine is all the rage. EMR is simple copy and paste and has nothing to do with patient care and instead has everything to do with billing and “quality metrics.” Dr. Khaitan: Multiple tools exist, and it somewhat depends on the incoming skillset of the surgeon when learning a new skill. This current pandemic has also affected how this teaching is disseminated. Currently online webinars and discussions are a great way to get introduced to new technologies. These can be done through societies, social media groups, and industry. Hands-on courses were also a great asset, but with COVID we have to be more creative as this is harder to do now. So, simulation is a key part of this. Surgeons can be coached virtually. Also, there are new technologies where a deliverable simulator can be sent to the learner and then he/she uses the hands-on tool while being coached remotely. This is a very new approach and has been adopted for hernia, for example, by SAGES. Have surgical associations adapted and grown accordingly? Dr. Khaitan: Yes, the online offerings for zoom's, webinars, interactive courses have exploded over the last year. Dr. Blackstone: Actually, the society that—to my mind—has played the most consistent role in developing crucial adjuncts to training is SAGES. Early on, they saw a need to develop standardized curricula around energy use, for instance, and laparoscopic skill sets, and the society has provided tremendous value through the now required instruction. Dr. Voeller: Somewhat but not significantly. They, like training programs, are trying to come to grips with the profession-destroying regulations of the ACGME and new technologies but it is not easy to do. With the COVID mess, it is even more challenging. They are guilty of perpetuating the educational downfall of the trainees by bending to the will of the masses and not taking a stance on things that matter regarding training. The ACS is a perfect example. They are more interested in the politically correct social issues and societal “norms” and are so out of touch with the practicing surgeon. What is the biggest challenge today in training residents? Dr. Ponce: There are some limitations in training time (restricted hours), in mandatory supervision (less autonomy), and in some programs, the lack of the technology to improve the learning curve. Dr. Voeller: The biggest challenge is training them. With the profession destroying work hour restrictions and the politically correct environment of academia it is impossible. We also have the “inmates running the asylum” so to speak in that the trainees, who have no idea what they are doing, yet are telling the training programs what they want and how to train them. The training programs in surgery should be focused on one thing—training young men and women how to operate on humans and not harm or kill them. This is not the case. Grand Rounds are now spent on Equity and Diversity topics and other things that, while important, have nothing to do with being able to operate on people properly. Dr. Khaitan: Training residents is as fun as it always was. I think the training part continues to evolve with the addition of simulation labs, local teaching, and online lectures. I think the harder part is getting quality residents in the program, as so much of the interview process will be virtual this year. For practicing general surgeons who seek to learn new techniques and procedures, has social media become more of an educational tool or a weapon? Dr. Khaitan: Absolutely. Social media is a great way to learn from others, review challenging cases, and get multiple opinions. For learning new techniques, it is helpful and a great way to get exposed to a new technique. But this cannot replace the hands-on training that is needed for more complex procedures. Dr. Ponce: I think social media, used by professional organizations, actually has become a useful tool for practicing surgeons. It may need to be more closely monitored. But certainly, what it is not monitored is the independent sharing of “how I do it” videos and forums of questions in social media. Even though some of these social media resources are very valuable, easily accessible, and inexpensive, we sure sometimes need a little bit of vetting. But the future will continue to be driven by the easiness of social media and the web to obtain some information. Dr. Blackstone: "Social media” is a broad term. Tweets, Facebook, LinkedIn, Doximity, etc., can be very interesting, raising awareness of specific techniques or new data. New surgical education platforms such as that offered by the AIS Channel are delivering high-quality information in a fun and exciting way. No matter what platform surgeons are using, bias may be introduced by the nature of the media.
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MISS E-News COVID Resource Center: Link to these!American College of Surgeons Recommendations Concerning Surgery Amid the COVID-19 Pandemic Resurgence: The New England Journal of Medicine Editorial Perspective: Evaluating and Deploying Covid-19 Vaccines — The Importance of Transparency, Scientific Integrity, and Public Trust American College of Surgeons Bulletin Brief—October 27 Issue: 2020 Medical Innovation Summit: Has COVID-19 Extinguished Innovation? Not If These Robotic Startups Can Help It. November 3, 2020 1:00 PM – 2:00 PM EST. Register here: IBC Hot Topics in Surgery Webinar: Lexington Stapler Sleeve Gastrectomy—Watch here:
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Suggested ReadingsColonArticle: taTME can be safe and efficacious. Steven D. Wexner. Obesity Surgery (2020) 30:707–713. Dr. Steven Wexner: I was privileged to coauthor an editorial in Gastroenterology Report with Liang Kang, Patricia Sylla, Sam Atallah, Massaki Ito, and Jian-Ping Wang. Our editorial reiterates the importance of training, volume, and experience in obtaining oncologically optimal outcomes following taTME. Quite simply it appears that high per surgeon case volume and multidisciplinary team efforts are essential prerequisites to achieve these outcomes. I am optimistic that the American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer will help us achieve these goals.
