Introduction

We 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. 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!

–Colleen Hutchinson

Interview with Dr. Ajita Prabhu

Colleen: 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?
Dr. Prabhu: It is well-established that much of the commentary on social media websites is derived from skimming articles prior to sharing them and commenting on them, as opposed to thoroughly reading them and critically analyzing their content (Anspach, Research & Politics, 2019). I suspect that practice drove a lot of the narrative related to that article. In the editorial, the term “quantity” refers to the voluminous amount of peer-reviewed surgical literature that has failed to answer some of our most pressing questions in hernia surgery.
The editorial is meant as a call to action for all of us to contribute in a more meaningful way, whether it be through registry participation, or the onerous contribution of well-designed prospective clinical trials. The article is equally critical of both peer review and social media. I daresay we can all unite in the statement that we have a long way to go in truly understanding hernia disease.
 
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.”
You also state: “It [peer review] is beleaguered by an inundation of submissions of varying quality, reviews which are not compensated and potentially (therefore) of varying quality, significant lag time in the transmission of new and significant information, and potential for bias—whether on the part of the author, the editor, and/or the reviewer. There is also an acknowledged high rate of medical reversals, where practices once standardized based on evidence are later debunked by newer evidence, the result of which is a slow erosion of the credibility of peer-reviewed research at its core. Some detractors also submit that many submissions are disingenuous in their intent to begin with, even going so far as to suggest the underlying agenda is self-promotion and/or financial gain.”
In the evolution of research, publishing, and information sharing in our digital age, how do you see the role of peer-reviewed medical literature and the role of social media—both with their faults and neither mutually exclusive—shaping modern medicine and education?
Dr. Prabhu: In a healthy surgical ecosystem, both peer-reviewed medical literature and social media should have their relative and meaningful contributions. One cannot and should not replace the other. Surgeons ideally should work together and respect each other’s contributions. Both methods of information-sharing have some glaring limitations, and both also have a lot to add. Many of the surgeons participating in the online social media forums are incredibly talented and innovative, and when the system is productive, it serves as an invaluable resource for sharing new techniques, coaching/mentoring younger or less experienced surgeons, and advising or help troubleshooting for those in need of support. Many of those who contribute to the Facebook groups are doing a great job of leveraging their platform to unify the surgical community, even going so far as to live-stream events and conferences. There are also plenty of participants whose contributions are damaging or unhelpful, particularly towards participants who express a difference of opinion. That said, in an ideally balanced system, new techniques would get introduced in these types of social media forums, surgeons could continue to learn from each other regarding the execution of the operations, and then the peer-review system should be engaged to help vet the innovations and give them further context. This essentially completes the cycle. It’s a slow process, and new concepts and technology need to be studied and re-studied over time to determine their ultimate roles. Just like social media, peer review is not perfect by a long shot. However, it provides a balance for the large volumes of social media content which are often not well vetted and heavily rely on anecdote. Randomized controlled trials are one aspect of peer-reviewed literature which are only able to truly answer specific questions usually of narrow scope, and still there are often design flaws, bias, etc. that can limit the interpretation or applicability of the findings. That’s why registry data (really population-based data) is so important and can help to generate hypotheses but also serve as a space in which to follow the outcomes of interventions with specificity. A step in the right direction would be for contributors of both modalities to acknowledge the strengths and weaknesses of their platforms in a dispassionate manner, and to accept that both modalities can and should contribute. Sadly, I fear we are a long way from that happening.
 
Colleen: Another point you bring up is the problem of so-called “crowdsourcing” of medical information, which is then put into use in the clinical environment. Can you tell us what it is, how it has developed, and its current role (good or bad) in medical education?
Dr. Prabhu: Crowdsourcing is a word that, in this context, refers to the practice of asking a group of people to opine on a topic. It can also be used for fundraising and other endeavors. Crowdsourcing is interesting because it is a rapid way to accumulate data, financial support, signatures for petitions, or other endeavors that require large numbers of participants. As far as the role of crowdsourcing for medical education or clinical practice, I think it is important to note that there is no way to fully elucidate the source of information gathered in social media forums. Contributors may have competing interests, lack of experience, or other factors that limit the applicability of their opinions. It would be a real challenge to establish the specific conflicts and experience levels of the contributors at baseline, and on top of that, we are often discussing challenging clinical scenarios for which there are not high-level evidence publications. Still, data often follow the initial concepts introduced in social media forums, and a truly savvy doctor or surgeon should be taking all of this into account. For instance, when the Coronavirus pandemic came to the United States, multiple online groups rapidly mobilized to help each other treat the sickest patients when other information was not available. These groups conjectured about hydroxychloroquine, remdesivir, and antibody-rich plasma from previously affected patients. This was understandable given the desperation and uncertainty of the situation. Still, over time as data is accrued, we have an obligation to investigate the roles of the various medications and treatments that were touted on social media through peer-reviewed literature. I have also discussed cancer in the same context previously. Most of us probably wouldn’t want treatment that was only vetted from a Facebook group’s opinion, particularly if peer-reviewed literature on the topic were available. That’s not a slight against the social media contributors; it’s just the reality. That doesn’t mean that crowdsourcing doesn’t contribute to our greater knowledge, either. It just means that we all need to be able to understand the various content that is available, and to consider it in its proper context with relation to other content.
 
