General Surgery News - February 2021

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

February 2021 • Volume 48 • Number 2

Necessity Prompts Foray Into Virtual ‘Hands-on’ Surgical Courses

Busting Myths About Diverticulitis Management

After In-Person Meeting Is Canceled, SAGES Moves Mentoring Online

By MONICA J. SMITH

S

By VICTORIA STERN

P

edro P. Gomez, MD, FACS, had everything ready to go.

On his enclosed deck, Dr. Gomez had created a mini-OR: surgical tools, a webcam and an iPad laid out precisely across a large wooden table. In the center sat a pig abdomen, modified to mimic a complex hernia.

Dr. Gomez had originally planned to be in a bustling lab surrounded by other general surgeons at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, which was supposed to take place in Cleveland. But the COVID-19 pandemic moved the entire SAGES meeting online, including a hands-on course Continued on page 22

Dr. Pedro Gomez, at home in Bangor, Maine, ready for a virtual hands-on course in complex hernia repair.

Ultrasound for Diagnosing Appendicitis: A Potentially Valuable Adjunct

D

espite more than 280,000 appendectomies being performed in the United States every year, appendicitis remai remains a diagnostic challenge.

Up to 40% of cases do not present in the classic manner and the ne negative appendectomy rate has sstayed the same for decades.

During the American College of Surgeons Clinical Congress 2020, Norma T. Walks, MD, a general surgeon at Yuma

OPINION

Lifelong Financial Planning: A Road Map

What Will Follow the Virtual World of COVID-19 For Medical Practitioners?

P

lanning for retirement is a priority for most physicians, but with hefty student loan debt, home mortgages and car loan payments, about one in five say they are behind schedule. For many, the pandemic has added a new level of uncertainty, as investment and income-related losses mount.

At the 2020 virtual Clinical Congress of the American College of Surgeons, Edward M. Barksdale Jr., MD, FACS, FAAP, described his family’s personal financial journey over the past three decades, offering some perspective and a road map for surgeons.

Continued on page 17

T H E SURGICAL PA U SE

12 The Limits o of Resilience OP IN ION

14 The Complexity of Conspiracy Theories T H E SURGEONS’ LO U N G E

18 Update on the National Accreditation Program for Rectal Cancer facebook.com/generalsurgerynews

Continued on page 8

MONEY MATTERS

By VICTORIA STERN

By CHASE DOYLE

hould patients with uncomplicated diverticulitis be prescribed antibiotics? What is the role of colonoscopy after recovery? Is Hartmann’s procedure the best we can do? Laparoscopic lavage, anyone?

At the 2020 Clinical Congress of the American College of Surgeons, held remotely, surgeons discussed facets of diverticulitis management that remain controversial or problematic.

As the understanding of diverticulitis has evolved, so have recommendations for treatment. “More patients are being treated in outpatient settings, and we’ve seen a concomitant move from open surgeries to laparoscopic and elective procedures,” said Michael Arvanitis, MD, the section chief of colon and rectal surgery at Monmouth Medical Center, in Long Branch, N.J. In a similar less-is-more vein, data suggest that the

@gensurgnews

Continued on page 16

By HENRY BUCHWALD, MD, PhD

A History of Communication Courier: Caveman Mail service: 62 B.C., Rome, Julius Caesar Telegram: 1844, Samuel Morse Telephone: 1876, Alexander Graham Bell Hologram: 1943 science, 1985 entertainment, Dennis Gabor Continued on page 20

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IN THE NEWS

FEBRUARY 2021 / GENERAL SURGERY NEWS

How Surgeons in New York City Stepped Up During COVID-19 Surgical Traits, Skills Played Essential Role in Early Days Of the Pandemic

By KAREN BLUM

W

hen many elective operations were postponed during the surge of the COVID-19 pandemic in the spring of 2020, surgeons at New York-Presbyterian Columbia University Irving Medical Center, in New York City, stepped up to fill in for infected emergency room personnel and perform other tasks to keep the hospital going. Their ability to pivot as part of new teams, act in the face of uncertainty and be comfortable with triage were just some of the traits common among surgeons that made them invaluable players, according to their chief surgeon.

“We may need some surgery during a pandemic, but what we really need is surgeons, because of who they are,” said Craig Smith, MD, the hospital’s surgeon-in-chief, during the Americas Hernia Society 2020 annual meeting. “We are who we are, not what we do.”

Dr. Smith made news headlines for the daily emails he sent to faculty and staff about the pandemic, response and

priorities for leaders, which found a following on Twitter. Many found the writeups, which included mentions of poetry or literature, inspiring. During Dr. Smith’s meeting talk, he discussed surgeons’ core skills that helped during the pandemic.

By the middle of last March, 20% of the hospital’s ER physicians were already out sick, elective operations were shut down and the facility was very close to exhausting its supply of personal protective equipment (PPE). Almost immediately, on March 18, five surgeons volunteered to work on the ER’s front lines, and another four followed suit.

“These are natural team players who instinctively stepped in the gaps to protect the quarterback,” Dr. Smith said.

“For most surgeons, the hospital is our turf, where we spend most of our professional lives. The instinct to defend the hospital runs deep.”

It’s no different from an operating room, where surgeons are accustomed to shifts in responsibility, such as when the anesthesiologist takes charge. At New York-Presbyterian, the surgery department helped repurpose 24 of its 32 ORs to new roles as ICUs in a matter of days, Dr. Smith said. This change allowed three to four patients to be placed in a

Frederick L. Greene, MD Charlotte, NC

Lauren A. Kosinski, MD Chestertown, MD

Editorial Advisory Board

Marina Kurian, MD New York, NY

Maurice Arregui, MD Indianapolis, IN Philip S. Barie, MD, MBA New York, NY L.D. Britt, MD, MPH Norfolk, VA James Forrest Calland, MD Charlottesville, VA David Earle, MD Lowell, MA Sharmila Dissanaike, MD Lubbock, TX Edward Felix, MD Pismo Beach, CA Robert J. Fitzgibbons Jr., MD Omaha, NE Michael Goldfarb, MD Long Branch, NJ Leo A. Gordon, MD Los Angeles, CA

Breadth of Patient Care Skills Most general, vascular and cardiothoracic surgeons are adept at managing the pathophysiology of disease and are accustomed to participating in the care of very sick ICU patients, Dr. Smith said.

Regardless of specialty, surgeons have training and experience with active care such as placing chest tubes and performing tracheostomies.

‘For most surgeons, the hospital is our turf, where we spend most of our professional lives.

The instinct to defend the hospital runs deep.’

—Craig Smith, MD Very early in the New York City COVID-19 surge, general surgery residents organized the surgical workforce activation team (SWAT) to take on supportive activities. They used portable ultrasound machines; stocked “go bags”

MISSION STATEMENT OF GSN It is the mission of General Surgery News to be an independent and reliable source of news and analysis about the current state of surgery. It strives to provide a venue for discussion and opinions, from all viewpoints, on the issues most important to surgeons.

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Gina Adrales, MD, MPH Baltimore, MD

room and enabled using ventilators for more than one patient. The new, 78-bed OR ICU saw the same survival rates as permanent ICUs.

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Raymond J. Lanzafame, MD, MBA Rochester, NY

disclosures from all interviewees and rely on our sources to accurately provide this information, which we believe can be important in evaluating the research discussed in this publication.

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filled with essential supplies; worked 12-hour shifts around the clock on call in the ER and ICUs; and placed IVs, monitoring lines and dialysis catheters in newly diagnosed COVID-19 patients. In the first week, they treated 174 patients, placed 77 arterial lines and 137 central lines, Dr. Smith said. “It doesn’t get much more front line than that.”

Acting in the Face of Uncertainty Part of being action-oriented is learning not to be paralyzed by uncertainty, Dr. Smith said. At the height of the COVID-19 surge last mid-April, a coughing, febrile patient in the ER had only a 60% chance of testing positive for the SARS-CoV-2 virus. While waiting for test results, physicians could not hesitate to treat patients aggressively, presuming they had COVID-19, for fear of harming the 40% who had influenza or other respiratory ailments.

Some people might consider detachment not to be a positive character trait, Dr. Smith said, “but surgeons must be capable of distancing themselves emotionally from their patients at times when unregulated empathy might stand in the way of action.” Surgeons need courage continued on the following page

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GENERAL SURGERY NEWS / FEBRUARY 2021

The Scientific Greats: A Series of Drawings

COVID Surgeons

By MOISES MENENDEZ, MD, FACS

and decision-making skills, he said. During various procedures on COVID-19 patients who were too unstable to be anesthetized, there were critical maneuvers that had to be performed, even if they caused pain in their patients.

Detachment also helps during triage, Dr. Smith said. Historically since World War I, the three categories of triage are people likely to live regardless of treatment, those unlikely to live regardless of treatment, and those more likely to live with immediate treatment. At a time when almost all hospital beds were full and nearly every ventilator was in use, surgeons and other physicians had to weigh the risks versus benefits of treatment for patients. They also had to assess the usefulness versus futility of treatment. These are skills that surgeons are well accustomed to in their decisions whether to operate, he said.

Louis Pasteur (1822-1895) Louis Pasteur was a French chemist and microbiologist renowned for his discoveries of the principles of vaccination, microbial fermentation and pasteurization. He was also a gifted artist, but is most known for proving that microbes cause disease and showing the world how to stop them. His work has led to the salvation of millions.

Pasteur’s work helped reduce the mortality from puerperal fever, and he created the first vaccines for rabies and anthrax. His medical discoveries provided direct support for the so-called germ theory of disease and its application in clinical medicine and surgery. He is best known to the general public for his invention of the technique of treating milk and wine to stop bacterial contamination, a process now called pasteurization.

In 1885, a brief news item appeared in some U.S. papers noting that a French scientist, Luis Pasteur, had successfully treated a patient with an experimental anti-rabies vaccine. At the time, apart from some scientists and scientifically-minded physicians, Pasteur was largely unknown in America. Meanwhile, Joseph Lister, the renowned British surgeon–scientist, learned about some experiments that Louis Pasteur (1822-1895) had been conducted by Pasteur. Lister introduced to the Work was done using charcoal and pencil on a white paper. world the use of the antiseptic method for the prevention of 2012 wound sepsis. Using the ideas of Pasteur regarding the role Artist: Moises Menendez MD, FACS of microorganisms in infections, or the germ theory of disease, he advanced the surgical field by using antiseptics, such as carbolic acid, in the treatment of contaminated wounds.

This was a breakthrough in the treatment of wound infection and also prophylaxis to avoid sepsis. After 1867, it was possible to appropriately treat or prevent wound infections with the use of antiseptics at the site of the operated wound.

Pasteur continued his experiments showing that germs could be destroyed in three ways: by heat, by filtration or by antiseptics. Lister used carbolic acid as an antiseptic agent with excellent results, thanks to Pasteur. Through sterilization, surgery was made safer, and the fatal outcomes suffered by many patients were averted. He established bacteriology and immunology as branches of medicine and biology.

■

Sources: Fitzharris L. The Butchering Art: Joseph Lister’s Quest to Transform the Grisly World of Victorian Medicine. Farrar, Straus and Giroux;2018:1-304.

Gossel PP. Pasteur, Koch and American Bacteriology. Hist Phil Life Sci. 2000;22:81-100.

Cordero-Moreno R. An evocation of Pasteur. Rev Soc Venez Hist. 1992;41(61):101-119.

—Dr. Menendez is a general surgeon and self-taught portrait artist in Magnolia, Arkansas. Since 2012, Dr. Menendez has completed a series of portraits of selected historical figures, in particular well-known physicians and surgeons. These portraits are rendered with charcoal and pencils.

A Surgeon and His Art “At the Pantheon: Piazza della Rotondo,” A Watercolor by Gerald Marks, MD One of the strongest tourist magnets in Rome is the famed Pantheon and its piazza. The piazza, ringed by inviting restaurants boasting exceptional cuisine, helps to attract the crowds and promote a festive air. Those with serious interest may visit the Pantheon where they can explore an architectural wonder known for being the building in longest continuous use, dating to the first century.

Built as a temple and converted to a Roman Catholic church, its dome is the world’s largest nonreinforced concrete dome and its interior is spellbinding. The piazza with its atmosphere is one of my favorites and this painting of the piazza is my fourth. This depicts the far side beyond the Pantheon, and now all sides have been covered.

continued from the previous page

Realistic Attitude Toward Mitigation Most people know the big three actions to reduce the risk for contracting or spreading COVID-19 are to wear a mask and to practice good hand hygiene and social distancing. Surface cleaning, quarantining and contact tracing are valid but less important, according to Dr. Smith. Surgeons spend their professional lives dealing with masks, PPE and hand hygiene, navigating a crowded OR without touching anything, and addressing a breach in sterility and moving on with the case. This familiarity helps in a pandemic by making surgeons realistic about mitigation.

