ACS Surgery News

CHICAGO – Use of an enhanced recovery protocol for oncology patients has been shown to improve outcomes in colorectal surgery but has been largely unproven in other types of major oncology operations. That prompted researchers at the University of Texas MD Anderson Cancer Center in Houston to investigate enhanced recovery protocols in multispecialty, major oncologic procedures. They found that the enhanced recovery protocol led to a reduction in complication rates and a decrease in hospital stay with no increase in readmissions, according to an analysis of more than 3,000 oncologic operations presented at the Society of Surgical Oncology Annual Cancer Symposium here.

lyosha_nazarenko/Thinkstock

“Patients treated with enhanced recovery did better,” Rebecca Marcus, MD, said in reporting the results. “There were decreased rates of perioperative transfusions, decreased rates of surgical site infections, decreased rates of complications, including severe complications such as wound dehiscence, pneumonia, renal failure, and unintended returns to the operating room.” She noted that the shorter hospital stays – 4 days for patients on the enhanced recovery protocol versus 5 days for those on the traditional postoperative protocol – did not result in increased readmissions.

The study reviewed 3,256 operations performed during 2011-2016 in the MD Anderson institutional American College of Surgeons National Surgical Quality Improvement Program database. The operations were colorectal (20.4%), gynecologic (19.5%), hepatobiliary (8.9%), thoracic (41.9%) and urologic (9.3%). Most employed the traditional postoperative protocol (53.4%). Colorectal and thoracic/vascular surgery were early adopters of the enhanced recovery protocol at MD Anderson.

Dr. Marcus noted that the overall complication rates were 21.9% for those treated with enhanced recovery–protocol versus 33.9% for those treated with traditional postoperative protocol (P less than .0001). The group treated with enhanced recovery protocol also had lower rates of severe complications: 8.7% vs. 11.7% (P =.0048). The study also noted a trend toward reduced National Surgical Quality Improvement Program 30-day mortality with the enhanced recover protocol (0.4% vs. 0.86%; P = .097). Readmission rates were similar between the two groups: 8.3% for enhanced recovery protocol versus 8.9% for traditional postoperative protocol.

SOURCE: Marcus RK et al. SSO 2018, Abstract 21.

CHICAGO – Use of an enhanced recovery protocol for oncology patients has been shown to improve outcomes in colorectal surgery but has been largely unproven in other types of major oncology operations. That prompted researchers at the University of Texas MD Anderson Cancer Center in Houston to investigate enhanced recovery protocols in multispecialty, major oncologic procedures. They found that the enhanced recovery protocol led to a reduction in complication rates and a decrease in hospital stay with no increase in readmissions, according to an analysis of more than 3,000 oncologic operations presented at the Society of Surgical Oncology Annual Cancer Symposium here.

lyosha_nazarenko/Thinkstock

“Patients treated with enhanced recovery did better,” Rebecca Marcus, MD, said in reporting the results. “There were decreased rates of perioperative transfusions, decreased rates of surgical site infections, decreased rates of complications, including severe complications such as wound dehiscence, pneumonia, renal failure, and unintended returns to the operating room.” She noted that the shorter hospital stays – 4 days for patients on the enhanced recovery protocol versus 5 days for those on the traditional postoperative protocol – did not result in increased readmissions.

The study reviewed 3,256 operations performed during 2011-2016 in the MD Anderson institutional American College of Surgeons National Surgical Quality Improvement Program database. The operations were colorectal (20.4%), gynecologic (19.5%), hepatobiliary (8.9%), thoracic (41.9%) and urologic (9.3%). Most employed the traditional postoperative protocol (53.4%). Colorectal and thoracic/vascular surgery were early adopters of the enhanced recovery protocol at MD Anderson.

Dr. Marcus noted that the overall complication rates were 21.9% for those treated with enhanced recovery–protocol versus 33.9% for those treated with traditional postoperative protocol (P less than .0001). The group treated with enhanced recovery protocol also had lower rates of severe complications: 8.7% vs. 11.7% (P =.0048). The study also noted a trend toward reduced National Surgical Quality Improvement Program 30-day mortality with the enhanced recover protocol (0.4% vs. 0.86%; P = .097). Readmission rates were similar between the two groups: 8.3% for enhanced recovery protocol versus 8.9% for traditional postoperative protocol.

SOURCE: Marcus RK et al. SSO 2018, Abstract 21.

CHICAGO – Use of an enhanced recovery protocol for oncology patients has been shown to improve outcomes in colorectal surgery but has been largely unproven in other types of major oncology operations. That prompted researchers at the University of Texas MD Anderson Cancer Center in Houston to investigate enhanced recovery protocols in multispecialty, major oncologic procedures. They found that the enhanced recovery protocol led to a reduction in complication rates and a decrease in hospital stay with no increase in readmissions, according to an analysis of more than 3,000 oncologic operations presented at the Society of Surgical Oncology Annual Cancer Symposium here.

lyosha_nazarenko/Thinkstock

“Patients treated with enhanced recovery did better,” Rebecca Marcus, MD, said in reporting the results. “There were decreased rates of perioperative transfusions, decreased rates of surgical site infections, decreased rates of complications, including severe complications such as wound dehiscence, pneumonia, renal failure, and unintended returns to the operating room.” She noted that the shorter hospital stays – 4 days for patients on the enhanced recovery protocol versus 5 days for those on the traditional postoperative protocol – did not result in increased readmissions.

The study reviewed 3,256 operations performed during 2011-2016 in the MD Anderson institutional American College of Surgeons National Surgical Quality Improvement Program database. The operations were colorectal (20.4%), gynecologic (19.5%), hepatobiliary (8.9%), thoracic (41.9%) and urologic (9.3%). Most employed the traditional postoperative protocol (53.4%). Colorectal and thoracic/vascular surgery were early adopters of the enhanced recovery protocol at MD Anderson.

Dr. Marcus noted that the overall complication rates were 21.9% for those treated with enhanced recovery–protocol versus 33.9% for those treated with traditional postoperative protocol (P less than .0001). The group treated with enhanced recovery protocol also had lower rates of severe complications: 8.7% vs. 11.7% (P =.0048). The study also noted a trend toward reduced National Surgical Quality Improvement Program 30-day mortality with the enhanced recover protocol (0.4% vs. 0.86%; P = .097). Readmission rates were similar between the two groups: 8.3% for enhanced recovery protocol versus 8.9% for traditional postoperative protocol.

SOURCE: Marcus RK et al. SSO 2018, Abstract 21.

ORLANDO – Preoperative electrocardiograms (EKGs) had no effect on management or perioperative complications in women undergoing benign hysterectomy over a 12-month period at a single medical center, according to a review of records.

Of 587 patients included in the review, 182 (31%) underwent EKG as part of their preoperative evaluation, and the majority of those were indicated according to institutional criteria (166; 28%) or National Institute for Health Care Excellence (NICE) guidelines (177; 30%), Nemi M. Shah, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

“EKG was indicated in 91% of these patients according to institutional criteria, and in 97% of patients per NICE criteria,” said Dr. Shah, a third-year resident at the University of Texas Southwestern Medical Center, Dallas.