Colleen: With fundamental flaws in our current peer review system and flaws in deriving medical direction from social media, what is the practicing general surgeon to do in order to best serve the patient?
Dr. Prabhu: In my opinion, we all need to use our critical thinking skills a bit more, rather than trying to force information to meet our biases and discarding it when it doesn’t. We have to appreciate that technology should be praised and critically appraised in equal measure, and a critical appraisal doesn’t mean that a surgeon is against or attacking a certain technology. Surgeons should be able to look at social media forums and take away what is meaningful. That doesn’t mean that we are off the hook for reading contemporary literature, though. We all should be reading and thinking objectively about the information we are getting from articles. It is up to each surgeon to be responsible for sifting through the information and applying it to his or her specific practice scenario. Our current culture assumes that each surgeon with a platform or public visibility is either right or wrong, either loves or hates something, or supports social media or peer review but not both. We can see that manifested currently in many other ways, including politics and public health. In surgery, we are fortunate to be afforded a certain amount of autonomy in our practices. What we do with the information available is entirely up to us.

Dr. Prabhu’s articles can be accessed here (General Surgery News) and here (Surgical Innovation).

MISS E-News COVID Resource Center: Link to these!

IBC Hot Topics in Surgery Webinar: Diversity and Burnout in Surgery—Watch here:
https://www.youtube.com/watch?v=LPtknt2DlQo

The New England Journal of Medicine Editorial Audio Interview: Guidelines for Covid-19 Vaccine Deployment
https://www.nejm.org/doi/full/10.1056/NEJMe2029435?query=featured_home

American College of Surgeons Bulletin Brief—September 15 Issue:
https://www.facs.org/publications/bulletin-brief/091520

Annals of Surgery Article: Patterns of NIH Grant Funding to Surgical Research and Scholarly Productivity in the United States
https://journals.lww.com

IBC Hot Topics in Surgery Webinar: The Nemesis for the General/Bariatric Surgeon: The Difficult Gallbladder in Severely Obese Patient—Watch here:
https://www.youtube.com/watch?v=oW_tNz6uTvA

Suggested Reading

Bariatric

Article: 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.
https://pubmed.ncbi.nlm.nih.gov/31749107/
Dr. Eric DeMaria: This is an interesting survey of major health insurers regarding their policies for bariatric surgery.

Hernia

Article: 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.
https://pubmed.ncbi.nlm.nih.gov/31353033/
Dr. Ajita Prabhu: This article is interesting because it's starting to scratch at the surface of disparities in hernia care. While disparities in healthcare are a relatively hot topic across our country, relatively little literature exists to elucidate these issues. This article was written using a large database (NSQIP) as the data source and is somewhat limited by the inherent limitations of large data. However, it highlights that despite a known and established clinical advantage to performing laparoscopic inguinal hernia repair in women, that doesn't seem to be happening commonly in practice in the US. More work is needed in this area to improve this problem, which is likely multifactorial; however, identifying the issue is a good start.

Introduction

First 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!

–Colleen Hutchinson

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 4^th  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.

Suggested Reading

Artificial Intelligence

Article: Artificial Intelligence in Surgery: Promises and Perils. Hasimoto DA, Rosman G, Rus D, Meireles OR. Ann Surg. 2018 Jul: 268(1):70-76.
https://pubmed.ncbi.nlm.nih.gov/29389679/

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.
https://pubmed.ncbi.nlm.nih.gov/30617336/

Robin Blackstone: Please see interview response above for feedback and insights on this article topic.

Bariatric

Article: 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.
https://pubmed.ncbi.nlm.nih.gov/32773144/

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.

Introduction

Don’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!

–Colleen Hutchinson

Interview with Dr. Mary Hawn

Colleen: 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?
[Background: The novel coronavirus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE).]
Dr. Hawn: The main takeaways from this publication are that all team members need to understand the risk of potential exposure throughout a surgical procedure. Intubation/extubation has the ability to generate aerosols, so only the minimally necessary team members should be in the OR room with appropriate PPE—likewise for surgical procedures that have the risk of generating aerosols of the aerodigestive tract such as endoscopy. Preoperative testing should be done whenever feasible to de- escalate PPE use.