“We know we do the best we can to eliminate infection but despite our best efforts, infections still occur,” Dr. Smith said. “When they do, we study them and analyze each case looking for ways to reduce the risk of infection further. We know it’s not perfect, but lack of perfection can’t stand in the way of doing the job.”

Surgeons excel in assessing risk, Dr. Smith said. Medical personnel who show their confidence in mitigation “raise everyone’s confidence, and help everyone else deal with the immutability of risk. We model the truth so that you observe the recommended precautions, probably won’t get infected even when exposed, and you can do your job.”

Dr. Smith’s talk was “transformative and inspiring,” commented Benjamin Poulose, MD, a professor of general and gastrointestinal surgery at The Ohio State University College of Medicine, in Columbus.

“It’s one of those situations where no one thinks it could actually happen to that degree,” Dr. Poulose said. “It was transformational in that it wakes us up regarding how we would handle what they experienced in New York City, and it’s inspiring because of the leadership he demonstrated using a team that was ready, willing and able to follow his lead.

“We never know when the next crisis is going to hit,” Dr. Poulose added. “We just have to do the best we can in the situation we’re handed, and it really relies on people like him and also surgeons who are willing to step up to the plate ■ in very difficult circumstances.”

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IN THE NEWS

GENERAL SURGERY NEWS / FEBRUARY 2021

Busting Myths About Diverticulitis Management continued from page 1

use of antibiotics in healthy patients with uncomplicated diverticulitis should no longer be the standard of care.

In the AVOD trial, initially published in 2012 with an update in 2019, among the 623 patients randomly assigned to antibiotic therapy or no antibiotic therapy, there was no difference in complications, recurrence or time to recovery, Dr. Arvanitis said (Br J Surg 2019;106[11]:1542-1548).

The most recent randomized controlled trial (RCT), which randomized 528 patients with a firsttime episode of sigmoid diverticulitis to a 10-day course of antibiotics or observation, had essentially the same findings at 24 months (Am J Gastroenterol 2018;113[7]:1045-1052).

“A Cochrane review also found no difference with or without antibiotics, and other meta-analyses also support this approach,” Dr. Arvanitis said.

Despite Level I evidence and surgical society consensus statements recommending against antibiotic use, this reversal has not been met with wide acceptance.

“This is the area where we’ve made the most progress with several well-designed, Level I RCTs and universal agreement among the three societies, but based on our consensus conference, the public does not agree with that recommendation,” said Patricia Sylla, MD, an associate professor of surgery at Icahn School of Medicine at Mount Sinai, in New York City, referencing a survey of members of the Society of American Gastrointestinal and Endoscopic Surgeons who showed while a majority agreed with the evidence, few agreed to change practice (Surg Endosc 2019;33[9]:2726-2741).

“But consensus among the societies regarding colonoscopy is a bit more nebulous,” Dr. Sylla said.

‘Patients with imaging findings such as “shouldering,” obstruction and retroperitoneal lymphadenopathy, symptoms ly such suc as bleeding, or atypical recovery should undergo evalrec uation uat with colonoscopy if not rrecently done.’

—Michael Arvanitis, MD Colonoscopy is generally recommended six weeks after resolution of diverticular symptoms, “but this is a strong recommendation based on low-quality evidence,” Dr. Arvanitis said.

A 2014 meta-analysis showed the risk for malignancy in patients with complicated diverticulitis was 11%, but only 0.7% in those with uncomplicated diverticulitis, suggesting colonoscopy may not be needed by everyone (Ann Surg 2014;259[2]:263-272).

“But patients with imaging findings such as ‘shouldering,’ obstruction and retroperitoneal lymphadenopathy, symptoms such as bleeding, or atypical recovery should undergo evaluation with colonoscopy if not recently done,” Dr. Arvanitis said.

Alternative to Hartmann’s Procedure The most common operation for acute diverticulitis, Hartmann’s procedure (HP), includes resection of the perforated segment of the sigmoid colon, creation of an end colostomy and oversewing of the distal stump.

Originally described in the early 1900s as a surgical treatment for obstructive colorectal cancer, HP gained ground as a diverticulitis surgery in the early 2000s when an RCT demonstrated its superiority over the three-stage approach in terms of morbidity, reoperations and length of stay (Br J Surg 2000;87[10]:1366-1374).

‘I do believe that [laparoscopic lavage] is a useful adjunct for all surgeons who take call and see these types of patients, as it can often be done with only three 5-mm ports and does not burn any bridges if additional intervention is needed.’

—Daniel A. Popowich, MD “So why would we ask about alternatives to HP?” said Dana Hayden, MD, an associate professor of surgery at Rush Medical College, in Chicago.

For starters, there are significant complications associated with HP: a wound infection rate of up to 30%, anastomotic leaks after stoma reversal, and the fact that nearly half of patients may never have their colostomy reversed.

“The other reason to seek an alternative is because I really hate the reversals; they’re always tough,” Dr. Hayden said. “So, let’s find something different to do.”

From the early 2000s to more recent studies, comparisons of HP with primary resection anastomosis (PRA) have found more or less equivocal results; a 2012 RCT found no difference in re-interventions or mortality, and a 2013 meta-analysis found lower mortality associated with PRA in patients with Hinchey stage III or IV disease (Colorectal Dis 2012;14[11]:1403-1410; Int J Colorectal Dis 2013;28[4]:447-457).

Dr. Hayden said HP may be the safest operation in patients who are severely ill with increased morbidity; but in healthier patients, she performs PRA whenever possible. “If the patient is stable, there is not a large amount of uncontrolled puss or stool spillage, and if the proximal colon and rectal tissues appear healthy, I would strongly consider primary resection anastomosis.”

Dr. Sylla advises trying to avoid diversion in PRA. “But if you really have to divert, at least do an ileostomy. Just don’t do an HP. It’s not controversial; across the board, the consensus is that HP is an incredibly morbid procedure.”

But considering that a 2015 review of more than 13,000 patients who underwent surgery for acute diverticulitis found that nearly 84% underwent an HP, acceptance of PRA lags behind the data (Am J Surg 2015;210[5]:838-845).

“We know surgeons in the United States are not quite adopting primary resection anastomosis as much as we think, but at least we’re in agreement that it’s a better operation,” Dr. Sylla said.

Laparoscopic Lavage Complicated diverticulitis—Hinchey stage II, III and IV disease—happens more and more frequently, and despite the difficulty of the technique and the morbidity associated with it, HP is still the go-to procedure for these patients, said Daniel A. Popowich, MD, the

chief of colon and rectal surgery at St. Francis Hospital, in Roslyn, N.Y. “That’s largely because it’s definitive management of the disease and allows the surgeon to sleep at night. But I feel that laparoscopic lavage has a role for all-comers: young, old, immunocompetent and immunocompromised, but also for Hinchey II patients when interventional radiology drainage is not possible because of lack of a window.”

Although there is no full consensus on laparoscopic lavage, it has gained some popularity in recent years, Dr. Sylla said.

“Laparoscopic lavage used to be considered a no-no, but that’s gone full circle after a series of RCTs showed that though it is associated with a higher risk of complications in the early postoperative period, it’s safe in the long run.”

Dr. Popowich acknowledged that much of the current data on laparoscopic lavage, dating from the 1990s, are negative, and that much of the positive data are not reproducible. But a recent comparison of quality of life (QOL) and stoma rate in Hinchey stage III patients undergoing HP, laparoscopic lavage and PRA found the stoma rate to be 40%, 14% and 17% after the three procedures, respectively (Dis Colon Rectum 2020;63[8]:1108-1117).

“They concluded that when you consider both the surgical risks and QOL, laparoscopic lavage and PRA provide greater quality per adjusted life-years in patients

‘If the patient is stable, there is not a large amount of uncontrolled puss or stool sp spillage, and if the proximal c colon and rectal tissues appear healthy, I would strongly consider primary resection anastomosis.’

—Dana Hayden, MD with Hinchey III diverticulitis,” he said.

In his 10 years of experience with laparoscopic lavage, 22 of the 36 patients selected for the procedure were successful after initial lavage, and 18 presented later for elective minimally invasive resection. Six patients had to be converted to HP during the index operation, largely due to an uncontrollable hole in the colon. Eight patients had ongoing sepsis or fistulas to drain; four of these patients underwent successful minimally invasive PRA, and four went for attempted minimally invasive PRA but were converted to HP. “In total, 72% of these patients avoided a stoma after index treatment, with 17% requiring conversion to a HP after the first operation,” Dr. Popowich said. All of the patients who underwent HP were subsequently reversed within six to 12 months.

Dr. Hayden is not a proponent of laparoscopic lavage.

“The literature has been equivocal, but if a patient is sick enough to take to the OR, I’m uncomfortable leaving the source of sepsis in the patient’s abdomen,” she said.

Dr. Popowich noted that laparoscopic lavage is not for all patients or surgeons. “It requires patient selection and counseling by the surgeon.

“I do believe, however, that it’s a useful adjunct for all surgeons who take call and see these types of patients, as it can often be done with only three 5-mm ports and does not burn any bridges if additional intervention is ■ needed.”

LETTER TO THE EDITOR

FEBRUARY 2021 / GENERAL SURGERY NEWS

The Future of Resident Interviews To the Editor: [Re: “2021: Managing Expectations,”

by Frederick Greene, MD, January 2021] I would only disagree about one prediction in Dr. Greene’s article. I will bet money that we will continue resident interviews by video conferencing rather than in person for the following reasons: 1) They are cheaper and less time-consuming for the residents; 2) they are cheaper and less time-consuming for the programs; and 3) all hospitals and ORs look about the same and the interviewees only care that they get a good education.

Traveling all over the place for interviews is a waste of time, money and effort. Interviewees don’t spend enough time in the town to really get to know it (excluding away rotations that are currently COVID-19 prohibited). So, flying one afternoon, eating a meal with the residents, spending the night, interviewing, and then flying to the next place that afternoon is a pain for everyone.

With video conferencing, interviewees get to meet the residents in the morning before the interviews. I had my doubts about the process until we actually did it.

I had prepared by reviewing each candidate’s transcript (a waste of time—they are all some form of pass/fail now anyway), their personal statements (they all sound the same—“I wanted to be a surgeon ever since [insert: mother, father, brother, sister, grandmother, etc.] had a surgical procedure to treat [insert: cancer, appendicitis, traumatic injury, etc.], and I saw how one operation could make such a difference”), looked at their class rank (this can be useful), read their letters of recommendation (sometimes revealing, sometimes not so much), looked at their Step 1 and Step 2 scores (probably the most important, but unfortunately Step 1 is moving to a pass/fail format), and looked at their awards and publications.

All of this was done before their 12-minute interview via Zoom with me, during which I could tell whether or not they were geeks, psychopaths and had a sense of humor (very important). The only thing I could not determine was whether they were short or tall. Thus, no need for in-person interview. Since we cannot give them a Minnesota Multiphasic Personality Test, the 12-minute interview, with an additional threee minutes to write down impressions, will need to do the trick.

One of the interviewees in our last batch was wearing pajama bottoms under a nice blouse and jacket. That was a no-no that probably wouldn’t have happened with an in-person interview. Maybe I should wear pj’s for the next batch.

Harold I. Friedman MD, PhD, FACS Columbia, SC

Medical Licensing Exam Goes Pass/Fail To the Editor: I read with great interest Dr. Frederick Greene’s recent editorial, “Just OK Is Not OK” [November 2020], and appreciate his bringing this important information to the attention of the readership. I share his concern regarding the decision to change the United States Medical Licensing Examination Step 1 from the traditional three-digit scoring system to a pass/fail format. Although I have never participated in residency selection, I can think of no greater responsibility than identifying those best equipped for success in both surgical training and practice.

Certainly, objective performance benchmarks remain critical to the integrity of this process. That is not to decry the

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value of subjective material; I am simply stating that all available information helps generate sound decisions. Dr. Greene’s thoughts on this matter are further supported by two excellent “Viewpoint” articles in JAMA Surgery, one by Dr. Danielle Walsh (JAMA Surg 2020;155[12]:1094-1096), and one by Drs. Faisal Aziz and Carlos Bechara (JAMA Surg 2020;155[12]:1098-1099).

As surgeons, we must remain vigilant in identifying and proactively addressing those decisions by medical examination and licensing boards that potentially undermine our mission of “Inspiring Quality: Highest Standards, Better Outcomes.”

Patrick A. Cleary, MD, PhD Coldwater, Mich.

