January 2014 by McMahon Group

CONVENTION ISSUE:

The Society of Critical Care Medicine Annual Meeting

GENERALSURGERYNEWS.COM

January 2014 • Volume 41 • Number 1

The Independent Monthly Newspaper for the General Surgeon

Opinion

Surgeons and the First Surgeon General’s Report B Y F REDERICK L. G REENE , MD

anuary 2014 commemorates the 50th anniversary of a milestone in public health in the United States. On Jan. 11, 1964, Luther L. Terry, Surgeon General of the U.S. Public Health Service, released the first report of the Surgeon General’s Advisory Committee on Smoking and Health. On the basis of more than 7,000 articles in the biomedical literature relating to smoking and disease available at that time, the Advisory Committee concluded that cigarette smoking is 1) a cause of lung cancer and laryngeal cancer in men; 2) a probable cause of lung cancer in women; and 3) the most important cause of chronic bronchitis. For several days, the report furnished newspaper headlines across the country and lead stories on television newscasts. Later, it was ranked among the top news stories of 1964. The release of the report was the first in a series of steps, still being taken 50 years later, to diminish the impact of tobacco use on the health of the American people. During the 50 years that have SURGEON GENERAL page 6

EXTENDED HERNIA COVERAGE Pullout Section Page 7

The Surgery Job Market: Most Positions Do Not Require Fellowship Training

Surgeons Develop Strategy To Save Lives After Mass Casualty Events

Many Employers Seek Broadly Trained General Surgeons

Physicians, Police Team Up: Goal Is To Reduce Time to Treatment

B Y C HRISTINA F RANGOU WASHINGTON—Just as senior general surgery residen nts crisscross the country for fellowship interviews comes a new study showing that the increeasing trend toward fellowship p training is out of step with th he current demands of the general surgery job market. Only one-third of general surgery job postings over the past two years listed fellowship as a requirrement, according to the study, which was presen nted at the 2013 Clinical Congress of the American College of Surgeons. Oveer the same period, almost 70% of general surgery traineees who finished residency sough ht fellowship training. Study co-author Nath han W. Bronson, MD, chief residentt iin generall surgery at Oregon Health & Science University, Portland, said the findings suggest twice as many fellowship-trained surgeons are produced than are needed. “These data suggest a disparity between the training general surgery trainees pursue and the skills that general surgery employers

INSIDE In the News

Liposomal Bupivacaine Boosts Postoperative Pain Relief for Incisions of the Midand Lower Abdominal Wall

Submit a video to our new Video Arcade. an interesting case or video opinion. Visit www.generalsurgerynews.com/ videosubmission for simple instructions. The site receives 25,000+ visits every month.

B Y C HRISTINA F RANGOU

seek,” he said in an interview. The study Th t d iis b based d on d data t collected ll t d in Oregon and Wisconsin. Investigators acknowledge that their research is limited to a very small sample of the U.S. job market, covering only 3.1% of the population. However, these two states represent an important sample of the overall job market in the United States. Based on

WASHINGTON—On the morning of Dec. 14, 2012, trauma surgeon Lenworth M. Jacobs, MD, got word that gunshots had just been fired in an elementary school in nearby Newtown, Conn. The Trauma Institute at Hartford Hospital, in Connecticut, where Dr. Jacobs is director, went on alert. Staff readied for patients to arrive. They waited and waited. But no patients arrived from Sandy Hook Elementary School that morning. Instead, Dr. Jacobs received a call from the medical examiner’s office, requesting his assistance in the autopsies of the 26 bodies of schoolchildren and their teachers. “It [was] the single most powerful thing that I have ever done,” said Dr. Jacobs, during a press conference at the 2013 Clinical Congress of the American College of Surgeons (ACS). “I felt some good had to come out of this. … [It] has to be everyone’s responsibility and everyone, from law enforcement to the public, has to be part of the solution.” What Dr. Jacobs saw that morning has spurred a large-scale initiative that, organizers hope, will change the

see JOB MARKET page 26

see MASS CASUALTY page 23

In the News

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

Post-Mastectomy Radiation Should Be Restricted to High-Risk Patients: Study CHICAGO—Recent research supports restricting post-mastectomy radiation therapy to high-risk patients ((Ann Surg Oncc 2013;20:3169-3174). “In studies that have been done in the United States, the LRRs [locoregial recurrences] are usually between 12% and 15%, and we believe that those rates have changed now that patients are being treated with systemic and hormonal therapy,” said Tracy-Ann Moo, MD, assistant professor of surgery, NewYork Presbyterian/Weill Cornell Medical College, New York City. “The need for PMRT in all these patients is not really apparent. Furthermore, there are currently no formal guidelines for the selection of patients who are at higher risk within this group [who would benefit from PMRT],” she added. Dr. Moo and her colleagues sought to determine the rate of LRR in patients with T1 to T2 tumors and one to three positive axillary lymph nodes undergoing current adjuvant therapy, to examine the clinical pathologic criteria used to select patients for PMRT, and to compare

outcomes of LRR, recurrence-free survival and overall survival in patients with and without PMRT. Using a prospectively maintained database, they identified a cohort of 1,087 patients with T1/T2 tumors and one to three positive axillary lymph nodes who underwent mastectomy between January 1995 and December 2006, of whom 163 received PMRT. They also assessed demographics, clinical pathologic tumor features and the use of adjuvant therapy. The patients were 98% female with a median age of 51 years (range 20-90) and median tumor size of 1.8 cm. Most patients had some form of adjuvant therapy; 15% had PMRT, and 98% received chemotherapy or hormone therapy. All patients who underwent PMRT received radiation to the chest wall and 84% received radiation to the supraclavicular field; fewer than 5% received radiation to the axilla or intramammary nodes. Patients who underwent PMRT were more likely to have larger tumors, to be younger, to have a higher pathologic grade and to have more positive axillary lymph nodes. “With a median follow-up of seven years, the five-year outcomes of LRR, recurrence-free survival and overall

survival were comparable between the two groups,” Dr. Moo said. “At five years, LRR was 3.2% in the PMRT group compared with 4.3% in the no-PMRT group.” One statistically significant predictor of LRR was age 50 years or younger, which tripled the risk for LRR. “Also significant

was the presence of LVI, which resulted in a 2.5-fold increase in the risk for LRR,” Dr. Moo said. Macroscopic axillary lymph node metastasis was associated with a borderline significant increase in LRR. Predictors see RADIATION PAGE 5

Correction—December 2013 Issue Figure 3 from the Special Reportt entitled “ENTEREG® (alvimopan) for Gastrointestinal Recovery Following Bowel Resection” (December 2013, insert at page 12) contained errors in the plot lines within the graph. The following is the corrected version. 1.0

Estimated Probability of Achieving End Point

B Y M ONICA J. S MITH

0.9 0.8 0.7 0.6 0.5 0.4 0.3

ENTEREG Placebo

0.2 0.1 0.0 0

120

144

168

192

216

240

264

Hours After End of Surgery

Figure 3. Time to GI-2 recoverya for radical cystectomy patients using ENTEREG. GI, gastrointestinal a

GI-2 recovery was defined as time to toleration of solid food and first bowel movement.

Based on references 4 and 19.

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Editorial Advisory Board Maurice E. Arregui, MD Indianapolis, IN

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Code of the Month

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

‘Change’ May Be Operative Word in Medicine: 2014 Coding Update B Y L UCIAN N EWMAN III, MD

n reality, 2014 is little different from the past in terms of Current Procedural Terminology (CPT) code changes. Each year, the American Medical Association (AMA) releases updates to reflect changes in the way physicians report the

work they perform via the CPT reporting system. Initially developed in 1966 as a way to report work done by providers, it was modified in 1970, and by 1983 was mandated by Medicare as the system to be used to report the work performed by physicians and non-physicians alike. The original intent was not meant to be a vehicle to bill insurance carriers, but it is the basis now. This year, the AMA announced 335 changes to the CPT that include roughly 9,700 entries. The

changes involve code additions, deletions and revisions. As a historical comparison, in 2010 there were 219 new codes, 141 revisions and 63 deletions. In 2012, there were 278 new codes, 139 revisions and 98 deletions. Each modification is intended to reflect changes in the way we practice adopting new approaches accordingly. The immense undertaking is broken down annually to address the items needing critical attention. Nearly 25% of the 2014

Surgical Spring Week

Held in conjunction with the Military Surgical Symposium

SAGES 2014

º ĺ Putting the Patient First:Promoting Innovation and Safety in the OR and Beyond

April 2 - 5, 2014 · Salt Lake City, UT Wednesday, April 2 SAGES/CAGS/ERAS Full-Day Postgraduate Course: Enhanced Recovery After Surgery Pathways SAGES/ASMBS Half-Day Postgraduate Course: Endoscopic Management of Bariatric Complications Symposium: Career Development SAGES/SSAT Panel: Optimizing Results of Fundoplication SAGES Foundation Awards Luncheon 12:00pm - 1:30pm SAGES/ASMBS Half-Day Hands-On Course: Endoscopic Management of Bariatric Complications Panel: Getting Your Video Accepted Panel: POEM Panel: Reoperative Pelvic Surgery, Benign and Malignant Panel: FUSE, Fire and Fiasco – OR Safety 101 Panel: Product Development – Innovations for Patients Beneﬁts Updates in Benign CRS Panel Exhibits Opening Welcome Reception 5:30pm - 7:30pm

Thursday, April 3 Exhibits/Posters/Learning Center open 9:30am - 4:00pm Full-Day Military Surgical Symposium Half-Day Postgraduate Course: Common Bile Duct (CBD) Stones Half-Day Postgraduate Course: Ventral Hernia Repair – Technical Considerations and Strategies for Success Hepato-Pancreato-Biliary Panel NOSCAR™ Symposium – Advances in Natural Orifice Surgery Karl Storz Lecture – David Williams, MD 11:15am - 12:00pm Educator’s Luncheon 12:00pm - 1:00pm Scientific Session - MIS Other Postgraduate Video-based Course: Ventral Hernia Repair – Technical Considerations in Challenging Scenarios Half-Day Hands-On Course: CBD Stones Half-Day Didactic and Hands-On Course: Flexible Endoscopy Symposium: Ethics of Innovation SAGES/KSELS Panel: Gastric Cancer Scientific Session - Video 1 Current Management of Rectal Cancer Panel Industry Education Symposia 5:30pm - 7:30pm Davol Inc., Intuitive Surgical, and Stryker Endoscopy