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GeneralArticle: Using databases to improve outcomes in rectal cancer surgery. (An Expert Commentary on: A NSQIP analysis of trends in surgical outcomes for rectal cancer: What can we improve upon? Am J Surg. 2020 Aug;220(2):401-407. doi: 10.1016/j.amjsurg.2020.01.004. Epub 2020 Jan 10. Steven D. Wexner. Dr. Steven Wexner: This article assessed patients with colorectal cancer who had data reported in the ACS National Surgical Quality Improvement program (NSQIP) database. We were able to identify 34,000 patients who we divided into abdominal colonic and pelvic rectal cohorts. Several interesting findings emerged including the fact that patients in the latter group were more likely to have suffered major complications than were patients in the former group. In addition, there was an overall significant reduction in the length of stay perhaps due to the increased prevalence of minimally invasive surgery and/or enhanced recovery protocols. Many of these important data were unfortunately lacking within the ACS NSQIP database highlighting the need for constant review and updating of data fields in order to ensure that the ACS NSQIP database represents the most comprehensive clinically relevant data repository for patients undergoing colorectal cancer surgery.
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MISS NEWSVol. 8 No. 51IntroductionThis is a special tribute issue that is dedicated to the memory of Harvey J. Sugerman. When I first started in medical publishing, I was the editor of a new bariatric journal. I wore many hats, managing all steps of publication from editorial board development to content acquisition and issue planning right down to the graphic design and printing of the journal! As such, I oversaw inclusion of ads as well as the peer-reviewed articles. My first experience with Harvey Sugerman was both scary and enlightening. He called and left a message, and my heart dropped when I heard this giant of bariatric surgery on my voice mail. We finally connected, and he took me to task for including an Allergan ad on the Lap-Band, explaining sternly to me—insisting actually—that the ad MUST be removed from all future issues, as its claims in the small print were not published. This was a tall order (especially from someone who was not our Clinical Editor), about removal of an ad from a corporate titan in our newly launched journal! But this was also a lesson to me on journalistic integrity and the importance of vetting everything you publish—not just the peer-reviewed content. That lesson and his constant fostering of ethics in journalism (that he pushed people to adhere to) have stayed with me and were a critical help particularly when I started my own company and became an independent publisher. I learned to not only thoroughly vet what I publish, but also to be extremely careful, thoughtful, and critical of any project on which I am asked to collaborate, and cautious regarding those with whom I choose to partner. I owe him a great debt for this influence, and I wish I could have told him that. Stay safe and thank you for reading!
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MISS Special Issue: A Tribute to Harvey J. Sugerman, MDIs there a specific publication/article/manuscript that comes to mind when you think of Harvey, in his role as surgeon author, mentor, or editor? Dr. Michael Schweitzer: I still quote this study today and use it in my practice, “A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss” (Sugerman HJ, et al. Am J Surg. 1995 Jan;169(1):91-6; discussion 96-7; https://pubmed.ncbi.nlm.nih.gov/7818005/). It is a multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric bypass-induced rapid weight loss. Dr. Corrigan McBride: Many people will quote Harvey’s randomized trial of vertical banded gastroplasty versus gastric bypass. But just a few weeks ago, surgical oncologists published a study about ursodiol after gastrectomy to prevent cholelithiasis, and I was amazed. Dr. Sugarman did this study in 1995. He was a visionary, and other disciplines are now just learning and repeating his work. Dr. Raul Rosenthal: His Ed Mason lecture. He showed how he battled adversity in life and despite all hurdles, he still came out victorious. Dr. Jaime Ponce: There were several memorable times working with Harvey in research and publishing. During one of my first oral paper presentations in the ASBS plenary session, I presented our center’s experience with the laparoscopic adjustable gastric band (LAGB) and diabetes/hypertension, and he was very critical, as you can imagine. But he took the time to listen and make extensive and constructive comments. Then I followed him in the ASMBS Centers of Excellence Bariatric Surgery Review Committee as a Chair and worked alongside him, learning how to run a sometimes-difficult meeting among peers. Dr. Marina Kurian: The article on sweets and non-sweet eaters was really a landmark paper to understand patient selection and outcomes. He always pushed the ASMBS to be data-driven and elevated bariatric surgery to be a field of surgical excellence and improved patient outcomes. Dr. Samer Mattar: I think the most important role that Harvey played was as advocate and protector of patients. He dedicated his entire career to helping distraught, downtrodden, and disenfranchised patients with obesity, always stepping up to defend them at regional and national forums and in the nation's capital. He was one of the few surgeons to refuse to get on the LAGB bandwagon and strongly criticized it during the FDA trial—and boy, has anyone's opinion ever been more prescient? Dr. Phil Schauer: So many Sugerman contributions to choose from! I agree with Raul, his Mason lecture “My Journey” encapsulates his entire life and is a must see. He had “many ups and downs, but mostly ups and would not change a thing.” Do yourself a favor and watch it here: https://www.youtube.com/watch?v=8_1Ugr1Vp1k. His vertical banded gastroplasty versus gastric bypass randomized controlled trial (RCT) taught me the value of an RCT, which has been my obsession ever since. What has Harvey’s impact been on you (personally or professionally)? Dr. Michael Schweitzer: Harvey was the one who mentored me on bariatric surgery and life. Dr. Walter Pories: Thank you for the opportunity to add my tribute to one of the true giants, Harvey Sugerman. I do not need to reiterate my admiration for his contributions as a surgeon, as a scientist and as one of the moving leaders in our specialty. Dr. Raul Rosenthal: I worked alongside Harvey as Co-Editor-in-Chief of SOARD for the last three years and learned how to be a better academician. Harvey, was, however, a role model and mentor for most bariatric surgeons worldwide, including myself. Dr. Ninh Nguyen: I first met Harvey when he was the discussant on one of my very first publications on laparoscopic gastric bypass. (Nguyen NT, Ho HS, Palmer