HAVE RECEIVED

EXPAREL SINCE 20121

BUILT TO WEATHER POSTSURGICAL PAIN Non-opioid EXPAREL, powered by DepoFoam® technology, delivers precise pain control for the critical first few days after surgery to enable enhanced recovery.

In laparoscopic colorectal surgery, ERAS and multimodal protocols with EXPAREL improved clinical and economic outcomes2: FEWER OPIOIDS % over 3 days*†

65

(overall opioid consumption)

Significantly better PAIN CONTROL

1 DAY SHORTER LOS

In the PACU‡ (P=0.001)

2.96 days vs 3.93 days (P=0.003)

Learn more at: www.EXPAREL.com ERAS=enhanced recovery after surgery; PACU=post-anesthesia care unit; LOS=length of stay. *The clinical benefit of the decrease in opioid consumption was not demonstrated in pivotal trials. † A retrospective observational study of 140 patients who underwent laparoscopic colon surgery, comparing local infiltration with EXPAREL 266 mg/20 mL expanded with 20 mL normal saline and 20 mL of 0.25% bupivacaine HCl to a historical matched control group for postsurgical pain, opioid use, and length of stay. Opioid utilization was measured using the World Health Organization’s defined daily dose (DDD), converting each opioid used into the respective DDD (intravenous fentanyl [1 DDD = 100 mcg], intravenous dilaudid [1 DDD = 2 mg], oral dilaudid [1 DDD = 4 mg], oral oxycodone [1 DDD = 20 mg], and hydrocodone [1 DDD = 10 mg]). ‡ Pain was measured using a visual analog scale (0 to 10).

Indication EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information EXPAREL is contraindicated in obstetrical paracervical block anesthesia. Adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation. If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine. EXPAREL is not recommended to be used in the following patient population: patients <18 years old and/or pregnant patients. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL. EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use. The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression. Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability which may lead to dysrhythmias, sometimes leading to death. Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients. Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use. Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to brief summary of Prescribing Information on adjacent page.

For more information, please visit www.EXPAREL.com or call 1-855-793-9727.

References: 1. Data on File. 6306. Parsippany, NJ: Pacira BioSciences, Inc.; July 2020. 2. Keller DS, Pedraza R, Tahilramani RN, Flores-Gonzalez JR, Ibarra S. Impact of long-acting local anesthesia on clinical and financial outcomes in laparoscopic colorectal surgery. Am J Surg. 2017;214(1):53-58.

Scan the QR code to see how EXPAREL improves postsurgical outcomes

Warnings and Precautions for Bupivacaine-Containing Products Central Nervous System (CNS) Reactions: There have been reports of adverse ©2020 Pacira BioSciences, Inc. Parsippany, NJ 07054 PP-EX-US-6100 10/20

B I O S C I E N C E S ,

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LETTER TO THE EDITOR

GENERAL SURGERY NEWS / FEBRUARY 2021

Surgical Errors To the Editor: I read with complete dismay the article written by Dr. Bruce Ramshaw in the October 2020 issue [“My Worst Surgical Error,” page 25].

Although Dr. Ramshaw and I practice different aspects of surgery (I am a pediatric surgeon), I feel that my position as a surgeon, health care provider and, most importantly, as an individual who expects better than the care provided by Dr. Ramshaw, allows me to voice my opinion and strong concerns.

Brief Summary (For full prescribing information refer to package insert) INDICATIONS AND USAGE EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia.

Limitation of Use: Safety and efficacy has not been established in other nerve blocks.

CONTRAINDICATIONS EXPAREL is contraindicated in obstetrical paracervical block anesthesia. While EXPAREL has not been tested with this technique, the use of bupivacaine HCl with this technique has resulted in fetal bradycardia and death.

WARNINGS AND PRECAUTIONS Warnings and Precautions Specific for EXPAREL As there is a potential risk of severe life-threatening adverse effects associated with the administration of bupivacaine, EXPAREL should be administered in a setting where trained personnel and equipment are available to promptly treat patients who show evidence of neurological or cardiac toxicity.

Caution should be taken to avoid accidental intravascular injection of EXPAREL. Convulsions and cardiac arrest have occurred following accidental intravascular injection of bupivacaine and other amide-containing products.

Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL. EXPAREL has not been evaluated for the following uses and, therefore, is not recommended for these types of analgesia or routes of administration.

• epidural • intrathecal • regional nerve blocks other than interscalene brachial plexus nerve block • intravascular or intra-articular use EXPAREL has not been evaluated for use in the following patient population and, therefore, it is not recommended for administration to these groups.

• patients younger than 18 years old • pregnant patients The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days as seen in clinical trials.

ADVERSE REACTIONS Clinical Trial Experience Adverse Reactions Reported in Local Infiltration Clinical Studies The safety of EXPAREL was evaluated in 10 randomized, double-blind, local administration into the surgical site clinical studies involving 823 patients undergoing various surgical procedures. Patients were administered a dose ranging from 66 to 532 mg of EXPAREL. In these studies, the most common adverse reactions (incidence greater than or equal to 10%) following EXPAREL administration were nausea, constipation, and vomiting. The common adverse reactions (incidence greater than or equal to 2% to less than 10%) following EXPAREL administration were pyrexia, dizziness, edema peripheral, anemia, hypotension, pruritus, tachycardia, headache, insomnia, anemia postoperative, muscle spasms, hemorrhagic anemia, back pain, somnolence, and procedural pain.

Adverse Reactions Reported in Nerve Block Clinical Studies The safety of EXPAREL was evaluated in four randomized, double-blind, placebocontrolled nerve block clinical studies involving 469 patients undergoing various surgical procedures. Patients were administered a dose of either 133 or 266 mg of EXPAREL. In these studies, the most common adverse reactions (incidence greater than or equal to 10%) following EXPAREL administration were nausea, pyrexia, and constipation.

The common adverse reactions (incidence greater than or equal to 2% to less than 10%) following EXPAREL administration as a nerve block were muscle twitching, dysgeusia, urinary retention, fatigue, headache, confusional state, hypotension, hypertension, hypoesthesia oral, pruritus generalized, hyperhidrosis, tachycardia, sinus tachycardia, anxiety, fall, body temperature increased, edema peripheral, sensory loss, hepatic enzyme increased, hiccups, hypoxia, post-procedural hematoma.

Postmarketing Experience These adverse reactions are consistent with those observed in clinical studies and most commonly involve the following system organ classes (SOCs): Injury, Poisoning, and Procedural Complications (e.g., drug-drug interaction, procedural pain), Nervous System Disorders (e.g., palsy, seizure), General Disorders And Administration Site Conditions (e.g., lack of efficacy, pain), Skin and Subcutaneous Tissue Disorders (e.g., erythema, rash), and Cardiac Disorders (e.g., bradycardia, cardiac arrest).

DRUG INTERACTIONS The toxic effects of local anesthetics are additive and their co-administration should be used with caution including monitoring for neurologic and cardiovascular effects related to local anesthetic systemic toxicity. Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL. Patients who are administered local anesthetics may be at increased risk of developing methemoglobinemia when concurrently exposed to the following drugs, which could include other local anesthetics: Examples of Drugs Associated with Methemoglobinemia: Class Examples Nitrates/Nitrites nitric oxide, nitroglycerin, nitroprusside, nitrous oxide Local anesthetics articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, tetracaine Antineoplastic cyclophosphamide, flutamide, hydroxyurea, ifosfamide, agents rasburicase Antibiotics dapsone, nitrofurantoin, para-aminosalicylic acid, sulfonamides Antimalarials chloroquine, primaquine Anticonvulsants Phenobarbital, phenytoin, sodium valproate Other drugs acetaminophen, metoclopramide, quinine, sulfasalazine Bupivacaine Bupivacaine HCl administered together with EXPAREL may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. Therefore, bupivacaine HCl and EXPAREL may be administered simultaneously in the same syringe, and bupivacaine HCl may be injected immediately before EXPAREL as long as the ratio of the milligram dose of bupivacaine HCl solution to EXPAREL does not exceed 1:2.

Non-bupivacaine Local Anesthetics EXPAREL should not be admixed with local anesthetics other than bupivacaine.

Nonbupivacaine 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. There are no data to support administration of other local anesthetics prior to administration of EXPAREL.

Dr. Ramshaw believes that the hospital dictated the manner of care that he provided to his patients. When a physician makes a contract with a patient to provide care and surgery, they do not do so with the idea that they will be present only for the “critical” part of the procedure. What exactly is the critical part of a procedure? Is the critical part not dependent on the ability of the resident, fellow or

Other than bupivacaine as noted above, EXPAREL should not be admixed with other drugs prior to administration.

Water and Hypotonic Agents Do not dilute EXPAREL with water or other hypotonic agents, as it will result in disruption of the liposomal particles USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary There are no studies conducted with EXPAREL in pregnant women. In animal reproduction studies, embryo-fetal deaths were observed with subcutaneous administration of bupivacaine to rabbits during organogenesis at a dose equivalent to 1.6 times the maximum recommended human dose (MRHD) of 266 mg. Subcutaneous administration of bupivacaine to rats from implantation through weaning produced decreased pup survival at a dose equivalent to 1.5 times the MRHD [see Data]. Based on animal data, advise pregnant women of the potential risks to a fetus.

The background risk of major birth defects and miscarriage for the indicated population is unknown. However, the background risk in the U.S. general population of major birth defects is 2-4% and of miscarriage is 15-20% of clinically recognized pregnancies.

Clinical Considerations Labor or Delivery Bupivacaine is contraindicated for obstetrical paracervical block anesthesia.

While EXPAREL has not been studied with this technique, the use of bupivacaine for obstetrical paracervical block anesthesia has resulted in fetal bradycardia and death.

Bupivacaine can rapidly cross the placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity. The incidence and degree of toxicity depend upon the procedure performed, the type, and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus, and neonate involve alterations of the central nervous system, peripheral vascular tone, and cardiac function.

Data Animal Data Bupivacaine hydrochloride was administered subcutaneously to rats and rabbits during the period of organogenesis (implantation to closure of the hard plate).

Rat doses were 4.4, 13.3, and 40 mg/kg/day (equivalent to 0.2, 0.5 and 1.5 times the MRHD, respectively, based on the BSA comparisons and a 60 kg human weight) and rabbit doses were 1.3, 5.8, and 22.2 mg/kg/day (equivalent to 0.1, 0.4 and 1.6 times the MRHD, respectively, based on the BSA comparisons and a 60 kg human weight). No embryo-fetal effects were observed in rats at the doses tested with the high dose causing increased maternal lethality. An increase in embryo-fetal deaths was observed in rabbits at the high dose in the absence of maternal toxicity.

Decreased pup survival was noted at 1.5 times the MRHD in a rat pre- and post-natal development study when pregnant animals were administered subcutaneous doses of 4.4, 13.3, and 40 mg/kg/day buprenorphine hydrochloride (equivalent to 0.2, 0.5 and 1.5 times the MRHD, respectively, based on the BSA comparisons and a 60 kg human weight) from implantation through weaning (during pregnancy and lactation).

Lactation Risk Summary Limited published literature reports that bupivacaine and its metabolite, pipecoloxylidide, are present in human milk at low levels. There is no available information on effects of the drug in the breastfed infant or effects of the drug on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for EXPAREL and any potential adverse effects on the breastfed infant from EXPAREL or from the underlying maternal condition.

Pediatric Use Safety and effectiveness in pediatric patients have not been established.

Geriatric Use Of the total number of patients in the EXPAREL local infiltration clinical studies (N=823), 171 patients were greater than or equal to 65 years of age and 47 patients were greater than or equal to 75 years of age. Of the total number of patients in the EXPAREL nerve block clinical studies (N=531), 241 patients were greater than or equal to 65 years of age and 60 patients were greater than or equal to 75 years of age. No overall differences in safety or effectiveness were observed between these patients and younger patients. Clinical experience with EXPAREL has not identified differences in efficacy or safety between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Hepatic Impairment Amide-type local anesthetics, such as bupivacaine, are metabolized by the liver.

Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations, and potentially local anesthetic systemic toxicity. Therefore, consider increased monitoring for local anesthetic systemic toxicity in subjects with moderate to severe hepatic disease.

Renal Impairment Bupivacaine is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. This should be considered when performing dose selection of EXPAREL. OVERDOSAGE Clinical Presentation Acute emergencies from local anesthetics are generally related to high plasma concentrations encountered during therapeutic use of local anesthetics or to unintended intravascular injection of local anesthetic solution.

Signs and symptoms of overdose include CNS symptoms (perioral paresthesia, dizziness, dysarthria, confusion, mental obtundation, sensory and visual disturbances and eventually convulsions) and cardiovascular effects (that range from hypertension and tachycardia to myocardial depression, hypotension, bradycardia and asystole).

