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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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Vol. 8 No. 25


This month’s issue features an interview with Dr. Aurora Pryor, who is Professor of Surgery in Stony Brook, New York and the new Co-Director of the 2019 MISS Foregut Program in Las Vegas. Dr. Pryor is also currently President-Elect of SAGES. In addition to serving in these critical leadership roles, this past year Dr. Pryor hosted the second Women’s Leadership in Surgery conference, which I was honored to speak at and thoroughly enjoyed. The agenda comprised topics that were of great benefit to both new and seasoned female surgeons. In this interview, Dr. Pryor takes time to share insights on her meeting, the leadership roles she fulfills, and what’s new in foregut surgery.

Click here for my video interview with Dr. Robin Blackstone, a leader in the bariatric field, for her thoughts on being a female surgeon and how bariatric surgery has evolved during the course of her career.

I hope you also enjoy this month’s article recommendations from thought leaders in minimally invasive surgery, brought to you by leaders at the forefront of research and innovation. Contributors include a new face—Dr. Talar Tejirian, a hernia specialist from Los Angeles, California.


Colleen Hutchinson


An Interview with Aurora Pryor: Taking the Academic Surgery World by Storm!
(Dr. Pryor is a speaker for Medtronic, Merck, Ethicon, Gore and Stryker, and has received research support from Obalon and Baronova.)

As the new MISS Foregut Co-Director, what are your plans for MISS 2019?
Dr. Pryor: The Minimally Invasive Surgery Symposium (MISS) always encompasses the most up to date and relevant information in surgery. This year’s MISS Foregut Program faculty will discuss new technologies and new approaches to the full spectrum of benign foregut disease, plus delve into the diagnosis and management of complex foregut problems. With major advances in the endolumenal management of reflux disease and motility disorders, there is an expanded array of technologies on the horizon. We will have a session focusing particularly on these technologies and how to incorporate them into a foregut practice.

Please tell us about your Women’s Leadership in Surgery conference—its origins and how attending can benefit female surgeons.
Dr. Pryor: I trained at a time when there were not as many women in surgery. I was the first woman to have a child during the Duke residency and was often asked how I made things work. Early on in my faculty career, I met with partners from industry and learned that work life balance issues and struggles with navigating a surgical career were widespread. We were able to hold a conference for women surgeons at Duke in 2009 to address these issues. With the help of industry partners, Caitlin Halbert and I held a NYC conference, with Dana Telem as Co-Chair. I held the conference this year in Philly, with Caitlin Halbert as Co-Chair, and we look forward to hosting it again next fall.

Can you talk about your current role as SAGES President-Elect, including what your goals and key priorities will be serving in the position of President next year?
Dr. Pryor: I am honored to have the opportunity to serve as the SAGES President. One year is a very short time, so much of what I will focus on is moving forward with the current key initiatives of the society. One project that I am particularly excited about is our new effort in video-based assessment of practicing surgeons. This will expand on our Mastery program with assessments in each of our anchoring procedures in Foregut, Bariatrics, Hernia, Colorectal and more. This initiative, being led by Matt Ritter and Liane Feldman, will allow practicing surgeons a comprehensive tool to measure their operative performance. We are also working hard to increase diversity in our leadership and I will continue to focus on this area. I will continue supporting the success of our innovative and enthusiastic members across all the SAGES missions.

What can general surgeons expect regarding new technology advances in foregut surgery?
Dr. Pryor: There have been major advances in the endolumenal management of reflux disease and motility disorders, and an expanded array of technologies is on the way. The 2019 MISS Foregut Program will include a session focused on these technologies and how to incorporate them into your foregut practice.

What are the biggest challenges facing female surgeons today?
Dr. Pryor: I think the biggest challenges facing female surgeons today are the same challenges facing our male colleagues – we are asked to do more, in less time, for less money. All of us are faced with the potential of burnout that can impact our careers as well as our personal lives. Initiatives to address wellness and job satisfaction are essential, but awareness in general is a great place to start.

Dr. Pryor, thank you for taking the time to speak with me, for being an excellent role model for female surgeons everywhere, and for serving as the Foregut Co-Director of the 2019 MISS in Las Vegas!



Suggested Readings


Article: Long-term follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass versus one-anastomosis gastric bypass: a prospective randomized comparative study of weight loss and remission of comorbidities. Ruiz-Tovar J, Carbajo MA, Jimenez JM, Castro MJ, Gonzalez G, Ortiz-de-Solorzano J, Zubiaga L. Surg Endosc. 2018 Jun 25. [Epub ahead of print]
Dr. Luke Funk: Single anastomosis gastric bypass is a relatively new procedure that has increased in popularity over the past decade. Medium and long-term outcomes from this procedure are not well described in the literature. This study randomized patients in Spain to 1 of 3 arms: sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB) and single anastomosis gastric bypass. The authors report that single anastomosis gastric bypass patients had greater weight loss and comorbidity resolution 5 years after surgery compared to sleeve and RYGB. These findings suggest that single anastomosis gastric bypass is an effective and durable weight loss option for patients with severe obesity.