LS, Wolfe BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg 2000;191:149-155.) This study was presented at the ACS in 1999, which was the early period when data were just coming out regarding the procedure. There was skepticism in this new minimally invasive technique, including from Harvey. As a true scientist and pioneer in the field of bariatric surgery, Harvey was critical of the new technique (rightly so) and pointed out many of the limitations of the technique and the retrospective nature of our study. All of his points were spot on and his words of wisdom pushed me even further to perform a randomized trial, which we completed and presented at the American Surgical Association in 2001. Harvey is someone who pushes you to make you better. It's called tough love and we are all in debt to his contribution to our field. Dr. Corrigan McBride: I was fortunate enough to be the second MIS bariatric fellow that Dr. Sugarman trained, and that year changed the entire focus of my career from being an MIS general surgeon to being a bariatric surgeon. He was in the final years of his operative career then, yet he was learning and mastering the minimally invasive approach. This showed me that we always have to be open to learning new things and new approaches if it is the best thing for our patients. Dr. Samer Mattar: Harvey gave me candid and direct advice at many stages of my career. I remember many years ago approaching him at a national meeting to ask if I could be on the Editorial Board of SOARD, which he had just launched. He quietly turned to me and said it was too early to consider that, because I was not experienced enough. A few years later, I did receive an invitation from him to sit on the Editorial Board, and he subsequently "promoted" me to Associate Editor (CME editor). As always, he was correct in making me wait until I accrued more experience. Dr. Jaime Ponce: Harvey was always committed to his work. He was not shy to share his viewpoint or to tell me when he disagreed. I learned from his leadership, participation, and commitment. Dr. Daniel B. Jones: Dr. Sugerman corralled a group of pioneering surgeons to advance the science of obesity and establish the field of bariatric and metabolic surgery. Dr. John Morton: Dr. Sugerman's approval meant the world to me—I felt I had arrived in style. I admired his wide breadth of interests and his willingness to speak up, no matter the consequences. He was strong and brave in all—adversity, personal, clinical, and academic. I will miss him, and the world is poorer without him. Dr. Marina Kurian: Professionally, Harvey always pushed you to offer your best to your colleagues and to your patients. He took on high-risk cases to help patients, and those discussions I had with him were impactful. Dr. Robin Blackstone: Harvey Sugerman impacted metabolic and bariatric surgery in many ways, including scientifically and politically. His most fundamental non-academic contribution was to expand the inclusion of women in the executive leadership of ASMBS when he nominated and supported me to become the first woman President of our Society. That one act opened the door to diversity and inclusion within our society, established the opportunity for collaboration with the American College of Surgeons on quality through MBSAQIP, and helped establish metabolic/bariatric surgery as a fully accepted and endorsed part of American surgery. His foresight and vision were remarkable. Dr. Matthew Hutter: Harvey was an amazing man and is an inspiration to us all. To me, Harvey exemplifies how an individual can have a profound impact on countless patients and an entire field of medicine through dogged determination, indefatigable energy, remarkable resiliency, and a genuine inquisitiveness. We all should look closely at our field and think critically about what needs to be done to make surgery better for our patients and ask, “What would Harvey have done?” and then do it. No matter how challenging it might be. That is what Harvey did his whole life. He will be greatly missed. Dr. Scott Shikora: I never worked directly with Dr. Sugerman but knew him well via our mutual involvement in the leadership of the ASMBS. I was an executive council member during his presidency. Harvey had a significant role in improving the field of bariatric surgery not just for his benefit or that of a few, but instead for all bariatric clinicians and their patients. His efforts and influence ran the gamut from leadership, advocacy, research, and education. Dr. Phil Schauer: Harvey was a quintessential Surgeon, Scientist, Educator, and Leader. Beyond that he was a good personal friend, mentor, and loyal MISS faculty member. He was very influential to me personally in pursuing an academic career focusing on bariatric surgery. Way back in the 1980s, I first heard him, already a doyen of bariatric surgery, speak about bariatric surgery at Surgical Grand Rounds at UT San Antonio. At that time, I never imagined I would spend my entire carrier endeavoring to make a contribution to what we now call metabolic surgery. But his lecture planted a seed of interest that was destined to sprout in my future. Later, after finishing fellowship in advanced laparoscopy, and dazzled by what Alan Wittgrove was doing with laparoscopic gastric bypass, I plunged into bariatric surgery as a major career focus shortly after joining the faculty at the University of Pittsburgh. To gain credibility for pursuing such a career, I sought support from Harvey. He became a life-long mentor to me as he has to many surgeons. He had all attributes of a great mentor – very encouraging, critical at times, and frankly inspiring. On the other hand, Harvey never let friendship and admiration get in the way of a stiff reprimand! “What’s good for the goose is good for the gander,” he would say. After missing a couple of SOARD editorial review deadlines, he fired me from the board. He eventually let me back in, but I do think I hold the record for being fired at least times by Harvey! One final but important comment apropos to MISS is that Harvey Sugerman deserves credit for the initial idea of MISS! Around 1999 or 2000, during a faculty dinner of one or our bariatric surgery training courses at University of Pittsburgh, Harvey, an avid skier, said, “Why don’t you have a bariatric teaching conference at a ski resort?” Hence, MISS was born in the winter of 2001. As many of you know, the first 10 years of MISS were at world class ski resorts until we were forced to change venue (that’s another story!). Harvey was a regular and dedicated faculty member at MISS—so generous sharing his knowledge and wisdom. One year, he even participated in MISS right after neck surgery! See photos for proof! Pardon the pun, but we really are going to miss Harvey at MISS! God bless you, Harvey, and thanks for your friendship. I think we can all say that we were privileged to have known and worked with Harvey Sugerman!