Plasma levels of bupivacaine associated with toxicity can vary. Although concentrations of 2,500 to 4,000 ng/mL have been reported to elicit early subjective CNS symptoms of bupivacaine toxicity, symptoms of toxicity have been reported at levels as low as 800 ng/mL. Management of Local Anesthetic Overdose At the first sign of change, oxygen should be administered.

The first step in the management of convulsions, as well as underventilation or apnea, consists of immediate attention to the maintenance of a patent airway and assisted or controlled ventilation with oxygen and a delivery system capable of permitting immediate positive airway pressure by mask. Immediately after the institution of these ventilatory measures, the adequacy of the circulation should be evaluated, keeping in mind that drugs used to treat convulsions sometimes depress the circulation when administered intravenously. Should convulsions persist despite adequate respiratory support, and if the status of the circulation permits, small increments of an ultra-short acting barbiturate (such as thiopental or thiamylal) or a benzodiazepine (such as diazepam) may be administered intravenously. The clinician should be familiar, prior to the use of anesthetics, with these anticonvulsant drugs. Supportive treatment of

circulatory depression may require administration of intravenous fluids and, when appropriate, a vasopressor dictated by the clinical situation (such as ephedrine to enhance myocardial contractile force).

If not treated immediately, both convulsions and cardiovascular depression can result in hypoxia, acidosis, bradycardia, arrhythmias and cardiac arrest. If cardiac arrest should occur, standard cardiopulmonary resuscitative measures should be instituted.

Endotracheal intubation, employing drugs and techniques familiar to the clinician, maybe indicated, after initial administration of oxygen by mask, if difficulty is encountered in the maintenance of a patent airway or if prolonged ventilatory support (assisted or controlled) is indicated.

DOSAGE AND ADMINISTRATION Important Dosage and Administration Information • EXPAREL is intended for single-dose administration only.

• Different formulations of bupivacaine are not bioequivalent even if the milligram strength is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL. • DO NOT dilute EXPAREL with water for injection or other hypotonic agents, as it will result in disruption of the liposomal particles.

• Use suspensions of EXPAREL diluted with preservative-free normal (0.9%) saline for injection or lactated Ringer’s solution within 4 hours of preparation in a syringe.

• Do not administer EXPAREL if it is suspected that the vial has been frozen or exposed to high temperature (greater than 40°C or 104°F) for an extended period.

• Inspect EXPAREL visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not administer EXPAREL if the product is discolored.

Recommended Dosing in Adults Local Analgesia via Infiltration The recommended dose of EXPAREL for local infiltration in adults is up to a maximum dose of 266mg (20 mL), and is based on the following factors: • Size of the surgical site • Volume required to cover the area • Individual patient factors that may impact the safety of an amide local anesthetic As general guidance in selecting the proper dosing, two examples of infiltration dosing are provided: • In patients undergoing bunionectomy, a total of 106 mg (8 mL) of EXPAREL was administered with 7 mL infiltrated into the tissues surrounding the osteotomy, and 1 mL infiltrated into the subcutaneous tissue.

• In patients undergoing hemorrhoidectomy, a total of 266 mg (20 mL) of EXPAREL was diluted with 10 mL of saline, for a total of 30 mL, divided into six 5 mL aliquots, injected by visualizing the anal sphincter as a clock face and slowly infiltrating one aliquot to each of the even numbers to produce a field block.

Regional Analgesia via Interscalene Brachial Plexus Nerve Block The recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults is 133 mg (10 mL), and is based upon one study of patients undergoing either total shoulder arthroplasty or rotator cuff repair.

Compatibility Considerations Admixing EXPAREL with drugs other than bupivacaine HCl prior to administration is not recommended.

• 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.

• Bupivacaine HCl administered together with EXPAREL may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. Therefore, bupivacaine HCl and EXPAREL may be administered simultaneously in the same syringe, and bupivacaine HCl may be injected immediately before EXPAREL as long as the ratio of the milligram dose of bupivacaine HCl solution to EXPAREL does not exceed 1:2.

The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to local anesthetic systemic toxicity.

• When a topical antiseptic such as povidone iodine (e.g., Betadine®) is applied, the site should be allowed to dry before EXPAREL is administered into the surgical site. EXPAREL should not be allowed to come into contact with antiseptics such as povidone iodine in solution.

Studies conducted with EXPAREL demonstrated that the most common implantable materials (polypropylene, PTFE, silicone, stainless steel, and titanium) are not affected by the presence of EXPAREL any more than they are by saline. None of the materials studied had an adverse effect on EXPAREL. Non-Interchangeability with Other Formulations of Bupivacaine Different formulations of bupivacaine are not bioequivalent even if the milligram dosage is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL and vice versa.

Liposomal encapsulation or incorporation in a lipid complex can substantially affect a drug’s functional properties relative to those of the unencapsulated or nonlipid-associated drug. In addition, different liposomal or lipid-complexed products with a common active ingredient may vary from one another in the chemical composition and physical form of the lipid component. Such differences may affect functional properties of these drug products. Do not substitute.

CLINICAL PHARMACOLOGY Pharmacokinetics Administration of EXPAREL results in significant systemic plasma levels of bupivacaine which can persist for 96 hours after local infiltration and 120 hours after interscalene brachial plexus nerve block. In general, peripheral nerve blocks have shown systemic plasma levels of bupivacaine for extended duration when compared to local infiltration. Systemic plasma levels of bupivacaine following administration of EXPAREL are not correlated with local efficacy.

PATIENT COUNSELING Inform patients that use of local anesthetics may cause methemoglobinemia, a serious condition that must be treated promptly. Advise patients or caregivers to seek immediate medical attention if they or someone in their care experience the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath; lightheadedness; or fatigue.

Pacira Pharmaceuticals, Inc. San Diego, CA 92121 USA Patent Numbers: 6,132,766 5,891,467 5,766,627 8,182,835 Trademark of Pacira Pharmaceuticals, Inc. For additional information call 1-855-RX-EXPAREL (1-855-793-9727) Rx only November 2018

surgeon? I doubt that Dr. Ramshaw conveyed to his patients, before their surgical procedures, that he would not be present for the entirety of the operation.

At the hospitals where t I practiced—and in speaking i with my surgical peers— I was required to dictate at the th end of the procedure that I was present for the entire procedure. pr Dr. Ramshaw’s assertion that this practice was the result of a volume-based system of practice is complete and utter fabrication. Whatever he did, he did under his own volition. No one can make a surgeon be anywhere other than where he or she needs to be—at the patient’s side.

I have to believe that there was a strong financial incentive—hopefully not selfimposed—placed upon Dr. Ramshaw.

The placement of blame on anything and everything other than the assumption of accountability and responsibility saddens me and goes against everything that a surgeon should stand for and offer to their patients.

In his article, Dr. Ramshaw blames the volume-based system, the multiple comorbidities of his patient, his own unhealthy lifestyle, his long hours and surgical anomalies, all the time failing to place blame on his choice to practice medicine in the fashion that he chose.

His decisions to practice surgery the way that he did and to assume the lifestyle that he did were his and no one else’s. I cannot imagine that any hospital administrator specifically dictated the number of cases he needed to do, or the number of ORs he needed to be involved in at a single instance. Any of these directives, if dictated by the hospital, would be completely inappropriate.

I am not prone to voicing my opinion in a public forum in this manner, but the actions of Dr. Ramshaw, the outcome of his patient and his failure to accept appropriate responsibility both anger and sadden me. What does he teach his residents and fellows when he is present for a case at only the critical point, and when he is late for cases because he is in other ORs involved in another case?

I fear he is helping create future surgeons who believe that this behavior is appropriate.

Dr. Ramshaw, I am certain you are a well-trained surgeon, but in this situation, shame on you. On a basic level, the way you practice medicine violated the basic tenets of the Hippocratic oath: “Do no harm to the patient.”

Steven B. Palder, CSM, MD Washington, D.C.

LETTER TO THE EDITOR

FEBRUARY 2021 / GENERAL SURGERY NEWS

No Stone Left Behind To the Editor: I read with interest the “Great Debates” article in the December 2020 issue regarding bile duct injury (BDI) resulting from laparoscopic cholecystectomy (LC).

According to recent reports, the incidence of BDI remains a significant problem (Ann Surg 2020;272[1]:3-23 and Ann Surg 2020;272[1]:2). Dr. Brunt, in this debate, delineated in great detail the work of his group in organizing and teaching training sessions to improve the present results.

What are the reasons for these significant complications resulting from LC? Three decades ago, the promulgation of LC resulted from patient demand—the promise of less pain, shorter hospitalization and faster return to work. The number of surgeons trained in the principles of laparoscopy at that time was extremely small. Societies, particularly the Society of American Gastrointestinal and Endoscopic Surgeons, arranged courses on the weekends. As a result, surgeons with limited training were providing service to patients. There were no plans or systems created to generate data or record outcomes. More recently, LC has been performed in outpatient surgical centers and acute cases are being managed by acute care surgeons. After three decades, we would have benefited from a well-organized, controlled study with data in order to decrease mortality, morbidity and the cost of this very common disease. There is also no question that any intraoperative diagnostic aid delineating biliary anatomy would have been found beneficial.

Intraoperative cholangiography (IOC) is well known to me and my colleagues.

I published a monograph with J. Andrew Hamlin, a radiologist, in 1981, which also highlighted the role of IOC in reducing the incidence of retained common duct stones. We also realized the value of using the choledochoscope in removing common bile duct (CBD) stones and introduced the video choledochoscope to locate and facilitate stone removal. Between 2014 and 2020, my colleagues at CedarsSinai Medical Center performed LC using IOC and the video choledochoscope in 663 cases to facilitate removal of 60 CBD stones during the same session.

There were no BDIs during this period.

In my opinion, IOC should be performed routinely. Appropriate training, especially in our academic surgical residency programs, is essential. Outside of residency training, organized tutorial sessions (including proper cystic duct approaches) and instruction on the interpretation of IOC radiographs are essential. Proper records are crucial, especially for the coding of IOC use in residency training. Attendings in surgical training programs must be dedicated to the use of IOC and the training of their residents in

this technique. Once mastered, the operative time is extended by approximately 15 minutes. Every OR has a mobile image amplifier for orthopedic procedures. The success of IOC depends on commitment to education and training.

In addition, with the philosophy of avoiding IOC in lieu of alternative anatomic road maps (e.g., fluorescent cholangiography), how do we identify the 10% of patients (70,000 plus) with a CBD stone? Nobody explains to the patient that there is a “small” potential complication of

Intraoperative cholangiography should be performed routinely.

Appropriate training using this technique, especially in our academic surgical residency programs, is essential. pancreatitis from ERCP in 5% of patients, with a need for additional hospitalization.

Nobody mentions the 0.1% to 0.2% possibility of perforation or bleeding resulting from ERCP, requiring additional operative management. What about the additional cost of these complications?

We have to ask ourselves and the

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George Berci, MD, FACS Los Angeles

11

12

THE SURGICAL PAUSE

GENERAL SURGERY NEWS / FEBRUARY 2021

The Limits of Resilience Issues in Surgical Palliative Care

By MELISSA RED HOFFMAN, MD

A

little more than one year ago, I walked into the surgeons’ lounge after an early morning case.

As I sat down to dictate my notes, I heard a colleague remark, “There’s an active shooter in the hospital.”

My throat tightened and my voice squeaked as I asked, “Are you kidding?”

Fellow surgeons, including some of my residents, looked up from their computers but appeared unfazed.

Whether this calm exterior was secondary to years of training during which we learn to maintain equanimity during stressful moments or simply because they truly were not alarmed, I can’t say. Meanwhile, I transformed from a reasonably confident adult, capable of making multiple life-and-death decisions throughout a typical workday, to a trapped, frightened child—breath short, heart racing, eyes darting toward the door, needing desperately to escape.

“At least there’s a trauma surgeon in the room,” someone quipped as they looked my way and chuckled.

At that point, my internal world again shifted and my adult mind realized, “Wow, these folks really don’t get it. I need to go!”

I turned to my residents, told them I would be back and left the room. I walked down a long corridor, frantically searching for an exit sign; we had recently moved into a new hospital tower, and in my panic, I became completely disoriented. An announcement rang out overhead: “Shots fired! This is not a drill!” I was forced to accept that my fantasy of busting out through a steel door into the chilly winter day was not going to happen. Instead, I walked past an empty bathroom and scurried inside, locking the heavy door behind me. I set the plastic garbage can between the door and the corner, where I sunk to the floor, wrapped my arms around my knees and wept.