Program Chairs: Tonia Young-Fadok, MD, MS & Jeffrey Marks, MD

Friday, April 4 Exhibits/Posters/Learning Center open 9:30am - 4:00pm Full-Day Military Surgical Symposium Scientific Sessions - Video 2; NOTES; Quick Shots 1 SAGES/JSES Panel: Endoscopic Submucosal Dissection Plenary Session 1 Presidential Address – Gerald Fried, MD 10:00am - 10:45am Gerald Marks Lecture – Amitai Ziv, MD 10:45am - 11:30am Scientific Sessions - Education; Outcomes; Bariatric 1; Basic Science Fellowship Council Luncheon 12:30pm - 1:30pm Postgraduate Course: Humanitarian The Great Presidential Debates of 2014 Panel: Emerging Frontiers in Simulation – Based Surgical Education SAGES/ALACE Panel: Evolution and Clinical Applications of Minimal Access Surgery in Latin America Panel: MIS Jeopardy Session: Emerging Technology Panel: MIS for Acute Care Surgeons SAGES/EAES Panel: Benign Foregut Resident/Fellow Scientific Session Meet the Leadership Reception 6:00pm - 7:00pm Main Event - SAGES Gala & Sing-Off 7:00pm - 11:00pm

Saturday, April 5 Exhibits/Posters/Learning Center open 10:00am - 12:30pm Scientiﬁc Sessions - Hernia; Robotics/Ergonomics; HPB Plenary Session 2 Panel: Bariatric Complications for the non-Bariatric Surgeon Panel: Why Haven’t Conversion Rates Improved? SAGES General Business Meeting 11:00am - 11:45am FREE Lunch in Exhibit Hall 11:45am - 12:30pm Scientiﬁc Sessions - Colorectal; Flexible Endoscopy; Foregut; Bariatric 2; Quick Shots 2

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 11300 W. Olympic Blvd., Suite 600 · Los Angeles, CA 90064 · Phone: 310-437-0544 · Fax: 310-437-0585 · Email: sagesweb@sages.org

Early Housing & Registration Deadline: February 21, 2014 web: www.sages.org | Twitter: @SAGES_Updates Register on-line at www.sages.org/registration/

CPT update is devoted to upper endoscopy, while lower gastrointestinal (GI) procedures will be addressed in 2015. It would be prudent for all to understand the process by which these changes occur. The CPT exists to create a consistent system to report work to Medicare and Medicaid as well as most private third-party payors. In this manner, a fee schedule is produced for reimbursement. The CPT is maintained by a committee that includes 11 physicians who are nominated by the representative medical societies. As changes in practice require CPT changes, the work group reviews these ideas to make recommendations to the Relative Value Scale Update Committee (RUC). This committee is composed

Table. Current Composition of the RUC • Chair • American Medical Association representative • CPT Editorial Panel representative • American Osteopathic Association representative • Health Care Professionals Advisory Committee representative • Practice Expense Review Committee representative • Anesthesiology • Cardiology • Dermatology • Emergency medicine • Family medicine • General surgery • Geriatric medicine • Infectious diseasea • Internal medicine • Neurology • Neurosurgery • Obstetrics/Gynecology • Oncology/Hematologya • Ophthalmology • Orthopedic surgery • Otolaryngology • Pathology • Pediatrics • Pediatric surgerya • Plastic surgery • Primary carea • Psychiatry • Radiology • Thoracic surgery • Urology RUC, Relative Value Scale Update Committee a Indicates rotating seat Source: American Medical Association, www.ama-assn.org

Code of the Month

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

of 31 members, 21 of whom are nominated by a broad cross section of medical specialty societies (Table). The criteria for review are known as screens and include site of service anomalies, fast-growing procedures and new technologies, among others. The reviews may look at low value/high frequency codes, bundling issues and unused codes, as well as any codes that influence the balance of the CPT process. The resource-based relative value scale (RBRVS) system is also pertinent to discuss. In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into three components: physician work, practice expense and professional liability insurance. Payments are calculated by multiplying the combined costs of a service by a conversion factor (a monetary amount that is determined by the Centers for Medicare & Medicaid Services). Payments are also adjusted for geographic differences in resource costs (www.ama-assn.org). Specifically, 2014 includes changes as mentioned to upper endoscopy, abscess drainage with image guidance, breast biopsies with image guidance, radiological and cardiology embolization procedures, and molecular pathology diagnostic codes. As expected, when changes occur, there are intended and unintended consequences. The American Society of Breast Surgeons and the Society of Breast Imaging have opposed the reductions that will affect physicians in non-facility settings. The new payment bundling system will include the biopsy and the localization service together, resulting in a lower total reimbursement. If insufficient reimbursement is the result, the fear is that more invasive open biopsies will be done. Imaging service, in general, is the recipient of substantial cuts in 2014. It is anticipated that radiation therapy centers will be cut by approximately 13%, radiation oncology by 5%, diagnostic testing by 7%, interventional radiology by 3% and nuclear medicine by 3%. The gastroenterology code changes include new codes, revised codes and the addition of sedation options. The focus on upper GI procedures separates rigid and flexible approaches to therapeutic interventions. Newer therapeutic options are described. As always, the exact description by the physician is required to bill the specific code. All too often, the report produced by the proceduralist is not specific enough to distinguish between the CPT codes. The take-home message is that as medicine changes, our ability to differentiate between approaches becomes more difficult. We are moving to ICD10 in 2014, and similarly, the diagnostic

specificity is paramount. ICD-10 PCS [procedure coding system] is the facility analog to the physicians’ CPT. It also has requirements that documentation must accommodate to generate accurate reimbursement. Adopting a strategy to survive professionally in the future seems imperative. Software solutions are being developed to help in these endeavors. —Dr. Newman is founder and CMO — of ComplyMD (complymd.com), a company that provides procedural documentation solutions. He is a general surgeon in Gadsden, Alabama.

RADIATION

jContinued from page 3 were similar in patients who did not undergo PMRT. The use of clinicopathologic criteria resulted in 15% of the patients receiving PMRT, and LRR at five years occurred in less than 5% whether or not they received PMRT. Factors influencing the use of PMRT were larger tumor size, younger patient age, greater number of axillary lymph node metastases and LVI. “Traditional factors that predict recurrence, both locoregional and

systemic, are really surrogates for the biology of the cancer itself. Size, grade, patient age and even nodal status were previously the best and only way to get at the actual biology of the cancer,” said Peter Beitsch, MD, FACS, director, Dallas Breast Center, in Texas, and president of the ASBS. Recently, multigene classifiers have demonstrated superior ability to predict biological behavior, he added. Also, additional genomic tests can determine the subtype of the breast cancer and help to determine which are more likely to recur.

For the Management of Postsurgical Pain

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Pivotal studies have demonstrated the safety and efficacy of EXPAREL in patients undergoing bunionectomy and hemorrhoidectomy procedures. The clinical benefit of the attendant decrease in opioid consumption was not demonstrated. EXPAREL is a liposome formulation of bupivacaine indicated for administration into the surgical site to produce postsurgical analgesia.

Important Safety Information: EXPAREL is contraindicated in obstetrical paracervical block anesthesia. EXPAREL has not been studied for use in patients younger than 18 years of age. Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Other formulations of bupivacaine should not be administered within 96 hours following administration of EXPAREL. Monitoring of cardiovascular and neurological status, as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations. In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea, constipation, and vomiting. Reference: Gorfine SR, et al. Dis Colon Rectum. Dec 2011;54(12):1552-1559.

EXP-AP-0039-201302

Opinion elapsed since that report, individual citizens, private organizations, public agencies and elected officials have pursued the Advisory Committee’s call for “appropriate remedial action.” Following Dr. Terry’s report, the U.S. Congress adopted the Federal Cigarette Labeling and Advertising Act of 1965 and the Public Health Cigarette Smoking Act of 1969. These laws required a health warning on cigarette packages, banned cigarette advertising in the broadcast media and called for an annual report on the health consequences of smoking. Throughout the past several decades,

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

increasing attention has been given to smoking cessation, especially with regard to children and adolescents in the United States. Recent legislation banning the sale of cigarettes to those under the age of 21 in New York City reflects a recognition that smoking is the primary inciting agent for a variety of benign and malignant diseases and that the consequences of smoking are additive over time. More recently, we have been challenged with the unknown consequences of electronic cigarettes and the possible addictive nature of this increasingly popular antismoking technique. The question

I recognize that it may be emotionally difficult to refuse a patient’s request for an operation solely based on his or her continued use of tobacco products, but perhaps we have to take a hard line, especially for elective operations.

EXP-AP-0020-201301

remains: Is it only the carcinogens in cigarette and tobacco smoke or is it nicotine as an antismoking crutch that has its own evil consequences? As surgeons, we see firsthand every day the detrimental effects of smoking as we manage a variety of surgical illnesses, including the wounds that we create and the organs that we repair. Morbidity and mortality can be increased significantly in patients who continue to smoke and use tobacco products. Most of us have spent at least some time in counseling our patients to quit smoking before their surgical procedures. But despite all of our protestations, our morbidity and mortality conferences continue to be punctuated by discussions about the adverse consequences of smoking and the morbid results of this behavior. The antismoking campaign over the past half-century can be viewed as a major public health success, but have we done enough in our individual discussions with patients about the adverse consequences of smoking? Even though we are incentivized with CPT [Current Procedural Terminology] codes (99406, 99407, G0436 and G0437) that provide increased revenue for documenting antismoking discussions with our Medicare patients, the adverse consequences of tobacco use continue to be seen in the postoperative period, and this is realized in the increasing incidence of wound infections and incisional hernias requiring subsequent operations, use of expensive mesh products, additional hospital stay and the risk for further postoperative morbidity and mortality. Coincident with the new year 2014, since we are recognizing a significant anniversary in our anti-tobacco campaign, perhaps all of us should make a resolution that we will commit ourselves to educating our patients about the consequences of smoking and the potential life-threatening adverse outcomes for their surgical procedures. I recognize that it may be emotionally difficult to refuse a patient’s request for an operation solely based on his or her continued use of tobacco products, but perhaps we have to take a hard line, especially for elective operations. It is hard to imagine a world in which tobacco will not be used, but the surgical community must continue to take the lead and highlight the significant consequences of smoking to our surgical patients. All of the efforts that have been made to improve health care and to support legislation such as the Affordable Care Act will be totally meaningless, unless we challenge patients to take responsibility for their own health and to reduce habits that, if nothing else, portend extremely poor and preventable surgical outcomes. —Dr. Greene is Clinical Professor of — Surgery, UNC School of Medicine, Chapel Hill, North Carolina.