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MISS NEWSVol. 8 No. 50 |
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IntroductionWe are back in your inbox this month with a new MISS E-News! This issue features an interview with Dr. Ajita Prabhu, who is with the Department of Surgery at Cleveland Clinic, Ohio. We are excited to introduce Dr. Prabhu additionally in this issue as the newly elected Treasurer serving on the Executive Council of the Americas Hernia Society. Congratulations, Dr. Prabhu! Ajita and I discuss two recent publications of hers—the first is a recent article in Surgical Innovation titled “In Defense of Peer Review”, and the second is an editorial she had published in General Surgery News titled “Quantity Over Quality in Hernia Data: It’s Time to Up Our Game.” Dr. Prabhu adroitly identifies the strengths and weaknesses of both educational resources and provides an insightful, balanced perspective on utilization of both. Special thanks to Dr. Prabhu for devoting the time to conduct this interview and discuss the ever-evolving roles of peer review medical literature and social media as a vehicle for surgical education. The August issue featured an interview with MISS faculty Leena Khaitan, Bradley Davis, Phil Schauer, Robin Blackstone, and John Dixon, who discussed the role of AI within healthcare and specifically within minimally invasive surgery. If you missed it, that interview can be accessed here. We again include the most current best practice resources in our MISS E-News Resource Center. **Don’t forget to link to the Virtual MISS 2020 Symposium here.** Stay safe and thank you for reading!
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Interview with Dr. Ajita PrabhuColleen: You recently published an editorial, “Quantity Over Quality in Hernia Data: It’s Time to Up Our Game,” in General Surgery News. Some surgeons interpreted this piece as a war on social media, yet that interpretation is not supported by the content of the article. What is the understanding you want readers to take away from your editorial? Colleen: Given your new role at Americas Hernia Society (AHS), you have a unique perspective on females in leadership roles in hernia surgery. How would you characterize the current state? Colleen: What are your hopes for AHS this coming year? Colleen: In your recent article in Surgical Innovation, you speak on some drawbacks of both peer-reviewed medical literature and social media and state: “While social media forums can offer an easily accessible and convenient resource to busy physicians, it would be a mistake, to say the least, to allow these to replace evidence-based medicine as the foundation upon which we offer care to our patients.” Dr. Prabhu’s articles can be accessed here (General Surgery News) and here (Surgical Innovation).
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Resource CenterIBC Hot Topics in Surgery Webinar: Diversity and Burnout in Surgery—Watch here: The New England Journal of Medicine Editorial Audio Interview: Guidelines for Covid-19 Vaccine Deployment American College of Surgeons Bulletin Brief—September 15 Issue: Annals of Surgery Article: Patterns of NIH Grant Funding to Surgical Research and Scholarly Productivity in the United States IBC Hot Topics in Surgery Webinar: The Nemesis for the General/Bariatric Surgeon: The Difficult Gallbladder in Severely Obese Patient—Watch here:
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Suggested ReadingBariatricArticle: Insurance Coverage Criteria for Bariatric Surgery: A Survey of Policies. Selim Gebran, Brooks Knighton, Ledibabari Ngaage, John Rose, Michael Grant, Fan Liang, Arthur Nam, Stephen Kavic, Mark Kligman, Yvonne Rasko. Obesity Surgery (2020) 30:707–713.
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HerniaArticle: Laparoscopic inguinal hernia repair in women: Trends, disparities, and postoperative outcomes. Am J Surg. 2019 Oct;218(4):726-729. Nicole Ilonzo, Jeanie Gribben, Sean Neifert, Erica Pettke, Michael Leitman. |
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MISS NEWSVol. 8 No. 49 |
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IntroductionFirst and foremost, we would like to take this opportunity to extend our deepest condolences to the families, friends, and colleagues of Dr. Morris Franklin and Dr. Harvey Sugerman. Both icons in this field, they have contributed immeasurably to the field of surgery on not just a clinical level, but as mentors and leaders outside of the OR. Both men were an important part of MISS since its inception, and we will miss them greatly. Please look for a special tribute issue in your inbox shortly that will pay tribute to these great men. This month’s issue features an interview with several members of our MISS faculty, including Leena Khaitan, Bradley Davis, Phil Schauer, Robin Blackstone, and John Dixon. These thought leaders devoted their time to discuss the role of artificial intelligence (AI) within healthcare and their particular areas of minimally invasive surgery. I hope you also enjoy this month’s article recommendations from thought leaders in surgery, brought to you by leaders in surgical research and innovation. Thank you to these doctors for sharing their thoughts and opinions with us, and also to all of this month’s contributors!