The situation felt eerily inevitable. Twenty-five years ago, my father had been shot to death as he stood up from his table at a restaurant in Cairo. I’ve spent the last 2.5 decades painfully aware that none of us are immune to random acts of violence. And my job—I practice as both a trauma surgeon and as a hospice and palliative care physician—confirms this on an almost daily basis.

Hiding in the small, dark room, I called my boyfriend and cried quietly into the phone, but the fear of being discovered led me to cut the conversation short.

I switched my phone to silent as a message appeared on my screen: “SECURITY ALERT. Active shooter on 9A. Please secure your areas and follow appropriate precautions.” I wondered what exactly constituted appropriate precautions while I texted my residents and co-workers, checking to see if they were OK. I was particularly anxious to hear back from those who I knew were rounding on the ninth floor, where the majority of

our trauma patients were admitted, most lying helplessly in their beds.

In between texts, I thought mostly about my dead dad, one year older than I was at the time, lying on a restaurant floor, alone, choking as his lungs filled with blood. Was he scared? Was he in pain? Did he know he was dying? I almost never allow myself to perseverate on the details of my father’s final minutes, but having read his autopsy report and having trained as a trauma surgeon, I know more than enough to accurately imagine what he experienced as he died. Alone in the bathroom, crouching next to the garbage can, I was acutely aware of everything I was thinking and feeling. Yet I also felt like an innocent bystander, witnessing my present situation and my past trauma collide in my head, leading my mind to places it had no business visiting and then abandoning me there. I was stranded with my thoughts, feeling utterly helpless, but somehow also secure in the knowledge that I was the only one in charge of my own rescue.

At what point did the expectation of my resilience begin to extend to threats upon my personal safety? Why is it assumed that I, and so many others, will simply ‘bounce back’ after experiencing such a threat?

Despite visions of my dying dad and what I imagined to be bodies strewn along the ninth-floor hallway, my training did eventually kick in. I was painfully aware that I had abandoned my residents in an attempt to secure my own safety. “Are you guys okay?” I texted again. “Please stay safe.”

Another 10 minutes passed and a voice overhead announced, “Active shooter all clear.” I was skeptical and terrified as I turned on the light in the bathroom, rubbed at my eyes and emerged into a fairly normalappearing world. Multiple employees walked by without even glancing in my direction. The OR control desk buzzed with activity. My residents were animated but appeared unfazed, despite my asking them multiple

times if they were OK. We headed up to the wards to continue rounding on our patients.

Many patients knew nothing about the incident; apparently the overhead announcements were not audible in their rooms. Others were too sick to care. Some staff shared stories of hiding in locked medication rooms, fearing for their lives, while others shared stories of securing doors that failed to lock with sheets tied around door handles. I also encountered an odd mix of arrogance and ignorance, particularly among those tasked with caring for our sickest patients, as if they felt they would be somehow immune to the violence.

Or perhaps they felt called to care for their patients and were simply braver than I could ever be. The variety of responses was disturbing, particularly at a time when a well-coordinated effort might ensure both provider and patient safety.

As the day wore on, multiple stories emerged about what really happened: There was no gun; there was a man with a gun, but no shots were fired; there was a man with a gun and a bogus threat called into the hospital at the exact same time. The day ended with a short note in my inbox, thanking me for my resilience.

One year later, I am still left feeling anxious, angry and ashamed. I am anxious because I still don’t know exactly what triggered this event. And despite a recent active shooter simulation, I’m not convinced that I will feel any safer the next time this occurs.

I am angry because I am left wondering: Who is tasked with my well-being? Who, in the setting of recent security cuts, is in charge of protecting me? And who, besides me, is fretting over the fact that there is a small part of me still stuck on the bathroom floor? Like most surgeons, I am remarkably resilient; I show up to work and maintain a relatively positive attitude despite difficult operations, sometimes disastrous complications and occasional devastating deaths.

At what point, however, did the expectation of my resilience begin to extend to threats upon my personal safety? Why is it assumed that I, and so many others, will simply “bounce back” after experiencing such a threat?

And I am ashamed because I so quickly left my residents in an attempt to flee to safety, and so willingly abandoned my patients in an effort to save myself. I watched, passively, as the past dictated my response to the present. As someone who views herself as dedicated to both her team and to her patients, I exposed myself as both a flawed human being and as a coward.

Over the years, my father’s murder has become a prism through which I view the world. Through this prism, I found my purpose: as a trauma surgeon working to save lives and as a hospice and palliative medicine physician striving to ease suffering. It is through this prism that I’ve attempted to process my anxiety, anger and shame, all of which I know were inevitably amplified because of my history. It is through this prism that I continue to connect with my colleagues, my patients and their families. And it is through this prism that I’m still searching for those exit signs, just ■ in case.

—Dr. Hoffman is an acute care surgeon and hospice attending in Asheville, N.C., as well as the host of The Surgical Palliative Care Podcast. To learn more about her, visit her website at www.redhoffmanmd.com.

OPINION 13

FEBRUARY 2021 / GENERAL SURGERY NEWS

Gratitude in Surgery

By WILLIAM HOPE, MD

H

appy new year! There is no doubt that 2020 was a trying year, and I think almost everyone is looking forward to 2021 with the anticipation of getting back to our “normal” lives. Besides the havoc that the COVID-19 pandemic has wreaked on our lives, communities and health care system, there have also been unanticipated consequences, including the effects it has had on the mental health of our nation. While no one knows for sure what the long-term effects of this year of quarantining and isolation will have on our future, there is no doubt that we all need to take care of ourselves mentally and physically during this tough time.

Although they have been few and far between, there have been a few silver linings that I have experienced during the pandemic. For one, I have been able to spend more time with my family and take a break from a hectic schedule. I have also been able to connect with many people through our new “Zoom” culture.

While attending a Zoom meeting for a conference doesn’t hold a candle to the real thing, it has been nice to see some friends and colleagues during this period of isolation. Another silver lining is that I have discovered some new hobbies and reinvigorated some older ones that had gotten lost with my busy schedule.

One thing I was able to do with some of my downtime was take a hospitalsponsored course on mentoring. This course was set up to teach physicians how to better mentor younger physicians in our community or to help those struggling during the pandemic or with the everyday stressors of work in health care.

One of the main themes of this course was that of gratitude, a subject about which I had little knowledge.

There are many definitions of gratitude, and a good deal of research has been published on its impact on our mental health. In general, gratitude is the feeling of appreciation of what one has. It can be practiced in many ways, and during our course, we were encouraged to keep a gratitude journal or to discuss things we were thankful for at family dinners.

As I experimented with some of these techniques to help “practice” gratitude, I began to experience how this mindset of gratefulness could help change one’s perspective in a positive way.

About the time when I took my course, I also began to find some time to do something that was long overdue at work: cleaning out my office. During this much-needed process of getting rid of useless clutter, I came across

several important mementos from patients. These ranged from kind notes, to works of art, to one of my prized possessions: a framed portrait of one of my patients, signed by all the health care workers and friends who helped save him after a major trauma.

One of the things I noticed is that while many of the mementos were from patients who I had helped get through a surgical problem, many were from family members whose loved ones did not survive their illness, and others were even from those who had surgical complications and prolonged courses.

Some of the gifts Dr. William Hope has received over the years from grateful patients.

continued on the following page

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OPINION

GENERAL SURGERY NEWS / FEBRUARY 2021

The Complexity of Conspiracy Theories

By BRUCE RAMSHAW, MD

I

’m embarrassed to admit that I went through a conspiracy theory phase as I transitioned from lower-brain to higher-brain thinking. For some reason, I struggled with the concept that our world is so complex that control by a small group of people conspiring to manipulate major catastrophes or whole industries is not very likely. Technology and greater transparency have made the concealment of facts and actions increasingly more complicated.

I began to develop my higher-brain thinking when we moved our hernia team from Missouri to Florida about 10 years ago. I had an “aha” moment while reading a fiction novel that described the unintended consequences of simplistic solutions attempting to address complex problems. However, it would be many years before I deeply understood the science of biological systems and further developed higher-brain thinking.

As I was trying to develop this higher-brain understanding of our complex world, I would often get caught up thinking about the multifaceted problems in health care and how our current understanding of science is lacking.

I would get so preoccupied with this that I once ran out of gas on the highway, not because there were no gas stations available, but I just forgot to look at the gas gauge. I’ve also driven away from the gas station with the pump handle still in my gas tank—twice! My early higher-brain development was chaotic, but by about 2012, I was no longer acting like I had early-onset dementia—as some thought I might have had.

One of the reasons that conspiracy theories are attractive is that our lower brain craves certainty. We want to see patterns that explain cause-and-effect relationships, usually related to events that have resulted in harm. Conspiracy theories are especially attractive during times of uncertainty in our world (e.g., after 9/11 and during our current pandemic). Our competitive lower brain wants to blame something or someone that is causing the harm. When suffering occurs in our world, our lower brain is most comfortable with simple causation. In reality, there are usually many contributing factors that result in these tragic situations.

Another problem evaluating conspiracy theories is the fact that the information available is rarely conclusive. Sometimes there is a lack of transparency. Often, there is contradictory information due to the complexity of the problem. Unfortunately, there also may be misinformation, sometimes including intentional disinformation. Further, information is sometimes presented to defend or market a position or product related to the problem; there are certainly people and companies that try to profit from complex issues that may or may not improve the situation.

From the book “The Believing Brain,” the author, Michael Shermer, PhD, describes how a conspiracy theory is less likely to be true the more complex the event is and the more people who are required to be involved. The problem is when we only see the information that supports our belief in the conspiracy as valid, known as confirmation bias. And we desire to avoid the discomfort and fear of uncertainty.

In my case, I think it was the need for my brain to attempt to explain the patterns in the complex problems I was trying

Gratitude continued from the previous page

As I became more aware and grateful for such things, I was reminded of a particular case of gratitude from a patient, one many of us have likely encountered. It started out as a typical busy surgical day. I had four to five cases on my schedule and I was on call. One of my patients in the hospital needed a small-bowel resection for a strictured ileocolonic anastomosis from a previous operation for Crohn’s disease. I told her that I would put her on the waiting list and do her surgery after I finished the cases I already had on my schedule. She was very understanding, and I planned to do her surgery around 4 to 5 p.m. As we have all experienced, the scheduled procedures went longer than expected and new emergencies came in, adding to my list.

Around 6 p.m., I started to get close to catching up, and told my patient that I likely would be able to get to her in one to two hours, only to have three more emergent cases arrive. Fast-forward to about 10 p.m., I visited

One of the reasons that conspiracy theories are attractive is that our lower brain craves certainty. We want to see patterns that explain cause-and-effect relationships, usually related to events that have resulted in harm. to understand and hoping to solve that led me to consider conspiracy theory thinking. Before I had adequately developed higher-brain thinking, my desire to see causation in inappropriate patterns and connections led my brain to consider the potential truth in health care–related conspiracy theories, as well as for 9/11, former President John F. Kennedy’s assassination and other questionable world events. Fortunately, my motivation wasn’t to blame and shame a person or group of people.

It was to learn and try to figure out why our health care system was not sustainable and what we can potentially do about it.

So, I never wrote letters or tried to recruit others to believe in these theories during that time. And although I did some research about several conspiracy theories, I was pretty sure that no world leaders— or any other people, for that matter—were shape-shifting reptilian humanoids.

Part of the reason for the prevalence

her again and told her I had one more case and likely wouldn’t get to her case until after midnight. I told her I was willing to stay up and do the case, but also that we are able to secure some OR time for the following morning, and since she wasn’t on the waiting list, her case would be more likely to go on time. The patient, exhausted, agreed that it was likely best to push the surgery to the next day and was transferred back to her room while I continued to chip away at the rest of my cases. I was able to get home that night for some muchneeded sleep. I went to see the patient in pre-op the next morning and again apologized for her long day of waiting, hour after hour, in the preoperative area without any food. Thankfully, the patient was once again understanding, but what she said was something I hadn’t expected, and it really embodied this sense of gratitude. She told me that she totally understood and hoped that I was OK and had gotten some rest. She also said she hoped the patients who had bumped her surgery were doing well, as she knew that they were sicker than her and needed my care more urgently—wow, a true sense of gratitude!

of conspiracy theories and why so many people consider them to be truthful is the number of past conspiracies that actually happened, such as the U.S. government’s MK-Ultra program and the tobacco industry cover-up about the link between cigarettes and cancer, among others.

Another major problem that perpetuates conspiracy theories is the lack of transparency from organizations and the divisiveness between groups on either side. For example, there are many health care–related conspiracy theories, but one of the most prevalent is whether vaccines are harmful and/or cause autism.

Although there is no proof that vaccines are related to autism, I’ve mentioned in a prior article [“Is There a Magic Bullet for COVID-19,” Sept. 2020, page 22] that any treatment could result in a benefit, be wasteful or contribute to unintended harm in different patient subpopulations.