Article: Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015–2016 PUF. Demeusy A, Sill A, Averbach A. Surg Obes Relat Dis. 2018 Jul 5.
Dr. Ponce: In this updated review of the MBSAQIP Participant Use File 2015-2016 data of a total of close to 200,000 laparoscopic sleeve gastrectomies (LSG), staple line reinforcement (SLR) was used in 77% of cases. Bleeding and reoperation rates were statistically lower in the SLR group and no differences in leak rate, which is different than an earlier MBSAQIP review of data 2012-2014 (Ann Surg. 2016 Sep;264(3):464-73), which showed more leak rates in the SLR group. As I have stated before (Ann Surg. 2018 Mar;267(3):e52), I think leaks in LSG happen mainly from technical issues, and as surgeons are getting better and passing the learning curve, the leaks are actually less. The use of SLR is not an associated factor for leaks.




Article: Three-way comparative study of endoscopic ultrasound-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis: clinical outcomes and success in an International, Multicenter Study. Siddiqui A, Kunda R, Tyberg A, Arain MA, Noor A, Mumtaz T, Iqbal U, Loren DE, Kowalski TE, Adler DG, Saumoy M, Gaidhane M, Mallery S, Christiansen EM4, Nieto J6, Kahaleh M. Surg Endosc. 2018 Sep 12. [Epub ahead of print]
Dr. Douglas Adler: Gallbladder drainage in nonsurgical candidates is typically accomplished by percutaneous drainage, which is deeply unpopular with patients. This study compared percutaneous drainage with two types of endoscopic drainage (transampullary and transmural). The paper shows very encouraging results with the newer method (transmural drainage) despite the increased invasiveness of the procedure when compared to transampullary drainage.

Article: Phase I study of EUS-guided photodynamic therapy for locally advanced pancreatic cancer. DeWitt JM, Sandrasegaran K, O'Neil B, House MG, Zyromski NJ, Sehdev A, Perkins SM, Flynn J, McCranor L, Shahda S. Gastrointest Endosc. 2018 Sep 14. [Epub ahead of print]
Dr. Douglas Adler: Photodynamic therapy for pancreatic cancer delivered via EUS is the focus in this single center, prospective, dose escalation Phase I study. It is a novel and interesting study offering proof of concept.



Article: Impact of inadvertent enterotomy on short-term outcomes after ventral hernia repair: An AHSQC analysis. Krpata DM, Prabhu AS, Tastaldi L, Huang LC, Rosen MJ, Poulose BK. Surgery. 2018 May 26. pii: S0039-6060(18)30149-1. [Epub ahead of print]
Dr. Luke Funk: Inadvertent enterotomies during ventral hernia repair introduce uncertainty regarding the optimal operative approach, use of mesh and position of mesh (e.g. underlay vs. sublay). This study used data from the Americas Hernia Society Quality Collaborative (AHSQC), which includes outcomes from thousands of patients and hundreds of surgeons at non-academic and academic institutions throughout the US. The authors found that inadvertent enterotomies were uncommon (<2%) and were associated with an increased risk of reoperations, readmissions, fistulas, and death. The authors recommended that surgeons use caution regarding the type and location of mesh if they make an inadvertent enterotomy and choose to proceed with a definitive hernia repair that involves mesh.

Article: Ventral hernia management: expert consensus guided by systematic review. Liang MK1, Holihan JL, Itani K, Alawadi ZM, Gonzalez JR, Askenasy EP, Ballecer C, Chong HS, Goldblatt MI, Greenberg JA, Harvin JA, Keith JN, Martindale RG, Orenstein S, Richmond B, Roth JS, Szotek P, Towfigh S, Tsuda S, Vaziri K, Berger DH. Ann Surg. 2017 Jan;265(1):80-89.
Dr. Tejirian: The article is a great combination of a systematic review and a consensus of a panel of experts. This go-to guide highlights the most relevant topics pertaining to ventral hernias and evidence-based best practices. In addition to the evidence, each topic is associated with expert consensus and a recommendation for future research to help improve knowledge on that topic. The information contained is helpful for all surgeons who repair ventral hernias including both general and plastic surgeons. The section on modifiable risk factors includes information on smoking, obesity, malnutrition and diabetes. It acts as a guide for patient selection and preoperative optimization. Surgical topics about mesh reinforcement, mesh type, mesh location, component separation, primary fascial closure, emergency repair, and incisional hernia prevention are all discussed. This is balanced with a section on nonoperative management of ventral hernias. No matter what percentage of your practice is ventral hernia repair, you will find the concise information contained in this article useful and a worthwhile read.