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How would you characterize the current and/or future role of AI within your surgical specialty? What do you have concerns about in this regard, if any? Bradley Davis: We have embarked on the 4th industrial revolution and are experiencing a digital transformation in a variety of industries that impact the lives of providers and patients alike. With most of the information that we capture in the OR being digital, the next step is to develop platforms that can process these enormous amounts of data and create something meaningful that surgeons can use to assist in decision making. This is where machine learning and both predictive and prescriptive analytics will likely revolutionize the way we plan for and conduct surgical procedures. This technology is still maturing and will take several more years to see meaningful changes, but it will come and it will be impactful. To some extent we are victims of our successes – the tools and equipment that we now have in our operating rooms are so effective that iterating around the next best thing has become a difficult value proposition. Cost is going to always be a consideration as it pertains to what incremental improvement we will realize in outcomes. This has been the biggest barrier in my opinion and has held us back in terms of these kinds of technology investments. Ultimately who is going to pay for it and what will be the ROI? Robin Blackstone: The use of artificial intelligence in augmenting surgical therapy is coming to surgical treatment whether we engage in its development or resist it. Adoption of new technologies will be necessary to cope with the avalanche of information, research and patient-specific data that will inform surgical therapy in the future. One of the most promising is the use of artificial intelligence, potentially allowing surgeons to move beyond traditional search engines to integration of information from multiple sources, including big data, peer-reviewed research, and direct patient input. Increasingly, surgical therapy is one choice among a group of medical options that include less invasive options, or part of a strategy that involves multimodality care. Determining the precise course of care optimal to a given individual will require integration of multiple data streams and logical choices, ideally offering decisions that are unbiased by personal experience in individual cases. Surgery has a unique component of physical interaction with human tissues to achieve specific goals. Increasingly, the changes in anatomy are being understood in the context of the effect they achieve on physiology (metabolic surgery), an effect only now being understood and quantified. This casts outcomes into a different light – not only to realize a short-term objective but to avoid downstream negative consequences (eg, hypoglycemia). Technology development and implementation is accelerating. There are significant challenges like interoperability of the data streams, privacy, and cost. There is a fear that use of AI integration will increase the distance between engagement with patients; ideally, though, if we can concentrate on feedback that is integrated into our course of care, it should free up our time and attention to engage in a more impactful way with our patients and ease working relationships between surgeons, colleagues, and teams. Phil Schauer: AI is in its infancy regarding surgical specialties, so it’s hard to say right now its true benefit. But, especially in the area of decision support, I think it’s very promising. Smart phone apps are appearing that I believe are early forms of AI and aid surgeons in vital pre- and post-decision making based on strong data—for example, which operation to choose for bariatric surgery based on patient characteristics like BMI, age, diabetes, GERD, etc. Such AI can lead us a step closer to personalized medicine. My main concern with such AI support is the validation of accuracy. If such decision support tools are not based on sound, high level evidence, it’s the same old garbage in/garbage out conundrum that could potentially hurt patients. John Dixon: AI has and will continue to impact all areas of healthcare. It’s here and will not go away – so let’s embrace it and learn about how we can use it and manage it. It’s early days, so all results are exploratory. AI will provide the opportunity to simplify the complex—or what may previously have been considered impossible. All aspects of patient care will be impacted. In a bariatric-metabolic surgery practice, patient assessment will be streamlined to provide a higher level of complication detection and risk profile. A personalized approach to risk versus benefit will assist in a patient choosing to have an intervention, and guide which intervention. Enhancing the patient experience through personalizing, simplifying, educating, and selecting an appropriate clinical pathway will be possible. In addition, it will be based on the best available evidence. The assessment-to-treatment phase of care should be logical, timely, and without inappropriate barriers. AI in biomedical research and engineering will accelerate discovery and the development of pharmacotherapy, devices, and performing surgery itself. Advances in robotics will change the complexity and nature of surgery that can be performed. Of course there will be winners and losers; there will be disruption; and any change is threatening. Do you have a choice? No. Engage the future, and be a winner for yourself and your patients. Leena Khaitan: I practice mostly foregut and bariatric surgery. Currently AI is not a part of the specialty, but I can see AI playing a role in the future. AI cannot replace surgeons in my opinion as human anatomy still has significant variation. However, there is great potential to make what we do better. For example, in laparoscopic cholecystectomy, AI technology can help identify/confirm the anatomy and ensure the “critical view” has been obtained. In the world of foregut surgery, we still have a lot of variability in the way antireflux procedures and hiatal hernias are performed. AI may help us to make this more standardized across surgeons to maybe improve the outcomes for everyone. AI technology may help with imaging to identify abnormalities using 3D reconstruction of the hiatal region and planning the surgery better. In bariatric surgery, there is great variability in sleeve construction. Using AI, we may better be able to identify the best way to make a sleeve for the best outcomes regarding weight loss and GERD, and may be a more effective approach than a multicenter trial to examine every step of the surgery. Regarding concerns about AI…have you seen the movie Terminator and the way the machines took over the world?! But seriously, any technology can be used the wrong way. Medicolegally, there can be many issues surrounding AI as although the technology can provide insight, AI is still run by a computer and humans are unique. AI may miss things and vice versa. Also, any new technology is expensive. I think it will be many years until AI is mainstream in surgery.
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Suggested ReadingArtificial IntelligenceArticle: Artificial Intelligence in Surgery: Promises and Perils. Hasimoto DA, Rosman G, Rus D, Meireles OR. Ann Surg. 2018 Jul: 268(1):70-76. Robin Blackstone: Please see interview response above for feedback and insights on this article topic. Article: The practical implementation of artificial intelligence technologies in medicine. He J, Baxter SL, Xu J, Hu Ji, Zhou X, Zhang K. Nat Med 2019 Jan 25(1):30-36. Robin Blackstone: Please see interview response above for feedback and insights on this article topic.
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BariatricArticle: Unintended consequences for patients denied bariatric surgery: a 12-year follow-up. Tsuda S, Barrios L, Schneider B, Jones DB. Factors affecting rejection of bariatric patients from an academic weight loss program. Surg Obes Relat Dis 2009 5(2):199-202. Dr. Dan Jones: Approximately one third of screened patients were not accepted for surgery by an academic bariatric program. Self- or social referral appeared to correlate with rejection because the BMI did not meet the criteria for surgery. This suggests inadequate information among social referral networks and/or in the media. Long-term follow-up will determine the health outcomes of patients not cleared for weight loss surgery.