It’s no different for vaccines. Vaccines have

In reflecting on this experience, I am reminded of one of the greatest parts of our jobs of being a surgeon—that of the gratitude we receive from our patients. I think this is what probably keeps most of us going during the stressful times and is likely why many of us decided to become surgeons in the first place. I know many of you have similar stories and feelings about the special relationship we get to form with our patients. We would love to hear from you about any such stories or special ■ gifts you have received from a grateful patient!

—Dr. Hope is the general surgery program director at New Hanover Regional Medical Center, in Wilmington, N.C. He is an editorial advisory board member of General Surgery News.

We would like to hear from you. If you have a story about a positive interaction with a patient or other story of gratitude as a surgeon, please send for consideration to the editor at khorty@mcmahonmed.com.

OPINION

FEBRUARY 2021 / GENERAL SURGERY NEWS

been valuable for many diseases, completely eradicating smallpox, for example. But several vaccines are harmful and have been withdrawn from the market.

Vaccines are a complex preventive treatment for complex biologic diseases. Different vaccines will have different levels of effectiveness, variable outcomes and potential side effects in various subpopulations. For example, the flu vaccine is not entirely effective, and the effectiveness varies from season to season.

Lower-brain thinking leads some of us to believe in a vaccine conspiracy theory out of fear that pharmaceutical companies are not being transparent due to a sole focus on the profit motive. But some of us blame and shame these people who believe in vaccine conspiracy theories and try to convince them to get them or their children vaccinated. This doesn’t help and is lower-brain thinking and behavior.

I’ve heard many well-intended physicians on national television, and even more on social media, say, “Vaccines are safe; they don’t cause harm.” But that isn’t wholly true. Since 1989, the National Vaccine Injury Compensation Program has paid almost $4.5 billion to people injured after receiving a vaccination. This lower-brain thinking and behavior from both sides leads to divisiveness and doesn’t help address complex problems in our world.

Here’s how higher-brain thinking can help us deal with complex events and problems in our world that could lead to fear-induced conspiracy theories: • Remember that we should not allow these types of beliefs to divide us. The majority of people on either side of a conspiracy theory belief are only trying their best to do the right thing for themselves and their families.

• Transparency is critical. Don’t put a public relations spin on the information. Give people the benefit of the doubt that they will appreciate honest, transparent information.

Embrace the vulnerability of transparency and a higher-brain mindset of learning and improvement.

• Don’t judge people’s and organizations’ behavior or motives. Give people and organizations the benefit of the doubt that they are trying to do their best.

• Try not to worry about things you can’t control or something you can’t change. No matter who killed JFK, he’s still dead.

• Listen genuinely to others who disagree with you, as long as they’re willing to have a civil dialogue. If they aren’t, don’t engage in or escalate a conflict. Avoid the subject or end the relationship, if necessary.

• Realize that what divides us can destroy us at a societal, community and even at a personal level. But working

together with different perspectives and talents to solve the complex problems in our world will unify us.

• Be humble and realize you might not be right.

• Recognize that most issues, like vaccinations, are not all good or all bad; they are complex issues. When two groups choose a side, right or wrong, both sides are wrong for any complex problem.

As I continued to deepen my personal growth and the development of my higher-brain thinking, the anxiety and focus

on things I couldn’t control, or know for sure, seemed to melt away. I learned that our health care system has major structural flaws and that there are structural solutions. This knowledge helped me to become very motivated and hopeful. I now know that no one intends to have a health care system that is tragically harmful to many people through physical, financial and psychological harm.

These are unintended consequences.

The challenge in front of us is to resist the lower-brain impulse to blame people or organizations. Instead, we should all work together toward the transformation

15

of a health care business model from one based on volume, revenue growth and competition to one that collaboratively learns how to measure and improve value for patients and the system as a whole.

The most important thing holding us back is our lower-brain thinking, and ■ that is not a conspiracy theory.

—Dr. Ramshaw is a general surgeon and data scientist in Knoxville, Tenn., and a managing partner at CQ Insights. He is an editorial advisory board member of General Surgery News. You can read more from him on his blog: www.bruceramshaw.com/blog.

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GENERAL SURGERY NEWS / FEBRUARY 2021

Lifelong Financial Planning: A Road Map continued from page 1

Personalizing a Financial Strategy Key questions: What can my money do for me?

What are my aspirations in 10, 20 and 30 years?

For Edward M. Barksdale Jr., MD, FACS, FAAP, those priorities come down to family, home, education and planning for retirement.

But priorities may be different for others, which is why Dr. Barksdale advises young surgeons to reflect on their personal goals “over a steering wheel, dinner table or the pillow,” and “find a financial adviser you can grow with over time.”

“How we manage our finances isn’t just about how much money we have; it’s also about how much life we have gained in the process,” he said.

Following the Road Map (Financial Pyramid) Protection (zero to 10 years) • Build a strong foundation by investing in insurance • Establish a budget and cash flow • Develop a savings strategy: 10% of income Planning (five to 15 years) • Boost retirement savings and investments • Save for college education • Accelerate mortgage paymentss • Plan for emergencies Prioritization (15-30 years) (Figure 2) • Build wealth and diversify investments • Reduce discretionary spendingg Distribution/Retirement (>30 years) • Consider charitable contributions and family legacy • Make plans for the estate • Enjoy retirement!

Distribution

Prioritizing (15-30 years) Aggression

Planning Edward M. Barksdale, Jr., MD, FACS, FAAP. (Right) Figure 1.

The four-tier financial pyramid the Barksdales used.

(5-15 years) Offense

Protection (0-10 years) Defense

Life/ Health Insurance

(Below right) Figure 2.

An example of a diversified portfolio.

home and starting a family—and created a budget and savings strategy to support those aims.

“After a year, we realized we didn’t have the time or insights to meet our goals, so we decided to hire a financial planner, someone who had experience working with other academic physicians, someone who we felt we could trust,” Dr. Barksdale said.

Trust is key for Dr. Barksdale, more important than getting the highest financial return.

“I’m a relationship person, and I wanted to find someone who would get to know me and understand my risk tolerance,” he said.

To get started, the couple’s financial advisor presented a four-tier financial pyramid (Figure 1). The first rung—the protection phase—allowed the Barksdales to establish a protective shell, a foundation for saving and investing over the next decade. This meant getting life and health insurance, purchasing a home and putting 10% of their income, outside of a 401(k), into savings.

About five years in, the next stage—the planning phase—began. The aim of this more proactive period is to accelerate retirement savings, mortgage payments, college education funds for their growing family and, lastly, allow them to plan for emergencies.

Having this infrastructure helped Dr. Barksdale and his wife weather several unexpected expenses in 1998: a major electrical house fire, for which they were underinsured, and a decision to move their son from public to pr private school after he was diagnosed with a readingba based learning disability.

Although the family adjusted by making changes t their monthly budget, these surprises highlighted to t importance of building a financial foundation that the cou bend, but would not break, under pressure. Hancould dli personal surprises and fluctuations in the market dling ov 25 years has left Dr. Barksdale rather unfazed by over the current crisis.

“I don’t get too shaken by any one downswing because the market will eventually recover,” Dr. Barksdale said. “The key is to reassess your financial plan and rem remain flexible.”

Dr. Barksdale is currently in the third tier of the f financial planning pyramid—prioritizing or wealth building. In this highly aggressive phase, the goal is to rapidly grow and diversify investments, maximize contributions and cut discretionary spending in

Wealth Building and Diversified Asset Accumulation

College Education Planning

Retirement Savings Systematic Investing Maximize Tax Efficiency

Cash & ShortTerm Liquidity

Financial Pyramid

Legacy Planning and Charitable Giving

(>30 years) Progression

Initial Risk Mgmt.

Review

Diversified Commodities 5%

ary ion ret ding sc Di pen S

Before diving into specifics, Dr. Barksdale stressed the importance of understanding and staying true to who you are and what you value.

“My identity and values were carved by my childhood and early adult experiences,” said Dr. Barksdale, the surgeon-in-chief at University Hospitals Rainbow Babies & Children’s Hospital, and a professor of surgery and pediatrics at Case Western Reserve University School of Medicine, in Cleveland.

At a young age, he saw how financially savvy and frugal his parents were. His father, a mailman, and his mother, a sock seamstress, grew up during the Great Depression, which shaped a careful approach to saving.

“I learned the importance of living below your means and planning for rainy days,” Dr. Barksdale said. “But I also had a different philosophy than my parents. It wasn’t just save, save, save. I wanted to enjoy life without being wasteful.”

In 1994, after 10 years of medical training and accruing $50,000 in student loan debt, Dr. Barksdale embarked on his career in pediatric surgery. In that first year, Dr. Barksdale and his wife established their priorities—buying a

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preparation for retirement.

Although retirement, the final phase, is still almost 10 years away, Dr. Barksdale is already thinking about the legacy he wants to leave behind. In the last few years, he and his wife gathered their four children for a family meeting after the Christmas holiday to discuss the family assets and how to shift from the concept of financial success to one of social significance.

One cause in particular speaks to Dr. Barksdale. He and his wife support women and children who have been abused and neglected.

“In my work, I see fragile children who suffer from living with fragmented families and women who lack security,” he told General Surgery News, recalling a 2-year-old and 3-year-old who were brought to the hospital with gunshot wounds on the previous night.

“Some of these children will never get stronger while living in broken places.”

Dr. Barksdale supports shelters for women and children, and in 2019, started the Antifragility Initiative—a hospital-based violence intervention program for children who have experienced severe interpersonal violence, such as gunshot or stab wounds. Since launching the program, more than 80 teenagers have been connected to therapy, mentorship or other services.

For Dr. Barksdale, the pandemic has brought the relationship between his financial goals and life priorities into sharper focus.

“The pandemic has helped me recognize the importance of the intangible,” he said. “Tangibles are money; the intangibles are mental health and the love of my ■ family. Money is a tool but it’s not the end goal.”

17

FEBRUARY 2021 / GENERAL SURGERY NEWS

Appendicitis and Ultrasound continued from page 1

Regional Medical Center, in Arizona, discussed the benefits of using ultrasound to diagnose appendicitis and compared it with the current gold standard of CT. “Although it has its limitations, ultrasound can be a valuable tool for evaluating appendicitis,” Dr. Walks said. “The specificity of ultrasound approaches that of CT scan without the concurrent risks, and it can be a valuable adjunct for indeterminate cases.”

Problems With the Gold Standard As Dr. Walks reported, the use of CT imaging for diagnosing appendicitis has been increasing steadily since the 1990s.

Although fast and accurate, with a sensitivity and specificity of approximately 95% in both adults and children, CT scans present some problems.

“CT scans are expensive; you have to deal with IV or oral contrast; and rural access can be particularly challenging,” Dr. Walks explained.

A 2008 study of the imaging capabilities of various emergency departments in the United States found that although CT scanners were available in most (96%), 5% of rural hospitals had on-call CT technicians and 1% had no after-hours access. Rural hospitals also tended to have lower-resolution CT scanners of less than four slices, Dr. Walks said.

Another problem is that CT scans are associated with radiation exposure. A 2013 study from the National Institutes of Health found that CT scans of the abdomen and pelvis cause one cancer for every 300 to 390 scans in girls and 670 to 760 scans in boys, respectively.

Advantages of Ultrasound Imaging In contrast, ultrasound has the benefit of being fast and low cost with no radiation risks. In addition, no contrast is needed, Dr. Walks said, and it provides immediate point-of-care imaging.

Although ultrasound is easily repeatable, it’s considered operator dependent and technician skill can affect its utility.

The patient’s anatomy can also be a barrier. “When the appendix is in the retrocecal position, it can change the field of view,” Dr. Walks noted. “Obesity, previous surgeries and perforation can also influence the effectiveness of ultrasound.”

The sensitivity and specificity of ultrasound are inferior to CT scans.

A meta-analysis comparing CT scans and ultrasounds in children and adults found that ultrasound had a sensitivity and specificity of 88% and 94%,

respectively (Radiology 2018;288[3]:717727). Although CT scans had a higher sensitivity at 94%, the specificity of 95% did not differ by much, Dr. Walks said.

In addition, ultrasound has been used to reduce the negative appendectomy rate. Guidelines for appendicitis introduced in the Netherlands in 2010, that made ultrasound imaging mandatory for suspected appendicitis in children, helped to decrease the rate of negative continued on page 19

‘Ultrasound is cheap, fast, safe and relatively easy to learn. Basically, if you see something on ultrasound, it means something.’