EXTENDED HERNIA COVERAGE

Presidential Address

Study Reveals Staggering Costs of Ventral Hernia Repair Complication

AHS 2014 and Continuous Quality

Mesh Infection Can Lead to $100,000 Price Tag

Improvement: Patient-Centered and Surgeon-Focused

B Y C HRISTINA F RANGOU WASHINGTON—The cost of a mesh infection after ventral hernia repair can reach six figures for a single patient’s care in the year following surgery, according to a study presented at the 2013 Clinical Congress of the American College of Surgeons (ACS). An analysis of the cost of complications in ventral hernia repair showed that a patient who develops a mesh infection after surgery will incur inpatient hospital charges of $44,000 plus an additional $63,400 in follow-up p costs in the next year. Total expenses associated with a mesh infection came to $107,000. In comparison, a patient without hernia repair complications will incur hospital costs of $38,700 and an additional $1,400 in follow-up charges over the next 12 months, according to the analysis. “We know that if you get an infection in hernia surgery, you may need a repeat operation with possibly a new mesh. It is expensive. We knew that. But it’s astounding how much repeat hospitalizations, repeat reoperations and clinic visits add up in terms of cost,” said co-author Paul Colavita, MD, surgical resident at Carolinas Medical Center, Charlotte, N.C. He presented the study at the ACS meeting. It’s important that surgeons are aware of the costs of complications for procedures they regularly perform, said Benjamin K. Poulose, MD, MPH, assistant professor of surgery and director of the Hernia Center at Vanderbilt University Medical Center, Nashville, Tenn. “Surgeons need to become more involved with keeping

IN THIS ISSUE

The Surgeons’ Lounge: A morbidly obese patient with worsening pain and history of multiple hernias

On the Spot With Colleen Hutchinson: Controversial Issues in Hernia Repair Discussed by Experts

In the News: Update on the Americas Hernia Society Quality Collaborative: Now Free and Expanding

February 2014

B Y B RENT M ATTHEWS , MD

rates of infection, recurrence and mesh removal associated with the use of synthetic mesh in contaminated ventral hernia repair (2013;217:991-998). The study was a small one, with 100 patients, a retrospective design and limited follow-up. As such, it would be considered low-quality evidence. Even so, experts say it represents the beginning of a change in the way hernias in contaminated fields are repaired in the United States. “This article represents the potential

he 16th annual meeting of the American Hernia Society (AHS) will be held March 12-15, 2014, in Las Vegas. The AHS continues to foster scientific investigation, innovation and collaboration among surgeons in North, Central and South America. The involvement of surgeons from Europe and Asia-Pacific continues to demonstrate the global outreach of the science of hernia. The society is the primary representative and advocate for herniology, for surgeons performing herniorrhaphy and for patients requiring hernia repair in the Western Hemisphere. It is our responsibility as the leadership of the society to provide a forum for collegial interaction to disseminate the most current information available on clinical and basic research topics related to the care of the hernia patient, and evidence-based surgical and perioperative processes of care. The meeting will build on the momentum of Dr. Bruce Ramshaw’s presidential mission of “Learning Together and Improving Clinical Care,” and the strategic planning retreat for the Board of Governors in August 2013 that focused on patient-centered continuous quality improvement. As such, the AHS has supported the development and launch of the Americas Hernia Society Quality Collaborative (AHSQC) under the leadership of surgeons from the AHS Board of Governors, Michael J. Rosen, MD, and Benjamin K. Poulose, MD. The AHSQC aims to improve value in hernia care. The AHSQC uses concepts of continuous quality improvement to improve outcomes and optimize costs. This is accomplished through patient-centered

see SYNTHETIC MESH page 18

see PRESIDENTIAL ADDRESS page 21

costs at a reasonable level while improving quality of care for patients. This type of evaluation enables surgeons to take a good look at indications for a particular procedure and the risk profile for that operation, and the benefits we can offer patients.” The study showed that all wound complications were associated with significant increases in cost. A single patient with a wound infection incurred inpatient hospital costs of $65,200, and an additional $20,200 for the next year. Wound complications, including wound breakdowns, seromas requiring interventions, and cellulitis, were associated with hospital costs of $51,800, and $6,200 in charges over the next year. The study was based on an analysis of 500 consecutive patients who underwent open ventral hernia repair between 2007 and 2011 at Carolinas Medical Center. The investigators assessed all inpatient charges during a patient’s initial hospitalization and charges for office visits, imaging, readmissions and interventions for one year. The study is focused on the financial experience of a single referral center that receives many high-risk patients. Even so, the investigators say they expect that patients treated at see MESH INFECTION page 17

Synthetics May See Reprise for Contaminated Ventral Hernia Fields Lightweight Polypropylene Mesh Performs Well in Study; Broad Reproducibility Still in Question B Y C HRISTINA F RANGOU

new study challenges the widespread belief that synthetic mesh is contraindicated for ventral hernia repairs in contaminated fields. The study, published in the December issue of the Journal of the American College of Surgeons, demonstrated favorable

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Dear Readers, Welcome to the January issue of The Surgeons’ Loungee and a Happy New Year to you all! I hope all of our readers had a safe and happy holiday season. I am excited about our guest experts for 2014, who expect to be challenged! We start the 2014 lineup with a special issue on hernia repair. We are honored to have Emanuele Lo Menzo, MD, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, as our guest expert. Dr. Lo Menzo discusses the case of a patient who is morbidly obese with complaints of worsening sharp abdominal pain and a history of multiple hernias. Also, take the first challenge of the year, submitted by Shadi Al-Bahri, MD, and David V. Nasrallah, MD, FACS, Department of Surgery, Union Memorial Hospital, Baltimore. We look forward to another wonderful year and our readers’ correspondence and feedback. Sincerely, Samuel Szomstein, MD, FACS Editor, The Surgeons’ Lounge Szomsts@ccf.org

Question for Dr. Lo Menzo From Jorge Huaco, MD, Swedish Medical Center, Seattle, Washington

51-year-old morbidly obese man (body mass index [BMI], 39.1 kg/m2) was referred to our general surgery clinic with complaints of worsening sharp abdominal pain that was localized to his surgical scars. He believed that his previously repaired ventral and umbilical hernias were causing pain due to recurrence. The patient had undergone multiple abdominal hernia repairs, the first of which was approximately eight years before for what seemed to be a ventral hernia with significant diastasis recti. The patient reported that this had been repaired using an open approach with mesh, due to increased abdominal pain and cosmetic concerns. The patient did well until 2011, when the hernia recurred, requiring another repair (elective open umbilical and ventral hernia repair with prosthetic mesh). His postoperative course was complicated by an abdominal mesh infection with methicillin-resistant Staphylococcus aureus, that required mesh explantation and a new hernia repair with a biologic prosthesis. He subsequently developed small bowel obstruction secondary to adhesions that required open partial small bowel resection with primary anastomosis. The patient presented to our clinic with complaints of nausea, vomiting and abdominal pain. The nausea and vomiting started in January 2012, a few months after the small bowel resection. It was noted that he was not able to tolerate a regular diet after surgery for an extended period of time. His physician prescribed metoclopramide without effect, and the nausea occurred three to four times weekly with vomiting at least once or twice per week. Eating sometimes exacerbated the nausea and vomiting. He also complained of intermittent bloating and abdominal distention. The patient’s past medical history is significant for

Dr. Szomstein n is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.

diabetes mellitus with complications such as peripheral neuropathy, well-controlled hypertension, hyperlipidemia, chronic back pain requiring intermittent nonsteroidal anti-inflammatory drugs, and urolithiasis. On physical examination, he had a soft, large mid-abdominal defect, with partial loss of domain. He had some discomfort but no tenderness and no peritoneal signs. The patient had several imaging studies, including a computed tomography (CT) enterography that showed a wide-mouth ventral hernia with no evidence of bowel obstruction. A repeat nuclear scan was reported as normal gastric emptying of the solid meal (Figures 1-3). After several visits to the emergency department because of abdominal pain and feeding intolerance, he was finally admitted to the hospital for rehydration and reconsideration of earlier ventral hernia repair. Aside from the abdominal pain, the patient explained that his functional status had been declining due to the hernia, and that he was unable to perform basic activities of daily living (i.e., tying his shoelaces) and to work. Consequently, he had lost his job.

Figure 1. Upper cut of CT abdomen showing mesh anterior to the abdominal fascia.

Figure 2. CT abdomen showing marked distension of mesh with bowel content.

Question 1. What is the proper management and surgical indications for symptomatic diastasis recti? Question 2. Is this a true recurrence of a ventral hernia? What should be done?

Question 3. What is the most appropriate approach for a recurrent ventral hernia? Question 4. Would you consider bariatric surgery prior to definitive ventral hernia repair in this specific patient? How about in obese patients in general? Figure 3. Lower cut of CT abdomen showing large herniation of abdominal contents through abdominal wall (small and large bowel). continued ON PAGE 10

Surgeonsâ&#x20AC;&#x2122; Lounge

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

continued FROM PAGE 9

Dr. Lo Menzoâ&#x20AC;&#x2122;s

Question 1. Diastasis recti is a common problem, especially in multiparous women, but it also can occur in men. Essentially, this is a gradual separation of the rectus abdominis with widening of the anterior rectus sheath. This usually does not cause

pain or discomfort but, with straining, an elongated bulge can be seen from below the xiphoid process to the umbilicus. When the diastasis extends to the periumbilical area, it often is associated with a true umbilical hernia. The most common cause of diastasis recti in women is secondary to the abdominal wall stretch from the pregnant uterus. In men, the most common causes of diastasis recti are obesity (causing similar pressure on the muscles), or a history of vigorous straining exercises such as sit-ups or weightlifting.

Physical therapy and core exercises have shown some improvement for the defect. The condition almost never produces complications, and therefore surgical correction is not routinely recommended. However, many patients find the defect unsightly and request treatment. The presence of a symptomatic ventral or umbilical hernia in addition to the diastasis recti has been advocated as an indication for a definitive surgical repair. Whenever a true hernia is diagnosed, open or laparoscopic repair is warranted. The goal of the procedure should be

to medialize the recti in the midline and recreate the linea alba, whenever possible. This repair can be accomplished with an open technique by primary repair with or without a prosthetic mesh for larger defects, or in the presence of risk factors for recurrence. Laparoscopically, the midline can be approximated using intracorporeal sutures or unidirectional braided sutures and reinforcing with prosthetic mesh, when necessary. In laparoscopic cases, it is paramount to open the peritoneum and fully reduce the preperitoneal fat before the hernia repair. Failure to complete this step will result in persistence of the subcutaneous lump, and potentially, the symptoms.

Question 2. The CT scan shows an onlay mesh in the upper part of the repair and a welldefined layer circumferentially around the viscera. There may be an interruption of this layer in the right lower quadrant. It is difficult to confirm if this was a mesh or a pseudosac from a previous biologic mesh based on imaging studies. The patientâ&#x20AC;&#x2122;s history and physical examination, as well as the availability of the previous operative report, will help in the decision making. In this specific case, the main indication for revision and reconstruction of the abdominal wall would not be the defect per se (large and unlikely to cause bowel incarceration or strangulation), but the significant loss of functional status of the patient, aggravated by chronic pain issues. The foreign materials from multiple previous repairs and the dense adhesions could be the cause of chronic, debilitating abdominal pain.

Question 3.