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MISS NEWSVol. 8 No. 48 |
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IntroductionDon’t miss any of the past few weeks’ successful Virtual MISS 2020 panels and presentations. You can continue to obtain MISS CME right from your home because all meeting content has been archived and recorded and is available for viewing at your convenience. Check out the courses, presentations, and recorded live events here. Additionally, we are back in your inbox this week with a new MISS E-News Surgeon Resource to keep you current. Last issue we gave you key insights from Dr. Delia Cortés Guiral, surgical oncologist, Colorectal Surgeon at King Khalid Hospital in Saudi Arabia. We discussed her recent article published in Colorectal Disease on validated occupational health safety measures to protect healthcare workers from accidental exposure to toxic aerosols in PIPAC procedures that could be implemented during laparoscopic surgery in COVID-19 patients. She also discussed how COVID-19 has affected her specialty and how she has adapted, and the COVID scene in both global locations where she operates—Madrid and Saudi Arabia. This issue we speak with Dr. Mary Hawn, Chair of the Department of Surgery at Stanford University, about the paper she published recently on an algorithm she and her colleagues devised that has lead to better protection of OR team members during the pandemic and better conservation of personal protective equipment. Her JACS article can be read in full here. We also discuss what has been most challenging for her during COVID19, what may be challenging for other programs to implement regarding her published algorithm, and what permanent improvements may come out of the changes that the pandemic has necessitated from an OR standpoint. A special thanks to Dr. Hawn for devoting the time to conduct this interview! We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. **Don’t forget to link to the Virtual MISS 2020 Symposium here.** Stay safe and thank you for reading!
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Interview with Dr. Mary HawnColleen: Can you share with us the main takeaways or key pearls from your recent popular JACS publication, Precautions for Operating Room Team Members During the COVID-19 Pandemic? Colleen: Do you foresee challenges in implementing components of the Stanford algorithm elsewhere? Colleen: What has been the most challenging thing for you personally in your surgeon role during the COVID pandemic? Colleen: Do you think that coming out of this pandemic, there will be permanent improvements in certain processes, protocols, and patient care?
Dr. Hawn’s JACS article can be read in full here.
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MISS E-News COVID Resource Center: Link to these!Surgical Endoscopy article: The role of surgeons during the COVID-19 pandemic: impact on training and lessons learned from a surgical resident’s perspective IBC Hot Topics in Surgery Webinar: Covid-19, Thrombosis & Bariatric Surgery Webinar—Watch here: The New England Journal of Medicine article: Multisystem Inflammatory Syndrome in U.S. Children and Adolescents American College of Surgeons: Assistance and Well-Being: The ACS offers this as a free resource to Fellows, Associate Fellows, and resident surgeons in the United States and Canada. Consider using the ACS Surgeon Well-Being Index to assess and track your overall well-being and identify areas of risk compared to physicians and residents across the nation. The New England Journal of Medicine Article: Genomewide Association Study of Severe Covid-19 with Respiratory Failure: IBC Hot Topics in Surgery Webinar: The Psycho-Sexual impact of Bariatric & Metabolic Surgery - Uncovering the Truths—Watch here: AIS Channel: 5 Things You Should Know About Watch & Wait Strategy for Rectal Cancer
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Suggested ReadingBariatricArticle: Comparing the 5-Year Diabetes Outcomes of Sleeve Gastrectomy and Gastric Bypass: The National Patient-Centered Clinical Research Network (PCORNet) Bariatric Study. Kathleen M McTigue, Robert Wellman, Elizabeth Nauman, Jane Anau, R Yates Coley, Alberto Odor, Julie Tice, Karen J Coleman, Anita Courcoulas, Roy E Pardee, Sengwee Toh, Cheri D Janning, Neely Williams, Andrea Cook, Jessica L Sturtevant, Casie Horgan, David Arterburn, PCORnet Bariatric Study Collaborative. JAMA Surg 2020 Mar 4;e200087. Online ahead of print. Dr. Luke Funk: Understanding differences in type 2 diabetes mellitus (T2DM) outcomes between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) is critical, given that patients with severe obesity and diabetes are commonly evaluated by bariatric surgery programs. Previously published randomized trials have not identified differences in T2DM outcomes between SG and RYGB, likely because they have not been powered for this outcome. This observational study followed over 10,000 SG and RYGB patients from 34 PCORnet institutions and found that more than 80% of patients experienced T2DM remission during the 5-year follow-up period. Yet, 33% and 42% of RYGB and SG patients, respectively, experienced T2DM relapse. Nearly half of the patients who underwent RYGB and one-third of patients who underwent SG had well- controlled hemoglobin A1c levels 5 years after surgery. These findings are relevant for bariatric surgeons because they summarize outcomes from a real-world setting (as opposed to a trial) and suggest that RYGB may be associated with better T2DM
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MISS NEWSVol. 8 No. 47 |
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IntroductionDon’t miss any of the past few weeks’ successful Virtual MISS 2020! If you were unable to view sessions or live “Best of” panels, don’t worry. You can continue to obtain MISS CME right from your home because all content is archived and recorded for viewing at your convenience. Check out the latest live event of the last week, including Monday 6/22 and Wednesday 6/24’s Best Of Metabolic – Bariatric Surgery Parts I & II, and the recent Best of Foregut. Additionally, we are back in your inbox this week with a new MISS COVID-19 Surgeon Resource to keep you current during this challenging time. Last week we gave you key insights from Dr. Mariana Berho, MD, Chair of Pathology and Laboratory Medicine at Cleveland Clinic Florida, and Dr. Gary Procop, Medical Director of Clinical Virology at the Cleveland Clinic, Ohio. This week we speak with Dr. Delia Cortés Guiral, surgical oncologist, European Certification on Peritoneal Surface Oncology, Consultant Peritoneal Surface Malignancies & Colorectal Surgeon, King Khalid Hospital, Saudi Arabia. We discuss her recent article published in Colorectal Disease on validated occupational health safety measures to protect healthcare workers from accidental exposure to toxic aerosols in PIPAC procedures that could be implemented during laparoscopic surgery in COVID-19 patients, how COVID-19 has affected her specialty and how have she has adapted, and the COVID scene in both global locations where she operates—Madrid and Saudi Arabia. I’d like to thank Dr. Cortés Guiral for taking the time to speak with me for MISS E-News! We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center. **Don’t forget to link to the Virtual MISS 2020 Symposium here!** Stay safe and thank you for reading!