Article: Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Fleshman J, Branda ME, Sargent DJ, et al. Ann Surg 2018;Aug 3 [epub ahead of print]
Dr. Sean Langenfeld: This followup to the ACOSOG Z6051 randomized trial focuses on the secondary endpoints of 2-year disease-free survival (DFS) and local recurrence (LR). Laparoscopic resection is found to have similar DFS and LR when compared to open surgery, suggesting that laparoscopic surgery for rectal cancer is safe in experienced hands.

Article: Have Recent Modifications of Operating Room Attire Policies Decreased Surgical Site Infections? An American College of Surgeons NSQIP Review of 6,517 Patients. Farach SM, Kelly KN, Farkas RL, Ruan DT, Matroniano A, Linehan DC, Moalem J. J Am Coll Surg. 2018 May;226(5):804-813.
Dr. Steven Wexner: Surgical site infection is a major cause of morbidity and cost. Environmental factors that have been thought to potentially impact surgical site infections include personnel attire. In 2015, the Association for Perioperative Registered Nurses (AORN) published recommendations on operating room attire. Some of the areas addressed by their guidelines included minimization of exposed areas of hair and skin. In the absence of scientific evidence, these recommendations were not universally adopted. In order to answer the question of if surgical attire, including implementation of the AORN recommendations, influenced surgical site infection, Farach et al utilized the American College of Surgeons National Surgical Quality Improvement Program database. Data on 6,517 patients operated on between 2014 and 2016 were analyzed. Despite the fact that patients in the post-AORN recommendation implementation group were statistically significantly older and had statistically significantly higher rates of hypertension, hemodialysis dependent, steroid use, and systemic inflammatory response syndrome and were more likely to be ASA class IV, no differences were noted in the rates of SSI before and after implementation. The most significant predictors of SSI were, as potentially suspected, preoperative infection, operative time, and dirty, contaminated, or open wounds. The authors concluded that “implementation of stringent operating room attire policies do not reduce SSI rates.” Moreover, they noted that a hypothetical analysis indicated that almost 500,000 patients would be required to demonstrate a 10% SSI reduction in patients with either a clean or clean contaminated wound. On the basis of this excellent study, for which the senior investigator was my friend Jacob Moalem, implementation of the AORN guidelines do not seem to offer any benefit to SSI reduction.


Article: Higher surgical morbidity for ulcerative colitis patients in the era of biologics. Abelson JS, Michelassi F, Mao J, Sedrakyan A, Yeo H.
Ann Surg. 2018 Aug;268(2):311-317.
Dr. Steven Wexner: Since their introduction in 2005, anti-TNF agents have become widely used in the treatment of patients with mucosal ulcerative colitis. Since 2008, a variety of studies have demonstrated significantly increased postoperative complications in patients receiving anti-TNF therapy prior to surgery (Mor et al; Gu et al; Selvaggi et al). However, a few have failed to identify the increased morbidity associated with anti-TNF agents (Yang et al; Ferrante et al; Gainsbury et al; Coquet-Reinier et al). Abelson et al utilized the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) database and identified 3,803 patients who underwent surgery for ulcerative colitis between 1995 and 2005 and another 3,267 patients between 2006 and 2013. The authors sought to evaluate in-hospital death as well as major in hospital postoperative complications. Other secondary variables included length of stay, discharge to skilled nursing facility or rehabilitation charges, 30-day readmissions, and subsequent surgeries. There were some differences between groups relative to age, ethnicity, and comorbidity. Authors confirmed a higher rate of in-hospital death of 8.1% during the anti-TNF era as compared to 5.5% prior to that time. Similarly, there were significant increases in major events from 5.3% to 7.4%, post-procedural complications from 9.9% to 12.3%, and discharge to settings other than home from 46% to 73%. The authors also noted higher median charges of $66,861 as compared to $46,593 after the introduction of anti-TNFs. The authors adjusted for comorbidity as well as for surgical timing (emergent or urgent, hospital volume, gender, and insurance status).
Following these adjustments they still found that in anti-TNF era, patients were more likely to experience major adverse events, post procedural complications, to require transfusion, and to require discharge to a skilled nursing or rehabilitation facility. Very importantly, there was a significant increase in the percentage of patients who underwent a minimum of three procedures for mucosal ulcerative colitis, from 9% to 14%. The authors concluded that patients having surgery during the anti-TNF era have significantly worse outcomes during hospitalization as well as at both 90- and 365-day follow-up. They acknowledged the shortcomings of the SPARCS database and cited issues such as coding errors; however, they also state that given the large sample size and highly statistically significant differences between the two groups, they do not feel that such coding errors “were a significant issue.” I am impressed by this work produced by Dr. Yeo and her coworkers and trust that this information will be used during the informed consent process with our preoperative patients with mucosal ulcerative colitis. These data also serve as further evidence that it may be best, when medically possible, to delay surgery in patients with mucosal ulcerative colitis receiving anti-TNF agents until the drugs have fully washed out of circulation.


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