Colleen: Do you foresee challenges in implementing components of the Stanford algorithm elsewhere?
Dr. Hawn: The main challenge is to get the COVID-19 result back prior to going to the OR for emergency cases and getting a workflow for COVID-19 testing that is efficient for a busy elective schedule.

Colleen: What has been the most challenging thing for you personally in your surgeon role during the COVID pandemic?
Dr. Hawn: The most challenging issues are ensuring that everyone understands different risk levels for transmission and how to protect themselves and others while conserving PPE. Our colleagues all have different risk tolerance and concerns, with some being too complacent and some being overly cautious. Striking that balance of reassuring everyone of the safety of proceeding with elective surgery and not fostering complacency is tricky.

Colleen: Do you think that coming out of this pandemic, there will be permanent improvements in certain processes, protocols, and patient care?
Dr. Hawn: I think that the pandemic has improved communication across the OR team regarding caring for each other and minimizing exposure to potentially harmful secretions. I believe it will improve the safety of the OR environment.

Dr. Hawn’s JACS article can be read in full here.

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
https://link.springer.com/article/10.1007/s00464-020-07790-3

IBC Hot Topics in Surgery Webinar: Covid-19, Thrombosis & Bariatric Surgery Webinar—Watch here:
https://www.youtube.com/watch?v=gq2pC0VArgc

The New England Journal of Medicine article: Multisystem Inflammatory Syndrome in U.S. Children and Adolescents
https://www.nejm.org/doi/full/10.1056/NEJMoa2021680?query=featured_home

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.
Available here:
https://www.facs.org/member-services/surgeon-wellbeing

The New England Journal of Medicine Article: Genomewide Association Study of Severe Covid-19 with Respiratory Failure:
https://www.nejm.org/doi/full/10.1056/NEJMoa2020283?query=featured_coronavirus

IBC Hot Topics in Surgery Webinar: The Psycho-Sexual impact of Bariatric & Metabolic Surgery - Uncovering the Truths—Watch here:
https://www.youtube.com/watch?v=kEBFjTsgzZU

AIS Channel: 5 Things You Should Know About Watch & Wait Strategy for Rectal Cancer
https://aischannel.com/society/5-things-you-should-know-about-watchwait-strategy-for-rectal-cancer/

Suggested Reading

Bariatric

Article: 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.
https://www.ncbi.nlm.nih.gov/pubmed/32129809

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
outcomes compared to SG.

Introduction

Don’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!

–Colleen Hutchinson

Interview with Delia Cortés Guiral

Colleen: 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?
Dr. Cortes-Guiral: Thanks for your question, Colleen. As soon as a concern emerged about the possibility of aerosol COVID-19 transmission during laparoscopic or robotic surgeries, we realized that there were some lessons about safety in the OR during minimally invasive surgery (MIS) that we had learned from the 10 years of experience with pressurized intraperitoneal aerosolized chemotherapy (PIPAC), which could be really useful. Specifically, the PIPAC system must be safely hermetically sealed to prevent escape of any of the intraperitoneal gas or fluid that contains chemotherapeutic agents. PIPAC is a laparoscopic procedure for delivering chemotherapeutic agents as an aerosol to treat advanced peritoneal metastases with a palliative or neoadjuvant intent.

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?
Dr. Cortes-Guiral: The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems, with the collapse in many institutions forced to cancel and postpone elective colorectal surgeries; however, the need for urgent and emergency colorectal surgery (symptomatic cancer as well as patients with perforated diverticulitis, toxic colitis, and other acute problems) in COVID-19 patients was a risk of exposure for OR staff. This publication aims to present several recommendations and alternatives according to the resources of the centers for a safe laparoscopic colorectal surgery or the recommendation for open surgery with adequate PPE in case laparoscopic surgery cannot be performed under the mentioned protective measures. These include all the validated security measures from PIPAC protocols to create a hermetic system to avoid escapes of gas, other alternatives such as use of an active smoke evacuator connected to a proper filter, the addition of a system of intra-abdominal electrostatic precipitation—which is able to sediment the aerosolized virus to the peritoneum, and the importance of negative pressure ORs (in the corner of the surgical area preferably).