—Norma T. Walks, MD

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GENERAL SURGERY NEWS / FEBRUARY 2021

An Interview With Dr. Steven D. Wexner On the NAPRC

By Lisandro Montorfano, MD, surgical resident, Cleveland Clinic Florida, Weston What is the National Accreditation Program for Rectal Cancer?

elcome to the February issue of The Surgeons’ Lounge. We dedicate this issue to the National Accreditation Program for Rectal Cancer (NAPRC) that uses a multidisciplinary team approach to achieve better outcomes for patients with rectal cancer. Steven D. Wexner, MD, PhD (Hon), the director of the Digestive Disease Institute and chair of the Department of Colorectal Surgery at Cleveland Clinic Florida, in Weston, provides timely responses to the most common questions regarding the NAPRC. Also in this issue, we present “The History of Colonoscopy.”

We look forward to our readers’ questions, comments and interesting cases to present.

W

Sincerely, Samuel Szomstein, MD, FACS Editor, The Surgeons’ Lounge Szomsts@ccf.org

Dr. Steven Wexner: The National Accreditation Program for Rectal Cancer (NAPRC) is one of the more than 20 quality programs offered by the American College of Surgeons (ACS). Like all ACS quality programs, the NAPRC accredits institutions based upon fulfillment of process and performance measures. Adherence to the established standards with the ACS quality program has repeatedly been proven to improve patient outcomes. It was demonstrated in Europe that the implementation of these programs indeed improved patient outcomes specifically measurable by decreased rates of permanent colostomy and of local tumor recurrence, as well as improved survival. Similarly, extensive research in the United States showed tremendous disparities in rectal cancer outcomes. The NAPRC was designed to optimize outcomes by adopting best practices in which metrics could be evaluated and with which compliance would mirror improvements in patient outcomes already experienced in multiple European countries.

How is the program structured? What specialties does it involve?

Dr. Wexner: The NAPRC is administered by the American College of Surgeons Commission on Cancer (CoC) with participation in the executive, quality, accreditation and education committees by representatives from the American Society of Colon and Rectal Surgeons (ASCRS), Society for Surgical Oncology (SSO), Society for Surgery of the Alimentary Tract (SSAT), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), College of American Pathologists (CAP) and American College of Radiology (ACR). On an individual program level, the multidisciplinary team approach requires active participation in the review of the details of every patient with rectal cancer presenting to an accredited institution from surgery, pathology, radiology, medical oncology and radiation oncology.

What is the benefit of implementing the NAPRC?

improving. The NAPRC was designed between 2011 and 2014, and then refined by the ACS CoC between 2014 and 2017. After beta testing in 2017, initial accreditation began in mid-2018. Although 15 programs were relatively quickly accredited, COVID-19 thwarted the accreditation process. At present, there at least another 45 programs awaiting accreditation. The expectation is that we will see measurable improvements in outcomes. In one study which we have not yet published, we modeled that several thousand lives per year would be saved if all patients in the country were treated according to the process and performance standards of the NAPRC. How do hospitals get accredited? Are the standards of the NAPRC reproducible in rural and community hospitals?

Dr. Wexner: Hospital accreditation is undertaken by application through the NAPRC website (www.facs. org/quality-programs/cancer/naprc). The idea behind the program was not to be exclusive but rather inclusive and, therefore, yes, if a rural and/or community hospital were interested in accreditation, they would be eligible, provided they were able to achieve fulfillment of the same process and performance standards as larger and/or urban teaching hospitals. Proof of the success of this concept can be gleaned by looking at the list on the NAPRC website of the already accredited programs. Moreover, programs awaiting accreditation span the gamut of hospitals from large urban academic centers to smaller rural community hospitals.

Do patients with rectal cancer understand the value of the NAPRC? Dr. Wexner: I always describe the NAPRC to every patient with rectal cancer who I treat. However, by virtue of the program being very new and not yet having results proving improvement based upon accreditation, we do not yet have evidence with which we can convince patients. Moreover, because so few hospitals are currently accredited, accreditation is not necessarily relevant to patients in many geographic regions. I am optimistic and confident that the situation will rapidly change.

Dr. Wexner: The benefits of implementing the NAPRC are assurance of evidence-based optimal care through the implementation and adherence to standards.

In addition to what I already mentioned above, patients Are similar guidelines being implemented in the rest treated in accredited centers are likely to receive treat- of the world? ment based upon evidence-based guidelines than are Dr. Wexner: The program in the United States patients treated in nonaccredited centers—again, based is actually predicated on programs from the United upon European experience and experience within other ACS quality programs. It is our expectation nting that this same advantage will be true within the The benefits of implementing NAPRC. Additional benefits are the “wisdom of the NAPRC are assurance e the crowd,” in that every patient has their particulars discussed with the entire group. Ultimately, the of evidence-based expectation is that because of those two benefits, optimal care through the e patients should have the best possible chance of living a colostomy–free, recurrence-free longer life. implementation Are rectal cancer outcomes improving nationwide since the program has been implemented?

Dr. Wexner: Unfortunately, it is premature to judge whether or not outcomes have been

and adherence to standards.

—Steven D. Wexner, MD, PhD

SURGEONS’ LOUNGE

FEBRUARY 2021 / GENERAL SURGERY NEWS

Kingdom, Norway, Denmark, Sweden and many other countries. We have had significant interest from countries including Israel, India and others seeking to follow the NAPRC standards. Currently, although the ACS offers some of its quality programs such as trauma overseas, the CoC does not yet accredit any international programs. Ideally, particularly given our current scenario of virtual site visits, this scenario may change.

What are the future goals of the NAPRC? Dr. Wexner: The future goals are to enable reasonable geographic access to a NAPRC-accredited center to every patient in the United States with rectal cancer, to prove the goals which we adopted within our initial mission of decreasing the rates of stoma formation, [reducing] local recurrence, and improving survival by following the process and performance standards. Lastly, as these patient benefits are realized, we would hope to see the public embrace the NAPRC and payors recognize the benefits of care in NAPRC-accredited centers, therefore helping to direct patients with rectal cancer to NAPRC-accredited centers knowing that patients in those centers will receive evidence–based, multidisciplinary team treatment.

■

Suggested Reading Brady JT, Xu Z, Scarberry KB, et al. Evaluating the current status of rectal cancer care in the US: Where we stand at the start of the Commission on Cancer’s National Accreditation Program for Rectal Cancer. J Am Coll Surg. 2018;226(5):881-890. Erratum in: J Am Coll Surg. 2018;227(4):484-487.

Montroni I, Ugolini G, Saur NM, et al. Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer.

Eur J Surg Oncol. 2018;44(11):1685-1702.

Orangio GR. A national accreditation program for rectal cancer: a long and winding road. Dis Colon Rectum.

2018;61(2):145-146.

Sharp S, Malizia R, Skancke M, et al. A NSQIP analysis of trends in surgical outcomes for rectal cancer: what can we improve upon? Am J Surg. 2020;220(2):401-407.

The History of Colonoscopy

By Mileydis Alonso, DO, and Lisandro Montorfano MD, surgical residents, Cleveland Clinic Florida, Weston Colonoscopy is a diagnostic and therapeutic tool that allows the ability to endoscopically examine the inside of the large bowel and distal part of the small bowel. It is now considered the gold standard for colon cancer screening, which has led to a decreased incidence of colon cancer.

The colonoscopy and how it is implemented has changed in multiple ways over the years.

The inside of a human was first examined with rigid sigmoidoscopy in 1805 by Phillipp Bozzinni. Rigid sigmoidoscopy is similar to colonoscopy but only examines the distal part of the colon.

It was not until the 1960s that the modern-day colonoscopy came into being.

Dr. Hiromin Shinya, a general surgeon, and Dr. William Wolff, a cardiothoracic surgeon, Endoscopic examination of a patient’s gut by both from New York City, studied whether a Dr. AI Morris, Royal Liverpool University Hospital. fiber-optic endoscope could be used to exam- Drawing by Julia Midgley, 1998.

Wellcome Images. ine the entire large intestine. In June 1969, they used a softer, more flexible scope to perform one of the first colonoscopies. Later that same year, Shinya and Wolff made their most significant advance, using an electrosurgical polypectomy snare to remove colorectal polyps. As a result, in 1969, physicians at Beth Israel Medical Center, in New York City, began removal of colorectal polyps by this means. They also developed a protocol for colonoscopy to be performed by one physician.

Significant opposition to colonoscopy was generated in the early years by some individuals who claimed the procedure was unnecessary and dangerous. Through their publications, Shinya and Wolff proved both the success and efficacy of colonoscopy. They waited until they had performed 100 successful procedures before publishing their findings. Their article describing the procedure was published in the New England Journal of Medicine in 1973 (288[7]:329-332), and it became one of the landmark medical articles of the 20th century.

In the 1970s and 1980s, colonoscopy became more widely accepted. In 1971, Olympus and Machida began to develop longer scopes of more than 100 cm. The new tool had a four-way tip control, channels for water infusion, suction, lens cleaning and tip retroflexion. During this 10-year period, endoscopes were directed toward inspection of the colon. By the end of the 1980s, colonoscopies were being performed routinely by gastroenterologists and surgeons.

The video endoscope was introduced in 1983 by the Welch Allyn Corporation, but it was not until 2006 that the American Society of Gastrointestinal and Endoscopic Surgeons (SAGES) and American College of Gastroenterology (ACG) established 14 quality indicators for colonoscopy. The latest update came about in 2018, when the American Cancer Society (ACS) changed its guidelines to start screening colonoscopy at age 45 years, instead of 50. With advances in technology, innovations in colonoscopy have occurred rapidly. The future appears promising. New technology will allow for better visualization of challenging areas such as the right colon, which in turn will further help prevent colorectal cancers and save lives.

Suggested Reading

Wexner SD, Berho ME. The rationale for and reality of the new National Accreditation Program for Rectal Cancer. Dis Colon Rectum. 2017;60(6):595-602.

Biggers L. A brief history of colonoscopy. November 30, 2018. Accessed October 29, 2020. www.colowrap.com/blog/history

Wexner SD, White CM. Improving rectal cancer outcomes with the National Accreditation Program for Rectal Cancer. Clin Colon Rectal Surg.

2020;33(5):318-324.

Unterberg M, Zwiren A, Staff T, et al. The history of colonoscopy and polypectomy—invented and pioneered by general surgeons in the USA. August 20, 2015. Accessed October 29, 2020. https://blogs.timesofisrael.com/ the-history-of-colonoscopy-and-polypectomy-invented-and-pioneered-by-general-surgeons-in-the-usa/

Appendicitis continued from page 17

appendectomy to 2.7% without increasing the frequency of CT scans.

Learning the Technique For competence in ultrasound, there’s a shallow learning curve, according to Dr. Walks, who noted that studies have shown rapid improvement in performance with minimal experience. In one study, for example, third-year surgery

Martin D. Dr. William Wolff, colonoscopy co-developer, dies at 94. September 2, 2011. Accessed October 29, 2020. www.nytimes.com/2011/09/02/nyregion/dr-william-wolff-94-colonoscopy-co-developer-dies.html

residents being trained in ultrasound on children improved their accuracy from 85% at the start of a three-day course to 93% by the end.

As Dr. Walks explained, ultrasound technicians use a technique called graded compression and look for the following primary signs: blind tubular structure, diameter greater than 6 mm and a “target sign” as with CT imaging. Secondary signs include free fluid, compression, fat changes and a phlegmon.

“Ultrasound is cheap, fast, safe and

relatively easy to learn,” Dr. Walks concluded. “Basically, if you see something on ultrasound, it means something.”

The moderator of the session, Daniel L. Dent, MD, the director of the general surgery residency program and a professor of surgery at the University of Texas Health Science Center at San Antonio School of Medicine, acknowledged “trust issues” concerning ultrasound, given the “fuzziness of the pictures.”

Dr. Dent said: “I’ve been spoiled by having good CT imaging. How much

practice should it take to develop trust in my own ability to interpret ultrasound, and where is it typically performed?”

“Personally, I would just practice wherever I have access, whether it’s in the pre-op area or the operating room, but it’s really not that complicated,” Dr. Walks said. “You don’t have to be that sophisticated in your ultrasound skills to see an appendicitis. If you see a tubular structure in the right lower quadrant, there’s probably something wrong with the patient’s appendix.”

■

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OPINION

GENERAL SURGERY NEWS / FEBRUARY 2021

Virtual World continued from page 1

Virtual reality headsets: 1990s, Ivan Sutherland and Robert Sproull iPhone: 2000, Steve Jobs/Apple Skype: 2003, Niklas Zennstrőm and Janus Friis FaceTime: 2007, Roberto Garcia/Apple Zoom: 2011, Eric Yuan Before COVID-19, Zoom and similar devices, telephone landlines, iPhones, the U.S. Postal Service, and FedEx were supplements to person-to-person communication. Today, in the conflagration of COVID19, these services—particularly services such as Zoom, Skype and others—have replaced group meetings, professional and family, as well as the camaraderie of having a drink and meal together, traveling and sightseeing.