By institutional criteria, hypertension was the most common indication (68% of cases), and by NICE criteria, American Society of Anesthesia class 2 physical status was the most common indication (80% of cases), she noted, adding that obesity, which was present in 70% of patients, was the most common comorbidity classifying patients with American Society of Anesthesia class 2 or above.

Of the 182 EKGs performed, findings were abnormal in 89, but further workup was pursued in only 16 patients, and included repeat EKG, echocardiogram, and/or stress testing and cardiology consultation. Surgical delays of 1 and 4 months occurred in 2 patients as a result of the additional workup, and ultimately, all planned hysterectomies were completed by the primary surgical team without changes in management, she said.

Perioperative complications occurred in two patients, and included nonspecific postinduction EKG changes that led to surgery being aborted in one patient who had left ventricular hypertrophy on the preoperative EKG, and failed extubation in a patient with airway edema whose preoperative EKG showed a nonacute inferior infarct.

For the first, cardiology was consulted and determined the findings to be benign; the patient underwent hysterectomy at a later date without complications. The second patient was taken to the surgical intensive care unit for management, Dr. Shah said.

[email protected]

SOURCE: Shah N et al. SGS 2018 Oral Poster 3.

ORLANDO – Preoperative electrocardiograms (EKGs) had no effect on management or perioperative complications in women undergoing benign hysterectomy over a 12-month period at a single medical center, according to a review of records.

Of 587 patients included in the review, 182 (31%) underwent EKG as part of their preoperative evaluation, and the majority of those were indicated according to institutional criteria (166; 28%) or National Institute for Health Care Excellence (NICE) guidelines (177; 30%), Nemi M. Shah, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

“EKG was indicated in 91% of these patients according to institutional criteria, and in 97% of patients per NICE criteria,” said Dr. Shah, a third-year resident at the University of Texas Southwestern Medical Center, Dallas.

By institutional criteria, hypertension was the most common indication (68% of cases), and by NICE criteria, American Society of Anesthesia class 2 physical status was the most common indication (80% of cases), she noted, adding that obesity, which was present in 70% of patients, was the most common comorbidity classifying patients with American Society of Anesthesia class 2 or above.

Of the 182 EKGs performed, findings were abnormal in 89, but further workup was pursued in only 16 patients, and included repeat EKG, echocardiogram, and/or stress testing and cardiology consultation. Surgical delays of 1 and 4 months occurred in 2 patients as a result of the additional workup, and ultimately, all planned hysterectomies were completed by the primary surgical team without changes in management, she said.

Perioperative complications occurred in two patients, and included nonspecific postinduction EKG changes that led to surgery being aborted in one patient who had left ventricular hypertrophy on the preoperative EKG, and failed extubation in a patient with airway edema whose preoperative EKG showed a nonacute inferior infarct.

For the first, cardiology was consulted and determined the findings to be benign; the patient underwent hysterectomy at a later date without complications. The second patient was taken to the surgical intensive care unit for management, Dr. Shah said.

[email protected]

SOURCE: Shah N et al. SGS 2018 Oral Poster 3.

ORLANDO – Preoperative electrocardiograms (EKGs) had no effect on management or perioperative complications in women undergoing benign hysterectomy over a 12-month period at a single medical center, according to a review of records.

Of 587 patients included in the review, 182 (31%) underwent EKG as part of their preoperative evaluation, and the majority of those were indicated according to institutional criteria (166; 28%) or National Institute for Health Care Excellence (NICE) guidelines (177; 30%), Nemi M. Shah, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

“EKG was indicated in 91% of these patients according to institutional criteria, and in 97% of patients per NICE criteria,” said Dr. Shah, a third-year resident at the University of Texas Southwestern Medical Center, Dallas.

By institutional criteria, hypertension was the most common indication (68% of cases), and by NICE criteria, American Society of Anesthesia class 2 physical status was the most common indication (80% of cases), she noted, adding that obesity, which was present in 70% of patients, was the most common comorbidity classifying patients with American Society of Anesthesia class 2 or above.

Of the 182 EKGs performed, findings were abnormal in 89, but further workup was pursued in only 16 patients, and included repeat EKG, echocardiogram, and/or stress testing and cardiology consultation. Surgical delays of 1 and 4 months occurred in 2 patients as a result of the additional workup, and ultimately, all planned hysterectomies were completed by the primary surgical team without changes in management, she said.

Perioperative complications occurred in two patients, and included nonspecific postinduction EKG changes that led to surgery being aborted in one patient who had left ventricular hypertrophy on the preoperative EKG, and failed extubation in a patient with airway edema whose preoperative EKG showed a nonacute inferior infarct.

For the first, cardiology was consulted and determined the findings to be benign; the patient underwent hysterectomy at a later date without complications. The second patient was taken to the surgical intensive care unit for management, Dr. Shah said.

[email protected]

SOURCE: Shah N et al. SGS 2018 Oral Poster 3.

The rate of major and minor 30-day complications from the treatment of uterine fibroids has increased significantly since the Food and Drug Administration’s black-box warning against the use of power morcellation, data suggest.

Researchers examined the incidence of 30-day posthysterectomy complications in 75,487 women who underwent treatment for benign gynecologic indications before and after November 2014, when the FDA’s edict was issued over concerns about the risk of disseminating benign or malignant disease. Of these women, 25,571 had uterine fibroids as the indication for hysterectomy.

The retrospective cohort study, published online April 11 in JAMA Surgery, showed that while the overall rate of complications in the cohort was relatively unchanged before and after the FDA’s warning, complication rates increased significantly in women undergoing treatment for uterine fibroids.

Before the FDA’s announcement, the 30-day major complication rate in women undergoing hysterectomy for uterine fibroids was 1.9%, which increased to 2.4% after the FDA’s warning (odds ratio, 1.23; 95% confidence interval, 1.04-1.47; P = .02). Similarly, the rate of minor 30-day complications increased from 2.7% before the warning to 3.3% after the warning (OR, 1.21; 95% CI, 1.04-1.40; P = .01), after adjustment for factors such as age, body mass index, comorbidities, and other associated procedures.

“This 20% increase in the odds of major and minor complications could translate into a large number of additional complications among the 200,000 hysterectomies performed annually for uterine fibroids in the United States,” wrote Francesco Multinu, MD, of the department of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., and his coauthors.

Overall, the researchers saw a much higher rate of major complications in women undergoing open abdominal surgery, compared with women who underwent minimally invasive surgery or vaginal hysterectomy (3.5% vs. 1.7% vs. 1.7%). A similar pattern was seen in the subgroup of women who underwent hysterectomy for uterine fibroids (2.8% vs. 1.8% vs. 1.8%).

However, minor 30-day complication rates were higher in women who underwent vaginal hysterectomy (4.5%), compared with open abdominal surgery (4.1%) and minimally invasive surgery (3.2%). In women with uterine fibroids, the minor complication rates were slightly higher in those who underwent open hysterectomy or vaginal hysterectomy than in those who had minimally invasive surgery, but this was not statistically significant.