STAGED ABDOMINAL REPAIR

Recurrent ventral hernias are frequent occurrences in general surgery practices and have become a problem that few surgeons are eager to deal with, especially in patients with multiple recurrences. Several factors contribute to these recurrences: obesity; collagen abnormalities; immunosuppressive medications; improper surgical repair or use of prosthetic and biologic materials; and postoperative complications, such as seromas and/or infections, among others. Over the past 30 years, the change from primary repair to the widespread use of prosthetic materials has decreased the recurrence of ventral hernias significantly. Without question, other than for minimal ventral defects, the use of a mesh is always indicated. Selecting the most appropriate material depends on the conditions of the patient and the type of repair. In my opinion, patients with small recurrences of previous repairs (primary or mesh) would be ideal candidates for a subsequent laparoscopic repair. There

Surgeons’ Challenge

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

are some technical aspects that would improve the outcomes and include avoidance of dead spaces and seromas. (Some surgeons would advocate removal of the sac by a small open incision or laparoscopically.) Also, optimal apposition of a double-sided mesh (to avoid bowel adhesions) with transfascial sutures and tacks, maintaining a flat lie of the mesh, would help decrease the chances of further recurrence. For larger defects, especially when abdominal wall function is one of the primary objectives of the repair, abdominal wall reconstruction should be considered. This includes medialization of the musculoaponeurotic complex by one of the types of component separation described. The repair should be reinforced with either synthetic or biologic mesh, preferably in the retrorectus space, which will keep the integrity of the peritoneal lining and maintain the mesh in a constrained space. An important aspect, especially in obese patients, is avoidance of large dead space and seroma formation; this could be achieved by excision of redundant skin and subcutaneous tissue (panniculectomy), broad drainage of subcutaneous and subfascial space, and possibly the use of incisional negative pressure systems.

Surgeon’ Challenge Surgeon

Submitted by Shadi Al-Bahri, MD, and David V. Nasrallah, MD, FACS, Department of Surgery, Union Memorial Hospital, Baltimore, Maryland

A 27-year-old man presented to the emergency department with a week-long history of abdominal pain, readmitted with worsening symptoms, associated with fever and loss of appetite. His medical history was not significant except for recent travel to Mexico

and Canada, and a questionable diagnosis of Crohn’s disease. An abdominal CT scan performed a week before this presentation showed thickened small bowel loops in the right lower quadrant consistent with Crohn’s disease. His repeat CT scan on this presentation (Figure), however, revealed pneumoperitoneum consistent with a perforated viscus as well as a more

Figure. The patient’s repeat scan revealed pneumoperitoneum consistent with a perforated viscus as well as a more pronounced circumferential small bowel wall thickening of the distal ileum.

pronounced circumferential small bowel wall thickening of the distal ileum. At that time, his white blood cell count was elevated at 12,400/mL, and his abdominal examination revealed a rigid abdomen with rebound tenderness, localized to the midline below the umbilicus. The above findings were concerning for perforated small bowel, and therefore the patient was taken emergently to the operating room. What is the diagnosis? A. Perforated appendicitis B. Crohn’s disease C. Foreign body D. Carcinoid tumor

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Question 4. Obesity is one of the leading causes of hernia recurrence. In this patient population, the presence of increased abdominal pressure, a chronic inflammatory state and frequent association with comorbidities such as diabetes, could very likely contribute to hernia recurrence. Also, obese patients are more prone to developing surgical site infections. In the management of a morbidly obese patient with ventral hernia, especially if recurrent, weight loss should be the primary goal before hernia repair options are discussed. Given that diet and exercise alone have very limited results, discussion about bariatric surgery should be started. If patients are not interested in bariatric surgery, then as part of the surgical consent process, we must initiate a clear and thorough discussion about higher recurrence rates and surgical wound events, including surgical site infection. If bariatric surgery is an option, this should be carried out first and the hernia should be left undisturbed, as much as possible. In the case presented here, given that the patient had multiple hernia repairs and previous bowel surgery with extensive adhesions, the best bariatric surgery option would be a sleeve gastrectomy. Definitive abdominal wall reconstruction can be performed at the time of maximum weight loss (12-15 months after surgery), and should be combined with a panniculectomy.

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On the Spot

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

Controversies in Hernia Repair

Spot

hernia care a field that demands an individualized approach to treatment, and therefore, one in which we really cannot implement generalized therapy approaches among subpopulations of hernia patients? This month, I target that question directly as I ask my colleagues to respond to the declaration that hernia treatment is something that, at this point, really cannot be standardized. Read on for responses and let us know your thoughts on these issues as well by visiting this column online and sharing your thoughts. Don’t miss the Gut Reaction table on page 16, and as always, feel free to email me at colleen@cmhadvisors.com with any ideas for debate in hernia and other areas of general surgery. Happy 2014! —Colleen Hutchinson

PARTICIPANTS

B. Todd Heniford, MD, is chief, Division of Gastrointestinal and Minimally Invasive Surgery; co-director, Carolinas Laparoscopic and Advanced Surgery Program; director, Carolinas Hernia Center, Charlotte; and clinical professor of surgery, University of North Carolina at Chapel Hill. Dmitry Oleynikov, MD, is professor of surgery and director of minimally invasive surgery at the University of Nebraska Medical Center, Omaha.

Michael J. Rosen, MD, FACS, is associate professor of surgery and chief of the Division of GI and General Surgery at University Hospitals of Cleveland, Case Medical Center, and the director of the Case Comprehensive Hernia Center in Ohio. Michael G. Sarr, MD, FACS, is the J.C. Masson Professor of Surgery and vice chair of research in the Department of Surgery, Mayo Clinic in Rochester, Minnesota.

Guy R. Voeller, MD, is professor of surgery, University of Tennessee Health Science Center, Memphis.

e gre

It is safe to place lighter-weight synthetic meshes in clean-contaminated or contaminated wounds.

David Chen, MD, FACS, is assistant clinical professor at UCLA Lichtenstein Amid Hernia Clinic, David Geffen School of Medicine at the University of California, Los Angeles.

with Colleen Hutchinson

re e

As we approach the season of annual hernia meetings and the debates that come with them, I am honing in on some critical hernia topics. I’d like to thank all of the contributors and Guy Voeller in particular for helping me navigate the world of mesh, which is the main focus of this month’s column. After reading this On the Spot, you will at least know what some of the experts think about mesh variants, based on their specialized experience and their knowledge of current and forthcoming data. In addition, I once again address the topic of standardization in hernia care. Last year (General Surgery News, February 2013, page 20), you read our contributors’ opinions on whether hernia treatment should be standardized and monitored via a Center of Excellence application, or at least via identification and definition of basic gold standards and standards of care. The question became clear: Is

O nthe

Happy New Year to On the Spot Readers!

Dr. Sarr: Disagree, but I am hearing about people who have placed lightweight, large-pore polypropylene in clean-contaminated cases, and even if a wound infection develops, it will granulate through. We need a study, but at the current time I would have to say “disagree.” Dr. Voeller: Agree. There is no question that this is true. Randomized trials that have just been completed will show this to be safe. We at the University of Tennessee Health Science Center, and many other places, have been doing it for years. We especially like to use an onlay technique with fibrin glue for mesh fixation. Even if a wound infection develops, the lightweight mesh can always be salvaged by opening the wound and placing a wound vac [vacuumassisted wound closure]. Dr. Rosen: Agree, so far. There is a large series of 100 patients with medium-term follow-up that suggests this is safe. We also are currently enrolling patients in a randomized controlled multicenter trial that hopefully will provide level 1 evidence on this question. However, there are some key technical points that allow one to place synthetic mesh in contaminated fields that should be carefully considered. Dr. Heniford: On the fence. There is little clinical data that explore lightweight polypropylene mesh use in clean-contaminated and contaminated fields. Our lab data in animals show that lightweight polypropylene mesh has a reduced infection rate compared with the more traditional heavyweight mesh. Lightweight

mesh is also more likely salvaged than its traditional, heavyweight counterpart if it becomes infected. But, in a recent paper presented at the Southern Surgical Association detailing outcomes in more than 750 complex ventral hernia repair patients, we found that synthetic mesh used in a hernia in which an enterotomy had occurred had significantly increased odds of a mesh infection. This data does not exclude its use, but it does give me some pause in using synthetic mesh in these fields.

There is a series of 100 patients with medium-term follow-up that suggests this is safe. —Michael J. Rosen Dr. Oleynikov: On the fence. There is new evidence to suggest that you can get away with this practice, but much remains to be worked out, such as how much is too much contamination and how to check the vascularity of the bed. Dr. Chen: On the fence. I would agree, with caveats, depending on degree of contamination, type of mesh, position of mesh placement and the type of repair. I don’t have a problem placing lightweight mesh in the sublay position with a retrorectus repair for a clean-contaminated case. For a grossly contaminated case, there is a lot of mesh that is at risk and biologic [mesh] may still be safer. Soon enough, we will have some good data on this. Continued ON PAGE 14

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On the Spot

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

Hernia care and treatment is something in medicine that, certainly at this point, by and large can’t be standardized.

Dr. Chen: On the fence. Biologic mesh is being more properly utilized for the right indications. When used with proper technique and selected for appropriate cases, the outcomes are good and it is good for us to have [biologic mesh] available. Like all tools in surgery, it has a role and a use but won’t correct for bad judgment or technique. Dr. Heniford: Agree. In general, I agree, but there are a number of factors that go into its increased risk for failure. Our data do show a four to five times increased risk for recurrence when a biologic implant is used compared with when a synthetic mesh is used. The fact that these implants expand or stretch over time is disappointing. However, they are largely used in the most challenging surgical fields, and this fact does play a role in the increased recurrence rates. Certainly, if we expect these meshes to be the “be all and end all” and to behave like a synthetic, we will be disappointed. They must be accepted as different, and at times, very helpful. If you want something to behave as a synthetic, use a

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Dr. Sarr: Agree. Several things are definite. A hernia-former [patient] needs a prosthetic mesh. A non–hernia-former may not, but the current use of component separation without a biologic mesh

Biosynthetics, or new bioresorbable meshes, are the next best thing and will replace biologic mesh at a lower price and provide a better chance of leaving a ‘good’ scar and disappearing.

Dr. Sarr: Agree. The biosynthetics can be used in the same place that a biologic mesh is placed at a much cheaper price. Whether they have a better chance of leaving a good scar is unknown. I have used them; I like them; and they are much cheaper than biologic meshes. Dr. Rosen: On the fence. Like biologic mesh, there are certainly early appealing results. Whether this will translate into long-term durability is unknown. However, the more reasonable price tag of some of these materials is encouraging. Dr. Heniford: “Agree,” butt we need to study these materials diligently. We completed an experiment that answers exactly this question in an animal study. In a blinded evaluation, we found that GORE BIO-A [Gore Medical] incorporates faster with greater cellular and vascular ingrowth and had significantly increased type I collagen deposition compared with Strattice [LifeCell], FlexHD [Ethicon] and Permacol [Covidien]. It did indeed leave a “good scar.” The data we have gathered from the biologic implants will provide a very good comparison among the absorbable synthetics.

re e

Dr. Voeller: Agree. I was never a believer in the biologic mesh fairy tale. They were introduced without any clinical data. I never used the products because I did not believe the hype. Yuri Novitsky and others have confirmed what I believed—the scar that is formed has no good-quality collagen. Maybe there’s a role for salvage situations, but there are less expensive alternatives.

Dr. Oleynikov: Disagree. We have far more evidence for a number of hernia-related techniques and principles today than we did even five years ago. We can standardize many aspects of hernia repair today and should do so, as I see great variability in hernia repair principles that do not serve patients well.