Colleen: How has COVID-19 affected your specialty and how have you adapted?
Dr. Cortes-Guiral: As a surgical oncologist, I have lived two different scenarios in Spain (Madrid) and in Saudi Arabia. In Madrid, the surge was so severe that there was a real shortage of ICU beds. Consequently, all major elective oncologic surgeries requiring (or potentially requiring) an ICU bed had to be postponed. Best strategies to deal with that situation were to propose the patients receive extended neoadjuvant therapy or to be relocated to COVID-free hospitals when possible. In Saudi Arabia, early containment and physical distancing measures as well as implementation of healthcare capability allowed us to keep on operating on all oncologic patients during the peak of the surge in the country. Surgical oncologists and colorectal surgeons around the world have experienced the impact of the pandemic on the care of cancer patients with important delays or alteration in the timing for diagnosis, treatment, and follow-up. The main surgical societies are demanding authorities define strategies to guarantee treatment of cancer patients during plausible future surges.

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?
Dr. Cortes-Guiral: Currently in Madrid, staff is tested if they have any symptoms or have suffered any potential risky exposure; for patients, every patient admitted to the hospital or undergoing emergent or elective surgery is tested (at least 48 hours before admission in the case of elective surgery). Clinical and epidemiological tests are required as well. In Saudi Arabia, some centers are testing all patients before admission but other centers only test patients with a positive clinical test, according to the availability of quick tests.

Colleen: What are the main takeaways of the publication regarding COVID-19’s impact on colorectal surgery?
Dr. Cortes-Guiral: The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems, with the collapse in many institutions forced to cancel and postpone elective colorectal surgeries; however, the need for urgent and emergency colorectal surgery (symptomatic cancer as well as patients with perforated diverticulitis, toxic colitis, and other acute problems) in COVID-19 patients was a risk of exposure for OR staff. This publication aims to present several recommendations and alternatives according to the resources of the centers for a safe laparoscopic colorectal surgery or the recommendation for open surgery with adequate PPE in case laparoscopic surgery cannot be performed under the mentioned protective measures. These include all the validated security measures from PIPAC protocols to create a hermetic system to avoid escapes of gas, other alternatives such as use of an active smoke evacuator connected to a proper filter, the addition of a system of intra-abdominal electrostatic precipitation—which is able to sediment the aerosolized virus to the peritoneum, and the importance of negative pressure ORs (in the corner of the surgical area preferably).

Colleen: How has COVID-19 affected your specialty and how have you adapted?
Dr. Cortes-Guiral: As a surgical oncologist, I have lived two different scenarios in Spain (Madrid) and in Saudi Arabia. In Madrid, the surge was so severe that there was a real shortage of ICU beds. Consequently, all major elective oncologic surgeries requiring (or potentially requiring) an ICU bed had to be postponed. Best strategies to deal with that situation were to propose the patients receive extended neoadjuvant therapy or to be relocated to COVID-free hospitals when possible. In Saudi Arabia, early containment and physical distancing measures as well as implementation of healthcare capability allowed us to keep on operating on all oncologic patients during the peak of the surge in the country. Surgical oncologists and colorectal surgeons around the world have experienced the impact of the pandemic on the care of cancer patients with important delays or alteration in the timing for diagnosis, treatment, and follow-up. The main surgical societies are demanding authorities define strategies to guarantee treatment of cancer patients during plausible future surges.

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?
Dr. Cortes-Guiral: Currently in Madrid, staff is tested if they have any symptoms or have suffered any potential risky exposure; for patients, every patient admitted to the hospital or undergoing emergent or elective surgery is tested (at least 48 hours before admission in the case of elective surgery). Clinical and epidemiological tests are required as well. In Saudi Arabia, some centers are testing all patients before admission but other centers only test patients with a positive clinical test, according to the availability of quick tests.

MISS E-News COVID Resource Center: Link to these!

AIS Channel: Care for the Cancer Patient with Heidi Nelson
https://covid19.aischannel.com/leadership2b/videos/care-for-the-cancer-patient-heidi-nelson

AIS Channel: The impact on surgical journals with Susan Galandiuk
https://covid19.aischannel.com/leadership2b/videos/the-impact-on-surgical-journals-susan-galandiuk

Surgical Endoscopy article: COVID-19 and impact on peer review
https://www.springer.com/journal/464/updates/17818222

American College of Surgeons Bulletin: ACS COVID-19 Update
https://www.facs.org/covid-19/newsletter/050820

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.
https://www.facs.org/covid-19/newsletter/050820/frontlines

ASMBS position statement entitled, "Safer Through Surgery," published online in the journal SOARD:
https://www.soard.org/article/S1550-7289(20)30318-X/fulltext

IBC COVID-19 Webinar: Redefining New Standards in Metabolic Medicine & Surgical Research—Watch here:
https://www.youtube.com/watch?v=Ld7H-GqGaNQ&feature=emb_title

Suggested Reading

Bariatric

Article: 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.

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

–Colleen Hutchinson

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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