The type of surgery in women with uterine fibroids changed significantly after the FDA announcement. Before the black-box warning against power morcellation was issued, 37.2% of hysterectomy procedures for uterine fibroids were open, 56.1% were minimally invasive, and 6.7% were vaginal. After the announcement, the percentage that were open procedures increased to 43%, minimally invasive procedures decreased to 49.7%, and vaginal hysterectomies increased to 7.3% (P less than .001).

A similar but less pronounced trend was seen across all hysterectomies for benign gynecological indications.

The authors noted that the study analyzed data on 30-day complications, so they weren’t able to draw conclusions about longer-term outcomes.

“Although caution is required to avoid morcellation of unexpected uterine malignant neoplasms, our results should be considered by women and clinicians during the process of shared decision making and by medical societies and regulatory bodies when issuing safety communications,” the authors wrote.

The study was supported by a grant from the National Center for Advancing Translational Sciences, and one author was supported by the University of Insubria, and by Fondo Miglierina, Varese, Italy. No conflicts of interest were declared.

SOURCE: Multinu F et al. JAMA Surg. 2018 Apr 11. doi: 10.1001/jamasurg.2018.0141.

The rate of major and minor 30-day complications from the treatment of uterine fibroids has increased significantly since the Food and Drug Administration’s black-box warning against the use of power morcellation, data suggest.

Researchers examined the incidence of 30-day posthysterectomy complications in 75,487 women who underwent treatment for benign gynecologic indications before and after November 2014, when the FDA’s edict was issued over concerns about the risk of disseminating benign or malignant disease. Of these women, 25,571 had uterine fibroids as the indication for hysterectomy.

The retrospective cohort study, published online April 11 in JAMA Surgery, showed that while the overall rate of complications in the cohort was relatively unchanged before and after the FDA’s warning, complication rates increased significantly in women undergoing treatment for uterine fibroids.

Before the FDA’s announcement, the 30-day major complication rate in women undergoing hysterectomy for uterine fibroids was 1.9%, which increased to 2.4% after the FDA’s warning (odds ratio, 1.23; 95% confidence interval, 1.04-1.47; P = .02). Similarly, the rate of minor 30-day complications increased from 2.7% before the warning to 3.3% after the warning (OR, 1.21; 95% CI, 1.04-1.40; P = .01), after adjustment for factors such as age, body mass index, comorbidities, and other associated procedures.

“This 20% increase in the odds of major and minor complications could translate into a large number of additional complications among the 200,000 hysterectomies performed annually for uterine fibroids in the United States,” wrote Francesco Multinu, MD, of the department of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., and his coauthors.

Overall, the researchers saw a much higher rate of major complications in women undergoing open abdominal surgery, compared with women who underwent minimally invasive surgery or vaginal hysterectomy (3.5% vs. 1.7% vs. 1.7%). A similar pattern was seen in the subgroup of women who underwent hysterectomy for uterine fibroids (2.8% vs. 1.8% vs. 1.8%).

However, minor 30-day complication rates were higher in women who underwent vaginal hysterectomy (4.5%), compared with open abdominal surgery (4.1%) and minimally invasive surgery (3.2%). In women with uterine fibroids, the minor complication rates were slightly higher in those who underwent open hysterectomy or vaginal hysterectomy than in those who had minimally invasive surgery, but this was not statistically significant.

The type of surgery in women with uterine fibroids changed significantly after the FDA announcement. Before the black-box warning against power morcellation was issued, 37.2% of hysterectomy procedures for uterine fibroids were open, 56.1% were minimally invasive, and 6.7% were vaginal. After the announcement, the percentage that were open procedures increased to 43%, minimally invasive procedures decreased to 49.7%, and vaginal hysterectomies increased to 7.3% (P less than .001).

A similar but less pronounced trend was seen across all hysterectomies for benign gynecological indications.

The authors noted that the study analyzed data on 30-day complications, so they weren’t able to draw conclusions about longer-term outcomes.

“Although caution is required to avoid morcellation of unexpected uterine malignant neoplasms, our results should be considered by women and clinicians during the process of shared decision making and by medical societies and regulatory bodies when issuing safety communications,” the authors wrote.

The study was supported by a grant from the National Center for Advancing Translational Sciences, and one author was supported by the University of Insubria, and by Fondo Miglierina, Varese, Italy. No conflicts of interest were declared.

SOURCE: Multinu F et al. JAMA Surg. 2018 Apr 11. doi: 10.1001/jamasurg.2018.0141.

The rate of major and minor 30-day complications from the treatment of uterine fibroids has increased significantly since the Food and Drug Administration’s black-box warning against the use of power morcellation, data suggest.

Researchers examined the incidence of 30-day posthysterectomy complications in 75,487 women who underwent treatment for benign gynecologic indications before and after November 2014, when the FDA’s edict was issued over concerns about the risk of disseminating benign or malignant disease. Of these women, 25,571 had uterine fibroids as the indication for hysterectomy.

The retrospective cohort study, published online April 11 in JAMA Surgery, showed that while the overall rate of complications in the cohort was relatively unchanged before and after the FDA’s warning, complication rates increased significantly in women undergoing treatment for uterine fibroids.

Before the FDA’s announcement, the 30-day major complication rate in women undergoing hysterectomy for uterine fibroids was 1.9%, which increased to 2.4% after the FDA’s warning (odds ratio, 1.23; 95% confidence interval, 1.04-1.47; P = .02). Similarly, the rate of minor 30-day complications increased from 2.7% before the warning to 3.3% after the warning (OR, 1.21; 95% CI, 1.04-1.40; P = .01), after adjustment for factors such as age, body mass index, comorbidities, and other associated procedures.

“This 20% increase in the odds of major and minor complications could translate into a large number of additional complications among the 200,000 hysterectomies performed annually for uterine fibroids in the United States,” wrote Francesco Multinu, MD, of the department of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., and his coauthors.

Overall, the researchers saw a much higher rate of major complications in women undergoing open abdominal surgery, compared with women who underwent minimally invasive surgery or vaginal hysterectomy (3.5% vs. 1.7% vs. 1.7%). A similar pattern was seen in the subgroup of women who underwent hysterectomy for uterine fibroids (2.8% vs. 1.8% vs. 1.8%).

However, minor 30-day complication rates were higher in women who underwent vaginal hysterectomy (4.5%), compared with open abdominal surgery (4.1%) and minimally invasive surgery (3.2%). In women with uterine fibroids, the minor complication rates were slightly higher in those who underwent open hysterectomy or vaginal hysterectomy than in those who had minimally invasive surgery, but this was not statistically significant.

The type of surgery in women with uterine fibroids changed significantly after the FDA announcement. Before the black-box warning against power morcellation was issued, 37.2% of hysterectomy procedures for uterine fibroids were open, 56.1% were minimally invasive, and 6.7% were vaginal. After the announcement, the percentage that were open procedures increased to 43%, minimally invasive procedures decreased to 49.7%, and vaginal hysterectomies increased to 7.3% (P less than .001).

A similar but less pronounced trend was seen across all hysterectomies for benign gynecological indications.