What will happen after the COVID-19 pandemic?

We recognize that our lives will be changed forever. The social and communication impacts have already become the everyday conduct of business, private lives and health care. The implications of voice and image services, combined in the future with holography, will be as transformative as the introduction of electricity, the automobile and the airplane.

My father, a wise man, taught me that with any major world upheaval there are losers and winners. With the advent of the automobile, carriage makers lost their livelihood and car manufacturers gained theirs. Who will be the losers and winners after COVID-19? What will happen in commerce, the hospitality industry and entertainment? Will planes fly less often and aviation fuel stocks plummet? Will all those cruise ships, large and small, stand idle or sail half-empty? Will movie theaters fold and live theater diminish? Will there perhaps be a biphasic response? When COVID-19 is eliminated by vaccines and eventually herd immunity, we can expect that people will leave sheltered environments and shed face masks and social distancing. At that time, they may seek crowded venues and the freedom of travel, filling restaurants and bars to legal capacity.

What will be the outcome of the pandemic innovations and restrictions on our professional lives? I believe some reasonable predictions can be made based on current data and trends in considering the transformations—present and potential—in the doctor–patient relationship, continuing medical education and professional meetings, and health care in general.

Doctor–Patient Relationship The doctor sitting at the home bedside of a sick patient disappeared long ago. Virtual patient visits were becoming a reality prior to COVID-19. During COVID-19, they became the norm. A virtual visit cannot include a hands-on physical examination; however, the physical exam has been superseded by laboratory tests and radiography. Even here the necessity of coming to a laboratory for tests has, for certain assessments, been replaced by home test kits and devices. One could argue that, at least for surgery, there needs to be a physical relationship between the surgeon and patient. Not necessarily: Robotic surgery can be performed with the operating surgeon miles, even continents, away. The first documented robot-assisted surgical procedure was performed in 1985 in a nonlaparoscopic neurosurgical biopsy operation; the first robotic cholecystectomy was performed in Belgium in 1997; and in 2001, a transAtlantic cholecystectomy was performed by Dr. Michel Gagner in New York with the patient in Strasbourg,

Taking personal responsibility for the doctor–patient relationship, its performance and outcomes, in and out of the OR, has always been the cardinal ethos of surgery. Let us not be maneuvered into negating that heritage of trust.

France, under the supervision of Dr. Jacques Marescaux.

We have embraced the virtual world, and in doing so, we are obligated to make it work not only for us but for our patients. Long-range robotic surgery can bring skills and technology to people and places deprived of these benefits. Virtual doctor– patient visits can enhance frequency of communication and, by their availability, actually rekindle the intimacy of patient care. By eliminating the need for a dedicated clinical space and the personnel to run it, virtual patient visits may be cost-effective.

At the same time, we, as the providers of patient care, must be vigilant in this virtual age, cognizant of how technology can negate the personal bond of trust inherent in the doctor–patient relationship. Empowering administration to set the time allotted for a patient visit implies tacit approval by physicians for administration to regulate the spacing of patient visits, the exchange of patient care physicians, the utilization of service lines and eventually even extending impersonality by substituting surgeons during an operation dependent on OR time spent.

Steps such as these, made one at a time, lead toward our profession becoming, in effect, part of a business firm run

by CEOs, with surgeons as employees performing a service and patients representing paying clients. Taking personal responsibility for the doctor–patient relationship, its performance and outcomes, in and out of the OR, has always been the cardinal ethos of surgery. Let us not be maneuvered into negating that heritage of trust.

Continuing Education Every day I receive an email with an offer to view a video or join a Zoom presentation on timely topics of medical/surgical therapy, including COVID-19. Most offers are free; some require a registration fee. Some offer CME credit, whereas others do not. This barrage of information has increased a thousandfold since virtual communication became a necessity. Will it continue after COVID-19? Although many of these offers are not useful or appealing, some present opportunities for self-selected continuing medical education (CME) made conveniently available. Will this trend further decrease subscriptions to peer-reviewed journals? Perhaps. As stated, with every major societal upheaval, there are losers and winners.

An integral aspect of our professional lives, especially for those of us in academia, has been attending the regional, national and international meetings of the societies to which we subscribe. These occasions provide continuing education, but they are also occasions for camaraderie, for seeing friends, eating out, sightseeing and, quite often, person-to-person discussions in hallways or over coffee or a drink on job opportunities, changes in locale, and for ongoing research and innovation. In the past, those occasions for learning were combined with pleasure involving travel, the need for accommodations and other expenses, which have been partly or wholly reimbursed as business or academic travel, as well as tax write-offs.

COVID-19 changed all that. Meetings were canceled, deferred or held virtually. A virtual meeting offers continuing education but not the personal moments of being in the same room with colleagues. Virtual meeting attendees are deprived of the free give-and-take after an in-person presentation and the discussion possible in a meet-the-expert session. These meetings do not offer the varied pleasures of travel, or of being accompanied by family and friends.

The advantages of virtual meetings are many, however—advantages that may well carry over to the post–COVID-19 era, including increased registration, especially from overseas, enhancing the primary objective of continuing education with a wider dissemination of knowledge. With the elimination of travel expenses, virtual meetings will allow entire medical departments, practice partnerships and hospital divisions the ability to attend a distant meeting. For the same reason, more people could register and attend more meetings than they ordinarily might have. By streaming, attendees could select the time to watch a session, for example, a time not in competition with the OR. And, the organizing society can collect registration fees from a larger group of attendees without the expense of renting meeting venues, paying for staffing and staff travel.

I am certain that meeting exhibitors were at first distressed by virtual meetings that deprived them of the opportunity for product display booths. On the other hand, company leadership probably welcomed the huge reduction of expenses for rental of space, etc. At a lesser expense, exhibitors were able to advertise on the virtual meeting broadcasts, comparable to their current ads on commercial TV. continued on page 22

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Necessity Prompts Foray Into Virutal ‘Hands-on’ Surgical Courses continued from page 1

known as ADOPT, which begins training in the lab and extends mentorship throughout the year.

On Friday, Oct. 23, at his home in Bangor, Maine, Dr. Gomez scrubbed in virtually with a surgeon proctor and another mentee logging on at their homes for a two-on-one virtual session. The focus of the course: a review of complex abdominal wall hernia repair.

“Even though the proctor wasn’t physically by my side, it still felt like she was sitting next to me, like a co-pilot advising me on where to go next,” Dr. Gomez, a general surgeon at St. Joseph Hospital in Bangor, said.

Making the hands-on course a virtual one took careful planning. Sharon Bachman, MD, the course chair, wondered whether it could even be done.

“We knew we needed a technical platform that could accommodate live mentoring and a model adapted to mimic a human abdominal wall that could be sent to participants,” Dr. Bachman, the director of minimally invasive surgery at Inova Fairfax Hospital in Falls Church, Va., said. “One fascinating thing about COVID-19 has been the rapid development of innovative technology.”

After speaking with several companies, Dr. Bachman and the course’s co-chair, Jacob Greenberg, MD, decided to partner with two: Kindheart, which creates realtissue simulations and specially designed a porcine model of a human abdominal wall for this course; and Proximie, a technology platform that allows surgeons to scrub in virtually. Proximie also set up a coursespecific webpage that the SAGES faculty populated with videos and talks to prep participants before the training began.

The next step: making sure the technology and porcine model shipped to 15 attendees. A few days before the session, Dr. Gomez received a rather large package with the pig abdomen carefully nestled on dry ice. A second package arrived with a collapsible box to house the pig

(Above left). For Dr. Gomez, one of the best parts of the course was the reaction from his 2-year-old daughter. “She kept asking to play with piggy,” he said. “I may have a surgeon in the making.”

(Above right) Dr. Gomez received a collapsible box to house the pig abdomen and tubing to mount retractors.

(Inset) Dr. Gomez’s full setup for his virtual hands-on course.

(Below) SAGES proctor Dr. Jacob Greenberg’s setup at home.

abdomen and tubing to mount retractors. For the telementoring, SAGES shipped a webcam and an arm on which

Virtual World continued from page 20

Future scientific meetings may well be hybrid affairs.

It is difficult to imagine the advantage of a greater dissemination of knowledge at a lesser cost being discarded in the world beyond COVID-19. At the same time, hands-on, same-site presence will continue to be essential for certain professional learning and transactions.

In addition, the human social instinct will find plausible reasons for coming together for personal contacts.

The lure of travel will also provide an impetus for justifying live meetings. Thus, the solution may, in fact, be hybrid affairs: certain groups meeting in person, others by virtual and streaming presentations and discussions.

While offering less personal enjoyment, virtual hybrid

to mount it. Proximie’s augmented reality platform allowed participants to operate while proctors watched and interacted with the livestreaming video.

Dr. Gomez wanted to focus on mesh fixation techniques while performing a transversus abdominis muscle release (TAR) technique for posterior component separation.

“When you are close to the ribs during a complex abdominal wall repair, things can get tight, and I wanted some pointers on how to release this TAR plane to fixate the mesh and avoid wrinkles,” Dr. Gomez said. “My proctor guided me through, telling me to pull the retrorectus plane with my left hand using Allis clamps while dissecting a plane just underneath the xiphoid with the Bovie, reaching this beautiful plane where the mesh can lie flat.”

This tip came in handy during a procedure Dr. Gomez performed just a week later in his small community-based practice. Dr. Gomez called the virtual training potentially “lifesaving” for his patient.

On the proctor side, Dr. Greenberg divided the training time between his two attendees, each of whom had familiarity with the procedure but wanted to focus

professional meetings may offer a greater opportunity for continuing education at a lower cost.

Health Care Proof of the decline of U.S. health care is evident in hard global statistics. In essentially every measure of excellence we are not world leaders, not even close. We markedly trail other nations in life expectancy, mortality rate, years of potential life lost, disease-specific mortality, infant mortality and the availability of health care.

We are, however, indisputably world leaders in the cost of health care.

As illustrated, there are certain dangers for medical practitioners and our patients in the virtual world post–COVID-19. With respect to national health care, however, I am more optimistic. Advanced technology

on different aspects of it: one on tips and tricks during more challenging parts of the component separation and the other on mesh fixation. As the first attendee moved through the hernia repair, the second could watch and absorb the session, and then they swapped.

While the attendees operated, Dr. Greenberg could see a close-up of their pig model on his screen, as they moved through each step of the procedure.

“But because I can’t put my hands in the pig and demonstrate what to do next, I had to ask the surgeon to stop, tell me what they’re seeing and thinking, what they want to do next,” Dr. Greenberg, an associate professor of surgery at the University of Wisconsin–Madison, said. “I’d draw on my screen, which would appear on their screen, to show them what I would do and where I would be. This approach forced both of us to slow down and share our thinking.”

Dr. Bachman, one of the eight faculty teaching the course, found that the virtual aspect of the course enhanced the learning experience. “In every course I’ve taken, you have to share your cadaver or faculty’s time with a lot of other surgeons, or the faculty takes over the procedure when they teach,” she said. “But, in this course, the participants had their own model and the undivided attention of their mentor.”

Another benefit: For surgeons who work in small community practices, taking days away to attend a conference may not be feasible. Having a hands-on virtual course can provide access to techniques and training that some surgeons otherwise wouldn’t have.

“Amid the COVID pandemic and upheaval of 2020, it was great to be able to continue learning and growing as a ■ surgeon,” Dr. Gomez said.

A video of Dr. Greenberg’s training session is in the online version of this article at www.generalsurgerynews.com.

made available to health care has been uniformly advantageous: The stethoscope was an improvement over an ear to the chest; x-rays were more convincing than palpation; radiation could ameliorate cancers; rapid transport enhanced availability of care in war and in peace; and instant communications have increased the dissemination of knowledge and expertise. The technology imposed by COVID-19, therefore, may help our nation take the path to remedy our health care statistics.

■ —Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis. His articles appear every other month.

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GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

Management News The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C Suite

FOR SOME ELITE SOLDIERS, THIS IS ADVANCING. As a general surgeon and officer on the U.S. Army health care team, you will work in cutting-edge facilities as you see and study cases that are not usually encountered in civilian practices. You will also receive benefits that ensure you are taken care of, including student loan repayment programs, paid continuing education, retirement plans and much more. Joining this team will allow you to advance your career and focus on why you became a physician in the first place—to care for your patients.

To see the benefits of being an Army medical professional call 800-431-6717 or visit healthcare.goarmy.com/aqqb