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Interview with Delia Cortés GuiralColleen: According to the paper you just published in Colorectal Disease, PIPAC’s mechanism allows important parallels to be drawn in relation to laparoscopy in the COVID‐19 era. Can you elaborate? In this article, we present the validated occupational health safety measures to protect healthcare workers from accidental exposure to toxic aerosols during PIPAC procedures that could be implemented during laparoscopic surgery in COVID-19 patients. These protective measures include the following: Controlling the abdominal distension by reducing the number of trocars to a minimum, by the use of balloon trocars, and by verifying zero gas flow on the panel of the CO 2 insufflator. Since some insufflators are able to reabsorb CO 2 in order to prevent intra-abdominal pressure peaks, a microparticle filter should be intercalated on the CO 2 inflow line between the insufflator and the patient. Desufflation of the toxic aerosols occurs over a closed aerosol waste system (hermetic tubing with two consecutive microparticle filters); this system is then connected to a mobile high-efficiency particulate air (HEPA) filter. As an additional safety measure, the patient is completely covered with a large plastic drape extending to the floor. The plastic drape is perforated, and a stoma bag is used to seal around the hermetic tube system connected to a mobile HEPA filter system. Colleen: What are the main takeaways of the publication regarding COVID-19’s impact on colorectal surgery? Colleen: How has COVID-19 affected your specialty and how have you adapted? Colleen: What are the current policies in the two countries where you practice for COVID-19 protocols, such as testing of patients and staff prior to surgery or other in-hospital treatment? Colleen: What are the main takeaways of the publication regarding COVID-19’s impact on colorectal surgery? Colleen: How has COVID-19 affected your specialty and how have you adapted? Colleen: What are the current policies in the two countries where you practice for COVID-19 protocols, such as testing of patients and staff prior to surgery or other in-hospital treatment?
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MISS E-News COVID Resource Center: Link to these!AIS Channel: Care for the Cancer Patient with Heidi Nelson AIS Channel: The impact on surgical journals with Susan Galandiuk Surgical Endoscopy article: COVID-19 and impact on peer review American College of Surgeons Bulletin: ACS COVID-19 Update American College of Surgeons: Surgeon Voices in the COVID-19 Era Nancy Gantt, MD, FACS, sends a message to colleagues in the health care community encouraging well-being and use of the ACS COVID-19 Registry. ASMBS position statement entitled, "Safer Through Surgery," published online in the journal SOARD: IBC COVID-19 Webinar: Redefining New Standards in Metabolic Medicine & Surgical Research—Watch here:
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Suggested ReadingBariatricArticle: Bariatric peri-operative outcomes are affected by annual procedure-specific surgeon volume. Altieri, M.S., Pryor, A.D., Yang, J. et al. Surg Endosc (2019). https://www.ncbi.nlm.nih.gov/pubmed/31388803 Dr. Jessica Ardila-Gatas & Dr. Aurora Pryor: This article highlights how the peri-operative outcomes of bariatric surgery are affected by the annual surgeons’ operative volume. It shows the importance of procedure-specific volume to predict outcomes, including length of stay, overall morbidity, and readmission rate, for both Roux-en-Y gastric bypass and sleeve gastrectomy. This article shows thatthe surgical skills for one procedure did not predict outcomes for the other bariatric procedure. Limitations are that this is an administrative database, it may not capture all patients, and it doesn’t include the effect of weight on the peri-operative risk. However, the importance of annual volume in maintaining skills translating into good outcomes can be appreciated. |
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Introduction
Don’t miss Virtual MISS 2020! It’s going on now—but if you missed sessions or live “Best of” panels, don’t worry—all live content is archived for viewing at your convenience. Get your CME right from your home—with superior content that requires no travel. If you want to view the live events of the last week, including Tuesday 6/9 Best of Colon and Thursday 6/11 is Best of Hernia, or the most recent Best of Enhanced Recovery after Surgery, click here!
Additionally, we are back in your inbox this week with a new MISS COVID-19 Surgeon Resource to keep you current during this challenging time. Last week we gave you key insights from Dr. Francesco Rubino, world-renowned surgical expert on the pathophysiology of diabetes and obesity, on 2020 MISS and the power of a quality meeting in-person and online, current COVID publications and peer review, the recent surgeon recommendations from the Diabetes Surgery Summit COVID-19 webinar, and COVID’s impact on several facets of healthcare in the United Kingdom.