The authors noted that the study analyzed data on 30-day complications, so they weren’t able to draw conclusions about longer-term outcomes.

“Although caution is required to avoid morcellation of unexpected uterine malignant neoplasms, our results should be considered by women and clinicians during the process of shared decision making and by medical societies and regulatory bodies when issuing safety communications,” the authors wrote.

The study was supported by a grant from the National Center for Advancing Translational Sciences, and one author was supported by the University of Insubria, and by Fondo Miglierina, Varese, Italy. No conflicts of interest were declared.

SOURCE: Multinu F et al. JAMA Surg. 2018 Apr 11. doi: 10.1001/jamasurg.2018.0141.

LAS VEGAS – Adhesions occur after just about every abdominal operation, hernia repair in particular, whether they are open or laparoscopic. Small bowel obstructions can result, and management decisions can be complex. What if the patient resolves? Should you offer elective adhesiolysis? If it doesn’t resolve, can the surgery be done laparoscopically or should the procedure be open?

Bradley R. Davis, MD, FACS, discussed some of these options, and the case circumstances that inform the surgeon’s choices at the Annual Minimally Invasive Surgery Symposium by -Global Academy for Medical Education. Dr. Davis is chief of general surgery and of rectal surgery at Carolinas Medical Center, Charlotte, N.C.

Laparoscopic surgeries are associated with significantly lower rates of small bowel obstruction, but it can still happen. More often, patients will have had a previous open surgery, and this should be a selling point for doing first-time surgeries using minimally invasive techniques. “That’s one thing I tell my patients when I see them in the office. There’s a real reduction in adhesive small bowel obstruction and certainly in hernia formation, so there are long-term benefits that I don’t think we talk enough about,” said Dr. Davis.

Although the majority of obstructions are caused by adhesions, some are the result of malignancies or hernias, and Dr. Davis encourages his residents to do exams to determine if a hernia is to blame. “That’s harder and harder to do now that everyone does a CT scan, but that’s always an interesting question to ask a resident,” he said. Inflammatory bowel disease is sometimes also a cause, but that’s rare.

CT scans are the diagnostic mode of choice for small bowel obstructions. Some believe that oral contrast agents may help resolve obstructions, but Dr. Davis mentioned evidence from a study showing that contrast agents don’t change the course of obstructions or reduce laparotomy rates. However, contrast agents can help predict the clinical course of an obstruction. If the contrast agent is present in the colon at 24 hours, then that predicts that the patient will resolve with conservative treatment. “You have a pretty good idea that the patient is going to get better,” said Dr. Davis.

The American Association for the Surgery of Trauma severity grade is helpful for adhesive small bowel obstructions. Grade 2 cases involve intestinal distension and possibly a transition zone, some passage of contrast on follow-up films, and no evidence of intestinal compromise. Grade 3 cases have no distal contrast flow and evidence of complete obstruction or impending bowel compromise. In the latter cases, “we’re scratching our heads wondering whether to take the patient to the operating room. Certainly most of these cases we’ll manage initially nonoperatively, but those patients will end up getting an earlier operation,” said Dr. Davis.

The majority of surgeries are adhesiolysis, sometimes with a bowel resection. Whether or not the surgery can be performed laparoscopically or as an open surgery depends on several factors. If the index operation was done laparoscopically, chances are good that the adhesiolysis can be performed the same way. On the other hand, “if a patient has a known hostile abdomen, I wouldn’t even try. I would basically go straight to an open procedure,” said Dr. Davis.

Generally speaking, though, reoperative surgeries can be attempted laparoscopically and then converted to open procedures if needed, he added. The most common reasons for conversion are dense adhesions and ischemia-related resection.

However, iatrogenic injuries can also occur as a result of trocar access. “Just keep in mind that if you put the trocar into the bowel, the worst thing you can do is take it out because you won’t always find that hole. Just leave the trocar in the bowel, convert to an open procedure, and find the hole and fix it,” said Dr. Davis.

Cases are particularly challenging when the transition zone is in the pelvis. Those procedures are difficult to do laparoscopically because of a difficult angle, and they are more likely to convert to open surgery. “To be honest, that’s not an easy operation to open either, so beware that transition zone in the pelvis can be a difficult case.

“I don’t try to do anything heroic laparoscopically. If you put a camera in and you find it’s going to be a massive adhesiolysis laparoscopically, you might just be better off to open,” said Dr. Davis. In cases like that it can be hard to find the transition zone, which must be identified in order to ensure that the underlying problem is fixed.

An aggressive option in difficult cases is to use a PEEK Port, which starts with a 6-8 cm incision. The surgeon can open up a minimum of disposables and put a hand in to assist the laparoscopic view and determine if the procedure can be completed laparoscopically. “If you encounter extensive adhesions, you just convert to a laparotomy and you haven’t lost any time or spent any money in terms of disposables,” he said.

Dr. Davis had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

LAS VEGAS – Adhesions occur after just about every abdominal operation, hernia repair in particular, whether they are open or laparoscopic. Small bowel obstructions can result, and management decisions can be complex. What if the patient resolves? Should you offer elective adhesiolysis? If it doesn’t resolve, can the surgery be done laparoscopically or should the procedure be open?

Bradley R. Davis, MD, FACS, discussed some of these options, and the case circumstances that inform the surgeon’s choices at the Annual Minimally Invasive Surgery Symposium by -Global Academy for Medical Education. Dr. Davis is chief of general surgery and of rectal surgery at Carolinas Medical Center, Charlotte, N.C.

Laparoscopic surgeries are associated with significantly lower rates of small bowel obstruction, but it can still happen. More often, patients will have had a previous open surgery, and this should be a selling point for doing first-time surgeries using minimally invasive techniques. “That’s one thing I tell my patients when I see them in the office. There’s a real reduction in adhesive small bowel obstruction and certainly in hernia formation, so there are long-term benefits that I don’t think we talk enough about,” said Dr. Davis.

Although the majority of obstructions are caused by adhesions, some are the result of malignancies or hernias, and Dr. Davis encourages his residents to do exams to determine if a hernia is to blame. “That’s harder and harder to do now that everyone does a CT scan, but that’s always an interesting question to ask a resident,” he said. Inflammatory bowel disease is sometimes also a cause, but that’s rare.

CT scans are the diagnostic mode of choice for small bowel obstructions. Some believe that oral contrast agents may help resolve obstructions, but Dr. Davis mentioned evidence from a study showing that contrast agents don’t change the course of obstructions or reduce laparotomy rates. However, contrast agents can help predict the clinical course of an obstruction. If the contrast agent is present in the colon at 24 hours, then that predicts that the patient will resolve with conservative treatment. “You have a pretty good idea that the patient is going to get better,” said Dr. Davis.

The American Association for the Surgery of Trauma severity grade is helpful for adhesive small bowel obstructions. Grade 2 cases involve intestinal distension and possibly a transition zone, some passage of contrast on follow-up films, and no evidence of intestinal compromise. Grade 3 cases have no distal contrast flow and evidence of complete obstruction or impending bowel compromise. In the latter cases, “we’re scratching our heads wondering whether to take the patient to the operating room. Certainly most of these cases we’ll manage initially nonoperatively, but those patients will end up getting an earlier operation,” said Dr. Davis.