When used with proper technique and selected for appropriate cases, the outcomes are good and it is good for us to have [biologic mesh] available. —David Chen, MD

Dr. Oleynikov: Agree, this is a true statement, but only because we were asking too much of biologics, and not all biologics perform in the same way under similar conditions. Cost also has been a significant drawback.

Dr. Voeller: Agree. Even though there is a broad standardization, we do not have enough stratification data to tell us who benefits most from what type of repair. Hopefully, things such as the Americas Hernia Society Quality Collaborative will begin to allow more refined standardization.

Dr. Rosen: Agree. I think, like all new medical devices that come on the market, there are many claims that are made that often do not pan out with long-term experience and data. The biggest problem with biologic mesh is it was initially priced to regenerate into fascia. We now know that does not happen. The current cost of this material and the disappointing long-term durability issues make other less expensive alternatives appealing appealing. If biologic mesh companies could more reasonably price these materials for what they actually do, they might have a role in contaminated abdominal wall reconstruction.

synthetic. Now, interestingly, the consideration of a synthetic, absorbable mesh has entered into the conversation. [See next statement.]

is Dr. Sarr: Agree. In my practice, biologic meshes are prolonged wound dressing. I never rely on a biologic mesh to span a defect and expect it to remain repaired. I think biologic meshes are best used to reinforce tenuous repairs or when a permanent prosthetic cannot be placed.

re e

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The market for biologics is dropping off; there are few indications for them based on current data; and generally, their outcomes are disappointing.

re e

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Co t ued from Continued o PAGE G 12

Dr. Chen: On the fence. Let’s see what the long-term outcomes look like. It may not be “the next best thing,” but it is another good option that we have available. For the case in which you are just trying to get closure and bridge with biologic, this is definitely a more cost-effective alternative. For definitive repair, we need to see how these remodeled scars behave over time with regard to strength and recurrence rates. We will probably find that, like everything else when used with good technique, it will be effective (and hopefully cost-effective). Dr. Oleynikov: On the fence. There is great promise from these engineered materials, but much remains to be worked out. The reabsorption characteristics vary significantly based on the tissue bed and use of these products. Dr. Voeller: On the fence. We don’t have enough data on the biosynthetics at present. Only time will tell. I think they will replace the biologics as they are now doing since they are less expensive, but we don’t know if they will leave a good-quality scar plate.

or without a permanent mesh for herniaformers (obese or multiply recurrent hernias) is unconscionable, in my opinion. Dr. Rosen: Disagree. First, we need definitions of what we are actually talking about. We desperately need a validated, easy-to-use classification system to allow unified reporting of outcomes and staging of hernia care. I think it is important to remember that one size will never fit all hernias. That is the fun of this field.

I think it is important to remember that one size will never fit all hernias. —Michael J. Rosen, MD

Dr. Chen: Agree, mostly. We definitely don’t want to take decision making, judgment and technique out of the hands of surgeons. Individual patient circumstances and surgeon expertise and experience are all important in surgical decision making. That being said, we need to look at collaborative experiences and outcomes to help direct better technique and standardize the lowhanging fruit. Dr. Heniford: Disagree. There are indeed situations where we cannot fully standardize care, but through the use of true, well-designed, randomized studies, we can much better regulate and conform preoperative management, techniques and postoperative care for hernia operations, the most commonly performed operations in the world.

—Colleen Hutchinson is a communications consultant who specializes in the areas of general surgery and bariatrics. She can be reached at colleen@ cmhadvisors.com.

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On the Spot

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

Gut Reaction: Surgical Potpourri Contributor

Mesh or no mesh for hiatal hernia?

For a 2-cm umbilical hernia, laparoscopic repair is indicated.

If you cannot bring the anterior rectus fascia together after a component separation, you should bridge the gap with a biologic, not a permanent, mesh.

Obamacare is …

Best advice to the community surgeon in cleancontaminated cases …

Best advice to the community surgeon regarding sportsman hernia …

The FDA’s approval process for medical devices is …

The one thing residents and fellows forget most is …

The one thing The one patients forthing I forget get most is … most is …

Dr. Rosen

No mesh

It certainly is easier than open.

Depends on the wound class of the case and the goals of the surgeon/patient. But most of the time, permanent synthetic.

Why the U.S. government can’t do anything well.

Do a good hernia operation.

It doesn’t exist; let it go.

Broken, but be careful what you wish for. See response on Obamacare.

Be prepared for every case.

You have to be part of the solution; there is no surgical magic.

Use the electronic medical record.

Dr. Oleynikov

Mesh for hernia 2 cm and greater

Yes, especially in obese patients

I would use a permanent mesh and place onlay synthetic biologic over the defect.

Not good for anyone

Use lightweight monofilament prolene mesh in the retrorectus pocket.

Don’t do it!

Very slow

Patient factors determine outcomes far more than surgical technique.

Personal responsibility

When there is a crisis, always check your own pulse first!

Dr. Voeller

Mesh

Ventralex ST (Davol) open repair cheaper/ better

Only in a salvage situation

A mess

Avoid biologics.

Find a true expert and learn.

Poor

To be humble

Respect is a two-way street.

I forgot.

Dr. Heniford

Thickness of crus provides the answer.

Sure, lap-assist- Permanent or expect to ed is a good re-operate later technique.

Scary …

Talk options with patient before surgery.

Fully understand the issues before operating.

Daunting, variable, a moving target

To get in their daily nap

Avoid Rosen’s operating room.

How truly thankful I should be

Dr. Chen

Depends on size and the patient

Good for obese and incarcerated

Not necessary

An imperfect solution but a start

Biologic or retrorectus repair with lightweight mesh

Conservative management

A necessary evil

How lucky we are to do what we do

Perfection doesn’t exist.

How important it is to get home

Dr. Sarr

Sometimes but No, too expenusually not sive; cheaper done open

Definitely not! Permanent mesh is indicated.

Too early to tell

Don’t place prosthetic mesh; consider reinforcing with biosynthetic mesh.

Refer to a sportsman hernia expert.

Too complicated

Place mesh sub- Hernias recur lay versus onlay, and hernias large pore verget infected. sus small pore.

Honesty in terms of recurrence

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

MESH INFECTIONS

Table. Effects After Ventral Hernia Repair

jContinued from page 7

other institutions would incur similarly high costs. Care costs escalated due to the additional interventions and visits needed for patients with complications, the study showed. Reoperations, drainage by interventional radiology, bedside interventions, extra days in the hospital and additional office visits accounted for much of the added expense. Compared with patients who had no complications, patients with wound infections required an additional 4.3 postoperative visits, had longer hospital stays (8.3 vs. 5.8 days), underwent more reoperations (32.2% vs. 1.0%) and required more drainage by interventional radiology (19.5% vs. 0%). They needed more interventions of any type (70.1% vs. 0%). Interventions, lengthy hospital admissions and follow-up office visits were also more common among patients who developed mesh infections and wound complications. This is not the first study to show that costs associated with infection are enormous. A 2004 paper published in The New England Journal of Medicinee estimated that direct medical costs associated with such infections exceed $3 billion annually (2004;350:1422-1429). However, previous studies have not closely examined the costs of infection in ventral hernia repair. Infections and wound complications are quite common in ventral hernia repair, with studies suggesting that one-third to two-thirds of these patients develop wound complications. Complications have consequences far beyond cost, the investigators noted. “Patients who have complications require more office visits, which means there’s a burden on the patient to travel to the clinic and to take time out of their day,” Dr. Colavita said. “It’s also a burden on the physician and the physician’s staff, who now have to see a higher number of patients on clinic days. This impacts both patient and physician quality of life.” The study confirmed that patients with complications experienced worse quality of life six months after surgery than those without complications. Using the Carolinas Comfort Scale, patients who experienced a complication reported more discomfort (57.6% vs. 35.4%), greater limitations on activities (58.6% vs. 29.9%) and more mesh sensation (52.5% vs. 34.2%) than those without a complication. Factors associated with complications such as infections included previous hernia repair, previous infection, active infection, defect area size and concomitant panniculectomy. Compared with

At 1 year

Patients With a Complication

Patients Without a Complication

Hospital stay, days

8.3

5.8

More operation, %

32.2

1.0

More drainage by IR, %

19.5

IR, interventional radiology

patients who underwent repairs using biologic mesh, patients who were implanted with synthetic mesh had fewer wound infections (13.5% vs. 46.2%) and fewer wound complications (21.6% vs. 30.8%), but had more mesh infections (2.6% vs. 0%). The authors attributed the higher infection and complication rates to a higher risk profile among patients who had

biologic mesh placement. Women accounted for just over half of the study population (57.2%). The patients had a mean age of 56.4 years and a mean body mass index of 33.1 kg/m2, and 60.6% had a prior recurrence. The mean defect area was 198.3±293.9 cm2. Nearly one-third of the patients underwent a concomitant panniculectomy, and 25.8% had a component separation. The investigators say they plan to do follow-up steps to identify the patients most at risk for these complications and develop strategies to reduce the risk.

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In the News SYNTHETIC MESH jContinued from page 7

for a paradigm shift in the management of contaminated abdominal wall defects,” said co-author Alfredo M. Carbonell II, DO, associate professor of surgery, University of South Carolina School of Medicine and co-director of the Hernia Center, Greenville Health System, in Greenville, and his colleagues. “Our collective experiences challenge the surgical dictum that a synthetic mesh is contraindicated in a contaminated surgical field during open abdominal wall

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

reconstruction,” Dr. Carbonell said. Gina Adrales, MD, MPH, associate professor at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., said she has been “wary” of using permanent synthetic mesh in contaminated cases, but the results are “compelling.” “I think that [this study] is enough to consider using a macroporous lightweight polypropylene mesh in a retrorectus position in clean-contaminated and contaminated cases,” she said. “[Synthetic mesh repair] needs to be part of a herniologist’s armamentarium to safely care for these complex patients, but

’[Synthetic mesh repair] needs to be part of a herniologist’s armamentarium to safely care for these complex patients, but the ultimate decision of the type of repair and the type of prosthetic is ultimately a judgment call by the surgeon that should center on the patient.’ —Gina Adrales, MD, MPH the ultimate decision of the type of repair and the type of prosthetic is ultimately a judgment call by the surgeon that should center on the patient,” she added. She noted that the four surgeons who

Hernia Outcomes How do you compare? Compare your outcomes to the Collaborative outcomes • • • •

Post-op complications Risk factors Mesh type utilization Wound class

• • • •

Total patients Laparoscopic operations Total operations Myofascial release

The Americas Hernia Society Quality Collaborative aims to improve the value in hernia care delivered to patients. AHSQC utilizes concepts of continuous quality improvement to advance outcomes and optimize costs through patient-centered data collection, ongoing clinician performace feedback, and analysis of collected data and collaborative learning.