This week I speak with Dr. Mariana Berho, MD, Chair of Pathology and Laboratory Medicine at Cleveland Clinic Florida, and Dr. Gary Procop, Medical Director of Clinical Virology at the Cleveland Clinic, Ohio. Dr. Procop oversees molecular diagnostic testing and has evaluated numerous molecular platforms for COVID testing and we discuss various aspects of testing with both doctors.
I’d like to thank Drs. Procop and Berho for taking the time to speak with me for MISS E-News! We again include the most current COVID-related best practices resources in our new MISS E-News Resource Center.
**Don’t forget to link to the Virtual MISS 2020 Symposium here!**
Stay safe and check back next week for more!—Colleen Hutchinson
MISS NEWSVol. 8 No. 46 |
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Interview with Dr. Gary Procop & Dr. Mariana Berho
Colleen: How would you characterize the reliability of testing of COVID-19 currently—diagnostic molecular and diagnostic antigen, and antibody tests?
Dr. Procop and Dr. Berho: The molecular diagnostic assays may be characterized as highly to moderately sensitive. All but one of these assays hold the FDA Emergency Use Authorization only for symptomatic patients, although it is clear that many providers are using these for screening in asymptomatic patients. The pre-test likelihood (ie. symptomatic versus asymptomatic patients) has a direct influence on the reliability of the test result. It is important that these nuances are understood by the end users.
The COVID antigen detection test will likely have sensitivities similar to other antigen detection tests, which will be similar to a moderately sensitive molecular test. Both of these assays will need followup with a highly sensitive molecular assay, if the provider suspects COVID-19.
The use of the antibody test is highly controversial and has been commercialized in a manner that has outpaced scientific knowledge. There are recognized issues with false positive reactions. It is important that the presence of antibody is not assumed to represent immunity. The presence of antibody has never been demonstrated to correlate with immunity. Clarifying studies are ongoing.
Colleen: How has COVID-19 affected your specialty and how have you adapted?
Dr. Procop and Dr. Berho: Many pathologists have become SARS virus experts! Members of the laboratory have needed to adapt to the insourcing of rapid and routine diagnostic testing for SARS-CoV-2. We have had to struggle with limited allocation, as well as the limited-to-non availability for reagents, instruments, swabs, and transport media. Theneed to quickly adapt to these challenges in conjunction with our clinical colleagues has necessitated clear communication and many, many meetings.
Colleen: Do you think that all patients should be tested for COVID-19 prior to surgery or other in-hospital treatment?
Dr. Procop and Dr. Berho: This is a challenging question and we are learning as we go. We are currently testing all pre-surgical patients. The positivity rate in these asymptomatic patients in this setting is extremely low (about 1/200 or 0.5%). Additionally, many of these represent low-level viral fragment shedding of remote disease, which is not considered infectious. Therefore, as we learn more and prevalence rates change, I could foresee these practices being modified.
Colleen: Do you think that all staff at a medical institution should be tested for COVID-19?
Dr. Procop and Dr. Berho: No. Medical professionals should be on an honor system and not come to work sick. Temperature monitoring, social distancing when possible, and the consistent wearing of masks has served our institution as appropriate. The testing of asymptomatic caregivers would cause the same issues as described above for asymptomatic pre-surgical patients.
MISS E-News COVID Resource Center: Link to these!
Annals of Surgery Brief Clinical Report (Online only): Abdominal Surgery in Patients with COVID-19: Detection of SARS-CoV-2 in Abdominal and Adipose Tissues
https://journals.lww.com
Surgical Endoscopy article: Detect to protect: pneumoperitoneum gas samples for SARS-CoV-2 and biohazard testing
https://link.springer.com/article/10.1007/s00464-020-07611-7
American College of Surgeons Joins New Surgical Care Coalition:
https://www.surgicalcare.org
ASMBS Webinar: Keeping Your Patients Engaged During the COVID-19 Crisis & Care for the Caregivers to Avoid Professional Burnout
https://asmbs.org
OR Management News Article: Key Steps to Regain OR Capacity After COVID-19
https://www.ormanagement.net
SAGES Guidelines: Safe Cholecystectomy Multi-Society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury during Cholecystectomy
https://www.sages.org
IBC COVID-19 Webinar: How Extended Reality (XR) Can Have a Positive Impact on Surgical Education During the COVID-19 Pandemic—Watch here:
https://www.ibcclub.org/hot-topics-june-2
Suggested Readings
Bariatric
Article: Micronutrient Intake and Biochemistry in Adolescents Adherent or Nonadherent to Supplements 5 Years After Roux-en-Y Gastric Bypass Surgery.
Henfridsson P, Laurenius A, Wallengren O, et al. Surg Obes Relat Dis. 2019 Sep;15(9):1494-1502.
https://www.ncbi.nlm.nih.gov/pubmed/31371184
Dr. Dimitrios Pournaras: The number of children and adolescents affected by obesity continues to grow and, as seen in adult populations, lifestyle interventions have been met with limited success. Bariatric surgery in this age group remains a controversial issue; however, there is a growing body of evidence to support it as a treatment for adolescents suffering from severe obesity. Nutrient supplementation following Roux-en-Y gastric bypass in the adult and adolescent population is essential; however, not only are nutritional needs higher in adolescents, but they also present unique challenges with regard to adherence. This study demonstrated that about half of adolescents were adherent with supplementation, supporting recommendations for ongoing monitoring of micronutrient intake and biochemistry postoperatively.
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