The majority of surgeries are adhesiolysis, sometimes with a bowel resection. Whether or not the surgery can be performed laparoscopically or as an open surgery depends on several factors. If the index operation was done laparoscopically, chances are good that the adhesiolysis can be performed the same way. On the other hand, “if a patient has a known hostile abdomen, I wouldn’t even try. I would basically go straight to an open procedure,” said Dr. Davis.

Generally speaking, though, reoperative surgeries can be attempted laparoscopically and then converted to open procedures if needed, he added. The most common reasons for conversion are dense adhesions and ischemia-related resection.

However, iatrogenic injuries can also occur as a result of trocar access. “Just keep in mind that if you put the trocar into the bowel, the worst thing you can do is take it out because you won’t always find that hole. Just leave the trocar in the bowel, convert to an open procedure, and find the hole and fix it,” said Dr. Davis.

Cases are particularly challenging when the transition zone is in the pelvis. Those procedures are difficult to do laparoscopically because of a difficult angle, and they are more likely to convert to open surgery. “To be honest, that’s not an easy operation to open either, so beware that transition zone in the pelvis can be a difficult case.

“I don’t try to do anything heroic laparoscopically. If you put a camera in and you find it’s going to be a massive adhesiolysis laparoscopically, you might just be better off to open,” said Dr. Davis. In cases like that it can be hard to find the transition zone, which must be identified in order to ensure that the underlying problem is fixed.

An aggressive option in difficult cases is to use a PEEK Port, which starts with a 6-8 cm incision. The surgeon can open up a minimum of disposables and put a hand in to assist the laparoscopic view and determine if the procedure can be completed laparoscopically. “If you encounter extensive adhesions, you just convert to a laparotomy and you haven’t lost any time or spent any money in terms of disposables,” he said.

Dr. Davis had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

LAS VEGAS – Adhesions occur after just about every abdominal operation, hernia repair in particular, whether they are open or laparoscopic. Small bowel obstructions can result, and management decisions can be complex. What if the patient resolves? Should you offer elective adhesiolysis? If it doesn’t resolve, can the surgery be done laparoscopically or should the procedure be open?

Bradley R. Davis, MD, FACS, discussed some of these options, and the case circumstances that inform the surgeon’s choices at the Annual Minimally Invasive Surgery Symposium by -Global Academy for Medical Education. Dr. Davis is chief of general surgery and of rectal surgery at Carolinas Medical Center, Charlotte, N.C.

Laparoscopic surgeries are associated with significantly lower rates of small bowel obstruction, but it can still happen. More often, patients will have had a previous open surgery, and this should be a selling point for doing first-time surgeries using minimally invasive techniques. “That’s one thing I tell my patients when I see them in the office. There’s a real reduction in adhesive small bowel obstruction and certainly in hernia formation, so there are long-term benefits that I don’t think we talk enough about,” said Dr. Davis.

Although the majority of obstructions are caused by adhesions, some are the result of malignancies or hernias, and Dr. Davis encourages his residents to do exams to determine if a hernia is to blame. “That’s harder and harder to do now that everyone does a CT scan, but that’s always an interesting question to ask a resident,” he said. Inflammatory bowel disease is sometimes also a cause, but that’s rare.

CT scans are the diagnostic mode of choice for small bowel obstructions. Some believe that oral contrast agents may help resolve obstructions, but Dr. Davis mentioned evidence from a study showing that contrast agents don’t change the course of obstructions or reduce laparotomy rates. However, contrast agents can help predict the clinical course of an obstruction. If the contrast agent is present in the colon at 24 hours, then that predicts that the patient will resolve with conservative treatment. “You have a pretty good idea that the patient is going to get better,” said Dr. Davis.

The American Association for the Surgery of Trauma severity grade is helpful for adhesive small bowel obstructions. Grade 2 cases involve intestinal distension and possibly a transition zone, some passage of contrast on follow-up films, and no evidence of intestinal compromise. Grade 3 cases have no distal contrast flow and evidence of complete obstruction or impending bowel compromise. In the latter cases, “we’re scratching our heads wondering whether to take the patient to the operating room. Certainly most of these cases we’ll manage initially nonoperatively, but those patients will end up getting an earlier operation,” said Dr. Davis.

The majority of surgeries are adhesiolysis, sometimes with a bowel resection. Whether or not the surgery can be performed laparoscopically or as an open surgery depends on several factors. If the index operation was done laparoscopically, chances are good that the adhesiolysis can be performed the same way. On the other hand, “if a patient has a known hostile abdomen, I wouldn’t even try. I would basically go straight to an open procedure,” said Dr. Davis.

Generally speaking, though, reoperative surgeries can be attempted laparoscopically and then converted to open procedures if needed, he added. The most common reasons for conversion are dense adhesions and ischemia-related resection.

However, iatrogenic injuries can also occur as a result of trocar access. “Just keep in mind that if you put the trocar into the bowel, the worst thing you can do is take it out because you won’t always find that hole. Just leave the trocar in the bowel, convert to an open procedure, and find the hole and fix it,” said Dr. Davis.

Cases are particularly challenging when the transition zone is in the pelvis. Those procedures are difficult to do laparoscopically because of a difficult angle, and they are more likely to convert to open surgery. “To be honest, that’s not an easy operation to open either, so beware that transition zone in the pelvis can be a difficult case.

“I don’t try to do anything heroic laparoscopically. If you put a camera in and you find it’s going to be a massive adhesiolysis laparoscopically, you might just be better off to open,” said Dr. Davis. In cases like that it can be hard to find the transition zone, which must be identified in order to ensure that the underlying problem is fixed.

An aggressive option in difficult cases is to use a PEEK Port, which starts with a 6-8 cm incision. The surgeon can open up a minimum of disposables and put a hand in to assist the laparoscopic view and determine if the procedure can be completed laparoscopically. “If you encounter extensive adhesions, you just convert to a laparotomy and you haven’t lost any time or spent any money in terms of disposables,” he said.

Dr. Davis had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

NEW ORLEANS – When complete resection of advanced-stage, epithelial ovarian cancer is not possible, surgical resection that leaves a small volume of residual tumor at a single site produces significantly better outcomes than leaving minimal residual cancer at multiple sites, according to a review of 510 patients at two U.S. centers.

Mitchel L. Zoler/MDedge News

Dr. Manning-Geist had no disclosures.

[email protected]

SOURCE: Manning-Geist B et al. SGO 2018, Abstract 43.

NEW ORLEANS – When complete resection of advanced-stage, epithelial ovarian cancer is not possible, surgical resection that leaves a small volume of residual tumor at a single site produces significantly better outcomes than leaving minimal residual cancer at multiple sites, according to a review of 510 patients at two U.S. centers.

Mitchel L. Zoler/MDedge News

Dr. Manning-Geist had no disclosures.

[email protected]

SOURCE: Manning-Geist B et al. SGO 2018, Abstract 43.