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Participation is FREE for AHS members Help Advance Hernia Care www.ahsqc.org

participated in the study are highly skilled and experienced. “It remains to be seen whether their good results can be replicated by other surgeons at tertiary and community hospitals.” In 100 patients who underwent ventral hernia repair with lightweight polypropylene mesh placed in the retrorectus position in clean-contaminated and contaminated fields, surgical site infections (SSIs) were reported in 7.1% of clean-contaminated cases and 19% of contaminated cases. The incidence of surgical site occurrence was 26.2% in clean-contaminated cases and 34% in contaminated cases. These rates are lower than those reported for biologic mesh implantation in contaminated fields in the prospective, multicenter RICH (Repair of Infected and Contaminated Hernias) trial, which is considered the highest-quality data for biologic mesh performance. In that trial, the investigators reported a 66% surgical site occurrence rate and a 30% SSI rate. In the current study, there were seven recurrences in a mean follow-up of 10.8 months. The investigators acknowledged that the follow-up was short, but noted that major wound complications would have been identified in that period. Today, biologic mesh is widely considered the standard of care in contaminated fields. Synthetic mesh began to fall out of favor in the late 1990s, after a series of studies demonstrated high rates of complications such as SSIs, intra-abdominal adhesions and enteric fistulas. This led to rapid adoption of biologic meshes in the early 2000s, despite a lack of high-quality data to support their use. In 2010, the Ventral Hernia Working Group recommended that synthetic mesh be considered contraindicated for patients in whom the risk for SSI is high; instead, bioprosthetics were recommended. However, recent data have shifted the balance away from biologics. Long-term follow-up has shown high rates of recurrence and wound morbidity with use of biologics. Moreover, biologic meshes can be unpredictable once they are implanted. “We cannot reliably predict what that mesh is going to do in a patient,” Dr. Adrales noted. Surgeons from Greenville Hospital System University Medical Center and Cleveland’s Case Comprehensive Hernia Center set out to examine the clinical

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

Hernia Tracking System Going Strong at Six Months; Now Free and Expanding Organizers Note Ease of Use, Excellent Follow-Up and Real-Time Feedback B Y C HRISTINA F RANGOU

ix months after the launch of a quality collaborative designed to improve standards in hernia repair, the program is being expanded and offered for free to surgeons in the United States who perform ventral hernia repair.

outcomes associated with implanting new-generation lightweight polypropylene mesh in contaminated fields. The study focused on 100 patients (50 men, 50 women) with a mean age of 60±13 years and a mean body mass index of 32s9.3 kg/m2. There were 42 cleancontaminated and 58 contaminated cases. Mean hernia defect size was 246s280 cm2 with a mean mesh size of 631s654 cm2. Component separation was done in 49% of patients. Overall, four patients underwent mesh removal, which is “perceived as one of the most influential outcome measures preventing synthetic mesh use,” according to the authors. Two meshes were removed because of early anastomotic leaks, one due to a stomal disruption and retraction in a morbidly obese patient, and the other due to a long-term enterocutaneous fistula. The study builds on the results of two prospective, randomized trials recently conducted in Europe, where reluctance to use synthetic mesh in contaminated fields does not exist (Trials 2012;13:226; World J Surgg 2010;34:1637-1640). Both studies showed that lightweight polypropylene mesh placed prophylactically at the time of stoma creation in the retrorectus position has excellent long-term results. “It will be truly revolutionary for North Americans to buy into the concept that you can use synthetic mesh in clean-contaminated and contaminated fields, but that’s what we’re seeing,” Dr. Carbonell said. “Not only are biologics 20 times more expensive, the recurrence rate is three to four times higher than synthetics and the complication rate is higher,” he said. Investigators are currently enrolling patients in a randomized controlled trial that will compare biologic and synthetic meshes used in contaminated fields. The trial is expected to have a major influence on the care of hernia patients. Dr. Carbonell is a paid consultant for W.L. Gore & Associates, and Ethicon Inc. Other study authors are paid consultants for Covidien, LifeCell and Davol.

“We’d like surgeons who do 50 hernia repairs a month to sign up; we’d like surgeons who do one a month. This initiative is intended so that we can learn from everybody,” said Michael J. Rosen, MD, professor of surgery at Case Western Reserve University School of Medicine, in Cleveland. The Americas Hernia Society Quality Collaborative (AHSQC), which Dr. Rosen co-directs, is a voluntary performance tracking system for ventral

hernia repair. The program consists of three components: a registry that collects detailed clinical information on a surgeon’s practice and outcomes on a case-by-case basis; a system for real-time performance feedback to clinicians; and a broader process for quality improvement across the hernia field based on analysis of the collected data. The program was introduced at the 2013 annual meeting of the American Hernia Society (AHS). For the pilot

phase, participation was restricted to a small group of institutions, including University Hospitals Case Medical Center, Vanderbilt University Medical Center, Greenville Health System (South Carolina) and Carolinas Medical Center, while the organizers refined the database. The organizers have opened the program now to all surgeons who are members of the AHS. They also have eliminated the fees associated with joining see TRACKING SYSTEM PAGE 20

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TRACKING SYSTEM jContinued from page 19 the collaborative, initially set at $1,000. The organizers hope to attract more community surgeons, who perform the bulk of hernia repairs in the country. Input from community surgeons is essential to learn what repairs are being performed, what the outcomes are and how to improve patient care across the country, the organizers said. â&#x20AC;&#x153;Our health care system is inevitably changing from a volume-based system to a value-based system. If we, as hernia

surgeons, donâ&#x20AC;&#x2122;t take ownership in defining our own value-based outcomes, we will be doing ourselves and our patients a big disservice,â&#x20AC;? said co-director Benjamin K. Poulose, MD, MPH, assistant professor of surgery and director of the Vanderbilt Hernia Center, Nashville, Tenn. Surgeons or their staff input information on patient demographics; preoperative evaluation; and operative details, including things like type of mesh used, mesh position and mesh fixation. This is the only surgical registry that collects such hernia-specific information. The

data input takes three to five minutes, Dr. Rosen said. Surgeons also submit 30-day follow-up data. At any point, a surgeon can log in and see how he or she compares with other unidentified surgeons. â&#x20AC;&#x153;You can see your surgical site infection rate versus the collaborative, your recurrence rate versus the collaborative, your reoperation rate. Youâ&#x20AC;&#x2122;re able to see that at the click of a button,â&#x20AC;? Dr. Rosen said. Programs that depend on physician-entered data are often criticized as potentially biased and inaccurate. To counter potential inaccuracies, the

Optimizing the Prevention and Management of Postsurgical Adhesions To participate in this FREE CME activity, log on to

www.CMEZone.com and enter keyword â&#x20AC;&#x153;MN125â&#x20AC;? Release date: December 1, 2012

Chair

Jon Gould, MD Chief, Division of General Surgery Alonzo P. Walker Chair in Surgery Associate Professor of Surgery Medical College of Wisconsin Senior Medical Director of Clinical Affairs Froedtert Hospital Milwaukee, Wisconsin

Faculty

Michael J. Rosen, MD Associate Professor of Surgery Division Chief, General Surgery University Hospitals Case Medical Center Cleveland, Ohio

Statement of Need Adhesions are the most common complication of abdominopelvic surgery, developing postoperatively in 50% to 100% of all such interventions. They can lead to serious medical complications, substantial morbidity, high monetary costs, large surgical workloads, dangerous and diďŹ&#x192;cult reoperations, and an increasing number of medicolegal claims. An oďŹ&#x192;cial deďŹ nition of the Sponsored by

Expiration date: September 1, 2014 condition has not been established, and an unequivocally eďŹ&#x20AC;ective prevention method has not been identiďŹ ed. A standardized classiďŹ cation for adhesion assessment and scoring also is lacking, as are guidelines for diagnosis and management. To close these gaps, clinician education is necessary.

Goal The goal of this educational activity is to provide surgeons with up-to-date, clinically useful information concerning the prevention and management of postoperative adhesions.

Learning Objectives 1 Review the pathophysiology and complications of postoperative adhesion formation. 2 Summarize current strategies used to prevent postoperative adhesion formation. 3 Describe the various types of barrier materials used to prevent postoperative adhesion formation.

Intended Audience The intended audience for this educational activity includes general surgeons, vascular surgeons, colon and rectal surgeons, critical care surgeons, surgical oncologists, trauma surgeons, and thoracic surgeons. Supported by an Educational Grant from

Estimated Time for Completion: 60 minutes Course Format Monograph (print and online)

Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Medical College of Wisconsin and Applied Clinical Education. The Medical College of Wisconsin is accredited by the ACCME to provide continuing medical education for physicians.

Designation of Credit Statement The Medical College of Wisconsin designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Creditâ&#x201E;˘. t Physicians should only claim credit commensurate with the extent of their participation in the activity.

Method of Participation There are no fees for participating in or receiving credit for this activity. To receive CME credit, participants should read the preamble and the monograph and complete the post-test and evaluation. A score of at least 70% is required to complete this activity successfully. Distributed via

â&#x20AC;&#x2DC;If we ... donâ&#x20AC;&#x2122;t take ownership in defining our own value-based outcomes, we will be doing ourselves and our patients a big disservice.â&#x20AC;&#x2122; â&#x20AC;&#x201D;Benjamin K. Poulose, MD patients also submit validated questionnaires on long-term issues such as quality of life and pain. Dr. Rosen said 60% of eligible patients have completed the follow-up questionnaires, a response rate that is 20% to 25% higher than that in the Michigan Bariatric Surgery Collaborative, which is the model for the hernia program. The Michigan program has been credited with reducing bariatric mortality rates in the state to a fraction of the national average. â&#x20AC;&#x153;This is the first step in the right direction for hernia repair. For the first time in the history of hernia surgery, surgeons are putting their data in a prospective database, accurately and honestly with the sole goal of figuring out how we can get better and improve patient care. That we already have 500 patients is monumental in this field,â&#x20AC;? Dr. Rosen noted. By the end of 2013, there were 30 surgeons enrolled in the program, with data collected on more than 500 patients. The first detailed analysis of data will be presented at the societyâ&#x20AC;&#x2122;s 2014 annual meeting, in March, in Las Vegas. â&#x20AC;&#x153;Right now, weâ&#x20AC;&#x2122;re still sifting through a lot of the information weâ&#x20AC;&#x2122;ve gathered. So far, we were surprised at the wide variation in surgical site infection and surgical site occurrences,â&#x20AC;? Dr. Poulose said. The wide variation demonstrates the need for a quality improvement process that can identify the factors that influence site infections and site occurrence rates, he added. The AHS currently funds the collaborative. The organizers are working to set up a sponsorship arrangement with companies that make meshes and other products for hernia repair. Additionally, the AHSQC has been developed in close partnership with the FDA. More information on the program is available at www.ahsqc.org.

khorty@mcmahonmed.com.

GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

PRESIDENTIAL ADDRESS jContinued from page 7 data collection, ongoing performance feedback to clinicians and improvement based on analysis of collected data and collaborative learning. The AHSQC enables transition to shared accountability of care and payment models; it enables peer and institutional comparison review to improve the quality and safety of care; it enables longitudinal outcomes analysis and reporting; it mitigates clinical and cost variation; it provides best practices, decision support and care pathways to enhance patient care and safety; it allows organizations to make decisions that improve surgical care and increase throughput and deliver return on investment; and it improves the value of hernia care by improving outcomes and decreasing costs. This concept will be the universal theme of this year’s annual meeting. The AHSQC platform has been operational since July 2013. The AHS meeting in Las Vegas will have a session dedicated to the AHSQC with a demonstration of its functionality and reporting of data, and a demonstration of its utility in continuous quality improvement. I encourage surgeons from communitybased practice and academic medical centers alike to attend as the initial step in becoming an active participant in the AHSQC. In an effort to provide the attendees with an evidence-based surgical and perioperative processes-ofcare educational environment, the 16th annual meeting of the AHS will have sessions entitled “AHS Journal

Club: Sentinel Articles in Hernia Surgery,” “Biomaterial Science: Evidence-Based Literature,” “Complication Management: Morbidity Conference at AHS,” and expert debates entitled “Ventral Hernia Repair: This Is the Ideal Location for Mesh Placement” and “Fixation for Laparoscopic Inguinal Hernia Repair.” Panel discussions on abdominal wall reconstruction, chronic inguinodynia, athletic pubalgia, controversies in open and laparoscopic inguinal hernia repair, and an instructional video session on laparoscopic and open ventral hernia repair will provide an open forum for faculty experts to discuss perioperative surgical management. In all of these sessions, faculty will be accountable for disseminating peer-reviewed literature and patient-centric standards of practice to enable surgeons attending the meeting to optimize value-based care for hernia patients. The Nyhus-Wantz Lectureship will honor an invited faculty for untiring attention to the study and skill of abdominal wall surgery. This lectureship is a tribute to two surgeons, Lloyd M. Nyhus, MD, and George E. Wantz, MD, who pioneered scientific investigation in hernia surgery and dissemination of evidencebased approaches to hernia management. Scientific sessions, on March 12-14, will allow research investigators the opportunity to present current clinical, basic and/or applied research that ultimately may alter practice patterns of the hernia surgeon to improve patient-centered outcomes. Posters of Distinction will be presented on March 15, to honor investigators for their accomplished research. The 2013 American Hernia Society Foundation/Davol, Inc. resident/fellow

research grant entitled “A Risk Prediction Model for Ventral Hernia Recurrence and Surgical Site Occurrences Requiring Procedural Intervention Following Ventral Hernia Repair in Clean-Contaminated and Contaminated Surgical Sites” will be presented, highlighting the society’s commitment to the academic development of future herniologists. As many members of the AHS have participated in global missions serving patients with hernias and there is a great interest within our membership to contribute, a session on humanitarianism will provide an opportunity to review the World Health Organization’s concern for hernia as a disease as well as access to care. Additionally, leaders from not-for-profit organizations will discuss their experiences serving in global missions. Completing the meeting will be a session demonstrating the use of social media to promote the exchange of information on the preoperative care, surgical decision making/technique and postoperative management of the hernia patient. The International Hernia Collaboration is an innovative social media site developed by Brian P. Jacobs, MD. I invite all to share in the exchange of knowledge and expertise in Las Vegas, as the AHS strives to improve patient care through continuous quality improvement that is patient-centered and surgeon-focused. —Dr. Matthews is professor of surgery; chief, section of minimally invasive surgery, Washington University School of Medicine, Barnes-Jewish Hospital; co-director, Institute for Minimally Invasive Surgery, St. Louis, Missouri.

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MASS CASUALTY jContinued from page 1

way surgeons, health care workers, law enforcement officers, first responders and even ordinary citizens work together to save lives in future shootings and mass casualty events. In the aftermath of previous gun rampages like those in Aurora or Columbine, both in Colorado, much of the national conversation focused on how to prevent future tragedies. That hasn’t stopped these tragedies from happening. “They’re now a reality of modern American life,” Dr. Jacobs said. So in the days after that morning in Newtown, a group of trauma surgeons began to look more closely at how to improve survival rates of victims who are caught in these horrible events. What was abundantly clear in most mass shooting events over the past decade is that many victims die from uncontrolled hemorrhage before medical personnel can get to them. Sandy Hook was an exception to this pattern: The first-grade students and their teachers who were shot died almost immediately at the hands of a shooter who used a semiautomatic weapon with high-velocity ammunition ((JACS 2013;217:947-953). In most mass casualty shootings, the shooting itself lasts less than 15 minutes. Many victims bleed to death within five minutes from their severe injuries. They die in the time between wounding and when emergency medical services can reach them. In the past, that gap has sometimes been quite long. Famously, at Columbine, emergency responders were held back for 40 minutes because law enforcement didn’t want to put them in danger. This spring, the ACS and FBI assembled national representatives from medicine, law enforcement and the military to find a way to improve the survival rates of gunshot and mass casualty victims. Their focus was largely on reducing the gap between wounding and receipt of medical attention. In the group’s first report, called “Improving Survival from Active Shooter Events: The Hartford Consensus,” the authors recommended that law enforcement personnel be trained in hemorrhage-control techniques so that victims with uncontrolled bleeding can be attended to before emergency medical services are on the scene ((J Trauma Acute Care Surg 2013;74:1399-1400). In the past, police response to an active shooter typically involved three phases: a law enforcement phase, in which officers isolate and capture or kill the shooter; a rescue, triage and rapid transport phase; and a recovery phase. “Each of those phases is important, but what the Hartford Consensus is designedto do is help blend those

Bill Iffrig, 78, lies on the ground as police officers react to a second explosion at the finish line of the Boston Marathon in Boston, on April 15, 2013. AP Photo/The Boston Globe, John Tlumacki

Parents leave a staging area after being reunited with their children following a shooting at Sandy Hook Elementary School in Newtown, Conn., Dec. 14, 2012. It was the worst school shooting in the country's history. (AP Photo/Jessica Hill)

phases into a more seamless care system,” said Alexander Eastman, MD, MPH, assistant professor of surgery and interim chief of trauma, University of Texas Southwestern Medical Center/Parkland Memorial Hospital in Dallas and lieutenant, SWAT Unit, Field Services Division, Dallas Police Department. “If hemorrhage control doesn’t occur early in the response to one of these events, you don’t need to worry about things like rapid extraction because it frankly doesn’t matter at that point,” Dr. Eastman said. Many lives were saved in the Tucson, Ariz., shooting because law enforcement implemented the same techniques the Hartford Consensus recommends, Dr. Eastman explained. “If you give these officers training and equipment to control bleeding, they will use it; they will use it well and they will save lives.”

The Hartford Consensus developed the acronym THREAT to outline the ideal response to active shooter and intentional mass casualty events. THREAT stands for: • Threat suppression • Hemorrhage control • Rapid Extrication to safety • Assessment by medical providers • Transport to definitive care In a second call-to-action piece published in the September 2013 edition of the Bulletin of the American College of Surgeons, the Hartford Consensus group called for educating the public and training ordinary citizens in hemorrhage control, much like individuals who are trained in CPR. They hope that uninjured and minimally injured victims will be able to act as rescuers. “Everyone can save a life,” said Dr. Jacobs. “In that sense, we’re all first

responders, every last one of us. … The public is a responder; they are phenomenally helpful. Our job as surgeons is to teach them how to be helpful. That will increase survival from these events.” Hartford Consensus II also called for improved coordination and communication among emergency responders, such as law enforcement and emergency medical, fire and rescue workers. The group cited a wide variety of potential partner organizations that could help implement these new strategies in each state. The Hartford Consensus draws heavily on lessons learned by the military over the past few decades. Uncontrolled hemorrhage from penetrating trauma has been a major cause of fatalities for combat troops since antiquity. However, recent studies done by military surgeons and physicians have shown that survival from these injuries is largely dictated by what happens in the field, not what happens later in a hospital. As a result, combat troops today are trained in management of hemorrhage through a program called Tactical Combat Casualty Care. They all carry tourniquets and combat gauze. The outcome has been a remarkable drop in preventable deaths. A series of published reports from combat support hospitals in Iraq have shown that tourniquets are saving lives on the battlefield. In a 2011 study published in the Journal of Emergency Medicine, survival rates of wounded patients who had tourniquets placed to control hemorrhage after they went into shock hovered around 4%; however, if the tourniquet was placed before the injured person went into shock, the chance of survival rose to 80% (2011;41:590-597). Similarly, all law enforcement personnel should carry tourniquets in their pockets and the public should be trained in use of tourniquets, said Norman E. McSwain Jr., MD, professor of surgery at Tulane University, New Orleans, and medical director of PreHospital Trauma Life Support. “If the American Heart Association can teach the world how to do CPR, the American College of Surgeons can teach the world how to put on tourniquets and control bleeding. It’s not a complicated process and it will save lives.” Experts point to the Boston Marathon bombing as a perfect example of how lives can be saved when members of the public are trained in hemorrhage-control techniques. Many of the now iconic images of the bombing depict people rushing injured victims away from the scene with impromptu tourniquets wrapped around remaining parts of their legs. The quick response of bystanders in Boston saved many lives, said David S. Wade, MD, a surgeon and chief medical officer of the FBI. “What we saw from the Boston experience is that once see MASS CASUALTY PAGE 24

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GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

Liposomal Bupivacaine Boosts TAP Block B Y A JAI R AJ

linicians may have an effective new anesthetic at their disposal for 72 hours or more of postoperative pain relief. Liposomal bupivacaine (Exparel, Pacira) has been found to be effective for postoperative pain relief following surgical procedures involving incisions of the mid- and lower abdominal wall, according to the results of a study presented at the New York School of Regional Anesthesia (NYSORA) 2013 annual meeting on regional anesthesia, pain management and perioperative medicine. The study found that the drug, a recently approved extended-release form of liposomal bupivacaine, provided pain relief for up to 72 hours after surgery when injected by infiltration of the transversus abdominis plane (TAP), along the fascial planes of the abdomen. Previously, using bupivacaine for TAP infiltration was found to provide pain relief for 12 to 18 hours after surgery involving incisions of the mid- and lower abdominal wall. “The results were confirmatory of what we had expected,” said Eduard Logvinskiy, DO, a pediatric anesthesiologist at Maimonides Medical Center, in New York City, who helped conduct the study. “We just didn’t know how well it was going to work. We thought it wouldn’t last that long—about a day— but it lasted about three days in most of the patients.” Three patients required oral analgesia within the first 12 hours or surgery, and three others reported taking pain medication 24 hours after discharge from the hospital, Dr. Logvinskiy said. For their study, Dr. Logvinskiy and his colleagues selected 13 patients undergoing open umbilical hernia repair under general anesthesia, with an incision length between 3 and 12 cm. Using ultrasound guidance, a