NEW ORLEANS – When complete resection of advanced-stage, epithelial ovarian cancer is not possible, surgical resection that leaves a small volume of residual tumor at a single site produces significantly better outcomes than leaving minimal residual cancer at multiple sites, according to a review of 510 patients at two U.S. centers.

Mitchel L. Zoler/MDedge News

Dr. Manning-Geist had no disclosures.

[email protected]

SOURCE: Manning-Geist B et al. SGO 2018, Abstract 43.

Almost 75% of physicians support the new federal policy that permits states to attach work requirements to Medicaid participation, according to a survey by physician recruitment firm Merritt Hawkins.

“Many physicians have been frustrated for years because Medicaid often pays less than their costs of providing care. Physicians have to limit the number of Medicaid patients they treat for that reason and want to focus on those who need care the most,” Travis Singleton, executive vice president of Merritt Hawkins, said in a statement.

[email protected]

Almost 75% of physicians support the new federal policy that permits states to attach work requirements to Medicaid participation, according to a survey by physician recruitment firm Merritt Hawkins.

“Many physicians have been frustrated for years because Medicaid often pays less than their costs of providing care. Physicians have to limit the number of Medicaid patients they treat for that reason and want to focus on those who need care the most,” Travis Singleton, executive vice president of Merritt Hawkins, said in a statement.

[email protected]

Almost 75% of physicians support the new federal policy that permits states to attach work requirements to Medicaid participation, according to a survey by physician recruitment firm Merritt Hawkins.

“Many physicians have been frustrated for years because Medicaid often pays less than their costs of providing care. Physicians have to limit the number of Medicaid patients they treat for that reason and want to focus on those who need care the most,” Travis Singleton, executive vice president of Merritt Hawkins, said in a statement.

[email protected]

NEW ORLEANS – U.S. clinicians prescribe opioid tablets to postsurgical patients too often and at too high a pill count, according to results from two independent studies that examined prescribing patterns and opioid use in patients following gynecologic surgery.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

• Patients undergoing minimally invasive or outpatient surgery and with no history of chronic pain and low opioid need while hospitalized received the default dispense of 600 mg ibuprofen every 6 hours as needed for 7 days and 500 mg acetaminophen every 6 hours as needed for 7 days.
• Patients who underwent this surgery but required 5 or more opioid tablets while hospitalized or those with a history of chronic pain and opioid use received the ibuprofen and acetaminophen regimen plus 12 opioid tablets, a 3-day supply with 1 tablet taken every 6 hours as needed.
• Patients who underwent laparotomy and had no chronic pain and opioid history and low opioid use while hospitalized received the ibuprofen and acetaminophen regimen plus 12 opioid tablets, a 3-day supply.
• Patients who underwent laparotomy and showed a higher opioid need based on their use during the 24 hours before discharge received the ibuprofen and acetaminophen regimen plus 24 opioid tablets for 3 days so they could take 2 tablets every 6 hours as needed.

Dr. Mark and his associates collected data from 337 patients managed with these guidelines during June 2017–January 2018 and compared them with 626 patients who underwent gynecologic surgery at Roswell Park during July 2016–June 2017. The data showed the average number of opioid tablets dispensed per patient for all discharges fell from 31.7 before the new guideline to 3.5, an 89% reduction. For the subgroup of patients who had undergone a laparotomy, the average pill number fell from 43.6 to 11.6, a 72% drop. Among patients treated with minimally invasive or outpatient surgery, average tablets dispensed fell from 28.1 before to 0.9 after, a 97% reduction. The reduction among opioid-naive patients was 90%, and it was 83% among patients who used opioids prior to their surgery.

Dr. Mark, Dr. Weston, and Dr. Dowdy had no disclosures.

[email protected]

SOURCE: Mark J et al. SGO 2018, Abstract 7. Weston E et al. SGO 2018, Abstract 8.

NEW ORLEANS – U.S. clinicians prescribe opioid tablets to postsurgical patients too often and at too high a pill count, according to results from two independent studies that examined prescribing patterns and opioid use in patients following gynecologic surgery.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

• Patients undergoing minimally invasive or outpatient surgery and with no history of chronic pain and low opioid need while hospitalized received the default dispense of 600 mg ibuprofen every 6 hours as needed for 7 days and 500 mg acetaminophen every 6 hours as needed for 7 days.
• Patients who underwent this surgery but required 5 or more opioid tablets while hospitalized or those with a history of chronic pain and opioid use received the ibuprofen and acetaminophen regimen plus 12 opioid tablets, a 3-day supply with 1 tablet taken every 6 hours as needed.
• Patients who underwent laparotomy and had no chronic pain and opioid history and low opioid use while hospitalized received the ibuprofen and acetaminophen regimen plus 12 opioid tablets, a 3-day supply.
• Patients who underwent laparotomy and showed a higher opioid need based on their use during the 24 hours before discharge received the ibuprofen and acetaminophen regimen plus 24 opioid tablets for 3 days so they could take 2 tablets every 6 hours as needed.

Dr. Mark and his associates collected data from 337 patients managed with these guidelines during June 2017–January 2018 and compared them with 626 patients who underwent gynecologic surgery at Roswell Park during July 2016–June 2017. The data showed the average number of opioid tablets dispensed per patient for all discharges fell from 31.7 before the new guideline to 3.5, an 89% reduction. For the subgroup of patients who had undergone a laparotomy, the average pill number fell from 43.6 to 11.6, a 72% drop. Among patients treated with minimally invasive or outpatient surgery, average tablets dispensed fell from 28.1 before to 0.9 after, a 97% reduction. The reduction among opioid-naive patients was 90%, and it was 83% among patients who used opioids prior to their surgery.

Dr. Mark, Dr. Weston, and Dr. Dowdy had no disclosures.

[email protected]

SOURCE: Mark J et al. SGO 2018, Abstract 7. Weston E et al. SGO 2018, Abstract 8.

NEW ORLEANS – U.S. clinicians prescribe opioid tablets to postsurgical patients too often and at too high a pill count, according to results from two independent studies that examined prescribing patterns and opioid use in patients following gynecologic surgery.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

• Patients undergoing minimally invasive or outpatient surgery and with no history of chronic pain and low opioid need while hospitalized received the default dispense of 600 mg ibuprofen every 6 hours as needed for 7 days and 500 mg acetaminophen every 6 hours as needed for 7 days.
• Patients who underwent this surgery but required 5 or more opioid tablets while hospitalized or those with a history of chronic pain and opioid use received the ibuprofen and acetaminophen regimen plus 12 opioid tablets, a 3-day supply with 1 tablet taken every 6 hours as needed.
• Patients who underwent laparotomy and had no chronic pain and opioid history and low opioid use while hospitalized received the ibuprofen and acetaminophen regimen plus 12 opioid tablets, a 3-day supply.
• Patients who underwent laparotomy and showed a higher opioid need based on their use during the 24 hours before discharge received the ibuprofen and acetaminophen regimen plus 24 opioid tablets for 3 days so they could take 2 tablets every 6 hours as needed.

Dr. Mark and his associates collected data from 337 patients managed with these guidelines during June 2017–January 2018 and compared them with 626 patients who underwent gynecologic surgery at Roswell Park during July 2016–June 2017. The data showed the average number of opioid tablets dispensed per patient for all discharges fell from 31.7 before the new guideline to 3.5, an 89% reduction. For the subgroup of patients who had undergone a laparotomy, the average pill number fell from 43.6 to 11.6, a 72% drop. Among patients treated with minimally invasive or outpatient surgery, average tablets dispensed fell from 28.1 before to 0.9 after, a 97% reduction. The reduction among opioid-naive patients was 90%, and it was 83% among patients who used opioids prior to their surgery.

Dr. Mark, Dr. Weston, and Dr. Dowdy had no disclosures.

[email protected]

SOURCE: Mark J et al. SGO 2018, Abstract 7. Weston E et al. SGO 2018, Abstract 8.

While U.S. death rates have declined overall, marked geographic disparities exist at the state level in burden of disease, injuries, and risk factors, according to a comprehensive analysis.

Life expectancy varies substantially, for example, ranging from a high of 81.3 years in Hawaii to a low of 74.7 years in Mississippi, according to results from the analysis of data from the Global Burden of Disease (GBD) study (JAMA. 2018;319[14]:1444-72).

Previously decreasing death rates for adults have reversed in 19 states, according to the analysis, which covers the years 1990 to 2016.

Hardest hit were Kentucky, New Mexico, Oklahoma, West Virginia, and Wyoming, which had mortality increases of more than 10% among adults aged 20-55 years. Those increases were largely due to causes such as substance use disorders, self-harm, and cirrhosis, according to the US Burden of Disease Collaborators, who authored the report.

“These findings should be used to examine the causes of health variations and to plan, develop, and implement programs and policies to improve health overall and eliminate disparities in the United States,” the authors wrote.

SOURCE: The US Burden of Disease Collaborators. JAMA 2018;319(14):1444-72.

While U.S. death rates have declined overall, marked geographic disparities exist at the state level in burden of disease, injuries, and risk factors, according to a comprehensive analysis.

Life expectancy varies substantially, for example, ranging from a high of 81.3 years in Hawaii to a low of 74.7 years in Mississippi, according to results from the analysis of data from the Global Burden of Disease (GBD) study (JAMA. 2018;319[14]:1444-72).

Previously decreasing death rates for adults have reversed in 19 states, according to the analysis, which covers the years 1990 to 2016.

Hardest hit were Kentucky, New Mexico, Oklahoma, West Virginia, and Wyoming, which had mortality increases of more than 10% among adults aged 20-55 years. Those increases were largely due to causes such as substance use disorders, self-harm, and cirrhosis, according to the US Burden of Disease Collaborators, who authored the report.

“These findings should be used to examine the causes of health variations and to plan, develop, and implement programs and policies to improve health overall and eliminate disparities in the United States,” the authors wrote.

SOURCE: The US Burden of Disease Collaborators. JAMA 2018;319(14):1444-72.

While U.S. death rates have declined overall, marked geographic disparities exist at the state level in burden of disease, injuries, and risk factors, according to a comprehensive analysis.

Life expectancy varies substantially, for example, ranging from a high of 81.3 years in Hawaii to a low of 74.7 years in Mississippi, according to results from the analysis of data from the Global Burden of Disease (GBD) study (JAMA. 2018;319[14]:1444-72).

Previously decreasing death rates for adults have reversed in 19 states, according to the analysis, which covers the years 1990 to 2016.

Hardest hit were Kentucky, New Mexico, Oklahoma, West Virginia, and Wyoming, which had mortality increases of more than 10% among adults aged 20-55 years. Those increases were largely due to causes such as substance use disorders, self-harm, and cirrhosis, according to the US Burden of Disease Collaborators, who authored the report.

“These findings should be used to examine the causes of health variations and to plan, develop, and implement programs and policies to improve health overall and eliminate disparities in the United States,” the authors wrote.

SOURCE: The US Burden of Disease Collaborators. JAMA 2018;319(14):1444-72.

JACKSONVILLE, FLA. – Post-hospital care after major surgery is a significant driver of overall surgery-related spending, and hospitals are focused on reducing this spending as payers move away from the fee-for-service model.

Post-acute care following complications after major surgery can add from $1,700 to more than $4,000 to the patient’s bill, with a trend toward utilizing more expensive inpatient post-acute care and less outpatient care, according to an analysis of more than 700,000 Medicare procedures presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Hospitals’ efforts to reduce post-acute care spending must focus on preventing complications. “Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform,” Dr. Kanters noted

Session moderator Courtney Balentine, MD, of the University of Alabama at Birmingham, asked Dr. Kanters whether the research considered the incentives hospital systems have for referring patients to their own post-acute care facilities. “Post-acute care association with a single hospital has been documented as a likely incentive for discharge to a non-home destination,” Dr. Kanters replied, which leads to higher utilization of “certain” post-acute care facilities and higher costs. However, she said, this study’s dataset could not parse out that trend. “That’s certainly something that needs to be investigated,” she said.

Dr. Kanters and her coauthors had no financial relationships to disclose.

Source: Kanters AE. Annual Academic Surgical Congress 2018.

JACKSONVILLE, FLA. – Post-hospital care after major surgery is a significant driver of overall surgery-related spending, and hospitals are focused on reducing this spending as payers move away from the fee-for-service model.

Post-acute care following complications after major surgery can add from $1,700 to more than $4,000 to the patient’s bill, with a trend toward utilizing more expensive inpatient post-acute care and less outpatient care, according to an analysis of more than 700,000 Medicare procedures presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Hospitals’ efforts to reduce post-acute care spending must focus on preventing complications. “Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform,” Dr. Kanters noted

Session moderator Courtney Balentine, MD, of the University of Alabama at Birmingham, asked Dr. Kanters whether the research considered the incentives hospital systems have for referring patients to their own post-acute care facilities. “Post-acute care association with a single hospital has been documented as a likely incentive for discharge to a non-home destination,” Dr. Kanters replied, which leads to higher utilization of “certain” post-acute care facilities and higher costs. However, she said, this study’s dataset could not parse out that trend. “That’s certainly something that needs to be investigated,” she said.

Dr. Kanters and her coauthors had no financial relationships to disclose.

Source: Kanters AE. Annual Academic Surgical Congress 2018.

JACKSONVILLE, FLA. – Post-hospital care after major surgery is a significant driver of overall surgery-related spending, and hospitals are focused on reducing this spending as payers move away from the fee-for-service model.

Post-acute care following complications after major surgery can add from $1,700 to more than $4,000 to the patient’s bill, with a trend toward utilizing more expensive inpatient post-acute care and less outpatient care, according to an analysis of more than 700,000 Medicare procedures presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Hospitals’ efforts to reduce post-acute care spending must focus on preventing complications. “Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform,” Dr. Kanters noted

Session moderator Courtney Balentine, MD, of the University of Alabama at Birmingham, asked Dr. Kanters whether the research considered the incentives hospital systems have for referring patients to their own post-acute care facilities. “Post-acute care association with a single hospital has been documented as a likely incentive for discharge to a non-home destination,” Dr. Kanters replied, which leads to higher utilization of “certain” post-acute care facilities and higher costs. However, she said, this study’s dataset could not parse out that trend. “That’s certainly something that needs to be investigated,” she said.