MASS CASUALTY jContinued from page 23

you get to a hospital or to a Level I or II trauma center, you’ve got a good chance of making it through if you are a wounded victim,” he explained. Members of the Hartford Consensus are calling on general surgeons across the country to become involved in this initiative. They stress that it’s “not a ‘big city’ issue” or a problem isolated to places near trauma centers. Mass casualty shootings should concern people in all cities and towns across the country, they said. Dr. Wade emphasized that surgeons can help break down some of the barriers that exist in the emergency medical system in America. The system currently is fragmented, split between multiple agencies and stakeholders. But, he said, surgeons can start to pull those forces together locally, acting as community leaders to coordinate efforts. The Hartford Consensus group wants surgeons to get involved with

bilateral TAP infiltration was performed at the end of surgery, but before the general anesthesia wore off. The patients were first injected with 5 mL of saline to identify the TAP. That was followed by 20 mL of liposomal bupivacaine that had been diluted with 10 mL of sterile saline, for a total injectate volume of 30 mL, 15 mL of which was injected into each patient on either side of the TAP. The patients, who ranged in age from 28 to 65 years, reported their level of pain on a scale of 0 to 10 before the injection and after, at regular intervals up to 120 hours after TAP block. “We also made daily phone calls up to four days post-op as part of their follow-up. The forms were submitted at the time of their surgical follow-up approximately two weeks later, and later were forwarded to our department,” Dr. Logvinskiy said. Although one TAP infiltration failed immediately due to significant pain, the remaining 12 were successful, with mean satisfaction scores of 4.4 at discharge and 4.6 at the follow-up visit. The patients reported an average pain score of 1.6 at 72 hours after the TAP infiltration, with a standard deviation of 1.4. None of the patients reported any serious adverse events or complications as a result of the drug, according to the researchers. “This study demonstrates the excellent efficacy nonopioid analgesics can provide with minimal to no side

developing an integrated response system, customized to the needs of their community. They called for emphasis in two areas: initial actions to control hemorrhage and improved communication across agencies. Dr. Wade suggested surgeons set up meetings with their local chief of police, fire or emergency medical services, as well as city or county government officials to discuss how the Hartford Consensus principles can be enacted locally. He stressed the importance of having a strong local strategy. “It’s finding an individual strategy for a particular locality that will make this a reality.” Michael F. Rotondo, MD, outgoing chair of the ACS committee on trauma and co-moderator of the panel session, offered surgeons six key strategies to ready their hospitals and communities for a mass casualty event. They are: 1. Review the structures and processes you have in place at your hospital to meet this kind of a need. “What standards do you hold in your hospital to be able to respond to an

effects,” said Christopher Gharibo, MD, director of chronic pain management at New York University’s Langone Center for Musculoskeletal Care in New York City. “The benefits here are cleaner, more functionally relevant pain relief that is also more convenient for the patient.” However, Dr. Gharibo, who was not involved in the study, had reservations about the study, noting that it had few patients and lacked a control group. Dr. Logvinskiy and his colleagues acknowledged that their study was not a randomized controlled trial. “We basically wanted to see if this would actually work,” he said. The results further suggest that nerve blocks have the potential to supplant local anesthetics for postsurgical pain relief for operations involving incisions of the abdominal wall between 3 and 12 cm. “As of now, we apply local anesthetic for postoperative analgesia,” Dr. Logvinskiy said. “With nerve blocks we insert catheters next to the bundle of nerves, connected to continuous infusion pumps, where we insert medication. We have the associated costs of filling the pumps, creating the solution, nursing care—which can potentially be eliminated if you’re using a drug like liposome bupivacaine, with a single injection.” Pacira funded the study.

active shooter incident where you may receive a large influx of bleeding patients?” 2. Work with your community to plan how you would respond to these problems as a group. Plan how you can work with your colleagues across town and other hospitals in the region, city and county. 3. Get educated and keep your skills up to date. He recommends surgeons maintain their Advanced Trauma Life Support courses and complete the ACS Committee on Trauma’s Disaster Management and Emergency Preparedness (DMEP) course. The course is designed to teach surgeons the necessary skills for an effective response to mass casualties in disasters. Other valuable courses are the ACS’ Advanced Surgical Skills for Exposure in Trauma and Advanced Trauma Operative Management course. 4. Imagine the unimaginable. “That’s really what we need to do to prepare

for these circumstances.” 5. Have a plan for your hospital. The ACS’ DMEP course includes a section on planning for disasters and mass casualty events. 6. Practice. Follow the lead of Israeli hospitals, which are constantly prepared to accept a sudden surge of casualties. To do so, the Israeli Ministry of Health requires hospitals frequently conduct rigorous, full-scale drills including one annual mass casualty event exercise ( (JAMA A 2009;302:565-567). The Federal Emergency Management Agency (FEMA) recently released a report, “Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents,” which serves as a response guide for fire and emergency medical personnel. In it, FEMA noted that more than 250 people have been killed in the United States in active shooter and mass casualty incidents since the Columbine High School shootings in 1999.

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jContinued from page 1 race and ethnicity, income and education, housing prices and neighborhoods, Wisconsin is the most representative state and Oregon the seventh most representative state for the U.S. population. â&#x20AC;&#x153;It is reasonable to believe that Oregon and Wisconsin demonstrate similar needs for general surgical services as most of the United States,â&#x20AC;? said Dr. Bronson. Investigators examined all publicly listed positions for board-eligible and board-certified general surgeons in Oregon and Wisconsin from 2011 to 2012, after reviewing job positions and contacting hospitals, private practice groups and physician recruiters. Data was gathered to determine if fellowship training or specialized skills were required, preferred or not required. The findings were compared with information on fellowship training of general surgery graduates from one residency program in Oregon and four in Wisconsin. In 2011 and 2012, 71 job openings for general surgeons were advertised in the two states. In both, about one-third of postings stipulated that applicants be fellowship-trained. The jobs that required fellowships were

GENERALS SURGERYNEWS.COM / GENERAL SURGERY NEWS / JANUARY 2014

It is widely believed d that many factors drive ive residents to pursue fellowship training. A perception persists that subspecialization on brings with it a better er quality of life, higher income and more prestige. generally at academic metropolitan centers, where 92% of all job postings mandated fellowship training. In comparison, only 18% of rural positions and 28% of nonacademic metropolitan positions sought fellowship-trained applicants. But these rural and nonacademic metropolitan practices accounted for 80% of all general surgery openings. Rural postings alone represent 46% of all available jobs. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m not surprised by the study. Increasingly, we see that the needs of care in general surgery arenâ&#x20AC;&#x2122;t necessarily met by fellowship training. Today, there are countless opportunities in rural America for general surgeons without the need for additional fellowship training,â&#x20AC;? said

David C. Borggstrom, MD, program director for general surgery s and director of traum ma and surgical critical care, Bassett M Medical Center, Cooperstown, N.Y. It is widely believed that many factors drive residents to pursue fellowship p training. A perception persists that su ubspecialization brings with it a better q quality of life, higher income and more prestige. Moreover, residents have minimal exposure to broad-based general surgeons in their training. Most academic training programs are staffed by fellowshiptrained attendings who mentor residents as they decide their career paths. Finally, and perhaps most importantly, many residents fear they are inadequately trained after five years of residency, â&#x20AC;&#x153;despite the fact that this simply isnâ&#x20AC;&#x2122;t true,â&#x20AC;? Dr. Bronson said. Some programs in the United States are tailoring their general surgery programs to address the needs of the job market and help residents feel prepared for practice when they finish residency. The University of North Dakota offers a committed rural surgery training track. Oregon Health & Science University gives residents the option of spending a year in a rural environment. These programs give residents the

skills they need to be effective general surgeons, said Dr. Borgstrom. â&#x20AC;&#x153;If you look at the results of this study, the kinds of skills employers are looking for, they are things that can be provided in a general surgery residency as long as effort is made to find that experience for the resident.â&#x20AC;? In the study, employers stressed that they wanted broad-based surgeons, often with specialized skills not generally attained in fellowship. They placed high importance on skills in obstetrics and gynecology and endoscopy, although there was some geographic variation. In Wisconsin, 43% of postings sought surgeons trained in obstetrics and gynecology; this need was not noted in Oregon. The discrepancy may reflect regional differences in the medicolegal environment, the authors said. The gulf between the fellowship training of residents and the general surgery job market may have important financial implications, said the authors. Previous research has demonstrated that subspecialists drive up health care costs more than general surgeons. One study showed that a higher general surgeon-to-population ratio correlated with lower Medicare costs, whereas the opposite was true if the ratio favored subspecialists (Ann ( Surg 2012;255:474-477).

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Rationale, Reversal, and Recovery of Neuromuscular Blockade Part 1: Framing the Issues Case Study Harold is a 74-year-old man undergoing a video-assisted right upper lobectomy for stage I non-small cell lung cancer. Current Symptoms • Dyspnea • Coughing with hemoptysis • Chest pain Vital Signs • Height: 177.8 cm (70”) • Weight: 65 kg (143 lb) Signi¿cant Medical History • Hypertension • Chronic obstructive pulmonary disease (moderate) Current Medications • Metoprolol succinate ER 50 mg/d • Tiotropium bromide inhalation powder Laboratory Results • 2-cm lesion in right upper lobe revealed on chest computed tomography (CT) scan; malignancy con¿rmed with needle biopsy • No abnormal bronchopulmonary or mediastinal lymph nodes; brain CT, isotopic bone scan, abdominal ultrasonography negative for distant metastases • Forced expiratory volume in the ¿rst second: 43.6% of predicted value (1.44 L) • Carbon monoxide diffusing capacity: 71.7% of predicted values (20.19 mL/min/mmHg) • Cardiac ultrasonography: normal pulmonary artery pressure (22 mm Hg) At induction, Harold receives propofol 1.5 mg/kg and rocuronium 0.6 mg/kg. During the procedure, movement of the diaphragm interferes with surgery. This activity is jointly sponsored by Global Education Group and Applied Clinical Education. Supported by an educational grant from Merck.

Applied Clinical Education is pleased to introduce a new interactive 3-part CME series featuring challenging cases in neuromuscular blockade. Each activity will present a clinical scenario that you face in your daily practice. After reading the introduction to the case, consider the challenge questions, and then visit www.CMEZone.com/nmb1 to ¿nd out how your answers stack up against those of our multidisciplinary faculty panel. Access the activities on your desktop, laptop, or tablet to explore the issues surrounding safe, effective, neuromuscular blockade and reversal via a unique multimedia learning experience and earn 1.0 AMA PRA Category 1 Credit.™ Participate in the coming months as well to complete the whole series and earn a total of 3.0 AMA PRA Category 1 Credits.™ This activity’s distinguished faculty Jon Gould, MD Glenn S. Murphy, MD Chief, Division of General Surgery Alonzo P. Walker Chair in Surgery Associate Professor of Surgery Medical College of Wisconsin Senior Medical Director of Clinical Affairs Froedtert Hospital Milwaukee, Wisconsin

Clinical Professor, Anesthesiology University of Chicago Pritzker School of Medicine Director Cardiac Anesthesia and Clinical Research NorthShore University HealthSystem Evanston, Illinois

Challenge Questions 1. What would you do next? 2. What potential postoperative risks does this patient face?

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