Dr. Kanters and her coauthors had no financial relationships to disclose.

Source: Kanters AE. Annual Academic Surgical Congress 2018.

CHICAGO – As Medicare transitions to a value-based model that uses bundled payments, oncologic surgeons and medical institutions may want to take a close look at enhanced recovery pathways and more minimally invasive surgery for colectomy in both benign and malignant disease to close potential gaps in reimbursement and outcomes, according to a retrospective study of 4-year Medicare data presented at the Society of Surgical Oncology Annual Cancer Symposium here.

• DRG poorly differentiates between benign and malignant disease. This problem is evidenced by the higher cost for the index admission in benign disease. “Whereas in malignant disease, there is a greater unrecognized cost-shifting to post-acute care services which are not addressed by the DRG system,” he said.
• The dominance of open colectomy where MIS could reduce episode costs. The study cited research that reported the advantages of MIS include lower episode costs in both younger and older patients, by $1,466 and $632, respectively; shorter hospital stays by 1.46 days; 20% lower 30-day readmissions rates; and lower rates of post-acute care services (J Laparoendosc Adv Surg Tech A. 2017 Dec 13. doi: 10.1089/lap.2017.0521)
• Potential for DRG migration from code 331 (benign disease) to 330 (colon cancer but not with metastasis). Dr. Hughes and his coauthors published a study that reported a 14.2% rate of DRG migration in this same Medicare cohort, that is, classified as 331 on admission but migrated to 330. So, compared with other patients, this group ended up with longer LOS (7.6 vs. 4.8 days); higher total charges ($63,149 vs. $46,339); and higher CMS payment ($11,159 vs. $7,210) (Am J Surg. 2018;215:493-6). “We also identified a potential role for enhanced-recovery pathways to mitigate these factors,” he said.

He noted that the different stakeholders – hospitals, surgeons, anesthesiologists, hospitalists, other physicians, nurses, and extenders – will have to resolve how to divide bundled payments. “The biggest thing is communication between these groups, because moving forward CMS is trying to step away from the role of determining who gets paid what,” Dr. Hughes said. He noted this finding is consistent with his own previously published findings, along with those from senior study coauthor Anthony J. Senagore, MD, FACS, on resource consumption in value-based care.

Dr. Hughes and coauthors reported having no financial disclosures. Dr. Hughes is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

SOURCE: Huges BD. SSO 2018.

CHICAGO – As Medicare transitions to a value-based model that uses bundled payments, oncologic surgeons and medical institutions may want to take a close look at enhanced recovery pathways and more minimally invasive surgery for colectomy in both benign and malignant disease to close potential gaps in reimbursement and outcomes, according to a retrospective study of 4-year Medicare data presented at the Society of Surgical Oncology Annual Cancer Symposium here.

• DRG poorly differentiates between benign and malignant disease. This problem is evidenced by the higher cost for the index admission in benign disease. “Whereas in malignant disease, there is a greater unrecognized cost-shifting to post-acute care services which are not addressed by the DRG system,” he said.
• The dominance of open colectomy where MIS could reduce episode costs. The study cited research that reported the advantages of MIS include lower episode costs in both younger and older patients, by $1,466 and $632, respectively; shorter hospital stays by 1.46 days; 20% lower 30-day readmissions rates; and lower rates of post-acute care services (J Laparoendosc Adv Surg Tech A. 2017 Dec 13. doi: 10.1089/lap.2017.0521)
• Potential for DRG migration from code 331 (benign disease) to 330 (colon cancer but not with metastasis). Dr. Hughes and his coauthors published a study that reported a 14.2% rate of DRG migration in this same Medicare cohort, that is, classified as 331 on admission but migrated to 330. So, compared with other patients, this group ended up with longer LOS (7.6 vs. 4.8 days); higher total charges ($63,149 vs. $46,339); and higher CMS payment ($11,159 vs. $7,210) (Am J Surg. 2018;215:493-6). “We also identified a potential role for enhanced-recovery pathways to mitigate these factors,” he said.

He noted that the different stakeholders – hospitals, surgeons, anesthesiologists, hospitalists, other physicians, nurses, and extenders – will have to resolve how to divide bundled payments. “The biggest thing is communication between these groups, because moving forward CMS is trying to step away from the role of determining who gets paid what,” Dr. Hughes said. He noted this finding is consistent with his own previously published findings, along with those from senior study coauthor Anthony J. Senagore, MD, FACS, on resource consumption in value-based care.

Dr. Hughes and coauthors reported having no financial disclosures. Dr. Hughes is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

SOURCE: Huges BD. SSO 2018.

CHICAGO – As Medicare transitions to a value-based model that uses bundled payments, oncologic surgeons and medical institutions may want to take a close look at enhanced recovery pathways and more minimally invasive surgery for colectomy in both benign and malignant disease to close potential gaps in reimbursement and outcomes, according to a retrospective study of 4-year Medicare data presented at the Society of Surgical Oncology Annual Cancer Symposium here.

• DRG poorly differentiates between benign and malignant disease. This problem is evidenced by the higher cost for the index admission in benign disease. “Whereas in malignant disease, there is a greater unrecognized cost-shifting to post-acute care services which are not addressed by the DRG system,” he said.
• The dominance of open colectomy where MIS could reduce episode costs. The study cited research that reported the advantages of MIS include lower episode costs in both younger and older patients, by $1,466 and $632, respectively; shorter hospital stays by 1.46 days; 20% lower 30-day readmissions rates; and lower rates of post-acute care services (J Laparoendosc Adv Surg Tech A. 2017 Dec 13. doi: 10.1089/lap.2017.0521)
• Potential for DRG migration from code 331 (benign disease) to 330 (colon cancer but not with metastasis). Dr. Hughes and his coauthors published a study that reported a 14.2% rate of DRG migration in this same Medicare cohort, that is, classified as 331 on admission but migrated to 330. So, compared with other patients, this group ended up with longer LOS (7.6 vs. 4.8 days); higher total charges ($63,149 vs. $46,339); and higher CMS payment ($11,159 vs. $7,210) (Am J Surg. 2018;215:493-6). “We also identified a potential role for enhanced-recovery pathways to mitigate these factors,” he said.

He noted that the different stakeholders – hospitals, surgeons, anesthesiologists, hospitalists, other physicians, nurses, and extenders – will have to resolve how to divide bundled payments. “The biggest thing is communication between these groups, because moving forward CMS is trying to step away from the role of determining who gets paid what,” Dr. Hughes said. He noted this finding is consistent with his own previously published findings, along with those from senior study coauthor Anthony J. Senagore, MD, FACS, on resource consumption in value-based care.

Dr. Hughes and coauthors reported having no financial disclosures. Dr. Hughes is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

SOURCE: Huges BD. SSO 2018.